So, you need a lumbar discectomy. You and I both. In June of last year, I went from scanning patients with disc problems (I’m a radiographer!) to becoming one myself. I tried it all - physical therapy, injections - before it became clear that a discectomy was the best course of action for me. I was super scared, especially as I also work as a personal trainer, and feared how I could physically prepare myself.
So, I spent hours combing Google Scholar for what the science says on how we can optimise our preparation for discectomy. Score!
Whilst it may seem scary at first, patients like us with persistent pain are fortunate in that we have time to prepare physically for the surgery itself. This helps put us in the best headspace for surgery and recovery.
Golden Rule: Medical Advice First, Google Scholar Second
First and foremost, when structuring any preoperative programme, especially when it comes to spinal injuries, please follow the advice of your healthcare professional first and foremost. If they have advised against certain exercises, movement patterns or loads, listen.
You might want to deadlift more than anything, but if the physician thinks it could affect your surgical outcome, don’t risk it. If this is the case, that’s ok. There will be plenty of time to safely reintegrate the deadlift after surgery!
Lumbar Discectomy: An Overview
To best optimise our rehabilitation, it can help to understand what’s going to happen, and where. During a lumbar discectomy, you are going to be lying prone on the operating table. An incision will be made to allow access for instruments. Your posterior spinal musculature will be exposed, to allow access to the nerve root.
Following this, the fragments of the offending disc causing you so much heartache are removed from the nerve root, known as decompression [1]. You awaken from your beautiful anaesthetic coma and then start the recovery process. So, what can you do before the surgery to set yourself up for success after?
Why Preoperative Strength Training Anyway?
A comprehensive discectomy preoperative plan aims to improve physical condition and mental perception of pain and how it relates to movement [2]. For lumbar discectomies, this typically encompasses physiotherapy and cognitive behavioural therapy.
In fact, improving your health in general, is associated with better surgical outcomes and lesser hospital stays [3,4]. Furthermore, with lumbar discectomy patients, prehabilitation is associated with better functional outcomes [2].
However, the literature isn’t so straightforward here, with two separate meta-analyses suggesting prehabilitation isn’t studied enough to definitively say it affects patient lumbar discectomy outcomes [5,6].
So does this mean you should scrap your preoperative strengthening programme altogether? Not quite. Rather, it suggests there is no one programme that fits all lumbar discectomies.
Barriers to Preoperative Success
No discectomy patient is the same. We all have our own movement limitations and movement patterns that aggravate us. It is important to recognise the difference between pushing yourself and putting yourself in harm’s way. This can take some trial and error, and it is important to take it easy when introducing any new movement patterns or loads. In general, there is no exercise that is inherently dangerous to perform at this stage of the game, but if any movement causes increased pain or numbness into either leg or significantly increases your back pain, it would be best to hold off on those for now.
The key to achieving a tolerable training effect in this preoperative phase really comes down to listening to your body. Find what movements you can tolerate, and work from there. For me, this meant that Romanian deadlifts and any similar movement patterns were out. Any hip hinge with major hamstring involvement caused increased back pain and sciatic pain to run down the length of my leg.
Is this because these exercises are dangerous for patients with herniated discs? Not necessarily, and we discussed this in a lot more detail here. Rather, it’s the limitations of the athletes’ movement prevent them from carrying out the movement safely and effectively. And that’s not to say RDLs will be off the table for everyone!
Core-nerstone of Prehabilitation
Aside from being an excellent pun, the core musculature is the solid basis of surgical success. Increased core muscle size is associated with higher survival rates from surgery [7]. Now, that’s not to say the world will end if you haven’t done a few planks in the lead up to surgery. Rather, it can help provide a good structural base for you as you commence recovery.
Building up abdominal trunk strength is a huge focus of post-operative rehabilitation [8]. You can get a head start on recovery by strengthening the abdominal muscles through whatever movement patterns you can tolerate – planks, crunches, mountain climbers etc. Indeed, strengthening the trunk muscles was identified as a key focus of returning Olympic athletes to competition following discectomies [9].
Preventing Muscle Atrophy. Build That Buffer!
While studies show that core work can be beneficial in the preoperative phase, it is important to continue to train if you can, through whatever movement patterns you can tolerate. Are you a powerlifter who primarily trains the squat, bench press, and deadlift? Regress and modify these exercises as needed (if allowed by the physician) in order to facilitate a tolerable training effect. Or, maybe you just strength train for general health purposes. The same caveat would stand. Modify your painful exercises as warranted. The key is to focus on what you CAN do, not what you CAN’T do. Finding your entry point exercises can really help here.
What’s the point of strength training if you’re going to have surgery any way? Some studies have shown that a lower skeletal muscle mass is associated with less favourable surgical outcomes and a longer recovery [10,11]. Indeed, lower muscle mass is associated with poorer lumbar spinal surgery outcomes specifically [12].
Realistically, you can expect some degree of muscle loss if you are in any way athletic – you won’t be able to maintain your usual level of activity. So, it makes sense to create as much of a “buffer” for muscle loss between now and your operation.
Limiting Kinesiophobia and Building Mental Robustness
Kinesiophobia, or fear of movement, is another great reason why you should keep on training to tolerance prior to your lumbar discectomy. Kinesiophobia is one of the biggest predictors of chronic lower back pain after injury, and it makes sense right [13]? Suffering from sciatica or any lower back pain that warrants surgery is undeniably painful and terrifying. It makes sense that you would want to avoid re-injuring it, or doing anything that could cause that same pain. By training and moving in a way that is comfortable for you, you are challenging that kinesiophobia. It was my own neurosurgeon who told me, “You can wrap yourself up in cotton wool, and it’ll only make it worse”.
No one is saying to keep training through pain or performing unsuitable exercises for the sake of proving you’re not afraid. Rather, this is about getting you back to a level of activity and maintaining that quality of life as you recover from surgery. Kinesiophobia will only make things worse [14].
Final Thoughts
Getting a lumbar discectomy is not to be sniffed at. The prospect of spinal surgery can be a challenge for anyone, athletic or not. However, the time you spend preparing yourself can optimize your outcome, from a physical and mental perspective. Overall, it is really important to work within your own individual abilities and limits, and remain as active as your condition and healthcare provider allows.
About the Author
References
- Kulkarni, A.G., Bassi, A., Dhrav, A. (2014) ‘Microendoscopic lumbar discectomy: Technique and results of 188 cases’, Indian Journal of Orthopaedics, 48(1), p. 81.
- Santa Mina, D., Clarke, H., Ritvo, P., Leung, Y.W., Matthew, Katz, J. (2014) ‘Effect of total-body prehabilitation on postoperative outcomes: a systematic review and meta-anaysis’, Physiotherapy, 100, pp. 196-207.
- Carli, F., Gillis, C., Scheede-Bergdahl, C. (2017) ‘Promoting a culture of prehabilitation for the surgical cancer patient’, Acta Oncology, 56(1), pp. 128-133.
- Delgado-López, P., Rodríguez-Salazar, A., Castilla-Díez, J.M. (2019) ‘”Prehabilitation” in degenerative spine surgery: A literature review’, Neurocirugía, 30(3), pp. 124-132.
- Gometz, A., Maislen, D., Youtz, C., Kary, E., Gometz, E.L., Sobotka, S., Choudhri, T.F. (2018) ‘The effectiveness of prehabilitation (prehab) in both functional and economic outcomes following spinal surgery: A systematic review’, Cereus, 10(5), p. 2675.
- Janssen, E.R., Punt, I.M., Clemens, M.J., Staal, J.B., Hoogeboom, T.J., Willems, P.C. (2021) ‘Current prehabilitation programs do not improve postoperative outcomes of patients scheduled for lumbar spine surgery: A systematic review with meta-analysis’, Journal of Orthopaedic & Sports Physical Therapy, 51(3), pp. 103-114.
- Englesbe, M.J., Lee, J.S., He, K., Fan, L., Schaubel, D.E., Sheetz, K.H., Harbaugh, C.M., Holcombe, S.A., Campbell, D.A., Sonnenday, C.J., Wang, S.C. (2012) ‘Analystic Morphomics, Core Muscle Size and Surgical Outcomes’, Annals of Surgery, 256(2), pp. 255-261.
- Filliz, M., Cakmak, A., Ozcan, E. (2005) ‘The effectiveness of exercise programmes after lumbar disc surgery: a randomized controlled study’, Clinical Rehabilitation, 19(1), pp. 4-11.
- Watkins, R.G., Williams, L.A., Watkins, R.G. (2003) ‘Microscopic lumbar discectomy results for 60 cases in professional and Olympic athletes’, The Spine Journal, 3(2), pp. 100-105.
- Xiao, j., Caan, B.J., Caspedes Feliciano, E.M. (2020) ‘Association of low muscle mass and low muscle radiodensity with morbidity and mortality for colon cancer surgery’, JAMA, 155(10), pp. 942-949.
- Yuill, K.A., Richardson, R.A., Davidson, H.I., Garden, O.J., Parks, R.W. (2005) ‘The administration of an oral carbohydrate containing fluid prior to major elective upper-gastrointestinal surgery preserves skeletal mass postoperatively – a randomized clinical trial’, Clinical Nutrition, 24(2), pp. 32-37.
- Inose, H., Yamada, T., Hirai, T., Yoshii, T., Abe, Y., Okawa, A. (2018) ‘The impact of sarcopenia on the results of lumbar spinal surgery’, Osteoporosis and Sarcopenia, 4(1), pp. 33-36.
- Picavet, H.S., Vlaeyen, J.W., Schouten, A.G. (2002) ‘Pain Catastrophizing and Kinesiophobia: Predictors of Chronic Low Back Pain’, American Journal of Epidemiology, 156(11), pp. 1028-1034.
- Luque-Suarez, A., Martinez-Calderon, J., Falla, D. (2018) ‘Role of kinesiophobia on pain, disability and quality of life in people suffering from chronic musculoskeletal pain: a systematic review’, British Journal of Sports Medicine, 53(9).
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