The effects of postoperative activity restrictions on outcomes after spine surgery: a systematic review

Abstract

Background

Postoperative activity restrictions are commonly prescribed after spine surgery. However, it is unclear whether postoperative restrictions improve clinical or surgical outcomes after spine surgery. The primary aim of this study was to investigate the effects of postoperative activity restrictions in spine surgery on patient-reported outcomes. The secondary aim of the study was to assess whether these postoperative activity restrictions were associated with recurrence (reherniation), adverse events, and complications after spine surgery.

Methods

This review included studies discussing degenerative spine surgery patients with postoperative activity restrictions, defined as limitations on specific movements such as bending or twisting, or activities such as driving or weightlifting. Electronic searches were conducted using PubMed, CENTRAL, Embase, and Web of Science databases in November 2024. The Revised Cochrane risk-of-bias tool for randomized trials (RoB 2) and Risk Of Bias In Non-randomized Studies – of Interventions, Version 2 (ROBINS-I V2) tools were used to evaluate included studies for risk of bias. Meta-analysis was initially planned but was not performed due to the heterogeneity of the included studies. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to determine the certainty of the body of evidence.

Results

A total of 3,723 studies were screened. Four studies met the inclusion criteria: one randomized controlled trial and two prospective single-arm cohort studies discussing open lumbar discectomy, and one prospective non-randomized two-group cohort study discussing percutaneous endoscopic lumbar discectomy (PELD). Notably, there are no studies discussing restrictions after cervical or thoracic spinal surgery. Pain, function/disability, and data on recurrence (reherniation), adverse events and complications were collected from each study. The certainty of evidence was low for all outcomes analyzed, making it difficult to provide a definitive conclusion for or against the use of postoperative activity restrictions in spine surgery.

Conclusions

Current literature prevents a definitive conclusion regarding the effectiveness of postoperative restrictions in spine surgery. Future studies should address the limitations and heterogeneity of the current literature to provide the basis for standardized, evidence-based postoperative activity restriction protocols.

Highlight box.

Key findings

• Limited evidence exists regarding the effectiveness of postoperative activity restrictions on outcomes after lumbar spine surgery and there is no evidence for postoperative activity restrictions after cervical spine surgery.

• The certainty of evidence was low for all outcomes analyzed, making it difficult to provide a definitive conclusion for or against the use of postoperative activity restrictions in spine surgery.

What is known and what is new?

• Prescription of postoperative activity restrictions after spine surgery is common with high variability between clinicians. It is unclear if postoperative restrictions improve clinical or surgical outcomes after spine surgery.

• This review synthesizes the current literature surrounding activity restrictions after spine surgery and highlights the lack of evidence regarding the effectiveness of such restrictions on outcomes after spine surgery. In the absence of high-quality evidence, the findings suggest that restrictions are largely dependent on individual surgeon experience and preference.

What is the implication, and what should change now?

• Using non-evidence-based protocols, which can include the use of postoperative restrictions, can have significant medical, legal and financial implications on practice. More research is needed to determine the effectiveness of postoperative activity restrictions after spine surgery on clinical and surgical outcomes, particularly in the form of randomized controlled trials. Large randomized controlled trials should be organized to create evidence-based restriction protocols.

Introduction

Activity restrictions following spine surgery for degenerative conditions remain a subject of ongoing debate. Postoperative activity restrictions are commonly prescribed and often include bed rest, delayed mobilization, avoidance of bending, lifting, and twisting motions, and limitations in activities of daily living (ADLs) such as driving and sexual intercourse (1-7). While the aims of establishing postoperative activity restrictions are most often to reduce the risk of complications, such as reoperation, hardware failure, wound dehiscence, and pseudoarthrosis, there is limited evidence supporting their effectiveness in improving patient clinical outcomes (3,4,8-11).

Furthermore, there is significant variability among spine surgeons regarding the specific activity restrictions recommended across many common spinal surgeries, including single-level anterior cervical discectomy and fusion (ACDF), multi-level ACDF, lumbar discectomy, minimally invasive lumbar fusion, and open lumbar fusion (5-7,12,13). Historically, traditional practice has involved long bed rest and extensive activity restrictions, but spine surgeons’ perceptions of such restrictions lack agreement. Multiple studies have documented the heterogeneity of postoperative recommendations after spine surgery, and a survey study in Sweden and the Netherlands found that the typical recommended time point for starting home activities ranged from 1 week to 6 months between surgeons (12,14). A similar study exploring return to sports found that no consensus exists among the spine surgeons surveyed regarding return to activity and rehabilitation protocols; 35% of surgeons recommended stopping weightlifting permanently, while 48% of surgeons recommended return to high-level play after 3 months (15). These glaring differences highlight the inconsistency of postoperative recommendations after spine surgery, with some surgeons upholding traditional methods and others moving in a new direction.

The inconsistency in practice patterns regarding postoperative management for spine surgery can have medical, legal, and financial impacts on the healthcare system (13). While a clear lack of surgeon consensus underscores the need for evidence-based guidance concerning postoperative restrictions for spine surgery, a better understanding of the value and requirements of postoperative activity restrictions after spine surgery may help to improve postoperative patient-reported outcomes, surgical outcomes, and cost-effectiveness after spine surgery. Therefore, the primary aim of this study was to investigate the effects of postoperative activity restrictions in spine surgery on patient-reported outcomes. The secondary aim of the study was to assess whether these postoperative activity restrictions were associated with recurrence (reherniation), adverse events and complications after spine surgery. We present this article in accordance with the PRISMA reporting checklist (available at https://jss.amegroups.com/article/view/10.21037/jss-25-87/rc) (16).

Methods

This systematic review was designed based on the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions (17).

Electronic searches

Electronic searches were conducted using PubMed, CENTRAL, Embase, and Web of Science databases in November 2024. The search strategy included: (I) terms for spine surgery, including “lumbar”, “cervical”, and “spine”; (II) terms for surgical interventions, such as “surgery”, “fusion”, and “discectomy”; (III) terms for postoperative recovery, such as “postoperative” and “postsurgical”; (IV) terms for ambulation, such as “ambulation” and “activity”; (V) terms for activity restrictions, such as “restriction” and “immobilization”. These search terms were combined using “AND” and “OR” Boolean operators, along with specific database functions. The full search strategy is outlined in Appendix 1. No restrictions were made on the basis of year of publication or country of origin. The results of the electronic search were imported into Covidence systematic review software (18). The WHO ICTRP Search Portal (19) and ClinicalTrials.gov (20) were queried using the same search strategy as the original search to check for unpublished literature.

Eligibility criteria

All peer-reviewed studies in English reporting clinical outcomes for adult patients (18 years or older) undergoing cervical and/or lumbar spine surgery for degenerative pathology and discussing postoperative activity restrictions were considered for inclusion. For the purposes of this review, activity restrictions are defined as limitations on specific movements or activities outlined by the surgeon after surgery. Examples include limitations on bending or twisting movements, as well as limitations on activities such as lifting weight or driving. Studies focusing on patients with other etiologies, including adult spinal deformity, adolescent idiopathic scoliosis, malignancy, infection, or trauma, were excluded. Studies in which a rehabilitation or physical therapy (PT) program, bracing, and/or orthoses was the primary postoperative intervention were excluded. Despite relatively extensive research exploring PT and bracing, there is little literature discussing the effects of activity restrictions. While these interventions often overlap and are typically co-prescribed in real-world practice, the aim of this study was to isolate the effects of activity restrictions alone.

Study selection

The articles were first screened based on title and abstract using the aforementioned eligibility criteria. Articles that passed the title and abstract screening were screened for inclusion based on a thorough full-text review using the same eligibility criteria. Each step of the screening process was performed by two independent reviewers (K.M. and C.F.). Any conflicts between these two reviewers were resolved by a third independent reviewer (W.K.).

Data extraction

Data extraction was performed by two independent reviewers (K.M. and C.F.). The data from each study were manually extracted into an Excel spreadsheet (K.M.), then independently verified by a second reviewer (C.F.). Any discrepancies were discussed and resolved by the two reviewers. The following data were extracted from each included study: (I) the study design, including details of any experimental and control groups and the total length of follow-up; (II) information about the patient population, including the number of patients and any preoperative diagnoses; (III) details of postoperative restriction protocols, including restrictions on specific activities and their durations; (IV) reported clinical outcomes, including recurrence and reoperation rates as well as patient-reported outcomes such as Back Visual Analogue Scale (BVAS), Leg Visual Analogue Scale (LVAS) and Oswestry Disability Index (ODI) scores. Funding sources for each study and potential conflicts of interest were also noted.

Risk of bias assessment

The Revised Cochrane risk-of-bias tool for randomized trials (RoB 2) (21) was used to assess randomized trials for risk of bias in the following areas: (I) the randomization process; (II) deviations from intended interventions; (III) missing outcome data; (IV) measurement of the outcomes; and (V) selection of the reported result. For the non-randomized trials, the Risk Of Bias In Non-randomized Studies – of Interventions, Version 2 (ROBINS-I V2) (22) was used to assess the included studies for risk of bias in the following areas: (I) confounding; (II) classification of interventions; (III) selection of participants into the study; (IV) deviations from intended interventions; (V) missing data; (VI) measurement of the outcome, and (VII) selection of the reported results. Section 25.5 (risk of bias in uncontrolled before-after studies) of the Cochrane Handbook (16) for Systematic Reviews of Interventions was followed to assess non-randomized trials with no control group. Each assessment was performed by two independent reviewers (K.M. and C.F.). Disagreements were discussed and resolved by the two reviewers.

Data synthesis

Meta-analysis was initially planned but was not performed due to the heterogeneity of the included studies and the lack of uniformity regarding details of postoperative restrictions. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, as defined by the Cochrane Back and Neck Review Group (23), was used to determine the certainty of the body of evidence.

Results

Study selection

A total of 3,723 studies were screened for potential inclusion, of which 1,295 duplicates were automatically removed, and the remaining 2,428 articles were screened by title and abstract. Fifty-five studies were eligible for full-text review, and four met the inclusion criteria (Figure 1). Two studies were initially screened in but subsequently removed upon further review. Daly et al. was initially deemed eligible; however, it was ultimately excluded as it outlines a trial protocol without results (3). Similarly, Narayanan et al. was initially deemed eligible (24). However, it was ultimately excluded from subsequent analysis because it does not meet the previously established definition of activity restrictions; the study does not outline limitations on specific movements or activities, instead focusing on broader liberal versus restricted ambulation protocols. This left four studies that met the inclusion criteria. The studies included in this review included one randomized controlled trial, one prospective non-randomized two-group cohort study, and two prospective single-arm cohort studies (Table 1). Notably, all included studies pertained to lumbar spine surgery; there were no eligible studies regarding the effects of postoperative activity restrictions after cervical or thoracic spine surgery. While less common than lumbar spine surgeries, cervical and thoracic spine surgery carry critical mobility ramifications for daily activities. At the moment, there is no literature outlining the effectiveness of activity restriction protocols for these cases. No unpublished literature met the inclusion criteria.

Figure 1.

Results of article screening. 2,428 articles were screened after removing duplicates, of which four met the final inclusion criteria.

Table 1. Characteristics of included studies.

Reference (country of origin)	Study design	Procedure	Activity protocol vs. comparator	Key demographics	Follow-up duration	Outcome measures
Bono et al. 2017 (2) (USA)	Randomized controlled trial	Open lumbar discectomy	2-week activity restrictions vs. 6-week activity restrictions	N=108 (2-week group: N=53; 6-week group: N=55)	2 weeks, 6 weeks, 3 months, 1 year, 2 years	Recurrence, BVAS, LVAS, ODI
				Mean age ± SD (P=0.23): 2-week group, 42.0±12.5 years; 6-week group, 44.6±9.4 years
				Sex (P=0.39): 2-week group: 47.2% female; 6-week group: 38.2% female
				Concomitant PT (P=0.87): 2-week group, 83.0%; 6-week group, 81.8%
Carragee et al. 1996 (25) (USA)	Prospective single-arm cohort study	Open lumbar discectomy	No activity restrictions, no comparator	N=50	3 months, 6 months, 1 year, final follow-up exam (mean 3.8 years)	Recurrence, BVAS, LVAS, return-to-work time
				Mean age: 37 years
				Sex: 30% female
Carragee et al. 1999 (4) (USA)	Prospective single-arm cohort study	Open lumbar discectomy	No activity restrictions, no comparator	N=152	3 months, 6 months, 1 year, final follow-up exam (mean 4.8 years)	Recurrence, return-to-work time
				Mean age [range]: 38 [19–59] years
				Sex: 24% female
Liang et al. 2022 (26) (China)	Prospective non-randomized cohort study	PELD	2-week activity restrictions vs. no activity restrictions	N=213 (restriction group: N=108; non-restriction group: N=105)	1 month, 3 months, 1 year	Recurrence, BVAS, LVAS, ODI
				Mean age ± SD (P=0.30): restriction group, 51.5±12.7 years; non-restriction group, 49.6±14.0 years
				Sex (P=0.85): restriction group, 45.4% female; non-restriction group, 46.7% female

BVAS, Back Visual Analogue Scale; LVAS, Leg Visual Analogue Scale; ODI, Oswestry Disability Index; PELD, percutaneous endoscopic lumbar discectomy; SD, standard deviation.

Overview of included studies

In the randomized controlled trial performed by Bono and colleagues in 2017, 108 patients undergoing index open lumbar discectomy aged at least 18 years and experiencing radicular leg pain associated with a single-level central or posterolateral lumbar disc herniation were recruited between 2011 and 2013 (2). Patients were randomized to either the 2-week restriction group or the 6-week restriction group after surgery. Fifty-six patients were assigned to the 2-week restriction group, of whom 55 were compliant with the assigned restrictions and included in subsequent analysis. Fifty-six patients were assigned to the 6-week restriction group, of whom 53 were compliant and included in subsequent analysis. Demographic characteristics and baseline clinical parameters were collected for both groups (Table 1). Both groups were given the same activity restrictions by their surgeon; the only difference was the restrictions’ duration. The specific details of these restrictions are outlined in Table 2. Compliance with prescribed restrictions was evaluated for all patients at the termination of their respective restriction periods. BVAS, LVAS, and ODI were collected at the following time points: 2 weeks, 6 weeks, 3 months, 1 year, and 2 years postoperatively. Recurrence rate was recorded at 2 years postoperatively. Concomitant rehabilitation was prescribed on a case-by-case basis according to the surgeon’s judgment.

Table 2. Details of activity restriction protocols.

Study	Group	Duration	Prohibited movements	Rehabilitation protocol	Additional precautions
Bono et al. 2017 (2)	Traditional restriction group	6 weeks	Forward bending at the waist, twisting motions	Case-by-case basis, as recommended by surgeons	No lifting more than 5–10 lbs
	Shortened restriction group	2 weeks	Forward bending at the waist, twisting motions	Case-by-case basis, as recommended by surgeons	No lifting more than 5–10 lbs
Carragee et al. 1996 (25)	No restrictions	None	None	None	None
Carragee et al. 1999 (4)	No restrictions	None	None	None	None
Liang et al. 2022 (26)	Out-of-bed activity restriction group	2 weeks	Waist bending, rotation, burden, sedentariness (extended periods of sitting)	In-bed exercises: five-point support exercise, ankle pump movements, straight leg lifting	Out-of-bed activity time limited to 1 hour, each session limited to 30 minutes; waist supported at all times and sitting up done sideways
	Out-of-bed activity non-restriction group	None	Weight-bearing, waist bending (as tolerated)	Begin walking with waist support and daily activities the day after surgery	None

The two prospective single-arm cohort studies were performed by Carragee and colleagues in 1996 and 1999, respectively (4,25). In a study by Carragee et al. (25) published in 1996, 50 patients undergoing limited open discectomy for severe sciatica caused by lumbar disc herniation with no history of previous lumbar surgery, spinal infection, fracture, or deformity were recruited following at least 6 weeks of failed conservative treatment. Mean age of the cohort was 37 years, and 30% of the patients were female. Patients were not provided any postoperative activity restrictions and were told to return to their full daily activities as soon as they were able. Follow-up examinations were performed 3 months, 6 months, and 1 year or more postoperatively. The study primarily focused on return-to-work time and recurrence rate; however, final follow-up examination also included BVAS and LVAS scores (Table 1). Carragee et al. [1999] (4) replicated the original cohort with a larger sample size (N=152) and a longer final follow-up duration. The inclusion criteria for patients in the 1999 study were identical to those of the original 1996 study and patients were given no postoperative activity restrictions. The 1999 cohort had a mean age of 38 years and was composed of 24% female patients. The 1999 study also collected baseline clinical data, as outlined in Table 1. Follow-up examinations were performed at 3 months, 6 months, and 1 year or more postoperatively, along with a final follow-up evaluation.

The prospective non-randomized two-group cohort study performed by Liang and colleagues in 2022 observed patients undergoing percutaneous endoscopic lumbar discectomy (PELD) for unilateral lower limb pain caused by a single-level lumbar disc herniation following at least 6 weeks of failed conservative treatment (26). Two hundred and thirteen patients were recruited for the study and were offered two options for postoperative activity restrictions. For the out-of-bed restriction group, out-of-bed time was limited to one hour per day (limited to up to 30 minutes at a time) during the first 2 weeks postoperatively, with additional restrictions on waist bending, rotation, burden, and extended sitting (Table 2). For the out-of-bed activity non-restriction group, patients were instructed to begin walking with waist support and participating in daily activities the day after surgery. Patients chose between these two options following surgery; 108 chose the restriction group and 105 chose the non-restriction group. The mean age was 51.5 years for the restriction group and 49.6 years for the non-restriction group. The restriction group was 45.4% female, compared to 46.7% in the non-restriction group. Baseline BVAS, LVAS, and ODI scores were collected for both groups. BVAS, LVAS, and ODI were measured at 1 and 3 months postoperatively, and recurrence frequency was recorded at 12 months.

Risk of bias

The included randomized controlled trial by Bono et al. was at high risk of bias due to concerns regarding missing outcome data and lack of blinding for patient-reported outcomes (2) (Figure 2). Both single-arm cohort studies performed by Carragee and colleagues were at critical risk of bias due to uncontrolled confounding within the cohorts, with further assessment discontinued following initial evaluation (4,25). The prospective two-group cohort study by Liang et al. was at moderate risk of bias due to uncontrolled confounding and a lack of blinding during outcome measurement (26) (Figure 3).

Figure 2.

Risk of bias in randomized trials. The randomized trial included in the review had high risk of bias due to concerns surrounding missing outcome data.

Figure 3.

Risk of bias in nonrandomized trials. The nonrandomized trial included in the review had moderate risk of bias; the single-arm cohort studies were not assessed for individual domains due to critical risk of bias upon initial evaluation.

Pain

Patient-reported pain was represented by BVAS and LVAS scores. VAS scores were reported in cm (out of 10) for Carragee et al. (25) and Liang et al. (26), and in mm (out of 100) for Bono et al. (2). For open discectomy, BVAS (P<0.001) and LVAS (P<0.001) for both the 2-week and 6-week restriction groups were improved significantly 2 weeks postoperatively compared to baseline, and both groups continued to show significant improvement between 2 weeks and 1 year postoperatively (P<0.001) (Table 3). No significant difference between the 2-week and 6-week restriction groups was reported at any follow-up period. Patients without any postoperative restrictions reported a mean BVAS of 1.4 and a mean LVAS of 0.7 (Table 3). For PELD, BVAS and LVAS scores were significantly improved at both 1 and 3 months compared to baseline for both the out-of-bed activity restriction and non-restriction groups (Table 3). However, the only significant difference between the two groups at any time point was LVAS at 1 month postoperatively, for which the restriction group reported lower pain than the non-restriction group (P<0.01).

Table 3. Outcomes of included studies.

Reference	Recurrence rate (reherniation)	Follow-up duration	BVAS	LVAS	ODI
Bono et al. 2017 (2)	2-week group: 6/53 (11.3%); 6-week group: 4/55 (7.3%) (P=0.52)	Baseline	2-week group: 51.9±26.4; 6-week group: 45.5±29.9 (P=0.25)	2-week group: 69.9±22.2; 6-week group: 68.7±23.2 (P=0.79)	2-week group: 56.4±17.5; 6-week group: 52.6±18.8 (P=0.20)
		2 weeks	2-week group: 20.3±19.5; 6-week group: 22.4±20.1 (P=0.60)	2-week group: 22±18.8; 6-week group: 27.8±23.6 (P=0.18)	2-week group: 30.3±17; 6-week group: 32±16.4 (P=0.62)
		6 weeks	2-week group: 16.6±20.4; 6-week group: 18.8±18.8 (P=0.61)	2-week group: 23.3±27; 6-week group: 22.5±23.4 (P=0.89)	2-week group: 19.9±18.0; 6-week group: 20.2±17.4 (P=0.95)
		3 months	2-week group: 17.0±20.2; 6-week group: 15.6±14.2 (P=0.71)	2-week group: 21.2±22.6; 6-week group: 15.3±15.4 (P=0.18)	2-week group: 18.6±17.1; 6-week group: 14.3±13.8 (P=0.24)
		1 year	2-week group: 11.6±18.1; 6-week group: 13.9±14.3 (P=0.56)	2-week group: 16.1±25.1; 6-week group: 15.2±16.9 (P=0.87)	2-week group: 13.9±14.9; 6-week group: 11.6±10.2 (P=0.50)
Carragee et al. 1996 (25)	3/50 (6%)	Mean: 3.8 years	Mean [range]: 1.4 [0–8]	Mean [range]: 0.7 [0–7]	Not reported
Carragee et al. 1999 (4)	17/152 (11.2%)	Mean: 4.8 years	Baseline: mean [range], 5.9 [0–10]	Baseline: mean [range], 7.6 [5–10]	Not reported
Liang et al. 2022 (26)	Restriction group: 5/108 (4.6%); non-restriction group: 13/105 (12.4%) (P=0.042)	Baseline	Restriction group: 3.84±1.25; non-restriction group: 3.91±1.19 (P=0.67)	Restriction group: 7.05±1.38; non-restriction group: 7.25±1.52 (P=0.31)	Restriction group: 53.0±15.5; non-restriction group: 53.4±14.7 (P=0.84)
		1 month	Restriction group: 1.14±0.66; non-restriction group: 1.60±0.91 (P=0.00)	Restriction group: 12.56±7.36; non-restriction group: 13.60±7.71 (P=0.31)	Restriction group: 1.60±0.84; non-restriction group: 1.59±0.87 (P=0.31)
		3 months	Restriction group: 1.06±0.75; non-restriction group: 1.12±0.80 (P=0.52)	Restriction group: 1.60±0.84; non-restriction group: 1.59±0.87 (P=0.30)	Restriction group: 8.04±3.75; non-restriction group: 8.90±3.99 (P=0.10)

Data are presented as mean ± SD unless otherwise specified. BVAS, Back Visual Analogue Scale; LVAS, Leg Visual Analogue Scale; ODI, Oswestry disability index; SD, standard deviation.

Function and disability

Function and disability were measured using ODI scores in Bono et al. (2) and Liang et al. (26), and return to work time in Carragee et al. (4,25). For open discectomy, ODI scores for both 2-week and 6-week restriction groups were improved significantly 2 weeks postoperatively compared to baseline (P<0.001) (Table 3). Both groups showed significant improvement between 2 weeks and 1 year postoperatively (P<0.001). Scores did not show a consistent pattern of improvement or worsening between 1 and 2 years postoperatively. For patients with no restrictions, average return to work time was 1.7 weeks for the 1996 cohort (25) and 1.2 weeks for the 1999 cohort (4). For PELD, ODI scores were significantly improved at both 1 and 3 months compared to baseline for both the out-of-bed activity restriction and non-restriction groups, but no significant differences were observed between the groups at any time point (Table 3).

Recurrence rate

Recurrence was defined as the incidence of reherniation for all of the included studies. For open discectomy, there was no significant difference in the recurrence rate between the 2- and 6-week restriction groups within the 2-year follow-up period (Table 3). For patients with no restrictions, a total of 20 out of 202 patients had reherniation events (9.9%). For PELD, the restriction group also had a significantly lower 12-month recurrence rate compared to the non-restriction group (P=0.042) (Table 3).

Evidence summary

With regards to pain, the certainty of evidence was low for open discectomy and PELD due to concerns regarding risk of bias and imprecision (Table 4). Regarding function and disability, the certainty of evidence was low for open discectomy and PELD due to concerns regarding risk of bias and imprecision (Table 4). Regarding recurrence (reherniation), the certainty of evidence was low for open discectomy and PELD due to concerns regarding risk of bias and imprecision (Table 4).

Table 4. Summary of evidence table.

Procedure	Finding	Risk of Bias	Indirectness	Inconsistency	Imprecision	Publication bias	Certainty of evidence
Open discectomy	Pain (BVAS/LVAS)	Serious limitations, downgraded one level	No serious limitations	No serious limitations	Serious, downgraded one level	Not serious	Low
	Function (ODI)	Serious limitations, downgraded one level	No serious limitations	No serious limitations	Serious, downgraded one level	Not serious	Low
	Recurrence	Serious limitations, downgraded one level	No serious limitations	No serious limitations	Serious, downgraded one level	Not serious	Low
PELD	Pain (BVAS/LVAS)	Serious limitations, downgraded one level	No serious limitations	No serious limitations	Serious, downgraded one level	Not serious	Low
	Function (ODI)	Serious limitations, downgraded one level	No serious limitations	No serious limitations	Serious, downgraded one level	Not serious	Low
	Recurrence	Serious limitations, downgraded one level	No serious limitations	No serious limitations	Serious, downgraded one level	Not serious	Low

BVAS, Back Visual Analogue Scale; LVAS, Leg Visual Analogue Scale; ODI, Oswestry Disability Index; PELD, percutaneous endoscopic lumbar discectomy.

Discussion

This is the first systematic review to describe and evaluate the effects of postoperative activity restrictions for spine surgery on clinical and surgical outcomes for degenerative spine disorders. There are very few studies available that discuss specific activity restrictions after spine surgery; the four studies included collectively presented data on two types of lumbar spine surgery (open discectomy and PELD), which represent a small fraction of the lumbar spine surgical procedures that are commonly used in clinical practice. In the included studies, the postoperative activity restrictions studied were limited and did not encompass many ADLs such as sexual intercourse and driving. The absence of evidence to guide postoperative ADL restrictions results in activity restrictions that are dictated by surgeon opinion or anecdotal evidence (27). Furthermore, only one of the four studies was a randomized controlled trial. The included randomized controlled trial possessed a small sample size and was not blinded, thereby limiting the validity and reliability of the findings. The non-randomized studies included in this review also had serious limitations, primarily due to the high risk of uncontrolled confounding. When combined with small sample sizes, these factors severely limit the validity and reliability of the findings across the various studies. The certainty of evidence was low for all outcomes analyzed, making it difficult to provide a definitive conclusion for or against the use of postoperative activity restrictions in spine surgery.

This early data surrounding activity restrictions mirrors previous trends in bracing after spine surgery. Historically, postoperative bracing was advocated to reduce the risk of complications, but the advantages of bracing have been shown to be largely theoretical (28). There is a high degree of variation in bracing practices between individual surgeons, with no established guidelines to guide care (28). Several randomized controlled trials have critically evaluated the efficacy of postoperative bracing, with recent literature demonstrating no significant differences in clinical outcome measures between bracing and non-bracing groups after spine surgery (29). It appears the evidence surrounding activity restrictions is moving in a similar direction, with one completed randomized controlled trial and another accepted trial protocol (2,3). As more randomized data emerge regarding the effects of postoperative activity restrictions on clinical outcomes in spine surgery, increased clarity of the benefits and drawbacks of postoperative activity restrictions should become more apparent. These findings reflect a broader trend in surgical care, where long-standing dogma, such as the necessity of prolonged postoperative restrictions, is increasingly being questioned. As with bracing, the theoretical benefits of limiting activity may not be borne out in future comparative effectiveness studies.

The current lack of evidence on the effectiveness of postoperative restrictions along with the consistency of prescription can carry several potential consequences. Clinical outcomes could be negatively affected by suboptimal postoperative restriction protocols. Highly restrictive protocols can delay ambulation following surgery, which has been demonstrated to increase the risk of deconditioning, venous thromboembolism, and the need for discharge to rehabilitation facilities (24). Overly restrictive postoperative instructions may also contribute to fear-avoidance behaviors, which have been shown to delay recovery and exacerbate chronic pain syndromes in musculoskeletal populations (30). Healthcare costs could be unnecessarily increased by the prescription of excessive out-of-bed restrictions, which are believed to lead to longer hospital stays and increased usage of healthcare resources (24). With restrictions on activities such as walking and driving, the increased need for caregiver assistance reflects an added societal cost as well (24). Furthermore, implementing strict or prolonged postoperative activity restrictions can impede early mobilization protocols and rehabilitation following spine surgery, which have been associated with improved clinical outcomes, reduced complications, shortened hospital stays, and lower healthcare costs (31-34). The absence of evidence demonstrating that stricter activity restrictions improve clinical outcomes calls into question many surgeons’ predilection toward restrictive postoperative protocols; without strong evidence documenting the concrete benefits of such strict protocols with regards to clinical outcomes, these findings prompt urgent re-evaluation of whether such restrictions should be the default prescription after spine surgery (24). The inconsistency of postoperative restrictions also influences downstream factors for all parties involved. Patients’ expectations are largely set by physician guidance, and the lack of evidence on this topic can make it more difficult for physicians to provide consistently accurate recovery projections. Without an adequate understanding of their recovery path, patients may be more likely to over- or under-estimate their functional status, which comes with additional financial implications; if patients over-estimate their functional status, they may be at risk of getting reinjured by returning to work too early or overexerting themselves, while returning to work too late or not at all comes at the cost of lost income. Patients with inaccurate expectations are also more likely to pursue litigation against their surgeons, adding an additional facet to the cost burden (35). The development of standardized guidelines surrounding activity restrictions would allow physicians and patients to be on the same page regarding the plan and expectations, potentially ameliorating some of the consequences of this disconnect.

This study is not without limitations, which may have influenced the results and conclusions presented. While meta-analysis was originally planned, it was ultimately deemed inappropriate due to the limited availability of suitable primary studies. Only two of the four included studies possessed comparators, and the heterogeneity of activity restriction protocols outlined in those two studies was high enough as to make even limited subgroup analysis unfeasible. This reduced the reliability of the presented synthesis, as the reliance on narrative synthesis introduces subjective differences in reviewer interpretation into the review process. The limited evidence surrounding this topic is likely the result of several factors. Firstly, there is a great deal of heterogeneity between patient populations and surgeons. For a given spinal pathology, individual surgeon preferences and experience heavily influence the surgical technique that is implemented for treatment. This can complicate the development of trials to analyze restrictions’ efficacy on specific pathologies, as several surgical techniques must be analyzed to produce results that are applicable to a breadth of surgeons. Additionally, isolating the effect of postoperative activity restrictions on clinical outcomes presents a substantial challenge, as outcomes are influenced by a multitude of confounders such as comorbidities, patient beliefs, and baseline fitness levels (36). The strong historical precedent of substantial postoperative activity restrictions has also limited exploration of more liberal restriction protocols (3). While there is preliminary evidence suggesting that early ambulation does not increase risk of reinjury or worsen clinical outcomes, fears of such complications have limited the prescription of liberal ambulation protocols for research purposes (24). Additionally, only studies available in English were included in this review, introducing potential selection bias against papers published in other languages.

Ultimately, the optimal role and effectiveness of postoperative activity restrictions in spine surgery remains inconclusive and largely unexplored. Spine surgeons must remain cognizant of the limitations of the current evidence and reflect on the efficacy of their own practices regarding postoperative activity restrictions. As the body of evidence expands, they must continue to reassess best practices and incorporate the growing evidence into their own clinical practice. Further research is needed to provide robust data on patient outcomes across several types of spine surgeries using a variety of activity restriction protocols. Randomized controlled trials investigating the effects of no activity restrictions would provide important baseline data to determine the necessity of activity restrictions. The spinal loads of various ADLs have been studied and outlined in previous research, but these findings have not yet been correlated to clinical results; randomized controlled trials studying restrictions on specific activities could further clarify their influence on recovery (37). Previous studies have also found that discrepancies between patient and surgeon understanding of the patient postoperative restrictions after surgery (38). Future survey studies could help to identify where these discrepancies lie to improve communication between physicians and patients. These studies would provide the requisite evidence to create precise and standardized guidelines for postoperative activity restrictions. Such protocols, if readily available to patients, could greatly improve the consistency of postoperative recovery after spine surgery. Furthermore, this study did not yield any published literature regarding the effects of postoperative activity restrictions on clinical outcomes for cervical surgery. While it is clear that the lumbar evidence is limited, the cervical and thoracic evidence appears to lag even further behind, and more research is desperately needed. Future research should be directed toward laying the foundation for subsequent randomized controlled trials, as outlined previously. Given the inherent complexity and high-stakes nature of spine surgery, it is critical to strengthen the body of evidence supporting spine surgeons’ decision making regarding postoperative activity restrictions to ensure optimal patient clinical outcomes.

Conclusions

Limited evidence exists regarding the effectiveness of postoperative activity restrictions on outcomes after lumbar spine surgery and there is no literature discussing postoperative activity restrictions after cervical or thoracic spine surgery. The certainty of evidence was low for all outcomes analyzed, making it difficult to provide a definitive conclusion for or against the use of postoperative activity restrictions in spine surgery. Using non-evidence-based protocols, which can include the use of postoperative restrictions, can have significant medical, legal, and financial implications on practice. Clinical recommendations for postoperative activity restrictions continue to be rooted in individual surgeon preference rather than empirical evidence. Robust randomized controlled trials are needed to determine the impact of various types of activity restriction protocols across several types of spinal surgery. Future studies could provide the basis for the creation of standardized, evidence-based postoperative activity restriction protocols to ensure optimal patient outcomes after spine surgery.

Supplementary

The article’s supplementary files as

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.