Driving after spine surgery: biomechanics, recovery pathways, and medico-legal insights

Abstract

Returning to driving is a significant milestone for patients recovering from spine surgery, representing restored independence, mobility, and mental well-being. However, this decision involves numerous challenges, including biomechanical restrictions, the effects of pain management, cognitive recovery, patient-reported outcomes, and diverse medico-legal considerations. This review consolidates current evidence on recovery timelines, biomechanical factors, and the influence of medications on driving ability. It also examines the role of regional legal frameworks and professional guidelines in shaping decisions by both patients and surgeons. Additionally, it highlights interdisciplinary approaches to enhance post-operative care and discusses the broader relevance of these findings for other medical fields, proposing future research to advance understanding in this area.

Introduction

Driving is a vital aspect of independence and quality of life in modern society, requiring the integration of biomechanical, cognitive, and psychological functions. For patients recovering from spine surgery—a procedure often associated with temporary impairments in mobility, reaction time, and pain management—the question, “When can I drive again?” is both common and complex. Addressing this involves assessing multiple factors, including the type of surgery, anatomical and neurological recovery, medication effects, and legal considerations.

Safe driving depends on a combination of physical abilities, such as reaction time, foot transfer, and braking force, alongside cognitive skills like decision-making and alertness [1,2,3]. Spine surgery can temporarily compromise these abilities due to postoperative pain, restricted mobility, sedation from anesthesia, and the use of medications such as opioids [4, 5]. Recovery timelines also vary depending on the procedure type—cervical versus lumbar or fusion versus decompression—which directly impacts functional benchmarks [3, 6]. The absence of standardized guidelines further complicates recommendations, leaving clinicians to rely on subjective judgment rather than evidence-based protocols [4, 7, 8]. Jurisdictional differences in assessing driving readiness add another layer of variability, leaving both patients and clinicians with inconsistent guidance.

This paper presents a narrow review of the existing research on returning to driving after spine surgery, focusing on post-operative recovery timelines, biomechanical and cognitive recovery, medication effects, and psychosocial outcomes. Rather than providing a broad overview of the entire field, we selectively include the most relevant and recent studies to offer a concise yet insightful analysis. This approach ensures that our discussion remains directly applicable to clinical practice and patient care. Additionally, we explore the broader implications for interdisciplinary practices, highlighting how insights from spine surgery research could inform protocols in other medical fields.

Timelines for returning to driving after spine surgery

The appropriate timing for resuming driving after spine surgery varies based on the procedure and individual patient factors (Table 1). Recommendations are primarily derived from professional societies and surgeon surveys [1, 4, 6,7,8,9]. However, there is no clear consensus among surgeons regarding post-operative driving restrictions, with experienced surgeons often favoring earlier timelines for return to driving [10].

Table 1 Driving recovery time after spinal surgery

Cervical spine surgery

Recent studies offer valuable insights into recovery timelines following cervical spine surgeries. For anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA), most patients resume driving and work within 16 days post-surgery [5]. Nevertheless, some evidence suggests a 6-week recovery period before safely returning to driving after anterior cervical procedures [9, 11]. Kelly et al. [12] reported that the majority of patients undergoing single-level ACDF or CDA can safely resume unrestricted driving within 6 weeks post-surgery. CDA has shown better long-term outcomes compared to ACDF, including improved driving-related disability, higher overall success rates, and reduced need for secondary surgeries [13, 14]. For patients with cervical spondylotic myelopathy (CSM), 72% reported improved driving ability within 24 months post-surgery, driven by reduced neck pain and enhanced leg function [15]. Recovery is influenced by preoperative disability, occupation type, and education level [5]. Functional metrics such as the Neck Disability Index (NDI) and modified Japanese Orthopaedic Association (mJOA) scores are strongly correlated with post-surgical driving ability [9]. These findings are critical for preoperative counseling and setting realistic recovery expectations for cervical spine surgery patients.

Lumbar spine surgery

Studies on resuming driving after lumbar spine surgery present mixed results. For patients undergoing surgery for lumbar disc herniation, driving may be resumed shortly after hospital discharge [16]. One study found no significant differences in driver reaction time (DRT) before and after lumbar surgery, suggesting that patients undergoing single-level lumbar fusion may safely drive within 2–3 weeks post-surgery if they are not taking opioids [6]. However, a more cautious approach recommends avoiding driving for up to three months after lumbar spinal fusion, as increased reaction times have been observed at discharge [17]. For minimally invasive transforaminal lumbar interbody fusion (MI-TLIF), a median return-to-driving time of 18.5 days was reported, with 96.4% of patients resuming driving [18]. Overall, evidence regarding safe driving timelines after spinal surgery remains limited and inconsistent, underscoring the need for further research to establish clear, evidence-based guidelines.

Biomechanical recovery and driving readiness

Importance of driving biomechanics

Driving requires the coordination of several biomechanical functions, including reaction time, trunk stability, neck mobility, and limb coordination. Spine surgery, particularly cervical fusion and lumbar decompression, can significantly impact these components. Studies indicate that impairments in brake response time (BRT) and foot transfer speed can persist for weeks or months following surgery, which may compromise driving safety [3, 19].

Evidence from driving simulators

Successful driving depends on the recovery of critical biomechanical factors, such as reaction time, neck mobility, trunk stability, and pain-free strength. Research on DRT and BRT has been crucial for assessing post-surgical driving readiness. Driving simulators are often used to collect these metrics [2, 3, 6]. Liebensteiner et al. [2] observed prolonged BRTs in lumbar fusion patients, with significant deficits lasting up to 3 months after surgery. Similarly, Hofmann et al. [3] found weaker braking force in lumbar fusion patients compared to their preoperative levels. Thaler et al. [16] reported that driving reaction times improved after surgery for lumbar disc herniation in patients with left-side and right-side radiculopathy, though they remained slower than those of healthy controls. DRT, a key indicator of safe driving, is influenced by factors such as pain, opioid use, and cognitive function [1]. The type of spinal intervention, the number of levels involved, and the anatomical location of the surgery all impact the recovery of DRT [1, 6]. These findings highlight that driving readiness is not just about general physical recovery, like walking ability, but also about specific functions essential for vehicle operation, such as braking force and the range of motion in the neck for head checks.

Despite growing evidence from simulator-based studies, the real-world applicability of these findings remains limited. Few studies have incorporated on-road driving assessments [9], which could help validate simulator results. Additionally, research has not sufficiently integrated other factors like trunk strength and cognitive distraction into functional driving assessments. Longer follow-up studies are also needed to determine whether driving capabilities decline over time due to sustained biomechanical limitations or chronic post-operative pain.

The cognitive and pharmacological impact on driving safety

Role of opioids

Pain can significantly impair driving readiness by affecting reaction time and physical capability [20, 21]. Effective pain management strategies, such as physical therapy, are crucial for improving recovery and facilitating a return to safe driving [3]. While opioids remain essential for post-surgical pain relief, they pose concerns about driving safety due to their effects on reaction time, coordination, and alertness [22]. The impact of opioids on driving ability is mixed. Some studies suggest that patients on stable opioid regimens for chronic pain perform similarly to healthy controls [23], while driving impairment is more likely when opioids are used during therapy initiation, illicitly, or combined with other psychoactive substances [24]. Given the variability in opioid response and other factors like pain intensity, driving safety assessments should be individualized [25]. Though opioids are vital for recovery, a balance must be struck between effective pain management and minimizing patient and societal risks [26].

Preoperative opioid use is associated with adverse outcomes in patients undergoing spine surgery. Studies have shown that increased preoperative opioid consumption predicts worse patient-reported outcomes, including decreased quality of life and increased disability scores [27]. Greater preoperative opioid use is also linked to increased postoperative opioid demand and decreased likelihood of opioid independence at 12 months post-surgery [28]. The duration of preoperative opioid use is a significant predictor of continued use following surgery, with longer use associated with higher risk [29]. In workers’ compensation settings, preoperative opioid use is associated with reduced odds of returning to work after spine surgery. Patients using opioids preoperatively have approximately half the odds of achieving stable return to work or returning to work within one year post-surgery compared to non-users [30]. However, Subramanian T et al. [5] found that preop narcotics had no impact on return to drive by 15 d after cervical spine surgery. While preoperative opioid use is generally associated with poorer postoperative outcomes and reduced likelihood of returning to work, its specific impact on return to driving remains unclear. Future research should focus on larger cohort studies and objective assessments of driving performance to better understand the relationship between preoperative opioid use and postoperative driving readiness.

Muscle relaxants, neuromodulators, and epidural steroid injections

Centrally acting muscle relaxants, commonly prescribed for musculoskeletal issues, have been linked to impaired driving performance and increased traffic risks [31]. These medications can cause sedation and other side effects, raising concerns about their abuse potential [32]. Research has shown an increase in muscle relaxants in blood tests of suspected drug-impaired drivers, particularly carisoprodol and its metabolite meprobamate [33]. While these drugs may offer short-term relief for acute low back pain, their effectiveness is limited, and they are not superior to alternatives like acetaminophen or NSAIDs [34]. Clinicians should consider safer pain management options, educate patients about the risks of impaired driving, and choose medications based on side effects and potential interactions [31, 34].

Gabapentin, a neuromodulator, has shown efficacy in managing postoperative pain following spine surgery. Research on neuromodulators like gabapentin and pregabalin suggests potential impacts on driving ability. Gabapentin use in driving under the influence cases has increased, with a 7.9% positivity rate observed from 2020 to 2022 [35]. Side effects such as drowsiness and loss of coordination can affect driving performance [35, 36]. Comparative studies found that gastroretentive gabapentin showed less driving impairment than standard gabapentin [37]. Pregabalin, another gabapentinoid, did not significantly impair driving performance in simulator tests but mildly reduced training effects [38]. These findings emphasize the need for careful consideration when prescribing gabapentinoids to patients who drive and highlight the importance of further research to better understand their effects on driving ability after spine surgery.

Epidural steroid injections (ESI) are widely used for managing spinal pain. A study by Zachary L. McCormick et al. [39] evaluated the effects of ESI without sedation on driving ability, finding no significant impact on reaction time or neurocognitive function. However, individual responses may vary depending on factors such as pain relief, neurological sensitivity, and overall health. The authors suggest that driving recommendations should be tailored to each patient rather than applying uniform restrictions, allowing for a safe return to driving based on individual recovery. Similarly, research by Marion Hanley et al. [40] found no significant changes in brake response time following CT-guided cervical spine nerve root injections, indicating that most patients can resume driving shortly after the procedure. Nonetheless, individual differences should be accounted for when providing guidance on driving readiness. Future studies should focus on larger patient cohorts and incorporate objective driving simulations to further assess the impact of these procedures on real-world driving performance.

Medication tapering and readiness

Guidelines now recommend tapering opioids for patients with chronic non-cancer pain, though there is no consensus on managing withdrawal symptoms or monitoring outcomes during this process [41]. A patient-centered, integrative approach involving collaboration between physicians, physical therapists, and patients has shown promise in addressing both pain management and opioid tapering [42]. This approach shifts the focus from complete pain relief to minimizing its impact on quality of life [43]. A biopsychosocial model of care is vital to ensure patient safety during tapering, with physical therapists playing a crucial role in understanding pain mechanisms and coordinating care across disciplines [44].

Psychological aspects

Cognitive behavioral therapy (CBT) has proven effective in addressing psychological barriers related to driving and recovery post-surgery. A pilot study showed that CBT significantly reduced driving-related fear, improving cognitive factors associated with driving [45]. For spine surgery patients, CBT has also been beneficial in reducing fear-avoidance behaviors and enhancing psychological well-being [46]. A case series focused on cognitive-behavioral-based physical therapy (CBPT) for patients with high fear of movement after lumbar surgery found significant reductions in pain and disability [47]. Furthermore, a meta-analysis of CBT for spinal cord injury patients revealed substantial improvements in assertiveness, coping, self-efficacy, depression, and quality of life [48]. These findings suggest that CBT and similar interventions are valuable tools for addressing the psychological aspects of recovery and rehabilitation after spine surgery or injury.

Future research should focus on exploring the relationship between opioid tapering schedules and driving performance. Additionally, studies should examine the feasibility of integrating non-opioid pain management strategies with CBT to mitigate driving-related impairments in spine surgery patients.

Patient-reported outcomes and psychosocial considerations

Quality-of-life measures linked to driving readiness

Measures such as the NDI driving subscale and the EQ-5D have consistently demonstrated the link between driving readiness and key recovery factors like independence, mobility, and overall life satisfaction [15, 49, 50]. The ability to drive significantly improves post-recovery quality of life by enabling patients to resume daily activities and reduce reliance on caregivers. While some studies associate driving with the ability to return to work and decreased dependence on others, there is still a lack of comprehensive quantitative data on the broader economic impacts, such as workforce reintegration and long-term financial stability [15, 18]. Filling this research gap could provide deeper insights into the economic advantages of regaining the ability to drive.

Psychosocial impacts and gaps

Post-surgical driving restrictions often result in a loss of autonomy, increased dependence, and heightened psychosocial stress. These limitations are particularly challenging for individuals with jobs requiring regular commuting, as they can lead to financial strain and reduced productivity. The issue is even more pronounced in areas with limited alternative transportation options.

However, there is a significant gap in studies that comprehensively measure the long-term psychosocial and economic effects of driving restrictions. Expanding research in this area is crucial to better understand the relationship between driving readiness, workforce participation, and overall well-being.

Medico-legal considerations

Legal requirements for reporting unfit drivers vary across jurisdictions, with most Canadian provinces mandating physician reporting [51]. In Canada, physicians have a legal responsibility to identify and counsel patients about medical conditions that may impair driving ability [52]. Australian cases have raised concerns about doctors’ legal liability for decisions regarding patient fitness to drive [53]. In multiple countries, transport regulatory bodies often fail to provide explicit guidelines for returning to driving after surgical procedures, including spine surgery, hip arthroplasty, or knee arthroplasty. This lack of clear guidance places the burden of decision-making on treating physicians, who must assess recovery timelines and individual patient capabilities [54]. Physicians are frequently relied upon not only by patients but also by insurance companies, who defer to medical opinions when determining fitness to drive post-surgery [54]. This reliance can expose physicians to significant legal risks. For example, physicians may face lawsuits from patients for failing to provide adequate counseling on the risks of returning to driving prematurely. Additionally, they may be held liable by accident victims if it can be demonstrated that they should have reasonably foreseen the danger posed by allowing an unfit patient to resume driving [52].

To mitigate these risks, thorough documentation of discussions about driving restrictions and recovery milestones is strongly recommended. This includes providing patients with clear, evidence-based guidance tailored to their condition, documenting their understanding of the advice, and outlining any uncertainties about recovery timelines [54]. Collaboration with multidisciplinary teams, including occupational therapists and physical therapists, may further assist in providing a comprehensive assessment of driving readiness. Nonetheless, the medico-legal challenges highlight the need for standardized guidelines to support physicians in making informed decisions while minimizing legal exposure.

Conclusion and future directions

This review underscores the multifaceted nature of assessing driving readiness after spine surgery, shaped by biomechanical factors, medication effects, clinical guidelines, and regional legal frameworks. Clinicians should provide individualized recommendations based on surgical type, functional recovery, and medication use. Conducting reaction time tests or on-road driving assessments may help determine readiness.

Future research should focus on integrating simulator-based and real-world driving evaluations to establish clear, evidence-based timelines for safe driving resumption. Additionally, efforts are needed to develop standardized recommendations that can be applied consistently across different jurisdictions and surgical procedures. Furthermore, the insights gained from this research should be extended to inform return-to-driving policies for individuals recovering from other types of surgeries or managing chronic health conditions. By uniting biomechanics, patient recovery outcomes, and legal considerations, the goal is to create standardized and globally applicable strategies to optimize post-surgical recovery and reintegration.