LOW BACK PAIN IN ATHLETES: THE LUMBAR DISK

Ken Mautner, MDAssistant Proffesor Dept of PM&R,Dept of OrthopedicsEmory Sports Medicine SymposiumMarch 6, 2009

EPIDEMIOLOGY ATHLETIC LOW BACK PAIN

Common in athletics 10 – 15% of all athletic injuries

One of the most common complaints seen in the training room

Affects males and females equally in the athletic population

Will leave the psychosocial factors that affect LBP out of equation for this talk and discuss true structural and mechanical aspects of LBP Psychosocial factors presumably less in the athletic

population but needs to be screened for as well

SPORT SPECIFIC

Most studies done on young adults 1 – 30% incidence across multiple

studies Gymnastics (70%) and wrestling

(59%) have a very high lifetime incidence Contact sports/ repetitive twisting/

extending sports most commonly affected

Soccer, tennis, football, golf and weightlifting each have a 30 – 40% lifetime incidence

AGE SPECIFIC

Age specific < 18 y/o

spondylolysis

18 – 50 y/o discogenic pain and HNP

>50 y/o spondylosis/spinal stenosis

DEGENERATIVE SPINAL CASCADE

Described by Kirkaldy-Willis in the 1970’s to explain spinal instability Implicates the disc as

the center of this process

Three phases Often overlap Each has different

clinical presentations

DEGENERATIVE CASCADE3 PHASES

Segmental dysfunction

Segmental

instability

Segmental

stabilization

ADVANCED IMAGING IN ASYMPTOMATIC ADULTS

MRI: Abnormal in 34% asymptomatic

subjects 20-39 y/o. Almost all of 60-80 y/o had

degenerative changes on at least one disc level (T2-weighted). ₁

52% asymptomatic individuals had a bulging disc at least one lumbar level. ₂

28 % prevalence of HNP in asymptomatic individuals. ₃

CT 23% asymptomatic individuals found

to have HNP or spinal stenosis. ₄

1. Boden, S. et al. 19902. Jensen, M. C. et al. 19943. Boden et al; Jensen et al.4. Wiesel, Spine 1984

WHAT ABOUT IN ATHLETES?

Healy et al, Journal of Computer Assisted Technology, 1996 Looked at 19 asymptomatic lifelong male

athletes ages 41-69 11 with central disk protrusions 4 with LDH –none currently symptomatic, but

had been 1 severe spinal stenosis

Evidence of asymptomatic degenerative changes similar to those in published series in other populations.

WHAT ABOUT IN ATHLETES?

Lumbar Intervertebral Disc Degenertion in Athletes: Hangai et. al. 2009 (AJSM) University athletes vs. age matched

university nonathletes Baseball players and swimmers had

more disc degeneration and back pain episodes

Runners, soccer and basketball players showed no differences

DOES PLAYING SPORTS INCREASE RISK OF LBP LATER IN LIFE ?

Hangai et al, AJSM, 2010 Analyzed 4667

university students who participated in sports at a young age

Found significant correlation between duration of years played (classified as no, mid, or high) and incidence of LBP

This relationship existed amongst all sports

DISC AS PAIN GENERATOR

Discogenic pain Pain attributed to a mechanical and/or

chemical stimulus of the nociceptor nerve endings in the anulus fibrosis

PRESENTATIONDISCOGENIC LBP

Acute (flexion/rotation injury) or Insidious onset

Pain with flexion > extension

Sitting intolerance Pain mostly limited

to the back Worse initial part

of day

EXAMDISCOGENIC LBP

Pain with forward flexion May get relief of pain with

extension Normal Neurologic exam Negative SLR test +/- pain to palpation in associated

muscles Pain with Sustained Hip Flexion

Test

EVIDENCE FOR SHF TEST

Depalma et al, ISIS, 2009 Midline LBP

exacerbated by SHF in young adults is strongly predictive of IDD as source of symptoms

Absence of midline LBP , regardless of SHF or age is strong predictor that disk is not source of LBP

Should look for other source of LBP

DISC AS PAIN GENERATOR Disc herniation produces acute radicular pain

due to inflammatory mediators around nerve root (not the nerve root compression) Mechanical neurocompression: dysaesthesias,

motor deficits without pain (Macnab ,Pain ,1971) Biochemical factors as result of a local

inflammatory response may be the main pain generator!

Lindahl: Acta Orthop Scand 1951 Nachemson: Acta Orthop Scand 1969 McCarron: Spine 1987 Saal JS et al: Spine 1990

Phospholipase A2 Found in high concentration in HNP‘s

Prostaglandin E2 Greatest in sequestered > extruded > protruded Greater in those with + SLR

PRESENTATION:RADICULAR PAIN SYNDROMES

Presentation Acute and chronic

radicular pain present differently

Primarily single limb pain ± back pain

Not all leg pain is radicular Not all radicular pain goes

below knee Often will not want to

sit/ bend forward Often worse the initial

part of day

PRESENTATIONRADICULAR PAIN SYNDROMES

Exam Pain worse with sitting/

leaning forward Relief with extension

(except lateral/ foraminal HNP)

+/- back pain (may start in glute)

Often will have associated trigger points/ tender points

+/- Neurologic deficits Be sure to check reflexes and

LE strength/ sensation +SLR/ Slump test / FS (esp

younger/ acute HNP)

MEDICAL TREATMENT OF DISCPRODUCING PAIN SYNDROMES

PATIENT SELECTION

PATIENT SELECTION

NATURAL HISTORY– ACUTE LBP

• Generally extremely favorable• Studies show resolution of 90% for acute

LBP between 4 and 12 weeks• (Hakelius) Compared bed rest, corset x 2

months vs surgery:• Marked reduction in pain and functional

improvement with time in non-sx group: 6 weeks: 80% 12 weeks: 90% 24 weeks: 93%

NATURAL HISTORY- HNP

(Saal, Saal, and Herzog) 80% had > 50% regression of LDH over time Larger herniations regress more Correlation between regression

and resolution of symptoms

ACUTE LBP/ RADICULAR PAIN MANAGEMENT

• Bed rest/Activity Modification• Not recommended >24-48hrs.

When possible, relative rest is advisable

Hagen KB et al. ( Spine 2000)…no considerable difference between advice to stay active and advice for bed rest.

Potential harmful effects of prolonged bed rest “It is reasonable to advise people with acute low back

pain and sciatica to stay active”...

Reassurance of natural history Brief education Medications for pain/symptom control

NSAIDS, Oral Steroids, Muscle relaxants, Narcotics Possible use for neuropathic meds– gabapentin/

pregabalin

PHYSICAL THERAPY FOR ACUTE LBP

Since favorable natural history, most assume no need for PT for acute LBP

However, studies demonstrate 25%-84% recurrent episodes of LBP within 1 year

Can P.T. prevent recurrent LBP which often leads to chronic LBP?

“Non-specific exercises for non-specific low back pain produces non-specific results” --Joel Press, MD

INTERVENTIONAL AND SURGICAL TREATMENT OF DISC AND

RADICULAR PAIN SYNDROMES

INTRADISCAL PROCEDURES Methylene Blue Injection

May destroy nerve endings/ block nerve condution in paindul disk areas

Platelet Rich Plasma/ biological agents Animal models suggest that disk regeneration is possible

Ozone Oxygen like substance injected into discs to “shrink” the

HNP and reduce pain/ inflammation Intradiscal Steroid

Temporary relief by reducing inflammation in disk to treat annular fissure/ DDD that causes pain

Good results when associated with endplate inflammatory changes (Modic changes) – Fayad, European Spine Journal, 2007

Intradiscal electrothermic Therapy (IDET) “heating- up” of disk to dennervate pain and scar down

any tears/ fissures in disk

INTERVENTIONAL TREATMENT FOR LUMBAR RADICULAR PAIN

WEST study (Arden et al. Rheumatology 2005): Transforaminal lumbar epidural steroid injection

(TFESI) offered short term benefit (3wks) in patients with sciatica

No sustained benefits in terms of pain, function or need for surgery

Buttermann et al. 2002 ESI vs. Discectomy: 96% good outcomes with

surgery vs. 49% good outcomes with ESI in large herniations

Conclusion: ESI’s do not alter LDH regression. Less hydrated discs may have prolonged symptoms, but many improve with ESI’s

EPIDURAL INJECTIONS - RESULTS

Riew, K.D.et al “The effect of

nerve-root injections on the need for operative treatment of lumbar radicular pain. A prospective, randomized, controlled double- blind study”

JBJS Volume 82-A,2000

Riew, K.D. et al “Nerve Root

Blocks in the Treatment of Lumbar Radicular Pain: A Minimum Five Year Follow- Up”

JBJS, 2006

SURGICAL INTERVENTION FOR DISCOGENIC PAIN

Done as last resort for intractable/ progressive axial LBP

Options include Fusion vs Lumbar disc replacement Many different techniques employed

which all affect outcomes

The Spine Patient Outcomes Research Trial (SPORT): A Randomized Trial Weinstein, J. et al JAMA. 2006;296:2441-2450

501 surgical candidates (imaging-confirmed lumbar

HNP) and persistent radiculopathy for 6 wks Interventions:  Standard open diskectomy vs nonop.

treatment.

Main Outcome Measures Primary: changes from baseline for the Medical Outcomes

Study 36-item Short-Form Health Survey bodily pain and physical function scales and the modified Oswestry Disability Index at 6 weeks, 3 months, 6 months, and 1 and 2 years from enrollment.

Secondary : sciatica severity as measured by the Sciatica Bothersomeness Index, satisfaction with symptoms, self-reported improvement, and employment status.

SURGICAL INTERVENTION FOR LUMBAR RADICULAR PAIN

SURGICAL INTERVENTION FOR LUMBAR RADICULAR PAIN

The Spine Patient Outcomes Research Trial (SPORT): A Randomized Trial Weinstein, J. et al JAMA. 2006;296:2441-2450

There were statistical differences in the secondary measures of sciatica severity and self-rated improvement in favor of surgery group.

Conclusions: “…Because of the large numbers of patients who crossed over in both

directions, conclusions about the superiority or equivalence of the treatments are not warranted based on the intent-to-treat analysis”.

SURGICAL INTERVENTION FOR LUMBAR RADICULAR PAIN

743 patients who did not want to be “randomized” were followed in observational cohort study 521 choose surgery; 221 choose non-operative care 528 received surgery in first 2 years; 191 no surgery

Weinstein, J. N. et al. JAMA 2006;296:2451-2459

CONCLUSIONS

Lumbar disk is most common cause of young adults with LBP

Lumbar radicular pain sec. to HNP is common in 25-45 year old age group

Most acute discogenic and radicular pain improves in a timely manner without aggressive interventions No need for extended work- up unless red flags,

neurologic compromise, or severe pain that is not improving

Need more evidence and research into minimally invasive/ conservative treatment of disc/ radicular pain syndromes

Ken.mautner@emory.org

Office: (404)- 778- 7142