Management of Lumbar Spine Injuries

Gino Chiappetta, MDClinicalAssociateProfessorofOrthopaedic

Surgery,RutgersRobertWoodJohnsonMedicalSchool;Orthopaedic Surgeon,UOA

I have no disclosures

Lumbar Spine

• Youngerathletestypicallydonothaveadultproblems

• Lumbarsprains/strainsnotascommoninyoungerpopulation

• Backpainthatstopsparticipationneedsevaluation

Low Back Pain

• Oneofthemostcommonreasonsformissedplayingtimebyprofessionalathletes

• Publishedratesoflow-backpaininathletesrangefrom1%to>30%

• Mostcasesareself-limited,manyathleteshavepersistentsymptoms

Epidemiology

• LBPaccountedforlossofplayingtimeby30%(forty-four)of145collegefootballplayersMcCarrolletalAJSM 1986

• 38%ofprofessionaltennisplayersreportedLBPasthereasonformissingatleastonetournamentHainlineClinSportsMed 1995

• NinetypercentofalltourinjuriesinprofessionalgolfersinvolvetheneckorbackDudaPhysSportsMed1989

• Highestingymnasts,wrestlers&rowers

Differential Diagnosis

• Musclestrain/ligament• Degenerativediscdisease• Isthmicspondylolysis(no

slip)• Sacroiliacjointdysfunction• Facetsyndrome• Ringapophysealinjury

(adolescents)• Sacralstressfracture

• Centraldischerniation(withoutradiculopathy

• SacralizationofL5/tranverseprocessimpingement

• Facetstressfracture• Acutetraumaticlumbar

fracture• Discitis/osteomyelitis• Neoplasm

Non-operative Treatment• Initialperiodofbedrest(no

morethan3days)• NSAIDs• Medroldosepack• Trunkstabilizationprogram• Epiduralsteroids• Seletivenerverootinjections

areeffectiveandmayavertsurgery

• NFLstudy• 2003-2010• 89%successrateRTP• Avg losstime2.8practices(range0-12),.6games• Failures:(DidnotRTP)– SequestrationofdischerniationonMRI(p=0.01)–WeaknessonPE(p=.002)

• Safeandeffective

Microdiskectomy

Wang,JC,etal,Spine1999• 14eliteathletescompetingatNCAAlevel• Meanage20.7yrs• Sports:

– Football(4)– Basketball(2)– Swimming(2)– Waterpolo(2)– Soccer,track&field,volleyball,diving

MicrodiskectomyWang,JC,etal,Spine 1999• Minimumnon-operativetreatmentperiodof8weeks

• 5didnotreturntocompetition,2football– 2single-levelopendiscectomy– 3two-levelopendiscectomy– 1percutaneousdiscectomy

• Of9whoreturned,onefootballplayerplayed3yrsatcollegelevel,reststillplayedprofessionally

Microdiscectomy Results

WatkinsSpine2003• 60Olympic&proathleteshadmicrodiscectomy• Surgerycriteria:HNPonMRI,legpainwithplaying

sport,failed6wksnon-optreatment• 53(83%)returnedtotheirsport,avg5.2monthspost-

op• Allptsstartedontrunkstabilizationandsportspecific

PTavgof3weekspost-op

Return to Sport Rate

Watkins et al Spine 2003

Adolescent Discectomy

• 72patients16yooryoungerhadlumbardiscectomy

• 20patients(28%)requiredrevisionsurgery

• Oftheother50patients,46notedoccasionalornopainwithactivityPapagelopoulosetalJBJS 1998

Spondylolysis• Defectwithintheboneof

theposteriorpartoftheneuralarch

• Widelybelievedtobeastressfracturecausedbyrepetitiveloading,notacongenitaldefect

• Prevalence3-6%ingeneralpopulation

• Athletes,variable• Throwingathletes,divers,

gymnasts,wrestlers,weightlifters&rowersSoler,CalderonAJSM 2000

• 1025adolescentathleteswLBP(15+/-1.8y.o)– HospitalbasedSportsMedicineClinic

• 308– 30%SpondylolisisBoys Girls

- Baseball54% Gymnastics34%-Soccer48% Band31%- Hockey44% Softball30%

*MostcommoncauseofLBPinadolescents- Incidencecorrelatesw/growthspurt

Spondylolysis

• Only50%ofobliquefilmswillshowthedescribed“Scottydogcollar”sign.

SaifuddinetalJBJSBr 1998

Treatment

• Non-opforvastmajorityofpatients

• Periodofrest,PT

• Returntoplaywhenathleteispainfree

Bracing• Servesasananti-lordoticorthosis,preventhyperextension

• Theroleandbesttypeofexternalimmobilizationcontinuetobedebated

• Immobilizeforaninitial4-6weekperiodtoallowforhealingpriortoactivity/PT

Non-Operative Treatment

• 91%goodtoexcellentresultswith11yearfollow-up,MilleratalAJSM 2004

• 80%goodtoexcellentresultswithbracing&PT– d’Hemecourtetal ClinSportsMed 2000

Blanda et al J Spinal Disorder 1993

• 62athleteswithsymptomaticspondylolysis,F/U4.2yrs

• Treatmentincludedrestrictionofactivityandbracingfortwotosixmonths

• Fifty-twopatients(84%)werereportedtohaveanexcellentresult;eight(13%),agoodresult;andtwo(3%),afairresult

• 8ptseventuallyhadafusionduetoslipprogression

Operative Treatment• Indicationsforearlysurgical

managementare:– Neurologicdeficitrelated

tospondylolisthesis– Progressiveslip– Grade-IIIorhigher-grade

slipatpresentation

• TheseareindependentofLBP

Operative Treatment

• DebnathetalJBJSBr2003• 22competitiveathletes,prospectivewithrepairofparsdefect

• Bestresultswithscrewfixation• 18/19returnedtosports• Allbut1withwiringfailed,nonereturnedtosports

• Bracingnotneededpost-opforplay

Unilateral Pars Defects• Unilateraldefectmayleadtoa12foldstress

increaseincontralateralpedicleandpars

• Upto25%mayhaveacontralateralstressfx

• Unilateralspondylolysiscouldleadtostressfractureorsclerosisatthecontralateralsideduetoanincreaseinstressesintheregion

• SuspectcontralateralinjuryifLBPpersists

Sairyo K. Am J Sports Med Apr 2005

Case 1

• 16yofemalegolferwithchronicprogressiveLBPandRLEpain

• Priortreatment:PT,NSAIDs,rest

• Painpreventedherfromsportsaswellasactivitiesasateenager(school,socialactivites,etc)

Case 1

Case 1

Case 1

Outcome• SurgerywasaMISAnterior/PosteriorL5/S1spinalfusion

• NoComplications

• DischargedtohomeonPOD#2

• Startedswinginggolfclubsat4weeks

• Painfree,hasnotfeltbetterinmanyyears

Case 2

• 53yofemalenurseinL&Dunit

• ChronicworseningLBPwithR>Llegpain

• Limitingabilitytoexercise,increaased painwithwork

• PT,NSAIDs,ESI’snothelpful

X-Rays

X-Ray

MRI

Post-Op

Outcome

• Ptreturnedtoworkin3months

• Nowpainfree,nomeds

• Bestshehasfeltinyears

Return to Play

• Athleteshouldhavesignificantimprovementofsymptomstoreturntoplay

• Fullstrength&ROMdocumented

• Painmanageableenoughtoplaywithoutneedofanalgesicsorabnormalmovementpatterns

Return to Play• AfterMicrodiscectomy

– 6-8weeksfornon-contactsports– 4-6monthsforcontactsports

• WatkinsCriteria1.Thetrunkstabilizationprogramhadbeencompleted2.Excellentaerobicconditionhadbeenachieved.3.Theathletehadreturnedtoasatisfactorylevelof

masteryoftheskillsnecessarytoperforminthesport.

4.Thestretchingandstrengtheningexercisesspecifictothatsportcouldbeperformed.

Return to Play

• LumbarFusionforspondylolysiswillrequire6-12monthsofrecoveryfornon-contactsports

• Nodataavailableforadultathletesundergoingspinalfusionforreturntoplay

• Discreplacementlikelynotgoodoptionforcontactsports

Summary

• Backpainthatstops/limitsparticipationneedsevaluation

• Conservativetx oftenfirstchoice• ConsiderSpondylolisis inadolescentorextensionsportathletes

• Areoptionsfordiscinjuryinathletes–Microdiscetomy

• GoalisRTPinappropriatetimeframe

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