Lumbar disc herniations in athletes Gino Chiappe+a, M.D. - PowerPoint PPT Presentation

Lumbar disc herniations in athletes Gino Chiappe+a, M.D. University Orthopaedic Associates Assistant Clinical Professor Dept of Orthopaedic Surgery Rutgers Medical School

Disclosure • Nothing to disclose

Clinical Question: • In the athleCc populaCon, what are the treatment opCons for paCents with a herniated lumbar disc who wish to return to normal physical acCvity?

Lumbar HNP • Background • Anatomy • Clinical PresentaCon • Imaging • Treatment

Background • Very common condiCon encountered • ~200,000 surgeries/year in US

Anatomy

Anatomy

Disc Herniations

Anatomy Perfectly healthy discs DO NOT herniate

Clinical Presentation • Acute LBP followed by leg pain (uni vs. bilateral) • Radiculopathy (SciaCca): Pain originaCng in the lumbar spine radiaCng in a dermatomal pa+ern down the LE • Paresthesias/Numbness, E shocks, Burning, etc

Physical Signs • Antalgic Gait • Decreased Lumbar ROM • +SLR, Ipsi and Contra Lateral • Motor Strength 0-5, L1-S1 • Sensory FuncCon • Reflexes/Clonus • Pulses • Skin Changes • Hip/Knee Exam

Types of HNPs • Bulge – Symmetrical bulge of annulus(NOT a herniaCon) • Protrusion – HNP where diameter of base>herniated fragment • Extrusion – Herniated fragment diameter>base – Subligamentous or transligamentous • Sequestered – Fragment is not in conCnuity with disc space

Disc Bulge

Disc Extrusion

Sequestered HNP

Annular Tear

Non-operative Treatment • IniCal period of rest, acCvity avoidance • NSAIDs • Medrol dose pack • Trunk stabilizaCon program • Epidural steroids • SeleCve nerve root injecCons are effecCve and may avert surgery

Operative Options • Discectomy – Open/Microdisectomy – Percutaneous – Endoscopic

Microdiscectomy Surgery

Microdiscectomy Wang, JC, et al, Spine 1999 • 14 elite athletes compeCng at NCAA level • Mean age 20.7 yrs • Sports: – Football (4) – Basketball (2) – Swimming (2) – Water polo (2) – Soccer, track & field, volleyball, diving

Microdiscectomy Wang, JC, et al, Spine 1999 • Minimum non-operaCve treatment period of 8 weeks • 5 did not return to compeCCon, 2 football – 2 single-level open discectomy – 3 two-level open discectomy – 1 percutaneous discectomy • Of 9 who returned, one football player played 3 yrs at college level, rest sCll played professionally

Microdiscectomy Results Watkins Spine 2003 • 60 Olympic & pro athletes had microdiscectomy • Surgery criteria: HNP on MRI, leg pain with playing sport, failed 6 wks non-op treatment • 53 (83%) returned to their sport, avg 5.2 months post- op • All pts started on trunk stabilizaCon and sport specific PT avg of 3 weeks post-op

Return to Sport Rate Watkins et al Spine 2003

Elite Athletes • Large study June 2015, CORR • Included pro, Olympic or DI level athletes only • (1) What proporCon of athletes return to play aner lumbar discectomy, and what is the effect of sport? • (2) What is the expected recovery Cme aner lumbar discectomy in elite athletes? • (3) What is the expected career length and performance of elite athletes aner lumbar discectomy?

Outcomes for Elite Athletes • 75-100% returned to play sport • Highest proporCon was baseball players • The reported recovery period aner lumbar discectomy ranged from 2.8 to 8.7 months. • The average career length aner lumbar discectomy ranged from 2.6 to 4.8 years. • Elite athletes reached an average of 64.4% to 103.6% of baseline preoperaCve staCsCcs aner lumbar discectomy with variable performance based on sport

SPORT Study • Surgical vs. Non-Op Outcomes • Subset Analysis • Lumbar Level differences • Short vs. Long Term Outcome • PaCent Factors

Long Term Outcomes • There is nothing worse for outcomes than long term follow up! • What is the fate of the damaged disc? • Recurrent HerniaCon • Disc DegeneraCon • Need for Fusion???

Return to Play : Watkins • 171 athletes treated: 85 surgery (MLD), 86 nonop • Of surgically treated paCents, 89.3% returned to sport. • The average Cme it took operaCve paCents to return to their sport (return Cme) was 5.8 months. • Progressive return data for surgically treated paCents showed the percentage of athletes who returned increased from 50% at 3 months to 72% at 6 months to 77% at 9 months and 84% at 12 months.

Adolescent Discectomy • 72 paCents 16yo or younger had lumbar discectomy • 20 paCents(28%) required revision surgery • Of the other 50 paCents, 46 noted occasional or no pain with acCvity • Papagelopoulos et al JBJS 1998

Endoscopic Discectomy

Complications • InfecCon rate <1% – DisciCs • Nerve Injury <1% • Dural Tear ~1-3% • Reccurent HNP 4-8%, higher in adolescents • Vascular Injury – Rare but possibly fatal

Take Home Points • Lumbar disc herniaCons are common and affect athletes at all levels • Non-operaCve care can be successful • Surgery is minimally invasive with high success of pain relief • Return to sport is very high, 89%

References • 1. Am J Sports Med. 2013 Nov;41(11):2604-8. doi: 10.1177/0363546513499229. Epub 2013 Aug 16.Performance-based outcomes aner nonoperaCve treatment, discectomy, and/or fusion for a lumbar disc herniaCon in NaConal Hockey League athletes. Schroeder GD, McCarthy KJ, Micev AJ, Terry MA, Hsu WK. • 2. Clin Orthop Relat Res. 2015 Jun;473(6):1971-7. doi: 10.1007/ s11999-014-3762-z.Outcomes of Lumbar Discectomy in Elite Athletes: The Need for High-level Evidence. Nair R, Kahlenberg CA, Hsu WK. • 3. Am J Sports Med. 2012 Nov;40(11):2530-5. doi: 10.1177/0363546512458570. Epub 2012 Sep 17.Return-to-play outcomes aner microscopic lumbar diskectomy in professional athletes.Watkins RG 4th, Hanna R, Chang D, Watkins RG 3rd. • 4. Spine J. 2003 Mar-Apr;3(2):100-5. Microscopic lumbar discectomy results for 60 cases in professional and Olympic athletes. Watkins RG 4th1, Williams LA, Watkins RG 3rd.

References 5. Spine (Phila Pa 1976). 2010 Apr 1;35(7):825-8. doi: 10.1097/BRS. • 0b013e3181d3cf45. AthleCc performance outcomes following lumbar discectomy in professional basketball players. Anakwenze OA1, Namdari S, Auerbach JD, Baldwin K, Weidner ZD, Lonner BS, Huffman GR, Senne+ BJ. 6. Instr Course Lect. 2012;61:499-511. Spine problems in young athletes. • Sucato DJ1, Micheli LJ, Estes AR, Tolo VT. 7. Orthopedics. 2012 Jan;35(1):43-9. doi: 10.3928/01477447-20111122-40. • Effects of lumbar disk herniaCon on the careers of professional baseball players.Earhart JS1, Roberts D, Roc G, Gryzlo S, Hsu W. 8. Clin Orthop Relat Res. 2015 Jun;473(6):2000-6. doi: 10.1007/ • s11999-014-3671-1. Which Variables Are Associated With PaCent-reported Outcomes Aner Discectomy? Review of SPORT Disc HerniaCon Studies. Koerner JD1, Glaser J, Radcliff K. 9. Spine (Phila Pa 1976). 2014 Jan 1;39(1):3-16. doi: 10.1097/BRS. • 0000000000000088. Surgical versus nonoperaCve treatment for lumbar disc herniaCon: eight-year results for the spine paCent outcomes research trial. Lurie JD1, Tosteson TD, Tosteson AN, Zhao W, Morgan TS, Abdu WA, Herkowitz H, Weinstein JN.

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