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-
• p
• 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

• n 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

• utcomes 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

• utcomes 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.

Thank You