Lumbar disc herniations in athletes

GinoChiappe+a,M.D.

UniversityOrthopaedicAssociatesAssistantClinicalProfessorDeptofOrthopaedicSurgery

RutgersMedicalSchool

Disclosure

•  Nothingtodisclose

Clinical Question:

•  IntheathleCcpopulaCon,whatarethetreatmentopConsforpaCentswithaherniatedlumbardiscwhowishtoreturntonormalphysicalacCvity?

Lumbar HNP

•  Background

•  Anatomy

•  ClinicalPresentaCon

•  Imaging

•  Treatment

Background

•  VerycommoncondiConencountered

•  ~200,000surgeries/yearinUS

Anatomy

Anatomy

Disc Herniations

Anatomy

PerfectlyhealthydiscsDONOTherniate

Clinical Presentation

•  AcuteLBPfollowedbylegpain(univs.bilateral)

•  Radiculopathy(SciaCca):PainoriginaCnginthelumbarspineradiaCnginadermatomalpa+erndowntheLE

•  Paresthesias/Numbness,Eshocks,Burning,etc

Physical Signs

•  AntalgicGait•  DecreasedLumbarROM•  +SLR,IpsiandContraLateral•  MotorStrength0-5,L1-S1•  SensoryFuncCon•  Reflexes/Clonus•  Pulses•  SkinChanges•  Hip/KneeExam

Types of HNPs

•  Bulge–  Symmetricalbulgeofannulus(NOTaherniaCon)

•  Protrusion–  HNPwherediameterofbase>herniatedfragment

•  Extrusion–  Herniatedfragmentdiameter>base–  Subligamentousortransligamentous

•  Sequestered–  FragmentisnotinconCnuitywithdiscspace

Disc Bulge

Disc Extrusion

Sequestered HNP

Annular Tear

Non-operative Treatment

•  IniCalperiodofrest,acCvityavoidance

•  NSAIDs•  Medroldosepack•  TrunkstabilizaConprogram•  Epiduralsteroids•  SeleCvenerverootinjecCons

areeffecCveandmayavertsurgery

Operative Options

•  Discectomy– Open/Microdisectomy– Percutaneous– Endoscopic

Microdiscectomy Surgery

Microdiscectomy

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

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

Microdiscectomy Wang,JC,etal,Spine1999•  Minimumnon-operaCvetreatmentperiodof8weeks

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

•  Of9whoreturned,onefootballplayerplayed3yrsatcollegelevel,restsCllplayedprofessionally

Microdiscectomy Results

WatkinsSpine2003•  60Olympic&proathleteshadmicrodiscectomy•  Surgerycriteria:HNPonMRI,legpainwithplayingsport,failed6wksnon-optreatment

•  53(83%)returnedtotheirsport,avg5.2monthspost-op

•  AllptsstartedontrunkstabilizaConandsportspecificPTavgof3weekspost-op

Return to Sport Rate

Watkins et al Spine 2003

Elite Athletes

•  LargestudyJune2015,CORR

•  Includedpro,OlympicorDIlevelathletesonly•  (1)WhatproporConofathletesreturntoplayanerlumbardiscectomy,andwhatistheeffectofsport?

•  (2)WhatistheexpectedrecoveryCmeanerlumbardiscectomyineliteathletes?

•  (3)Whatistheexpectedcareerlengthandperformanceofeliteathletesanerlumbardiscectomy?

Outcomes for Elite Athletes

•  75-100%returnedtoplaysport•  HighestproporConwasbaseballplayers•  Thereportedrecoveryperiodanerlumbardiscectomyrangedfrom2.8to8.7months.

•  Theaveragecareerlengthanerlumbardiscectomyrangedfrom2.6to4.8years.

•  Eliteathletesreachedanaverageof64.4%to103.6%ofbaselinepreoperaCvestaCsCcsanerlumbardiscectomywithvariableperformancebasedonsport

SPORT Study

•  Surgicalvs.Non-OpOutcomes

•  SubsetAnalysis

•  LumbarLeveldifferences

•  Shortvs.LongTermOutcome

•  PaCentFactors

Long Term Outcomes

•  Thereisnothingworseforoutcomesthanlongtermfollowup!

•  Whatisthefateofthedamageddisc?

•  RecurrentHerniaCon

•  DiscDegeneraCon

•  NeedforFusion???

Return to Play : Watkins

•  171athletestreated:85surgery(MLD),86nonop

•  OfsurgicallytreatedpaCents,89.3%returnedtosport.•  TheaverageCmeittookoperaCvepaCentstoreturntotheirsport(returnCme)was5.8months.

•  ProgressivereturndataforsurgicallytreatedpaCentsshowedthepercentageofathleteswhoreturnedincreasedfrom50%at3monthsto72%at6monthsto77%at9monthsand84%at12months.

Adolescent Discectomy

•  72paCents16yooryoungerhadlumbardiscectomy

•  20paCents(28%)requiredrevisionsurgery

•  Oftheother50paCents,46notedoccasionalornopainwithacCvity

•  PapagelopoulosetalJBJS1998

Endoscopic Discectomy

Complications

•  InfecConrate<1%– DisciCs

•  NerveInjury<1%

•  DuralTear~1-3%

•  ReccurentHNP4-8%,higherinadolescents

•  VascularInjury–Rarebutpossiblyfatal

Take Home Points

•  LumbardischerniaConsarecommonandaffectathletesatalllevels

•  Non-operaCvecarecanbesuccessful

•  Surgeryisminimallyinvasivewithhighsuccessofpainrelief

•  Returntosportisveryhigh,89%

References •  1.AmJSportsMed.2013Nov;41(11):2604-8.doi:

10.1177/0363546513499229.Epub2013Aug16.Performance-basedoutcomesanernonoperaCvetreatment,discectomy,and/orfusionforalumbardischerniaConinNaConalHockeyLeagueathletes.SchroederGD,McCarthyKJ,MicevAJ,TerryMA,HsuWK.

•  2.ClinOrthopRelatRes.2015Jun;473(6):1971-7.doi:10.1007/s11999-014-3762-z.OutcomesofLumbarDiscectomyinEliteAthletes:TheNeedforHigh-levelEvidence.NairR,KahlenbergCA,HsuWK.

•  3.AmJSportsMed.2012Nov;40(11):2530-5.doi:10.1177/0363546512458570.Epub2012Sep17.Return-to-playoutcomesanermicroscopiclumbardiskectomyinprofessionalathletes.WatkinsRG4th,HannaR,ChangD,WatkinsRG3rd.

•  4.SpineJ.2003Mar-Apr;3(2):100-5.Microscopiclumbardiscectomyresultsfor60casesinprofessionalandOlympicathletes.WatkinsRG4th1,WilliamsLA,WatkinsRG3rd.

References •  5.Spine(PhilaPa1976).2010Apr1;35(7):825-8.doi:10.1097/BRS.

0b013e3181d3cf45.AthleCcperformanceoutcomesfollowinglumbardiscectomyinprofessionalbasketballplayers.AnakwenzeOA1,NamdariS,AuerbachJD,BaldwinK,WeidnerZD,LonnerBS,HuffmanGR,Senne+BJ.

•  6.InstrCourseLect.2012;61:499-511.Spineproblemsinyoungathletes.SucatoDJ1,MicheliLJ,EstesAR,ToloVT.

•  7.Orthopedics.2012Jan;35(1):43-9.doi:10.3928/01477447-20111122-40.EffectsoflumbardiskherniaCononthecareersofprofessionalbaseballplayers.EarhartJS1,RobertsD,RocG,GryzloS,HsuW.

•  8.ClinOrthopRelatRes.2015Jun;473(6):2000-6.doi:10.1007/s11999-014-3671-1.WhichVariablesAreAssociatedWithPaCent-reportedOutcomesAnerDiscectomy?ReviewofSPORTDiscHerniaConStudies.KoernerJD1,GlaserJ,RadcliffK.

•  9.Spine(PhilaPa1976).2014Jan1;39(1):3-16.doi:10.1097/BRS.0000000000000088.SurgicalversusnonoperaCvetreatmentforlumbardischerniaCon:eight-yearresultsforthespinepaCentoutcomesresearchtrial.LurieJD1,TostesonTD,TostesonAN,ZhaoW,MorganTS,AbduWA,HerkowitzH,WeinsteinJN.

Thank You