eMedicine Specialties > Sports Medicine > Spine
Lumbar Disk Problems in the Athlete: Differential Diagnoses & Workup
Updated: Oct 12, 2007
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Differential Diagnoses
Other Problems to Be Considered
Abdominal aneurysm
Degenerative disorders
Developmental abnormalities
Discitis in children
Infections
Inflammation
Lumbar strain
Metabolic disorders
Neoplasm (cancer)
Neurologic disorders
Pars fracture
Psychiatric disorders
Referred pain
Renal stones
Sacroiliac joint sprain
Spinal stenosis
Workup
Laboratory Studies
- A complete blood cell (CBC) count may demonstrate evidence of infection or malignancy.
- The erythrocyte sedimentation rate (ESR) level is elevated in the presence of infection.
- Alkaline phosphatase is a marker of bone destruction (among other diseases) and may be elevated in cases in which there are tumors or infection.
Imaging Studies
Imaging studies should be interpreted with caution and correlated with the patient’s symptoms because abnormalities are commonly noted in asymptomatic populations. Imaging modalities for the evaluation of LBP include radiographs, MRI, computed tomography (CT) scanning, nuclear bone scanning, and discography.
Radiographs
- Anteroposterior (AP), lateral, and oblique views are commonly obtained.
- Radiographs are limited for the evaluation of disc herniations, but they may demonstrate disc space narrowing.
- Radiographs are best utilized to view:
- Fractures
- Osseous lesions
- Sacroiliitis
- Infection
- Overall bony architecture
- Radiographs are not routinely needed in the first 4-6 weeks of symptoms, but radiography should be performed in the presence of trauma or any red flags (see History).
- MRI is the gold standard for visualization of herniated discs and should be performed in patients who have neurologic symptoms such as bowel/bladder incontinence and sexual dysfunction, as well as in those who have a history of lumbar spinal stenosis with neurologic deficit.
- MRI is a good method to evaluate vertebral discs, nerve root compression, and spinal cord impingement.
- Evidence of disc degeneration is present in 35% of patients aged 20-39 years, and in nearly 100% of subjects aged 60-80 years.10 Therefore, patient symptoms should be well corroborated with MRI findings. Note: Radicular symptoms alone are not an indication for an MRI scan, and the study should not be ordered unless the results are likely to change the patient’s management.
Single photon emission CT (SPECT) scanning is the most sensitive test to evaluate for spondylolysis.
CT myelography can be used if MRI and electromyography (EMG) are nondiagnostic, if patients have a contraindication for MRI, or for preoperative planning.
- Disadvantages of this modality include its high level of ionizing radiation exposure, its invasive nature, and its limited ability to evaluate the neuroforaminal and extraforaminal areas.
- Some advantages include CT myelography's ability to evaluate abnormalities at the nerve root sleeve and to detect abnormalities not seen on MRI.
Nuclear bone scanning is useful for ruling out cancer, stress fractures, and osteomyelitis. (See also the eMedicine article Osteomyelitis.)
The use of provocative discography remains controversial. This study is performed based on the principle that normal discs are not painful when injected at low pressures (with dye or saline). The goal of discography is to reproduce the patient’s clinical symptoms or to demonstrate leakage by injecting fluid into the disc. Some spine surgeons routinely order provocative discography before surgery.
Indications for discography include the following:
- Several months of LBP of unclear etiology despite thorough evaluation
- Equivocal findings on MRI or CT scans
- No clinical improvement with nonoperative measures
Other Tests
Electromyography (EMG) and nerve conduction studies (NCSs) evaluate nerve root function, help in the presence of inconclusive imaging studies, and aid in the assessment of nonstructural causes of radicular symptoms (infection and infiltration). These studies locate the level of the lesion, determine acuity, and are used for preoperative planning.
Procedures
Epidural steroid injections are performed under fluoroscopic guidance and are used for diagnostic or therapeutic purposes with varying results. Successful outcomes for steroid injections have been seen in up to 84% of nonathletes4 ; however, their use in athletic populations has not been studied.
Epidural steroid injections are indicated when other nonoperative measures have failed, and they are commonly administered before surgical intervention.
More on Lumbar Disk Problems in the Athlete |
| Overview: Lumbar Disk Problems in the Athlete |
 Differential Diagnoses & Workup: Lumbar Disk Problems in the Athlete |
| Treatment & Medication: Lumbar Disk Problems in the Athlete |
| Follow-up: Lumbar Disk Problems in the Athlete |
| Multimedia: Lumbar Disk Problems in the Athlete |
| References |
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References
McCormack RG, McLean N, Dasilva J, Fisher CG, Dvorak MF. Thoraco-lumbar flexion-distraction injury in a competitive gymnast: a case report. Clin J Sport Med. Jul 2006;16(4):369-71. [Medline].
Ong A, Anderson J, Roche J. A pilot study of the prevalence of lumbar disc degeneration in elite athletes with lower back pain at the Sydney 2000 Olympic Games. Br J Sports Med. Jun 2003;37(3):263-6. [Medline].
Kinkade S. Evaluation and treatment of acute low back pain. Am Fam Physician. Apr 15 2007;75(8):1181-8. [Medline]. [Full Text].
Smeal WL, Tyburski M, Alleva J, Prather H, Hunt D. Conservative management of low back pain, part I. Discogenic/radicular pain. Dis Mon. Dec 2004;50(12):636-69. [Medline].
Baker RJ, Patel D. Lower back pain in the athlete: common conditions and treatment. Prim Care. Mar 2005;32(1):201-29. [Medline].
Peng B, Zhang Y, Hou S, Wu W, Fu X. Intradiscal methylene blue injection for the treatment of chronic discogenic low back pain. Eur Spine J. Jan 2007;16(1):33-8. Epub 2006 Feb 22. [Medline].
Kraft DE. Low back pain in the adolescent athlete. Pediatr Clin North Am. Jun 2002;49(3):643-53. [Medline].
Harwood MI, Smith BJ. Low back pain: a primary care approach. Fam Pract Clin. 2005;7(2):279-303.
Xin SQ, Zhang QZ, Fan DH. Significance of the straight-leg-raising test in the diagnosis and clinical evaluation of lower lumbar intervertebral-disc protrusion. J Bone Joint Surg Am. Apr 1987;69(4):517-22. [Medline]. [Full Text].
Eck JC, Riley LH 3rd. Return to play after lumbar spine conditions and surgeries. Clin Sports Med. Jul 2004;23(3):367-79, viii. [Medline].
Cooke PM, Lutz GE. Internal disc disruption and axial back pain in the athlete. Phys Med Rehabil Clin N Am. Nov 2000;11(4):837-65. [Medline].
[Best Evidence] Freeman BJ, Fraser RD, Cain CM, Hall DJ, Chapple DC. A randomized, double-blind, controlled trial: intradiscal electrothermal therapy versus placebo for the treatment of chronic discogenic low back pain. Spine. Nov 1 2005;30(21):2369-77; discussion 2378. [Medline].
Bono CM. Low-back pain in athletes. J Bone Joint Surg Am. Feb 2004;86-A(2):382-96. [Medline]. [Full Text].
Cherkin DC, Deyo RA, Battié M, Street J, Barlow W. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. N Engl J Med. Oct 8 1998;339(15):1021-9. [Medline].
Day AL, Friedman WA, Indelicato PA. Observations on the treatment of lumbar disk disease in college football players. Am J Sports Med. Jan-Feb 1987;15(1):72-5. [Medline].
Deyo RA, Loeser JD, Bigos SJ. Herniated lumbar intervertebral disk. Ann Intern Med. Apr 15 1990;112(8):598-603. [Medline].
Dreisinger TE, Nelson B. Management of back pain in athletes. Sports Med. Apr 1996;21(4):313-20. [Medline].
Faas A. Exercises: which ones are worth trying, for which patients, and when? Presented at: The International Forum for Primary Care Research on Low Back Pain; October 12-14, 1995; Seattle, Wash.
Franklin BA. Low back exercises. In: Roitman JL, Kelsey M, eds. American College of Sports Medicine's (ACSM's) Guidelines for Exercise Testing and Prescription. 3rd ed. Baltimore, Md: Lippincott Williams & Wilkins; 1998:116-25.
Gerbino PG 2nd, Micheli LJ. Back injuries in the young athlete. Clin Sports Med. Jul 1995;14(3):571-90. [Medline].
Kahanovitz N. Surgical disc excision. Clin Sports Med. Jul 1993;12(3):579-85. [Medline].
Montgomery S, Haak M. Management of lumbar injuries in athletes. Sports Med. Feb 1999;27(2):135-41. [Medline].
Regan JJ. Clinical results of charité lumbar total disc replacement. Orthop Clin North Am. Jul 2005;36(3):323-40. [Medline].
Schenck RC Jr, ed. Athletic Training and Sports Medicine. 3rd ed. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1999:389-90.
Singh V. Percutaneous disc decompression for the treatment of chronic atypical cervical discogenic pain. Pain Physician. Jan 2004;7(1):115-8. [Medline]. [Full Text].
Stinson JT. Spine problems in the athlete. Md Med J. Aug 1996;45(8):655-8. [Medline].
Tall RL, DeVault W. Spinal injury in sport: epidemiologic considerations. Clin Sports Med. Jul 1993;12(3):441-8. [Medline].
Wang JC, Shapiro MS, Hatch JD, et al. The outcome of lumbar discectomy in elite athletes. Spine. Mar 15 1999;24(6):570-3. [Medline].
Watkins RG. Lumbar disc injury in the athlete. Clin Sports Med. Jan 2002;21(1):147-65, viii. [Medline].
Windsor RE. Lumbosacral discogenic pain syndrome. eMedicine from WebMD. Updated June 5, 2006. Accessed October 10, 2007. Available at http://www.emedicine.com/cgi-bin/foxweb.exe/checkreg@/em/checkreg?http://www.emedicine.com/sports/topic64.htm.
Young JL, Press JM, Herring SA. The disc at risk in athletes: perspectives on operative and nonoperative care. Med Sci Sports Exerc. Jul 1997;29(7 suppl):S222-32. [Medline].
Further Reading
Keywords
athletes and back pain, low back pain and sports, strained back, back is out, herniated disc, slipped disc, herniated nucleus pulposus, HNP, ruptured disc, degenerative disc disease, DDD, lumbago, mechanical low back pain, LBP, lumbar disc problems
