Lumbar Disk Problems in the Athlete Treatment & Management

Rehabilitation Program

Physical Therapy

Patients should avoid prolonged bed rest to prevent joint stiffness, muscle wasting, bone mineral loss, pressure sores, and deep venous thrombosis. Two days or less of relative rest may be prescribed initially.

Cooke and Lutz described a staged approach to LBP as the following^[12] :

• Stage I involves early, protected mobilization with brief rest (48-72 h). Medications and therapeutic modalities including heat, ice, nonsteroidal anti-inflammatory drugs [NSAIDs], soft-tissue mobilization, and epidural injection are considered.
• Stage II involves dynamic spinal stabilization exercises with co-contraction of the abdominal and lumbar extensors to stabilize the injured segment. Isometric exercises (muscle contraction without changing its length) retrain muscles to maintain a neutral postural position.
• Stage III involves exercises to strengthen lumbar musculature beginning with extension exercises and progressing to flexion exercises. Flexion exercises are delayed due to their increased load on the disc.
• Stage IV involves sports-specific exercises and plyometrics such as eccentric strengthening (resisted stretching of the muscle), followed by an explosive concentric contraction.
• Stage V involves maintenance exercises (home program) to prevent recurrence.

Surgical Intervention

Types of Surgical Intervention

Discectomy  has been recommended for athletes with LBP because there is less anatomic disruption during the procedure, although some investigators argue that athletes have worse outcomes than the general population.^[10] These less-favorable outcomes are believed to be secondary to return to play before complete recovery has occurred. In one large case series, pediatric patients made up 0.4% of patients that underwent discectomy.^[5]

Percutaneous lumbar disc decompression is indicated in patients with LBP that is associated with radicular symptoms down a lower extremity. Patients should undergo provocative discography examination before surgery.

Criteria for spinal fusion include multiple recurrences of lumbar disc problems or vertebral instability, and at least 4-6 months of symptoms with failed nonoperative therapy. The patient's pain should correlate with imaging studies (MRI). Midline spinal tenderness should correspond to the level of disease.

Randomized, controlled clinical trials have not shown significant long-term benefit with spinal fusion relative to aggressive physical and cognitive rehabilitation protocols.^[4] A disadvantage of spinal fusion includes loss of motion at the fused segment that leads to increased stress to the adjacent disc levels, which places the adjacent discs at risk of injury and degenerative changes.

Lumbar total disc replacement has been used in patients with purely discogenic symptoms secondary to DDD. There are, however, many contraindications and possible complications limiting the use of total disc replacement.

Consultations

Consultations with specialists in primary care sports medicine, orthopedic surgery, neurosurgery, neurology, or physiatry should be sought as indicated.

Rehabilitation Program

Physical Therapy

• Goals for physical therapy include pain reduction, reinforcement of a comfortable body position, core strengthening, and stabilization of the spine.
• Tight musculature, including the hamstrings, hip flexors/rotators/extensors, and abdominals, should be stretched.
• A home program should be tailored for performance on a lifelong basis.

Lifestyle modifications

• Exercise is not beneficial for the acute symptoms of LBP, but it is beneficial for chronic LBP sufferers. Increased activity reduces pain as well as improves functional status.
• Tobacco cessation improves outcomes for LBP.
• Weight loss in overweight patients

Medical Issues/Complications

If a patient continues to have pain in the back, buttock(s), and back of the thigh(s) without pain below the knee (true sciatica causes pain below the knee), then the diagnosis can be confusing in cases in which a disc herniation is present on MRI. A large percentage of patients have disk abnormalities on MRI without symptoms.

Surgical Intervention

Considerations for surgical referral include the following:

• Leg pain greater than back pain
• Cauda equina syndrome
• Progressive or profound neurologic deficit
• Severe and disabling pain that is refractory to nonoperative treatment
• Herniated disc (at least 4-6 wk)
• Spinal stenosis (at least 8-12 wk)
• Confirmation of the lesion on imaging studies

There are no data that prove surgical intervention restores neurologic deficit(s) more rapidly than natural history or nonoperative care.

Surgical complications  include the following :

• Infection
• Bleeding
• Nerve damage
• Worsened pain
• Recurrence of herniation
• Paralysis
• Idiosyncratic reaction
• Anaphylaxis
• Death

Consultations

Surgical consultation is indicated in the presence of any red flags (see History).

Referral for epidural spine injection or EMG should also be considered, if indicated.

Primary care sports medicine, neurosurgery, orthopedic surgery, neurology, and physiatry are specialties that have expert clinicians who often treat lumbar disc problems.

Other Treatment (Injection, manipulation, etc.)

Steroids may be injected into the epidural space of the spinal canal if the patient's sciatica persists even with bracing. Bracing may take as long as 4 months to be successful.

Rehabilitation Program

Physical Therapy

During the maintenance phase, the performance of exercise stimulates tissue growth, slows or possibly reverses degenerative conditions, and enhances nutrition to the disc. Increasing the strength and endurance in the major muscle groups (eg, quadriceps, hamstrings, hip, and abdominal muscles) is important. Spine flexibility has not been shown to reduce the risk of future injury. Hip flexibility and abdominal strength exercises, however, has been demonstrated to be important, as well as hip ROM stretching and strengthening activities and hamstring and quadriceps stretching and strengthening activities.

Muscle contraction with the spine in neutral position is the most successful exercise program. Sport-specific exercises may now be integrated, and lifelong activity and lifestyle modification should be maintained.

Other Treatment

• Intradiscal electrothermal therapy (IDET)  – There have been anecdotal reports of high failure rates with IDET in athletes.^[5] A randomized, double-blind control trial reported that IDET is a relatively safe procedure, but patients rarely experienced improvement and did not experience better results when compared to sham treatment.^[13]
• Transcutaneous electrical nerve stimulation (TENS)  is not effective for chronic LBP.^[5] Limited evidence supports the use of TENS, but this is a safe modality and could be utilized in the acute phase of LBP.
• Acupuncture lacks controlled randomized studies to prove its efficacy. This therapy is generally safe, but it is not routinely recommended.
• Conflicting evidence exists regarding spinal manipulation ,^[5] which is not routinely recommended, but it is generally a safe modality.
• Prolotherapy  attempts to treat pain through injection of irritant solutions. This therapy is not recommended for the treatment of disc herniation, and there are limited long-term safety data.^[8]
• Back school has been used for patients with chronic LBP and marked functional impairment. There is a question of whether or not back school is a cost-effective option.
• Intradiscal methylene blue injection  has been studied and reported to be effective in a prospective clinical trial by Peng et al.^[6] Methylene blue has a neurotropic effect that results in blocking nerve conduction and destruction of nerve endings. These neurologic changes result in pain relief when the patient's pain is discogenic in nature.