Lumbar Disk Problems in the Athlete Workup

Updated: May 17, 2017
  • Author: Luis E Palacio, MD; Chief Editor: Sherwin SW Ho, MD  more...
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Workup

Laboratory Studies

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  • 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.

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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

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  • 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 (see image below).

    Radiograph of the lumbar spine. This image demonst Radiograph of the lumbar spine. This image demonstrates L5-S1 disk space narrowing (the most common location).
  • 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).

Magnetic resonance imaging

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  • MRI is the gold standard for visualization of herniated discs (see image below) 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.

    Magnetic resonance image of the lumbar spine. This Magnetic resonance image of the lumbar spine. This image demonstrates a herniated nucleus pulposus at multiple levels.
  • 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. [11] 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.

CT scanning is better utilized to evaluate bony pathology that involves cortical bone, trabecular bone, lateral recesses, foramina, and the central spinal canal.

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 Medscape Reference article Osteomyelitis in Emergency Medicine.)

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

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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.

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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 nonathletes [4] ; however, their use in athletic populations has not been studied.

One study evaluated the efficacy of epidural corticosteroid injections for lumbar disk herniation in National Football League players and found them to be a safe and effective treatment option in this highly selective group of professional athletes, with a high success rate of return to play and no reported complications. [12]

Epidural steroid injections are indicated when other nonoperative measures have failed, and they are commonly administered before surgical intervention.

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