Internal Disc Disruption and Axial Back Pain in the Athlete

Outcomes of Various Treatment Modalities for Lumbar Spinal Ailments in Elite Athletes: A Literature Review

Lumbar spinal injuries are common in elite athletes, who can present with a spectrum of ailments ranging from lumbar strain to prolapsed intervertebral discs. Sequelae can include neurological impairment and lumbar instability among other possible outcomes. This group of patients is unique in terms of their clinicoradiological presentation and treatment modalities. The primary goals of treatment are a rapid return to play and prevention of recurrence, thus prolonging the athlete’s professional career. Treatment modalities can range from activity restriction to nerve root blocks and surgery. A successful treatment outcome is based on timely diagnosis, treatment suiting the demands of the particular sport, and early rehabilitation. A multidisciplinary team approach involving the coach, rehabilitation specialist, pain management specialist, and spine surgeon helps in planning appropriate treatment. In this article, we review special considerations in the elite athletic population with lumbar spinal ailments as well as the outcomes of various treatment modalities.

Assessment and rehabilitation of chronic low back pain in baseball: part II

Repetitive throwing and hitting motions in baseball place mechanical stresses to the lumbar spine which may cause low back pain (LBP). Pain may be due to vertebral stress reactions or insufficiency fractures, intervertebral disc degeneration or intervertebral disc herniation. Untreated chronic conditions have high potential to lead to a more significant injury such as spondylolysis. Chronic LBP increases the risk for missed playing time, early career termination and lower quality of life after retirement. Proper clinical assessment and prevention/rehabilitation of LBP in this population is thus important for performance, play time and overall long-term quality of life. This narrative review synopsizes the available evidence for assessment and rehabilitation of baseball players with LBP, including the structured rehabilitative techniques and programmes which should be administered to affected players. The state of the evidence suggests that there are deficits in identifying the optimal prevention and rehabilitation prescription components for the variety of LBP-inducing injuries in this athletic population.

Tissue Engineering a Biological Repair Strategy for Lumbar Disc Herniation

The intervertebral disc is a critical part of the intersegmental soft tissue of the spinal column, providing flexibility and mobility, while absorbing large complex loads. Spinal disease, including disc herniation and degeneration, may be a significant contributor to low back pain. Clinically, disc herniations are treated with both nonoperative and operative methods. Operative treatment for disc herniation includes removal of the herniated material when neural compression occurs. While this strategy may have short-term advantages over nonoperative methods, the remaining disc material is not addressed and surgery for mild degeneration may have limited long-term advantage over nonoperative methods. Furthermore, disc herniation and surgery significantly alter the mechanical function of the disc joint, which may contribute to progression of degeneration in surrounding tissues. We reviewed recent advances in tissue engineering and regenerative medicine strategies that may have a significant impact on disc herniation repair. Our review on tissue engineering strategies focuses on cell-based and inductive methods, each commonly combined with material-based approaches. An ideal clinically relevant biological repair strategy will significantly reduce pain and repair and restore flexibility and motion of the spine.

Low Back Pain in Athletes

CONTEXT

Low Back Pain (LBP) in athletes is common and has a broad spectrum of differential diagnoses that must be taken in to account when a clinician approaches the patient with LBP. The physicians should take into account spinal and extra spinal causes of low back pain in athletes.

EVIDENCE ACQUISTION

A literature review was performed for the years 1951 through 2013. Keywords used were Low Back Pain and Athletes. We searched MEDLINE, EMBASE, OVID, PUBMED, the Cochrane Library, ELSEVIER, and the references of reviewed articles, for English-language of Low Back Pain in Athletes.

RESULTS

The two most common causes of LBP arising from spine in athletes are degenerative disc disease and spondylolysis with or without listhesis. Although most athletes, respond well to conservative treatment, surgical treatment is indicated when conservative treatment failes.

CONCLUSIONS

The major concern in athletes with LBP is return to play and previous level of their activity after treatment. There is insufficient evidence regarding this issue in literature to define the optimal time of return to play following treatment.

Spine surgery in athletes with low back pain-considerations for management and treatment

While degenerative lumbar spine conditions are common in the general population, there are unique considerations when diagnosed in high-level athletes. Genetic factors have been identified as a more significant contributor to the development of degenerative disc disease than occupational risks, however, some have postulated that the incessant training of young, competitive athletes may put them at a greater risk for accelerated disease. The evidence-based literature regarding lumbar disc herniation in elite athletes suggests that it is reasonable to expect excellent clinical outcomes and successful return-to-sport after either operative or non-operative treatment regardless of sport played. However, those athletes who require repetitive torque on their lumbar spines may have poorer long-term outcomes if surgical treatment is required for this condition. Painful spondylolysis in the athlete can often be treated successfully with non-operative treatment, however, if surgery is required, pars repair techniques provides a motion-sparing alternative that may lead to successful return to sport.

The young adult spine in sports

In summary, LBP is a common problem for the young adult athlete, with discogenic pain being the most common of all etiologies. Although rare, more serious etiologies such as tumor or infection should be included in the differential diagnosis until effectively ruled out. Regardless of the cause, nonoperative and conservative strategies should be the cornerstone of treatment, owing to the favorable natural history of most LBP etiologies. Short-term non-narcotic medications are helpful, and avoidance of bed rest is critical for the athletic population. Rehabilitation should focus on stabilization and strengthening of the core and pelvic muscle groups, and biomechanical imbalances should be addressed. Surgical intervention ought to be utilized as a last resort in this population. Return to play should be considered only when the athlete is pain free with full range of motion and daily medications have been discontinued. Careful monitoring of the training regimen should always be undertaken,especially with chronic pain or recurrent injuries.

High-Intensity Zone on L-spine MRI: Clinical Relevance and Association with Trauma History

Study Design

This is a retrospective study.

Purpose

We wanted to investigate the clinical relevance of the lumbar high intensity zone (HIZ) on magnetic resonance imaging (MRI) and the relationship of trauma history to internal disc disruption (IDD).

Overview of Literature

HIZs on lumbar spine (L-spine) MRI have been suggested as a reliable marker of IDD by some authors. The prevalence and type of spinal trauma in IDD have not yet been carefully analyzed.

Methods

L-spine MRIs of 737 patients with low back pain with or without associated leg pain were reviewed for the presence of HIZs. HIZs on T2-weighted MR images were determined according to the Aprill and Bogduk criteria. A review of medical records and a telephone interview were performed for further analyses of pain.

Results

HIZs were found in 117 patients and 153 discs among a total of 737 patients who met the inclusion criteria. Both a medical record review and a telephone interview were possible with 99 patients. Among these, 42 patients had had an episode of trauma. Seventeen of these had a relatively high-energy injury such as a traffic accident or a fall. Regarding back pain, 27 patients complained of typical discogenic back pain. Only 11 patients had both a trauma history and typical discogenic pain and 41 patients (42%) had neither a trauma history nor typical natural pain.

Conclusions

Given the low incidence of discogenic pain, a HIZ on an L-spine MRI appears less meaningful than often assumed as a specific marker of IDD. Trauma, such as a traffic accident, seems unlikely to be the main cause of IDD.

Back pain in athletes

The athlete with back pain presents a clinical challenge. Self-limited symptoms must be distinguished from persistent or recurrent symptoms associated with identifiable pathology. Athletes involved in impact sports appear to have risk factors for specific spinal pathologies that correlate with the loading and repetition demands of specific activities. For example, elite athletes who participate in longer and more intense training have higher incidence rates of degenerative disk disease and spondylolysis than athletes who do not. However, data suggest that the recreational athlete may be protected from lumbar injury with physical conditioning. Treatment of athletes with acute or chronic back pain usually is nonsurgical, and symptoms generally are self-limited. However, a systematic approach to the athlete with back pain, involving a thorough history and physical examination, pertinent imaging, and treatment algorithms designed for specific diagnoses, can facilitate symptomatic improvement and return to play. There are no reliable studies examining the long-term consequences of athletic activity on the lumbar spine.

Lower Back Pain in the Athlete: Common Conditions and Treatment

Athletes younger than 12 years of age commonly have pathology related to the lower back pain. Spondylolysis is the most common condition in these athletes. Other conditions, including lumbar Scheuermann's disease,scoliosis, disc herniation, fractures, and muscular stains, can occur. Most of the mature general population experiences low back at some time in life. Athletes may be at increased risk, but outcomes are good. The majority of low back pain in mature athletes is mechanical in nature. Herniated discs,spinal stenosis, sacoilitis, and sacral stress fractures can also cause low back pain in these athletes. Low back conditions mentioned above may be treated with rest, specific exercise programs, and medication. Surgery is indicated for severe spinal stenosis, pain with evidence of neurological compromise,and some painful deformities. Newer treatments for back pain are emerging,but few controlled clinical trials are available.

Low-back pain in athletes

While most occurrences of low-back pain in athletes are self-limited sprains or strains, persistent, chronic, or recurrent symptoms are frequently associated with degenerative lumbar disc disease or spondylolytic stress lesions. The prevalence of radiographic evidence of disc degeneration is higher in athletes than it is in nonathletes; however, it remains unclear whether this correlates with a higher rate of back pain. Although there is little peer-reviewed clinical information on the subject, it is possible that chronic pain from degenerative disc disease that is recalcitrant after intensive and continuous nonoperative care can be successfully treated with interbody fusion in selected athletes. In general, the prevalence of spondylolysis is not higher in athletes than it is in nonathletes, although participation in sports involving repetitive hyperextension maneuvers, such as gymnastics, wrestling, and diving, appears to be associated with disproportionately higher rates of spondylolysis. Nonoperative treatment of spondylolysis results in successful pain relief in approximately 80% of athletes, independent of radiographic evidence of defect healing. In recalcitrant cases, direct surgical repair of the pars interarticularis with internal fixation and bone-grafting can yield high rates of pain relief in competitive athletes and allow a high percentage to return to play. Sacral stress fractures occur almost exclusively in individuals participating in high-level running sports, such as track or marathon. Treatment includes a brief period of limited weight-bearing followed by progressive mobilization, physical therapy, and return to sports in one to two months, when the pain has resolved.

The diagnostic value of contrast-enhanced magnetic resonance imaging in the detection of experimentally induced anular tears in sheep

STUDY DESIGN

An investigation of the visualization of experimental anular tears using contrast-enhanced magnetic resonance imaging.

OBJECTIVES

To investigate how different kinds of experimentally induced anular tears can be visualized on contrast-enhanced magnetic resonance imaging.

SUMMARY OF BACKGROUND DATA

Because the outer part of the anulus is innervated, tears of this part of disc are considered one cause for lumbar back pain. Moreover, clinical and experimental studies suggest that anular injuries may lead to a progressive degeneration of the entire disc. In the human disc, vascularized anular tears associated with disc degeneration can be visualized with contrast-enhanced magnetic resonance imaging, but acute peripheral anular injuries, probably caused by sudden trauma, have not been studied with this method.

METHODS

Two adjacent lumbar discs in adult sheep (n = 11) were injured with a scalpel blade. The L2-L3 discs were injured superficially, whereas in the L3-L4 discs, the incision reached the nucleus pulposus (full-thickness injury). In seven animals, only a stab incision was made to the disc, and in four animals, a small fragment (5 x 2 x 3 mm) of anulus was cut and removed. The animals were killed 3 weeks (acute injury, n = 5) and 3 months (subacute injury, n = 6) after surgery. Five minutes before death, gadolinium-diethylenetriaminepentaacetic acid was injected intravenously. After death, the whole lumbar spines were excised and 1.5-T high-field magnetic resonance imaging was immediately performed. Thereafter, the disc samples were examined histologically to determine the existence of blood capillaries.

RESULTS

In all injured discs, the injured area was macroscopically visible. Histologically, blood capillaries, lamellar destruction, and granulation tissue were clearly seen in every injured anulus. Contrast-enhanced magnetic resonance imaging showed that the superficial injuries were only occasionally visible in magnetic resonance imaging (3 of 11), whereas the full-thickness injuries were visible in a majority of the discs (8 of 11). In magnetic resonance imaging, the size of the injury did not relate to the enhancement intensity. The subacute injuries, particularly the full-thickness injuries, were more often visualized than the acute ones.

CONCLUSION

Even though macroscopically visible and histologically evident, it was not always possible to demonstrate experimental anulus injuries by contrast-enhanced magnetic resonance imaging. This experimental study shows that further research work is needed to develop more sensitive methods to detect peripheral, relatively small, but probably clinically important disc injuries.