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LOW BACK PAIN IN ATHLETES: THE LUMBAR DISK
Ken Mautner, MDAssistant Proffesor Dept of PM&R,Dept of OrthopedicsEmory Sports Medicine SymposiumMarch 6, 2009
EPIDEMIOLOGY ATHLETIC LOW BACK PAIN
Common in athletics 10 – 15% of all athletic injuries
One of the most common complaints seen in the training room
Affects males and females equally in the athletic population
Will leave the psychosocial factors that affect LBP out of equation for this talk and discuss true structural and mechanical aspects of LBP Psychosocial factors presumably less in the athletic
population but needs to be screened for as well
SPORT SPECIFIC
Most studies done on young adults 1 – 30% incidence across multiple
studies Gymnastics (70%) and wrestling
(59%) have a very high lifetime incidence Contact sports/ repetitive twisting/
extending sports most commonly affected
Soccer, tennis, football, golf and weightlifting each have a 30 – 40% lifetime incidence
AGE SPECIFIC
Age specific < 18 y/o
spondylolysis
18 – 50 y/o discogenic pain and HNP
>50 y/o spondylosis/spinal stenosis
DEGENERATIVE SPINAL CASCADE
Described by Kirkaldy-Willis in the 1970’s to explain spinal instability Implicates the disc as
the center of this process
Three phases Often overlap Each has different
clinical presentations
DEGENERATIVE CASCADE3 PHASES
Segmental dysfunction
Segmental
instability
Segmental
stabilization
ADVANCED IMAGING IN ASYMPTOMATIC ADULTS
MRI: Abnormal in 34% asymptomatic
subjects 20-39 y/o. Almost all of 60-80 y/o had
degenerative changes on at least one disc level (T2-weighted). ₁
52% asymptomatic individuals had a bulging disc at least one lumbar level. ₂
28 % prevalence of HNP in asymptomatic individuals. ₃
CT 23% asymptomatic individuals found
to have HNP or spinal stenosis. ₄
1. Boden, S. et al. 19902. Jensen, M. C. et al. 19943. Boden et al; Jensen et al.4. Wiesel, Spine 1984
WHAT ABOUT IN ATHLETES?
Healy et al, Journal of Computer Assisted Technology, 1996 Looked at 19 asymptomatic lifelong male
athletes ages 41-69 11 with central disk protrusions 4 with LDH –none currently symptomatic, but
had been 1 severe spinal stenosis
Evidence of asymptomatic degenerative changes similar to those in published series in other populations.
WHAT ABOUT IN ATHLETES?
Lumbar Intervertebral Disc Degenertion in Athletes: Hangai et. al. 2009 (AJSM) University athletes vs. age matched
university nonathletes Baseball players and swimmers had
more disc degeneration and back pain episodes
Runners, soccer and basketball players showed no differences
DOES PLAYING SPORTS INCREASE RISK OF LBP LATER IN LIFE ?
Hangai et al, AJSM, 2010 Analyzed 4667
university students who participated in sports at a young age
Found significant correlation between duration of years played (classified as no, mid, or high) and incidence of LBP
This relationship existed amongst all sports
DISC AS PAIN GENERATOR
Discogenic pain Pain attributed to a mechanical and/or
chemical stimulus of the nociceptor nerve endings in the anulus fibrosis
PRESENTATIONDISCOGENIC LBP
Acute (flexion/rotation injury) or Insidious onset
Pain with flexion > extension
Sitting intolerance Pain mostly limited
to the back Worse initial part
of day
EXAMDISCOGENIC LBP
Pain with forward flexion May get relief of pain with
extension Normal Neurologic exam Negative SLR test +/- pain to palpation in associated
muscles Pain with Sustained Hip Flexion
Test
EVIDENCE FOR SHF TEST
Depalma et al, ISIS, 2009 Midline LBP
exacerbated by SHF in young adults is strongly predictive of IDD as source of symptoms
Absence of midline LBP , regardless of SHF or age is strong predictor that disk is not source of LBP
Should look for other source of LBP
DISC AS PAIN GENERATOR Disc herniation produces acute radicular pain
due to inflammatory mediators around nerve root (not the nerve root compression) Mechanical neurocompression: dysaesthesias,
motor deficits without pain (Macnab ,Pain ,1971) Biochemical factors as result of a local
inflammatory response may be the main pain generator!
Lindahl: Acta Orthop Scand 1951 Nachemson: Acta Orthop Scand 1969 McCarron: Spine 1987 Saal JS et al: Spine 1990
Phospholipase A2 Found in high concentration in HNP‘s
Prostaglandin E2 Greatest in sequestered > extruded > protruded Greater in those with + SLR
PRESENTATION:RADICULAR PAIN SYNDROMES
Presentation Acute and chronic
radicular pain present differently
Primarily single limb pain ± back pain
Not all leg pain is radicular Not all radicular pain goes
below knee Often will not want to
sit/ bend forward Often worse the initial
part of day
PRESENTATIONRADICULAR PAIN SYNDROMES
Exam Pain worse with sitting/
leaning forward Relief with extension
(except lateral/ foraminal HNP)
+/- back pain (may start in glute)
Often will have associated trigger points/ tender points
+/- Neurologic deficits Be sure to check reflexes and
LE strength/ sensation +SLR/ Slump test / FS (esp
younger/ acute HNP)
MEDICAL TREATMENT OF DISCPRODUCING PAIN SYNDROMES
PATIENT SELECTION
PATIENT SELECTION
NATURAL HISTORY– ACUTE LBP
• Generally extremely favorable• Studies show resolution of 90% for acute
LBP between 4 and 12 weeks• (Hakelius) Compared bed rest, corset x 2
months vs surgery:• Marked reduction in pain and functional
improvement with time in non-sx group: 6 weeks: 80% 12 weeks: 90% 24 weeks: 93%
NATURAL HISTORY- HNP
(Saal, Saal, and Herzog) 80% had > 50% regression of LDH over time Larger herniations regress more Correlation between regression
and resolution of symptoms
ACUTE LBP/ RADICULAR PAIN MANAGEMENT
• Bed rest/Activity Modification• Not recommended >24-48hrs.
When possible, relative rest is advisable
Hagen KB et al. ( Spine 2000)…no considerable difference between advice to stay active and advice for bed rest.
Potential harmful effects of prolonged bed rest “It is reasonable to advise people with acute low back
pain and sciatica to stay active”...
Reassurance of natural history Brief education Medications for pain/symptom control
NSAIDS, Oral Steroids, Muscle relaxants, Narcotics Possible use for neuropathic meds– gabapentin/
pregabalin
PHYSICAL THERAPY FOR ACUTE LBP
Since favorable natural history, most assume no need for PT for acute LBP
However, studies demonstrate 25%-84% recurrent episodes of LBP within 1 year
Can P.T. prevent recurrent LBP which often leads to chronic LBP?
“Non-specific exercises for non-specific low back pain produces non-specific results” --Joel Press, MD
INTERVENTIONAL AND SURGICAL TREATMENT OF DISC AND
RADICULAR PAIN SYNDROMES
INTRADISCAL PROCEDURES Methylene Blue Injection
May destroy nerve endings/ block nerve condution in paindul disk areas
Platelet Rich Plasma/ biological agents Animal models suggest that disk regeneration is possible
Ozone Oxygen like substance injected into discs to “shrink” the
HNP and reduce pain/ inflammation Intradiscal Steroid
Temporary relief by reducing inflammation in disk to treat annular fissure/ DDD that causes pain
Good results when associated with endplate inflammatory changes (Modic changes) – Fayad, European Spine Journal, 2007
Intradiscal electrothermic Therapy (IDET) “heating- up” of disk to dennervate pain and scar down
any tears/ fissures in disk
INTERVENTIONAL TREATMENT FOR LUMBAR RADICULAR PAIN
WEST study (Arden et al. Rheumatology 2005): Transforaminal lumbar epidural steroid injection
(TFESI) offered short term benefit (3wks) in patients with sciatica
No sustained benefits in terms of pain, function or need for surgery
Buttermann et al. 2002 ESI vs. Discectomy: 96% good outcomes with
surgery vs. 49% good outcomes with ESI in large herniations
Conclusion: ESI’s do not alter LDH regression. Less hydrated discs may have prolonged symptoms, but many improve with ESI’s
EPIDURAL INJECTIONS - RESULTS
Riew, K.D.et al “The effect of
nerve-root injections on the need for operative treatment of lumbar radicular pain. A prospective, randomized, controlled double- blind study”
JBJS Volume 82-A,2000
Riew, K.D. et al “Nerve Root
Blocks in the Treatment of Lumbar Radicular Pain: A Minimum Five Year Follow- Up”
JBJS, 2006
SURGICAL INTERVENTION FOR DISCOGENIC PAIN
Done as last resort for intractable/ progressive axial LBP
Options include Fusion vs Lumbar disc replacement Many different techniques employed
which all affect outcomes
The Spine Patient Outcomes Research Trial (SPORT): A Randomized Trial Weinstein, J. et al JAMA. 2006;296:2441-2450
501 surgical candidates (imaging-confirmed lumbar
HNP) and persistent radiculopathy for 6 wks Interventions: Standard open diskectomy vs nonop.
treatment.
Main Outcome Measures Primary: changes from baseline for the Medical Outcomes
Study 36-item Short-Form Health Survey bodily pain and physical function scales and the modified Oswestry Disability Index at 6 weeks, 3 months, 6 months, and 1 and 2 years from enrollment.
Secondary : sciatica severity as measured by the Sciatica Bothersomeness Index, satisfaction with symptoms, self-reported improvement, and employment status.
SURGICAL INTERVENTION FOR LUMBAR RADICULAR PAIN
SURGICAL INTERVENTION FOR LUMBAR RADICULAR PAIN
The Spine Patient Outcomes Research Trial (SPORT): A Randomized Trial Weinstein, J. et al JAMA. 2006;296:2441-2450
There were statistical differences in the secondary measures of sciatica severity and self-rated improvement in favor of surgery group.
Conclusions: “…Because of the large numbers of patients who crossed over in both
directions, conclusions about the superiority or equivalence of the treatments are not warranted based on the intent-to-treat analysis”.
SURGICAL INTERVENTION FOR LUMBAR RADICULAR PAIN
743 patients who did not want to be “randomized” were followed in observational cohort study 521 choose surgery; 221 choose non-operative care 528 received surgery in first 2 years; 191 no surgery
Weinstein, J. N. et al. JAMA 2006;296:2451-2459
CONCLUSIONS
Lumbar disk is most common cause of young adults with LBP
Lumbar radicular pain sec. to HNP is common in 25-45 year old age group
Most acute discogenic and radicular pain improves in a timely manner without aggressive interventions No need for extended work- up unless red flags,
neurologic compromise, or severe pain that is not improving
Need more evidence and research into minimally invasive/ conservative treatment of disc/ radicular pain syndromes
Office: (404)- 778- 7142