Sports-related spine injuries, spine surgery do not always end sports participation

Catastrophic spinal cord injuries in sports are rare, but soft tissue spine injuries and concussions are fairly common in most levels of sports play. According to sources who spoke with Spine Surgery Today, whether these injuries can be treated depends on their type, cause and severity, as well as the age of the athlete. The same is true for an athlete who undergoes spine surgery. Return to play is dependent on several factors, they noted.

According to Robert G. Watkins III, MD, of the Marina Spine Center, most physicians presented with an athlete with a possible spine injury will first confirm the diagnosis and then go through his or her treatment program to determine whether the patient can be treated nonoperatively or with surgery.

“The physical examinations are always the critical factor in determining if surgery is needed. If there is pressure on the nerve, you evaluate the nerve injury to see how bad it is. Is the patient weak? Numb? There are parts of our physical, the exam we do, that emphasizes stretching of the nerve, and if that is very symptomatic we are more than likely going to recommend surgery,” Watkins told Spine Surgery Today.

Usually not catastrophic

The most common sports-related spine injures are not catastrophic, according to a study conducted at the National Center for Catastrophic Sport Injury Research at The University of North Carolina at Chapel Hill. From July 1, 2012 to June 30, 2013, 41 catastrophic spinal cord injuries in sports were reported to the center for a rate of 0.53 injuries per 100,000 participants in the United States.

The most common spine injury seen in athletes at all levels is disc herniation. Athletes with these injuries experience stressful rotation when playing their sports so they end up tearing the supporting structure of the disc and, “just like a piece of rubber stripped off the outside of a truck tire,” these structures break off on the inside and come out through the rupture, according to Watkins.

Stress fractures are also common in athletes due to the repetitive stresses and repetitive actions of the sports played. After a diagnosis, Watkins said he then makes a determination if the athlete can be treated conservatively or with surgery.

Conservative treatment first

Using a rehabilitation program and a rehabilitation center is important when it comes to treating athletes with one of these injuries, Watkins said.

“Usually we start with conservative treatment. We know how to treat people conservatively and we have a great program designed to return people nonoperatively to performance. We first use strong anti-inflammatory medication or injections, and we will start patients in our rehab program most of the time. That gives a player a way to return safely and successfully to sport,” he said.

The number one goal for surgeons who treat a spine-injured athlete is to get him or her back to their respective sport without surgery, Joseph C. Maroon, MD, of the University of Pittsburgh, told Spine Surgery Today.

Maroon, a Spine Surgery Today Editorial Board Meeting said traction, selective nerve blocks for diagnostic and therapeutic methods, anti-inflammatories, analgesics and muscle relaxers are all proven conservative treatments that can be used for athletes with these injuries who have limited neurological deficits.

Typical lumbar injuries in athletes are a herniated disc, lateral recess stenosis and occasionally spinal stenosis is seen, whereas typical cervical injuries that are sports-related include cervical spondylosis and herniated discs with associated spinal stenosis, according to Maroon. However, when a surgeon sees a patient with spinal stenosis with neurapraxia as the result of sports, he said the course of action becomes more difficult to determine.

“We see several cases of neurapraxia yearly that do not clear completely in terms of neurological symptoms and signs. Some are left with focal spinal stenosis and possibly even a hyperintensity area in the cord. Then the decision may come down to giving up the sport if they are asymptomatic or having surgery with the goal to return to the sport if it is a single-level decompression of the cord. A two-level decompression is a relative contraindication,” Maroon said.

In a study published in 2007, Maroon and colleagues analyzed the outcomes of five National Football League (NFL) athletes with cervical neurapraxia who underwent anterior cervical microdiscectomy and fusion. If the athletes were neurologically intact, the investigators found they could most likely return to professional football. However, the chances of repeated herniation above or below the fused level increased significantly, based on the study results.

Role of imaging, physical exam

A physical examination and imaging can help increase the diagnosis accuracy of a spinal injury in an athlete, Charles Y. Liu, MD, PhD, of Keck Medicine of USC, in Los Angeles, said.

Liu told Spine Surgery Today that based on his experience, most spine injuries from sports involve the cervical spine, including strained ligaments and injuries to the intervertebral discs.

“Injuries are diagnosed by both clinical examination by a skillful and knowledgeable physician, as well as imaging studies, such as X-rays, CT scans and MRI scans. Sometimes, electrophysiological tests are helpful,” he said.

Concussions still loom

Concussions in sport have been highly publicized in recent years, but according to Maroon, concussion management has taken several important steps in the past 25 years to reduce the number of those injuries due to sports, especially football.

“When I compare the management of concussions in the 1980s and early 1990s to the management now, there has been a huge improvement in safety precautions and diagnosing and recognizing concussions and management. In 1990, Mark Lovell, Mickey Collins and I introduced the neurocognitive test, ImPACT, which is now the standard of care used to manage patients, [and is] one of the tools in neurocognitive testing. We have now baselined more than 10 million athletes with this test,” Maroon said.

Professional football players have neurocognitive baseline registered while they are healthy and cannot return to play after an injury until they return to the “healthy baseline,” he said.

If the athlete cannot return to baseline, he or she cannot return to play.

Reduction in concussions

The NFL now requires a certified athletic trainer to be in the stadium press box for each game watching the action. That individual has the authority to stop the game and remove an athlete who displays signs of a concussion. As a result of this practice, in the last 3 years there has been a 35% reduction in concussions in the NFL, Maroon said.

In addition, youth football leagues across the United States have adopted similar safety approaches. They are teaching “heads-up” tackling techniques to reduce concussions. More importantly, according to Maroon, there has been a widespread effort in the last 15 years to 20 years to reduce concussion across all sports and all skill levels.

Age at injury makes a difference

According to Andrew B. Dossett, MD, of W.B. Carrell Memorial Clinic, in Dallas, it is significantly different to treat high school athletes who sustain spinal injuries compared with collegiate or professional athletes.

“In a young athlete, like a teenage athlete or an adolescent athlete, exposure to hyperextension will lead to stress fractures of the pars interarticularis, which is common. It probably happens in 15% of the active, athletic young population,” he told Spine Surgery Today.

Disc injuries are also common in young athletes, with most caused by training and weightlifting. Athletes who are still growing often do not experience a pure disc herniation, but have an injury to the growth plate instead. This can be more problematic to treat than a common and straight forward disc herniation, according to Dossett.

He noted in the older athletes who are typically 16 years to 18 years old when the growth plate is closed, disc herniations and pars interarticularis fractures are the most common types of injuries he sees.

“It is a region of the lamina that gets fractured. It is usually 15% across the board, but in certain athletic endeavors it is much higher, such as gymnastics and baseball. We did a study over 2 years with the Texas Rangers, where we took X-rays of everyone on the 40-man roster. We found approximately 25% of athletes had an old, unhealed stress fracture. It is endemic in some things you do, but even if you have an old stress fracture that has never healed, you can progress to the highest level in sport,” Dossett said.

Weekend warriors

When a recreational athlete or “weekend warrior” injures his or her spine or develops a spine condition, the treatment approach is vastly different than what is used for competitive athletes. Smaller surgeries, such as microscopic lumbar discectomy or microcervical discectomy, coupled with proper rehabilitation and rest, usually allow recreational athletes to fully return to their activities, according to Dossett.

“The things that are more difficult are back fusions or lumbar fusions,” he said.

Most people have difficulty returning to full activity after those procedures, Dossett noted.

“For people who have had a lumbar fusion, I do not generally recommend they run. There is too much pounding and that can affect the adjacent levels and cause them to degenerate. So, I ask them to stay in shape, do some non-impact aerobic conditioning, such as an exercise bike, spin class, stair stepper or elliptical training,” he said.

The magnitude of the spine surgery a patient undergoes should dictate the types of post-surgical activities in which a patient can participate. For example, a patient who had a small surgery, such as a microscopic cervical discectomy or anterior cervical fusion, should be able to return to full activity, according to Dossett. However, if they have a procedure that is any larger than that, such as a lumbar fusion, the physician needs to tell them to “be smart and reel it in some,” he said.

Quick rehabilitation can help

The rehabilitation program following a spine injury due to sport is important, according to Oluseun A. Olufade, MD, at The Emory Spine Center, in Atlanta. He is board certified in Physical Medicine & Rehabilitation, Primary Care Sports Medicine and Interventional Pain Medicine. Professional and college athletes can be entered into a rehabilitation program to treat their injury as soon as possible to get them back to their sport. High school and younger athletes, due to a lack of resources and time for rehabilitation, can hold off for a while in order to see how the injury responds to rest, he said.

“A thorough neurological history, physical examination and imaging studies are important to differentiate if the injury is a soft tissue, disc herniation or something a bit more serious, such as a fracture or spinal cord injury. We start with modalities, such as ice and heat, in addition to anti-inflammatories and muscle relaxants to calm things down. If it is a high school kid, I am more conservative with medications due to possible side effects, but will start treatment sooner for a college or professional athlete,” Olufade told Spine Surgery Today.

If the injury does not respond to these approaches, he said physical therapy is begun that involves range of motion exercises, stretching, strengthening regimens, nerve gliding exercises and ultrasound treatment to accelerate recovery. A stepwise approach to return to play is very important, Olufade noted.

Surgery with high rates of success

According to Liu, a solid rehabilitation program and rest can treat most of the spinal injuries that stem from sports, but several types of surgery can also be effective and have high rates of success returning athletes to competition.

“The majority of injuries are treated with rest and rehab alone. Only those that involve fractures, dislocations and disc herniations with spinal cord or nerve root compression require surgery. The most common surgeries involve microdiscectomy and/or decompression and possibly fusion surgery,” Liu said.

Physicians who have control over their patients, rehabilitation programs or have rehabilitation programs of their own can often provide the best treatment for these types of injuries, according to Watkins.

Monitor the athlete’s progress

Having control over the entire process can streamline treatment and allow complete monitoring of an athlete’s progression in his or her recovery, he noted.

“Part of the problem is, if you do not have a good rehabilitation program to treat someone nonoperatively, as a surgeon it completely limits your ability to know how to recommend someone for surgery or not. By having a good rehab program it enables the surgeon to have an alternative for treatment and to be effective in his or her treatment,” Watkins said.

However, a rehabilitation program is only as good as the athlete’s dedication to his or her treatment. If an athlete does not buy into the program, then it will not be effective, Watkins said.

Buying into rehabilitation

Getting younger athletes, such as those in high school or even college, to take their rehabilitation process seriously and do what is asked of them is the most important factor in their treatment, according to Watkins.

“Most of the time, what I try to get across to adolescent athletes is you need to shut the sport down, you cannot do the sport. You need to do our rehab program, and the rehab program determines when they can return to their sport. If you cannot do a level-3 exercise, then you cannot get into the weight room or throw a baseball. You have to work through the rehab program. That determines what you can do in a sport and the athletes have to buy into a program,” Watkins said.

Best options for the patient

For patients at any level of play, the physician must remember to keep the best interest of their patients at heart and keep outside influences at bay. It is unethical, according to Watkins, to let an athlete put himself or herself at risk by either returning to their sport too quickly or deviating from a treatment plan to fit either a sports organization’s wishes or a team’s plan.

“The treatment has nothing to do with [the player’s] contract, the team [or] anything else. He is your patient and your approach to that patient is to do what is best for him. Their motivation is to return to sport,” Watkins said.

The physician should advise the athlete on the risks of returning to sport now vs. in the future. It is also the physician’s responsibility to set up a program to allow the patient to accomplish what he or she wants.

“Whether it is the fifth game of the season or the twelfth game; that does not figure into the equation. I often say the season just does not fit the timetable for this type of injury. You cannot pay attention to that. This is how long it is going to take to get well with our rehab program, this diagnosis, and we will see where the season fits into all of this,” Watkins said. – by Robert Linnehan

• References:
• Maroon JC. imPACT Concussion Testing. www.josephmaroon.com/impact-concussion-testing. Accessed Oct. 7, 2015.
• Maroon JC, et al. J Neurosurg Spine. 2007;6:356-363.
• Mueller FO, et al. Catastrophic Sports Injury Research Thirty-First Annual Report. Fall 1982-Spring 2013. National Center for Catastrophic Sport Injury Research at The University of North Carolina at Chapel Hill. https://nccsir.unc.edu/files/2015/02/NCCSIR-31st-Annual-All-Sport-Report-1982_2013.pdf. Accessed Oct. 9, 2015.

• For more information:
• Andrew B. Dossett, MD, can be reached at W.B. Carrell Memorial Clinic, 9301 N. Central Expressway, #400, Dallas, TX 75231; email: docdrew@sbcglobal.net.
• Charles Y. Liu, MD, PhD, can be reached at Keck School of Medicine of USC, 1975 Zonal Ave., Los Angeles, CA 90033; email: meg.aldrich@med.usc.edu.
• Joseph C. Maroon, MD, can be reached at Neurological Surgery Department, University of Pittsburgh, UPMC Presbyterian, Suite B-400, 200 Lothrop St., Pittsburgh, PA 15213; email: maroonjc@upmc.edu.
• Oluseun A. Olufade, MD, can be reached at Emory Orthopaedics, Sports, & Spine, Emory University Sports Medicine, Emory Sports Concussion Program, 6335 Hospital Parkway, Suite 302, Johns Creek, GA 30097; email: oolufad@emory.edu.
• Robert G. Watkins III, MD, can be reached at Marina Spine Center, Marina Del Rey Hospital, 4640 Admiralty Way, Marina Del Rey, CA 90292; email: spinergw@earthlink.net.

Disclosures: Dossett reports he is a spine consultant for the Dallas Cowboys, Texas Rangers and Dallas Stars. Maroon reports he is co-founder of ImPACT, is a medical consultant to the Pittsburgh Steelers, is a medical consultant to World Wrestling Entertainment and is a senior advisor to the NFL. Liu, Olufade and Watkins report no relevant financial disclosures.

What spine-related injury or condition absolutely prevents a patient from ever returning to play?

 

 

Several contraindications exist

Return to play after spine injury remains a widely debated, controversial topic. Most of the literature focuses on cervical spine-related injuries/conditions due to the high-stakes associated with catastrophic cervical spine injury.

There are several absolute contraindications to return to play for cervical spine injuries, such as congenital anomalies involving the mass fusion of the occipitocervical vertebrae (multilevel Klippel-Feil anomaly), basilar invagination and atlantoaxial instability greater than 3.5 mm and greater than 4 mm in a child. Also, atlantoaxial rotatory fixation, subaxial instability greater than 3.5mm or 11° angulation and post-traumatic or degenrative kyphosis greater than 11°. Patients typically cannot return to play after three-level anterior cervical discectomy and fusion (ACDF) or posterior cervical fusion, C1-2 fusion, cervical laminectomy or any fusion involving occipitocervical vertebra (no clear guidelines exist for disc replacement).

Previous episodes of transient quadriparesis without “complete” resolution of all post-injury symptoms, acute fractures, canal compromise with bony fracture following previous trauma, and symptomatic disc herniations also do not allow for return to play. Also, ACDF in the presence of diffuse congenital stenosis.

For all spine conditions, persistent/ongoing symptoms of pain, numbness, tingling or weakness and MRI-documented spinal cord injury/edema (acute, sub-acute) do not typically allow for return to play.

Fixed kyphosis (multilevel congenital or iatrogenic fusion masses) creates abnormal kinematics at adjacent segments that become potential points of failure/injury in the event of significant forces generated during contact or high velocity sports. Spinal instability arising from trauma or degenerative conditions inherently induces inflammation of the neural elements, which can easily be exacerbated with a catastrophic event leading to irreversible damage. An MRI finding of edema indicates ongoing cord injury and additional exposure to trauma should be avoided to allow for recovery and prevent worsening.

Gbolabo Sokunbi, MD, is attending spine surgeon at St. Luke’s Orthopaedic Specialists in Easton, Pa.

Disclosure: Sokunbi reports no relevant financial disclosures.

 

Return often contraindicated after upper spine injury

Cervical spine injuries are common in athletes. When we reviewed the medical records of almost 3,000 consecutive athletes who attended the National Football League pre-draft combine, we found 4.8% of athletes had a history of a cervical spine injury. However, injuries to the cervical spine are not isolated to contact sports, such as American football and ice hockey, as these injuries have been reported in almost every sporting activity including common non-contact sports, such as baseball, basketball and gymnastics.

Fortunately, the majority of athletes who suffer these injuries are able to return to athletic activities, although there are a few absolute contraindications to returning to play.

Obviously, any patient with a permanent spinal cord injury (complete or incomplete) should not return to play, but the ability of neurologically intact players to return to play varies by the specific injury. Any athlete with an injury that necessitates either an occipital-cervical fusion, such as an occipital-cervical dislocation or a C1-2 fusion, such as a significantly displaced odontoid fracture, should not return to competitive athletic activity.

Fifty percent of the total cervical spine flexion occurs at the OC-C1 joint and 50% of the cervical spine rotation occurs at the C1-2 joint. It is widely accepted that, prior to returning to play, an athlete should have full, painless cervical spine range of motion. While this may be possible after a single-level fusion in the subaxial spine, it is not possible after an upper cervical spine fusion.

Gregory D. Schroeder, MD, is a spine research and clinical fellow at The Rothman Institute at Thomas Jefferson University in Philadelphia.
Disclosure: Schroeder reports he receives funds from AOSpine for travel. His institution received grants from Medtronic for his travel when he was a resident/fellow.

• References:
• Schroeder GD, et al. Am J Sports Med. 2015;doi:10.1177/0363546514562548.



 

Cervical stenosis too risky

The first condition that comes to mind is the collision athlete who presents with congenital cervical stenosis after a transient quadriparetic episode. In an all-too-familiar scenario, a football player can sustain a hit to the head/neck region that causes a paralytic effect that eventually subsides. While the details surrounding the injury are important (time for neurologic recovery, loss of consciousness and/or arm/leg symptoms), perhaps the most challenging decision comes afterwards when the appropriate advanced spinal imaging demonstrates a congenitally stenotic canal in the setting of early degenerative changes as a result of daily collisions/contact.



Wellington K. Hsu


While most spine practitioners would agree a patient who has cervical stenosis who sustains a quadriparetic episode is at a higher risk of developing a permanent neurologic injury should a similar hit be sustained, the absolute nature of that risk and definition of stenosis are debatable. While some authors have postulated only canal diameters smaller than 5 mm can predict a higher incidence of neurological symptoms, others have shown a higher threshold can subject one to a permanent neurologic deficit should another traumatic incident ensue. While there is yet no absolute criteria to follow based on the dearth of data in the evidence-based literature, recent efforts have increased our understanding of expectations after cervical spine injuries in this population.

A recent retrospective clinical study of National Football League players who have sustained a cervical disc herniation demonstrated that return-to-play after surgical treatment does not lead to an increased risk of neurologic injury. Consequently, for most players without stenosis, the ability to return to the field is not questioned. However, for others who have a narrow spinal canal with a similar injury, the catastrophic risk of an irreversible spinal cord injury following return to play, is too real to ignore.

Wellington K. Hsu, MD, is the Clifford C. Raisbeck Distinguished Professor of Orthopaedic Surgery and Director of Research at Northwestern University Feinberg School of Medicine in Chicago.
Disclosure: Hsu reports no relevant financial disclosures.

• References:
• Aebli N, et al. Spine J. 2013;doi:10.1016/j.spinee.2013.02.006.
• Hsu WK. Spine (Phila Pa 1976). 2011;doi:10.1097/BRS.0b013e3181e50651.
• Presciutti SM, et al. J Neurosurg Spine. 2009;doi:10.3171/2009.3.SPINE08642.