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Back Pain in Athletes: Evaluation and Treatment Scott C. McGovern, M.D. Spine Surgery Peninsula Orthopaedic Associates Peninsula Orthopaedic Associates Prevalence • EXTREMELY EXTREMELY COMMON COMMON • 8 out of 10 adults have back pain • 85% suffer recurrences Socio‐Economic Socio Economic Impact Impact • MOST MOST EXPENSIVE AILMENT FOR EXPENSIVE AILMENT FOR 30‐60 YEAR OLDS • #1 impairment leading to time lost from work from work • #1 cause of permanent disability • 50‐100 billion $ per year NATURAL HISTORY NATURAL HISTORY • Back pain ONLY Back pain ONLY – 85% OF CASES RESOLVE WITHIN 2 WEEKS – …but, one must look carefully for potential causes Differential Diagnosis Differential Diagnosis Fracture Tumor Osteomyelitis/diskitis Nephrolithiasis Pyelonephritis Muscular/ligamentous injury • Facet arthritis • • • • • • • Aortic Aortic aneurysm aneurysm • Pelvic inflammatory disease • Spondylolysis • Spondylolisthesis • Degenerative Disc Disease • What differs in the athlete? What differs in the athlete? • • • • Often chronic, repetitive injuries Of h i ii i j i MOST COMMON: SPONDYLOYSIS Gymnasts (20%) vs 5‐6% Spinal hyperextension and twisting Spinal hyperextension and twisting – Gymnastics, football, weightlifting Spine Anatomy Cervical = C1-C7 Dura Dorsal/Thoracic = T1-T12 Normal Disc Lumbar = L1-L5 Sacral = S1-S5 Spinous Process Body of Vertebra Functions of the Spine • Structure and stability • Motion • Protect neural elements Functions of the Spine • Flexibility of motion in six degrees of freedom Flexion and Extension Left and Right Side Bending Left and Right Rotation Functions of the Spine • Structural support and balance for upright balance for upright posture Intervertebral Discs Annulus Fibrosis Nucleus Pulposis Vascular Anatomy Vascular Anatomy Arteries • Radicular branches • Anterior spinal artery • Posterior spinal arteries Posterior spinal arteries Vascular Anatomy Vascular Anatomy Veins • Vena Cava • Azygous yg • Lumbar segmental • Left, right, & common iliac Left right & common iliac Vascular Anatomy Vascular Anatomy Veins Veins • External Vertebral Plexus • Internal Internal Vertebral Vertebral Plexus (of Batson) • Intervertebral Veins Ligaments • ALL • PLL • Ligamentum Flavum • Intraspinous • Supraspinous Ligaments PLL Ligamentum Flavum Muscles Gluteus Serratus Posterior Muscles Multifidus Rotator Brevis Spinal Cord and Nerve Roots Spinal Cord and Nerve Roots 2 roots Dorsal - sensory Ventral e t a - motor oto Lumbar Spine Terminology Lumbar Spine Terminology Laminectomy Laminotomy Lumbar Spine Terminology Lumbar Spine Terminology Myelopathy: Symptoms due to loss of spinal cord function due to compression due to compression Radiculopathy: Symptoms due to nerve root compression Lumbar Spine Terminology Lumbar Spine Terminology Osteophyte Pseudarthosis Lumbar Spine Radiographic Imaging IMAGING STUDIES Lumbar b – – – – – – – AP/Lateral AP/L t l oblique views Fl i / t i Flexion/extension views i CT / 3D Reconstructions MRI Myelogram Discography Discography Pelvis P l i Scoliosis Views Plain films –Alignment • kyphosis vs. lordosis –Soft tissue –Bony anatomy –Bony anatomy –Instability RADIOGRAPHS • College College athletes with spondylolysis, disc space athletes with spondylolysis disc space narrowing and instability • Greater incidence LBP (80.5 v 59.8 v 52.5) Greater incidence LBP (80 5 v 59 8 v 52 5) • Compared to normal radiographs (32.1) • Asymptomatic abnormailities in the general y p g population may become symptomatic with vigorous physical activity g p y y SPECT Plain Films Oblique View Oblique View S Spondylolisthesis Spondylolysis d l li h i S d l l i Look for the “Scotty Dog” 3D Reconstructions MRI • Protons spin through p g magnetic fields • T1 & T2 Images • Fat/fluid always white on T2 • Visualize neural tissue/soft tissue/disc • Very sensitive Myelogram www.roseradiology.com Discography g p y • Dye injected into disc • Patient monitored for pain response • Controversy: – Injection can cause pain i in normal disc of l di f asymptomatic patient Spine Cross‐Section p Spinous Process Superior Articular Facet Transverse Process Lamina Pedicle Spinal Cord in Spinal Canal Spinal Canal (Intravertebral Foramen) Body Vertebral Arches • Anterior Arch – Vertebral body – Anterior 1/3 pedicles • Posterior Arch • • Posterior 2/3 pedicles and posterior elements Arches form the vertebral foramen Vertebral Structures Body Pedicle Transverse Process Vertebral Foramen Lamina Spinous P Process Superior Articular Process Vertebral Structures • Articular Articular processes processes Pars • Pars interartic laris interarticularis Zygapophyseal Joint (Facet Joint) Superior p Articular Process Inferior Articular Process Lumbar Disk Anatomy Lumbar Disk Anatomy • • • • • Annulus N l Nucleus pulposus l Endplate Vascularity:Stops at endplates Neuroanatomyy annulus Outer third of Vertebral Structures • Intervertebral disc • End plate • • • Cartilaginous C til i Bony Apophyseal ring Vertebral Structures • Pedicle notches Pedicle notches • • Slight Notch Intervertebral f foramen Deep Nerve roots exit Notch Intervertebral Foramen Intervertebral Disc • Fibrocartilaginous joint of the motion segment f th ti t • Makes up ¼ the length of the spinal column the spinal column • Present at levels C2‐C3 to L5‐S1 to L5 S1 • Allows compressive, , tensile, and rotational motion • Largest avascular structures in the body Intervertebral Disc • Annulus fibrosus Annulus Fibrosus – Outer portion of the disc • • • Made up of lamellae Layers of collagen fibers • Arranged obliquely 30 30° • Reversed contiguous layers Great tensile strength Lamellae Intervertebral Disc • Nucleus pulposus Nucleus pulposus • • • • Inner structure Gelatinous High water content Resists axial forces Nucleus Pulposus Intervertebral Disc • Largest Largest avascular avascular structure • Blood supply by Bl d l b diffusion through end plates l t • Damage to the blood supply leads to degradation of the disc Spinal Nerve Structures Spinal Nerve Structures • Spinal Cord Spinal Cord – Contained in epidural space p – Network of sensory and motor nerves – Firm, cord‐like structure – Extends from foramen magnum to L1 magnum to L1 – Terminates at conus medularis – Cauda equina below L1 – Filum terminale Most back disorders are the result of: th lt f • • • • • • Poor muscle tone caused by lack of exercise y Poor posture Faulty body mechanics Faulty body mechanics Stressful living and working habits Loss of strength and flexibility Excessive weight g The most common disorders are: The most common disorders are: • • • • • • Acute strains and sprains p Muscle guarding and spasm Disc strain or bulge Disc strain or bulge Disc herniation Disc degeneration or osteoarthritis Joint stiffness Spinal Abnormalities Arthritis Pinched Nerve Ruptured Disc Patient Assessment Patient Assessment • • • • History Evaluation Imaging i Treatment –Non‐operative –Operative Operative History • Pain history – Exacerbates E b – Alleviates • • • • Numbness & tingling Weakness Bowel/bladder incontinence Medication history Medication history RED FLAGS RED FLAGS – Constitutional Sx – Weight loss Weight loss – Night pain – Neurologic changes N l i h Physical Examination Physical Examination • • • • Positive straight leg raise Positive straight leg raise Weakness of foot/ankle muscles Decreased sensation calf/foot d i lf/f Diminished reflexes Imaging g g • • • • Plain x‐rays MRI Myelogram Discography All give information about the appearance of the spine but not necessarily the pathology Why Your Back Hurts y Back Problem Hurts to Move Weakness Stop p Moving Stiffness Acute Strains and Sprains Acute Strains and Sprains • Cause – Improper lifting, twisting, falls or other injuries • Pathology P th l – Tearing, bleeding and/or irritation of muscles or ligaments • Treatment – If minor injury, a few days of rest – If severe injury, extended time required for healing; If i j d d i i d f h li muscles will often become weaker, joints stiffen and poor posture develops. Corrected with reconditioning good posture Physical therapy may be necessary posture. Physical therapy may be necessary. Muscle Guarding and Spasm Muscle Guarding and Spasm • Cause – Pain of any kind produces muscle guarding – Prolonged muscle guarding produces muscle spasm – While painful, spasms not necessarily a sign of serious problems • Pathology – Tender, painful muscle, slowed circulation, inflammation • Treatment – Muscle guarding should be examined and corrected g g – Ice packs, warm moist packs or baths, heating pads, muscle relaxant medications or plain relaxation relieve problems Disc Strain or Bulge Disc Strain or Bulge • Cause – – – – • Sitting or standing in a forward slumped position d f d l d Forward bending and lifting Not the result of one injury, takes months or years to develop Loss of flexibility and poor physical fitness are related y p p y Pathology – Center of disc squeezed through cartilage rings causing disc bulge – Pressure on disc wall nerves send back and leg pain messages to the brain • Treatment – – – – Many “treatments” Many treatments , most of which are of no value, may harm disc most of which are of no value may harm disc Proper treatment includes correcting faulty habits and posture Backward bending flexibility must be regained Proper balanced posture maintained until disc heals Disc Herniation ( (Advanced Stage of Disc Strain or Bulge) f ) • Cause – Slumped sitting, forward bending and lifting • Pathology P th l – Numbness, weakness, reflex changes in leg (for low back problems) or arm (for neck problems), as well as pain • Treatment – Requires Requires medical attention and physical therapy medical attention and physical therapy treatments – Severe cases may require surgery – If small bulge is recognized and managed, condition may If ll b l i i d d d diti never reach this stage Disc Herniation or Osteoarthritis • Cause – Aging wears away discs along with back posture, muscle weakness or old injury – Disc dries out causing nerve pressure Disc dries out causing nerve pressure • Pathology – Painful and tender back, stiffness and muscle guarding • Treatment – Warm moist packs, flexibility exercises to back and leg, anti‐inflammatory medications, steroid injections, physical therapy and muscle strengthening therapy and muscle strengthening Disk Aging Disk Aging Newborn b Child/Adolescent hild/ d l Di ti t cartilage Distinct til end-plates d l t Dense annulus fibrosis Small vessels in outer lamellae Numerous free nerve endings Nucleus pulposus = ½ the disk Clear matrix with clusters of notochordal cells Adult d l Elderly ld l Disk Aging Disk Aging Newborn b Child/Adolescent hild/ d l Adult d l Disk volume and diameter increase Annulus and end-plate vessels shrink, less numerous Relative volume of nucleus maintained Notochordal cells ↓,Chondrocytes ↑ gy size and Decrease in pproteoglycan aggregation Elderly ld l Disk Aging Disk Aging Newborn b Child/Adolescent hild/ d l Adult d l Elderly ld l Peripheral vessels disappear Nucleus becomes fibrotic, firm and white Myxomatous degeneration in annulus Sharp decline in cellularity Proteoglycan and H2O ↓ Protein concentration ↑ Disk Aging Disk Aging Newborn b Child/Adolescent hild/ d l Adult d l Elderly ld l Entire disc is stiff fibrocartilage Almost no cells Small diameter densely Small-diameter densely-packed packed collagen fibrils Lost height, g , fissures,, and clefts Pathologic Disc Degeneration Pathologic Disc Degeneration • Changes beyond normal aging cascade • Total loss of disc height • Vertebral osteophytes Vertebral osteophytes • Small vessel proliferation • Nerve ingrowth to inner layers of h l f annulus • Begins in second decade R di Radiographic Characteristics hi Ch t i ti • Disc Disc space preserved or space preserved or narrowed on plain radiography • MRI typically shows “black di ” disc” on T2‐weighted T2 i ht d images (at one or more l l) levels) • Can MRI pinpoint “the pain generator” ? MRI and the Pain Generator MRI and the Pain Generator • Abnormal Abnormal Magnetic Resonance Scans of the Magnetic Resonance Scans of the Lumbar Spine in Asymptomatic Subjects Abnormal scans in 50% of those over 60 Boden SD, et al. JBJS 1990 • Low Back Pain in Relation to Lumbar Degenerative Disk Degeneration • Cross sectional MRI study • 104 laborers, 60 office workers pain is associated with signs of DDD strongly associated with occupation strongly associated with occupation Luoma K, et al. Spine. Feb 2000. Low back Most MRI and the Pain Generator MRI and the Pain Generator Natural History of Individuals with Natural History of Individuals with Asymptomatic Disc Abnormalities in MRI •46 patients followed prospectively for 5 years 46 patients followed prospectively for 5 years •Job characteristics and psychological aspects of work were more predictive than initial MRI findings work were more predictive than initial MRI findings Boos N, et al. Spine Spine,, Jun 2000 Disk Degeneration and Pain 3 Possible Mechanisms: • Loss of disk structure and biomechanical Loss of disk structure and biomechanical properties • Release of mediators that sensitize nerve Release of mediators that sensitize nerve endings • Nerve and vessel in‐growth into degenerated N d li hi d d disc Disk Degeneration and Pain Structural / biomechanical Disruption Proposed that high forces applied to the disc play a role in causing di degeneration disc d i Single high-stress event more likely culprit that multiple smaller stresses t Changes in vertebral body architecture develop secondary to DDD; Independent of age-related osteoporosis Contributing factor in the development of compression fracture mpson EK, et al. J Bone Miner Res Apr 2001 utton WC, et al. Spine, Dec 2000 Di k D Disk Degeneration and Pain ti dP i Structural / biomechanical Disruption Mechanical Initiation of Intervertebral Disc Degeneration •Cadaveric d i study d off 38 lumbar l b specimens i •Complex mechanical loading protocol ; light labor Vertebral V t b l endplate d l t damage d reduced d d pressure in i the th nucleus l by b 2525 75% •Marked increase in annulus stress concentration •Minor damage to the vertebral endplate leads to progressive structural change in the adjacent disc Adams MA, et al. Spine Jul 2000. Disk Degeneration and Pain R l Release of Chemical Mediators f Ch i l M di t Multiple investigations of chemical mediators in DDD & Back pain Substance P, Calcitonin gene-related peptide (CGRP), vasoactive intestinal peptide (VIP), (VIP) matrix metalloproteinase, aggrecanase, NO Others Oth Disk Degeneration and Pain R l Release of Chemical Mediators f Ch i l M di t Nitric Oxide mediates the change of proteoglycan synthesis in the human lumbar intervertebral disc in response to hydrostatic pressure •NO is inhibitory with regards to disc proteoglycan synthesis, and is endogenously generated by disc cells •Hydrostatic pressure influenced NO production •Chemical basis for mechanical theories of degeneration ? Liu GZ, et al. Spine ,Jan 2001 Genetic Factors Genetic Factors Genetic Influences on cervical and lumbar disc degeneration: an MRI study in twins disc degeneration: an MRI study in twins MRI features of DDD in 172 monozygotic / 154 yg dizygotic twins Overall score for disc degeneration – disc height, bulge, osteophytes, signal intensity Heritability was 74% overall gg p g p Results suggest an important genetic component to intervertebral disc degeneration Paassilta P, et al. JAMA, April 2001 PLAIN X PLAIN X‐RAY RAY IN DISC IN DISC DEGENERATION • • • • • • NORMAL DISC SPACE NARROWING SPONDYLOPHYTES SCHMORL’SS NODES SCHMORL NODES SPONDYLOLYSIS SPONDYLOLITHESIS SUSPICIOUS FINDINGS ON PLAIN X RAY X‐RAY • PEDICLE EROSION • ENDPLATE EROSION ENDPLATE EROSION • COMPRESSION FRACTURE MRI • CONCERN FOR TUMOR OR INFECTION • NEURAL COMPRESSION FINDINGS IN ASYMPTOMATIC SUBJECTS 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% DEG DISK BULDGE HNP STEN Age 20-39 Age 40-59 Age 60-80 BASIC MR SEQUENCES • T1‐ WEIGHTED • TRUE T2 TRUE T2‐ WEIGHTED • PROTON DENSITY CASCADE OF DEGENERATION CASCADE OF DEGENERATION • DEHYDRATION • ANNULAR TEARS ANNULAR TEARS • MARROW CHANGES HIGH INTENSITY ZONE ANNULAR TEARS (HIZ) CORRELATION WITH PAINFUL CONCORDANT DISCOGRAPHY AND RADICULAR PAIN MARROW CHANGES • TYPE I TYPE II • TYPE II WHEN TO USE CONTRAST? GADOLINIUM • POSTOPERATIVE POSTOPERATIVE PATIENTS • TUMOR • INFECTION • What it does? What it does? – Differentiates more vascularized from less vascularized tissue FINDINGS IN SYMPTOMATIC PATIENTS NOW ASK IS THE ABNORMALITY RESPONSIBLE FOR THE PATIENT’S PAIN? NONOPERATIVE OPTIONS • • • • • MEDICATION PHYSICAL THERAPY PHYSICAL THERAPY MANIPULATION INJECTIONS BRACES MEDICATION ‐ OPTIONS • NSAIDS / ACETOMINOPHEN / ASPIRIN • NARCOTICS • MUSCLE RELAXANTS EFFICACY • NSAIDS ‐ ODDS RATIO 1 WEEK 0.53 • PROBABLY BETTER THAN THAN ALTERNATIVES • GI SIDE EFFECTS GI SIDE EFFECTS 1/1000 • NARCOTICS MORE POTENT … • … BUT NO MORE EFFECTIVE NARCOTIC ANALGESICS SHOULD NARCOTIC ANALGESICS SHOULD BE AVOIDED IN THE NONOPERATIVE TREATMENT OF LOW BACK PAIN LOW BACK PAIN NEWER NON‐NARCOTIC NON‐ NSAIDS MAY ULTIMATELY BE NSAIDS MAY ULTIMATELY BE USEFUL ULTRAM DURAC ULTRAM, DURAC MUSCLE RELAXANTS • • • • BETTER THAN PLACEBO MECHANISM UNCLEAR SIDE EFFECTS 20 ‐ 40 % FIRST LINE USE NOT JUSTIFIED FIRST‐LINE USE NOT JUSTIFIED PHYSICAL THERAPY FOR PAINFUL PHYSICAL THERAPY FOR PAINFUL DISK DEGENERATION • STRENGTHENING ‐ EXTENSION • AEROBIC CONDITIONING • MODALITIES ONLY FOR ACUTE FLARES MODALITIES ONLY FOR ACUTE FLARES RATIONALE FOR EXTENSION BRACING • CAN HELP WITH PAIN COMPLAINTS • NO OVERWHELMING EVIDENCE IN FAVOR NO OVERWHELMING EVIDENCE IN FAVOR • NOT A SUBSTITUTE FOR MUSCLE STRENGTHENING • COMPLIANCE LOW (POPE et al) INJECTION INJECTION THERAPY EPIDURAL STEROIDS • ACT TO DECREASE INFLAMMATION • FLOUROGRAPHY MAY ADD PRECISION FLOUROGRAPHY MAY ADD PRECISION • NO PROVEN SUSTAINED EFFICACY WITH CHRONIC SYMPTOMS CHRONIC SYMPTOMS ARE MORE APPROPRIATELY CONSIDERED FOR RADICULAR CONSIDERED FOR RADICULAR COMPLAINTS FROM HERNIATION OR STENOSIS IN THAT SETTING STUDIES DEMONSTRATE 40 ‐ 60 % EFFICACY • Yates, Heyse‐Moore, Dielke et al, Cuckler et al. • May be tried for PARS injection May be tried for PARS injection • RF unproven NONOPERATIVE TREATMENTS EXTENSION STRENGTHENING AEROBIC CONDITIONING BRACING INJECTIONS MANIPULATION Treatment • Non‐operative – Bed rest 2 to 3 days – Anti‐inflammatory drugs – Analgesics for acute Analgesics for acute exacerbations – Antidepressants – Lumbosacral orthosis h – Diet – Exercise Surgery for Low Back Pain: Indications and Techniques Indications for Surgery Indications for Surgery • Instability • Spondylolisthesis (isthmic/degen) • Fractures • Instability SPONDYLO ‐ISTHMIC SPONDYLO ISTHMIC Adult Isthmic Spondylolisthesis Adult Isthmic Spondylolisthesis • Grade I/Low II ( Grade I/Low II (<37%) 37%) – Gill – L5 root decompression L5 root decompression – Instrumented PLF TLIF / DISTRACTION / TRANSLATIONAL REDUCTION REVISION Spondylolisthesis / Spondylolysis Spondylolisthesis / Spondylolysis • May cause mechanical back mechanical back pain • Identify pain source – Pars – Disc – Nerve Root Column Support and Fusion Rates Column Support and Fusion Rates • Posterolateral spinal fusion with pedicle fusion with pedicle screws and interbody fusion • 91% fusion rate Minimally Invasive Techniques Minimally Invasive Techniques Ruptured Disc Tubular Access Nerve Root Compression Roostral Surgical Technique Surgical Technique 1.5 cm incision SPONDYLOLYSIS • Excellent Excellent potential for healing in athlete who potential for healing in athlete who has a spondylolysis noted only on bone scan imaging. imaging TREATMENT • Analgesics Analgesics as needed as needed • activity modification (e.g. avoiding extension and repetitive loading of the spine) and repetitive loading of the spine) • core and glutei strengthening • lumbar and lower extremity stretching for a period of up to 8‐12 weeks RETURN TO PLAY RETURN TO PLAY • • • • Sypmtoms and PE Sypmtoms and PE no pain with ADLs Full and pain‐free range of motion ll d i f f i Completed physical therapy – then a gradual return to sports activities is e a g adua e u o spo s ac es s allowed. SURGERY??? • INTRACTABLE PAIN INTRACTABLE PAIN • PROGRESSIVE SLIP • RADICULOPATHY C O Summary • Back pain is common in athletes – Radiographs may be helpful – SPECT CT best for stress injuries • Stress injuries – spondylolysis – respond well to PT • Disc Herniations – Surgery enables early return to play – Safe following course of non‐op treatment
