Lumbar Spine Surgery in Athletes:

Is it possible to return to skiing following long-construct spinal deformity surgery?

BACKGROUND

Alpine skiing requires flexibility, endurance, strength and rotational ability, which may be lost after long fusions to the pelvis for adult spinal deformity (ASD). ASD patients may worry about their ability to return to skiing (RTS) postoperatively. There is currently insufficient data for spine surgeons to adequately address questions about when, or if, their patients might RTS.

METHODS

Patients with a history of spinal fusion to pelvis from T10 or higher were screened for skiing participation during the November 2023-April 2024 season. Adolescent and adult patients ≥12 years old with >2-year minimum follow-up who were recreational skiers (skied ≥5 times in their life and ≥1 time in the 5 years prior to their surgery) provided the following metrics: visual analogue scale (VAS) pain level, self-perceived ski ability, highest slope difficulty comfort level, ski runs completed per day, days skied per year, pain while skiing, participation in pre- or postoperative physical therapy (PT), and satisfaction. Predictive factors for ability to RTS were evaluated. Scoliosis Research Society-22 (SRS-22) and Oswestry Disability Index (ODI) scores were collected at baseline, one year postoperatively, and final follow-up (FFU). Twenty six skiers from 2015-2023 were included (age 56.5 ± 15.2 years, BMI 23.8 ± 4.2 kg/m2, female composition 85.6%, follow-up 5.3 ± 1.8 years). 42.3% (n = 11) patients returned to ski at an average of 2.6 ± 1.6 years. Patients who returned to ski maintained or improved their performance in the following metrics: 72.7% (n = 8) in self-assessed ski ability, 72.7% (n = 8) in slope difficulty comfort level, 63.6% (n = 7) in number of ski runs per day, 81.8% (n = 9) in number of days skied per year, and 81.8% (n = 9) in pain while skiing. Pain scores improved from baseline to FFU: VAS (7.1 ± 1.9 vs 1.8 ± 1.9; p < 0.01), SRS (71.8 ± 8.6 vs 89.9 ± 14.5; p < 0.01), ODI (30.8 ± 13.1 vs 13.4 ± 14.1; p < 0.01). Age, sex, BMI, surgical history, self-assessed ski ability, baseline pain scores and PT participation were not predictive of ability to RTS.

CONCLUSION

This was the first in-depth analysis of RTS after corrective spine surgery. Almost half of the skiers returned to skiing after long-construct fusion to pelvis, and the majority reported similar or improved performance based on their slope ratings, runs skied per day, days skied per year, pain while skiing, and overall self-assessment. Mean pain and quality of life scores improved significantly for the whole group. ASD patients who RTS can reasonably expect equal or improved performance following spine surgery compared to their presurgical ability.

Return to sporting activities following long fusions to the pelvis in adult spinal deformity

BACKGROUND CONTEXT

Returning to recreational sporting activities after adult spinal deformity (ASD) correction may significantly impact the patient's perceived quality of life.

PURPOSE

This study sought to characterize participation in sporting activities before and after ASD surgery, and to identify factors associated with impaired return to sports.

STUDY DESIGN

Cross-sectional survey and retrospective review of prospectively collected data.

PATIENT SAMPLE

Patients who underwent posterior-only thoracolumbar ASD surgery between 2016 and 2021 with ≥1 year follow-up and ≥3 levels of fusion to the pelvis were included.

OUTCOME MEASURES

Preoperative and postoperative participation in sports, timing of return to these activities, and reasons for limited sports participation postoperatively were assessed.

METHODS

A survey was used to evaluate outcome measures. Differences in demographic, surgical, and perioperative variables between patients who reported improved, unchanged, or worsened activity tolerance were evaluated.

RESULTS

Ninety-five patients were included (mean age: 64.3±10.1 years; BMI: 27.3±6.1 kg/m2; median levels fused: 7). The survey was completed at an average of 43.5±15.9 months after surgery. Sixty-eight (72%) patients participated in sports preoperatively. The most common sports were swimming (n=33, 34.7%), yoga (n=23, 24.2%), weightlifting (n=20, 21.1%), elliptical (n=19, 20.0%), and golf (n=11, 11.6%). Fifty-seven (83.8%) returned to at least one sport postoperatively, most commonly 6-12 months after surgery (45%). Elliptical had the highest rate of equal or improved participation (53%). Patients generally returned below their preoperative level to all other sports. Reasons for reduced sporting activities included physical limitation (51.4%), fear (20.0%), pain (17.1%), and surgeon advice (8.6%). There were no differences in the demographic, surgical, or perioperative characteristics between those who returned to sports at the same or better level compared with those who returned at a lower level.

CONCLUSIONS

About 84% of patients successfully resumed sporting activities after undergoing fusion to the sacrum/pelvis for ASD. However, this return is typically at a lower level of participation than their preoperative participation, particularly in higher demand sports. Understanding trends in sporting activity may be valuable for counseling patients and setting expectations.

The Impact of Spine Injuries on Amateur Athletes: An Exploratory Analysis of Sport-Related Patient-Reported Outcomes

INTRODUCTION

There is a lack of information on return to sport and patient-reported outcome measures (PROMs) in amateur athletes after isolated spine injuries.

METHODS

A single-center cohort study in amateur athletes aged 18 to 60 with isolated spine injuries; clinical data collection and follow-up via telephone interview and standardized PROMs (Short-Form 36, Oswestry and Neck Disability Index, Tampa Scale of Kinesiophobia, Hospital Anxiety and Depression Scale, Pain Visual Analog Scale). Bivariate analyses of potential influencing factors on PROMs were conducted using the Wilcoxon Signed-Rank Test. p-values < 0.05 were considered statistically significant.

RESULTS

Out of the 80 included participants, 78% (n = 62) were active in sport at follow-up. PROMs were slightly worse than those described for the age-adjusted general population. There were consistent associations of better PROMs with having reached the subjective preinjury level of performance in sport, while injury severity and surgical or conservative therapy did not show consistent associations with PROMs.

CONCLUSION

Most amateur athletes resume their sports activity after a spine injury. Better outcomes are associated with individuals' resumption of sport and subjective level of performance, while injury severity and surgical or conservative therapy do not show consistent associations with PROMs, highlighting the importance of patient education, rehabilitation, and encouragement.

Is Golf a Contact Sport? Protection of the Spine and Return to Play After Lumbar Surgery

STUDY DESIGN

Narrative review.

OBJECTIVE

To address the gap in the literature on specific return to play protocols and rehabilitation regimens for golfers undergoing lumbar spine surgery with a high impact swing.

METHODS

This review did not involve patient care or any clinical prospective or retrospective review of patient information and thus did not warrant institutional review board approval. The available literature of PubMed, Medline, and OVID was utilized to review the existing literature.

RESULTS

Studies have shown that the forces through the lumbar spine in the modern-era golf swing are like other contact sports. Methods of protecting the lumbar spine include proper swing mechanics, abdominal and paraspinal musculature strengthening and flexibility as well as physical fitness. There are a variety of treatment options available to treat lumbar spine pathology each with a different return to play recommendations from doctors in the field.

CONCLUSIONS

With the introduction of a high impact, modern-era swing to the game of golf, the pathology is seen in the lumbar spine of both young, old, professional, and amateur golfers with low back pain are similar to other athletes in contact sports. Surgery is effective in returning athletes to a similar level of play even though no protocols exist for an effective and safe return. There have been many studies conducted to determine appropriate treatment and return to play for these injuries, but there is a gap in the literature on specific return to play protocols and rehabilitation regimens for golfers undergoing lumbar spine surgery with a high impact swing. As return to competitive play is important, especially with professional golfers, studies combining the use of swing mechanics changes, rehabilitation regimens and the type of surgery performed would be able to provide some insight into this topic now that golf may begin to be considered a contact sport.

[Results of minimally invasive lumbar fusion in professional athletes: a single-center retrospective study]

Professional athletes have a high basic level of physical fitness and significant motivation for returning to previous rhythm of functional activity within the shortest period after trauma without deterioration of baseline level of sportsmanship. Despite the well-presented results of lumbar spine fusion in general population, these data among professional athletes are not well understood.

OBJECTIVE

To analyze the results of minimally invasive lumbar fusion in professional athletes.

MATERIAL AND METHODS

A retrospective study included 27 athletes (19 men and 8 women) aged 29 (26; 34) years after minimally invasive lumbar spine decompression and fusion via anterior, lateral and posterior approaches. Total lumbar lordosis, degenerative changes in adjacent segment, area of multifidus muscle, perioperative complications and timing of sports rehabilitation were analyzed within 3-5 (mean 4) years after surgery.

RESULTS

We found an increase of total lumbar lordosis from 35.2° to 44.1° (p=0.02), no significant muscle atrophy (<30%) and degeneration of adjacent segment (p>0.05). There were 5 perioperative complications (18.5%). Mean period of sports rehabilitation was 14 (9; 17) weeks. One (3.7%) patient did not return to his previous sports career.

CONCLUSION

Minimally invasive short-segment lumbar interbody fusion in professional athletes is characterized by low risk of fixation element failure, no significant degeneration of adjacent level and postoperative muscle atrophy. This procedure ensures early rehabilitation and returning to sports.

Clinical-Instrumental Results and Analysis of Functional Activity Restoration in Professional Athletes After Lumbar Total Disk Replacement

OBJECTIVE

To analyze the clinical and biomechanical outcome of professional athletes after lumbar total disk replacement, with a focus on restoration of the functional activity.

METHODS

This nonrandomized retrospective single-center study included 11 professional athletes who underwent lumbar disc replacement surgery using the prosthesis M6-L (Spinal Kinetics, Schaffhausen, Switzerland). The average postoperative follow-up was 3.18 ± 1.14 years. The following outcomes were evaluated: intensity of pain in the lumbar spine and lower limbs, Oswestry Disability Index, Short-Form 36, complications, time of return to previous sports activity, range of movement, degree of lumbar lordosis, degenerative changes of the adjacent levels, and degree of heterotopic ossification.

RESULTS

The operated patients reported significant decrease of pain on visual analog scale (P < 0.001) as well as significant improvement of Oswestry Disability Index (P = 0.001) and Short-Form 36 (P < 0.001). For the duration of follow-up, the patients maintained segmental range of motion at L4-L5 (P = 0.04) and L5-S1 (P = 0.03) levels. There was also some statistically insignificant increase of global lumbar lordosis (P = 0.84). We did not identify any significant degeneration of the adjacent intervertebral disks (P > 0.05) or progression of the facet joint degenerative changes at the implantation level and in the adjacent segments (P > 0.05). One patient (9.1%) developed grade I heterotopic ossification 5 years after surgery and in 1 patient (9.1%), a lesion of superior hypogastric plexus was recorded. The average time of return to previous sports activity was 9.72 ± 3.03 weeks.

CONCLUSIONS

Total lumbar disc replacement using M6-L prosthesis in professional athletes made it possible to achieve statistically significant reduction of pain and facilitated early return to normal sports activities. In our opinion, preservation of movement of the operated lumbar segment can help to reduce the mechanical stress with beneficial impact on the rate of degeneration of the adjacent level.

Rehabilitation in adult spinal deformity

Adult spinal deformity causes significant health-related problems such as pain and disability in adults. Currently, there are several non-operative management strategies such as pain medications, physical modalities, exercises, bracing or interventional procedures. Specific exercises including strengthening of back and abdominal muscles, neuromuscular re-education for daily tasks, and active self-correction are vital to improve postural control and spinal stability. Bracing for a few hours a day can help reduce pain and provide spinal stability in adults. In case of severe disability and pain unresponsive to non-operative treatments, spinal fusion with instrumentation is an alternative. Postoperative rehabilitation can help to reduce pain and disability and improve return to activity or work. Protecting the spine early after surgery and timing of initiation of exercises with respect to osseointegration and bone remodeling phases are important principles of postoperative rehabilitation. In this review, rehabilitation in adult spinal deformity is discussed in the light of the literature.

Diagnostic accuracy of MRI for identifying posterior element bone stress injury in athletes with low back pain: a systematic review and narrative synthesis

Objective

To investigate the diagnostic accuracy of MRI for identifying posterior element bone stress injury (PEBSI) in the athletic population with low back pain (LBP).

Study Design

A systematic review searched for published sources up until July 2020. Eligibility criteria: prospective cohort design, MRI diagnosis, adolescents/young adults, chief symptoms of LBP, PEBSI as the clinical diagnosis and SPECT-CT as reference standard. Risk of bias and overall quality were assessed using QUADAS-2 and GRADE, respectively. A narrative synthesis was conducted.

Results

Four studies were included, with three included in the quantitative synthesis. Compared with SPECT-CT, two studies involving MRI demonstrated sensitivity and specificity of 80% and 100%, and 88% and 97%, respectively. Compared with CT, one study involving MRI demonstrated sensitivity and specificity of 97% and 91%, respectively. Risk of bias was moderate to high although consistency across studies was noted.

Conclusion

Findings support further research to consider MRI as the modality of choice for diagnosing PEBSI. MRI was consistent with SPECT-CT for ruling-in PEBSI, but the clinical value of cases where MRI had false negatives remains uncertain due to possible over-sensitivity by SPECT-CT.

PROSPERO registration number

CRD42015023979.

Endoscopic Spine Surgery in Athletes: Case Series and Review of Literature

BACKGROUND

Degenerative spine disease is common in athletes and can progress to requiring surgical intervention. Traditional open surgical techniques necessitate prolonged recovery time and time away from play. Newly developed endoscopic surgical techniques may promote faster healing and recovery, and increased return to play. The goal of this paper is to summarize the current evidence in return to play after spine surgery and to present our series of 3 athletes who underwent endoscopic spine surgery.

METHODS

A complete search of all PubMed indexed articles pertaining to spine surgery in athletes was conducted. This was supplemented by a 3-patient case series of our own endoscopic spine experience in athletes.

RESULTS

There are no current widely accepted guidelines for return to play after spinal surgery. The best evidence available cites a return to play of 81% at 5.2-8.7 months after traditional open and minimally invasive surgery, and endoscopic surgery produces an average 88% return to play rate at 3 months.

CONCLUSIONS

Although return to play can vary widely, case-based evidence as well as biomechanical principles support endoscopic spine surgery as a viable surgical modality for the treatment of spinal pathologies in athletes.

Impact of CrossFit-Related Spinal Injuries

INTRODUCTION

Exercise-related injuries (ERIs) are a common cause of nonfatal emergency department and hospital visits. CrossFit is a high-intensity workout regimen whose popularity has grown rapidly. However, ERIs due to CrossFit remained under investigated.

METHODS

All patients who presented to the main hospital at a major academic center complaining of an injury sustained performing CrossFit between June 2010 and June 2016 were identified. Injuries were classified by anatomical location (eg, knee, spine). For patients with spinal injuries, data were collected including age, sex, body mass index (BMI), CrossFit experience level, symptom duration, type of symptoms, type of clinic presentation, cause of injury, objective neurological examination findings, imaging type, number of clinic visits, and treatments prescribed.

RESULTS

Four hundred ninety-eight patients with 523 CrossFit-related injuries were identified. Spine injuries were the most common injuries identified, accounting for 20.9%. Among spine injuries, the most common location of injury was the lumbar spine (83.1%). Average symptom duration was 6.4 months ± 15.1, and radicular complaints were the most common symptom (53%). A total of 30 (32%) patients had positive findings on neurologic examination. Six patients (6.7%) required surgical intervention for treatment after failing an average of 9.66 months of conservative treatment. There was no difference in age, sex, BMI, or duration of symptoms of patients requiring surgery with those who did not.

CONCLUSIONS

CrossFit is a popular, high-intensity style workout with the potential to injure its participants. Spine injuries were the most common type of injury observed and frequently required surgical intervention.

Lumbar Spine Injuries in Sports: Review of the Literature and Current Treatment Recommendations

Low back pain is one of the most prevalent complaints of athletes at all levels of competition. The purpose of this literature review is to provide an overview of sport-specific injuries and treatment outcomes that can be used by healthcare providers to better recognize injury patterns and treatment options for different groups of athletes. To our knowledge, no prior comprehensive review of lumbar spine injuries in sports is currently available in the literature, and it is essential that healthcare providers understand the sport-specific injury patterns and treatment guidelines for athletes presenting with low back pain following an athletic injury. Injury mechanisms were found to vary significantly by sport, although some broad recommendations can be made with regards to optimal treatment for these injuries and return to play. Additionally, it was found that certain treatments were more beneficial and resulted in higher rates of return to play depending on the specific sport of the injured athlete. Healthcare providers need to be aware of the different injury patterns seen in specific sports in order to properly evaluate and treat these injuries. Furthermore, an individualized treatment plan needs to be selected in a sport-specific context in order to meet the needs of the athlete in the short and long term.

Posterior Dynamic Stabilization With Direct Pars Repair via Wiltse Approach for the Treatment of Lumbar Spondylolysis: The Application of a Novel Surgery

STUDY DESIGN

A retrospective study to evaluate the clinical outcomes of a novel surgical method for treating patients with lumbar spondylolysis.

OBJECTIVE

The aim of this study was to investigate the effectiveness of posterior ISOBAR TTL stabilization of the lumbar spine with direct pars repair using Wiltse approach for the treatment of lumbar spondylolysis with or without slight spondylolisthesis and discuss the indications of this surgery.

SUMMARY OF BACKGROUND DATA

Surgical treatment of lumbar spondylolysis has yielded relatively good results. However, there are still many limitations of the current surgical methods, including, adjacent level degeneration, restricted indications, and soft tissue damage.

METHODS

Between August 2010 and January 2013, 13 (9 males and 4 females; mean age: 28.2 yrs), patients with lumbar spondylolysis with or without slight spondylolisthesis underwent posterior ISOBAR TTL stabilization of the lumbar spine, with direct pars repair via Wiltse approach. All patients were followed up for at least 24 months at outpatient visits or telephonically. Pre-operative and postoperative radiological assessments included anteroposterior, lateral and flexion extension radiographs, 3-dimensional reconstruction computed tomography (CT), and magnetic resonance imaging (MRI). Data pertaining to intraoperative blood loss, duration of operation, visual analog score (VAS), Oswestry disability index (ODI) scores, and other assessments were collected.

RESULTS

The median follow-up duration was 36 months (range, 24-53 months). Surgery was successful in all patients with no complications; bony fusion of pars was confirmed on CT scan at postoperative 2 years. Significant pain relief was achieved in all patients including those with discogenic pain, those >30 years of age, and those with severe disc degeneration (P < 0.01).

CONCLUSION

We evaluated a new surgical technique for the treatment of patients with spondylolysis with or without slight spondylolisthesis. Besides the good clinical results, the indications for this new surgery are much wider and can potentially overcome the limitations of earlier techniques.

LEVEL OF EVIDENCE

4.

Return-to-Play Recommendations After Cervical, Thoracic, and Lumbar Spine Injuries: A Comprehensive Review

CONTEXT

Currently, there is a national focus on establishing and disseminating standardized guidelines for return to play for athletes at all levels of competition. As more data become available, protocols and guidelines are being refined and implemented to assist physicians, coaches, trainers, players, and parents in making decisions about return to play. To date, no standardized criteria for returning to play exist for injuries to the spine.

EVIDENCE ACQUISITION

Electronic databases including PubMed and MEDLINE and professional orthopaedic, neurosurgical, and spine organizational websites were reviewed between 1980 and 2015.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Although clinical guidelines have been published for return to play after spine injury, they are almost exclusively derived from expert opinion and clinical experience rather than from well-designed studies. Furthermore, recommendations differ and vary depending on anatomic location, type of sport, and surgery performed.

CONCLUSION

Despite a lack of consensus and specific recommendations, there is universal agreement that athletes should be pain free, completely neurologically intact, and have full strength and range of motion before returning to play after spinal injury.

ISASS Policy Statement - Lumbar Artificial Disc

PURPOSE

The primary goal of this Policy Statement is to educate patients, physicians, medical providers, reviewers, adjustors, case managers, insurers, and all others involved or affected by insurance coverage decisions regarding lumbar disc replacement surgery.

PROCEDURES

This Policy Statement was developed by a panel of physicians selected by the Board of Directors of ISASS for their expertise and experience with lumbar TDR. The panel's recommendation was entirely based on the best evidence-based scientific research available regarding the safety and effectiveness of lumbar TDR.

[Sporting loads to Spondylodesis of lumbar spine: The return-to-play process]

BACKGROUND

Return to play (RTP) and competition following spinal fusion is of particular importance for athletes. There is a lack of guidelines for decision making in RTP processes.

OBJECTIVE

The purpose of this work was to provide a systematic review of the criteria and time of return in the RTP decision process for adults undergoing lumbar spinal fusion.

METHODS

Two independent investigators searched MEDLINE using MeSH terms. Targeted outcomes were criteria for return to play decisions and total duration of the RTP process.

RESULTS

So far, no prospective randomized controlled trials on RTP after spinal fusion considering inclusion and exclusion criteria are available. Five of the included studies are based on original data. Most of the identified studies are narrative reviews and, thus, exhibit low evidence levels. In addition to the narrative reviews, one observational study, two expert opinion surveys and two model development studies were found.

CONCLUSION

Based on the literature research, a positive RTP decision can be made if the following criteria are fulfilled: (1) anatomical and functional healing is complete, (2) safety of the athlete and secondary subjects during training and competition is guaranteed, (3) sport-specific skills are regained, and (4) patient is psychosocially ready. The RTP process can often be successfully initiated 6 months after surgery; some patients however, will never manage the return to full-contact sports and/or sports with risk of collision.

Diagnosis and treatment of low back pain in the pediatric population

Back pain in the pediatric population is a common complaint presenting to sports medicine clinics. There is a wide differential that should be considered, including mechanical, infectious, neoplastic, inflammatory, and amplified musculoskeletal pain. The history, pain quality, and examination are key components to help distinguish the etiologies of the pain and direct further evaluation. Laboratory investigations, including blood counts and inflammatory markers, can provide insight into the diagnosis. The HLA-B27 antigen can be helpful if a spondyloarthropathy is suspected. Imaging as clinically indicated typically begins with radiographs, and the use of MRI, CT, or bone scan can provide additional information. Proper diagnosis of back pain is important because prognosis and treatments are significantly different. We review the pertinent evaluation, differential diagnoses, and treatment of low back pain in the pediatric population.