Between 9% and 15% of all athletic injuries involve the spine, and most can be treated non-surgically (1). Some, however, require surgery either soon after the onset of symptoms or after an attempted period of rest and rehabilitation. For most, the goals of surgery focus upon allowing the patient to return to play at his or her pre-injury intensity. As clinicians, our responsibility is to recommend a plan that allows a safe return to play. Unfortunately, there is little level I or II evidence supporting return to play protocols after spine surgery. This paper will discuss this evidence as well as the prevailing expert opinion on return to play after lumbar spine surgery for the following conditions:spondylolysis, spondylolisthesis, disc herniation, spinal stenosis, Scheuermann's disease, scoliosis, and spinous process fractures.
Pars interarticularis fractures are a relatively common etiology of back pain in younger athletes, especially those participating in sports that overload the pars by either extension or extension and rotation. Treatment of these fractures focuses upon bony healing, pain relief, and restoration of normal pain-free function (2). Regardless of the age of the fracture, the treatment is conservative and may require some form of brace to facilitate healing and pain relief. Early diagnosed unilateral fractures afford greater chances for healing, but mature bilateral pars fractures are less likely to heal with a bony union. Most non-listhesis pars fractures (unilateral or bilateral) do well even if bony healing does not occur. Surgery is rarely required for these fractures unless non-union and pain persist after conservative therapy beyond 9 to 12 months, significant listhesis develops, or neurologic changes occur (3).
In a study by Nozawa et al., 20 athletes with unilateral spondylolysis (18 with L5 pars fractures, 1 with an L4 pars fracture, and 1 with an L4 and L5 pars fracture) and persistent back pain underwent segmental wire fixation repair of their pars defects. All participated in non-collision sports (baseball, tennis, and golf) and all returned to their sports. Postoperatively, 18 were able to return without loss of intensity (4).
Reitman et al. utilized buck screws to repair the pars defects in four non-collision sport athletes after failing 6 months of conservative therapy (rest, bracing, and medication). All four gradually returned to their pre-injury activities over a 6-month period, and at 1 yr they participated at their pre-injury competitive levels (5).
Debnath et al. prospectively studied the surgical outcomes of 22 athletes competing in football (soccer) (N = 13), cricket (N = 4), hockey (N = 3), tennis (N = 1), and golf (N = 1) who had symptomatic non-union fractures (most were bilateral and at L5). Nineteen patients underwent a modified buck screw repair, and the other three (one football and two hockey players) underwent a Scott's fusion technique. Eighteen of the patients undergoing buck screw fixation returned to their previous level of sport after a mean of 7 months; however, none of the three Scott's fusion repair patients returned to sport (the two hockey players required revision secondary to non-union). The small sample size prohibits any meaningful conclusions to be drawn regarding the effectiveness of one technique over another (6).
Jarolem et al. described the repair of a persistently painful pars defect at L3 using a rigid intrasegmental fixation device in a high school track athlete. Postoperatively, the patient wore a thoracolumbosacral orthosis for 6 wk, but was able to compete the following season at the state level and remained pain-free at the 2-yr follow-up (7). Other techniques have been described in the literature with similar results and minimal complications.
While the literature does not offer much in the way of recommendations regarding collision sport return to play after surgical repair of a persistently painful pars defect, most patients from non-collision sports who underwent repair returned to their previous levels of participation.
If bilateral pars interarticularis fractures result in anterior translation of a vertebral body, then the clinician must assess the condition with more scrutiny. Grade I and II spondylolisthesis fractures (those with anterior translation less than 50%) do not need surgical referral unless pain persists for more than 6 to 12 months and conservative therapy (adequate rest and immobilization) has failed. Asymptomatic lower grade slips should be followed with serial CTs to verify either bony healing or no progression of the listhesis (8). Regardless of age, sport, or level of competition, indications for surgical referral include symptomatic spondylolisthesis for 6 months after failed conservative therapy, Grade III or IV spondylolisthesis fractures, progression of a spondylolisthesis, and any neurologic changes (8,9).
The medical literature describes many surgical techniques for treating spondylolisthesis, but in general, a decision is made to either repair the pars defect or to perform a posterior lateral fusion of the involved vertebrae with or without decompression of the canal and nerve roots (2). Specific indications for each procedure are beyond the scope of this paper. There are few good studies regarding return to play after these repairs because multiple factors contribute to the success of the surgery.
It is generally accepted that low-grade slips repaired by direct fusion of the pars defect offer a favorable outcome and optimism for return to play in non-collision sports (10). Controversy over return to play involves collision sport participation after spinal fusion surgery. Wright et al. surveyed 208 respondents out of the 450 members of the North American Spine Society in search of expert opinions regarding return to play after spinal fusion surgery. Of the respondents, 19%-36% discouraged collision sports (football, gymnastics, wrestling, and hockey) following the diagnosis and surgical repair of a spondylolisthesis. Up to 80% of the respondents allowed their patients to return to selected high school athletics, whereas only 62% allowed their patients to return to collegiate athletics. Seventeen percent of the surgeons never allowed their lumbar fusion patients to return to the same level of pre-injury competition. Of those that allowed their patients to return to play, 33% did so within 6 months of surgery, and all returned within 18 to 24 months postoperatively (11).
Members of the Scoliosis Research Society who, as a part of their practice, perform spinal fusion surgery in children and adolescents to treat high grade listheses were surveyed. Twenty-four percent never allowed their athletes to return to collision sports. However, 82% of the surgeons allowed patients to return to non-collision sports at 6 months to 1 yr after fusion for high-grade listhesis (12).
In a study of 30 active U.S. servicemen (average age 36 yr, range 22-45 yr) with low grade spondylolisthesis, a bilateral posterolateral fusion was performed because each patient had persistent chronic back pain for over 1 yr. Of the 30, 19 (63%) were allowed to return to full unrestricted duty on an average of 6 months after surgery. Eight (27%) required some form of permanent physical activity limitation to permit return, and three (10%) requested and received a disability discharge from the military because of persistent back pain (13).
As with spondylolysis repair, spondylolisthesis repair of low and high grade listheses allowed for at least a 6-month return to non-collision sports, but return to collision sports remains highly controversial.
LUMBAR DISC HERNIATION
Typically a condition afflicting mature athletes, lumbar disc herniation can initially be managed non-operatively. Emergent decompression is only indicated in the rare cases of significant neurologic deficit (e.g., cauda equine syndrome), progressive neurologic deficit, or loss of bowel or bladder function. Most patients with disc herniations typically have unilateral lower extremity radicular symptoms and will gradually improve to resolution over a 3-6-wk period with conservative care only. Should symptoms persist or worsen after 6 wk of conservative care and magnetic resonance imaging (MRI) findings correlate and support the physical exam findings, surgery to excise or partially excise the disc may relieve the symptoms (14). Elite athletes often consider surgical management sooner if the pain persists and the condition affects their athletic performance.
According to Eck et al., following a traditional microdiscectomy, pain relief and normal range of motion are required for return to play. This usually requires at least 6-8 wk for non-collision sports and 3 months for collision sports (1).
Percutaneous discectomy/nucleotomy procedures are minimally invasive and allow for less disruption to the musculature, bone, and neural structures (1). The typically recommended protocols require 2-3 months of rest and rehabilitation post-surgery before retuning to play. Cooney reports two cases of a state-ranked swimmer and an Olympic skater who returned to the same high level of competitiveness 2 wk post-surgery. Dunn et al. reports a collegiate All-American basketball player who returned to full competition 3 wk after a minimally invasive discectomy at the L4-5 level (10). Wang et al. found that 9 out of 10 athletes competing at the Division I NCAA level were able to return to their respective varsity level following single-level microdiscectomy surgeries (sports included basketball, football, shot-putter, water polo, volleyball, and soccer). However, the three two-level discectomies and the one percutaneous discectomy were unable to return to competition (football, swimming, and diving, respectively). While all the athletes failed an 8-wk trial of conservative therapy before surgery, the study does not reveal the period of rehabilitation nor the time for attempted return to play after surgery (15).
Watkins describes a post microdiscectomy protocol to include only walking for 3 wk after the procedure; heavy lifting, bending, and driving are prohibited. After this period of relative inactivity, trunk strengthening and stabilization may begin, followed by a gradual increase in sport-specific training, weight-lifting, aerobic conditioning, and finally practicing on a limited basis (16).
Matsunaga et al. compared three different surgical techniques for the treatment of lumbar disc herniation in manual laborers, student athletes, and professional bicycle racers: simple disc excision (N = 30), percutaneous discectomy (N = 51), and disc excision with spinal fusion (N = 29). Of the athletes, 87% of those undergoing percutaneous discectomy returned to play in an average of 7.5 wk (N = 15). However, only 54% of those undergoing simple disc excision returned to play after 18 wk (N = 11). Only 2 patients underwent disc excision with spinal fusion, but both returned to play at 23 wk post-surgery (17).
Mochida et al. discovered that when compared with age matched non-athlete control subjects, elite athletes demonstrated worse success rates, determined by postoperative questioning, after a percutaneous nucleotomy. At 6 months, the surgical group showed a 73% success rate versus 79% in non-athletes. At 2 yr, the gap widened; 57% success rate for the surgical group versus 74% for the non-surgical group. This unexpected outcome indicates that return to play at less than 3 months post-procedure may be too short and results in worsening back symptoms (18). Another theory suggests that the remaining disc cannot withstand the load forces demanded by the athletes (1). The authors found that preservation of the intervertebral disc height appears to have a direct correlation on success, and thus this procedure should be limited to only those athletes who fail conservative treatment and who are willing to refrain from return to sport for at least 3 months after surgery (18).
Spinal fusion is recommended for more complicated conditions involving multiple levels, 4-6 months of symptoms that correlate with imaging, failed conservative treatment, or spinal instability (1,2). By eliminating the motion at a segment that normally has motion, stress shifts to the levels above and below the fusion site. This increases the risk of degeneration and subsequent injury (1). Return to collision sports is controversial, but Wright et al. found that of those surgeons allowing return to collision and non-collision sports, 91% allowed return in 1 yr or less (11).
LUMBAR SPINAL STENOSIS
Younger athletes with symptomatic spinal stenosis (reporting signs and symptoms consistent with neurogenic claudication, paresthesias, sensory deficits, motor loss, and reflex abnormalities) are usually initially managed non-operatively. Typical protocols include flexion exercises, physical therapy with home instruction, and medications (NSAIDs or epidural steroid injections) (1,19). However, should significant neurologic symptoms persist or worsen, or a cauda equina syndrome develop, decompressive surgery can help relieve these patients. A decompressive laminectomy will increase the space around the spinal cord and nerve roots. However, spinal fusion procedures are necessary for severe or complicated cases of spinal stenosis. Some of these cases involve coexisting spondylolisthesis, scoliosis or kyphosis, recurrent spinal stenosis at the previously decompressed segment, and disc herniation (19). Studies are lacking for return to play criteria for those undergoing decompression procedures for symptoms of spinal stenosis, likely because spinal stenosis afflicts an older population that is less active. Post-surgery, when the athlete is pain-free, has sufficient range of motion, and has no neurologic deficits, he or she may return to full non-collision competitive play. Persistent neurological deficits, spinal instability, or post-fusion procedures usually prohibit the athlete from any future collision sport activity (1).
For the older athlete, return to play decisions depend upon a number of factors: age, type of surgery performed, post-operative severity, operative success, sport in question, patient's desire to return to play and at what level of intensity, and the overall medical condition of the athlete. The return to play protocol for the older athlete having undergone a decompression only requires no heavy lifting for 6 wk, gentle conditioning (swimming) at 3 wk, and physical therapy at 1 month (14). For spinal fusion patients, lifting restrictions and the initiation physical therapy are delayed for 3 months post-operatively. In general, laminectomies with or without discectomies afford the older patient the allowance for golf at 3-6 months after surgery. However, fusion surgeries require a minimum time of 6 months for golf after surgery (14).
Scheuermann's disease (excessive thoracic kyphosis) typically affects youth, but rarely requires surgery. Skeletally immature patients with kyphosis less than 50-60 degrees should begin a postural and flexibility exercise program with regular follow-up radiographs. In patients with a kyphosis greater than 50°-60°, bracing should be initiated. Curves greater than 70°-80° or adults with kyphosis greater than 75° and persistent pain after failed conservative therapy should consider a two-stage surgical repair (anterior release with fusion followed by a posterior fusion). Post-operatively, these patients are immobilized for several months and withheld from athletics (except for swimmers) for 1 yr. Unfortunately, collision sports and gymnastics are prohibited (20).
Scoliosis (side-to-side curvature of the vertebral column) may occur in the lumbar spine, but more commonly occurs in the thoracic column. Commonly affecting dancers, gymnasts, and swimmers, scoliosis rarely requires surgery. Although athletes with scoliosis may present with back pain, it is rarely the cause. When conservative bracing fails to prevent progression of the disease (curvature greater than 50°), cardiopulmonary function decreases, or the deformity results in an unacceptable posture, surgery may prove effective and definitive (2). Randomized studies that would evaluate the effectiveness of surgery upon scoliosis do not exist. Members of the Scoliosis Research Society were surveyed regarding their opinions on whether athletes who undergo surgical repair of their scoliosis may return to their original participation levels in sports. Of those responding, 43% (N = 316) allowed their patients to resume low-impact, non-contact sports such as swimming and cross-country skiing at 6 months. Tennis and running sports were allowed by 46% at 6 months and 34% at 1 yr. Sixty-one percent allowed contact sports (e.g., basketball, soccer, baseball, European football) at 1 yr (11% advised against and 2% prohibited this activity). High-collision sports (football, ice hockey, and gymnastics) were allowed by 32% at 1 yr, but 36% advised against and 24% prohibited their return to these sports (12).
SPINOUS PROCESS FRACTURES
Fractures of the transverse processes, spinous processes, facets, vertebral bodies, and endplates, all classified as minor fractures, are uncommon and generally present with back pain with no radicular symptoms following a direct blow, forceful rotation, flexion, or compression (2,10). If spinal stability is not compromised after a spinous or transverse process fracture, conservative treatment will allow return to play when the patient has achieved full, pain-free range of motion (2,10). Fayyzi reports a 16-yr-old basketball player who sustained an isolated L3 spinous process fracture and failed 2 yr of conservative therapy (NSAIDs, physical therapy, and steroid injection). Surgery was offered because the persistent pain prevented him from playing basketball. The avulsed L3 spinous process fragment was excised, and the pseudoarthrosis that had formed was debrided to bleeding bone in hopes of stimulating healing of the incised supraspinous ligament. Post-operatively, the patient started a self-directed physical therapy program, was pain free 6 wk later, and returned to basketball 1 yr later (21).
Compression fractures, usually sustained by excessive axial loads applied to the spine (as with heavy squatting or military press), warrant restriction from future repetitive lifting as the athlete may be more prone to future injury (10).
Although current return to play recommendations following lumbar spine surgery are based mainly upon expert opinion, the observational studies referenced in this article provide helpful guidance. Patients who have had minimally invasive procedures for minor lumbar spine conditions usually are able to regain full and pain-free range of motion post-operatively. They have the greatest likelihood of return to play at pre-injury levels. Athletes whose conditions were more severe and required invasive surgical procedures, such as spinal fusion, have less chance for return to play at pre-injury levels. While collision sports are generally discouraged in most instances after spinal surgery, it is important to consider each case on an individual basis.
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