Dynamic Stabilization and Sports. Low back pain is a common problem with 60-80% of the world s population suffering from

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1 Dynamic Stabilization and Sports Assoc. Prof. Dr. Olcay ESER Prof. Dr. Ali Fahir ÖZER Low back pain is a common problem with 60-80% of the world s population suffering from low back pain (1). Although most of the patients with low back pain can be treated by conservative treatment, chronic low back pain can develop in 5-10% of the patients. Among all sports injuries, spine injury is relatively less common in athletes with a rate of ranging from 9% to 15% (2,3). This rate is approximately 30% in football players (4-8). Lumbar spine injuries in athletes can be classified as muscle injuries, disc degeneration, disc herniation, facet arthrosis, spondylosis, spondylolisthesis and spinal stenosis. Lumbar disc degeneration has been found to be more common in athletes as compared to general population (7). Pain related to disc herniation or degeneration is much more anticipated in athletes since disc degeneration is the underlying cause of lumbar disc herniation. In a study on football players, the rate of lumbar spondylosis and spondylolisthesis was reported to be ranging from 15% to 50% (6-8) (Figure 1). During exercises and competitions, the spine of athletes is continuously exposed to dynamic loads as well as abrasions, and distractive and unilateral or compressive forces to entire spine. The degenerative process in spine is therefore accelerated due to these dynamic loads. Spinal pathologies occurring in athletes affect the game performance of athletes, reduce the number of matches played and the number of trainings, shorten the duration of active sports life, and as a result lead to a decrease in earnings. Therefore, spinal pathologies should be immediately repaired and more rapid return to active sports life should be provided. In pathologies of the lumbar spine, various treatment algorithms can be employed such as

2 conservative treatment, surgical treatment, fusion treatment, non-fusion treatment and percutaneous interventions. Most athletes with lumbar disc herniation respond well to conservative treatment. Yet, surgical treatment should be considered in case of cauda equina compression or progressive neurologic deficits or if the patients have no pain relief or suffer from more severe pain. Surgical treatment should quickly cease the complaints and should provide early mobilization of the patient as far as possible. Although percutaneous discectomy is performed in appropriate cases, micro-discectomy is more commonly performed in athletes with lumbar disc herniation (1). In general population, satisfaction rate has been reported to be more than 90% in patients treated with lumbar micro-discectomy (9). The rate of return to active sports life after lumbar discectomy has been reported to be 78% (10) in professional American football players and 75% (11) in professional basketball players. Professional athletes possess more powerful and overdeveloped muscle systems as compared to normal population; however, it must be remembered that athletes are exposed to higher range of loads during exercises and matches compared to general population. Regardless of how minimally invasive procedure is performed in simple discectomy, pain would persist due to ongoing overloading to the degenerated disc (Figure 2). In lumbar disc herniation, spinal fusion can be employed in the treatment of acute or mostly chronic low back pain caused by spinal instability that develops following discectomy or repeated procedure. Spinal fusion decreases the motion at the operated segment of the spine, increases the motion and loading at the neighboring segment, and thus, leads to degeneration and injury of this segment. Most surgeons allow athletes to return to their active sports life one year after the spinal fusion surgery (1). In their study, Jason Eck et al (1) did not certainly recommend return to active sports life in

athletes underwent spinal fusion for various reasons; however, if they had to return to active sports life, recovery period should have been one year (1).

3 athletes underwent spinal fusion for various reasons; however, if they had to return to active sports life, recovery period should have been one year (1). The importance of the temporary loss of sport activities becomes more apparent if we consider workouts that would take minimum three to six months for the athlete to revive at the end of this one-year period. Psychological and social aspects are other conditions to be considered. The usual approach of fans and club management to professional athletes is that the athlete will not able to catch up his past performance and may no more be useful. Figure 1: Twenty-six-year-old patient, a football player, has been suffering from low back pain for 2 years. He has had difficulty in completing the workouts for the last 3 months and

together with degenerative disc disease at L5-S1 are observed.

4 has been suffering from pain radiating to right leg after workouts. Lytic deformity at the fifth lumbar (L5) segment and isthmic spondylolisthesis with 1-mm in diameter together with degenerative disc disease at L5-S1 are observed. Figure 2: Twenty-five year old patient, a professional athlete, has been suffering from low back pain. He had undergone micro-lumbar discectomy due to disc herniation at the fourth

5 and fifth lumbar (L4-L5) vertebra. He was admitted to our clinic due to recurrence of the disease. Dynamic stabilization was performed following re-discectomy to the fourth and fifth lumbar (L4-L5) vertebra. The patient completed 3 years after the surgery and he continues his active sports life. For this reason, they often try to part ways with the athletes that were operated from the spine. It is extremely challenging for an athlete to get over this difficulty and there are many athletes putting an end to their sports life. Spinal fusion is widely used in the treatment of degenerative disc diseases of the lumbar spine, spondylosis, spondylolisthesis, facet joint syndrome, spinal trauma and for the correction of spinal deformities (12,13). Clinical outcomes following fusion surgery were evaluated by Turner et al. (14); they reported that satisfactory results ranged from 16% to 95%, with a mean satisfaction rate of 68%. Consequently, low back pain will not resolve in 30% of the patients and will turn into chronic low back pain (Figure 3). It is apparent that long-term treatment course such as spinal fusion will eventually make the athletes lose their sports lives and popularity, considering that the athletes earn their living from sports and the duration of active sports life is limited for most of the athletes.

a) Direct x-ray shows isthmic defect and spondylolisthesis, b) Magnetic resonance (MR) imaging shows anterior shift due to mechanical

6 Figure 3: Twenty-three-year-old patient, a licensed rowing athlete, has been suffering from low back pain which has gradually increased in the last 6 months and become intolerable for the last 1 month. a) Direct x-ray shows isthmic defect and spondylolisthesis, b) Magnetic resonance (MR) imaging shows anterior shift due to mechanical overload without marked disc degeneration, c) X-ray graphs obtained after fusion surgery. The athlete terminated his/her active sports life after a 6-months rehabilitation period. Now, he/she does not have any complaints.

7 Thus, a support should be provided such that athletes regain their health while continuing their sports lives. The importance of dynamic stabilization becomes prominent at this point. Providing not a heavy support to the spine of these individuals with extremely powerful muscle compartments would ease the treatment course while reducing time to return to active sports life and participate to workouts. It must be kept in mind that disc degeneration observed in most of the athletes is a consequence of their professional life and a chronic condition developing in time. The logic of using dynamic stabilization systems should be first understood in order to better comprehend how they work in the management of chronic low back pain. The purpose in dynamic stabilization is to provide the control of abnormal motions, in other words, bringing to a normal range, to keep the load distribution on the spine within physiological limits and thereby relieving the pain. The system employed is considered successful as far as it conforms to the biomechanics of the spine. They key purpose here is having the disordered system operated in its normal rhythm and keeping the load transition across the motion segments under control. Recovery of the disordered segment or getting turned into a fusion needs a certain time, but the patient feels no pain during this period. Both are acceptable and reasonable results, because, recovery of the disordered segment and getting into spontaneous fusion are both included in the natural repair process of an organism. Unlike fusion, dynamic stabilization is suggested to cause minimal loading to the neighboring segment; however, this has not been verified by further biomechanical studies. Mulholland et al. (15) reported that abnormal load distribution occurring after disc degeneration was the underlying mechanism of chronic low back pain. Range of motion is augmented due to degeneration but motion itself is not the only factor leading to pain; instead, pain is caused by translational motions which may arise together with abnormal load distribution. The authors therefore explained that the primary purpose of using dynamic

for the last 1 year due to low back pain. She had to leave the match twice due to sudden low back strain.

8 systems was reducing the load on disc/facet joint and avoiding abnormal motions while protecting the motions (Figure 4). Figure 4: Twenty-two-year-old female patient, a professional basketball player, reported that she has had difficulty in workouts and matches for the last 1 year due to low back pain. She had to leave the match twice due to sudden low back strain. a) Dynamic stabilization was performed to L5-S1 due to isthmic spondylolisthesis and annular tear at L4-L5 was left untreated, b) Direct X-ray graphs of the patient. The patient started dynamic low back

9 exercises program at 2 months after the surgery. With powerful paravertebral muscles for being an athlete, additional support to L5-S1 space led the patient to continue her professional sports life. In a prospective study, Kaner et al. (13) classified patients with lumbar degenerative disc disease with disc herniation according to Carragee disc classification system. All patients were in Carregee class II; patients with defect ( 6 mm in size) in posterior annulus were in Carregee class III and IV and underwent posterior dynamic transpedicular stabilization (with dynamic pedicular screw-rigid rod). After an average two-year follow-up, the authors demonstrated that degeneration in the disc spaces was reduced in patients with no advanced degeneration who underwent limited discectomy and dynamic pedicular fixation (12). Grob et al. (16) investigated low back and leg pain, changes in professional life, quality of life, ability to do physical activities and sports, and overall improvement in patients who were treated with dynamic stabilization. They reported that the ability to do physical activities alone (sports/hobbies) improved in 40%, did not change in 33% and worsened in 27% of the patients. Quality of life was found to be improved in 50%, did not change in 37% and worsened in 13% of the patients. They suggested that dynamic stabilization was not superior to fusion even in this not well-designed study. These rates are to the favor of dynamic stabilization considering that dynamic stabilization offers more simple operation compared to fusion and has almost no mortality and morbidity. The most prominent characteristics of the athletes undergoing operation for lumbar disc degeneration are early pain relief, early mobilization and early return to active sports life. Jason Eck et al. (1) did not recommend return to sport activities in athletes undergoing fusion operation. In this case, athletes undergoing fusion would put an end to their sport career at an early stage and would incur financial loss. For this reason, providing pain relief, early return

to sport activities and prolonging sport career should be targeted by dynamic stabilization without fusion in patients requiring fusion due to lumbar disc herniation.

Dynamic stabilization can be conveniently used in such cases to ensure early return to sports provided that this does not impair stabilization (Figure 5).

10 to sport activities and prolonging sport career should be targeted by dynamic stabilization without fusion in patients requiring fusion due to lumbar disc herniation. In addition to degeneration, other pathologies may rarely affect the sport lives of the patients. Dynamic stabilization can be conveniently used in such cases to ensure early return to sports provided that this does not impair stabilization (Figure 5). In this regard, we employ dynamic stabilization system as an alternative treatment method and as a first choice for the sake of sport career of athletes who require fusion due to lumbar disc degeneration. Figure 5: Twenty-four-year-old patient, a basketball player; a) Lumbar MR images reveals a tumor mass involving L3-L4 facet joint and extending from L3 pedicle to L3 vertebra body, b) The tumor mass was totally excised, facet joint was removed and unilateral facet joint replacement was performed using Safinaz dynamic system. Post-operative lumbar MRI

11 showed that tumor mass was completely removed. The patient is still continuing sport life 2 years after the surgery.

12 References 1- Eck JC, Riley LH 3rd: Return to play after lumbar spine conditions and surgeries. Clin Sports Med 23: , Sward L: The thoracolumbar spine in young elite athletes: Current concepts on the effects of physical training. Sports Med 13: , Williams JG: Biomechanical factors in spinal injuries. BrJ Sports Med 14(1): 14-17, Day AL, Friedman WA, Indelicato PA: Observations on the treatment of lumbar disk disease in college football players. Am J Sports Med 15(1):72-75, McCarroll JR, Miller JM, Ritter MA: Lumbar spondylolysis and spondylolisthesis in college football players: A prospective study. Am J Sports Med 14(5): , Peterson L, Junge A, Chomiak J, et al: Incidence of football injuries and complaints in different age groups and skill-levels. Am J Sports Med 28:S51-S57, Ong A, Anderson J, Roche J: A pilot study of the prevalence of lumbar disc degeneration in elite athletes with lower back pain at the Sydney 2000 Olympic Games. BrJ Sports Med 37(3): , McCarroll JR, Miller JM, Ritter MA: Lumbar spondylolysis and spondylolisthesis in college football players: A prospective study. Am J Sports Med 14(5): , Semon RL, Spengler D: Significance of lumbar spondylolysis in college football players. Açıklama [Y1]: 5 numaralı referans ile aynıdır, lütfen kontrol ediniz. Spine 6: , Buttermann GR: The effect of spinal steroid injections for degenerative disc disease. Spine J 4(5): , Hsu WK: Performance-based outcomes following lumbar discectomy in professional athletes in the National Football League. Spine 35: , Anakwenze OA, Namdari S, Auerbach JD, Baldwin K, Weidner ZD, Lonner BS,

13 Huffman GR, Sennett BJ: Athletic performance outcomes following lumbar discectomy in professional basketball players. Spine 35(7): , Kaner T, Sasani M, Oktenoglu T, Ozer AF, Cosar M: Clinical outcomes after posterior dynamic transpedicular stabilization with limited lumbar discectomy: Carragee system classification of lumbar disc herniations. SAS J 4:92-97, Turner JA, Ersek M, Herron L, et al: Surgery for lumbar spinal stenosis. Attempted metaanalysis of the literature. Spine 17(1):1-8, Mulholland RC, Sengupta DK: Rationale, principles and experimental evaluation of the concept of soft stabilization. Eur Spine J 11 (Suppl 2):S198-S205, Grob D, Benini A, Junge A, Mannion AF: Clinical experience with the Dynesys semirigid fixation system for the lumbar spine. Spine 30(3): , 2005.

Comprehension of the common spine disorder.

Objectives Comprehension of the common spine disorder. Disc degeneration/hernia. Spinal stenosis. Common spinal deformity (Spondylolisthesis, Scoliosis). Osteoporotic fracture. Anatomy Anatomy Anatomy