The Athlete s Lumbar Spine: Current Concepts
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1 The Athlete s Lumbar Spine: Current Concepts Content / Objectives Anatomy Common injuries Treatment and prevention Pablo Vazquez Seoane, M.D. 44 th Annual Sports Medicine Symposium January 19 21, 2017 Anatomy Anatomy
2 Neurologic Testing L2 Hip flexors (iliopsoas) L3 Knee extensors (quadriceps) L4 Ankle dorsiflexors (tibialis anterior) L5 Long toe extensor (extensor hallucis longus) S1Ankle plantiflexors (gastrocsoleus) Grading Strength 0 5 Acute / Traumatic (Fall, Collision) Look for on the field Red Flags : Weakness, incontinence, cannot stand or jog, impaired flexibility, loss of consciousness (Concussion, upper extremity weakness, all part of head/neck/spine broader trauma considerations) Acute Injury Algorithm Red Flag finding = Assume structural problem (fracture / instability of the C T LS spine) Expedite ER / spinal evaluation, with: Spinal precautions (head neck immobilization and spine board) Advanced Trauma Life Support, ABCs Athletes and Low Back Pain Trend / suggestion of higher incidence of LBP Age, prior injury/lbp, females, Volleyball, contact sports Significant lost time from athletic participation
3 LBP Contributing factors Subacute or Chronic LBP Acute LBP: Growth spurt Abrupt increases in training intensity or frequency Improper technique Unsuitable sports equipment Leg length inequality Soft tissue injuries Chronic LBP: Poor core strength Structural issues (pars, disk) Tight hamstrings Degenerative disc disease Intrapelvic, gynecologic conditions (e.g., Isthmic spondylolysis (no slip) ovarian cysts) Isthmic spondylolisthesis Renal disease Facet syndrome Ring apophyseal injury (adolescents) Sacral stress fracture Central disc herniation (without radiculopathy) Sacralization of L5/tranverse process impingement Facet stress fracture Sacroiliac joint dysfunction Lumbar vertebral body fracture Discitis/osteomyelitis Neoplasm (CANCER) Low Back Pain Treatment (strain, no fracture) Soft tissue injury Core strengthening (PT) Stretch Hamstrings Short term medications: anti inflammatory (NSAIDs), muscle relaxant Weight optimization Lessen impact activities during active symptoms Prevention Sports specific training Flexibility. YOGA?? Rest Manageable reps/goals Case #1 Fractures 15 year old receiver In game injury Complains of low back pain, lying on field Tries once, cannot get up (SEVERE pain) and/or weak in legs Management? Possible / likely injury?
4 Pars fracture Spondylolysis aka pars fracture, stress reaction/fracture 3 6% prevalence Non athletic population: Often asymptomatic Often incidental Risk of slip: 25 50% May develop as stress fracture in athletics Adolescent athletes: 38% with slip progression (avg. 10%) 8% with slip decrease Spondylolysis Risks Spondylolysis Twisting, hyperextension Repetitive axial loading Offensively linemen, gymnasts, soccer, baseball, volleyball, weightlifting, rowing, wrestlers
5 Exam Tight hamstrings Pain with lumbar hyperextension Restricted range of motion Diagnosis Imaging Oblique films not useful; extra radiation Rely on SPECT bone scan + CT (radiation) MRI useful for excluding other processes (disk degeneration, herniation) Spondylolysis Scenarios and Treatment Spondylolysis Pars fracture With acute MRI or bone scan findings Brace treatment 6 12 weeks, rehab Without acute findings Rest, rehab Flexibility Case #2 Even in (ESPECIALLY IN) football Think outside the traditional box i.e. Shannon Turley Stanford Football 17 y.o. club and HS volleyball player Acute onset of radiating posterior L leg pain Decreased sensation left leg Absent ankle reflex Stanford s Distinct Training Regimen Redefines Strength New York Times, Dec. 30, 2013 For the subtle art of injury prevention, the Cardinal stretch and stretch and stretch. They stretch before and after lifts and before and after practice. They stretch for fun.
6 Lumbar disk herniation The buzz Stem cells (mesenchymal stem cells) Adipose based Bone marrow based Needs rigorous study Jesse DeLee, MD Ajeya Joshi, MD Thank you!!
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