Back Injuries, Surgery for

Athletes with back injuries are commonly divided into two groups on the basis of diagnosis: (1) those with stress fractures and (2) those with lumbar disk herniations. Stress fractures of the lumbar spine are termed spondylolysis. Spondylolysis is caused by repetitive hyperextension forces on the spine in an area termed the pars interarticularis. The pars refer to the part, and interarticularis refers to the bony area connecting the facet joints. Hyperextension causes tension in this area of the spine, and the repetitive motion eventually leads to a fatigue crack in the spine. The incidence of spondylolysis in the normal population is believed to be around 8%, with a higher incidence in the athletic population. Athletes who are involved in activities that entail hyperextension of the spine are at a greater risk of developing this injury. Gymnasts who perform many back-spring activities and down linemen in football, who rise from a forward stance and are pushed back, represent the athletes who most commonly sustain this injury.

Patients with spondylolysis generally present with significant low back pain related to their sports activities. The examination of these patients will indicate pain in the affected area with hyperextension. Plain X-rays may aid in the diagnosis; however, many times, a computed tomography (CT) scan or magnetic resonance imaging (MRI) is required to make the definitive diagnosis. These studies reveal a fracture of the pars interarticularis, which sometimes is acute; however, often there is evidence that these are long-standing injuries that have recently become symptomatic. Nonoperative treatment of these patients is generally sufficient for resolution of symptoms and return to full sporting activities. It revolves around physical therapy working on strengthening the core musculature of the body and stretching to improve flexibility. The use of bracing is indicated in those patients who have specific symptoms such as pain and spasm of the back. Surgical treatment is deemed appropriate in long-standing stress fractures in which the athlete is unable to become painfree despite physical therapy and bracing.

Herniation of the lumbar disk is the other common type of sports-related back pain; disk herniation is brought about by an increase in pressure and strain on the intervertebral disk. This increase in stress causes a weakening of the ligament surrounding the disk, which results in weakening and failure of the annulus, or outer fibrocartilaginous rings, of the disk surrounding the nucleus pulposus at the center. The resulting outpouching of the pulposus material causes back pain; however, most symptoms are caused by the disk area that has herniated exiting and touching a nerve root. The resultant pressure on the nerve root leads to radiculopathy.

Pressure against a nerve root causes irritation in the nerve root, which can lead to pain signals down the leg from the irritated nerve, weakness in muscles innervated by that nerve, numbness in areas that are innervated by that nerve, and resultant reflex changes. On examination, the athlete will present with significant pain and, occasionally, listing to one side, which is the body's way of splinting [Page 134]the affected area. Nerve tension signs are physical exam findings that are seen when the nerve is stretched, causing irritation due to pressure by the herniation, as in a straight leg raise test.

...