Cervical Disk Herniation in Athletes

Andrew C. Hecht, MD

Steven McAnany, MD

Sheeraz Qureshi, MD, MBA

Dr. Hecht or an immediate family member has received royalties from Zimmer; serves as a paid consultant to Medtronic Sofamor Danek, Stryker, and Zimmer; has stock or stock options held in Johnson & Johnson; and serves as a board member, owner, officer, or committee member of the AAOS, Musculoskeletal Transplant Foundation, the American Journal of Orthopedics, the Global Spine Journal, the Journal of Spinal Disorders and Techniques, the Orthopaedic Knowledge Online Journal, and Orthopedics Today. Dr. Qureshi or an immediate family member has received royalties from Zimmer; is a member of a speakers’ bureau or has made paid presentations on behalf of Globus Medical, Medtronic Sofamor Danek, and Stryker; serves as a paid consultant to Medtronic, Orthofix, Stryker, and Zimmer; and serves as a board member, owner, officer, or committee member of the AAOS, the Cervical Spine Research Society, the Clinical Orthopaedics and Related Research, the Contemporary Spine Surgery, the Global Spine Journal, the Musculoskeletal Transplant Foundation, the NASS, the Spine, and the Spine Journal. Neither Dr. McAnany nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article.

Introduction

Cervical disk injuries carry with them the risk of prematurely ending an athlete’s career with the associated financial ramifications for both the player and the team when at the professional level.¹ Symptoms associated with cervical disk injury in athletes are similar to those seen in the general population with upper extremity radiculopathy (arm pain, paresthesia, or weakness), neck pain, and coordination difficulties being the most common.²^,³ Although the symptoms may be similar between the two groups, Mundt et al⁴ found that the symptoms may be more pronounced in athletes given the demands of the specific sport.

Cervical disk injuries in athletes are less common than lumbar disk injuries and tend to affect older athletes. In fact, it has been shown in contact sports such as wrestling and football that there is an age-related increase in the likelihood of sustaining a cervical disk injury over the lifetime of these athletes.⁵ Similar findings have not been shown in noncontact athletes, with Mundt et al⁴ concluding that athletes in noncontact sports may actually have a conferred protective effect against the development of either cervical or lumbar herniations. The authors hypothesized that improved muscular conditioning protected the disks from the pathological stresses placed on the spine.

In a population-based study, the annual incidence of cervical radiculopathy was found to be 107.3 per 100,000 for men and 63.5 per 100,000 for women.⁶ In a more recent study of military personnel, 24,742 people were found to have cervical radiculopathy for an incidence of 1.79 per 1000 person-years.⁷ As with nonathletes, the initial treatment for almost all herniated disks should be nonoperative care. Treatment options include rest, activity modification, anti-inflammatory medication, immobilization, cervical traction, and therapeutic injections.²^,³^,⁸^,⁹ Most athletes have complete resolution of their symptoms after nonoperative care. For those who fail to improve, operative intervention should be considered. Potential surgical options include anterior cervical discectomy and fusion (ACDF), a posterior cervical foraminotomy (PCF), and cervical disk replacement (CDR).

Return to play (RTP) after conservative or operative treatment of a cervical disk injury is often the most important question for the athlete and the team (Figure 12-1). Comprehensive and definitive guidelines for RTP have yet to be developed, and often the decision to allow an

athlete to RTP is based on anecdotal evidence and surgeon experience.

FIGURE 12-1 Flow diagram detailing the return to play guidelines after cervical disk injury in an athlete. ACDF = anterior cervical discectomy and fusion.

Nonoperative Management

Nonoperative management remains the initial standard if care for all patients presenting with symptomatic cervical disk disease without associated neurological deficit, cord signal change, or intractable pain. The natural history of cervical radiculopathy as described by Lees and Turner is considered to be generally favorable with nonoperative management.¹⁰ In their series with long-term follow-up, 45% had only a single episode of pain without recurrence, 30% had mild residual symptoms, and only 25% had persistent or worsening symptoms. Other studies have shown a significant improvement in symptoms in up to 90% of patients with nonoperative care.¹¹^,¹² Although nonoperative management remains the standard of care for patients without significant neurologic sequela, there have been no randomized controlled trials (RCTs) comparing the various types of nonoperative with the natural disease history with no intervention. Furthermore, there have been no randomized studies that have shown superior outcomes of nonoperative treatment compared with surgery.

The goals of nonoperative management of an acute cervical disk injury in athletes are to treat the pain and to initiate a treatment plan that can allow the athlete to RTP. The ideal nonoperative treatment algorithm has not been strictly defined in the general population or in competitive elite athletes. The most commonly used medications are anti-inflammatory medications, including nonsteroidal anti-inflammatory (NSAIDs) or corticosteroids (i.e., Medrol dose pack or prednisone taper) and, in severe cases, narcotic analgesics. Additionally, cervical soft collars, ice or heat, cervical traction, narcotics, and muscle relaxants can also be used with variable efficacy. The use of collars in the athletic population has not been directly studied. Caution should be used because a recent study in the general population demonstrated that prolonged collar wear has been associated with atrophy of the cervical musculature.¹³

Physical therapy in the acute setting can often worsen the pain and may prolong the duration of symptoms. Cervical range of motion (ROM) and associated strengthening exercises are generally discouraged while the patient remains acutely symptomatic. After resolution or control of the painful symptoms, the patient can begin these exercises, although there is minimal literature to support the efficacy of these treatments for acute pain.¹⁴^,¹⁵ Supervised cervical traction has also been advocated as a temporary adjuvant to help relieve pain. Physical therapy remains a key component to help an athlete regain ROM and strength.

Cervical epidural steroid injections are less commonly used than in the lumbar spine. To date, there are both retrospective and prospective data to support the use of epidural steroid injections in the cervical spine. A recent systematic review suggested that the evidence for cervical pain relief with transforaminal epidural steroid injections was moderate.¹⁶ Two recent studies showed that up to 60% of patients may experience long-term symptomatic relief with an injection.¹⁷^,¹⁸ A recent RCT assigned 169 patients to one of three arms: cervical epidural injections; physical therapy plus pharmacotherapy; or a combination of injection, physical therapy, and pharmacotherapy.¹⁹ At 3-month follow-up, all groups had improvement with the largest improvement seen in the combination therapy group. By 6 months, however, there was no significant difference between the three groups. To date, there have been no studies that have directly looked at the use of epidural steroid injections in athletes. Furthermore, there is currently no method for determining in which patient the injection will prove to be efficacious. When taken in the context of significant potential risks, including neurologic deficit, epidural hematoma, and possible vascular infarct, cervical epidural injections should be used with caution in the athlete population and only by experienced interventional physiatrists or pain management physicians.

Evidence-Based Review

In a recent study by Hsu,¹ RTP after acute cervical disk herniation was examined in 99 National Football League (NFL) players. Nonoperative treatment was defined as epidural steroid injections, physical therapy, activity modification, or any treatment other than surgical intervention. Overall, at a minimum follow-up of 2 years, only 21 of 46 (46%) players successfully returned to the field to play after treatment for 15 games over a 1.5-year period, which was significantly less than what was seen in the operative group (P <0.04). Hsu concluded that patients treated nonoperatively returned at a lower rate, played fewer games, and had shorter careers posttreatment.

Roberts et al²⁰ recently published on the outcomes of cervical and lumbar disk herniations in Major League Baseball (MLB) players. Successful RTP was defined as being on the active roster of an MLB team for at least 1 season after treatment. Time to RTP was calculated as the length of time between the last game played before injury and the first game played after treatment at the
MLB level. Overall, 11 pitchers were identified as having an acute cervical disk herniation. The majority of pitchers with cervical disk herniation successfully returned to play (8 of 11; 73%) at an average time of 11.6 months after diagnosis. Pitchers with cervical disk herniation treated with surgery returned to play at a higher rate (7 of 8; 88%) than those treated without surgery (1 of 3; 33%), but the difference was not statistically significant (P = 0.15).

Clark et al²¹ reported a retrospective case series of five elite wrestlers with an acute cervical disk herniation resulting in cervical radiculopathy. All athletes were treated conservatively with initial activity modification; strengthening; rehabilitation; NSAIDs; and, ultimately, cervical epidural steroid injections. All five athletes were able to successfully return to competition without any negative clinical sequela or the need for operative intervention. The athletes demonstrated a subjective improvement in symptoms and strength, and all were able to return to an elite level of competition. The authors concluded that the epidural steroid injections were safe, efficacious, and well tolerated in this population.

Case Examples

A 28-year-old NFL running back sustained what was thought to be a burner or stinger after sustaining a hit during a game. Symptoms did not resolve, and the patient noted some mild numbness and paresthesias in the C6 distribution that persisted for 1 week after the injury. Radiographs at the time of injury showed no significant spondylosis and a normal cervical canal diameter, with some loss of the normal cervical lordosis (Figure 12-2). An MRI was obtained that revealed a C5 to C6 disk herniation with a foraminal disk herniation. The patient was withheld from play, given NSAIDs, and underwent physiotherapy. With these conservative measures, the patient was able to RTP after 6 weeks with a painless arc of cervical spine motion and no neurologic deficits.

Recommendations for Return to Play

Most athletes are able to return to same-level competition after conservation management of a cervical disk herniation. Specific RTP criteria have not yet been established. In general, when a patient becomes asymptomatic and has a painless normal range of cervical spine motion and no corresponding neurologic symptoms, the athlete may be cleared to return. Exceptions to this include patients who have sustained a cervical cord neurapraxia should not RTP until the underlying disk herniation is treated surgically even if asymptomatic over time. The reason for this is that disk herniation caused a cord level event that must be addressed before return to contact sports. The likelihood of recurrence of symptoms in this setting is more than 50%.

FIGURE 12-2 Lateral cervical radiograph showing loss of cervical lordosis, minimal spondylosis, and a normal cervical canal diameter.

Operative Management

Operative management of athletes should follow an appropriate trial of nonoperative treatment, assuming there is no neurologic deficit or cord signal change. For an acute disk injury in an athlete, there are three primary operative interventions that should be considered: ACDF, PCF, and CDR. The decision on which procedure to perform is determined by the location of the pathology, surgeon experience, and the need for the athlete to return to competition and if so, the level of contact required for the given sport.

Anterior Cervical Discectomy and Fusion

Anterior cervical discectomy and fusion for the treatment for the overwhelming majority of cervical disk herniation because it allows for direct access to the pathology without violation of the posterior muscle sleeve. Furthermore, ACDF eliminates the need for direct neural manipulation and also allows for the indirect decompression the neural elements through restoration of foramina height and direct removal of disk fragments. Overall, the anterior approach to the cervical spine is well tolerated by patients. The most common postoperative complication is dysphagia, with rates after
ACDF ranging from 20% to 50%, although this tends to be a transient complication.

Anterior cervical discectomy and fusion is the most commonly performed procedure for acute disk herniation with associated radiculopathy and has the longest track record of proven success. Smith and Robinson first described the procedure in 1955. Multiple studies have shown the efficacy and safety of ACDF in treated acute disk injuries or cervical radiculopathy. The results of ACDF are often reported in terms of achieving a successful fusion. In a landmark study comparing the use of anterior cervical plates versus no plate in single-level ACDFs, Samartzis et al²² demonstrated fusion rates of 100% with an anterior plate and 90% when no plate was used. There was no difference in clinical outcome between the two groups. Similar fusion results have been seen in the Food and Drug Administration (FDA) trials comparing ACDF and CDR.²³^,²⁴^,²⁵^,²⁶

Clinical outcomes are generally good after ACDF. Gore and Sepic²⁷ reported an initial improvement in 96% patients, with 64% of patients maintaining this improvement out to 21 years. Pain typically recurred at an average of 7 years from surgery, with only a small percentage of patients requiring a secondary surgery. Similarly, Klein et al²⁸ reported on the outcomes of 28 patients who underwent ACDF for symptomatic cervical radiculopathy. Statistically significant improvements were found in postoperative scores for bodily pain (P <0.001), vitality (P = 0.003), physical function (P = 0.01), role function/physical (P = 0.0003), and social function (P = 0.0004). No significant differences were found before and after surgery for general health, mental health, and role function associated with emotional limitations. Age, educational status, and history of compensation litigation did not appear to affect outcome measures.

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