This is a case presentation of a 21-year-old elite baseball player who presented to our clinic with 8 weeks of left C6 radiculopathy. He had no weakness on examination. He was unable to participate in his off-season workout despite extensive conservative treatment. Panels (a, b) show lateral flexion/extension radiographs demonstrating full range of motion with minimal spondylosis. Panels (c, d) show a T2-weighted cervical MRI demonstrating a soft paracentral disc herniation on the left at C5-6. After extensive discussion with the patient, he elected to move forward with a CDA for surgical treatment. Panel (e) shows the post-op radiograph at 6 weeks demonstrating the C5-6 CDA. The patient was released to return to play at 3 months when the patient had full range of motion, no pain, and no persistent neurologic symptoms
This is a case presentation of a 26-year-old professional body builder. He presented to our clinic with complaints of left arm pain and triceps weakness that had progressed over several months. He did demonstrate weakness in his left triceps compared to his right side. He had received to two prior ESIs which temporarily provided relieve. Panel (a) shows a parasagittal CT scan showing the left foramen. The arrow points to the left neuroforamen and demonstrates a bony osteophyte extending from the superior articulating process causing stenosis. Panel (b) shows a CT scan axial image of the C6-7 neuroforamen. The left neuroforamen is stenotic compared to the contralateral side. MRI (not shown) again demonstrated neuroforaminal stenosis with a disc herniation. We had a discussion with the patient and elected to move forward with a left-sided C6-7 laminoforaminotomy. Panel (c) demonstrates an AP radiograph at 6 months post-op. The yellow area shows the decompressed foramen. Panel (d) is a lateral radiograph at 6 months post-op demonstrating maintained lordosis with minimal spondylosis. The patient was able to return to weight lifting at 3 months post-op
Expert Opinion
While some authors have opined that an acute disc herniation is an absolute contraindication for return to play for professional athletes engaging in contact sports [16], most of the peer-reviewed studies available in the current literature would suggest otherwise. Kang et al. endorses that there is a strong consensus among the current literature that return to contact sports after single-level ACDF are safe and feasible [2]. Some have even proposed that spinal cord signal change on MRI is not a contraindication for return to play in contact sports, as long as the player is asymptomatic and neurologically intact [11]. Overall, when accounting for the results from all of the currently available studies of cervical disc herniations in elite athletes, more than 50% of players were able to return to all professional sports [17], which is probably equivalent regardless of operative vs. non-operative treatment. Notably, these types of injuries have a much different prognosis than those associated with myelopathy or even transient neuropraxia.
While single-level ACDF has been extensively studied as the primary surgical treatment for athletes with cervical disc herniations, there remain significant controversy and limited evidence regarding return to play to contact sports after 2- and 3-level ACDF, TDR, and with posterior approaches, including posterior laminectomy and fusion, posterior laminoforaminotomy, and laminoplasty [2]. In a study of active military personnel, Tumialan et al. found that posterior laminoforaminotomy allowed for faster return to unrestricted full duty and was more cost-effective than ACDF [18].
Ultimately, further investigation is needed to address the optimal treatment strategies for elite athletes with cervical disc herniations. At present, the available data suggest that athletes can be successfully treated non-operatively and return to play at high rates. It is acceptable to allow athletes to return to contact sports if they are asymptomatic, neurologically intact, and have full, painless cervical range of motion. For those who fail conservative treatment, it is both safe and feasible to return to contact sports after cervical disc surgery, if the previously mentioned criteria, along with a solid fusion mass, are met. Further studies are needed to address return to contact sports after TDR, multiple-level ACDF , and posterior surgical approaches, including laminoforaminotomy with discectomy, laminectomy and fusion, and laminoplasty. Due to the small population of elite athletes and highly individualized nature of these injuries in players who depend on their athletic careers, it is likely that treatment of cervical disc herniations in athletes will remain a controversial topic. Personalized treatment plans and shared decision-making between the athlete and surgeon are critical to exploring the benefits and risks of surgical intervention and returning to play.
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