Lateral and AP radiograph of the lumbar spine with relevant anatomy labeled. (From: Valladares-Otero [33]. Reprinted with permission from Springer Nature) (a) X-Ray Lateral View Lumbar Spine. (b) X-Ray Anterior-Posterior View Lumbar Spine
When back pain does not improve after treatment with rest, NSAIDS, and physical therapy, or if presenting with neurologic deficit or following significant traumatic situations, then advanced imaging is warranted. Also, when dealing with thoracolumbar pain/injury in high-level athletes, advanced imaging is usually required. Advanced imaging includes computed tomography (CT) and/or magnetic resonance imaging (MRI) . CT is best for detailing bony anatomy; MRI is best for detailing soft tissue and neural anatomy. CT is best for identifying pars defects and fracture as it allows for high-fidelity evaluation of complex three-dimensional bony anatomy of the spine. In an athletic injury patient, MRI is useful to evaluate for neural compression, posterior ligamentous complex injury, or an occult stress fracture. CT and MRI can both be used to determine if the patient has a pars injury or pars defect [19, 38]. A 1.5T MRI using short tau inversion recovery (STIR) and T2-weighted imaging can show bony edema or impending fracture/stress reaction.
Lumbar Injuries
The most common lumbar injury in the athlete is a simple lumbar strain, accounting for 54% of reported lumbar spine injuries in collegiate athletes [1]. This can range from a simple bruise to a traumatic tearing or shearing of muscle fibers in the paraspinal muscles or core musculature that supports the thoracolumbar spine. The patient will usually have posterior paraspinal tenderness that is non-radiating. Pain is worsened with activity and range of motion and improves with NSAIDs and rest. Contact injuries to the paraspinal musculature may result in similar symptoms but are frequently associated with bruising or abrasions overlying the injury. Athletes that sustain injuries with a hyperflexion moment may injure the supraspinous and interspinous ligaments and will have midline pain over the spinous processes of the affected area. Splaying of the spinous processes can be seen on routine lateral XR if a significant posterior ligamentous complex injury has occurred.
Athletes with a blow to the gluteal region can develop inflammation of the sciatic nerve that is independent of lumbar disc pathology. Patients are tender to palpation deep in the gluteal region over the piriformis muscle, and pain can be recreated by forced internal rotation of the thigh or with resisted abduction and external rotation. These tests put the piriformis muscle on tension and irritate the sciatic nerve. MRI will demonstrate no lumbar disc pathology despite radicular symptoms from piriformis aggravation.
The lumbar intervertebral discs are commonly injured in football players as well as those undergoing repetitive axial loading of the spine [3, 4, 20–23]. The annulus fibrosis and nucleus pulposus are affected by rotation and axial loading, respectively. An acute traumatic injury to the spine or chronic repetitive microtrauma can damage the annulus fibrosis. Small rents in the annulus fibrosis may develop allowing the nucleus pulposus to herniate, potentially causing nerve root compression and radiculopathy. Most commonly, herniation of the nucleus pulposus occurs in the posterolateral aspect of the disc where the posterior longitudinal ligament thins. Low back pain with radicular pain can indicate a herniated disc. Most symptomatic disc herniations occur at L4-L5 or L5-S1. It is imperative to rule out cauda equina syndrome when large lumbar disc herniations are identified. L4-L5 posterolateral disc herniations affect the L5 nerve root and can cause pain and sensory deficits to the lateral leg and dorsum of the foot with weak great toe extension. L4-L5 far lateral disc herniation affects the L4 nerve root and causes anterior shin pain and numbness with weakness to ankle dorsiflexion. L5-S1 posterolateral disc herniations affect the S1 nerve root and cause radicular pain and sensory deficits on the posterior aspect of the leg into the plantar aspect of the foot with weakness to plantar flexion. L5-S1 far lateral disc herniations affect the L5 nerve root and present the same as stated above. Toe-off weakness and slapping gait are subtle findings of motor deficit that may be difficult to detect on physical exam in very strong athletes.
Isolated facet injuries are rare and typically occur in the lumbar spine. Increased motion in this region as well as the sagittal orientation of the facet joints makes these structures more vulnerable to injury compared to the thoracic spine. Facet fractures are usually the result of violent rotational forces, such as those that occur in contact and extreme sports. Most athletes report axial and paraspinal pain that is made worse with flexion, extension, and rotation. Fortunately, isolated facet injuries rarely result in neurologic injury or instability, respond well to conservative treatment, and are unlikely to cause long term pain or disability.
Spondylolysis is a common cause of lumbar back pain in athletes. Traumatic spondylolysis may occur with forced hyperextension with axial loading and/or rotational forces and will typically result in acute low back pain and point tenderness over the area of injury. In contrast isthmic spondylolysis typically occurs in growing adolescent athletes as a result of repetitive microtrauma from hyperextension and rotational forces as well other genetic and environmental factors [39–43]. Additionally, McClellon et al. found 63% of adolescents with a new diagnosis of symptomatic spondylolysis had deficient or insufficient serum vitamin D levels [44]. For this reason, we recommend routine testing for vitamin D deficiency and supplementation for all patients with symptomatic pars interarticularis defects.
The posterior elements are the primary restraint to anteriorly directed shear forces in the lower lumbar spine [39, 42, 43]. Defects in the pars intraarticularis disrupt the osseous anchor between the effected vertebra and caudal levels and may lead to instability and anterolisthesis of the effected level. Although most symptoms will improve with time and most patients will follow similar course of degenerative changes as the general population, some patients will experience persistent instability and progressive anterolisthesis [45]. Significant instability will frequently result in back pain that is made worse with extension activities as well as stranding from a seated position. Additionally, patents with high grade anterolisthesis, congenital narrowing of the spinal canal, or hypertrophic extraneural tissue from degenerative processes may report symptoms of neurogenic claudication or radiculopathy of the exiting nerve roots. These patients may also have associated paraspinal muscle spasm and posterior chain contracture that alters kinematics an contributes to disability.
Acute fractures of the lumbar spine are rare, potentially devastating injuries. As with long bones, classically described morphologic patterns of these injuries are dependent on the mechanism of injury. Additionally, the three-column theory of spine stability is a useful conceptual framework for lumbar and thoracolumbar trauma (Fig. 18.2). Compression fractures of the superior end plate typically occur with low energy axial loading in flexion [46, 47]. High energy axial loading in neutral or extended alignment typically results in burst fractures of the vertebral body [46–49]. Violent flexion or extension mechanisms accompanied by distraction and/or torsional forces tend to produce three column injuries that are highly unstable [46]. Most fractures can be treated conservatively with bracing and monitoring, particularly if there is low concern for injury of the posterior ligamentous complex. Fractures that demonstrate instability on advanced imaging or upright plain radiographs as well as those with associated neurologic deficits usually warrant operative fixation with or without decompression and or fusion [50]. The senior authors routinely use the AO Spine Thoracolumbar Spine Injury Classification System (TLICS) to help guide operative decision making for lumbar and thoracolumbar fractures in this population. In general, when high energy lumbar spine injuries occur, standard trauma principles should be applied to decompress neural elements when necessary and provide adequate fixation correct and prevent deformity.
At times, athletes may present with chronic sacroiliac (SI) joint pain. These patients present with low back and posterior hip pain that is worse with activity and improves with rest. Any athlete or adolescent patient presenting with these symptoms should be evaluated for hip pathology as well. Adolescents that are overweight or have certain genetic and metabolic disorders are at risk for developing slipped capital femoral epiphysis (SCFE) and AP and frog-leg lateral imaging should be obtained of both hips to rule out this diagnosis. Additionally, patients with pain elicited by hip flexion, adduction, and internal rotation (FADIR) are likely to have intra-articular hip pathology whereas hip flexion, abduction, and external rotation (FABER) stresses the ipsilateral SI joint. SI joint pain in general and arthritis in particular may be the first symptom of ankylosing spondylitis (AS), psoriatic arthritis, or other inflammatory spondyloarthropathies and these patients should be referred to primary care or rheumatology for a complete rheumatologic workup. Sacral stress fractures should also be included in the differential diagnosis of caudal low back pain, particularly when the female athlete triad is suspected [51–54].
Magnified view of the thoracolumbar spine with lines demarcating the three-column theory of spinal division. (From: Valladares-Otero [33]. Reprinted with permission from Springer Nature)
Management
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Nonoperative Treatment
Most soft tissue injuries respond well to conservative treatment. Rest, ice, and non-steroidal anti-inflammatory medications should be initiated immediately after an injury has occurred to control the acute inflammatory response. Patients with neurogenic pain and radiculopathy due to nerve root compression will often benefit from gabapentenoid medications such as pregabalin or gabapentin, where pregabalin appears to be more effective [55–59]. Although gabapentin and pregabalin are effective for some patients, approximately 10-20% of patients discontinue therapy due to medication related somnolence. Additionally, treatment with gabapentinoid medications should continue for several weeks to reach maximum benefit and patients should be monitored for medication related depression and anxiety [56, 57, 59]. Corticosteroids are commonly used to reduce inflammation, control symptoms, and improve short term function in patients with acute radiculopathy secondary to intervertebral disk herniation. A short oral corticosteroid taper or single IV or IM administration may modestly improve neurogenic pain. However, these medications do not improve pain or functional outcomes long term [60–63]. Athletes with axial back pain or paraspinal muscle strain may be treated with non-habit forming muscle relaxants such as cyclobenzaprine, tizanidine, or methocarbomol [64]. Physicians should avoid prescribing opiate pain medications for non-surgical or non-fracture related pain due to high risk dependence and addiction. If necessary, providers should always prescribe the lowest potency and lowest dose pain medication to achieve functional pain relief.
If adequate pain relief is not achieved or if the athlete reports chronic low back pain, referral to interventional pain management may be warranted. Many different treatment options including epidural steroid injections, facet joint injections, and radiofrequency ablation of facet joint innervation may be utilized to achieve symptomatic control. The specific indications and relative efficacy of these treatment modalities are highly variable and outside the scope of this text.
Once the acute inflammatory phase of soft tissue injury has passed, the athlete should be started on a structured physical therapy program. Maintaining strong anterior abdominal and paraspinal musculature is critical to postural control. Additionally, deconditioning can occur very quickly after injury and poor core strength may predispose athletes to reinjury [65]. Physical therapy protocols should begin with truncal stability and core strengthening exercises [66]. With time, athletes may be progressed to more sports specific activities as symptoms resolve and adequate truncal stability is achieved [67]. Lastly, many physical therapists and athletic trainers are trained in a myriad of alternative physiotherapy modalities such as targeted transcutaneous electrical nerve stimulation, therapeutic massage, and dry needling that may improve myofascial pain after injury [68–72].
Operative Treatment
Most injuries and pathology of the lumbar spine are best treated with conservative means as described above. Lumbar disc herniations causing radiculopathy and significant weakness typically warrant operative intervention. In athletes, microdiscectomy may be performed with predictably good results with approximately 80% of patients returning to competitive play after surgery [73, 74]. Cauda equina syndrome, which may result from large central disc herniations, causes urinary retention, fecal incontinence, and saddle anesthesia with a variable pattern of weakness and radiculopathy is a surgical emergency and should be decompressed expediently [75, 76]. High energy spinal column injuries resulting in instability or neurologic comprise should be urgently decompressed and stabilized to optimize neurologic outcomes and prevent deformity [50]. Any fusion that is performed at a high motion segment is at risk for non-union and many athletes requiring fusion or longer segment instrumentation should refrain from contact sports until fusion or fracture healing is confirmed on radiography.
Rehabilitation and Return to Play
Most athletes are principally concerned with return to play and achieving their pre-injury level of performance, particularly at higher levels of competitive play. Additionally, athletes experience significant social and, at times, financial pressure to return to play as quickly as possible. It is important to establish clear return to play criteria and develop a treatment plan jointly with the physical therapists, coaches, athletic trainers, and the athlete. Failure to utilize a multidisciplinary approach and communicate clearly with all parties involved may lead to treatment failure and ultimately delay or prevent the athlete from returning to their pre-injury level of performance. Regardless of the treatment chosen, a progressive trunk stability and core strengthening rehabilitation program should be completed with the athlete demonstrating sufficient truncal control to safely meet the demands of their sport on formal return to play testing before they are released to resume unrestricted athletic activity [66, 67, 77–80].
Controversies and Expert Opinion
When dealing with the elite athlete, there is an incredible amount of pressure from the coach and trainers to return the athlete to play regardless of whether the athlete is ready to return. It is the responsibility of the physician to maintain their beliefs and recommendations in the best interest of the athlete despite this pressure. Although some surgeons believe in operating on acute pars defects in the thoracolumbar spine, we treat these patients conservatively initially. Only if they develop spondylolisthesis with radiculopathy do we entertain surgical intervention. Vertebral augmentation is a valid treatment option for ligamentously stable compression/burst fractures that surgeons should be more comfortable offering to athletes for them to potentially mobilize and return to play in an expedited fashion. Vertebral augmentation, such as kyphoplasty, should be in a surgeon’s armamentarium in treating compression/burst fractures in the athlete population. Unstable lumbar fractures that require operative intervention are the result of a high-energy mechanism. These patients should be evaluated and treated as any other acute spinal injury presenting to a trauma center. Care should be focused on safe transport and evacuation from the playing field.
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