Surgical management of cervical and lumbar disc herniation in the athletic population. Eric Guazzo 7 th November 2015

Pathogenesis of disc herniation. Disc generation is a requirement Disc degeneration is mostly constitutional in origin Life events may influence Disc herniation is common and usually asymptomatic Bulge / Herniation / prolapse / rupture / sequestration / “blown out”

Symptoms of disc herniation Depend on relationship to nerve root and or spinal cord Should correlate with imaging anatomically Vary in reported severity between patients Are significantly influenced by psychosocial factors The natural history is usually benign

Treatment Options: Wait and see (time is our friend) with restriction of physical activity Medications Analgesia, NSAI, Corticosteriods Anticonvulsant medication Antidepressants Foraminal block Epidural steriod Physical therapies A vast range of alternate therapies surgery

Candidates for surgery: persistent severe cervical radiculopathy or lumbar radiculopathy (sciatica) pain Persistent or worsening weakness or numbness Progressive myelopathy Threatened or actual cauda equina syndrome

Outcomes from surgery for disc Herniation. 90% good outcome with respect to resolution of radiculopathy < 10% incidence of recurrence of disc prolapse 1-2% risk of adverse events Modern techniques important, MRI, microscopes, improved procedures case selection

Who are the athletic population? 18 year old rugby player 21 year old netball player 34 year old club rugby payer Keen “ exercisers” of all ages Gym/boot camp participants Professional athlete Rugby league, basketball. Athlete is a person who is proficient in sports and other forms of physical exercise. Oxford Dictationary

What differentiates this population? Motivation Expectations Level of fitness Reporting of symptoms Financial impacts Protecting the player External factors.

Causation of degenerative disc changes has as undergone a paradigm shift with the replacement of physical loading replaced by genetic related factors, Whilst loading has only a modest effect on degenerative disc changes, elite athletes experience greater forces over prolonged and consistent training periods which typically start in childhood, These forces have been postulated to contribute to early degenerative changes and result in a higher prevalence of disc degenerative changes compared to non-athletes Hangai et al Am J Sports Med 2009

Surgical Options : ACDF (anterior cervical discectomy and fusion) Cervical foraminotomy Disc arthroplasty

Considerations, Mechanical changes to the spine Response to loading / forces Adjacent segment disease Very effective and proven procedure

Disc replacement/arthroplasty Preserves movement Similar outcomes to ACDF (medium term) Not suitable for degenerative spines

Cervical foraminotomy / microdiscectomy Microsurgical approach Only suitable for lateral root compression Avoids altering mechanics of spine Earlier return to physical activity Same outcomes with respect to symptom relief cheaper

Neurosurg Clin N Am.Neurosurg Clin N Am Jan;4(1): Lumbar disc disease. Microdiscectomy. Williams RW Williams RW 1. Author information Abstract This article discusses a rationale for the use of microsurgical technique when treating lumbar disc herniations. The rigid surgical discipline of microlumbar discectomy is presented along with a suggested means to best preserve the future competence of the anulus fibrosis. PM

Outcome of disc herniation surgery in athletes. Disc herniation can be a devastating injury in athletes with the potential to reduce an athlete’s career longevity and performance Discectomy is a successful treatment in the general population However, the outcome in athletes may vary because of he high post-operative demands to reach elite athletic performance A high proportion of elite athletes return to play after discectomy but there is variable performance on return Nair et al Clinical Ortho and Research 2015

My experience in Townsville over 20 years Majority of disc herniations in athletes treated non – operatively, Only one player (cowboy) has been advised to retire When surgery was performed in athletes minimally invasive procedures were performed (three cervical foraminotomies two lumbar micro-discectomies, in Cowboys) Majority have returned to playing at high levels

What have I learnt. Never regretted being conservative I have always taken on the players protection as my role Rehabilitation / Return to play Relied on colleagues for support and second opinions To manage the expectations

“What would Dr Eric Guazzo know about concussion ……………………………….?” “ the neurosurgeon stopped him playing because of a disc bulge in his neck, we all have those………….” Coach of NQ Cowboys Reported in the Townsville Bulletin Back Page.