Robert Watkins, MD, co-director of Marina Spine Center at Marina Del Rey (Calif.) Hospital, discussed lumbar disc herniation in the elite athlete at the 2013 North American Spine Society Annual Meeting.
"The key thing is to make the diagnosis as soon as possible. If an elite athlete comes to us with a back problem, we try to give them a diagnosis that day with a recommendation and a prognosis. We sit down with the athlete, see what they want to do about the problem, what their feelings are, and then try to convey that information to all interested parties," said Dr. Watkins.
Acute lumbar disc herniation general estimated return to play time is six to 12 weeks; if there is radiculopathy, its closer to 12 weeks, according to Dr. Watkins. Return to play depends on the patient and the player's ability to do core exercises and perform on the field.
"You have to have some ball park idea despite the changes we all know in disc herniation," said Dr. Watkins. Surgery often depends on the severity of symptoms, response to the non-operative program, size of the fragment, degree of underlying stenosis and whether the sport is in-season — or how far away the season is.
"It's your job to protect the patient during that period of time and understanding the timing of the surgery in relation to their life and physical findings," said Dr. Watkins. Before performing microscopic discectomy for lumbar herniation, he recommends:
• Check for pars fracture prior to surgery
• Check flexion/extension X-rays
• Check for underlying congenital stenosis
• Check foramen for far-lateral herniation
"Be an accurate diagnostician is a key part of starting on the right course," said Dr. Watkins. Depending on the player, the trunk stabilization program begins when postoperative pain is minimal, typically three to six weeks; return to play can be six weeks to six months depending on the athlete's completion of the trunk stabilization program, conditioning, level of skills to perform and sport-specific exercises, among other factors.
For a successful return to play, the athlete continues the trunk stabilization for a year after returning to the sport. That's not always easy, but working in the stabilization program is important to achieve peek performance. Average return to sport is 89 percent after microscopic lumbar discectomy, according to an American Journal of Sports Medicine study published in 2012.
If the season is in-play when the athlete returns, 50 percent return after three months; 72 percent after six months and 77 percent after 12 months. After returning to play, athletes may not return to the same peek level as before surgery. About 13.5 percent of athletes undergoing spine surgery for disc herniation require a revision surgery and 86 percent of those athletes return to play after the revision, according to a 2011 study published in the American Journal of Sports Medicine.
"The success to returning the athlete to a sport in my opinion depends on controlling and directing the rehabilitation program," says Dr. Watkins. "If you don't understand and can't control the rehabilitation, don't do the surgery."
Dr. Watkins and his team developed a core strengthening and rehabilitation program allowing them to quantify the rehabilitation process and meet key goals before returning to the weight room and then to play. As a result, he is able to monitor and help coordinate rehabilitation for athletes from around the country.
"As the surgeon you need to understand the sport and what people need to do to get back to those kinds of things," says Dr. Watkins. "The key part of taking care of elite professional athletes I think is the decision making and it's the decision making that requires some experience. You sit down and make the decisions with the athlete. Ask who you want you to call and you call in front of the athlete to discuss the problem with the people concerned and dictate the report in front of the athlete so there is no miscommunication."
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