A spine surgeon’s perspective to common sports related spine injuries, disc herniation, and stress fractures
BY DR PETER DERMAN, DR VENU NEMANI, AND DR PHILIP LOUIE
With the Paris Olympic Games and several international elite sports events this summer, sports related injuries and recovery strategies are also making headlines. High-performing athletes commonly face spine injuries such as disc herniations or stress fractures due to their rigorous training and the extreme strain on the body. Various novel treatments and minimally invasive techniques aim to ensure quick return to play and medical research with an individualized approach required for each athlete's specific condition and sport is evolving quickly. But for the best outcomes, the importance of core strength in preventing and gradually recovering from these injuries cannot be stressed enough.
Disclaimer: The article represents the opinion of individual authors exclusively and not necessarily the opinion of AO or its clinical divisions.
Most spine surgeons don’t grow up with a background in high-level sport activities but watch it from a different perspective: we look at the positions that for example gymnasts are in, and the risks they seem to be taking. We cringe at what could happen if they don't land a specific routine or a specific move, and we can only imagine how rigorous the training to get to that point must be. With notable gymnastic achievements and being named a 3-time all-American on rings, Peter Derman (in photo) shares with us some of his his insider knowledge.
It comes as no surprise that several Olympians have experienced spine surgery or dealt with significant spine problems. For example, the legendary Jamaican sprinter Usain Bolt dealt with scoliosis throughout his career but managed with physiotherapy. Tiger Woods underwent multiple spine surgeries, including a fusion surgery, the Spanish basketball player Pau Gasol has dealt with back issues throughout his career, including a significant back injury that required surgery. Or the American gymnasts Simone Biles, who has struggled with back injuries and intensive rehabilitation to maintain her elite performance level, and gold medalist Shawn Johnson who had several surgeries, including one for a herniated disc.
Most high-level gymnasts start at a very early age to get to the top, latest by the age of seven. The ‘air awareness’ is something you can only learn very early on. One of the first things that you're taught is how to fall. The techniques around falling are crucial because flying through the air leaves a lot of room for injury. And even if you know how to fall, there's still the chance of injury.
The common sports related spine injuries
The most catastrophic fracture, the one people are most scared of, is breaking your back or your neck. Severing or damaging your spinal cord can result in paralysis or other neurologic injuries. Fortunately, this is very rare, but the fear of it is there. Most gymnasts or horseback riders will know someone who required surgery after neck or back injuries. Even if these injuries are very rare and don’t always lead to neurologic issues, it puts things in perspective.
The most common injuries for the general population of athletes and humans are soft tissue injuries, and this applies also to the back. You can sprain, strain, irritate, and pull muscles, tendons and ligaments around the neck and the lower back exactly as you can in your shoulders, knees, and hips. Soft tissue injuries can cause a lot of pain. Like pulling your hamstring while running, you can strain muscles around your spine, resembling a whiplash, and it will take weeks or months to improve.
Stress fractures are another common type of injury in sports alongside acute traumatic injuries and soft tissue injuries. Pars interarticularis (pars) fractures are most common in the lower back, at L5–S1 level, in sports where the back is repeatedly bent backwards, such as gymnastics, martial arts, football, or basketball. The pars lies between the superior and inferior articular process, bilaterally at each vertebral level. It is the region between a superior and an inferior zygapophyseal joint and prevents the vertebrae from sliding forward. Over time, like wiggling a paperclip, bending it repeatedly enough times will make it break.
Sometimes athletes can have pain, but often these fractures go unnoticed for years. Over time, the L5 will slip forward on the S1, causing spondylolisthesis resulting in back pain. When patients get to their forties or fifties, it starts to pinch the nerves and cause sciatica.
So, a stress injury often happens when athletes are in their adolescence but doesn't manifest until later. These injuries are common and don’t always require surgery. There are lots of patients who are actively training at a high level with pars fractures, which goes to show we can continue to live “normally” with some of the pathologies we have.
Disc herniation is another category of common sports related spine injuries, where piece of the ‘shock absorber’ between your vertebrae breaks off due to wear and tear. This causes pressure on the adjacent nerves and sciatica down the leg. This can happen also in the neck causing pain down the arm. Interestingly, it is younger people who more commonly tend suffer from disc herniation. As you get older, due to natural discs degeneration the discs don't tend to herniate as much.
So, how to deal with these disc herniations? The good news is that the vast majority, around 80%, of disc herniations can be treated nonoperatively. But for the remaining 20%—after exhausting options for physical therapy, non-narcotic medications, epidural steroid injections—surgery can make sense. Also, if you have a foot drop and a lot of weakness due to the disc herniation, you may want to progress to surgery more quickly because it can indicate nerve damage. Red flag situations include the Cauda Equina Syndrome, a massive disc herniation that causes complete obliteration of the area for the nerves and can cause numbness in the groin and difficulty with going to the bathroom. This is an emergency, but fortunately very rare.
Minimally invasive techniques for disc herniation surgery
For the run-of-the-mill disc herniation causing sciatica pain, numbness, and tingling, most people get better without surgery. However, disc herniation surgery is very successful. Patients are usually healthy, active people who are suddenly sidelined by an injury. The traditional microdiscectomy will heal the sciatica, but it is no longer considered the state of the art: the approach involves an open incision, burning and stripping the muscles off the side of the spine. It is not removing the herniation that is considered problematic, it's getting there and the collateral damage.
There are some more advanced techniques like minimally invasive tubular retractors that allow for open surgery through a smaller incision that is more friendly to the surrounding tissues, or endoscopic spine surgery which is a paradigm shift. Previously it was about ever smaller incisions, but still fundamentally the same open surgery.
In endoscopic surgery you use a camera; so rather than making an incision the surgeon will peer down to see and remove the disc herniation, you place a camera down an eight-millimeter incision. The camera in inserted between the muscle fibers so you don’t disrupt those important stabilizing structures. The surgeon sees everything on a big screen rather than looking into the patient. The camera is so small that you can usually get it into the spinal canal, where the nerves and the disc herniation are, without removing any bone whatsoever. As a result, the patient has very little surgical site discomfort and is back home within a couple of hours of surgery. They usually manage with over-the-counter pain medication and are back at work within a couple of days.
The advantage of endoscopic techniques is you're not destroying the muscle. Traditionally, patients have been restricted for four to six weeks after disc herniation surgeries. With endoscopy, theoretically, patients are physically able to return to normal activities immediately, keeping in mind there is still a weak spot in the back of your disc due to the removal of the disc herniation. Currently there is no effective way of patching that hole and it takes up to six weeks for the body to heal. This is why patients should avoid heavy bending, lifting, twisting for six weeks. But physical therapy for example with stationary bike can start as soon as the patient feels comfortable, and many people are doing this the day after surgery.
People who have a disc herniation in the neck often end up with either a fusion or a disc replacement from the front, which are the two most common options in the US. Young patients would normally get a disc replacement, but athletes might have problems with a prosthetic device in the head that's constantly getting pummeled back and forth. Posterior cervical foraminotomy and discectomy allows access to the disc herniation, removing the pressure from the nerves in the neck without using a prosthetic device and the patient is stable to return to the high-level activities.
Interestingly, in the spine field, we often refer to research studies done 20 or even 30 years ago, but the way that patients are treated today is so different that you can hardly apply the findings. But obviously not everything can be treated by an endoscope and as surgeons we apply the best available technique to the pathology.
Learning to fall and a few words before you start crunching
Learning to fall is one way to prevent acute traumatic injuries. The preventative efforts for repetitive overuse type of injuries are all about core strengthening, especially for the low back. Often people think of abs when talking about the core but doing crunches may actually be harmful: your discs are in the front of the spine and with crunching you are compressing the discs over and over again. Planks, side planks, reverse bridges, and other isometric activities are better for building the core muscles, including the obliques and paraspinal muscles, to create an internal back brace to hold you up and take the pressure off some of these structures and protect them when you're doing these kinds of extreme activities.
Listen to more insights from spine surgeons on the Athlete Spine, a series hosted by spine surgeons Venu Nemani and Philip Louie. This Guest Blog post is based on a 2024 Summer Olympics Spotlight episode with Peter Derman as guest.
About the authors:
Dr. Peter Derman, MD, MBA, attended Stanford University and competed as a Varsity Gymnast as an undergraduate. He cited his greatest athletic achievement as being named a 3-Time All-American on Rings.
Derman went on to earn his MD from Perelman School of Medicine, University of Pennsylvania and MBA from Wharton School, University of Pennsylvania in Health Care Management. After completing his residency and fellowship in Spine Surgery,
Dr. Derman now works at the Texas Back Institute, specializing in minimally invasive and endoscopic procedures.
You might also be interested in:
AO Surgery Reference—a resource for the management of fractures, based on current clinical principles, practices and available evidence.
AO Spine Injury Classification Systems—download the toolkit and start using the classification today.
Minimally Invasive Spine Surgery (MISS)—explore the AO Spine MISS resources.
Golf-related spinal injuries and outcomes following spinal surgery—AO Spine Guest Blog post on current knowledge.