The chief indications for spine surgery in the athlete are the same indications for spine surgery in any patient:
1. Sufficient morbidity to warrant surgery.
2. Failure of conservative care.
3. An anatomic lesion that can be corrected with a safe, effective operation.
4. A proper, fully developed postoperative rehabilitation program. A proper postoperative rehabilitation program cannot be overemphasized. The failure to do postoperative spinal rehabilitation would be similar to a failure to do postoperative knee strengthening after reconstruction of the knee. The patient wants restoration of function. The surgeon should be able to guide the patient through his or her restoration to function. The morbidity of the patient, amount of pain, loss of function, and occupation are the critical factors.
Spinal operations to enhance performance rather than relieve disabling pain are a part of managing the care of athletes, a part that requires a great deal of experience not only in spinal surgery but also in dealing with athletes.
There are numerous factors to consider. One must always keep in mind the full longevity of the patient. Young players can lay out a year after a significant spinal surgery and still return to play. Older players are less likely to return to play after a major spinal reconstructive operation.
What the player will be like after his or her career and condition of his or her spine at that time should be of major importance in decision making early in the player's career.
A major factor is calculating the risk if the operation is successful. In many sports, after a spinal fusion or a major resection of a supporting structure in a lumbar decompression, the percentage chance of return may be no greater after the operation than without the operation.
A surgeon must carefully question his or her advice concerning surgery if he or she does not have a proper alternative to the surgery and good, effective nonoperative care. Frankly, if all one knows is the surgical technique and if one does not have a proper understanding of and delivery system for a nonoperative care program, then that person should not advise surgery for the athlete. An appropriate team approach among specialists in nonoperative care and specialists in operative care can be worked out so that the decision for surgery is well founded, but the surgeon must understand and participate in that portion of the decision-making process, namely, a sufficient nonoperative treatment plan.
The anatomic lesion is critically important. A simply extruded disk herniation, of course, can be very amenable to a one-level microscopic lumbar diskectomy, but an annular tear of the intervertebral disk with mild nerve root irritation will not be made better by a decompressive laminectomy and usually will be made worse because of abnormal motion in the injured disk, segmental instability, if you will, now with a nerve root scarred to the back of the annulus. In spondylolisthesis, the obvious solution may be, as it is in the majority of the patients facing surgery for this problem, a spinal fusion. Some athletes can return to their sport after a successful spinal fusion and some may not be able to. Part of the danger is in curing the radiograph and not the patient. Another possibility is curing the patient with a successful operation and leaving the player without a job.
As with everyone, an absolute indication for surgery with lumbar disk disease is progressive cauda equina syndrome or progressive neurologic deficit. Strong, relative indications are static significant neurologic deficit, unrelenting night pain, and major loss of functional capability. Mild relative indications for surgery fall more under the category of performance enhancement and return to play. There will always be patients who could live the way they are but cannot perform the way they are. This is a relative indication for surgery but must be a frequent consideration in lumbar spine injuries in athletes.
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