Thank you for being with us. I'm Daniel Liu from UCLA, and I will be covering return to play after lumbar spine surgery. I have no relevant disclosures. This is a case illustrating the relevance of this talk. This is a 22-year-old college senior basketball player with EHL weakness and L5 radiculopathy treated with L4-5 discectomy. In the images below, you can see that there's an L4-5 disc herniation that essentially obliterates the spinal canal. Another illustrative case is this 54-year-old golf pro with history of L4-5 redo microdiscectomy and one month after presents with acute foot drop after return to play. MRI shows reherniation, and he was treated with L4-5 T-LIF. So the question is, when should this guy be allowed to return to golf activities? Or, this is a 17-year-old high school football junior linebacker position with intermittent back pain only after games. A patient currently is competing for Division I football scholarship, and you can see here that there is a pars fracture bilaterally that's chronic in nature. And the question is, when should this person be allowed to return to play? So previous cases highlight the questions often posed to us as neurosurgeons, particularly in cases where the patient is an athlete. And lumbar pathology is quite common in athletes. Approximately 30% of athletes experience low back pain during careers. Sports involving hyperextension, twisting, axial loading, and direct contact are at particularly high risk, such as football and gymnastics. 75% of elite athletes or gymnasts have evidence of disc degeneration compared to 31% of non-athletes. In terms of loss of productivity in athletes, low back pain is the reason for lost playing time in 30% of college football players, and 38% of professional tennis players miss at least one tournament secondary to low back pain. We all know that Tiger Woods struggled with his back since 2013. He's had issues, and in 2014, it got to a point where he had to withdraw. He underwent a lumbar microdiscectomy in March 31 of 2014. He did not play in the 2014 Masters, and shortly thereafter, he had a redo lumbar microdiscectomy in 2015, which was surgery number two. And in October 30, 2015, he also had another surgery, which was surgery number three. And you can see from this video, after his first surgery, that he was obviously still contending with his back issues. And in looking at his performance after his first surgery, which he only took three months off for, he was obviously not himself. In 2014, after three months of hiatus, he missed a cut. He withdrew in July and subsequently really was not back to his pre-surgical performance. So after his third surgery, he missed a Masters tournament, which is six months after six months hiatus, and withdraws after attempting to play in October 2016 and safely open, which would mark the one year after his surgery. And subsequently, he really wasn't back in shape in February 2017, withdraws again, and missed a cut at Arnold Palmer Interventional and misses the Masters in March 2017 for a third time in four years. In April of 19, 2017, he had a mini-open ALIF as surgery number four, which he struggled with with a recovery, having been involved in a DUI with multiple pain and sedative medications in his system. For 2018 season, he played Hero World Challenge, which was an unofficial event at PGA TOUR seven months after his fusion surgery. He formally competed on September 20th as a first TOUR Challenge nine months after surgery, and 2018 Masters, he came in 32nd, which is pretty good considering how many surgeries he went through. And we all know in 2019, he won the Masters, which is his first in 14 years, or about two years after his last surgery. I presented Tiger Woods as an example of an elite athlete where the calculus of his return to play has significant implications. Too early return to play risks re-injury and jeopardizing future career, which may or may not have happened here with Tiger Woods. Too late return to play risks deconditioning lost wages and income and enjoyment of the sport. So optimal timing should allow for safe return to play while minimizing loss of competitiveness and enjoyment in wages. We certainly do want to make sure that we get it right, and there are potential malpractice implications in clearing someone too early to return to play, and this is actually an actual case, which appears to be without merit. But nonetheless, we are subject to such pressures and scrutiny. And obviously in these elite athletes, there's probably very little chance that we're going to be able to conduct a randomized controlled trial to randomize these elite athletes to various different time points of return to play. So that's certainly not feasible. So the literature for return to play for lumbar surgery, our majority are level three, which is retrospective cohort studies. So back to this topic. This is a 22-year-old college senior basketball player with EHL weakness and L5 radiculopathy status post L4-L5 discectomy, and the question is when this patient should be able to return to play. So the data for the efficacy of lumbar discectomy for herniated discs is pretty clear. The spine patient outcome research trial, SPORT trial, the observational cohort study demonstrated significant improvement in pain and physical function scores after lumbar discectomy at three months, one year, and two years after original surgery. The SPORT randomized trial also demonstrated transverse positive significance in the surgical group, which was published in JAMA in 2016. So data for application of discectomy in the setting of lumbar disc herniation is pretty clear. So I'll start presenting some data related to return to play in lumbar discectomy in competitive and sports pro athletes. This is a paper that was published in the Spine Journal in 2011. It's a retrospective cohort study with 342 patients, and these subjects are identified through press releases, team injury reports, and newspaper reports. The successful return to play was evaluated for games, and there's about 82% success for return to play with a career length of 3.4 years. There's no statistical difference between surgical versus non-operative cohort, consistent with common sense, which is age is a negative predictor of career length. Major league baseball appears to have higher return to play versus NFL, which likely relates to the fact that NFL is a contact sport. So looking at the NFL players, this is a retrospective cohort study of the NFL players with available public records. It was published in 2010 in Spine. The return to play rates for non-operative and operative are the same. There's about 78% return to play, which is the same general population. The career length after treatment is greater for athletes who have undergone a lumbar discectomy. However, it's confounded by older age of patients in the non-surgical treatment group. The performance scores before and after treatment were about the same, 8% in surgical group with reherniation, and in terms of reherniation rates, it's about 8% in the surgical group, which is about the same in general population. So based on this study, it actually bodes well for the patients, athletes who are in NFL who actually had undergone lumbar discectomy, and they seem to have a preserved function. And Antonio Romo, who is actually no longer in NFL, but he's a broadcaster, in 2013, he was diagnosed with herniated disc before the last game of the season. He underwent decompressive surgery, and subsequently in 2014, actually had a great year, which is 3,700 yards passing with a passer rating of 113. So this suggests that this is an effective procedure. So what happens in an NFL lineman who actually has a lot more contact than a quarterback? So this is a return to play of lumbar discectomy in NFL linemen. This is a case series, and the source, again, was from public records. There's 52 number of surgeries, 14 are non-surgical patients. There's about 80.8% return to play with 33 games over three years, versus 28.6% return to play after non-operative treatment. There's 13.5% re-operation rate, 85.7% successful return to play. So these rates of re-operation and return to activity appears to be the same as a normal population. And in the NBA athletes, this is a retrospective case control series study that was published in Spine. Again, the source is from public records, 24 surgery versus 12 age-matched NBA controls. There's a 75% return to play versus 88% control, which is not significant. And apparently, there's improved block shots and rebounds in lumbar discectomy versus control per game. And again, this is another paper looking at NBA athletes' return to play outcome after lumbar herniation in NBA. This was published in Orthopedic Surgery. It's a retrospective case series. Again, the source is from public records with 34 patients versus 28 age-matched NBA patients. There's 78% return to play versus 80% control, although it did demonstrate the player played fewer games, lower player efficiency in the first post-operative season. However, in the subsequent seasons, there's no difference in second, third years after surgery and there's no difference in career length. So it appears that there's some conditioning issues after initial post-season, actually first year after surgery, that requires some acclimation and attaining reconditioning. And Dwight Howard actually back then was playing with the Houston Rockets, was diagnosed with a herniated disc in the last game of the season, underwent lumbar discectomy surgery with a six-month hiatus, and 2012-13 apparently had lowest scoring average season. And he's currently actually still playing with, in 2016, had average career stats. He's actually now part of the Lakers. So more studies in pro and Olympic athletes. This is a case series of 50 lumbar discectomies on 29 professional and Olympic athletes. The 88% return to play in 5.2 months, which varied from one to 15 months after surgery. Return to play involved intensive post-operative rehab focused on trunk stabilization and strengthening. So this study attempts to assess all the available literature in terms of outcomes after lumbar discectomy in elite athletes. And it was essentially a literature review from 1947 to 2013, and looking at elite athletes' recovery time, return to sport, career performance, and length of career after surgery. And as you can see, the authors actually looked at all these football players, basketball, baseball, hockey, swimming, skiing, so on and so forth. And in terms of what they found was that return to play was about 75% to 100%. And the timing of return to play is 2.8 months to 8.7 months. The shortest is two months for a pro ballerina. The career longevity is 2.6 to 4.8 years. In terms of the number of games that was actually played subsequent to surgery was, you know, NHL had 129 games, Major League Baseball has 232, NFL's 36 games. And in terms of baseline performance, it varied from 64% to 103.6% of baseline performance with NHL having 64%, while NFL appears to have greater than 100% performance. So they actually improved after the surgery. The rate is about 8.3% recurrence that required intervention. So that's in line with historical data. So in terms of based on the expert opinion, really there's no randomized controlled study. So this is, you know, this is all based on expert opinion. Return to play, it could happen once there's demonstrated completion of trunk stabilization program by physical therapy. There's achievement of aerobic conditioning and satisfactory level of skill in the sport. Perform stretching and strengthening exercises during the rehabilitation period. There's others that showed, you know, demonstrated adequate pain relief and range of motion as criteria for return to play. And this is a summary of recommendations for return to play based on certain sports, which is in certain studies. For precutaneous discectomy, two to three months for all sports, this study demonstrated. And another study demonstrated six to eight weeks for non-contact sports. And potentially for contact sports, it's probably six months, up to six months. So average I think would be probably three months after micro discectomy and that's I think in line with what I do it for my patients. Of course you know there if there's individual issues the one can extend or shorten those those those the time to return to play. So switching gears and looking at spondylolisis and spondylolisthesis surgery. Spondylolisthesis and spondylolisthesis are responsible up to 47% of low back pain in adolescent athletes. Repetitive lumbar hyperextension is prone to these conditions. So that accounts for 43% of all divers, 30% of all wrestlers, 23% of all weightlifter, 17% of all gymnasts and 17% of all rowers have this condition. Generally surgery for this condition is pretty effective. There's prostate lateral fusion for spondylolisthesis and spondylolisis. It's an it's an effective treatment. There's satisfactory long-term outcome that can be achieved with surgery you know such as in situ fusion as well with follow-up for third 20.8 years which is substantial long follow-up. And in another set of studies 69 young patients with high-grade listhesis underwent instrumented fusion and reported good ODS scores with average follow-up of 17.2 years. However there are no studies looking at instrumented fusion in athletes. Another possible motion preservation type of approach is direct PARS repair which is using buck screws or Morshire hook screw and also wiring techniques to help stabilize a PARS defect. This is an older type of approach and 95% of the evidence of return to play with average of seven months period in 22 athletes. And similar results as above with all athletes that had returned to pre-injury level performance in this spine journal study published in 2002. There's another study that demonstrated return to play not with all previous levels participation and that was published in 2003. There are more novel ways to instrument spondylolisthesis which is the direct lateral approach. In this patient there's an L4-5 spondylolisthesis in which direct lateral was employed and as you can see that this cost was inserted laterally in appropriate space along with a clamp that was placed. But regardless of what approach it is essentially it's a fusion operation so those fusion concepts of fusion needs to be employed which is important to ultimately stability is imparted after solid fusion. So essentially the return to play criteria after fusion there's scarce literature for return to play after fusion for spondy. There's emphasis on post-operative PT and rehab. Core strengthening and non-impact aerobic exercises can be started two weeks after surgery. Essentially neutral spine at three months with higher impact after three months. So before three months essentially non-loading and non-impact exercises and after by higher impact after three months. Sports specific training can occur at four to six months. So for example if the patient you know is a golfer then you probably could return the patient to some sort of a maybe some sort of a club swinging exercise and start hitting golf balls. And return to play can happen when there's normal strength, range of motion, no pain in sports specific activities and this has been demonstrated in this publication. However it could be career-ending for activities that require extreme lumbar hyperextension such as gymnastics and dance. Heavy load sport may be reduced from competitive to recreational if these things cannot be achieved. That's outlined here. So this is a summary of return to play criteria after fusion surgery and it's based on the type of sport. So for golf return to play is at six months. For non-contact is also at six months and for contact sports is at one year. Collisional sports is not recommended and this kind of you know six months to one year time period is kind of consistent with various different studies. Essentially it allows time. Six months is probably the time that fusion has occurred and that's a timeline that's earliest time that's allowed. And total displacement or dysarthroplasty is also done in setting of degenerative disease and so one could ask like what happens in that setting. Perhaps there's no fusion that needs to be happened so could earlier return to play occur. One thing to note that while there's no fusion across the spinal segment there is localized fusion of the you know instrument and instrumented end plate metallic end plate to the bony end plate itself. So there is some local fusion that occurs that provides stability and that usually occurs also at three six months. So some reports on the outcome of lumbar total disc replacement in athletes and military. Return to play after 39 total disc replacement in athlete was observed in this study. In a study that showed 94.9% with improved VAS and ODI scores and the outcome is 26.3 months at follow-up with 9 out of 12 pro athletes returning to competitive level of activity. And full recovery and peak fitness at 3.2 months can be achieved in this group of patients three to six months. And return to play after in another separate study return to play after 12 total disc replacement versus 12 fusion in Marines over three months period of time. So in comparison of these two different cohorts in terms of average follow-up there's 10.7 months of average follow-up. 83 percent return to play that's totally unrestricted at 22.6 weeks versus 67 percent of the fusion patients which occurred later at 32.4 weeks. But because of the number of patients there's only 12 in 12 it's not significant but trends towards significance and this is published in Neurosurgery 2012 by Toomey-Allen et al. So this is a return to play criteria for surgery for degenerative disc disease and in summary there is for return to play can happen when there is regular graphic evidence of fusion on CT scan with resolution of pain, restoration of strength, flexibility, endurance and these are recommendations. Non-contact sports can happen in the first three months pre-operative sport occurring at three to six months with full contact four to six months after total disc replacement. In the military population the TDR the non-impact training can occur at three months, light impact training and with weights at four to five months and fitness tests can happen at six months and restricted full duty if passed can occur afterwards. Now fitness tests you know sounds pretty benign but that's a pretty rigorous test that the military put their personnel through. So table 3 outlines this summary of recommendations of return to play for lumbar fusion and lumbar total disc replacement. Return to play allows for contact sport but no defined time frame in this study. In terms of TDR three months for non-contact sports four to six months for contact sports. In a separate set of study it's the same thing about three months for non-impact training four to five months for light impact and weight training and six months for unrestricted full military duties. So in conclusion which is based on expert opinion based on several publications that we went over above, rehabilitation regimen is important for recovery and athlete and specific rehabilitation for that specific sport that the athlete is in and return to play can happen when there's achieved rehabilitation goals for that sport. Different timing for different sport and different surgery. Middle invasive surgery may decrease the time of recovery however the above and fusion principles may apply so either when you do a direct lateral approach or mini open or minimally invasive T lift even though it's less invasive however to return to play you really still have to accomplish the rehabilitation goals and so on average it's about two months for micro discectomy as soon as two months six months for fusion and three months for a total disc replacement and these are just expert recommendations you know minimum timelines that can be stretched out and you know if necessary if things are the rehabilitation goals are not accomplished. And so what what happens in rehabilitation in terms of the clearance what do we look for we we're looking for resolution of pre-operative symptoms full painless range of motion and maintain neutral spine position during sports specific exercises so be able to maintain that neutral spine position and also return of muscle strength endurance and control during that sport specific activity. So armed with this knowledge let's go over some of these cases that we presented earlier. So this is a 22 year old college senior basketball player with EHL weakness and L5 radiculopathy treated with L4-5 discectomy. So what happened with this patient the patient had resolved radiculopathy with the residual numbness with 5L5 motor strength at one month after surgery. Patient was prescribed physical therapy with core strengthening at one month and patient started returning to play at two months non-contact sports. He missed the rest of his senior season. He ultimately only plays recreationally. He finished his business school but enjoys basketball recreationally. Our next patient is a 54 year old golf pro with history of redo L4-5 micro discectomy and subsequent to that micro discectomy presents with acute foot drop after a return to play at one month. MRI shows reherniation and patient was subsequently treated with L4-5 teleth and obviously you know he has other areas of issue however that L4-5 is is the issue at hand so that was addressed. So and the patient actually resulted in improved foot drop after the surgery at with a 4 out of 5 strength at six weeks post-op stable at two-year post-op. Physical therapy for core strengthening and cardiovascular conditioning was prescribed at two weeks and patient returned to golf teaching and swings at three months and currently he has returned to full golf activity at two years. Our third clinical illustrative case is a 17 year old high school football junior with intermittent back pain only after games. Patients on track for a D1 football scholarship and on CT scan there is a pars fracture that's chronic in nature as demarcated by the arrow. So patient was treated conservatively with pars injections and physical therapy and with such patient is stable without neurological symptoms however patient may require surgery if symptoms progress and patient continues a sports activity. Thank you for your attention. I think surgery in an elite athlete could have an excellent outcome but proper rehabilitation regimen and safe timeline of returning to play is important.

return to play

lumbar spine surgery

athletes

lumbar pathology

risks and considerations

timing and criteria

rehabilitation