My Aching Back – Lumbar Disc Injuries
Laurence Mermelstein, M.D.
In the general population, lower back pain is one of the most common reasons people see their doctor. In the younger athletic population, this is not the most common injury, but common enough to warrant serious consideration when it occurs. The majority of the time, lower back injuries are self-limiting problems such as sprains and strains, which will resolve with rest, anti-inflammatory medication, stretching and exercise. As discussed in a previous article in this space, young athletes have a predilection for “stress-type injuries” to the lower lumbar vertebrae (spondylolysis). These injuries also have a good overall prognosis if treated early and appropriately. Whereas injuries to the intervertebral disc are more commonly associated with older athletes (and “non-athletes”), disc injuries do occur in younger athletes and in my opinion, we are seeing a higher frequency of these specific injuries over the last decade.
There are several theories to explain this finding. One of which is that we as clinicians are more likely to order MRI scans on adolescents and young adults with ongoing low back pain, especially if associated with sciatica (leg pain – see below). Because of this, we are seeing more and more disc injuries than in the past that might have improved with conservative measures anyway. I do believe that the more aggressive training regimens seen in competitive high school athletes also plays a roll in the higher rate of disc injuries. Sports such as football and gymnastics are requiring full year-round training regimens and in susceptible athletes, the lumbar discs appear to be paying the price.
Clinically differentiating lumbar disc injuries from other back injuries is sometimes challenging for physicians who see these injuries on a regular basis and is beyond the scope of this discussion. However, we do get suspicious when the pain is more severe and episodic in nature. The pain can be centered in the low back, or may be more localized to one side of the back than the other. In more severe injuries, the pain will radiate down one or both legs – commonly described as “sciatica”. When disc injuries begin to affect the spinal nerves in the lower back, we frequently see pain associated with numbness and/or weakness in the leg all the way to the foot.
Disc injuries can also be differentiated by the fact that they frequently take longer to heal. Instead of a a couple of days to a week for a sprain to heal, disc injuries make take up to 6 weeks or more to improve. Disc injuries and even outright herniated discs can (and should) be treated as conservatively as possible with most improving with a course of medication, rest, chiropractic, physical therapy, etc. Sometimes special injections called Epidural steroid injections can help ease the pain of a herniated disc.
Surgery is reserved for those patients with severe intractable pain or progressive neurologic deficits. Fortunately, over the last 15 years the surgical options for treatment of disc injuries have blossomed. In the young athlete, the least invasive procedure that will return the athlete to his/her pre-injury activity level the fastest is desirable. In the contained disc herniation, “bulging disc” or annular tear, we have found that certain types of endoscopic procedures have been very successful. These procedures are performed as an outpatient basis with local anesthesia and mild sedation.
For ruptured discs or larger discs causing severe nerve compression – more traditional “laminotomy/laminectomy” type procedures are indicated. With the improvement in microsurgical techniques, these procedures are frequently performed through 1 inch “microdiscetomy” incisions and patients routinely recover at home the same day.
In the most chronic of cases rarely seen in the young patient, the disc is found to be beyond repair. It is only in these cases that a radical discectomy and replacement or fusion of the disc is contemplated. After years and years of wear and tear, the older athlete may be contemplating such a procedure – usually at the end of an athletic career.
Despite being a less common injury to the young athlete, disc injuries can sometimes be very persistent and nagging. If the young athlete has persistent low back pain, especially associated with sciatic pain, weakness or numbness he/she needs to be evaluated more fully. More aggressive care usually can return that athlete to full activity, even if that treatment necessitates surgery.