What is Special About Sports Spinal Injuries?
Whilst we marvel at our Sports men and women, many are afflicted with Degenerate Disc Disease, degeneration of the spine and its joints (Spondylosis) postural problems (malposture) “instability” and congenital abnormalities (structural anomalies). The state of these factors renders the sports person vulnerable to sports injuries such as:
- Hyperflexion injuries
- Hyperextension injuries
- Disc Wall Tears or Leaks
- Slipped or ruptured Discs
- Repetitive nerve injury & scarring
If you have been given a diagnosis then please read the relevant condition page on this site after you have read this page.
WHO IS AT RISK?
Sports men and women may represent younger members of the population but the “veteran” population is increasing markedly – our oldest veteran was an 80 year old veteran “Fell Runner”. The pathology requiring treatment becomes increasingly complex in older patients as the age related “wear and tear” factors become more pronounced.
- In the younger sports people leaking discs, High Intensity Zones, disc protrusions or extrusions, repetitive nerve injury & scarring are common causes of disability.
- In older contenders loss of disc height, dehydrated (Black) discs, arthritic overgrown facet joints, slippage of one vertebra upon another, bone spurs digging in nerves, scarring and tethering of nerves play an increasing role in causing symptoms.
- Those with seemingly minor elements of malposture can be placing specific segments of the spine under abnormal loading and strain and ultimately under greater vulnerability to deterioration and failure.
Almost all sports have a risk(s). Rugby and Football players, Rowers and Runners, Dancers and Jumpers, Divers and Drivers, Riders & Cyclists, Martial Artists and a great many more suffer spinal injuries and have been successfully treated by Endoscopic Minimal Invasive Spine Surgery and Endoscopic Transforaminal Lumbar Decompression and Foraminoplasty.
WHAT ARE THE PARTICULAR MECHANISMS OF SPORTS INJURIES?
- When the spine is forced forwards into a tight curve suddenly this may damage the blood supply to the cord resulting in paralysis especially where there is an element of rotation and a fracture of the vertebra.
- This needs the fracture to be stabilised and the cord to be treated with stem cell augmentation as appropriate.
- Where the disc wall is weakened then this manouvre can force the softer degenerate mobile internal contents of the disc to make the disc wall to bulge and press on the nerve producing sciatic or arm pain and or loss of function.
- This can be readily treated by Endoscopic Lumbar Decompression and Foraminoplasty rather than conventional microdiscectomy.
- When the spine is forced backwards into an exaggerated arch this forces the facet joints to override with bruising of the nerve, stretching and laxity of the joints and may result in subsequent abnormal microvements at this segemental level or a disc rupture.
- This needs initial treatment with non steroidal anti-inflammatory therapy and core and segmental active stabilisation with Muscle Balance Physiotherapy. Recalcitrant cases can be effectively treated my Endoscopic Lumbar Decompression and Foraminoplasty rather than fusion and injections with sugars to thicken the capsule (Prolotherapy).
Disc Wall Tears or Leaks
- As the disc starts to degenerate so fissures develop and coalesce causing the in-growth of vessels and nerves from the rim of the vertebra in to the disc. The breakdown products in some people are extremely painful. These may leak on to adjacent nerves and other structures such as the Posterior Longitudinal Ligament, filled with pain nerve fibres. The result is local back or neck pain and referred pain in to the limb with sometimes a sense of scalding or freezing pins and needles, numbness, sphincter dysfunction and limb weakness. Their presence is often ignored by conventional surgeons.
- This needs initial treatment with non steroidal anti-inflammatory therapy and core and segmental active stabilisation with Muscle Balance Physiotherapy. Recalcitrant cases can be effectively treated my Endoscopic Lumbar Decompression and Foraminoplasty and or Laser Disc Decompression rather than chronic pain management, Interbody Fusion or Total Disc Replacement.
Slipped or ruptured Discs
- As the disc degenerates the disc wall weakenss and thins in places. A sudden increase in internal pressure within the disc causes the soft internal portion of the disc to press upon the weakened areas causing them to bulge (protrusion) or rupture (extrusion) and pieces of disc material may even leave the disc (sequestrate) and settle in the spinal canal space.
- This needs initial treatment with non steroidal anti-inflammatory therapy and core and segmental active stabilisation with Muscle Balance Physiotherapy. Recalcitrant cases can be effectively treated my Endoscopic Lumbar Decompression and Foraminoplasty and or Laser Disc Decompression rather than chronic pain management, microdiscectomy, open decompression, Interbody Fusion or Total Disc Replacement.
Repetitive nerve injury & scarring
- Many Athletes are “Loose Jointed” or “Double Jointed” in other words they have an element of ligament laxity. This allows the joints to shift through an extended range and when this is poorly controlled by supporting muscles, supporting disc or when forced by a straining athlete then this can result in repetitive bruising of the nerves as they leave the spine, scarring and tethering of the nerves, back / neck pain and pain spreading down the limb.
- This needs initial treatment with non steroidal anti-inflammatory therapy and core and segmental active stabilisation with Muscle Balance Physiotherapy. Recalcitrant cases can be effectively treated my Endoscopic Lumbar Decompression and Foraminoplasty and or Laser Disc Decompression rather than chronic pain management, open decompression, Interbody Fusion or Total Disc Replacement.
- Normal posture takes load correctly through each disc and supporting facet joints. Through a series of saggittal curves (Neck, Thorax and Lumbar spine) load is taken from the head just in front of the hip to the ankle joint. Movement patterns are linked at each disc and controlled by the small muscles of each segment to ensure precise control of this process. Pain impairs their reflex control and weakens these muscles and laxity of the segment (disc level) or may cause spasm and stiffness of the segment. Thus the natural curves are eith exaggerated or flattened with overload of the adjacent segments which may undergo accelerated degeneration.
- This needs initial treatment with non steroidal anti-inflammatory therapy and core and segmental active stabilisation with Muscle Balance Physiotherapy. Recalcitrant cases may need the pain sources to be effectively treated my Endoscopic Lumbar Decompression and Foraminoplasty and or Laser Disc Decompression to relieve the pain and release the spasm or remove the nerve impinging effects of the laxity rather than repeated facet joint or root block injections during chronic pain management, Interbody Fusion or Total Disc Replacement.
- Fractures are classified by the elements of the vertebra involved and the degree of instability of these elements and the detrimental effects that these fragments may be causing by pressure on to the spinal cord or nerves. However sporting injuries may cause a Wedge fracture in which the front of the vertebra is crushed downwards. This results in a wedged appearance when viewed from the side.
- These can now be simply treated by Kyphoplasty and much of the angulation can be corrected.
- Leaving the angulation untreated radically changes the alignment and loading of the spine with increased strain on vulnerable adjacent levels.
How is the condition conventionally diagnosed?
MRI & CAT scans enable the Consultant to gain good anatomical detailed images and definition of pathological changes. But because pathology becomes prevalent with increasing age even in Sports people without symptoms MRI images cannot be used as the sole diagnostic tool. This means that clinical examination and consideration of the patient’s history must also be taken into account. However the loss of disc height and dehydration which results from disc degeneration can result in exiting nerve roots becoming nipped by the vertebrae and so causing irritation and pain such changes may be evident at several disc levels in the same patient. The distribution of the pain is supposed to guide the Consultant as to the disc level causing the symptoms but these distribution patterns may be in error for instance in the lumbar spine in excess of 15% of patients. So a more accurate method of diagnosis is called for hence our development of aware state diagnosis.
What is wrong with conventional diagnosis?
Clinical examination as a means of identifying the causal segment is unreliable, although the use of weight bearing X-rays in flexion and extension, both standing and sitting, does demonstrate the way in which each patient individually moves their back. MRI and CAT scans demonstrate the presence of pathology e.g. degenerate disc bulges etc, as well as overgrown facet joints, bone spurs and swelling of the nerve. However this can grossly underestimate the presence of the essential tethering of the nerve which is causal.
How is the condition treated by Conventional Management?
Sports Injuries are usually treated by multi-level open surgery including decompression, solid or flexible fusion, Total Disc Replacement and is an ‘overkill’ with negative side-effects including blood loss, potential nerve and tissue damage, extended post-operative care and unnecessarily operating on pain-free levels. It is not as effective as Foraminoplasty in addressing and ameliorating the causation, rather it runs the risk of increased complications including recurrent disc bulging, infection, nerve damage and scarring round the nerve, implant failure, major vessel damage or sexual dysfunction.
Why is aware state diagnosis better?
Conventionally the cause of the pain is diagnosed from the pattern of the pain and MRI scans but these techniques are inaccurate. However, the causal pain sources can now be accurately defined through aware state surgical examination, during which the surgeon seeks to replicate the pain by spinal probing. When this provokes a response, the patient, who is protected by circulating intravenous pain killers, offers feedback to the surgeon regarding the type and distribution of the pain produced. Sometimes, when the response is only partially akin to the presenting symptoms or when the response is at more than one spinal level, additional techniques are used to determine the relative importance of each site in the totality of the patient’s pain and condition. This defines whether the operated disc or an additional disc level is the cause of the pain
Can the diagnosis be confirmed?
This can be achieved by the use of spinal probing of the nerve, contents of the foramen and epidural space to determine contributory levels. Hydraulic discography to re-tension the disc and ligaments and restore disc height at the suspected level can be used to determine levels causing compression of the nerve in the epidural space or foramen. These techniques which include the injection of an X-ray visible liquid into the disc, open up the ‘Foramen’ or spinal spaces and effectively liberate the nerve. If this temporarily reverses the symptoms, then the specific causal segment has been identified without having to open the back at several levels. Where pain rather than compression is the predominant symptoms then insertion of anaesthetic or steroid in to the disc (Differential Discography) can be used to distinguish the role played by each level in the symptom complex.
Is there a better alternative means of treatment?
We have established truly minimalist treatment pathways for these conditions. To find out more about how we may be able to help you, please register as we would really like to help you.