Back Pain in a Sport Cyclist

 

Clinical Key Points

This patient is a keen sportsman who was disabled from his sport (cycling) by severe back pain.

History & Prior Treatment

In 1996 Colin presented to the Spinal Foundation with a four years history of back pain initiated by lifting his bicycle over a gate. Immediately he experienced back pain and pins and needles in the left lateral thigh. This resolved with physiotherapy with one or two minor recurrences. In July 1995 when back packing he suffered a complex tear of the right medial meniscus. During rehabilitation, he felt his back “go”. Physiotherapy resolved his knee pain but the back continued to deteriorate with increasing back and left buttock pain.

Whilst his sitting duration was unlimited and cycling eased his pain at the time, getting out of a chair required that he had to use his arms and straighten very slowly to reduce pain particularly in left buttock. Extension aggravated all his pain, When standing absolutely still he was pain free but any movement triggered the buttock pain.

He also suffered with celiac disease and secondary osteoporosis.

Initially he was treated with further Muscle Balance Physiotherapy.

Distribution of symptoms

His pain could be sub-divided as follows: Low Back Pain 10%, Left Buttock Pain 90%.

Investigations

Weight bearing X-rays revealed reduced height at several levels in good alignment. He triangulated at L5/S1 with dynamic retrolisthesis which only partially corrected. He triangulated in extension but formed a rectangle in flexion.
He had a left sacral tilt which caused the spine to lean to the left and a presumed short left leg.

His MRI Scan of January 2006 revealed at L4/5 partial settlement, complete disc degeneration, central annular tear, a posterior bulge, mild facet joint and discal osteophytosis, small broad based central posterior disc bulge, moderate flaval buckling and central canal stenosis. At L5/S1 the scan showed retrolisthesis, partial settlement, a left annular tear, posterior bulge, Modic II changes, mild facet joint and discal osteophytosis, a large posterocentral protrusion extending into the lateral recess with left canal stenosis and compression of the left canal root.

Endoscopic Minimally Invasive Spinal Surgery: February 2006

Left L5/S1, Endoscopic Lumbar Decompression, Endoscopic Intradiscal Discectomy, Neurolysis, Osteophytectomy, Undercutting, Biopsy, Adcon-L and Therapeutic Discogram. On probing, the L5/S1 facet disc interval and annulus reproduced back and buttock pain and revealed a 20% disc bulge.

Endoscopic Lumbar Decompression was performed and revealed a large protrusion displacing the nerve, reactive scarring with a hyperaemic tender nerve adherent to the Superior Foraminal Ligament, disc and facet joint margin.

Neurolysis was carried out freeing the nerve from the disc, Superior Foraminal Ligament and facet joint. The Superior Foraminal Ligament was resected until a positive fat sign was achieved. The facet joint was undercut and osteophytes removed. Access to the epidural space was gained.

Endoscopic Intradiscal Discectomy was performed which resulted in a good harvest bilaterally with annuloplasty and biopsy. Adcon-L was inserted to protect the nerve from adhesions.

Outcome

Initially he was pain free but at day 6 he was so pleased with the result that he embarked on more vigorous activities despite instructions. This caused a significant flare with pain radiating in to both legs. However over the next 4 months all these symptoms resolved. By October 2006 he had been cycling in Wales and Scotland and scramble trekking and had accumulated 1,000 miles of off-road cycling. You will see in the testimonials that Colin went on to cycle across India and remains well to date.

The moral of this study is that however well you feel after this operation, please remember that despite the 7mm incision you will have had a large operation and the back and nerve need to heal before resuming full activities.