I apologize that my talk is shy on science, but heavy on what goes on. So what I'm going to talk about is non-emergent conditions of the lumbar spine, how to manage them in season. There is some bench research that we did with giant squid axons and using a ball peen hammer and some cytochemistry. I'm just kidding. This is 29 years of just dealing with athletes and their loved ones, parents, coaches, GMs, trainers, and surgeons in the surgical lounge. So when you're dealing with a professional athlete, treating a high-profile athlete is work comp, but it's with an audience. And so everybody knows how they did. You know, the plumber that you fix, you know, it takes them a while to get back to work. The athlete that you work on, if he doesn't play the next season, everybody knows about that. The three things I want you guys to go home with are the three lessons from today is lumbar disc herniation, how to manage it, a stress fracture in the PARs, and a transverse process fracture. These are all fairly common. Lesson one is the lumbar disc herniation. So here's an axial picture, and the arrow is pointing to a lumbar disc herniation, which is quite large, which is invading the spinal canal and the neural elements. That's kind of a classic picture. And so lumbar disc herniations, when you're dealing with them, you know, size does matter. Location matters. A lot of times it's like real estate. It's location, location, location. If it's a small herniation in a tight spot, it can be a problem. The thing I wanted to impact with you today is that you need to try to discern between a contained versus an extruded herniation. The extruded herniation, think of the disc like a jelly donut, and you push down on it, and some of the jelly comes out, and sometimes there's still a little bit of donut around it, okay, or it breaks all the way free and it's out. And so if it's all the way free and it's out, it's extruded, and it's really kind of lost its connection to the mothership, so to speak. Those have an excellent chance of reabsorbing. So here's a picture on the left side, correct, left side, at L5S1, the lower level, you can see a disc herniation. It's there in the canal. Is there a... Is it on here? No. That's not it. This one. Okay. There you go. Thank you. And it's this one here? No, the bottom one. The bottom one? Yeah. Okay. So here's a disc herniation that is contained, okay. Okay, over here, here's a disc herniation. If you look up here, it's left the disc space and now it's come all the way up. And so it was extruded out of the disc space. And so it's pretty much lost contact with the disc space. And so when they come out, when they're extruded, they're incredibly painful, okay? There's usually a pretty significant injury for it to be completely extruded out. And so when you have a disc herniation, there's really two things going on. There's mechanical pressure of the disc against the nerve, okay, and then there's the chemical inflammation, the proverbial salt in the wound. And if you can get the salt in the wound or the inflammatory response under control, then you have a shot at getting them better. So this is, once again, a extruded disc. Oh, come on, there it is right here. And on this STIR image over here, you see how white this is here? And so that just means that it's extruded and it's got a whole lot of fluid in it, okay? Which means that, to me, I look at that and think, okay, if we can get this guy out of pain, okay, get his inflammation under control, we have a chance of getting him through the season. So here's a little vignette. We had an all-pro guard. He'd never missed a game before. He got injured August 3rd, training camp injury, had back pain, right lower extremity pain. When I examined him for the first time, I do a straight leg raise on him, laying down, straight leg raising. He wouldn't say his back hurt or his leg hurt, but he had to roll his entire hemipelvis over so that he wouldn't hurt. He had some weakness, which was mild to moderate. His extensor haliasis was weak, three over five, which is not a big functional concern. The tibialis anterior is a bigger functional concern, but this was his baseline examination. So what did we do? We managed him with a MedDRAW dose pack, okay, to try to get the inflammation under control. It did help a little bit. And then we decided to do an epidural steroid injection, or what I call a selective nerve root block. So we targeted the fifth root, which was the one that was being irritated. And then I did serial examinations, and we placed him on core strengthening. And once again, this is a professional football player. This is an all-pro guy that's never missed a game. And he's a, you know, frankly, he's a beast. So he missed all of the preseason. He started the opening game, and he played the entire year without missing a play. Post-season imaging. So he has had a complete resolution of this disc herniation. And so once again, the lesson there is, if you can discern that it's really an extruded disc, then if you can get the inflammation under control and you monitor their neurological function, then you can usually get them through without having any type of surgery. So the take-home, try to discern between contained versus extruded. The extruded disc, once again, has an excellent chance of reabsorption. Aggressive targeted treatment. Once again, the selected nerve root block targeted the nerve that was involved. Serial exams of the player to make sure he's not getting a neurological deficit. And having these multiple data points helps you when you're talking to the player and the agent and the GM. Lesson two, stress fractures in the lumbar spine. New versus old. So lumbar spondylolisis, or stress fractures, or PARS fractures, pretty common. Four to 6% in the general population. Probably 15% in an athletic adolescent population. And for two years, when I was covering the Texas Rangers, they allowed us to take x-rays of everybody. So a 40-man roster. And about 20% of a major league roster for those two years had a old, unhealed stress fracture. So very common. And obviously, asymptomatic. So how do you evaluate somebody? So here's a Jackson's Maneuver, named after Doug Jackson, who trained with a very famous spine surgeon named Dr. Wiltsy in Long Beach. But Doug Jackson, I believe, is a fairly well-known sports guy. So one-legged hyperextension, also called the STORC test. And it produces focal stress on the PARS interarticulars. And that's where most of these stress fractures occur. It's fairly specific and it's fairly sensitive. X-rays, I get five views. I do not get oblique views. If you have, the oblique views will show you a chronic PARS defect, but you can usually see those on a lateral x-ray. And I'd rather have flexion extension laterals to determine whether there's any instability. So there is a lateral view, and you can see right here is the defect. I typically go to an MRI and lean on the STIR images on the sagittal. And you can see that on the T2 axial and the STIR images. So here you see edema starting in the pedicle. And so that's indicative of a stress reaction. There's a continuum between stress reaction and stress fracture. So what's the treatment? Well, it's a fracture. And so what I usually do is I do four to six weeks of rest. If it was an arm, it would be in a cast. It's hard to immobilize the spine. So I ask them to self immobilize it. Once they come back at six weeks, if their exam normalizes, then at that point in time, I start them on a cardio routine and a spine neutral rehab program. And then at three months, I return them to a sport specific program. But it's three months you're out. And when talking to the family, and it's usually teenagers you're talking to, only about 50% of them heal at L4 and L5. Chronic fractures, you can confirm chronicity of it. You can see it on the x-ray. A lot of people have pain in extension and this becomes recurrent. And I've had my pain management guy do multiple injections into the PARS defects and even doing a PARS rhizotomy. And of course, do their core rehab and more core rehab. And they do pretty well. One of the pearls I've learned is that I have a number of people that come in and they'll have a clear-cut PARS defect and they'll have symptoms that'll be isolated to one side that just don't match. And what I'll find is that on MRI or CAT scanning, they'll have another fracture above or below where they have this typical chronic PARS fracture. So just because you can see it on x-ray doesn't mean that that's the only one that they have. Surgery for the PARS fractures, there's a bunch of different ways to do it. But in reality, I've been doing it for 29 years. I've never operated on a PARS fracture to try to fix it. Time and rehab work. It's hard to know what you can play with. So although this is not a football player, it's a baseball player that I took care of for a long time. Had bilateral defects at L3 and L5. He had a disc herniation at L4-5. Had a degenerative disc at L2-3. He was unstable at L2-3. But he did core like you can't believe he did core. And this was his career. First ballot Hall of Famer. And so it shows you that with proper dedication to an appropriate core rehabilitation program, you don't need to do surgery on these things. So what's the take home? Comagen athletes. Test for chronicity is the best one is an MRI. Need to rule out an acute fatigue fracture at another level in the setting of a chronic fracture and don't operate on them. Transverse process fractures. Seen commonly in football. It's usually a direct blow to the flank. Typically more than one level, but sometimes just one. CAT scan needs to be done. It's the best way. It's very difficult to see this on a plain x-ray. And you need to rule out a renal injury as well. They usually can finish the game. The next game, they're usually out. And then the following game, the majority of them play. And it seems that offensive and defensive linemen who are fractionally tougher seem to tolerate this a little bit better. So really it's just supportive care, rule out other injuries, analgesics, modalities. I might have injected one or two of these before a game before, but they usually do pretty well. So our NFL experience in the 20 years with the Cowboys, we had four players. Two completed the game, all missed the next game, and the typical back to return to play was nine days. And pain was clearly just a rate-limiting step. None of them had a neurological injury. So this was kind of interesting. Byron Donsies is the guy that invented the flak jacket. The flak jacket, flak comes from this German word, which was anti-aircraft gun. And then flak later became known as the stuff that you dropped out of the airplane so that they confuse it. And so flak comes from that word, and the F and the L, and the A and the K in that word, because that is so long. And so the story about Byron Donsies was that when Dante Pastorini broke his ribs playing for the Houston Oilers, he was a Houston guy. He went to his hospital room, wore this flak jacket, and had the person he was with take a baseball bat to him and hit it. And that's when Dan Pastorini started wearing a flak jacket playing football. So what did we learn? Lumbar disc herniation, assess for extrusion and high signal intensity. Those have the best chance of reabsorption. Aggressively manage the inflammation. Stress fractures, you need to figure out if it's new or old. MRI is the best for that. Takes about three months to get them back safely. And transverse process fractures is just supportive care. Thank you.

lumbar spine

disc herniation

stress fractures

evaluation

athlete safety