From the Department of Orthopaedic Surgery, University of California Los Angeles School of Medicine.
Study Design. An outcomes assessment of 14 elite college athletes who had undergone lumbar disc surgery was performed using the SF-36, a validated questionnaire that assesses quality of life.
Objectives. To determine the outcomes and results of lumbar disc surgery in an elite group of athletes and compare the results with those in the general population and in age-matched control subjects.
Summary of Background Data. Lumbar disc surgery is reported to be a highly successful procedure with excellent results. The outcome in elite athletes has not been assessed and compared with population norms and age-matched control subjects.
Methods. Fourteen athletes from schools in the National Collegiate Athletic Association with a mean age of 20.7, underwent lumbar discectomy for radiculopathy refractory to conservative treatment. Ten had a single-level microdiscectomy, three a two-level microdiscectomy, and one a percutaneous discectomy. Patients were evaluated at a mean follow-up of 3.1 years, underwent a detailed clinical evaluation, and filled out the SF-36 questionnaire.
Results. All 14 patients had improvement of pain with elimination of the radicular component, took less medication than before surgery, and returned to recreational sports. Nine patients, all with a single level microdiscectomy, returned to varsity sports. Five athletes prematurely retired from competitive sports because of continued symptoms. Three of the athletes who retired underwent two-level procedures, and one had a percutaneous discectomy. SF-36 scores for bodily pain, physical role, and social and mental health roles were significantly lower in those athletes who retired. Patient scores were also compared with those in a group of noninjured age- and sport-matched college athletes. There were no differences between injured and noninjured athletes, but both groups had scores significantly lower than normal values in an age-matched group for bodily pain, physical role, general health, and social function.
Conclusions. All patients were satisfied with their surgeries, were greatly improved, and were pain free in activities of daily living. For a single-level microdiscectomy, the success rate in elite athletes is excellent, with 90% of athletes able to return to a high level of competition. Two-level disease may be associated with a less favorable outcome.
Discectomy is a commonly performed surgical procedure in the general population, with high success rates reported in the literature.1,6 Patients are generally able to return to their previous levels of activity, including participation in recreational sports. This surgery, however, can be associated with a long recuperation and a protracted period of disability.2-4 Social factors such as age, concomitant litigation, and workers' compensation, have been shown to affect the likelihood of a complete recovery.2-4,7
Elite athletes at the college level are thought to have no such conflicting issues. They are highly motivated to return to their previous level of activity as quickly as possible and to return to competition. To assist them in this endeavor, these athletes have access to the highest level of rehabilitation and athletic training, services that may not be available to the average patient.
The benefits and outcomes, of discectomy in the elite athlete have not been evaluated, in terms of returning to competition. The results are particularly interesting because the athlete is subject to a higher level of physical activity than the average spine patient and may be free from many of the negative social factors that can bias outcome measures. This descriptive study presents a retrospective determination of the outcome of surgical discectomy in a group of elite college athletes.
Fourteen varsity college athletes in a National Collegiate Athletic Association (NCAA) Division I program underwent lumbar discectomy (13 had microdiscectomy; 1, a percutaneous discectomy) between 1988 and 1995. Ten had a single-level open microdiscectomy, three a two-level discectomy, and one a single-level percutaneous discectomy. These patients were observed for an average of 3.1 years after surgery. Four of the single-level herniations were at L4-L5, whereas seven were at L5-S1. One patient had herniations at L3-L4 and L4-L5, and two had herniations at L4-L5 and L5-S1.
These athletes had symptoms of low back pain radiating down one or both legs, which prevented them from participating in normal practice and play. All had a positive straight leg raising results and radicular pain that corresponded to the level of a herniated disc shown on a magnetic resonance study. Four had mild weakness (5-/5) of the extensor hallucis longus that corresponded to the affected nerve root, an L4-L5 herniation (none had more than a full grade of weakness), and none reported bowel or bladder dysfunction. Three of the patients with two-level herniation had symptoms relating to two separate nerve distributions that corresponded with nerve impingement at both levels of herniation. None of the patients with single-level herniation had asymptomatic herniation or disc degeneration at other levels of the lumbar spine.
There were 12 men and two women, with an average age at the time of surgery of 20.7 years (range, 18-25 years). The patients participated in a variety of NCAA sports including: football (n = 4), basketball (n = 2), swimming (n = 2), water polo (n = 2), soccer (n = 1), track and field (n = 1), volleyball (n = 1), and diving (n = 1).
Each patient was initially treated with a standard conservative rehabilitation program directed by an orthopedic surgeon specializing in sports medicine. This program included activity modifications, physical therapy (ice, moist heat, ultrasound, and microcurrent electrical stimulation), therapeutic exercise, a lumbar corset, nonsteroidal antiinflammatory medications, oral corticosteroids, and a formal education program in care of the back. A few also had a corticosteroid injection and/or manual traction therapy. Patients were treated for a minimum of 8 weeks, but some had intermittent treatment during a period of several years. Patients were then referred to a consultant for surgical evaluation.
All 14 patients were followed up until they returned to their previous level of competition or retired from competition. Thirteen patients were evaluated with a detailed assessment and filled out a SF-36 validated questionnaire assessing quality of life. The follow-up evaluation quantified postoperative pain, morbidity, function, and return to intercollegiate competition. One patient could not be reached because he was playing professional basketball in Europe. Although there were no detailed clinical data or a completed SF-36 survey for him, he was regarded as a clinical success because of his continued high level of play. There were no workers' compensation issues, and none of the patients smoked cigarettes.
SF-36 scores were compared between two groups. Surveys were obtained from 37 randomly selected NCAA varsity athletes who reported no injuries and served as the control group. These surveys were analyzed and compared with those of the 13 surgical patients who participated in this part of the evaluation process. A second group, a standard set of population norms for men and women aged less than 25 years was also used for comparison.
All 14 patients had normal or nearly normal function in daily activities, with little residual pain in recreational sports. All reported that they were able to participate in several activities at a recreational level without difficulty. Six of the patients took nonsteroidal antiinflammatory medications intermittently for pain. At the time of follow-up, none of the patients had taken narcotic pain medications since recuperation, and none had had another operation.
Nine patients (eight men, one woman) returned to their previous competitive sport and continue to participate at the varsity level. All returning patients had single-level discectomy, three at L4-L5, and six at L5-S1. In this group, there were two basketball players, two football players, one shot-putter, two water polo players, one volleyball player, and one soccer player.
One football player returned to competition and played for another three seasons at the college level. He retired from sports after his college career and did not play professional sports. His spine surgery did not play a role in his decision to retire. The remaining athletes who returned to competition are still competing at the professional level in their sports.
Five athletes did not return to competition because of continued low back symptoms and retired from sports prematurely. In this group, there were one diver, two swimmers, and two football players. Of these five athletes, one had a single-level open discectomy at L5-S1, and three had two-level discectomies, one at L3-L4 and L4-L5, and two at L4-L5 and L5-S1. The remaining patient had a single-level percutaneous discectomy. All these athletes are currently pain free during normal activities and are able to participate in recreational athletics but could not continue to compete in their sports at the college varsity level.
Thus, 9 (90%) of the 10 athletes with single-level microdiscectomy were able to return to their sports at the varsity level. The three athletes with two-level discectomies and the one with a percutaneous discectomy were unable to return to competition. The athletes who returned to sports were slightly older at the time of surgery (mean age, 21.25 years) than were the athletes who retired (mean age, 19.83 years). The athletes who retired prematurely were involved in swimming (n = 2), football (n = 2), and diving (n = 1), although there is not a demonstrable association of particular sports with premature retirement.
Of the 14 patients, 13 were subjectively satisfied with their surgery regarding the resolution of symptoms. The one patient who was not "satisfied" had significant physical improvement but had some personal issues regarding his medical care that precluded a better result.
Table 1 shows the results for the SF-36 evaluation of the surgical patients. Group means that differ by 10 or more points are considered to represent significant (by the SF-36 scale) differences in quality of life. The mean difference was greater than 10 (significant on the SF-36 scale) for five of the eight domains and was statistically significant in two of eight domains: physical function. 98 versus 84 (P = 0.009); and bodily pain, 81 versus 43 (P = 0.003). Domains in which the difference in athletes who returned was greater than 10 include physical function, physical role, emotional role, bodily pain, and vitality. There was no difference in social function, and SF-36 scores were slightly higher for general health in the athletes who retired. The physical summary was significantly higher in patients who returned than in those who retired (P = 0.009). These data clearly indicate that the athletes who returned to competition had better quality-of-life scores than those who did not return.
Table 1. SF-36 Scores for the Patients After Surgery: Comparison Between the Group of Athletes Returning to Competition and the Athletes Who Did Not Return: Mean (SEM)
The comparisons of SF-36 scores for the entire group of surgically treated patients with those for uninjured athletes and population norms are shown in Table 2. The scores were not significantly different for surgical patients and uninjured athletes. Scores were substantially lower, however, in athletes than in age-matched control subjects for bodily pain, physical role, social function, and general health. Physical function scores were significantly higher (more than 10 on SF-36 scale) in athletes than in control subjects (97 vs. 80). Athletes, injured or uninjured, had significantly (more than 10 on SF-36 scale) lower quality-of-life scores in several categories, when compared with those of age-matched population norms.
Table 2. SF-36 Scores for the Entire Group of Surgically Treated Patients Compared With Age-Matched Control Athletes and Standard Population Norms
Microdiscectomy is reported to have a high success rate, more than 90% in some studies.1,6 Patients generally have very little pain, are able to return to preinjury activity levels, and are subjectively satisfied with their results. The results of microdiscectomy in the elite athlete have not been reported. There is anecdotal evidence that there are many high-level athletes who return to their previous levels of competition. However, there are many well-known and popular professional athletes who have been severely incapacitated by a herniated lumbar disc and have been forced to alter their activity levels or to retire.
The results of this study can be favorably compared with those in previous reports of discectomy performed in the general population.1,5,7,8 All 14 patients had relief of pain and improvement in function. After surgery, all took less medication than before surgery, with most patients taking none. All were able to perform activities of daily living without problems, and all were able to participate in recreational athletics. Judged by general population norms, all the surgeries would be considered a success. However, successful results in a population of elite athletes must take into consideration whether the athlete is able to return to sporting activities at their prior levels of competition.
In the current study, 90% (nine patients) of the athletes who had single-level microdiscectomy were able to return to competitive sports and participate at the varsity level. Despite these excellent results for single-level microdiscectomy, however, five athletes (four of whom did not undergo open single-level microdiscectomy) were forced to retire prematurely from varsity college athletics. All three of the patients with two-level discectomies were unable to return to competitive sports.
The level of activity required of a varsity level college athlete is considerably different from that of the average person, and the patients represented by previous studies did not subject their spines to the severe stress of competitive athletics. These stresses may be too great for patients with discs removed at two consecutive levels. The indications for two-level discectomies, especially in athletes, are rare and must include symptoms attributed to nerve impingement by herniated discs at both levels. Because of the small sample size, there were no factors that could be determined to differentiate between the athletes who were able and unable to return, other than the number of levels involved in the surgeries.
Although there were significant differences between the scores of patients who compete currently and those who have retired, there were no differences between patients and the control group of athletes. There are observable differences between the athletes as a whole and age-matched control subjects from the general population. Although physical performance scores are very high, significantly above those of the control group, scores for bodily pain, physical role, general health, and social function are remarkably low when compared with those of age-matched control subjects.
Therefore, general population norms cannot be reliably used for outcome studies on groups of athletes. The higher physical performance scores seen in athletes are expected, because they maintain and strive for high levels of physical activity and conditioning. The lower mental health and social scores indicate that the athletes had a poor self-image. Perhaps this poor self-perception helps them to succeed in athletics, causing them to strive for better performance and motivating them to succeed. On the whole, this evaluation of SF-36 outcomes raises many questions about the quality of life perceived by NCAA competitive athletes, and indicates that more study of this issue should be undertaken.
Discectomy performed in elite athletes is not disabling and is associated with an excellent outcome in pain relief, return to daily activities, and return to recreational athletics. From a standpoint of return to competition, almost all patients with a single-level herniation returned to their sports at the same high capacity. Informed consent for elite athletes with multilevel disc herniations should include the possibility that even if an excellent overall outcome is achieved with lumbar spine surgery, the athlete may not be able to resume the high level of activity required to excel at the elite athletic level.
Acknowledgment date: March 19, 1998.
First revision date: June 1, 1998.
Acceptance date: August 6, 1998.
Device status category: 1.
Address reprint requests to: Jeffrey C. Wang, MD; Department of Orthopaedic Surgery; UCLA School of Medicine; Box 956902; Los Angeles, CA 90095-6902; E-mail: email@example.com.