Return to Sport and Back Surgery
We have previously written on low back pain and the dramatic rise in surgeries with this patient population, despite evidence of superior outcomes over conservative treatment and Physical Therapy. Prior research has documented the dramatic rise in the number of lumbar MRI imaging for the low back and a corresponding increase in the number of lumbar surgeries (figure 1 below). One of the main predictors of spinal surgery over age or degree of injury in the spine remains how many MRI machines are in your area. These images are highly sensitive and find even the smallest pathology, but often lack the specificity (high false positives) to correctly diagnosis every patient without an appropriate clinical examination. The high false positives, finding pathology in asymptomatic people, is noted on the 2nd figure below in a study of 3,000 people. As we age there is a higher probability of finding pathology making a negative image less likely past age 30. Interestingly, many of these severe injuries on our spine heal and improve if given time (3rd figure).
Tiger Woods has experienced a difficult recent history of injury with missed tournaments due to injuries including back pain. He recently underwent a discectomy to remove disc material from his spine, but has yet to return to prior levels of play. His upcoming return highlights a key question, what is the likelihood an athlete return to the same level of play following a lumbar surgery. A recent review article in the British Journal of Sports Medicine reviewed the recent literature to answer this question (Reiman et al. 2015). The authors reviewed 14 articles on the return to sport rate after either conservative (including physical therapy) or surgical treatment for lumbar disc herniations. The authors reported no difference in the return to sport rate between surgical and conservative treatments. Only 59% of the athletes undergoing surgery return to the same level of play after this procedure.
This study highlights the limitations of focusing on only pathology/MRI scan in the treatments of patients with low back pain and injury. Given the equivalent outcomes between Physical Therapy and surgery patients should consider conservative treatments prior to surgical interventions for disc injury.