Lumbar Degenerative Disc Disease in a Basketball Player

History

The patient is a 23-year-old male scholarship basketball player who noted back pain when weightlifting one year ago. Pain progressed and has limited his ability to play basketball. He has a potential professional career if he can return to play.

He reports his pain as being 50% low back and 50% radicular. Pain radiates from the low back into the buttock and right anterior thigh.

Examination

The examination is normal.

Prior Treatment

NSAIDs, occasional narcotics for exacerbations, physical therapy, and epidural steroid injections three times; the last injection was not effective.

Images

Figure 1. Posterior anterior x-ray

Figure 2. Lateral x-ray; flexion / extension x-rays are stable

Figure 3. Sagittal T 2 MRI

Figure 4. Axial T 2 MRI of L3-L4

Figure 5. Axial T 2 MRI of L4-L5

Diagnosis

• Low back pain
• Right L3 radiculopathy
• Degenerative disc disease L3-L4 and L4-L5

Selected Treatment

The patient was between seasons and wanted to get treatment to enable him to return to his senior year of basketball. Nonoperative treatment had failed to enable him to play. Because of his large back pain component, it was felt that a discectomy would not provide sufficient decrease in his pain. Artificial disc was discussed but rejected by the patient. Ultimately, a right, unilateral minimally invasive TLIF using PEEK cage, BMP, and percutaneous screws and rods was performed.

Figure 6. Postoperative posterior anterior x-ray at 1 year

Figure 7. Lateral x-ray at 1 year

Outcome

The patient returned to playing basketball for his senior year. Ultimately, he went on to professional basketball. He is pain free at four years postop.

Case Discussion

This young patient presents with a very challenging injury. One missing aspect of nonoperative care is facet injections. It is reasonable to consider injecting the facets for both diagnostic and therapeutic purposes in patients with a component of axial pain. The disc injury is not an actual herniation and therefore, a decompression would not likely yield good results.

As this patient did not improve with nonoperative care and has a career-threatening injury, it is reasonable to consider surgical stabilization with a fusion. Artificial discs are not approved for use above the L4-L5 level and this patient's facet joints may already be degenerated, which is a contraindication for total disc replacement.

The results of other "dynamic stabilization" procedures for an injury such as this are still unproven. Prior to such a significant intervention in an athlete, it is essential that the patient and his family understand that there is no guarantee of return to high-level athletics.

A minimally invasive TLIF is a reasonable choice. Another approach option is a lateral (transpsoas) approach for the interbody fusion followed by either a lateral plate or posterior instrumentation.