Approximately 30% of athletes will have at least one episode of acute low back pain during their career [5]. Recently, in a cross-sectional study of 1,114 elite athletes, Fett et al. [6] reported that the lifetime prevalence of back pain in an elite athlete was 88.5%; the 12-month prevalence was 81.1%; the 3-month prevalence was 68.3%; and the point prevalence was 49.0%, compared with 80.7%, 69.9%, 59.0%, and 42.8%, respectively, in a control group. Increased trunk length and stiff lower extremities are known predisposing factors for acute low back pain in athletes [7]. In a study of 4,790 college students involved in over 17 various sports over a 10-year period, lumbar spinal injury rates were significantly higher in American football players and gymnasts [8]. Footballers, particularly offensive and defensive linemen, are more prone to lumbar disc herniations [9].

Athletes involved in sports requiring repetitive axial loading, hyperextension, direct impact, and twisting are highly prone to lumbar spinal injuries [10]. It is therefore important for the treating physician to understand the basic anatomy of the lumbar spinal and to be aware of the injury patterns that can occur. Repetitive axial loading of the low back can lead to lumbar disc herniation, which can even lead to a surgical emergency in cases of compression of the cauda equina [11]. Athletes involved in sports leading to repetitive hyperextension and causing excessive stress on posterior elements of vertebral body are at high risk for spondylolysis, with or without spondylolisthesis [12].

In general, lumbar disc herniation in athletes has a favorable outcome. More than 90% of players respond well to nonoperative treatment, and most patients RTS within 6 weeks of sciatica onset [23]. In a review, Iwamoto et al. [24] analyzed seven studies (n=71 athletes) regarding symptomatic lumbar disc herniations after conservative treatment. Treatment consisted of rest, oral medications, and physical therapy. The RTS rate was 79%, after an average period of 4.7 months. These athletes were able to maintain their participation in sports for at least 6 months. The severity of symptoms was found to have a negative correlation with the timing of their return to sporting activities. The authors also noted that radicular pain responded better to conservative treatment compared with axial back pain and neurological weakness. In another retrospective study of 342 professional athletes, Hsu et al. [25] studied the outcome of nonoperative and surgical treatment of lumbar disc herniations. Athletes involved in this study belonged to four major American sports groups (hockey, football, basketball, and baseball). Of 226 athletes undergoing surgical treatment for lumbar disc herniation, 82% successfully returned to sports, with an average 3.3-year sporting career following surgery. Of 116 patients treated by nonoperative means (activity modification, physical therapy, and epidural steroid injections), 84% returned to sport, with an average career length of 3.5 years [25]. RTS rates also varied depending upon the sport in which the athlete was involved. Overall, baseball players had the highest rate of RTS whereas football players had the lowest rate. Football players gained maximum benefits from surgery compared with players involved in other sports, and football players undergoing surgical treatment had longer career lengths compared with the nonsurgical group. Baseball players undergoing surgery had a shorter career compared with the nonoperative group [25].

Earhart et al. [26] analyzed 64 professional baseball players with 69 herniated lumbar discs. Some 40 players were treated surgically, whereas 29 were treated by nonoperative modalities (physical therapy, epidural steroid injection, and activity modification). Overall, 97% of athletes returned to sport at an average period of 6.6 months. Players treated nonoperatively had an early RTS (average 3.6 months) compared with players treated surgically (average 8.7 months).

Vangelder et al. [27] devised a phased rehabilitation protocol in athletes undergoing nonoperative treatment for lumbar disc herniation based upon the rehabilitation framework around the healing phases of the disc.

Phase 1: nonrotational/nonflexion phase (acute inflammatory phase) lasts from 0 to 6 days; phase 2: counter-rotation/flexion phase (repair phase) lasts from 3 to 20 days; phase 3: rotational phase/power development (remodeling phase) lasts from 9 days to full rotation; and phase 4: full RTS. The authors concluded that it is vital that the physical therapy prescription be individualized depending upon the assessment of the athlete, addressing movements in all necessary planes of motion, and under all extrinsic and intrinsic demands of the athlete.

Indications for selective nerve root blocks and epidural steroid injections include lumbar disc herniation or annular tear with or without radiculopathy. A selective nerve root block involves injecting a local anesthetic around the involved nerve under fluoroscopic guidance. Corticosteroids are frequently added to achieve long-term relief, based on their anti-inflammatory properties. Various techniques have been described including the transforaminal, interlaminar, and caudal epidural techniques. Transforaminal epidural steroid injections allow more ventral placement of the drug and are thus a more precise treatment compared with interlaminar and caudal epidural steroid injections. In a case control study on transforaminal versus interlaminar steroid injections for the treatment of symptomatic disc herniations, Schaufele et al. [28] reported that the transforaminal group had significant short-term improvement and fewer surgical interventions in the long term compared with the interlaminar group.

In a retrospective analysis of a prospective study, Jackson et al. [29] studied 32 competitive athletes treated with epidural steroid injections for symptomatic lumbar disc herniation with radiculopathy. Each athlete was also managed by other modalities of nonoperative treatment for an average period of 3.6 months (minimum 2 weeks) from the onset of symptoms. The authors reported that 44% of patients achieved significant pain relief and rapidly returned to their sport.

In another retrospective analysis, Krych et al. [30] studied 17 National Football League athletes with 27 distinct lumbar disc herniations, who received a total of 37 lumbar epidural steroid injections. The procedure was performed either using a transforaminal or the interlaminar approach, at an average period of 4 days from the onset of symptoms. The players were able to RTS 24 times (89%) out of 27 distinct episodes of lumbar disc herniations. Four patients required repeat injections for the same episode, of which three eventually required surgery. The authors also analyzed the risk factors for failed intervention. They found that athletes with a poor response correlated with having an magnetic resonance imaging (MRI) finding of disc sequestration and neurological deficit. They concluded that epidural steroid injections are a safe and effective treatment for lumbar disc herniations in athletes and that the injections provided either an alternative to surgery or offered relief until the surgery could be performed off-season. There was no difference in outcomes between the transforaminal and the interlaminar approach in this study.

The Spine Patient Outcomes Research Trial found excellent clinical outcomes in patients with lumbar disc herniation, irrespective of the treatment modality (conservative or surgical) [20]. There was a significant crossover of patients between the two groups in this randomized trial. Though the intent to treat analysis had shown a trend toward greater improvements in a group undergoing surgery, these differences were statistically insignificant [31]. These randomized trials described the outcomes of lumbar disc herniation treatment in the general population; however, these results do not necessarily hold true in the case of professional athletes involved in competitive contact sports. Parameters such as career longevity, performance, and RTS can aptly be described as representative outcome measures when evaluating any intervention in this subset of the population. The Professional Athlete Spine Initiative [25] was a retrospective cohort study of 342 professional athletes from four major North American sports from 1972 to 2008 who were diagnosed with lumbar disc herniations. Some 226 underwent surgical treatment (lumbar discectomy), whereas 116 underwent conservative treatment. Functional outcomes were evaluated by return to play (RTP) rates, number of games played after intervention, and length of career in years. Approximately 81% (184 of 226) of the operated patients returned to play at an average of 3.3 years following surgery. Survivorship analysis has shown that approximately 62.3% of players were expected to remain active for approximately 2 years following treatment. There was a significant difference in RTP rates between the individual sport cohorts: baseball players had the highest RTP rates, whereas football players had the lowest. The player’s professional experience before the injury was a positive predictive factor for length of career, and increased athlete age was a negative predictor. An analysis of independent cohorts suggested that NFL players undergoing lumbar microdiscectomy demonstrated significantly longer career lengths than the players treated nonoperatively when compared with other sports cohorts. The authors also calculated the performance score for each individual player depending on their playing position; there was no statistical difference between the treatment groups. Nor were differences found in the performance scores before and after treatment. The authors concluded that players at all positions can return to a preinjury level of performance following either nonoperative or surgical treatment for lumbar disc herniations.

In another descriptive study, Schroeder et al. [32], evaluated 87 ice hockey players to determine performance-based outcomes following nonoperative and surgical treatment for lumbar disc herniations. Some 85% of the patients had returned to sport, with a significant decrease in all players’ performance after a lumbar disc herniation in games played per season, points scored per game, and performance score. Analysis of posttreatment results showed that there was no significant difference in performance scores between the nonoperative and surgical groups.

The approach to disc pathology differs in children compared with adults. Pediatric patients do not respond well to nonoperative treatment and usually require surgical treatment. Patients and parents are frequently concerned about RTP following lumbar discectomy [21]. Although there is scarce literature, Burnett and Sonntag [22], Eck and Riley [33], and Cahill et al. [34] have suggested that there is no contraindication for pediatric patients to RTS following lumbar discectomy. Cahill et al. [34] reviewed 87 pediatric patients who had undergone lumbar microdiscectomy; 64% of the patients were athletes who were allowed to RTS at 8 to 12 weeks postoperatively.

Although lumbar microdiscectomy does not risk spinal instability, the possibility of recurrent disc herniations and further disc degeneration should be discussed with the patients and their parents before allowing a complete RTS. An athlete is expected to undergo structured rehabilitation following nonoperative or surgical treatment before returning to sport. Physical therapy should aim at building strong core muscles with lumbar stretching and sport-specific activities. Haus and Micheli [15] recommended that athletes usually return to activity at 3 to 6 months after nonoperative treatment and at 6 to 12 months after surgery.

In a retrospective review of 59 professional and Olympic athletes undergoing lumbar microdiscectomy, Watkins et al. [35] found that 88% of patients returned to active sport at an average period of 5.2 months following surgery. However, there was no performance-based outcome assessed in this study. The authors highlighted the role of trunk stabilization and strengthening exercises for athletes to be able to return to their respective sports.

Nonsurgical management is the mainstay of treatment for lumbar DDD in professional athletes. Physical therapy along with NSAIDs are routinely prescribed. There are multiple physical therapy protocols for the management of lumbar DDD; however, the combination of lumbar mobilization, core strengthening, and biopsychosocial support provide the optimum outcome [39].

Cooke and Lutz [14] described a 5-stage rehabilitation protocol for nonoperative management of an acute episode of DDD in professional athletes. Stage 1 (early protected stabilization) consists of bed rest limited to less than 2 days, followed by pharmacological and nonsurgical modalities (NSAIDs, superficial heat and cold, epidural steroid injections). Once the pain is under control, early lumbar range of movement exercises are started. Stage 2 (dynamic spinal stabilization) involves isometric strengthening of the lumbar extensor and abdominal muscles so as to reinforce the injured motion segment. Stage 3 (lumbar strengthening) comprises further lumbar strengthening to maintain the initial gains resulting from neuromuscular firing. Stage 4 (RTS activity) involves plyometric exercises composed of eccentric contraction, explosive concentric contraction, and resisted stretching. The authors also established criteria for RTS, involving (1) full, painless range of motion; (2) restoration of endurance and muscular strength; and (3) the ability to maintain the neutral posture of the spine during specific sport-related exercises. Stage 5 (maintenance program) consists of regular warm-up exercises. The time duration of each stage varies according to each athlete’s individual recovery.

Pain arising from facet joints will present with axial, nonradiating, paraspinal back pain, worsening on extension. The prevalence of facet joint pain is between 15% and 52% of the general population with chronic low back pain [40]. Young athletes are typically prone to facet joint synovitis, whereas degenerative arthritis of the facet joints is noted in elderly athletes. Athletes involved in repetitive extension and torsion of the lumbar spine, specifically golfers and throwers, frequently encounter facet-related pain [41]. Medial branch block with intra-articular injections with local anesthetic and steroids can serve as a diagnostic modality and have therapeutic potential. Radiofrequency neurotomy involves ablating the medial branch using electric current to reduce the pain originating from the facet joint [42].

In a prospective audit of 15 patients with chronic low back pain, Dreyfuss et al. [43] recommended that careful patient selection through positive response to medial branch block was the only solid predictor of positive outcomes to facet joint denervation. The authors also suggested that parallel placement of needles under direct fluoroscopy had a denervation rate of over 90%.

In a prospective study of 12 baseball pitchers with bilateral L4–L5 facet synovitis, Vad et al. [42] evaluated the role of radiofrequency ablation of the medial branch in suppressing the pain arising from facet joints. All 12 athletes having evidence of bilateral L4–L5 facet synovitis on MRI underwent fluoroscopic-guided intra-articular steroid injections. However, all the patients reported persistent pain at 8 weeks, and they underwent a diagnostic medial branch block, following which all the patients had positive results after undergoing radiofrequency neurotomy of the bilateral L4–L5 and L5–S1 facet joints. The authors reported significant improvements in pain (assessed by patient-reported VAS scores), and 83% of the patients were able to RTS at their preinjury level. These results were sustained for a minimum follow-up period of 1 year. The authors concluded that radiofrequency neurotomy of the facet joints provided safe, effective, and long-term relief of pain arising from facet synovitis in this specific group of athletes.

Patients with DDD can be treated surgically either by lumbar fusion or lumbar total disc replacement (TDR), and outcomes in the general population are variable. To date there is a paucity of literature on lumbar fusion for DDD in professional athletes. In a series of athletes who returned to play after lumbar fusion, Schroeder et al. [32] reported on 8 hockey players who underwent single-level lumbar spinal fusion. There was no significant difference in the number of games played per season or the performance score either before or after the treatment.

Recently, Shifflett et al. [44] reviewed 34 golfers undergoing a fusion procedure for degenerative pathologies of the lumbar spine. Some 65% of the patients returned to practice and 52% of the patients returned to course play within 1 year of surgery. Some 77% of the patients were able to play the same amount of golf or more than before the fusion surgery. Of those patients who had not returned to their sport at 1 year, less than one-third of the patients stated that their back pain or leg pain was the limiting factor for returning to their sport.

Siepe et al. [45] reviewed 39 high-demand professional athletes who underwent TDR for lumbar DDD. The average follow-up period was 26.3 months, and the RTS rate was 94.9% (35 of 37 patients). Some 85% of the patients were completely satisfied with their procedure, and the average time for peak fitness was 5.2 months based on patient-reported surveys. Following TDR, 69% of the patients returned to play within 3 months. It is noteworthy that in the entire cohort only two patients were involved in contact sports, and neither player was able to RTP after TDR.

Military personnel are a special group of individuals whose lumbar spines bear a great deal of force. They are involved in strenuous activities such as running long distances with heavy loads, diving, valley crossing, parachute jumping, and rope climbing. In an cohort-matched comparative analysis between TDR and lumbar fusion, Tumialan et al. [46] reported 10 (83%) of 12 patients undergoing TDR returned to unrestricted full duty in an average period of 22.6 weeks. In a fusion cohort, eight (67%) of 12 patients had returned to unrestricted activity in an average period of 32.4 weeks. Although this study suggested that TDR outcomes are favorable compared with the fusion study, the authors found some potential confounding factors. Although all symptoms resolved, the return to work in the fusion group depended on radiographic evidence of fusion; however, there are no such radiographic indicators for TDR that dictate the safe return to work. Moreover, surgeons tend to permit an early return to patients involved in a sedentary work environment.

The majority of patients with acute symptomatic spondylolysis can be managed successfully with nonoperative treatment. The primary aim of treatment of spondylolysis in athletes is to minimize pain while restoring function and motion. Acute symptomatic pars defects are managed initially with activity modifications, bracing, rest, and physical therapy. Lumbar extensions should be avoided so as to prevent shearing forces and thus prevent spondylolisthesis. In a review of the literature on spondylolysis among fast bowlers, Kothari et al. [52] suggested that early diagnosis and a short rest period is the key factor for an early RTS. The authors also proposed enforcing strict strategies for prevention of these injuries in adolescent fast bowlers. Klein et al. [53] reported a healing rate approaching 90% in patients with acute spondylolysis. Patients with chronic spondylolysis, however, are less likely to respond to conservative treatment. In a case control study of 132 athletes with spondylolysis, El Rassi et al. [54] demonstrated that athletes who refrained from sports for 3 months had an outcome 16.39 times better than those who continued with sports. Miller et al. [55] suggested that the majority of athletes managed nonoperatively for acute spondylolysis had good functional outcomes for up to 11 years.

Although there is a great deal of peer-reviewed literature reported on the outcome of pars injections for spondylolysis in the general population, there is a paucity of such studies specifically aimed at athletes with chronic pars defects. These injections are performed under fluoroscopy with anesthetics alone (diagnostic) or with anesthetics and corticosteroids (therapeutic). The injections are made directly into the pseudarthrosis in the pars, given the direct site of pain generation is the pars fracture. Kershen et al. [56] retrospectively reviewed 121 patients undergoing pars injection with the aim of determining the accuracy and short-term efficacy of fluoroscopy-guided steroid/anesthetic injections for symptomatic pars defects. Patient-reported VAS scores were used to measure outcomes. The authors concluded that 92% of fluoroscopy-guided injections were technically successful in patients with symptomatic spondylolysis, resulting in statistically significant pain reduction immediately post-injection and at 1 week post-injection.

Despite the lack of literature on pars injections for the treatment of symptomatic spondylolysis, it appears to be an attractive alternative for short-term management of chronic pars-related pain in athletes. Injecting anesthetic alone in cases of pars defect can identify pars as the pain generator, whereas the use of a corticosteroid along with a local anesthetic could be diagnostic as well as therapeutic.

Surgical treatment is recommended for athletes who fail to improve after 6 months of nonoperative treatment. Surgery is also the preferred modality of treatment for adolescent athletes with high-grade spondylolisthesis because they are at significant risk of a further increase in vertebral slip [57]. Patients with spondylolisthesis can be treated with either direct pars repair or decompression with or without fusion.

Young patients with minimal spondylolisthesis, no radicular symptoms, and mild degenerative changes are ideal candidates for direct pars repair [58]. To date, many pars repair techniques have been described, including the Scott wiring technique, Morscher hook screw technique, and Buck’s screw technique [59]. Of these approaches, Buck’s screw is biomechanically the strongest and stiffest, whereas Scott’s wiring is the least stable repair [60]. In a retrospective study of 16 patients with spondylolysis undergoing direct pars repair with the Buck’s screw technique, Snyder et al. [61] demonstrated that Buck’s screw repair provided a satisfactory clinical and radiological outcome, including an early RTS. In a review of minimally invasive versus conventional direct repair of pars for spondylolysis in athletes, Kolcun et al. [62] reported that patients undergoing minimally invasive pars repair had significantly higher rates of pain resolution and shorter recovery times. Both groups were comparable in terms of complication rates and RTP rates. Reitman and Esses [63] reported on four athletes who returned to sports within 6 months of Buck’s repair for spondylolysis. All the athletes in this study had returned to their preinjury level of performance by 1 year. Gillis et al. [58] studied eight young athletes undergoing pars repair using minimally invasive techniques. Some 75% (6 of 8) of the athletes returned to their preinjury level of performance. Two patients who were unable to achieve the previous level of performance had spondylolysis that failed to fuse. Overall, there was improvement in patient-reported outcomes as measured by the VAS, ODI, and SF-36 scores. In a prospective study of 22 athletes, Debnath et al. [13] studied the clinical outcome and RTS rate after surgical treatment of spondylolysis. ODI and SF-36 scores were used to measure the outcome. Three patients received Scott’s fusion and 19 patients received Buck’s fusion. At the end of 2 years, there were statistically significant improvements in both the ODI as well as the SF-36 scores. Some 82% (18/22) of the patients returned to their sporting activity in an average period of 7 months (range, 4–10 months). Hardcastle [64] reported good results of local screw fusion of pars interarticularis defects in 10 cricket bowlers. Unrestricted athletic activity was permitted once union was evident on oblique computed tomography scans. Some 70% (7/10) of the patients had returned to sport at 3–6 months. In a study of 20 athletes involved in baseball, tennis, and golf, Nozawa et al. [65] analyzed the results of pars interarticularis defect repair by segmental wire fixation. Outcomes were evaluated by radiographic examination, Japanese Orthopaedic Association (JOA) score, preoperative and postoperative activity levels, and the rates of intensity and complications. The authors reported bony fusion at the repair site in all the patients, with a significant improvement in JOA scores (recovery rate 80.4%). All the patients returned to sporting activity, although to varying degrees. The authors reported no major complications.

Spondylolysis with spondylolisthesis and degenerative changes that are refractory to nonoperative treatment are amenable to posterolateral fusion, with success rates close to 90%. Helenius et al. [66] studied 108 young patients undergoing in situ posterolateral fusion for low-grade spondylolisthesis, with a mean follow-up period of 20.8 years. The authors reported satisfactory functional outcomes as measured by the Scoliosis Research Society questionnaire and the ODI. Lamberg et al. [67] reviewed 69 young patients with high-grade spondylolisthesis undergoing either posterolateral, anterior, or circumferential in situ fusion. At an average follow-up of 17.2 years, all the treatment groups had good ODI scores. The circumferential fusion group had slightly better outcomes compared with the other treatment groups.