Orthopedics

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Feature Article 

Sporting activity following discectomy for lumbar disc herniation

Verena Dollinger, MD; Alois A. Obwegeser, MD, MSc, MAS; Michael Gabl, MD; Peter Lackner, MD; Michael Koller, MD; Klaus Galiano, MD

Abstract

The aim of this study was to investigate to what extent patients could resume physical activity following surgery for herniated lumbar disks. We analyzed a cohort of 1003 patients who underwent lumbar spine surgery within 1 year. Out of this cohort, 93 patients were selected according to our inclusion criteria (age 20-35 years, mediolateral single level disk herniation, no comorbidity at the lumbar spine, and treatment with conventional subtotal diskectomy). This group was evaluated after a minimum follow-up of 28 months in a telephone questionnaire; participants were questioned about pre- and postoperative physical activities. The questionnaire was answered by 67 patients. Twenty-six patients were lost to follow-up because they had relocated. The follow-up group had a mean age of 30 years. Five patients were operated again due to recurrent disk herniation. All patients showed a pain reduction. At follow-up, no patient needed constant pain medication. Eighty-two percent of the patients were pain free during practicing sports. Sixty-two patients performed some kind of sport after surgery. Concerning the type and frequency of physical activities, no significant change between pre- and postoperative behavior occurred. The 5 patients with recurrent disk herniation did not behave differently. Single-level lumbar disk surgery does not limit or compromise sportive activity in young people.

Low back pain is a major problem in industrialized countries,1,2 and patients from these countries make up for most part of the economic and social burden associated with low back pain.3 Several studies have been looking at pain and work-related issues after lumbar disk surgery,4-7 but lack of data exists concerning leisure activities after spinal disk surgery. This study was undertaken to investigate the outcome in terms of the ability to re-engage in sport-related activities after surgically treated lumbar disk herniation.

Consecutive patients who had undergone a conventional subtotal8 lumbar diskectomy without fusion at our department between January and December 2002 were selected for this study. From 1003 patients treated surgically, 847 were living in our country. Out of these, 116 patients were between 20 and 35 years (Figure). Before contacting patients, we carefully examined surgical reports and histories to exclude patients with additional spinal diseases (ie, stenosis, listhesis, and scoliosis). After excluding all patients with comorbidities of the lumbar spine such as listhesis, spinal stenosis, or pre-existing surgery, or patients with far-lateral locations of the herniation or multilevel herniations, 93 patients remained.

Preoperative data were obtained by electronic chart review. Follow-up data were collected at least 28 months after surgical treatment in a telephone questionnaire. Data included age, gender, body mass index (BMI), surgical dates, drug administration, pain during physical activity and during rest, working conditions, and type and frequency of sports activity.

Data were analyzed using the SPSS 14.0 software package (SPSS Inc, Chicago, Illinois). The two-tailed Wilcoxon’s rank sum test was used to compare preoperative to postoperative measures. The McNemar test was used to analyze for changes in sporting activity.

Of 93 patients, 67 were available for the telephone interview. The remaining patients had changed their address and telephone number, and no relatives were available to provide us with actual data. All patients who were contacted answered the questionnaire.

Average patient age at the time of surgery was 30 years: 33 patients were female. Mean time to follow-up was 3 years. Five patients had a recurrent disk herniation.

Preoperative versus follow-up data for both subgroups are shown in the Table.

None of the patients had a constant pain medication at follow-up.

During movement, 82% of the patients were pain free. During rest, 30% of the patients reported some type of pain.

Concerning type and frequency of sportive activity, no significant…

Abstract

The aim of this study was to investigate to what extent patients could resume physical activity following surgery for herniated lumbar disks. We analyzed a cohort of 1003 patients who underwent lumbar spine surgery within 1 year. Out of this cohort, 93 patients were selected according to our inclusion criteria (age 20-35 years, mediolateral single level disk herniation, no comorbidity at the lumbar spine, and treatment with conventional subtotal diskectomy). This group was evaluated after a minimum follow-up of 28 months in a telephone questionnaire; participants were questioned about pre- and postoperative physical activities. The questionnaire was answered by 67 patients. Twenty-six patients were lost to follow-up because they had relocated. The follow-up group had a mean age of 30 years. Five patients were operated again due to recurrent disk herniation. All patients showed a pain reduction. At follow-up, no patient needed constant pain medication. Eighty-two percent of the patients were pain free during practicing sports. Sixty-two patients performed some kind of sport after surgery. Concerning the type and frequency of physical activities, no significant change between pre- and postoperative behavior occurred. The 5 patients with recurrent disk herniation did not behave differently. Single-level lumbar disk surgery does not limit or compromise sportive activity in young people.

Low back pain is a major problem in industrialized countries,1,2 and patients from these countries make up for most part of the economic and social burden associated with low back pain.3 Several studies have been looking at pain and work-related issues after lumbar disk surgery,4-7 but lack of data exists concerning leisure activities after spinal disk surgery. This study was undertaken to investigate the outcome in terms of the ability to re-engage in sport-related activities after surgically treated lumbar disk herniation.

Materials and Methods

Consecutive patients who had undergone a conventional subtotal8 lumbar diskectomy without fusion at our department between January and December 2002 were selected for this study. From 1003 patients treated surgically, 847 were living in our country. Out of these, 116 patients were between 20 and 35 years (Figure). Before contacting patients, we carefully examined surgical reports and histories to exclude patients with additional spinal diseases (ie, stenosis, listhesis, and scoliosis). After excluding all patients with comorbidities of the lumbar spine such as listhesis, spinal stenosis, or pre-existing surgery, or patients with far-lateral locations of the herniation or multilevel herniations, 93 patients remained.

Preoperative data were obtained by electronic chart review. Follow-up data were collected at least 28 months after surgical treatment in a telephone questionnaire. Data included age, gender, body mass index (BMI), surgical dates, drug administration, pain during physical activity and during rest, working conditions, and type and frequency of sports activity.

Data were analyzed using the SPSS 14.0 software package (SPSS Inc, Chicago, Illinois). The two-tailed Wilcoxon’s rank sum test was used to compare preoperative to postoperative measures. The McNemar test was used to analyze for changes in sporting activity.

Figure: Histogram of subject age for the whole group of patients
Figure: Histogram of subject age for the whole group of patients (n1003). The stacked black and gray bars correspond to the number of subjects fulfilling the inclusion criteria, while the black bars denote patients who answered the protocol.

Results

Of 93 patients, 67 were available for the telephone interview. The remaining patients had changed their address and telephone number, and no relatives were available to provide us with actual data. All patients who were contacted answered the questionnaire.

Average patient age at the time of surgery was 30 years: 33 patients were female. Mean time to follow-up was 3 years. Five patients had a recurrent disk herniation.

Preoperative versus follow-up data for both subgroups are shown in the Table.

None of the patients had a constant pain medication at follow-up.

During movement, 82% of the patients were pain free. During rest, 30% of the patients reported some type of pain.

Concerning type and frequency of sportive activity, no significant difference was found pre- or postoperatively, with the exception of an increase in the number of patients practicing uncommon activities (all activities not listed particularly, ie, climbing).

Interestingly, only patients with an increased BMI (>25), working in standing positions, or not practicing sports on a regular basis preoperatively underwent surgery due to recurrent disk herniation.

Gender, BMI, or labor did not significantly influence sports participation.

Discussion

This is the first study evaluating the ability to re-engage in sports activities after lumbar disk herniation.

In clinical practice, many patients are concerned about the effects of disk surgery on leisure activities. Until now, only opinions of experts in the specific discipline were available as a basic guideline in answering this important question. The goal of this study was to provide reliable information based on actual data for addressing this question.

As biking, swimming, walking, skiing, and running are the most popular types of sports in our country,9 we examined these specific activities.

Our study may provide guidance and information for physically active patients with spinal lumbar disk herniation. The restriction on isolated lumbar disk herniation without fusion or comorbidities and thus on a single factor is a strength of this study.

The retrospective design and incomplete follow-up of this study are a limitation. We conducted extensive research to contact each patient, but due to the high mobility in this age group and due to marriage, we only reached 72% by telephone. However, we do not believe that this restriction distorts our data, as relocation should be unrelated to sport activity.

As this is the first study of its kind, we can only compare our results with recently published data from knee surgery, which seem to be similar.10

As residual symptoms and pain after disk surgery are common,11 we initially thought our patients would have some restrictions in sports participation postoperatively. However, when comparing preoperative to postoperative measurements, we detected no difference. The only significant change was an increase in “other” types of sports, which includes back-gymnastics. Otherwise, there were no restrictions for young patients in the ability to resume participation in sports activities following single-level lumbar disk herniation.

Fewer patients reported pain during physical activity than during rest. As patients primarily reported lumbar pain, this fits well with the advice given to low back pain patients to stay active.12

Table: Preoperative Versus Follow-up Comparisons of BMI, Working Condition, Medication, Pain, and Sports Activity

Concerning recurrent disk herniation, our data are similar to data reported for the same type of surgery in a comparable university setting.8 However, the intake of pain medication was lower in our study (0% versus 20% on daily non-narcotics; 10% versus 46% on occasional non-narcotics), which might be an effect of the younger age of our patients (30 versus 37.5 years).

Patients with recurrent disk herniation did not show a significantly worse outcome than patients without recurrence. Interestingly, recurrent disk herniation was limited to the subgroup of patients who were not practicing sports on a regular basis. We are not sure how to interpret this finding, as the number of patients with recurrent disk herniation was too small to draw any conclusions.

When examining the effects of preoperative factors on sports activities, no confounding variables were found.

Conclusion

Single-level lumbar disk surgery does not limit sport participation in young patients.

References

  1. Deyo RA, Phillips WR. Low back pain. A primary care challenge. Spine. 1996; 21(24):2826-2832.
  2. Waddell G. Low back pain. A twentieth century health care enigma. Spine. 1996; 21(24):2820-2825.
  3. Williams DA, Feuerstein M, Durbin D, Pezzullo J. Health care and indemnity costs across the natural history of disability in occupational low back pain. Spine. 1998; 23(21):2329-2336.
  4. Hansson E, Hansson T. The cost-utility of lumbar disc herniation surgery. Eur Spine J. 2007; 16(3):329-337.
  5. den Boer JJ, Oostendorp RA, Beems T, Munneke M, Evers AW. Continued disability and pain after lumbar disc surgery: the role of cognitive-behavioral factors. Pain. 2006; 123(1-2):45-52.
  6. den Boer JJ, Oostendorp RA, Beems T, Munneke M, Evers AW. Reduced work capacity after lumbar disc surgery: the role of cognitive-behavioral and work-related risk factors. Pain. 2006; 126(1-3):72-78.
  7. Gallagher RM, Williams RA, Skelly J et al. Workers Compensation and return-to-work in low-back-pain. Pain. 1995; 61(2):299-307.
  8. Carragee EJ, Spinnickie AO, Alamin TF, Paragioudakis S. A prospective controlled study of limited versus subtotal posterior discectomy: short-term outcomes in patients with herniated lumbar intervertebral discs and large posterior anular defect. Spine. 2006; 31(6):653-657.
  9. Pratscher H. Sportverhalten in Österreich. Journal für Ernährungsmedizin. 2000; 2(5):18-23.
  10. Fisher N, Agarwal M, Reuben SF, Johnson DS, Turner PG. Sporting and physical activity following Oxford medial unicompartmental knee arthroplasty. Knee. 2006; 13(4):296-300.
  11. Atlas SJ, Keller RB, Chang YC, Deyo RA, Singer DE. Surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: five-year outcomes from the Maine Lumbar Spine Study. Spine. 2001; 26(10):1179-1187.
  12. Hagen KB, Jamtvedt G, Hilde G, Winnem MF. The updated Cochrane Review of bed rest for low back pain and sciatica. Spine. 2005; 30(5):542-546.

Authors

Drs Dollinger, Obwegeser, Gabl, Lackner, Koller, and Galiano are from the Department of Neurosurgery, Innsbruck, Austria.

Drs Dollinger, Obwegeser, Gabl, Lackner, Koller, and Galiano have no relevant financial relationships to disclose.

Correspondence should be addressed to: Alois A. Obwegeser, Department of Neurosurgery, Anichstrasse 35, 6020 Innsbruck, Austria.

10.3928/01477447-20080801-05

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