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Perspectives of Endoscopic Spine Surgery in Athletes and Practitioners of Physical Activity
Written By
João Paulo Machado Bergamaschi,
Marcelo Botelho Soares de Brito, Ariel Falbel Lugão,
Thiago Queiroz Soares, Gustavo Vitelli Depieri,
Edgar Takao Utino, Fábio da Silva Forti,
Kai-Uwe Lewandrowski and Fernanda Wirth
Submitted: 02 March 2023Reviewed: 02 March 2023Published: 18 April 2023
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Spinal degenerative diseases are common in physical activity practitioners and even athletes and may require surgical intervention. A great training routine, especially at young ages may lead to raised chances of spine degeneration and back pain. However, endoscopic spine surgery (ESS) seems to be a viable alternative, especially in the case of athletes, as recovery time and time away from the play are much shorter than in open surgery. Open surgery requires longer hospitalization time, has higher rates of infection, and, consequently, longer recovery time. Athletes and practitioners of physical activity can benefit from ESS as it is a minimally invasive procedure, with less tissue damage and shorter recovery time, which in many cases has the same benefits as open procedures for spinal disorders, but often with a shorter return to play (RTP) time.
*Address all correspondence to: jberga@clinicaatualli.com.br
1. Introduction
Physical activity has been seen as beneficial in spinal health, but spinal overuse has been associated with degenerative pathologies in the athletes and practitioners of some types of physical activity populations [1]. Degenerative pathology of the spine may be associated mainly with competitive sports activities [2] probably because of the placement of heavy loads on the intervertebral discs involved in some sports modalities. Due to this fact, athletes and practitioners of physical activity in some sports modalities have an increased predisposition to disc herniations because these heavy loads may predispose them to a raised risk for degenerative disc disease [3].
The treatment for symptomatic disc herniations in athletes is the same as in the non-athletic population [3]. Treatment of lumbar spine problems usually starts with conservative treatment, when there is no red flag sign or symptom, such as reduced anal sphincter tone, hyperreflexia, hyporeflexia or areflexia, lower extremity muscle weakness, and saddle anesthesia [4]. Conservative treatment can be composed of treatments such as physiotherapy, acupuncture, and pharmacological treatment. Medications usually involve nonsteroidal anti-inflammatory drugs and may include muscle relaxants if the athlete is undergoing muscle spasms [5]. In case of failure of conservative treatment and sufficient patient morbidity, surgery may be required [5, 6].
However, postoperative rehabilitation after spine surgery is another challenge. Some authors suggest that for the athlete over the age of 60 who underwent spine surgery, it is possible but not probable to RTP (return to play) in the previous level of athletic activity. Those under the age of 60, they should be able to RTP at a moderate level of sports participation [6]. This may be due to the damage to the back muscle [7]. For this reason, defining the ideal surgical approach is fundamental for the athletes’ livelihood [8]. In this population, the minimally invasive spine procedures (MISP) may be welcome because they have been suffering rapid development because they confer less muscle crush injuries; pain; prevent soft tissue stripping, including muscles and ligamentous structures; confer decreased blood loss, bony resection, and hospitalization; besides they can promote high patient satisfaction and absence of arthrogenic inhibition due to the small incision and tissue adhesion due to scarring [9, 10]. Regarding the advantages of these procedures, the literature confirms the efficiency and efficacy of MISP concerning morbidity and safer complication profiles [9].
The RTP capability is frequently measured as a success factor in the athlete and practitioners of physical activity populations [3]. RTP is progressive according to the improvement of symptoms [5, 11, 12]. Some authors recommend that individuals are able to RTP if they have a full painless range of movement, the capability to preserve a neural spine position during specific exercises, control, endurance, and return of muscle strength [5, 11].
There are just a few case reports about ESS in athletes and no study or case report about ESS in practitioners of physical activity and for this reason, the aim of this chapter is to discuss the role of ESS in athletes and practitioners of physical activity through a literature review about the application of ESS in athletes and the role of physical activity in the context of ESS.
2. Advantages, indications, and techniques in the context of ESS
The increasing improvements in spine surgery over the last decades progressively reduced the size of skin incisions and gave rise to spine minimally invasive surgery [13, 14]. Yeung gave rise to ESS by developing microdiscectomy, percutaneous nucleotomy, and tubular discectomy with the use of tubular dilators. Finally, he introduced a multichannel endoscope with saline irrigation and a camera [13, 15].
The new surgical intervention methods aim to produce better functional preservation and faster recovery [16]. Endoscopic techniques provide a minimal approach while maximizing functional visualization and correction of pathological tissues [17]. In this context, the main method for the treatment of diseases such as lumbar disc herniations (LDH), cervical stenosis, thoracic disc herniations, and revision surgeries in different vertebral segments is ESS [8, 10, 18]. ESS may offer many advantages over other surgical approaches [19]. It involves minimal muscle dissection and a small incision [7, 20] while effectively treating spinal stenosis and/or disc herniation [8, 21, 22] and due to this fact, it can be performed under sedation and local anesthesia, which facilitates communication between the patient and the surgeon, so the surgeon can have the intraoperative feedback and improve safety during spinal surgery, besides the shorter recovery time and fewer side effects [23, 24].
Some of the benefits of the endoscopic approach are: decreased blood loss, shorter hospitalization, reduced postoperative pain, improved functional status, lower infection rates, improved biomechanical stability, absence of arthrogenic inhibition, reduced collateral damage, preservation of facet joint, better cost-effectiveness, and low risk of surgery-related morbidity [8, 10]. As a result of a great decrease in approach-related tissue damage, ESS is also related to low rates of perioperative complications [8, 25], with current estimates ranging from around 3% to 9.76% [8, 18, 26]. These features lead to faster rehabilitation for patients [27]. Regarding all these benefits, the ESS approach for spinal canal decompression is becoming a good option for athletes and practitioners of physical activity instead of traditional open surgical approaches [8] because biomechanical stability and postoperative time to recovery are critical points for the athletic population and all these benefits make this surgical approach adequate to athletes and practitioners of physical activity [8]. Biomechanical stability contributes to the control of postural and core stability and consequently to more effective functional movements specific to some particular sports [28]. The postoperative recovery time is a critical situation in terms of athletes’ performance and financial terms since this population in general has sponsors. The result in general needs to be quick to meet the expectations of the athlete, the club, the sponsor, the family, and the fans. Furthermore, when compared with open discectomy and microdiscectomy, the ESS outcomes are similar to open spine surgery in terms of symptomatic relief [8] but with lower overall complications according to recent publications [13, 29]. Concerning professional athletes, ESS could be considered the ideal surgical intervention because of the minimum damage to the back muscles due to the use of small tubular retractors [7]. Previous studies on this topic appear to confirm the premise that minimization of approach-related tissue damage may help rehabilitation and increase functional recovery [8, 30, 31, 32, 33, 34]. Non-surgical treatments may improve RTP rates, but there is no consensus about this topic and more studies are necessary to better guide the treatment [35]. Another factor to be considered is that athletes have differentiated muscle conditioning, which can help in the recovery of the individual. Because of this differentiated muscle conditioning, the athlete will RTP much faster than the general population. It is worth bearing in mind that injured athlete usually receives care from various providers during rehabilitation and generally have a better commitment to their rehabilitation, due to the factors mentioned above [36]. Due to the development of better endoscopic equipment, new endoscopic approaches were developed, and the number of indications also increased during the last two decades [10], so this minimally invasive treatment is possible. Nowadays, endoscopes can provide optimal visualization, reducing the necessity for large incisions and changes in the biomechanics of the affected vertebral segment [8].
The indications for ESS expanded considerably during the last decade and they continue to evolve. They can involve degenerative pathology in all parts of the spine from low-complexity procedures like lumbar microdiscectomy to high-complexity procedures (for example, cervical stenosis and thoracic herniations) [8, 10, 18]. The lumbar ESS may include interbody fusion, spinal stenosis, disc herniations, infections, medial branch rhizotomy [17], dural injury [37], and osteoid osteoma [38]. Nevertheless, the viability of ESS and its approach should be determined according to the anatomical and clinical conditions of the patient [39]. In addition, the understanding of the various types of the disc prolapses pathology related to the neuroforamen often results in better surgical outcomes [17].
Owing to the continued evolution of these surgical techniques, the approaches for the cervical and thoracic spine gained wider appeal [18, 40, 41]. Endoscopic techniques have been used to treat many pathological conditions in terms of degenerative, and even cancer [42]. Several full-endoscopic spinal approaches have been reported and performed over the past three decades. The main approaches used in the context of ESS are transforaminal (TF) and interlaminar (IL) approaches. TF approaches were developed after the description of the medial aspect of the foraminal annular window as a safe area for disc space access, known as the Kambin triangle [43, 44]. This approach utilizes endoscopic visualization, and high-speed burrs [13]. A recent study demonstrated that ESS is superior to open discectomy regarding the rate of adverse events and total length of hospital stay [45]. It is possible to perform foraminoplasty and decompression of structures that may participate in the genesis of the degenerative disease of the segment approached (Figure 1) [46]. TF techniques can be separated into inside-out and outside-in techniques considering the surgical method. The inside-out is the technique that requires access to the intervertebral disc through an annulotomy and moves to the outside of the intervertebral disc to protect the epidural space. The outside-in technique starts from the outside of the intervertebral disc, protecting the epidural space and entering the disc space. Yet, the approach technique is based on the type of disc herniation [47]. Figure 2A shows a complete set of instruments from ESS. Figure 2B shows a surgical team performing a transforaminal approach in an ESS.
Figure 1.
Endoscopic view of the intervertebral foramen with stenosis (preoperative) and after foraminoplasty for root decompression (postoperative) using the full-endoscopic technique on the lumbar spine.
Figure 2.
A. Complete set of instruments from ESS. B. Surgical team performing a TF approach in an ESS.
In more recent years, with the development of camera technology and better instruments, it has become possible the direct approaches to the spine by IL techniques thus facilitating the treatment of degenerative spinal pathology and resecting yellow ligament (ligamentum flavum) [43, 48]. This technique was developed to treat mainly disc herniations at the L5-S1 level. With the development of IL endoscopic techniques, the indications for ESS have further broadened. The entrance to the vertebral canal through the posterior approach is called the IL window. Regarding anatomy, the width at the bottom of the lower back increases, but its height decreases. Even though the IL window reduces in the lower lumbar segments, it will usually be about >10 mm at the L4-L5 and L5-S1 levels, thereby allowing endoscopic instruments to access the canal. Furthermore, the flexion position can increase the height [49].
Athletic activity has been seen as beneficial for spinal health, but spinal overuse has been associated with degradation in the athletic population [50]. A common type of overuse injury of the spine is stress fracture through pars interarticularis. These injuries are usual in all sports with high reclination load to the lumbar spine, early start of high training load, and year-round sports with insufficient time for recovery [51]. For this reason, athletes tend to have back pain (BP) more commonly than the general population, probably because of the repetitive physical exercises of their training, due to their training load and the overuse [8, 50, 52]. All this can result in repetitive traumatic discopathy (RTD), which is characterized by degeneration or herniation of the intervertebral discs. This happens mainly because of repeated traumatic movements, instability, and deterioration of the spine. RTD occurs more commonly at the spine level that is exposed to considerable mechanical stress [50]. Due to this mechanical stress, the intervertebral disc tissue loses volume and stability leading to a significantly higher prevalence of disc degeneration and RTD in athletes (75%) than in non-athletes (31%) [50, 53]. Some studies report that up to 75% of athletes that train and compete, experience one or more episodes of BP during their career [50, 54].
Spine injuries can be related to participation in sports that involve repetitive hyperextension, flexion, rotation, and axial loading. Mechanical loading of the spine during physical activity plays an important role in the etiology of BP and back injuries [5]. Gymnastics, ballet, rowing, football, swimming, wrestling, diving, dance, hockey, tennis, and soccer are examples of sports that are related to these repetitive movements and can consequently be related to spine problems [5, 55, 56, 57, 58]. The main spine problem in the young athletic population is probably overuse injuries [57, 58]. These injuries can result from two types of force generation: acute macrotrauma or repetitive microtrauma, resulting in overuse injuries [59]. Overuse injuries often result in unsatisfactory performance or even incapability to perform, which may lead to a reduced career and financial loss because of absence from important championships [5].
Concerning professional athletes, ESS could be considered the ideal surgical intervention because of the minimum damage to the back muscles due to the use of tubular retractors [7]. Previous studies on this topic appear to confirm the premise that minimization of approach-related tissue damage may help rehabilitation and increase functional recovery [8, 30, 31, 32, 33, 34]. Yet, elite athletes are not usually considered in debates about spinal surgery [8]. Perhaps the main reason for that is the difficulty to apply to athletes the surgical outcomes from the general population to determine the success of the surgery because athletes are part of a special population in which the outcome must include factors such as the ability to RTP, endurance, flexibility, return to baseline strength, pain-free with a full range of motion [8, 58].
However, it is suggested that elite athletes may successfully RTP after ESS because this procedure has a favorable impact on the rehabilitation process, improving the outcome, especially on the subject of time to RTP. Still, there are no formal guidelines considering RTP aspects until now. The only pieces of evidence available in the literature include case series, case reports, and retrospective reviews. Although these data are narrow due to the lack of homogeneity and small sample size, they can support the idea that ESS provides advantages over traditional open surgery in terms of time and rate of RTP. Thus, ESS approaches to the spine may be the best choice for athletes that need to RTP as soon as possible because of the small tissue disruption and better and faster postoperative functional outcomes when compared to open approaches given the minimal approach applied [8].
Until this moment, there are only three randomized controlled trials compared ESS with traditional microdiscectomy published in the literature [60, 61, 62], and none of them include athletes or practitioners of physical activity. The first clinical trial was published in 2008 and found significantly lower postoperative opiate use, a shorter period of incapacity, and a similar reduction of leg pain when compared to traditional surgery [62]. The second clinical trial was published in 2017 by Gibson et al. This study found the advantage that at a 2-year follow-up the patients who underwent ESS improved leg pain better (decreased by 55 and 65% in the two groups) than the patients who underwent traditional discectomies [61]. The last clinical trial until this moment was published one year later, in 2018, by Chen et al. who did not find differences in outcomes between FESS and microendoscopic discectomy for LDH [60].
Considering the case reports and case series available in the literature, here we summarized them in Table 1. Current data available include various sports modalities, such as football, baseball, volleyball, tennis, basketball, bicycle race, boxing, soccer, golf, weightlift, etc., but something important to point out is that lumbar levels are the most frequent regarding injuries. Baseball and football seem to be the most frequent sports involved in spine injuries according to these case series and case reports. In ESS, there are low rates of complications in athletes reported in the literature, as well as high rates of rapid RTP. The spine level that is most often associated with injuries or herniations is the L4-L5 level. The cervical levels are infrequent, but there is one case report including full recovery after FESS in a weightlifter [65]. There are low rates of complications and the most common approach is a transforaminal endoscopic discectomy. The average time for rehabilitation varies from 1 to 3 months for training activities and most of the athletes return to their previous levels of sports activity and competitive level.
IL endoscopic L5/S1 discectomy; TF endoscopic L4/L5 discectomy; and full-endoscopic unilateral approach for bilateral decompression
3
Soccer, football
No
L4-L5 and L5-S1
Case 1: at 2 weeks postoperatively, the patient was cleared to return to light exercise. In the season after the surgery, the patient earned all-conference honors in one of the top collegiate divisions 1A conferences
Case 2: by 3 months after surgery, the patient returned to full play, earning all-conference honors
Case 3: RTP at 3 months and rejoined the active roster with playing time in one of the top division 1 collegiate conferences
3.6% of patients expressed dysesthesia directly after surgery, but it was alleviated at the 6-week follow-up examination with conservative treatment
L3-L4, L4-L5 and L5-S1
100% of patients returned to their previous levels of sports activity at 6.7 weeks on average (ranging from 6 to 7 weeks)
RTP percentage was 100%
Table 1.
Case series and case reports available in the literature.
TF — transforaminal; IL — interlaminar.
In summary, there is good evidence that ESS would be the ideal surgical intervention for athletes, but to confirm this hypothesis, more studies are necessary, preferentially clinical trials. Until now, there is no clinical trial in athletes published in the literature and all this information is based on case reports and case series.
BP seems to be the main cause of disability worldwide and its consequences are healthcare and loss of productivity costs [67]. BP does not seem to be directly related to physical activity, but to its intensity or sedentary lifestyle. In a recent prospective cohort study, the authors aimed to observe the association between total sitting time, low BP, LDH, and different levels of leisure physical activity. They found that 3.8% of all subjects reported BP and 1% had LDH. Moderate and vigorous physical activity were strongly associated with low BP compared to light physical activity [68]. In this context, another review concluded that continued heavy sports may increase the risk of low BP, however, a dose-response association regarding volume is unknown [69]. However, not all people with BP have a herniated disc. Considering only LDH, the study conducted by Balling and colleagues (2019) concluded that moderate physical activity had a positive relationship with LDH while no association was found for vigorous physical activity. The probable explanation for this finding could be that the individuals who practice vigorous physical activity may be practicing particular types of activity which are not connected to LDH [68].
There is a necessity to study the role of physical activity in the context of ESS [70, 71]. Some studies present a beneficial association between physical activity and improved outcomes after ESS because it improves physical and mental health in adults and children [72]. Besides that, physical activity has the collateral advantage of facilitating weight loss, which is beneficial for spinal health [72, 73]. Another point to remember is that after the treatment of LDH by a percutaneous transforaminal endoscopic discectomy, it is easier to recover the biomechanical balance of the spine in patients, even mainly due to less soft tissue injury [74, 75]. Furthermore, studies have demonstrated that it is required to conduct a functional exercise to promote early recovery and prevent relapses [76, 77, 78]. It occurs because muscles without functional exercises tend to have a worse capillary response, which produces an inadequate blood supply of muscles, and the consequences of that are: failure to guarantee a supply of nutritional components; makes muscle produce glycogen and accumulate a large amount of lactic acid under hypoxia conditions. This accumulation of lactic acid generates pain and leads to muscle edema [75, 76, 77, 78].
In this context, Zhang and colleagues [75] conducted a study to evaluate the effects of postoperative functional exercise on patients who underwent percutaneous transforaminal endoscopic discectomy for LDH. They found that after 1 year after the procedure, patients who had functional exercise (intervention group) after surgery had a significantly more effective treatment than the control group (patients who did not have functional exercise after the procedure). After 3 years of follow-up, patients in the intervention group had a significantly more effective treatment than the control group. In summary, this study showed that postoperative functional exercise significantly improved short-term and long-term rehabilitation in patients with LDH [75].
For practitioners of physical activity, ESS may also be considered the ideal technique for spinal surgery in this population, as well as in athletes, due to the rapid return to physical and everyday activities and may have a protective factor for optimal recovery because practitioners of physical activity have greater muscle conditioning than sedentary patients. As with athletes, this conditioning facilitates recovery and makes it faster and more effective. Besides that, physical activity plays a protective effect against peripheral insult. This protective state often results from regular physical activity and is not obtained in physically inactive individuals [79].
Due to minimally invasive surgeries that have been developing in recent years, many patients with LDH have already been efficiently treated with ESS [80]. This procedure leads to a faster recovery because it requires minimal soft tissue injury [80, 81]. The main problem is that LDH provokes nerve root compression and lower kinetic chain dysfunction [80, 82]. For this reason, postoperative rehabilitation should give priority to avoid the recurrence of LDH, improve function and return to the patient’s routine more quickly by permitting a more accelerated protocol compared to open surgery protocols. When the procedure (ESS) withdraws the herniated intervertebral disc, the correspondent ligamentum flavum and articular process, it naturally leads to modified kinematics of the total kinetic chain and a reduced capability to combat abnormal external forces. For this reason, physical therapy and rehabilitation are necessary to reach important postoperative goals like strengthening the low back muscles to recompense the surgical damage and to avoid degeneration and instability of the adjacent segments. In the case of ESS, this technique does not cause relevant damage that impedes physiotherapy. The hypothesis that spine rehabilitation accentuates the whole movement is suitable for postoperative rehabilitation because it has the aim of improving surgical effectiveness, reducing postoperative complications and pain, in addition to restore patients to maximum physical function [80]. Nonetheless, physical therapy and rehabilitation after lumbar decompression surgery are useful regarding the functional recovery of individuals [80, 83, 84, 85, 86]. When talking about rehabilitation, several modalities are included. The main ones are exercise therapy, strength and mobility training, multidisciplinary programs (MP), and physiotherapy [87]. The main modalities of rehabilitation used after spine surgery are standard physiotherapy and MP.
Some studies show a close relationship between disc degeneration and paraspinal muscle weakness [88, 89, 90]. For this reason, it is important to increase lumbar stability and because of this, core muscle training is usually performed after lumbar spinal surgery. Optimal human core strength also helps normal dynamic stability to produce forces and counteract unusual stresses [80]. In this context, McKenzie therapy is a broadly recognized nonsurgical therapy for low BP [91, 92], mainly by physical therapists. This therapy has some principles such as returning the spinal joints to a better position through significant posture training and exercise and preventing movements or postures that favor disc herniation or re-herniations [80, 91, 93]. This treatment is effective in aligning the spine, so it avoids the recurrence of LDH in the surgical segment after ESS and prevents the degeneration of the adjacent segment [80].
Therefore, it is important that the individual begins rehabilitation as soon as possible after spine surgery. However, the time at which postoperative rehabilitation is applied is not well known due to the lack of consistency of the results [80] but a review published in 2014 reports that an immediate rehabilitation program for patients who underwent LDH surgery and cognitive intervention with positive reinforcement at the same time is an efficient treatment. Early postoperative physical therapy or rehabilitation results are usually excellent and do not involve complications [94], but it is important to take into account the diagnosis and surgical procedure used to develop rehabilitation programs to relieve pain and help functional recovery [80].
When the patient is a professional athlete or a practitioner of physical activity, the objective is the same: re-establish strength, performance, normal movement patterns, and the highest level of function, in addition to the least amount of pain and return to work or RTP.
Another important observation to be pointed out is that adherence to treatment is barely addressed in the studies. The literature is quite controversial in this respect since the variability is high. One study found that 86% of the patients attended all rehabilitation sessions of the 8-week program and 83% of patients did only home exercises during this period [95]. Erdogmus et al. found worse indexes, that during the rehabilitation period of 3 months, only 50% of patients frequently performed exercises at home [96]. In long-term rehabilitation, it is necessary an intensive supervision to maintain patient’s motivation and besides that, it is important to consider patient preferences for treatment [87]. Ivarsson et al. concluded that successful RTP after a sport injury is related to rehabilitation adherence and a low level of negative affective response [97]. Athletes tend to have better adherence to rehabilitation programs than the general population, mainly due to the fact they have important championships to participate in and sponsor [98].
After spine surgery, the athletic population demands different criteria such as RTP rate, career longevity, and performance-based results [99]. RTP is widely discussed in the terms of recovery from injuries suffered while playing a sport [100]. RTP guidelines have significant importance for professional athletes and are also effective for the treatment of non-athlete patients who want to RTP their favorite recreational activities. In spite of many years of study, there is still a lack of universal guidelines for the management of the cervical, thoracic, and lumbar spine and about the return to sport. Randomized controlled clinical trials are absent in the literature, so the guidelines are driven by case reports, case series, reviews, and expert opinions. General recommendations are that an athlete should have a painless active range of motion, painless for specific exercises, and total strength without neurological deficit [100]. Regarding cervical spine surgery, RTP is indicated in cases of a single-level anterior cervical discectomy and fusion, in the lack of neurological deficits and normal cervical range of motion [101, 102, 103]. In case of multilevel fusion or other surgical options like laminoplasty, posterior laminectomy and fusion or laminoforaminotomy, there is no consensus about RTP. In the athlete population, available data about RTP after cervical surgery is narrow because other factors other than health issues should be considered, such as personal finances and team performance [101]. As thoracic injuries are not common, there is no case report or case series in the literature regarding ESS of thoracic levels in athletes or practitioners of physical activity, therefore, there is no consensus about RTP in these cases. For traditional open surgery, the estimated time is approximately 3 months [50]. For the lumbar spine, Reiman and colleagues (2016) published a meta-analysis involving 14 studies. The surgical treatment included was any form of discectomy (traditional open or minimally invasive). The authors concluded that the RTP rate was 81% pooled across all studies for surgical intervention and a pooled RTP of 76% in athletes managed conservatively. Nevertheless, the authors acknowledged that due to the low methodological quality and heterogeneity of the studies involved in the analysis, the correct rate of RTP could not be precisely determined [99]. The time to RTP ranged from 5.2 [104] to 8.7 months [105] for professional athletes and from 7.5 [106] to 6 months for non-athletes [107].
In addition, there is an important variability of RTP rates between sports after spinal surgery. According to Cook and Hsu [58], baseball players have a significantly higher RTP rate than other sports, and football players have the lowest RTP rate when they underwent open microdiscectomy. They also concluded that open microdiscectomy was associated with a significantly shorter career in baseball players when compared with nonoperative controls. It is also important to point out that different intrinsic physical demands of some particular sports may influence RTP rates for athletes [58].Table 1 shows that there is no clinical study to date evaluating RTP aspects in athletes. All literature is based on case reports and case series, but it is noteworthy that 127 patients underwent ESS and were able to return to normal work a few weeks after the procedure, except one weightlifter that had commitment of cervical and two lumbar segments. This athlete returned to sport 3 months after surgery and competed in the 2016 Rio Olympics 7 months after the procedure, winning the gold medal. Besides that, 3 patients could not RTP and only 1 patient did not return to previous performance. Moreover, these data are limited due to the lack of homogeneity and low sample size but they can sustain the concept that ESS provides advantages over traditional open surgery regarding RTP rates, time, and also in terms of performance. Considering ESS, RTP rates are greater and in better physical conditions and performance, considering case reports and case series in the literature.
Back pain seems to be more associated with some types of sport than others, due to different spinal overload requirements. In the context of athletes, baseball seems to be associated with spinal injuries.
ESS may be considered a very useful tool because the spine surgeon can access the spinal pathology using various surgical techniques. For practitioners of physical activity, ESS may also be considered the ideal technique for spinal surgery in this population, as well as in athletes, due to the rapid return to physical and everyday activities and this may have a protective factor for optimal recovery because practitioners of physical activity have greater muscle conditioning than sedentary patients. This muscle conditioning facilitates recovery and makes rehabilitation faster and more effective.
Rehabilitation is a key part of the ESS because it is important to increase lumbar stability. Optimal human core strength may help normal dynamic stability to produce forces and counteract unusual stresses, but adherence to rehabilitation programs appears to be an indispensable factor for very rapid RTP. Athletes usually have a better adherence to the rehabilitation programs than the general population. RTP after ESS may be faster than in open techniques and athletes usually return to the same performance, maybe due to some factors such as the early start of the rehabilitation process, previous privileged muscular condition, and psycho-socio-economic factors.
However, there is a necessity of clinical trials in this area to evaluate the role of ESS for athletes and practitioners of physical activity in the context of a larger population of athletes and practitioners of physical activity.
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Written By
João Paulo Machado Bergamaschi,
Marcelo Botelho Soares de Brito, Ariel Falbel Lugão,
Thiago Queiroz Soares, Gustavo Vitelli Depieri,
Edgar Takao Utino, Fábio da Silva Forti,
Kai-Uwe Lewandrowski and Fernanda Wirth
Submitted: 02 March 2023Reviewed: 02 March 2023Published: 18 April 2023
Open access peer-reviewed chapter
