Return-to-Play Outcomes of Athletes After Operative and Nonoperative Treatment of Lumbar Disc Herniation

Abstract

Purpose of Review

Lumbar disc herniation (LDH) is a common injury experienced by athletes and has important clinical considerations for athletes including the timing of return to sport. Lumbar disc herniation may result in loss of individual training and playing time for athletes. Current literature is inconclusive on whether surgical or conservative treatment of LDH is superior in athletes. Our aim was to review the literature to identify return-to-play (RTP) rates and performance outcomes following operative and nonoperative treatment of LDH in the athletic population.

Recent Findings

Athletes have unique measurements of successful treatment for LDH such as time to return to their sport and performance outcomes that are not as applicable as traditional metrics. It is suggested that surgical treatment may provide a quicker return to sport than nonoperative care in athletes. Additionally, conflicting findings have been seen in career length and performance status based on sport, often due to short and tumultuous career patterns. These differences may be seen based on the unique physical demands of each sport, different motivations to prolong sport, or other confounding factors that could not be controlled for or unrelated to LDH.

Summary

Recent literature on RTP outcomes in athletes treated for LDH show variable results based on sport. Further research is needed to assist physicians and athletes in making the decision to undergo conservative or surgical treatment of LDH in the athletic population.

Introduction

Low back pain (LBP) is a common complaint among adults and athletes. More than 30% of athletes report low back pain during their careers [1]. Because it can account for missed training and playing time, LBP can be detrimental to an athletic career. The rigorous demands of competitive sports involving extreme torsion, flexion and extension, and strain on the lumbar spine may predispose athletes to spinal injuries such as LDH [2, 3]. While there are many causes of low back pain, lumbar disc herniation (LDH) is one of the most common. In a study of 31 Olympic athletes examined with magnetic resonance imaging (MRI) who presented with LBP, 58% of athletes were found to have an element of disc displacement [4]. The majority of studies focus on professional sports due to the centralization of treatment at major research institutions and the objective nature of data points and metrics such as games missed, duration of career, and statistical comparisons. Thus, there is a paucity of data on non-professional athletes due to the lack of centralized treatment centers and objective nature of post-treatment modality comparison data metrics.

In the general population, treatment in patients with LDH with or without neurological deficits typically begins with 6–8 weeks of nonsurgical conservative management. Conservative treatment usually consists of a combination of physical therapy and oral medications such as non-steroidal anti-inflammatories and steroids. Numerous phased rehabilitation protocols have been described and generally consists of a regimen focusing on core and back strengthening and flexibility (Table 1) [5]. Additionally, epidural steroid injections may be used as an adjunct to treat radicular symptoms associated with LDH by decreasing inflammation and nerve root irritation from impingement. Similar conservative treatment interventions are used in the athletic population. A study by Krych et al. demonstrated 14 of 17 (82.4%) National Football League (NFL) players returned to play with an average missed playing time of 2.8 practices and 0.6 games after receiving 1 or 2 epidural lumbar steroid injections for incapacitating pain associated with an MRI confirmed acute LDH [6].

Table 1.

Typical conservative physical therapy regimen for low back pain and lumbar disc herniation without neurological symptoms

Phase	Time frame	Treatment focus
Phase I: non-rotational/non-flexion phase	0–6 days	Acute inflammation
Phase II: counter-rotation/flexion	3–20 days	Repair
Phase III: Rotational/power development phase	9 days–full resolution	Remodeling
Phase IV: Full return to sport	After full resolution	Unrestricted activity

Surgical intervention for stable lumbar disc herniations includes conventional open discectomy, microdiscectomy, microendoscopic discectomy (MED), and percutaneous endoscopic discectomy. Open discectomy has historically been the standard surgical approach providing excellent outcomes in the general population for pain relief, resolution of radicular symptoms, and patient satisfaction [7]. However, with more recent advances in surgical techniques microdiscectomy has shown similar efficacy as a treatment modality for LDH with added benefits of smaller surgical incisions, and less soft tissue compromise [8, 9]. Further developments have led to continued progression of minimally invasive techniques such as microendoscopic discectomy (MED) and percutaneous endoscopic discectomy (PED), which have shown success in the treatment of LDH [10, 11].

The decision of operative and nonoperative treatment for LDH in athletes can present a unique clinical problem when compared to the general population. Literature has shown satisfactory outcomes in the general population in terms of self-reported improvement, return to work, and decreased pain after both surgical and nonsurgical care [12, 13]. Studies that measure success with standardized questionnaires such as the visual analog scale, Oswestry Disability Index, and Short Form-36 Health Survey are useful measures in the general population. However, these measures may not hold the same utility to athletes whose primary concerns are return to play and maintenance of their pre-injury athletic performance status. Thus, consensus is lacking on the treatment of athletes with LDH. The purpose of this review is to compare return to play and functional performance outcomes in athletes undergoing operative and nonoperative management of LDH.

Anatomy/Biomechanics

The intervertebral disc consists of a central nucleus pulposus (NP) surrounded by the outer annulus fibrosus (AF). The central NP is composed of type II collagen, while the outer AF is composed mainly of concentric layers of type 1 collagen. The type II collagen of the NP is associated with proteoglycans that bind water, thus maintaining a high water content. Together, this allows the NP to function to provide flexibility and absorb compression. In contrast, the AF contains far fewer proteoglycans and lower water content allowing it to function as a tense fibrocartilaginous ring containing and anchoring the NP to its vertebral body [14]. When the intervertebral disc is placed under stress, the AF functions to resist the force. Repetitive loads, sudden force, and degenerative changes within the intervertebral disc can alter the ability of the NP to handle compressive forces, resulting in increased stress on the AF and propensity for disruption [14]. LDH forms as a consequence of loss of integrity in the AF, allowing the NP to herniate outside the annulus margins [14].

Lumbar Disc Herniation Classification

Dewing et al. studied the outcomes of microscopic lumbar discectomy (MLD) in active military men and women diagnosed with LDH. The authors classified disc herniation by level and type as sequestered, extruded, or contained (Fig. 1). An extruded herniated disc is present when the highest measure of displaced disc is greater than the base of the displaced disc at the disc space of origin. When no continuity exists between the displaced disc material and the parent disc, the herniated disc is classified further as sequestered. Lastly, herniated discs are categorized as contained if the displaced disc material is covered by outer annulus fibers or the posterior longitudinal ligament [15]. Patients with sequestered disc fragments had significantly greater improvements in mean VAS leg and Oswestry outcome scores than extruded or contained disc types. Additionally, patients with contained discs were associated with the smallest improvements in these parameters. The level of disc herniation was also associated with differences in VAS leg and Oswestry outcome scores. Disc herniations at the L5-S1 level had significantly greater improvements in both outcome scores when compared to disc herniations at the L4-L5 level.

Fig. 1.

a–d Axial images show normal lumbar disc anatomy (a), a sequestered herniated disc (b), an extruded herniated disc (c), and a contained herniated disc (d)

Incidence of Lumbar Disc Herniation in Asymptomatic Athletes

Several studies have also evaluated asymptomatic athletes and the presence of any lumbar spine pathology. Alyas et al. evaluated 33 asymptomatic, elite adolescent tennis players with a mean age of 17.3 years via MRI and found that 39.4% subjects had evidence of a disc herniation, with 80% classified broad central and 20% as focal heniations [16]. Rajeswaran et al. evaluated 98 asymptomatic, elite junior tennis players with a mean age of 18 years via MRI of the lumbar spine [17]. This study found disc herniations in 30.6% of players, with 86.1% broad based and 13.9% focal. Another study performed by Bezuglov et al. used MRI to evaluate 40 asymptomatic professional male soccer players with a mean age of 26.6 years [18]. Fifteen percent of players showed evidence of disc protrusions, 7.5% with disc herniations, and 30% with Schmorl nodes. While the presence of asymptomatic lumbar disc herniations among athletes is variable, further sport-specific investigation can possibly be used for application of preventative measures with regard to development of future lumbar spine pathology.

Return-to-Play Outcomes by Sport

The Professional Athlete Spine Initiative compared return-to-play rates and post-injury careers in 342 professional athletes across the 4 major sports, who underwent treatment for LDH with either surgical (n = 226) or nonsurgical treatment (n = 116). They found an average 82% of players returned to play for at least one professional regular season game [19]. Watkins et al. retrospectively reviewed 171 professional athletes (mean age 28.0) that were treated for LDH with either microdiscectomy (n = 85) or nonoperative care (n = 86). This study focused on the return to play of the operatively treated patients and similarly found that 89.3% of surgically treated patients successfully returned to their sport after an average of 5.8 months [20]. A review by Sedrak et al. examined RTP outcomes in elite athletes (mean age 28.3 years) undergoing lumbar discectomy (LD) versus nonoperative care. A total of 663 of 799 patients (83%) returned to play after a mean time of 5.18 months in the operative group. Of the 251 nonoperatively treated patients, 308 patients (81.5%) returned to play after a mean time of 4.11 months [21]. There was no significant difference in return to play rates between operatively vs. nonoperatively treated patients in these studies (Table 2). A recent study by Cordover et al. evaluated RTP rate after lumbar microdiscectomy for athletes with an average age of 19 years. They found that of the 38 patients, 71% had returned to their sport at an average of 4.5 months postoperatively (Table 2.). However, various reasons for not returning to play were cited including 55% of non-returning players graduating high school or college. Additionally, they found no significant difference in RTP rates between high school or collegiate athletes, genders, or patients with 2-level and 1-level discectomy [22].

Table 2.

Return to play outcomes of athletes in studies after operative or nonoperative care, not stratified by sport

Author	Year	Mean age	Operative RTP rate	Nonoperative RTP rate	Significant difference?
Hsu	2010	30.0	81%	84%	No
Watkins	2012	28.0	89.3%	NA	NA
Sedrak	2021	28.3	83%	81.5%	No
Cordover	2022	19	71%	NA	NA

Basketball

In a study of 61 NBA players diagnosed with LDH, 34 underwent discectomy and 27 were managed nonoperatively. The authors found that 79.4% of surgically treated patients and 77.8% of non-surgically treated patients returned to play for at least 1 game the season after treatment (p > 0.05) (Table 3.). While time to return to play was not recorded, the authors did compare post-treatment career lengths between the 2 groups. When compared with controls, surgically treated patients played significantly fewer games than controls in their first postoperative season, but not in their 2nd and 3rd postoperative seasons. No changes were seen in career length. Nonoperatively treated players had no difference in games played but played significantly fewer post-injury seasons when compared to controls [23]. Similar findings were seen in another study by Anakwenze et al., who evaluated 24 NBA players with LDH who underwent LD matched with players without LDH. Eighteen of 24 players (75%) treated with LD returned to sport compared to 42 of 48 (88%) treated nonoperatively (p = 0.31) (Table 3.). Similar to previously discussed study, the LD group played an average of 20.1 games fewer in the first season after surgery when compared to the control group.

Table 3.

Return to play outcomes of athletes in studies after operative or nonoperative care, stratified by sport

Author	Year	Age	League	RTP rate operative	Nonoperative RTP rate	Significant difference?
Savage	2010	28.5	NFL	74%	NA	NA
Weistroffer	2011	27.6	NFL	80.8	28.6%	Yes
Hsu	2010	28.5	NFL	78%	59%	No
Schroeder	2013	28.8	NHL	82.1%	90.3%	No
Roberts	2011	31.4	MLB	100%	100%	No
Earhart	2012	30.8	MLB	97.5%	96.6%	No
Minhas	2015	NA	NBA	79.4%	77.8%	No
Anawkenze	2010	28.2	NBA	75%	88%	No

Football

Hsu et al. studied 137 National Football League players diagnosed with LDH treated either with lumbar discectomy or conservative treatment. Seventy-eight percent of surgically treated patients (age 27.5) returned to play, while 59% of patients treated conservatively (age 29.4) returned to play, although the difference was not statistically significant (p = 0.26) (Table 3). However, patients treated operatively had a significantly longer post-treatment career length (36 games over a 3.1 year period) compared to nonoperatively treated patients (18 games over 2.0 year period) (p < 0.03) [24]. Similar return-to-play outcomes were seen in a study of 23 NFL offensive skill position players who underwent a discectomy for LDH. Seventy-four percent (n = 17) of players returned to play for an average of 36 games over a 4.1-year period (Table 3.) [25]. Another study of NFL players diagnosed with LDH evaluated a total of 66 linemen with 52 treated surgically (age 27.1) and 14 treated conservatively (age 29.6). Of the surgically treated patients, 80.8% returned to play with only 28.6% of conservatively treated patients returning to play (p < 0.05) (Table 3.). Patients treated operatively also had statistically significantly longer post-treatment career lengths than the nonoperative cohorts, averaging 33 games over a 3-year versus 5.1 games over a 0.8-year period [26]. While these studies did not evaluate time to return to play, operatively treated players in the NFL tend to have higher return-to-play rates and longer post-injury careers when compared to their conservatively treated counterparts. However, these patients tended to be younger, which may have impacted surgical decision-making.

Baseball

Earhart et al. evaluated 69 professional baseball players with LDH via news reports and compared RTP outcomes between operatively and nonoperatively treated players. The return-to-play rate for both cohorts was 97.1%, and not statistically significant between operative and nonoperative patients (Table 3.). They found that operatively treated players had significantly longer recovery times than nonoperatively treated players (8.7 vs 3.6 months). Additionally, they found that operatively treated players participated in fewer post-injury games than nonoperatively treated players (432.4 vs 232.8 games, p = 0.08) [27]. However, his study has significant limitations. Mainly this was a review of news reports, and no medical information was actually obtained by the authors including specifics and extents of herniations, which limits the ability to form conclusive treatment determinations. Secondly, an additional analysis was not completed that evaluated the date of surgical intervention to account for the seasonality of sports (i.e., and off-season surgery affecting return to play). Another study of 29 Major League Baseball pitchers treated operatively or nonoperatively for LDH also found high return-to-play outcomes. All 29 players returned to play, regardless of treatment (Table 3). Those treated operatively also took more time to recover than those treated nonoperatively (8 months vs, 5.7 months), although these results were not statistically significant. Operatively treated players had no significant difference in post-treatment career lengths than nonoperatively treated players [28].

Hockey

Schroeder et al. examined the RTP outcomes of a total of 87 NHL players with LDH. Thirty-one players underwent nonoperative care, 48 underwent a discectomy, and 8 received a single-level fusion. After surgical treatment, 82.1% of athletes successfully returned to play which was not statistically significantly different than the 90.3% of nonoperatively treated players successfully returning to play (Table 3.). The authors did not evaluate players’ time to return to sport. All treatment groups combined demonstrated a significant decrease in average games played per season, with a larger but insignificant decrease in surgical players when compared to nonsurgical players (20.02 vs 12.19 games per season). However, it was noted that players who underwent a lumbar fusion successfully returned to play 100% (8 of 8) of the time for an average of 203 games over a 4-year period, which may represent and entirely different cohort than what we are trying to understand in the scope of this study. Additionally, there was no significant difference between the number of games played per season before and after a lumbar fusion [29]. Although a small sample size in the lumbar fusion group makes it difficult to draw conclusions, these findings suggest that a single-level lumbar fusion does not define a career-ending surgery for elite hockey players as previously suggested [30].

Various studies have examined the RTP outcomes of athletes undergoing specific types of surgery. A study of 59 professional and Olympic athletes with lumbar HNP evaluated their return to active participation in sport after undergoing lumbar microdiscectomy. It was found that of the 60 cases, 53 (88.3%) of players returned to play an average of 5.2 months after surgery [31]. More recent studies examined outcomes in athletes undergoing surgical treatment for LDH using more minimally invasive techniques. A study examining 25 competitive athletes who underwent MED found that 82.6% of players successfully returned to competition an average of 10.8 weeks after surgery [10]. Yamaya et al. examined the outcomes of transforaminal percutaneous endoscopic lumbar discectomy (PELD) in high school athletes suffering from LDH and found even higher RTP rates of 94.4% an average of 7 weeks after surgery [32]. While this procedure did allow for high RTP rates and short recovery times, there are some barriers in selecting this intervention. Surgeons must be trained to perform transforaminal PELD without causing complications such as exiting nerve root injury. Additionally, long-term prognosis and possibility of symptom recurrence are not yet as thoroughly understood as more traditional methods like LD.

Performance Outcomes By Sport

Football

Hsu et al. examined the performance outcomes in NFL players following operative or nonoperative treatment for HNP. Performance measures such as percentage of games started, and a performance score calculated from a player’s pertinent statistics were measured pre- and post-treatment. He found no significant difference in these measures between operative and nonoperative groups, and no difference within each cohort when pre- and post-treatment performance measures were compared [24]. A study by Savage and Hsu evaluated the performance outcomes of offensive NFL players after LD. The measures they evaluated were power rating (scoring system based on a player’s statistics) per game and % games started before and after LD. They also found no significant difference in power rating (6.1 vs 5.6) or % games started (0.57 vs 0.61) before or after treatment [25]. These data show that for this physically demanding population, LDH does not have to be a career-ending event. Both operative and nonoperative treatments of LDH may be viable options in preserving pre-injury performance in the NFL population.

Basketball

Performance outcomes in 61 NBA players of which 34 were operatively treated and 27 were nonoperatively treated were evaluated. A standardized measure of player statistics called a player efficiency rating (PER) was used to evaluate performance outcomes. Operatively treated players had a decline in PER in the first post-index season when compared with controls, but no difference was observed in post-index season 2 or 3. Nonoperatively treated players had no significant decline in PER in any of the seasons when compared with controls [23]. Anakwenze et al. also examined performance outcomes in NBA players, with 24 players who underwent LD matched with 48 control players without LDH. Performance measures evaluated included number of minutes played per game, points per 40 min, rebounds per 40 min, steals per 40 min, blocks per 40 min, and shooting percentage. Statistically significant changes between surgically treated players and controls were only observed in blocked shots and rebounds. The LD group had an average increase of 0.18 blocks per 40 min compared to an average decrease of 0.33 in the control group. Additionally, the LD group had an average decrease of 0.25 rebounds per 40 min compared to a decrease of 1.42 in the control group [33]. These studies provide promising data for athletes of this caliber returning to play after treatment for LDH. Performance outcomes of operatively treated players may slightly decrease upon first post index season, however. NBA players may be able to achieve their pre-injury performance upon surgical treatment for LDH.

Hockey

Schroeder et al. examined performance outcomes in 87 NHL players with HNP, 31 of which were treated nonoperatively and 56 of which were treated surgically (48 underwent an LD, 8 underwent a single level fusion). The authors evaluated points per game and a performance score calculated from a player’s pertinent statistics from all seasons before and after the diagnosis. They found that all career statistics significantly decreased after the diagnosis of HNP. Players treated nonoperatively had a significant decrease in points per game and performance score, while operatively treated players only had a significant decrease in performance score [29]. This finding is different from what was previously seen in NFL and NBA players who generally have preserved athletic performance after treatment for LDH. However, of the 8 players who underwent lumbar fusion for treatment of their LDH, these findings were not the case. Players treated with lumbar fusion had no significant difference in performance score after treatment, and instead had a significant increase in points per game postoperatively [29]. Although the sample size was small, these findings demonstrate potential for players at this elite level to successfully continue their preinjury level of sport.

Baseball

Performance outcomes were evaluated in MLB athletes diagnosed with LDH treated with operative or nonoperative measures. Parameters used to evaluate athletic performance for pitchers included total wins, earned run average (ERA), saves, innings pitched, strikeouts, and walks plus hits divided by innings pitched (WHIP). Runs, home runs, runs batted in (RBI), stolen bases, and batting averages were used for hitters, and the sub-cohorts of infielders, outfielders, and catchers. These statistics were gathered for 3 years prior to injury, and these averages were compared with their post-treatment values at 1- and 3-year time points. For pitchers, they found that operatively treated players had a significantly poorer ERA and WHIP at both 1 and 3 years compared to preinjury values. Nonoperatively treated pitchers had no significant change in any performance measure when compared with preinjury statistics. Operatively treated pitchers showed a significant decrease in runs and RBIs only at the 1-year time point, while nonoperatively treated showed no significant changes at either 1- or 3-years post-injury. Infielders showed no significant changes in any production statistics in either operative or nonoperative cohorts, but a decrease in runs and RBIs at 1-year postoperative approached significance (p = 0.1 and p = 0.08). Lastly, operatively treated outfielders showed significantly fewer runs and a lower batting average at the 1-year time point, while nonoperatively treated players showed no changes in any performance statistic [27]. Roberts et al. also evaluated performance outcomes of players in the MLB; however, they only studied pitchers. Operatively treated players pitched significantly fewer innings per season and had significantly higher WHIP after treatment when compared to preinjury statistics. Nonoperatively treated players showed no significant difference in any post-treatment performance statistic when compared to preinjury values [28]. While performance outcomes appear to be preserved in NFL and NBA athletes after undergoing surgical treatment for LDH, MLB players appear to have a less positive outcome. While many factors may contribute to this difference, it is important to note the surgical cohort was significantly older prior to treatment. It is possible that surgical intervention may impair the ability of the lumbar spine to handle repetitive torsional motion imparted by pitching; however, literature has yet to investigate this claim. Additionally, external factors such as concomitant injuries or natural progression of sporting decline may have affected outcomes.

Sport Comparisons

In a study by Hsu et al., a total of 342 professional athletes across multiple sports were treated for an LDH operatively or nonoperatively. Return-to-play outcomes differed among sports. NFL athletes had a lower RTP rate than players of all other sports (p < 0.05). The positions of quarterback and punter were positive predictors for career length [19]. This may be due to the nature of these positions. However, these findings may also in part be due to the longer expected career length of these positions. While NFL athletes did have a significantly lower RTP rate than other sports, the authors demonstrated equivalent years adjusted return to sport. NFL athletes that underwent a LD had significantly longer careers than their conservatively treated counterparts (36 games in 3.1 years vs. 20 games in 2.0 years) [19]. Watkins et al. also examined return-to-play outcomes in athletes across multiple sports treated for LDH with LD. In this study, RTP rates were also lowest in the athletes that played football (81.8%) when compared to all other sports [20].

In the same study conducted by Hsu et al. as described previously, MLB players demonstrated a significantly higher RTP rate than those of all other sports. Conflicting evidence was found in comparing positions to career length. Hsu et al. found that the positions of infielder and outfielder were negative predictors in career length in games and years [19]. However, Earhart et al. found no significant difference in post-treatment career lengths between positions [23]. Hsu et al. found a LD led to a shorter career (256 games over 4.1 years) in MLB athletes compared to their nonoperative cohort (471 years over 5.3 years). [19] These findings contrast those seen in NFL athletes that underwent LD. A number of factors may have contributed to this. First, player age may have affected career length outcomes as the older cohort from both NFL and MLB patients demonstrated shorter post-treatment careers (nonoperative in the NFL and operative in the MLB). Sport-specific expectations and motivations may also have affected outcomes. NFL players have shorter seasons and less guaranteed contacts compared to MLB athletes, which may contribute more financial motivation to continue playing.

Surgical Complications

Complications from single-level microdiscectomy are typically low in the general population, with some studies reporting approximately 10% of patients experiencing re-herniation symptoms [34, 35]. In a study of outcomes of lumbar microdiscectomy in a population of active-duty military personnel by Dewing et al., 6 out of 196 (3.1%) patients suffered a recurrent disc herniation at a mean of 9.3 weeks after the index surgery. Two of these patients underwent repeat microdiscectomy, 2 were treated using transforaminal lumbar fusion, and 2 were treated with conservative measures. One patient had a superficial wound infection which resolved with oral antibiotics. Of the patients who sustained complications, 6 out of 7 (86%) returned to full military duty within 12 months [36]. While the literature evaluating RTP outcomes after LD in MLB, NHL, or NBA players did not discuss complications, multiple studies in NFL athletes did address this. In a study of NFL players returning to playing after LD, 2 of the 23 players (8.7%) had a recurrence of LDH that required reoperation [25]. Similarly, a study of NFL players undergoing LD by Hsu documented recurrent disc herniations requiring revision discectomy in 8 out of 96 (8.3%) players [24]. Both of these recurrence rates were comparable to those of the general population. However, higher herniation recurrence rates were seen in a study of NFL players that consisted solely of linemen treated with LD. Seven of 52 players (13.5%) required revision decompression, and ultimately 6 of 7 (85.7%) of these players successfully returned to play [26]. Linemen typically have the highest BMIs of any football position, and increased force on the lumbar spine combined with the repetitive squatting and hyperextension movements needed to block may contribute to a higher risk of re-herniation injuries [37, 38]. Even lower complication rates than those of LD in the general population are seen using the more minimally invasive surgical techniques. A study of 18 high school athletes that underwent PELD exhibited no complications such as dural tear, exiting nerve root injury, or hematoma. One patient (5.6%) experienced a recurrence of HNP [32].

Authors’ Proposed Treatment Algorithm

For the treatment of lumbar disc herniation in athletes, the authors propose a treatment algorithm based on the needs of individual athlete. The literature shows that there is evidence to support both surgical intervention and conservative care in the treatment of lumbar disc herniations. However, the results of these studies have numerous confounding variables which affect time to return to sport and productivity level, mainly age at time of intervention as the career of high-level athletes can be extremely short. While high-level athletes and professional organizations may be eager to return to sport expeditiously, surgical intervention is not without risk. As such, our approach to athletes with lumbar disc herniations should be treated with a trial of conservative management in the form of oral analgesics, anti-inflammatory medications, and steroid medications (including lumbar epidural steroid injections) in conjunction with a comprehensive physical therapy program for a period of no less than 6 weeks. Should these methods fail to alleviate symptoms, it is then reasonable to consider surgical intervention in the form of an open or minimally invasive lumbar microdiscectomy.

Conclusion

Lumbar disc herniation is a not an uncommon occurrence in athletes of all ages.

Based on our review, there is evidence for successful treatment of lumbar disc herniations resulting in return to play in both nonoperative and operative care in the athletic population.

While the complication profile for lumbar discectomy in athletes is favorable, undergoing an operation is still an invasive procedure that poses risks. Athletes and their physicians should consider these risks and determine treatment options on an individual basis with shared decision-making. Based on our review, both operative and nonoperative treatment options have successful outcomes and LDH does not preclude return to high level athletics.

Compliance with Ethical Standards

Conflict of Interest

The authors declare no competing interests.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.