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Treatment-Indications and Timing

A positive correlation between the history, physical examination, and diagnostic imaging is needed to confirm the presence of a surgically amenable lesion. The patient must have failed conservative therapy or have a lesion that would have a poor outcome if left to nonoperative care, such as a cauda equina syndrome in a weight-lifting bodybuilder.

Neurological deficits, especially those with progression of neurological sign, usually are an indication for urgent decompression; generally, these are associated with high-velocity spinal injuries. Emergent imaging, ideally with MRI, will delineate the location of the lesion.

Decompression of the lesion should be done as soon as the patient is stable enough for an anaesthetic and surgery. Resuscitation of any life-threatening respiratory or cardiac injuries must be done first, because a decompressed spinal cord with inadequate perfusion will still do poorly.

Decompression of individual nerve roots without cord or cauda equina compression can be done on an elective basis if nonoperative treatment has failed. Despite the minimally invasive incisions being used to protect the soft-tissue structures or the dramatic pain relief postoperatively, the athlete must comply with the rehabilitation program to be fit enough for return-to-play consideration.

Indications for spinal realignment procedures of the unstable spine include burst fractures and fracture dislocations. In some cases, realignment of the spine will decompress the spinal canal without need for the surgical removal of bone from the canal. The need to reduce a spondylolisthesis is not as important as stabilization of the spinal segment to prevent the defect from progressing.

The same is said for scoliosis surgery in adults, in whom the goal is to prevent further deformity. Partial correction of the scoliotic deformity with instrumentation is an added benefit. Except in the cases of severe neurological deficits, the need for realignment alone usually is an elective consideration.

Stabilization with bony fusion of a spinal mobile segment is unphysiological, in that the end result is, hopefully, a complete loss of motion. If the unstable motion is causing intermittent nerve compression and unremitting mechanical back pain refractory to nonoperative treatment, the stiff, painfree segment would be ideal.

The athlete must realize that all spinal surgery will have some pain from the soft-tissue dissection, and as minimally invasive as the newer surgical techniques are, muscle stripping and dissection are still incurred in every fusion.

The patient may want a “quick fix,” but the natural history of a slow responder with patterns of mechanical or nerve irritation pain may still resolve nonsurgically if given adequate time. The length of rehabilitation can be estimated from the prognostic factors that are found during the early assessments.

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