Epidural steroid injection for lumbar disc herniation in NFL athletes

Key points

1. 0117 NFL players received 37 injections across 27 distinct disc herniation episodes from 2003 to 2010.
2. 0289% of episodes (24 of 27) returned to play, losing on average only 2.8 practices and 0.6 games after the injection.
3. 03A sequestered (fragmented) disc on MRI and weakness on physical exam were the factors linked to failure of injection therapy.
4. 04Three of the four players who needed a repeat injection for the same episode ultimately failed conservative care and needed surgery.
5. 05No complications were reported, and no player who returned to play had any residual weakness or sensation loss.

How it was conducted

Design

Retrospective case series from one professional American football team, 2003 to 2010, with IRB approval

Participants

17 NFL players (average age 25 years, range 22 to 32) with MRI-confirmed acute lumbar disc herniation and incapacitating pain

Intervention

Epidural injection of 80 to 160 mg triamcinolone plus lidocaine or bupivacaine, transforaminal (81%) or interlaminar (19%)

Primary outcome

Success defined as return to play in a professional football game

Secondary outcome

Risk factors for failure, tested via logistic regression and chi-square (P < 0.05 significant)

What they found

• Success rate of returning to play per herniation episode was 89% (24 of 27 episodes).
• Average loss after injection was 2.8 practices (range 0 to 12) and 0.6 games (range 0 to 2).
• After 27 of the 37 injections, the player returned to play without missing any games.
• Disc sequestration on MRI was a significant risk factor for failure (P = 0.01).
• Weakness on physical examination was a significant risk factor for failure (P = 0.002).
• Presenting symptoms (P = 0.96), anatomic level (P = 0.47), presence of spondylolysis (P = 0.19), and injection technique (P = 0.55) did not significantly affect return to play.
• Disc morphology distribution: 23 protrusions, 2 extrusions, 2 sequestrations; episodes occurred at L4-5 (15), L5-S1 (11), and L3-4 (1).
• Four players required a repeat injection for the same episode, and 3 of those 4 ultimately failed conservative management and required surgery.
• After successful return, 13 players played an average of 2.8 NFL seasons (range 1 to 6), and 10 were still actively playing as of the end of the 2010 season.

Limitations

• No control group, so some players might have returned to play without injection.
• No long-term follow-up with physical examination or repeat MRI, and patient pain was not rated.
• Other concurrent treatments such as NSAIDs and physical therapy were not tracked, so their contribution cannot be separated out.
• Small, single-team, highly selected professional-athlete sample that cannot be generalized to the general population.

Why it matters

For patients

For elite athletes with an acute disc herniation, an epidural steroid injection may offer fast pain relief and a quick return to activity, but ordinary patients should know most disc pain resolves with conservative care within 12 weeks.

For clinicians

Consider epidural steroid injection as a low-complication option in high-demand athletes, but expect lower success when the disc is sequestered on MRI or the patient shows weakness on exam.

For readers

This is a small uncontrolled case series showing favorable return-to-play outcomes, useful as preliminary evidence in athletes but not as proof of efficacy for the general population.