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Return To Play After Cervical Disk Herniation Brian N. Morelli, MD Assistant Professor, Dept. of Orthopaedics Stony Brook University Medical Center Spine.

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Presentation on theme: "Return To Play After Cervical Disk Herniation Brian N. Morelli, MD Assistant Professor, Dept. of Orthopaedics Stony Brook University Medical Center Spine."— Presentation transcript:

1 Return To Play After Cervical Disk Herniation Brian N. Morelli, MD Assistant Professor, Dept. of Orthopaedics Stony Brook University Medical Center Spine & Scoliosis Center or What Really Happened To Peyton Manning

2 Image From: Harvard Beats Yale 29-29

3 No Disclosures In no way was I involved in this patients care. Data was assembled using publicly available news reports, knowledge of the surgical techniques employed, and literature regarding sports participation and spine injuries

4 Peyton Manning 1998 First overall NLF draft pick 2006 Winning QB and Superbowl MVP 4x league MVP 11x ProBowl 11x 4,000 yd passing seasons 2000s - SportsIllustrated NFL player of the Decade

5 Timeline Feb 2010 completes season. 4th time league MVP Mar st surgery - Post. Cervical Foraminotomy Dr. Rick Fessler, Northwestern Memorial Hospital, Chicago No starts 2011 season. Possible 3rd surgery (reported by SI) Foraminotomy again? May st surgery - Post. Cervical Foraminotomy, different level Dr. Rick Fessler, Northwestern Memorial Hospital, Chicago 2010 Season No missed starts? Possible unreported injury during week 1 Sept rd/ 4th surgery - Cervical fusion Manning had residual triceps weakness from prior surgery Drs. Robert Watkins, Sr. & Jr. Marina Del Ray Hospital (CA) March 2012 Manning signs with the Broncos Manning is RHD, all surgeries were for R sided radiculopathy

6 Athletes & Cervical Disk Herniations Cervical Disk Herniation Corrective Surgeries Return to Play

7 Cervical Disk Herniation Normal Anatomy Spine segment is 2 vertebrae, the disk and all ligamentous attachements Disk Annulus Fibrosus Collagen Type I & II Nucleus Pulposus Proteoglycan & water

8 Cervical Disk Herniation Herniated Nucleus Pulposus (soft disk) Younger Patient Acute Trauma Nuclear material Minimal Underlying Degeneration Cervical Spondylosis (Hard Disk Herniation) Older patient Insidious Onset Disk & Bone Spur Chronic Degeneration



11 Radiculopathy Syndrome of nerve root dysfunction Pain Numbness Weakness Pattern of pain depends upon the affected nerve root Axial Neck Pain in acute HNP

12 Non-surgical Options Time Activity Modification Out of contact sports until symptoms resolved Physical Therapy Strengthening McKenzie Extension Program Pain Relieving Modalities Medications Anti-inflammatories Ibuprofen/ Naproxyn orCOX-2 Muscle Relaxants Oral Steroids Neuromodulators +/- Narcotic Analgesics Interventional Procedures Transforaminal Epidural Steroid Injections

13 Surgical Options Posterior Cervical Foraminotomy Minimally Invasive (1cm) Motion Preserving HNP - Direct Decompression Spondylosis - Indirect Decompression Allows for same level recurrence Anterior Anterior Diskectomy & Fusion Small Incision (3-4cm) Obligatory Fusion 10% loss of motion per level Direct Decompression for both pathologies Possible pseudarthrosis 30% chance of adjacent level surgery within 10 years.

14 Posterior Cervical Foraminotomy Posterior Keyhole Foraminotomy Well established procedure Carefully selected patients with radiculopathy Open Via MIS tube Microendoscopic Technique YearPatientsF/U Ex/Gd Results Author y96%Henderson y96%Simeone y92%Krupp %Aldrich <2y97%Zeidman y86%Davis y94%Woertgen

15 Fessler & Khoo. Neurosurgery consecutive MIS microendoscopic & 26 consecutive open foraminotomy cases Equivalent relief of pain Decreased EBL, OR time, LOS Decreased Narcotic Use 3 dural injuries requiring lumbar drain Posterior Cervical Foraminotomy

16 Endoscopic Cervical Foraminotomy Ruetten, et al. Germany. Spine ACDF, 91 FPCF 2 year results 6.7% revision rate for recurrence of symptoms after pain-free interval. ACDF EPCF Posterior Cervical Foraminotomy

17 Endoscopic PCF CephaladCaudal Medial

18 Anterior Cervical Diskectomy & Fusion (ACDF) The gold standard procedure >90% successful relief Remove disk & Osteophytes Use Allograft of Autograft bone. May use metal or PEEK cage Most often done with a small anterior plate and screws for stabilisation

19 Return to Play No Consensus on RTP No Contraindication conservative treatment resolved radicular symptoms full, painless ROM No severe central stenosis (spinal cord compression) operative treatment Single-level ACDF --> radiographic solid fusion Foraminotomy --> flexion/extension XR without instability resolved neurologic symptoms painless ROM c-spine (expect 10% loss)

20 Return to Play Relative Contraindication 2 or 3 level ACDF (depending on author) Subluxation without frank instability of a foraminotomy C2-3, C3-4 ACDF - forces concentrated at the upper C-spine Absolute Contraindication Disk Herniation with Neuro symptoms Either Myelopathy (Central) or Radiculopathy (Lateral) Unresolved painful or stiff neck with loss of cervical alignment 3 or greater fused levels Severe central Stenosis (Torg ratio)

21 Return to Play First cervical disk herniation elite athlete outcomes study Review of publicly available records Injury Reports & Newspapers 99 NFL players with cervical disk herniation Operative Group 38/53 (72%) RTP Non-op 21/46 (46%) RTP

22 Return To Play 5.3% underwent second operation Postitive Factor Quaterback position Negative Factors Advanced age/ career Defensive Back position need to react quickly to opponents movements need unhindered ROM alter style of play significantly

23 Fantasy Football 2012/13? Should I pick Peyton? Pros- no loss of performance after single level ACDF on average 2.8y play Quaterbacks perform better Still has better stats than most current QBs Cons- Already had 3 (4) neck surgeries Report from SI noted already had spurs at the level above fusion (is this the first foraminotomy?) at the end of the 2011 season, despite being cleared by his surgeon, he did not play Team physician cited continued muscle atrophy and still hadnt regained full ROM Dominant arm

24 Fantasy Football 2012/13 Peyton probably a good choice for this season, perhaps next, but his longevity is fast approaching. After working out with Peyton Manning this spring, Eric Decker says there's "no question" that Manning still possesses plenty of arm strength after multiple neck operations.

25 References Andrews, J., Jones, A., Davies, P. R., Howes, J., & Ahuja, S. (2008). Is return to professional rugby union likely after anterior cervical spinal surgery? Journal of Bone and Joint Surgery - British Volume, 90-B(5), 619–621. doi: / X.90B Banks, Don. As Colts near deadline on Manning, more troublesome details emerge. Retrieved 5/9/12 from: Brophy, R. H., Lyman, S., Chehab, E. L., Barnes, R. P., Rodeo, S. A., & Warren, R. F. (2009). Predictive Value of Prior Injury on Career in Professional American Football Is Affected by Player Position. American Journal of Sports Medicine, 37(4), 768–775. doi: / Hayes, Julie. What if Peyton Mannings neck injury is more serious that what the Colts are claiming? Retrieved 5/10/12 from: Hsu, W. K. (2011). Outcomes Following Nonoperative and Operative Treatment for Cervical Disc Herniations in National Football League Athletes. Spine, 36(10), 800– 805. doi: /BRS.0b013e3181e K. (2011). Outcomes Following Nonoperative and Operative Treatment for Cervical Dis Moretensen, Chris. More neck surgery for Peyton Manning. Retrieved 5/9/12 from: surgery-neck Peyton Manning. Retrieved 5/10/12 from: Riew, Daniel. (2006). Standing Room Only: Spine Surgery: Evolving Applications and TechnRiew, Daniel. (2006). Standing Room Only: Spine Surgery: Evolving Applications and Techniques. American Academy or Orthopaedic Surgeons. DVD. Scherping, S. (2002). Cervical disc disease in the athlete. Clinics in sports medicine.dicine. Torg, J. S., Vegso, J. J., SennettTorg, J. S., Vegso, J. J., Sennett, B., & Das, M. (1985). The National Football Head and Neck Injury Registry. 14-year report on cervical quadriplegia, 1971 through JAMA: The Journal of the American Medical Association, 254(24), 3439–3443. Wilson, Phillip B. Clearing up facts on Manning surgery timeline. Retrieved 5/9/12 from: surgery-timeline/ Zmurko, M. G., Tannoury, T. Y., Tannoury, C. A., & Anderson, D. G. (2003). Cervical sprains, disc herniations, minor fractures, and other cervical injuries in the athlete. Clinics in sports medicine, 22(3), 513–521.

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