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Return To Play After Cervical Disk Herniation

Return To Play After Cervical Disk Herniation. or “What Really Happened To Peyton Manning”. Brian N. Morelli, MD Assistant Professor, Dept. of Orthopaedics Stony Brook University Medical Center Spine & Scoliosis Center. Image From: “Harvard Beats Yale 29-29”.

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Return To Play After Cervical Disk Herniation

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

  2. Image From:“Harvard Beats Yale 29-29”

  3. No DisclosuresIn no way was I involved in this patient’s 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 Manning is RHD, all surgeries were for R sided radiculopathy 2010 Season No missed starts? Possible unreported injury during week 1 No starts 2011 season. Possible 3rd surgery (reported by SI) Foraminotomy again? Feb 2010 completes ‘09-’10 season. 4th time league MVP March 2012 Manning signs with the Broncos Sept 2011 3rd/ 4th surgery - Cervical fusion Manning had residual triceps weakness from prior surgery Drs. Robert Watkins, Sr. & Jr. Marina Del Ray Hospital (CA) May 2011 2st surgery - Post. Cervical Foraminotomy, different level Dr. Rick Fessler, Northwestern Memorial Hospital, Chicago Mar 2010 1st surgery - Post. Cervical Foraminotomy Dr. Rick Fessler, Northwestern Memorial Hospital, Chicago

  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

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

  10. 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

  11. 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.

  12. Posterior Cervical Foraminotomy • Posterior “Keyhole” Foraminotomy • Well established procedure • Carefully selected patients with radiculopathy • Open • Via MIS tube • Microendoscopic Technique

  13. Posterior Cervical Foraminotomy • Fessler & Khoo. Neurosurgery 2002. • 25 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

  14. Posterior Cervical Foraminotomy • Endoscopic Cervical Foraminotomy • Ruetten, et al. Germany. Spine 2008 • 84 ACDF, 91 FPCF • 2 year results • 6.7% revision rate for recurrence of symptoms after pain-free interval. ACDF EPCF

  15. Endoscopic PCF Medial Caudal Cephalad

  16. 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

  17. 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)

  18. 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)

  19. 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

  20. 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

  21. 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 hadn’t regained full ROM • Dominant arm

  22. 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. espn.com

  23. 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:10.1302/0301-620X.90B5.20546 Banks, Don. As Colts near deadline on Manning, more troublesome details emerge. Retrieved 5/9/12 from: http://sportsillustrated.cnn.com/2012/writers/don_banks/02/15/peyton/index.html#ixzz1mTp9ON4e 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:10.1177/0363546508329542 Hayes, Julie. What if Peyton Manning’s neck injury is more serious that what the Colts are claiming? Retrieved 5/10/12 from: http://sportingjules.blogspot.com/2011/08/what-if-peyton-mannings-neck-injury-is.html 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:10.1097/BRS.0b013e3181e50651 Moretensen, Chris. More neck surgery for Peyton Manning. Retrieved 5/9/12 from: http://espn.go.com/nfl/story/_/id/6944302/indianapolis-colts-peyton-manning-more-surgery-neck Peyton Manning. Retrieved 5/10/12 from: http://en.wikipedia.org/wiki/Peyton_Manning Riew, 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. Torg, 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 1984. 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: http://blogs.indystar.com/philb/2011/09/11/clearing-up-facts-on-manning-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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