Return To Play After Cervical Disk HerniationBrian N. Morelli, MD

Assistant Professor, Dept. of OrthopaedicsStony Brook University Medical Center

Spine & Scoliosis Center

or “What Really Happened To Peyton

Manning”

Image From:

“Harvard Beats Yale 29-29”

No Disclosures

In 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

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

Timeline

Feb 2010 completes

‘09-’10 season. 4th time

league MVP

Mar 20101st surgery - Post. Cervical Foraminotomy

Dr. Rick Fessler, Northwestern

Memorial Hospital, Chicago

No starts 2011 season.

Possible 3rd surgery

(reported by SI)

Foraminotomy again?

May 20112st 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 20113rd/ 4th surgery - Cervical fusion

Manning had residual triceps weakness from prior surgeryDrs. Robert

Watkins, Sr. & Jr.

Marina Del Ray Hospital (CA)

March 2012Manning signs

with the Broncos

Manning is RHD, all surgeries were for R sided radiculopathy

Athletes & Cervical Disk Herniations

Cervical Disk Herniation

Corrective Surgeries

Return to Play

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

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

Radiculopathy

Syndrome of nerve root dysfunction

Pain

Numbness

Weakness

Pattern of pain depends upon the affected nerve root

Axial Neck Pain in acute HNP

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

Surgical OptionsPosterior

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.

Posterior Cervical Foraminotomy

Posterior “Keyhole” Foraminotomy

Well established procedure

Carefully selected patients with radiculopathy

Open

Via MIS tube

Microendoscopic Technique

Year Patients F/UEx/Gd

ResultsAuthor

1983 846 2.8y 96% Henderson

1986 50 1-7y 96% Simeone

1990 230 3.5y 92% Krupp

1990 36 2 100% Aldrich

1993 172 <2y 97% Zeidman

1996 170 15y 86% Davis

1997 54 1y 94% Woertgen

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

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

Posterior Cervical Foraminotomy

Endoscopic PCF

Cephalad

Caudal

Medial

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

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)

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)

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

Return To Play5.3% 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

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

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

ReferencesAndrews, 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.