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Surgery not a career-ender for NFL players with cervical disk herniation

By Mary Ann Porucznik

Results in higher return-to-play rates, longer careers

Listen to Dr. Hsu’s interview about treating elite athletes

Football players are no strangers to injury. But cervical disk injuries are particularly worrisome. The high-velocity collisions sustained by players can lead to cervical disk herniations (CDH), which can, in turn, cause symptoms such as neck pain, radiating pain in the upper extremities, and coordination problems.

Surgery to treat CDH has a high satisfaction rate in the general population, but Wellington K. Hsu, MD, wondered about outcomes among National Football League (NFL) players. Would fusion affect performance-based outcomes by altering the playing strategies of elite athletes who sustained such injuries?

In examining “Outcomes following nonoperative and operative treatment for cervical disk herniations in NFL athletes,” Dr. Hsu found that players who were treated surgically had higher return-to-play rates and longer careers than those who were treated nonsurgically. He presented the results of his retrospective cohort study at the North American Spine Society 2010 annual meeting.

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In this study, players diagnosed with a CDH included 12 defensive linemen, 11 offensive linemen, 17 linebackers, 31 defensive backs, 8 running backs, 4 tight ends, 7 wide receivers, 8 quarterbacks, and one kicker.

Identifying the cohort
Dr. Hsu relied on public records—including team medical and injury records, newspaper and press releases, and player profiles—to identify the 99 NFL players in his study. Each treatment plan was confirmed by at least 2 independent sources. Surgical treatment was defined as “a 1-level anterior cervical discectomy and fusion (ACDF), posterior foraminotomy, or indeterminate”; nonsurgical treatments included anything other than surgery (ie, physical therapy, epidural steroid injections, activity modifications).

Nearly one third of the players diagnosed with a CDH between 1979 and 2008 were defensive backs (31). Slightly more than half of the players (53) were treated surgically—32 players were treated with ACDF, 3 with posterior foraminotomy, and 18 with an “indeterminate” procedure (exact procedure could not be identified based on available records). Each player served as his own control in measuring performance outcomes such as yards gained, touchdowns scored, interceptions, games started or played, and seasons played.

Comparing outcomes
Nearly 3 out of 4 (72 percent) of NFL players who were treated surgically for CDH returned to play and continued to play in an average of 29.3 games over a 2.8-year period after surgery. In contrast, less than half (46 percent) of those treated nonsurgically returned to play; those who did played an average of 14.7 games over a 1.5-year period before retiring.

After treatment for CDH, players in general had lower performance scores and started fewer games than they had before their injury. But, noted Dr. Hsu, this difference was not statistically significant.

“What was surprising was that the position you played mattered,” Dr. Hsu said. “Defensive backs seemed to be overrepresented in the population.” Outcomes for the defensive backs were significantly poorer compared to other positions. Among defensive backs who sustained CDH and were treated surgically, just half (6 of 12) returned to play. They participated in 17 games over a 1.85-year period. Of the 19 defensive backs who sustained CDH and were treated nonsurgically, just 7 returned to play, and their careers were limited to just 6 games in less than 1 year.

“The defensive back is a unique position on the field,” explained Dr. Hsu. “They’re tackling players who are 60 pounds to 70 pounds heavier than they are; they may be more sensitive to subtleties in range of motion in the neck than other positions. They’re among the most athletic players on the field and could be more attuned to changes after surgery than other positions.”

None of the players who returned to the field sustained a spinal cord injury after surgery, noted Dr. Hsu, although 5.3 percent did have a second surgical procedure in the cervical spine, either at the original or an adjacent level.

“Clinical success as defined by professional athletes requires a completely different set of outcome measures than those used for the general population,” said Dr. Hsu. “The performance-based outcomes we used were significantly better than expected, and our institution is now conducting a prospective study on outcomes after spine surgery in professional athletes.”

Dr. Hsu reports no conflicts.

Mary Ann Porucznik is managing editor of AAOS Now. She can be reached at porucznik@aaos.org

Listen to Dr. Hsu’s interview about treating elite athletes

Bottom line

  • This retrospective cohort study tried to define performance outcomes after treatment for CDH sustained by NFL players.
  • Players treated surgically had a higher return-to-play rate and a longer career after surgery than those treated nonsurgically.
  • Defensive backs had a poorer prognosis after CDH than players in other positions.
  • This study has several limitations, including the lack of radiographic data and the possibility of reporting errors, misdiagnoses, and selection bias.

AAOS Now
November 2010 Issue
http://www.aaos.org/news/aaosnow/nov10/clinical2.asp