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June 15, 2011

Collateral Damage

Spining Away

by Corey Dawkins and Ben Lindbergh

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Vicente Padilla, LAN (Microdiscectomy in neck)
We've discussed the debilitating nature of intervertebral disc injury and briefly talked about approaches to managing the condition. The conservative course of treatment involves exercises designed to stabilize the core and prevent the area from being subjected to too much motion. Conservative treatment doesn't always work, though, and symptoms can reach a point where surgery becomes necessary in order to restore an athlete to a high level of performance.

Both in the past and in some current cases, surgery on a herniated disc (discectomy) is performed in an open procedure through an incision. The patient is placed face-down on a special table, and an incision about three to five centimeters long—depending on the size of the patient—is made over the injured disc. Muscles, tendons, and general connective tissue all have to be cut and retracted in order to reach the spine, and spinal ligaments and small pieces of bone need to be removed in order to get to the actual disc.

After the surgeon creates a clear path to the spine, the herniated portion of the disc is removed, and the remainder of the disc is evaluated for any other troublesome spots. Soft tissue is reattached to the bones, and the remaining connective tissue is stitched before closing the skin. Many different structures must be severed and/or removed, resulting in subsequent biomechanical changes of the spine and back.

As you might imagine, this amount of tissue damage leads to a long recovery. The disc, vertebra, nerves, muscles and their attachments, and general connective tissue all have to heal, and each part heals at its own rate.

Microdiscectomy changes the recovery equation by approaching the disc in a less invasive way. A small incision is still used, but the superficial muscles are moved out of the way rather than cut, which often leads to a much less painful recovery and a shorter hospital stay. Operative microscopes or glasses are used to obtain appropriate magnification of the area, allowing the surgeon to remove any bone or disc material that is impinging on the nerves. The soft tissue is then put back in place and stitched where necessary before the skin is closed. The minimalistic nature of the surgery allows the biomechanics of the spine to closely resemble those prior to the disc herniation or bulge.

The time it takes to return from microdiscectomy surgery ranges from two months to six months or more, but the outcomes are generally better than those that follow open discectomies. In general, athletes return from microdiscectomy to their previous levels of performance about 15 percent more often than they do in the wake of an open procedure.

One recent study examined over 342 professional athletes, broken down by sport and procedure type. Major League Baseball players returned from the surgery 96 percent of the time. This study discusses the possibility of decreased career length after surgery in baseball players, as opposed to members of the NFL, but we feel that the disparity is more closely related to the typical age at the time of surgery. Considering age at time of surgery and subsequent career length, both groups finish their careers at approximately 35.

Padilla is already 33 and will turn 34 in September, so he is likely approaching the end of the line. If the above studies are any indication, he may be able to buy himself some time, but the road back is going to be difficult. The second linked study examined injuries that occurred from 1972 to 2008, and while career length after surgery has improved in the last decade, successful procedures still aren’t guaranteed. We may see Padilla back this year, but there is a good chance that he won’t return until 2011.

Derek Jeter, NYA (Strained right calf)
Jeter's quest for 3000 hits will be put on hold for a few weeks after he suffered a strained right calf on Monday night. It's a mild strain, but the Yankees are going to play it cautious. Jeter has played in at least 148 games in every year since 1996, except for 2003, when he dislocated his shoulder on Opening Day. That durability has served him well in his pursuit of 3000, a milestone attainable only by those who possess a rare talent for hitting and are skilled at staying healthy. Jeter will likely be back to continue his quest for history before the month is out.

Brett Anderson, OAK (Left elbow soreness)
Oakland received good news whenDr. Andrews recommended rehabilitation and a PRP injection into the area surrounding Anderson’s left elbow rather than surgery. PRP requires several weeks of specific exercises to avoid disrupting the injected material and jeopardizing recovery. The southpaw will spend the next six weeks rehabilitating the elbow, progressing from simple motion exercises to strengthening exercises in later weeks. The procedure is not guaranteed to alleviate his symptoms, but it carries very little risk other than the possibility of delaying an inevitable surgery. Anderson will be reevaluated as he approaches the six-week mark.

Justin Morneau, MIN (Left wrist soreness)
The structures of the wrist are very complicated: everything has to fit together and glide perfectly for the whole to operate as intended. Morneau's problematic wrist has landed him on the disabled list despite a corticosteroid injection. Earlier MRIs did not disclose any structural damage but did show some swelling. Swelling is always present for a reason, even if a clear orthopedic issue isn’t responsible, and MRIs aren’t always up to the task of determining the cause. Injuries that fall between the slices of the MRI don't show up but can still cause symptoms that do, such as swelling. What’s more, like labrum injuries in the shoulder and hip, damage to the cartilage of the wrist doesn’t always show up on MRI and must be detected by other specialized tests.

Morneau will likely undergo further testing as the Twins try to get to the bottom of this. Rotoworld reported that “Morneau was told by doctors that the only thing that will improve his wrist is for him to stop swinging.” As Neil DeMause observed, given the way his season has gone, a strict no-swinging rule is also the only thing that might improve his OBP.

Flesh Wounds: Ryan Doumit's ankle fracture showed significant healing on a CT scan, allowing him to progress in his rehabilitation... Scott Cousins traded places with Hanley Ramirez on the disabled list, thanks to a lower back strain... Fernando Rodney went on the DL with an upper back strain... Cole Hamels had to leave last night's start with an injury. We’re still trying to track down more details... Adam LaRoche will have season-ending surgery tomorrow on a torn labrum in his shoulder.

Corey Dawkins is an author of Baseball Prospectus. 
Click here to see Corey's other articles. You can contact Corey by clicking here
Ben Lindbergh is an author of Baseball Prospectus. 
Click here to see Ben's other articles. You can contact Ben by clicking here

Related Content:  Surgery,  Broken Wrist

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