Peyton Manning update

Apologies, folks. It's been a while since I've posted here with any sort of substance. The last few rotations have been a lot busier, and we've been going through residency applications which is its own monster.

As news broke earlier this week, Peyton Manning is entering his next stage of rehab following his X-ray and CT scans that have revealed appropriate fusion of his vertebrae from surgery.

He has mentioned he will likely start throwing and lifting weights in the start of this next phase of what I'm sure will be intense physical therapy needed for a high performance athlete to return to optimal function. Considering he hasn't been able to do any practice for so long, his muscles likely have a lot of catching up to do.

As I mentioned in my previous post on this topic, the long-term prognosis after this surgery is not certain. However, like most sports injuries, how he does with his rehabilitation in these next few months will be an enormous factor in the success of this treatment.

Peyton Manning - cervical disc herniation and disc fusion surgery

Likely the biggest story in the NFL right now is the Indianapolis Colts without their future all-star quarterback Peyton Manning. Last week was the first time he missed a start for the first time in 227 games. The last time Colts fans saw someone else start a game behind center was in 1997.

The reason he isn't starting (or projected to play for at least another couple months) is that he has a herniated disc in his neck (cervical spine). 

Fig. 1

Let's start with the basics. The first seven vertebrae that make up our backbone are known as the cervical vertebrae, or "C-spine". In between each of these vertebra (in our entire "backbone") are intervertebral discs that act as buffers between the vertebrae, shock absorbers, and like mini-joints to provide flexibility/mobility. These discs are made primarily of two parts: the annulus fibrosus and the nucleus pulposus. The annulus fibrosus is made of cartilage and forms the outside of the disc, containing the nucleus pulposus. The nucleus pulposus is made of proteins but has a gel-like consistency. 

Fig. 2
Photo credit: myhealth.alberta.ca

With normal wear and tear or injury, the annulus fibrosus can become damaged or rupture, allowing the jelly-like nucleus pulposus to herniate or prolapse out of the disc. As you can see in Fig. 1, the discs and vertebrae sit neatly on top of each other. When one of these discs is herniated or prolapsed (Fig. 2), it can put physical pressure on the nearby spinal cord and cause the patient a wide range of  symptoms, depending on which nerve roots are affected.

In the case of a cervical herniated disc, it can start with some non-specific neck pain and can progress to pain shooting into the arms or shoulders as well as muscle weakness, numbness, and/or tingling. 

As for treatment, usually conservative measures are tried first. These treatments include rest, anti-inflammatories, glucocorticoids (oral or injections), and physical therapy with increasing mobilization. Out of the above, epidural steroid injections currently have the best evidence for relief of symptoms. 

Surgery is usually considered as an option if 6-8 weeks of conservative therapy provide no improvement in symptoms. Other guidelines propose requiring all of the following: (1) symptoms/signs of nerve root impingement, (2) evidence of nerve root compression on CT or MRI, and (3) persistence of pain despite 6-12 weeks of conservative therapy.

In Peyton Manning's case, he received anterior cervical discectomy and fusion surgery. The ESPN article also states Manning had surgery on two other occasions earlier, but I don't think the procedures were ever specified, so it would be difficult to speculate why he's having his third surgery this year. From the article: 

"An anterior fusion procedure usually involves... removing soft disk tissue between the vertebrae and fusing the bones together with a graft... Recovery from the procedure typically takes at least eight to ten weeks."

So taking what we've learned so far, this make sense that the entire disc is being removed because its physical presence was causing compression of the nerve roots.

In terms of prognosis, from what I've read, previous evidence has produced a mixed bag of results. In many cases, patients improve spontaneously over time. For cervical radiculopathy, it seems that the line between conservative management and surgery is still relatively blurry. A relatively small randomized control trial (n = 81) revealed that patients that received surgery had, at 4 months, less pain and sensory loss and better muscle strength than non-surgical patients. At 1 year, the only difference between the two groups was that the surgical patients reported better muscle strength.

In the end, I guess it's tough to say how Manning's long-term prognosis will be with this issue. It's reassuring to see that many people tend to do well with a cervical herniated disc, but as always, we don't know the full medical story. What were the two previous surgeries for? How long has he dealt with this problem? Only time will tell...

Sources: UpToDate and DynaMed