Demystifying the lower body injury.
December 16, 2011 Leave a comment
Hey, look! More stuff on the Backhand Shelf! This week I’m looking at some injury weirdness around the league – Chris Higgins’ infected foot, Marty St. Louis’ broken face, and Patty Wiercioch’s throat-puck.
Aaaaaand Rick DiPietro is hurt. Again. Poor Rick.
December 4, 2011 Leave a comment
Here’s my latest from The Score’s Backhand Shelf – A look at Patty Eaves’ truly unpleasant fractured jaw.
September 21, 2011 Leave a comment
This is the third (and last) in a series of posts looking at historic hockey injuries, intended to keep me busy and you interested while we wait for October to get here.
The history was provided by Jen aka @NHLhistorygirl. Jen is a librarian and graduate student at the University of North Dakota in the last stage of her MA in history: writing her thesis on the 1972 Summit Series, media, and notions of national identity.
Badass Bobby Baun
The history…
Bob Baun is not afraid of pain. During Game 6 of the 1964 Stanley Cup Final, he was hit in the ankle by a Gordie Howe shot. He continued playing, but when he circled to clear the puck from the zone, he heard an audible pop and went down.
The trainers carried Baun off the ice on a stretcher, and an examination of the ankle in the dressing room revealed major swelling and a large welt. Baun insisted the trainer inject painkillers and tape the leg to keep the swelling down. With his leg wrapped from foot to nearly his knee, Baun squeezed back into the skate and finished the period.
For whatever reason though, the painkiller wore off quickly, and so Baun needed several more shots. When he returned to the bench in overtime after one of the shots, coach Punch Imlach was sending Carl Brewer and Kent Douglas onto the ice. Baun took Douglas’ place, caught the pass from Bob Pulford, and scored the game winner, tying the series with Detroit at 3-3.
On the train back to Toronto, Baun knew his leg was broken. Imlach knew it too, ordering Baun to see the team doctor at 9 am the next morning. Rather than see the doctor and sit out Game 7, Baun packed an overnight bag and went to a friend’s farm to hide out. He refused to even tell his wife where he was.
After almost two days of hiding, rest, and ice, Baun appeared at Maple Leaf Gardens 30 minutes before Game 7, because he knew that was “too late for them to check me out and stop me from playing.” He suited up and played a shift or two in the 4-0 victory over the Red Wings. He wasn’t allowed to celebrate much, as he was sent almost immediately to hospital, where x-rays revealed a jagged fracture immediately above the ankle, in the fibula.
The medicine…
As broken legs go, fibula fractures are among the most interesting, and yet they get the least attention. Poor fibula fractures. No respect.
Fibuwhat?
The fibula. It’s that other bone in your lower leg. The one you don’t think about. It’s not part of your shin, it doesn’t bear much weight, and when it breaks it doesn’t look anywhere near as spectacular as a broken tibia. It’s also fairly scrawny.
Tibiwho?
The tibia. It’s the bone in your lower leg that you know and love. It’s your shin. It’s the weight-bearer. It’s the one you whack on the coffee table in the dark. When it breaks, it’s generally pretty obvious, and pretty gross.
Anterior (front) view of the right leg
The question is how Bob Baun could last two days and a hockey game with a broken leg. The answer is because it was his fibula that was broken, and because he was an enormous badass. Generally when you break your lower leg, you break the tibia, or the tibia and fibula (which we call a tib-fib fracture because that sounds cooler). The tibia and fibula are attached together by a flat ligament (the interosseous membrane), which is why they’re frequently broken together. In Baun’s case, the isolated lateral force from Howe’s shot resulted in just a fibular fracture.
Treatment
Fibular fractures are fairly easy to treat assuming they’re not open (bone poking through skin), displaced (bone going somewhere it shouldn’t), or comminuted (bone broken into multiple pieces). The first order of business is pain control. Bones are covered by periosteum, a membrane that has the distinction of being lousy with pain receptors. That would be why broken bones hurt so much (SCIENCE!).
Since the fibula is non-weight-bearing (or minimally weight-bearing – a distinction we won’t get into, but that orthopods love to fight about), simple fractures are treated with a cast for the first two or three days, and a pair of crutches if needed. That gives you time to get into the ortho office, where they’ll put you in a walking cast or a cam walker, which you can buy on Amazon, but probably shouldn’t. They’ll also take away your crutches if you’re still using them. After three to four weeks of immobilization, the cast comes off, and a splint is used on an as-needed basis for exercise. Athletes can generally return to light training after just a few weeks, but full recovery is a six- to eight-week process. Sports that consist of a lot of twisting and trauma to the leg (like hockey or soccer), however, can require a much longer healing period (as much as 18 to 24 weeks) in order to prevent refracture.
As with any injury, the healing process for fibula fractures is helped along by physical therapy, consisting of strengthening exercises and getting yelled at.
The Take-Home
Basically, Bob Baun was a complete animal. He had a fracture that you can walk on, but broken bones HURT. He sucked it up and hid out so he could play in game 7. Smart decision? No, probably not. Understandable? Yes, probably.
Oh, and in case you weren’t aware – hockey season starts again soon. I know, I know, I’m excited too. Many thanks to Jen for collaborating on this series!!!
September 6, 2011 4 Comments
Wade Belak, 1976-2011
It’s been a rough summer for hockey. The deaths of Derek Boogaard, Rick Rypien and Wade Belak have raised questions about the role of fighting in the NHL, and whether the NHL/NHLPA are doing enough to support players with mental health issues. I was astounded to find I was consistently finding people questioning the link between head injury and depression in the numerous news stories and blog posts on the subject.
The CBC recently published an interview with Dr. Robert Cantu, co-director of the Centre for the Study of Traumatic Encepholopathy at Boston University. Dr. Cantu (a neurosurgeon) explains that depression, anxiety and substance abuse are all common in athletes with CTE (chronic traumatic encephalopathy). He goes on to state something any rational person could have guessed – that NHL players have admitted to him that they’ve had concussive-type injuries far more frequently than they’ve actually reported to their coach or trainers.
In a truly spectacular show of idiocy, the CBC’s story received comments like these, questioning the head injury/depression link:
IMHO, hockey players kids are raised as prima donnas who are encouraged to win at atl costs. I find a lot of them to be incredibly immature. Scientists should be looking at their lifestyle first. I would think the depression came from excesses in lifestyle, and an immaturity with which they cannot cope with the stress related to that lifestyle.
– GordonRobertson
Nice try.
These tragedies likely have more to do with the moral conflict one would have to deal with after having been paid a large sum of money to inflict violence on others.
Once again nice try Dr. Cantu.
Obviously the NHL did a good shopping job.– Hihohum
Wow. So here we have the (apparently not uncommon) opinions that depression comes from lifestyle excess, immaturity, and moral conflict. No doubt GordonRobertson and Hihohum’s opinions are based on their extensive reading on traumatic brain injury.
Right?
Hell no, because they’re completely wrong. There are literally thousands of studies linking traumatic brain injury to depression, and not just in CTE (a condition so dramatic that it actually changes the gross appearance of the brain), but also in mild concussive injuries. Something that keeps coming up is the argument that correlation does not imply causation. Do the concussions actually result in depression, or do people who’ve had concussions just happen to also be depressed?
Yes, concussions can cause depression.
Researchers at McGill’s Montreal Neurological Institute did a study using fMRI (functional MRI), a technology which looks at blood flow to specific areas of the brain as related to neural activity. Put simply, the more neural activity in an area, the more blood flow to that area. The McGill team examined athletes suffering from post-concussive syndrome both with and without depression, and compared them to athletes who had never been head injured. None of the athletes studied had been diagnosed with depression prior to their injury. The team found that the fMRI results on the depressed post-concussion athletes were very similar to those seen in people with major depressive disorder. Let’s make this crystal clear – after a concussion, athletes with no history of depression became depressed. Fancy brain imaging on these athletes looked like fancy brain imaging done on people with regular (non-head injury-related) depression. What’s truly scary is that the concussed athletes (both depressed and not depressed) were also found to have areas of grey matter loss in their brains. Let me say that again another way. The actual anatomy of their brains had changed.
Not convinced?
How about the 3rd International Conference on Concussion in Sport? In 2008 a group of neurologists, neurosurgeons and representatives from various hockey organizations sat down in Zurich and spent a long time discussing nothing but concussions. The idea was to produce a list of recommendations for the management of head-injured athletes that could be used by doctors, trainers, and other people involved in their care. The group encouraged evaluating head injured athletes for depression, as “Mental health issues (such as depression) have been reported as a long-term consequence of traumatic brain injury, including sports related concussion.” They also provide about 11 references for that statement, which you’re more than welcome to look up on your own.
The implications
It’s difficult to pin down an exact percentage of people with concussions who end up with depression as well. A review article published in 2001 suggests the number could be as high as 42%. Dr. Cantu’s experience, as well as that of anyone who is an athlete, who’s been around an athlete, or who’s ever spoken to an athlete tells us that a lot of concussions go unreported. The implication is also that there are a lot of athletes (in the NHL and elsewhere) who could be suffering from depression and other mental health problems.
The NHL/NHLPA Substance Abuse and Behavioural Health Program has come under fire in the wake of Boogaard, Rypien and Belak’s deaths. The suggestion is that not enough is being done to protect the well-being of NHL players and alumni. The NHL and NHLPA released a joint statement on September 1st addressing the deaths.
While the circumstances of each case are unique, these tragic events cannot be ignored. We are committed to examining, in detail, the factors that may have contributed to these events, and to determining whether concrete steps can be taken to enhance player welfare and minimize the likelihood of such events taking place. Our organizations are committed to a thorough evaluation of our existing assistance programs and practices and will make immediate modifications and improvements to the extent they are deemed warranted.
It is important to ensure that every reasonable step and precaution is taken to make NHL Players, and all members of the NHL family, aware of the vast resources available to them when they are in need of assistance. We want individuals to feel comfortable seeking help when they need help.
Obviously NHL players are either not “aware of the vast resources” or not “comfortable seeking help”. Whatever is currently being done can’t be enough if three players have (directly or indirectly, intentionally or not) killed themselves in under 5 months. Were Rypien and Belak’s depression issues linked to head injuries? Does it matter? Whether their depression was pre-existing or the result of an injury, it was real, and it killed them.
Having said that, knowing that depression is found in as many as 42% of people suffering head injuries, it behooves the NHL to find a way to reduce those injuries. Fighting has been named as a culprit, as has contact with the head, hits from behind, and I’d add poorly fitted helmets to the list. The NHL has made efforts to reduce injury with Rule 43 (checking from behind), but remains miles behind other hockey organizations. One of the few sane commenters on the CBC article noted that the most exciting hockey game they’d watched in recent memory was the 2010 USA-Canada Olympic gold medal game – a game played under IIHF rules, where hits to the head and fighting aren’t permitted.
Take-home points
Some concussions cause depression. Period. No, no, we don’t need to talk about it. The science is there.
Fighting for the sake of fighting (I’m looking at you, Matt Carkner and Colton Orr) has no place in an NHL interested in the well-being of its players. Rule changes need to be made to reduce the incidence of head injuries. Obviously the very nature of the game dictates that you can’t eliminate every injury. The point is to eliminate what you can. The IIHF, NCAA and Olympics all have more protective rules, and all have exciting hockey.
The NHL/NHLPA need to do more to ensure their players and alumni’s mental health and substance abuse needs are taken care of. Three deaths in less than five months should be an enormous wake up call – one that never should have happened.
The folks at puckscene are hosting the Wade Belak Memorial Charity Drive to benefit the Tourette Syndrome Clinic at Toronto Western Hospital, the charity he’d chosen to skate for on Battle of the Blades.
September 4-10 is National Suicide Prevention Week in the US. Your contribution can be as simple as educating yourself on the warning signs of depression and suicidality. Extensive resources can also be found at The Canadian Association for Suicide Prevention.
References:
Jen-Kai Chen; Karen M. Johnston; Michael Petrides; Alain Ptito
Neural Substrates of Symptoms of Depression Following Concussion in Male Athletes With Persisting Postconcussion Symptoms
Arch Gen Psychiatry. 2008;65(1):81-89.
M Aubry; R Cantu; J Dvorak; K Johnston; P McCrory; W Meeuwisse; M Molloy
Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008
Br J Sports Med 2009;43:i76-i84.
August 11, 2011 3 Comments
This is the second in a series of posts looking at historic hockey injuries, intended to keep me busy and you interested while we wait for October to get here.
The history was provided by Jen aka @NHLhistorygirl. Jen is a librarian and graduate student at the University of North Dakota in the last stage of her MA in history: writing her thesis on the 1972 Summit Series, media, and notions of national identity.
Trent McCleary, huge frigging badass.
The history…
It’s a play we’ve seen hundreds of times: a player winds up for a shot, another player attempts to block it. The puck slides away, the players skate after it. No harm done. Every once in a while though, something goes wrong, and a player ends up bruised or needing a few stitches.
And in the case of Trent McCleary, it went horribly wrong.
On January 29, 2000, the Habs were playing the Flyers at the Molson Centre. Habs right wing Trent McCleary hadn’t logged much ice time (only 4:02) but he played aggressively. It was no surprise that he attempted to block defenceman Chris Therien’s shot.
The shot hit him directly in the throat, and McCleary fell to the ice, unable to breathe. He struggled on the ice for a few moments, then his instincts drove him to skate to the bench, where he tried to tell the trainer he couldn’t breathe before collapsing.
Not quite unconscious, McCleary’s throat was filling with blood and every breath became more difficult, causing him to thrash about frantically. His adrenaline level was so high that when Habs therapist Graham Rynbend tried to hold him down for examination, he threw Rynbend over the table.
When the doctor could not get a breathing tube down McCleary’s throat, he was then rushed to the hospital and directly to an operating table. McCleary had a collapsed right lung and a complex fracture of the larynx, two life-threatening injuries that required an emergency tracheotomy and putting him on a respirator.
Events happened so quickly that of none of McCleary’s equipment had been removed before emergency surgery. It was the first time the doctors had ever operated on someone still in skates. Had events not moved as quickly as they did, according to the surgeons, McCleary would have died. “It was a matter of seconds,” said Dr. Mulder.
Two days later, unable to speak, he wrote a note to his teammates (who were about to play the Hurricanes): “Doing well. Here’s $500 on the board for the win. I’ll be listening. Battle Hard. Go Habs. Trent no. 6”
After three surgeries and months of therapy, McCleary was able to regain his voice and resume a normal life. However, the tracheotomy site formed enough scar tissue to reduce his breathing capacity, and he was forced to retire.
The medicine…
Every patient assessment algorithm begins with the ABCs – airway, breathing, and circulation. If one of these elements is compromised, you can’t proceed until you’ve fixed it. McCleary’s injury brought the assessment algorithm to a screeching halt at A. When Therien’s shot hit him in the throat, it fractured his larynx, and almost completely occluded his airway. Without A, there’s no B. Without B, C quickly stops.
The Larynx
Bonus pro tip: Don’t pronounce this lair-nix. That’s wrong, and you’ll sound stupid. It’s lair-inks.
The larynx is a complicated combination of cartilage, muscles, and ligaments that sits just below the base of the tongue. It forms the topmost segment of the trachea (windpipe), and protects the vocal cords. It’s also an invaluable player on the airway team with a limited no-trade clause. With very, very few exceptions, you can’t live without it.
So THAT's where my larynx is!
What you know as your Adam’s apple is actually the front of your thyroid cartilage. Just below that you’ll feel a little gap, which is the cricothyroid membrane. That’s of huge significance in an injury like McCleary’s, as it’s an easily identified way of getting into the airway in a hurry.
The Larynx: It doesn't want to go to Edmonton either.
When Trent McCleary took a puck in the throat and fractured his larynx (i.e. the cartilage), two things immediately happened: He started bleeding, and he started swelling. The only method of getting air to his lungs was rapidly filling up with things air doesn’t like to go through. McCleary had the presence of mind to get up and move towards the bench, and with assistance made it off the ice before he collapsed. We have to assume that he was moving some air, as the brain won’t last longer than 4-6 minutes without it, and McCleary suffered no brain injury as a result of this incident.
A is for airway
McCleary was moved to the dressing room where team doctor David Mulder (a cardiothoracic surgeon) and trainer Graham Rynbend very quickly began trying to establish an airway. The usual way of doing so is intubation – sticking a plastic tube into the trachea (through the larynx) to provide a secure way of ventilating the patient. McCleary’s fractured larynx, along with swelling and bleeding, made tube placement impossible. Worse yet, the injury meant that the tissues of McCleary’s neck were beginning to fill with air that was leaking from his damaged trachea. This is called subcutaneous emphysema (if you’re a professional), or rice krispies (if you’re a paramedic or ER doc) because it really feels like there’s a layer of them under the skin.
With no way to intubate McCleary and what was left of his airway rapidly disappearing, some sources state Dr. Mulder performed a needle cricothyroidotomy with the assistance of Dr. David Fleizser, a surgeon who was a spectator at the game. Remember that little gap below your Adam’s apple? That’s the cricothyroid membrane, and a needle cric (say it like crikey without the y) involves punching through it with a big needle to provide a (very) temporary way of getting air into the lungs. The needle used is generally 14 gauge, which is about 2mm wide. To put it into perspective, 2mm is REALLY DAMN SMALL. Smaller than a drinking straw. The information we have doesn’t tell us if they stopped at the needle cric, or if they widened it to accomodate a larger tube. We do know that McCleary arrived at the emergency room 17 minutes after the puck hit his throat, and was immediately taken to the OR.
Dr. Mulder performed an emergency tracheotomy, a common surgical procedure that involves cutting a hole into the trachea at the base of the neck between the cartilage rings (which you can see in the figure above). The trach saved McCleary’s life by providing him with a way to get air past the horrendous damage in his throat. The A portion of the ABCs was complete.
B is for Breathing
Somewhere along the way, Trent McCleary also suffered a collapsed lung (pneumothorax). Pneumothoraces can happen in any number of ways – blunt trauma, penetrating trauma, and even spontaneously. McCleary’s pneumothorax could well have been a consequence of the air escaping his mangled larynx looking for places to go. The basic premise is that instead of filling the lung, air fills the cavity between the lung and the chest wall, keeping the lung from inflating and preventing proper ventilation. Keep in mind also that throughout this ordeal, McCleary was being aggressively ventilated, with air being forced into his mouth and nose by way of a BVM (bag-valve mask, or ‘bag’ – you’ve seen it on ER, and they’re always using it completely wrong).
Note the arrow pointing at the edge of the collapsed lung (which is conspicuously nowhere near where it should be)
A pneumothorax is a condition that can quickly become fatal. It’s not hard to figure out that if you fill your chest cavity with air, the heart and lungs end up getting shoved out of the way. Much as the brain is touchy about getting pushed around, the heart and lungs aren’t fans of it either. Your breathing suffers, your heart can’t fill or pump efficiently, and organs that need oxygen stop getting it.
Dr. Mulder inserted a thoracostomy tube (what you and I have lovingly come to know as a chest tube), which allows trapped air to escape the chest cavity and the lungs to reinflate. The tracheostomy was a more permanent answer to the B of the ABCs, and the chest tube ensured that the C of the ABCs wasn’t compromised.
The Aftermath
Once McCleary’s airway had been re-established, he was still left with the problem of a badly damaged larynx. He spent a few days on a ventilator, which is not surprising considering the extensive swelling and damage to his airway. It also takes practice to learn how to breathe with a trach, and patients who are intubated and on a vent usually take a little time to transition back to breathing on their own.
Several surgeries were required to repair the fracture (most likely with wire sutures), and his voice was restored with the final procedure (yes, you can suture vocal cords). Over the course of his recovery McCleary received his nutrition first by way of TPN, or total parenteral nutrition – essentially a solution of fat, glucose, amino acids and vitamins that’s administered via IV. He eventually graduated to a small-bore (narrow) feeding tube that was placed through his nose into his stomach. In time the tube was removed, as was the trach.
McCleary attempted a comeback with the Habs the next season, but scarring had narrowed his airway by approximately 15% and he found himself so out of breath that he couldn’t complete a shift.
Things I don’t believe:
In an incredibly boring video featuring Swift Current’s 5 most fascinating people of 2009, McCleary says that Mulder dislocated his jaw in his attempts to establish an airway. The way you open the airway of a patient who may have a spinal injury is by using a jaw thrust – placing the thumbs behind the angle of the lower jaw and pulling it forwards. This serves to straighten out the airway, making intubation easier, and limits movement of the c-spine. There’s plenty of yapping about whether or not this actually results in a jaw dislocation. All I can offer is that in 11 years of performing this maneuver, I’ve never dislocated a jaw (nor heard of one being dislocated). A search of the literature yielded very little on the topic, suggesting that mandibular dislocation isn’t entirely uncommon, but is generally seen in patients under general anesthesia. So is it possible? Sure. Do I think it happened? No, probably not. It takes a lot of force to dislocate someone’s jaw, especially if they’re not sedated. Does it matter? No. McCleary is fine now, and Drs. Mulder and Fleiszer and Mr. Rynbend are total badasses.
Speaking of badasses…
Note Trent McLeary’s gigantic cojones as he gets up and skates off the ice with a shattered throat. Absolutely amazing. Most of the credit in this situation probably needs to go to McLeary for getting up and getting help. Had he stayed on the ice and waited for the medical staff, his outcome might not have been as good as it was.
Enjoy a trip back to 2000 with this truly terrible quality video:
August 2, 2011 5 Comments
The Vancouver Canucks announced today that interview-bombing center Ryan Kesler has had a successful repair on his hip labrum. Kesler is no stranger to hip injuries, having had a labrum repair once already in 2007. Frantic googling and help from @ArtemChubarov via @BotchonCanucks seems to indicate that the repair in 2007 was on the right hip, and today’s procedure was on the left.
What’s a hip labrum?
Back it up. First let’s look at how the hip is built. The hip joint is a ball-and-socket joint, which is exactly what it sounds like. There’s a socket on the side of the pelvis, and a ball on top of the femur (thigh bone) that fits in there. The femoral head (the ball) and the acetabulum (the socket) are both covered in cartilage. The cartilage provides cushioning as well as allowing the bones to articulate – bone on bone doesn’t slide too well (and hurts like a bitch). In addition to the articular cartilage of the bones that make up the hip joint, there’s a ring of fibrous cartilage around the outside of the acetabulum (that’s the labrum) that adds to the stability of the hip joint. The labrum deepens the socket, provides extra surface area to spread out the load the hip is carrying, and essentially provides a seal around the joint that keeps the femoral head in place (with help from a whole lot of ligaments).
The hip joint
So how do you tear your labrum?
Labral tears are common in sports with a lot of hip flexion (that’s the motion you get when you pull your leg up to your chest), external rotation (rotation of the leg so the toes point out) and twisting (duh). The usual culprits are hockey, soccer, dance (not a sport, I don’t care what the IOC says) and golf (the twistiest of the twisty sports).
Oh look, hip flexion.
How do I know if I’ve torn my labrum?
The most common symptom of a torn labrum is hip pain – most often in the front of the hip. There can also be limitation of range of motion of the joint, as well as joint weakness, clicking, catching and locking. Frequently labral tears go undiagnosed for a while (typically as much as two years), as the symptoms can be very non-specific and there’s usually not one particular incident that the patient can identify as the cause of the injury.
When Kesler had his hip problem in 2007, he was having issues with joint stiffness and locking, and was said to have been unable to walk up a flight of stairs prior to his repair. This time the Canucks revealed after the playoffs ended that he’d been playing with a hip injury sustained in game 5 of the series with the Sharks. Kesler had been trying to avoid surgery with therapy, but team management and medical staff decided that a repair now was better than compounding problems later.
The diagnosis is usually made with an MRI, although in 2007 Kesler’s hip was diagnosed with an MRI arthrogram – where dye is injected into the joint.
So how do you fix a labrum?
The definitive treatment is surgery, and there are several options. Depending on the extent of the damage, it could be as simple as an outpatient arthroscopy (little cameras poked through little holes) to trim off the torn cartilage. Other options would be a repair using sutures or other anchoring devices (similar to what we saw in Huselius’ pectoral repair). The worst case scenario involves damage to the articular cartilage, and not just the labrum. In that case, there could be a need for what’s called microfracture surgery – where small holes are drilled in the bone underlying the cartilage, stimulating the growth of new cartilage. Microfracture requires no weightbearing for 6 to 8 weeks after the procedure, and 4 to 6 months before a return to play can even be contemplated. The worst WORST case scenario would be a total hip replacement.
Torn labrum
In the picture above you can just see the smooth femoral head on the left, and the labrum hanging off the acetabulum (which the probe is hooked around). This is bad.
What’s ahead for Kesler?
It takes about 4 to 6 weeks for the repaired cartilage to really re-attach to acetabulum. Generally you’d be looking at anywhere from an 8 week to 6 month recovery time, but Kesler came back in only 10 weeks last time (only to break his finger 3 days later). The earliest you could reasonably expect him to be back would likely be mid to late October.
It’s also a safe assumption that Kesler’s injury and surgery won’t be keeping him from his finely-honed interview bombing techniques.
July 24, 2011 Leave a comment
This is the first in a series of posts looking at historic hockey injuries, intended to keep me busy and you interested while we wait for October to get here.
The history was provided by Jen aka @NHLhistorygirl. Jen is a librarian and graduate student at the University of North Dakota in the last stage of her MA in history: writing her thesis on the 1972 Summit Series, media, and notions of national identity.
The night of December 12, 1933 was just like any other game night at Boston Gardens. The Bruins had a two-man advantage. The Leafs sent Ace Bailey and Red Horner out as part of the penalty kill. Red checked Bruin Eddie Shore into the boards, picked up the puck, and headed for the Bruins net. Bailey moved into Horner’s defensive position near the blueline. It’s the last thing Bailey would remember about that night.
Shore mistook Bailey for Horner, and took Bailey’s feet out from under him. In an era without helmets, this was a dangerous move on Shore’s part. Bailey hit the ice head first, and began convulsing.
While Bailey’s teammates gathered around and the Boston trainers frantically tended to him, Horner punched Shore, who also hit the ice, bleeding. In the stands, a fan taunted Bailey, calling him a diver. Leafs owner Conn Smythe punched the fan, knocking teeth loose.
Bailey was awake when they took him to the dressing room, where Shore asked his forgiveness. Bailey replied, “It’s all part of the game,” before losing consciousness and falling into convulsions again. He was transported to Audubon Hospital, where he was diagnosed with a fractured skull. By morning, his condition was critical due to cerebral hemorrhaging.
He was moved to City Hospital, where neurosurgeon Dr. Donald Munro operated to relieve the cranial pressure on two different occasions. After the second surgery, the doctor pronounced Bailey’s chances as “very slim” and a priest was called to give Bailey last rites. His pulse was 160 and he had a fever of 106. Newspapers had an obituary written and waiting. Reportedly, Bailey’s nurses would slap his hand or his cheek if it appeared he was slipping away. They kept telling him his team was down two men and needed him.
His condition finally improved, though Bailey says he did not regain full consciousness for fifteen days. With his playing days over and a plate in his head, Bailey asked the league’s permission to suit up as a linesman. Worried that any hit may cause Bailey further serious damage, his request was denied and he served many years as an off-ice official for the Leafs.
Ace Bailey suffered what’s obviously best described as a devastating head injury. It’s amazing that he lived, even more so when you consider this happened in 1933. Penicillin had just been discovered (but wasn’t in widespread clinical use yet), and the concepts of tracheal intubation (breathing tubes) and IV anesthesia for surgery were brand new.
It’s hard to say exactly what Bailey’s specific head injury was. As such, this can really only be a look at a condition he may have had. There’s really no way to know what actually happened. We know his head hit the ice, he seized, was briefly awake and lucid, seized again, then stayed unconscious for a long time. During that period he had intracranial bleeding requiring surgical intervention, and developed an extremely high temperature.
The description of Bailey’s lucid interval could suggest he suffered an epidural bleed, which is the result of torn arteries between the skull and the dura mater (the tough covering around the brain and spinal cord). This is an uncommon type of traumatic head bleed, but made headlines in 2009 when actress Natasha Richardson died two days after a head injury sustained while skiing. She initially refused EMS care, then after a few hours was rushed to hospital with head injury symptoms and later died.
The stereotypical textbook progression of loss of consciousness-lucid interval-loss of consciousness actually doesn’t happen in most epidural bleeds. Patients can lose consciousness (or not), and may wake up (or not). The thing about the lucid interval is that’s the classic wording healthcare providers associate with the injury (and it’s extraordinarily unlikely to see it in other head bleeds).
A theory on why this happens is that the impact of the initial injury causes a loss of consciousness (from which the patient awakes), and the lucid interval represents the bleeding taking time to affect the brain as it happens between the hard skull and the relatively unyielding dura. Of course it’s important to note that this is just a theory, and the lucid interval can be of varying duration – anywhere from seconds to hours.
Why did Ace seize?
Seizures happen when the neurons in your brain aren’t firing in the nice, orderly pattern they’re used to. Seizures can be the result of a seizure disorder (like epilepsy), or an insult to the brain (like trauma, stroke, lack of oxygen, etc). In Bailey’s case, the impact of his head on the ice would have caused a cascade of events that set him up for seizure.
When his skull hit the ice, it stopped. His brain stopped when it hit the inside of the skull. The brain is a delicate thing, and it doesn’t like sudden changes. Not only would an impact with the skull likely cause a contusion (bruise) on the brain, it could potentially cause another on the other side thanks to something called a coup-contrecoup injury (French for blow-counterblow). The brain hits the skull on the side of the impact, and then in essence bounces back and hits the skull on the opposite side, causing a second contusion. Now you’ve got two areas of pissed-off brain that could misfire and cause a seizure.
Coup-Contrecoup
Treatment
Current treatment for a head injury of this type would start with transport to a trauma center. Obviously the treatment would also include the basics of pre-hospital trauma care (which I’ll grossly oversimplify here): Management of the airway with intubation if necessary, spinal immobilization, and IV fluids to replace volume loss from bleeding.
On arrival at the ER, head injured patients are often placed into the ominous-sounding medically-induced coma, which is to say they’re sedated and intubated. There are a lot of reasons this is done – for the patient’s comfort (they’re in pain, and probably scared to death), to have complete control of the airway (there’s no better airway control than having a tube stuffed into it), and for the now-controversial practice of reducing their intracranial pressure (ICP) by hyperventilating them. As we learned in this post, carbon dioxide (CO2) causes the vessels in your head to dilate, which would increase the amount of blood in there, and thus increase pressure. If you force hyperventilation, more CO2 is exhaled, reducing blood flow and therefore ICP. Hyperventilation of head injuries is falling out of favour now, as studies have shown that it doesn’t improve outcomes, and in fact can lower brain perfusion (which is bad for obvious reasons). CT scans and x-rays determine the extent of the injuries, and the patient is given IV steroids to reduce brain swelling. The patient may receive anti-seizure medications whether they’re seizing or not (to stop or prevent a seizure).
At this point the smart kids take over (that would be the neurosurgeons) and decide what sort of surgical intervention is needed. In rare cases epidural bleeds can be managed non-surgically with just steroids and observation. More often, however, the blood that’s filling the space between the skull and dura has to be taken out.
Epidural hematoma - Big red arrow provided for those who are immune to the obvious
Assuming you’re in a trauma center with neurosurgery on staff (as opposed to asleep in their golf course home with a pager on the nightstand) the treatment is craniotomy, evacuation of the blood, and ligation of the artery that’s bleeding. Translation: Take off part of the skull, suck out the blood, find what’s bleeding and tie it off. The piece of the skull may go back on at this point, or it may get stored in a fridge in the hospital basement until they’re sure the brain is done swelling and they can put it back on. If you’re in some outlying hospital with no hope of a neurosurgeon for a while, studies have shown that drilling a burr hole in the skull at the injury site is a good bridge to definitive care (yes, I saw that episode of Medical Incredible too).
As far as Bailey goes, it’s hard (impossible) to say what the two surgical procedures that he had actually were. He’s said to have had a plate in his head, which suggests fragments of his fractured skull were removed (hello, craniotomy) and replaced. Why did he have two surgeries? Good question. It’s possible the bleeding wasn’t controlled the first time, and it’s possible it was done as a staged procedure – the first surgery to take the skull fragments out, and the second to put in the plate.
Post-Surgical Complications
After his two procedures, Bailey developed a pulse of 160 and a fever of 106, neither of which is part of a healthy recovery. There are two possible reasons for these symptoms, both of which have catchy acronyms – SIRS and PAID.
SIRS – Systemic Inflammatory Response Syndrome
SIRS is basically whole-body inflammation. It can be a result of infection (as one might get from brain surgery in 1933), or non-infectious events (trauma, burns, severe allergic reactions, etc). In Bailey’s case it could have been either. SIRS manifests as a high heart rate, a very high or very low body temperature, rapid breathing, and a very high or very low white blood cell count (those are the ones that fight infection). SIRS is pretty common in both the medical/surgical and trauma ICUs. Generally it’s treated with symptomatic management and control (where possible) of the cause (i.e. antibiotics). In 1933 it would have been treated by cooling Bailey, and having nurses slap him to keep him from dying. Super hi tech, and apparently pretty effective.
PAID – Paroxysmal Autonomic Instability with Dystonia
PAID is a scary complication of severe head injuries where the body loses its ability to control the autonomic nervous system – that’s the one that does all the automatic things you don’t pay attention to. Things like controlling your body temperature, your heart rate, digestion, and sweating. Patients with PAID have episodes of elevations in pulse, respiratory rate, blood pressure and body temperature. They also have dystonia – episodes of rigidity or posturing (abnormal body movements in response to brain injury).
PAID is generally seen in low-functioning head-injured patients in the ICU and rehab setting. It’s treated with medications to manage the symptoms, including muscle relaxants, beta blockers to lower heart rate, anti-hypertensive medications, and more. PAID can persist for months in these patients, and those who have it generally have head injuries so severe that they rarely return to full function. PAID seems like the less likely of the two possibilities, mostly because Bailey was awake within about two weeks of the injury, and went on to lead an essentially normal life.
Ace Bailey suffered a significant head injury by 21st century standards. The fact that he did it in 1933, had serious complications, and lived a full life afterwards is frankly amazing. An injury like this is unlikely now given the mandated use of helmets, but as we’ve seen in all the players whose lives and careers have been permanently affected by concussion, it doesn’t take a broken skull to change things forever.
July 13, 2011 5 Comments
Want to know what it takes to gross me out? This:
Gross.
That’s Scott Howson, GM of the Columbus Blue Jackets. I could easily fill a post on the subject of how kickass it is that there’s a GM on Twitter (solid PR move, Columbus), but let’s talk about the pectoralis major and what happens when you tear it (other then me getting grossed out).
Pectoralis Major (aka the pec, pec major, moobs, etc.)
Pectoralis major
Pectoralis major is the muscle that makes up the bulk of what your personal trainer calls your pec. You’ve got one on each side, and if you’ve ever benched too much, then you know exactly where they are.
The pec originates at the sternum, clavicle and aponeurosis of the external abdominal oblique, and inserts on the bicipital groove of the humerus.
Huh?
The pec is connected to the sternum, collarbone, top of the abs, and the upper arm.
That’s better.
It has several jobs, mostly involving shoulder movement (and holding your arm on), and the NCAA guide to “Ice Hockey Officials’ Signals” will illustrate them nicely:
Arm flexion
Arm flexion: In order to get your hands up in front of you to signal cross-checking, you’d first have to raise them up in front of your body. That’s arm flexion.
Arm adduction
Arm adduction: To signal kneeing, you reach across your body and slap the opposite knee. To do this you have to adduct your arm (the opposite of raising it away from your body to the side).
Medial rotation of the humerus
Medial rotation: Delay of game? Well, actually this isn’t really close. Imagine your arm is bent at the elbow with your hand pointed straight in front of you. Rotate your arm so that it’s across your chest (like you’ve got it in a sling). That’s medial rotation.
Deep inspiration: The NCAA can’t help me here. If you take a really deep breath, the pectoralis helps expand your chest.
Assorted scapula (shoulder blade) jobs: Flex your pec and you’ll have a better idea of what it does to the shoulder blade than I could possibly explain.
Holding your arm on: Obviously your arm is connected to the rest of your body by a lot more than your pec, but it definitely contributes. The tendon that attaches the pec to the humerus (upper arm) is about 2 inches wide – that’s not insignificant where tendons are concerned.
The Injury
Pectoralis tears aren’t exactly common, which just as well because they’re painful and take a long time to heal. The tear generally happens during the bench press, and results in sudden pain, swelling, bruising, and a dimple above the armpit (from the missing muscle). This is a gross injury on a lot of levels – there’s horrible pain, your arm stops working properly, and many patients who’ve had this injury say they actually heard their muscle tearing when it happened.
Two thirds of pec tears involve pulling the tendon off the humerus. The rest are scattered amongst pulling off one of the other attachments, or rupture of the pectoral muscle itself (which is thankfully uncommon). Since rupture of the tendon that holds the pec to the arm is the most common, that’s what we’ll be looking at.
The Repair
The best results are achieved with a quick repair. Older or sedentary patients can be managed conservatively and non-operatively, but since the majority of these injuries occur in athletes, they’re almost always repaired surgically. The repair involves opening the shoulder, scraping what’s left of the tendon off the bone, and re-attaching the severed end of the pectoralis tendon. Traditionally the repair was done by drilling holes through the humerus and threading suture through the holes and the end of the tendon. Recent research has shown that you can get as good a result using absorbable sutures threaded onto an anchor that’s screwed into the bone (which is a far easier surgical technique).
Anchor suture
The suture takes years to be absorbed, and maintains full strength for 5 months – plenty of time for the tendon to heal to the bone.
The Recovery
The ugly part of this injury (other than hearing your own muscle ripping) is the recovery. After surgical repair, it can take four (more likely six) months to get back to pre-injury activity:
As with any major injury, it can take a long time to feel good again. The same study that looked at absorbable sutures found that at fourteen months post-op all patients were happy with their result.
What this means for Kristian Huselius
He’s in for a long, long rehab. He could be back mid-November at the earliest, more likely early January. He may not feel right or play to his fullest for a year. On the other hand, he could heal quickly and be fine. This is one of those injuries that would be a bad idea to rush back with (honestly, there’s no good injury to rush).
Things I didn’t mention, and will spend very little time discussing
Pectoralis minor: Pec minor is a tiny version of pec major that lives directly underneath it. It attaches to the underside of the scapula (shoulder blade) and the top few ribs. Its job is to hunch the shoulders forward. Boooooooring. That’s why I didn’t bother discussing it.
Many thanks to the NCAA refs for beautifully demonstrating the actions of pec major.
– Jo
June 30, 2011 Leave a comment
After Mason Raymond’s hit from Johnny Boychuk in game 6 of the Stanley Cup final, nobody could have been more surprised than I when he left the ice on his feet after what seemed like several minutes of face-down on-ice discussion with a Vancouver trainer. When a player goes down (and stays down) for that long, we’re used to seeing them stretchered off in full spinal immobilization.
The purpose of full spinal is to keep the spine still (amazing, I know). It involves being strapped to a hard plastic spine board with your head held completely still looking straight ahead (or straight up, as is the case once you’re laying flat on your back). There’s an algorithm used to decide who needs full spinal precautions – at its simplest it’s a question of whether there’s potential for a head, neck, or back injury. Is there neck pain? Spine board. Head injury? Spine board. Penetrating injury that could compromise the spine? Spine board. Too drunk to stand up and fell off the porch/bicycle/moped/roof of your brah’s SUV? Spine board.
So the question is why Raymond left the ice on his feet. There are actually several reasons this could have been completely appropriate, despite what Twitter’s many, many experts seem to believe. I kicked off a Twitter explosion the likes of which I hadn’t previously seen with two simple tweets:
Lots of criticism for skating Raymond off. Trainers aren’t stupid, guys. Guarantee they tried to get him on a spineboard and he refused.
And as if that weren’t enough expert-bait, I followed it up with:
So let’s give up the “Skating him off is malpractice!”. Were you there? Are you an expert? Cue Andy Sutton.
Now let’s back it up just a bit and take a look at the hit:
The first thing worth noticing is that Raymond doesn’t seem to lose consciousness. He’s also moving his arms and legs. Next, he and Canucks head trainer Mike Burnstein actually spend a full minute in discussion before Kesler and Higgins help Raymond up and off the ice. In an injury situation a minute is a really, really long time. Usually the way it goes is you get the equipment you need, get the patient on it, and get the patient out. You know what situation usually gets in the way of keeping things moving? Arguing. My suspicion is that Burnstein was doing his best to convince Raymond to get on a board, and ultimately couldn’t do it. That wasn’t malpractice, Vancouver’s trainers are experts, and I’ll gladly explain why.
The Algorithm
To be clear, there are two types of spinal clearance algorithms. The kind that determines if an injured person needs to be on a spine board at all (used in the field by EMS, athletic trainers, and other first responders) and the kind emergency physicians use to determine if someone with a spinal injury can come off of the spine board, and if they need imaging (x-rays). I’m talking about the first algorithm. Let’s walk through it.
1. The patient gets injured. The ambulance gets called.
2. Spinal exam: Do they have neck and/or back pain? This can be on movement or palpation.
3. Neuro exam: Are there any focal neurological deficits? Examples would be numbness, tingling, weakness/inability to move.
4. Mechanism of injury: Is it significant? “Significant” is different just about everywhere. Several state EMS formularies define it as such (and yes, most of these relate to motor vehicle crashes):
Common sense (and the more clever formularies) add axial loading to this list. An axial load is a force applied to the head that causes spinal compression (or loading). Think of someone jumping into a pool and hitting their head on the bottom. The Canadian Journal of Emergency Medicine did a nifty little study wherein they found that in non-car-crash incidents, you’re at greatest risk for a spinal fracture with axial loads, falls, diving accidents, and motorized non-car vehicles (ATVs, snowmobiles, etc – If anyone’s interested I have a great rant about why you should stay the hell away from those evil, evil, contraptions).
5. Impairment: Is the patient impaired (ie. by drugs/alcohol)?
6. Distracting injuries: Does the patient have any painful injuries that might distract from their spinal issue? For example, if your leg is hanging off, we’re probably not going to spend time discussing whether you need a spine board.
If you answered yes to any of those questions, the patient needs to be immobilized. Problematically, some people still refuse. Even more problematically, those people are often sober and intelligent.
Okay, so what do you do if someone needs to be put on a spine board and they refuse?
Well, contrary to what the Twitter experts believe, you don’t force them. You explain to them the consequences of their actions. You beg. You plead. You might bully a little bit. You might even threaten just a touch. Have I ever told someone that by refusing treatment they could die? You bet. Have I had a patient actually die as a result of refusing treatment? Almost. It’s hard to understand just how completely useless you feel trying to explain to an unwilling patient that you’re trying to help them. So let’s spend a moment in Mike Burnstein’s shoes, and in Mason Raymond’s skates.
In Raymond’s case, he’s just hit the boards ass-first in one of the most important hockey games he’ll ever be a part of. Maybe he’s in pain, maybe he isn’t. Spinal compression fractures are tricky little beasts – usually they’ll present with midline back pain, but they can also present with pain in a completely unrelated area (the lateral back, buttocks, hip, etc.) or no pain at all. Since none of us are Mason Raymond, none of us know where or if he was hurting. There’s no way of knowing what his neuro exam was, but he was definitely moving his extremities after he went down. As far as mechanism goes, the video of the hit makes it look like there was probably an axial load from Boychuck driving him into the boards. Did Burnstein know that? Probably not. Did Raymond know that? If you’ve ever taken a hit (or been in a car wreck, or had any kind of sudden trauma) you know that even if you aren’t knocked out, you’re usually not able to immediately describe the mechanics of what happened. And let’s be honest – Raymond probably didn’t care what the mechanics were. More than likely he just wanted to get back up and keep playing.
Given Burnstein’s extensive training and experience, you have to assume he was trying to get Raymond on a board. Any assertion that he doesn’t know what he’s doing or committed malpractice makes about as much sense as trading Chara for Daigle (which is actually kind of a dumb example since that actually happened). To soothe the Twitter experts, why don’t we go ahead and define medical malpractice, just so it’s clear why Burnstein’s actions don’t qualify.
Malpractice: There’s more to it than you think.
Medical malpractice may vary from state to state, province to province, and country to country. I’m not a lawyer, so don’t expect any complex legalese here. This is just an overview of what’s involved. There are four requirements for a charge of medical malpractice:
So is Burnstein guilty of medical malpractice? No. Clearly not. If you’re not convinced, then maybe a quick discussion of consent will help.
Consent: Wherein medical providers would rather not assault people.
In order to administer treatment to a patient, a health care provider must first obtain that patient’s informed consent (unless the patient is unable to provide consent and the treatment is absolutely required, in which case consent is implied). Informed consent consists of informing the patient of:
If your patient doesn’t consent to the treatment and is in possession of their faculties (not drunk, not high, not a minor, not head injured, etc), and you treat them anyway, then you’ve just committed medical battery. That’s a real thing, and people get sued for it. It’s defined as violating a patient’s rights to direct their medical treatment, and involves the unauthorized touching of a patient. Health care providers are acutely aware of what they can and cannot do, and assessing a patient’s ability to make an informed decision is a skill that comes with time and experience. Any Twitter expert assertion that “They should have just made him get on the spine board!” is frankly ignorant. It’s never that simple. You can’t just make someone do something.
Trying to paint the Raymond incident in black and white strokes isn’t possible. There are a lot of factors involved, and screaming malpractice doesn’t make sense. Yes, Raymond broke his back. Yes, he should have been immobilized. The long and the short of it is that Burnstein knew that, and more than likely tried to make it happen. In the end he had to get Raymond off the ice and into treatment, and when he was transported to the hospital it was reportedly in full spinal immobilization.
Still not happy? The Globe and Mail had a few experts of their own opine on the incident, among them a spinal surgeon and a physiotherapist. You’ll notice that one of the physicians in the article states that “…the team should err on the side of caution and insist he be taken off on a stretcher” – didn’t I say something about this not being black and white? Again this comes down to one’s ability to convince/cajole/bully the patient into doing what’s appropriate. In Raymond’s case, it seems like it just didn’t work.
Raymond’s Injury
Raymond suffered a compression fracture of the L5 (lumbar aka lower back) vertebrae. Per Vancouver GM the fracture is through the belly of the vertebrae, which is to say the big fat round part in the front.
These fractures can be managed through injection of special cement into the vertebrae, or surgery to immobilize the bone from the inside through the placement of plates or rods, although this is generally a last resort. Most often this is treated with a back brace to immobilize the spine, pain medication, time, rest, and physical therapy. The brace generally used in injuries like Raymond’s is the TLSO (thoracic-lumbar-sacral orthosis) brace, which you can conveniently buy on Amazon (although you probably shouldn’t). Raymond is expected to miss 3 to 4 months.
In case you have no idea what the Andy Sutton reference is all about, here you go. I will never, ever tire of this. Ever.
– Jo
June 7, 2011 2 Comments
Time heals all wounds. Actually, it’s time, physical therapy, medication, possibly surgery, and not pushing yourself for no reason.
In a show of truly spectacular self-defeatism, talented hockey players will often push themselves to come back before their body is ready. How often do we hear about someone “Playing through it”? And why are some injuries somehow more acceptable to play through than others? Nobody would expect a player to suit up after an eye injury or a giant laceration (helloooooo Malarchuk), but this year we saw player after player limping through the playoffs on injuries that should have had them out for the duration. Was Dany Heatley really contributing more by playing with a broken hand and a high ankle sprain than he would have by packing it in for the season? Was that one point in the Western Conference finals worth the pain? If you asked him he’d probably say yes. How about Steven Stamkos – he hurt his shoulder in the Pittsburgh series, and played through to the Eastern Conference finals where he tallied seven points. So absent of my sneaking suspicion that Stamkos is basically infinitely better than Heatley (sorry, Sharks fans), for him it probably was worth it.
Stamkos: He is tougher than you.
Daniel Alfredsson was the perfect example this year (and last) of playing with injuries that should have put him in the press box. Ottawa Senators fans scratched their heads and wondered what was wrong as their captain’s point production dropped off towards the end of the 2009-10 season. After the Sens were eliminated in the first round of the playoffs (as usual) by the Pens, Alfie admitted he’d been playing with a sports hernia since February (which isn’t really a hernia, but groin pain caused by any number of different injuries in the… ahem… area). He still finished the season with 71 points, more or less on par with his usual production.
This year Alfie only played 54 games, and finished with 31 points – the fewest games and points he’s put up since he started with the Sens in 1995-96. The problem this time was a back injury that he tried to fight through, and to which he finally conceded defeat in early February. He admitted he’d been having weakness in his right leg, and today Ottawa GM Bryan Murray made the following statement:
“Daniel will have surgery on Friday. He’s done a lot of rehab. He felt to continue his career at the level he wants to, it’s the right thing to do. It’s just to relieve a little pressure on the nerve that has taken away some of the strength in his leg and affected his skating and overall game, obviously… It was a decision that he, during the latter part of the year and the off-season now, was hoping that he wouldn’t have to have. I guess the fact the nerve is touching and being affected … in particular on the left side of his body … that he felt it was the right thing after much thought.”
Let’s go ahead and overlook the fact that all the interviews earlier this year said the problems were in the right leg, and discuss this injury, and the surgery that will (hopefully) fix it.
Theory: The stress of carrying around so much hair destroyed his spine.
The Injury
Although the interviews disagree on which leg was affected, the common thread is that Alfredsson has a lower back injury that’s causing one of his legs to be weak, tingly, and “heavy”. Murray said today that there was pressure on a nerve that needed to be relieved. The best way to understand why an injury in the back is affecting the leg is to learn a little something about the spine and dermatomes.
Whatatomes?
The nerves that make up the spinal cord exit the vertebrae through little canals called intervertebral foramina and proceed on to whatever part of the body they’re responsible for. Those parts are very specific, and beautifully demonstrated by this fellow:
Best Halloween costume ever: A guy dressed up like dermatomes.
Each zone on the dermatome map represents the area that the specific listed nerve innervates. So if you hurt L4 or L5, the top of your foot will suffer for it.
Your spine isn't this pretty. Sorry.
You have 24 vertebrae, plus 9 more that are fused to form the sacrum and coccyx (which make up the back wall of your pelvis). The vertebrae are lettered and numbered according to where they are. From the top, you’ve got
The spinal nerves are named for the associated vertebra. Those among you who are clever (or smartasses) have probably already noticed that although you have seven cervical vertebrae, there are eight cervical spinal nerves. Feel free to impress girls at (nerdy) parties with the following bit of spine trivia: The spinal nerves exit the vertebral column above the associated vertebral bone until nerve C8 – the first one to exit below the bone (specifically vetebra C7) – cleverly paving the way for an extra nerve.
Bored yet?
The vertebrae are cushioned by discs, which are tough cartilage rings around a jelly-like center. It’s a great design – they’re shock absorbers, allow for movement, and hold things together. Unfortunately, they can also get badly out of place and cause awful symptoms.
When good discs go bad…
Injury or aging can cause discs to go to new and exciting places (that you’d rather they didn’t visit). You can have a disc bulge – where the outer cartilage ring sticks out (usually posteriorly) from between the vertebrae and can put pressure on spinal nerves (or the spine itself). A bulge can become a herniation, where the outer cartilage ring loses integrity completely and the jelly-like inside protrudes. These injuries are best seen on MRI, like so:
Spot the disc bulges!
If you look at the information available, it should be clear to you at this point that Alfredsson most likely has a disc bulge or herniation that’s pressing on one of his lumbar nerve roots. He tried rehabbing the injury for a long time, and in fact there’s good data to show that non-surgical treatments are usually very effective for this sort of injury. Pain control, steroids to relieve inflammation and physical therapy can bring relief in the majority of patients. The exception is patients who have symptoms exceeding 6 weeks despite appropriate treatments, specifically those with neurologic deficits – Weakness, sensory deficit (numbness), and tingling. This is Alfredsson’s picture. Obviously he tried far longer than 6 weeks to avoid surgery, which was smart. He also made loud noises after the all-star break about wanting to come back and play out the end of a dismal season, which was dumb. There was no point, and there would have been a risk of worsening the injury.
FYI…
According to the World Health Organization, spinal manipulation (chiropractics) in the setting of a disc herniation is contraindicated.
The Surgical Fix
If Alfie does indeed have a herniation that’s pressing on a spinal nerve root, the likelihood is that he’ll be having a discectomy of some sort. The operation is exactly what it sounds like – part of the disc is removed. First a laminectomy is performed, where a tiny portion of the lamina (part of the vertebra) is removed to allow access to the disc and nerves. The actual disc surgery can be done as an open procedure (cut the back open, remove part of the disc), percutaneously (through a small incision in the skin – less effective than open), or as microdiscectomy – where the surgeon operates using a special microscope allowing for more precise cuts and thus less damage to surrounding tissues. A retractor holds the nerve roots out of the way while a device called a rongeur (what’s labeled here as ‘grasping device’ removes the offending disc tissue. This should relieve the pressure on the nerve, allowing a return of strength and relief of pain. The material that’s removed in surgery will eventually fill itself in with new disc material.
After the surgery patients are encouraged to get up and walk as soon as possible, and physical therapy is started two weeks post-op. It consists of stretching, strength training, and all the usual torture PTs put patients through (I love PTs, but they’re giant bullies – just ask one).
What we learned…
Alfredsson took from February until June to decide that he needed back surgery. Although I admire his attempts to keep from being operated on, the research shows that if he was still having symptoms after 6 weeks he would have been better off just having the discectomy. Did his hesitation stem in large part from his clear (and often-stated) desire to come back and play at the end of the season? Probably. With any luck, he’ll be looking at about a 6-week recovery, which puts him back in action at the end of July. This should have him good to go for training camp on what is widely seen as likely his last season with the Sens.
– Jo
Puck, that hurts! 