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Sunday, June 22, 2014

What Surgery did Tiger Woods have? Microdiscectomy Shown and Explained

Tiger Woods has announced his return to competitive Golf for the Quicken Loans National this weekend after recuperating from a Microdiscectomy Back Surgery for the last three-and-a-half months. He had been struggling with Back Pain since last Summer, starting in the final round of the PGA Championships. After that, his painful episodes became more frequent. Following almost 9 months of escalating symptoms, he finally underwent Surgery by Neurosurgeon, Dr. Charles Rich on March 31st in Park City, Utah. The choice of Surgeon and location took many Spine Surgeons by surprise. Park City, Utah is primarily known as a Ski Resort, not a Mecca for Spine Surgery. Most experts would have expected the Surgery to take place at a well known Spine Institute by a very well known Spine Surgeon. It is almost certain that Tiger Woods had multiple consultations by a variety of Spine Surgeons to see if Surgery could be the answer. Is it possible that he was told "no" by at least some of the them? That could explain the unusual choice of Surgeon and location of the Surgery.

Is this the end of Tiger's back troubles? Not necessarily. As we saw today, he reinjured his back after jumping into a bunker at Bridgestone.

To further understand the answer, we have to first take a look at Disc Herniations in general and specifically Microdisctomy Surgery.

Microdiscectomy Surgery is performed for Disc Hernations of the Low Back. These Disc Herniations frequently put pressure on the Spinal Nerves located next to them. The Nerves becomes irritated and inflamed which often causes back spasms and pain, as well as numbness or even weakness in the legs (Sciatica). A Microdiscectomy is primarily performed for leg pain (Sciatica) related to the Disc Herniation. While back pain can be a byproduct of a Disc Herniation, most Spine Surgeons would not offer Surgery for patients whose main complaint is Low Back Pain. Why? Because the Surgery addresses specifically the pressure on the Spinal Nerve. Removing the pressure typically resolves the Nerve Pain to the leg, not specifically Low Back Pain. The Media Reports did not mention Leg Pain (Sciatica) as Tiger Woods's primary issue, but rather Back Pain. If that has been consistently the case, why did he have a Microdiscectomy?

Lets first take a look at the Anatomy of the Low Back  to help us understand Disc Herniations and Microdiscectomy Surgery. Here is a Color MRI of the Low Back (Lumbar Spine) which shows us the Anatomy of the Spine. Notice the location of the Spinal Disc and the Spinal Nerves. This Image is Interactive. Just move your Mouse Cursor over the Image and see the Image Tags come alive. Each tag displays text to explain a specific structure (If the tags do not load correctly due to slow Browser Speeds, just refresh the page).

Sagittal Color MRI Lumbar Spine Anaotmy Medical Image
Interactive Color MRI of the Anatomy of the Low Back (Lumbar Spine)

Here is another view of the Anatomy of the Low Back. This Image shows a perspective of a horizontal slide across the Low Back. Combining this view with the one above will give you a 3-Dimensional understanding of the Spine. This Image is also Interactive.

Axial Color MRI Lumbar Spine Anatomy Medical Images
Interactive Color MRI of the Anatomy of the Low Back

The next Image shows a Disc Herniation of the lowest Disc in the Low Back (L5/S1). Notice the red material which has migrated (herniated) from the center of the Disc backwards. This Image is also Interactive.

Sagittal Lumbar Spine Color MRI of a Disc Herniation
Interactive 3-D Color MRI showing a Disc Herniation

This Image shows you a Disc Herniation from the perspective of a horizontal slice across the Low Back. This is a very important perspective because now you can see how a Disc Herniation can push on a Spinal Nerve. The top Image on the right shows a Normal Disc and Spinal Nerve. The Image below it shows a Disc Herniation and a compressed Spinal Nerve. This Image is also Interactive.

Axial Color MRI Lumbar Spine Normal Disc and Disc Herniation
Interactive Color MRI of the Low Back showing a Normal Disc and a Disc Herniation
During the 9 months of suffering from the symptoms of a herniated Disc, Tiger Woods likely underwent numerous non-surgical treatments. These typically include Physical Therapy (PT), Medications, and Epidural Steroid Injections amongst others. Statistically only 5% of patients suffering from pain related to Disc Herniations undergo Surgery. However, that is only true for the general public, rather than elite athletes like Tiger Woods. Professional Golfers experience an enormous amount of force to their lower backs due to the force of the Spine's rotation which is inherent in a high powered Golf Swing. Once Professional Athletes sustain a Disc Herniation, especially one of Tiger Woods's caliber, it is far less likely that it will heal on its own. Add to that the fact that these athletes are under great pressure to return to full function to keep their endorsements and play schedules. So, trying to find a "surgical fix" is only natural and logical.

The question quickly becomes one of "what is the best Surgery"? There are a number of surgical options for Disc Herniations in the Low Back.
The least invasive types are Endoscopic Surgeries, done with the help of small fiberoptic tubes which are placed through tiny incisions (cuts). However in the practice of Spine Surgery, the success of the Surgery in large part depends on the Surgeon's ability to see and remove the entire Disc Herniation. Endoscopic Surgery often does not guarantee a full view of a Disc Herniation. This can jeopardize the success of the Surgery.
A Microdiscectomy is essentially one step up from an Endoscopic Surgery. It is more invasive because a larger incision (cut) is involved and more tissue has to be moved out of the way (dissection) in order to gain access to the Disc Herniation. In addition, at least some bone has be removed from the backbone (lamina) as well as from one of the motion joints (facet joints) of the Spine. While this is usually only a small part of the bone anatomy of the Spine, it can still have an impact on the stability, integrity and function of the Spine. This is certainly a concern for an athlete who functions at the highest level of their sport, like Tiger Woods. While the general surgical dogma states that removing less than 50% of the Facet Joint during a Microdiscectomy Surgery would not cause instability, it is generally unknown if this applies to top athletes as well. It is conceivable that removing even a fraction of the Facet Joint could change the function of this particular "motion segment" of the Spine, which could lead to ongoing Low Back Pain.
More aggressive and invasive Spine Surgeries, such as Spinal Fusions and Artificial Disc Replacements are not typically performed for patients who suffer from a first time Disc Herniation. These are more invasive options reserved for more significant Disc problems such as Degenerative Disc Disease, where the entire Disc looses function.

Let take a look at Color MRI Images which show how a Microdiscectomy is performed. A small Surgical Rectractor (blue) is placed from the back of the Spine to get access to the Herniated portion of the Disc. A Surgical Grasper is then used to remove the Disc Herniation. The Interactive Tags display text to explain the Surgery in more detail.

Sagittal Color MRI Lumbar Spine Microdiscectomy for Disc Herniation
Interactive Color MRI of  the Low Back showing a Microdiscectomy
Here is another view of the Surgery from the perspective of a horizontal slice across the Spine. Notice how part of the Facet Joint bone has to be removed to get access to the Herniated portion of the Disc (red), next to the Spinal Nerve (yellow).  This Image is also Interactive.

Axial Lumbar Spine Color MRI of a Microdiscectomy performed for a Disc Herniation
Interactive Color MRI of a Microdiscectomy

So, how successful are Microdiscectomy Surgeries? Overall they are quite successful in removing the herniated Disc material and relieving the compression of the Spinal Nerve. Usually this means pain relief of the leg pain (Sciatica) and return to function, which is often quoted as over 90%. However, the risk of re-herniating a Spinal Disc is a legitimate concern, especially for athletes involved in sports which create significant force and stress on the Disc. The reports of re-herniation amongst scientific publications vary widely. Most studies quote numbers in the 5-15% range. It is likely that these rates would be much higher in Professional Golfers.
What about Scar Tissue after a Microdiscectomy Surgery? Any Surgery causes scarring, of course. However, with Spine Surgery it is not the scarring on the Skin which is a cause for concern, but rather the scarring deep in the Spine, specifically around the Spine Nerve which was previously compressed by the Disc Herniation. In the process of the Surgery, this Spinal Nerve has to be touched and manipulated, which these Nerves are very sensitive to. Which of these Nerves develop scar tissue is thought to be related to numerous factors including how long a Nerve has been compressed, how much the Nerve is touched and manipulated during Surgery, how prone a patient is to developing scar tissue, etc. Scarring around the Nerve is a concern since it can lead to chronic Nerve Pain and also has the potential to jeopardize the Nerve's function.
Another variable in the outcome from Microdiscectomy Surgery is how long a Nerve has been compressed prior to Surgery. By reports, Tiger Woods waited approximately 9 months after he first had symptoms until the Microdiscectomy was performed. Is that too long? Not necessarily. Much depends on the degree of Nerve Compression and how much impairment of the Nerve's function existed during these 9 months. Nerve compression can manifest itself in a wide range of symptoms, ranging from mild numbness of part of the leg all the way to severe leg weakness and muscle atrophy. In the latter case, the function of the Nerve is severely impaired and the clock is ticking, meaning there is a limited amount of time before permanent Nerve damage occurs. Fortunately this is a very uncommon situation and not at all likely in Tiger Woods's case.

So, what happens if Tiger Woods develops a re-herniation of the injured Disc or develops instability of the Spine from the Surgery? If either of these events should require Surgery, things can get complicated for professional athletes at this level. With regard to re-herniations, the most common surgical options are to repeat the Discectomy, Lumbar Fusion Surgery and Artificial Disc Replacements. Repeating a Microdiscectomy or making a larger incision and performing an ordinary open Discectomy are logical options. However, the success rates decline and further scarring of the Spinal Nerves and potentially impairments of the stability of the Spine are real concerns.

What about a Spine Fusion or Artificial Disc Replacement. Neither of these may be very good options to maintain a career as a Professional Golfer competing at the highest level. A Spine Fusion would likely inhibit enough Spine motion and change the mechanics of the Spine to a point where his Golf Swing could change significantly.
An Artificial Disc Replacement would maintain some the Spine's natural motion, but it would likely not be the same quality or degree of motion. Artificial Disc Replacement devices were not designed for the types of forces the Spine experiences during a powerful Golf swing. The concern is not just damage to the Artificial Disc but also to the Anatomy around the Disc. Point in case is Retief Goosen, who suffered from Degenerative Disc Disease and had an Artificial Disc Replacement implanted in England in 2012. Subsequent to that he fractured a Facet Joint. It is possible that the Artificial Disc Replacement may have transferred too much force to the Facet Joints in the back of the Spine, which then caused the Facet Joint fracture. The bottom line is that these Devices may be good options for the general public, but are by and large untested in elite athletes.

Today, Tiger Woods had to withdraw at Bridgestone due to severe Spine Spasms. This is not a good sign and may indicate that the Microdiscectomy failed. He will likely undergo another MRI of his spine in the coming days to assess if he re-herniated the surgically repaired Spinal Disc.

We can only hope that Tiger Woods can play out his incredible career without any further Back trouble. His surgical options, if he needs another one, are very limited and not likely to maintain his career anywhere near the current level.

If you enjoyed this Blog, here are some recent blogs of related Spine topics:

1. What is Sciatica? Shown and Explained with Color X-Ray and Color MRI Images
2. What is an Epidural Injection? Shown and explained with Color MRI Images
3. What is a Spinal Fusion Surgery of the Low Back (Lumbar Spine)? Shown and explained with Color X-Ray Images
4. What are Artificial Disc Replacements of the Low Back? Shown and Explained with Color X-Ray Images
5. What is Degenerative Disc Disease (DDD) of the Low Back (Lumbar Spine)?
6. Disc Herniations of the Low Back (Lumbar Spine) shown and explained with Color MRI Images

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