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The Tale of Tiger Woods

Despite having what has been called a “successful” microdiscectomy, the ultimate tale (tail?) of Tiger Woods’ career is yet to be determined.  To better appreciate the uncertainty he faces, I will provide an overview of:

  • The nature of Tiger’s injury.

  • The indications for and expectations of a microdiscectomy.

  • The outcomes of competitive athletes undergoing similar procedures.

It is also my opinion that Tiger’s game will once again need to be re-engineered, using more finesse and less pure power, to regain and sustain any type of golfing success.  

Lumbar Disc Herniation: Tiger's Injury

Lumbar disc herniations occur when the outer restraining fibers of a disc have weakened (either due to acute injury, or more commonly chronic wear and tear) and can no longer contain the softer, more hydrated, inner portion of the disc within normal anatomic boundaries.  In a simplified framework, the type of symptoms experienced depend on 4 factors.

  • Inflammation.

  • Pressure.

  • Tension-Stretch.

  • Containment.

Each of these 4 can work independent of, or in conjunction with, the others and are typically present in varying degrees.

Overview of a Normal Lumbar Disc

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Normal Lumbar Disc

On the left is a view of a normal lumbar spine segment from above.  The disc (in light blue) is to the front.  The nerve elements are in the middle and towards the sides (yellow).  The boney ring and joints are in the rear. (light brown) Note that the disc has 2 components.  The central inner “core” is well hydrated and “pressurized.”  It is restrained by an outer, tougher, fibrous ring containing the inner core. Together, a hydrated disc and healthy outer core help to resist torsional stress and distribute pressure equally throughout the disc. You will also note the smooth contours of the disc and how the nerve elements have no contact from the disc material.

Stages of Disc injury, Tension, and Degree of Containment. 

disc_herniation

Early degeneration occurs with the loss of hydration of the inner portion of the disc and/or small tears in the outer restraining fibers.  The disc is weaker but not necessarily symptomatic.  A prolapse develops as the inner disc material extends through a weakened outer ring creating tension on external fibers. The tension can be painful, and in the absence of direct nerve compression may cause low back pain that is much greater than leg pain. Extrusion and Sequestration occur when the outer disc ring has lost the ability to contain the inner disc material.  The “tension effect” on the outer disc fibers lessens but profound inflammation and nerve compression often result.

Nerve Compression and Inflammation: Tiger’s Problem.

difference-between-normal-disc-and-herniated-disc

The illustration to the left (looking at a lumbar disc from a “birds-eye” view) likely represents the type of disc injury suffered by Tiger.  The inner disc material has “extruded or protruded” towards the right side and is compressing a nerve branch contributing to the sciatic nerve.  A disc protrusion or herniation causing nerve pressure but still contained by the outer ring causes a combination of low back and leg pain (with possible numbness or weakness).  An extruded disc herniation, although causing nerve pressure, is no longer contained by the outer disc ring thus reducing the tension effect. With pressure on the nerve but tension on the disc reduced, the majority of symptoms are in the leg.  Judging from the way Tiger is holding his back, I would expect that he had been experiencing a combination of low back pain, due to disc tension, and nerve pain (in the leg) due to pressure and inflammation.  This is critically important in assessing the expected outcomes from his “minimally invasive” surgery.  

Will Micro or Minimally Invasive Discectomy Solve the Problem?

Lumbar minimally invasive, or micro-discectomy is designed  to improve a patient’s leg pain, numbness and/or weakness.  The goal is to:

  • Remove disc material that is compressing the nerve causing the leg symptoms.

  • Do so in a way that prevents “collateral tissue damage” by attempting to spare important soft tissues such as the back (paraspinal) muscles. 

Minimally invasive, or micro-discectomy is NOT designed to:

  • Be a primary treatment for LOW BACK pain, although many patient’s do see improvement in their back symptoms as well.

  • HEAL a damaged lumbar disc.  At least for now, once a disc has degenerated and been damaged, there is not much that can be done to restore its complete structural integrity.  This is true even if symptoms abate. 

So what can Tiger expect from his micro-discectomy?

Published outcomes of lumbar discectomies vary, depending on the study reviewed.  This is true with all forms of lumbar discectomies, regardless of whether they are “open”, “micro” or “minimally invasive.”  In fact, even though minimally invasive and micro procedures are becoming more popularized; there has been no clear research consensus that outcomes are any better than prior, “open” discectomies.  

Taking into consideration the wide variation in reported “success” rates, most people (including Tiger) who undergo either open or microdiscectomy can expect the following: 

  • A significant improvement in leg pain.  Most studies report 70% or greater improvement.  It should also be noted that 50% improvement is considered a surgical “success.”

  • Improved leg weakness, if it was present.  However, the extent of recovery varies, based more on the severity of initial weakness than the duration of nerve compression.  Thus, some degree of permanent weakness is possible despite successful surgery.

  • Around 30 % of patients will continue to experience moderate to severe low back pain despite the improvement in leg pain.  Many studies have also reported the occurrence of progressive disc degeneration at the operative level along with the tendency for increasing back pain.  This, along with the tremendous force placed upon the low back by the golf swing, is what I believe will be Tiger’s limiting problem, despite his successful surgery.

  • Between 5-20% of patients will experience a re-herniation at the site of the original surgery.  

It is also important to know that, while most studies show surgery resulting in a more rapid decrease in leg pain, the overall success rates at 2 years are very similar when comparing those undergoing surgery versus those being treated more conservatively.  

Lumbar Discectomies and the Professional Athlete

Professional Elite Athletes:  4 BIG differences from the rest of us.

The statistics provided above pertain to the general population of individuals undergoing any form of lumbar discectomy.  But, professional athletes differ from us in 4 main ways:

  • Their baseline level of fitness.

  • The ability to obtain and afford most any type of ancillary care to assist in their healing.

  • They generally have the time to spend on their recovery and rehabilitation without excessive financial concerns or “job pressures.”

  • Once “recovered” the demands placed on their bodies exceed those most of us are exposed to. In fact, sports or position specific demands are often a big determinant in return to “play.” 

Let’s take a look at some of the published outcomes on lumbar discectomy for professional or elite athletes.

  • The Spine Journal (March 2011) reported that 81% of the athletes returned to their sport for an average of 3.3 years post surgery.  This study also stated that there was no difference in return to play rates between those having surgery versus those who chose to have their disc herniation treated conservatively.

  • Clinical Orthopedics (July 2014) performed a review of all related studies on lumbar discectomy in elite athletes noting that at least 75% of the athletes returned to play reaching a performance level of at least 64% of pre-surgical capacity.  

  • A study of professional hockey players (Am J. Sports Med, 2013) looked at 87 players suffering lumbar disc herniation noting no difference in return to play between those treated surgically versus conservatively.  Perhaps more important, however, is that they found a significant decrease in performance, after return to play, in all athletes suffering this injury.  

  • 20 out 29 baseball players with lumbar disc herniation were treated with surgery.  All of these returned to play as did the 9 being treated conservatively. (Orthodedics 2011)

  • Professional basketball was also studied finding that 75% of those having lumbar discectomy returned to play with a small decrease in performance (Spine, 2010)

For some reason, professional golfers seem to be left out of the scientific outcomes studies.  In searching Pub Med, I could only find one article discussing return to golf after surgery and this was nothing but an “opinion poll” amongst North American Spine Society members.

Lumbar Disc Injury: Taming the Tiger

I am not optimistic about Tiger Woods being able to regain, let alone sustain, golfing excellence in his original form.  My reasons for this are:

  • While the lumbar micro-discectomy may have provided relief from his nerve compression and leg pain, it will do very little to prevent him from future episodes of low back pain.  As discussed earlier in this post, I expect that in addition to Tiger’s disc herniation, there is likely a component of disc degeneration and there is no surgery that will currently reverse or heal this aspect of his problem.

  • The nature of the golf swing places tremendous strain on even healthy lumbar spines.  Studies have shown a compressive force of up to 8G’s.  This is greater than that of a Division I lineman hitting a blocking sled at full speed and is also above the 5G compressive strain found to cause lumbar disc herniation in experimental studies.  A single force of this magnitude, on an unhealthy disc, is enough for concern.  The cumulative effect of such forces is obviously worse. 

Reflecting on the studies of athletes mentioned previously, it is my opinion that Tiger Woods would’ve been better served by taking a lengthy absence, either after his surgery, or to have undergone conservative care and possibly avoided surgery.  

His leg pain may now be markedly improved or completely resolved.  But, the damaged disc and it’s susceptibility to tremendous compressive and torsional strain remains.  

Without a doubt, Tiger Woods is one of the fittest and finest golfers of our generation.  His real challenge in rehabilitation is not to restore his “fitness” but to re-engineer his game to the point where precision replaces power.  

If he can do this, I believe he has a chance.  I would love to see this happen.  But, one way or another, the Tiger of old is gone forever.  

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