Lumbar Flexion Injury

Tony Romo’s season, if not career, are at risk because of ego and poor judgement.  This is understandable from an injured, elite, competitive athlete desiring return to the field of play.  It’s even understandable from an owner like Jerry Jones.

Jerry has always envisioned himself as a GM and coach.  He has now given tangible evidence of his capabilities as a medical advisor.  Hey Jerry, we know you are not a doctor but did you stay at a Holiday Inn last night?  Heck, this guy probably even writes poetry in his spare time, such a man of many talents.  Perhaps he can even pilot a 747.

What is least understandable, and perhaps most irresponsible, is the poor clinical judgement of the team physician authorizing Romo’s return with the presumptive diagnosis of a “bruised muscle.”

Given Romo’s past surgical history, and that he had a Toradol (powerful anti-inflammatory medication) injection for back pain the week prior; the team doctor should’ve know better.  Clinically, to not suspect the potential for a more significant injury would be bad enough.  Suspecting the possibility of more serious damage, yet acquiescing to the whims of an overzealous owner would be even worse, calling into question his professional integrity and accountability to the athletes he ostensibly serves to protect.

In the brief video below, I want you to notice the mechanism of Tony Romo’s injury.  

  • Romo abruptly plants his foot, flexes (bends a bit forward), then pivots (twists) backward towards his right.
  • In this position, Romo’s back is facing the oncoming defender and still in a somewhat flexed (bent forward) position.
  • The oncoming defender makes contact at Romo’s shoulder level, causing further forced flexion of Romo’s low back.

The combination of rotation and flexion, compounded by the abrupt forced flexion resulting from where and how hard Romo was hit makes a lumbar disc injury more plausible as a diagnosis. It is also much more serious, especially considering that Romo’s prior micro-discectomy could increase the susceptibility of his lumbar disc to further deterioration.  

 

 

The side-line diagnosis of “bruised spine” lacks credibility for 3 main reasons.

  • Unless Romo suffered a fracture, or significant spinal instability, routine x-rays would be normal and neither argue for nor against any other type of injury.
  • The type of pain Romo experienced cannot be used to diagnose one structural source of pain from another.  In fact, numerous studies have shown that all spinal structures produce similar types and patterns of pain. (1)  This means that muscle pain is similar to disc pain which is also very similar to joint or ligament pain.  It can confuse clinicians as much as it does patients.
  • There are no completely reliable “bedside tests” or “on field procedures” capable of accurately diagnosing the spinal structure responsible for pain. (2,3)

Recognizing the limitations discussed above, most experienced spine-care professionals will lean heavily on mechanism of injury and past medical history in making a provisional diagnosis.  Romo’s on field physician (or Jerry Jones’ enabler) seemed to ignore each of these.  Let me explain.

To reach the point of having sciatica leading to a lumbar micro-discectomy, Tony Romo’s lumbar disc had already been compromised.  Here is a simplified illustration of a “birds-eye” or axial view of a herniated lumbar disc.

Lumbar Disc Herniation

Lumbar Disc Herniation

 

  •  Note that the outer disc fibers (annulus) are disrupted (torn).  This is typically the first thing that occurs when a disc is injured, often resulting in considerable back pain.
  • The tears of these outer (annular) fibers eventually coalesce allowing the inner, more jelly like, material of the nucleus to work its way through the tears to the point where it extends beyond disc boundaries.  This is called a herniation.  Disc herniations like the one illustrated often compress the nerve and cause a great deal of leg pain, weakness, or numbness.
  • This is the situation for which Tony Romo had his lumbar microdiscectomy.

 

Tony Romo’s prior lumbar microdisectomy was designed to relieve his sciatica (leg symptoms) and not to “heal” his back.  In fact, this surgery could have rendered his lumbar disc more susceptible to further deterioration.  Studies have shown that, post surgically, there is an increased risk of disc degeneration over time and that this is associated with increased pain and disability. (4,5)

It is also important to understand that once damaged, discs have a limited capacity for healing, and any healing that does occurs is slow, incomplete, and comprised of tissue that is structurally inferior. (6)  It is likely that Dr. Dossett (Romo’s surgeon) used a closure technique to seal the defect created by removing a portion of his disc.  However, such techniques have not been shown to compensate for the lost disc material, restore the necessary hydration to the disc, or to prevent further damage to disc fibers. (7,8)

The simplified version of what I have stated above is:

  • To reach the point of a disc herniation, Tony Romo’s lumbar disc had already sustained internal degenerative damage, weakening this structure.
  • His surgery, although designed to treat one problem (leg pain, numbness, weakness), probably led to further deterioration of his already compromised lumbar disc.
  • In other words, it is impossible (at least at present) to “regenerate” a previously degenerated disc.  

So how does all of this relate to Tony Romo’s recent injury and his future?

Romo’s degenerated lumbar disc will forever have a reduced internal water content leading to inadequate pressurization, and an abnormal load-stress bearing pattern.  This leads to a disc that will deform under lower loads, increasing susceptibility to re-injury. (9,10,11) Spinal ligament injury (and the disc can be considered a ligament) also leads to a loss of stability, especially when subjected to complex movements or force. (12) This is particularly important with the forces he is exposed to on regular basis.

That Tony Romo is now experiencing problems similar to Tiger Woods is not unexpected.  In fact, I would encourage you to read my articles about Tiger Woods HERE, HERE, and HERE.  You can also view THIS for a very brief and understandable video about lumbar disc pain.

Romo’s ability to compete will depend on his tolerance for pain and the effectiveness of any pain management he undergoes.  But again, it is important to understand that the lack or lessening of pain does not imply that he has healed.   

In closing, diagnosing Tony Romo with a bruised spine was a severe underestimation of the complexity of his injury.  His immediate return to competition placed him at increased risk for additional damage at a time when his impaired mobility further limited his ability to protect himself.

It seems that Tiger Woods has now figured out the detrimental effect of returning to forceful competition too early.  Good thing for him that Jerry Jones is not his “owner”.  

 

References

  1. Deyo, RA, RAinville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA 1992;288:760
  2. Sidney M. Rubinstein DC, MSc.       Maurits van Tulder PhD. A best-evidence review of diagnostic procedures for neck and low-back pain.       Best Practice & Research Clinical Rheumatology Vol. 22, No. 3, pp. 471–482, 2008
  3. May S; Littlewood C; Bishop A.       Reliability of procedures used in the physical examination of non-specific low back pain: A systematic review. [Aust J Physiother] 2006; Vol. 52 (2), pp. 91-102.
  4. Schroeder JE et al. Disc degeneration after disc herniation: are we accelerating the process? Evid Based Spine Care J. 2012 Nov;3(4)
  5. Barth M et al. Two-year outcome after lumbar disctomy versus microscopic sequestrectomy: part 2: radiographic evaluation and correlation with clinical outcome. Spine 2008;33
  6. Bron JL et al. Repair, regenerative and supportive therapies of the annulus fibrosus: achievements and challenges. Eur Spine J. 2009;18
  7. Bourgeault C. et al. Biomechanical assessment of annulus fibrosus repair with suture tethered anchors. Spine Arthroplasty Society, Berlin.
  8. Gorensek M. et al. Clinical investigation of intrinsic therapeutics. Barricaid, a novel device for closing defects in the annulus. NASS 2006
  9. Adams MA et al. Sustained loading generates stress concentration in lumbar intervertebral discs. Spine. 1996;21
  10. Kazarian LE. Creep characteristics of the human spinal column. Orthop Clin North Am 1975;6:3
  11. Virgin W. Experimental investigations into the physical properties of the intervertebral disc. J Bone Joint Surg 1951;338
  12. White AA, Punjabi MM. Clinical Biomechanics of the Spine. Philadelphia, Lippencott-Raven 1990.
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