Peyton Manning Undergoes Surgery Again; Medical Expert Explains Why

INDIANAPOLIS, IN - AUGUST 19: Peyton Manning of the Indianapolis Colts watches the action during the game against the Washington Redskins at Lucas Oil Stadium on August 19, 2011 in Indianapolis, Indiana. (Photo by Andy Lyons/Getty Images)

Peyton Manning underwent a third surgery on his neck Thursday, this time for cervical fusion. SB Nation's medical expert explains this procedure, and why Manning has been forced to have so many operations for the same injury.

Indianapolis Colts QB Peyton Manning had a third surgery to repair a herniated disc in his neck on Thursday, and given the limited details that have emerged regarding the procedure thus far, it is impossible to speculate how lengthy the recovery process will be going forward. One report speculates Manning could return to action in as few as 2-3 months after today's anterior cervical fusion procedure, but it is clear that patients who have undergone similar procedures require a wide range of recovery times depending on the extent of the injury, the individual's overall health, and the surgical approach itself.

What is known about Manning's medical history prior to today is this:

In March, 2010, Manning underwent his first surgery to relieve pain in his throwing arm that was related to pressure from a bulging (herniated) disc being applied to nerves in his cervical spine. By all accounts, the procedure, which was performed by reknowned spinal surgeon Dr. Richard Fessler at Northwestern in Chicago, was a success, with Manning back to working out within a week, lifting weights in two weeks, and earning another Pro Bowl trip that same year.

However, during the early offseason Manning's pain returned. An MRI of the neck again revealed a herniated disc, prompting a second neck surgery (also by Dr. Fessler) in May of this year. Because it was his second procedure, Manning was expected to require 6-8 weeks of rest and rehabilitation before resuming full football activity, but there was little concern it would affect his ability to start the team's season opener against the Houston Texans on September 11.

It is clear, though, that the recovery from this second procedure did not go according to plan, prompting Thursday's reported surgery.

A herniated disc occurs when the contents of the cartilage that normally separate the vertebrae spill out and start "pinching" on the nerves that exit the spine. The type of radiating pain that often follows is referred to as radicular pain (or radiculopathy) and may be felt in other parts of the body such as the leg or arm. Along with pain, numbness tingling, and muscle weakness can be present in the affected extremities. Although a herniated cervical disc (located in the neck) may originate from trauma or injury to the spine, the symptoms commonly start spontaneously and without warning.

Treatment options for cervical herniated discs can range from conservative therapies to invasive surgeries, depending on the symptoms and duration of injury. The primary goal of treatment is to relieve pain, with the chosen option based on the source of the pain, the severity of the pain, and the specific symptoms the patient exhibits.

Patients are often advised to start with a course of non-surgical care (medications, rest, physical therapy) for at least 4-6 weeks prior to considering spinal surgery for a herniated disc. However, when a patient has progressive major weakness in the extremities due to nerve root pinching from a herniated disc, earlier surgery can help stop any progression and speed the healing process. In such cases, failing to perform surgery expeditiously can result in permanent nerve damage and persistence of symptoms.

Surgical treatment for a cervical herniated disc can be approached either anteriorly (incision made from the front/side of the neck, such as today's procedure) or posteriorly (incision made from the back of the neck). Commonly, the anterior approach (anterior discectomy) is chosen. During this procedure, the offending disc is removed through the front of the neck and then the vertebrae above and below the empty disc space are usually fused using a combination of bone grafts, plates, screws and/or rods. This cervical fusion process stabilizes the spine, keeping the vertebrae in position and out of the way of the offending nerves.

Another surgical option, which is the method Dr. Fessler chose for Manning's second procedure, by report, is a posterior cervical approach, in which the disc material is removed through the back of the neck. Although surgeons can opt to fuse the disc space in this approach as well, studies have shown that this is somewhat more difficult to accomplish than with the anterior approach, and so fusion is less commonly performed.

Therefore, a key difference between the approaches is that it is more common to perform cervical fusion with anterior versus posterior surgery. The main concerns with fusion are that patients run the risk of losing range of motion of the cervical spine,and that the recovery period, in particular for athletes in contact sports, can be on the order of months rather than days to weeks. In May, Irsay was quoted as saying that Manning did not undergo spinal fusion during his second procedure.

As a whole, the major advantages of a posterior approach include:

  • Superior for treatment of herniations that are lateral to (to the side of) the spinal cord;
  • Safer in patients with bone spurs involving the spinal column;
  • Allows patients to avoid cervical fusion.

The major disadvantages of a posterior approach include:

  • Opting against fusion may allow for continued disc collapse and pressure on the affected nerves;
  • The disc may not be removed completely and may re-herniate;
  • More technically difficult approach that runs higher risk of failure.

Typically, patients who undergo cervical discectomy are back to full activity within a matter of weeks, with a longer recovery period if fusion is performed as in today's procedure. However, as evidenced by Manning's second procedure, when complications arise, the healing process can take months and may require additional surgery regardless of whether fusion is performed. 

The question in the coming weeks will be whether the Colts superstar will be able to return at all this season. Although the early reports put Manning back on the field as early as November, given the chain of events leading to today's procedure it is distinctly possible he will miss the entire 2011 season.

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