by G. John Mullen, DPT 2011 | email@example.com
As a kid, my friends and I always got together to play tackle football. None of us weighed over 100 pounds and, as such, we threw our bodies at one another like Adam Sandler in The Waterboy. We didn’t think twice about going head first into someone on the opposing team. Little did we know, throwing our bodies around like this could potentially be extremely damaging. This general disregard could have caused a plethora of injuries, the most common of which (caused by Goldberg-esque spear shots) being neck injuries. Neck injuries are a serious concern in the NFL. Millions of dollars are poured into research looking at the long-term effects of head injuries, specifically concussions. This past week, Indianapolis Colts’ quarterback and Saturday Night Live star, Peyton Manning, underwent neck surgery to relieve symptoms of a pinched nerve that he has been suffering from for the past four years. Despite the enormous media coverage his surgery received, the exact type of surgery he underwent was not disclosed…luckily we have a pretty good idea of what went down (one of the few perks of medical training). This article will dive head first into the injury, from the anatomy of the nerves (called spinal nerves… ingenious!) to symptoms associated with a pinched nerve and the surgeries and physical therapy commonly used treat them.
Stat Fact: As of February 1st, 2010 more than 250 current and former athletes have volunteered to donate their brains to research the effects of repeated head trauma.
Spinal Nerve Anatomy
The cervical spine has seven bones called vertebrae. Each vertebra contains a vertebral disc that acts as the “air bag” or cushion between adjacent vertebra. Each of these vertebrae is associated with a spinal nerve root that exits the spine between the vertebrae. Once the nerve exists, it travels a distinct path relaying sensation and providing motor control to specific regions of the body. The nerves are the electrical system of the body. One of their functions involves sending information to muscles causing activation and contraction. The nerves in the cervical spine provide information to various areas of the neck and arms. Pinched nerves are caused by a variety of anatomical adaptations to stress. With the majority of pinched nerves, the gel-like disc between the vertebrae loses it’s elasticity and is compressed, decreasing the amount of space between vertebrae and subsequently causing compression of the nerve. Another common cause of pinched nerves is from a bulged disc; in this pathology the gel-like center of the intervertebral disc bulges through the tough outer layer. This bulging region then presses on the nerve root decreasing conductance of the nerves and causing excruciating pain.
Stat Fact: Vertebral discs begin to lose their size and absorption capacity by the third decade of life.
Signs and Symptoms
Pinched nerves present in a variety of ways, most of which involve pain and discomfort…not a good thing for any athlete, let alone a 10-time pro bowl quarterback. Despite the fact that the “pinching” of the nerve occurs just outside the spinal cord, most signs and symptoms occur in the area that the nerve innervates (i.e. the region of the body to which the nerve supplies electrical connections). As stated, most of the nerves in the cervical region of the spinal cord distribute sensation to the arms and neck. Common symptoms of a pinched nerve include:
Sharp or burning pain radiating over the region supplied by the nerve
Symptoms become more severe with coughing or sneezing
Muscle weakness or twitching in the affected area
Feeling that the area involved has “fallen asleep”
These symptoms can be felt on one or both sides of the body. Medical doctors or physical therapist can confirm these symptoms with a variety of tests:
Reflexes: Reflexes are typically decreased in patients with a pinched nerve
Nerve Conduction Study: This involves the application of an electrode to the farthest point of a potentially compressed nerve followed by a mild electrical pulse (don’t worry…not Frankenstein style) to a point higher up the nerve. The study is testing the speed with which that impulse is carried down the nerve. Slowed conduction speeds can indicate that the nerve is being compressed at some point along the path.
Electromyography: This test measures the electrical activity produced by a muscle. This test is performed by placing a needle (which sounds scarier than it really is…think acupuncture needle not horse tranquilizer) into the muscle and record the electrical discharge made by the muscle during movement.
Magnetic Resonance Imaging: This technique uses a magnetic field and radio waves to produce an image of the affected area and look for a region of nerve compression.
These tests, as well as the patient’s symptoms, will provide the doctor (either a physical therapist or an MD) with a better idea of the severity of the injury and the ideal treatment course. The more we know, the more we can help you…thus all the tests (they really aren’t as fun for as to perform as you think).
Stat Fact: 70% of cervical radiculopathies (a.k.a. the pain and loss of function caused by pinched nerve) occur at the 7th cervical vertebrae (indicated by the white arrow in the x-ray shown). This nerve innervates the triceps (We don’t play football anymore but we’re pretty sure the triceps are important…yes, our sources have just confirmed they are).
Most surgeries for a pinched nerve are part of the “otomy” family: foraminotomy, laminotomy, hip-hopotomy (OK, one of those is fake. Any guesses?) The suffix “-otomy” is Latin for “partial removal” and “-ectomy” is total removal (for example, a cholecystectomy is the removal of the gall bladder). If I had to guess, I would say Mr. Manning had an “-otomy”, considering that the press releases proclaim it was minor surgery. Nowadays, these types of surgeries are minimally invasive endoscopic surgeries (meaning that they are performed through small incisions with a video camera and tiny instruments). In Peyton Manning’s case, we do not know which form of surgery he received but it is most likely a foraminotomy or laminotomy:
Foraminotomy: This outpatient surgical procedure is used to widen the foramen (the round opening that exists between the two vertebra) by removing small pieces of the vertebrae to relieve the pressure being placed on the nerve.
Laminotomy: This surgery can be performed in the outpatient setting as well and is used to clear space on the spinal cord. This surgery relieves pressure placed on the nerve by removing part of the lamina of the vertebra (the portion of the vertebra seen in the picture above and below the intervertebral foramen) creating more space for the nerve to pass through.
Another typical surgery to relieve pressure is a discectomy. A discetomy is performed when a bulging disc is the cause of the nerve compression. The procedure involves the removal of the intervertebral disc that is putting pressure on the spinal nerves (you can see in the picture to the left that the inner gel-like part of the disc has ruptured through the tough outer ring of the disc and is now pressing on the nerve root…and a pinched nerve is born). Total removal of an intervertebral disc increases the likelihood of degeneration since it takes away the cushion between the vertebrae at that level. Newer minimally invasive procedures have been developed to decompress the bulging disc without removing the whole disc itself (easier to do AND you may be able to salvage your intervertebral disc).
In therapy, enhancing the strength of the muscles that hold the head upright is essential. Most pinched nerves and bulging intervertebral discs are caused by poor posture for extended periods of time. Hunched behind the center, the quarterback keeps their neck extended (to keep their eyes on the defense rather than the center’s robust butt) decreasing the space between the vertebrae. Repeated bouts of poor posture may have lead to Manning’s pinched nerve…that or repeated bone-crushing blows from 300 pound linebackers moving at lightening fast speeds. Our guess: The latter. Since Manning was able to play with the injury for 4 years, it is likely that it was not an acute injury (enter the mental image of Manning being speared by Goldberg), but rather a progressive injury. With these types of injuries, consistent neutral neck posture is mandatory (Good luck staring at the center’s booty, Peyton). Increasing strength and flexibility will alleviate pain and prevent reoccurrence of the injury. The goal of strengthening exercises is to increase strength in the front and back of the neck. Recommended neck-strengthening exercises can be seen in our previous article, Pain in the Neck.
Even though you’re not a 6’5”, 230 pound, 10-time Pro Bowl quarterback, you may still end up with the same neck problems if you do not address them now. Proper posture, strength and flexibility of the neck and shoulders are key to preventing pinched nerves. Keep this in mind next time you spend 8 hours sitting at a desk in front of a computer…nobody wants to end up as another Office Space neck pain statistic. Help us help you.
Questions? E-mail John: firstname.lastname@example.org