The Dallas Cowboys announced that Tony Romo had back surgery on Friday morning. He was placed on injured reserve and is done for the season, including the playoffs. The Romo story has been one of the more confusing ones over the course of the last week, so let's take a look at the major questions surrounding Romo's injury, surgery and impending rehab.
What Was the Problem?
Romo had a herniated disc repaired surgically. The herniated disc was, according to multiple sources and reports, in the low back, though the level of the repair was not noted. Given the reports of motor nerve issues and hip pain, it is likely that the L4/5 disc was the problem. (Certain nerves come out between certain vertebrae, which makes this kind of deduction possible.)
What Surgery Did Tony Romo Have?
The Cowboys did not announce it officially, but they did say that Romo was expected to be home on Friday. That indicates that this surgery was done endoscopically and likely indicates a microdiscectomy. This type of surgery removes a small portion of the disc and repairs the herniation. In some cases, surgeons will create a small "tunnel" for the impinged nerve to run.
This surgery is normally quite successful in the short- and medium-term. Peyton Manning had two microdiscectomies on his neck that lasted several years before a fusion was done.
The surgery was performed by Dr. Drew Dossett, who is not only the spinal consultant for the Cowboys, but one of the top spinal surgeons in sports. Dossett performed the previous surgery for a cyst removal on Romo earlier this year. Dossett is also on the Cowboys sidelines each week, so he would have an intimate knowledge of any issues and treatments done.
When Did This Problem Start?
The Cowboys have not addressed this directly, but the standard of care for this type of injury indicates that this happened sometime during the season rather than being a traumatic injury that occurred in last week's game against Washington. If the Cowboys were able to maintain Romo's function for a period of time, allowing him to play through the condition and likely through significant pain, this would not be unusual.
Normally, the conservative measures including painkillers, regular treatment, stretching and traction and epidural injections would all take place before the discussion of surgery would occur. It is reasonable to expect that this was a problem for a matter of weeks and perhaps the entire season.
Reports that Romo lost some motor nerve function would have been a major factor in moving toward surgery. While Romo appeared to have no functional issue during the Washington game, it is not unusual to have symptoms show up after a game, especially if he was given anti-inflammatories or painkillers prior to the game.
Could Romo Have Played in Week 17?
This question was asked multiple times on Twitter when I asked what questions my followers had about the situation. Simply put, the need for surgery answers this question. Any sort of back surgery is significant and undertaken only when necessary. Surgeons regularly advise patients that surgery, even minor surgery, is the therapy of last resort, done only when all other more conservative measures have failed. Romo could not have played through this any longer.
While Romo does appear to have played through the injury for a while, the maintenance seems to have failed to the point where surgery was not only necessary but demanded. The loss of motor nerve function must be addressed. Any damage done to those nerves has a more extended recovery period, such as what we saw with Manning's arm.
In other words, don't question Romo's desire or toughness on this.
Why Did Romo Have an Injection and Then Surgery in Quick Succession?
The epidural injection on Monday, paired with statements from Jerry Jones saying that Romo could be cleared to play, indicate that the Cowboys weren't sure. While some may call this a bluff, it would not be unusual to see this play out in just this way. The last desperate hope of calming an exacerbation would be the epidural injection. The doctors and trainers would have tried to reduce the symptoms and hope to avoid surgery by doing this kind of injection and waiting to see the reaction.
Dr. Neel Anand told me in a conversation we had about Steve Nash that epidural injections have a widely varying rate of success for long-term management of back injuries. Having the injection on Monday and surgery on Friday is unusual, but the kind of three-day "waiting period" that we see in many cases does give an insight into the timeline. The Cowboys and likely Romo did everything they could to avoid surgery. The injection was a medical Hail Mary.
Does Romo's Earlier Back Surgery Affect His Comeback?
Not much is known regarding Romo's previous spinal surgery. A lot more questions have been raised over what was, at the time, considered a minor procedure. Romo had a cyst removed from his spine. This is not an uncommon or dangerous surgery, but any cyst could grow and impinge the normal structure of the spine. Removal is normally done endoscopically and has little or no issues with recovery. Romo appears to have had no issues in his rehab.
However, because we do not know what level the cyst was removed from, it is impossible to say whether there was any interplay with Romo's current issue. If the cyst was located at the same level as the herniated disc, Dr. Dossett would have been able to visualize the disc and see any issue. That would indicate that at the very least, Romo was healthy this spring, but again, we do not know that the levels matched.
Why Was This Not Reported Earlier?
Romo has not been on the NFL official injury report all season, which causes a lot of confusion. This does not mean that Romo was not dealing with an injury, but that the condition never threatened his ability to play or practice.
Many do not understand that the OIR is about availability and not health. The OIR's purpose is to give a generalized overview of availability to avoid any "inside info" on a player's health from giving gamblers an advantage. The NFL takes this very seriously, monitoring the way that each team reports injuries under its specific procedures.
Did the Cowboys Bluff?
It's possible that the Cowboys' reporting of this verges on the deceptive. B/R's Mike Freeman reported Thursday that the NFL is investigating the handling of this situation and how it was reported. More interesting to me is his tweet calling this a "bluff." As I stated above, it is unlikely that the Cowboys definitively knew that Romo would need surgery and be unavailable until after the injection.
While it is easy to see now that it was a small chance that Romo would return, especially given the strong early reports from ESPN's Chris Mortenson and Adam Schefter, I don't believe that they definitively knew this was the course things would take. It was the most probable course, certainly, but as Jim Carrey might say, there was a chance of him playing.
What Is the Normal Rehab for This Type of Surgery?
Microdiscectomies tend to have a very short period of recovery. Standard timelines used in the disability insurance industry are as low as two weeks. Romo's period will be longer; he's an elite athlete, not a desk worker. For a quarterback, the normal recovery would be between eight and 10 weeks. However, the normal timeline should not apply here.
The reason is not the surgery or the rehab, but the calendar. If Romo is ready to play eight weeks from now, there are no games on the Cowboys schedule until September. There's simply no need to rush anything. The Cowboys won't dawdle. They will want to know that Romo is having a normal recovery so that they can make any necessary adjustments or even in the most extreme case, cut Romo. I mention this only as a possibility, since unfortunately, NFL players are cut due to similar factors regularly.
I would expect Romo could be seen at mini-camps in April, though I doubt he will be "full go" for those, just as a precaution. Romo should be at full function and maximum improvement well before training camp begins ahead of next season.
Will Romo Have Issues with This Again?
Back injuries do tend to be both chronic and recurrent. Peyton Manning's case might be instructive here. Manning had two microdiscectomies and a series of injections (often erroneously referred to as a third surgery) before having his single-level fusion. While Manning's injury was to his neck rather than the lower back issue than Romo is experiencing, Romo could face a similar course with his spine.
Romo is expected to return and continue his career as an NFL quarterback, so additional trauma and simple aging could create additional problems or symptoms. As a known issue, the Cowboys will start a system of strengthening and flexibility as well as a maintenance program. Players often "get religion" after back problems and take avoiding further surgery very seriously. Romo's ability to come back from other injuries in the past gives him a strong base for the near future.
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