The fact that the NFL remains an inherently violent league comes as a surprise to no one, but the recent apparent spike in neck and cervical spine injuries is hard to ignore.
Peyton Manning's recent battle with cervical spine issues remains the most prominent case of a serious neck problem in a big-name NFL athlete—as well as one of the most impressive injury comebacks in recent memory—but several other cases continued to dot the football landscape throughout the following months and years, including:
- Indianapolis Colts running back Ahmad Bradshaw, who made his preseason debut last week after undergoing neck surgery last October.
- Former Green Bay Packers safety Nick Collins, who officially retired from the NFL earlier this month after being unable to obtain medical clearance to return to the field following his 2011 neck injury.
- Former Green Bay Packers tight end Jermichael Finley, who remains a free agent after a violent collision left him briefly paralyzed last season.
- San Diego Chargers wide receiver Malcom Floyd, who appears ready to go this season, despite a serious neck injury that cut his 2013 campaign short.
- Dallas Cowboys linebacker DeVonte Holloman, whom doctors advised to retire after he suffered another neck injury on Aug. 21—less than one year after missing a significant amount of playing time due to a spinal cord contusion.
- New York Giants linebacker Jameel McClain, who successfully returned to NFL action following a violent injury in Dec. 2012 that caused a spinal cord contusion.
- Former Pittsburgh Steelers running back Isaac Redman, who retired from the game last week due to a spinal cord injury.
- Former New York Giants running back David Wilson, who, shortly after receiving medical clearance following spinal surgery, left the league after a hit to the upper body during practice caused a recurrence of his neurological symptoms.
With the above list of neck injuries continuing to lengthen, several questions come to mind: Are they increasing in frequency? Why are some career-ending, while others aren't? Are they all the same?
As might be expected, the answers to these questions aren't exactly simple, and the spinal surgery field is incredibly specialized and complex—far beyond the scope of this article.
Nevertheless, to paint a clearer picture, let's take a surface-level look at just what, exactly, happens when spine injuries take place—and why some athletes' careers end and others do not.
As always, it helps to first zero in on the underlying anatomy.
The Neck, Cervical Spine and Spinal Cord
As the information and electrical highway from the brain to the rest of the body, the spinal cord represents one of the most important structures in the human body. It travels from the base of the brain to the uppermost portion of the lower back.
The cord—in essence a large bundle of nerve fibers—sits within the numerous vertebrae that encase and protect it, thereby making up the spine. Between each pair of vertebrae rests a soft, cushioning intervertebral disc, which allows for the flexibility of the spine. The vertebrae and discs in the neck make up the so-called "cervical" spine.
For a better, though anatomically incorrect, mental picture of the spine and spinal cord, imagine a long, narrow PVC pipe with a rope dangling down the center. The PVC pipe represents the spinal column, and the rope depicts the spinal cord itself.
Cervical Spine and Spinal Cord Injuries
Every single spine and spinal cord injury is unique and usually requires specialist evaluation. With that in mind, what follows in this article admittedly represents an oversimplification of the underlying concepts of an NFL spine injury.
As before, the rope and pipe analogy can help simplify those concepts.
Generally speaking, a spine or spinal cord injury interferes with the overall structure of the rope and pipe.
For instance, if a blow to the head or neck suddenly squeezes one of the intervertebral discs too sharply, the inner portion of the disc can leak into the pipe. If, as a result, this "herniation" places pressure on the cord—or rope, so to speak—neurological symptoms such as localized pain, weakness or numbness can result.
Somewhat similarly, if a hit quickly snaps the neck to one side and, as a result, pinches the tissue in or around the spinal canal, inflammation and swelling inside the pipe can follow. As the pipe is a rigid, closed space, the resulting collection of fluid can press on the spinal cord rope, compressing the nerves and causing the above symptoms.
The above two examples represent a herniated cervical intervertebral disk and a spinal cord contusion, respectively. A third type of injury, a "stinger," stretches a bundle of nerves as they leave the pipe, producing temporary numbness, weakness or pain in the arm or shoulder.
Lastly, cervical cord neurapraxia (CCN) is akin to a whole-body stinger, producing transient numbness or paralysis—or both—in up to all four limbs.
What Is Spinal Stenosis, and Why Does It Matter?
Cervical stenosis came to the forefront of the NFL draft scene last year when news surfaced that former University of Georgia linebacker Jarvis Jones carried the diagnosis—in his case, a condition he probably had since birth.
Spinal stenosis refers to any condition that narrows the pipe, thereby leaving less room between the inside wall of the pipe and the spinal cord rope.
Stenosis can exist since birth, showing up as an inherently narrow opening in one or more vertebrae in which the cord sits. It can also develop as a result of trauma, long-term disc degeneration or an acutely herniated disc—think of stenosis from a herniated disc as a dent in the pipe.
A spinal stenosis diagnosis carries weight because the condition increases the risk of a stinger or CCN.
That said, studies from the 1990s by Dr. Joseph Torg and colleagues show that suffering from CCN does not necessarily increase the risk of a future permanent, catastrophic neurological injury, such as paralysis. However, the study also suggests that one instance of CCN likely predisposes a person to further such episodes.
Additionally, many doctors still exercise caution, such as Dr. Andrew Hecht—co-chief of spine surgery and director of the Spine Center at Mount Sinai Medical Center in New York City—who discussed the issue with The Austin Chronicle's Alex Dunlap when Jones' condition started gaining more attention from the press:
While Dr. Hecht says that it goes against what the research and literature universally support, it just seems logical to expect that with each instance of neuropraxia, there may be an increased risk of a more serious spinal cord injury at some point.
If "multiple" instances of neuropraxia do occur, players are best advised to give serious consideration to their respective futures playing the sport.
What Is Spinal Fusion Surgery?
If the above types of injuries lead to severe or persistent neurological symptoms—often, symptoms resolve on their own without issue—doctors may advise a spinal fusion surgery.
During this operation, doctors remove an intervertebral disc to decompress the spinal canal and fuse together the vertebrae above and below the resulting gap. The bones then eventually heal together with time—and sometimes the assistance of a bone graft.
To keep with the metaphor, during a fusion, a surgeon removes a small section of the pipe and bridges the gap with metal until pipe closes on its own.
In the best-case scenario, a fusion surgery addresses the only area of stenosis—a single herniated disc, for example—symptoms completely resolve and the athlete returns to normal football activities.
Dr. Neel Anand—clinical professor of surgery and director of spine trauma at Cedars-Sinai Spine Center in Los Angeles—weighed in on such a best-case scenario as it relates to Peyton Manning.
"If surgery was successfully performed to correct (a) cervical spinal stenosis, there are no further risks. Peyton Manning is a perfect example of this." Dr. Anand explained.
It's also important to note that Manning's case likely stemmed from the cumulative effect of many hits—a degenerative process—rather than one more significant blow, as in Jermichael Finley's case.
Are Serious Neck Injuries Increasing in Frequency?
The availability heuristic describes a cognitive bias where events that are easy to recall seem more likely to occur. A plane crash—an incredibly rare event by any respect—is a prime example.
When serious neck injuries occur in the NFL, they garner mass attention—and appropriately so. However, one must wonder if the recent apparent spike in cases seems like more of an increase than it actually is.
That is not to take anything away from the sobering nature of the acute versions of serious neck injuries, but without calculating the numbers, the availability heuristic is worth at least some consideration.
A mathematical calculation of the validity of the increasing rate of serious neck injuries—or, just as importantly, the lack thereof—may also prove interesting, but definitively proving a trend toward an increasing or decreasing rate of an already rare event is difficult.
What Makes a Neck Injury Career-Ending?
There is no easy answer to the above question, and comparing one athlete to another often resembles comparing apples to oranges.
For proof, look no further than the large range of differing outcomes.
Jameel McClain suffered a spinal cord contusion but returned to action. Jermichael Finley, on the other hand, remains a free agent, likely primarily as a result of his medical history.
Ahmad Bradshaw saw live-game action last week, while David Wilson recently left the league for good.
Peyton Manning underwent a spinal fusion under completely different circumstances—a long-term degenerative process—and is now playing arguably his best football yet.
In other words, every case is unique. Important return-to-play questions include but are not limited to:
- What injury—or combination of injuries—occurred? Was it an acute injury or a long-term degenerative condition?
- Is there underlying spinal stenosis?
- Did the athlete suffer from an episode of CCN? Has this happened in the past? Are neurological symptoms, stingers or episodes of CCN recurring, even after medical or surgical intervention and rehab?
- What neurological symptoms developed after the injury in the first place? Did they resolve on their own or persist? Was surgery necessary?
- Did surgery successfully address any existing spinal stenosis?
- What about the athlete's preferences, which, in the end, reign supreme?
The answers to the above questions, among many others, will help determine an athlete's ultimate disposition, but nothing replaces an extended conversation about the risks and benefits of returning to the game.
Dr. Dave Siebert is a second-year resident physician at the University of Washington and a member of the Professional Football Writers of America. He plans to pursue fellowship training in Primary Care (non-operative) Sports Medicine.
Quotes were obtained firsthand unless otherwise noted.