I apologize for the lack of content lately as I have been extremely busy. I have a few extremely detailed posts on the way. In the meantime, Rashek Kazi, a medical student at Stonybrook University (and Rangers fan), volunteered to write this article. With my editing I think it's an excellent synopsis of Lecavalier's injury. Thanks for reading!
BACKGROUND
On Sunday
December 8th, Philadelphia Flyers GM Paul Holmgren announced that
center Vincent Lecavalier would be missing the next 3-4 weeks with a
“non-displaced fracture in the lower back.” The injury was speculated to have
taken place in the third period of the game against the Predators on November
30th. Surprisingly, there was no hit registered against Lecavalier
in the third period of that game. In fact, Lecavalier played the remainder of
the game and scored the game-winning shootout goal.
Pertinent
player information from game of injury:
G: 0
A: 0
+/-: +1
TOI:
14:40
|
Time
|
Play
|
|
17:37, Per. 1
|
Hit, Lecavalier on Ellis
|
|
|
17:29, Per. 1
|
Hit, Bartley on Lecavalier
|
|
|
8:52, Per. 3
|
Hit, Lecavalier on Ellis
|
|
|
SO, Round 1
|
Goal,
|
|
|
|
|
He was
sidelined since the game against the Preds game, diagnosed with “back spasms.” Lecavalier was initially listed as “day-to-day” but was formally placed on IR December 8th.
This injury is a significant blow to the Flyers lineup Lecavalier, who signed a
5-year, $22.5 million contract with the Flyers this past summer, was the team
leader in goals (and 3rd in points) at the time of his IR placement.
Furthermore, the team is 2-5-0 with him out of the lineup. Clearly a vital
pivot for the team, the former first-overall has already missed 4 games due to
previous, unrelated injuries and now may miss upwards of 16 games.
A bad
break for the Flyers, but an interesting injury to analyze.
THE INJURY
Lecavalier initially missed the week following the
Predators game with “back spasms.” This is the dorsal side version of
“lower/upper body injury.” The vague announcement of Lecavalier having back
spasms was a way to avoid media speculation since a clinical diagnosis hadn’t
been made yet. Vinny traveled with the Flyers but his back problems flared up
during a pre-game skate in Dallas. The initial x-ray was indecisive and an MRI
back in Philadelphia was necessary to diagnose the injury.
The wide wide world of traumatic vertebral body
fractures.
From a
medical perspective, fractures can often easily be identified and diagnosed,
even by a rookie physician. Hell, anyone watching Steven Stamkos crashing into
the post knows what a fracture looks like. Stamkos suffered the more commonly
seen displaced fracture, which was a transverse break across the tibia.
This is what Clubber Lang envisions when he
predicts “pain” before fights.
On the
other hand, Lecavalier’s non-displaced fracture is a much more subtle injury.
The main difference between a displaced and non-displaced fracture is fairly
obvious on film. Non-displaced fractures will not be presented with a shift in
the two pieces of the bone. A parallel can be drawn to architecture with
non-displaced fractures paralleling a crack in a wall while a displaced
fracture would be a much clearer break. Continuing with the analogy, there is a
clear difference in severity as a broken wall will no longer be able to perform
its function while a crack still retains some of its shear strength. Again, a
broken wall can be easily visualized while a crack requires deeper attention.
This is the exact reason as to why the non-displaced vertebral fracture was speculated
upon from the x-ray but an MRI or CT scan was used for further confirmation.
This was the case for Vinny as the initial x-rays indicated some suspicion but
the MRI was needed to make the diagnosis.
If only Lecavalier fractured his spine like
this, it would make the radiologists life so much easier. And that’s what matters, am I right? Injury shown was suffered by Olympic snowboarding hopeful
Danny Davis in 2010.
The spine
is the bony vertebral column which houses the spinal cord – the structure which
connects our body to the brain. It is also the structure, which, in combination
with our postural back muscles, allows us to stand and ambulate as bipedal
organisms. To put it in perspective, the reason young Forrest Gump had leg
braces was because of issues with how his spinal column formed.
We value
the spine because spinal cord injuries are among the most devastating and least
curable. In second year of medical school, our professor reminded us that no matter
how much medical research has progressed, “paralysis is permanent.” This
relates to Lecavalier’s injury because in most fractures, the main cause of
pain comes from the fracture itself. In vertebral injuries, some of the
earliest symptoms might be a chronic leg pain either at rest or during
movement. This is because the nerves that wire our leg muscles emanate from
fenestrations along the vertebral column. When bones become fractured, there is
a massive recruitment of biological chemicals termed “trophic factors” which
recruit the cells needed to repair the injured tissue. It’s akin to how your
body “knows” you have a skin cut and how it works to clot it. As with any superficial
injury, you will note that the region swells up. No different in a bone break.
And when you have swelling along your vertebrae, there may be increasing
pressure of the nerves. Therefore, this injury Lecavalier suffered may have
lacked the symptoms of more severe fractures, but, if untreated, this injury
could quickly cause irreversible pain and movement problems.
So
why wasn’t this injury immediately found out and treated? Indeed, it’s likely
that Lecavalier may have further tweaked his injury by trying to practice with
the injury. But really no one is to blame. It’s likely that his chief complaint
consisted of “Doc, my back hurts a bit, what say you?” to which the team
physician likely replied “What say me? Try some pain killers”. And the sports
doctor is not to blame because lower back pain is fairly common in all sports
and can have even the most benign of causes. Just ask Dustin Penner. So when a
player comes in with back pain, it is generally not a cause for serious concern,
especially when the player is largely clinically asymptomatic. This is the type
of injury that many players would “fight through” come playoff time. Further,
unlike most serious back injuries and bone fractures, the cause was so subtle
that we can’t even isolate the inciting event. Again, recall that Lecavalier
stayed in the game against the Preds and won it for the Flyers. Why should
there have been a concern? Now having the diagnosis at hand, we know that the
injury probably occurred before November 30th and Lecavalier was
toughing it out and it was just the Predators game where he caved. This is
common among athletes.
More often, serious back injuries
and fractures as a whole require the dreaded stretcher to be brought out onto
the ice. When all of these factors are brought in, the medical staff has to
make the cost-effectiveness decision. From what we are given, is it worth
running the gamut of tests to find the cause or do we watch the player with a
close-eye and see where this goes. That’s what the training staff opted and if
you asked 100 physicians and trainers, 100 would have done the same. The one-week
watch was a precautionary one and it was the lack of improvement during the
morning skate in Dallas that prompted further scrutiny.
TREATMENT
We
discussed the initial treatment for the symptoms the patient presented with.
Watch carefully, Percocet, and re-analyze in a week. The initial symptoms hint
at a lower back “tweak.” This is usually a muscle strain in the lumbar region,
which happens from lack of stretching and flexibility. When this did not subside and, indeed, there
was likely a worsening of the symptoms, the doctors ran films. As we delineated
earlier, non-displaced fractures lack the radiographic “flare” of displaced
injuries. These x-rays were largely inconclusive which prompted deeper imaging
in the form of MRI imagining. While x-rays use the reflection of waves of
light, MRIs provide greater resolution by looking at the relative distance
between atoms. It was in the MRI that doctors concluded he had a non-displaced
fracture. They did not detail whether it was fully penetrating (all the way
through the bone) or a partial fracture. Since the bone remained aligned, there
was no need for surgical intervention, as was needed in the case of Stamkos.
However, a similar injury at the femoral head may require the placement of
screws/rods to ensure that a displacement would not arise.
The
overall treatment approach is largely conservative and similar to treatment of
post-surgery displacement fractures: stay still and wait. While he doesn’t need surgical intervention,
that doesn’t mean he’s all-well. First off, he’s removed from all physical
contact. Nothing makes fractures worse than being on the ice. Second, he will
be on painkillers to help him cope with the injury. He will be scanned likely
once a week to chart progress of the fracture. The recovery likely will be
complete and he can resume full contact play without future concern.
In terms
of future prevention in the game, it is likely very low. The cause of the
injury could have come from on ice or off ice factors. It is not worth it for
the league to address preventing this issue since the causes are largely
nebulous but treatment/outcomes are largely successful.
