Steve Kerr’s situation has been the talk of the basketball and orthopedic world. How much do we really know? What can we learn from his situation?
Known: He Had Back Surgery for a “Ruptured Disk”
This doesn’t really tell us much though. There are as many potential sources for pain as there are structures in the back, and one thing that we know from science, is that in cases of BACK PAIN it’s very difficult to nail down any specific anatomical cause. Most everyone by his age (he was 49 at the time) will have multiple abnormalities on a spinal MRI, not to mention an MRI done of anything else on a 49 year old.
Unknown: Why Did He Have Back Surgery in the First Place?
It has been assumed that he had surgery for BACK PAIN, however, there are other areas of pain related to the back that can be appropriate for surgery. You’ll see why I put that in all caps later.
The most appropriate cause for back surgery is SCIATICA, which is pain, numbness, tingling, or weakness in the lower extremity (leg and/or thigh, in medical terms) due to compression or adhesion of one of the nerve roots, in or around the lateral foramen – a hole of sorts that the spinal nerve root has to pass through in order to get from the spine to the extremities.
A common cause for compression in this area can be a herniated, or ruptured disk, but it can also be due to compression of the disk (degeneration) making the foramen smaller, and worsened with ligament thickening and osteophytes (commonly called “bone spurs”) around the foramen.
Unknown: What Kind of Surgery Did He Have in the First Place?
The least complicated surgery, and one that has stood the test of time after about a century of use, believe it or not, is called a laminectomy. In this surgery, the area that the nerve root has to pass through is widened by cutting out a bony window. This is not a complicated surgery, recovery is relatively quick, it’s relatively non-invasive, but sometimes a more aggressive surgery has to be performed later, if it doesn’t resolve the problem.
A more complicated option is the microdiskectomy. In this procedure (performed with or without a laminectomy) a portion of the disk that is ruptured or extruded (sticking out) is removed. Disk material is gently removed until only viable (mostly undamaged) disk tissue remains. This surgery has a relatively quick recovery, and many of these are done in ways that are considered to be “minimally invasive” but that can also sometimes mean that the surgeon cannot see as well as he or she could, were the surgical site larger. About 5% of microdiskectomies fail, and the disk reherniates as a result, leading to another similar surgery, or a more complex and invasive surgery.
The next more complicated option would normally be some kind of spinal fusion, or in some situations, a disk replacement. A spinal fusion (there are several different times) fuses two or more vertebrae together, after enlarging the foramen. This surgery stops motion at the segment, and over time, causes faster wear and tear of the segments around it. This is also the go-to solution in cases of significant spondylolisthesis – where the back segment has become so degenerated that it is unstable, and sliding forward and back with movement.
Known: Why Did He Have Another Surgery?
During or just after his first surgery, he experienced a tear in the dural sac, which holds the cerebrospinal fluid that surrounds the brain and spine. CSF pressure is pretty well-controlled normally, and a leak can cause headaches, nausea, neck stiffness, and a range of other symptoms. These can occur during the surgery and be immediately fixed, or can be missed during surgery and leak afterward, or can be the result of a sharp piece of bone rubbing across the dura and tearing it after the surgery.
As with the first surgery, no details were given as to the cause or the surgical intervention.
Unknown: Why Is He Still Having Problems?
Depending on the interview I read this evening, he either does not complain about any residual back pain, or plainly states that his back feels fine. His only symptoms are related (it is thought) to CSF leakage. However, problems this long after surgery are rare, and can sometimes result in a pain syndrome – where the initial cause of the headache is no longer present, but the pain continues for other reasons.
He has tried many things over the past two years to resolve his current pain, including medicinal marijuana, physical therapy (unspecified interventions), yoga, and meditation.
Unknown: Should He Have Had Surgery? Should You?
As with most athletes and public figures, details of his situation are not clear. It was said that he had difficulty walking even 30 feet due to pain, but I have never read specifically what pain (back pain or sciatica, or something else) he was having, that lead him to surgery. It is also not clear what other treatments he may or may not have tried before surgery. Based on his publicly expressed sentiments about avoiding back surgery at all costs, and never mentioning sciatica or physical therapy, I’m going to guess that he might have seen surgery as a way of “fixing a problem” quickly and easily, to get him back to his regular activities. Of course, it could also be true that he had a seriously unstable spondylolisthesis (see below), and the only viable option was surgery, and he is simply playing “what if?” in his head regarding the whole situation.
Generally Speaking: Surgery is not a good option for BACK PAIN unless there is a relatively large instability related to spondylolisthesis. While segmental instability is implicated as a source of low back pain, this is not the same thing. It should be noted that much research has been done into what some call “simple back ache” and there are many forms of physical therapy (the exact interventions are based on problems observed during the examination) proven to be quite effective. Surgery has not proven to be helpful. Neither have corticosteroid injections, for that matter.
Generally Speaking: Surgery is a good option of last resort for sciatica that has not responded to therapy and corticosteroid injections. Physical therapy never killed or paralyzed anyone, but surgery can be complicated and is permanent. Surgery should be considered earlier if weakness is getting worse, numbness and tingling is present in the “saddle area” or if troubles creep up regarding urination or defecation. In some cases, surgery must be performed quickly, in order to avoid dire consequences down the road.
