A Problem more common than you might think
By Dr. Michael Hisey
After watching Texas Rangers first baseman Prince Fielder, and pitcher Matt Harrison both end their seasons because of spinal issues, sports fans again saw another top player go down to a back injury - Neymar Jr from host Brazil. It happened in the World Cup quarterfinal in Fortazela with the entire world watching.
Neymar Jr had helped his side all but secure victory over Colombia when he was struck from behind by a rash challenge from Colombia's Juan Zuniga. After the Impact, Neymar was in obvious discomfort and was stretchered off of the field for evaluation.
As a spine surgeon at Texas Back Institute, several questions occurred to me. More on these later.
The news that followed was quite alarming. The 22 year old Neymar Jr (short for Neymar da Silva Santos Júnior) had reportedly suffered a fracture to his third lumbar vertebra, ending his World Cup and making host country Brazil's quest for a 6th championship that touch more difficult.
There are Many Questions
Early reports were that the player would miss 4-6 weeks to allow healing of his fracture. Images of his radiographs (a CT scan reconstruction) have been widely circulated and described as a “clean break”. But is that really the case?
This image is one slice of what would typically be a several hundred slice study, so any diagnosis based on a single slice is quite limited. It is not even clear that this is truly an image of Neymar’s back or that the level is L3 – in fact, it appears lower.
But taking all of that at face value, what does the image tell us? First, there is a break in the bone at an area called the “pars interarticularis”. But this break does not have the x-ray characteristics of a new injury. There is healed bone on the surfaces of the fracture.
These images are showing a problem called “spondylolysis". If this really is his only injury, his prognosis for recovery is very different than if he truly had an acute fracture.
What is Spondylolysis and How is it Treated?
Anatomically, spondylolysis is a defect in the ring portion of the vertebra, at what is known as the pars interarticularis. Each vertebra has joints connecting to the vertebra above and below. These defects occur between these joints (hence the name “interarticularis”).
There are several theories about just what causes these defects, but common elements to the theories is repetitive stress to this portion of the bone. The stress may be due to loading in extension – similar to what football linemen experience when they are blocking or impacts gymnasts bear when landing. This stress is amplified by the presence of the joint above acting like a fulcrum at the weak area of the bone.
If all of this happens in the teenage years, when this portion of the bone is trying to solidify, then a stress fracture can develop. This can happen with or without symptoms of back pain. This problem is quite common and is a leading cause of back pain in teen athletes.
If caught early enough, spondylolysis can be successfully treated with activity modification. Often, though, these defects don’t cause symptoms or the symptoms resolve without the bone fully healing, leaving a “pars defect”. This is such a common problem that most of us probably know several people with it even if they don’t know about it.
What About Neymar?
This defect does, however, leave a “weakness” in the back. It might be vulnerable to injury from an impact which might not cause problems if the spondylolysis were not present. Which brings us back to Neymar.
If these pictures are to be believed, Neymar had a structural defect in his back that was aggravated by a blow to the back in the quarterfinals. In this case, it is not necessary to wait for the bone to heal to return him to play. In fact, it is very unlikely for Neymar’s bone to heal, but bone healing is not necessary to return him to play.
It is very likely that, if a CT scan were taken the day before his injury, the “fracture” would look the same. If I were his physician, the goals I would set for Neymar’s treatment would be to rehab him to the point that he is pain free. This may be able to be accomplished much more quickly than he could heal bone. A few of the pars defects that become aggravated by an injury could possibly not recover and eventually require surgery, but that is a very small percentage.
There are literally thousands of athletes performing at a very high level with spondylolysis or pars defects or pars interarticularis stress fractures.. There are even more recreational athletes with the same issue. So, if the images on the web are really Neymar Jr, don’t be surprised to see him back for the final in Rio, should Brazil make past Germany today in Belo Horizonte.
About the author of this post:
Dr. Michael Hisey is an orthopedic spine surgeon at Texas Back Institute. He is a member of the American Board of Orthopedic Surgery and the American Board of Spine Surgery. He is the official spine specialist of professional soccer team - FC Dallas - and is one of the world's biggest sports fans! Click here to schedule an appointment with Dr. Hisey.