Being a Sabres fan has not been easy for the better part of a decade. The product on the ice has been abhorrent and there has been little to look forward to even in the offseason. The latest news that star center Jack Eichel and the Sabres are at a crossroads regarding his herniated disc in his neck is all the more frustrating. While neck injuries and surgeries are nothing new with professional athletes, what is new is the type of procedure that Eichel would like to have to resume his career.
Several weeks ago, it was reported that Eichel would have surgery which typically involves an anterior cervical discectomy with fusion. I had detailed that out in the Die By The Blade article here and the risks along with the timeline to return. However, Eichel would prefer to have an artificial disc replacement according to GM Kevyn Adams. This approach has not been performed on any NHL players or extensive research to support a safe return to play in any major North American professional sports. The Sabres team doctors would prefer to use conservative measures to continue to treat his neck and believe that this is the long-term approach needed.
I do not know what is ultimately the best course of action or what will eventually be done as I do not have all the information. However, I will outline the anatomy, procedure, research, and thoughts on the most appropriate treatment plan moving forward.
Cervical Vertebrae Anatomy
The neck is made up of 7 cervical vertebrae that allow the spinal cord to pass through the middle, acting as a cage of sorts. In between these vertebrae are intervertebral discs which help provide space for the nerves that branch off the spinal cord to go out to innervate their respective areas of the body. The discs also allow for the movement of the vertebrae over each other. This provides stability around the spinal cord and nerves but also allows for mobility for all neck movements.
Disc Herniation
When a disc herniation occurs, the tough outer annulus fibrosus tears, allowing the nucleus pulposus to push out through the tear, which in turn, pushes on either the spinal cord or more likely, the spinal nerve that branches off the spinal cord. That pressure on the nerve can send pain down that nerve pathway, usually into the arm, and cause what is known as radiculopathy. This can be felt as pain, numbness, tingling, and weakness, leading to difficulty with everyday activities.
As mentioned above, I had thought he would have the ACDF as that has become a common procedure in the sports world to ensure that there is stability within the neck to withstand further hits. The type of procedure that Eichel would prefer is artificial disc replacement. This is when they remove the disc between the vertebrae and put it in a device made up of metal, mesh, and a shock-absorbing polyurethane core. There is also metal on metal devices or a combination of metal and polyurethane-based on the manufacturer. This allows for all the movements of motion similar to the original disc without sacrificing stability and loss of range of motion seen with the more accepted fusion surgery.
Artificial Disc History
Looking at the available research, this is something that has been around for 30+ years in various stages of development and not yet widely used. Within the past 15 years, the FDA has approved the use of these devices as an option for intervention. After these devices were found to be safe to use, research is performed on the long-term benefits and use of the devices to see if this outperforms fusion repairs. From what I have been able to find, the total disc replacements have some evidence that they are slightly better with regards to outcomes with pain, mobility, and fewer complications. However, there is not any research to support these procedures in high-level athletics.
There are concerns with this surgery such as heterotrophic ossification where excess bone grows in the muscle and surrounding tissue which could limit movement and cause pain. This can occur with any joint replacement or surgery indicating this is a generalized risk. There is a slight decline in mobility with the artificial disc when compared to five and ten-year re-checks, however, this is far better than a fusion where all motion at the segment is eliminated.
Looking at this from a physical therapy perspective, this seems far more ideal long-term for anyone who requires spinal surgery, The above-mentioned research seems to support this approach. I see fusion surgeries as rather barbaric, stabilizing areas together to reduce pain and sacrificing mobility. Research is still being done on how long these prosthetics last in a human body as new models and techniques are developed. Simulated models suggest 40 years and upwards to 100 years, though nothing can truly replace the natural materials of the human body.
Eichel’s Dilemma
Addressing Eichel on a case study basis is where it gets more complicated. Eichel is an elite athlete and very young with potentially two decades of elite-level hockey he can still play. He wants a procedure that has shown promise regarding similar and in some cases, better outcomes than traditional fusion surgery. Unfortunately, it doesn’t have the long-term research quite yet to support widespread use as the gold standard to replace fusion surgery in athletes.
All these studies are found to be performed on people with normal lives and activities, not ones seen at professional level athletics. There is a study that has shown professional athletes have received an artificial disc with good outcomes, but only two athletes were studied and I am unable to access the original article to identify the type of athlete.
There are well-documented reports that Chris Weidman has had the same procedure and has returned to fighting, most recently breaking his fibula and tibia with a devastating kick, requiring surgery. But Weidman is a 1-of-1 case; his success does not and should not dictate Eichel’s decision.
Other studies show that professional athletes have had a similar procedure, specifically a lumbar disc replacement. Those that were successful were not engaged in contact sports; instead performed ballet, soccer, and a fitness instructor. Two subjects were involved in contact sports (wrestling and karate) that did not fare as well. The wrestler had unrelated reasons to stop participating but the karate subject reported low back pain following a high-level rotational activity, requiring a modification of activities to limit pain.
Eichel would certainly perform a variety of neck movements that could stress the artificial disc at times. If Eichel does have the procedure, he could return by training camp based on this protocol, but even in the protocol, the highest level contact sport is basketball that is listed.
Crossed Swords
Looking at everything, Jack Eichel and the Sabres are stuck at the moment. Eichel wants a procedure that appears to have a good short-term track record, but the long-term results for athletics aren’t there yet. He also likely wants to avoid some of the complications of the more common fusion surgeries such as adjacent segment degeneration or further revisions. I can’t fault him for that.
While it is not confirmed, there is a possibility that Eichel and his camp may have been talking to Dr. K. Daniel Riew, the surgeon who performed Chris Weidman’s surgery. Dr. Riew would probably like to show that more professional athletes return to full sporting activities and have confidence in their abilities, as most doctors would. The progression for this has to start somewhere. If Eichel does have the procedure, he could return by training camp based on this protocol, but the highest level contact sport is basketball even in the protocol.
On the opposite end of the spectrum, the Sabres are looking to perform conservative care that likely includes physical therapy, chiropractic, and injections. They are likely to open to surgery, but a fusion that has a better track record. Add in the fact that they were giving the rehab timeline 12 weeks for the disc protrusion to reduce and see whether they could manage this so that it does not become a recurring issue.
Eichel has reportedly wished to schedule the surgery in June as a backup in case the conservative measures fail to take. Hopefully, the disc does reduce on its own and heals, but recurrent cervical disc herniations occur at various rates in the literature, but as high as 27 percent based on the size of the herniation. However, only 26 percent of people require surgery for cervical radiculopathy. This means that 74 percent address their complaints with more conservative means.
What scares me from a physical therapist’s perspective is how serious will Eichel take his rehab? He is a professional athlete and it is his job to ensure his body is as healthy and conditioned as possible to perform every night. But if he has it made up in his mind that he needs this surgery and is simply going through the motions, then I don’t believe it will be successful.
I have seen this happen often with patients referred to therapy, going through a trial of rehab before going under the knife. Some benefit but some see it as a necessary evil to reach the ultimate goal of surgery. Ultimately, it wastes everyone’s time, and then even afterward, sometimes the patient is still not satisfied with the outcomes. Surgery is not always the answer to correct a problem.
Add in the uncertainty of whether the artificial disc can hold up to contact sports in that there won’t be anything dislodged or other segments taking the brunt of the prosthetic in the area. Could there be severe complications that could be career-ending if hit the wrong way or the high-level athletics shorten the device’s longevity? Could he have recurrent revisions that force him to miss time later in his career?
There’s a reason we don’t see players getting hip and knee replacements during their playing careers, the prosthetics simply don’t hold up. The only athlete I can recall that returned to play following a hip replacement was Bo Jackson, but he was on the tail end of his career. There are simply too many unknowns.
Research must be done on this and maybe lesser players or players nearing the end of their career would be willing to take the risk knowing that they either can do the procedure and play or they retire. With Eichel, the stakes are higher not only for him but for the Sabres or whoever else if he ends up getting traded.
Decision Time
Normally I am pro-player, but I’m siding with the Sabres medical team on this argument. Jack Eichel needs to be saved from himself. The research isn’t there. Talk to me in 10 years and I might have a different answer. I wouldn’t risk the youth of an elite athlete on a procedure that doesn’t have a proven track record in contact sports. Either be successful with conservative care or get fusion surgery.
I really don’t believe he will have this disc replacement. I know Eichel is unhappy with the Sabres and disagrees with a lot of what they’ve done, but I think that this could be career-altering and short-sighted to push for the artificial disc. He either rehabs the neck and returns with conservative care on time or he has fusion surgery and has a delayed start to the season. This procedure may be the future, I like where things are heading, but it’s not the right decision right now for Jack Eichel.