Vincent Lecavalier's Lower-Back Fracture

EDITOR'S NOTE

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 8^th, 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 30^th. 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, Lecavalier

Source: http://www.nhl.com/scores/htmlreports/20132014/PL020398.HTM

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 8^th. 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 3^rd 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 30^th 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.