Instant Analysis: J.J. Watt Undergoes Surgery

Scott Peak

J.J. Watt, defensive end for the Houston Texans, recently underwent surgery to repair a disc herniation, and his return is reportedly 6-8 weeks or longer (~10 weeks). Watt is the most valued asset in IDP formats, and this news naturally rocked the fantasy landscape. At DLF, we think about not only short-term but long-term impact of these injuries on our fantasy teams. In this article, we will discuss lumbar disc herniations, treatment options and how it might impact Watt (2016 production and overall dynasty value).

There are 31 spinal nerves originating from the spinal cord, two exiting both sides of the spinal column from the cervical, thoracic and lumbosacral spine. Spinal nerves serve a variety of roles, but at its basic level, transmit electrical signals from the brain and deliver them to a variety of end-points such as muscles, tendons and organs. Spinal nerves take information from the body and deliver it to the brain (sensory), such as pain.  Spinal nerves also serve a motor function, delivering messages that execute movements. The concern with a disc herniation is that it can result in pain, loss of sensation and/or weakness if not treated promptly.

Here is a useful diagram1 that shows a disc herniation and how it impacts nerves exiting the lumbar spine:

back 1

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Intervertebral discs are shock absorbers, and help distribute force down the spine. Vertebral bodies are bones at each level of the spine, and serve a protective role. Note how vertebral bodies stack on top of each other, from the upper (cervical) to the lower (lumbosacral) spinal column. Ligaments in the spinal column are weaker behind discs, and fluid contents in the disc can rupture, resulting in pressure on a nerve as it exits the spinal column (hence ‘pinched nerve’).

In anatomical terms, the spine can flex and extend. For example, bending over to tie shoes wouldn’t be possible without our spinal column being able to flex and extend. Force is also transmit from top to bottom of the spinal column. There are muscles on either side of the spinal column that help to stabilize it, and maximize efficiency of movement. This is why being overweight or poor conditioning can lead to a back injury, as either excessive force is transmitted down the spinal column, and/or muscles important to maintain efficient movement may not be strong enough. The bodies of elite athletes are placed under much greater stress, and the impact of poor conditioning (see Karlos Williams) can increase risk of injury. Lastly, once the normal dynamics of spine movement have been altered, there is an increased risk for future injury, as force is not distributed as efficiently, placing greater stress on intervertebral discs.

Here is an MRI of a disc extrusion2:

back 2

Take a look at the disc, in this case at the L5/S1 level. Disc height is much smaller than at upper levels, as the disc material has ruptured into the spinal canal, pushing on spinal nerves. Pressure on nerves can result in pain, weakness or even bowel/bladder problems.

Reports are that Watt underwent surgery for a disc herniation, and is predicted to return in 6-8 weeks. This timeline is consistent with a percutaneous microdiscectomy, and this is a minimally invasive approach to removing disc fragments pushing on nerves. As compared to surgical removal of the disc, bone grafts and fusions, recovery is faster with a percutaneous microdiscectomy. Elite athletes often choose this approach, as it gets them back to playing much faster than invasive surgical removal of the disc. There is a sizable difference in timeline to recovery for microdiscectomy (6-8 weeks) versus more invasive surgical disc removal (20 weeks or longer).

In reviewing the literature, there aren’t optimal data on microdiscectomy for this issue, and that would entail prospective, randomized controlled trials. Still, there are published data for our reference that may prove helpful in this case. Keep in mind that Watt is truly elite, a top-of-the-spear player in a sport with world-class athletes. Watt is not the typical situation for anything published in the literature, so his outcome may ultimately be determined by himself. I expect Watt to far exceed expectations, but the question is, what are those expectations in the medical realm?

There are several published articles on microdiscectomies on elite athletes. Overley et al3 published a meta-analysis on it, and concluded that 83.5% of athletes are able to return to competition after a microdiscectomy for a single-level lumbar disc herniation. In this meta-analysis, one cited reference (Weistroffer, 2011, 66 athletes) evaluated NFL defensive linemen, 80% were able to return to play, and played an average of 36 games for 3.2 years (+/- 2.4 years) after surgery. In this study, microdiscectomy had superior outcomes (80% return to play) compared to non-surgical management (28% return to play). Without surgery, defensive linemen had a lower return to play (3 out of 9 or 33%), played fewer games (4 games +/- 8) and an average of 0.8 years played (+/- 1.3). These data might explain why Watt opted for surgery now, although non-surgical management can successfully treat lumbar disc herniations in most cases. A second cited reference (Watkins, 2003, 171 athletes) noted 89% of athletes returned to play an average of 23 weeks after surgery.

Eddy et al4 noted some success with conservative treatment for lumbar disc herniations (MRI resorption of 75% to 100% disc material in 46% of patients), and 42-56% of patients who failed conservative treatment responded to epidural steroid injections. Importantly, for those who underwent discectomies, 92-98% had improvement in symptoms. A critical piece of information in this article concerns timelines for outcomes. Athletes who undergo microdiscectomies who play non-contact sports need 6-8 weeks recovery before returning to play, as compared to 4-6 months for contact sports.

I’m not suggesting that Watt will need 4-6 months to recover from surgery.  Watt is an incredible physical specimen, and outcomes for most athletes may not be predictive of his return to play. Notably, these studies are low quality, and how to apply these data to truly elite athletes like Watt is debatable. We know Watt will get the fullest attention from an elite group of doctors and trainers. The Texans have a lot invested in Watt, and he doesn’t have to worry about getting cut or waiting in line for his rehabilitation. The value in published literature is in understanding that a 6-8 week timeline is the best possible scenario for Watt. If published literature is correct, Watt is at risk for missing more than just a few games.

Watt is a defensive lineman, playing a contact sport, and is pushing against 300+ pound offensive linemen every play. Per Pro Football Focus, Watt played 651 pass snaps, 404 run snaps, for a total of 1055 snaps in 2015, or 65 snaps per game. That’s a lot of stress on his body. I’m not at all concerned about Watt returning to play, and as a dynasty asset, his value is secure. I have no doubt that Watt will return to play, and at his previous level of dominance. But, will that be 6-8 weeks or will it take longer? Robert Quinn played only 8 games in 2015, and his season ended with a back injury and surgery for it. Quinn is still recovering, and his participation in training camp remains to be seen. Quinn seems to be following that 4-6 month timeline. Jason Pierre-Paul had back surgery in June 2013, had a projected recovery of 12 weeks, and played 11 games in 2013 on a down year (20 solo tackles, 2 sacks).

While Watt has a shot to return in 6-8 weeks, I think that timeline is a bit generous. Realistically, Watt seems likely to miss some games, but it’s tough to predict when exactly when he will return. Based on present literature, I feel comfortable that he will eventually return to play, and at his usually dominant level. I don’t think his dynasty value is adversely impacted, and I’d be looking to acquire him in IDP leagues from panicked owners. There may be a window to get Watt at a discount, especially if his recover takes longer than 6-8 weeks, and his IDP owners get nervous. How effective he will be in 2016 is questionable right now, but his long-term outlook is good.

References:

  1. com staff. “Blausen gallery 2014“. Wikiversity Journal of Medicine. DOI:10.15347/wjm/2014.010. ISSN 20018762. – Own work
  1. https://en.wikipedia.org/wiki/Spinal_disc_herniation
  1. Overley et al. Return to Play in Elite Athletes After Lumbar Microdiscectomy. Spine 2016; volume 41(8): pp 713-718.
  1. Eddy et al. A Review of Spine Injuries and Return to Play. Clin J Sport Med 2005; 15: pp 453-458.

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