By Laurence E. Mermelstein, M.D.
I must admit that I got emotional watching Tiger Woods knock in his short put on the 18th green at August National and in doing so win his 5th Masters Championship. I am not a die-hard golf fan or a Tiger Woods apologist. But I am a Long Island orthopedic surgeon who has cared for people every week for the last 25 years whose lives have been altered irrevocably by spinal injuries. And where as I was never about to make a living playing golf, I am also a person who had given up golf due to issues with my own lower back. I am more aware than almost anyone how acute or chronic back issues cannot only cripple your body, but also your mind.
It Happens to the Best of Us
I am in no way making excuses for Tiger’s marital indiscretions – these have been well chronicled in the media over the last 10 years. But the infamous mug shot of him after being pulled over for driving under influence in May of 2017 hit me like a punch to the gut. Here was a golf “superman” – once the most dominant golfer on the planet and one of the world’s most famous athletes, reduced to a shell of a person. A person strung out on a mix of medications anyone with back pain and who has had surgery knows well – Xanax, Ambien, hydrocodone and Dilaudid. What came to my mind was a phrase I tell patients when they ask me “Why me? Why am I afflicted with back problems?” My answer is – with tongue in cheek – ”It happens to the best of us”. Meaning of course that it happens so commonly that someone does not need to be a professional athlete to have back issues. Simply being a human being puts you at risk. After watching all the news coverage of Tiger’s triumphant return at Augusta, and the re-birth of his golf career after his miraculous 4th surgery on his lower back, it dawned on me that that infamous night in Palm Beach, Florida, was a mere 1 month after this “life saving” operation. This made this story all the more real for me as I have witnessed the same struggles in my own patients – a real life and death struggle to combat pain and disability.
I have already been asked by a few of my patients if they were candidates for the “Tiger Woods surgery”, making me think of that other famous athlete whose name has become the colloquial name for an orthopedic operation – “Tommy John”. The difference was in 1974, when Dr. Frank Jobe performed this operation on the then Los Angeles Dodger’s pitcher, there were no other pitchers with a similar injury that had returned to throw after this injury. This was truly a novel surgery performed by a ground-breaking orthopedic surgeon.
The Surgeon’s Training and Experience Are Key
Tiger’s last surgery, an anterior lumbar interbody fusion (ALIF), was NOT a novel, new surgery performed by a ground-breaking surgeon. In fact, anterior lumbar fusion surgery has been performed for a variety of indications since the 1930s (initially described to treat TB of the spine). That being said, it is a select group of spinal surgeons today who maintain a busy surgical practice incorporating this surgery into their “armamentarium” of surgical options. My own training in anterior approaches to the spine dates back to my residency at Yale University with Dr. Wayne Southwick, one of the grandfathers of modern spinal surgery. We were trained to understand spinal anatomy and approaches from ALL directions – from the back (posterior), the front (anterior) and the side (lateral) to all areas of the spine (cervical, thoracic and lumbar). Having this knowledge and experience allows a spinal surgeon to choose from different approaches to treat a given patient’s spinal issue, if a surgery is justified. Each approach carries its own advantages and disadvantages, and potential complications. I tell patients that having these extra “tools in my bag” make the decision making a bit more complicated for me, but otherwise I feel that certain surgeries are a bit like forcing a square peg into a round hole – anything will fit with a big enough hammer!!!
The specific risk and benefits of each approach are beyond the scope of this article and would be best to discuss personally with your surgeon. Suffice it to say that if a surgeon is not experienced in ALL the different approaches to the spine, he may not offer or even discuss an anterior approach. Be sure to ask him how many he has done of each approach before you trust his opinion – or be sure to get another opinion.
Tiger’s Prior Spine Surgeries
In Tiger’s specific case, he had had at least three prior surgeries to his L5-S1 disc – the lowest disc in the lumbar spine. He had his first “microdiscectomy” – a minimally invasive partial removal of a herniated disc in March of 2014, followed by a second and probably third partial discectomy in September and October of 2015. He never fully recovered from these surgeries. The images of him taking a swing on the golf course and then crumpling to the ground in severe pain were heart wrenching to me. He continued to deteriorate until he was at times “unable to get out of bed”. He could not even think about playing golf, much less “going out to dinner” because it hurt to sit. He was distraught not being able to play sports with his two children. He relates in interviews that he had his last surgery for “quality of life issues”. He consented to his last surgery in order to resume a reasonable life with less pain, not in order to return to professional golf.
Why Not Use the Posterior Approach Again?
So when Tiger Woods’ surgeon offered him an “ALIF” surgery, I could appreciate the probable thought process that led to this choice of approaches. Tiger’s L5-S1 disc was completely worn out, “bone-on-bone” to use the expression from my joint replacement colleagues. It was probably relatively “unstable” – meaning that it was unable to withstand the stresses of normal daily activity, much less the torque of a golf swing, without out shifting painfully. So the “salvage” procedure is to remove the rest of that worn out disc and “fuse” the L5 and S1 vertebrae together and eliminate the painful unstable motion at that segment. This COULD be performed from a traditional posterior approach, using the scar that was already on his back and extending its length. The disadvantages of this approach are that it is impossible to remove the entirety of the worn out disc this way, it would necessitate placement of stabilizing screws and rods (or equivalent) instrumentation and would require manipulation of nerves that are encased in scar tissue from the previous surgeries. Most importantly, this approach would cause more damage to the important muscles of the back and cause more scar tissue to form in these muscles. This would create a longer recovery and in some cases, the muscles never fully recover. Some surgeons may advocate a “minimally invasive” posterior approach (a “TLIF”), thereby sparing some of the muscle injury, but the other issues would remain. To be clear, the procedure could be accomplished in this fashion, but would it be right for Tiger Woods? If the surgeon were not familiar or comfortable with the anterior approach, would he be trying to jam that square peg into the round hole?
Advantages of the Anterior Approach
Using the anterior approach to the L5-S1 disc by itself avoids injuring the back muscles altogether. The disc is directly visualized and the entirely of the disc can be removed. The disc space that was collapsed can be restored to normal height and alignment in a fashion that would be difficult otherwise. Now the advantages of doing this surgery in 2019 allow us to use the most modern prosthetic disc fusion spacers – or implants – in addition to using titanium screw anchors to rigidly fix the spacers to the bones. This allows rigid fixation without using supplemental “screws and rods” which would require additional incisions. The healing rate of a fusion performed in this approach is greater than 95% in most modern studies of the newest bone grafts and implant technology.
There Are Downsides as Well
As I stated above, every approach has it up- and downsides. One downside of an anterior approach is that is an abdominal operation. So in theory, the abdominal contents – bladder, bowel, blood vessels, kidneys, etc., can be injured. Abdominal muscles must be entered, but frequently these muscles are stretched, not cut. These muscles usually recover much quicker and more completely than the back muscles. There is also a small plexus of nerves too small to see that can be injured in men that may cause “retrograde ejaculation” – essentially a potential fertility issue. But in experienced hands, the incidences of these complications are less than 1-2% – but not zero.
Achieving the “Impossible”
So here I was in April of 2019, just over two years after Tiger’s “miraculous” surgery, watching him win his first major championship in over 10 years and the scene that literally brought me to tears was him leaning over to pick up his son and hug him. I can’t pretend to know exactly what was in Tiger’s mind at that moment, but to me, it was a hug of pure joy known to someone who had been to the depths of despair. Of someone who had reached for drugs like Xanax, Ambien, hydrocodone and Dilaudid to stop the physical and emotional pain that chronic pain can cause. Of someone who thought that picking up his son would never be possible again. Of someone who only wanted to be able to live a relatively normal life again. He, of course, was able to achieve much more than this. But in my practice, if I am able to restore my patients’ own quality of life, whatever that may mean to them, it is I that share in that pure joy with them. And if it can happen for Tiger Woods, why can’t it happen for them. After all, it can “happen to the best of us” and I hope it happens for all of us!
Disclaimer: Please note that the author of this article has not been involved in the medical care of Tiger Woods. Opinions expressed in this post are based on medical experience only.