Neymar Back Fracture… Ney-More Neymar: Out for 6-8 Weeks, at Least
I am sure you couldn’t miss the headlines over the weekend regarding the injury to star of the Brazilian World cup team, Neymar. I have seen thousands of patients with spinal injuries, but I rarely get the chance to see it occur in real time. In the clinical setting, I have to rely on what a patient recalls, often days after the event. My initial reaction, like many other fans, was that he was play-acting more than anything else. However, it was soon apparent that this was not the case.
What type of low back fracture has Neymar sustained?
There has been much speculation online with many reports making little sense. The first report I read suggested that he had a suspected compression fracture of the vertebrae. This type of injury is one of the most common types of spinal fracture I have come across in practice, but typically this low back fracture occurs with compression and flexion (forward bending) of the spine.
The most recent cases, which have presented at clinic, have related to one patient landing awkwardly when skydiving and another falling off a ladder. Both are classic mechanisms for a vertebral body compression fracture and involve considerable force. This was not at all in keeping with what I witnessed on television. Compression fracture can be associated with lower force, but only if the integral strength of the vertebrae body has been compromised by pathology (disease process), such as osteoporosis or a tumour. Neither are very likely to occur in a 22-year-old healthy male footballer. The other possibility was that the compression fracture was an old injury, may be a fall as a teen, previously missed on imaging, and was just an incidental finding that did not relate to injury during the game. Again, unlikely, given the level of medical experts at hand to assess Neymar.
More recent unofficial reports I have read give reference to a C-T scan and a much more credible diagnosis of a transverse process fracture at the L3 level (the third lumbar vertebrae). C-T scanning is the imaging of choice for bony injuries of the spine, as MRI scans are not as sensitive when looking at bone. The transverse process is a bony prominence which protrudes from the side of the vertebrae. This bony prominence serves as an anchor for muscle attachments, which stabilise the spine. It is a much less common injury for me to see in private practice. The cases I have come across have been avulsion type fractures. This means that the muscle that attaches to the transverse process had pulled so fiercely on the bone that they have detached it from the vertebrae body. My most recent case involving this type of fracture resulted from a patient falling off a horse into a ditch. This type of fracture is very unlikely to cause any nerve or spinal cord damage and the transverse process is a considerable distance away from the spinal canal.
My most recent online search regarding Neymar’s injury has revealed C-T scan images, allegedly of Neymar’s spine, and show a spondylolysis, a defect of the pars interarticularis, at the L4 level. It is beyond this blog to go into too much detail about this defect, but this is a very common diagnosis which I see on an almost monthly basis in private practice. It is very common amongst young athletes and is more often than not a fatigue type fracture which results from the bone failing due to repetitive flexion and extension (forward and backwards bending), particularly in young athletes who may have been exposed to these movements before they are skeletally mature. There is also good research to suggest some individuals are more predisposed to such injuries due to the shape of their spinal bones and joints. Again, this is very often an incidental finding which may have been present for years prior to the injury and may have only come to light due to imaging.
The C-T image shown is very suggestive of an older injury, as the bony edges of the defect appear sclerotic and rounded. This suggest the body has started to lay down more dense bone in response to the defect and reabsorbed some of the more jagged bone from the edges of the defect. This process occurs over months and years, which would suggest this is not a new injury, but an old one which is very frequently found in young athletes such as Neymar. I have also reviewed the video clip several times and normally a traumatic spondylolysis is associated with forced hyper extension (backwards arching) and compression of the lower back, but Neymar is very clearly flexed forward and not backwards when the knee hits his back. The blow is also half way up the number 10 on his shirt, not likely to be at the L4 level.
So where does this all leave us? Well not much better off than when I first witnessed the injury on Friday. My educated guess is it’s a transverse process fracture. The medical team involved should have access to the most advanced imaging technique available, as well as a wealth of other techniques such as MRI scans to see if there are any indication of local bony oedema (swelling) relating to recent injury/trauma. In addition, Neymar will no doubt have a wealth of previous imaging including spinal Xrays, MRI scans, particularly in light of his recent 57-million-Euros transfer to Barcelona. This would go a long way to answer my question and, obviously, will serve a far more reliable way of diagnosing his injury than my speculation based on dubious online reports and images!