On Thursday, we learned that the Colts’ star quarterback Peyton Manning underwent a third neck surgery, this one a one-level anterior cervical fusion procedure. That mouthful of a description means that only one disc in his neck was affected (“one-level”), that the entry was through the front (“anterior”) of his neck, that they removed the disc that had been causing him trouble, and that they inserted a graft to create a spinal fusion between the two surrounding vertebrae. Fusion stabilizes the space through which the spinal cord and nerves run, allowing the associated limbs to have feeling and strength. Given that the symptoms affected Manning’s triceps muscle (and confirmation from Sports Illustrated’s Will Carroll), we know that it was the C6 and C7 vertebrae (sixth and seventh from the base of the skull) that were affected. There are a number of things to write about this third surgery, some retrospective and some prospective. Starting with the retrospective… many are questioning why Manning didn’t have the initial surgery immediately following the 2010 AFC Wild Card loss. Despite rumors that Manning was injured early in 2010, despite the mysterious sleeve that Manning wore on his right, then left, elbow throughout the season, and even despite my eyes telling me that he was having difficulty with throws (I choose to forget that awful 3-game, 12-interception stretch), it was reported by Bob Kravitz on Friday, and again on Saturday by Peter King and by Mike Chappell that Manning’s troubles didn’t surface until after the end of the 2010 season. So the answer seems to be that he didn’t have surgery earlier because he didn’t have the pain or weakness until February or March. As I had conjectured in early June, and Will Carroll also explained, once Manning determined he needed some sort of medical attention, he likely put off surgery until the final moment where he could still be reasonably expected to recover and play in the 2011 season. If therapeutic means for recovery were available, it was more prudent to pursue those than to immediately go under the knife. So presumably, when the therapy wasn’t getting the job done, and training camp was looming (uncertainty due to the lockout notwithstanding), he opted for surgery. By all accounts, the expectation was a 6-8 week recovery with no implications for missed time in training camp. The next retrospective question has to do with the procedure chosen to address the injury itself. Manning’s procedure in May was performed by top neurosurgeon Dr. Richard Fessler in Chicago. The procedure chosen was a microdiscectomy, in which access to the offending disc is gained through the back of the neck. According to Dr. Rick Sasso of the Indiana Spine Group, Fessler is known for preferring this method over the anterior approach, probably due to its possibility of a speedier recovery as well as not compromising flexibility of the patient – clearly an important consideration for a professional athlete. The procedure is also preferred if the patient has bone spurs impacting the nerve, as they are more easily accessible from the back of the neck, and can also be removed or reduced during surgery. The risk of this surgery though, in terms of full recovery, is that the disc is either not sufficiently reduced or it ruptures again. Given Manning’s continued lack of triceps strength and his most recent surgery, it is logical to assume that this is what happened. Now looking ahead… lost amidst the predictions that the Colts will go 3-13 under QB Kerry Collins, and the “breaking news” that the Colts could opt out of Manning’s contract by February 2012, is the reality that Manning is a human being who has to heal and rehabilitate from a serious surgical procedure to a delicate part of his body. The Colts have announced that Manning’s rehab regimen will begin “immediately,” but what does that entail? Initially, Manning will be in a cervical collar “for an extended period.” For the first week or so, I would anticipate that exercise will be limited to short, easy walks and maybe light stretches. He may be able to participate in non-jarring cardio workouts, like riding a stationary bike. The bone graft will need to start integrating itself into the vertebrae it joins (an interesting side note – the graft may have been taken from Manning’s hip, from a cadaver, or made of man-made materials packed with shavings of Manning’s spine; regardless, because the graft does not have veins, it won’t be rejected). UPDATE: Jay Glazer reported that Manning opted for the more painful hip option bone. Don't let Glazer's report mislead you, however. That option is not as unusual as he indicates. In fact, according to Dr. Peter Ullrich, Jr., "This technique has been the gold standard since the 1950s." Manning may be able to be a bit more active if the bone graft has been reinforced with a metal plate screwed in to the C6 and C7 vertebrae, but he won’t be lifting weights or doing laps. He will also have to stay quiet for a while, as this surgery can impact the recurrent laryngeal nerve (i.e., his vocal cords). If that impact is long-term, this could affect his ability to be heard over the din at visitor stadiums. The final prospective question is whether this most recent procedure will “work.” Based on numerous reports, the answer is “most likely.” This article by the Mayfield Clinic cites a study that found that fusion (and its resulting stability) is successful in 93% of cases where just bone was used, and 100% where a plate has been screwed to the vertebrae. A study by spine surgeon Dr. Wellington Hsu found that many football players – including 4 quarterbacks – have successfully returned to the field after such a surgery. The real question is how well it will work. Doctors declared that the surgery went “’very well, without complication,’ and that his prognosis for recovery is ‘good.’” However, there is no information as to the extent to which Manning had been impaired. He had gotten to the point of throwing the ball, but there’s no knowing how much it hurt him each time to do so (especially when his grimace seems ever-present). Did he decide to undergo this surgery to simply sustain his quality of life? Or was it to have a serious opportunity to take the field again? Given the speed with which the decision was made, the surgery option he chose, and the simple fact that Manning hasn't yet retired, my assumption is the latter. Still, he has a tough, aggressive road ahead.