Michael Porter Jr’s Microdiscectomy: Draft Steal or Buyer Beware?

microdiscectomy
Credit – Christopher Hanewinckel-USA TODAY Sports

After canceling his second pro day workout in the lead-up to the NBA draft, there’s been growing concern over Michael Porter Jr’s recovery from a microdiscectomy. This procedure on his lower back forced him to miss all but 53 minutes of his one and done season at Missouri.

The lingering questions and uncertainty surrounding his injury and recovery have bumped his stock from a sure-fire top 3 pick to a potential low lottery pick.

***Update: Michael Porter Jr. was drafted 14th overall by the Denver Nuggets***

With the NBA draft nearly upon us, I figured it’s as good of a time as any to give a quick rundown of his microdiscectomy procedure, recovery considerations, some of the lingering questions, and ultimately figure out the risk/reward of drafting him.

To understand his surgery, we have to first understand a little bit about the spine. Lets start with the anatomy and function..

I. The anatomy and function

The spine is a column made up of bones called vertebrae and between them are rigid yet flexible discs called intervertebral discs.

Here’s a picture of the entire spinal column (each segment is numbered):

microdiscectomy
Credit – Mayfield Clinic

A side-by-side of the spine and a segment:

microdiscectomy
Credit – spine institute

And now a zoomed in picture on a vertebrae and disc segment:

microdiscectomy
Credit – eorthopod.com

The primary function of the spine is to protect the nerves that run within it, which send nerve signals back and forth between the brain and rest of your body. They leave the spinal canal and travel to parts of your body.

Here’s a picture:

microdiscectomy
Credit – HealthLinkBC

The vertebrae themselves are tasked with supporting most of the weight that is placed on the spine whereas the discs function as shock absorbers and allow the vertebrae to move efficiently.

An intervertebral disc is comprised of an outer layer called the annulus and a soft inner core or nucleus (called the nucleus pulposus). Take another look:

microdiscectomy

The outer layer, annulus, is made up of strong fibers that help keep the softer core, nucleus, intact. This nucleus is comprised predominant of water which gives the disc its flexibility and shock-absorbing abilities.

A common analogy for the disc is to think of it as a jelly doughnut. The outer layer of the doughnut, analogous to the annulus, is the container for the soft jelly inside, analogous to the nucleus.

microdiscectomy
Credit – TheLittleLoaf

That’s the basic anatomy and function of the overall spine so now lets get into the injury itself…

II.  Michael Porter Jr’s Injury

Michael Porter Jr played just 2 minutes in his debut for Missouri before being pulled out of the game with what was originally called a “tweaked hip”. After the game, Coach Cuonzo Martin clarified that it was in fact Porter Jr’s leg that was causing him trouble. 

A week later, news broke that Michael Porter Jr’s injury was in fact a lower back injury, and he would undergo a “L3-L4 microdiscectomy”. L3-L4 refers to the third and fourth vertebrae in the lumbar (lower back) spine.  Each of your vertebrae are numbered top to bottom – from the neck down to your lower back/butt.

Here’s the same spine picture we started with:

microdiscectomy
Credit – Mayfield Clinic

If you feel the back of your neck or upper back (it’s a little tougher in the lower back), each of those bumps (known as a “spinous process”) corresponds to a specific vertebrae. Feel free to count them when bored.

So…if his original problem was in the leg or hip, what does that have to with the lower back?

Lemme explain.

If tears develop in the outer layer of the intervertebral disc, the inner core (nucelus) leaks (imagine poking a hole into the outside of a jelly doughnut with the jelly leaking out) into the spinal canal.

Like this:

microdiscectomy
Credit – Bandaide

This is commonly referred to as spinal herniation or disc prolapse. The disc nucleus leaking into the canal mechanically impinges onto the nerves and causes a chemical inflammatory reaction, both of which the nerves aren’t chill with. This can cause radiating nerve pain and muscular weakness.

The most common area for this is the lumbar (lower back) spine, accounting for nearly 95% of cases. When those nerves running through the lower back get upset, pain and changes in sensation can travel down into your hip and legs, with potential muscle weakness as well.

That’s why even though Michael Porter Jr. was feeling pain and weirdness in the hip and leg, the root cause being his lower back isn’t all that surprising.

So what caused tears in his disc?

Generally, every person develops small tears in their discs over time – it’s a natural part of wear and tear. If I took an MRI of the lower back of everyone in the US over 35, I could probably find a degenerative disc in most of them. However, there’s plenty of evidence showing that a spinal herniation doesn’t correlate to pain or dysfunction.

In some athletes, and most likely what happened with Michael Porter Jr, is that stress is being repeatedly placed to that specific area and disc, resulting in small tears over time. That’s known as a repetitive stress injury.

With all the jumping, landing, running, leveraged positioning, dynamic and high-impact movement, the disc is repeatedly and constantly stressed, resulting in micro tears and then the inner core starts to leak out.

For Michael Porter Jr, that leaking out did result in nerve pain and weirdness so it needed to be addressed. After evaluating and imaging, his medical team decided the best approach was a microdiscectomy of the disc between the L3-L4.

III. The Microdiscectomy

When a disc prolapse is accompanied by persistent nerve issues (termed radiculopathy), research shows that patients who undergo surgery like a microdiscectomy experience quicker improvements in the short-term compared to those who take more conservative approaches (like physical therapy management).

However, research further shows that substantial improvements are observed regardless and there appear to be similar outcomes in the long-term (within 2 years).

This was backed up a study on NBA players which compared those who underwent a microdiscectomy to those who had conservative (non-operative) treatment.  The surgery group performed better than the non-surgery group in the first year but no difference was seen in years 2, 3, or onwards.

That being said, in the case of a high-level athlete like Michael Porter Jr. who is trying to get back on the floor as quickly as possible and vying for the NBA draft, those short-term quick benefits are of the essence. A microdiscectomy makes sense.

So what is a microdiscectomy?

I know the words “back surgery” can result in a lot of fretting by fans and management alike; there’s a huge stigma and anxiety around any back-related injury. However, a microdiscectomy is a relatively basic (compared to other back surgeries), minimally invasive procedure that lasts about an hour.

A microdiscectomy is an outpatient surgery, like say a knee scope, where you’re only in the hospital for the day of the surgery and then go home. Michael Porter Jr. was likely moving and walking around pretty quickly after waking up.

The point of the microdiscectomy is to remove the portion of the disc that has leaked into the canal in order to relieve the pressure and reduce the inflammatory reaction.

It’s done by making a small (usually 1 to 1.5 inch) incision in the muscles to the lower back, inserting a tiny microscope to visualize the anatomy and guide the procedure, followed by removing a small portion of bone that protects the nerve root, and then, while making sure to not touch any nerves, removing any portions of disc that have prolapsed.

Here’s a helpful video (this is of the L4-L5 segment specifically but same concept):

https://www.youtube.com/watch?v=zg_YUYrTpDk

Once his surgery was complete, the next phase of Michael Porter Jr’s process began…

IV. Rehab and Recovery

Physical

The usual return to play timeline for a contact sport athlete recovering from a microdiscectomy is 3 to 4 months. Michael Porter Jr. returned to play for Missouri in March 8th (2018), very nearly 4 months post injury.

In those 4 months, the initial focus (commonly for 6 weeks but increasing evidence shows that early mobility is beneficial to long-term outcomes) was to allow the tissues to heal and restrict movements – such as bending over too far, extreme rotation, and combined bending/twisting/lifting that put a high load on the lower back.

After that initial period, the key focus of his physical rehab was increasing the strength and endurance of his core, hips, and back – I refer to these three as the “foundation”. They are central to all compound movements and provide a stable foundation that allows for effective and efficient movement of the limbs and entire body. In physical therapy, this is called “proximal stability for distal mobility”.

All three regions work in conjunction with each other (termed “interdependence”) during movement and provide support and stability – teamwork makes the dream work.

I think of interdependence like a series of chain links – the load and responsibility is spread out amongst each of them.  Here’s a nice visual:

microdiscectomy
Credit – Focus Physio

For example, when you rotate your upper body, there’s rotation occurring at both your spine and pelvis. Additionally, the core and hip muscles are helping to control that movement.

The core muscles actually extend most of the circumference of our torso, circling around to the back.  Check that out:

microdiscectomy
Credit -Brookbush

If one of these “links” gets weakened, then the rest have to pick up the slack. Over enough time and repetition, these chain links become over-stressed and eventually start to crack.

Same thing with the body. If there’s limited range of motion at the spine or pelvis or the core or hip muscles are weak or fatigued,that increases the stress and responsibility on the others, eventually leading to injury.

That’s why it was critical for Michael Porter Jr. to bolster and reinforce his core, hips, and back in order to get back from the microdiscectomy, and alleviate stress from his lower back.

Once he was cleared for on-court activities, on Feb 22nd, his progress followed an incremental progression from that to contact to full-contact and then to games.

During his return on March 8th,  he was on a minutes restriction. This stepwise progression of minutes is critical to allow his body to re-acclimate gradually and appropriately.  No amount of training or physical therapy is equal to the intensity and stress of actual games.

Throughout this process, he likely had muscle soreness and occasional spasms as his muscles continue to be challenged.  We have to recognize that injury recovery isn’t a straight line process (we all wish it was), especially when it comes to foundational areas of the body, like the back, that are involved in so many movements.

I’m not surprised he had some muscle spasms after this recent slew of high-intensity workouts and pro day. When you ramp up intensity level, the body reacts.

Mental/Emotional

Additionally, it was imperative to handle his mental and emotional state after he got injured and throughout his recovery.

Lets think about the full context of events for Michael Porter Jr:

  • He’s a the #1 recruit in his high school class coming off the holy trifecta high school awards: MVP of the McDonald’s All-American Game, Naismith National Player of the Year and and Gatorade Boys National Player of the Year
  • Considered the likely top pick in the 2018 NBA draft
  • He’ll be playing at Missouri alongside his brother, with their dad on the coaching staff
  • He gets hurt literally 2 mins into the season
  • Regardless of severity, he’s told that he has a back injury and needs back surgery. Those are never comforting words, especially for an athlete.
  • He now has to go through an extended rehab process where he isn’t with his team or teammates and not able to play the sport he loves
  • All the while, everyone is wondering how he’ll come back or if he’ll be the same player.
  • He comes back for 2 games and doesn’t look great. This is completely natural considering he hasn’t played a real game in 4 months but, as we see too often, there’s more hand-wringing and consternation about his return.
  • Most recently he re-schedules his 2nd pro day due to muscle spasms. This is accompanied by more worry from teams, additional testing and MRIs (all which came back completely sound)

This is an 18 and now 19 year old kid who went from likely #1 pick to having back surgery and not being able to play or be around his teammates like had envisioned to possibly sliding into the low lottery. That’s a whole lot to chew on.

That series of events could create anxiety, stress, and frustration in even the most stoic of individuals (that does make me wonder how Marcus Aurelius would deal with back pain).

These types of emotional and cognitive stressors aren’t conducive to healing so it was crucial for Porter Jr’s family, team, and support system to help him through these tough times. From everything I’ve seen, they have done so really well.

So now that he’s ramping back up to full or near-full activity, are there any short or long-term consequences for him….

IV. What Are the Short and Long-Term Implications for Michael Porter Jr?

Short-Term

In the short-term, we’ve already seen some of the negative consequences.

When he came back to play for Missouri, it was clear he wasn’t in game shape from an endurance or strength perspective.  His cardiovascular conditioning and physical strength will continue to improve throughout the summer and leading up to training camp.

Additionally, with all the NBA pre-draft workouts, pro days, and spotlight on his injury, he’s putting his body and musculature through a lot.  As I said before, I’m not surprised he had muscle spasms after this recent slew of activity.  However, I can certainly understand why he’s doing it because most lottery teams want to see what he can do after not having any tape on him from last season.

Long-Term

For the long-term, there’s a common thread amongst all the research studies that looked at athletes following microdiscectomy.

There’s a dip in performance for the first season but after that year performance rebounds to pre-injury levels.  This has been found across multiple sports including studies done on NFL and NBA players who had a microdiscectomy.

To that point, there was a really cool study of post microdiscectomy NBA players which tracked their respective performance (using PER as a metric, I know it’s not the best statistic but still a good reference point) in the years following the microdiscectomy.  The results found a decrease in games played and PER the 1st year back but no differences going forward after that, including career length.

Lastly, research shows that the chances of re-herniating the disc are about 10-12% for approximately the next 10 years.  That’s inherent to any person who gets microdiscectomy.

Some have compared Michael Porter Jr’s situation to that of Tiger Woods and Coach Steve Kerr’s, using the fact that all had a microdiscectomy as a fair comparison.

That comparison shows a lack of nuance as the similarities between the 3 start and end with the procedure.

In Tiger’s case, he plays a sport in golf that puts the highest load through the lower back, up to 10g forces of rotational force.

In Coach Kerr’s case, the issue wasn’t the microdiscectomy but rather the surgeon made a mistake and didn’t repair something he had nicked, leading to a plethora of problems (look up CSF fluid leak).

So what does this all mean for NBA teams?

V. The Overall Risk/Reward Takeaway

So here’s the takeaway with Michael Porter Jr:

Yes, he has an increased risk for re-injury and he likely won’t re-gain his complete form until next season.  However, he’s an extremely talented player and could become the prototypical wing that is a 3-level scorer, playmaker, and difference maker defensively.

In terms of pure risk/reward, I feel the 4 spot is where it begins to heavily tilt towards reward***.  You’re past the top 3 of Ayton, Doncic, and Bagley so at that point Porter Jr’s ceiling is arguably the highest of any remaining player.

***Update: He was drafted 14th***

From the standpoint of his career, his best landing spot is being drafted by a team that can ease him in slowly, allow him to re-acclimate, and take some of the pressure off of him.

If he somehow drops to #10 for Philly, that would be the ideal situation for him. The Sixers already have a great front-court with Embiid, Simmons, Saric, Covington, the spotlight is on their emerging stars, and Brett Brown’s offensive sets predicated on ball movement would set him up for a lot of advantage positions.

On the other hand, the worst spots I see for him are the Hawks and Cavs. In the former, he’s playing on one of the worst rosters in the league which puts a ton of pressure on him to deliver and he’s paired with a very one-sided big in John Collins.  In the latter, assuming Lebron leaves, he will have high hopes riding on him to fill a humongous pair of shoes.

High usage, pressure, and unfair expectations never mix well with a player trying to recover from injury.  Give the kid a season to gradually rebuild, strengthen, get into NBA level conditioning, and he could be a great wing.

***Update: I never thought he would drop to 14th so I didn’t even consider the Nuggets but they meet all the criteria I mentioned above to a tee – they have depth in the front-court, all-star and high-level players who take the brunt of the workload, and a system predicated on movement (with Jokic’s high post passing being the key) and unselfishness.  

All of these factors take the pressure and impetus off Michael Porter Jr. from having to shoulder the burden under a microscope and expectations, and he can take his time getting back onto the floor. 

As a Laker fan I hate that we went to an upcoming Western Conference team but for his health, career, and longevity, I’m very happy for him.***

Until next time.

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