August 19, 2011

Collateral Damage

Pain in the Neck

by Corey Dawkins and Ben Lindbergh

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Michael Cuddyer, MIN (Cervical disc herniation) [AGL: 4 (73DL), ATD: +.011 (-.011DL)] (Explanation)
Cuddyer's neck pain was the result of inflammation from a herniated disc, and he underwent an epidural injection. He’s had a bulging disc in his upper back/lower neck since at least 2004 and has dealt with the periodic flare-ups well enough. The goal of the epidural injection is to allow him to recover more quickly.

We've talked about epidural injections before, but we haven’t discussed how they are performed. An epidural is an injection of strong anti-inflammatories similar to cortisone in the area just outside the sheath surrounding the spinal cord, called the dura. Injections follow a pretty standard protocol and take between 15 and 30 minutes to perform. Often the injections are performed in a series of three or more, spread out over several weeks, in order to provide maximal benefit.

After entering the room, the patient will usually change into a hospital gown for improved visualization and easier access to the injection site. The patient will then lie face down on an x-ray table under a fluoroscope—a machine that takes real-time x-rays—to make sure the needle will be in the proper position. The area of the neck designated for the injection will then be cleaned and draped to ensure a sterile field.

After a local anesthetic numbs the skin, the epidural needle will be inserted and guided under fluoroscopy to the proper spot. Often when the needle reaches the proper position, the patient can report feeling a cold sensation or sense of pressure in the back away from the injection site. In order to ensure that the anti-inflammatory medication reaches everywhere it needs to be, a very small amount of dye is often used and injected into the epidural space. The anti-inflammatory is then injected before the needle is slowly withdrawn. The procedure may be uncomfortable but not overly painful, much like the preceding paragraph may have been for those of you who don’t like thinking about needles.

The medication usually takes anywhere from 24 to 72 hours to take full effect, although some people report immediate relief. These injections are geared to relieve symptoms caused by the inflamed nerves of the neck and not other injuries like stress fractures. For the best chance at full resolution of symptoms, repeated injections are often performed over a three- to six-week period.

Cuddyer's symptoms will likely improve following the injection, but the degree of improvement remains to be seen.

Kevin Youkilis, BOS (Sore back) [AGL: 3, ATD: -.004]
Youkilis' back has been bothering him for some time now, and lately it started to flare up more. The Red Sox called it soreness when they placed him on the disabled list, but that term could include anything from disc injuries to stress fractures, as we have seen this season.  He has battled through back spasms a few times in his career, so having back pain now is nothing new to him, raising the concern level. He did have an injection, though, which makes a stress fracture less likely. Manager Terry Francona and Youkilis don’t seem too worried about the pain, and both believe he will be able to return when eligible on September 1st.

David Ortiz, BOS (Right heel bursitis) [AGL: 3 (50DL), ATD: +.028 (+.021DL)]
Big Papi’s bursitis seems to be a bigger issue than the Sox originally thought it would be. Ortiz now hopes that he doesn't miss more than a week, but these injuries can be difficult to resolve in a short amount of time. One of the more common areas of bursitis in the foot is the retrocalcaneal bursa, which is located between the Achilles and the heel bone. The bursa is often pinched between the two as a result of friction that thickens the bursa and starts a painful cycle that is difficult to break. By the end of the weekend, we should know more about where this is headed.

Jason Kipnis, CLE (Right Hamstring Tightness) [AGL: 1 (23DL), ATD: -.017 (+.018DL)]
When Kipnis started his major-league career, he did it in true rollercoaster fashion, starting off slow and then hitting home runs in four straight games. A large component of success at the major-league level is the ability to stay healthy, an area in which Kipnis will hopefully improve.

Already battling a right oblique injury for the past several days, Kipnis was scratched from the lineup Thursday with right hamstring tightness. It would be extremely rare for an oblique muscle to cause the hamstring to tighten. Therefore, the hamstring has also likely been an issue; now that his oblique has improved, the hamstring has become the main focus. Other than the hamstring not being better after several days off, there are no signs that a move to the disabled list is in his near future.

Philip Humber, CHA (Head contusion) [AGL: 1 (TBD DL), ATD: -.043 (TBD DL)]
The line drive off of Kosuke Fukudome's bat struck Humber just above the right eye and knocked him to the ground. There has not been an official diagnosis yet for Humber, but he will be reevaluated over the next several days. He got up quickly enough and was standing on the mound with his cap back on by the time the athletic trainers reached him. He walked off the field under his own power and appears to have avoided major injury. We will see how quickly he progresses through the concussion protocol over the next several days, and whether he’ll be diagnosed with a concussion at all.

Randy Choate, FLA (Left elbow inflammation) [AGL: 36, ATD: -.037]
A pitcher's performance doesn't always suffer prior to his being diagnosed with elbow inflammation. Choate had been pitching well all season before being placed on the disabled list Thursday with inflammation in his left elbow. As you can imagine, inflammation takes a longer time to calm down in pitchers, but the limited amount of pitches that he is expected to throw may allow him to return sooner than a starting pitcher could. Regardless, he's going to miss at least a few weeks, and if there is any setback he may miss the rest of the season.

Flesh Wounds: Carlos Ruiz, testicle contusion. Enough said... Oakland pitcher Trystan Magnuson was placed on the disabled list with right shoulder inflammation... Denard Span was placed on the disabled list with migraine symptoms... Brian Wilson remained sidelined from right elbow soreness, although there were no structural issues, according to Dr. Andrews... Rickie Weeks has been taking some light batting practice, an important step in his recovery from an ankle sprain. He's likely at least a week away, though... Bryce Harper left yesterday's Double-A game with a strained right hamstring. It should be minor, given that he walked off the field showing only a slight limp... Reliever Brian Sanches was placed on the disabled list with a right elbow strain... Ryan Westmoreland will watch live pitching for the first time since undergoing brain surgery.

Corey Dawkins is an author of Baseball Prospectus. Follow @CoreyDawkinsBP
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Ben Lindbergh is an author of Baseball Prospectus. Follow @benlindbergh
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