32 Thoughts: The Podcast - Why Eichel Wants a Disc Replacement

Episode Date: July 31, 2021

Dr. Chad Prusmack is a neurosurgeon based in Colorado who has provided Jack Eichel with a recommendation to correct a herniated disc in his neck by proceeding with artificial disc replacement surgery. Jeff and Elliotte chat with Dr. Prusmack about the procedure, the recovery and the risk associated with the surgery, and why this surgery […]

I'm rolling. Here we go. Coming down in three, two, and one. At the heart of the issue between Jack Eichel and the Buffalo Sabres is a surgery that many in hockey consider controversial, while others maintain it should be commonplace in the sport as it is in others. Welcome to 31 Thoughts, the podcast presented by the GMC Sierra AT4. Elliot, our guest today is Dr. Chad Prusmak.

He's a neurosurgeon out of Denver, Colorado. And if it were up to him, Jack Eichel would have artificial disc replacement and Prusmak himself would perform the surgery. Yeah, this is an interview, Jeff, we've chased for a long time. And for a while, Dr. Prusmak was not willing to do it. They wanted to keep it quiet. They didn't want to put it out there, but I guess it's been long enough now that he's finally agreed. And as you said, he's a neurosurgeon. His specializations include the spine and in concussion recovery. And he's also the founder of a data-driven human performance center called Resilience Code in the Denver area. Now, as you said, he would like to perform the disc replacement on Jack Eichel.

As many of you know out there, hockey fans, people around the game, the Sabres are against this idea and believe to prefer a fusion. Now, this is key, and you'll hear Dr Dr. Prosmak refer to this a couple of times. Under the terms of the CBA modified in the summer of 2020, the Sabres do have final say on the matter. The way it's written, they have the power. And one of the reasons Buffalo has said no to this point is that no NHL player has ever had this procedure and returned to play. So like a lot of fans, we have questions. Why do this?

Why would it be better than a fusion? What are the risks? Jeff, are you a doctor? No, I play one on the podcast sometimes though. You stayed at a Holiday Inn last night. I'm not a doctor either. So we've wanted Dr. prasmac here to explain and the key thing that we all felt here jeff and i and amal who produces is that we wanted it to be on

the podcast i i didn't want to write a story about it we wanted it on the podcast so everyone can listen and formulate their own opinion no editing no tone misunderstood we ask he responds you know a lot of us following the eichel saga are not qualified and have no clue about the medical dispute hopefully you all hear this and have a better understanding of what eichel is wanting to do okay dr prussmack did some research into him he's consulted with the NFL's Denver Broncos for 17 years and I found some positive reviews into his work one of the players was a wide receiver by the name of Emmanuel Sanders who's been in the league 12 years and now plays for the Buffalo Bills another player who credited him with really helping his neck area was a defensive end Derek Derek Wolfe. There was one player I found who challenged the diagnosis of his,

linebacker Al Wilson, and Wilson pursued a lawsuit a decade ago because Prusmak said he didn't need surgery. Wilson later failed a physical with the New York Giants. When it went to court, Prusmak was exonerated. He won the case. More recently, one of the players I understood he helped was Nolan Patrick, recovering from concussion issues. And I reached out to his agent, Rich Evans, as part of this. And Evans called Patrick, who gave Dr. Prusmak a positive review. Earlier this year, he also performed back surgery on Dr. Mark Lindsay. Dr. Lindsay is well known in the sports world, chiropractor, soft tissue specialist. A lot of players believe in him. He's highly sought after. A couple years ago he was a key part of Connor McDavid's recovery from the serious knee

injury and you'll remember that that was a process that was new at the time. So I was comfortable pursuing Dr. Prusmak for the podcast based on all the information we were able to collect about him, Jeff. Okay. And one thing that you will hear over the course of the interview is the acronym ACDF. That stands for anterior cervical decompression and fusion. So when you hear ACDF, that's what Dr. Presmak is referring to. And just so you know, in the notes and on the tweets, some of the studies he's referred to, we asked him to send us the links and he sent them and we included them. So you have more

information about that as well. I freely admit this is way out of my depth, but I think it's important for everyone to hear what exactly it is that Eichel would like to pursue and why. This is Elliot and I punching above our weight here on 31 Thoughts. Dr. Chad Prusmak, neurosurgeon, talking about Jack Eichel. Dr. Presmak, first of all, thank you so much for joining us today. And just so we sort of begin with an understanding, because Elliot and I aren't doctors, we just play one here on the podcast. What is the issue with Jack Eichel?

Let's begin there. Thank you for having me on, guys. I appreciate the opportunity to explain this really important story. Jack Eichel has a disc injury in his neck. That disc injury is causing impingement of neurologic structures, and it has not responded to conservative care, meaning that physical therapy, therapy, sports therapy, etc., he's still symptomatic, and follow-up scans has showed this persistent issue. So I believe that there's a unanimous sort of understanding that he needs a surgery. There are two surgeries that are offered in the neck for

this problem. One is called an anterior cervical discectomy infusion that's been around much longer than the second treatment, which is newer since the year 2000, which is an artificial disc replacement. And so the treatment for a lot of disc injuries has to do with going through the front of the neck, removing the disc, which is the problem. And then the question becomes, well, what do you do after the disc is removed? In the first surgery that I talked about, the anterior cervical discectomy infusion, anterior cervical discectomy and fusion, you put a little graph in and you then put a plate and screws and you hold those bones together so that it becomes one bone. That's called a fusion. The other option is once that disc is out to put in an artificial disc. In concept,

just like an artificial hip, artificial knee. It maintains motion and it allows better flexibility. And these are both just, you know, no, like these are both phenomenal procedures. The difference is it's what procedure you use in each particular person and why. particular person and why. So there are a lot of pros and cons to either of those procedures. The fusion is a very good success rate. And these success rates for both of them are in the 90s. However, it's been well documented in the literature, an ACDF, sometimes the bones don't heal. Sometimes, you know, the screws and instrumentation extrudes or fails. And it then has a bit of a higher complication rate. With an artificial disc, you're not waiting for anything to fuse. The neck is already moving. It's just the opposite. You want their neck to move so you can sort of lubricate that new joint. The most important

thing, not specific in this case, but what was bothering people about the fusion, which made such a pressure on getting this artificial disc to market, was there's one problem with fusion that happens later in life. And that's because when you restrict motion in a specific disc level fusing say bones five to six that gives you extra pressure on the discs above and below that's called a decent segment breakdown or adjacent segments stress and this is a very key component in Jack's case and in just, you know, our total outcomes. Because around 25% of patients who've had a fusion need another fusion within 10 years. In fact, it's something like after two-year follow-up, you're having double the amount of degenerative disc findings at the above and below level with the fusion than you are with the artificial disc. These are big differences because at the end of the day, every surgery has a risk.

If one surgery is leading to another surgery, and because Jack is so young, it is more likely than not he will need another fusion if he is to get that, where an artificial disc does not have that issue. In fact, the 10-year reoperation rate for an artificial disc is around 4.5% to 5% in comparison to that 25%. So what then, I mean, we understand from how you're describing the two, artificial disc replacement and ACDF, it sounds like the artificial disc replacement is less risky. And obviously, as you mentioned, there'll be less stress involved. I do wonder about what type of post-surgery issues would there be for Eichel as an athlete looking to get back as soon as he could, what type of post-surgery issues or post-surgery rehab would Eichel be looking at? So they vary differently from both of those procedures. So let me start with the fusion. Remember, goal one from the discectomy and fusion is get the patient out of pain and get that disc

off of that spinal cord or nerve. That's why we're doing it. The second part, which is what you do with the joint by stabilizing it, you want that to stay still. So like the reason we break our arm and we need a cast, the cast needs to keep things still so that the bones have a high propensity to grow right back across where they were fractured from. Well, the same thing goes into a spine fusion. If you remove the disc and you put in a spacer of bone, that bone needs to be held in place. And held in place means not moved around. That's what the the plate is, the screw and plate that goes into the front. Now, because the recovery depends on, okay, now I'm out of pain. Okay, now things are off of my spinal cord. Now I need this thing to fuse. Well, you can't do a lot when you're waiting for it to fuse. Sure, you can walk,

you can do low impact exercises, keeping the neck in the stationary, you know, region. But at the end of the day, you're looking at an evaluation in three months in order to see whether that's fused, where a doctor says, you know what, you can go out and play and not worry about the fusion. And when you look at the studies, like there is, I think, a study where someone went back to play six weeks after a fusion, which is very uncommon. But the average, when you look at these meta-analyses, are somewhere in the seven, eight, and nine-month range. So that's a big difference because the type of post-operative instructions I give to a patient with an artificial disc is almost the opposite. I say move your neck normally right after surgery. We're going to do low impact exercises, core exercises and physical therapy for six weeks. Well, at six weeks, if the x-rays

look good, you look good. It's around that time where the bone actually grows into the disc. So it's not going to come out. And the patient can go back to playing, you know, return to performance at that time. So the difference between six weeks and six months, especially in Jack's case, because this unfortunate issue is deferred the kid from getting a surgery. And, you know, this makes a difference. The question that the Sabres have brought up repeatedly, Dr. Prosmak, as you know, is this has never been done on a hockey player. They don't want to be the first case. How can that concern or that worry be overcome? How can that concern or that worry be overcome?

I first want to say that I respect all of the spine and neurosurgeons who have weighed in on this. And he's been seen by good doctors. I would also like to comment that, you know, the vantage point with which we make decisions as doctors, I have one invested interest. It's the well-being today to perform and for the life of Jack Eichel. That's what's important. And I have to see that 360-degree view of his future because I'm the one that has the experience in having done over a thousand of these things. Okay, if you're from the vantage point of the Sabres, or any team for that matter, just to keep it out of the Sabres' hands, in any teams, it's like, well, they have to mitigate risk for their team. I mean, it's a business.

I believe everyone cares for each other. But, like, the sort of glass that they look through is a different color than the one I am. And so that intrinsically, you have a different decision-making process. I obviously can't tell you why or what they're thinking, what they do. I think a cervical fusion is an excellent option. I don't think it is the best option for Jack, nor do I feel that it is for any hockey player, if you ask my opinion. Now, using the statements that, well,

in the NHL, it's never been done. Okay, from a risk management standpoint, that's great. But from this young adult standpoint, that's not optimal. And I think that he would perform better. I think that he has a safer, I think he'll have a better outcome. I think that he'll be more of the natural elite athlete he is, restoring the motion that he earned from all of his workouts and all of his brain-body connections. Well, let's restore the motion so he can perform at the elite level he does. So the fact that it hasn't been done in an NHL hockey player, it has been done in hockey players, just not in the NHL, is important because I don't think that's an argument or you would never make medical advances in any rhyme or reason. This is not an experimental procedure.

This is established in the literature, the artificial disc, of being superior to the ACDF. The difference is in the NFL, not at NHL, they've studied this anterior cervical discectomy infusion, and they have shown that you have over 70% return to play. In a different sport, in a different mindset, and in a different way that you use your neck, they've said that that's safe and that's established. Well, once a doctor can rely on the literature, their liability gets sort of diffused.

And it's also helpful to know that, hey, my peers and I are thinking the same thing. That still does not mean that the same doctors that are saying ACDF, if it was their kid, they would want, in my opinion, an artificial disc. Now, that's notwithstanding the NHL issues he's going through, but it is exactly what I would give my kid, and it would be exactly what I would get if i was in jack eichel's shoes i just want to ask you a bit more doctor about hockey players who've had it before can you go a bit more in depth on where that is or who that is so we can have a frame of reference to it let me go into

the athletes and i'll end up there so just we're aware, this is done and published in rugby players for several years. The artificial disc has been put in UFC champions who have fought several fights. And just mind you, they're getting kicked in the head. They're getting neck cranks. They're getting forces that are completely different than hockey and they're battle tested in football there hasn't been one with an artificial disc well i kind of agree with that and why is that well it's because of the type of hit you get it's a blunt head-to-head impact now you can't spear anyone in hockey. And when people get quote unquote laid out, you know, it's like a whip. I mean, their head gets whipped back and so forth. Like that's what the artificial disc is made for.

It's made to handle motion. It's made to handle those movements. That's why athletes do so good with it. In comparison, I will tell you, I would be much more concerned if I had a fusion patient that got hit. Why? Because that impact is being imparted to the levels above and below, and that is an accelerated risk. In fact, in one of the studies of NFL players, sure, there was about an 80, 80-something percent rate of return to play but they only played an average of 1.5 years since that there were people that had career ending injuries to

the neck that had to stop playing within three years so it's not a free ride i mean i don't know why this is such a conclusive you know argument eyes because, heck, I mean, there's not great literature to say that it's optimal. There's literature to say that it's been done in the NFL. To answer your question specifically, yeah, we have patients that we've done hockey, high school, the collegiate level, but there has not been anyone in pro. I have done them in UFC fighters. I have done them in rugby players. I've done them in non-NFL football players. I'm very confident that this is a safe implant, and I'm very confident that this is the right choice for Jack. And most importantly, Jack Eichel wants the surgery. It's his human right to get a surgery. It's his body.

Is there one or are there a couple of athletes, doctor, that you're using to guide this process with Jack Eichel, whether it's a football player, rugby player, MMA fighter, whomever? Is there one sort of model that you look at and you say, maybe, and this is really base here, but Jack, it worked for him and I think it'll work for you. So the answer is twofold. One, if you look at Chris Weidman, UFC champion, and see what he's been through since he had the artificial disc, this is public knowledge. This is not a HIPAAAA violation you'll see this thing can take damage rugby players we have patients that have go out and just get their their heads torn off we have never had a problem in the industry I have talked to several engineers from several

companies and in these companies I asked them has there ever been a catastrophic injury not reported you know that you find from car accidents or for other sports that I wouldn't know? And they say, no, there's very minimal catastrophic injuries that you can point the finger at an artificial disc. It doesn't mean they're not out there, but you'd be surprised at how many people in car accidents who unfortunately pass, their autopsy shows that their disc is still intact. And it's also the experience. I mean, once you do this as many times as I have, you don't need to be a brain surgeon to figure out like, this is a better

health choice. And yeah, I don't know what it will be like in an NHL 100%. But an NHL player, the ice allows the physics in order for the head to move more freely, you know, take less impact. And importantly, like that guy's slap shot and the way he's got to use his position sense, he's going to lose that if he gets a fusion. When you fuse the spine, like, it's hard to know where your head is on top of your shoulders. That's very interesting you mentioned that, because that's one of the things I did want to ask you about. The idea of, and this happens to, you know this a lot better than I do,

with athletes, when you're hesitant in play because you're not sure about your body, when you're hesitant in play because you're not sure about your body, that can lead to further injury. You know, the idea that, you know, clothes are at its best function when you don't notice you're wearing them. What has been the feedback from athletes going back into their sport after A, having the surgery and B, doing the rehab? You know, it's very rare in life surgeons say this. This is one of those operations. They wake up from surgery and they want to hug you. It is extremely effective. It's extremely safe.

Of course, things happen. But nonetheless, not only does it translate into directly post-operatively excellent outcomes, you know, from my standpoint, but the speed with which they can get back to sport in six weeks, the excellent way that they can continue their training to continue to handle more load, do higher speeds. And then at six weeks or eight weeks, if they're in shape, start contact. It's been excellent. From a performance standpoint, especially in MMA fighters, like the amount of what's called proprioception or position sense of the head relative to the body is critical or you get knocked out. This is a term called neuromechanical coupling.

It's the coupling of the system of the brain and the body that needs to work as a symphony, such that your wind instruments pay perfectly with your brass instruments. And, you know, if one person's playing off tune, well, then the music sounds horrible. Well, that's the brain being the conductor, such that every body part works to Jack Eichel's music. Well, you put a fusion in there i'll tell you like that is disrupted gary wilkerson a very bright doctor from university of tennessee published a lot of papers on musculoskeletal injury after head injuries and neck injuries because people lose their position sense of the rest of their body so you want to make Jack Eichel as close of an identical twin to what Jack

Eichel is after the surgery. And by restoring a same or very close amount of motion to a person that now you take out of pain, that's your best bet. I'm very confident with that. And the MMA fighters that have had them will definitely corroborate that as will the rugby players the buffalo news did like a piece on this a couple weeks ago where they interviewed a dr meckler who's a neurologist locally and his question was a lot of professional athletes have used this procedure for the lower back with relatively good results was his quote patients improved in about 84 of cases that's the lower back but we're not talking about the lower back here the fact that it's the neck area is that any more of a concern it's much less of a concern

and i don't know any professional hockey or football player that has the lumbar. But I think honestly bringing that up, this is a whole different set of circumstances. The physics of the low back versus the physics of the head. The low back is a load-bearing segment. It handles weight. A motion-bearing segment is what the neck is used for. These are extremely, extremely effective in the neck. And every study will show it. I mean, it is shown to be not only the same as the fusion,

but has now surpassed it in outcomes. So I don't know what parallel he's making or why. I don't know professional NFL or NHL players that have that. I don't even know really how we could use that in a academic way to make a just decision about a human being I've examined, I've taken care of, and that I recommend what I've recommended. I respect and understand the ACDF element. It's a good option, but it's inferior in this case barring this one question of hey no one's that in the nhl well all right well that's fine but chris weidman uh and others um had the same choice and it's not like they had a uh you know a rolodex of people they could call to say how am i going to do in this and the the fact is, is as a doctor, I got to look at the whole picture. I mean, I don't want to see Jack Eichel because we defaulted to a surgery he did

not want. That again, ACDF is a great option. And that when he's 60 taking care of his grandchildren, he's had fusions up and down the spine and maybe has difficulty swallowing, et cetera. And it's my job to make sure that he not only performs in a safe way, but he wants to perform as him and that he has someone, although he doesn't know the importance of how, when we get older, how important your function is, I have to be his advocate for that. And if anyone says a fusion is better for someone in the long run, they are not telling the truth or they don't know the literature. You know, a couple of quick conversations and a cursory gloss of the internet.

When it comes to the ECDF, the two things that jump out for me, as you mentioned, you know, long-term, one, the chance for arthritis and two, progressive weakness as well. Two things. What am I leaving out when it comes to long-term effects of the ACDF? And what do you see as long-term effects for disc replacement? all to do with once you, again, fuse to a part of the spine, the adjacent level takes up the stress. Therefore, if you double the amount of forces in a given day of someone, you're going to over double the force on the adjacent levels. So it's a fulcrum, right? Now you have a fulcrum right next to a fuse non-mobile segment. You can't just take up the slack like a whip or a snake does. Instead, you have a very stiff bamboo trunk that's now adjacent to the joint, which will put pressure on. So in the long term, it will degenerate faster. You will potentially need 25% chance every 10 years that you're going to need another fusion. And that doesn't mean it

stops there. If you do a fusion in 10 years, you reset the clock, 25% chance we'll need another fusion. So now you're taking this decision today of, well, are we really assessing the risk today of one surgery or should we be telling Jack, hey, Jack, just so you know, it will most likely be three surgeries before your elderly. And we should talk about all of those complications and risks. Where when you look at the artificial disc, it offloads the adjacent level. It becomes mobile. Now that mobility gets to distribute the load and the motion and the performance around his neck. So there is no adjacent levels or segment problems. So it's a one and done surgery

most of the time. I think that the 10-year follow-up study showed somewhere in the 4.8% re-operation rate for an ADR relative to in the 20s for ACDF. Is there any danger of the discs moving or anything like that? You have to go back in and fix something like that. moving or anything like that you have to go back in and fix something like that i'm glad you brought that up so when you look at these obviously if something's still moving you don't want it to dislocate or fail or break and you know once a bone fuses that level is protected but that's not the risk that you've just incurred in the patient. It's the level above and below that are moving and their disc could herniate. And that's what happened in patients who played in the NFL for two, three years. They had injuries to their neck and the adjacent level herniated. So in the artificial disc, yeah, you don't have that problem.

And the artificial disc allows for movement that's natural and it shares the load. So when it doesn't work, I have never had any of them fail or break. I have had to replace about five of them because despite my best efforts and x-rays, they still hurt or there was some other problem. Guess what the salvage procedure is? It's a fusion. So at the end of the day, Jack's worst day is, well, we converted to a fusion and people can point their finger at me, which I'm fine with. But on the other hand, the reality is, is there's not a lot of catastrophic injury. We've operated on Navy SEALs, special ops. They get sent back six weeks.

They can be fighting by eight weeks. So we have a really, really good track record. We just don't have a track record in the NHL, but we have no catastrophic injuries abroad that are recurrent or at a level that's unexpected and concerning. How did you meet Jack? you know, unexpected and concerning. How did you meet Jack? So I do see independently a fair amount of hockey players from several different teams, whether it be for concussion, neck evaluation, just performance stuff. But there is a Dr. Mark Lindsay, who is a phenomenal PhD neuroscientist and phenomenal body work guy who is smart as heck. And he sees these patients conservatively and sends them to me. And I serve as, I think, a good, well-read, well-experienced neurosurgeon who's the independent consultant for the Denver Broncos

for the past 17 years. He sends me and I give a lot of opinions and take care of a lot of his patients, including him. Okay. I have a couple more. Number one, could he play without a surgery? I would recommend against it. Okay. Secondly, what are our timelines here? We're seven weeks away from the start of training camp now. If he was to get the fusion for argument's sake, how long would he be out? In my practice, three months. That varies across the nation. Understood. What about if he was to have the artificial disc replacement? How long would he be out? Everything goes well. Implant in place on flexion ascension x-rays, asymptomatic, and he is in shape six weeks. So training at full velocity, no contact at week six,

and then potentially contact at somewhere between weeks eight and 12. But that's more of a return to performance thing, you know, based off the strength and conditioning coaches, the PT, mobility and stuff like that. But at six weeks, studies show that the implant, the artificial disc has been integrated into the bone. The bone has grown in it that it's as strong as it's going to get. And his neck muscles haven't atrophied. He's not in the neck brace. He's moving his neck normally.

He's doing the light to moderate exercise from day one. It's just not the heavy strenuous and contact stuff. Well, you got to hope also if you do the fusion, we're sitting around at month three. If that x-ray doesn't show fusion, now what do you do? Okay. Damn. I don't know if it's fused.

Should we let them play? I mean, I've had to evaluate a lot of football players about that that have played for the Broncos and it's a hard call, but every call is a person to person judgment. It is not a blanket vaccination about what everyone should get. That's not the way that it works. We treat people. We don't treat governing bodies. We don't treat 10, 12 people in one fell swoop.

Here's one. I'm trying to get half the National Hockey League in trouble. Have any other teams surreptitiously reached out to you to ask what it is that Eichel wants to do here? Absolutely none. Zero. Okay. I tried.

You can't fault me for trying. Yeah. No, I mean, not even close. I wish I had enough time, but no, honestly, not nobody. I've said a couple of different, in a couple of different places that if we, if we took the NHL rule book and handed it to doctors and said, here, rewrite the rules so you'll be happy, the game would look profoundly different. I think that's a pretty easy assumption to make. If we handed you the NHL rule book and said, redo this so you're happy, what would you do? I mean,

you see players that have significant head, neck, spine trauma. If you could, how would you change the rulebook? In any event, it has to preserve the human right that a person gets to choose what happens to their body as long as they've had in force sense that is a basic human right that could be a violation of his human rights to feel that he feels coerced to going back to a team or not being cleared once he gets the artificial disc. As a doctor, I can't fathom this. And I don't understand why the collective bargaining agreement has some discrepancies here.

I mean, I'm not a lawyer or anything, but at the end of the day, I was Jack's second opinion. The gentleman at Buffalo were their first opinion. They have a great surgeon one of the best in the world and us together we had differing opinions yet Jack who wants to undergo the correct informed consent surgery based off of what his and my beliefs are he can't I mean okay so what are we going to do just start tell anyone can tell me what surgery i can and cannot perform and what surgeries get performed on me and i don't have a

choice of my body it's absurd so you ask me the question of like how would i like to see it you know i don't know the specifics but it's very easy The player chooses at the end of the day. And you do need representation from the team because the vantage point with which they're looking at this is more of a risk mitigation. And I have no problem with that. I've helped the Denver Broncos do that. And we have a great relationship. The guys at the Broncos are great. And I understand, you know, what our role is. Our role is to inform consent, you know, assess risk and treat with consent of the patient. At the end of the day, no matter how many opinions you get, if there is a balanced argument for two procedures, which this is, remember, this is probably superior in the NHL. I can't say that I have the literature, but it's safe because someone's published it in the NFL and maybe five NHL players for an ACDF. That's the basis of saying, well, haven't done it now. Maybe optimal, or we don't go to medical school and we don't go to meetings. We don't argue about this. We do this because at the end of the day, my responsibility is to get Jack what I think is best for him in the context of his case. And as the, one of the best players, that kid deserves, you know, this option. And if he chose the fusion, I disagree with it, but I totally get it.

And I would back him for it because that's his choice. And if he said, you know, I don't want to be the first guy in hockey to get this. And that worries me. And you got it. No problem. Then have at it. But it's not the case. The case is, this is a smart man with a smart family who's done his research and he's a great person and I just don't know how a job can get in

such of a way of a person getting the right surgery for their well-being I don't understand it. High tops, they start You're on the run High tops, they start What are you afraid of? We can figure it out I'ma pick you down I'll wait around

On the other side of town Stay up through the night I'll drive if you ride I'ma pick you down On the other side Nighttime stays tough And I bet you wanna get around It's all too much Can we try to make it better now? You only call me when it's Saturday Bye.