Cervical Spine Injuries In Athletesi

Robert G. Watkins, IV, MD, and Robert G. Watkins, III, MD O

1. What sports are associated with the highest risk for head and neck injuries?

The organized sports with the highest risk for head and neck injuries are football, gymnastics, wrestling, and ice hockey. Football is the sport associated with the highest risk of such injuries. Head and neck injuries also occur in a variety of nonorganized sports activities including diving, skiing, surfing, and trampoline use.

2. What types of cervical injuries must be considered in an athlete injured in a sporting event?

Sports-related cervical injuries can involve the muscles, ligaments, intervertebral discs, osseous structures, and the neural structures they protect. Injuries to consider include muscular strains, intervertebral disc injuries, major/minor cervical spine fractures, stinger/burner injuries, and transient quadriplegia. In addition, preexisting cervical conditions predispose an athlete to neurologic injury and may be discovered during subsequent evaluation. These include congenital cervical stenosis, Klippel-Feil syndrome, and os odontoideum.

3. If a player suffers a traumatic neck injury on the athletic field, should the headgear be removed?

It is important to engage in spinal precautions and leave the headgear in place until the cervical spine can be completely evaluated. The team personnel should have a means available for removal of the facemask so that the airway is readily accessible. Immediate removal of the helmet should not be performed until the proper medical personnel are prepared for an emergency situation. If circumstances require helmet removal, the shoulder pads should be removed at the same time because removal of only one piece of equipment can lead to a significant change in spinal alignment. When lifting a player with a suspected cervical injury, the physician should stabilize the head and neck to the torso by placing his or her hands under the scapulas and stabilizing the head between his or her forearms. Details of the methods and techniques for on-the-field management and transportation of the spine injured athlete are available at http://www.spine.org/ Documents/NATA_Prehospital_Care.pdf

4. What is the most common sports-related injury of the cervical spine?

The most common sports-related injury of the cervical spine is a muscle strain. Direct trauma to the head or neck leads to eccentric contraction and muscle stretch injury. Sprains of the facet joint capsular ligaments may also occur. Patients report neck pain, muscle spasm, and limited cervical motion. Initial radiographs are obtained to rule out significant injury. The neck is immobilized, and symptoms are treated with nonsteroidal antiinflammatory drugs (NSAIDs), analgesics, and immobilization. In patients with persistent symptoms, magnetic resonance imaging (MRI) is performed to rule out a traumatic disc herniation or major ligamentous injury.

5. What is a "hidden flexion injury" of the cervical spine?

This term refers to a purely ligamentous injury associated with three-column disruption of the spine, including injury to the posterior longitudinal ligament, facet capsule, ligamentum flavum, and interspinous ligament in the absence of osseous injury. Such injuries can be missed on plain radiographs. Persistent posterior cervical tenderness following an acute injury should raise concern about this injury pattern. The lateral cervical radiograph should be carefully evaluated for subtle increase in the distance between adjacent spinous processes. Cervical MRI is useful to evaluate for posterior cervical ligamentous disruption. Physician-supervised flexion-extension lateral radiographs are considered only for alert, cooperative, and neurologically intact patients and are not advised or considered useful in the immediate postinjury period. Commonly used criteria for defining instability between motion segments in the subaxial cervical region are 11° greater angulation than an adjacent segment or 3.5-mm translation relative to an adjacent vertebra (Fig. 60-1).

6. What is the clinical presentation of a traumatic cervical disc herniation?

The clinical presentation of a traumatic cervical disc herniation is variable. Patients may present with isolated neck pain, radiculopathy, or an anterior cord syndrome with paralysis of the upper and lower extremities. In contrast to adults, immature athletes most commonly develop disc herniations at C3-C4 and C4-C5. Disc injury is associated with axial loading and hyperflexion during activities such as wrestling, diving, and football.

Figure 60-1. Hyperflexion ligament injury not apparent on neutral lateral cervical radiograph. A, Neutral position lateral radiograph of a trauma patient with cervical spine tenderness is unremarkable. B, Repeat view shows C4-C5 injury (arrowhead) with mild flaring of the spinous processes (open arrow) and facet joint widening. (From Mirvis SE. Spinal imaging. In: Browner BD, Jupiter JB, Levine AM, et al. Skeletal Trauma. 4th ed. Philadelphia: Saunders; 2008.)

Figure 60-1. Hyperflexion ligament injury not apparent on neutral lateral cervical radiograph. A, Neutral position lateral radiograph of a trauma patient with cervical spine tenderness is unremarkable. B, Repeat view shows C4-C5 injury (arrowhead) with mild flaring of the spinous processes (open arrow) and facet joint widening. (From Mirvis SE. Spinal imaging. In: Browner BD, Jupiter JB, Levine AM, et al. Skeletal Trauma. 4th ed. Philadelphia: Saunders; 2008.)

7. What biomechanical force is the primary cause of fracture dislocations involving the cervical spine during football?

The National Football Head and Neck Injury Registry demonstrated that most cervical fracture dislocations occurred with axial loading of the cervical spine during headfirst contact. However, the full spectrum of major and minor spinal injuries has been reported in association with football injuries.

8. What is spear tackler's spine?

Spearing refers to contact at the crown of the head while the neck is maintained in a flexed posture. In this posture, the normal cervical lordosis is no longer present, and the cervical spine is predisposed to injury. Injuries due to this mechanism have been described in football, diving, and hockey. Spear tackler's spine was defined by analysis of football players with spearing injuries and is considered to be a contraindication to participation in contact sports. Criteria for diagnosis include:

• Developmental narrowing of the cervical spinal canal

• Persistent straightening or reversal of cervical lordosis on erect lateral cervical radiographs

• Posttraumatic radiographic changes on cervical radiographs

• History of use of spear tackling techniques during athletics

9. What is the most common neurologic injury in an athlete following impact to the head, neck, or shoulder?

Stingers or burners are the most common athletic cervical neurologic injuries in this setting. Symptoms result from injury to the brachial plexus or cervical nerve roots. Stingers have been reported to occur in up to 50% of athletes involved in contact or collision sports.

10. What is a stinger or burner?

A stinger or burner (burner syndrome) is a peripheral nerve injury associated with burning arm pain and paresthesias. A stinger presents with unilateral dysesthetic pain that often follows a dermatomal distribution. It may be accompanied by weakness, most often in the muscle groups supplied by the C5 and C6 nerve roots (deltoid, biceps, supraspinatus, infraspinatus) on the affected side. Although pain frequently resolves spontaneously in 10 to 15 minutes, it is not uncommon to have trace abnormal neurologic findings for several months. Normal, painless motion of the cervical spine is generally present and is crucial in distinguishing a stinger from other types of cervical pathology, such as disc herniation, foraminal stenosis, or fracture. Bilateral symptoms suggest a different etiology, such as a neurapraxic injury of the spinal cord.

11. What injury mechanisms are responsible for a stinger or burner?

Three different mechanisms have been described:

1. Hyperextension, compression, and rotation toward the involved arm, thereby closing the neural foramen and causing a nerve root contusion. This mechanism is essentially a replication of Spurling's maneuver

2. Lateral neck flexion associated with a shoulder depression injury, resulting in brachial plexus stretch

3. Direct blow to the brachial plexus with resultant injury

12. Describe a rational treatment protocol for an athlete with a stinger.

Most stingers resolve within minutes. For an athlete's first episode, with only brief transitory symptoms, treatment is conservative and no special testing is required. The athlete is permitted to return to unrestricted activity after complete resolution of symptoms if a normal neurologic examination, negative head compression test, and pain-free and unrestricted cervical range of motion are present. The athlete should not be allowed to return to sports until symptoms completely subside. Further workup is directed at patients with persistent symptoms or recurrent episodes to assess for other cervical problems, such as fracture, stenosis, disc herniation, or instability. Workup includes cervical radiographs with physician-supervised flexion-extension views, single-photon emission computed tomography (SPECT) bone scan, MRI, and electromyography (EMG).

13. What is the role of EMG in assessing the athlete who experiences a stinger?

If the symptoms have not resolved by 3 weeks, it is reasonable to obtain an EMG. This test can help define the specific nerve root involved and determine the degree of injury. Results of this test may lag behind an athlete's recovery, however. Players who demonstrate clinical weakness and moderate fibrillation potentials on EMG are withdrawn from play. When sequential EMG studies reveal spontaneous, mild, or scattered positive waves with end-motor recruitment (findings consistent with reinnervation), the athlete may return to sports provided painless and unrestricted cervical range of motion and full muscle strength are present.

14. What types of cervical stenosis affect athletes?

The same types of cervical stenosis affect athletes and the general population:

1. Developmental or congenital stenosis (typified by short pedicles and decreased sagittal diameter of the spinal canal)

2. Acquired stenosis (associated with osteophytes and degeneration at the level of the disc space)

15. What is cervical cord neurapraxia?

Cervical cord neurapraxia with transient quadriparesis and quadriparesthesia is characterized clinically by an acute transient episode of bilateral sensory and motor abnormalities. Sensory changes may include numbness, burning, tingling, or anesthesia. Motor changes may include paresis or paralysis of the arms, legs, or both. Neck pain is generally not present. An episode of cervical cord neurapraxia generally resolves in less than 10 to 15 minutes. The most commonly described mechanism of injury is axial compression with a component of either hyperflexion or hyperextension. This syndrome has been reported in association with cervical spinal stenosis, kyphosis, congenital fusions (Klippel-Feil syndrome), cervical instability (traumatic or developmental), and intervertebral disc herniation.

16. Is transient cervical cord neurapraxia associated with permanent neurologic injury?

A single event of uncomplicated transient cervical cord neurapraxia is not associated with permanent neurologic injury. However, two or more events increase the risk of permanent neurologic injury.

17. What is the risk of reoccurrence of transient cervical cord neurapraxia after the athlete returns to contact sports?

Studies have shown that 56% of athletes returning to contact sports experienced a recurrent episode of transient cervical cord neurapraxia. This number was higher when an athlete returned to football as compared with other sports.

18. Define the Torg ratio.

The Torg ratio is determined on a lateral cervical radiograph as the sagittal diameter of the spinal canal (a) divided by the anteroposterior vertebral body diameter (b) (Fig. 60-2). The sagittal diameter of the spinal canal is determined by measuring the distance between the middle of the posterior surface of the vertebral body and the nearest point on the spinolaminar line. This ratio method avoids the potential for error secondary to radiographic magnification when absolute numbers are used to determine the sagittal diameter of the cervical canal.

Figure 60-2. The ratio of the spinal canal to the vertebral body is the distance from the midpoint of the posterior aspect of the vertebral body to the nearest point on the corresponding spinolaminar line (distance a) divided by the anteroposterior width of the vertebral body (distance b). (From Torg JS, Pavlov H, Genuario SE, et al. Neurapraxia of the cervical spine cord with transient quadriplegia. J Bone Joint Surg 1986;68A:1354-70.)

Figure 60-2. The ratio of the spinal canal to the vertebral body is the distance from the midpoint of the posterior aspect of the vertebral body to the nearest point on the corresponding spinolaminar line (distance a) divided by the anteroposterior width of the vertebral body (distance b). (From Torg JS, Pavlov H, Genuario SE, et al. Neurapraxia of the cervical spine cord with transient quadriplegia. J Bone Joint Surg 1986;68A:1354-70.)

19. What is the significance of the Torg ratio?

A ratio less than 0.8 suggests the presence of cervical spinal stenosis. The Torg ratio is a highly sensitive method of determining cervical stenosis (93% sensitivity) but has an extremely low positive predictive value for determining future injury (0.2%). It is not a useful screening method for determining athletic participation in contact sports and should not be used as the sole criterion for the diagnosis of cervical stenosis in an athlete. Although an athlete may have the same size spinal canal as a nonathlete, the athlete's vertebral body may be larger, thus falsely lowering the Torg ratio and implying stenosis. In addition, the Torg ratio has not been correlated with the development of permanent quadriparesis in athletes. The Torg ratio should not be used as the sole criterion in making a return-to-play decision after an episode of transient quadriplegia.

20. What is the most reliable way to identify cervical spinal stenosis?

MRI or computed tomography (CT)-myelography is the most reliable way to identify cervical spinal stenosis. Cross-sectional imaging with these modalities permits the relationship between the osseous spinal canal and spinal cord diameter to be determined. The most important parameter is the presence of an adequate protective cushion (functional reserve) of cerebrospinal fluid (CSF) around the spinal cord.

21. Describe a rational treatment protocol after an episode of transient quadriparesis.

Immediately following an episode of transient quadriparesis, the athlete should be prohibited from continuing to participate in the sport for that particular event, even if a full recovery occurs soon after the episode. A thorough history of all events leading up to and following the episode should be carefully documented. A complete onsite physical examination should be performed. Even if symptoms are momentary or resolve, a radiographic examination should be performed on a timely basis. The athlete should be considered to have a fracture until proven otherwise, especially if the patient complains of persistent or significant neck stiffness or pain. If a neurologic deficit is present at the time of evaluation, then a cervical orthosis should be applied and the patient should be transported for medical treatment and appropriate imaging studies.

22. What factors should be considered in making a return-to-play decision for an athlete after the first episode of transient quadriplegia?

Return to play guidelines following a single episode of transient quadriplegia have been proposed by Cantu and permit return to contact sports if there is complete resolution of symptoms, unrestricted cervical range of motion, normal cervical alignment, lack of spinal instability, and absence of stenosis on cervical MRI or CT-myelography. Contraindications to return to sports include instability, deformity, and loss of CSF functional reserve.

23. When should an athlete be allowed to return to play following cervical injury?

There are no universally accepted guidelines for determining when an athlete may return to play after a cervical injury. Basic principles guiding decision making include:

• The athlete should be symptom free with respect to neck pain

• Unrestricted and pain-free cervical motion should be present

• Neurologic evaluation should be normal

• Full muscle strength should be present

• There should be no evidence of radiographic instability, abnormal spinal alignment, or other spinal abnormalities on advanced imaging studies

General guidelines for return to play following cervical injury have been defined and are modified appropriately according to individual clinical factors. It is helpful to divide athletes into three general groups:

1. No contraindication to return to play

2. Relative contraindication to return to play

3. Absolute contraindication to return to play

24. Summarize guidelines for return to contact sports without contraindication for commonly encountered cervical spinal conditions.

The following conditions are considered to permit return to contact sports without restriction after comprehensive patient assessment:

POSTTRAUMATIC

• Healed, stable C1 or C2 fracture (treated nonoperatively) with normal cervical range of motion

• Healed stable subaxial spine fracture without sagittal plane kyphotic deformity

• Asymptomatic clay shoveler's fracture (C7 spinous process fracture) CONGENITAL

• Single-level Klippel-Feil deformity (excluding the occipital-C1 articulation) without evidence of instability or stenosis noted on MRI

• Spinal bifida occulta DEGENERATIVE

• History of cervical degenerative disc disease that has been treated successfully in the clinical setting of occasional cervical neck stiffness with no change in baseline strength profile

POSTSURGICAL

• After anterior single-level cervical fusion (below C3-C4), with or without instrumentation, that has healed

• After single- or multiple-level posterior cervical microlaminoforaminotomy OTHER

• Prior history of two stingers within the same or multiple seasons. The stingers should last less than 24 hours, and the athlete should have full range of cervical motion without any evidence of neurologic deficit

25. Explain what is meant by a relative contraindication to return to contact sports.

A relative contraindication to return to contact sports is defined as a condition associated with a possibility for recurrent injury, despite the absence of any absolute contraindication. The athlete, family, and coach must be counseled that recurrent injury is a possibility and that the degree of risk is uncertain.

26. List commonly encountered cervical conditions that are relative contraindications to return to play.

• Previous history of transient quadriplegia or quadriparesthesia. The athlete must have full return to baseline strength and cervical range of motion with no increase in baseline cervical neck discomfort and imaging evidence of mild-to-moderate spinal stenosis

• Three or more stingers in the same season

• A prolonged stinger lasting more than 24 hours

• A healed single-level posterior fusion with lateral mass segmental fixation

• A healed single-level anterior fusion at C2-C3 or C3-C4 (sports that require head contact increase the risk of future injury)

• A healed, stable, two-level anterior or posterior cervical fusion with or without instrumentation (below C3-4) (sports that require head contact increase the risk of future injury)

• A healed cervical laminoplasty (sports that require head contact increase the risk of future injury)

• Cervical radiculopathy secondary to foraminal stenosis

27. List absolute contraindications to return to contact sports.

PREVIOUS TRANSIENT QUADRIPARESIS

• More than two previous episodes of transient quadriplegia or quadriparesthesia

• Clinical history or physical findings of cervical myelopathy

• Continued cervical neck discomfort or any evidence of a neurologic deficit or decreased range of motion from baseline after a cervical spine injury

POSTSURGICAL

• History of C1-C2 cervical fusion

• Three-level spine fusion

• Status post cervical laminectomy SOFT TISSUE INJURY OR DEFICIENCIES

• Asymptomatic ligamentous laxity (i.e. greater than 11° of kyphotic deformity compared with the cephalad or caudal vertebral level)

• Radiographic evidence of C1-C2 hypermobility with an anterior dens interval of 4 mm or greater

• Radiographic evidence of a distraction-extension cervical spine injury

• Symptomatic cervical disc herniation OTHER RADIOGRAPHIC FINDINGS

1. Plain radiography

• Evidence of a spear-tackler's spine on radiographic analysis

• A multiple-level Klippel-Feil deformity

• Clinical or radiographic evidence of rheumatoid arthritis

• Radiographic evidence of ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis

• A healed subaxial spine fracture with evidence of a kyphotic sagittal plane or coronal plane abnormality

2. Magnetic resonance imaging

• Presence of cervical spinal cord abnormality noted on MRI

• MRI evidence of basilar invagination

• MRI evidence of Arnold-Chiari malformation

• MRI evidence of significant residual cord encroachment after a healed stable subaxial spine fracture

3. Computed tomography

• C1-C2 rotatory fixation

• Occipital-CI assimilation

Key Points

1. During on-field evaluation of the injured athlete, a significant cervical spinal injury should be suspected until proved otherwise.

2. In the absence of special circumstances, such as respiratory distress combined with inability to access the patient's airway, the helmet should not be removed during the prehospital care of the injured athlete with potential head or neck injury. However, the facemask should be removed at the injury scene to permit airway access.

3. A stinger or burner represents a neuropraxia of cervical nerve roots or brachial plexus and typically presents with unilateral symptoms.

4. Cervical cord neuropraxia is characterized by an acute transient episode of bilateral sensory and/or motor abnormalities involving the arms, legs, or both.

Websites

Brachial plexus injury: http://emedicine.medscape.com/article/91988-overview Cervical spine injuries in sports:

http://emedicine.medscape.com/article/1264627-overview Prehospital care of the spine-injured athlete: http://www.spine.org/Documents/NATA_Prehospital_Care.pdf

BiBLiOGRAPHY

1. Cantu RV, Cantu RC. Current thinking: return to play and transient quadriplegia. Curr Sports Med Rep 2005;4:27-32.

2. Clancy WG Jr, Brand RL, Bergfield JA. Upper trunk brachial plexus injuries in contact sports. Am J Sports Med 1977;5:209-15.

3. Levitz CL, Reilly PJ, Torg JS. The pathomechanics of chronic, recurrent cervical nerve root neurapraxia: The chronic burner syndrome. Am J Sports Med 1997;25:73-6.

4. Torg JS, Corcoran TA, Thibault LE, et al. Cervical cord neurapraxia: classification, pathomechanics, morbidity, and management guidelines. J Neurosurg 1997;87:843-50.

5. Torg JS, Pavlov H, Genuario SE, et al. Neurapraxia of the cervical spinal cord with transient quadriplegia. J Bone Joint Surg Am 1986;68A:1354-70.

6. Torg JS, Sennett B, Pavlov H, et al. Spear tackler's spine: An entity precluding participation in tackle football and collision activities that expose the cervical spine to axial energy inputs. Am J Sports Med 1993;21:640-9.

7. Vaccaro AR, Klein GR, Cicotti M, et al. Return to play criteria for the athlete with cervical spine injuries resulting in stinger and transient quadriplegia/paresis. Spine J 2002;2:351-6.

8. Vaccaro AR, Watkins rG, Albert TJ, et al. Cervical spine injuries in athletes: Return to play criteria. Orthopedics 2001;24:699-705.

9. Watkins RG. Spine in sports—criteria for return to athletic play after a cervical spine injury. Spine Line 2001;2(4):14-16.

10. Weinstein SM. Assessment and rehabilitation of an athlete with a stinger: A model for the management of noncatastrophic athletic cervical spine injury. Clin Sports Med 1998;17:127-35.

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