Cervical-Spine Injuries: Catastrophic Injury to Neck Sprain. Seth Cheatham, MD

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1 Cervical-Spine Injuries: Catastrophic Injury to Neck Sprain Seth Cheatham, MD 236

2 Seth A. Cheatham, MD VCU Sports Medicine I have no financial disclosures Contact sports, specifically football, places athletes at risk for cervical spine injuries Affects players of all positions and levels of play Can range in severity from a cervical strain to catastrophic cervical fractures/dislocations with complete neurologic deficit 237

3 Significant efforts have been made to minimize injury Changes in technique Rule changes Equipment modifications Improvements of on and off field care of injured athletes Despite these efforts, cervical spine injuries remain a serious concern in sports The purpose of this talk is to cover a range of cervical spine injuries encountered in today s athlete and touch on appropriate recognition and treatment Commonly referred to as a stinger One of the most common injuries in contact sports Represents a reversible peripheral nerve injury of the upper extremity that results from temporary physiologic block in nerve conduction 238

4 Characterized as a unilateral burning pain radiating from neck, down the arm to the hand Pain lasts seconds to hours, and rarely beyond 24 hour period Also associated weakness of the deltoid, spinati, biceps On exam, pain free ROM of neck, no TTP of cervical spine, Spurling s test negative 3 mechanisms of injury: Compression of cervical nerve root Traction/stretching of brachial plexus Direct trauma to brachial plexus at erb s point 5 10% of players w/ stingers have more serious injuries Symptoms > 2 weeks, 2 or more stingers, or neurologic deficits should be evaluated for possible spinal cord injury AP and Lateral flex/ex films, MRI Return to play criteria include absence of symptoms, normal strength, and painless full ROM of cervical spine 239

5 Collision injury frequently seen in contact sports Athlete complains of jamming their neck with pain in cervical area Presents with limited ROM but no radicular symptoms or paresthesias Neurologic exam is negative If the athlete does not have full, pain free ROM on sidelines, they are done for that game Cervical strains usually resolve with or without tx Using a soft collar, NSAID s, PT may be appropriate in some players AP and lateral flex/ex films are indicated after symptoms resolve (usually normal) Marked limitation of cervical motion, persistent pain, or radicular sx may require MRI 240

6 Also referred to as transient quadriplegia First described by Torg et al. in 1986 as clinical manifestation of neuropraxia of the cervical spinal cord due to hyperextension, hyperflexion or axial loading. Characterized by temporary pain, paresthesias and/or motor weakness in > 1 extremity with rapid and complete resolution of symptoms and normal exam within 10 minutes to 48 hours after the initial injury Torg reported incidence of 7 per 10,000 NCAA football players per year in 1984 More recent studies have demonstrated lower rates possibly due to changes addressed earlier Routine x rays show no evidence of fracture or dislocation, but cervical stenosis present Defined as having 1 or more vertebra having a canal body ratio of 0.8 or less (Torg Ratio) 95% of cases have fallen below this value at 1 or more levels 241

7 Of note, Herzog and colleagues, pointed out that although the Torg ratio has a high sensitivity, it had a poor positive predictive value in football players due to their size Space available for the cord (SAC) may be better predictor Absolute contraindications include a documented episode of cervical cord neuropraxia with any of the following: ligamentous instability, MRI evidence of cord injury, symptoms lasting > 48 hours, more than 1 recurrence Criteria: Cervical stenosis Loss of cervical lordosis Post traumatic findings on x ray Documentation of spear tackling techniques Absolute contraindication to play contact sports 242

8 Spinal cord injury (SCI) is a devastating event that often results in permanent neurologic sequelae Since 1990, 7.5% of all SCI s have been sustained in sports C spine injuries reported in rugby, skiing, snowboarding, equestrian sports but football and hockey account for majority of injuries Most common mechanism is often forced hyperflexion/axial loading (i.e. spear tackling) Spear tackling occurs when player initiates contact with crown of helmet, with neck slightly flexed Axial force applied to helmet is transmitted to c spine, and spine fails in flexion in form of fracture and/or dislocation In 1976 the NCAA banned spear tackling Over the next decade, there was a 70% drop in the rate of cervical injuries in HS athletes and 83% decrease in traumatic quadriplegia Over same period there has been a rise in hockey related c spine injuries Boarding 243

9 Most common cause of catastrophic spine trauma in collision sports is an unstable fracture/dislocation of the lower cervical region 2 major patterns of spinal column damage caused by compressive load: compressionflexion fracture and the vertical compression fracture Compression flexion injury more common variant Progressive deformation leads to failure of discs and vertebral body Historically termed flexion teardrop injury Extremely unstable, often presents with associated SCI Vertical compression burst fractures result from pure axial load Retropulsion of bone and disc material can compromise spinal cord 244

10 Evaluation usually begins on the field A standard protocol should be in place Basic equipment includes spine board, stretcher, tools to remove protective gear, items for airway management and CPR As with any traumatic injury, primary objective is to address any lifethreatening conditions (ABC s) During on field evaluation, helmet and shoulder pads remain on. Facemask may be removed for airway management Quick on field history and exam then transport to tertiary medical facility Once in the ER, the primary and secondary survey are repeated Cervical films including AP/Lateral/Odontoid views obtained CT also obtained (largely replacing plain x rays) Any signs or symptoms of spinal cord injury warrant an MRI 245

11 Bracken et al. demonstrated that patients who receive high dose steroids before 8 hours after injury had improved outcomes Authors concluded patients with acute spinal cord injury should receive loading dose of 30 mg/kg followed by 5.4 mg/kg/h for 24 hours if within 3 hours of injury, 48 hours if between 3 8 hours after injury. Healed stable compression fx s, end plate fx s, or spinous process fx s that are asymptomatic may return to play Unstable fx s requiring bracing or surgery are not allowed to play As with all injuries, any neurologic abnormalities or painful motion should not be allowed to play There is no contraindication to play for 1 level stable fusion 2 3 level fusion is relative contraindication 4 level fusion is absolute contraindication 246

12 247

Return to same game if sx s resolve within 15 minutes. Return to next game if sx s resolve within one week Return to Competition

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