CERVICAL SPINE INJURIES IN ATHLETES. Steven Fulop, MD

Transcription

1 CERVICAL SPINE INJURIES IN ATHLETES Steven Fulop, MD University Hospitals Neurosurgery

2 SPINAL CORD INJURY - EPIDEMIOLOGY 12,000 new spinal cord injuries (SCI) occur in USA every year 50% of all SCI occur between ages 16 and 30 81% of SCI are male Ethnicity Caucasian: 67% African American: 24% Hispanic: 8% Asian: 2%

3 ANATOMY Vertebral artery enters at C7 Facets richly innervated 8 cervical nerve roots for 7 bodies C0-1 and C1-2 highly specialized C1 = Atlas C2 = Axis

4 ROM AND STABILIZING ANATOMY 7 cervical vertebrae Large ROM comes at expense of stability in trauma Relies on ligaments 50% of flex-ex at C0 1 50% of rotation at C1-2 Primary stabilizers: Anterior Longitudinal Ligament Posterior Longitudinal Ligament Intervertebral Disc Ligamentum Flavum Facet capsules Inter/supraspinous ligaments

5 CERVICAL STRAIN/SPRAIN Mechanism: Cervical loading or eccentric muscle contraction Pathology: Ligament sprain Muscle strain Symptoms: Neck pain and spasm Radiculopathy Diagnosis and Treatment: Cervical collar Flex-Ex X-Ray after spasms resolve If unstable, may require surgery Return to sport: Once symptoms resolve Full ROM No instability

6 STINGERS AND BURNERS Mechanism: Traction/compression of brachial plexus Pathology: Brachial plexus neuropraxia Symptoms: Episode of unilateral upper extremity weakness, numbness or neuropathic pain Diagnosis and Treatment: Observation If recurrent, EMG and brachial plexus MRI Return to sport: Once symptoms resolve

7 TRANSIENT QUADRIPLEGIA Mechanism: Axial loading Hyperextension Pathology: Spinal cord contusion and edema Symptoms: Motor and/or sensory deficit 2 4 limbs Diagnosis and Treatment: MRI Steroids Return to sport: Once symptoms resolve If no stenosis on MRI

8 CERVICAL DISC DISEASE Mechanism: Multiple episodes of axial loading or twisting Pathology: Herniated soft disc Disc osteophyte complex Symptoms: Upper extremity radiculopathy Myelopathy Diagnosis and Treatment: MRI PT/OT Epidural steroids Surgery for persistent radiculitis or myelopathy Return to sport: 1 level fusion if asymptomatic 2-3 levels relative contraindication >3 levels absolute contraindication

9 SPEAR TACKLER S SPINE Mechanism: Multiple episodes of cervical trauma with axial loading Pathology: Cervical stenosis Loss of lordosis Spondylosis Symptoms: Neck pain Catastrophic fractures Diagnosis and Treatment: X-Rays, CT, and MRI PT for restoration of ROM Return to sport: Controversial Consider avoidance of contact sports

10 SPINAL STENOSIS Mechanism: Multiple episodes of trauma Congenital Pathology: Narrowing of canal by ligamentous hypertrophy Disc bulges Congenitally short pedicles Symptoms: Radiculopathy Myleopathy Diagnosis and Treatment: MRI Conservative or surgical management Return to sport: If associated with TQ or generally symptomatic avoid contact sports

11 VASCULAR TRAUMA Blunt trauma to neck or rotation and bending Carotid dissection May lead to stroke like symptoms Visual loss one eye (amaurosis fugax) Horner syndrome Neck pain Vertebral dissection Loss of coordination Visual loss hemianopsia (occipital cortex) Typically treated with anticoagulation and sometimes stenting

12 SPINAL STENOSIS AND SCI RISK Torg Ratio Ratio of 1.0 normal Stenosis at 0.8 Ratios less than 0.7 associated with SCI Torg JS et al. J Bone Joint Surg Am. 84(1): (2002).

13 Torg JS et al. J Bone Joint Surg Am. 78(9): (1996)

14 MANAGEMENT OF AN INJURY Standard ABCs Consciousness and focused neurologic exam Cervical spasm, significant tenderness and decreased ROM should raise suspicion of injury even w/o neuro deficit All unconscious athletes should be presumed to have a cervical spinal injury Spine immobilization with C- spine precautions when moving Leave helmet and shoulder pads on Remove facemask for airway

15 RETURN TO SPORT ALGORITHMS Meredith DS et al. Am J Sports Med. 78(9): (2013) Burnett MG JS & Sonntag V Neurosurg Focus. 15;21(4):E5 (2006)

16 CASES 35 yo with loss of arm strength and coordination Myelopathic on exam C5 stenosis with myelomalacia Avid golfer Unable to play currently Failed PT

17 CERVICAL MYELOPATHY/MYELOMALACIA

18 CERVICAL CORPECTOMY

19 CASES 63 yo man with progressive difficulty walking Severe burning pain in hands Florid myelopathy on exam Concentric stenosis C3-7 with Maintained cervical lordosis

20 SEVERE SPINAL STENOSIS

21 SEVERE MULTILEVEL STENOSIS

22 NONFUSION SURGERY Open door laminoplasty Posterior approach Can be combined with foraminotomy Mobility sparing Instrumentation required Useful over long segments Indirectly decompresses the cord from anterior disease

23 RESTORATION OF TORG RATIO

24 MAINTAINS RANGE OF MOTION

25 CASES 40 yo woman with severe neck pain and fatigue Unable to hold head up at end of the day Minimal radicular signs C4-7 spondylosis with kyphotic deformity Failed PT

26 NO NEUROLOGIC SYMPTOMS

27 RESTORE LORDOSIS

28 PERMANENT DECREASED ROM

29 IMPROVED NECK PAIN/FATIGUE

30 CASES 50 yo man with progressive balance loss and grip weakness Myelopathic on exam C4-7 spondylosis with stenosis and myelomalacia

31 CERVICAL SPONDYLOTIC MYELOPATHY

32 2 LEVEL CERVICAL CORPECTOMY

33 TROUBLE SWALLOWING 6 weeks post op patient sneezed and felt neck pain with swallowing difficulty Intra op found C4 vertebral body sheared off anterior half Cage kicked forward into retropharangeal space

34 3 LVL CERVICAL CORPECTOMY C4 corpectomy and C3-7 Cage placed for support Patient taken back to OR next day for posterior backup Posterior instrumentation added as a back-up

35 360 DEGREE FUSION

36 ANTERIOR VS POSTERIOR?

37 SURGICAL MANAGEMENT SUMMARY Take home points: No clinical superiority to anterior vs. posterior All guidelines recommend individual plan I tend to go anteriorly with kyphosis and anterior lesions I use ACDF when possible to increase sagittal correction and stabilization I use laminoplasty when spine straight to lordotic and ROM maintenance prioritized I go posteriorly if multiple anterior surgeries make complications more likely I favor anterior procedures when higher cardiac risk present (due to easier rescuscitation efforts) The 1-2 level ACDF with plate is my go to procedure for degenerative disease under most circumstances. (I am not in a major trauma center)

38 THANK YOU!

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