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1 emedicine.medscape.cm emedicine Specialties > Orthpedic Surgery > Spine Cervical Spine Injuries in Sprts Andrew A Sama, MD, Directr f Orthpedic Spine Surgery at the New Yrk Hspital f Queens, Assistant Prfessr f Orthpedic Surgery at the Weill Medical Cllege, Crnell University; Cnsulting Staff, Department f Orthpedic Surgery, Hspital fr Special Surgery Federic P Girardi, MD, Instructr, Department f Orthpedic Surgery, Weill Cllege f Medicine f Crnell University; Frank P Cammisa, Jr, MD, Chief, Spinal Surgery Service, Directr, Spine Care Institute, Hspital fr Special Surgery; Assciate Prfessr, Department f Clinical Orthpedic Surgery, Weill Medical Cllege-Crnell University Updated: Jun 25, 2008 Intrductin One f the mst challenging rles f the team physician invlves the interventin and decisin-making prcesses regarding cervical spine (C-spine) injuries in cntact sprts. The team physician must be well versed in the preventin, evaluatin, stabilizatin, and treatment f C-spine injuries. A high index f suspicin and an understanding f cervical alignment and architecture, as well as cmprehensin f the mechanics exerted during a sprting event, are imperative t diagnsing cervical injuries. 1, 2 Well mre than half f catastrphic injuries in sprts are cervical spine injuries. C-spine injuries have been reprted in mst cntact sprts, including ftball, hckey, rugby, and wrestling, as well as in several nncntact sprts, such as skiing, track and field, diving, surfing, pwer lifting, and equestrian events. C-spine injuries are estimated t ccur in 10-15% f all ftball players, mst cmmnly in linemen and defensive players. Serius injuries with neurlgic sequelae remain infrequent, and mst f these injuries are self-limited. Injuries ccur in 3, 4, 5 all levels f play, frm the high schl t the prfessinal level. Ftball and rugby have the highest incidence f C-spine injuries f all sprts. 6, 7, 8 Injury usually is secndary t high-velcity cllisins between players, causing acceleratin r deceleratin f the head n the neck. 9 Acceleratin usually causes a whiplash type f extensin frce n the neck, while deceleratin usually results in flexin frces. 10 Spearing, which has been banned in American ftball since 1976, ccurs when a player uses the helmet/head as the first pint f cntact with anther player. Spearing is a significant cause f C- spine injuries and quadriplegia. The frce transmitted t the cervical spine in these cases is ne f axial cmpressin with the vertebrae in psitins f slight flexin. 11 The natural architecture f the nrmal C-spine assumes a lrdsis f the vertebrae. This lrdsis allws fr cntrlled mtin and the transmissin f frces t the supprting muscles and sft tissues. When the neck is slightly flexed, apprximately 30, the nrmal lrdsis is straightened, and the frces f the axial lad are transmitted t the bnes and disks. If the impact frce is greater than the yield strength f the vertebrae, a fracture and pssible dislcatin with crd injury can ccur. Spectrum f injury Cervical injuries that result frm participatin in sprts usually are self-limited and can be divided int the fllwing categries: Nerve rt r brachial plexus injuries Acute cervical sprains/strains Intervertebral disk injuries Cervical fractures and dislcatins Cervical stensis Related Medscape tpics: Resurce Center Back Pain Resurce Center Exercise and Sprts Medicine Resurce Center Fracture

2 Resurce Center Spinal Disrders Specialty Site Emergency Medicine Case Q & A - Open Fractures Epidemilgy f Back Disrders: Prevalence, Risk Factrs, and Prgnsis reflexions and repercussions: Gdley Intentins - Examining fr Pains in the Neck Nerve Rt/Brachial Plexus Injuries The mst cmmn cervical injury in ftball players is the transient lss f functin with searing r lancing pain dwn ne arm fllwing a cllisin. These are cllquially referred t as stingers, r burners. 12, 13 Prspective studies perfrmed at Tulane University have shwn a 7.7% incidence f stingers in a grup f cllege ftball players. Initially, the player cmplains f ttal arm weakness and a radiating burning sensatin that usually reslves. Numbness in the C-6 dermatmal distributin may persist. Mtr weakness f shulder abductrs, elbw flexrs, external humeral rtatrs, and wrist and finger extensrs als may persist. The duratin f symptms is frm 2-10 minutes t 24 hurs. Symptms are reprduced by the Spurling maneuver. Functin gradually returns frm the prximal muscle grups t the distal muscle grups. The severity f the injury crrelates with the underlying pathphysilgy. Neurpraxia is a selective demyelinatin f the nerve sheath, and it is the mst benign injury. Axntmesis is a disruptin f the axn and the myelin sheath, but the epineurium is intact. The mst severe injury is a neurtmesis r a cmpete disruptin f the endneurium. This injury is assciated with the mst unfavrable prgnsis. The differential diagnses f burners include acute cervical disk herniatins, framinal stensis, and extradural intraspinal masses. Stingers are thught t be the result f either f the fllwing mechanisms: A distractin r stretch injury in which the head is driven t the side ppsite the painful arm and the ipsilateral shulder is depressed. This causes a mmentary stretch injury t the upper crds f the brachial plexus. The extended C-spine is cmpressed and rtated tward the painful arm. Injury ccurs because the cervical nerves are tethered by fibrus tissue between the vertebral arteries and the distal framina at each cervical level. These dentate ligament attachments becme taut and stretch the cervical nerve rts as they leave the spine. Because mst burners are self-limited, the mst imprtant treatment bligatin f the team physician is t rule ut an unstable cervical injury. The key t assessment is that patients with burners have full pain-free neck range f mtin (ROM). If neck mtin is decreased r painful, withdraw the athlete frm play and btain cervical radigraphs t rule ut fracture/dislcatin. If symptms persist fr 3-4 weeks fllwing injury, btain an electrmygram (EMG) t evaluate upper trunk functin. 14 Acute Cervical Sprains/Strains & Intervertebral Disk Injuries Acute cervical sprains/strains A sprain is defined as an injury t the paraspinal muscultendinus unit. A strain is defined as an injury f the paraspinal muscle itself. An athlete with a sprain r strain usually presents after jamming his/her neck. The pain is lcalized t the C-spine and limits cervical ROM. Pain and paresthesias d nt radiate t the arms. The neural examinatin is nrmal, and radigraphs are negative fr evidence f fracture r dislcatin. Take the player thrugh a series f mvements t evaluate the ROM. If the patient has full ROM with n radiatin f pain, n paresthesias, and a nrmal neurlgic examinatin, treat with nnsteridal anti-inflammatry

3 medicatins and a sft cervical cllar (C-cllar) fr cmfrt. Once the pain has reslved, the athlete can return t activity. If the player has limited ROM, prtect the neck and remve him r her frm activity. Obtain a radigraphic series t include anterpsterir (AP) and lateral flexin/extensin views. If a fracture r dislcatin is encuntered, institute prper immbilizatin and stabilizatin. If these radigraphs are negative but symptms persist, btain an MRI t rule ut disk herniatin. Intervertebral disk injuries Acute disk herniatins in ftball are rare. Hwever, with the acute nset f transient neurlgic deficits and negative cervical radigraphs, the pssibility f a ruptured cervical disk must be cnsidered. Symptms f herniatin vary frm radiculpathy t anterir crd syndrme. Anterir crd syndrme ccurs with an acute paralysis f the upper, lwer, r all 4 extremities. An assciated lss f pain and temperature sensatin t the level f the lesin ccurs. 15 The psterir clumn vibratry, prpriceptive, and light tuch sensatins are preserved. A high degree f clinical suspicin is necessary t avid missing the diagnsis f a disk injury. If disk injury is suggested, cnfirm the diagnsis with a CT myelgram r an MRI (see Images 1-4). Once the diagnsis f acute disk herniatin with neurlgic symptms is made, an anterir diskectmy with interbdy fusin may be necessary. In cntrast t the rare nature f acute disk herniatins in cntact sprts, disk injuries withut frank herniatin r neurlgic injury can be cmmn and are characterized by chrnic changes. Chrnic disk changes frequently are seen in athletes wh cmpete in cntact sprts. Albright studied cervical spine radigraphs f 75 University f Iwa freshmen ftball recruits. 16 The radigraphs were btained after the individuals played high schl ftball but befre they played cllege ftball. Albright fund that 32% had 1 r mre f the fllwing cnditins: Occult fracture Vertebral cmpressin fracture Disk space narrwing Ostephytes and degenerative changes Albright's findings illustrate that the cnstant lading f the C-spine in cntact sprts leads t chrnic degeneratin. MRI scans f patients with chrnic disk injuries reveal a disk bulge with n bvius herniatin. Treatment f these patients is cnservative, and cntact activity shuld be withheld until the athlete has regained a painless full ROM f the C-spine. Cervical Fracture/Dislcatins Cervical fractures and dislcatins ccur when the axial lading frces applied t the C-spine are greater than the yield strength f the vertebral bdies r the supprting ligamentus structures. A spectrum f pathlgy exists, including the fllwing: Subluxatin withut fracture, with r withut neurlgic injury Dislcatins, with r withut neurlgic injury Fractures, with r withut neurlgic injury The mst imprtant cnsideratin when discussing cervical fractures and dislcatins is the cncept f stability. Stability, as described by White et al, is the ability f the spine t limit its patterns f displacement during physilgic lads t prevent damage r irritatin t the spinal crd and nerve rts. 17 Instability f the adult spine therefre is defined as dysfunctin f the psterir elements with mre than 3.5 mm displacement (r >20% translatin) in the hrizntal sagittal plane. See Image 28. Instability is als apparent by analyzing the angular measurements between mtin segments. Greater than 20 f sagittal plane rtatin n flexin/extensin films is cnsidered abnrmal and ptentially unstable. In the acute

4 setting where flexin/extensin radigraphs are nt btainable, greater than 11 f relative sagittal plane angulatin between cervical mtin segments n a static lateral C-spine radigraph is cnsidered unstable. See Image 29. White and Panjabi's wrk n cervical instability culminated in the creatin f a scring checklist t serve as an algrithm and an bjective assessment f instability. This checklist is illustrated in the White and Panjabi Scring Cervical Instability Table in Image 27. Patients are assessed anatmically, radigraphically, neurlgically, and physilgically. The patient is graded n each f these criteria, and the grades are added t btain the final scre. A ttal scre f 5 r mre is indicative f a patient with an unstable spine. Subluxatin r dislcatin withut fracture results frm disruptin f the psterir sft tissue supprting elements. Angulatin and anterir translatin f the superir vertebrae ccurs. N assciated fractures exist, and assciated neurlgic injuries may r may nt exist. The diagnsis is made by flexin/extensin lateral C-spine radigraphs, which shw active mtin, anterir intervertebral disk space narrwing, and fanning f the spinus prcesses psterirly. Obtaining the flexin/extensin radigraphs in the presence f the treating spine surgen and in a patient wh is awake and cmmunicative is imperative (see Images 5-10). An alternative t the flexin/extensin radigraphs is the use f cntrlled axial-tractin lateral radigraphs, als referred t by White as the "stretch test." 18 The stretch test is perfrmed after a standard nntractin lateral C- spine radigraph has been btained and examined t rule ut bvius instability r subluxatin. In the stretch test, the patient is placed supine with the head supprted n a rller platfrm t reduce frictin. The head is placed in a tractin rig with either Garner-Wells tngs r a head halter, and incremental 10-lb lads f weight are applied. The 10-lb weights are added in the presence f the treating physician. The maximum weight allwed is equivalent t 33% f the patient's bdy weight. The physician perfrms serial neurlgic assessments f the patient with each additin f weight. A lateral C- spine radigraph is btained with each additin f weight. The time interval between weight increments shuld be at least 5 minutes. The stretch test is cnsidered psitive fr instability if ne f the fllwing situatins ccurs: (1) the patient sustains a change in neurlgic functin, (2) n cmparisn with the pretractin radigraph, there is greater than 1.7 mm f interspace separatin f the anterir r psterir elements, r (3) there is greater than 7.5 change in the angle between vertebrae. The prgnsis in patients with subluxatin withut fracture depends n the degree f displacement. Instability is likely despite nnperative treatment, and if anterir subluxatin is mre than 20% f the vertebral bdy width, treatment shuld be psterir cervical fusin. Atlantccipital dislcatins (see Image 11) result frm high-speed cllisins and have never been reprted in ftball. They are described as cmplete injuries. These injuries usually are fatal secndary t cmplete respiratry arrest. When this injury is suspected, cervical tractin is cntraindicated. If the patient survives the injury, treatment is t align the spine and place the patient in a hal vest until C0-C2 fusin can be perfrmed. A traumatic rupture f the transverse ligament f the atlas (see Images 12-13) leads t widening f the atlantdens interval and decreased space fr the spinal crd. C1 r atlas fractures C1 r atlas fractures (see Images 14-15) usually result frm axial lading and are decmpressive fractures that rarely result in neurlgic deficits. They can be classified as fllws: Anterir arch fractures Psterir arch fractures Lateral mass fractures Jeffersn (burst) fractures

5 All C1 r atlas fractures can be treated with hal vest immbilizatin until fracture healing ccurs. Odntid fractures The 3 types f dntid fractures are as fllws: Type I Type II Type III Type I dntid fractures are cephalad t the transverse ligament and are secndary t avulsin f alar ligaments. They rarely are assciated with neurlgic injury r C1-C2 instability. Stability can be assessed with lateral flexin/extensin views. Mst type I dntid fractures can be treated with a C-cllar. Type II dntid fractures (see Image 16) are thrugh the neck f the dntid prcess. These fractures usually are secndary t hyperextensin, flexin, r rtatinal frces. The verall unin rate f type II fractures is 68% with hal treatment. Type II dntid fractures with mre than 10 f angulatin r mre than 5 mm f translatin shuld be treated with surgery rather than a hal t decrease the pseudarthrsis rate. Nnunins can be cmmn amng type II dntid fractures. In patients with significant risk factrs, primary C1-C2 fusin by a variety f techniques shuld be emplyed. Patients with lw risk factrs fr nnunin can be treated with reductin and hal immbilizatin fr 12 weeks. The risk factrs fr nnunins include the fllwing: Age lder than 50 years Displacement f mre than 5 mm Psterir versus anterir displacement Excessive hal vest treatment Type III dntid fractures (see Images 17-18) extend int the cancellus bne f the bdy f C2 and therefre have a high rate f unin. These fractures usually can be treated with hal immbilizatin fr 12 weeks. If the fracture is impacted and has a stable pattern, treatment with a rigid C-cllar in a cmpliant patient fr 12 weeks can be an ptin. Traumatic spndyllistheses f C2 Traumatic spndyllistheses f C2 als can ccur. These fractures als are knwn as hangman's fractures. They usually are diagnsed n lateral C-spine radigraphs. Neurlgic injury usually des nt ccur unless a C2-C3 facet dislcatin is present. The 4 types f traumatic spndyllistheses f C2 are as fllws: Type I A type I hangman's fracture (see Image 19) is either nndisplaced r has less than 3 mm f C2-C3 translatin. N angulatin f the fracture fragments exists. The injury ccurs secndary t a cmbined hyperextensin/axillary cmpressin frce. This type f fracture usually can be treated with a C-cllar fr 3 mnths. Type II These fractures are assciated with significant translatin f mre than 3 mm with angulatin. These injuries are secndary t initial hyperextensin-lading frces, fllwed by cmbined flexin/cmpressin frces. Treatment fr type II injuries depends n the amunt f initial translatin, as fllws: Fr 3-6 mm f initial translatin, treat with a hal vest fr 3 mnths. Fr mre than 6 mm f translatin, treat with 4-6 weeks f hal tractin, fllwed by hal vest immbilizatin fr 3 mnths. Type IIA

6 Type III This injury als is knwn as the Starr-Eismnt variant (see Image 20) and is assciated with significant angulatin and minimal translatin. Tractin in these injuries is cntraindicated because it leads t significant translatin and assciated neurlgic injury. Treatment includes immediate hal vest with mild axial cmpressin fr reductin. These injuries are assciated with severe angulatin and translatin. Unilateral r bilateral facet dislcatins usually accmpany them. The mechanism f injury is a cmbined flexin/cmpressin frce. Clsed reductin is exceedingly difficult. Open reductin and internal stabilizatin usually is required. Injuries f the subaxial cervical spine generally are assciated with an increased likelihd f neural cmpressin due t a decreasing rati f canal diameter t crd diameter. Types f injuries Avulsin fractures The spinus prcess is the usual lcatin f avulsin fractures. When these fractures ccur at C7 (see Image 21), they are termed clay shveler's fractures. This injury results frm frceful cntractin f trapezius and rhmbid muscles r frm a sudden severe flexin frce transmitted t psterir spinus ligaments. Treat with a C-cllar fr cmfrt. Cmpressin fractures Cmpressin fractures are defined as the vertebral bdy having an intact middle clumn and lss f anterir bdy height. Evaluate cmpressin fractures with flexin and extensin radigraphs, CT scan, and MRI scan. Treatment depends n the degree f anterir cmpressin, as fllws: If there is less than 25% anterir cmpressin, treat the patient with a C-cllar. If there is mre than 50% anterir cmpressin, patients ften have psterir ligamentus failure, which results in significant instability that requires psterir fusin with r withut anterir clumn recnstructin. Images shw the lateral radigraph and axial CT scans f a patient with a C5 cmpressin fracture. Facet jint injuries These subluxatins and dislcatins (see Images 5-10) ccur as a result f disruptin f the supraspinus ligaments, interspinus ligaments, ligamentum flavum, and facet capsule. Facet jint injuries can be unilateral r bilateral, and neurlgic injury varies. Lateral radigraphs help the physician cnfirm the diagnsis. CT scan helps rule ut bny invlvement, and MRI delineates assciated disk herniatins. The mechanism f injury crrespnds t whether the lesin is unilateral r bilateral. Unilateral lesins are the result f flexin and rtatin with axial frce. Bilateral lesins are the result f severe flexin with axial lading. Treatment is cntrversial because f the risk f further neurlgic injury frm further disk herniatin with the reductin maneuver. The gals f treatment are as fllws: Prevent further neurlgic injury Reduce the subluxatin/dislcatin Stabilize the spine in the reduced psitin The fcus f cntrversy is the questin f whether t btain an MRI befre perfrming a clsed reductin f the subluxatin r dislcatin. Eismnt and thers have recmmended an MRI prir t reducing a subluxatin t rule ut a herniated nucleus pulpsus that culd further herniate during the reductin and result in catastrphic crd sequelae. 19

7 Ctler and thers believe that high-weight rapid reductin shuld be perfrmed as sn as pssible and that the MRI shuld be perfrmed fllwing the reductin. Vaccar et al have shwn in a prspective study f 11 patients with cervical dislcatins wh had prereductin and pstreductin MRI scans that disk herniatins were identified in 2 f the 11 patients befre reductin. 20 They perfrmed awake clsed reductin by high-weight rapid tractin. Reductin was successful in 9 f the 11 patients. Of the 9 patients with successful clsed reductin, 2 had disk herniatins befre reductin and 5 mre had disk herniatins n the pstreductin MRI. Nne f the patients had neurlgic wrsening after reductin. Ctler and Vaccar therefre cnclude that an MRI can be dne after the subluxatin r dislcatin is reduced t assess the crd and disk. In cases f acute paraplegia, the mments saved can be crd saving. Eismnt agrees with this last pint in patients with cmplete distal mtr lss, with r withut distal sensatin (Frankel Grades A and B), as these patients have the mst t gain and least t lse by rapid reductin and the pssible assciated risks. Eismnt des nt agree in the circumstance f a patient wh is neurlgically intact r near nrmal (Frankel Grade D and E), as these patients have the greatest t lse in the event f further disk herniatin with clsed reductin leading t paralysis. 19 Eismnt recmmends prvisinal immbilizatin with a rigid C-cllar, 10 lb f skull tractin, and an MRI befre reductin is attempted. If n disk herniatin is detected, perfrm reductin with skeletal tractin f 5-7 lb/level, up t a maximum f 50 lb. Clsely mnitr radigraphic results and neurlgic functin during the reductin. Once the reductin is btained, psterir fusin shuld be perfrmed if there is n assciated disk herniatin. If a disk is encuntered n the prereductin MRI, Eismnt recmmends an anterir cervical diskectmy, reductin, and plate fixatin. 19 Vertebral burst fractures Cervical burst fractures result frm severe axial lading in cmbinatin with hyperflexin frces. Burst fractures include a cmminuted fracture f the middle spinal clumn, and if destabilized psterirly, they can result in kyphsis. Crd injury usually is present because f retrpulsin f fracture fragments. Perfrm a radigraphic series, a CT scan, and an MRI t evaluate severity f neural cmpressin, intramedullary crd injury, and ligamentus damage. Emply skeletal tractin fr spinal realignment and decmpressin f the canal by ligamenttaxis f retrpulsed fragments. Perfrm an MRI with the patient in tractin t assess the severity f canal cmprmise pstreductin. In patients with canal cmprmise and neural defects, perfrm an anterir decmpressin and recnstructin with strut graft and plate fixatin. If unstable (ie, a 3-clumn lesin), the patient may require an anterir and psterir fusin/stabilizatin. Teardrp fractures Teardrp fractures (see Images 24-25) result frm severe flexin-axial lading frces and are 3-clumn injuries. They are characterized by (1) a displaced fracture f the anterinferir crner f the superir bdy, (2) segmental disk disruptin, (3) psterir ligamentus injury, and (4) retrpulsin f the prximal bdy int the neural canal. Radigraphically, retrlisthesis f the psterinferir prtin f the invlved bdy ften results in neural cmpressin with deficits ranging frm nerve rt injuries t cmplete spinal crd injuries. Diagnstics and treatment are the same as fr burst fractures. Risk fr further injury The issue f returning t play after a patient sustains a C-spine injury shuld be based n the risk fr further injury, as fllws:

8 Cnditins with a slightly increased risk f reinjury fllwing the initial insult include the fllwing: Asymptmatic bne spurs Healed nndisplaced fractures Stingers/burners Healed disk herniatins Healed laminar fractures Asymptmatic framinal stensis Mderate risk cnditins that are assciated with a significant chance fr recurrence f symptms and an increased risk fr permanent injury include the fllwing: Facet fractures Lateral mass fractures Nndisplaced healed dntid fractures Nndisplaced healed C1 ring fractures Acute lateral disk herniatins Cervical radiculpathy secndary t framinal spur Extreme risk cnditins that have the highest risk f recurrence and f permanent damage include the fllwing: Os dntideum Ruptured transverse ligament f C1-2 Occipitcervical dislcatin Displaced dntid fractures Unstable fracture dislcatins Cervical crd anmalies Acute central disk herniatins Cervical Spinal Stensis Cervical spinal stensis is defined as the diminutin f the anterpsterir diameter f the spinal canal, either as an islated cngenital bservatin r with disk herniatin, degenerative changes, r psttraumatic instability. 21 Methds f measuring the degree f spinal stensis cntinue t evlve with the evlutin f imaging technlgies. In 1956, Wlfe et al described measuring the space fr the crd n plain lateral C-spine radigraphs by measuring the distance frm the middle f the psterir surface f the vertebral bdy t the mst anterir pint n the spinlaminar line fr vertebrae C3-7. The nrmal range was mm. A measurement f less than 13 mm was cnsidered stensis. Values btained by measurement n the lateral plain radigraphs culd be skewed because f radigraphic magnificatin r variatins in radigraphic techniques. The actual size f the canal is better assessed by CT scan. T cmpensate fr these variances in radigraphic techniques, Trg and Pavlv described the Trg/Pavlv rati. 22 This rati is a measurement f the width f a given vertebral bdy n the lateral C-spine radigraph divided by the crrespnding space allwed fr the crd at the same level (see Image 26). A value f less than 0.8 was cnsidered t be cervical stensis and a serius risk factr fr neurlgic injury in cntact sprts. Herzg illustrated that the Trg/Pavlv rati may have resulted in false-psitive indicatins. 23 Herzg reviewed the CT scans f ftball players with abnrmal Trg/Pavlv ratis and fund that 70% f players with abnrmally small Trg/Pavlv ratis had nrmal-sized cervical spinal canals. 23 These findings are explained by the fact that ftball players have abnrmally large vertebral bdies. This fact makes the denminatr in the Trg/Pavlv rati larger, and the rati value is artificially decreased, resulting in a false psitive. Additinally, Herzg fund n crrelatin between a Trg/Pavlv rati f 0.8 and any transient neurpraxia r permanent neurlgic deficits. Castr et al, in the American Jurnal f Sprts Medicine, illustrated that crd diameter als varies, and it is the relative difference between the canal size and the crd diameter that creates the clinical cnditin f stensis. Epstein cncluded that the presence f a stentic canal influenced the mrbidity and prgnsis f a spinal crd injury and that patients with the smallest anterir-psterir canal diameter had the mst severe myelpathy

9 fllwing injury. 24 Eismnt et al eched Epstein's cnclusins when they lked at 98 patients with C-spine fractures and/r dislcatins and fund that the sagittal size f the cervical canal crrelated with the extent f neurlgic injury. 25 They cncurred that patients with small diameter canals had mre significant neurlgic sequelae. Matsura et al fund a crrelatin between the shape f the spinal canal, the central canal diameter, and the predispsitin t spinal crd injury. Cantu advcates the functinal definitin f spinal stensis. 26 Functinal spinal stensis is present when the size f the canal is s small that the prtective spinal fluid cushin arund the crd is bliterated r when the crd is defrmed n CT myelgram r MRI. Any athlete with functinal cervical stensis is at increased risk fr quadriplegia and shuld be prhibited frm participating in cntact sprts. Return T Play T help establish bjective guidelines fr return t play fllwing an injury, Watkins et al prpsed a pint grading system t quantify the patient's clinical situatin. 27 This grading system was meant as a guideline fr return t play. The physician must cnsider the entire scenari fr each individual player. Watkins et al lked at the fllwing 3 tpics and assigned pint values accrding t the player's cnditin, as fllws: Extent f the neurlgic injury 1 pint - Unilateral arm numbness r dysesthesias r lss f strength 2 pints - Bilateral arm lss f mtr r sensry functin 3 pints - Ipsilateral arm and leg symptms 4 pints - Transitry quadriparesis 5 pints - Transitry quadriplegia The time frm injury t treatment 1 pint - Less than 5 minutes 2 pints - Less than 1 hur 3 pints - Less than 24 hurs 4 pints - Less than 1 week 5 pints - Mre than 1 week The narrwing f the central canal diameter 1 pint - Mre than 12 mm 2 pints - Between 12 and 10 mm 3 pints - 10 mm 4 pints - Between 10 and 8 mm 5 pints - Less than 8 mm The pints tabulated frm each f the 3 categries then are added tgether and cmpared t the fllwing scring scale: 0-6 pints - Minimal risk assciated with return t play 6-10 pints - Mderate risk assciated with return t play pints - Severe risk assciated with return t play These criteria serve as a guide fr the team physician; hwever, the physician shuld cnsider each case individually and request the apprpriate cnsultatins as needed. 28 Cnclusin The incidence f catastrphic cervical injuries in sprts has significantly decreased ver the last 30 years. This decrease is the result f mnumental rule changes, such as the ban n spearing in American ftball, better caching n cntact and tackling techniques, the presence and instructin f athletic trainers at all levels f play, and the imprvement in prtective gear including helmets and shulder pads. Unfrtunately, when catastrphic neurlgic injuries d ccur, they are permanent and life changing. The team physician plays a crucial rle in the

10 crdinatin f medical assessment n the playing field, immbilizatin and transprtatin t a qualified facility fr evaluatin and treatment, and decisin making regarding return t play fllwing an injury. These decisins shuld be discussed with the athlete and the athlete's parents, caches, trainers, and agents. The ultimate decisin shuld be made in the best interest f the patient. 29 Fr excellent patient educatin resurces, visit emedicine's Back, Ribs, Neck, and Head Center. Als, see emedicine's patient educatin article Whiplash. Multimedia Media file 1: T1-weighted MRI f a cervical disk herniatin.

11 Media file 2: T2-weighted MRI f cervical disk herniatin. Media file 3: Axial CT scan f cervical herniated nucleus pulpsus.

12 Media file 4: Myelgram f cervical herniated disk. A filling defect is shwn. Media file 5: Plain radigraph f jumped facets f C4 n C5.

13 Media file 6: Sagittal CT scan f jumped facet. Media file 7: Sagittal MRI f facet dislcatin f C7 n T1.

14 Media file 8: Jumped facets. Media file 9: Jumped facet shwing anterir displacement f ne vertebra n the adjacent inferir vertebrae.

15 Media file 10: Jumped facets with cmplete anterir displacement f the prximal vertebrae. Media file 11: Atlantccipital dislcatin.

16 Media file 12: Axial CT scan f an increased atlantdens interval. Media file 13: Sagittal CT scan recnstructin that shws widening f the atlantdens interval.

17 Media file 14: Three-dimensinal CT scan f C1. Media file 15: Axial CT scan f a Jeffersn fracture.

18 Media file 16: Displaced type II dntid fracture. Media file 17: Anterpsterir view f type III dntid fracture.

19 Media file 18: Crnal CT scan f type III dntid fracture. Media file 19: Type I C2 traumatic spndyllisthesis. Nte the anterir translatin but lack f angulatin.

20 Media file 20: Clse-up lateral radigraph f type IIA (Starr-Eismnt variant) C2 traumatic spndyllisthesis. Nte the significant angulatin with minimal translatin. Media file 21: Avulsin fracture f C7 (the clay shveler's fracture).

21 Media file 22: C5 cmpressin fracture. Media file 23: Axial CT scan f C5 cmpressin fracture. Intact middle and psterir clumns are shwn.

22 Media file 24: Teardrp fracture. Media file 25: Psterir teardrp fracture.

23 Media file 26: Lateral cervical spine plain radigraph illustrating the Trg/Pavlv rati.

24

25 Media file 27: White and Panjabi Scring Scale fr Cervical Instability. Media file 28: The distance (a) is measured frm the psterir-inferir crner f the vertebral bdy abve the allegedly unstable disk space, t the psterir-superir crner f the vertebral bdy belw the allegedly unstable disk space. The distance (b) is the anterirpsterir sagittal-plane diameter f the vertebral bdy abve the allegedly unstable disk space. Accrding t White and Panjabi's utline, evidence f instability exists if the distance (a) is greater than 20% f distance (b). Alternatively, if the linear distance (a) is greater than 3.5 mm, instability is evident. In cnclusin: If (a)/(b) x 100 > 20%, r if (a) > 3.5 mm, then instability is evident. In this example (a) = 5.5 mm, (b) = 13.0 mm. 5.5/13 x 100 = 42.3%, and 42.3% > 20%; therefre, instability is evident. Als, (a) = 5.5 mm, which is greater than 3.5 mm; therefre, instability is evident.

26 Media file 29: This is a schematic representatin f White and Panjabi's descriptin f abnrmal angulatin. The finding f abnrmal angulatin greater than 11 between supraadjacent and subadjacent cervical mtin segments n a static lateral cervical spine (C-spine) radigraph is cnsidered unstable. The basic mathematical frmula t analyze this is as fllws: The angle f the mtin segment in questin minus the angle f the supra-adjacent segment r the subadjacent mtin segment. The difference is less than 11 in the nrmally stable C-spine. In this image, the frmula is illustrated by the fllwing examples: Fr the supra-adjacent level: 30-(-8) = 38, 38 > 11. Fr the subadjacent level 30-(-4) = 34, 34 > 11. References 1. Gill SS, Bden BP. The epidemilgy f catastrphic spine injuries in high schl and cllege ftball. Sprts Med Arthrsc. Mar 2008;16(1):2-6. [Medline]. 2. Bden BP, Jarvis CG. Spinal injuries in sprts. Neurl Clin. Feb 2008;26(1):63-78; viii. [Medline]. 3. Clarke KS. Epidemilgy f athletic neck injury. Clin Sprts Med. Jan 1998;17(1): [Medline]. 4. Marn JC, Bailes JE. Athletes with cervical spine injury. Spine. Oct ;21(19): [Medline]. 5. Olympia RP, Dixn T, Brady J, Avner JR. Emergency planning in schl-based athletics: a natinal survey f athletic trainers. Pediatr Emerg Care. Oct 2007;23(10): [Medline]. 6. Thmas BE, McCullen GM, Yuan HA. Cervical spine injuries in ftball players. J Am Acad Orthp Surg. Sep-Oct 1999;7(5): [Medline]. 7. Fuller CW, Brks JH, Kemp SP. Spinal injuries in prfessinal rugby unin: a prspective chrt study. Clin J Sprt Med. Jan 2007;17(1):10-6. [Medline].

27 8. Lark SD, McCarthy PW. Cervical range f mtin and prpriceptin in rugby players versus nn-rugby players. J Sprts Sci. Jun 2007;25(8): [Medline]. 9. Langer PR, Fadale PD, Palumb MA. Catastrphic neck injuries in the cllisin sprt athlete. Sprts Med Arthrsc. Mar 2008;16(1):7-15. [Medline]. 10. Villavicenci AT, Hernández TD, Burneikiene S, Thramann J. Neck pain in multisprt athletes. J Neursurg Spine. Oct 2007;7(4): [Medline]. 11. Bell K. On-field issues f the C-spine-injured helmeted athlete. Curr Sprts Med Rep. Jan 2007;6(1):32-5. [Medline]. 12. Meyer SA, Schulte KR, Callaghan JJ. Cervical spinal stensis and stingers in cllegiate ftball players. Am J Sprts Med. Mar-Apr 1994;22(2): [Medline]. 13. Weinstein SM. Assessment and rehabilitatin f the athlete with a "stinger". A mdel fr the management f nncatastrphic athletic cervical spine injury. Clin Sprts Med. Jan 1998;17(1): [Medline]. 14. Warren WL Jr, Bailes JE. On the field evaluatin f athletic neck injury. Clin Sprts Med. Jan 1998;17(1): [Medline]. 15. Trg JS, Ramsey-Emrhein JA. Management guidelines fr participatin in cllisin activities with cngenital, develpmental, r pst-injury lesins invlving the cervical spine. Clin Sprts Med. Jul 1997;16(3): [Medline]. 16. Albright JP, Mses JM, Feldick HG, Dlan KD, Burmeister LF. Nnfatal cervical spine injuries in interschlastic ftball. JAMA. Sep ;236(11): [Medline]. 17. White AA 3rd, Jhnsn RM, Panjabi MM. Bimechanical analysis f clinical stability in the cervical spine. Clin Orthp. 1975;(109): [Medline]. 18. White AA 3rd, Panjabi MM. Update n the evaluatin f instability f the lwer cervical spine. Instr Curse Lect. 1987;36: [Medline]. 19. Eismnt FJ. Pint f View regarding Magnetic Resnance Evaluatin in Clsed Tractin Reductin f Cervical Dislcatins by Vaccar. Spine. 1999;24: Vaccar AR, Falatyn SP, Flanders AE, et al. Magnetic resnance evaluatin f the intervertebral disc, spinal ligaments, and spinal crd befre and after clsed tractin reductin f cervical spine dislcatins. Spine. Jun ;24(12): [Medline]. 21. Fehlings MG, Farhadi HF. Cervical stensis, spinal crd neurapraxia, and the prfessinal athlete. J Neursurg Spine. Apr 2007;6(4):354-5; discussin 355. [Medline]. 22. Trg JS, Pavlv H, Genuari SE. Neurapraxia f the cervical spinal crd with transient quadriplegia. J Bne Jint Surg Am. Dec 1986;68(9): [Medline]. 23. Herzg RJ, Wiens JJ, Dillingham MF. Nrmal cervical spine mrphmetry and cervical spinal stensis in asymptmatic prfessinal ftball players. Plain film radigraphy, multiplanar cmputed tmgraphy, and magnetic resnance imaging. Spine. Jun 1991;16(6 Suppl):S [Medline]. 24. Epstein JA, Carras R, Hyman RA. Cervical myelpathy caused by develpmental stensis f the spinal canal. J Neursurg. Sep 1979;51(3): [Medline]. 25. Eismnt FJ, Cliffrd S, Gldberg M. Cervical sagittal spinal canal size in spine injury. Spine. Oct 1984;9(7): [Medline].

28 26. Cantu RC. The cervical spinal stensis cntrversy. Clin Sprts Med. Jan 1998;17(1): [Medline]. 27. Watkins RG. Neck injuries in ftball players. Clin Sprts Med. Apr 1986;5(2): [Medline]. 28. Ellis JL, Gttlieb JE. Return-t-play decisins after cervical spine injuries. Curr Sprts Med Rep. Jan 2007;6(1): [Medline]. 29. Davis PM, McKelvey MK. Mediclegal aspects f athletic cervical spine injury. Clin Sprts Med. Jan 1998;17(1): [Medline]. Keywrds C-spine injuries, back injury, brachial plexus injuries, cervical spine fracture, disk herniatin, lwer cervical spine fractures, sprts-related spinal injury, sprts-related back injury, neck injury, sprts-related neck injury, sprain/strain Cntributr Infrmatin and Disclsures Authr Andrew A Sama, MD, Directr f Orthpedic Spine Surgery at the New Yrk Hspital f Queens, Assistant Prfessr f Orthpedic Surgery at the Weill Medical Cllege, Crnell University; Cnsulting Staff, Department f Orthpedic Surgery, Hspital fr Special Surgery Andrew A Sama, MD is a member f the fllwing medical scieties: Alpha Omega Alpha Disclsure: Orthdevelpment Crpratin Ryalty fr Implant Design & Develpment Cauthr(s) Federic P Girardi, MD, Instructr, Department f Orthpedic Surgery, Weill Cllege f Medicine f Crnell University Federic P Girardi, MD is a member f the fllwing medical scieties: Medical Sciety f the State f New Yrk Disclsure: Nthing t disclse Frank P Cammisa, Jr, MD, Chief, Spinal Surgery Service, Directr, Spine Care Institute, Hspital fr Special Surgery; Assciate Prfessr, Department f Clinical Orthpedic Surgery, Weill Medical Cllege-Crnell University Frank P Cammisa, Jr, MD is a member f the fllwing medical scieties: American Assciatin fr the Advancement f Science, American Medical Assciatin, American Spinal Injury Assciatin, Eastern Orthpaedic Assciatin, Medical Sciety f the State f New Yrk, New Yrk Academy f Sciences, New Yrk Cunty Medical Sciety, and Nrth American Spine Sciety Disclsure: Nthing t disclse Medical Editr James F Kellam, MD, Vice-Chair, Department f Orthpedic Surgery, Directr f Orthpedic Trauma and Educatin, Carlinas Medical Center James F Kellam, MD is a member f the fllwing medical scieties: American Academy f Orthpaedic Surgens, Orthpaedic Trauma Assciatin, and Ryal Cllege f Physicians and Surgens f Canada Disclsure: Nthing t disclse Pharmacy Editr Francisc Talavera, PharmD, PhD, Senir Pharmacy Editr, emedicine Disclsure: Nthing t disclse Managing Editr

29 William O Shaffer, BS, MD, Prfessr, Vice-Chairman and Residency Prgram Directr, Department f Orthpedic Surgery, University f Kentucky at Lexingtn William O Shaffer, BS, MD is a member f the fllwing medical scieties: American Academy f Orthpaedic Surgens, American Orthpaedic Assciatin, Internatinal Sciety fr the Study f the Lumbar Spine, Kentucky Medical Assciatin, Kentucky Orthpaedic Sciety, Nrth American Spine Sciety, Suthern Medical Assciatin, and Suthern Orthpaedic Assciatin Disclsure: DePuySpine (nt presently) Ryalty fr Cnsulting; DePuySpine (clsed) Grant/research funds fr SacrPelvic Instrumentatin Bimechanical Study; DePuyBilgics (clsed) Grant/research funds fr Heals study just clsed CME Editr Dinesh Patel, MD, FACS, Assciate Clinical Prfessr f Orthpedic Surgery, Harvard Medical Schl; Chief f Arthrscpic Surgery, Department f Orthpedic Surgery, Massachusetts General Hspital Dinesh Patel, MD, FACS is a member f the fllwing medical scieties: American Academy f Orthpaedic Surgens, American Assciatin f Physicians f Indian Origin, American Cllege f Internatinal Physicians, and American Cllege f Surgens Disclsure: Nthing t disclse Chief Editr Mary Ann E Keenan, MD, Prfessr, Vice Chair fr Graduate Medical Educatin, Department f Orthpedic Surgery, University f Pennsylvania Schl f Medicine; Chief f Neur-Orthpedics Prgram, Department f Orthpedic Surgery, Hspital f the University f Pennsylvania Mary Ann E Keenan, MD is a member f the fllwing medical scieties: Alpha Omega Alpha, American Academy f Orthpaedic Surgens, American Orthpaedic Assciatin, American Orthpaedic Ft and Ankle Sciety, American Sciety fr Surgery f the Hand, and Orthpaedic Rehabilitatin Assciatin Disclsure: Nthing t disclse by Medscape. All Rights Reserved (