Cervical Spine & Spinal Cord Injuries in Athletes

Introduction

Cervical spine and spinal cord injuries (SCI) are uncommon in athletes but carry significant risk of morbidity and mortality as well as implications for the athletes future. The most commonly implicated sports include football, hockey, wrestling, gymnastics, and rugby however they can occur during any athletic event. Between the years 1977 and 2004, an average of 40 vertebral column injuries and 7 spinal cord injuries were reported annually [1]. Approximately 2.4% of athletic-related hospitalizations are related to SCI [2] and 9.2% of all SCIs in the United States are sustained during athletic activity [3]. Most of these occur in athletes younger than 30 years of age and the majority occur in high school athletes [4, 5]. In American football, these injuries speaked in the 1960s when new, harder helmets were introduced and spear tackling was still legal [6]. The majority of these injuries among football players occur during tackling and most cervical spine and spinal cord injuries involve an axial load on the neck with some degree of flexion or extension. Although the differential diagnosis of neck pain in athletes is broad, this review will focus on limb and life threatening cervical spine and spinal cord injuries.

Case Vignette

You are providing coverage for a high school football game. One of your players goes to tackle the opponent and has a helmet to helmet collision. Afterwords, he lays on the ground and calls for help. As you arrive you realize he is endorsing neck pain. Which of the following would be an indication for cervical spine immobilization and transport to the emergency department for imaging?

A) Paraspinal tenderness along the right trapezius muscle
B) Normal level of consciousness
C) Inability to abduct arm
D) Normal pupillary response.

On Field Management

One challenge in managing these potential injuries is rapidly identifying these athletes and applying the proper treatment. The sideline physician and athletic trainer should work together as a team to identify these potential injuries. A thorough neck and neurological exam should be performed. Any objective or subjective neurological deficits, altered mental status, or cervical spine tenderness should raise suspicion of an injury. Furthermore, any co-occurring injuries can be a painful distraction. If any injury of the cervical spine is suspected other than a stinger, a cervical collar should be immediately applied and the athlete should be placed in the supine position. In most cases, a rigid backboard is used (although the evidence favoring a backboard is lacking [7]) and the athlete should be transferred to the nearest trauma center. The sports medicine team on the field should accompany the athlete to the emergency department to assist in removal of the helmet if this is not done on the sideline.

Image 1: CT and MRI Demonstrating Severe Cervical Stenosis

CERVICAL SPINE CENTRAL STENOSIS

Cervical spine stenosis is defined as narrowing of the central canal. Most commonly, this is due to acquired microtrauma but can also be a result of osteoarthritis and congenital etiologies among others. Physical Exam should include a thorough cervical spine exam and neurological examination. Patients may have a positive Hoffman sign which is elicited by flicking the middle finger and observing flexion of the thumb and index finger, suggesting an upper motor neuron lesion. Imaging initially includes C-spine radiographs typically followed by MRI (or CT myelogram if MRI not obtainable). Management of these athletes and includes observation and activity restriction. If symptoms are persistent despite this, then surgical laminectomy is indicated. Return to play is controversial. Some physicians advocate no return to contact sports; in other cases athletes have been allowed to return. Regardless, the physician needs to have a serious conversation with the athlete about the risks of spinal cord injury and cervical cord neurapraxia.

Image 2: Normal CT and XR of the Cervical Spine

The posterior tibialis muscle and spring ligament also support the medial longitudinal arch (Amy Y I Ting, 2008). Damage to the posterior tibialis muscle can lead to development of a pes planus deformity (Amy Y I Ting, 2008). Injury to the posterior tibialis muscle can be acute or chronic. Tendon degeneration starts slowly with tenosynovitis and tendinosis but can progress to partial tearing, which can lead to insufficiency of the tendon (Amy Y I Ting, 2008). The spring ligament spans from the calcaneus to the navicular (Amy Y I Ting, 2008). Injury of the spring ligament typically occurs with tendinosis or tearing of the posterior tibialis tendon (Amy Y I Ting, 2008).

Stinger

Also known as ‘transient brachial plexus neuropraxia’ is a transient compression or traction of an upper extremity nerve of the cervical spine. Patients will endorse transient weakness, numbness and tingling of one extremity with C5 and C6 nerve roots most commonly affected. On exam patients will have altered sensation and diminished strength. Management generally involves removal from sport until return to full strength and asymptomatic and then they can return to sport. By definition, this injury pattern is transient. If they have persistent symptoms greater than 24 hours or more than 3 episodes then they must be worked up. Workup includes MRI to evaluate the cervical spine and consideration should be made for EMG/NCS to evaluate other peripheral neuropathies.

Image 3: Example of Spear Tackling

Cervical Cord Neuropraxia

Cervical cord neuropraxia is the more severe neuropraxia and is often termed ‘transient quadriplegia’. By definition it affects at least 2 extremities. The mechanism typically includes spear tackling in american football producing an axial load with hyperextension. The athlete may have an abnormal neurological exam or may have returned to baseline. They need to be removed from sport until they can have radiographs and MRI. Treatment is supportive as this is considered a transient illness with temporary myelin sheath injury. First time presentations may continue but recurrence is an indication to discontinue the athlete from sport. Prevention involves banning spear tackling, which has led to a reduction in overall neck injuries.

Image 4: Illustration of Atlas and Axis

Atlanto-Axial Instability

Atlanto-Axial Instability (AAI) is defined as laxity between cervical vertebrae C1 (Atlas) and C2 (Axis). Associated conditions include down syndrome, rheumatoid arthritis and the juvenile subtype, and os odontoideum. The instability can lead to spinal cord injury in athletes. History and exam can be noteworthy for loss of bowel or bladder control, unsteady gait and abnormal sensation in hands and feet. Diagnosis is made based on history, risk factors and MRI. Patients with risk factors should be screened prior to sports participation. Management includes at least a surgical evaluation. Asymptomatic patients may participate in some sports with restrictions. Excluded sports include gymnastics, diving, pentathlon, butterfly stroke, diving starts in swimming, high jump, soccer.

Read More: https://wikism.org/Atlantoaxial_Instability

Image 5: C1 fracture of the anterior and posterior facets on CT

C1 Fracture

A Jefferson fracture, or C1 burst fracture, is defined by fractures of the anterior or posterior arches. This is most commonly seen with an axial load such as diving into shallow water or falling. Physical exam is usually noteworthy for neck pain and neuro exam may be normal. Imaging includes radiographs, CT and MRI. Management includes a hard cervical collar and neurosurgical evaluation. Stable fractures can be managed nonoperatively, however unstable or complicated cases require ORIF. There are no clear return to play guidelines although athletes should be excluded from contact sports at a minimum.

Image 6: Odontoid Fracture on sagittal CT and odontoid view radiograph

C2 Fracture

C2 fractures can present as an odontoid (or dens) fracture or a hangmans (or pars interarticularis fracture). Etiology often involves axial load with hyperextension or flexion. Patients will have localized neck pain with or without neurological deficits. Imaging includes radiographs, CT and MRI. Management includes a hard cervical collar and neurosurgical evaluation. Type I and III odontoid fractures can typically be nonoperative while type II and most hangman’s fractures require surgical intervention. There are no clear return to play guidelines although athletes should be excluded from contact sports at a minimum.

– More Neck Pain from Sports Medicine Review: https://www.sportsmedreview.com/by-joint/neck/

– Read More: http://wikism.org/Odontoid_Fracture

– Read More: http://wikism.org/Hangmans_Fracture

Case Conclusion

Answer C. Cervical spine trauma can be catastrophic. There are several decision making rules which can be used to help sports medicine providers with decision making on the sideline. These are endorsed by the NAEMSP, ACS and NATA.

NEXUS criteria. Radiography is not necessary if the patient satisfies ALL of the following low risk criteria:

No midline cervical tenderness
No focal neuro deficits
Normal alertness
No intoxication
No painful distracting injury

Indications for C-spine immobilization and transport include:

Blunt trauma and altered level of consciousness
Spinal pain or tenderness
Neurologic complaint (e.g., numbness or motor weakness)
Anatomic deformity of the spine
High-energy mechanism of injury and any of the following:
Drug or alcohol intoxication
Inability to communicate
Distracting injury

References

[1] Mueller FO, Cantu RC. National Center for Catastrophic Sports Injury 22nd Annual Report. Chapel Hill, NC: National Collegiate Athletic Association, American Football Coaches Association, and the National Federation of State High School Associations; 2004

[2] UAB Spinal Cord Injury Model System Information Network: The UAB-SCIMS Information Network. University of Alabama School of Medicine, 2013. www.spinalcord.uab.edu. Accessed August 2014.

[3] Bailes JE, Hadley MN, Quigley MR, Sonntag VK, Cerullo LJ: Management of athletic injuries of the cervical spine and spinal cord. Neurosurgery 1991;29(4):491-497.

[4] Bailes JE, Hadley MN, Quigley MR, Sonntag VK, Cerullo LJ: Management of athletic injuries of the cervical spine and spinal cord. Neurosurgery 1991;29(4):491-497.

[5] Mueller FO, Cantu RC: Annual Survey of Catastrophic Football Injuries: 1977-2012, 2015.
http://nccsir.unc.edu/files/2014/05/FBAnnual2012.pdf. Accessed September 15, 2015.

[6] Bailes JE, Petschauer M, Guskiewicz KM, Marano G: Management of cervical spine injuries in athletes. J Athl Train 2007;42(1):126-134.

[7] White CC IV, Domeier RM, Millin MG; Standards and Clinical Practice Committee, National Association of EMS Physicians: EMS spinal precautions and the use of the long backboard: Resource document to the position statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma. Prehosp Emerg Care 2014;18(2):306-314.