Cervical Disc Injury in a Division I Collegiate Football Player

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Cervical Disc Injury in a Division I Collegiate
Football Player

• Kelli Frye Pugh, MS, ATC, CMT
• Susan Saliba, PhD, PT, ATC
• Ethan Saliba, PhD, PT, ATC, SCS
• David Diduch, MD
• Christopher Schaffrey, MD
• University of Virginia, Charlottesville, VA

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Cervical Injuries in Sport

• Annual incidence of catastrophic c-spine inj was
• 1.10 per 100,000 high school players
• 4.72 per 100,000 college players
• 3 times more common in games than practices
• Mean annual incidence of quadriplegia was 0.52
  per 100,000
• Most inj resulting in quadriplegia occurred to
  players on defense, with the highest percentage
  of inj involving DBs

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Transient Quadriplegia

• Common complication of cervical cord neurapraxia
  (CCN, aka spinal cord concussion)
• MOI rapid hyperflexion or hyperextension causing
  a pinchers mech, also axial loading (spearing)
  - causing a sudden decrease in the A-P diameter
  of the canal at that cerv level, resulting in
  cord compression and neurologic symptoms

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CCN classification
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Types of athletic spinal injuriesTable from
Maroon and Bailes, 1996
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Case Study

• UVA vs. Georgia Tech
• November 12, 2005
• 20 year old African American male defensive back
  sustained a possible axial load then a definite
  rapid hyperextension mechanism while tackling
• History of one prior brachial plexus neurapraxia
  (stinger) with full resolution of symptoms
  within minutes and normal cervical spine x-rays

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Injury
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On Field Management

• Prone and conscious
• Paralysis and numbness in all extremities
• Immobilized on spine board while wearing helmet
  and shoulder pads
• Face mask removed prior to being transported to
  UVA Emergency Department
• Solu-Medrol drip started in the ED

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Clinical Examination

• Full motor function returned to lower extremities
  within 10 minutes, to upper extremities within
  several hours
• Cervical tenderness
• Residual hyperesthesia in bilateral shoulders

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Differential Diagnosis

• Cervical spine fracture/dislocation
• Cervical disc injury
• Spinal cord injury

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Differential Diagnosis

• X-rays ruled out acute fracture and alignment
  abnormalities in the cervical, thoracic, and
  lumbar spine
• Head and cervical CT scan revealed degenerative
  changes at C4 and C5 vertebrae

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Differential Diagnosis

• MRI determined
• C3-C4 disc herniation resulting in mild spinal
  cord compression with central cord contusion
• Small posterior annular tear at C4-C5 disc

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Plan

• Hospitalized for 48 hours to continue IV
  steroidal anti-inflammatory medicine
• Discharged wearing soft cervical collar
• F/U cervical spine x-rays in 2 weeks, repeat MRI
  in 6 weeks
• Only ADLs allowed

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2 Weeks post-injury

• Flexion and extension views showed no evidence of
  vertebral instability
• Minimal neck pain
• Moderate dysesthetic pain in shoulders
• D/C use of cervical collar

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6 Weeks post-injury

• Still experiencing resolving dysthesia in
  shoulders
• MRI showed no significant change in the C3-C4
  disc protrusion, resulting in moderate central
  canal stenosis and posterior cord displacement
• Resolution of abnormal signal within the cord at
  the C3-C4 level
• No evidence of ligamentous injury
• Some disc dessication of C4-C5 and C5-C6, with
  minimal bulging of C4-C5 disc

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Management Options

• No surgery, retire from sport
• Surgery, retire from sport
• Surgery, with hopes of returning to sport
• Surgical options
• One level anterior or posterior fusion with
  discectomy
• Multi-level anterior or posterior fusion with
  discectomy
• Disk arthroplasty

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Surgical Procedure

• 12 weeks post-injury
• left sided approach to a C3-C4 anterior cervical
  discectomy fusion (single level) with bone graft

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Post-Op Restrictions

• Wound care for incision
• Soft collar for 6 weeks - avoid cervical rotation
• No lifting gt10 lbs for 6 weeks
• Gradual resumption of ADLs

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2 weeks post-op

• Incision healing well
• Motor strength 5/5 in bilateral UE/LE
• 2/4 and symmetric reflexes in UE/LE
• Experiencing occasional tingling in bilat UE with
  full neck flexion
• Allowed to begin recumbent bike for light CV
  exercise

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6 weeks post-op

• Incision well healed
• X-rays showed good positioning of bone graft and
  hardware
• Tingling in bilat UE had resolved over past 4
  weeks and was no longer present
• 5/5 motor strength
• 1/4 and symmetric reflexes in UE/LE

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6 weeks post-op rehabilitation

• No resisted neck ROM
• No valsalva
• Began increasing intensity of CV exercise,
  including running
• Began body weight exercises and resisted single
  muscle group training

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Plan

• Progressive increase in rehab activities
• Repeat flex and ext x-rays in 8 weeks (early
  June) to evaluate bony healing
• Obtain x-ray, CT, and MRI in late July to
  determine possibility of RTP

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RTP criteria

• Good integration of cervical graft (x-ray CT)
• Spinal cord decompression (MRI)
• Complete resolution of symptoms
• Discussion of appropriate tackling techniques

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14 weeks post-op

• Bone graft evident at C3-C4 intervertebral disc
  space, unchanged from prior films
• Cervical alignment WNL
• No evidence of abnormal motion with flex and ext
  views

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6 months post-opX-ray results

• Full, normal cervical ROM
• Stable appearance of C3-C4 anterior fusion

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6 months post-opCT results

• Bone plug was partially incorporated
• Screws in good position with no evidence of
  hardware loosening or fatigue
• Mild straightening of normal cerv lordosis
• Mild early degenerative changes at C4-C5

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6 months post-opMRI results

• Post-op changes of C3-C4 ant fusion
• C3-C4 no sig central canal stenosis, mild right
  neural foraminal stenosis
• C4-C5 mild central canal stenosis
• Improved substantially from MRI at time of injury

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Team Meeting

• Athlete, neurosurgeon, orthopedist, athletic
  trainers, and coach
• Review of imaging studies
• Discussion of tackling techniques
• Athlete signed an informed consent reviewing the
  outcome of the conversation

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Current Status

• Six months after surgery the athlete was cleared
  to resume full football participation
• Played entire season at starting safety with no
  recurrence of symptoms

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Conclusions

• Advance preparation and communication between all
  parts of medical team is essential.
• Athlete education on proper tackling techniques
  can help prevent cervical injuries.
• While transient quadriplegia alone may not
  preclude further participation, evaluation of the
  cervical anatomy is required to ensure there is
  no pathologic condition that may predispose the
  athlete to further injury.