Neck Injuries in Sports

1
Neck Injuries in Sports

• Thomas M. Howard, MD
• Sport Medicine

2
Anatomy

• 3-joint complex
• 50 Flex-Ext Atlanto-occipital
• 50 rotation C1-C2
• Center of motion
• Flex C 5-6
• Ext C 6-7
• C2 and C7 most prominent spinous processes

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Anatomy

• 8 cervical roots
• Normal lordodic curve helps absorb energy of
  blows to head and neck
• This lordosis is lost _at_ 30 deg forward flexion

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Exam- Motor

• C5-Deltoid, biceps
• C6- Biceps, wrist ext
• C7-elbow ext, wrist flex, finger ext
• C8- finger flexors
• T1-hand intrinsics

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Exam-sensory

• C5-lateral Deltoid area
• C6-dorsal thenar web space
• C7-MF RF
• C8-ulnar side of hand
• T1-axilla

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Diagnoses

• Cervical Strain
• Stingers
• CCN
• Transient Quadraparesis
• Burning Hands Syndrome
• Cervical Instability
• Fractures/subluxation

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Epidemiology

• 10,000 C-spine injuries/yr in US
• 5-10 related to sports
• Football risk 1.9/100,000 player-yrs
• Football, wrestling, gymnastics, diving, surfing,
  skiing, hockey, rugby

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Risk Mechanisms

• Football-tackling w head down
• Rugby-scrummage
• Hockey-checked from behind, aggressive play
• Wrestling-takedown
• Gymnastic-more likely at practice
• Diving-alcohol, reckless behavior

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Cervical Strain

• AKA Whiplash injury
• Up to 40 w sx _at_ 15 yrs
• Disability highly associated with job
  dissatisfaction, female gender, low back pain and
  prior neck pain
• Single best estimate of handicap was return of
  normal ROM

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Stingers

• Transient UE neuropraxia of root or brachial
  plexus
• Traction-plexus
• Compression-root
• Burning in arm
• Weakness in C5 and C6 distribution
• Deltoid, biceps, RC, wrist extensors, pronator
  teres
• Positive Spurlings

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Stinger RTP

• Full cervical ROM w/o pain
• Neg Spurlings
• Full strength

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Complicated Stingers

• Recurrent, prolonged disability
• Consider EMG and MRI of C-spine and plexus
• Consider equipment changes upon return
• Cervical strengthening

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Cervical Cord Neuropraxia

• Cervical cord pinch
• Reduced AP diameter and in-folding of ligamentum
  flavum
• Axial load with hyperextension or flexion
• Sx last 10 min-48 hrs
• Pressure on cord causes local increase in
  intracellular calcium
• Mixed neuro findings in 2 limbs or all four

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Cervical Spinal Stenosis

• Acquired stenosis
• Normal AP diameter 15 mm
• 13 considered to be narrow
• Torg ratio lt 0.8 predictive of future risk of
  catastrophic injury
• Torg ratio lt 0.5 with one episode of neuropraxia
  have 75 risk of repeat episodes
• MRI-functional stenosis
• Spinal cord contour deformation and loss of
  surrounding CSF

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On-field Management

• Assess LOC and simple neuro exam by question
  without moving athlete
• Stabilize C-spine and log-roll if necessary to
  move athlete to back
• Leave helmet on
• Helmet and shoulder pads
• Manage airway by removing face mask

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Cervical Instability

• Often following whiplash-type insult
• Persistent pain after appropriate time to recover
• gt3.5 mm translatory displacement or 11 deg
  angulation w adjacent vertebrae

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Immediate Transport

• Unconscious athlete
• Neuro symptoms in 2 limbs
• Spinous process tenderness with concerning MOI
• Beware of distracting injuries

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Clearing C-spine on Field

• Awake and alert
• Nl neuro exam
• No spinous process pain
• Full voluntary range of motion
• FF 60 deg
• Ext 70 deg
• Lat Flexion 45 deg
• Rotation 80 deg

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Imaging Not Required if

• No midline tenderness
• No focal neuro sx
• Normal LOC
• No drugs/meds
• No distracting injuries

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Fractures

• C1
• C2
• Flexion injuries
• Extension injuries

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C1

• Jefferson fx
• Vertical compression
• Stable
• Atlantoaxial rotatory displacement
• Rotatory locking of facets

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C2

• Odontoid fx
• Hangmans Fx
• Hyperextension injury
• Bilat neural arch fx

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Flexion injuries

• Anterior wedge
• Anterior subluxation
• Post lig complex dispruption
• Unilateral locked facets
• Bilat locked facets
• Jumped and locked facets
• High incidence of cord damage

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Flexion Injuries

• Clay Shovelers Fx
• Avulsion of C6 or 7 spinous process
• Teardrop burst fx
• Simple or complex
• Most severe with posterior displacement into canal

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Extension injuries

• Pre-vertebral STS
• Posterior body displacement
• Anterior widening of IVDS
• Anterior-inferior avulsion fx
• Nerve root compression and cord injury

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RTP

• Full, pain-free Rom
• Normal neuro examination
• Appropriate imaging studies and specialty
  consultation
• Informed consent of athlete

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No Contraindication to ParticipationResolved
burnerSpina bifida occultaType 2 Klippel-Feil
congenital one-level fusionDevelopmental
stenosis of spinal canal (canal/vertebral body
ratio lt0.8)Mild ligamentous sprain with no
laxityHealed, stable compression fracture of
vertebral bodyHealed, stable end-plate
fractureHealed "clay shoveler's" fractureHealed
intervertebral disk bulgeStable, one-level
anterior or posterior surgical fusion
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Relative Contraindications to ParticipationRecur
rent acute and chronic burnersDevelopmental
canal stenosis with   - episode of cervical
cord neurapraxia   - intervertebral disk
disease   - MRI evidence of cord
compressionLigamentous sprain with mild laxity
(lt3.5 mm anteroposterior displacement and 11
rotation)Healed, nondisplaced Jefferson
fractureHealed, stable, mildly displaced
vertebral body fracture without a sagittal
component or neural ring involvementHealed,
stable neural ring fracturesHealed
intervertebral disk herniationStable, two-level
anterior or posterior surgical fusion
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Absolute Contraindications to Participation
1 Odontoid agenesis, hypoplasia, or os
odontoidiumAtlanto-occipital fusionType 1
Klippel-Feil mass fusionDevelopmental canal
stenosis with   - ligamentous instability   -
cervical cord neurapraxia with signs or symptoms
lasting more than 36 hours   - multiple
episodes of cervical cord neurapraxiaSpear
tackler's spineAtlantoaxial instabilityAtlantoax
ial rotatory fixation
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Absolute Contraindications to Participation
2 Acute cervical fractureLigamentous laxity
(gt3.5 mm anteroposterior displacement or 11
rotation)Vertebral body fracture with a sagittal
componentVertebral body fracture with associated
posterior arch fractures and/or ligamentous
laxityVertebral body fracture with displacement
into the spinal canalHealed fractures with
associated neurologic findings or symptoms,
pain, or limitation of cervical range of
motionIntervertebral disk herniation with
neurologic signs or symptoms, pain, or limitation
of cervical range of motionAnterior or posterior
fusion of three or more levels