Neck Injuries in Sports

Thomas M. Howard, MD

Sport Medicine

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

Anatomy 8 cervical roots Normal lordodic

curve helps absorb energy of blows to head and neck

This lordosis is lost @ 30 deg forward flexion

Exam- Motor C5-Deltoid, biceps C6- Biceps, wrist

ext C7-elbow ext, wrist

flex, finger ext C8- finger flexors T1-hand intrinsics

Exam-sensory C5-lateral Deltoid area C6-dorsal thenar web

space C7-MF & RF C8-ulnar side of hand T1-axilla

Diagnoses Cervical Strain Stingers CCN

– Transient Quadraparesis

– Burning Hands Syndrome

Cervical Instability Fractures/subluxation

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

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

Cervical Strain AKA Whiplash injury Up to 40% w sx @ 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

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 Spurling’s

Stinger RTP Full cervical ROM

w/o pain Neg Spurling’s Full strength

Complicated Stingers Recurrent, prolonged

disability Consider EMG and

MRI of C-spine and plexus

Consider equipment changes upon return

Cervical strengthening

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

Cervical Spinal Stenosis Acquired stenosis Normal AP diameter 15

mm– 13 considered to be narrow

Torg ratio < 0.8 predictive of future risk of catastrophic injury– Torg ratio < 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

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

Cervical Instability Often following

whiplash-type insult Persistent pain after

appropriate time to recover

>3.5 mm translatory displacement or 11 deg angulation w adjacent vertebrae

Immediate Transport Unconscious athlete Neuro symptoms in 2

limbs Spinous process

tenderness with concerning MOI

Beware of distracting injuries

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

Imaging Not Required if… No midline tenderness No focal neuro sx Normal LOC No drugs/meds No distracting injuries

Fractures C1 C2 Flexion injuries Extension injuries

C1 Jefferson fx

– Vertical compression

– Stable

Atlantoaxial rotatory displacement– Rotatory locking of

facets

C2 Odontoid fx Hangman’s Fx

– Hyperextension injury

– Bilat neural arch fx

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

Flexion Injuries Clay Shoveler’s Fx

– Avulsion of C6 or 7 spinous process

Teardrop burst fx– Simple or complex

– Most severe with posterior displacement into canal

Extension injuries Pre-vertebral STS Posterior body

displacement Anterior widening of

IVDS Anterior-inferior

avulsion fx Nerve root

compression and cord injury

RTP Full, pain-free Rom Normal neuro

examination Appropriate imaging

studies and specialty consultation

Informed consent of athlete

No Contraindication to Participation*Resolved burnerSpina bifida occultaType 2 Klippel-Feil congenital one-level fusionDevelopmental stenosis of spinal canal (canal/vertebral body ratio <0.8)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

Relative Contraindications to Participation*Recurrent acute and chronic burnersDevelopmental canal stenosis with:   - episode of cervical cord neurapraxia   - intervertebral disk disease   - MRI evidence of cord compressionLigamentous sprain with mild laxity (<3.5 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

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 instabilityAtlantoaxial rotatory fixation

Absolute Contraindications to Participation #2

Acute cervical fractureLigamentous laxity (>3.5 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