Cervical Spine Injuries in Athletes: Return to Play Mark F. Kurd, - PowerPoint PPT Presentation

Cervical Spine Injuries in Athletes: Return to Play Mark F. Kurd, M.D. Associate Professor, Sidney Kimmel Medical College Thomas Jefferson University The Rothman Institute

Disclosures • Duratap, LLC: Shareholder

INCIDENCE 10-15% of all cervical spine injuries are sports related NEUROLOGIC INJURY 0.6-1.0%

NEURO INJURY Common with : • Football • Trampoline • Water sports • Gymnastics • Rugby • Ice Hockey • Wrestling

WATER SPORTS • Majority injuries to cervical spine

DIVING INJURIES Avg. Patient • Male, 13 yr or older • No formal diving training • 50% - alcohol involved

Axial Loading Injury in Hockey Number of catastrophic injuries low, BUT the incidence per 100,000 is high

Other Sports • Pole Vaulting – 2 catastrophic injuries/ 1 fatality per year, despite only 25,000-50,000 participants each year • Cheerleading – 0.6 direct catastrophic injuries per 100,000 • Baseball – 0.5 direct catastrophic injuries per 100,000 • Wrestling – 1.0 direct catastrophic injury per 100,000 Boden, JAAOS. 2005

FOOTBALL Associated with the highest number of severe head and neck injuries per year for all high school and college sports

Younger Athletes • High school football players – 3x more likely severe injury – 47 c spine injuries (2007-11) permanent disability/death • Triage, management, RTP criteria Boden et al. Am J Sport Med 2007 Meuller et al. UNC ann 2009

Spear Tackling • Most cervical injuries occurred to defensive players during tackling • Axial load mechanism identified in 27% of tackling injuries Cantu, Neurosurgery, 2000

Proper Technique: Heads Up Tackling • See What You Hit • Knees Bent at Impact • Drive Through with Legs

Gill et al, SMAR . 2008

Cervical Spine Syndromes • Cervical Sprain - ligamentous • Burners / Stingers - root or brachial plexus neuropraxia • Transient quadriplegia – Cervical Cord Neuropraxia (CNN) • Permanent quadriplegia - permanent disruption (axonotmesis, neurotmesis) of the cervical cord

BURNERS/STINGERS

Burners / Stingers • Pain, numbness & weakness. . . neck, arm, hand • 50% football players ! • Defensive players & offensive lineman Clinical Presentation

Differential Diagnosis Jogging off field with arm hanging down: • Burner / Stinger • Clavicle / AC injury • Glenohumeral . . . Subluxation/Dislocation

Mechanism • Lateral flexion away from involved side • Shoulder depression from blow • Brachial plexus stretch Mechanism of Injury

Management Burners/Stingers • Rule out more serious injury (red flags) – Bilateral symptoms •Restrict play, – Lower extremity •Immobilize – Persistent burning •Radiographic evaluation – Painful ROM – Tenderness • Multiple episodes and those likely due to root mechanism should be evaluated radiographically

RTP Burners/Stingers • 1 st Stinger – Resolutions of symptoms and painless ROM • 2 nd Stinger – Sit out game – Imaging • 3 rd Stinger – Sit out season Kepler et al, ClinSportsMed . 2012

Cervical Stenosis • Definitions – Canal diameter < 13mm (nl: 14-23) –Torg ratio <0.8 Torg JBJS 1986

Controversy • Abnormal Torg ratio – 3- fold increase in stingers –Low predictive value - no more susceptible to permanent neurologic injury than members of the general population (Torg)

Trauma/SCI • Quadriplegia • Cervical Cord Neuropraxia (CCN) • Transient (mins to hours) • Bilateral motor/sensory symptoms • Sensory symptoms: ● burning ● numbness ● loss of sensation

CCN Management • Analogous to concussion of the brain • RTP: full resolution of symptoms • Long-term effects of repeated episodes unknown

Cervical HNP • 99 NFL players identified (1979 – 2008) w CDH • 53 where treated operatively/46 nonop • Surgery – Greater percentage return to play (72% vs 46%) – More games played (29.3 vs 14.7) – Longer careers after injury (2.8 vs 1.5 yrs) • 5.3% of players required revision surgery for adjacent level disease Hsu WH. Spine. 2011

Cervical HNP  When comparing NFL players with CDH those treated operatively had  Greater percentage return to play (72% vs 46%)  More games played (29.3 vs 14.7)  Longer careers after injury (2.8 vs 1.5 yrs)  5.3% of players required revision surgery for adjacent level disease Hsu WH. Spine. 2011

Return to Play- ACDF • No cord compression • Symptoms resolved • Solid Fusion – One level – Two level-controversial – Three level-contraindicated Meredith DS. Am J Sports Med. 2013. Kepler CK. Clin Sports Med. 2012.

ACDF in Rugby • 19 professional players- ACDF between 1998- 2003 • Symptoms improved in 17 patients • 13 returned to play Andrews J et al. JBJS Br. 2008

RETURN to PLAY Absolute Contraindications • Cervical myelopathy • H/O C1-C2 fusion • C1-C2 hypermobility • Multi-level Klippel-Feil deformity • Spear Tacklers Spine • Lack of solid fusion s/p ACDF Proctor et al. Clin Sport Med 2012 Vaccaro et al. The Spine J. 2002.

RETURN to PLAY Absolute Contraindications • >2 previous episodes of CCN • S/P cervical laminectomy • Continued cervical discomfort, neuro deficit, or ↓ ROM Vaccaro et al. The Spine J. 2002.

RETURN to PLAY Relative Contraindications • H/O transient quadriplegia with full symptom resolution • Cord abnormality • 3+ stingers in same season • Stable, healed 2-level subaxial ACF or PCF Proctor et al. Clin Sport Med 2012 Vaccaro et al. The Spine J. 2002.

Conclusion • Limited data • Prevention: Heads up tackling • Appropriate on field management • Elite athletes can return to high level competition following ACDF • RTP: – Guidelines: Expert opinion – Complete resolution of symptoms

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