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 0.6-1.0%

NEUROLOGIC INJURY

NEURO INJURY

• Football
• Trampoline
• Water sports
• Gymnastics
• Rugby
• Ice Hockey
• Wrestling

Common with:

WATER SPORTS

• Majority injuries to cervical spine

DIVING INJURIES

• Male, 13 yr or older
• No formal diving

training

• 50% - alcohol

involved

• Avg. Patient

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

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

FOOTBALL

Younger Athletes

• High school football

players

– 3x more likely severe injury – 47 c spine injuries (2007-11) permanent disability/death

• Triage, management,

RTP criteria

Meuller et al. UNC ann 2009 Boden et al. Am J Sport Med 2007

Spear Tackling

• Most cervical injuries
• ccurred 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

Clinical Presentation

Burners / Stingers

• Pain, numbness &
• weakness. . .

neck, arm, hand

• 50% football players !
• Defensive players &
• ffensive lineman

Differential Diagnosis

Jogging off field with arm hanging down:

• Burner / Stinger
• Clavicle / AC injury
• Glenohumeral . . .

Subluxation/Dislocation

Mechanism of Injury

Mechanism

• Lateral flexion away

from involved side

• Shoulder depression

from blow

• Brachial plexus stretch

Management

Burners/Stingers

• Rule out more serious injury (red flags)

– Bilateral symptoms – Lower extremity – Persistent burning – Painful ROM – Tenderness

• Multiple episodes and those likely due to root

mechanism should be evaluated radiographically

• Restrict play,
• Immobilize
• Radiographic evaluation

• 1st Stinger

– Resolutions of symptoms and painless ROM

• 2nd Stinger

– Sit out game – Imaging

• 3rd Stinger

– Sit out season

RTP

Burners/Stingers

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)

• Quadriplegia
• Cervical Cord Neuropraxia

(CCN)

• Transient (mins to hours)
• Bilateral motor/sensory

symptoms

• Sensory symptoms:
• burning
• numbness
• loss of sensation

Trauma/SCI

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

Hsu WH. Spine. 2011

 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

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

Vaccaro et al. The Spine J. 2002. Proctor et al. Clin Sport Med 2012

RETURN to PLAY

Absolute Contraindications

• >2 previous episodes of

CCN

• S/P cervical laminectomy
• Continued cervical

discomfort, neuro deficit,

• r ↓ 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

Vaccaro et al. The Spine J. 2002. Proctor et al. Clin Sport Med 2012

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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