Stingers and Transient Quadriparesis Stanley A. Herring, MD - - PowerPoint PPT Presentation

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Stingers and Transient Quadriparesis Stanley A. Herring, MD - - PowerPoint PPT Presentation

May 14, 2023 323 likes •1.04k views

Cervical Spine Stingers and Transient Quadriparesis Stanley A. Herring, MD Director of Sports, Spine and Orthopaedic Health UW Medicine Health System Co-Medical Director Seattle Sports Concussion Program Harborview Medical Center/Seattle

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Cervical Spine Stingers and Transient Quadriparesis

Stanley A. Herring, MD Director of Sports, Spine and Orthopaedic Health UW Medicine Health System Co-Medical Director Seattle Sports Concussion Program Harborview Medical Center/Seattle Children’s Team Physician Seattle Seahawks Team Physician Seattle Mariners Seattle, Washington

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Disclosures

I, Stanley A. Herring MD, nor any family member(s), have any relevant financial relationships to be discussed, directly or indirectly, referred to or illustrated with or without recognition within the presentation

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Stingers

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Stingers

Common

  • 50 to 65% of

college players – Clancy 1977 – Sallis 1992

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Stingers

Weinstein and Herring 2000

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Pathomechanics

  • Tensile injury to brachial plexus or cervical

nerve root/spinal nerve complex

  • Compression injury to brachial plexus or

cervical nerve root/spinal nerve complex

– Chrisman 1965,Bateman 1967,Clancy 1977,Rockett 1982, DiBenedetto 1984,Watkins 1986

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Pathomechanics

  • May be dependent upon skill level of athlete
  • Watkins 1986
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Neuroanatomy

  • Resistance to

tensile force – Number of funiculi

  • Sunderland

1978

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Neuroanatomy

  • Resistance to

tensile force – Number of funiculi – Amount of perineural tissue

  • Sunderland

1978

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Neuroanatomy

  • Resistance to tensile

force – Number of funiculi – Amount of perineural tissue – Structure of dorsal & ventral roots

  • Sunderland 1978
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Neuroanatomy

  • Resistance to tensile

force

– Number of funiculi – Amount of perineural tissue – Structure of dorsal & ventral roots – Linear vs. plexiform archtecture

  • Sunderland 1978
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Neuroanatomy

  • Resistance to

compressive force – Neuroforaminal narrowing – Epineural tissue of the brachial plexus

  • Sunderland 1978
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Neuroanatomy

  • The nerve root/ spinal nerve complex is the

most susceptible area to tensile or compressive injury

  • C5 – C7 (especially motor fibers) most

vulnerable

– Shortest – Direct alignment with upper trunk of plexus

  • Sunderland 1978
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Persistent stingers

  • Case study – 55

football players – 11 professional, 37 collegiate, 7 scholastic – Levitz 1997

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Persistent stingers

  • 83% extension/

compression mechanism

  • 70% Spurling’s sign

– Levitz 1997

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Persistent stingers

  • 87% disc disease by MRI
  • 93% disc disease or foraminal narrowing by

MRI

  • 53% Torg ratio <0.8

– Levitz 1997

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Persistent stingers

  • 266 collegiate football

players

  • 40 problematic

stingers – Meyer 1994

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Persistent stingers

  • 85% extension/

compression

  • 15% brachial plexus

stretch – Meyer 1994

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Persistent stingers

  • Pre-participation C-Spine X-rays
  • 10 cervical MRI’s – normal
  • 5 myelogram/ CT’s – normal
  • 8 electrodiagnostic studies – 6 normal

– Meyer 1994

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Persistent stingers

  • 47.5% of stinger group had Torg ratio <0.8
  • 25.1% of asymptomatic group had Torg

ratio <0.8 – p-value = 0.02 – Meyer 1994

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Stingers

Torg ratio Foramen/ vertebral body ratio

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Stingers

  • Torg ratio

– <0.8 scholastic – <0.7 collegiate

  • Foramen/ vertebral body ratio

– <0.73 (average) scholastic

  • Castro 1997 Kelly 2000
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Persistent stingers – Work- up

  • Cervical spine x-rays

– A/P & lateral – Obliques – Flexion/ extension

  • MRI
  • Myelogram /CT
  • EMG
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Persistent Stingers- Treatment

  • Rest
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Persistent Stingers- Treatment

  • Rest
  • Rehabilitation
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Persistent Stingers- Treatment

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Persistent Stingers- Treatment

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Persistent Stingers- Treatment

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Persistent Stingers- Treatment

  • Rest
  • Rehabilitation
  • Medications

– Oral – Selective injections

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Persistent Stingers- Treatment

  • Rest
  • Rehabilitation
  • Medications

– Oral – Selective injections

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Persistent Stingers- Treatment

  • Rest
  • Rehabilitation
  • Medications

– Oral – Selective injections

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Persistent Stingers- Treatment

  • Rest
  • Rehabilitation
  • Medications

– Oral – Selective injections

  • Equipment

modifications

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Persistent Stingers- Treatment

  • Rest
  • Rehabilitation
  • Medications

– Oral – Selective injections

  • Equipment

modifications

  • Surgery

– Foraminotomy – Fusion

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  • 23 year old professional football player
  • 9/29/02 made tackle on special teams
  • Extension/rotation of head to right
  • Cervical and shoulder girdle region pain

and burning

Case Report Stinger

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Case Report Stinger

  • Physical examination (09/29/02)

– + Spurling’s maneuver to the right side – C5 verses upper trunk weakness (4+/5) on right side – Subtle diminished sensation lateral deltoid on right side – Normal reflexes

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Case Report Stinger

  • 10/09/02

– - Spurling’s maneuver – External rotation and isolated supraspinatus testing 4+ to 5-/5 – Normal sensation

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Case Report Stinger

What to do?

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Case Report Stinger

  • Rehabilitation
  • Equipment

modificaton

  • Return to play

decision

– 10/14/02 – No recurrent stingers – 1/03 normal strength – Pro Bowl

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Persistent Stingers

  • Time to resolution of 1st stinger
  • Recurrences
  • Spurling’s vs. painless weakness
  • Imaging studies-compression vs “battered

nerve”

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Transient Quadriparesis

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Transient Quadriparesis

High Stakes Decision

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Cervical Spinal Cord Injury

Types

  • “Neurapraxia”

– transient motor and/or sensory loss – 2-4 limbs affected – duration up to 36 hrs.

  • Contusion

– permanent injury – various patterns

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Transient Quadriparesis

Mechanisms

  • Metabolic
  • Vascular
  • Structural

– Instability – Spinal stenosis

  • Congenital
  • Acquired
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Cervical Spinal Stenosis

Controversies

  • How to define

– bony dimensions – other factors

  • How to measure

– sensitivity – specificity

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Cervical Spinal Stenosis

  • Direct Measurement

– lateral c-spine x-ray with known magnification – cross sectional imaging with CT or MRI

  • Values for canal

diameters (bony)

– normal >15 mm (C2- C7) – narrow < 12mm

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Cervical Spinal Stenosis

  • Torg (Pavlov) ratio,

1986

– indirect measure – avoids magnification error – positive if <0.8 – high sensitivity, >90%

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Cervical Spinal Stenosis

Subsequent Studies

  • Herzog et al, Spine

1991

– 49% of professional football players had a Torg ratio <0.8 at one

  • r more levels

– only 13% had true spinal stenosis by advanced imaging

  • Odor et al, AJSM

1990

– 32% professional and 34% rookie football players had Torg ratio <0.8 at one or more levels

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Torg Ratio

Pitfalls

  • Athletes have large

vertebral bodies

  • Ratio is skewed

toward stenosis

  • Anatomic relationship
  • f spinal cord and

canal varies

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Functional Reserve of Spinal Canal

  • Amount of CSF

surrounding spinal cord

  • Shape of spinal cord
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Return to Play

Torg & Glasgow, CJSM 1991

  • No restriction

– no hx of TQ; Torg ratio <0.8

  • Relative restriction

– one episode TQ; Torg ratio <0.8

  • Absolute contraindication

– TQ with instability, hard disc, cord compression, symptoms > 36 hrs., more than

  • ne episode
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Return to Play

Cantu, Exercise and Sports Sciences Reviews 1995

  • No restriction

– one episode of TQ with full recovery and normal work-up

  • Relative restriction

– one episode of TQ as a result of minimal contact; minimal or mild disc herniation

  • Absolute contraindication

– TQ with functional spinal stenosis

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Cervical Cord Neurapraxia

Torg et al, J Neurosurg 1997

  • 110 athletes with CCN
  • 63 (57%) RTP
  • 35 (56%) 2nd episode of CCN

– 3.1 +/- 4.0 episodes (range 2-25)

  • Imaging (105 x-rays, 53 MRIs)

– only 7% nl x-ray, 8% nl MRI – 34% spinal cord compression

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Cervical Cord Neurapraxia

Torg et al, J Neurosurg 1997

  • Risk of recurrence ~ spinal stenosis

– smaller Torg ratio

  • (0.65 vs 0.72mm)

– smaller disc level canal diameter

  • (8.7 vs 10.1mm)

– less space available for the cord

  • (1.1 vs 2.0mm)
  • No permanent neurological injuries
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Cervical Cord Neurapraxia

Torg et al, J Neurosurg 1997

  • Correlation

– Canal stenosis – Recurrence

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Cervical Cord Neurapraxia

Torg et al, J Neurosurg 1997

  • “May be advised not at increased risk of

permanent neurologic injury with return”

  • “Presence of stenosis does not result in

irreversible cord injury”

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Cervical Cord Neurapraxia

Torg et al, J Neurosurg 1997

  • Uncontrolled case studies
  • No physical exam data
  • Imaging

– 110 athletes, 53 MRI’s

  • Follow-up

– 15- 228 months

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Cervical Cord Neurapraxia

Torg et al, J Neurosurg 1997

  • 10 players with cord compression
  • Repeat assessment over time
  • Subgroup susceptible?
  • Outcome was return to play
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Return to Play

Torg et. al. JBJS 2002

  • No restriction

– no hx of CNN; Torg ratio <0.8

  • Relative restriction

– one episode CNN; Torg ratio <0.8 – one episode CNN with DDD or DJD – one episode CNN with cord deformation

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Return to Play

Torg et. al. JBJS 2002

  • Absolute contraindication

– CNN with instability, symptoms > 36 hrs., and/or more than one episode – CNN with cord defect or cord edema

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Transient Quadriparesis

Return to Play

  • Is there a risk of permanent spinal cord

injury following TQ?

  • How should a team physician counsel a

player:

– with TQ and normal work-up? – with TQ and cervical disc herniation? – with TQ and spinal stenosis? – with TQ who is a high school athlete?

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If this was your son or daughter?

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Return to Sport After Cervical Injury Brigham 2003

  • Professional football

player -1998

– Lhermitte’s sign – Neck flexion – Spear tackle

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Return to Sport After Cervical Injury Brigham 2003

  • Tackling 2000

– Burning 4 extremities – Persistent upper extremity dysesthesias – C6 Radiculopathy

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Return to Sport After Cervical Injury Brigham 2003

  • 3 Months

– Burning C6 – LE parasthesias

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