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

3. Anatomy  8 cervical roots  Normal lordodic curve helps absorb energy of blows to head and neck  This lordosis is lost @ 30 deg forward flexion

4. Exam- Motor  C5-Deltoid, biceps  C6- Biceps, wrist ext  C7-elbow ext, wrist flex, finger ext  C8- finger flexors  T1-hand intrinsics

5. Exam-sensory  C5-lateral Deltoid area  C6-dorsal thenar web space  C7-MF & RF  C8-ulnar side of hand  T1-axilla

6. Diagnoses  Cervical Strain  Stingers  CCN –Transient Quadraparesis –Burning Hands Syndrome  Cervical Instability  Fractures/subluxation

7. 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

8. 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

9. 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

10. 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

11. Stinger RTP  Full cervical ROM w/o pain  Neg Spurling’s  Full strength

12. Complicated Stingers  Recurrent, prolonged disability  Consider EMG and MRI of C-spine and plexus  Consider equipment changes upon return  Cervical strengthening

13. 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

14. 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

15. 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

16. 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

17. Immediate Transport  Unconscious athlete  Neuro symptoms in 2 limbs  Spinous process tenderness with concerning MOI  Beware of distracting injuries

18. 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

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

20. Fractures  C1  C2  Flexion injuries  Extension injuries

21. C1  Jefferson fx –Vertical compression –Stable  Atlantoaxial rotatory displacement –Rotatory locking of facets

22. C2  Odontoid fx  Hangman’s Fx –Hyperextension injury –Bilat neural arch fx

23. 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

24. 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

25. Extension injuries  Pre-vertebral STS  Posterior body displacement  Anterior widening of IVDS  Anterior-inferior avulsion fx  Nerve root compression and cord injury

26. RTP  Full, pain-free Rom  Normal neuro examination  Appropriate imaging studies and specialty consultation  Informed consent of athlete

27. No Contraindication to Participation* Resolved burner Spina bifida occulta Type 2 Klippel-Feil congenital one-level fusion Developmental stenosis of spinal canal (canal/vertebral body ratio <0.8) Mild ligamentous sprain with no laxity Healed, stable compression fracture of vertebral body Healed, stable end-plate fracture Healed "clay shoveler's" fracture Healed intervertebral disk bulge Stable, one-level anterior or posterior surgical fusion

28. Relative Contraindications to Participation* Recurrent acute and chronic burners Developmental canal stenosis with: - episode of cervical cord neurapraxia - intervertebral disk disease - MRI evidence of cord compression Ligamentous sprain with mild laxity (<3.5 mm anteroposterior displacement and 11° rotation) Healed, nondisplaced Jefferson fracture Healed, stable, mildly displaced vertebral body fracture without a sagittal component or neural ring involvement Healed, stable neural ring fractures Healed intervertebral disk herniation Stable, two-level anterior or posterior surgical fusion

29. Absolute Contraindications to Participation #1 Odontoid agenesis, hypoplasia, or os odontoidium Atlanto-occipital fusion Type 1 Klippel-Feil mass fusion Developmental canal stenosis with: - ligamentous instability - cervical cord neurapraxia with signs or symptoms lasting more than 36 hours - multiple episodes of cervical cord neurapraxia Spear tackler's spine Atlantoaxial instability Atlantoaxial rotatory fixation

30. Absolute Contraindications to Participation #2 Acute cervical fracture Ligamentous laxity (>3.5 mm anteroposterior displacement or 11° rotation) Vertebral body fracture with a sagittal component Vertebral body fracture with associated posterior arch fractures and/or ligamentous laxity Vertebral body fracture with displacement into the spinal canal Healed fractures with associated neurologic findings or symptoms, pain, or limitation of cervical range of motion Intervertebral disk herniation with neurologic signs or symptoms, pain, or limitation of cervical range of motion Anterior or posterior fusion of three or more levels