Cervical spine injuries in football players

Magnetic Resonance Imaging Findings in High School Football Players: Brain and Cervical Spine

Football exposes its players to traumatic brain, neck, and spinal injury. It is unknown whether the adolescent football player develops imaging abnormalities of the brain and spine that are detectable on magnetic resonance imaging (MRI). The objective of this observational study was to identify potential MRI signatures of early brain and cervical spine (c-spine) injury in high school football players. Eighteen football players (mean age, 17.0 ± 1.5 years; mean career length, 6.3 ± 4.0 years) had a baseline brain MRI, and 7 had a follow-up scan 9–42 months later. C-spine MRIs were performed on 11 of the 18 subjects, and 5 had a follow-up scan. C-spine MRIs from 12 age-matched hospital controls were also retrospectively retrieved. Brain MRIs were reviewed by a neuroradiologist, and no cerebral microbleeds were detected. Three readers (a neuroradiologist, a neurosurgeon, and an orthopedic spine surgeon) studied the cervical intervertebral discs at six different cervical levels and graded degeneration using an established five-grade scoring system. We observed no statistically significant difference in disc degeneration or any trend toward increased disc degeneration in the c-spine of football players as compared with age-matched controls. Further research is needed to validate our findings and better understand the true impact of contact sports on young athletes.

Cervical Spine Injuries in the Ice Hockey Player: Current Concepts in Epidemiology, Management and Prevention

STUDY DESIGN

This review article examines the biomechanics that underly hockey-related cervical spine injuries, the preventative measures to curtail them, optimal management strategies for the injured player and return to play criteria.

OBJECTIVE

Hockey is a sport with one of the highest rates of cervical spine injury, but by understanding the underlying pathophysiology and context in which these injuries can occur, it is possible to reduce their incidence and successfully manage the injured player.

METHODS

Multiple online databases including PubMed, Google Scholar, Columbia Libraries Catalog, Cochrane Library and Ovid MEDLINE were queried for original articles concerning spinal injuries in ice hockey. All relevant papers were screened and subsequently organized for discussion in our subtopics.

RESULTS

Cervical fractures in ice hockey most often occur due to an increased axial load, with a check from behind the most common precipitating event.

CONCLUSIONS

Despite the recognized risk for cervical spine trauma in ice hockey, further research is still needed to optimize protocols for both mitigating injury risk and managing injured players.

Cervical Disc Herniations, Radiculopathy, and Myelopathy

The key to successful treatment of elite athletes is optimizing the medical care at every step: injury prevention and sport-specific training; comprehensive history and physical examination; high-quality and complete diagnostic studies; accurate diagnosis; control and completion of rehabilitation program; minimally invasive, safe, and effective surgeries; risk assessment for return to sport; guided and gradual return to sport; and continued rehabilitation and exercise program after return to sport.

Asymptomatic Spinal Cord Compression: Is Surgery Necessary to Return to Play

Advising athletes with asymptomatic cervical canal stenosis on their return to active play is a topic of considerable debate, with no definitive guidelines in place. Once cervical canal stenosis is identified, often through imaging following other injuries, it is difficult to predict the risk of future injury upon return to play in both contact and collision sports. Consequently, the decision can be a complicated one for the athlete, family, and physician alike. In this article, we identify radiographical and magnetic resonance imaging (MRI)-based criteria that may distinguish athletes "at-risk" for more severe consequences due to asymptomatic cervical canal stenosis from those who are safe to return to play. Using a Torg-Pavlov ratio <0.7 and MRI metrics, namely a minimal disc-level canal diameter <8 mm, a cord-to-canal area ratio >0.8, or space available for the cord <1.2 mm, can help when making these difficult decisions. Counseling can be a critical asset to patients with cervical stenosis who have had a previous episode of cervical cord neuropraxia, especially when they are involved in high-risk sports such as American football and rugby. We believe that while this remains an area of continued concern and controversy, improved MRI criteria will be a useful springboard for further studies, especially in the elite athlete population.

Brachial and lumbosacral plexopathies: A review

Diseases of the brachial and lumbosacral plexus are uncommon and complex. The diagnosis of plexopathies is often challenging for the clinician, both in terms of localizing a patient's symptoms to the plexus as well as determining the etiology. The non-specific clinical features and similar presentations to other root, nerve, and non-neurologic disorders emphasize the importance of a high clinical index of suspicion for a plexopathy and comprehensive clinical evaluation. Various diagnostic tests, including electrodiagnostic (EDX) studies, neuroimaging (including ultrasound, MRI, or PET), serologic studies, and genetic testing, may be used to confirm a plexopathy and assist in identifying the underlying etiology. EDX testing plays an important role in confirming a plexopathy defining the localization, pathophysiology, chronicity, severity, and prognosis. Given the complexity of the plexus anatomy, multiple common and uncommon NCS and an extensive needle examination is often required, and a comprehensive, individualized approach to each patient is necessary. Treatment of plexopathies often focuses on symptomatic management although, depending on the etiology, specific targeted treatments may improve outcome. This article reviews the clinical features, EDX approaches, and evaluation and treatment of brachial and lumbosacral plexopathies.

Brachial Plexus Injuries in Sport Medicine: Clinical Evaluation, Diagnostic Approaches, Treatment Options, and Rehabilitative Interventions

The brachial plexus represents a complex anatomical structure in the upper limb. This "network" of peripheral nerves permits the rearrangement of motor efferent fibers, coming from different spinal nerves, in several terminal branches directed to upper limb muscles. Moreover, afferent information coming from different cutaneous regions in upper limb are sorted in different spinal nerves through the brachial plexus. Severe brachial plexus injuries are a rare clinical condition in the general population and in sport medicine, but with dramatic consequences on the motor and sensory functions of the upper limb. In some sports, like martial arts, milder injuries of the brachial plexus can occur, with transient symptoms and with a full recovery. Clinical evaluation represents the cornerstone in the assessment of the athletes with brachial plexus injuries. Electrodiagnostic studies and imaging techniques, like magnetic resonance and high-frequency ultrasound, could be useful to localize the lesion and to define an appropriate treatment and a functional prognosis. Several conservative and surgical techniques could be applied, and multidisciplinary rehabilitative programs could be performed to guide the athlete toward the recovery of the highest functional level, according to the type of injury.

Traumatic Brachial Plexopathy in Athletes: Current Concepts for Diagnosis and Management of Stingers

Traumatic upper trunk brachial plexopathy, also known as a stinger or burner, is the most common upper extremity neurologic injury among athletes and most commonly involves the upper trunk. Recent studies have shown the incidence of both acute and recurrent injuries to be higher in patients with certain anatomic changes in the cervical spine. In addition, despite modern awareness, tackling techniques, and protective equipment, some think the incidence to be slowly on the rise in contact athletes. The severity of neurologic injury varies widely but usually does not result in significant loss of playing time or permanent neurologic deficits if appropriate management is undertaken. Timely diagnosis allows implementation of means to minimize the risk of recurrent injury. It is important for treating physicians to understand the pathogenesis, evaluation, and acute and long-term management of stingers to improve recovery and minimize chronic sequela.

Return to Play After Anterior Cervical Discectomy and Fusion in Professional Athletes

BACKGROUND

Data are limited on return to play after anterior cervical discectomy fusion (ACDF) in professional athletes.

PURPOSE

To determine the rate and time of return to play among professional athletes after ACDF.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This study involved the prospective and retrospective review of patient charts and diagnostic studies as well as an internet search to collect data on a consecutive series of professional athletes who underwent cervical fusion by 1 of the 2 senior authors between 1982 and 2016. Demographic data included sport, preoperative symptoms and radiologic findings, date of surgery, level of surgery, postoperative symptoms and radiologic findings, and confounding factors (eg, other orthopaedic injuries). An internet search engine was used to determine date of return to play and length of career after surgery.

RESULTS

A total of 27 ACDFs were performed on 26 professional athletes: 12 National Football League athletes, 5 National Hockey League athletes, 5 Major League Baseball athletes, 3 National Basketball Association athletes, and 1 Major League Soccer athlete. Twenty-six procedures (96.3%) showed clinical and radiographic evidence of fusion, and 20 of 25 eligible players returned to play (80%). At the conclusion of this study, 2 players were still in the rehabilitation phase and expected to return at the start of the next National Football League season. The mean time to return to play in a professional game was 9.5 months (range, 5.0-20.2 months). Of 15 players who returned to play but had retired by the time of this study, the mean career length after fusion was 3.2 years (range, 0.1-8.0 years). Clinical follow-up ranged from 1 to 96 months, with a mean of 22.1 months and mode of 11 months.

CONCLUSION

After single-level ACDF, 80% of professional athletes were able to return to sport at approximately 9 months. The study findings will help athletes, physicians, and teams better predict outcome after ACDF surgery.

Return to Play in Elite Contact Athletes After Anterior Cervical Discectomy and Fusion: A Meta-Analysis

STUDY DESIGN

Systematic literature review and meta-analysis of studies published in English language.

OBJECTIVE

Return to play after anterior cervical discectomy and fusion (ACDF) in contact athletes remains a controversial topic with no consensus opinion in the literature. Additional information is needed to properly advise and treat this population of patients. This study is a meta-analysis assessing return to competitive contact sports after undergoing an ACDF.

METHODS

A literature search of Medline, Embase, and Cochrane Reviews was performed to identify investigations reporting return to play following ACDF in professional contact athletes. The pooled results were performed by calculating the effect size based on the logic event rate. Studies were weighted by the inverse of the variance, which included both within and between-study error. Confidence intervals (CIs) were reported at 95%. Heterogeneity was assessed using the Q statistic and I². Sensitivity analysis and publication bias calculations were performed.

RESULTS

The initial literature search resulted in 166 articles, of which 5 were determined relevant. Overall, return to play data was provided for 48 patients. The pooled clinical success rate for return to play was 73.5% (CI = 56.7%, 85.8%). The logit event rate was calculated to be 1.036 (CI = 0.270, 1.802), which was statistically significant (P = .008). The studies included in this meta-analysis demonstrated minimal heterogeneity with Q value of 4.038 and I² value of 0.956.

CONCLUSIONS

Elite contact athletes return to competition 73.5% of the time after undergoing ACDF. As this is the first study to pool results from existing studies, it provides strong evidence to guide decision making and expectations in this patient population.

Degenerative changes in adolescent spines: a comparison of motocross racers and age-matched controls

OBJECT

Motocross racing is a popular sport; however, its impact on the growing/developing pediatric spine is unknown. Using a retrospective cohort model, the authors compared the degree of advanced degenerative findings in young motocross racers with findings in age-matched controls.

METHODS

Patients who had been treated for motocross-related injury at the authors' institution between 2000 and 2007 and had been under 18 years of age at the time of injury and had undergone plain radiographic or CT examination of any spinal region were eligible for inclusion. Imaging was reviewed in a blinded fashion by 3 physicians for degenerative findings, including endplate abnormalities, loss of vertebral body height, wedging, and malalignment. Acute pathological segments were excluded. Spine radiographs from age-matched controls were similarly reviewed and the findings were compared.

RESULTS

The motocross cohort consisted of 29 riders (mean age 14.7 years; 82% male); the control cohort consisted of 45 adolescents (mean age 14.3 years; 71% male). In the cervical spine, the motocross cohort had 55 abnormalities in 203 segments (average 1.90 abnormalities/patient) compared with 20 abnormalities in 213 segments in the controls (average 0.65/patient) (p = 0.006, Student t-test). In the thoracic spine, the motocross riders had 51 abnormalities in 292 segments (average 2.04 abnormalities/patient) compared with 25 abnormalities in 299 segments in the controls (average 1.00/patient) (p = 0.045). In the lumbar spine, the motocross cohort had 11 abnormalities in 123 segments (average 0.44 abnormalities/patient) compared with 15 abnormalities in 150 segments in the controls (average 0.50/patient) (p = 0.197).

CONCLUSIONS

Increased degenerative changes in the cervical and thoracic spine were identified in adolescent motocross racers compared with age-matched controls. The long-term consequences of these changes are unknown; however, athletes and parents should be counseled accordingly about participation in motocross activities.

Disc herniations in the national football league

STUDY DESIGN

Retrospective analysis of a prospectively collected database.

OBJECTIVE

To determine the overall incidence, location, and type of disc herniations in professional football players to target treatment issues and prevention.

SUMMARY OF BACKGROUND DATA

Disc herniations represent a common and debilitating injury to the professional athlete. The NFL's (National Football League's) Sports Injury Monitoring System is a surveillance database created to monitor the league for all injuries, including injuries to the cervical, thoracic, and lumbar spine.

METHODS

A retrospective analysis was performed on all disc herniations to the cervical, thoracic, and lumbar spine during a 12-season period (2000-2012) using the NFL's surveillance database. The primary data points included the location of the injury, player position, activity at time of injury, and playing time lost due to injury.

RESULTS

During the 12 seasons, 275 disc herniations occurred in the spine. In regard to location, 76% occurred in the lumbar spine and most frequently affected the L5-S1 disc. The offensive linemen were most frequently injured. As expected, blocking was the activity that caused most injuries. Lumbar disc herniations rose in prevalence and had a mean loss of playing time of more than half the season (11 games). Thoracic disc herniations led to the largest mean number of days lost overall, whereas players with cervical disc herniations missed the most practices.

CONCLUSION

Disc herniations represent a significant cause of morbidity in the NFL. Although much attention is placed on spinal cord injuries, preventive measures targeting the cervical, thoracic, and lumbar spine may help to reduce the overall incidence of these debilitating injuries.Level of Evidence: N/A.

Cervical spine injuries in American football

American football is a high-energy contact sport that places players at risk for cervical spine injuries with potential neurological deficits. Advances in tackling and blocking techniques, rules of the game and medical care of the athlete have been made throughout the past few decades to minimize the risk of cervical injury and improve the management of injuries that do occur. Nonetheless, cervical spine injuries remain a serious concern in the game of American football. Injuries have a wide spectrum of severity. The relatively common 'stinger' is a neuropraxia of a cervical nerve root(s) or brachial plexus and represents a reversible peripheral nerve injury. Less common and more serious an injury, cervical cord neuropraxia is the clinical manifestation of neuropraxia of the cervical spinal cord due to hyperextension, hyperflexion or axial loading. Recent data on American football suggest that approximately 0.2 per 100,000 participants at the high school level and 2 per 100,000 participants at the collegiate level are diagnosed with cervical cord neuropraxia. Characterized by temporary pain, paraesthesias and/or motor weakness in more than one extremity, there is a rapid and complete resolution of symptoms and a normal physical examination within 10 minutes to 48 hours after the initial injury. Stenosis of the spinal canal, whether congenital or acquired, is thought to predispose the athlete to cervical cord neuropraxia. Although quite rare, catastrophic neurological injury is a devastating entity referring to permanent neurological injury or death. The mechanism is most often a forced hyperflexion injury, as occurs when 'spear tackling'. The mean incidence of catastrophic neurological injury over the past 30 years has been approximately 0.5 per 100,000 participants at high school level and 1.5 per 100,000 at the collegiate level. This incidence has decreased significantly when compared with the incidence in the early 1970s. This decrease in the incidence of catastrophic injury is felt to be the result of changes in the rules in the mid-1970s that prohibited the use of the head as the initial contact point when blocking and tackling. Evaluation of patients with suspected cervical spine injury includes a complete neurological examination while on the field or the sidelines. Immobilization on a hard board may also be necessary. The decision to obtain radiographs can be made on the basis of the history and physical examination. Treatment depends on severity of diagnosed injury and can range from an individualized cervical spine rehabilitation programme for a 'stinger' to cervical spine decompression and fusion for more serious bony or ligamentous injury. Still under constant debate is the decision to return to play for the athlete.

Head and neck position sense

Traumatic minor cervical strains are common place in high-impact sports (e.g. tackling) and premature degenerative changes have been documented in sports people exposed to recurrent impact trauma (e.g. scrummaging in rugby) or repetitive forces (e.g. Formula 1 racing drivers, jockeys). While proprioceptive exercises have been an integral part of rehabilitation of injuries in the lower limb, they have not featured as prominently in the treatment of cervical injuries. However, head and neck position sense (HNPS) testing and re-training may have relevance in the management of minor sports-related neck injuries, and play a role in reducing the incidence of ongoing pain and problems with function. For efficacious programmes to be developed and tested, fundamental principles associated with proprioception in the cervical spine should be considered. Hence, this article highlights the importance of anatomical structures in the cervical spine responsible for position sense, and how their interaction with the CNS affects our ability to plan and execute effective purposeful movements. This article includes a review of studies examining position sense in subjects with and without pathology and describes the effects of rehabilitation programmes that have sought to improve position sense. In respect to the receptors providing proprioceptive information for the CNS, the high densities and complex arrays of spindles found in cervical muscles suggest that these receptors play a key role. There is some evidence suggesting that ensemble encoding of discharge patterns from muscle spindles is relayed to the CNS and that a pattern recognition system is used to establish joint position and movement. Sensory information from neck proprioceptive receptors is processed in tandem with information from the vestibular system. There are extensive anatomical connections between neck proprioceptive inputs and vestibular inputs. If positional information from the vestibular system is inaccurate or fails to be appropriately integrated in the CNS, errors in head position may occur, resulting in an inaccurate reference for HNPS, and conversely if neck proprioceptive information is inaccurate, then control of head position may be affected. The cerebellum and cortex also play a role in control of head position, providing feed-forward and modulatory influences depending on the task requirements. Position-matching tasks have been the most popular means of testing position sense in the cervical spine. These allow the appreciation of absolute, constant and variable errors in positioning and have been shown to be reliable. The results of such tests indicate that errors are relatively low (2-5 degrees). It is apparent that error is not consistently affected by age, a finding similar to studies undertaken in peripheral joints. Furthermore, the range of motion in which subjects are tested does not consistently affect accuracy in a predictable manner. However, it is evident that impairments in position sense are observed in individuals who have experienced whiplash-type injuries and individuals with chronic head and neck pain of non-traumatic origin (e.g. cervical spondylosis). While researchers advocate comprehensive retraining protocols, which include eye and neck motion targeting tasks and coordination exercises, as well as co-contraction exercises to reduce such impairments, some studies show that more general exercises and manipulation may be of benefit. Overall, there is limited information concerning the efficacy of treatment programmes.

Preventing spinal cord injuries in rugby union

Other countries should follow New Zealand's lead

Sideline and ringside evaluation for brain and spinal injuries

✓Participation in contact and collision sports carries an inherent risk of injury to the athlete, with damage to the nervous system producing the most potential for significant morbidity and death. Neurological injuries suffered during athletic competition must be treated promptly and correctly to optimize outcome, and differentiation between minor and serious damage is the foundation of sideline/ringside management of the injury. In this article the authors present a guide to the sideline or ringside identification and management of head and spinal injuries.

Catastrophic cervical spine injuries in the collision sport athlete, part 1: epidemiology, functional anatomy, and diagnosis

Catastrophic cervical spine injuries can lead to devastating consequences for the collision athlete. Improved understanding of these injuries can facilitate early diagnosis and effective on-field management. This article is the first of a 2-part series. The first part reviews the current concepts regarding the epidemiology, functional anatomy, and diagnostic considerations relevant to cervical spine trauma in collision sports. In the second part, to be published later, the principles of emergency care of the cervical spine-injured athlete are reviewed. This article provides a rational approach to the early recognition of the different clinical syndromes associated with catastrophic cervical spine injury. Rapid on-field diagnosis can help to optimize the outcomes of these catastrophic injuries.

Abnormal hand sensations after a football tackle

A high school football player developed bilateral transient abnormal hand sensations after a tackle. He went on to play the remainder of the season without symptoms. The following season, he again reported abnormal sensations in both hands after tackling. An MRI of the spine revealed cervical canal stenosis and spinal cord edema. This case report demonstrates the need to be responsive to symptoms that affect more than one limb simultaneously, however transient they may be. Prompt recognition and restricting patients from contact sports may prevent catastrophic spinal cord injury.

Football protective gear and cervical spine imaging

STUDY OBJECTIVE

We sought to assess the effect of football protective gear on the cervical spine radiographic evaluation of adult male subjects.

METHODS

The study used a prospective, randomized, matched-pairs, observational design. Subjects served as their own control subjects, with cross-table lateral and open-mouth odontoid cervical spine radiographs. Radiographs were obtained with protective head and shoulder equipment (pads group) and without protective equipment (no pads group). Two emergency physicians and 2 neuroradiologists reviewed study radiographs. Physicians assessed radiographic views for adequate cervical spine visualization to the C7-T1 level and the odontoid and related structures. Comparison of radiographic readings for the pads and no pads groups used the McNemar exact test. A McNemar test of equality of paired proportions was used to estimate a population of 20 paired individuals to detect a significant outcome difference.

RESULTS

Zero percent of the pads group's cross-table lateral structures were adequately visualized by all 4 reviewers (reviewer unanimity decision) compared with 25% of the no pads group's cross-table lateral films (between-group difference 25%; 95% confidence interval [CI] 6.0 to 44). When 3 of 4 reviewers noted adequate visualization (reviewer majority decision), 0% of the pads group's cross-table lateral structures were adequately visualized versus 40% of the no pads group's cross-table lateral radiographs (between-group difference 40%; 95% CI 19 to 62). With reviewer unanimity, 25% of the pads group's open-mouth odontoid structures were visualized versus 45% of the no pads group's open-mouth odontoid structures (between-group difference 20%; 95% CI -8.9 to 49). With reviewer majority analysis, 35% of the pads group's odontoid radiographs were adequately visualized versus 75% of the no pads group's open-mouth odontoid radiographs (between-group difference 40%; 95% CI 12 to 68).

CONCLUSION

Football head and shoulder protective equipment appears to be an impediment to cervical spine radiographic visualization. Guidelines for players' cervical spine imaging should incorporate procedures for removal of equipment before initial radiographic evaluation.