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How Important Are Stingers?

Robert C. Cantu

BRIEF ANSWER

Background

Stingers are also known as “burners.” Both terms are descriptive of a specific type of upper limb sensory disturbance that may occur as a result of athletic injury. Stingers are peripheral nerve injuries, not spinal cord injuries, and are not directly related to the presence of central cervical spinal stenosis. Stingers are also distinct from the burning hands syndrome,¹ which is a separate clinical entity reflective of a central cervical spinal cord injury.

Literature Review

Both compressive and tensile (i.e., traction or stretch) overload have been implicated as the cause of stingers, although precise localization of this injury; that is, cervical spine versus brachial plexus, has been controversial. A variety of mechanisms have been described, including tensile injury to the upper trunk of the brachial plexus,^2–8 tensile injury to the cervical nerve root—dorsal root spinal ganglion complex,^4,9–12 compressive injury to the cervical nerve root—dorsal root spinal ganglion complex,^8,12–14 and compressive injury to the brachial plexus.^15,16 Compelling neuroanatomic features of the cervical nerve root—dorsal spinal root ganglion complex place it at greater risk than the brachial plexus for this injury.¹⁷

Assessment

The clinical assessment of a stinger requires an understanding of the sport and of the skill level of the athlete. For example, a tensile overload mechanism of injury occurs when the head and shoulder of the symptomatic limb are forcefully moved in opposite directions. A compressive overload mechanism occurs when the head and neck are forced into the extreme ipsilateral posterolateral quadrant, narrowing the cervical intervertebral foramen and compressing the cervical nerve root-dorsal root spinal ganglion complex. In football, tackling and blocking are the most common activities that cause stingers, with the tacklers or blockers usually sustaining the injuries.

The hallmark of a stinger is unilateral upper limb involvement following a traumatic event like those described above. The development of simultaneous bilateral cervical radiculopathy is very uncommon, and involvement of more than one limb should always prompt a consideration of spinal cord injury. The athlete typically experiences a lancinating, burning pain and dysesthesia, usually in a nerve root or dermatome pattern. A detailed assessment on the sidelines should include determination of the mechanism of injury; distribution and duration of symptoms; and evaluation of active range of motion of the neck only within pain tolerance to determine the presence of rigidity and/or pain provocation (to avoid the development of complications from a potentially unstable spine). Passive range of motion examination; that is, the patient remains passive while the examiner moves the patient’s neck, is contraindicated if the player is symptomatic.