h1 class=”calibre8″>14 Sport-Related Cervical Spine Injuries and Return-to-Play Criteria

Amandeep Bhalla and Christopher M. Bono

Keywords: spinal cord injury, sport injuries, cervical fractures, sprains and strains, burners, cervical cord neurapraxia, cervical disc herniations

14.1 Epidemiology

Cervical spine injuries are common and range from relatively minor injuries, such as muscle strains, to life-threatening, unstable fractures or dislocations with spinal cord injury (SCI). Although cervical spine injuries are most common in athletes who participate in organized contact and collision sports, such as rugby, American football, and hockey, they frequently occur in those also who participate in noncontact sports, such as baseball, gymnastics, cycling, skiing, snowboarding, and diving. While organized sports injuries are well studied, the injuries that occur during recreational sporting activities are likely underreported but can be just as devastating. Athletes with underlying conditions, such as congenital spinal stenosis, may be more likely to sustain a serious spinal cord injury (SCI).

In the United States, cervical spine injuries are the most common axial skeletal injuries, though less than 1% result in fractures, dislocations, or SCI. ¹ Catastrophic cervical SCI, though rare, is an inherent risk of high-velocity collision sports. Sports-related SCI occurs at a mean age of 24 years. ² While the incidence of sports-related SCI was about 14% in the 1970s, ³ this has decreased over time due to increased public awareness, safer rules governing play, and improved protective equipment. Indicative of the progress made in prevention of sports-related catastrophic cervical spine injuries, recent studies report the rate of all SCI attributable to athletic activities has decreased to 8%. ^4,5

The most common mechanism for cervical SCI in contact supports is applied axial load. ⁶ Scrum and tackle in rugby account for most of the cervical trauma in that sport. Tackling and blocking are two of the most frequent mechanisms that result in cervical injuries in American football. Unfortunately, an increase in the rate of catastrophic cervical spine injuries coincided with the advent of modern helmets as head protection encouraged playing techniques that enabled use of the top of the helmet as the initial point of contact for blocks and tackles. ⁷ Similar phenomena have been observed in other sports such as ice hockey. ⁸

Increased awareness and public education about the dangers of spear tackling (i.e., tackling with the crown of the head) have led to a marked decrease in the number of serious cervical spine injuries in American football. ^6,9 In 1976, the National Collegiate Athletic Association Football Rules Committee and high school football governing bodies banned headfirst contact. ¹⁰ Repetitive traumatic axial loads from spear tackling result in loss of normal cervical lordosis, vertebral abnormalities, and eventual cervical spinal stenosis ⁹ (▶ Fig. 14.1). In the 12 years following the implementation of rules barring headfirst tackling and blocking, the rate of cervical SCIs in scholastic football declined by 70%. ^3,6 Changes in rules governing the play of Canadian ice hockey, specifically preventing checking from behind, have also markedly decreased the incidence of cervical injuries. ¹¹

In a study of spine injuries in the National Football League spanning from 2000 to 2010, 44.7% of injuries were of the cervical spine. The mean time missed for play was 120 days for a cervical fracture and 85 days for cervical disc degeneration/herniation. ¹ In an epidemiologic review of catastrophic cervical spine injuries in high school and collegiate athletes between 1989 and 2002, Boden et al ¹² noted an average of 15 catastrophic cervical spine injuries per year in scholastic football players, which included transient cord neurapraxia and C1 and C2 fractures. The reported traumatic quadriplegia rate was 5 per 100,000 high school athletes and 1 per 100,000 college athletes. In 2002, the incidence of traumatic quadriplegia for high school athletes and college athletes was down to 0.38 per 100,000 and 1.33 per 100,000, respectively. ⁷ Although rates of catastrophic injuries have decreased over time, participants in high-energy contact sports continue to be at risk.

14.2 Initial Management

An athlete who reports axial or radiating pain, decreased range of motion of neck, or loss of function should be removed from play and undergo full neurological examination. In the event a structural or neurological injury is suspected, the athlete’s neck should be immobilized in a rigid cervical collar. An unconscious player should be treated as though the cervical spine is unstable until proven otherwise. Strict spinal precautions are instituted, including placement on a rigid backboard, while the patient is transferred to a trauma center. Protective helmets and shoulder pads worn by some players can hinder initial evaluation. If the injured athlete is wearing a helmet, the facemask should be removed to facilitate access to the airway, however the helmet itself should remain in place until there are several people available to help with its removal in a controlled environment, usually in a hospital setting. To ensure appropriate alignment, the helmet and shoulder pads should be removed at the same time to avoid undue flexion or extension of the neck. Improper handling of an unstable cervical spine could lead to additional displacement and potentially worsening of neurological injury or even lead to cardiopulmonary compromise.

14.3 Specific Injuries

14.3.1 Strains and Sprains

Injuries to cervical paraspinal muscles and ligaments are commonly encountered in sports. Muscular strains, contusions, and ligamentous sprains are self-limited injuries. Of note, it is imperative to rule out occult destabilizing ligamentous injuries. With a high index of suspicion, stability can be confirmed with further imaging. Dynamic flexion-extension radiographs have played a vital role in the past. Based on classic cadaveric studies, when all cervical spinal ligaments are intact, horizontal movement of one vertebra on the next should not exceed 3.5 mm, and the angular displacement of one vertebra on the next is typically 11 degrees or less. ^13,14 However, many feel these thresholds are too high. Furthermore, distortions in measurements may occur in patients with cervical muscle spasms; while in younger athletes, additional physiologic ligamentous laxity can lead to pseudosubluxation. In cases of pseudosubluxation or significant neck spasm, it is prudent to maintain young athletes within a cervical collar for approximately 3 weeks, after which repeat dynamic cervical radiographs can be performed. At that time, if the athlete is free of pain and has full range of motion without radiographic instability, sports can be resumed.

Though somewhat outside the scope of this chapter, detecting occult cervical ligamentous injuries in obtunded injured athletes deserves some mention. As per general trauma protocols, high-energy injury mechanisms warrant at least computed tomography (CT) imaging to rule out subluxations or fractures not perceptible on plain radiographs. Furthermore, CT scan offers superior visualization of the occipitocervical and cervicothoracic junctions compared to plain radiographs. Though some disagree, magnetic resonance imaging (MRI) might be warranted if further suspicion of ligamentous disruption remains despite a negative CT scan. ^15,16

14.3.2 Cervical Fractures and Dislocations

A broad range of cervical fractures may be sustained during contact sports. Majority of fractures and dislocations occur in the lower cervical spine. Stable cervical spinal fractures involving a spinous process or lamina can be treated symptomatically. In such cases, flexion and extension radiographs should be obtained to rule out ligamentous injury. Sports may be resumed once osseous healing is complete and painless range of motion is restored. Upper cervical spinal fractures are relatively uncommon in this population. Of them, odontoid fractures are the most common in athletes. ¹⁷ Many odontoid fractures in the young athletes may be treated with a hard collar or a halo vest, however anterior screw fixation or posterior C1–C2 arthrodesis may be warranted in cases of neurological injury or significant displacement. ¹⁵ Most C1 fractures are stable; however, unstable C1 burst fractures associated with C1–C2 instability may require instrumented fusion. The functional limitations and risks of adjacent injury following upper cervical fusion represent one of the absolute contraindications to return-to-play.

Axial load mechanisms are a common cause of sports-related cervical spine morbidity. The response of the spine to applied axial load depends on the position of the neck at the time of injury. Axial forces applied across a relatively flexed neck result in flexion forces on the anterior elements and distractive forces on the posterior elements. Energy from this mechanism may result in a so-called teardrop fracture involving the anteroinferior vertebral body ⁷ while simultaneously causing distractive injury to the posterior structures. Disruption of the stabilizing posterior soft-tissue elements, including the supraspinous ligament, interspinous ligaments, and facet capsules, is the critical component leading to instability and decisions regarding management.

Disruption of the posterior ligamentous structures without vertebral body fractures can result in bilateral facet subluxation or frank dislocation with or without subsequent SCI. The addition of a rotational movement to an axial load in flexion can lead to unilateral facet dislocations that are inherently more stable than bilateral injuries and are less likely to lead to SCI. Regardless of the exact mechanism, disruption of the posterior ligamentous complex usually necessitates surgical stabilization to restore stability.

Axial load applied across a neutrally aligned neck is more likely to result in a compression fracture of the vertebral body. With greater and more abruptly delivered energy, a burst fracture may result in which there is, by definition, a free fragment of the posterior vertebral body wall. Burst fractures in neurologically intact patients with reasonable alignment are usually treated by a hard collar, unless there is concomitant disruption to the posterior ligamentous complex. Patients with C7 burst fractures, because of their location at the cervicothoracic junction, have a higher risk for developing progressive kyphotic deformity, thereby warranting more diligent radiographic observation and employment of nonoperative treatment regimen ⁴ (▶ Fig. 14.2). Surgical stabilization may be required to mitigate progressive deformity progression.

Related posts:

Traumatic Atlantoaxial Rotatory Fixation Cranioskeletal Traction for the Management of Trauma to the Cervical Spine Trauma in Patients with Rheumatoid Arthritis of the Cervical Spine Penetrating Injuries to the Cervical Spine Clinical Trials Update: Where Do We Go from Here? Initial Assessment (Including Imaging) of Cervical Spinal Cord Injury

Stay updated, free articles. Join our Telegram channel

Join