Neck Injuries in Athletes

Author: Tracy Jones

Topic updated on 02/01/13 7:28am

Introduction

Injuries to the cervical spine can occur in all sports and range from soft tissue injuries to quadriplegia
- spectrum of injuries include
  - ligament sprains in cervical spine
  - burners / stingers
  - spear tackler's spine
  - cervical fxs
  - transient quadriplegia
    - neuropraxia of the cervical cord
    - bilateral upper and lower extremity pain, parasthesias, and weakness
    - symptoms resolve within minutes to hours
  - quadriplegia
Epidemiology
- injuries to the cervical spine are primarily seen in contact sports
  - common among football and rugby players
  - evolution of protective gear has decreased incidence
Mechanism
- axial load (compression) with flexion of the spine
- most injuries in contact sports occur during tackling of another player
  - "spear tackling"
    - is the most common mechanism of neck injury in football
    - can lead to gradual cervical stenosis and loss of cervical lordosis
Associated conditions
- underlying conditions of the cervical spine can increase the severity of neck injuries and be contraindications to play. They include
  - previous trauma to cervical spine (fractures, ligamentous injuries)
  - cervical stenosis
  - congenital odontoid hypoplasia
  - os odontoideum
  - Klippel-Feil anomalies

Anatomy

Cervical spine

Presentation

History
- evaluate mental status
- spinal injuries should be assumed in the athlete with loss of or altered consciousness
Symptoms
- neck pain
- neurological symptoms such as numbness, tingling or weakness
Physical exam (on-field evaluation)
- when cervical spine injury is suspected in the field
  - stabilize the head and neck
  - log roll to supine position
  - remove facemask to protect airway as needed
    - do not remove helmet or shoulder pads
  - CPR as indicated
  - log roll place on backboard
  - transport to location to perform complete physical exam
- inspection
  - look for deformities of cervical spine
- palpate
  - spinous processes for step off or pain
- neurological exam
  - muscle testing of all 4 extremities
  - test sensation throughout extremities
  - test reflexes

Imaging

Radiographs
- indications
  - burner / stingers with recurring symptoms
  - neurologic symptoms and transient quadriplegia
- recommended views
  - cervical spine trauma series
- findings
  - cervical stenosis defined as AP diameter of 13mm
MRI
- indications
  - bilateral neurologic symptoms
- findings
  - look for spinal stenosis or loss of CSF around the spinal cord

Treatment

Nonoperative
- return to play criteria
  - indications
    - specific to diagnosis
      - burners/stingers
        
        may return to play when
        
        complete resolution of symptoms
        
        normal strength and range of motion
- NO to return to play
  - indications (contraindications to return to play)
    - transient quadriplegia with severe stenosis
    - spear tackler's spine
    - cervical neuropraxia with ligamentous instability
    - odontoid hypoplasia and os odontoideum
      - are absolute contraindications to play
    - Klippel-Feil anomalies
      - mass fusion of the cervical and thoracic vertebrae is an absolute contraindication to play
Operative
- treatment is the same as for other traumatic injuries to the spine

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Qbank (2 Questions)

TAG

(OBQ11.76) Proper tackling techniques should be taught to adolescent football players to prevent catastrophic cervical spine injury. These injuries most commonly occur through which of the following mechanisms? Topic

Review Topic

1. Axial loading of the subaxial spine that occurs with spear tackling
2. Traction injury leading to nerve-root avulsion from arm tackling
3. Excessive lateral bending from high impact shoulder tackling
4. Flexion-distraction injuries due to a whiplash mechanism during cut blocking
5. Rotational injuries from pulling on the face mask during a tackle

PREFERRED RESPONSE ▶

DISCUSSION: During collision sports, such as football, the most common type of traumatic neck injury involves fracture, dislocation, or ligamentous disruption of the subaxial cervical spine. These are typically due to axial loading mechanisms which, in football, most commonly occur during spear tackling by defensive backs.

Boden et al retrospectively reviewed 196 incidents of catastrophic high school and collegiate football neck injuries over a 13 year period. The events resulted in fracture, dislocation, or major ligamentous injury at a subaxial cervical level in 95 athletes, at the C1 or C2 level (or both) in 9 athletes, at combined upper and lower levels in 7 athletes, and at an unknown level in 41 athletes. In addition, 43 athletes were diagnosed with cervical cord neurapraxia, and 1 athlete had a cervical nerve root avulsion. Playing the defensive back position and spear tackling were shown to be the greatest risk factors for these fracture and dislocation type neck injuries.

REFERENCES:

1. Boden BP, Tacchetti RL, Cantu RC, Knowles SB, Mueller FO. Catastrophic cervical spine injuries in high school and college football players. Am J Sports Med. 2006 Aug;34(8):1223-32. Epub 2006 Jun 30. PMID:16816152 (Link to Abstract)

2. Torg JS. Section A: Cervical spine injuries. In: DeLee JC, Drez D, Miller MD, eds. Orthopaedic Sports Medicine. Vol 2. 3rd ed. Philadelphia, PA: Saunders-Elsevier; 2010:665-713.

Question Authors:

Joshua Blomberg MD, Jan Szatkowski MD, John Badylak MD,

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TAG

(OBQ06.203) A college football receiver is unconscious and in respiratory distress after sustaining a helmet to helmet collision. What is the correct initial management of this patient? Topic

Review Topic

1. Transfer player to emergency room
2. Remove the helmet and shoulder pads
3. Remove helmet and sit the player upright to help with breathing
4. Remove the facemask, leaving the helmet in place, followed by appropriate airway managment
5. Perform tracheostomy

PREFERRED RESPONSE ▶

DISCUSSION: Following ATLS protocol, airway management is the essential first step in the treatment algorithm. The facemask must be removed rapidly to gain access to the airway. The cervical spine should be immobilized in a neutral position. Attempting to remove the helmet is contraindicated because it could pull traction on an injured c-spine or result in immobilization in extension because the shoulder pads lift the chest forward.

This was shown radiographically in a cadaveric flexion-distraction model study by Gastel et al. They concluded that in order to maintain a neutral position and minimize secondary injury to the cervical neural elements, the helmet and shoulder pads should be either both removed or left on. While the other answers may be performed later on in a controlled environment, it is not correct because initial efforts need to focus on airway management.

REFERENCES:

1. Torg JS: Cervical spine injuries in the adult, in DeLee JC, Drex D Jr, Miller MD (eds): Orthopaedic Sports Medicine: Principles and Practice, ed 2. Philadelphia, PA, WB Saunders, 2003, pp 791-828.

2. Gastel JA, Palumbo MA, Hulstyn MJ, Fadale PD, Lucas P. Emergency removal of football equipment: A cadaveric cervical spine injury model. Ann Emerg Med 1998;32:411-417. PMID:9774923 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, John Badylak MD,

Please Rate Educational Value!

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Groups

ABOS II: Neck Injuries

General - Oral Boards Review

7/29/2011

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Evidence & References Show References

Level of Evidence 4 (Case Series)

Boden BP, Tacchetti RL, Cantu RC, Knowles SB, Mueller FO. Catastrophic cervical spine injuries in high school and college football players. Am J Sports Med. 2006 Aug;34(8):1223-32. Epub 2006 Jun 30. PMID:16816152 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Torg JS. Section A: Cervical spine injuries. In: DeLee JC, Drez D, Miller MD, eds. Orthopaedic Sports Medicine. Vol 2. 3rd ed. Philadelphia, PA: Saunders-Elsevier; 2010:665-713.

Undefined

Torg JS: Cervical spine injuries in the adult, in DeLee JC, Drex D Jr, Miller MD (eds): Orthopaedic Sports Medicine: Principles and Practice, ed 2. Philadelphia, PA, WB Saunders, 2003, pp 791-828.
Gastel JA, Palumbo MA, Hulstyn MJ, Fadale PD, Lucas P. Emergency removal of football equipment: A cadaveric cervical spine injury model. Ann Emerg Med 1998;32:411-417. PMID:9774923 (Link to Abstract)

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Neck Injuries in Athletes

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