Updated: 2/17/2022

Neck Injuries in Athletes

Review Topic
  • 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
          • definition
            • developmental narrowing (stenosis) of the cervical canal
            • persistent straightening or reversal of the normal cervical lordotic curve
            • concomitant posttraumatic roentgenographic abnormalities of the cervical spine
            • documentation of having employed spear tackling techniques
          • treatment
            • contraindication to play in contact sports
        • 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
    • Demographics
      • Injuries to the cervical spine are primarily seen in contact sports
        • common among football and rugby players
        • evolution of protective gear has decreased incidence
  • Etiology
    • 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
          • recent NATA guidelines allow remove of both helmet and shoulder pads if it can be done safely
        • 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
        • canal diameter of < 13mm (normal is ~17mm)
        • Torg-Pavlo ratio (canal/vertebral body width) of < 0.8 (normal is 1.0)
          • Torg ratio is technique dependent, not predictive, and not accurate in large athletes
    • 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
          • burners/stingers
            • complete resolution of symptoms
            • normal strength and range of motion
          • transient quadriplegia with normal MRI findings
          • congenital stenosis (Torg-Pavlov ratio <0.8) without instability (but patients should be counseled regarding the risks)
      • NO return to play (contraindications to RTP)
        • transient quadriplegia with severe stenosis
          • spear tackler's spine
          • cervical neuropraxia with ligamentous instability
          • upper C spine abnormalities (C0 to C2) are absolute contraindications for RTP
            • odontoid hypoplasia
            • os odontoideum
            • atlantooccipital fusion
          • Torg 1 Klippel-Feil anomaly (long fusion mass) absolute contraindication to play
          • Torg 2 Klippel-Feil (only 1 or 2 segments) with limited motion, secondary degenerative changes or instability
            • Torg 2 Klippel-Feil below C3, asymptomatic, is a relative contraindication to RTP
    • Operative
      • treatment is the same as for other traumatic injuries to the spine

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(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?

QID: 3499

Axial loading of the subaxial spine that occurs with spear tackling



Traction injury leading to nerve-root avulsion from arm tackling



Excessive lateral bending from high impact shoulder tackling



Flexion-distraction injuries due to a whiplash mechanism during cut blocking



Rotational injuries from pulling on the face mask during a tackle



L 1 C

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(OBQ05.81) 21-year-old college football player sustains transient loss of motor function in his arms after a collision. Which of the following is an absolute contraindication to return to play?

QID: 967

Anterior cervical diskectomy and fusion for one level disk herniation



Torg ratio of less than 0.8 with no other neurologic symptoms



Cord signal changes in the MRI



Frequent episodes of stingers when he was in high school



Chronic neck and back pain



L 3 D

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