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Updated: Jun 7 2023

Neck Injuries in Athletes


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  • 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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