Review Question - QID 219872

The patient had an on-field episode of transient quadriplegia with residual neurologic symptoms, imaging demonstrating a "spear-tackler's spine" and a disc herniation, and radiographic measurements consistent with congenital stenosis, making disqualification from participation in further contact sports the most appropriate recommendation.

Injuries to the cervical spine can occur in all sports and range from soft tissue injuries and stingers to quadriplegia and permanent neurological injury. By definition, a "spear-tackler's spine" involves developmental narrowing or canal stenosis with persistent straightening of the cervical spine, which lacks the normal lordotic curve (Figure B). This constellation of findings represents a contraindication to play in contact sports. Normal canal diameter should exceed 17 mm, with < 10 mm defined as absolute stenosis. Though the Torg-Pavlov ratio (Illustration A) is a technique-dependent measurement and not always accurate in larger athletes with big necks, it has historically been used to guide return to play, with congenital stenosis defined as a ratio of < 0.80.

Meredith et al. reviewed the operative and non-operative treatment of cervical disc herniation in national football league athletes. Out of 16 athletes with MRI–proven disc herniations concordant with their reported symptoms, the authors found that the most common presentation was radiculopathy after a single traumatic event. Still, three players were noted to have transient paresis. Eight players were treated nonoperatively and returned to sport, five of which had evidence of root compression and were treated symptomatically. In comparison, three players underwent one-level anterior cervical discectomy and fusion. They concluded that discs abutting the cord can be treated nonoperatively but do not allow for a return to sport until symptoms have improved and repeat imaging demonstrates no cord compression.

Yamaguchi et al. reviewed intervertebral disc herniation in elite athletes. The authors note the pathology is thought to be more prevalent in athletes than in the general population due to the consistent pressure placed on the spine and concurrent microtraumas precluding the ability to heal the herniation. They conclude that standard management includes a six-week trial of conservative treatment with a hiatus from injurious activity in conjunction with anti-inflammatory medications.

Figures A and B represent AP and lateral cervical spine radiographs demonstrating loss of normal lordosis and the appearance of a "spear-tackler's" spine. Illustration A demonstrates how to measure the Torg-Pavlov ratio.

Incorrect Answers:
Answer 1: Allowing the patient to return to play after signing a waiver is inappropriate and neither treats his disc herniation nor addresses his severe congenital stenosis.
Answers 3 and 4: Though cervical disc herniations can be managed non-invasively before allowing a return to play, a patient needs to have complete resolution of symptoms with repeat imaging demonstrating no evidence of residual cord signal change or compression.
Answer 5: Though the patient ultimately does require a referral to a spine surgeon to treat his acute pathology, a recommendation for return to play could result in catastrophic spinal cord injury based on his severe congenital stenosis.