Cervical Injuries and Sport Dr Janusz Bonkowski Neurosurgeon and Spinal Surgeon 06.08.2014 Cervical Injuries and Sport • • • • • • • • 29 yr old male, otherwise fit and healthy. Keen rugby player. Left arm “Stinger” during rugby training late 2007, subsequent MR (report only available) suggested narrowing of L C6 and L C7 nerve root channels. Further more acute and protracted L arm pain after training mid-January 2008. Pain, paraesthesiae into L index finger, slightly into L thumb. Mild weakness L Triceps with Dec L Triceps Reflex. Marked Spurling sign into L arm,restricted neck movements. Repeat MR before referral Central L parasagittal C 5/6 C 5/6 C 6/7 Surgical alternatives for Radiculopathic pain at one level, one side with adjacent segment changes on MR • • • • • • • Posterior cervical foramenotomy: one or two level Anterior cervical foramenotomy: one or two level Anterior cervical discectomy Anterior cervical fusion: at symptomatic level only Anterior cervical fusion: at both (radiologically abnormal ) levels. Cervical arthroplasty at symptomatic level 2 level cervical arthroplasty Scenario #1 • • • • 29 year old. Insurance agent. Keen rugby player, local club level. Would like to keep playing, but has alternative sports interests. Scenario #2 • • • • • 29 year old. Heavy manual work. Plays at senior club level. Has been in 2nd grade NPC squad and still has potential at rep level. Desperate to continue playing. Scenario #3 • • • • • • 29 year old. Professional rugby has been career for 10 years. NPC 1st division. Super 14 current player. All-Black. Being headhunted by overseas clubs. Cervical Cord Neuropraxia Torg J et al J Neurosurg 1997 • • • • • • • • • 110 cases of transient neurological phenomena in sports related activities. 96 in footballers (US) 12 underwent surgery: 9 had one level ACDF 5/9 returned to sports activities with no adverse effects (15 mo av f/u) -----------------------------------------------------------------------------------------Plain x-ray:7 Kippel-Feil 29 had “degenerative changes” 52 had osteophytic ridging 89 (86%) had canal stenosis Return to Contact Sport after Spinal Injury Sontag V et al Neurosurg Focus 2006 • • o o • o o • o o • o Recommendation: ?Return to sport Posterior foramenotomy single level yes multiple level yes Laminectomy/laminoplasty less then or up to 2 level yes more than 2 level no Anterior discectomy/fusion/arthro single/ 2 level yes more than 2 level no Anterior foramenotomy single/multi level yes Cervical Cord Neuropraxia in Elite Athletes Maroon J C et al Neurosurg Spine 2007 • • • • • 5 Footballers age range 20-32, 4 pro, one college All underwent 1 level ACDF with plates/ allogfaft All 5 resumed playing 3 continue playing( 3 years, 2 years, one retired after 3 years) One developed recurrent symptoms after 7 games: adjacent level bulge, stopped playing. • One developed recurrent symptoms after 28 games: adjacent level prolapse; has stopped playing and undergone further ACDF Rugby Union Injuries to the Cervical Spine and Spinal Cord Quarrie et al Sports Med 2002 Cite Berge (1999) 35 senior & veteran players c/w age-matched controls studied with MRI 71% had disc space narrowing (controls 17%) 31% had disc prolapses (controls 3%) Cite Hughes (2000) 85 Pt with cervical spine injuries treated Burwood Spinal Unit 1979-1999. 7 had congenital fusions of cervical vertebrae. Usual incidence of congenital fusion 7/1000. 1: Degenerative changes/ disc prolapses are common in Professional rugby players and do not require treatment unless symptomatic. 2: Fusions or stiffened segments of the spine probably predispose to further damage, either adjacent segment failure or neuropraxias and are a relative contraindication to continued playing 3: Theraputic fusions are associated with a high attrition rate on return to play, may share the same risk profile as other causes of cervical inelasticity and are best avoided if surgery becomes necessary. 4: If a player needs for career or personal reasons to continue to play at a competitive level motion preserving surgery may be preferrable. Alex McKinnon James Tamou James Tamou • “Pins and needles affecting one arm” • “…diagnosed he had aggrevated a previous injury.” • “Our medical staff believe he re-aggrevated a previous condition in the incident….” STINGERS • Painful sensation radiates from neck to fingers after extension impact to neck. • May be associated with prolonged or transient motor and sensory symptoms. • Mechanism is nerve root compression in intervertebral foramen (85%). • Alternative mechanism is Brachial Plexus stretch (15%). STINGERS • 45% will have recurrent episodes. • Most patients with recurrent stingers have either cervical spinal stenosis or foramenal encroachment by osteophytes/disc bulges. • Needs to be differentiated from “burning hands syndrome” which is bilateral and a form of central cord syndrome and an absolute contraindication to return to contact sport. Transient Quadraparesis • • • • • Occurs with Hyperxtension injuries. Is a form of Central Cord Syndrome. Usually affects upper limbs more than lower limbs. Can last from 10 min. to 36 hrs. High association with radiological changes; cervical stenosis, Klippel-Feil, disc prolapse, kyphotic deformity. Absolute Contraindications on RTP • • • • • • Previous transient Quadriparesis: 2 or more previous episodes Evidence of cervical myelopathy Continued cervical discomfort Decreased ROM Neurological deficit. Vaccaro, AR et al Curr Reviews MS Med 2008 Absolute Contraindications on RTP • • • • • • Postsurgical patients: C1-2 fusion Cervical laminectomy Anterior cervial fusion more than 2 levels Posterior cervical fusion more than 2 levels Cervical arthroplasty more than one level Absolute Contraindications on RTP • Soft tissue injuries: • Asymptomatic ligamentous laxity ( more than 11% kyphotic deformity) • C1-2 hypermobility (Atlantodens interval more than (3.5mm.) • Radiology suggesting distraction-extension injury. • Symptomatic cervical disc herniation Absolute Contraindications on RTP • • • • • Radiological Findings: Multilevel Klippel-Feil Spear-tacklers spine ( kyphotic spine with stenosis) Healed subaxial fracture with sagittal or coronal plane deformity Ankylosing Spondylitis or Diffuse Idiopathic Skeletal Hyperostosis or Rheumtoid Arthritis. Absolute Contraindications on RTP • • • • • • MR/CT Findings: Basilar invagination Fixed Atlanto-Axial rotatory subluxation Occipital-C1 assimilation Residual cord encroachment after healed subaxial spine fracture Any cord abnormality or cord signal change. Relative Contraindications to RTP • Prolonged symptomatic stinger/burner or transient quadriparesis more then 24 hr. • More than 3 prior episodes of stinger/burner • Failure to return to baseline ROM, neurological status or increasing neck discomfort. • Healed 2 level anterior or posterior fusion surgery. On-field assessment Zahir U et al Seminars in Spine Surgery 2010 Conclusion: Get him/her of the field! Conclusion All data is based on Grade III evidence or worse, no consensus even amongst experts on RTP criteria or management.