Cervical Spine Injuries: The common and the catastrophic

1
Cervical Spine InjuriesThe common and the
catastrophic

• William W. Dexter, MD, FACSM
• Maine Medical Center
• Sports Medicine

2
Goals and Objectives

• Range of Injury
• Diagnosis
• Treatment approach
• On-Field
• Off - Field
• Return to Play Decision Making
• Controversies
• Cases and a Quiz!

3
Epidemiology (excluding stingers)

• On increase hockey, skiing
• Football varies by code
• Gridiron 10-15gt Rugby gt Soccer
• 15/yr scholastic FB in US tackle
• 2006 revision spearing rule
• MC level C4-6
• gtcord/canal ratio
• Foul play MC cause
• spearing
• check from behind

Dec, CSMR, 2007 Boden, AJSM,2006 Bannerjee, AJSM,
2004
4
Range of Injuries

• Common !
• Management Plan
• Cut point dangerous v not
• Be prepared for worst case
• Stingers/burners
• Transient Quadraparesis
• Hyperflexion Injuries
• Spine fails in flexion

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Spine fails in flexion
Bannerjee, AJSM, 2004
6
Management on field

• Player down, take helmet off?
• YES
• NO
• How about if unconscious?
• YES
• NO
• Leave it ON! (QOEB)
• Many studies
• Wanninger,et al, AJSM, 2004

7
Management on field
From Bannerjee, AJSM, 2004
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When to Assume an Unstable Injury

• Quick, comprehensive neuro exam,
• ?? paresthesias or weakness
• Normal Abnormal
• Palpate for Cervical Yes Immobilize and
  prohibit
• Tenderness further activity, X-ray
  evaluation
• No
• Test Active ROM Abnormal, pain, restricted
  ROM
• Normal OK to Return to Play

9
Bannerjee, AJSM, 2004)
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Management on field

• DO NO HARM!
• 50 neurological deficits created after the
  initial traumatic insult
• BE PREPARED
• Whos the leader?
• Access to emergency care
• Know how to transport injured athlete
• Equipment know how to use it!
• ABCDE

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Airway (and Cervical Spine)

• Spontaneous breathing
• Chin/jaw lift, maintain in-line traction
• ASSUME cervical spine injury if
• injury above clavicle or
• head injury that results in loss of consciousness
• Remove facemask,
• LEAVE HELMET ON!
• Various techniques (trainers angel)
• Consider helmet off if helmet loose/cspine
  motion, unable to immobilize, cant secure
  airway, shoulder pads off (NCAA)
• NATA protocol for removal

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Airway (and Cervical Spine)

• Remove facemask,
• LEAVE HELMET ON!
• Various techniques
• Consider helmet off if
• helmet loose/cspine motion
• unable to immobilize
• cant secure airway
• shoulder pads off (NCAA)
• NATA protocol for removal

Helmet removal tools
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Breathing

• Look for spontaneous respirations. If none,
  insert airway
• If tachypneic or asymmetry in respirations
  consider
• Tension pneumothorax
• Massive hemothorax
• Cardiac tamponade
• Flail chest

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Circulation

• Check carotid pulse for quality, rate and
  regularity
• If present BP gt 60
• If radial pulse BP gt 80
• CPR if pulse absent
• Capillary blanch test
• white gt 2 sec some form of shock
• If suspect shock
• Check for hemorrhage
• Give IV fluids
• Get EKG
• O2

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Disability Exposure

• AVPU system
• A alert
• V vocal stimuli response
• P painful stimuli response
• U unresponsive
• Limited Neurological Exam
• Level of Consciousness
• Pupillary Size and Reaction
• Extraocular Movements
• Motor Response
• Inspect extremities for bleeding, fractures,
  contusions

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Neuro Specifics
Level Muscles Function Sensory
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In-Line Traction
Moving a downed athlete practice this!!
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Moving a downed athlete practice this!!
Log Roll
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Moving a downed athlete practice this!!
Boarded and stabilized (but remove mouthpiece)
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Who should get xrays?

• American College of Surgeons ATLS guidelines
• all with trauma above the clavicle cervical
  xrays
• can clear the cervical spine without if certain
  conditions are met
• The National Emergency X-Ray Use Study (Nexus)
• no midline cervical tenderness, no focal
  neurological deficits, normal alertness, no
  intoxication, and no painful distracting injuries
• low probability of cervical spine injury
• Canadian C-Spine Rule for Radiography in Alert
  and Stable Trauma Patients

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Imaging (Xrays)

• Good quality plain radiographs in at least two
  orthogonal planes
• Cervical spine (occiput to C7-T1 junction)
• AP, lateral, obliques, odontoid
• Flexion - extension
• Signs indicative of cervical instability (Webb)
• (1) interspinous widening
• (2) vertebral subluxation
• (3) Vertebral compression fracture
• (4) loss of cervical lordosis.

Zmurko,ClinSportsMed (2003) Wanninger, AJSM, 204
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Imaging (Xrays)

• ALSO (White)
• Horizontal displacement of 3.5 mm or
• Angular displacement of 11 degrees or more
• Consider CT

Zmurko,ClinSportsMed (2003) Wanninger, AJSM,
2004 Morganti, Sports Med, 2003
23
Follow up

• Thorough Neuro exam
• Frequent F/U
• If neck pain or neurological abnormalities
  persist
• Be aware of sub-acute injuries
• Imaging
• Xrays v CT (best, ? quickest, ?safest)
• MRI -?100 sensitive
• Transient quadriplegia, burning hands syndrome,
  or other bilateral motor or sensory symptoms
  warrant MRI
• EMG can help delineate extent of injury, though
  not evident until 2-3 weeks post injury

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Cervical Root NeuropraxiaBurner Syndrome
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Cervical Root NeuropraxiaBurner Syndrome

• Typically, recoverable injury to brachial plexus
  or cervical nerve root
• Quite common up to ½ of collegiate football
  players per year
• Lacinating, burning pain radiating down the arm
  /- weakness- typically lasts seconds to hours

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Cervical Root NeuropraxiaBurner Syndrome

• Pathomechanics
• Compression (A)
• Tension (B)
• Impingement cervical root
• Strong correlation cervical stenosis
• not with permanent neurological injury
• Diff Dx herniated disc, fracture, congenital
  central canal stenosis, lateral recess stenosis,
  cord anomalies such as AV malformations or tumor
• Consider if severe persistent pain, bilateral,
  lower extremity

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Cervical Root NeuropraxiaBurner Syndrome

• Where?
• Above clavicle flexor and extensor
• Below clavicle either/or not both
• C5-6 MC
• Elbow flexion (biceps)
• Abduction (deltoid)
• How often ???
• mean annual incidence in our study -
• (0.29 per 100 000 players) (Boden, AJSM, 2006)
• YEAH RIGHT..

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Cervical Root NeuropraxiaBurner Syndrome
Foraminal Stenosis

• Associated with increased risk of burners (Kelly
  et al)
• Foramen/Intervertebral body ratio A/B (as
  measured on oblique view)
• More useful in characterizing zone of injury in
  extension/compression burner

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Cervical Root NeuropraxiaBurner Syndrome

• Grade 1 neuropraxia
• Selective demyelination of axon sheath
• Complete recovery days - weeks
• Grade 2 axonotmesis
• EMG - axonal injury, epineurium intact
• Wallerian degeneration distal to injury site
• Regeneration 1 to 2 mm per day
• Full function usually restored
• Grade 3 neurotmesis
• Endoneurium disrupted, EMG - acute denervation
• Motor sensory deficits persist one year
• Often requires surgical intervention

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Cervical Root NeuropraxiaBurner Syndrome

• Little evidence on management
• ACUTE
• Most recover spontaneously and quickly
• RTP decision
• SEMI ACUTE
• 5-10 persist
• 50 recur
• ??RTP consider EMG, consider imaging, use same
  RTP

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Cervical Root NeuropraxiaBurner Syndrome

• Return to Play
• Pain resolved
• Full, pain free neck and UE ROM
• Normal strength (preferably compared with
  preseason)
• Normal DTRs
• Negative Spurling test,Erbs point
• Athlete WANTS to go back in
• Prevention ??

32
Bad Injuries, Uncommon in Sports Quick
Review(or things to think about in your
differential dx)
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Hyperflexion Injuries

• Anterior Subluxation
• Facet Joint Injuries
• Clay Shovelers Fracture (Spinous Process
  Avulsion Fracture)
• Flexion Tear Drop Fracture
• Wedge Fracture without posterior disruption
• Anterior Atlantoaxial Dislocation

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Anterior Subluxation

• Partial or complete tear of posterior ligaments
• Widening of interspinous or interlaminar spaces
• Mild anterior subluxation of vertebral body (may
  only be appreciated on flexion stress lateral)

35
Facet Joint Injuries

• Frequently missed in acute cervical spine trauma
• Oblique x-rays important
• Inferior process fractures typically
• at base
• stable
• Apical fracture of superior process
• associated with bilateral facet dislocation

36
Unilateral Facet Dislocation

• General
• Flexion-rotation injury
• Delay in diagnosis common
• Exam shows
• axial rotation to contralateral side
• lateral bend to injured side
• Associated disc herniation common

37
Unilateral Facet Dislocation

• Lateral view
• Mild anterior subluxation of above vertebral body
• Decreased overlap of articular processes
• Anterior soft tissue swelling
• bow-tie sign
• AP view
• involved spinous processes point to involved side
• Oblique
• anteriorly dislocated inferior articular process
  forces down into lower ½ of neuroforamen

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Bilateral Facet Dislocation

• An extreme form of anterior subluxation
• Usually gt 50 of A-P diameter of vertebral body
  in lateral view
• Extremely unstable !!
• Often accompanied by disc herniation

39
Clay Shovelers Fracture

• Avulsion fracture of spinous process
• Usually stable
• Most common at C7gtC8gtT1
• Non-operative treatment if segmental instability
  ruled out

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Flexion Tear Drop Fracture

• Most severe fracture of cervical spine,
  disruption of all 3 columns making this a very
  unstable fracture
• Associated with acute anterior cervical cord
  syndrome (quadreplegia, loss of pain, temp,
  touch)
• X-ray
• Widening of interlaminar space
• Narrowing of disc space
• Anterior subluxation of articular facets

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Simple Wedge Fracture

• Nuchal ligament complex remains intact, thus
  anterior vertebral body bears most of force
• Diminished height and increased concavity of
  anterior border of vertebral body
• Swollen pre-vertebral soft tissues
• Stable fracture

42
Atlantoaxial Subluxation

• Disruption of transverse ligament
• Very unstable injury
• Suspect if atlanto-dens interval is gt 3.5mm (5mm
  in children)
• Axial CT to confirm diagnosis
• Fusion is definitive treatment
• Risk Downs, RA

43
Hyperextension Injuries

• Hangmans fracture
• Extension Teardrop fracture of C2
• Lower Cervical Burst Fracture
• Hyperextension Fracture/Dislocation

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Hangmans Fracture

• Extension, compression
• Traumatic spondylolithesis of C2
• Bilateral fractures of pedicles due to
  hyperextension
• Disruption of spinolaminar line
• Can be associated with facet dislocation making
  it a very unstable injury.

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Vertical Compression Injuries

• Atlas Fracture
• Jefferson Fracture (burst fracture of C1)
• Burst Fracture
• Pillar Fracture

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Jefferson Fracture

• Fractures of anterior and posterior arches of C1
• displacement of the lateral masses of C1
  radiographically (best seen on odontoid view)
• Displacement gt 6.9mm complete disruption of
  transverse ligament cervical traction

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Burst Fracture

• Disruption of anterior and middle columns
• Always require axial CT of MRI to evaluate degree
  of middle column retropulsion
• gt25 loss of vertebral height cervical tongs
  traction
• Otherwise very stable

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Pillar

• Often associated injury
• subluxations
• May be missed in acute cervical spine trauma

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RTP Fractures, Instability

• MC cause catastrophic injury (C3-4)
• NO evidence expert opinion
• Some agreement
• Evidence of instability
• gt11 degrees, 3.5 mm translation
• C1-2 hypermobility (4mm)
• Post fusion c1-2

Ellis, CSMR, 2007
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Special Concern Transient Quadraparesis
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Case - Transient Quadriparesis

• HS FB, makes tackle, goes down. C/O numbness,
  tingling, weakness in both arms and hands. Sx
  last five minutes, resolve. No neck pain. hx
  for similar (unreported) episode last year.
• Exam is normal. He wants to play.

52
Case - Transient Quadriparesis

• What would your RTP advice be .
• Does he play
• This game?
• 1 week?
• 1 month?
• Never?
• What if player had full quadraparesis?
• Change your decision?
• YES
• NO

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Transient Quadriparesis

• Rare occurrence
• FB most common
• 1.2 million play
• 10-15 c-spine injury
• 7.3/100,000 motor/sensory
• Torg 1997

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Transient Quadriparesis

• Define neuropraxia of spinal cord
• Obersteiner 1879
• segmental demyelination
• anoxia, incr CA
• increased refractory
• period
• Hyperextension injury
• cord compresses
• adjacent vertebrae
• enfolded ligaments

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Transient Quadriparesis

• Symptoms
• bilateral
• burning pain
• numbness and tingling
• loss of sensation arms and/or legs
• variant burning hands
• Recovery 10 - 48 hrs
• Radiographs - neg

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Spear Tacklers Spine

• Defined by Torg
• C-spine injury
• Cervical spinal stenosis
• persistent loss of normal lordosis (on Xray)
• ? Absolute contraindication
• RTP if regain lordosis

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Spinal Stenosis

• Pavlov RatioA/B
• Ratiolt0.8 considered significant spinal stenosis
• However,
• low ratio has no associated predisposition to
  permanent neurological injury
• Low predicative value (33 in study by Odor)
• 88 false rate thought secondary to large
  vertebral bodies in larger athletes (Herzog et al)

58
TQ - Torg v. Cantu

• Torg (JNeurSurg 1997) 110 cases, 65 RTP, 56
  recurrent sx, NO permanent injury
• Developmental narrowing of the cervical canal in
  a spine that has no evidence of instability is
  neither a predictor of nor a contributor to
  permanent neurologic injury.

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TQ - Torg v. Cantu

• Firooznia et al, Matsuura et al, Wolfe et al,
  Alexander et al, Ladd and Scranton, Nugent,
  Penning
• all conclude
• spinal stenosis predisposes to spinal cord injury
  
• as measured by loss of functional reserve on MRI
  or myelography
• National Center for Catastrophic Sports Injuries
• 20 of initial quads without stenosis -- complete
  recovery
• 0 of those with functional spinal stenosis
  recovered

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Evaluation of TQ

• History previous Sx?
• Imaging
• AP, lateral, oblique, odontoid - flex/ext
• instability gt3.4 mm AP translation or gt11
  degrees sagital angulation
• consider thin cut CT
• MRI disc, cord, ligamentous injury
• EMG brachial plexus v radiculopathy

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RTP - TQ

• Consensus guidelines
• Asymptomatic
• Normal exam
• Desires return
• Controversial - Imaging abnormality
• instability
• disc
• stenosis
• congenital abnormality
• spear tacklers spine

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Tommy Maddux Case

• 11/17/02 Injured
• 30 minutes TQ
• unconscious, breathing
• boarded
• hospitalized (ICU, IV steroids, imaged)
• DX cord concussion
• 11/20 RTP (practice)
• 12/8 RTP (game)

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Tommy Maddux Case

• Dr. Joseph Maroon textbook way to manage this
  injury
• MRI - neg
• CT - neg
• Flex/Ext - neg
• RTP when recovered
• NB also had CHI, ImPACT testing

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RTP - TQ

• Absolute Contraindications
• Single episode with
• cord defect or edema
• ligamentous instability
• symptoms gt 36 hrs
• Multiple episodes
• Certain congenital abnl.
• Klippel Feil type I (mass fusion)
• Odontoid agenesis (C1-2 anomalies)
• A-O fusion

65
RTP - TQ

• Relative Contraindications
• Single episode with
• disc disease
• DJD/DDD
• ??? Abnormal Torg ratio
• Asymptomatic but with radiographic abnormalities
• significant bony/ligament
• injury
• spinal cord contusion
• stable healed injury (fx)

66
RTP - TQ

• Relative Contraindications
• Arnold Chiari
• Recent AMSSM listserve
• Chiari Malformation I is thought by some to be
  an incidental finding--but that is open for
  debate. If they are asymptomatic with a CM-I, I
• tend to think of it as relative
  contraindication, but would allow most to play
• Kevin Walter, MD
• Cases Fields, Benjamin
• Congenital (K-F type II)

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RTP - TQ

• NO Contraindications
• single episode
• NO imaging abnormalities