CERVICAL SPINE INJURIES IN ATHLETES

Steven Fulop, MD Univer sity Hospitals Neurosurger y

SPINAL CORD INJURY - EPIDEMIOLOGY  12,000 new spinal cord injuries (SCI) occur in USA every year  50% of all SCI occur between ages 16 and 30  81% of SCI are male  Ethnicity    

Caucasian: 67% African American: 24% Hispanic: 8% Asian: 2%

www.uab.edu/nscisc

ANATOMY  Vertebral artery enters at C7  Facets richly innervated  8 cervical nerve roots for 7 bodies  C0-1 and C1-2 highly specialized  C1 = Atlas  C2 = Axis

ROM AND STABILIZING ANATOMY  7 cervical vertebrae  Large ROM comes at expense of stability in trauma  Relies on ligaments

 50% of flex-ex at C0–1  50% of rotation at C1 -2  Primary stabilizers:  Anterior Longitudinal Ligament  Posterior Longitudinal Ligament  Intervertebral Disc  Ligamentum Flavum  Facet capsules  Inter/supraspinous ligaments

CERVICAL STRAIN/SPRAIN  Mechanism:  Cervical loading or eccentric muscle contraction

 Pathology:  Ligament sprain  Muscle strain

 Symptoms:  Neck pain and spasm  Radiculopathy

 Diagnosis and Treatment:  Cervical collar  Flex-Ex X-Ray after spasms resolve  If unstable, may require surgery

 Return to sport:  Once symptoms resolve  Full ROM  No instability

STINGERS AND BURNERS  Mechanism:  Traction/compression of brachial plexus

 Pathology:  Brachial plexus neuropraxia

 Symptoms:  Episode of unilateral upper extremity weakness, numbness or neuropathic pain

 Diagnosis and Treatment:  Observation  If recurrent, EMG and brachial plexus MRI

 Return to sport:  Once symptoms resolve

TRANSIENT QUADRIPLEGIA  Mechanism:  Axial loading  Hyperextension

 Pathology:  Spinal cord contusion and edema

 Symptoms:  Motor and/or sensory deficit  2 – 4 limbs

 Diagnosis and Treatment:  MRI  Steroids

 Return to sport:  Once symptoms resolve  If no stenosis on MRI

CERVICAL DISC DISEASE  Mechanism:  Multiple episodes of axial loading or twisting

 Pathology:  Herniated soft disc  Disc – osteophyte complex

 Symptoms:  Upper extremity radiculopathy  Myelopathy

 Diagnosis and Treatment:    

MRI PT/OT Epidural steroids Surgery for persistent radiculitis or myelopathy

 Return to spor t:  1 level fusion if asymptomatic  2-3 levels relative contraindication  >3 levels absolute contraindication

SPEAR TACKLER’S SPINE  Mechanism:  Multiple episodes of cervical trauma with axial loading

 Pathology:  Cervical stenosis  Loss of lordosis  Spondylosis

 Symptoms:  Neck pain  Catastrophic fractures

 Diagnosis and Treatment:  X-Rays, CT, and MRI  PT for restoration of ROM

 Return to sport:  Controversial  Consider avoidance of contact sports

SPINAL STENOSIS  Mechanism:  Multiple episodes of trauma  Congenital

 Pathology:  Narrowing of canal by ligamentous hypertrophy  Disc bulges  Congenitally short pedicles

 Symptoms:  Radiculopathy  Myleopathy

 Diagnosis and Treatment:  MRI  Conservative or surgical management

 Return to sport:  If associated with TQ or generally symptomatic avoid contact sports

VASCULAR TRAUMA  Blunt trauma to neck or rotation and bending  Carotid dissection  May lead to stroke like symptoms  Visual loss one eye (amaurosis fugax)  Horner syndrome  Neck pain

 Vertebral dissection  Loss of coordination  Visual loss hemianopsia (occipital cortex)

 Typically treated with anticoagulation and sometimes stenting

SPINAL STENOSIS AND SCI RISK  Torg Ratio  Ratio of 1.0 normal  Stenosis at 0.8  Ratios less than 0.7 associated with SCI

Torg JS et al. J Bone Joint Surg Am. 84(1):112-122 (2002).

Torg JS et al. J Bone Joint Surg Am. 78(9):1308-14 (1996)

MANAGEMENT OF AN INJURY  Standard ABCs  Consciousness and focused neurologic exam  Cervical spasm, significant tenderness and decreased ROM should raise suspicion of injury even w/o neuro deficit  All unconscious athletes should be presumed to have a cervical spinal injury  Spine immobilization with Cspine precautions when moving  Leave helmet and shoulder pads on  Remove facemask for airway

RETURN TO SPORT ALGORITHMS

Meredith DS et al. Am J Sports Med. 78(9):1308-14 (2013) Burnett MG JS & Sonntag V Neurosurg Focus. 15;21(4):E5 (2006)

CASES  35 yo with loss of arm strength and coordination  Myelopathic on exam  C5 stenosis with myelomalacia  Avid golfer  Unable to play currently  Failed PT

CERVICAL MYELOPATHY/MYELOMALACIA

CERVICAL CORPECTOMY

CASES  63 yo man with progressive dif ficulty walking  Severe burning pain in hands  Florid myelopathy on exam  Concentric stenosis C3 -7 with  Maintained cervical lordosis

SEVERE SPINAL STENOSIS

SEVERE MULTILEVEL STENOSIS

NONFUSION SURGERY  Open door laminoplasty  Posterior approach  Can be combined with foraminotomy  Mobility sparing  Instrumentation required  Useful over long segments  Indirectly decompresses the cord from anterior disease

RESTORATION OF TORG RATIO

MAINTAINS RANGE OF MOTION

CASES  40 yo woman with severe neck pain and fatigue  Unable to hold head up at end of the day  Minimal radicular signs  C4-7 spondylosis with kyphotic deformity  Failed PT

NO NEUROLOGIC SYMPTOMS

RESTORE LORDOSIS

PERMANENT DECREASED ROM

IMPROVED NECK PAIN/FATIGUE

CASES  50 yo man with progressive balance loss and grip weakness  Myelopathic on exam  C4-7 spondylosis with stenosis and myelomalacia

CERVICAL SPONDYLOTIC MYELOPATHY

2 LEVEL CERVICAL CORPECTOMY

TROUBLE SWALLOWING  6 weeks post op patient sneezed and felt neck pain with swallowing dif ficulty  Intra op found C4 vertebral body sheared of f anterior half  Cage kicked forward into retropharangeal space

3 LVL CERVICAL CORPECTOMY  C4 corpectomy and C3-7 Cage placed for support  Patient taken back to OR next day for posterior backup  Posterior instrumentation added as a back-up

360 DEGREE FUSION

ANTERIOR VS POSTERIOR…?

SURGICAL MANAGEMENT SUMMARY  Take home points:        

No clinical superiority to anterior vs. posterior All guidelines recommend individual plan I tend to go anteriorly with kyphosis and anterior lesions I use ACDF when possible to increase sagittal correction and stabilization I use laminoplasty when spine straight to lordotic and ROM maintenance prioritized I go posteriorly if multiple anterior surgeries make complications more likely I favor anterior procedures when higher cardiac risk present (due to easier rescuscitation efforts) The 1-2 level ACDF with plate is my go to procedure for degenerative disease under most circumstances. (I am not in a major trauma center)

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