The key to successful treatment of elite athletes is optimizing the medical care at every step: injury prevention and sport-specific training; comprehensive history and physical examination; high-quality and complete diagnostic studies; accurate diagnosis; control and completion of rehabilitation program; minimally invasive, safe, and effective surgeries; risk assessment for return to sport; guided and gradual return to sport; and continued rehabilitation and exercise program after return to sport.
Key points
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A burner in 1 arm probably is a nerve root injury and has a good prognosis. A burner in both arms probably is a spinal cord injury and requires significant work-up.
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Determining risk of return to play after transient paraparesis depends on severity of episode, number of episodes, and underlying anatomy.
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Fusion is the most common surgery performed in athletes because it has the safest chance to protect an injured nerve and allow for return to head contact in sports.
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Artificial disc replacement preserves motion and, therefore, may decrease the incidence of adjacent-level pathology but carries an unknown risk with head contact in sports.
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Posterior foraminotomy has the fastest healing and return to sports but the highest incidence of recurrent surgery at the index level.
Introduction
Treating high-level athletes requires the physician to deal with many confounding socioeconomic issues. A physician’s abilities to take a history, perform a comprehensive physical examination, obtain diagnostic studies, direct the rehabilitation program, and receive proper follow-up often are compromised by many factors. The key to successful treatment depends on the physician’s ability to overcome these obstacles and deliver the best possible care to each individual patient. The physician must be diligent and meticulous in order to make an accurate diagnosis, direct proper medical care, and follow-up with athletes on an ongoing basis. This article aims to help the medical team in providing comprehensive care for the elite athlete with spinal injury.
Traumatic injuries
In-game Management
In preparation for treating athletes with acute injuries, the medical staff needs to have a plan that includes prevention strategies to reduce the incidence of cervical spine injuries in sport; emergency planning and preparation to increase management efficiency; maintaining or creating neutral alignment in the cervical spine; accessing and maintaining the airway; stabilizing and transferring the athlete with a suspected cervical spine injury; managing the athlete participating in equipment-laden sports, such as football, hockey, and lacrosse; understanding emergent transportation by whom and to where; and considerations in the emergency department.
In American football, if a player is suspected of having a cervical spine injury on the field, it is important to engage in spinal precautions and leave the headgear in place until the cervical spine can be evaluated completely. The team personnel should have means available for removal of the face mask so that the airway is readily accessible. Immediate removal of the helmet should not be performed until the proper medical personnel are prepared for an emergency situation. When lifting a player with a suspected cervical injury, the physician should stabilize the head and neck to the torso by placing their hands under the scapulas and stabilizing the head between their forearms.
The team physician should have a high index of suspicion for a cervical spine injury for any player who goes down after a collision. If the player is unconscious, assume a cervical fracture. If the player has a stiff and painful neck, assume a cervical fracture. If the player has loss of sensation or motor in extremities, assume a cervical fracture. If any of these conditions is met, the player should be carted off the field on a spine board with cervical precautions.
If a player runs off the field on their own accord, but the sideline evaluation reveals limited range of motion, cervical tenderness, cervical radiculopathy with pain/weakness/numbness, or pain with head compression, then the player should be evaluated for possible fracture or disc herniation.
Burners/Stingers
The most common athletic cervical neurologic injuries are stingers, or burners. Symptoms result from injury to the brachial plexus or cervical nerve roots. Stingers have been reported to occur in up to 50% of athletes involved in contact or collision sports. A stinger or burner (burner syndrome) is a nerve injury associated with burning arm pain and paresthesias. A stinger may start with severe pain in the neck and arm and then quickly proceeds to unilateral dysesthetic pain that follows a dermatomal distribution. It may be accompanied by weakness, most often in the muscle groups supplied by the C5 and C6 nerve roots (shoulder abduction, elbow flexion, wrist extension, and grip) on the affected side. Although pain frequently resolves spontaneously in 10 minutes to 15 minutes, it is not uncommon to have trace abnormal neurologic findings for several months. Normal, painless motion of the cervical spine generally is present and is crucial in distinguishing a stinger from other types of cervical pathology, such as disc herniation, foraminal stenosis, or fracture. Bilateral symptoms (burning into both hands) are more indicative of a neurapraxic injury of the spinal cord, which requires much more caution and work-up.
Three different mechanisms of a burner syndrome have been described:
- 1.
The most common is hyperextension, rotation, and compression toward the involved arm, thereby closing the neural foramen and causing a nerve root contusion ( Fig. 1 ). This mechanism essentially is a replication of Spurling maneuver.
Fig. 1
Mechanism of stinger with ipsilateral cervical extension, rotation, and compression.
- 2.
Lateral neck flexion away from a shoulder depression injury, resulting in brachial plexus stretch, is more common in younger adolescents.
- 3.
A direct blow to the brachial plexus with resultant injury.
Most stingers resolve within minutes. For an athlete’s first episode with only brief transitory symptoms, treatment is conservative and no special testing is required. The athlete is permitted to return to unrestricted activity after complete resolution of symptoms, if a normal neurologic examination, negative head compression test, and pain-free and unrestricted cervical range of motion are present. Further work-up is directed at patients with persistent symptoms or recurrent episodes to assess for other cervical problems, such as fracture, stenosis, disc herniation, or instability. Work-up includes cervical radiographs with supervised flexion-extension views, single-photon emission computed tomography (SPECT) bone scan (which can identify acute injury vs congenital anomaly), magnetic resonance imaging (MRI), computed tomography (CT) scan, and electromyography (EMG).
If the symptoms have not resolved by 3 weeks, it is reasonable to obtain an EMG. This test can help define the specific nerve root involved and determine the degree of injury. Because results of this test may lag behind an athlete’s recovery, under certain circumstances, the player may be cleared to play when they are asymptomatic, even if the EMG has not returned normal.
Risk Categories by Sport
Sports can be categorized into several groups based on risk of injury: collision, contact, and repetitive. Collision sports have the highest frequency and risk of head contact; examples include football, ice hockey, rugby, martial arts, and wrestling. These sports have the highest risk for cervical spine problems. A sport, such as football, that has a premium on yardage gained, has an inherent risk of lowering the head and using the crown of the head to initiate blows; therefore, it has an inherent risk for creating cervical fracture dislocations. Lowering of the head causes straightening of the spine and axial load being borne directly down the anterior spinal column, much like pushing the ends of a soda straw and having it buckle in the middle.
Additional rules in football that attempt to eliminate use of the head as an offensive weapon were initiated to protect the person being hit, although in reality they protect the hitter from neck injury. Cervical injury is different in different sports, because a hockey player can be driven head first into the boards whereas in rugby there can be an unusual collapse of the scrum. Additionally, any sport in which a player can be dropped directly on their head has a significant risk of neck injury.
Contact sports are considered a medium risk for cervical injury. Sports not designed for high velocity head contact, such as soccer, basketball, volleyball, baseball, and water polo, still can have a cervical injury but at a lower frequency. There also are high-velocity injuries in certain noncontact sports, such as skiing, gymnastics, and cheerleading. Repetitive sports that require a lot of cervical motion, such as golf, baseball, and swimming, can produce wear and tear injury to the cervical spine but with a lower risk of a catastrophic head contact injury.
Risk Categories by Condition
There are no universally accepted guidelines for determining when an athlete may return to play after a cervical injury. The ideal criteria include
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The athlete should be symptom-free with respect to neck and radicular pain.
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Unrestricted and pain-free cervical motion should be present.
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Neurologic evaluation should be normal.
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Full muscle strength should be present.
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There should be no evidence of radiographic instability or other spinal abnormalities on advanced imaging studies.
Often, patients have residual symptoms, physical findings, and/or anatomic conditions that increase risk for future injuries with return to athletic competition. Risk assessment can be helpful by dividing patients into the following categories, although each case needs to be assessed individually :
- 1.
No contraindications to return to play ( Box 1 ): these conditions are considered to permit return to collision sports without restriction after comprehensive patient assessment.
Box 1
No contraindication to return to play
- 1.
Posttraumatic
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Healed, nondisplaced, stable C1 or C2 fracture (treated nonoperatively) with normal cervical range of motion.
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Healed stable subaxial spine fracture with no sagittal plane kyphotic deformity
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Asymptomatic clay shoveler fracture (C7 spinous process)
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- 2.
Congenital
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Single-level Klippel-Feil syndrome (excluding the occipital–C1 articulation) with no evidence of instability or stenosis noted on MRI
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Spinal bifida occulta
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- 3.
Degenerative
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History of cervical degenerative disc disease that has been treated successfully in the clinical setting of occasional cervical neck stiffness with no change in baseline strength profile
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- 4.
Postsurgical
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After anterior single-level cervical fusion (below C3-4), with or without instrumentation, that has healed
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After single-level or multiple-level posterior cervical microlaminoforaminotomy
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- 5.
Other
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Prior history of 2 stingers within the same or multiple seasons. The stingers should last less than 24 hours, and the athlete should have full range of cervical motion without any evidence of neurologic deficit.
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- 1.
- 2.
Relative contraindications to return to play ( Box 2 ): these conditions are associated with a possibility for recurrent injury despite the absence of any absolute contraindication. The athlete, family, and coach must be counseled that recurrent injury is a possibility and that the degree of risk is determined by each individual case.
Box 2
Relative contraindication to return to play
- 1.
Previous history of transient quadriplegia or quadriparesthesia. The athlete must have full return to baseline strength and cervical range of motion with no increase in baseline cervical neck discomfort and imaging evidence of no significant spinal cord compression.
- 2.
Continued cervical neck discomfort or any evidence of a neurologic deficit or decreased range of motion from baseline after a cervical spine injury.
- 3.
Three or more stingers in the same season
- 4.
A prolonged stinger lasting more than 24 hours
- 5.
A healed, displaced cervical fracture
- 6.
A healed single-level posterior fusion with lateral mass segmental fixation
- 7.
A healed single-level anterior fusion at C2-3 or C3-4 (sports that require head contact increase the risk of future injury, especially in a kyphotic spine)
- 8.
A healed, stable, 2-level anterior or posterior cervical fusion with or without instrumentation (below C3-4) (sports that require head contact increase the risk of future injury)
- 9.
A healed cervical laminoplasty (sports that require head contact increase the risk of future injury)
- 1.
- 3.
Absolute contraindications to return to play ( Box 3 ): these conditions most likely would not be allowed to return to collision sports.
Box 3
Absolute contraindication to return to play
- 1.
Previous transient quadriparesis
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More than 2 previous episodes of transient quadriplegia or quadriparesthesia
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Clinical history or physical findings of cervical myelopathy
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- 2.
Postsurgical
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C1-2 cervical fusion
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Three-level cervical spine fusion
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Multilevel cervical laminectomy
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- 3.
Soft tissue injury or deficiencies
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Asymptomatic ligamentous laxity (ie, >11° of kyphotic deformity compared with the cephalad or caudal vertebral level)
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Radiographic evidence of C1-2 hypermobility with an anterior dens interval of 4 mm or greater
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Radiographic evidence of a distraction-extension cervical spine injury
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Symptomatic acute cervical disc herniation
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- 4.
Other radiographic findings
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Plain radiography
- i.
Evidence of a spear tackler spine on radiographic analysis and history
- ii.
A multiple-level Klippel-Feil syndrome
- iii.
Clinical or radiographic evidence of rheumatoid arthritis
- iv.
Radiographic evidence of ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis
- v.
A healed subaxial spine fracture with evidence of a kyphotic sagittal plane or coronal plane abnormality
- i.
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MRI
- i.
Presence of cervical spinal cord abnormality noted on MRI.
- ii.
MRI evidence of basilar invagination
- iii.
MRI evidence of Arnold-Chiari malformation
- iv.
MRI evidence of significant residual cord compression after a healed stable subaxial spine fracture
- i.
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CT
- i.
C1-2 rotatory fixation
- ii.
Occipital–C1 assimilation
- i.
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- 1.
Office evaluation of cervical injuries
Athletes present to the clinic with cervical complaints that include neck pain, restricted range of motion, arm pain/weakness/numbness, balance disturbance, loss of fine motor control, and altered sensation in upper extremities affecting athletic performance. A detailed history and physical examination are essential to determine nerve root involvement ( Table 1 ) and presence of myelopathy and to rule out other conditions. The physician must be able to make an accurate diagnosis, determine acuity and risk for injury, and provide a structured timeline for diagnostic studies, treatment, and return to play.
| Nerve Root | Pain Distribution | Motor | Sensory | Reflex |
|---|---|---|---|---|
| C1, C2, C3 | Side of face, neck | — | Side of face | — |
| C4 | Lower neck | — | Cape distribution | — |
| C5 | Lateral arm | Deltoid, biceps | Lateral arm | Biceps |
| C6 | Lateral forearm, thumb | Biceps, wrist extension | Lateral forearm, thumb | Brachioradialis |
| C7 | Dorsolateral forearm, middle finger | Triceps, thumb extension | Dorsal forearm, middle finger | Triceps |
| C8 | Medial forearm, ulnar digits | Finger flexors, index finger extension | Medial forearm, ulnar digits | — |
| T1 | Medial forearm | Finger intrinsics | Medial forearm | — |
Head contact sports are at greatest risk for a cervical spine injury. Certain positions in certain sports involve repetitive axial loading of the cervical spine, which may cause acute injury and/or chronic degenerative changes. For example, in rugby, the front-line players in the scrum who sustain the largest loads and have higher rates of acute cervical spine injuries also had the highest incidence of severe cervical degenerative changes. Additionally, in a sample of National Football League (NFL) retirees aged 30 years to 49 years, 37% self-reported a diagnosis of arthritis and pain in the neck compared with 17% in the general population.
History
Patients with radiculopathy typically present with unilateral neck pain and radiation into the arm in a dermatomal distribution. The absence of pain in the arm, however, does not exclude the presence of radiculopathy. The most common symptom in cervical radiculopathy is radicular pain, followed by paresthesia. Weakness is reported by approximately 15% of patients. In most cases, the affected nerve root can be identified by history and physical examination alone. Patients often report worsening of symptoms with neck extension or rotation/lateral bending to the ipsilateral side. Pain referred to the medial border of the scapula usually is referred cervical pain but not necessarily radicular pain. Red flags in the history include pain at night (tumor), weight loss (malignancy), fever (infection), urinary urgency (myelopathy), and global weakness/tremors/spasticity (neurologic disorder).
Physical Examination
Physical examination should test for neck range of motion, motor and sensory of extremities, reflexes, gait, and special maneuvers, including Spurling maneuver, shoulder abduction test, shoulder impingement, Adson, Phalen, and Tinel at wrist and elbow. The most common physical examination findings in persons with cervical radiculopathy are painful neck movements and muscle spasm. Diminished deep tendon reflex is the most common objective neurologic finding, with triceps involvement being the most prevalent. Weakness is the next most common finding. The most common nerve root affected is C7, followed by C6. , , Yoss and colleagues found that diminished reflexes were correlated most commonly to the pathology identified at surgery (82%), followed by motor weakness (77%), and diminished sensation (65%).
The Spurling maneuver involves passively moving the patient’s neck into ipsilateral rotation and then extension and then applying gentle downward axial compression. If radicular pain is elicited at any point in maneuver, then it is stopped, and the other parts are not completed. The purpose of this test is to constrict the neural foramen; a positive result is the reproduction of radicular symptoms. A systematic review of physical examination maneuvers in the setting of cervical radiculopathy found that the Spurling maneuver was most sensitive and specific when rotation and extension were combined.
The shoulder abduction test is similar in specificity to the Spurling maneuver, based on electrodiagnostic correlation. The test involves placing the palm of the affected limb on top of or near a patient’s head. A positive result is the relief of radicular symptoms. The shoulder abduction test checks for the relief of symptoms with shoulder abduction as the nerve is taken off tension. Often, there is a history of sleeping with the arm in the abducted position for pain relief.
Shoulder abduction relieves radicular symptoms but provokes shoulder arthropathy. Shoulder pathology must be considered and ruled out in these patients because shoulder girdle pain frequently is the most common presenting symptom of cervical radiculopathy. Also, selective injections can be helpful in establishing a diagnosis.
When diagnosing a patient with radiculopathy, it is important to test for cervical myelopathy. Patients with myelopathy present with upper motor neuron signs, including hyperreflexia and changes in gait, and also have difficulty with fine motor tasks (handwriting, buttoning shirts, and so forth). Upper extremity myelopathy results from spinal cord compression at C4 and cephalad. It presents with loss of dexterity of fine motor movements of hands and physical examination shows hyperreflexia of upper extremities and positive Hoffman test (involuntary flexion movement of thumb and/or index finger with flicking of the middle finger down). Compression of the spinal cord caudal to C4 does not cause upper extremity myelopathy but may result in lower extremity myelopathy. This results in imbalance with heel to toe tandem gait, lower extremity hyperreflexia, clonus and positive Babinski sign.
Cervical radiculopathy must be distinguished from peripheral nerve entrapment or brachial plexopathy ( Table 2 ). Patients also may present with peripheral entrapment and cervical radiculopathy, a phenomenon known as double crush. Physical findings to test for other peripheral nerve issues include infraspinatus atrophy from suprascapular nerve compression, scapular winging from long thoracic nerve pathology, and deltoid weakness from axillary nerve injury. Other items on the differential diagnosis include cardiac pain, herpes zoster (shingles), infection, neurologic disorders (Guillain-Barré and amyotrophic lateral sclerosis) and intraspinal and extraspinal tumors.
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