Introduction
- Christopher K. Kepler, MD, MBA
- Nikolaus S. Hjelm, MD
- Gursukhmandeep S. Sidhu, MBBS
- David Gendelberg, MD
- Alexander R. Vaccaro, MD, PhD
- Nikolaus S. Hjelm, MD
Epidemiology
- •
Disc degeneration is exceedingly common although only a small percentage of individuals with disc degeneration will need surgical intervention to address axial neck pain or a symptomatic herniated disc causing radiculopathy or myelopathy.
- •
In this sense, although athletic participation and subsequent injury may accelerate disc degeneration, this injury is by no means exclusively sport related.
Age
- •
Late twenties, early thirties, mean age of approximately 28 in series of professional rugby and American football players who underwent surgery for disc herniation
Sex
- •
Although disc degeneration occurs in both males and females, sports that require axial loading where disc herniation and return to play has been characterized in the literature are predominantly played at the professional level by men (rugby, American football).
Sport
- •
Rugby, American football
Position
- •
Rugby—heavy predominance of forward, especially first row ( Figure 23-1 ); American football—most common in defensive players although also common in offensive lineman, running backs, and quarterbacks.
FIGURE 23-1
Rugby scrum in which the players in the front line on each side push forward with their shoulders, head, and neck to gain an advantage. This tendency for high impact, repetitive load is thought to contribute to the high incidence of symptomatic cervical spine pathology in this group of players.
Pathophysiology
Intrinsic Factors
- •
Genetic factors account for approximately 70% of individual susceptibility.
- •
Many environmental factors have been proposed (occupational loading, tobacco, traumatic injury) and likely contribute but to a lesser degree than genetics.
- •
Congenital stenosis may contribute to susceptibility to radiculopathy or myelopathy related to a herniated disc ( Figure 23-2 ).
FIGURE 23-2
Lateral cervical spine radiograph of a patient with congenital stenosis. This diagnosis is made based on a ratio of the width of the spinal canal ( A ) to the width of the vertebral body ( B ) which is less than 0.8, a threshold suggesting the patient has congenital stenosis.
Extrinsic Factors
- •
No extrinsic factors have been rigorously proved to be associated although predominance of defensive players in American football and front row players in rugby strongly suggests that repetitive axial loading is a risk factor.
Traumatic Factors
- •
Axial load
Classic Pathological Findings
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Radiculopathy
- •
Myotomal weakness
- •
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Myelopathy
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Gait instability
- •
Difficulty with fine motor control (e.g., buttoning shirt)
- •
Difficulty performing repetitive tasks rapidly ( Figure 23-3 )
FIGURE 23-3
Players with cervical myelopathy due to spinal cord compression often have difficulty performing repetitive tasks quickly, such as closing ( A ) and opening ( B ) closing a clenched fist rapidly or slapping the palm ( C ) and then dorsum ( D ) of their hand on their anterior thigh.
- •
- •
Disc degeneration
- •
None
- •
Clinical Presentation
History
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Radiculopathy
- •
May present with or without neck pain
- •
Dermatomal pain, paresthesias or dysesthesias
- •
- •
Myelopathy
- •
May present with or without neck pain
- •
Gait instability
- •
Difficulty with buttons or handwriting
- •
- •
Axial neck pain
- •
Waxing-waning course
- •
Pain may include any region of posterior head/neck from occiput to periscapular area
- •
Physical Examination
Abnormal Findings
- •
Radiculopathy
- •
Pain, paresthesias or dysesthesias found in dermatomal pattern
- •
Myotomal weakness
- •
Muscle atrophy in myotome possible but rare
- •
Skeletal reflexes may be attenuated or absent compared with contralateral side
- •
- •
Myelopathy
- •
May have symptoms consistent with radiculopathy
- •
Positive Hoffman’s sign ( Figure 23-4 ), Babinski’s sign
FIGURE 23-4
A, Hoffman’s test is performed by stabilizing the middle phalanx of the third finger and flicking ( arrow ) or tapping the distal phalanx of the third finger. B, The test is positive when this action results in a reflexive flexion of the interphalangeal joint of the thumb ( arrow ), a finding suggestive of spinal cord compression.
- •
Positive Romberg’s sign, difficulty with tandem walk
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Cannot perform repetitive activities rapidly (alternating hand slap on other hand) (see Figure 23-3 )
- •
Skeletal reflexes may be hyperactive, patient may demonstrate clonus
- •
- •
Axial neck pain
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None
- •
Pertinent Normal Findings
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Radiculopathy
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No Hoffman’s reflex or Babinski’s sign
- •
- •
Axial neck pain
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Normal neurological examination
- •
Imaging
- •
Radiographs—to evaluate canal anteroposterior diameter to rule out congenital stenosis. Significant stenosis may be contraindication to contact sports participation.
- •
MRI—to evaluate disc degeneration, neural element compromise.
- •
CT occasionally helpful for further anatomic detail regarding congenital stenosis
Differential Diagnosis
- •
Peripheral nerve entrapment—median and ulnar neuropathy may mimic C6 and C8 radiculopathy, respectively ( Figure 23-5 ). Differentiated by electromyogram (EMG).
FIGURE 23-5
Dermatomes of the hand. C6 and C8 radiculopathy can be confused with peripheral compression of the median nerve and ulnar nerve, respectively, which have a similar distribution in the hand.
- •
Neurological disease such as amyotrophic lateral sclerosis (ALS) or multiple sclerosis (MS). ALS diagnosed by EMG and findings that do not localize to cervical spine nerve roots, such as tongue fasciculations, MS differentiated by EMG and MRI and by discordant symptoms (e.g., cranial nerve involvement).
- •
Fibromyalgia—trigger points near cervical spine but also common over lower back, buttocks, and greater trochanter ( Figure 23-6 ). Associated sleep disturbance nearly universal on history.
FIGURE 23-6
Stereotypic locations ( red circles ) of trigger points in patients with fibromyalgia.
Treatment
Nonoperative Management
- •
Radiculopathy
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Activity avoidance, nonsteroidal antiinflammatory medications, possible brief period of immobilization using soft collar, avoid narcotic use
- •
Epidural steroid injections to nerve root at which symptoms localize
- •
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Myelopathy
- •
No role for nonsurgical treatment in young athlete
- •
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Axial neck pain
- •
Primarily nonsurgical treatment because the surgical result is often poor. Maintain range of motion (ROM), avoid prolonged immobilization.
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Nonsteroidal antiinflammatory medications useful, role of steroid injection unclear
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Avoid exacerbating activities.
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Pain management as necessary
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Guidelines for Choosing Among Nonoperative Treatments
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Radiculopathy
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Begin with activity avoidance and antiinflammatory medications and progress to epidural injections if the patient fails less invasive treatment.
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Myelopathy
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N/A
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Axial neck pain
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Initial treatment should focus on avoiding immobilization, maintaining range of motion with use of nonsteroidal antiinflammatory medication as necessary.
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If pain cannot be managed otherwise, referral to pain management specialist may be useful.
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Surgical Indications
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Radiculopathy
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Incapacitating pain with failure of nonsurgical treatment
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Progressive neurological deficit
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Neurological deficit that fails to improve
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Myelopathy
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Should be treated surgically in all young patients
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Axial neck pain
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Surgical indications are failure of nonsurgical modalities, although indications for neck pain operations are heavily surgeon-dependent.
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Aspects of History, Demographics, or Exam Findings That Affect Choice of Treatment
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History of improving radicular or axial neck pain symptoms may encourage longer trial of nonsurgical treatment as radiculopathy often resolves spontaneously, allowing the athlete to avoid surgery, and axial neck pain commonly has a waxing-waning course.
- •
Multiple affected levels (>2) in athletes with radiculopathy will preclude return to play if treated using spine fusion; athletes may elect for longer nonsurgical course rather than face career-ending surgery.
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Any signs or symptoms of myelopathy are an absolute indication for decompression and fusion.
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Patients with symptomatic disc herniation in the setting of congenital stenosis may be more likely to be treated with multilevel posterior surgery or anteroposterior surgery, which will often end the athlete’s career.
Aspects of Clinical Decision Making When Surgery Is Indicated
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Kyphotic alignment of the cervical spine is a contraindication for posterior-only decompression and fusion.
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Athletes undergoing surgery for more than three affected levels will usually be treated with posterior decompression and fusion.
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Athletes with severe axial neck pain who elect to undergo surgery should be counseled that results are less predictable and, in general, inferior to surgery for radiculopathy or myelopathy.
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Motion-preserving surgery such as cervical disc replacement is contraindicated for contact athletes owing to the potential risk of component dislocation and spinal cord injury.
Evidence
Multiple Choice Questions
- QUESTION 1.
Based on current evidence, approximately what percentage of individual susceptibility to disc degeneration is owing to genetic influences?
- A.
15%
- B.
40%
- C.
70%
- D.
90%
- A.
- QUESTION 2.
For which of the following ailments on the differential diagnosis for cervical radiculopathy or myelopathy is sleep disturbance nearly universally found on taking a thorough history?
- A.
Multiple sclerosis
- B.
Amyotrophic lateral sclerosis
- C.
Axial neck pain
- D.
Fibromyalgia
- A.
- QUESTION 3.
Which of the following treatment strategies is most appropriate for a young athlete presenting with signs of myelopathy?
- A.
Observation as long as the athlete can compete without limitations
- B.
Surgery
- C.
Initial use of aggressive PT with traction and core strengthening.
- D.
Expectant observation with surgery if the athlete has neurological decline
- A.
- QUESTION 4.
What is the likelihood of return to play of a football lineman treated with four level anterior cervical fusion?
- A.
Zero—return to play is contraindicated.
- B.
Unlikely—patients treated with four level fusion rarely are asymptomatic after surgery.
- C.
Likely provided that the player has painless range of motion after surgery
- D.
Likely, although the player will likely not attain the same level of competitiveness after surgery
- A.
Answer Key
- QUESTION 1.
Correct answer: C (see Pathophysiology )
- QUESTION 2.
Correct answer: D (see Differential Diagnosis )
- QUESTION 3.
Correct answer: B (see Treatment )
- QUESTION 4.
Correct answer: A (see Aspects of History, Demographics, or Exam Findings That Affect Choice of Treatment )
Nonoperative Rehabilitation of Cervical Spine Disc Injuries
- Christopher K. Kepler, MD, MBA
- Michael J. Ross, MD
- Christopher Peduzzi, MA, ATC
- Rick Burkholder, MS, ATC
- Alexander R. Vaccaro, MD, PhD
- Michael J. Ross, MD
Guiding Principles of Nonoperative Rehabilitation
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Allow acute symptoms to resolve. Although cervical spine should be protected from secondary injury, prolonged use of a cervical collar is discouraged.
- •
Gradually, range of motion must be resumed once axial pain has decreased and radicular pain is absent.
- •
Return to play is possible only when full, painless range of motion is possible.
Phase I : Acute Injury Phase (weeks 0 to 3)
Protection
- •
Cervical collar may be used if necessary to reduce painful muscle splinting, but its use should be minimized to prevent muscle atrophy and excessive stiffness caused by immobility.
| PHASE I (weeks 0 to 3) | PHASE II (weeks 1 to 8) | PHASE III (weeks 8+) |
|---|---|---|
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