Introduction
- Nelson S. Saldua, MD
Epidemiology
- •
Cervical injuries often occur in contact sports. Approximately 1.4 million athletes play tackle football annually at the high school, collegiate, or professional levels.
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Cervical injuries occur in 10% to 15% of football players. Although these injuries can occur in a player of any position, there does seem to be a predilection for linemen, defensive ends, and linebackers.
Pathophysiology
Intrinsic Factors
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Cervical ligament sprains can occur with any forced neck motion that results in stretching or tearing of the cervical ligaments.
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Athletes with preexisting cervical stenosis are predisposed to some cervical injuries during the collisions inherent to contact sports.
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The Pavlov-Torg ratio is a radiographic measurement for detecting the presence of cervical stenosis (or tight cervical spine canal). Using a lateral cervical radiograph, it is determined by measuring the anterior-posterior width of the spinal canal and dividing that by the anterior-posterior length of the cervical vertebral body. Cervical stenosis is present if this ratio is less than 0.8 ( Figure 22-1 ).
FIGURE 22-1
The Pavlov-Torg ratio is determined by dividing the anterior-posterior diameter of the spinal canal by the anterior-posterior length of the adjacent vertebral body.
- •
“Burners” or “stingers” usually occur after a direct blow to the neck and/or shoulder resulting in downward displacement of the ipsilateral shoulder with concomitant lateral neck flexion to the contralateral shoulder. This results in a traction injury to the ipsilateral brachial plexus. Another mechanism of injury includes an extension-compression model. In this case, the cervical spine is extended and then lateral flexion results in a compression injury of the brachial plexus ( Figure 22-2 ).
FIGURE 22-2
The two proposed mechanisms for stingers/burners are either traction to the brachial plexus or compression of the brachial plexus.
Extrinsic Factors
- •
Use of helmets in tackle football has decreased the incidence of head injuries but may have led to more cervical spine injuries. The postulated reason for this increase is the tackling technique of using the crown of the head as the initial point of contact with the opposing player ( Figure 22-3 ).
FIGURE 22-3
Use of the helmet as the initial point of contact is a risk factor for cervical injuries. In this position, the cervical vertebral column is straight, and this loss of normal lordosis is postulated to transmit more energy to the vertebral column directly rather than allowing the energy to be dissipated by the paraspinal muscles.
- •
The postulated reason for this increase is using the tackling technique of using the crown of the head as the initial point of contact with the opposing player.
Traumatic Factors
- •
Axial loading of the head and neck can lead to bony and ligamentous injuries to the cervical spine.
- •
Because of the normal lordosis of the cervical spine, when the cervical spine is flexed to approximately 30° the cervical spinal vertebral bodies become a straight column. Axial loading of this straight column does not allow the force applied to be dissipated by the paraspinal muscles and is therefore applied directly to the spinal column.
- •
Enforcement of tackling rules (spearing, helmet-to-helmet contact) may also continue to decrease the risk, although the data are still lacking.
Classic Pathological Findings
- •
A cervical sprain is a ligamentous injury that often results from a direct collision. The athlete will usually complain of pain localized to the neck without upper extremity radiation. This pain can be provoked or worsened with direct palpation.
- •
Because of the pain associated with a cervical sprain, the athlete will often guard against active or passive range of motion of the cervical spine.
- •
The neurologic exam after a cervical sprain is nonfocal, with full and symmetric strength in both upper and lower extremities as well as lack of sensory deficits.
- •
A “burner” or a “stinger” is a transient neurologic event that affects one single upper extremity. The athlete often describes tingling, burning, or numbness in a nondermatomal pattern. Because this condition is usually caused by either a traction injury or a compression injury to the brachial plexus and not an individual nerve root, the patient’s symptoms rarely follow a single dermatomal distribution.
Clinical Presentation
History
- •
A cervical sprain is a ligamentous injury that often results from a direct collision. The athlete will usually complain of pain localized to the neck without upper extremity radiation.
- •
A “burner” or a “stinger” is a transient neurologic event that affects one single upper extremity. The athlete often describes tingling, burning, or numbness in a nondermatomal pattern. Because this condition is usually caused by either a compression or a traction injury to the brachial plexus and not an individual nerve root, the patient’s symptoms rarely follow a single dermatomal distribution.
- •
In the compression mechanism of injury, the cervical spine is extended and laterally flexed toward the ipsilateral side of symptoms. This extension and lateral bending of the cervical spine results in compression of the brachial plexus.
- •
In the brachial plexus traction mechanism of injury, the cervical spine is a lateral bend toward the contralateral side, and concomitantly the ipsilateral upper extremity or shoulder is pushed downward. This results in a traction injury to the brachial plexus caused by the opposing directions of force applied.
Physical Examination
Abnormal Findings
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Cervical sprain: focal tenderness to palpation at maximum site of reported pain
- •
Burner/stinger: tingling, burning, or numbness of a single upper extremity in a nondermatomal pattern
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Transient quadriplegia/cervical cord neuropraxia (CCN): there is a focal neurologic deficit. Sensory symptoms can range from burning pain to tingling to loss of sensation.
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Motor symptoms can vary from mild weakness to complete paralysis. These abnormal neurologic exam findings can last from 10 minutes to 48 hours to resolve.
Pertinent Normal Findings
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The neurologic exam in cervical sprains and burners/stingers is generally nonfocal. There is full (5/5) and symmetric motor strength in both upper and lower extremities as well as lack of sensory deficits.
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In contrast, the neurologic exam in an athlete with transient quadriplegia with CCN will show a focal neurologic deficit that lasts from 10 minutes but can take up to 48 hours to resolve.
Imaging
- •
In a neurologically intact patient without cervical pain and without cervical tenderness to palpation, radiographic imaging may not be necessary. However, because almost all cervical sprains result in cervical pain and/or tenderness to palpation, this injury warrants further workup.
- •
Cervical fractures and dislocations can result in irreversible and permanent neurologic injury, there-by making cervical sprains and strains a diagnosis of exclusion. Cervical fractures and dislocations, as well as acute disc herniations, have potentially disastrous implications for the patient, so they must be ruled out when making the diagnosis of a cervical sprain.
- •
Plain radiographs of the cervical spine should include anterior-posterior, lateral, open mouth odontoid. A swimmer’s view is sometimes necessary to view the cervicothoracic junction.
- •
Patients with decreased Torg ratios and with decreased foraminal height have been found in patients with chronic, recurrent stingers.
- •
If not evident on plain radiographs, a computed tomography scan of the cervical spine can be done to rule out any fracture or dislocation of the cervical spine.
- •
Magnetic resonance imaging (MRI) of the cervical spine can help to identify any compression of the neural elements, to include the spinal cord as well as the nerve roots. In addition, an MRI can occasionally show some increased signal within the spinal cord itself. This increased signal, also called myelomalacia, implies the presence of edema or trauma to the spinal cord.
Differential Diagnosis
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Stinger or burner
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Pain and/or paresthesia in a single upper extremity
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Central cord syndrome
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Extremity weakness that affects the upper extremities more than the lower extremities. Often seen after a cervical hyperextension injury in a patient with preexisting cervical stenosis.
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CNN, also known as transient quadriplegia
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This results in deficits in motor and/or sensory function caudal to the level of the injury.
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Treatment
Nonoperative Management
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Cervical spine immobilization in cervical orthosis
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Restriction from returning to contact sports
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No activity restrictions to include full return to participation in contact sports
Guidelines for Choosing Among Nonoperative Treatments
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If there is any suspicion of unstable cervical spine injury, the patient must not return to play. The cervical spine should be immobilized and the patient transferred to an appropriate facility to complete the imaging workup.
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Relative contraindications to return to participation in contact sports
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Stinger that results in residual muscle weakness
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Torg ratio less than 0.8 with one episode of CCN
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MRI with degenerative disc disease after one episode of CCN
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MRI with presence of cord deformation after one episode of CCN
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Absolute contraindications to return to participation in contact sports
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MRI with cord edema or myelomalacia after one episode of CCN
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Ligamentous instability after one episode of CCN
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CCN lasting longer than 36 hours
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Multiple episodes of CCN
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Some authors recommend that spear-tacklers’ spine is a contraindication to return to contact sports. This is a clinical entity that includes:
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Congenital narrowing of the spinal cord with Torg ratio less than 0.8
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Loss of cervical lordosis or the presence of cervical kyphosis
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Posttraumatic radiographic abnormalities
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Prior history of using spear-tackling or helmet-to-helmet hitting techniques
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Surgical Indications
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Absolute
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Any fracture or dislocation that is etiology for abnormal neurologic exam finding
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Any injury that results in instability of the cervical spine
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Relative
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Recurrent episodes of transient quadriplegia/CCN that can be attributed to a compressive lesion on the spinal cord. The goal of any surgical intervention in this case would be to decrease the likelihood of further neurologic injury, not to return to competitive play.
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Aspects of History, Demographics, or Exam Findings that Affect Choice of Treatment
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Cervical sprains are injuries to the ligaments of the cervical spine. In the absence of concomitant cervical fracture of injury of the intervertebral disc, these ligamentous sprains are rarely sufficient to cause instability of the cervical spine.
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Burners or stingers are by definition transient events and therefore require no surgical intervention.
Aspects of Clinical Decision Making When Surgery Is Indicated
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The goal of any surgical intervention in this case would be for preservation of neurologic function. Sprains and burners/stingers rarely warrant surgical intervention. Often a restriction from return to sport is sufficient to prevent future symptoms.
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The sporting injury can be the antecedent event that leads to radiographic workup, which then reveals a compressive lesion on the spinal cord. This can be from a large cervical disc herniation or from congenital cervical stenosis. In this case, surgical intervention can be performed with the goal of preservation of neurological function.
Evidence
Multiple-Choice Questions
- QUESTION 1.
The Pavlov-Torg ratio is
- A.
the proportion of athletes who will sustain a cervical spine injury per season.
- B.
the anterior-posterior diameter of the spinal canal divided by the anterior-posterior length of the vertebral body.
- C.
abnormal when it is less than 0.8.
- D.
Both b and c
- A.
- QUESTION 2.
All of the following apply to the diagnosis of a cervical stinger/burner EXCEPT for:
- A.
unilateral upper extremity symptoms.
- B.
caused by a traction injury to the brachial plexus.
- C.
symptoms follow a specific dermatomal pattern.
- D.
symptoms are usually transient.
- A.
- QUESTION 3.
All of the following are contraindications to return to participation in contact sports EXCEPT for:
- A.
single episode of stinger/burner without residual muscle weakness.
- B.
single episode of stinger/burner with residual muscle weakness.
- C.
cervical injury in a neurologically intact patient with focal posterior midline tenderness to palpation and palpable stepoff.
- D.
single episode of cervical cord neuropraxia with a Pavlov-Torg ratio of less than 0.8.
- A.
- QUESTION 4.
A cervical sprain is a diagnosis of exclusion because
- A.
the workup, to include radiographs/CT scan/MRI, makes it impossible for the athlete to return to play in the same game.
- B.
cervical sprains happen infrequently.
- C.
the consequences of missing a cervical fracture or dislocation can include incomplete spinal cord injury or even paralysis.
- D.
cervical sprains are a common injury in contact sports.
- A.
Answer Key
- QUESTION 1.
Correct answer: D (see Pathophysiology )
- QUESTION 2.
Correct answer: C (see Clinical Presentation )
- QUESTION 3.
Correct answer: A (see Treatment )
- QUESTION 4.
Correct answer: C (see Clinical Presentation )
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