Fractures of the Cervical Spine and Spinal Cord Injuries

Gregory D. Schroeder, MD

Tristan Fried, BS

Christie Stawicki, BA

Peter Deluca, MD

Alexander R. Vaccaro, MD, PhD, MBA

Dr. Schroeder or an immediate family member has received research or institutional support from Medtronic Sofamor Danek; has received nonincome support (such as equipment or services), commercially derived honoraria, or other non-research–related funding (such as paid travel) from AO Spine and Medtronic; and serves as a board member, owner, officer, or committee member of Wolters Kluwer Health. Dr. Vaccaro or an immediate family member has received royalties from Aesculap/B.Braun, Globus Medical, Medtronic, and Stryker; serves as a paid consultant to DePuy, A Johnson & Johnson Company, Ellipse, Expert Testimony, Gerson Lehrman Group, Globus Medical, Guidepoint Global, Innovative Surgical Design, Medacorp, Medtronic, Orthobullets, Stout Medical, and Stryker; has stock or stock options held in Advanced Spinal Intellectual Properties, Avaz Surgical, Bonovo Orthopaedics, Computational Biodynamics, Cytonics, Dimension Orthotics, LLC, Electrocore, Flagship Surgical, FlowPharma, Gamma Spine, Globus Medical, In Vivo, Innovative Surgical Design, Location Based Intelligence, Paradigm Spine, Prime Surgeons, Progressive Spinal Technologies, Replication Medica, Rothman Institute and Related Properties, Spine Medica, Spinology, Stout Medical, and Vertiflex; has received nonincome support (such as equipment or services), commercially derived honoraria, or other non-research–related funding (such as paid travel) from Elsevier, Jaypee, Taylor Francis/Hodder and Stoughton, and Thieme; and serves as a board member, owner, officer, or committee member of AO Spine, the Association of Collaborative Spine Research, Clinical Spine Surgery, Flagship Surgical, Innovative Surgical Design, Prime Surgeons, and the Spine Journal. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. DeLuca, Mr. Fried, and Dr. Stawicki.

Introduction

More than 5 million patients seek medical care yearly in the United States after a sports-related injury,¹ and although the most common diagnoses are contusion, sprain or strain,² 2.4% of patients admitted to the hospital after a sports-related accident have a spinal cord injury (SCI).² Furthermore, sporting accidents are the fourth leading cause (9.2%) of SCIs,³ behind motor vehicle accidents, falls, and violence, in the United States. Although these injuries are often linked to collision sports, they have been reported in almost all sporting activity, including American football,⁴^,⁵^,⁶^,⁷^,⁸^,⁹^,¹⁰^,¹¹^,¹²^,¹³^,¹⁴^,¹⁵ ice hockey,¹⁶^,¹⁷ diving,¹⁸^,¹⁹^,²⁰ skiing and snowboarding,²¹^,²²^,²³ wrestling,²⁴ rugby,²⁵^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰ gymnastics,³¹ bicycling,³² basketball,³³ baseball,³³ and equestrian.³⁴^,³⁵ SCIs secondary to sporting activities are particularly devastating because they often occur in patients in the second or third decade of life.¹⁶^,³³

Temporary neurologic injuries without damage to the spinal column, such as transient cervical neurapraxia (stingers or burners),³⁶^,³⁷ and transient cervical cord neurapraxia (transient quadriplegia)⁵ have been covered in previous chapters, so this chapter focuses solely on cervical spine injuries that result in structural damages to the bony, ligamentous, or neural components of the spinal column.

Epidemiology

Because of the difference in popularity of sports across the globe, the primary sporting activity resulting in cervical spine injuries varies by country. In the United States, American football, wrestling, and gymnastics³³ are common causes of cervical spine injuries; comparatively, a high occurrence of cervical spine injuries occurs from ice hockey in Canada¹⁶ and rugby in Europe.²⁵^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰

An increased awareness of sports-related SCIs has led to rule changes designed to increase the safety for participants. With the advent of new helmets in the 1960s, American football players began using the crowns of their heads when tackling (spear tackling), and this new technique led to an increase in the number of cervical spine injuries and fatalities.³⁸ However, in 1976, the rules of American football changed to prohibit spear tackling, and the rate of serious cervical spine injuries dropped dramatically.³⁸ Despite this, cervical spine injuries are still the most common injury to the axial skeleton in the National Football League (NFL), but fortunately, severe injuries such as cervical fractures and SCIs now account for fewer than 1% of these injuries.⁹ Similarly, after the Canadian Amateur Hockey Association (presently Hockey Canada) began penalizing players for pushing or checking other players from behind,³⁹ the rate of SCIs in ice hockey decreased.¹⁶

Although injuries from American football and ice hockey often occur in organized practices and games, cervical spine injuries from recreational sporting activities can also occur.¹⁸^,¹⁹^,²⁰ Across the world, diving is a common cause of SCIs. However, these injuries are rarely seen in high-level competitive divers; rather, they usually occur in recreational divers.¹⁸^,²⁰

Common Mechanism of Injuries

Multiple common mechanisms can lead to cervical spine fractures in athletes. A strong contraction of the trapezius and rhomboid muscles can lead to an innocuous avulsion fracture of the spinous process. Comparatively, a high-energy collision may result in the transmission of an axial load across a flexed neck, causing a complete SCI.⁵^,⁷^,²⁷ The three most common mechanisms leading to significant cervical spine injuries are hyperflexion, axial compression, and hyperextension,¹²^,³⁹^,⁴⁰^,⁴¹^,⁴²^,⁴³^,⁴⁴^,⁴⁵^,⁴⁶^,⁴⁷^,⁴⁸^,⁴⁹ and although these injuries commonly occur in the subaxial cervical spine, upper cervical spine injuries are possible.⁵^,⁷^,¹⁶^,¹⁷^,²⁰^,²⁷^,³⁰

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