Neck and Cervical Spine Injuries
Richard Goldberg, DO
Athletes at any level of competition are at risk for injuries to the neck and spine. These injuries—whether soft tissue injuries, herniated discs, or fractures—can occur as acute events or as exacerbations of a chronic, degenerative process. Such injuries might cause mild, transient limitations in function or might be catastrophic and life changing. These injuries typically occur in contact sports such as football, wrestling, and ice hockey.
Prevention of spinal injuries includes educating athletes to protect themselves from trauma. This may include instruction in proper hitting and tackling of an opponent in football, or how to properly perform a header in soccer. Athletes should always maintain eye contact on the opposing player and avoid putting their head down and dropping the shoulders during contact. Proper contact prevents the head and neck from being driven into hyperflexion or hyperextension, which causes most cervical spine injuries. Flexion of the head during impact places the cervical spine in a straight line and prevents the neck musculature from assisting in force absorption (Bailes et al. 2007). Hyperextension of the cervical spine can compromise the spinal cord and associated nerves. Protective equipment, such as shoulder pads and neck rolls, can help absorb the shock at impact and prevent hyperextension and excessive lateral flexion (Schneider 1973). Pads should fit well and feel comfortable, but be stiff at the base to protect the neck. Exercises to improve neck and upper body strength are as important as assistive devices in reducing head and neck trauma. On-field preparation must ensure the availability of necessary first-aid equipment, such as a backboard, rigid cervical collar, and resuscitation equipment, in case of injury (Kleiner et al. 2001). For helmet sports such as American football, a Phillips screwdriver or cordless screwdriver should always be on hand for face-mask removal so that access to the airway without movement of the neck may occur (Decoster, Shirley, and Swartz 2005). Performing mock trials of protocols for spine injury on the field will ensure that appropriate steps are taken to reduce spinal cord injury. Also, the athletic trainer or doctor on the field should be designated as the primary responder at the time of a traumatic event.
In this chapter we review several neck and spinal injuries, including a sample case for each injury and the immediate and long-term management for each condition. Regardless of the type of injury, the injured athlete should be examined by medical personnel before resuming activity.
NECK AND CERVICAL SPINE INJURIES
Cervical Disc Injury
Common athletic mechanisms that produce whiplash injury (also known as hyperflexion–hyperextension injury) include falling on the neck after making a tackle in football or rugby, or falling backward after a reception. The most common cause outside athletics is a rear-end motor vehicle collision. Any impact that causes an acceleration or deceleration moment about the neck may cause whiplash injuries (Tsoumpos, P., K. Kafchitas, et al, 2013).
Whiplash, or cervical strain, injuries are generally stable injuries of the soft tissues of the neck caused by acute trauma when the neck is violently compressed, or forcibly flexed, extended, or rotated. Athletes might have diffuse neck pain anywhere from the base of the skull to the shoulder region (deltoid and trapezius muscles). They will generally complain of neck pain throughout the various ranges of motion of the neck and often have accompanying cervical muscle spasm; but they often have complete passive range of motion of the head, while active range of motion may be restricted by spasm, pain, or both. Athletes should not have tingling, numbness, or weakness of the arms, and the pain should not radiate into one or both arms.
Treatments should be customized for cervical strains based upon the severity of the injury and according to the athlete’s symptoms. Most cervical strains are self-limited conditions that resolve spontaneously over several days. Early pain and discomfort can be managed with over-the-counter medications such as ibuprofen or acetaminophen if there is no contraindication to their use. Professional management of pain with prescription-strength analgesics and anti-inflammatory medications may be prescribed, when appropriate. They may be continued until full, pain-free range of motion is reestablished unless otherwise discontinued by a physician. Muscle relaxant medications might also be prescribed by a physician, although these come with the usual side effects of lethargy and drowsiness. Massage therapy or physical therapy such as soft tissue massage, hot packs, electrical stimulation, and ultrasound aimed at reducing muscle spasms in the area to reestablish pain-free range of motion, as well as exercises to improve range of motion and strengthen cervical paraspinal and upper body muscles, can be helpful. X-rays, a computed tomography (CT) scan, or magnetic resonance imaging (MRI) should be considered if the athlete has point tenderness over the bony prominences of the neck, persistent pain, marked limitation of cervical range of motion, or neurological symptoms such as pain, numbness, or tingling that travels into the arm.
Return to Action
The athlete should be able to resume full athletic participation once comfortable and free of pain. Some athletes might choose to wear a neck roll, a cowboy collar, or another soft cervical collar to prevent neck extension and lateral bending so they can return more quickly to activity and avoid future injury. These devices are most commonly used in American football. Teaching proper tackling techniques also reduces the incidence of cervical strain and should be used as a preventive measure.
Also known as transient neuropraxia or “stingers,” this injury is almost always related to American football or rugby. The injury occurs during tackling or blocking when the neck is either pinched toward the side of injury or stretched to the opposite side.
A burner is a cervical nerve root contusion or injury outside the spinal canal. The nerve root is the start of the nerve, where it exits the spinal cord. Burners occur during neck extension combined with same-side lateral neck flexion. The athlete’s symptoms include a burning sensation that begins in the neck and radiates down the arm on the affected side along the path of the nerve root affected. These injuries are not typically bilateral. Athletes might also have associated numbness or tingling of the upper extremity on the affected side and possibly weakness of the upper extremity, especially those muscles affected by the upper trunk of the brachial plexus, namely, the shoulder girdle, biceps, and deltoid (Schneider 1973). (The brachial plexus is an area in the neck where the cervical nerve roots, prior to becoming actual nerves, congregate and are mixed with other nerve roots to become peripheral nerves.) The symptoms of burners are transient, usually lasting mere seconds up to 15 to 30 minutes. However, at times and on extreme occasions, they may last several days to weeks (Kuhlman and McKeag 1999). There is usually no neck pain or reduced cervical range of motion.
First, more serious pathology of the neck and arm must be ruled out via a thorough history and physical examination. The symptoms of burners subside spontaneously and do not require further treatment. Recurrent burners or prolonged symptoms lasting from hours to weeks require detailed evaluation by a physician. Recurrent burners or stingers may signify a spinal problem, entrapped nerve, or injury to the nerve such as an avulsion or tear of the nerve. Electromyography (EMG), a test done to assess nerve and muscle function, is indicated when persistent neurological symptoms occur. However, these tests do not typically yield information until three weeks or more after the time of injury.
Return to Action
Athletes may return to play under three conditions: when all symptoms have subsided, when they have painless and complete cervical range of motion, and when they have full upper-extremity and shoulder girdle strength. Prevention of burners and stingers includes year-round regimens of cervical muscle and shoulder muscle strengthening and conditioning. Proper tackling techniques in contact sports and properly fitting equipment, specifically shoulder pads in American football, are also imperative. Protective devices such as neck rolls, cowboy collars, and high-riding shoulder pads have also been developed to help prevent these injuries.
General guidelines exist that help determine level of risk in returning to play after burners. One guideline that most practitioners agree on is that players with any persistent neurological deficits should not return to play that day. Another is that any athlete with tenderness over bony prominences or painful limited neck range of motion should get X-rays, a CT scan, or both before returning to play. If the only symptoms are transient numbness and tingling and these symptoms quickly resolve, the athlete may return to play under three conditions: The neurological exam is normal, the range of cervical spine motion is normal, and the Spurling maneuver is negative. To perform the Spurling maneuver, an examiner first has the athlete extend the cervical spine (neck) and turn the head toward the injured or affected side; the examiner then gently compresses the spine by placing the hand on top of the athlete’s head and gently pushing down. In a positive test, the athlete notes pain radiating into the arm toward which the head is rotated. In a negative test, no such pain is noted by the athlete (local neck pain alone is considered a negative test) (Kuhlman and McKeag 1999, Vaccaro et al. 2002).
Cervical osteoarthritis is a chronic process most common in men and women over 60, unless history of a trauma exists. Cervical osteoarthritis is not caused at the time of an injury, but a prior injury might predispose athletes to future osteoarthritis. It could therefore be described as an exacerbation of a previously diagnosed or undiagnosed condition. More recent literature has identified a possible genetic link for the development of osteoarthritis (Fernandez-Moreno 2008).
Cervical osteoarthritis involves degeneration of the cervical vertebrae and intervertebral discs. The joints between vertebral bodies are known as facet joints, and the discs sit in between the vertebrae and act as “shock absorbers.” This degeneration might have several effects on the cervical spine, including formation of bone spurs, disruption or fusion of the facet joints, enlargement of the facet joints, calcification, folding in of the spinal ligaments, narrowing of the foramina (the openings in the bone through which the nerves pass), nerve root compression, and cervical stenosis (narrowing of the spine’s bony canals).
Characteristic symptoms of cervical osteoarthritis include vague or generalized neck pain—often most noted in the early morning, popping or grinding sensations in the neck, and reduced cervical range of motion. Spasms of the muscles supporting the spine might occur following a change in posture. As the process advances, other damage along the spine could occur, including cervical strain (injury to the soft tissue in the neck), cervical radiculopathy (“pinched nerve”), cervical disc herniation (rupture), and cervical stenosis. The symptoms might then progress to numbness, tingling, burning, or decreased sensation in the arms. Athletes might become weaker in the upper extremities, and if such is the case, evaluation by a physician is prudent. At that time, performing EMG may be recommended for evaluation of the nerves and muscles.
Treatment of cervical osteoarthritis is both preventive and reactive (symptom guided). Osteoarthritis does not have a cure. It occurs in all age groups, even in teenagers. Preventive measures include proper posture and proper athletic techniques (especially tackling). Cervical muscle strengthening programs might also provide a benefit. Once an athlete has cervical osteoarthritis, treatment focuses on pain management, muscle strengthening, and prevention of further deterioration. Initially, analgesic and anti-inflammatory medications may be prescribed. Cervical X-rays should be taken to evaluate foraminal narrowing, cervical stenosis, bone spurs, and intervertebral disc space. Physical therapy may be prescribed to decrease pain, improve cervical muscle strength and range of motion, and teach improved cervical posture. Medical massage therapy may help decrease spasm and reduce local inflammation. Cervical traction might provide benefits depending on the type of cervical pathology. Oral corticosteroids or corticosteroid injections (e.g., cortisone shots) into the epidural space (the area outside the tough membrane that covers the spinal cord, and above the space that contains cerebrospinal fluid) or the areas of the facet joints (the joints that provide spinal stability and allow the body to bend and twist) might also reduce inflammation and alleviate, or even eliminate, pain. Finally, surgical consultation might be warranted depending on the cervical damage present and its associated symptoms.
Return to Action
Future participation in sports and recreational activities can occur for athletes with cervical osteoarthritis, as long as there is no evidence of existing or pending nerve injury or neck instability. Athletes may, however, need to modify activities depending on the severity of symptoms and type of injury. Cervical muscle strengthening programs and improved cervical posture could certainly be beneficial.
CERVICAL DISC INJURY
Cervical disc injuries occur when the cervical intervertebral disc ruptures or herniates and the bulging tissue entraps or irritates cervical nerve roots, either by direct mechanical irritation or via chemical irritation (the ruptured disc exudes various chemicals, which can irritate local nerves and muscles). Cervical disc injury can result from pure rupture of the intervertebral disc, deterioration of the intervertebral disc space (secondary to “normal” aging), foraminal narrowing of the cervical spine, bony deterioration and osteophyte (bone spur) formation in the cervical spine, or any combination of these. Acute cervical disc rupture is rare in athletes; in most cases the rupture occurs gradually due to chronic injury, normal aging, or both.
Athletes with a cervical disc injury often have neck pain and progressively worsening numbness, tingling, and weakness in the arms associated with nerve irritation. They will sometimes complain of radiating pain into the shoulder blade region or into the upper extremity in a specific area. This may allow the doctor to localize the level of nerve impingement. Often the affected athlete can demonstrate specific movements that reproduce symptoms. As the condition gets worse, symptoms might become constant.
Treatment depends on the severity of symptoms. Cervical spine X-rays should be performed to rule out injury to the bone secondary to tumor or fracture. Anti-inflammatory medications or oral steroids (or both) may be prescribed to reduce inflammation around the irritated nerve. Physical therapy aimed at strengthening cervical musculature, improving upper body strength, and improving cervical posture can alleviate symptoms. Cervical traction, which in many U.S. states must be prescribed by a physician, might help reduce the pressure of the ruptured disc on the nerve root. If symptoms progress to cause constant, uncontrollable pain, or muscle weakness and atrophy, surgery might be recommended. As an alternative or precursor to surgery, epidural steroid injections (an injection directed centrally to the epidural space, above the level of space where there is cerebrospinal fluid) or a nerve block injection (an injection along the nerves directly alongside the cervical vertebrae) might be recommended by physicians to reduce the surrounding swelling. The size of the herniated disc will most likely spontaneously reduce over time due to normal healing by the body. Some therapies such as McKenzie techniques theoretically squeeze the disc away from the affected nerve. Surgery is indicated only for those with intractable pain in the extremity or progressive weakness in the limb. Surgery is not usually indicated for those individuals who have only neck pain from cervical disc herniations.
Return to Action
Management and return-to-play criteria for a cervical disc injury should be conservative and be managed by a physician. Most athletes will be able to return to full activity after treatment. Athletes who require surgery should follow the return-to-activity guidelines outlined by their surgeons. If suspicions of spinal instability arise, contact sports may be prohibited.
Cervical stenosis, or transient quadriplegia, is a condition in which the spinal canal is abnormally narrow. This condition might be congenital (present from birth) or the result of degenerative conditions such as osteoarthritis, excessive cervical ligament laxity, or cervical disc ruptures.
Most athletes will be unaware of congenital cervical stenosis. Athletes with acquired degenerative cervical stenosis might know of their condition if they have seen a physician and had images taken (e.g., X-ray or MRI). In the acute setting, a forced hyperextension, hyperflexion, or axial load on the cervical spine and spinal column initiates symptoms. Signs of cervical stenosis range from no symptoms to transient quadriplegia (temporary loss of sensation and muscle function in arms and legs) after an acute injury. The athlete might have numbness, tingling, burning pain, or loss of sensation of any or all extremities. Sometimes athletes complain of an acute electric shock-like sensation along the trunk, arms, and legs that recovers quickly. Neck pain need not be present. If the injury occurs in the middle to lower part of the neck (spinal cord) only, the upper extremities could be involved, and the athlete might experience “burning hand syndrome” because the nerves in the middle to lower part of the neck are the ones that travel to and supply sensation and strength to the hands (Wilberger, Abia, and Maroon 1988). Although transient quadriplegia and burning hand syndrome are caused by trauma, they are more likely seen in athletes with cervical stenosis. Episodes typically last from several minutes to hours and do not require treatment. Athletes should regain complete neurological function if the inciting event abates.
Treatment of cervical stenosis is very limited. Individuals with congenital stenosis are generally unaware of the condition. Knowledge of the condition influences the athlete’s future involvement in sports, particularly collision sports. Acquired cervical stenosis can be treated, depending on its cause. Initial cervical spine imaging (X-rays, CT scans, or MRI) will be ordered by a treating physician. Analgesic and anti-inflammatory medications are used for pain and symptomatic treatment. Physical therapy to strengthen cervical muscles might improve the athlete’s function. Cervical traction is sometimes an option to alleviate symptoms. Corticosteroid injections (e.g., cortisone shots) might be prescribed by a physician, depending on the cause of the stenosis. In some cases, surgery is necessary.
Athletes with a history of transient quadriplegia (weakening that comes and goes) should be checked for underlying spinal abnormalities including fractures at all cervical levels. Anyone with symptoms of quadriparesis (a weakening of all four limbs), no matter how transient, should have an MRI of the cervical spine. Cervical stenosis causing inflammation of the spinal cord is typically treated with steroids and a surgical release and fusion.
Return to Action
In general, athletes should not return to collision or contact sports unless the cause of the stenosis can be corrected (i.e., it is the acquired form). Once an athlete has no symptoms and no significant spinal stenosis, return to play is permitted. Congenital stenosis usually ends a collision-sport athlete’s career. In some cases, year-round neck exercises can help prevent future symptoms. Noncontact sports and activities are encouraged.
Most athletes with stenosis and a history of transient quadriplegia do not progress to permanent neurological injury. Athletes with permanent quadriplegia generally have no history of transient neuropraxia or significant spinal stenosis (Levitz, Reilly, and Torg 1997). Athletes with spinal stenosis may return to play as long as they have no symptoms. However, studies have shown that cervical stenosis is a factor in the occurrence and severity of neurological injury after spine trauma.
Some medical practitioners believe stricter criteria should be followed, recommending absolutes regarding circumstances in which an athlete should not return to play:
- If initial symptoms in the limbs last longer than 36 hours
- If the cervical cord is affected or involved or if ligaments are unstable
- If the athlete has congenital abnormalities (structural defects) in this region of the body or has any vertebral fusion
- If the athlete has a loss of range of motion in the neck or neurological deficits or disorders (dizziness, lapses in consciousness) that last over time
Cervical vertebral fractures occur when the bones of the cervical spine are crushed, chipped, or cleanly broken. Such fractures occur as a result of degenerative processes such as osteoporosis or as a result of direct trauma to the neck. These injuries typically occur when the head is flexed, placing the neck in a straight line that prevents the neck muscles from absorbing some of the force of the impact. This impact may cause spinal cord swelling, bony displacement, or bleeding, in which case the loss of blood supply can cause damage to the spinal cord.
Athletes with neck fractures might have various complaints and symptoms depending on the type and severity of the fracture. Possible symptoms include neck pain; painful neck range of motion; inability to move the neck; upper-extremity numbness, tingling, or weakness; or inability to move the extremities. Because of the complexity and potential severity of neck fractures, all athletes with neck pain, especially those with any history of trauma, should be evaluated by appropriate medical personnel. This evaluation should take place immediately after injury and while the athlete is on the field of play.
Treatment of cervical fractures is extremely complicated. The main function of the spinal column is to protect the spinal cord. Any fracture to this protective structure might in turn lead to injury of the spinal cord, which could cause permanent loss of leg function (paraplegia), loss of both arm and leg function (quadriplegia), or even death. Any athlete with a suspected catastrophic neck injury should be properly immobilized on a spine board and have a cervical collar carefully placed. Only trained medical staff should attempt to immobilize the athlete. In the case of football, the cage in the front of the helmet should be removed once the patient is secured on the back board so that proper airway access can be obtained. The helmet and shoulder pads should not be removed, but the helmet should be taped to the pads to avoid neck movement (Kleiner et al. 2001). Once transported, the athlete should receive X-rays or other imaging to rule out a neck fracture.
For stable types of fractures—those without obvious potential for spinal cord injury—treatment begins with pain management. Physicians may use analgesics or anti-inflammatory medications. Steroids are also an option. Once the athlete is stabilized, physical therapy may be prescribed to strengthen cervical muscles and improve posture. Soft collar devices may also be used. For unstable cervical fractures—those with potential for spinal cord injury—neurosurgical consultation is recommended, with imminent surgery likely. However, the best treatment for spinal cord fractures is prevention. Appropriate equipment should be used, and appropriate movement techniques should be taught prior to injury.
Return to Action
All return-to-play decisions should be determined by the treating physician. These decisions generally depend on the type of fracture and its stability. Fractures to the spinous process (the bone you feel when you run your hand down your back), chip fractures, and compression fractures tend to be stable. After symptoms and physical exam abnormalities have been resolved, athletes who have suffered these fractures might be able to return to play. Catastrophic or unstable fractures resulting in any ligament instability or disruption of the anterior or posterior vertebral elements make a return to play unlikely, especially in collision sports (Vaccaro et al. 2002).
The best treatment for cervical spine trauma is avoidance. Automobile companies continue to improve the safety standards of their vehicles; trainers should emphasize strengthening exercises of the cervical spine and upper body; and coaches should teach appropriate movement techniques, along with required use of protective equipment at all times.
*The author would like to acknowledge the contribution of Greg Rowdon and Hank Sherman to this chapter.