This is a case presentation of a 30-year-old professional basketball player. He presented to our clinic after an in-game hyperextension injury. He had experienced an episode of transient paralysis which lasted around 5–7 min. After ICU monitoring, he experienced a full return of motor strength. He presented to our clinic, because other providers had told him he would no longer be able to participate in contact sports. Panels (a–c) demonstrate standard upright lateral and flexion/extension cervical radiographs. No dynamic instability is identified. Even on this imaging, one can appreciate the degree of congenital stenosis. Panels (d–f) show T2-weighted sagittal MRI cuts in both neutral, flexion, and extension. The extension radiograph shows that the stenosis decreases below the C5-6 interspace. This is important in selecting the levels needed to be decompressed. Panels (g–j) show axial T2-weighted MRI images at C2-3, C3-4, C4-5, and C5-6, respectively. They demonstrate severe congenital stenosis. Panels (k–m) are sagittal CT c-spine images demonstrating an assimilation of the C1 and C2 arch. After an extensive discussion, we recommended a partial laminectomy of C2 and a C3-5 laminoplasty. We felt that this was the smallest surgery that could provide a complete decompression. It also allowed him the motion needed to return to play. Panel (n) shows the postoperative lateral radiograph. The player was able to return to play after a CT scan demonstrated healing of the laminoplasty fracture site and a MRI demonstrated adequate space available for the cord. In addition, he had to have no neurologic symptoms, full range of motion, and no pain. He was ultimately successful in his return to the NBA and played in multiple subsequent seasons
While ACDF has been a highly effective treatment in athletes, even in the best hands, pseudarthrosis can occur. There is no consensus as to how to approach a nonunion after ACDF in the professional athlete. Some experts feel that the risk after contact is too high, while others believe that pseudarthrosis after a one-level cervical fusion does not impart additional risk to the spinal cord. One important consideration is the presence of a stable “fibrous union ” in which there is documented stability at the index segment without full bony bridging. This finding contrasts with an unstable pseudarthrosis which can manifest as screw loosening or breakage, local kyphosis, or spondylolisthesis. Our opinion is that RTP protocols should differ depending on sport played, physical examination findings, nature of the nonunion, and full informed consent. It is reasonable that a stable “fibrous union ” may be compatible with repetitive contact activities, while an unstable cervical pseudarthrosis is not. More data is required to address this controversy.
Expert Opinion
There are many considerations that deserve attention when making decisions regarding cervical stenosis for an elite athlete’s career. While many of the treatment principles from the general population can be applied to the elite athlete, the unique demands of elite athletes require an individualized approach. Clinical history, physical exam, imaging characteristics, and sport played are the four critical factors to consider when providing recommendation to the elite athlete with CS. While each situation is unique, our experience suggests the following: absolute canal diameter less than 8 mm and/or evidence of functional stenosis should not return to play without a surgical intervention to decrease spinal cord injury risk. However, persistent myelomalacia alone should not preclude an athlete from returning to collision sports, if there is adequate area for the spinal cord and a normal, symptom-free, neurologic exam. When providing surgical counseling to elite athletes, good evidence exists that RTP should be the expectation for a one-level anterior cervical operation; a two-level operation is not an absolute contraindication to RTP. RTP protocols should differ depending on sport played, physical examination findings, and full informed consent. Ultimately, the athlete must make a well-informed decision based on their tolerance of risk and individual presentation.
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