Spine Trauma in Sports. Ben Hackett 1/29/16

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1 Spine Trauma in Sports Ben Hackett 1/29/16

2 Disclosures None

3 Cervical Spine Injuries Categories Nerve Root or Brachial plexus injuries Acute cervical sprains/strains Disk injuries Cervical fractures and dislocations

4 Nerve Root Injuries stingers or burners Most common cervical injury in football ~8% incidence in college football Initially complains of total arm weakness, and dysethetic pain which usually resolves from minutes to 24 hours Numbness and muscle group weakness may persist.

5 Nerve Root Injuries Exam: Positive Spurling s Weakness: Deltoid- C5 Biceps- C6 Triceps- C7 Intrinsic- C8 Numbness in dermatomal pattern

6 Nerve Root Injuries Treatment Can return to play when symptoms have resolved and player has full, non-painful ROM If player has pain with or limited ROM cervical x-rays should be done to r/o fracture/dislocation If neurological symptoms continue for 3-4 weeks EMG/NCV can be done to evaluate function

7 Acute Cervical Sprain/Strain Sprain/Strain injury to the paraspinal musculotendonous junction The pain is limited to the cervical spine with ROM Does not radiate into arms Neuro exam is normal

8 Acute Cervical Sprain/Strain Treatment If athlete has full ROM and no radicular symptoms Treat with NSAID, and soft collar for comfort May return to play when pain resolves (2-4 weeks) If they have decreased ROM obtain plain films AP, Lat, Flexion and Extension, +/- open odontiod If symptoms persist >4-6 weeks and x-rays are normal, consider MRI to r/o disk injury

9 Intervertebral Disk Injury Spectrum of injuries aggravation of degenerative disease annular tears herniation

10 Intervertebral Disk Injury Degenerative disease and annular tears Axial pain that persists past 4-6 weeks May take months to calm down Can be asymptomatic or incidental finding Albright et al. found 34% of freshman football recruits had (occult fracture, disk narrowing or degenerative changes)

11 Intervertebral Disk Injury

12 Intervertebral Disk Injury Disk herniations Symptoms can vary Axial Radicular (w/o nerologic findings) Anterior Cord syndrome (rare) Acute paralysis of Upper, Lower or all 4 extremities Sparing of light touch, vibratory, and proprioception Loss of pain and temp at level

13 Intervertebral Disk Injury Treatment based of symptoms soft collar, traction, NSAIDs, Oral steroids, narcotics, muscle relaxer, gentle manipulation, Epidural stroids Most improve with conservative care Athletes may return to full play when they have full non-painful range of motion

14 Intervertebral Disk Injury Indications for surgery Cord injury Progressive neurologic loss Pain not controlled by non-operative measures (6 weeks, failed 2 epidurals)

15 Intervertebral Disk Injury 45 y/o with 2 week h/o neck and right arm pain sustained after jumping her mountain bike. Exam decreased ROM (extension limited) Positive Spurling s for right C7 Numbness to right middle and index finger right triceps 4/5

16 Intervertebral Disk Injury

17 Intervertebral Disk Injury

18 Intervertebral Disk Injury

19 Intervertebral Disk Injury Started on Medrol dose pack, Norco, and valium, and scheduled for Right C7 transformational epidural. Had 2 epidurals 2 weeks apart Was back to work with restrictions couple days after first injection Strength returned slowly with PT Back to work without restrictions (prison guard) 4 months

20 Intervertebral Disk Injury 31 y/o soldier with 2 month h/o left C7 radiculopathy, after getting tackled playing flag football Exam decreased ROM (extension limited) Positive Spurling s for left C7, and periscapular pain Numbness to left middle finger No weakness

21 Intervertebral Disk Injury

22 Intervertebral Disk Injury

23 Intervertebral Disk Injury

24 Intervertebral Disk Injury PT, traction, and oral meds were failing to provide relief He under went a Left C7 and C8 transforaminal injection Good temporary relief, after 2 weeks was 50% better Was going to be deployed in 3 months to Iraq and did not want the pain to occur while overseas Elected to undergo ACDF at C6-7

25 Intervertebral Disk Injury

26 Cervical Fracture/Dislocation Fractures and dislocations again are a spectrum of injuries Subluxation w/o fracture or neurologic injury Fracture-Dislocations with cord injury Acutely there is painful ROM and guarding Immobilize and image.

27 Cervical Fracture/Dislocation Over the last 50 years there has been a significant decrease in morbidity associated with spine fractures due to adherence of spine precautions prior to arriving at the hospital Leave all equipment in place Log roll onto and transfer on back-board

28 Cervical Fracture/Dislocation Treatment is based on concept of stability Stable non-operative (immobilization) Unstable operative treatment/immobilization What constitutes spinal stability is sometimes hard to determine White et al described stability as the spines ability to limit it s patterns of displacement during physiologic loads to prevent damage or irritation to the spinal cord and nerve roots

29 Cervical Fracture/Dislocation Even among spine surgeons there is controversy In general instability is present if Cord injury Greater than 3.5mm of displacement in adult spine with flexion and extension films Greater than 20 deg in angulation with flexion extension films (or 11 deg in static lateral)

32 Cervical Fracture/Dislocation Alanto-occipital dislocation Not reported in non-vehicular sports

33 Cervical Fracture/Dislocation C1 or Atlas Fractures Lateral mass Anterior and Poterior arch Jefferson fracture or C1 Burst Treatment- Halo for 3 months

34 Cervical Fracture/Dislocation

35 Cervical Fracture/Dislocation

36 Cervical Fracture/Dislocation Reading Open Mouth Odoitoid View

37 Pre-reduction Post halo

38 Cervical Fracture/Dislocation C2 fractures Odontoid fractures Traumatic Spondylolisthesis Hangman s fracture Treatment based on classification Hard collar-surgery

39 Hangman s fracture Classification Type I Min displaced <3 mm translation No angulation of C2 Treat - ridged collar Type 2 > 3mm displaced > 11 deg. Angulation Treat Halo Vest Type 2a C2-3 disk injury Unstable in traction Halo Type 3 (post C2-3 fusion) Assoc d C2-3 facet disloc Posterior C2-3 fusion

41 Odontoid Fracture Anderson classification Type I: small avulsion off superolateral aspect Transverse ligament Avulsion Type I may also be a sign of Occipito-cervical dislocation Collar (isolated)

42 Odontoid Fracture Type II: neck fracture Halo v.s. Surgery High non-union rate

$Odontoid Fracture Type III: fracture$

43 Odontoid Fracture Type III: fracture extends into body of C2 Halo v.s. collar

44 Sub Axial Fracture/Dislocation Sub-Axial spine C3-L5 cervical spine have higher risk of neurological injury do to decreased canal Injury pattern determined by: The Load (compression/distraction/direct blow) The position of the spine at time load was applied (flexion/extension/rotation) Again treatment based on stability Boney fractures usually heal stable Ligamentous injuries unstable even after healing

45 Sub Axial Fracture/Dislocation

46 Sub-Axial Spine Injuries Avulsion Fractures Eccentric muscle contraction Spinous Process most common in C-Spine C7 clay shoveler s Transverse process Can also be direct blow in lumbar Treat in collar/corset for comfort

47 Sub-Axial Spine Injuries Compression Fractures Middle column is intact 30% or less anterior column height loss is tolerated well More than 50% loss in cervical spine is often associated with posterior ligament injury Treat in Collar or brace (hyperextension in T or L spine)

$Sub Axial Fracture/Dislocation Burst fractures Both middle and anterior column compressed and fractured More common in$

48 Sub Axial Fracture/Dislocation Burst fractures Both middle and anterior column compressed and fractured More common in Thoraco-lumbar spine Cord injury can occur do to retropulsed bone Root injuries due to foraminal stenosis Treatment depends on stability

$Spectrum from non-displaced fractures to dislocations Have pain with palpation of posterior$

49 Sub Axial Fracture/Dislocation Facet Injuries Usually a combination of Flexion and distraction Spectrum from non-displaced fractures to dislocations Have pain with palpation of posterior ligaments

50 Analysis of lateral C-spine xray 4 smooth longitudinal lines Prevertebral soft tissues 6 at 2, 22 at 6 Must see spine from occiput to T1 Swimmer s lateral CT

51 Facet Injuries Non-displaced fractures and unilateral dislocations may be able to be treated in collar After pain as resolved after 4-6 weeks Flexion and extension views will assess stability

52 Facet Injuries 72 y/o fell against kitchen cabnet during an episode of syncope. Neurologically intact Placed in rigid collar 2 weeks later followed up in office with complaints of neck and arm pain

53 Facet Injuries

54 Facet Injuries Admitted to hospital Had an awake closed reduction Then fusion

55 Facet Injuries 52 y/o had been drinking up north (valid Wisconsin sport) She got up in the middle of the night to use the facilities and slipped on a rug, flipping over backwards landing on her posterior neck She had immediate paralysis and lay there for at least an hours before her friends found her.

56 Uni lateral Facet dislocation (perched facet)

57 Uni lateral Facet dislocation (perched facet) On arrival to Aspirus, she had symptoms of a central cord injury Weakness worse in upper extremity than lower Sensory variable below the level Underwent awake closed reduction, and further imaging

58 Cord contusion and ligament injury

59 C5-6 C6-7

60 Post-Op

61 Uni lateral Facet dislocation (perched facet) 3 months after she is able to walk and gross use her upper extremities But due to weakness and numbness has difficulties with fine motor activities with her hands

62 Spine Injuries Serious injury to the spine during sports is uncommon With improvement in equipment, coaching, and prehospital care the incidence has decreased.

63 References Gill SS, Boden BP. The epidemiology of catastrophic spine injuries in high school and college football. Sports Med Arthrosc. Mar 2008;16(1):2-6. Boden BP, Jarvis CG. Spinal injuries in sports. Neurol Clin. Feb 2008;26(1):63-78; viii. Clarke KS. Epidemiology of athletic neck injury. Clin Sports Med. Jan 1998;17(1): Maroon JC, Bailes JE. Athletes with cervical spine injury. Spine. Oct ;21(19): Olympia RP, Dixon T, Brady J, Avner JR. Emergency planning in schoolbased athletics: a national survey of athletic trainers. Pediatr Emerg Care. Oct 2007;23(10): Thomas BE, McCullen GM, Yuan HA. Cervical spine injuries in football players. J Am Acad Orthop Surg. Sep-Oct 1999;7(5): Fuller CW, Brooks JH, Kemp SP. Spinal injuries in professional rugby union: a prospective cohort study. Clin J Sport Med. Jan 2007;17(1):10-6. Lark SD, McCarthy PW. Cervical range of motion and proprioception in rugby players versus non-rugby players. J Sports Sci. Jun 2007;25(8): Langer PR, Fadale PD, Palumbo MA. Catastrophic neck injuries in the collision sport athlete. Sports Med Arthrosc. Mar 2008;16(1):7-15. Villavicencio AT, Hernández TD, Burneikiene S, Thramann J. Neck pain in multisport athletes. J Neurosurg Spine. Oct 2007;7(4):

64 Bell K. On-field issues of the C-spine-injured helmeted athlete. Curr Sports Med Rep. Jan 2007;6(1):32-5. Meyer SA, Schulte KR, Callaghan JJ. Cervical spinal stenosis and stingers in collegiate football players. Am J Sports Med. Mar-Apr 1994;22(2): Weinstein SM. Assessment and rehabilitation of the athlete with a "stinger". A model for the management of noncatastrophic athletic cervical spine injury. Clin Sports Med. Jan 1998;17(1): Warren WL Jr, Bailes JE. On the field evaluation of athletic neck injury. Clin Sports Med. Jan 1998;17(1): Torg JS, Ramsey-Emrhein JA. Management guidelines for participation in collision activities with congenital, developmental, or post-injury lesions involving the cervical spine. Clin Sports Med. Jul 1997;16(3): Albright JP, Moses JM, Feldick HG, Dolan KD, Burmeister LF. Nonfatal cervical spine injuries in interscholastic football. JAMA. Sep ;236(11): White AA 3rd, Johnson RM, Panjabi MM. Biomechanical analysis of clinical stability in the cervical spine. Clin Orthop. 1975;(109): White AA 3rd, Panjabi MM. Update on the evaluation of instability of the lower cervical spine. Instr Course Lect. 1987;36: Eismont FJ. Point of View regarding Magnetic Resonance Evaluation in Closed Traction Reduction of Cervical Dislocations by Vaccaro. Spine. 1999;24:1217.

65 Vaccaro AR, Falatyn SP, Flanders AE, et al. Magnetic resonance evaluation of the intervertebral disc, spinal ligaments, and spinal cord before and after closed traction reduction of cervical spine dislocations. Spine. Jun ;24(12): Fehlings MG, Farhadi HF. Cervical stenosis, spinal cord neurapraxia, and the professional athlete. J Neurosurg Spine. Apr 2007;6(4):354-5; discussion 355. Torg JS, Pavlov H, Genuario SE. Neurapraxia of the cervical spinal cord with transient quadriplegia. J Bone Joint Surg Am. Dec 1986;68(9): Herzog RJ, Wiens JJ, Dillingham MF. Normal cervical spine morphometry and cervical spinal stenosis in asymptomatic professional football players. Plain film radiography, multiplanar computed tomography, and magnetic resonance imaging. Spine. Jun 1991;16(6 Suppl):S Epstein JA, Carras R, Hyman RA. Cervical myelopathy caused by developmental stenosis of the spinal canal. J Neurosurg. Sep 1979;51(3): Eismont FJ, Clifford S, Goldberg M. Cervical sagittal spinal canal size in spine injury. Spine. Oct 1984;9(7): Cantu RC. The cervical spinal stenosis controversy. Clin Sports Med. Jan 1998;17(1): Watkins RG. Neck injuries in football players. Clin Sports Med. Apr 1986;5(2): Ellis JL, Gottlieb JE. Return-to-play decisions after cervical spine injuries. Curr Sports Med Rep. Jan 2007;6(1): Davis PM, McKelvey MK. Medicolegal aspects of athletic cervical spine injury. Clin Sports Med. Jan 1998;17(1):

Common fracture & dislocation of the cervical spine. Theerachai Apivatthakakul Department of Orthopaedic Chiangmai University

$Common fracture & dislocation of the cervical spine. Theerachai Apivatthakakul Department of Orthopaedic Chiangmai University$ Common fracture & dislocation of the cervical spine Theerachai Apivatthakakul Department of Orthopaedic Chiangmai University Objective Anatomy Mechanism and type of injury PE.and radiographic evaluation