Cervical Spine in Baseball

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1 Cervical Spine in Baseball Robert G Watkins, IV, MD Co-Director, Marina Spine Center Marina del Rey, CA Vice Chief of Staff Cedars-Marina del Rey Hospital

2 Disclosures n Pioneer / RTI Consulting, Royalties n BACK DOCTOR APP - Owner

3 Athletes Presenting with Cervical Complaints

4 Presentation n Pain n Neurologic Deficit n Burner / Stinger n Transient Neuropraxia

5 Burner/Stinger Transient Neuropraxia n Nerve Root Injury n Pain/Numbness/Weakness n Unilateral n Dermatome / Myotome n Radicular Compression in Foramen n Prognosis Typically Good n Spinal Cord Injury n Pain/Numbness/ Weakness n Bilateral n Multi Levels n Trauma to Cord n Prognosis depends on Severity of Episode and Underlying Pathology

6 Burners/Stingers n Most Common Mechanism is Rotation and Extension to Ipsilateral Side (Spurling s) ncompression of DRG in Foramen n In Adolescents n Stretch Injury with Towards Opposite Side may occur

7 COMPRESSION

8 Burner / Stinger n First Time nany Significant Motor Weakness (C5 & C6) nremove from Game nneeds Workup: Neuro Exam, Xrays, MRI, and/or EMG

9 Burner / Stinger Treatment Chest-out Posture Exercises: 1. Decreases Weight of Head 2. Opens Foramen and Canal 3. Opens Thoracic Outlet ROBERTWATKINSMD@ YAHOO.COM

10 Burner / Stinger Treatment n Cervical Foraminotomy

11 Transient Neuropraxia n Temporary Concussion of the Spinal Cord

12 NFL Tight End Transient Quad > > 1 wk later

13 n Head Contact Buckles the Spinal Column and Pinches the Spinal Cord n Produces Loss of Strength or Alteration of Sensation in Both Arms, Arm and Leg, or Arms and Legs

14 Transient Neuropraxia n Risk of Future Permanent Injury Depends on: nseverity of Episode nnumber of Occurrences nunderlying Pathology

15 Return to Play: n Full ROM n Painfree n Non-Tender n No Neuro Deficit n Completed Rehab Program n Spine Studies Reviewed

16 College Football: No Pain, FROM, Only Slight Pain with Putting on Helmet

17 Same Player: Acute Fracture of C5 Lateral Mass 1 yr Post-Injury: Osteophyte signifies injury to Disc

18 Non-Traumatic Athletes with Pain or Neurologic Defecit

19 Patients in Clinic n Neck Pain vs Arm Pain n Neurologic Exam nradiculopathy nmyelopathy

20 Physical Exam n Neck ROM n Spurling s / Shoulder Abduction n Motor / Sensory n Peripheral Nerve / Vascular

21 Neck n Spurling s Test Positive = Arm Pain = Radicular Pain

22 Neck vs Shoulder n Shoulder Abduction Test n n Relief = Neck (Radiculitis) Pain = Shoulder (Arthropathy)

23 Diagnostic Studies n Plain X-rays Flex/Ext n MRI n Bone SPECT scan > CT scan n Stress Fracture n EMG/NCV n After 3 weeks n Nerve Root vs Brachial Plexopathy vs Peripheral Nerve Compression

24 Cervical Pathology n Herniated Disc n Foraminal Stenosis n Spinal Cord Compression

25 Cervical Treatment

26 Herniated Disc and/or Foraminal Stenosis 1. Anti-inflammatory Meds Medrol, Indocin 2. Chest-out Posture Exercises 3. Epidural n 4. Surgery Treats Pain, not Weakness

27 Surgical Indications n Unresolving Pain n Functional Neurologic Weakness not Improving n Timing of Season Effectiveness n Timing of Career n Risks of Future Issues

28 Surgery n Fusion n Artificial Disc Replacement (ADR) n Posterior Foraminotomy / Discectomy

29 Fusion vs ADR

30 ADR Flexion Extension

31 Fusion vs Disc Replacement n Both Decompress Nerve and Distract Foramen n Fusion Stops Motion - Most Reliably will Treat Nerve Irritation n Disc Replacement Good for Acute Soft Tissue Herniation n Results Equivalent

32 Fusion vs Disc Replacement n Trade-Off npost-fusion: 25% Adjacent Level Disease Maroon, J Neurosurg, 2007 npost-disc Replacement: 25% Recurrent Degeneration at the Surgical Level: Kyphosis, Facet Joint Pathology, Wear

33 NBA Guard: 1yr postop 5yr postop Return Sport 2 nd Injury

34 Anterior Cervical Fusion n Return to Play Depends on Completion of Rehab Program and Time for Bony Union n Example of Delayed Union

35 NFL Safety: 2 mo later

36 3mo 6mo 10mo Pain-free Return Sport

37 Third Surgical Option for Cervical Radicular Arm Pain: 1.Pathology Posterior 2.Positive Shoulder Abduction 3.Positive Spurling s 4.Remove Less than 50% Facet Foraminotomy Foraminal Stenosis

38 37yo 3 rd Baseman, mild neck pain, Right C6 burning pain with extension

39 Kyphotic, C5-6 Right Foraminal Stenosis, Neuro Intact, Positive Spurling s to Right. Failed PT, Epidural, Meds C5-6

40 n Fusion Treatment: Fusion vs Foraminotomy n Most reliably treats radiculitis n However, may increase long-term neck pain, especially with kyphosis n Foraminotomy n Treats radiculitis, especially if Spurling s or Shoulder Abduction positive

41 Underwent Microscopic Foraminotomy Right C5-6. Radicular symptoms resolved. Not able to make team next season, retired.

42 MLB: 7mo MRI post Foraminotomy with C6 Radiculopathy > 3mo XR post ACDF

43 Summary of Radiculopathy Treatment n Fusion - Most Reliable Treatment for Nerve Pathology, Long-term Neck Pain and Adjacent Disease n Foraminotomy Faster Recovery, More Likely to have Residual or Recurrent Sx n If Acute Soft Tissue Herniation n ADR and Posterior Discectomy Good Options

44 Postoperative Recovery n Foraminotomy n PT at 4 wks, Return Sport 2-4 mo n Artificial Disc Replacement n PT at 6 wks, Return Sport 3-6 mo n Fusion n PT at 6-8 wks, Return Sport 6-12 mo

45 Rehab: Trunk Stabilization and Chest Out Posture Exercises BACK DOCTOR APP

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SPINAL CORD CONCUSSION. Stephan du Plessis MD

SPINAL CORD CONCUSSION. Stephan du Plessis MD SPINAL CORD CONCUSSION Stephan du Plessis MD CASE PRESENTATION 23 yo Varsity Defensive Back Tackled with neck in extension Unable to walk from field No movement in arms or legs No sensation below neck