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Cervical Injuries and Sport
Dr Janusz BonkowskiNeurosurgeon and Spinal Surgeon06.08.2014
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• 29 yr old male, otherwise fit and healthy.• Keen rugby player.• Left arm “Stinger” during rugby training late 2007, subsequent MR (report only available)
suggested narrowing of L C6 and L C7 nerve root channels. • Further more acute and protracted L arm pain after training mid-January 2008.• Pain, paraesthesiae into L index finger, slightly into L thumb. • Mild weakness L Triceps with Dec L Triceps Reflex.• Marked Spurling sign into L arm,restricted neck movements.• Repeat MR before referral
Cervical Injuries and Sport
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Central L parasagittal
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C 5/6 C 5/6 C 6/7
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Surgical alternatives for Radiculopathic pain at one level, one side with adjacent segment changes on MR
• Posterior cervical foramenotomy: one or two level• Anterior cervical foramenotomy: one or two level• Anterior cervical discectomy• Anterior cervical fusion: at symptomatic level only• Anterior cervical fusion: at both (radiologically abnormal ) levels.• Cervical arthroplasty at symptomatic level • 2 level cervical arthroplasty
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Scenario #1
• 29 year old.• Insurance agent.• Keen rugby player, local club level.• Would like to keep playing, but has alternative sports interests.
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Scenario #2
• 29 year old.• Heavy manual work.• Plays at senior club level.• Has been in 2nd grade NPC squad and still has potential at rep level.• Desperate to continue playing.
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Scenario #3
• 29 year old.• Professional rugby has been career for 10 years.• NPC 1st division.• Super 14 current player.• All-Black.• Being headhunted by overseas clubs.
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Cervical Cord NeuropraxiaTorg J et al J Neurosurg 1997
• 110 cases of transient neurological phenomena in sports related activities.• 96 in footballers (US)• 12 underwent surgery: 9 had one level ACDF• 5/9 returned to sports activities with no adverse effects (15 mo av f/u)• ------------------------------------------------------------------------------------------• Plain x-ray:7 Kippel-Feil• 29 had “degenerative changes”• 52 had osteophytic ridging• 89 (86%) had canal stenosis
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Return to Contact Sport after Spinal InjurySontag V et al Neurosurg Focus 2006
• Recommendation: ?Return to sport• Posterior foramenotomyo single level yeso multiple level yes• Laminectomy/laminoplastyo less then or up to 2 level yeso more than 2 level no• Anterior discectomy/fusion/arthroo single/ 2 level yeso more than 2 level no• Anterior foramenotomyo single/multi level yes
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Cervical Cord Neuropraxia in Elite AthletesMaroon J C et al Neurosurg Spine 2007
• 5 Footballers age range 20-32, 4 pro, one college• All underwent 1 level ACDF with plates/ allogfaft• All 5 resumed playing• 3 continue playing( 3 years, 2 years, one retired after 3 years)• One developed recurrent symptoms after 7 games: adjacent level bulge,
stopped playing.• One developed recurrent symptoms after 28 games: adjacent level
prolapse; has stopped playing and undergone further ACDF
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Rugby Union Injuries to the Cervical Spine and Spinal CordQuarrie et al Sports Med 2002
Cite Hughes (2000) 85 Pt with cervical spine injuries treated Burwood SpinalUnit 1979-1999.7 had congenital fusions of cervical vertebrae.Usual incidence of congenital fusion 7/1000.
Cite Berge (1999) 35 senior & veteran players c/w age-matched controls studied with MRI
71% had disc space narrowing (controls 17%)
31% had disc prolapses (controls 3%)
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1: Degenerative changes/ disc prolapses are common in
Professional rugby players and do not require treatment unless symptomatic.
2: Fusions or stiffened segments of the spine probably predispose to further damage, either adjacent segment failure or neuropraxias and are a relative contraindication to continued playing
3: Theraputic fusions are associated with a high attrition rate on return to play, may share the same risk profile as other causes of cervical inelasticity and are best avoided if surgery becomes necessary.
4: If a player needs for career or personal reasons to continue to play at a competitive level motion preserving surgery may be preferrable.
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Alex McKinnon
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James Tamou
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James Tamou
• “Pins and needles affecting one arm”• “…diagnosed he had aggrevated a previous injury.”• “Our medical staff believe he re-aggrevated a previous condition in the
incident….”
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STINGERS
• Painful sensation radiates from neck to fingers after extension impact to neck.
• May be associated with prolonged or transient motor and sensory symptoms.
• Mechanism is nerve root compression in intervertebral foramen (85%).• Alternative mechanism is Brachial Plexus stretch (15%).
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STINGERS
• 45% will have recurrent episodes.• Most patients with recurrent stingers have either cervical spinal stenosis
or foramenal encroachment by osteophytes/disc bulges.• Needs to be differentiated from “burning hands syndrome” which is
bilateral and a form of central cord syndrome and an absolute contraindication to return to contact sport.
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Transient Quadraparesis
• Occurs with Hyperxtension injuries.• Is a form of Central Cord Syndrome.• Usually affects upper limbs more than lower limbs.• Can last from 10 min. to 36 hrs.• High association with radiological changes; cervical stenosis, Klippel-Feil,
disc prolapse, kyphotic deformity.
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Absolute Contraindications on RTP
• Previous transient Quadriparesis:• 2 or more previous episodes• Evidence of cervical myelopathy• Continued cervical discomfort• Decreased ROM• Neurological deficit.
Vaccaro, AR et al Curr Reviews MS Med 2008
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Absolute Contraindications on RTP
• Postsurgical patients:• C1-2 fusion• Cervical laminectomy• Anterior cervial fusion more than 2 levels• Posterior cervical fusion more than 2 levels• Cervical arthroplasty more than one level
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Absolute Contraindications on RTP
• Soft tissue injuries:• Asymptomatic ligamentous laxity ( more than 11% kyphotic
deformity)• C1-2 hypermobility (Atlantodens interval more than (3.5mm.)• Radiology suggesting distraction-extension injury.• Symptomatic cervical disc herniation
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Absolute Contraindications on RTP
• Radiological Findings:• Multilevel Klippel-Feil• Spear-tacklers spine ( kyphotic spine with stenosis)• Healed subaxial fracture with sagittal or coronal plane deformity• Ankylosing Spondylitis or Diffuse Idiopathic Skeletal Hyperostosis or
Rheumtoid Arthritis.
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Absolute Contraindications on RTP
• MR/CT Findings:• Basilar invagination• Fixed Atlanto-Axial rotatory subluxation• Occipital-C1 assimilation• Residual cord encroachment after healed subaxial spine fracture• Any cord abnormality or cord signal change.
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Relative Contraindications to RTP• Prolonged symptomatic stinger/burner or transient quadriparesis more
then 24 hr.• More than 3 prior episodes of stinger/burner• Failure to return to baseline ROM, neurological status or increasing neck
discomfort.• Healed 2 level anterior or posterior fusion surgery.
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On-field assessment
Zahir U et al Seminars in Spine Surgery 2010Conclusion: Get him/her of the field!
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Conclusion
All data is based on Grade III evidence or worse, no consensus even amongst
experts on RTP criteria or management.