Spine Trauma in SportsBen Hackett1/29/16

Disclosures• None

Cervical Spine Injuries• Categories

• Nerve Root or Brachial plexus injuries• Acute cervical sprains/strains• Disk injuries• Cervical fractures and dislocations

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.

Nerve Root Injuries• Exam:

• Positive Spurling’s• Weakness:

• Deltoid- C5• Biceps- C6• Triceps- C7• Intrinsic- C8

• Numbness in dermatomal pattern

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

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

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

Intervertebral Disk Injury• Spectrum of injuries

• aggravation of degenerative disease • annular tears • herniation

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)

Intervertebral Disk Injury

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

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

Intervertebral Disk Injury• Indications for surgery

• Cord injury• Progressive neurologic loss• Pain not controlled by non-operative measures (6 weeks,

failed 2 epidurals)

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

Intervertebral Disk Injury

Intervertebral Disk Injury

Intervertebral Disk Injury

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

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

Intervertebral Disk Injury

Intervertebral Disk Injury

Intervertebral Disk Injury

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

Intervertebral Disk Injury

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.

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

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”

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)

Cervical Fracture/Dislocation

• Alanto-occipital dislocation• Not reported in non-vehicular

sports

Cervical Fracture/Dislocation

• C1 or Atlas Fractures • Lateral mass• Anterior and Poterior arch• Jefferson fracture or “C1 Burst”

• Treatment- Halo for 3 months

Cervical Fracture/Dislocation

Cervical Fracture/Dislocation

Cervical Fracture/Dislocation• Reading Open Mouth Odoitoid View

Pre-reduction

Post halo

Cervical Fracture/Dislocation

• C2 fractures• Odontoid fractures• Traumatic Spondylolisthesis

“Hangman’s fracture”• Treatment based on classification

• Hard collar-surgery

Hangman’s fractureClassification• 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

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)

Odontoid FractureType II: neck fracture

• Halo v.s. Surgery• High non-union rate

Odontoid FractureType III: fracture extends

into body of C2• Halo v.s. collar

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

Sub Axial Fracture/Dislocation

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

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 Thoraco-lumbar spine

• Cord injury can occur do to retropulsed bone

• Root injuries due to foraminal stenosis

• Treatment depends on stability

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

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

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

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

Facet Injuries

Facet Injuries• Admitted to hospital• Had an awake

closed reduction• Then fusion

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.

Uni lateral Facet dislocation(perched facet)

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

Cord contusion and ligament injury

C5-6 C6-7

Post-Op

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

Spine Injuries• Serious injury to the spine during sports is uncommon• With improvement in equipment, coaching, and pre-

hospital care the incidence has decreased.

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