Cervical Disc Injury in a Division I Collegiate Football Player

1. Cervical Disc Injury in a Division I Collegiate Football Player Kelli Frye Pugh, MS, ATC, CMT Susan Saliba, PhD, PT, ATC Ethan Saliba, PhD, PT, ATC, SCS David Diduch, MD Christopher Schaffrey, MD University of Virginia, Charlottesville, VA

2. Cervical Injuries in Sport Annual incidence of catastrophic c-spine inj was 1.10 per 100,000 high school players 4.72 per 100,000 college players 3 times more common in games than practices Mean annual incidence of quadriplegia was 0.52 per 100,000 Most inj resulting in quadriplegia occurred to players on defense, with the highest percentage of inj involving DB�s According to the National Center for Catastrophic Sports Injury Research, FB has the highest number of catas inj for any sport. 13 yr epidemiology study performed by Boden et al, 2006, annual incidence was�.. Quadriplegia - while majority of inj occur at high school level, the incidence at the college level was 1.65 times higher than the high school level high school - 0.50 per 100,000 college - 0.82 per 100,000 DB�s - 44.3%, followed by special team players 18.6%, then linebackers 17.1% According to the National Center for Catastrophic Sports Injury Research, FB has the highest number of catas inj for any sport. 13 yr epidemiology study performed by Boden et al, 2006, annual incidence was�.. Quadriplegia - while majority of inj occur at high school level, the incidence at the college level was 1.65 times higher than the high school level high school - 0.50 per 100,000 college - 0.82 per 100,000 DB�s - 44.3%, followed by special team players 18.6%, then linebackers 17.1%

3. Transient Quadriplegia Common complication of cervical cord neurapraxia (CCN, aka spinal cord concussion) MOI: rapid hyperflexion or hyperextension causing a pinchers mech, also axial loading (�spearing�) - causing a sudden decrease in the A-P diameter of the canal at that cerv level, resulting in cord compression and neurologic symptoms CCN is a transient neurological condition that occurs in the absence of instability or struc deficiency of the cerv spine CCN is a transient neurological condition that occurs in the absence of instability or struc deficiency of the cerv spine

4. CCN classification According to study by Torg et al in 1997, some form of plegia (paralysis - 40%) or paresis (motor weakness - 25%) occurred in 65% of cases of CCN. The remaining 35% experienced only paresthesia (sensory changes) According to study by Torg et al in 1997, some form of plegia (paralysis - 40%) or paresis (motor weakness - 25%) occurred in 65% of cases of CCN. The remaining 35% experienced only paresthesia (sensory changes)

5. Types of athletic spinal injuriesTable from Maroon and Bailes, 1996

6. Case Study UVA vs. Georgia Tech November 12, 2005 20 year old African American male defensive back sustained a possible axial load then a definite rapid hyperextension mechanism while tackling History of one prior brachial plexus neurapraxia (�stinger�) with full resolution of symptoms within minutes and normal cervical spine x-rays

7. Injury

8. On Field Management Prone and conscious Paralysis and numbness in all extremities Immobilized on spine board while wearing helmet and shoulder pads Face mask removed prior to being transported to UVA Emergency Department Solu-Medrol drip started in the ED

9. Clinical Examination Full motor function returned to lower extremities within 10 minutes, to upper extremities within several hours Cervical tenderness Residual hyperesthesia in bilateral shoulders

10. Differential Diagnosis Cervical spine fracture/dislocation Cervical disc injury Spinal cord injury

11. Differential Diagnosis X-rays ruled out acute fracture and alignment abnormalities in the cervical, thoracic, and lumbar spine Head and cervical CT scan revealed degenerative changes at C4 and C5 vertebrae

12. Differential Diagnosis MRI determined: C3-C4 disc herniation resulting in mild spinal cord compression with central cord contusion Small posterior annular tear at C4-C5 disc

13. Plan Hospitalized for 48 hours to continue IV steroidal anti-inflammatory medicine Discharged wearing soft cervical collar F/U cervical spine x-rays in 2 weeks, repeat MRI in 6 weeks Only ADLs allowed

14. 2 Weeks post-injury Flexion and extension views showed no evidence of vertebral instability Minimal neck pain Moderate dysesthetic pain in shoulders D/C use of cervical collar

15. 6 Weeks post-injury Still experiencing resolving dysthesia in shoulders MRI showed no significant change in the C3-C4 disc protrusion, resulting in moderate central canal stenosis and posterior cord displacement Resolution of abnormal signal within the cord at the C3-C4 level No evidence of ligamentous injury Some disc dessication of C4-C5 and C5-C6, with minimal bulging of C4-C5 disc

16. Management Options No surgery, retire from sport Surgery, retire from sport Surgery, with hopes of returning to sport Surgical options: One level anterior or posterior fusion with discectomy Multi-level anterior or posterior fusion with discectomy Disk arthroplasty Torg 1997 - stable one level A or P fusion in a pt who is asymptomatic, neurologically normal, pain free, and has normal cerv ROM presents no contraindic to continued participation in contact activities stable 2 or 3 level fusion who are asymptomatic, neurologically normal, and have pain free full cerv ROM present a relative contraindication, b/c of inc stresses on the articulations of the adjacent uninvolved vertebrae and the likelihood for the development of degen changes at these levels - should not be permitted to resume contact activities 3+ level a or p fusion is an absolute contraindication regarding continued participation in contact sports Maroon, 1996 - cerv disc herniated centrally usually removed anteriorly, can be removed either anteriorly or posteriorly if herniated laterally advantage of anterior approach - has been suggested ant interbody fusion results in preservation of strength in the c-spine during flex and ext advantage of the posterior approach - maintains integrity of ant and post longitudinal ligTorg 1997 - stable one level A or P fusion in a pt who is asymptomatic, neurologically normal, pain free, and has normal cerv ROM presents no contraindic to continued participation in contact activities stable 2 or 3 level fusion who are asymptomatic, neurologically normal, and have pain free full cerv ROM present a relative contraindication, b/c of inc stresses on the articulations of the adjacent uninvolved vertebrae and the likelihood for the development of degen changes at these levels - should not be permitted to resume contact activities 3+ level a or p fusion is an absolute contraindication regarding continued participation in contact sports Maroon, 1996 - cerv disc herniated centrally usually removed anteriorly, can be removed either anteriorly or posteriorly if herniated laterally advantage of anterior approach - has been suggested ant interbody fusion results in preservation of strength in the c-spine during flex and ext advantage of the posterior approach - maintains integrity of ant and post longitudinal lig

17. Surgical Procedure 12 weeks post-injury: left sided approach to a C3-C4 anterior cervical discectomy fusion (single level) with bone graft

18. Post-Op Restrictions Wound care for incision Soft collar for 6 weeks - avoid cervical rotation No lifting >10 lbs for 6 weeks Gradual resumption of ADLs �If it hurts, don�t do it!��If it hurts, don�t do it!�

19. 2 weeks post-op Incision healing well Motor strength 5/5 in bilateral UE/LE 2/4 and symmetric reflexes in UE/LE Experiencing occasional tingling in bilat UE with full neck flexion Allowed to begin recumbent bike for light CV exercise Clinical presentation Grade Definition Absence of reflex 0 areflexia Diminished reflex 1 hyporeflexia Average reflex 2 normal Exaggerated reflex 3 hyperreflexia Markedly hyperactive 4 Often assoc w/ clonusClinical presentation Grade Definition Absence of reflex 0 areflexia Diminished reflex 1 hyporeflexia Average reflex 2 normal Exaggerated reflex 3 hyperreflexia Markedly hyperactive 4 Often assoc w/ clonus

20. 6 weeks post-op Incision well healed X-rays showed good positioning of bone graft and hardware Tingling in bilat UE had resolved over past 4 weeks and was no longer present 5/5 motor strength 1/4 and symmetric reflexes in UE/LE

21. 6 weeks post-op: rehabilitation No resisted neck ROM No valsalva Began increasing intensity of CV exercise, including running Began body weight exercises and resisted single muscle group training

22. Plan Progressive increase in rehab activities Repeat flex and ext x-rays in 8 weeks (early June) to evaluate bony healing Obtain x-ray, CT, and MRI in late July to determine possibility of RTP Would allow to resume all summer conditioning activities with team if those look ok - including weight training, running, and noncontact 7 on 7 drills Would allow to resume all summer conditioning activities with team if those look ok - including weight training, running, and noncontact 7 on 7 drills

23. RTP criteria Good integration of cervical graft (x-ray & CT) Spinal cord decompression (MRI) Complete resolution of symptoms Discussion of appropriate tackling techniques

24. 14 weeks post-op Bone graft evident at C3-C4 intervertebral disc space, unchanged from prior films Cervical alignment WNL No evidence of abnormal motion with flex and ext views Allowed to resume full training activities with the rest of the team, including squats, power cleans, etc. - still no neck RROM Allowed to resume full training activities with the rest of the team, including squats, power cleans, etc. - still no neck RROM

25. 6 months post-opX-ray results Full, normal cervical ROM Stable appearance of C3-C4 anterior fusion

26. 6 months post-opCT results Bone plug was partially incorporated Screws in good position with no evidence of hardware loosening or fatigue Mild straightening of normal cerv lordosis Mild early degenerative changes at C4-C5

27. 6 months post-opMRI results Post-op changes of C3-C4 ant fusion C3-C4: no sig central canal stenosis, mild right neural foraminal stenosis C4-C5: mild central canal stenosis Improved substantially from MRI at time of injury

28. Team Meeting Athlete, neurosurgeon, orthopedist, athletic trainers, and coach Review of imaging studies Discussion of tackling techniques Athlete signed an informed consent reviewing the outcome of the conversation Athlete was completely asymptomatic with no neck pain or any neurological symptoms. Bone graft will continue to heal, but spinal cord fully decompressed at C3-C4 level. AREA OF BIGGEST CONCERN: mild central stenosis at C4-C5 - this put the ath at some risk of another episode of transient quadriparesis (motor weakness) - if this occurred repetitively it would preclude the athlete from playing contact sports - at this point, not a contraindication Likely a slightly higher risk than avg FB player of having a severe cerv injury - lit shows that with cerv stenosis alone the risk of catastrophic neurological inj is quite low. Informed consent - no additional bracing - must report occurrence of any neurological symptoms Athlete was completely asymptomatic with no neck pain or any neurological symptoms. Bone graft will continue to heal, but spinal cord fully decompressed at C3-C4 level. AREA OF BIGGEST CONCERN: mild central stenosis at C4-C5 - this put the ath at some risk of another episode of transient quadriparesis (motor weakness) - if this occurred repetitively it would preclude the athlete from playing contact sports - at this point, not a contraindication Likely a slightly higher risk than avg FB player of having a severe cerv injury - lit shows that with cerv stenosis alone the risk of catastrophic neurological inj is quite low. Informed consent - no additional bracing - must report occurrence of any neurological symptoms

29. Current Status Six months after surgery the athlete was cleared to resume full football participation Played entire season at starting safety with no recurrence of symptoms

30. Conclusions Advance preparation and communication between all parts of medical team is essential. Athlete education on proper tackling techniques can help prevent cervical injuries. While transient quadriplegia alone may not preclude further participation, evaluation of the cervical anatomy is required to ensure there is no pathologic condition that may predispose the athlete to further injury. This clin case highlights the successful management of a potentially career ending injury. Advance prep and communication allowed for appropriate management and early diagnosis of the injury. This clin case highlights the successful management of a potentially career ending injury. Advance prep and communication allowed for appropriate management and early diagnosis of the injury.