Cervical Injuries and Sport

1. Cervical Injuries and Sport Dr Janusz Bonkowski Neurosurgeon and Spinal Surgeon 06.08.2014

2. Cervical Injuries and Sport • 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

3. Central L parasagittal

4. C 5/6 C 5/6 C 6/7

6. 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 Surgical alternatives for Radiculopathic pain at one level, one side with adjacent segment changes on MR

7. 29 year old. • Insurance agent. • Keen rugby player, local club level. • Would like to keep playing, but has alternative sports interests. Scenario #1

8. 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. Scenario #2

9. 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. Scenario #3

10. 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 Cervical Cord NeuropraxiaTorg J et al J Neurosurg 1997

11. Recommendation: ?Return to sport • Posterior foramenotomy • single level yes • multiple level yes • Laminectomy/laminoplasty • less then or up to 2 level yes • more than 2 level no • Anterior discectomy/fusion/arthro • single/ 2 level yes • more than 2 level no • Anterior foramenotomy • single/multi level yes Return to Contact Sport after Spinal InjurySontag V et al Neurosurg Focus 2006

12. 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 Cervical Cord Neuropraxia in Elite AthletesMaroon J C et al Neurosurg Spine 2007

13. Cite Hughes (2000) 85 Pt with cervical spine injuries treated Burwood Spinal Unit 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%) Rugby Union Injuries to the Cervical Spine and Spinal CordQuarrie et al Sports Med 2002

14. 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.

15. Alex McKinnon

16. James Tamou

17. “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….” James Tamou

18. 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%). STINGERS

19. 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. STINGERS

20. 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. Transient Quadraparesis

21. Previous transient Quadriparesis: • 2 or more previous episodes • Evidence of cervical myelopathy • Continued cervical discomfort • Decreased ROM • Neurological deficit. Absolute Contraindications on RTP Vaccaro, AR et al Curr Reviews MS Med 2008

22. 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 Absolute Contraindications on RTP

23. 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 Absolute Contraindications on RTP

24. 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. Absolute Contraindications on RTP

25. 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. Absolute Contraindications on RTP

26. 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. Relative Contraindications to RTP

27. On-field assessment Zahir U et al Seminars in Spine Surgery 2010 Conclusion: Get him/her of the field!

28. Conclusion All data is based on Grade III evidence or worse, no consensus even amongst experts on RTP criteria or management.