Sports Medicine: Just the Facts

CHAPTER 41 • CERVICAL SPINE 245

• Medical causes of neck pain, such as cardiovascular
  (MI), endocrine (thyroid), pulmonary (pneumomedi-
  astinum), infection (osteomyelitis or diskitis)

HISTORY

• Sideline physicians at an athletic event should keep in
  mind that most cervical spine injuries in athletes are
  cervical sprains or strains, followed by the stinger or
  burner. Fortunately, fracture-dislocation injuries are
  rare (Torg, Vesgo, and Sennett, 1985).


• That said, the sports medicine physician must err on
  the side of caution. Neck pain in any downed athlete
  is treated as an unstable cervical spine injury until
  proven otherwise.


• The stinger or burner (cervical nerve root, brachial
  plexus, or peripheral nerve neurapraxia) typically
  involves the C5 and C6 innervated muscles (i.e., deltoid,
  biceps, and rotator cuff), and so the athlete may com-
  plain of an inability to raise the arm (Feinberg, 2000).


• Head injuries frequently occur concomitantly with
  spinal injuries. An athlete with both a suspected con-
  cussion and neck pain should be considered to have a
  cervical spine injury until proven otherwise.


• Immobilize the spine-injured athlete immediately to
  prevent further neurologic deterioration. Manipulating
  an individual with an unstable cervical spine injury may
  worsen the neurologic outcome (McAlindon,2002).


• The examiner should always inquire about the follow-
  ing:
  a. Neck, shoulder, arm, and leg pain
  b. Arm or leg numbness, tingling, or weakness


• Rule of thumb:
  a. Symptoms in one arm →peripheral nerve injury
  b. Symptoms in two arms, or in one or both legs →
  spinal cord injury
  c. Signs of head injury such as headache, blurred
  vision, dizziness, and disorientation
  d. Previous head or neck injuries
  e. Bowel or bladder dysfunction
  f. Prior treatments and functional status (if not seen
  acutely)


• Athletes with Down’s syndrome (Trisomy 21) may be
  at increased risk for rupture of the transverse and/or
  alar ligaments and atlantoaxial instability. Minor
  trauma in such persons may cause complete atlantoax-
  ial dissociation.

PHYSICAL EXAMINATION

• Inspection for the normal spinal curvature, ecchymo-
  sis, laceration, and obvious deformity

•Palpation for deformity or step-off, bony or soft-tissue

tenderness

• Range of motion, including flexion, extension, lateral
  bending, and rotation


• Strength examination via manual muscle testing


• Sensation testing in all cervical dermatomes


• Reflex assessment of the C5 (biceps), C6 (brachiora-
  dialis), C6/7 (pronator), and C7 (triceps), as well as
  the L4 (patellar), L5 (medial hamstring), and S1
  (Achilles) myotomes
  •Pathologic reflex testing (Hoffman’s and Babinski)


• Special tests such as the Spurling’s and Lhermitte’s
  signs

ON-SITE ACUTE MANAGEMENT

•A physician and/or certified athletic trainer with skills

in the acute management of cervical spine injuries

should always be on-site at collision sporting events.

The aim of acute care is to prevent further neurologic

deterioration, immobilize the spine, and safely trans-

port the athlete to a trauma center for definitive eval-

uation and treatment. An emergency care plan should

be in place and rehearsed beforethe opportunity arises

to put it into action.

DIAGNOSTIC STUDIES

IMAGING

• Plain radiographs are appropriate if osseoligamentous
  disruption is a concern or in cases of recurrent stingers
  or burners or cervical cord neurapraxia. AP, lateral,
  and open-mouth views should always be obtained.
  Flexion and extension views may be indicated to rule
  out abnormal segmental motion.


• Studies of intact cadaver cervical spine segments have
  shown that horizontal movement of one vertebra on
  the next does not normally exceed 3.5 mm, and the
  angular displacement of one vertebral body on
  another is always ≤ 11 ° These measurements may be
  made with lateral neutral or flexion/extension radi-
  ographs. One caveat, however, is that younger athletes
  are more likely to demonstrate ligamentous laxity, and
  these criteria may not always be applicable (Cantu,
  2000; White et al, 1975; Albright et al, 1976).


• The Torg–Pavlov ratio compares the diameter of the
  spinal canal to that of the vertebral body. A ratio of
  less than 0.8 is used to predict cervical stenosis, and
  has been found commonly in persons with an episode
  of transient cervical cord neurapraxia. The ratio has
  been found, however, to have low positive predictive