Sports Medicine: Just the Facts

CHAPTER 83 • FOOTBALL 493

documented axial loading of the cervical spineas the

major mechanism of catastrophic cervical spine

injuries (Torg et al, 1990).

• The normal cervical spine is comprised on an arc of
  vertebral bodies that are able to withstand substantial
  loading by dissipating forces evenly across each ver-
  tebral level; however, when the neck is flexed forward
  30 °, it becomes a straight segmented column of bones
  that cannot dissipate force evenly. Axial loading of the
  neck in this flexposition may then result in excessive
  forces on the vertebral bodies leading to bony failure,
  fracture, and cervical spinal cord injury.

CERVICALCORDNEUROPRAXIA
•Transient reversible deformation of the spinal cord
resulting from significant trauma to the neck.

• The etiology of transient quadriplegia.


• Athletes may experience transient bilateral (differenti-
  ating this entity from a brachial plexus neuropraxia—
  see below) sensory changes, sensation loss, and
  variable motor changes including complete paralysis.


• Episodes typically last less than 15 min but may per-
  sist up to 2 days.
  •A spinal canal: Vertebral body ratio (as determined by
  lateral radiographs of the cervical spine) of <0.8 has
  been found reliably in athletes suffering cervical cord
  neuropraxia (Pavlov et al, 1987). Although this meas-
  ure has a high sensitivity for cervical cord neuro-
  praxia, it has a low specificity and low positive
  predictive value and should not be used as a screening
  tool. In addition, caution must also be used in the
  interpretation of this ratio in football players because
  their large vertebral bodies will falsely decrease the
  ratio in the absence of true cervical spinal stenosis.


• The average rate of recurrence for players who
  returned to football was 56% (Torg et al, 1997).


• Management of the football player with known cervi-
  cal spinal stenosis remains controversial as leading
  authorities in this area have expressed differing opin-
  ions with respect to return to play criteria. Cantu has
  suggested that cervical spinal stenosis is an absolute
  contraindication to return to contact sport. This belief
  is based on a known predisposition to spinal cord
  injury in these patients and a higher incidence of per-
  manent neurologic sequelae in this group as compared
  to those with normal spinal canal volumes (Cantu,
  2000; 1997).
  •Torg contends that despite its association with tran-
  sient quadriplegia, cervical spinal stenosis is not reli-
  ably associated with catastrophic spinal cord injury
  and does not mandate exclusion from participation in
  all cases (Torg and Ramsey-Emrhein, 1997). Torg
  proposes the following guidelines for participation in
  this group of athletes:
  
  
  1. Canal/vertebral body ratio of 0.8 or less in asymp-
     tomatic individuals—no contraindication
  
  
  2. Ratio of 0.8 or less with one episode of cervical
     cord neuropraxia—relative contraindication
  
  
  3. Documented episodes of cervical cord neuropraxia
     associated with intervertebral disc disease and/or
     degenerative changes—relative contraindication
  
  
  4. Documented episode of cervical cord neuropraxia
     associated with magnetic resonance imaging
     (MRI) evidence of cord defect or cord edema—
     relative/absolute contraindication
  
  
  5. Documented episode of cervical cord neuropraxia
     associated with ligamentous instability, symptoms of
     neurologic findings lasting more than 36 h, and/or
     multiple episodes—absolute contraindication
  
  
  
  

STINGERS/BURNERS

• Brachial plexus neuropraxia resulting from traction or
  compression of the brachial plexus with violent lateral
  flexion of the neck.


• The most common nerve injury in football with
  defensive players most commonly affected.


• Athletes note unilateral burning or stinging pain,
  numbness, or tingling radiating from the supraclavic-
  ular area down to the fingers, most commonly in a C5
  or C6 distribution. There may be weakness, most
  commonly of the deltoid, but no neck pain. Symptoms
  typically resolve in minutes. Symptoms that persist
  suggest more substantial injury to the brachial plexus,
  including cervical root avulsion, and mandate imag-
  ing and appropriate neurologic consultation.


• Athletes may resume competition when they demon-
  strate full range of motion, full strength, and a normal
  neurologic examination of the upper extremity.


• Prospective analysis of college football players revealed
  that a favorable overall spinal canal: vertebral body ratio
  (>0.9) is associated with a low initial incidence of
  brachial plexus injury (Castro et al, 1997). Players with
  multiple such injuries had significantly smaller ratios
  than those suffering only one event (0.75 vs. 0.87).

SPEARTACKLER’SSPINE

• Characterized by developmental narrowing of the cer-
  vical canal (a canal-vertebral body ratio of <0.8),
  straightening or reversal of the normal cervical lordo-
  sis, and posttraumatic radiographic abnormalities.


• These individuals are at such great risk for permanent
  spinal cord injury that they should be precluded from
  participation in tackle football (Torg et al, 1993).

MANAGEMENT OF THEPOTENTIALCERVICAL

SPINEINJURY

•Any unconscious athlete or any conscious athlete

complaining of neck pain must have the cervical spine