So we're going to just go through the differential diagnoses of cervical spine pain and how we evaluate them, especially as far as the athlete is concerned, how we evaluate the cervical spine injury. I'm sure Jeremy will build on that as well with sideline emergencies. And then return to play criteria for cervical spine conditions. So epidemiology, just there's about 10,000 cases of c-spine injury each year in the United States, about 10% of these are athletic event related. Again, major cause of spinal cord injury in the first three decades of life. But a smaller portion of all sports related injuries. But when they occur, they're very highly publicized. You know, about Sonny Bono, one of the Kennedys. A lot of these occur really during unsupervised sports. They're diving, skiing, sandlot games. And so not the majority during organized sports. This is a nice question because, again, we think of football. But in absolute numbers, recreational diving is actually the leading cause of SCI leading to quadriplegia. So it's usually, again, they're diving in shallow water. Usually alcohol is involved. They're bad technique with diving. But recreational diving is the leading spinal cord injury cause. But, you know, again, and we hear about the high profile cases that occur in sports as well. In high school sports, it's a small incidence, about three per 100,000. But as you'd expect, the contact sports are the greatest. So football, number one. Then wrestling and girls' gymnastics. Most of the time, there's muscle injury, nerve injury about one-fifth of the time. This is a contact injury in large cases. So about, as opposed to ACL, it's non-contact. About 70% here is contact with a player. About 16 to 20% contact with a playing surface. Again, as you'd expect, high-risk sports in the United States. Football, gymnastics, wrestling. In Europe, rugby. So there is a country differentiation there. Ice hockey, as you'd expect. In Canada, certainly the snow sports. Cycling and equestrian sports, again, at high risk. In football, this is our high-profile group. There's about 684 deaths in amateur and pro football. That was from the period of 1945 to 94. About 20% of those deaths were related to cervical spine injury. So certainly a larger problem in those earlier years. You know, again, you can kind of see the distribution of who gets it and where they get it. And as far as how experienced they are, more high schoolers, college as we get to the professional levels, less so. Deaths, there was 28 TBI and SCI in high school and college football players from 2005 to 2014. Eighteen percent TBI had concussions earlier. So again, that second impact syndrome. But these were actually spinal cord injury injured individuals as well, not just brain injured individuals. That was a nice study in college football from the NCAA database. Stingers, you can see the incidence there, about two per 10,000. Cervical strains, about 0.8 per 10,000. Again, as in a lot of things, nine times more common in games than practice. Highest in Division I athletes, again, a large amount of contact related. Most common positions, linebackers had about one-fifth of them. And most people did return to play within 24 hours. So these were more the cervical spine strains and not severe injuries. Ice hockey in Canada, nice study. Most involved contact with the boards. Some illegal checking. But again, how rule changes can make a difference. And we'll talk about this in football as you all are familiar with spearing. But in hockey, about a 70% decrease in cervical spine injuries following a penalty for checking from behind and for boarding. So huge difference that rule change made in hockey. Anatomy is testable. A lot of things, you know, in this board exam, you know, we could try and make it as clear as possible, but anatomy is not a gray area. So know your anatomy. Seven cervical vertebrae, as you know. Eight pairs of spinal nerves. They always like to ask that the cervical nerves exit above each vertebra. So they may give you an MRI and a little arrow pointing to a nerve root. And you'll know which it is because you'll know in the cervical spine that above is the exit of the nerves. We need cervical lordosis. Lordosis absorbs force. When that lordosis is gone, we'll talk about spearing a little bit later. When you create a rigidity, that's going to be a risk factor for injury. So we want a normal cervical lordosis. The cervical spinous processes are normally bifid. And again, just nice to have a root screen. So when somebody has upper extremity symptoms, C5, and again, these are, there's overlap. But in general, C5, biceps and deltoid. If you manual muscle test, C6, your wrist extensors. C7, triceps. And C8, T1, inner ossi. And that's a good root screen for each of those nerve roots. Again, sensory dermatomes, kind of the same. C6 is going to be your radial side, your thumb. Think of C6, shooter. Okay, a gun. That's C6, C7, basically the middle finger. C8, T1, the ulnar side. Again, these will vary depending on which dermatome, on which sensory dermatome map you see. But in general, you're going to have the radial side, C6, the middle, C7, C8, ulnar side. So pain is in these distributions. We can get a clue as to what nerve root is involved. There's a broad spectrum of injuries of the C-spine in sports. Fortunately, the large amount are not catastrophic and not very limiting. And there's an inverse relationship to the frequency of injury and severity, meaning the most frequent injuries are the least severe. But again, we want to pay attention because the most severe injuries are very significant. The entities we'll talk about, we'll talk about root and plexus lesions, the neuropraxias. We'll talk about cervical strain, the myofascial lesions, intervertebral disc lesions, twans and quadriplegia we'll touch on, and then cervical fractures and dislocations. So the neuropraxias, that's the burner or the stinger. And you can think of a neuropraxia as basically a stunning of the nerves. There's a temporary loss of function due to blockage of nerve conduction. And this is the most common cervical spine injury in football. One study had up to almost 70% of college football players during their career experienced a stinger. Very common in linemen and defensive ends. It can be due to the injury to the brachial plexus or the cervical root. And usually this will be, they'll come out, the dead arm sensation, they'll come out, the arm will be lifeless, they'll have maybe burning pain and paresthesias. Transiently, they'll feel like they can't move the arm. To be a stinger or a burner, it should resolve quickly. And usually within 24 hours definitely, but usually within seconds to minutes. Objective findings. You shouldn't have any problem with the C-spine. The C-spine range of motion should be full and pain-free. Shouldn't be tender on any of the spinous processes or inner spinous ligaments. Maybe there's some transient weakness or sensory exam dysfunction there for a temporary period. You need to do a complete neuro exam to ensure that everything is back to normal. And really, you don't have to have x-rays unless there's persistent pain or bilateral symptoms. Again, anytime bilateral, you think of cord, you think of myelopathy. Unilateral symptoms are usually root symptoms. Mechanism of injury, it can be compression or traction, either one. So it could be ipsilateral or contralateral compression or traction. And so I think this sells it best, actually. So you can actually have a stretch or compression injury. And the same mechanism can produce injuries on opposite sides or direct compression. So I think we think of it a lot as a brachial plexus stretch injury, which it can be. But it can also be a compression injury as well. Important to know what CSF reserve is. A lot of athletes who have burners have limited CSF reserve. And one study showed DJD and neuroforaminal layering, about 9 out of 10 of high school athletes. But CSF reserve is the, if you take the diameter of the cervical spinal cord, and that's over the diameter of the cervical spinal canal, the reserve is the amount you have cushioning basically that cervical spinal cord. You know, there isn't a lot of evidence-based research on how much is adequate reserve. We just need reserve. We need that cushioning around there. And with loss of those reserve, that's when we'll talk about transient quadriplegia and all when that is lost. But we don't have any evidence-based, hang your hat on concrete criteria for how much reserve. But we need to see that T2 signal. We need to see that fluid and that space around the spinal cord. One study in the combine showed less reserve in those who had chronic burners and stingers. So treatment and prevention, really neck strengthening is key. There's been a lot of studies on the equipment that people wear. You may have seen the collars and stuff that end up around the thoracic spine at the end of a game sometimes. So and the cowboy collar, none of them really have been shown to prevent these. So really well-fitting shoulder pads and good cervical thoracic stability, strengthening is probably the key to preventing these and treating these. Remember, you need normal neuro exam, complete resolution of symptoms before they go back. Strains, there are strains to the ligament or soft tissue structures of the cervical spine. If they're ligament strains, sprains, that's a potential for instability. This can be either a hyperflexion or extension injury. This will have localized pain usually not reading into the arms and they may have painful range of motion. Again, usually myofascial structures, the sprain is when the ligaments are actually involved as well. And again, a lot of these, you can have it from chronic conditions. You think of our road cyclists who are in a forward flex position a lot. So we say the golf ball on the tee, we need cervical thoracic stabilization when that golf ball falls off the tee, we overload myofascial structures. So the cervical paraspinal muscles and the posterior neck structures, the superior trapezius, that's cumulative microtrauma. And that's going to be from our road cyclists and from those in a forward flex neck position, poor aerobic conditioning also associated. Our world is in front with Zoom and all the stuff we're doing right now. So we tend to have that golf ball fall off the tee and then we have that posterior overload from that. Well, if it's just a cervical strain, a myofascial pain, it might be tender in the paraspinous soft tissues. You should not feel any step off or deformity. There should not be a neurologic deficit. If they have, and this is why we cover games, if they have tenderness to palpation over the spinous processes, over an interspinous ligament, if you're covering a game, athlete has an injury, you feel that, that requires immobilization. So that athlete should be C-spine immobilized in a rigid collar and boarded until you can get imaging. So again, focal tenderness palpation over the spinous process, C's, interspinous ligaments, pain with cervical spine range of motion, that's when we want to be cautious. We don't want to take a ligamentous injury that could have gotten better and make it worse by moving somebody who had that condition. The radiographs we get initially, really AP and lateral and odontoid are the key ones initially to see, just remembering we see all those structures. And really, you don't have to do, you shouldn't do flexion extension initially because they may have a lot of spasm and you may think they're falsely okay when they're not. Because when that spasm loosens, you may see the degree of instability that they have. So if AP, lateral, odontoid are okay, then you keep them in this hard cervical collar until about a week, 10 days, until those acute symptoms subside. Then you can do flexion extension after that muscle loosens up to rule out any instability. If they continue to have pain to palpation or painful neck range of motion, then you want further imaging, usually an MRI, the exam of choice, because it's going to visualize those ligaments that may be involved as well. Something they always like to ask about, what you don't want to see is what we're seeing here, in the sagittal plane, greater than three and a half millimeters of angulation or 11 degrees of greater than three and a half millimeters of displacement or 11 degrees of angulation, that's cervical spine instability. So that's what we don't want to see. But they always like to ask about these numbers. So again, hard cervical collar, analgesics, again, very gentle stuff initially. Eventually, if it's not involved, if it's a stable spine, you're going to do cervical thoracic stabilization exercise and get them going during that sense. We want to avoid extremes of range of motion during that acute phase. Disc pathology, it's common, can lead to central core compression and myelopathy if it's central, or it can cause radiculopathy if it's lateral. So there can be a wide range that we can see with disc involvement. And just to know, again, these are very testable questions. They may list categories. You can imagine in a stem, or the answers from A to E, upper motor neuron is usually, they're going to have spasticity and increased hyperreflexic status, not hypo. They're going to have a positive Babinski sign. And so that initially, that's going to be spastic, hyperreflexive and positive Babinski. Lower motor neuron, flaccid, decreased or asymmetric reflexes, asymmetrically decreased, atrophy, negative Babinski. So those are, and that may occur pretty quick. You can lose, drop a reflex pretty quick with a radiculopathy, whereas upper motor neuron may take a little bit more time. But very important to know, again, upper motor neuron symptoms, usually bilateral. Anytime somebody has bilateral, hey doc, all four, you know, my four limbs are numb, that automatically should cue you into cord and myelopathy. If there's a single-sided problem, again, more likely radiculopathy or root problem. But definitely know the upper motor neuron and lower motor neuron differentials there. Radiculopathy, again, disc herniation is the most common cause of this. Sorry, this is a lumbar spine. We're talking about cervical spine, but it's a nice disc here. But, you know, again, there's, as you know, there's a large number of studies that show that disc extrusion itself does not mean a problem and it does not correlate with pain. There's a lot of data suggesting that there's an inflammatory response around that disc, cytokines, chelokines, bradykines that cause a chemical radiculopathy. That's why we do epidural steroids sometimes to kind of settle that area down. Most common levels, C7, and you can see there at C6, C8, C5, but C7, most common level. Degenerative changes, again, may lead to that, that can lead to narrowing of the foramen, so can ligamentous hypertrophy, disc degeneration. All those things together cause foraminal stenosis. And when we have the osteophytes and the disc material together, that's a hard disc that can form some fairly significant neuroforaminal stenosis to cause impingement. So you're gonna evaluate the same thing we would usually, the mechanisms of injury, what they were like before. You want a neurologic review of systems, certainly motor, sensory and reflex exams, x-rays. And again, if there's a significant deficit, we're gonna want an MRI, especially with progressive neurologic deficit. Again, many people are gonna have an initial hit. They'll may have a minus one, just a subtle weakness. That's okay. If it's progressive, that's when you wanna get more advanced imaging. Oftentimes, they're gonna have associated degenerative changes. In one study, up to 75% of freshmen football players had early cervical spine degenerative change. Treatment, again, usually radiculopathies are treated non-surgically. Modalities for comfort initially, we talked about oral or epidural steroids if the pain is refractory. Again, the reasons for referral are progressive neurologic deficit, uncontrolled pain, myelopathy signs, bowel or bladder changes. Again, we wanna stay away from surgery. If it's done, usually ACDF, one to two level disease. With a one level disease, we'll talk about later, they are okay to go back to play. But again, we wanna, most of these will do better non-operatively. And we wanna, again, when we look at one year outcomes, it's very good for non-operative. So there's no reason to jump into surgery for these. Transient quadriplegia is something that they like to ask about as well. It's a fascinating entity first described by Joe Torg. In essence, we talked about that neuropraxia leading to burners and stingers. This is a neuropraxia of the cervical cord. Again, bilateral, that's cord. Bilateral burning pain, tingling, loss of sensation in both arms or both arms and both legs. It can vary from mild weakness to complete paralysis. Prayerfully, it's transient. And again, this can be up to two hours. You can see the incidence there during Joe Torg's era of when this was examined a lot. It's thought to be either axial load with hyperextension or hyperflexion. And it's thought to be a cord contusion via almost, you can think of the hip, FAI, the pincer mechanism, a pincer mechanism on the spinal cord causing that contusion. Again, we talked about that CSF reserve. That is the most effective method of diagnosing this. We talk about the Torg ratio, but there are flaws with the Torg ratio. Because you may have a football player with big vertebral bodies, and they're gonna come out with a Torg ratio that is suggestive of cervical spinal stenosis. But really, functional reserve is the key. So it's the disc level spinal canal diameter minus the spinal cord diameter. Seen on T2 images, because T2 is our, H2O, I always remember, T2 is water. So that's where we can see our fluid the best. And again, I don't think they can ask you for an exact number on what the reserve is, but you have to have adequate CSF reserve. Cervical fractures and dislocations. Again, this really spinal cord injury increased while head injury decreased in the 60s and 70s. New helmets and all, they helped. So we kind of saw a shift in the injuries, and we see less now cervical spinal cord injuries since rule changes in football, like we talked about in hockey. The spearing is deadly. And that's the thing, as if we talked about how many of the high school and college athletes have degenerative changes in the cervical spine. We talked about that lordosis being protective. If we eliminate that lordosis and we actually load it, that's when we get a problem. And that's when that cervical spine can buckle and cause, again, fracture and then cord involvement. So that's why spearing is not good. So, but it happens accidentally, and this was a game actually two seasons ago with the Bears, and this guy escaped it, but exact wrong position to be, and not through any fault of himself. It was just the nature of the play, how it followed. But that's what we want to present. We want to preserve that lordosis so it has a shock absorbing capability so the spine doesn't blow. And this is Daryl Stingley. That's the injury that paralyzed him there. So Torg described a population with a constellation of findings, the ratio of less than 0.8, that's the vertebral canal to the vertebral body width. And again, we saw that that was, it's not always that sensitive because you could have somebody with a big vertebral body, and that's going to be a low ratio, but they actually might be protected because they have adequate CSF reserve. But that low, that Pavlov ratio, loss of normal cervical lordosis and degenerative change, that's called spherotopilar spine. They may still test on this aspect. Those are risk factors for cervical spine injuries. And that if you have this congenitally, if you do have an inadequate CSF reserve and degenerative change and loss of lordosis, that's a contraindication to play. This is an athlete, actually, these are taken one week prior to him being rendered quadriplegic following a tackle. The fascinating study that he had, issues that they did this study before, but again, this is all ligamentous. This is not bony-wise. So again, the benefits of the research, because of that research, they banned spear tackling in 1976, and you can see the decreased incidence of quadriplegia starting with that ban. So how research can make a difference. Field evaluation, and Jeremy may be talking about this as well, but again, we wanna carefully take them off the field. We need to protect the airway if they're unconscious while protecting the C-spine. Usually leave the helmet on. We'll talk about that. If they have that midline tenderness, limited range of motion, or any neurologic symptoms, they need to be immobilized and transported. So they need to be on the spine board. Usually, again, this is a little bit of an area of controversy, usually with the helmet and pads on. If you have a crack team that does this all the time, and you're going to maybe not a level one trauma center where they may not be as familiar with this, okay, maybe that's the case where you take the pads off and stabilize before you transport. But most of the time, if you're going to level one trauma and you have someone who knows how to do this, you can immobilize and it's better to keep the pads on. But there may still be some controversy with that. This was, and again, there's been a just update to the task force on the pre-hospital care of the suspected spine injured athlete. When deemed necessary, protective equipment may be removed prior to transplant. So again, it's not a statement saying you have to remove it, and you may be going to a place that may not be as adept at it, that may be the indication to do it on site. So again, assume they have a spinal cord injury when you see the downed athlete, ABCs, remember them, activate the EMS, minimize movement, head and trunk as a unit, remove face mask, usually most of these will have little latches now, you can do them, or appropriate bolt cutters with your team. And again, helmet pad removal only if experienced. You got to practice this. I know Stan Herring tell me every Sunday they used to practice spinal boarding, every Sunday to make sure that team is moving in unison. Again, an acute injury, flexion extension x-rays are not the greatest, but CT scan, that was where we're going to get our sagittal plane translation. So again, greater than three and a half millimeters or 20% or rotation greater than 20 degrees. Those are indications of an unstable cervical spine. How do they get back? Everybody wants to get these guys back. They need to get them back as soon as possible. We really need to differentiate the minor from the serious. So stingers, really when they're neurologically intact, full strength, painless range of motion, normal neuro exam, they can go back. But, and we really don't have any evidence-based information on how many is too many in a year, but some consensus opinions favor holding from play if they have more than three within one year. I've had kids with big lanky necks and have had three in one game. So, but again, really need to ensure that neurologic exam is normal there. Cervical strain, if again, we got to take care of it if there's that focal tenderness and we have to get the appropriate X-ray imaging to ensure there's not that translation or rotation. If flexion extensions are normal, we got to have painless neck range of motion and good cervical thoracic stabilization. Ligamentous instability, again, they could be bony intact, but ligamentous unstable, if there's greater than three and a half millimeters horizontal displacement, or 11 degrees, greater than 11 degrees of angulation, that's an absolute contraindication to return. The disc, we want them to have normal neurologic exam. If they have surgery in one level, they may return once the fusion is solid and they have painless range of motion. Two levels is relative contraindication and three levels is absolute contraindication to return to contact sport. So that may be a testable question. So two level relative, three level absolute. But one level, again, good cervical thoracic instability, they can go. Transient quadriplegia, again, really, you need to ensure the functional reserve. And again, really not rather than the Pavlov ratio, the functional reserve is adequate. If they have developmental stenosis with one episode, relative, but I tell you, I think anybody with a functionally, if they have that narrow, if they do not have adequate functional reserve, they are at risk and they should not play. So there's gutsy individuals. I know Joe Torg, I call them about people sometimes and he let them go back as long as they had complete resolution. And even with adequate CSF reserve, there's something, there must be something in these individuals that causes that cord to contuse, even with adequate reserve. So I'd be very hesitant to send somebody back with this. Stan Herring and Mark Harris had a good paper. These are absolute contraindications for return to play after an episode of transient quadriplegia. And basically, if you have anything, any kind of finding, any cortispinal defect, any functional spinal stenosis, anything at all, don't do it. But even after an episode like that, even with all durable, whoa, I'd still think there's something in there that would be a risk factor. But again, for the test and all, these are the absolute contraindications. And lanoaxial instability is a common question that they ask because it's present in Downs individuals, about 10 to 20% have some degree of lanoaxial instability. With a minority of those symptomatic. If they're symptomatic, they need to have surgical evaluation and no sports. If they're asymptomatic, you wanna restrict them from the high risk activities. There's been a lot of controversy between screening with screening x-rays for this population as there's a very poor correlation between the x-rays and symptoms. But again, to know the lanoodontoid distance greater than three to four millimeters is considered lanoaxial instability. So there's threes are cropping up a lot with the instability. Just to know, they may ask you these or show you radiographs of these. The Jefferson fracture is a burst C1 fracture. This is the one that you can get when you dive headfirst into shallow water. But the blessed thing about these is a lot of times they don't have a neurodeficit unless that fragment is displaced. If there's greater than seven millimeters displacement, then that's considered unstable. But a lot of these can be treated with a hard collar or some degree of immobilization as long as they don't have neurologic compromise. C2 is the hangman's fracture. It's again, if they ask you about mechanism, there's two, it's usually hyperextension, then secondary flexion and distraction. And that rope, when it kicks in, that's why they call it the hangman's fracture. So again, the type ones, the less severe displaced would be a rigid collar. Type two and type three will be usually surgical because they violate that three-column, Denny's three-column theory. If more than two columns are involved, that's an unstable spine. But dont type fractures, they like to ask about these usually just to know type ones, they usually do very well. Type twos are the base of the dens and then type three are low in the body. So type two and type three, the base in the body usually requires surgical stabilization. Type ones do well non-operatively. Clay shoveler's fracture, it's interesting to see, but it usually doesn't cause any neurologic deficit. They're very stable, but it's a C7 spinous process fracture. So you may often have this pointed out as a clay shoveler's fracture. And again, the ones that you really don't worry about, they're healed compression fractures, healed end plate fractures, healed spinous process fracture, the clay shoveler's fracture, but anything else, if there's a depressed compression fracture, there's a posterior element fracture. If any of those other ones we talked about, those are relative contraindications. And certainly any acute fracture, vertebral body fracture that impinges on the cord, retropulsion, anything like that, those are absolute contraindications to return to play. And just to know, they love to ask about clipple file syndrome. That's a congenital fusion of any two of the seven cervical vertebra. Type one is a single fuse segment. Type two is multiple segments, but they're non-adjacent. So maybe a little more mobility is present. Type three is multiple fuse segments adjacent. So contact and collision restriction if type two or type three above C3. So if that creates a very rigid spine there that's not gonna be able to absorb force, but they tend to ask about that too if they're symptomatic surgical evaluation. I was a whirlwind, but that was it. You guys have any questions? Sorry if I went a little bit over there. We did have, thanks so much for that. That was great. We did have one question. Dr. Hamish Kerr kind of had answered it, but real quick, I'll run it by you as well. So Christine asks that she's run into some changes where EMTs that are covering would not spine board every suspected C-spine injury and would use the collar as an alternative. Have you heard of this and do you have any comments on it at all? You know, the collar really isn't enough if we're worried. And again, I think that's the thing. These aren't, you'll board a lot. You'll board 99% will be fine, but it's the 1% that we board for. And a collar alone just isn't enough to provide, it's like a walking boot versus a rigid shoe. It doesn't immobilize enough of the segments to really protect them. I think it's good practice really to talk with your EMS team in any event that you're covering and see where they're at and see, but most I think will be totally on board with it as long as they know you and they know your rationale and your concern for the athlete. But really a hard collar is just not gonna do it. It's not enough.

2nd Edition, CASE 51

2nd Edition

Spine

cervical spine injuries

athletes

differential diagnoses

spinal cord injuries

neurological assessments

preventative measures

return-to-play protocols