All right, so everybody welcome to the AMSSM fellow online education lecture series. Tonight's topic is cervical injuries in athletes, which will be presented by Dr. Julian Bales. I'll do an introduction more formally in just a moment. My name is Jim Muller. I'm the fellowship director at Henry Ford Health System in Detroit, Michigan. And I was part of the group that helped form this online education subcommittee, and we're very happy to have you with us today to listen to this lecture. I want to go over some basic ground rules and goals. So to start with the goals, we want this lecture to serve as an adjunct to your individual program's educational programming. We don't want this to take the place of what you're learning, but to supplement what you're learning. We want to provide fellows with direct access to educational experiences with experienced AMSSM members and invited guest experts, as we have tonight in a variety of formats. And this is going to be more of a classic didactic lecture, and we want to make sure that we're assisting you in your preparation for your CAQ examination. So some basic ground rules, we'd like you to make sure that you've muted your device so there's no interruptions for Dr. Bales. We want you to submit your questions through the chat function and include your name and program if you wish, but you don't have to. And what I'll do is I'll be monitoring the chat function with Andy Meyer, who is our representative from AMSSM, and when the lecture has ended and we get to the Q&A component, we'll just take the questions from the chat function, and we'll go ahead and ask those questions of Dr. Bales on everybody's behalf. And then after the program, there'll be an evaluation, which we'd like you to consider completing for us so we can make sure that we're making this program optimal for you in the future. And so please take a few minutes to fill out that survey for us. So with the goals and the ground rules completed there, what I'd like to do is introduce Dr. Bales, and it's an honor to introduce Julian Bales to you all. He'll be presenting tonight's lecture on cervical injuries in athletes. When it comes to sideline coverage, I find that the two situations which cause the most anxiety for the sports medicine physician are the collapsed athlete and the athlete with a possible cervical spine injury. So I'm really pleased that Dr. Bales has agreed to share his expertise with us tonight. He is the chairman of the Department of Neurosurgery at the North Shore University Health System and co-director of the North Shore Neurological Institute. Dr. Bales has interest and expertise in the diagnosis and surgical management of various neurological diseases. He is a recognized leader in the field of neurosurgery and the impact of brain injury on brain function. He's been involved in advancing the understanding of clinical evidence of chronic traumatic encephalopathy caused by multiple concussions and other forms of head injury. His laboratory research has focused upon mechanisms and treatments of concussions. He is also a founding member and director of the Brain Injury Research Institute, which focuses on the study of traumatic brain injuries and their prevention. And for 22 years, he's been a sideline physician at either the NFL and or NCAA levels. Since 1994, which is around the time I first crossed paths with Dr. Bales in Pittsburgh, he has been a neurological consultant for the NFL Players Association, which has supported research on the effect of head injuries on professional athletes. And he is the medical director of the Center for Study of Retired Athletes based at the University of North Carolina in Chapel Hill. He's been an advisor to the NCAA and also the medical director for Pop Warner Football, which is the largest youth sports association in the United States. And he's the director of the NFLPA's Second Opinion Network. Dr. Bales has over 120 scientific publications concerning various aspects of neurological surgery, including four books on neurological sports medicine and performs editorial duties for a number of medical journals. And again, I crossed paths with him many years ago, and he's a tremendous person, a tremendous surgeon, a tremendous clinician. And we're very fortunate to have him with us tonight. So I'm going to pass the baton over to Dr. Bales. And I'm really excited to hear what he has to say today about cervical injuries in athletes. Thank you. Okay. Thank you, Jim. Great to be here with you all this evening. And I'll try to share my knowledge. And I also agree that, you know, of all things that we handle on the sidelines, that this could be the most troublesome, because I don't feel a whole lot of responsibility for cardiac arrest, although we know it can occur. But, you know, the problem with a suspect or definite cervical injury is that, you know, if you're an orthopedic surgeon or sports medicine or neurosurgeon, you're on the line there for recognition and for proper management. And I always tell people who are going to be sideline physicians at any level that you have to sort of fight against, as I still do, the tendency to watch the play and to follow the excitement of the game. And really, you have to force yourself to kind of follow the ball, follow the action. And then particularly on high-velocity plays like kickoffs and punts, be careful to watch for those heavy collisions where bad things can happen and where most of the serious injuries occur. I'm in Chicago. We're based in Evanston, Illinois, about 10 miles north of downtown Chicago. I'm part of the University of Chicago Pritzker School of Medicine. I'm in a system, a 10-hospital system called North Shore University Health System, and I have no disclosures. So the history of cervical spine injury has really focused in sports, on football, for obvious reasons, because it was certainly a contact sport with high-velocity impacts. And we learned a lot, particularly starting around the early 1960s. Richard Schneider was the chairman of Neurosurgery University of Michigan, and he had a lot of research, which led to our greater understanding of how injuries occur and the role that helmets may or may not play. Excuse me, Joey, I'm not seeing your screen right now. You're not? Okay. No. I'm sorry to interrupt you. All right, hang on. You see it now? Got it now, yep. Yeah. You see me okay? I see you fine, and then if you can just hit slide show, and then... Is that good? That's perfect. There you go. Now we're cooking. All right, great. Sorry. So I think I was saying I have no disclosures. So the issue of head injury in athletes, particularly contact or collision sports, really dates to beginning around the early 1960s with our understanding of how axial loads to the cervical spine occur, how helmets may or may not play a role in that, and really led to our beginning of our understanding and ultimately, in my opinion, the impact of head injury on athletes. And really led to our beginning of our understanding and ultimately improvement. To understand and to be a part of the diagnosis, of course, you have to review your cervical spine anatomy, spinal cord anatomy, and I like to think of it in the descending motor pathways and the ascending sensory pathways. And that helps you to understand why a syndrome like central cord syndrome, which is a vascular-based injury to the center of the cord, how that affects the upper extremities predominantly or more than the lower extremities, how a syndrome like burning hand syndrome is believed to be a variant of that. And then with spinal cord injury, of course, you can have the full gamut of potential spinal cord injury patterns, whether it's anterior spinal cord syndrome, posterior spinal cord syndrome, and the others that I mentioned. So I think with that as a backdrop, it really helps you to understand and realize that in something about the size of your index finger, there is more important real estate than any other structure on the face of the earth. And teleologically, there's a lot of old tracks that go from the brainstem down to the cervical cord, the tracks that make you jerk your neck if you hear a loud sound, and many of the things that are involved with decorticoid and decerebral abnormal posturing that we see with serious brain injury. And then, of course, don't forget the vascular part. In sports, especially if you include recreational injuries, diving has for many, many years, decades, been known to be the number one cause of cervical spine injury. And diving injuries are about the fourth leading cause of all spinal cord injuries, and they're the number one cause of athletic or recreational injuries. And you know the mechanism. Sometimes as you get in practice and you're active in your community, knowing there's a high recidivism rate of people forgetting about how these occur, you can be an activist. It's fun. It's important. And you have to remind people that diving in shallow water is the number one cause. But there are other causes. Young athletic males can jump off a board 20 feet and hit the upslope of a pool. We've seen cervical spine injuries from people jumping into a lake, especially the first time of spring when a picnic table or some object was submerged and they didn't know it. So cervical spine injuries from diving are so poignant, very preventable. And I urge you to be on the bandwagon of prevention in your community. For sports injuries to the cervical spine, football has always been and continues to be number one. And as you know, it's ordinarily tackling, sometimes blocking. But a vertex impact with flexion are the most common causes. Wrestling is also not unusual. Driving the head of the opponent into the mat is the most likely way that occurs. And ice hockey is pushing or skating someone into the boards. Gymnastics, of course, from time to time, has certainly had cervical spine injuries. And most of them, in my experience, have been falls during a dismount or accidental falls during an exercise. And here shows the classic mechanism of a player being pushed from behind. And, you know, if you ever the next time you watch, particularly in a gel game, if you notice it by the time their pros, most of them have learned to put their hands out and break the break, the blow. So the top of the head doesn't first strike the boards or the glass. But this is the most common mechanism in hockey. Years ago, we came up with this classification scheme for the management of athletic injuries to the cervical spine. I'll take you through it. I think it has, for the most part, withstood the test of time. It is not specific criteria that that you have to know or would ever be on an exam. But to me, it's a way of thinking about it. And so for type one, that's where there is a transient episode. And if someone has a transient episode and they don't have anything which precludes either a neurological examination or more likely, radiographic examination, if they don't have a structural contraindication, then often we let them return to play if everything is clear. However, if they become a repeat offender, often they do not. Now, of course, that's predicated upon how old they are and what their body habitus and size is and especially how many they've had. A type two return were those that that had a spinal cord injury, a neurological injury. And of course, they never are allowed to return to play. And type three was those that had some sort of radiographic abnormality, either a fracture. And if it's a stable fracture, you have to decide whether it's stable just under normal physiology or would it stand up to the stress of a contact or impact? If it's not, then they don't return, they should not return. And it's been very, very unusual that anyone who had a fractured cervical spine and had to have fixation would be allowed to return to play. If the fracture is unstable, of course, they're fixated and that's it for their contact career. They become golfers if they don't have a spinal cord injury. The final type of classification of a type three, in our way of thinking, was another structural abnormality. So ligaments instability, canal stenosis and cord contusion ordinarily do not return. So, for instance, if you had seen a high school player who had a spinal cord contusion, I would not recommend that player return to play. We probably wouldn't let an NFL player return to play. And if you think you want to, you better really see why a in your in your notes and have a very good explanation. If you're going to take that on to allow someone with this sort of radiographic, either significant stenosis, instability or cord contusion return to play. And on the right hand side is really other structural abnormalities. And that's bony osteophytes, bony abnormalities or the most common would be a herniated disc. So this way of thinking, either it's a transient injury only and they're not repeaters. They can usually return to play spinal cord injury. They can't return to play. And the third type, a radiographic injury. And I think you have to understand and catalog them in your mind, sort of as we've done here. So to take you through there, this is a good example of of a cervical fracture dislocation. This patient ended up having a spinal cord injury, needing a fixation done and did not return. Here's another example of a burst fracture with neurological injury, did not return. And as you know, the issue is not just the bony abnormalities, the impingement or the momentary impact to the cord. And it's the primary injury. It's the secondary injury. And as you see here in this autopsy specimen, there is a lower hemorrhagic component. But the secondary injury begins right after the primary impact and it proceeds inexorably. And it has a resulting spread of edema and eventually a disruption of fiber transmission. And so far, we don't have a way to treat successfully complete neurological spinal cord injuries. Another example, this was a quadriplegic injury with a sagittal fracture. Another example, this was a 1990s case spinal cord injury in a college athlete resulting quadriplegia. Here's another example of a contusion, as you see here and here. And a better example in this player here of the contusion. So it shows up as high intensity in the spinal cord. And again, in every instance that I'm aware of, this is a career ending injury, radiographic injury, regardless if the player has has improved neurologically. You'd be hard set to to return this player to play that sport again where this happened. And most universities and probably most professional teams wouldn't allow it either. Then there's the concept, as I talked about, of instability. And a lot of times the instability is not that severe and will heal with time. Occasionally they are fused, but until this is corrected or it's noted to be stable on flex and extension films, this is another example of that third category of radiographic abnormality, which bears in decision making. Here's a herniated disc. You see this player right here. I had a central herniated disc, the myelographic CT. Here's the dye in the subarachnoid space. Here's the herniation. Now, these players often can return to play, but many times have to have the disc taken out and a fusion done ordinarily anteriorly and have to sit out for nine to 12 months. But it doesn't necessarily preclude their return to play. Here's an example here, an MRI of a disc fragment causing radiculopathy right here. And I got a call this week about a major collegiate program where there was a cervical fracture, significant fracture just a few days ago. So it still occurs and it occurs certainly every year, more often in high school, but it occurs at every level. And then, you know, for a disc procedure, one of the big questions is, do you do it anteriorly or posteriorly? If there's a soft disc posteriorly, you may you may be able to sneak in there, lift that root and do a posterior approach and not disrupt things anteriorly and have to do an anterior fusion. So this gets into the idea and the concept of decision-making for fixing these problems and how that impacts return to play. Here you see another adopted picture showing this, in this case, herniation right here hitting the spinal cord. So transient spinal cord injuries or spinal cord symptoms are a conundrum that if you do sports medicine for any length of time, you will experience a patient or player who has this or had had it. So this is a study we've done previously. This is looking at 35 examples of spinal cord transient symptoms and here's what they are. When you're looking for, is it spinal cord involvement or not, you want bilaterality. If you get lower extremities in addition to upper extremities, then that implicates a spinal cord and not the brachial plexus or an isolated nerve root. So in football, most common quadriplegia, quadriplegics was the largest number, and the duration is anywhere from two or three minutes up to 24-36 hours. In addition to motor, you can have centric symptoms. We had one case in our series of 35 total who had a hemiparesis from a cord injury. The issue that we'll get into in a few minutes is, well, how do you manage these and particularly, do you let them return to play? Are there any criteria? Transient injury usually is seen in football, hockey, soccer, and wrestling. So you need a high-velocity impact or being driven into the mat or the boards as I mentioned. As I said, it can be minutes up to 24-48 hours. There you see the symptoms. Almost half have no radiographic abnormality and cervical stenosis is seen in a little over half as well. So cervical stenosis is a very important concept. Depending on what textbook you read, some say if your anterior posterior canal diameter is less than 14 or 13, then that's the criterion for cervical canal stenosis. Certainly, if you get under 10 or nine and some people list eight, is a sine qua non that you should never be allowed to play with that sort of degree of stenosis. This is where you have to have a good handle on what makes a diagnosis of stenosis and how does it correlate. Do they have other changes as well, such as herniated disc or interchanges osteophytes? It may be a relative contraindication of play. Certainly, like everything in neurological sports medicine, it's an individualized return to participation. What are the radiographic findings? Does transient spinal cord injury really preclude you to other injuries? Which injuries have a higher recurrence rate? Is there something which is treatable, herniated disc or osteophyte? Then how do you recommend their return to play? The incidence is believed to be 7.3 in every 10,000 football participants. The pain can be described as burning, numbnance, paresthesias, as I mentioned, both arms, upper and lower extremities, all four extremities. You have to see them return to full function, normal neurological examination, the pain-free range of motion. What are the mechanisms? There have been several, three offered. How someone can lose function in their arms and legs and then that improved? Well, it's been said that it can be neuropraxia, which is really a peripheral nerve term that's been applied through the years. I think first mentioned by Joe Torg in Philadelphia years ago. But it just means that the conduction is not there, that it's a depolarization phenomenon, but there's no tearing, there's no hemorrhage, there's no edema, there's no structural abnormality that we can visualize anyway on MRI or CT. Others have like in a transient spinal cord injury in your neck to a concussion, so it's a blow. It's again a depolarization from a mechanical force causing the spinal cord not to work but not be injured, like we think for cerebral concussion. Then others have offered that it's a variant of central cord syndrome, which is a vascular injury as the cord is perfused from the center outward, and then it gives a variant of central cord syndrome. A neurologist in the 1960s named Penning said that this was a pincer's effect. What he meant was that there can be cases of extreme high-velocity impacts where the spinal cord is transiently impinged upon, but there's no demonstrable injury. There's no ligamentous injury, there's no bony injury or fracture, there's no hemorrhage, there's no disheartening agent. It's defined as the spinal cord being pinched by the posterior inferior edge of the body and the subjacent lamina, as you see in the red arrows there. This is very reminiscent of SIGURA, which is spinal cord injury without radiographic abnormality that we typically see in pediatric injuries where either the soft nature of their bones or the way they're able to absorb the blow of the injury, they don't break anything and they have a transient injury. You have to be aware that this transient injury occurs. It's not all that rare what the possible mechanisms are, and of course, it plays in very heavily to return to play. There's another syndrome that's related called spear-tackler spine. Spear-tackler spine has four characteristics. That is, they have a reversal of cervical lordosis, or as you see in this x-ray. They have evidence of previous minor healed vertebral body fractures. They have a relative cervical stenosis, and they're habitual user of spearing techniques. Through the years, being on several committees at the NCA level and NFL, we've tried to eliminate head contact with the top or crown of the helmet, and we have in big part. However, a spear-tackler, someone who is still using that technique, hopefully a lot less than it used to be. This is a famous case of a player called Chucky Mullins. It was a lot in the media about it several years ago when this occurred, but you see his premorbid cervical x-ray here. You see he certainly lost his lordosis. He's kyphotic. He may have old healed vertebral body injuries here. Then his final hit after suffering several transient injuries resulted in a fracture. Here he is at the moment of impact, demonstrating very demonstrably the way not to tackle and that is making contact with the crown or top of the helmet. If you see someone who has transient injuries, one of the things you have to be aware of is not only the presence of the phenomenon of spear-tackler spine with relative stenosis, loss of lordosis, and evidence of prior healed minor fractures. The fourth criterion is that they are habitual user of spearing techniques for hitting with the top of their helmet. Hopefully, this is going to be a thing in the past, but it's always out there. Even players who aren't trying to do it, and sometimes as you well know, still hit and make initial contact with the top or crown of the helmet. This is an important syndrome that's part of the concept of transient spinal cord injury. Stenosis, you see here, this is a 12-millimeter canal. This was an NFL player who had a small canal, not critically small, but by definition, consistent with stenosis. He was an NFL player, and on his fourth episode, he had prolonged quadriplegia. I hospitalized him. He was in the hospital two or three days. It finally started to recover and resolve, and finally it did. By a week later, he denied it ever happened, and he couldn't remember that he was ever truly not able to move, and wanted to continue to play. If someone has repetitive transient spinal cord injury, and they have a structural abnormality like this, I thought his career should end based on the repetitive nature. I think another way to look at it, and I don't like to always look at it this way, but you'd really be criticized and maybe indefensible, if you let someone who had been paralyzed transiently multiple times return to play, and they had a final injury. Here's just a plain x-ray showing what an x-ray looks like with stenosis. You look at the spinal laminar line here in the back of the body. This is so-called body canal ratio. It'd be bigger than 0.8. Some people call this the Torg ratio. Joe Torg popularized this in the 1970s and 80s, and it has withstood the test of time. We still enjoy using it because so many of these players get x-rays. You can throw it up, you can easily see and calculate for yourself if the player has the Torg ratio less than 0.8. However, we don't make treatment decisions or return to play decisions based on this anymore. We use MRI, and certainly MRI with dynamic measures. Here's again showing the flattened core that you get in stenosis and the inability to withstand for some players, maybe many players, a high velocity impact. I published this a few years ago. This was a series of 10 athletes who had stenosis only and temporary paralysis. This is the breakdown. Majority were football, one was gymnastics, one was wrestling, even ages. You'd see that symptoms are for the most part motor in all extremities. There were two that were sensory. We had certain criteria for returning them to play, which I'll take you through. The biggest thing in these players is if they have a smooth congenital stenosis without a focal impression, a focal disherniation or large osteophyte, and they've only had one or maybe two transient injuries, and everything else is normal, they don't have a herniated disc, they don't have a big osteophyte, and they have a relatively smooth symmetrical stenosis. Sometimes, as you see here, I've allowed them to return to play. Interestingly, if you get repeated transient injuries, if you get repeated episodes of spinal cord symptoms, that doesn't preclude you to breaking your neck. You don't get impingement, impingement, transient symptoms, and then the next game, you break your neck. Breaking your neck is a somewhat freakish, episodic, sporadic thing based on an axial impact, that sometimes as you go back and study those films, you can't really see what was different about that impact than any other. You probably know that and have thought about that and seen that before. However, if it's repetitive, as I said, I think you ought to consider with multiple episodes that they should continue to play. Certainly, if you are worried about a cervical injury, you have to think about other things as well. One is you see here in the MRI, and you see the operative picture below, subdural hematoma. Now, typically, a cranial problem will cause a hemipicture, and not both extremities or all four extremities, but it's possible. You have to think about a vascular injury, either to the vertebral artery or the carotid artery. You have to think about a brain injury itself. Subdural or epidural hematomas are most common in trauma. You got to think about concussion, brachial plexus injury, and you got to think about the inflammatory Parsonage-Turner syndrome, which ordinarily, you don't see after trauma. I have seen it come to the office, and that's inflammation of the brachial plexus, and that should be in your differential to rule out. I mentioned Burning Hand syndrome first described by Joe Maroon in JAMA around 1980. That was believed to be a transient minor version of central cord syndrome. They come literally because those fiber tracks to the hands are in the central part of the cortical spinal and the sensory pathways going up to the brain. They're in the central part where the blood supply is diminished momentarily, and this syndrome also resolves, and sometimes it's not necessarily with a single episode that precluding return to play in my opinion. Of course, you see the vertebral and the carotid arteries there, and the importance of taking them in the differential as you consider the etiology. Brachial plexus injury, stingers or burners are believed to be the upper trunk of the brachial plexus. They're pretty common. There are three mechanism by which they occur. One is shown here with a impact to the player with his head to the contralateral side, ipsilateral shoulder, and that's believed to cause that stretch injury. As you know, the players come off the field a lot of times with severe lancinating, burning pain that's just severe. It can lead to a pretty high recurrence rate, and it can be career ending. I've seen more than one NFL player just not be able to hit anymore because he had repeated land, it's like hitting your funny bone over and over again and getting that older nerve shock you get. This sort of stretch injury is one mechanism. The second mechanism is an axial load, which hits the top of the head and impacts the nerve root in his foramen. It's sort of a jackhammer effect from the top of the head. The third mechanism is a direct blow to the supraclavicular fossa impacting the brachial plexus directly. This picture here shows the most common form. What I do in these cases is I have the player come to the office, bring his helmet and the shoulder pads. Sometimes, especially in players with hypertrophic trapezii, there's too much of a gap between the shoulder pad up here and the chest. The trapezius is making the shoulder pad sit too high, and there can be a pounding in the supraclavicular fossa. You can look at shoulder pads, most of the good ones have pockets that sometimes I will insert foam in to obliterate that dead space. Then you always want to think of the helmet and shoulder pads coming together with a good solid fit so that the forces are in your mind, being directed down through the torso, anticipating and not being directed to the supraclavicular fossa. A couple of players, a couple of cases here. This was a 23-year-old Division I All-American wrestler. He had multiple episodes of right arm pain. Then he got new onset of left and bilateral arm pain. He had findings on exam, decreased range of motion, positive foramen compression test. He altered his techniques that didn't work. He had to have an inter-cervical discectomy infusion. Here was his large herniation, as you see here between four and five. This was corrected. It was fused with an allograft and plate, and I returned them to play or nearly 9-12 months after surgery. It was axial view of that herniation right here, hitting that nerve. Another example of Division I linebacker. He had a single episode of transient numbness in all limbs, normal neurological examination, pain-free, full range of motion, normal radiated rest, no fracture, no injury, had a congenital stenosis. This is about 12 millimeters, but as you see there's no focal fulcrum effect of an osteophyte or disc, and with a single episode and a normal exam, he was allowed to return to play and did not have a recurrence. So again, transient, you have to have a good working knowledge of transient cervical spine spinal cord injuries, but they don't go on to break their neck. Finally, as you know, the management of players on the field is important. I work with Northwestern University athletes and they're in games here in the Big Ten, and of course every season, even though we've done it for years, we will rehearse with all our trainers and student trainers and EMS, and you have to have your emergency action plan, and you have to rehearse equipment removal and transport to get them to the ED and then begin your workup. You know, for spinal cord injury, the athletic injury is really no different than any other spinal cord injury that's ordinarily managed at a trauma center and by standard spinal cord injury treatment protocols. We do this sort of evaluation. We like to look at starting with plain films and then CT. We're looking for bony injury primarily or a fractured dislocation or instability with flexion and extension films. We always get MRI. We're looking for what I call a functional MRI, which is looking for the CSF space and making sure that that's preserved. It probably isn't really the case, but we think that that sort of is a cushion, but it shows you sort of the relationship back to the vertebral body and to the spinal cord itself, so you want to look for that preservation of CSF signal. And look, as I've tried to emphasize, a lot of these players can go back to play, but it's your obligation to rule out these entities, and there's nothing more individualized in sports medicine than neurological injury. Everyone is different. You have to consider the age of the player, his expectations, his capabilities. Is he getting paid for this? Now, is this his livelihood? Is it the first time? What anatomical, structural abnormalities or predispositions does he have? Is he a spear tackler? Is he using a good technique? Is his equipment properly fitting? So a lot more than meets the eye in many cases, but it's fun and it's esoteric, so that makes it doubly interesting as you learn about it. So I'll stop there, and I think we have enough time for a little Q&A, Jim, if you want. Beautiful. Thanks, Julian. I really appreciate, again, your sharing your expertise with us. I always learn so much when I listen to you, and I've been on the sideline for 27 years now, and it's still the one thing that really gets me anxious, as I was saying at the beginning, and you see that hit, that big hit, and you're just, get up, get up, get up, and you're hoping that you're going to see something, and then you go out and you start going through your protocols, your ABCs, and trainers stabilizing the neck, and yeah, it's just a very, very frightening situation. I had a couple things. There are a couple questions from the group that I want to get to, and then I have a bunch of questions for you because, again, I find that the longer I've been doing this, the more questions I develop. One of them was regarding, you were talking about diving and football. Cheerleading has become a much bigger year-round sport, especially competitive cheer, where it has so much gymnastics involved, and lifts, and throws, and basket catches, and things like that, even with young kids. Have you seen a big uptick in the cheerleading injuries with regards to the cervical spine? Then also, if you could comment on trampoline use for me, recreational trampoline use. Well, I haven't seen cheerleading uptick, but certainly, it's out there, and it probably depends on your locale, and what the resources are, and what the schools are like, and so forth. I haven't really researched that lately, but of course, you always worry about the flyers, and when you see them on TV or in person, you kind of hold your breath for the potential because it's basically a fall that they get. It is very common. I'm the medical director, or the head of the medical advisory committee for Pop Warner Football. We're the oldest and largest youth football league in the country. We have over 4,000 games every weekend, and I've done it for about 13 years. We also have Pop Warner Cheerleading, so we're aware that we have not had any significant increase. That's at the youth level, but again, it's always out there, and you have to be prepared. Now, you talked about the fusion that you performed in the wrestler, the single-level fusion. You used that as one of your case studies. In most of the literature that I've read, after single-level fusion, as long as they're, again, everything's neurologically intact and no other problems for that athlete, return to play after single-level fusion is generally acceptable. Do you have a maximum number of levels that you will allow for return to play? Is it a single? Is it a three-level? Do you have anything on that? In my experience, most experts say single-level only for return, probably because the majority of these are younger and they haven't had the longevity to develop two-level disease. I'm sure somebody has sent someone back at some point, but I have never seen or done an athlete with more than one-level cervical fusion go back to play. That's the answer I gave on my last CAQ, everybody, by the way, when that came up. Must be correct then. I'm counting on that now. A question from, well, I won't read his name. I don't know if he wants me to read his name, but for transient spinal cord injuries, you mentioned that spinal cord contusion may be a potential mechanism of injury. However, spinal cord contusion is one of those injuries which precludes the athlete from return to sport. Could you comment on the difference? Also, what is the timeframe for you to consider transient? Well, there hasn't been a whole lot published. The publication says, as I showed in my slide, minutes to up to 48 hours. It goes much longer than that. I think a lot of neurologists and neurological people would say, well, maybe you do have an injury, a more permanent injury or longer lasting. In terms of a contusion, a contusion is like a brain contusion since the spinal cord is extension of the brainstem. That's a high-intensity lesion on an MRI. Ordinarily, at least as far as I know, that has precluded a return to play because the spectrum from contusion to definitive spinal cord injury is probably there and unpredictable. I always hate to think about things in medical legal terms, but you really have to in this area. You have to make every decision defensible. I would advise young physicians or anyone to collaborate with someone about that decision and get some consensus, especially if you have a demonstrable documented MRI injury to the nervous system. I've had a number of cases through the years, thankfully not many, where on a Monday, an athlete will come in to see me. At the Friday night football game, they had a heavy hit. They said that they lost feeling in both arms and both legs. Again, this is three days out. They're potentially asymptomatic at this point, neurologically intact. I usually go ahead and work them up just as if I had been there when it happened. What type of approach do you use to those people who come in after the fact and everything? Again, clinically at the time seems to be normal, but the history is such of a transient. It's usually sensory. I've never had anybody who had motor paralysis that didn't get looked at on the sideline, but they come in with these sensory symptoms in all four extremities, again, after the fact. How do you approach those? They would get plain films. They would get flexion, extension, lateral plain films, maybe a CT and certainly an MRI. MRI, you're looking for particularly herniation and contusion. I'm feeling better all the time talking to you, Julian. I tell you, I got to say, you brought up the torque ratio, the canal to body ratio. A lot of people went sour on that for a while because they said the size of the vertebral body and these really large players will throw the ratio off and it'll bring that number down. I never got rid of it in my own mind because I figured if it was 0.8 or higher, that was a really good sign that they probably didn't have stenosis. Like you said, stenosis, really to make the diagnosis on an x-ray, it's not appropriate because you don't know the size of the spinal cord, even though the cord is a little bit more consistent in its size compared to the canals. Was that correct? That's correct. I think I mentioned it's fun because almost always you have plain films. It gives you a little idea ahead of time. Like you just said, it'd be very unlikely that someone had a torque ratio of 0.9 and they would have significant stenosis. I think it's predictive, but it wouldn't withstand any medical legal challenge. You really want to see the nervous system. You want to see the relationship of the cord and disherniation, things like that, confusion. I do think it's certainly very important historically and it still does have some practical use. There's a question about spine boarding. The two primary techniques are the log roll technique and then the lift and slide where you lift the athlete up and then slide the board in, usually from the feet. Do you have a preferred technique for spine boarding? Or again, is it based on the number of people you have present and other things of that nature? Recent years we've used the lift and slide, but certainly I think you have to be versed in both. You could get in a situation, particularly in a high school game, where maybe you wouldn't have eight people do the lifting and things like that. I think you have to be versed in both. Principles are the same and that is maintain axial traction and axial neutrality. Now, the pendulum has swung back and forth a couple of times with regards to on the field removal of helmet versus just removal of face mask. If you remove the helmet, you need to remove the shoulder pads. Rob Blank at University of Pittsburgh way back in the day, he did a nice study with the people at University of Pittsburgh looking at you know, the spinal cord extension or the cervical extension. If you leave the football shoulder pads on and take the helmet off and then the head, the occiput drops back to the board. Do you have a preference from your perspective at this point as to whether or not we should be taking helmets and shoulder pads off or trying to leave them on during the course of an on-field attendance to one of these injuries? Yeah, you said it, Jim. You know, the thing is to maintain neutral position. I sort of, through the years, have liked to leave the helmet on, put the pads on both sides, tape them, put a collar on, and then transport that way and take the face mask off if you have any concern about airway, of course. It's a bigger deal to start, you know, taking off shoulder pads and cutting them and so forth, which you wouldn't do on the field anyway. So I think you're going to package them on the field and you're going to get them ready to transport and I prefer to remove the equipment in the ED in most cases. I just find it so hard to maintain stability when you're trying to get those shoulder pads off. I keep thinking how can we figure out maybe a shoulder pad mechanism where the shoulder pads can be in four pieces where we can unplug them and take them off more easily as opposed to trying to cut them up the front and then still try to slide it over the head and all these other things. Yeah, the best thing probably is that rip cord, you know, which allows you to buy valve in the shoulder pads like this, but I think, you know, unless there's an airway problem, I think that can be done better in a controlled setting and there's no urgency to do it as long as you maintain neutrality. So I, again, I apologize to everybody as you indulge me in my questions here along with the questions that have come through on the chat. I want to make one mention, you know, the Chucky Mullins case and the picture of him, you know, spear tackling the Vanderbilt player. If you actually look at, there are some copies of that instance where they have a wider shot of that same hit and if you look at that hit, his left hand, you know, when you go in to hit somebody and tackle somebody, your hands are open and when you, if you look at that, the photographer caught it at the perfect moment of impact. His thumb is actually adducted at the moment that the image was shot and I, to me, that's telling me that the injury has already taken place because instead of the thumb being up in a tackling position, he had already lost the motor control of that portion of his hand. So for those of you who are interested historically and looking back at those kinds of things, pull up that hit and take a look at that and, you know, if you think I'm crazy, you can email me and let me know, but that was just something I wanted to comment on because I went to the SEC conference, sports medicine conference, shortly after that and the entire conference basically was on cervical spine injury and catastrophic injuries. The last question I have for you is regarding stingers because we see a lot of these and, you know, kids come off and they're shaking their arm and, you know, within a few minutes they're feeling fine and their cervical exam is normal and they have a normal neurologic exam and, you know, we'll put kids back in the same game and if they have one, we'll let that go. If they start to have multiple, we start to work them up. Do you have a point where you say, hey, look, you know what, enough's enough, you know, you've had so many, yes, you've had full neurologic recovery, maybe the recovery is taking longer and longer each time. Is there a certain number? It's like concussions for me, you know, to pick a number isn't really as fair as trying to see how the person's doing, but I was wondering if you had something along that line with regards to recurrent stingers. Yeah, you're right, you know, we can't emphasize enough how problematic they are for many players. So, it depends on your level of play. Are you making a living doing it or are you getting a college scholarship for playing? So, a lot of factors, but if they recur several times and especially if it takes longer to recover or they have residual numbness or pain, then I think they need a prolonged layoff or maybe even retirement or especially if they have a neurological deficit weakness, you know, it's usually nerve root C5 and C6. So, biceps will be very commonly involved or wrist extension. So, it just depends on how many and if they are not recovering and are they a skinny kid in high school, they probably should retire. If they're making their living doing it, you really have to get a treatment plan with either, you know, steroids or anti-inflammatories, therapy, neck conditioning, strengthening equipment, all of those things, but it can be career ending for sure. Julian, I really appreciate your time and the effort you put into this for us and again, sharing your expertise is really a great pleasure for us and I do want to put in a plug for you guys getting to know your local neurosurgeons when you're taking care of athletes and doing sideline management. I have a very low threshold for consultation and second opinion when it comes to these kinds of things simply because even though I may feel confident in what I'm telling the patients and what I'm seeing in the patients, I do like that backup and I've never run into a situation where the neurosurgeon has called me and said, hey, why are you sending me this person? You know, they understand the importance from a long-term health perspective and our desire to do no harm and so I implore all of you to when you get to the place where you're going to practice is that you get to know your consultants and make sure they understand what your training is and what you're trying to accomplish and the types of patients you see because you see, you know, Dr. Bales is taking consults from multiple levels of participation from all over the country because this is his area of expertise that we just will never feel as comfortable with as he will and so again, I implore you to not take chances, to be confident in what you know, but also be comfortable in asking for help when it comes to some of these difficult cases so we're making the best choices for our patients and I'll get off my soapbox with that but again, Julian, really we appreciate it and thank you so much for your time and this will be recorded and we'll put it up on YouTube and we'll contact you with that link so you can use it for your purposes as well. Okay, thanks, great being with everyone tonight. Thank you so much. You're welcome. Good night everybody, we'll see you in Austin in a couple of weeks.

3rd Edition, CASE 53

3rd Edition

Spine

cervical injuries

athletes

neurosurgery

spine management

high-risk sports

sideline assessment

return-to-play

protective gear

emergency scenarios