Presentation on theme: "Cervical Injuries and Sport"— Presentation transcript:
1Cervical Injuries and Sport Dr Janusz BonkowskiNeurosurgeon and Spinal Surgeon
2Cervical 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
6Surgical alternatives for Radiculopathic pain at one level, one side with adjacent segment changes on MRPosterior cervical foramenotomy: one or two levelAnterior cervical foramenotomy: one or two levelAnterior cervical discectomyAnterior cervical fusion: at symptomatic level onlyAnterior cervical fusion: at both (radiologically abnormal ) levels.Cervical arthroplasty at symptomatic level2 level cervical arthroplasty
7Scenario #1 29 year old. Insurance agent. Keen rugby player, local club level.Would like to keep playing, but has alternative sports interests.
8Scenario #2 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.
9Scenario #329 year old.Professional rugby has been career for 10 years.NPC 1st division.Super 14 current player.All-Black.Being headhunted by overseas clubs.
10Cervical Cord Neuropraxia Torg J et al J Neurosurg 1997 110 cases of transient neurological phenomena in sports related activities.96 in footballers (US)12 underwent surgery: 9 had one level ACDF5/9 returned to sports activities with no adverse effects (15 mo av f/u)Plain x-ray:7 Kippel-Feil29 had “degenerative changes”52 had osteophytic ridging89 (86%) had canal stenosis
11Return to Contact Sport after Spinal Injury Sontag V et al Neurosurg Focus 2006 Recommendation: ?Return to sportPosterior foramenotomysingle level yesmultiple level yesLaminectomy/laminoplastyless then or up to 2 level yesmore than 2 level noAnterior discectomy/fusion/arthrosingle/ 2 level yesmore than 2 level noAnterior foramenotomysingle/multi level yes
12Cervical Cord Neuropraxia in Elite Athletes Maroon J C et al Neurosurg Spine 2007 5 Footballers age range 20-32, 4 pro, one collegeAll underwent 1 level ACDF with plates/ allogfaftAll 5 resumed playing3 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
13Rugby Union Injuries to the Cervical Spine and Spinal Cord Quarrie et al Sports Med 2002 Cite Berge (1999) 35 senior & veteran players c/w age-matched controls studied with MRI71% had disc space narrowing (controls 17%)31% had disc prolapses (controls 3%)Cite Hughes (2000) 85 Pt with cervical spine injuries treated Burwood Spinal Unit had congenital fusions of cervical vertebrae. Usual incidence of congenital fusion 7/1000.
141: 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 playing3: 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.
17James Tamou “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….”
18STINGERSPainful 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%).
19STINGERS 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.
20Transient Quadraparesis 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.
21Absolute Contraindications on RTP Previous transient Quadriparesis:2 or more previous episodesEvidence of cervical myelopathyContinued cervical discomfortDecreased ROMNeurological deficit.Vaccaro, AR et al Curr Reviews MS Med 2008
22Absolute Contraindications on RTP Postsurgical patients:C1-2 fusionCervical laminectomyAnterior cervial fusion more than 2 levelsPosterior cervical fusion more than 2 levelsCervical arthroplasty more than one level
23Absolute Contraindications on RTP 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
24Absolute Contraindications on RTP Radiological Findings:Multilevel Klippel-FeilSpear-tacklers spine ( kyphotic spine with stenosis)Healed subaxial fracture with sagittal or coronal plane deformityAnkylosing Spondylitis or Diffuse Idiopathic Skeletal Hyperostosis or Rheumtoid Arthritis.
25Absolute Contraindications on RTP MR/CT Findings:Basilar invaginationFixed Atlanto-Axial rotatory subluxationOccipital-C1 assimilationResidual cord encroachment after healed subaxial spine fractureAny cord abnormality or cord signal change.
26Relative Contraindications to RTP Prolonged symptomatic stinger/burner or transient quadriparesis more then 24 hr.More than 3 prior episodes of stinger/burnerFailure to return to baseline ROM, neurological status or increasing neck discomfort.Healed 2 level anterior or posterior fusion surgery.
27Zahir U et al Seminars in Spine Surgery 2010 On-field assessmentZahir U et al Seminars in Spine Surgery 2010Conclusion: Get him/her of the field!
28ConclusionAll data is based on Grade III evidence or worse, no consensus even amongst experts on RTP criteria or management.