Cervical Injuries and Sport Dr Janusz Bonkowski Neurosurgeon and Spinal Surgeon 06.08.2014

Cervical 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

Central L parasagittal

C 5/6 C 5/6 C 6/7

Surgical alternatives for Radiculopathic pain at one level, one side with adjacent segment changes on MR Posterior cervical foramenotomy: one or two level Anterior cervical foramenotomy: one or two level Anterior cervical discectomy Anterior cervical fusion: at symptomatic level only Anterior cervical fusion: at both (radiologically abnormal ) levels. Cervical arthroplasty at symptomatic level 2 level cervical arthroplasty

Scenario #1 29 year old. Insurance agent. Keen rugby player, local club level. Would like to keep playing, but has alternative sports interests.

Scenario #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.

Scenario #3 29 year old. Professional rugby has been career for 10 years. NPC 1st division. Super 14 current player. All-Black. Being headhunted by overseas clubs.

Cervical 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 ACDF 5/9 returned to sports activities with no adverse effects (15 mo av f/u) ------------------------------------------------------------------------------------------ Plain x-ray:7 Kippel-Feil 29 had “degenerative changes” 52 had osteophytic ridging 89 (86%) had canal stenosis

Return to Contact Sport after Spinal Injury Sontag V et al Neurosurg Focus 2006 Recommendation: ?Return to sport Posterior foramenotomy single level yes multiple level yes Laminectomy/laminoplasty less then or up to 2 level yes more than 2 level no Anterior discectomy/fusion/arthro single/ 2 level yes more than 2 level no Anterior foramenotomy single/multi level yes

Cervical Cord Neuropraxia in Elite Athletes Maroon J C et al Neurosurg Spine 2007 5 Footballers age range 20-32, 4 pro, one college All underwent 1 level ACDF with plates/ allogfaft All 5 resumed playing 3 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

Rugby 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 MRI 71% 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 1979-1999. 7 had congenital fusions of cervical vertebrae. Usual incidence of congenital fusion 7/1000.

1: 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 playing 3: 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.

Alex McKinnon

James Tamou

James 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….”

STINGERS Painful 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%).

STINGERS 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.

Transient 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.

Absolute Contraindications on RTP Previous transient Quadriparesis: 2 or more previous episodes Evidence of cervical myelopathy Continued cervical discomfort Decreased ROM Neurological deficit. Vaccaro, AR et al Curr Reviews MS Med 2008

Absolute Contraindications on RTP Postsurgical patients: C1-2 fusion Cervical laminectomy Anterior cervial fusion more than 2 levels Posterior cervical fusion more than 2 levels Cervical arthroplasty more than one level

Absolute 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

Absolute Contraindications on RTP Radiological Findings: Multilevel Klippel-Feil Spear-tacklers spine ( kyphotic spine with stenosis) Healed subaxial fracture with sagittal or coronal plane deformity Ankylosing Spondylitis or Diffuse Idiopathic Skeletal Hyperostosis or Rheumtoid Arthritis.

Absolute Contraindications on RTP MR/CT Findings: Basilar invagination Fixed Atlanto-Axial rotatory subluxation Occipital-C1 assimilation Residual cord encroachment after healed subaxial spine fracture Any cord abnormality or cord signal change.

Relative Contraindications to RTP Prolonged symptomatic stinger/burner or transient quadriparesis more then 24 hr. More than 3 prior episodes of stinger/burner Failure to return to baseline ROM, neurological status or increasing neck discomfort. Healed 2 level anterior or posterior fusion surgery.

Zahir U et al Seminars in Spine Surgery 2010 On-field assessment Zahir U et al Seminars in Spine Surgery 2010 Conclusion: Get him/her of the field!

Conclusion All data is based on Grade III evidence or worse, no consensus even amongst experts on RTP criteria or management.