1. Cervical Injuries and Sport
Dr Janusz Bonkowski
Neurosurgeon and Spinal Surgeon

2. 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

3. Central
L parasagittal

4. C 5/6
C 5/6
C 6/7

6. 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

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

8. 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.

9. 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.

10. 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

11. 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

12. 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

13. 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 had congenital fusions of cervical vertebrae. Usual incidence of congenital fusion 7/1000.

14. 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.

15. Alex McKinnon

16. James Tamou

17. 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….”

18. 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%).

19. 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.

20. 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.

21. 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

22. 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

23. 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

24. 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.

25. 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.

26. 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.

27. 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!

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