Sprains, stingers, cord neurapraxia among cervical spine injuries in young athletes

Researcher highlights a lack of data on prevention and systematic guidelines for return to sports.

The overall incidence of cervical spinal cord injuries in children younger than 16 years is about 13% and roughly 25% of those are due to sports participation.

At the American Academy of Orthopaedic Surgeons annual meeting, Laurel C. Blakemore, MD, discussed the epidemiology and patterns of cervical spine injuries in young athletes.

Blakemore noted that the average patient with a sports-related cervical spine injury is 10-years-old and 60% of these cases occur in boys.

---

advertisement

---

“The upper cervical spine injuries predominate in children less than 8 years old,” she said. “The lower cervical spine subaxial injuries predominate in children older than 8 years, but you can have a multilevel injury.”

Children with special risk-factors for these injuries include those with Down syndrome, Ehler-Danlos syndrome, Klippel Fei syndrome, skeletal dysplasias and odontoid anomalies. Football, gymnastics, equestrian and wrestling are among the sports with the highest rates of head and neck injuries, Blakemore said. When on-field evaluations reveal positive findings and require radiographic evaluation, physicians should search for pseudosubluxation.

“SCIWORA is something to consider in any child who comes in with neurologic symptoms and radiographic abnormalities that are not evidence on plain radiographs,” Blakemore said. She noted that a recent study from researchers in Cincinnati revealed that 75% of children with sports-related cervical spine injuries showed evidence of SCIWORA (spinal cord injury without radiographic abnormality).

Soft-tissue injuries

Common cervical soft-tissue injuries can be categorized as cervical sprains, stingers or burners or cervical cord neurapraxia.

“Paracervical sprains generally present after either a hyperextension or flexion episode or eccentric muscle contraction against a load,” Blakemore said. Symptomatic rehabilitation for these patients includes activity restriction, immobilization and the use of NSAIDs or muscle relaxants.

“Stingers [are] generally from either the forceful distraction of the head from the arm, which puts traction on the brachial plexus or a pincher effect or impingement at the neural foramen of the exiting nerve roots,” Blakemore said. Recovery can occur between a few seconds to 10 minutes.

It is generally safe to allow athletes to return to play if they are pain-free, show a full range of motion and lack tenderness to palpation in the cervical spine. Those with persistent symptoms, more than one involved limb or more than three prior episodes are restricted from play and require further evaluation and rehabilitation, she said.

Cervical cord neurapraxia occurs from forced hyperflexion or hyperextension and is commonly associated with spear tackling. “Football, particularly in America, gets a reputation for cervical cord neurapraxia when, in fact, it is probably due to the high participation of high school and adolescent athletes,” Blakemore said.

After adjusting the number of injuries by the number of participants, she noted that football has a lower rate of cervical spine injury than other sports such as wresting. She also cited research by Scott D. Boden, MD, and colleagues that found that only 1.1 out of 100,000 high school football players sustained catastrophic cervical spine injuries per year.

The Pavlov/Torg ratio has a high sensitivity, but a low specificity and predictive value for determining which injuries are caused by cervical congenital stenosis. However, Blakemore said that the ratio is useful for predicting recurrence.

Risk assessment

“We really do not have any good systemic guidelines to recommend who should go back to play,” she said. Blakemore noted that the relative contraindications for return to play include a Pavlov/Torg ratio of <8, a previous cervical cord neurapraxia and cervical disc disease or degenerative changes, MRI evidence of spinal cord deformation or two- to three-level fusions.

“It is an absolute contraindication if they have any MRI evidence of spinal cord edema, odontoid hypoplasia, more than three-level congenital fusions such as Klippel-Feil, C1-2 anomalies or if they have persistent pain, stiffness or neuropraxia at any point after one of these episodes,” Blakemore said.

She noted that the Special Olympics generally requires flexion-extension views for athletes with Down syndrome who want to participate in high-risk sports. Those with an Atlantal Dens Interval (ADI) of <5 mm can participate in such sports while those with an ADI between 5 mm and 9 mm can play low-risk sports. Athletes with an ADI >10 mm are restricted from play.

“In terms of prevention, we really do not have any good information,” Blakemore said. She also noted a lack of good radiographic screening methods for preventing these injuries.

For more information:

• Laurel C. Blakemore, MD, is the chief of orthopaedics and sports medicine at Children’s National Medical Center. She can be reached at 111 Michigan Avenue NW, Washington, D.C.20010; 202-476-4152; e-mail: LBlakemo@cnmc.org. She has no direct financial interest in any products or companies mentioned in this article.

Reference:

• Blakemore LC. C-spine issues. Symposia N: Spine problems in young athletes. Presented at the American Academy of Orthopaedic Surgeons 75th Annual Meeting. March 5-9, 2008. San Francisco.