Brain and Spinal Injuries and Sport Cervical injuries and sport Dr Janusz Bonkowski

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

2. • 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
Cervical Injuries and Sport

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
o single level yes
o multiple level yes
• Laminectomy/laminoplasty
o less then or up to 2 level yes
o more than 2 level no
• Anterior discectomy/fusion/arthro
o single/ 2 level yes
o more than 2 level no
• Anterior foramenotomy
o 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 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.
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%)

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. 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….”

16. 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%).

17. 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.

18. 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.

19. 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

20. 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

21. 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

22. 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.

23. 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.

24. 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.

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

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