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Cervical Spine

Injuries in Sport

“Its All in the Game”

Dr Jonathon R. BallFRACS BMed BMedSc(Hons)

GradDipBiomedE

Neurosurgeon and Spinal Surgeon

Royal North Shore Hospital

North Shore Private Hospital

Sydney, Australia

Head of Department, Neurosurgery

Royal North Shore Hospital

Sydney, Australia

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Cervical Fractures @ RNSHn = 389

RNSHsource :http://www.abc.net.au/7.30/

RNSHsource : www. trove.nla.gov.au

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Outline

• Acute spinal cord injury

• Cervical cord neurapraxia

• Burners/Stingers

• Cervical disc protrusions & fractures

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SCI in Australia (2007-2008)

• 285 traumatic SCIs

• 25 (9%) “struck by, or collision with another

person or object”

• 10 participating in sporting or leisure activities

(excludes water actives)

source : AIHW: Norton L 2010. Spinal cord injury, Australia 2007–08. Injury research and statistics series no. 52. Cat. no. INJCAT 128. Canberra: AIHW.

RNSHsource : http://irbplayerwelfare.com/pdfs/CI_Risk_Assessment_EN.pdf

RNSHsource : http://irbplayerwelfare.com/pdfs/CI_Risk_Assessment_EN.pdf

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Outline

• Acute spinal cord injury

• Cervical cord neurapraxia

• Burners/Stingers

• Cervical disc protrusions & fractures

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Classification of CCN

• type (neurologic

deficit)

• plegia

• paresis

• parasthesia

• grade (duration)

• 1 : < 15 mins

• 2 : 15 mins - 24 hrs

• 3 : > 24 hrs

• pattern

• quad : all 4 limbs

• upper : both upper

limbs

• lower : both lower

limbs

• hemi : ipsilateral

upper/lower limbs

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‘Pincer Mechanism’after Penning (1962)

source : Torg JS et al. J Bone Joint Surg Am. 84(1):112-122 (2002).

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Pathophysiology

source : Torg JS et al. Clin Orthop Relat Res. (321):259-69 (1995).

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Pathophysiology

source : Torg JS et al. Clin Orthop Relat Res. (321):259-69 (1995).

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Torg/Pavlov Ratio

source : Chao S et al. Sports Med. 40(1):59-75 (2010).

RNSHsource : Torg JS et al. J Bone Joint Surg Am. 78(9):1308-14 (1996).

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source : Meredith DS et al. Am J Sports Med. 78(9):1308-14 (2013).

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Outline

• Acute spinal cord injury

• Cervical spinal cord neurapraxia

• Burners/Stingers

• Cervical disc protrusions & fractures

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‘Burners/Stingers’

• temporary episode of unilateral upper extremity

dysaesthesia +/- motor weakness

source : Chang D & Bosco J. Bull NYU Hosp Jt Dis. 64(3-4): 119-129

(2006).

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Outline

• Acute spinal cord injury

• Cervical spinal cord neurapraxia

• Burners/Stingers

• Cervical disc protrusions & fractures

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To Operate or Not ?

• acute patent safety

• need for acute neurologic decompression

• need for acute stabilisation

• future RTP considerations

• higher functional demand - prevent further

injuries

• potential for ‘timely’ healing op vs non-op

based on : C. Prusmack, NASS

2013.

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Neurologic Decompression

• Clinical

• neuro exam : normal, improving, worsening,

fixed

• radicular vs cord vs plexus

• Radiographic

• SC compression : disc, fracture, haematoma

• Functional Reserve : ?? how much

• Stenosis : focal, diffuse, congenital,

degenerative

• Foraminal stenosis

• Contusionbased on : C. Prusmack, NASS

2013.

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Future RTP Considerations

• safety issues

• prevent further SCI

• prevent further neurologic symptoms

• consequence of surgical intervention

• professional issues

• level of player

• sport & position

• livelihood

• timing

based on : C. Prusmack, NASS

2013.

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• 99 x NFL players

• 53 x operative

• 32 x ACDF, 3 x foraminotomy, 16 not known

• RTP 72 % (29.3 games, 2.8 years)

• ASD 5.3%

• 46 x non-operative

• RTP 46 % (14.7 games, 1.5 years)

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• 16 x NFL players

• 9 x radicular Sx, 3 x CCN

• initial non-operative Mx

• 3 x ACDF - 1 x RTP

• 13 non-operative - 8 x RTP

RNSHsource : Burnett MG JS & Sonntag V Neurosurg Focus. 15;21(4):E5

(2006).

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• 15 subjects (7 x NFL, 8 x WWE)

• RTP 13/15

• adjacent disc herniation - 1 subject after 2 years

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• 19 professional rugby players (1998-2003)

• 17 x single level ACDF, 2 x double level

• 13 x RTP same level, 1 x RTP lower level

• 5 did not RTP

• 2 x recurrent neck/radicular symptoms

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Return to Play Criteria

• Clinical

• no neck pain, normal cervical range of motion,

normal neurologic exam

• no prohibitive history

• Radiographic

• flex-ext XR - no instability

• CT : no significant fracture

• MR : no cord compression (? functional reserve,

contusion, foraminal stenosis)

based on : C. Prusmack, NASS

2013.

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Outline

• Acute spinal cord injury

• Cervical cord neurapraxia

• Burners/Stingers

• Cervical disc protrusions & fractures

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