Degenerative Disease of the Cervical Spine and Its Relationship to Athletes

Prevalence, diagnosis and management of musculoskeletal disorders in elite athletes: A mini-review

Musculoskeletal injuries in elite sports are ones of the most impact issue because their remarkable impact on performance caused by drastic absence of training and competition and a progressive deterioration in physical health, emotional and social athletes' dimensions. Also, the prevalence of epidemiologic research found an incidence of musculoskeletal disorders vary within sports and in elite athletes which is even higher as a consequence of higher demand physical performance. This way, the loss of physical performance due to an sport injury impacts not only the individual economic sphere of the professional but also that ofsports entities, reaching, according to some studies, a loss estimated in the range of 74.7 million pounds. Thus, the purpose of this article is to review and to provide an overview of the most common musculoskeletal injuries in elite sports precipitating factors, clinical presentation, evidence-based diagnostic evaluation, and treatment recommendations with a view to preventing medical conditions or musculoskeletal injuries that may alter performance and general health in the elite athletes.

Risk factors for the development of degenerative cervical myelopathy: a review of the literature

Degenerative cervical myelopathy (DCM) encompasses various pathological conditions causing spinal cord (SC) impairment, including spondylosis (multiple level degeneration), degenerative disc disease (DDD), ossification of the posterior longitudinal ligament (OPLL), and ossification of the ligamentum flavum (OLF). It is considered the most common cause of SC dysfunction among the adult population. The degenerative phenomena of DDD, spondylosis, OPLL and OLF, is likely due to both inter-related and distinct factors. Age, cervical alignment, and range of motion, as well as congenital factors such as cervical cord-canal mismatch due to congenital stenosis, Klippel-Feil, Ehler-Danlos, and Down syndromes have been previously reported as potential factors of risk for DCM. The correlation between some comorbidities, such as rheumatoid arthritis and movement disorders (Parkinson disease and cervical dystonia) and DCM, has also been reported; however, the literature remains scare. Other patient-specific factors including smoking, participation in contact sports, regular heavy load carrying on the head, and occupation (e.g. astronauts) have also been suggested as potential risk of myelopathy development. Most of the identified DCM risk factors remain poorly studied however. Further researches will be necessary to strengthen the current knowledge on the subject, especially concerning physical labors in order to identify patients at risk and to develop an effective treatment strategy for preventing this increasing prevalent disorder.

On-Field Management of Suspected Spinal Cord Injury

Acute spinal cord injuries in athletes are rare. However, on-field management of such injuries requires a well-planned approach from a team of well-trained medical staff. Athletes wearing protective gear should be handled with care; a primary survey should be conducted to rule out life-threatening injury while concomitantly immobilizing the spine. Treatment with steroids or hypothermia have not been shown to be beneficial, ultimately time to surgery provides the athlete with the best chance of a good outcome.

Return-to-Play Outcomes in Elite Athletes After Cervical Spine Surgery: A Systematic Review

CONTEXT

Return-to-play (RTP) outcomes in elite athletes after cervical spine surgery are currently unknown.

OBJECTIVE

To systematically review RTP outcomes in elite athletes after anterior cervical discectomy and fusion (ACDF), cervical disc replacement (CDR), or posterior foraminotomy (PF) surgery.

DATA SOURCES

EMBASE, PubMed, Cochrane, and Medline databases from inception until April 2020. Keywords included elite athletes, return to play, ACDF, foraminotomy, and cervical disc replacement.

STUDY SELECTION

Eligible studies included those that reported RTP outcomes in elite athletes after cervical spine surgery.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Data were extracted by 2 independent reviewers.

RESULTS

The primary outcomes of interest were rates and timing of RTP. Secondary outcomes included performance on RTP. A total of 1720 studies were initially screened. After inclusion criteria were applied, 13 studies with a total of 349 patients were included. A total of 262 (75%) played football, 37 (11%) played baseball, 19 (5%) played rugby, 10 (3%) played basketball, 10 (3%) played hockey, 9 (3%) were wresters, and 2 (1%) played soccer. ACDF was reported in 13 studies, PF in 3 studies, and CDR in 2 studies. The majority of studies suggest that RTP after surgical management is safe in elite athletes who are asymptomatic after their procedure and may lead to higher rates and earlier times of RTP. There is limited evidence regarding RTP or outcomes after CDR or multilevel surgery.

CONCLUSION

The management and RTP in elite athletes after cervical spine injury is a highly complex and multifactorial topic. The overall evidence in this review suggests that RTP in asymptomatic athletes after both ACDF and PF is safe, and there is little evidence for decreased performance postoperatively. Surgical management results in a higher RTP rate compared with athletes managed conservatively.

Prevalence of sports-related spinal injury stratified by competition level and return to play guidelines

Spinal injury is among the most severe and feared injuries an athlete may face. We present an up-to-date review of the recent literature, stratifying recommendations based on injury location (cervical, thoracic, and lumbar spine) and type, as well as, the level of competitive play (high school, collegiate, professional). A literature search was completed to identify all publications reporting return to play guidelines for athletic injuries or injury-related surgery irrespective of the study design. Publication dates were not restricted by year. Search terms used included "return to play" and "spinal injury" on National Library of Medicine (PubMed) and Google Scholar. Selection criteria for literature included axial spine injury guidelines for athletic participation post-injury or post-surgery. Literature found from the search criteria was sorted based on level of competition and location of axial spine injury involved. It was found that professional athletes are more likely to suffer severe spinal injuries, require surgery, and necessitate a longer return to play (RTP), with high school and college athletes usually returning to play within days or weeks. Injuries occur mainly within contact sports and concordance exists between initial and subsequent spinal injuries. Adequate rest, rehabilitation, and protective equipment alongside the education of athletes and coaches are recommended. In conclusion, a multidisciplinary approach to patient management is required with consideration for the emotional, social, and perhaps financial impact that spinal injury may have upon the athlete. Consensus from the literature states that in order for an athlete to safely return to play, that athlete should not be actively suffering from pain, should have a full range of motion, and complete return of their strength in the absence of neurological deficit.

MRI-detected spinal disc degenerative changes in athletes participating in the Rio de Janeiro 2016 Summer Olympics games

Objective

To describe the frequency and the distribution of degenerative disc disease (DDD) detected in athletes who underwent spine MRI in the 2016 Summer Olympic Games in Rio de Janeiro.

Methods

Data on spine MRI examinations from the 2016 Summer Olympics were retrospectively analyzed. We assessed the frequency of DDD of the cervical (Cs), thoracic (Ts), and lumbar (Ls) spine using Pfirrmann’s classification. Grade II and III were considered as mild, grade IV as moderate, and grade V as severe disc degeneration. Data were analyzed according to the location of the degenerative disc, type of sport, age-groups, and gender of the athletes.

Results

One hundred out of 11,274 athletes underwent 108 spine MRI’s (21 C, 6 T, and 81 L) (53% Females (F), 47% Males (M)). The frequency of DDD was 40% (42% F, 58% M) over the entire spine (28% mild, 9% moderate and 3% severe). There were 58% (12%F, 88%M) of the cervical spine discs that showed some degree of degeneration (44% mild, 13.5% moderate and 1% severe). Athletics, Boxing, and Swimming were the sports most affected by DDD in the Cs. There were 12.5% of the thoracic discs that showed some degree of degeneration, all were mild DDD and were exclusively seen in female athletes. There were 39% (53% F, 47% M) of the lumbar discs with DDD (26% mild, 9% moderate, and 4% severe).

Conclusion

Athletes who underwent spine MRI during the 2016 Summer Olympic Games show a high frequency of DDD of cervical and lumbar spines. Recognition of these conditions is important to develop training techniques that may minimize the development of degenerative pathology of the spine.

Controversies in the Management of Cervical Spine Conditions in Elite Athletes

Cervical spine injuries in elite athletes can have detrimental consequences, which makes return to play for professional athletes after cervical spine injury controversial. Although most athletes can return to sport under some circumstances, such as single-level anterior cervical diskectomy and fusion for cervical disk herniation, return to play after cervical disk arthroplasty and multilevel fusion for cervical disk herniation remains controversial. Allowing athletes to return to play after a finding of cervical stenosis and in the incidence of pseudarthrosis remains unclear. This review provides a systematic framework to guide return-to-play decision-making in common cervical conditions in elite athletes. [Orthopedics. 2019; 42(4):e370-e375.].

The prevalence and associated factors of symptomatic cervical Spondylosis in Chinese adults: a community-based cross-sectional study

BACKGROUND

Cervical spondylosis adversely affects life quality for its heavy disease burden. The report on the community-based prevalence and associated factors of cervical spondylosis is rare, especially in Chinese population. Whether prevention is needed and how to prevent it is not clear. This study aims to explore its prevalence and related lifestyle factors and provide evidence on prevention of cervical spondylosis.

METHODS

A community-based multistage cross-sectional survey of six communities from the Chinese population was conducted. A face-to-face interview was conducted to obtain individual information, and prevalence was calculated. Single-factor analysis and multivariable logistic regressions were used to explore the associated factors in total and subgroup populations.

RESULTS

A total of 3859 adults were analyzed. The prevalence of cervical spondylosis was 13.76%, although it differed significantly among the urban, suburban, and rural populations (13.07%, 15.97%, and 12.25%, respectively). Moreover, it was higher in females than in males (16.51% vs 10.49%). The prevalence among different age groups had an inverted U shape. The highest prevalence was in the age group from 45 to 60 years old. The associated factors differed by subgroups. There were positive associations between engaging in mental work, high housework intensity, and sleep duration of less than 7 h/day with cervical spondylosis. Going to work on foot was a negative factor of cervical spondylosis in the total population. For people aged less than 30 years, keeping the same work posture for 1-2.9 h/day was a special related factor. Exposure to vibration was an associated factor for females aged 45-60 years. Menopause was a special related factor for women.

CONCLUSIONS

Prevalence of cervical spondylosis was high in Chinese population. People younger than 60 years were the focus of prevention for cervical spondylosis. Moreover, the characters between male and female and among different age groups were different and required targeted interventions.

RhoA inhibits the hypoxia-induced apoptosis and mitochondrial dysfunction in chondrocytes via positively regulating the CREB phosphorylation

Chondrocytes that are embedded within the growth plate or the intervertebral disc are sensitive to environmental stresses, such as inflammation and hypoxia. However, little is known about the molecular signalling pathways underlining the hypoxia-induced mitochondrial dysfunction and apoptosis in chondrocytes. In the present study, we firstly examined the hypoxia-induced apoptosis, mitochondrial dysfunction and the activation of cyclic adenosine monophosphate (cAMP) response element-binding protein (CREB) signalling in human chondrocyte cell line, C28/I2 and then investigated the regulatory role of RhoA, a well-recognized apoptosis suppressor, in such process, with gain-of-function strategy. Our results indicated that hypoxia induced apoptosis and inhibited CREB phosphprylation in chondrocytes, meanwhile, the dysfunctional mitochondria with up-regulated mitochondrial superoxide and reactive oxygen species (ROS) levels, whereas with a reduced mitochondrial membrane potential (MMP) and Complex IV activity were observed in the hypoxia-treated C28/I2 cells. However, the overexpressed RhoA blocked the hypoxia-mediated reduction in CREB phosphprylation and inhibited the apoptosis induction, along with an ameliorated mitochondrial function in the hypoxia-treated C28/I2 cells. In conclusion, the present study confirmed the reduced CREB phosphorylation, along with the apoptosis induction and mitochondrial dysfunction in the hypoxia-treated chondrocyte cells. And the overexpression of RhoA ameliorated the hypoxia-induced mitochondrial dysfunction and apoptosis via blocking the hypoxia-mediated reduction in CREB phosphorylation.

Risk of anterior cruciate ligament fatigue failure is increased by limited internal femoral rotation during in vitro repeated pivot landings

BACKGROUND

A reduced range of hip internal rotation is associated with increased peak anterior cruciate ligament (ACL) strain and risk for injury. It is unknown, however, whether limiting the available range of internal femoral rotation increases the susceptibility of the ACL to fatigue failure.

HYPOTHESIS

Risk of ACL failure is significantly greater in female knee specimens with a limited range of internal femoral rotation, smaller femoral-ACL attachment angle, and smaller tibial eminence volume during repeated in vitro simulated single-leg pivot landings.

STUDY DESIGN

Controlled laboratory study.

METHODS

A custom-built testing apparatus was used to simulate repeated single-leg pivot landings with a 4×-body weight impulsive load that induces knee compression, knee flexion, and internal tibial torque in 32 paired human knee specimens from 8 male and 8 female donors. These test loads were applied to each pair of specimens, in one knee with limited internal femoral rotation and in the contralateral knee with femoral rotation resisted by 2 springs to simulate the active hip rotator muscles' resistance to stretch. The landings were repeated until ACL failure occurred or until a minimum of 100 trials were executed. The angle at which the ACL originates from the femur and the tibial eminence volume were measured on magnetic resonance images.

RESULTS

The final Cox regression model (P = .024) revealed that range of internal femoral rotation and sex of donor were significant factors in determining risk of ACL fatigue failure. The specimens with limited range of internal femoral rotation had a failure risk 17.1 times higher than did the specimens with free rotation (P = .016). The female knee specimens had a risk of ACL failure 26.9 times higher than the male specimens (P = .055).

CONCLUSION

Limiting the range of internal femoral rotation during repetitive pivot landings increases the risk of an ACL fatigue failure in comparison with free rotation in a cadaveric model.

CLINICAL RELEVANCE

Screening for restricted internal rotation at the hip in ACL injury prevention programs as well as in individuals with ACL injuries and/or reconstructions is warranted.

Ascorbic acid provides protection for human chondrocytes against oxidative stress

Oxidative stress is considered to be an important cause of dysfunction in chondrocytes and articular cartilage degradation, which leads to the pathogenesis of osteoarthritis (OA) and cartilage aging. The present study aimed to assess the effects of the widely applied antioxidant, ascorbic acid (AA), on human chondrocytes against hydrogen peroxide (H2O2) in vitro. Using annexin V‑fluorescein isothiocyanate, 3‑(4,5‑dimethylthiazol‑2‑yl)‑2,5‑diphenyl tetrazolium bromide and senescence‑associated β‑galactosidase assays, the present study identified that AA reduced apoptosis, reduced the loss of viability and markedly decreased H2O2‑mediated senescence in cells treated with H2O2. Furthermore, AA not only stimulated the expression levels of collagens and proteoglycans, but also inhibited the differentiation of chondrocytes under conditions of oxidative stress. In addition, reverse transcription‑quantitative polymerase chain reaction and western blotting demonstrated that AA decreased the activity of nrf2, NF‑κB, AP1 and matrix metalloproteinase‑3, which is stimulated by H2O2. In conclusion, AA efficiently protected human chondrocytes against damage induced by H2O2 by regulating multiple regulatory pathways.

Degenerative changes in adolescent spines: a comparison of motocross racers and age-matched controls

OBJECT

Motocross racing is a popular sport; however, its impact on the growing/developing pediatric spine is unknown. Using a retrospective cohort model, the authors compared the degree of advanced degenerative findings in young motocross racers with findings in age-matched controls.

METHODS

Patients who had been treated for motocross-related injury at the authors' institution between 2000 and 2007 and had been under 18 years of age at the time of injury and had undergone plain radiographic or CT examination of any spinal region were eligible for inclusion. Imaging was reviewed in a blinded fashion by 3 physicians for degenerative findings, including endplate abnormalities, loss of vertebral body height, wedging, and malalignment. Acute pathological segments were excluded. Spine radiographs from age-matched controls were similarly reviewed and the findings were compared.

RESULTS

The motocross cohort consisted of 29 riders (mean age 14.7 years; 82% male); the control cohort consisted of 45 adolescents (mean age 14.3 years; 71% male). In the cervical spine, the motocross cohort had 55 abnormalities in 203 segments (average 1.90 abnormalities/patient) compared with 20 abnormalities in 213 segments in the controls (average 0.65/patient) (p = 0.006, Student t-test). In the thoracic spine, the motocross riders had 51 abnormalities in 292 segments (average 2.04 abnormalities/patient) compared with 25 abnormalities in 299 segments in the controls (average 1.00/patient) (p = 0.045). In the lumbar spine, the motocross cohort had 11 abnormalities in 123 segments (average 0.44 abnormalities/patient) compared with 15 abnormalities in 150 segments in the controls (average 0.50/patient) (p = 0.197).

CONCLUSIONS

Increased degenerative changes in the cervical and thoracic spine were identified in adolescent motocross racers compared with age-matched controls. The long-term consequences of these changes are unknown; however, athletes and parents should be counseled accordingly about participation in motocross activities.

HIF-1 α had pivotal effects on downregulation of miR-210 decreasing viability and inducing apoptosis in hypoxic chondrocytes

Hypoxia-inducible factor 1-alpha (HIF-1 α ) and some microRNA (miRNAs) play pivotal roles in response to hypoxia-related physiologic and pathophysiologic responses. Up to date, the regulatory mechanisms of these molecules were largely unknown in chondrocytes. In this study, to study the mechanisms of degradation and homeostasis of chondrocytes, the effects of miRNAs and HIF-1 α on chondrocytes in physiologic environment were investigated. We found that the overexpression of miR-210 and HIF-1 α was present on hypoxia in C28/I2 human chondrocytes significantly by qRT-PCR and western plot. Further study displayed that miR-210 played positive role as a promoter in regulation and its regulated molecules (bcl-xl and PHD-2) in C28/I2 cells on hypoxia by silenced miR-210, silenced HIF-1 α , and adding miR-210. Moreover, downregulated miR-210 could significantly repress the viability and increase the apoptosis in C28/I2 cells on hypoxia, compared to those on normoxia. Furthermore, miR-210 could not modulate viability and apoptosis in C28/I2 cells with the HIF-1 α knockdown on hypoxia and normoxia. Taken together, this study demonstrated that the MiR-210 was involved in an HIF-1 α -dependent way in C28/I2 human chondrocytes for the first time. It also suggested that miR-210 downregulation decreased viability and induced apoptosis in hypoxic chondrocytes depending on HIF-1 α .