Catastrophic Cervical Spine Injuries in Contact Sports

Community perspectives on spinal cord injury in rugby union: facts and fears

INTRODUCTION

The sport of rugby union, henceforth rugby, is associated with a risk of spinal cord injury (SCI). Perceived risks can impact participation. Understanding community perspectives on rugby-related SCI may provide insight for addressing concerns around risk. The aim of this study was to explore community perspectives through social media discussion about SCI in rugby union.

METHODS

Posts about SCI in rugby union were identified using the advanced search function on Twitter. Data (content as original post, retweet, quote tweet and comments) were included if focused on Rugby Union and written in English. Inclusion dates (July 2018 to June 2019) were chosen to capture a period when several SCI (n = 4) occurred in community rugby in Australia. Data were analysed using a thematic approach.

RESULTS

Four themes were derived from the collected data. The 'pendulum swing' relates to the disparate views of rugby, from being overly cautious to too dangerous to play. The 'role of rugby culture' described engrained behaviours and attitudes on and off-field toward safety. 'Media influence' describes the emotive narrative used when reporting rugby-related SCI. 'After the injury' looks at expressions of sympathy and inspiration. These findings showed how individuals' views of SCI were influenced through rugby culture, trust in governing bodies and the news media.

CONCLUSION

By 'listening in' to community views, their most pertinent safety concerns can be addressed. Both facts and fears on rugby-related SCI were evident, and these extreme views can be balanced with evidence-based education and sensible risk management.

The association between contact sport exposure and cervical sensorimotor dysfunction: a scoping review of implications for future musculoskeletal injury risk

BACKGROUND

While morphological changes to the cervical spine have been observed for over 40 years in response to contact sport participation, little is known about the secondary effects of the cervical impairment on future musculoskeletal injury and disability.

OBJECTIVES AND DESIGN

A scoping review was performed to discuss the relationship between contact sport participation and morphological changes to the cervical spine. Moreover, the correlation between morphological changes in the musculoskeletal structures of the cervical spine and resultant deficits in cervical sensorimotor and neuromotor function are discussed. Lastly, how alterations in cervical sensorimotor function may affect overall risk of musculoskeletal injury is discussed.

METHODS

The scientific literature was searched in PubMed, Sport Discus, and Web of Science pertaining to contact-sport athletes and/or cervical pathology and the cervicocephalic network. The Asksey and O'Malley's framework and PRISMA for Scoping Reviews were used to conduct and report the following review. Included articles were grouped into three categories: (1) Morphological changes to the cervical spine in contact sport athletes. (2) The role of the neuromotor pathways of the cervical spine in maintenance of postural tone and coordination of the extremities. (3) The correlation between altered cervical sensorimotor function and a resultant increase in musculoskeletal injury risk.

RESULTS

Our search identified 566 documents, of which 405 underwent full-text screening, resulting in 54 eligible studies for the review. Widespread cervical sensorimotor dysfunction was observed in contact sport athletes. Independently, cervical sensorimotor function was demonstrated to play a critical role in postural control and limb coordination. However, limited research exists exploring the interaction between contact sport participation and altered cervical sensorimotor function, as well as an associated increase in musculoskeletal injury risk.

CONCLUSIONS

Limited evidence exists linking cervical injury and/or observed deficits in cervical sensorimotor and neuromotor function to musculoskeletal injury risk. Longitudinal studies combining imaging measures (e.g., MRI, DEXA), cervical functional test, and prospective injury risk are needed to further explore the correlation between resultant cervical sensorimotor deficits following contact sport impacts and future musculoskeletal injury risk.

Management of Acute Subaxial Trauma and Spinal Cord Injury in Professional Collision Athletes

Sports-related acute cervical trauma and spinal cord injury (SCI) represent a rare but devastating potential complication of collision sport injuries. Currently, there is debate on appropriate management protocols and return-to-play guidelines in professional collision athletes following cervical trauma. While cervical muscle strains and sprains are among the most common injuries sustained by collision athletes, the life-changing effects of severe neurological sequelae (ie, quadriplegia and paraplegia) from fractures and SCIs require increased attention and care. Appropriate on-field management and subsequent transfer/workup at an experienced trauma/SCI center is necessary for optimal patient care, prevention of injury exacerbation, and improvement in outcomes. This review discusses the epidemiology, pathophysiology, clinical presentation, immediate/long-term management, and current return-to-play recommendations of athletes who suffer cervical trauma and SCI.

Management of thoracic spinal cord injury in a professional American football athlete: illustrative case

BACKGROUND

A case of catastrophic thoracic spinal cord injury (SCI) sustained by a professional American football player with severe scoliosis is presented.

OBSERVATIONS

A 25-year-old professional football player sustained an axial loading injury while tackling. Examination revealed a T8 American Spinal Injury Association Impairment Scale grade A complete SCI. Methylprednisolone and hypothermia protocols were initiated. Computed tomography scan of the thoracic spine demonstrated T8 and T9 facet fractures on the left at the apex of a 42° idiopathic scoliotic deformity. Magnetic resonance imaging (MRI) demonstrated T2 spinal cord hyperintensity at T9. He regained trace movement of his right lower extremity over 12 hours, which was absent on posttrauma day 2. Repeat MRI revealed interval cord compression and worsening of T2 signal change at T7-T8 secondary to hematoma. Urgent decompression and fusion from T8 to T10 were performed. Additional treatment included high-dose omega-3 fatty acids and hyperbaric oxygen therapy. A 2-month inpatient spinal cord rehabilitation program was followed by prolonged outpatient physical therapy. He currently can run and jump with minimal residual distal left lower limb spasticity.

LESSONS

This is the first known football-related thoracic SCI with idiopathic scoliosis. Aggressive medical and surgical intervention with intensive rehabilitation formed the treatment protocol, with a favorable outcome achieved.

Asymptomatic Spinal Cord Compression: Is Surgery Necessary to Return to Play

Advising athletes with asymptomatic cervical canal stenosis on their return to active play is a topic of considerable debate, with no definitive guidelines in place. Once cervical canal stenosis is identified, often through imaging following other injuries, it is difficult to predict the risk of future injury upon return to play in both contact and collision sports. Consequently, the decision can be a complicated one for the athlete, family, and physician alike. In this article, we identify radiographical and magnetic resonance imaging (MRI)-based criteria that may distinguish athletes "at-risk" for more severe consequences due to asymptomatic cervical canal stenosis from those who are safe to return to play. Using a Torg-Pavlov ratio <0.7 and MRI metrics, namely a minimal disc-level canal diameter <8 mm, a cord-to-canal area ratio >0.8, or space available for the cord <1.2 mm, can help when making these difficult decisions. Counseling can be a critical asset to patients with cervical stenosis who have had a previous episode of cervical cord neuropraxia, especially when they are involved in high-risk sports such as American football and rugby. We believe that while this remains an area of continued concern and controversy, improved MRI criteria will be a useful springboard for further studies, especially in the elite athlete population.

Treatment strategies for managing cervical spine injuries in rugby players

Background

Cervical spine fractures are potentially catastrophic injuries in rugby players. Here, we reviewed seven patients who sustained rugby-related cervical spine fractures. Notably, three of seven fractures were missed on initial X-rays, but were ultimately documented on CT studies obtained an average of 10 days later.

Methods

Seven patients sustained cervical spine fracture attributed to rugby (2009-2016) and were followed an average of 52 posttrauma months. Most injuries occurred at the C6-C7 level, and six of seven patients required surgery. Further, only two of seven patients exhibited resultant neurological deficits (e.g., one myelopathy and one radiculopathy).

Results

Although the rugby injury was sufficiently documented on initial X-rays in four patients, three initial X-rays missed fractures, which were documented on the CT studies obtained an average of 10 days later.

Conclusion

Rugby-related cervical fractures must be considered where players continue to complain of pain following trauma. Notably, routine X-rays may miss fractures in 3 of 7 cases (43%), thus warranting supplemental CT examinations to definitively rule out fractures.

Neck Injuries

Neck injuries are relatively uncommon but have the potential to cause serious and permanent disability. In athletes, injuries are most common in contact sports, and occur with direct axial loading with a forward-flexed neck. Soft tissue and peripheral nerve injuries are typically minor and self-limiting, with excellent recovery potential and return to activities based on symptoms. Concern for devastating spinal cord injuries has led to routine immobilization using spine boards and hard cervical collars. This approach may provide more harm than benefit when applied universally, and a more commonsense protocol can be used to better address potential neck injuries.

Neck and Cervical Spine Injuries in National College Athletic Association Athletes: A 5-Year Epidemiologic Study

STUDY DESIGN

Descriptive epidemiology study.

OBJECTIVE

The purpose of this study was to describe the epidemiology of neck and cervical spine injuries in collegiate athletes over a 5-year period.

SUMMARY OF BACKGROUND DATA

The incidence and etiology of neck and cervical spine injuries in National Collegiate Athletic Association (NCAA) athletes has not been well defined in recent years.

METHODS

The incidence and characteristics of neck and cervical spine injuries were identified utilizing the NCAA Injury Surveillance Program database. Rates of injury were calculated as the number of injuries divided by the total number of athlete-exposures (AEs). AEs were defined as any student participation in one NCAA-sanctioned practice or competition.

RESULTS

Nationally, there were an estimated 11,510 neck and cervical spine injuries over the 5-year period. These occurred at a rate of 7.05 per 100,000 athlete-exposures (AEs). The rate of neck and cervical spine injuries in men was 2.66 per 100,000 AEs, while women suffered injuries at a rate of 1.95 per 100,000 AEs. In sex-comparable sports, men were 1.36 times more likely to suffer a neck or cervical spine injury compared with women. Men's football (29.09 per 100,000 AEs) and women's field hockey (11.51 per 100,000 AEs) were the sports with the highest rates of injuries. These injuries were 3.94 times more likely to occur during competition compared with practice. In-season injury rates were the highest, at 8.18 per 100,000 AEs.

CONCLUSION

The vast majority of neck and cervical spine injuries in NCAA athletes are minor and uncommon. Across all sports in both sexes, the majority of injuries were new, and occurred during in-season competitions. Most athletes returned to play within 24 hours of injury. These data can inform players, parents, coaches, athletic trainers, and physicians regarding the prevalence and rates of these injuries and potentially inform decision-making regarding injury prevention, treatment, and rehabilitation.

LEVEL OF EVIDENCE

4.

Catastrophic Return to Play in Rugby After Double Cervical Arthrodesis

For high-level athletes, most experts consider that 1-level arthrodesis in cervical spine surgery does not prevent return to play. Nevertheless, return remains controversial in cases of 2-level fusions. We report the case of a 27-year-old professional rugby player. He had had a double cervical fusion C5C6 and C6C7 for cervical hernia and was allowed to continue rugby activities afterward. Four years after this surgery, his neck was forced in hyperflexion during a match and complete tetraplegia occurred. A computed tomography scan showed a C3C4 unilateral facet dislocation. The patient was rapidly operated on. At follow-up, 2 years after the accident, the patient remained tetraplegic with no neurologic improvement. If no definitive conclusion can be established on this first observation, many precautions must be taken before a return-to-play decision, especially in contact sports.

Spinal Cord Injury Due to Cervical Disc Herniation without Bony Involvement Caused by Wrestling - A Case Report

Introduction:

Many cases of cervical spinal disc herniation caused by sporting injury have been reported. Those cases generally accompanied high-energy trauma such as fractures and/or dislocations. The purpose is to present the case of spinal cord injury (SCI) due to cervical disc herniation without bony involvement caused by wrestling.

Case Report:

We report a case of a 23-year-old man who sustained a cervical SCI during the wrestling competition. He was quadriplegic with no sensory or motor function preserved in sacral segments S4-S5. Conventional radiographs and computed tomography did not reveal bony abnormalities. Magnetic resonance imaging (MRI) showed a free herniated cervical disc severely compressing the spinal cord from central at C3/4 level. He underwent anterior cervical discectomy and interbody fusion using autologous iliac crest bone graft and fixation with the cervical plate. He made an eventful recovery, and 5 years later, he was playing at high competitive level.

Conclusion:

Competitive wrestling-related injuries are quite high. Fortunately, the incidence of SCI among wrestlers is extremely low. Although rare, SCI due to cervical disc herniation without bony involvement is a serious debilitating injury that exerts a devastating effect on a wrestler from a physical, psychological, and socioeconomic point of view, and places an immense burden on society from a public health perspective. The MRI is the golden examination in diagnosing such lesion. The management comprises surgical decompression of neural elements, stabilization, and fusion to provide a higher recovery rate from cord damage to return to play. Wrestler who is completely pain free with full range of motion and strength may be eligible for return to play.

Epidemiology of Cervical Injuries in NCAA Football Players

STUDY DESIGN

Descriptive epidemiology study.

OBJECTIVE

The purpose of this study was to describe the epidemiology of cervical spine injuries in collegiate football players.

SUMMARY OF BACKGROUND DATA

The incidence and etiology of cervical spine injuries in National Collegiate Athletic Association (NCAA) football players has not been well defined in recent years.

METHODS

The incidence and characteristics of cervical spine injuries were identified utilizing the NCAA-ISP database. Rates of injury were calculated as the number of injuries divided by the total number of athlete-exposures (AEs). AEs were defined as any student participation in one NCAA-sanctioned practice or competition.

RESULTS

An estimated 7496 cervical spine injuries were identified. Of these, 85.6% were categorized as new injuries. These occurred at a rate of 2.91 per 10000 AEs. Stingers were most common (1.87 per 10000 AEs) followed by cervical strains (0.80 per 10000 AEs). Injuries were nine times more likely to occur during competition when compared with practice settings. When compared with the regular season, the relative risks of sustaining a cervical spine injury during the preseason and postseason were 0.69 (95% CI 0.52-0.90) and 0.39 (95% CI 0.16-0.94), respectively. The rate of cervical spine injuries was highest in Division I athletes. Direct contact-related injuries were most common, representing 90.8% of all injuries sustained. Injuries were most common in linebackers (20.3%) followed secondarily by defensive linemen (18.2%). Most players returned to play within 24 hours of the initial injury (64.4%), while only 2.8% remained out of play for > 21 days.

CONCLUSION

Fortunately, the rate of significant and disabling cervical spine injuries appears to be low in the NCAA football athlete. The promotion of safer tackling techniques, appropriate modification of protective gear, and preventive rehabilitation in these aforementioned settings is of continued value.

LEVEL OF EVIDENCE

4.

Sex- and Sport-Specific Epidemiology of Cervical Spine Injuries Sustained During Sporting Activities

BACKGROUND

Although several investigations have examined the epidemiology of cervical spine injuries in sports, few studies have analyzed the nationwide incidence and sex-specific epidemiology of cervical spine injuries.

METHOD

The National Electronic Injury Surveillance System database, which collects information on patients presenting to the emergency department at 100 hospitals across the United States, was queried for neck sprains and cervical fractures associated with sporting activities from 2000-2015.

RESULT

A total of 26,380 neck sprains and 1166 fractures were identified. Compared with females, the incidence for injuries in males was 1.7 times greater for neck sprains and 3.6 times greater for fractures (P < 0.0001). Football was the most common cause of cervical sprains in males, followed by cycling and weightlifting/aerobics. Females sustained most neck sprains in weightlifting/aerobics, trampoline, and cheerleading. From 2000 to 2015, the incidence of neck sprains from aerobics increased from 15.5 to 25.3 per million person-years (P < 0.0001). Similarly, the incidence of cervical fractures from cycling increased from 0.67 to 2.7 per million (P < 0.0001). For males, cycling was the most common cause of fracture, followed by diving/swimming and football. For females, horseback riding was most common, followed by cycling and diving/swimming.

CONCLUSIONS

Football is the leading cause of cervical sprains in the United States. The most common cause of cervical fracture in men is cycling, while in women it is horseback riding. The incidence of sport-related cervical fractures has increased by 35% from 2000 to 2015, which has been driven by an increase in cycling-related injuries.

Cervical Spine Evaluation in Pediatric Trauma: A Review and an Update of Current Concepts

The clinical presentation and diagnostic workup in pediatric cervical spine injuries (CSI) are different from adults owing to the unique anatomy and relative immaturity. The current article reviews the existing literature regarding the uniqueness of these injuries and discusses the current guidelines of radiological evaluation. A PubMed search was conducted using keywords "paediatric cervical spine injuries" or "paediatric cervical spine trauma." Six hundred and ninety two articles were available in total. Three hundred and forty three articles were considered for the review after eliminating unrelated and duplicate articles. Further screening was performed and 67 articles (original articles and review articles only) related to pediatric CSI were finally included. All articles were reviewed for details regarding epidemiology, injury patterns, anatomic considerations, clinical, and radiological evaluation protocols. CSIs are the most common level (60%-80%) for pediatric Spinal Injuries (SI). Children suffer from atlantoaxial injuries 2.5 times more often than adults. Children's unique anatomical features (large head size and highly flexible spine) predispose them to such a peculiar presentation. The role of National Emergency X-Ray Utilization Study, United State (NEXUS) and Canadian Cervical Spine Rule criteria in excluding pediatric cervical injury is questionable but cannot be ruled out completely. The minimum radiological examination includes 2- or 3-view cervical X-rays (anteroposterior, lateral ± open-mouth odontoid views). Additional radiological evaluations, including computerized tomography (CT) and magnetic resonance imaging (MRI) are obtained in situations of abnormal physical examination, abnormal X-rays, inability to obtain adequate X-rays, or to assess cord/soft-tissue status. The clinical criteria for cervical spine injury clearance can generally be applied to children older than 2 years of age. Nevertheless, adequate caution should be exercised before applying these rules in younger children. Initial radiographic investigation should be always adequate plain radiographs of cervical spine. CT and MRI scans should only be performed in an appropriate group of pediatric patients.

‘In a blink of an eye your life can change’: experiences of players sustaining a rugby-related acute spinal cord injury

Background

Though rare, rugby union carries a risk for serious injuries such as acute spinal cord injuries (ASCI), which may result in permanent disability. Various studies have investigated injury mechanisms, prevention programmes and immediate medical management of these injuries. However, relatively scant attention has been placed on the player’s experience of such an injury and the importance of context.

Aim

The aim of this study was to explore the injury experience and its related context, as perceived by the catastrophically injured player.

Methods

A qualitative approach was followed to explore the immediate, postevent injury experience. Semi-structured interviews were conducted with 48 (n=48) players who had sustained a rugby-related ASCI.

Results

Four themes were derived from the data. Participants described the context around the injury incident, which may be valuable to help understand the mechanism of injury and potentially minimise risk. Participants also described certain contributing factors to their injury, which included descriptions of foul play and aggression, unaccustomed playing positions, pressure to perform and unpreparedness. The physical experience included signs and symptoms of ASCI that is important to recognise by first aiders, fellow teammates, coaches and referees. Lastly, participants described the emotional experience which has implications for all ASCI first responders.

Significance

All rugby stakeholders, including players, first responders, coaches and referees, may gain valuable information from the experiences of players who have sustained these injuries. This information is also relevant for rugby safety initiatives in shaping education and awareness interventions.