Cervical spinal stenosis and sports-related cervical cord neurapraxia in children

Retrospective Case Series of Spinal Cord Neurapraxia in Male Adolescent Athletes: Can These Athletes Return-to-Play?

BACKGROUND AND OBJECTIVES

While spinal cord neurapraxia (SCN) is a documented pathology in athletes, guidance for neurosurgeons evaluating these patients is sparse. Therefore, in a cohort of adolescent athletes with SCN, we sought to (1) review their presentation and management and (2) describe outcomes and return-to-play (RTP).

METHODS

A single-center, retrospective case series was conducted to examine adolescent athletes diagnosed with SCN from 2017 to 2022. SCN was defined as an episode of bilateral upper and/or lower extremity weakness/numbness after an impact during sport. Collected variables included demographics, presentation, management, outcomes, and RTP.

RESULTS

Six patients were included (mean age = 14.5 ± 2.1 years, 100.0% male). Three American football players sustained tackle injuries, 1 ice hockey and 1 basketball player fell and landed on their head/neck, and 1 weight lifter sustained an axial load of weights to his neck. Motor symptoms ranged from quadriplegia to partial weakness. Full symptom resolution was seen in 6/6 patients: in <1 day for 3 patients, 2-3 days for 2 patients, and 1-2 months for 1 patient. All 6/6 patients received computed tomography of head/cervical spine and MRI of cervical spine, half of whom received computed tomography and MRI of thoracic/lumbar spine. No patient had congenital stenosis or abnormal T2 signal on MRI. Specific RTP recommendations varied. All 6 patients/parents were contacted at a mean of 16.6 ± 2.6 months from the injury. All patients returned to play at a mean of 5.7 ± 3.3 months. All 6 patients returned to their previous sports. Across all patients, no recurrence or neurological sequelae was endorsed in the follow-up period.

CONCLUSION

Six athletes with SCN with no imaging abnormalities and full symptom resolution were able to RTP to their previous sport without future consequence. Symptom duration may not be clinically useful in determining the feasibility of RTP. Follow-up studies are warranted in this patient cohort to standardize RTP recommendations.

Cervical Spine Injuries in the Ice Hockey Player: Current Concepts in Epidemiology, Management and Prevention

STUDY DESIGN

This review article examines the biomechanics that underly hockey-related cervical spine injuries, the preventative measures to curtail them, optimal management strategies for the injured player and return to play criteria.

OBJECTIVE

Hockey is a sport with one of the highest rates of cervical spine injury, but by understanding the underlying pathophysiology and context in which these injuries can occur, it is possible to reduce their incidence and successfully manage the injured player.

METHODS

Multiple online databases including PubMed, Google Scholar, Columbia Libraries Catalog, Cochrane Library and Ovid MEDLINE were queried for original articles concerning spinal injuries in ice hockey. All relevant papers were screened and subsequently organized for discussion in our subtopics.

RESULTS

Cervical fractures in ice hockey most often occur due to an increased axial load, with a check from behind the most common precipitating event.

CONCLUSIONS

Despite the recognized risk for cervical spine trauma in ice hockey, further research is still needed to optimize protocols for both mitigating injury risk and managing injured players.

Return to play in athletes with spinal cord concussion: a systematic literature review

STUDY DESIGN

This is a systematic review.

PURPOSE

The study aimed to evaluate whether spinal cord concussion (SCC) patients can safely return to play sports and if there are factors that can predict SCC recurrence or the development of a spinal cord injury (SCI).

BACKGROUND CONTEXT

Although SCC is a reversible neurologic disturbance of spinal cord function, its management and the implications for return to play are controversial.

METHODS

We conducted a systematic search of the literature using the keywords Cervical Spine AND Sports AND Injuries in six databases. We examined return to play in patients (1) without stenosis, (2) with stenosis, and (3) who underwent single-level anterior cervical discectomy and fusion (ACDF). We also investigated predictors for the risk of SCC recurrence or SCI.

RESULTS

We identified 3,655 unique citations, 16 of which met our inclusion criteria. The included studies were case-control studies or case series and reports. Two studies reported on patients without stenosis: pediatric cases returned without recurrence, whereas an adult case experienced recurrent SCC after returning to play. Seven studies described patients with stenosis. These studies included cases with and without recurrence after return to play, as well as patients who suffered SCI with permanent neurologic deficits. Three studies reported on patients who underwent an ACDF. Although some patients played after surgery without problems, several patients experienced recurrent SCC due to herniation at levels adjacent to the surgical sites. With respect to important predictors, a greater frequency of patients who experienced recurrence of symptoms or SCI following return to play had a "long" duration of symptoms (>24 hours; 36.36%) compared with those who were problem-free (11.11%; p=.0311).

CONCLUSIONS

There is limited evidence on current practice standards for return to play following SCC and important risk factors for SCC recurrence or SCI. Because of small sample sizes, future prospective multicenter studies are needed to determine important predictive factors of poor outcomes following return to play after SCC.

Cervical spinal cord contusion in professional athletes: a case series with implications for return to play

STUDY DESIGN

Retrospective case series.

OBJECTIVE

This report provides long-term follow-up on athletes who have sustained a cervical spinal cord contusion. Their magnetic resonance (MR) image is correlated with clinical signs and symptoms. Mechanism of injury and a hypothesis of etiology are reported.

SUMMARY OF BACKGROUND DATA

Current return-to-play criteria for athletes who sustain a cervical cord contusion are based on expert opinion only. Decision making for this clinical situation in athletes carries significant clinical, legal, and economic ramifications. The natural history, clinical correlation, and effect of surgery for athletic cervical cord contusions have not been established. The mechanism of injury for this entity has historically emphasized axial loading.

METHODS

The case histories, physical examination, and MR images were reviewed for 4 professional athletes. All athletes had documented cervical cord contusions. None of the athletes had an acute disc herniation, fracture, instability, or focal cord compression. All athletes were contacted by telephone to assess symptoms at a minimum follow-up of 2 years after injury.

RESULTS

All 4 athletes had congenital stenosis, defined as lack of CSF signal around the cord on an MR image. All underwent anterior fusions at the level of their contusion. In follow-up, 2 athletes developed new contusions: one more than 5 years later, adjacent to a fusion; and 1, 2 years later, not adjacent to his previous fusion. No athlete developed permanent neurological sequelae. The presence of a contusion did not correlate with athletes' signs and symptoms. The mechanism of injury was hyperextension.

CONCLUSION

It is hypothesized that the horizontal facet orientation of the C3-C4 level, congenital stenosis, and relative hypermobility in extension are the contributing factors in the cause of this clinical entity. An anterior fusion at the C3-C4 level seems to be the most reliable method of preventing or delaying the return of symptoms. Return-to-play guidelines should emphasize the athletes' history of symptoms in context with their MR image because there is poor correlation between the finding of a contusion and the clinical presentation. Recurrence of symptoms is common and the long-term consequences of repeated episodes remain unknown.

Comparação do Índice de Torg obtido por meio de radiografia e ressonância magnética nos pacientes com mielopatia cervical espondilótica

OBJETIVO: A Mielopatia Cervical Espondilótica (MCE) é uma disfunção da medula espinhal relacionada à degeneração típica do envelhecimento. No estudo de imagem podemos obter a medida do Índice de Torg, para estimar a estenose cervical. Objetivamos, assim, medir o Índice de Torg através de radiografia e ressonância magnética (RM), possibilitando verificar possíveis discrepâncias entre os métodos de medida. MÉTODOS: Realizada mensuração do Índice de Torg na radiografia e na RM da coluna cervical, sendo obtido através da relação entre a superfície posterior do corpo vertebral e o ponto mais próximo à linha laminar correspondente, dividido pelo diâmetro sagital do corpo vertebral. RESULTADOS: Participaram 29 pacientes, sendo 10 mulheres e 19 homens, com médias de idade 48,1 ± 11 anos, de peso 68,7 ± 5 Kg e de altura 1,68 ± 0,6 m. Houve diferença significativa entre o Índice de Torg calculado através de radiografia e RM, sendo menores os índices observados na RM (radiografia: 0,73 ± 0,17 vs. RM: 0,48 ± 0,14, p< 0,05). No entanto, ambas as aferições traduzem o mesmo resultado: estenose cervical absoluta (Índice de Torg < 0,8). CONCLUSÕES: Nossos resultados corroboram relatos de outros autores que acreditam que o Índice de Torg medido através da radiografia, como preconizado, minimiza a real estenose do canal cervical. Sugerimos em nosso estudo que a RM permite melhor estimativa do grau de estenose do canal, muito embora nossos resultados em relação ao grau de estenose cervical tenham sido semelhantes estatisticamente.

Cervical spinal stenosis and sports-related cervical cord neurapraxia

Cervical cord neurapraxia is a common sports-related injury. It is defined as a transient neurological deficit following trauma localizing to the cervical spinal cord and can be caused by hyperextension, hyperflexion, or axial load mechanisms. Symptoms usually last less than 15 minutes, but can persist up to 48 hours in adults and as long as 5 days in children. While a strong causal relationship exists between cervical spine stenosis and cervical cord neurapraxia in adult patients, this association has not been observed in children. Likewise, while repeated episodes of neurapraxia can be commonplace in adult patients, recurrences have not been reported in the pediatric population. Treatment is usually supportive, but in adults with focal cervical lesions or instability, surgery is an option. Surgery for neurapraxia in children is rarely indicated.

Pediatric cervical spine injuries: a comprehensive review

INTRODUCTION

Cervical spine injuries can be life-altering issues in the pediatric population. The aim of the present paper was to review this literature.

CONCLUSIONS

A comprehensive knowledge of the special anatomy and biomechanics of the spine of children is essential in diagnosis and treating issues related to spine injuries.

High-energy contact sports and cervical spine neuropraxia injuries: what are the criteria for return to participation?

STUDY DESIGN

Clinically based systematic review.

OBJECTIVE

To define optimal clinical care for patients after sport-related neuropraxic injuries using a systematic review supported with expert opinion.

SUMMARY OF BACKGROUND DATA

Athletes who participate in contact sports may experience cervical cord neuropraxia, with bilateral motor or sensory symptoms such as burning, numbness, or loss of sensation referable to the cervical spinal cord. The symptoms last from minutes to hours, but recovery is usually believed to be complete. The underlying condition is cervical spinal stenosis that predisposes the athlete to a transient compression or concussive injury to the spinal cord.

METHODS

Focused questions on the treatment of cervical spine sport-related injuries resulting in transient neuropraxia were refined by a panel of spine traumatology surgeons consisting of fellowship-trained neurologic and orthopedic surgeons. Medical subject heading keywords were searched through MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews to identify pertinent English-language abstracts and articles whose focus was human subjects. The quality of literature was rated as high, moderate, low, or very low. The proposed questions were answered using the Grading of Recommendations Assessment, Development and Evaluation evidence-based review system. These treatment recommendations were rated as either strong or weak based on the quality of evidence and clinical expertise.

RESULTS

The literature searches revealed low and very low quality evidence with no prospective or randomized studies. One hundred fifty-three pertinent articles were identified; these were supplemented with additional articles to form an evidentiary table with 17 original articles containing unique patient data.

CONCLUSION

Literature regarding the optimal treatment of patients with transient neuropraxia is of low quality. On the basis of expert opinion, there was a recommendation that a return to full participation in high-energy contact sports could be based on radiographic findings: patients with transient neuropraxia without stenosis could return as a strong recommendation, whereas stenotic patients could not return as a weak recommendation. Furthermore, a strong recommendation was made to permit players to return to full participation after decompression with a single-level anterior cervical fusion.

Cervical fracture with transient tetraplegia in a youth football player: case report and review of the literature

BACKGROUND/OBJECTIVE

Serious cervical spinal injuries in organized youth football are rare. Cervical fracture with neurologic injury is rarely reported in organized youth football players with no pre-existing risk fractures for transient tetraplegia.

METHODS

Case report and literature review.

RESULTS

After being improperly tackled by an opponent of significantly larger body size, a player sustained a C7 posterior cervical fracture with transient tetraplegia. He was immobilized in a cervical collar and sent to a level 1 trauma center for evaluation. Initial examination showed bilateral paresthesia of the limbs with normal motor function (ASIA D). Initial radiographs of the cervical spine showed a displaced extension-compression fracture of the C7 spinous process. Magnetic resonance imaging of the cervical spine showed edema in the spinal cord in the region of the injury along with significant posterior injury. Imaging studies showed normal volumetric measurements of the spinal canal and no pre-existing risk factors for spinal stenosis or spinal cord injury. Radiographs showed that cervical fracture was healed at 9-month follow-up examination. At 1-year follow-up, the patient was asymptomatic. Radiographs showed healed fracture with no residual instability and full range of cervical spine motion on flexion-extension views.

CONCLUSIONS

This case underscores the potential for serious cervical spinal injuries in organized youth sports when players are physically overmatched, and improper tackling technique is used.

Cervical spine injuries in children: attention to radiographic differences and stability compared to those in the adult patient

The relative rarity of pediatric cervical spine injuries can impede rapid response and efficient care of this patient population. An understanding of the unique anatomical, radiographic, and biomechanical characteristics of the pediatric cervical spine is essential to the appropriate care of these challenging patients. Patterns of injury, diagnosis, and issues related to operative and nonoperative management are discussed with a focus on the developing spine. Our aim is to improve the understanding of traumatic cervical spine injuries in children for all practitioners involved with their care.

Neurologic injuries in hockey

Ice hockey is a fast contact sport played on an ice surface enclosed by rigid boards. There is an intrinsic risk for injury in hockey, with many injuries potentially affecting the nervous system. This article provides an overview of neurologic injuries occurring in hockey as reported in the scientific literature. Among all injuries, a small but real risk for catastrophic cervical spinal cord injury and a high incidence of concussion emerge as the two most important neurologic issues.

Spinal cord injury in a 14-year-old male secondary to cervical hyperflexion with exercise

STUDY DESIGN

Case report.

OBJECTIVES

To present an interesting case of a 14-year-old male with acute paresis of upper extremities and progressive difficulty with lower extremities. The patient is a competitive wrestler and was performing his daily abdominal workout 'sit-ups' with hands interlocked behind his head. During the end and immediately following his abdominal workout, he felt progressive weakness in his upper extremities. He was rushed to the hospital within an hour and seen in the emergency room and admitted to the neurology service for a presumed thromboembolic event.

SETTING

New York, USA.

RESULTS

The patient was negative for any hematologic disease or coagulopathy. Magnetic resonance imaging was negative for any mass effect on the spinal cord and neurological examination revealed bilateral upper extremity paraparesis 3/5 and lower extremity spasticity and propioceptive dysfunction. The patient was treated with corticosteroids and rigid collar, follow-up examination at 3 months revealed resolution of symptoms.

DISCUSSION/CONCLUSION

The pathophysiology of central cord syndrome is thought to be primarily secondary to a hyperextension injury, which causes buckling of the ligamentum flavum and increasing spinal cord diameter which leads to cord compression. This syndrome is more commonly seen in the spondylotic elderly. This case involves a teenager with normal canal diameter; however, combining aggressive exercise with extreme cervical hyperflexion, one can plausibly account for an acute ischemic event or repetitive microinjury to the spinal cord.

Long-term urological outcomes in paediatric spinal cord injury

STUDY DESIGN

Retrospective review.

OBJECTIVE

This retrospective review observes the evolution of bladder management by time and reports adult urological outcomes and complications in paediatric onset spinal cord injury (SCI).

SETTING

Spinal Injuries Unit RNOH Stanmore.

METHOD

In total, 10 traumatic SCI patients with mean age at injury of 13.6 years underwent treatment, for a mean period of 13.1 years. Characteristics of injury were noted. Two diagnostic subgroups, neurogenic detrusor overactivity (NDO), and acontractile detrusor were made. Complications, treatment changes, operative procedures with follow-up were noted.

RESULTS

In group 1 (6/10 patients) with NDO, five had DSD. Initial bladder management was reflex/urge voiding (n=4), suprapubic catheterisation (SPC), (n=1) and self-intermittent catheterisation (SIC), (n=1). Two patients had multiple upper tract complications with decreased renal function, two recurrent symptomatic urinary infections and one; bladder calculus. In total, 12 operative procedures were performed to treat complications and change bladder management to, SIC+oxybutynin (n=3), ileal conduit (n=1), sacral anterior root stimulator implant (SARSI), (n=1), voiding on urge (n=1). In group 2 (4/10 patients) with a-contractile detrusor two had low compliance. Initial bladder management was SIC (n=3) and voiding on urge/straining (n=1). Two patients converted from SIC to permanent catheter drainage and reported complications. Incidental kidney stone was diagnosed in one. A total of four interventions were carried out with final management of SIC (n=2), voiding on urge/straining (n=1) and Mitrofanoff+ileocystoplasty (n=1).

CONCLUSION

Bladder management in paediatric SCI is dependent on neurological level and type of injury; it changes with growth and is affected by changes in bladder management.

Central nervous system injuries in sport and recreation: a systematic review

Many sports have been associated with a variety of neurological injuries affecting the central nervous system (CNS), with some injuries specific to that sport. A systematic review of sport-specific CNS injuries has not been attempted previously, and could assist in the understanding of morbidity and mortality associated with particular sporting activities, either professional or amateur. A systematic review of the literature was performed using PubMed (1965-2003) examining all known sports and a range of possible CNS injuries attributable to that sport. Numerous sporting activities (45) have associated CNS injuries as reported within the literature. The sports most commonly associated with CNS injuries are: football, boxing, hockey, use of a trampoline, and various winter activities. A number of sporting activities are associated with unique CNS injuries or injury-related diseases such as heat stroke in auto racing, vertebral artery dissection in the martial arts, and dementia pugilistica in boxing. Neurological injuries of the CNS due to sport comprise a wide collection of maladies that are important for the neurologist, neurosurgeon, orthopaedic surgeon, physiatrist, sports medicine doctor, athletic trainer and general physician to recognise.

A review of spine injuries and return to play

OBJECTIVE

To review the literature for evidence that pertains to return to play and spine injuries, including cervical spinal stenosis, congenital and developmental abnormalities of the cervical spine, stingers, herniated nucleus pulposus, and spondylolysis/spondylolisthesis.

DATA SOURCES

Electronic databases, Pubmed (1966-2005) and Sport Discus (1975-2005), were searched for pertinent literature. Also, additional articles were reviewed from bibliographies.

DATA SYNTHESIS/METHODS

Summation of literature is given. No formal statistical analysis is presented.

RESULTS

Even though the problems addressed in this paper can be serious, the literature is lacking evidence for guidance in return to play. The majority of the literature presented is expert opinion.

CONCLUSIONS

Cervical spinal stenosis continues to be controversial, with different experts giving different definitions and return to play recommendations. Authors discuss functional cervical spinal stenosis seen on MRI and how this can lead to permanent sequelae. In regard to stingers, herniated nucleus pulposus, and spondylolysis/spondylolisthesis, there are differing opinions on evaluation and treatment. These conditions have less disagreement with regard to return to play. Most experts agree that with these problems or any other problem in sports medicine, an athlete needs to be symptom-free and have full active range of motion with near to full strength, even though there is a lack of research evidence in the literature.

Progressive quadriparesis in adolescent with stenosis of the cervical spine

INTRODUCTION

Progressive quadriparesis in adolescents suffering from cervical stenosis is a very rare entity. Only three cases have been reported in the literature.

CASE REPORT

We report our own case of progressive quadriparesis in a young patient suffering from cervical stenosis, the first to be documented with pre- and postoperative magnetic resonance imaging.

Acute sports-related spinal cord injury: contemporary management principles

Improvements in helmet and equipment design have led to significant decreases in overall injury incidence, but no available helmet can prevent catastrophic injury to the neck and cervical spine. The most effective strategy for preventing this type of injury appears to be careful instruction, training, and regulations designed to eliminate head-first contact. The incidence of football-related quadriplegia has decreased from a peak of 13 cases per one million players between 1976 and 1980 to 3 per million from 1991 to 1993, mostly as a result of systematic research and an organized effort to eliminate high-risk behavior. An episode of transient quadriparesis does not appear to be a risk factor for catastrophic spinal cord injury. Torg reported that 0 of 117 quadriplegics in the National Football Head and Neck Injuries Registry recalled a prior episode of transient quadriparesis, and 0 of the 45 patients originally studied in his transient quadriparesis cohort have subsequently suffered quadriplegia. The significance of developmental spinal stenosis is unclear. Plain radiographic identification of a narrow spinal canal in a player sustaining cervical cord neurapraxia warrants further evaluation by MRI to rule out functional stenosis. The presence of actual cord deformation or compression on MRI should preclude participation in high-risk contact or collision sports.

Magnetic resonance imaging of sports injuries of the spine

Spinal injuries are relatively frequent events in professional athletes. Greater popularity of recreational athletic activities has increased the occurrence of sports-related spinal injuries in the general population. The demand of high-intensity sports places a constant load on the vertebral column. Several studies have demonstrated higher prevalence of spinal abnormalities in athletes than nonathletes. Direct correlation of the number and extent of injuries with the length in years of sports activity has been established. Diagnostic imaging, particularly magnetic resonance imaging (MRI), plays a crucial role in evaluating and detecting sports-related spinal injuries. Subtle bone marrow, soft-tissue, and spinal cord abnormalities, which may not be apparent on other imaging modalities, can be readily detected on MRI. Early detection often leads to prompt accurate diagnosis and expeditious management, in many cases avoiding unnecessary procedures. This article reviews the technical aspects of MRI for evaluation of the spine and the role of MRI in the assessment of sports-related spinal injuries.