Catastrophic Neck Injuries in the Collision Sport Athlete

Review article: Best practice management of neck pain in the emergency department (part 6 of the musculoskeletal injuries rapid review series)

Neck pain and whiplash injuries are a common presentation to the ED, and a frequent cause of disability globally. This rapid review investigated best practice for the assessment and management of musculoskeletal neck pain in the ED. PubMed, CINAHL, EMBASE, TRIP and the grey literature, including relevant organisational websites, were searched in 2017. Primary studies, systematic reviews and guidelines were considered for inclusion. English-language articles published in the past 12 years addressing acute neck pain assessment, management or prognosis in the ED were included. Data extraction was conducted, followed by quality appraisal to rate levels of evidence where possible. The search revealed 2080 articles, of which 51 were included (n = 22 primary articles, n = 13 systematic reviews and n = 16 guidelines). Consistent evidence was found to support the use of 'red flags' to screen for serious pathologies, judicious use of imaging through clinical decision rule application and promotion of functional exercise coupled with advice and reassurance. Clinicians may also consider applying risk-stratification methods, such as using a clinical prediction rule, to guide patient discharge and referral plans; however, the evidence is still emerging in this population. This rapid review provides clinicians managing neck pain in the ED a summary of the best available evidence to enhance quality of care and optimise patient outcomes.

The Epidemiology of Severe Injuries Sustained by National Collegiate Athletic Association Student-Athletes, 2009-2010 Through 2014-2015

CONTEXT

Few researchers have described the incidence of the most severe injuries sustained by student-athletes at the collegiate level.

OBJECTIVE

To describe the epidemiology of severe injuries within 25 National Collegiate Athletic Association (NCAA) sports in the 2009-2010 through 2014-2015 academic years.

DESIGN

Descriptive epidemiology study.

SETTING

Aggregate injury and exposure data from 25 NCAA sports.

PATIENTS OR OTHER PARTICIPANTS

Collegiate student-athletes in the 2009-2010 through 2014-2015 academic years.

MAIN OUTCOME MEASURE(S)

Injury data from the NCAA Injury Surveillance Program were analyzed. A severe injury (1) occurred during a sanctioned competition or practice, (2) required medical attention by an athletic trainer or physician, and (3) resulted in at least 21 days lost from sport activity or a premature end to the sport season. Injury counts, proportions, rates per 1000 athlete-exposures (AEs), rate ratios (RRs), and injury proportion ratios were reported with 95% confidence intervals (CIs).

RESULTS

A total of 3183 severe injuries were reported, for an injury rate of 0.66/1000 AEs. Wrestling had the highest severe injury rate (1.73/1000 AEs), followed by women's gymnastics (1.40/1000 AEs) and football (0.97/1000 AEs). Overall, the severe injury rate was higher in competition than in practice (RR = 4.25, 95% CI = 3.97, 4.56). Most severe injuries were reported during the regular season (69.3%, n = 2206); however, severe injury rates did not differ between the preseason and regular season (RR = 0.98, 95% CI = 0.91, 1.06). Common severely injured body parts were the knee (32.9%, n = 1047), lower leg/ankle/foot (22.5%, n = 715), and head/face/neck (11.2%, n = 358). Common severe injury diagnoses were sprains (32.9%, n = 1048), strains (16.9%, n = 538), and fractures (14.4%, n = 458). Common severe injury mechanisms were player contact (39.3%, n = 1251), noncontact (25.1%, n = 800), and surface contact (12.0%, n = 383).

CONCLUSIONS

Severe injuries occurred across many sports and by numerous mechanisms. By identifying these sport-specific patterns, clinicians' efforts can be tailored toward improving injury-prevention strategies and health outcomes.

Compressive follower load influences cervical spine kinematics and kinetics during simulated head-first impact in an in vitro model

Current understanding of the biomechanics of cervical spine injuries in head-first impact is based on decades of epidemiology, mathematical models, and in vitro experimental studies. Recent mathematical modeling suggests that muscle activation and muscle forces influence injury risk and mechanics in head-first impact. It is also known that muscle forces are central to the overall physiologic stability of the cervical spine. Despite this knowledge, the vast majority of in vitro head-first impact models do not incorporate musculature. We hypothesize that the simulation of the stabilizing mechanisms of musculature during head-first osteoligamentous cervical spine experiments will influence the resulting kinematics and injury mechanisms. Therefore, the objective of this study was to document differences in the kinematics, kinetics, and injuries of ex vivo osteoligamentous human cervical spine and surrogate head complexes that were instrumented with simulated musculature relative to specimens that were not instrumented with musculature. We simulated a head-first impact (3 m/s impact speed) using cervical spines and surrogate head specimens (n = 12). Six spines were instrumented with a follower load to simulate in vivo compressive muscle forces, while six were not. The principal finding was that the axial coupling of the cervical column between the head and the base of the cervical spine (T1) was increased in specimens with follower load. Increased axial coupling was indicated by a significantly reduced time between head impact and peak neck reaction force (p = 0.004) (and time to injury (p = 0.009)) in complexes with follower load relative to complexes without follower load. Kinematic reconstruction of vertebral motions indicated that all specimens experienced hyperextension and the spectrum of injuries in all specimens were consistent with a primary hyperextension injury mechanism. These preliminary results suggest that simulating follower load that may be similar to in vivo muscle forces results in significantly different impact kinetics than in similar biomechanical tests where musculature is not simulated.

Cervical spine immobilization in sports related injuries: review of current guidelines and a case study of an injured athlete

Cervical spine immobilization is an essential component of the ATLS^® system. Inadequate training in the management of trauma calls and failure of early recognition can have disastrous consequences. Pre-hospital personnel are routinely involved more in the assessment and stabilization of patients in comparison to other health care professionals.

This case study and review highlights the importance of early recognition, assessment and correct stabilization of cervical spine injuries both in the field and during the initial assessment in hospital.

Inadequate assessment, immobilization and lack of standard guidelines on the management of suspected cervical spine trauma can result in secondary injury. Regular assessment and training of pre-hospital and medical personnel is essential to the proper management of these potentially devastating 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.

A new biofidelic sagittal plane surrogate neck for head-first impacts

OBJECTIVE

To evaluate a prototype sagittal plane surrogate neck model designed to provide a biofidelic response to head-first impacts with a straightened cervical posture.

METHODS

Published biomechanical studies were used in the design to define the range of motion (ROM) and stiffness in both flexion-extension rotation and axial compression. The neck was tested in a series of head-first impacts on a drop tower to investigate the temporal aspects of the kinetic axial force response for the head and neck. A separate series of flexion-extension tests was conducted in a spinal motion simulator to assess its ROM and bending stiffness.

RESULTS

In impacts with a 104 N axial preload, the surrogate head and neck displayed a bimodal response to force development in agreement with published studies of cadaveric head-first impacts. In bending without an axial preload, the neck had an ROM and bending stiffness representative of cadaveric human spines and it included a large neutral zone, but with the incremental addition of axial preload these metrics were somewhat reduced.

CONCLUSIONS

The model appears suitable for studying the scenario of sagittal plane, aligned column impacts. Further design refinements are required to provide biofidelity in both sagittal bending and head-first impacts using a single level of axial preload. This would be necessary to study impact scenarios where considerable sagittal plane neck rotation occurs at impact. The model has identified some key concepts that must be considered for continued design and improvement of a dedicated dummy neck for head-first impacts.