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Pain in the Neck Cervical Spine Injuries in Athletes

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Pain in the Neck Cervical Spine Injuries in Athletes Pain in the Neck Cervical Spine Injuries in Athletes LESSON 19 By Herman Kalsi, MD; Elizabeth Kaufman, MD, CAQ-SM; and Kori Hudson, MD, FACEP, CAQ-SM Dr. Kalsi is a senior emergency medicine resident at Georgetown University Hospital/Washington Hospital Center in Washington, DC. Dr. Kaufman is an attending physician in the Department of Sports Medicine at Kaiser Permanente San Jose in San Jose, CA. Dr. Hudson is an associate professor of emergency medicine at Georgetown University School of Medicine in Washington, DC. Reviewed by Michael Beeson, MD, MBA, FACEP OBJECTIVES On completion of this lesson, you should be able to: CRITICAL DECISIONS 1. Devise a systematic approach for the evaluation of suspected c-spine injuries. n What is the appropriate initial assessment for a 2. Describe the history and physical examination findings suspected c-spine injury? that should raise suspicion for a c-spine injury. n What history and physical examination findings 3. Explain evidence-based clinical decision tools that help should raise concern for a c-spine injury? determine the need for imaging of the cervical spine. n When should the cervical spine be imaged? 4. Recognize transient neurological deficits that can mimic more serious diagnoses. n What are the most common vascular injuries 5. Define the initial stabilization and management of a associated with c-spine trauma? suspected c-spine injury. n What are the most common transient neurological injuries associated with c-spine trauma? FROM THE EM MODEL n What has changed in the management of patients 18.0 Traumatic Disorders with c-spine injuries? 18.1 Trauma Although musculoskeletal complaints are common among athletes who present to the emergency department, injuries to the neck, especially the cervical spine (c-spine), warrant serious concern. Clinicians must be prepared to recognize and manage the complex and potentially devastating complications associated with acute neck pain. In particular, injured athletes must be promptly evaluated for vertebral fractures, subluxation injuries, vascular injuries, intervertebral disc herniation, brachial plexus injuries, and/or nerve root injuries. October 2018 n Volume 32 Number 10 3 CASE PRESENTATIONS helmet lying approximately 10 feet the event and was able to immediately ■ CASE ONE away from her. She reported get up without assistance, remove his A 24-year-old woman with a tenderness in her cervical spine, but potential c-spine injury arrives via helmet, and walk over to the sideline, her field examination was otherwise helicopter. She was transported where he was evaluated by the athletic normal. EMTs applied a cervical from a nearby trail after being trainer. He denied headache, nausea, collar and used a “scoop stretcher” to thrown from her horse. Her group, or blurry vision. transfer the patient to a cot. which was 45 minutes away from At the time of the injury, he had no On arrival at the emergency the nearest access road, stabilized midline c-spine tenderness, no step- department, the patient complains of offs or deformities, and complained her head and neck while waiting increasing neck pain. for EMS. Rescue personnel found only of pain and paresthesias in his left arm. Approximately 10 minutes after the patient to be awake, oriented, ■ CASE TWO and in a supine position, but A 16-year-old boy presents after the injury, however, his left arm began complaining of severe neck pain. being tackled during a high school to feel weaker, so his parents brought She did not lose consciousness football game. Upon falling to the him to the emergency department at the scene and could move her ground, he experienced a sharp, for further evaluation. On arrival, extremities; she denied headache, “electric pain” that originated in his he continues to complain of neck nausea, and blurry vision. neck and moved down his left arm. pain and unilateral upper-extremity EMTs noted the patient’s intact He did not lose consciousness during paresthesias and weakness. Acute spinal cord injuries (SCIs) displays signs of impending respiratory degree of disability should be assessed. in athletes are rare (accounting for failure, the airway should be secured More specifically, athletes with suspected only 2.4% of all athletic-related before proceeding.4 c-spine injuries should be evaluated for hospitalizations), yet 9.2% of all SCIs Many physicians question the safety of signs of spinal and/or neurogenic shock. in the US are sustained during athletic emergency airway management — using Spinal shock — a state of transient loss activity.1 Although football players, orotracheal intubation — with known of spinal cord function below the level wrestlers, and gymnasts are at greatest or suspected c-spine injuries; however, of the injury, including hyporeflexia or risk for c-spine trauma involving axial several studies have shown orotracheal areflexia with associated autonomic loading, hyperextension, traction, intubation with in-line stabilization dysfunction — occurs immediately after or rotation, such injuries can occur to be a safe and effective method for an injury. Spinal shock can cause an during almost any recreational activity, definitive airway management in patients acute, incomplete SCI that mimics a including those traditionally considered with suspected c-spine injuries.5-8 No complete SCI. noncontact sports, including baseball.1 consensus has been reached on whether The severity and duration vary with video-assisted laryngoscopy (VAL) is the spinal level and degree of injury, CRITICAL DECISION safer than direct laryngoscopy (DL) with but spinal shock usually lasts less than What is the appropriate initial respect to minimizing vertebral body 24 hours. Patients can experience 6 assessment for a suspected movement during the intubation process. an initial increase in blood pressure Studies have produced mixed results due to the release of catecholamines, c-spine injury? on the use of VAL. One study concluded quickly followed by hypotension. The As with all traumatic injuries, that there was no significant difference bulbocavernosus reflex (S2-S4) can be emergency physicians should approach between DL and VAL at any level of used to help diagnose spinal shock; patients with suspected c-spine injuries c-spine injury, while another found it can be tested by monitoring for the using the Advanced Trauma Life Support that c-spine motion was reduced by contraction of the anal sphincter in (ATLS) protocols, which strive not only 50% at the C2-C5 segment when VAL response to squeezing the glans penis to identify immediate threats to life, but was used.9,10 Regardless, current ATLS or clitoris, or to a slight tug on an also to minimize the risk of overlooking guidelines list orotracheal intubation with indwelling Foley catheter, in patients secondary and tertiary injuries.2 in-line manual c-spine stabilization as with acute paralysis after trauma. Generally, if the neck of a patient with a the definitive airway procedure in apneic Presence of the reflex indicates spinal potential c-spine injury has not already patients with trauma.9 In addition, a cord severance; its absence indicates been stabilized to minimize movement, it surgical airway should be considered if a spinal shock. The return of the reflex is essential to do so by providing in-line definitive airway is required and cannot typically indicates that the spinal shock stabilization before proceeding with the be established by other means.6 is resolving.3 evaluation.3 If a patient is not breathing, Once the airway and breathing have By comparison, neurogenic shock is unable to manage secretions, or been addressed, circulation and the is the body’s response to the sudden 4 Critical Decisions in Emergency Medicine loss of sympathetic control. It is a occur prior to equipment removal, as if a helmet was used and whether or distributive shock that manifests itself most athletic equipment is radiolucent. not it was damaged in the incident, as clinically with bradycardia, hypotension, If a long spine board is used for spinal this information can help stratify the flaccidity, and areflexia. Neurogenic stabilization during transport, it should direction and force of the injury.3 shock typically occurs in patients be removed upon arrival, maintaining with SCIs above the T6 level, as these in-line stabilization of the spine. A CRITICAL DECISION translate into greater than 50% loss of slider board can be used to minimize What history and physical sympathetic innervation, which leads motion during additional transfers. examination findings should raise to unopposed vagal tone, a decrease Once the long spine board and sports concern for a c-spine injury? in vascular resistance, and associated equipment are removed, a rigid cervical C-spine injuries are classified vascular dilation. For hypotensive collar should be applied, if not already according to the mechanism of trauma, trauma patients, it is crucial not only placed in the prehospital setting, and the extent of vertebral stability, and to distinguish between spinal and should remain in place until the cervical the morphology of the injury. As such, neurogenic shock, but also to rule out spine is “cleared,” either clinically or the most common injury patterns in hypovolemia as the cause of shock.3 radiographically. athletes are related to axial loading, Disability should be assessed by A more detailed history should flexion, extension, and rotation. One key performing a head-to-toe neurological be obtained, in conjunction with a purpose of the physical exam is to detect examination. If an athlete arrives secondary survey and a more detailed primary injuries, such as damage from wearing protective equipment, the exam. Ideally, the mechanism of injury direct contusion and axonal stretch, equipment may need to be removed should be determined so that the spinal compression by bone fragments, prior to full evaluation. If a spinal injury presence of coexisting injuries can be hematoma or intervertebral discs, is strongly suspected, initial imaging can ascertained. It is important to know and ischemia from damage due to the impingement on the spinal arteries.6 The cervical spine should be carefully FIGURE 1.
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