Cervical Spine in Athletes: Return to Play

Mark F. Kurd, M.D. Associate Professor, Sidney Kimmel Medical College Thomas Jefferson University The Rothman Institute Disclosures

• Duratap, LLC: Shareholder INCIDENCE

10-15% of all cervical spine injuries are sports related

NEUROLOGIC

0.6-1.0% NEURO INJURY

Common with: • Football • Trampoline • Water sports • Gymnastics • Rugby • Ice Hockey • Wrestling WATER SPORTS

• Majority injuries to cervical spine DIVING INJURIES

Avg. Patient • Male, 13 yr or older • No formal diving training • 50% - alcohol involved Axial Loading Injury in Hockey

Number of catastrophic injuries low, BUT the incidence per 100,000 is high Other Sports

• Pole Vaulting – 2 catastrophic injuries/1 fatality per year, despite only 25,000-50,000 participants each year • Cheerleading – 0.6 direct catastrophic injuries per 100,000 • Baseball – 0.5 direct catastrophic injuries per 100,000 • Wrestling – 1.0 direct catastrophic injury per 100,000

Boden, JAAOS. 2005 FOOTBALL Associated with the highest number of severe head and neck injuries per year for all high school and college sports Younger Athletes

• High school football players – 3x more likely severe injury – 47 c spine injuries (2007-11) permanent disability/death • Triage, management, RTP criteria Boden et al. Am J Sport Med 2007 Meuller et al. UNC ann 2009 Spear Tackling

• Most cervical injuries occurred to defensive players during tackling

• Axial load mechanism identified in 27% of tackling injuries

Cantu, Neurosurgery, 2000 Proper Technique: Heads Up Tackling • See What You Hit • Knees Bent at Impact • Drive Through with Legs Gill et al, SMAR. 2008 Cervical Spine Syndromes

• Cervical Sprain - ligamentous • Burners / Stingers - root or brachial plexus neuropraxia • Transient quadriplegia – Cervical Cord Neuropraxia (CNN) • Permanent quadriplegia - permanent disruption (, ) of the cervical cord BURNERS/STINGERS Burners / Stingers • , numbness & weakness. . . neck, arm, hand • 50% football players ! • Defensive players & offensive lineman

Clinical Presentation Differential Diagnosis

Jogging off field with arm hanging down: • Burner / Stinger • Clavicle / AC injury • Glenohumeral . . . Subluxation/Dislocation Mechanism

• Lateral flexion away from involved side • Shoulder depression from blow • Brachial plexus stretch

Mechanism of Injury Management Burners/Stingers • Rule out more serious injury (red flags) – Bilateral symptoms •Restrict play, – Lower extremity •Immobilize – Persistent burning •Radiographic evaluation – Painful ROM – Tenderness • Multiple episodes and those likely due to root mechanism should be evaluated radiographically RTP Burners/Stingers • 1st Stinger – Resolutions of symptoms and painless ROM • 2nd Stinger – Sit out game – Imaging • 3rd Stinger – Sit out season

Kepler et al, ClinSportsMed. 2012 Cervical Stenosis

• Definitions – Canal diameter < 13mm (nl: 14-23)

– Torg ratio <0.8

Torg JBJS 1986 Controversy • Abnormal Torg ratio – 3- fold increase in stingers –Low predictive value - no more susceptible to permanent neurologic injury than members of the general population (Torg) Trauma/SCI • Quadriplegia • Cervical Cord Neuropraxia (CCN) • Transient (mins to hours) • Bilateral motor/sensory symptoms • Sensory symptoms: ● burning ● numbness ● loss of sensation CCN Management

• Analogous to concussion of the brain • RTP: full resolution of symptoms • Long-term effects of repeated episodes unknown Cervical HNP

• 99 NFL players identified (1979 – 2008) w CDH • 53 where treated operatively/46 nonop • – Greater percentage return to play (72% vs 46%) – More games played (29.3 vs 14.7) – Longer careers after injury (2.8 vs 1.5 yrs) • 5.3% of players required revision surgery for adjacent level disease

Hsu WH. Spine. 2011 Cervical HNP

 When comparing NFL players with CDH those treated operatively had  Greater percentage return to play (72% vs 46%)  More games played (29.3 vs 14.7)  Longer careers after injury (2.8 vs 1.5 yrs)  5.3% of players required revision surgery for adjacent level disease

Hsu WH. Spine. 2011 Return to Play- ACDF

• No cord compression • Symptoms resolved

• Solid Fusion – One level – Two level-controversial – Three level-contraindicated

Meredith DS. Am J Sports Med. 2013. Kepler CK. Clin Sports Med. 2012. ACDF in Rugby

• 19 professional players- ACDF between 1998- 2003 • Symptoms improved in 17 patients • 13 returned to play

Andrews J et al. JBJS Br. 2008 RETURN to PLAY Absolute Contraindications • Cervical myelopathy • H/O C1-C2 fusion • C1-C2 hypermobility • Multi-level Klippel-Feil deformity • Spear Tacklers Spine • Lack of solid fusion s/p ACDF

Proctor et al. Clin Sport Med 2012 Vaccaro et al. The Spine J. 2002. RETURN to PLAY Absolute Contraindications

• >2 previous episodes of CCN • S/P cervical laminectomy • Continued cervical discomfort, neuro deficit, or ↓ ROM

Vaccaro et al. The Spine J. 2002. RETURN to PLAY Relative Contraindications • H/O transient quadriplegia with full symptom resolution • Cord abnormality • 3+ stingers in same season • Stable, healed 2-level subaxial ACF or PCF Proctor et al. Clin Sport Med 2012 Vaccaro et al. The Spine J. 2002. Conclusion • Limited data

• Prevention: Heads up tackling

• Appropriate on field management

• Elite athletes can return to high level competition following ACDF

• RTP: – Guidelines: Expert opinion – Complete resolution of symptoms THANK YOU