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Spinal Injuries in Sports


Summary of Key Points

  • The five steps for on-field management of spinal injuries in sports are: (1) preparation for any neurological injury, (2) suspicion and recognition, (3) stabilization and safety, (4) immediate treatment and possible secondary treatment, and (5) evaluation for return to play.

  • Brachial plexus neurapraxia is characterized by pain and paresthesia in a single upper extremity following a blow to the head or shoulder. Residual muscle weakness, cervical anomalies, or abnormal electromyographic studies are exclusion criteria for return to play.

  • Burning hand syndrome is a variant of central cord syndrome characterized by burning dysesthesia in both upper extremities. Any athlete exhibiting this condition should be initially treated as having a spinal cord injury.

  • Cervical cord neurapraxia resulting in transient quadriplegia has a high recurrence rate and seems to be related to functional stenosis.

  • Stress fractures of the pars interarticularis can be discovered and treated before a frank bony separation occurs. The first sign of an impending pars defect is constant axial mechanical lower lumbar pain in an adolescent athlete that worsens with activity.

  • Relative contraindications for return to competition are fusions that cross the cervicothoracic or thoracolumbar junction.

  • Absolute contraindications to return to competition are fusions that terminate at a junctional zone.

  • Return to play can be considered following anterior discectomy and fusion at up to two levels once a successful bone fusion has been documented and the patient is pain-free/neurologically intact.

  • The stability of disc arthroplasty devices in sports has yet to be determined, and, given the risk of extrusion, athletes who undergo an artificial disc placement are generally barred from a return to contact sports.

In this chapter we discuss spinal injuries that are unique to the patient-athlete, and the optimal approach to be adopted by care providers. We summarize the current evidence and expert opinion on return to play following spinal injuries and surgical intervention. In the first section we detail the epidemiology of sports-related spinal injuries. In the second section we focus on the cervical spine and discuss the on-site management of catastrophic spinal cord injury (SCI). In the third and fourth sections we discuss the thoracic and lumbar spine, respectively.

Epidemiology of Sports-Related Spinal Injuries

Each year, approximately 10,000 cases of SCI occur in the United States. Participation in sporting activities accounts for nearly 10% of these injuries and is the fourth most common cause of SCI (after motor vehicle accidents, acts of violence, and falls). , Sports-related SCIs also occur at a younger mean age of 24 and are the second most common cause of SCI in the first three decades of life ( Box 40.1 ). ,

Box 40.1
Quick Spinal Cord Injury Facts
From Chan WL, Eng JJ, Tator CH, Krassioukov A, Spinal Cord Injury Research Evidence Team. Epidemiology of sport-related spinal cord injuries: A systematic review. J Spinal Cord Med. 2016;39(3):255-264.

Six countries in which sports account for the highest rates of spinal cord injury (SCI)

  • Russia (32.9%)

  • Fiji (32.0%)

  • New Zealand (20.0%)

  • Iceland (18.8%)

  • France (15.8%)

  • Canada (13.1%)

Six countries in which sports account for the lowest rates of SCI

  • Turkey (3.0%)

  • Jordan (2.6%)

  • Nepal (2.0%)

  • Malaysia (2.0%)

  • China (1.8%)

  • Nigeria (1.7%)

Sports with highest risk for SCI relative to total sport-related SCI

  • Diving (35.3%)

  • Rugby (23.4%)

  • Equestrian (11.4%)

  • Skiing (11.3%)

Most common level of injury for various sports

  • Almost entirely cervical for hockey, skiing, diving, and American football

  • Over half of horseback riding and snowboarding injuries are thoracic or lumbosacral

Spinal injuries are more common in nonorganized sports such as diving and surfing than in organized sports ( Box 40.2 ). , The challenge in the former athletic activities is that rules, supervision, and training are limited, which makes improvement of care for these injured athletes difficult. Spinal injury in organized sports is less frequent but has a much higher public profile. Several organized sports, including football, ice hockey, rugby, skiing, snowboarding, and equestrian sports, have been identified as placing the participant at high risk for SCI.

Box 40.2
Sports Resulting in the Most Spinal Cord Injuries by Country
From Chan WL, Eng JJ, Tator CH, Krassioukov A, Spinal Cord Injury Research Evidence Team. Epidemiology of sport-related spinal cord injuries: A systematic review. J Spinal Cord Med. 2016;39(3):255-264.

Diving

  • Canada

  • China

  • Denmark

  • Japan

  • United States

Skiing

  • Germany

  • Norway

Equestrian

  • Ireland

Sport-Specific Spinal Injuries

American Football

American football involves approximately 1.4 million athletes at the junior/senior high school level, 75,000 in college, and 1000 in professional play. American football has a lower mean rate of catastrophic cervical spine injuries than ice hockey or gymnastics, but the significantly larger number of participants translates into the largest overall number for this injury ( Fig. 40.1 ). High school participants are at the highest risk, accounting for over 80% of cervical injuries, largely owing to the wide discrepancies in player size, age, maturity, and speed at this level.

Fig. 40.1, Level of spinal cord injury by sport. SCI , Spinal cord injury.

Notably, a significant increase in catastrophic cervical trauma coincided with the development of the modern football helmet. However, rule changes in 1976 prohibiting techniques that used the top of the helmet as the initial point of contact for blocking and tackling (commonly known as “spearing”) have significantly reduced this trend. From 1976 to 1987, the rate of cervical injuries decreased 70%, from 7.72 per 100,000 to 2.31 per 100,000 at the high school level. Traumatic quadriplegia decreased approximately 82% over the same period. Almost all cervical spine injuries occur when a player strikes an opponent with high velocity using the vertex of the helmet or with the head down. This action results in a significant axial load, often with a degree of flexion.

Baseball and Softball

Minor spinal injuries are fairly common in baseball and softball, but catastrophic injuries do occur. Participants who slide headfirst into a base have a high risk of SCI. If the hands of the runner separate, the top of his head can collide with the leg of the defensive player, creating significant axial load. Although the use of breakaway bases substantially decreases the risk for occurrence of sliding-related injuries, serious injuries can still occur. The use of even lower-profile bases and the outlawing of sliding have been suggested to further reduce the risk of SCIs.

Basketball

Basketball involves rapid changes in direction and explosive movements, causing repeated stresses to the spinal vertebrae. Thus, the most common neurological risk in basketball is spine-related. A variety of acute back injuries, such as lumbosacral sprains, contusions, facet joint injuries, and pars injuries are common. , In addition, basketball is a leading cause of sports-related disc disease and has been reported to be the second most common cause of disc herniation among athletes. Herniated discs usually arise dorsally or dorsolaterally and occur as a consequence of numerous microtraumas to the intervertebral disc, compounded by chronic overstraining. Cervical cord neurapraxia has also been reported in basketball players.

Cycling

Cycling-related injuries to the spine can be secondary to acute trauma or overuse. Neck and back pain are common complaints in cyclists, occurring in over half of participants. The odds of female cyclists developing neck and shoulder overuse problems have been reported to be 1.5 and 2 times greater, respectively, than for their male counterparts. Neck pain is partially the result of a combination of the increased load on the arms and shoulders required to support the cyclist and hyperextension of the neck in the horizontal, bent-forward position of riding.

Equestrian Sports

Approximately 20% of the injuries sustained by an equestrian involve the central nervous system. One study found that 13% of the patients had injury to the spinal cord, with the cervical region most commonly involved. There does not seem to be any correlation between risk of injury and the participant’s age, gender, or experience. Equipment failure has been shown to be a common cause of injury. The particular type of equestrian activity with the most risk to the spinal cord is unequivocally rodeo roughstock riding (bull, bareback bronco, and saddle bronco riding). Common spinal injuries include cervical and lumbar sprain, acute torticollis secondary to cervical and lumbar sprain, and cervicothoracic strain.

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