Cervical spine injuries can occur during non-laborious activities and high-energy trauma, so it is understandable that neck injuries can and often do occur during sports activities. Neck muscle strains, ligament sprains, and disc injuries are reasonably common. However, there are two types of neck injuries that occur most frequently during sports: stingers (also called a burner) and transient quadriplegia (also called cervical cord neurapraxia). These injuries can affect athletes participating in almost any sport, but occur most often in football, wrestling, and other contact sports. Stingers are the most common, and have been reported to affect as many as 50% of athletes involved in collision sports. Transient quadriplegia is much less common, but more dangerous, and has an incidence of approximately 1.3 per 10,000 athletes. Although rare, catastrophic spinal cord injuries occur at rate of 0.5 to 2.5 per 100,000. The rate of spinal cord injuries is noted to be decreasing, primarily because of improvements in sports equipment and awareness of techniques, especially tackling (in football).
A stinger (also called a burner) is one the most common cervical sports injuries, especially in football and rugby. It is a neurapraxia of the cervical nerve roots or brachial plexus, and manifests as a sharp, stinging or burning pain down one of the arms. The nerve injury can occur because of a compression force or a traction force in the region of the neck and shoulder, such as the player’s head being abruptly twisted towards or away from an impact to one of the shoulders. Transient quadriplegia is usually caused by a hyperextension injury to the neck, which may also involve axial loading of the neck. This condition often occurs because there is some degree of cervical spinal stenosis or disc protrusion, which decreases the available space for the spinal cord within the spinal canal.
Players who have sustained a stinger (neurapraxia of the cervical nerve root-spinal nerve complex or brachial plexus) generally have sudden, unilateral (one arm only) pain and dysesthesias in the distribution of a nerve down the arm (dermatomal pattern). The pain usually lasts only seconds or minutes. The majority of the strength and sensation usually returns within 24 hours, however, it may take up to 6 weeks to return to completely normal. In contrast, patients with transient quadriplegia (TQ or CCN) have bilateral burning and tingling pain, with loss of strength and sensation in the arms and/or legs. There may be only mild weakness or complete paralysis. The symptoms of TQ are, by definition, transient, and last 15 minutes to 36 hours. If symptoms last longer than 36 hours, it cannot be TQ and another diagnosis should be considered.
The physical findings for patients with a stinger injury are limited. Patients may or may not demonstrate neck tenderness and spasm, but usually have decreased cervical range-of motion. Patients may have notable weakness or decreased sensation in the affected arm, but many times the injury so transient that function has returned by the time a clinician evaluates the athlete, even on the field or on the sideline. Deep tendon reflexes are usually normal. Pulses and vascularity of the arm should be normal. The physical findings for patients with TQ may quite dramatic, especially for the clinician evaluating the athlete on the playing field. If the athlete has paralysis or a profound neurologic deficit, spinal precautions should be instituted, the patient’s head and neck should be immobilized, and the athlete should promptly be taken by ambulance to the nearest emergency room. Although the strength and sensation will resolve if the diagnosis is TQ, it is not always known in the early time period when severe neurologic dysfunction persists. Even athletes with a rapid return of all neurologic function should be carefully observed, and not allowed to return to play until a complete evaluation by a spine specialist is performed.
Plain x-rays and a magnetic resonance imaging (MRI) test of the cervical spine are essential to adequately evaluate patients with stingers and transient quadriplegia (CCN). Plain x-rays are necessary to evaluate for a cervical spine fracture, and MRI is required to rule out a herniated disc injury, spinal stenosis, or spinal cord contusion. It is sometimes difficult to see a non-displaced or minimally displaced fracture or instability, therefore a Computed Tomography (CT) scan may also be ordered if a fracture is suspected. If no fracture is identified, but a patient has significant neck pain, cervical flexion/extension x-rays can be obtained to verify that there if no evidence of ligamentous instability.
There are numerous medical journal articles written discussing whether cervical x-rays, MRI, and/or CT scans can predict which athletes are likely to sustain a spinal cord injury during sports. Although the majority of patients who sustain an episode of transient quadriplegia do have underlying stenosis or disc herniation, the predictive value of these imaging modalities is extremely low, so low that it precludes their use as a screening method for participation in sports. In simple terms, these tests cannot predict which athletes will sustain a stinger, TQ, or catastrophic spinal cord injury with any reliability, therefore they cannot be used as a tool to “screen out” players from participating in sports.
There are no laboratory tests used to diagnose stingers or TQ. Occasionally, specific tests are ordered to rule out infection or other causes of neck pain and radiculitis.
If an athlete has a persistent neurologic deficit, such as arm and/or leg weakness or numbness, an EMG/NCV test may be ordered. Electromyography and nerve conduction velocity (EMG/NCV) tests are useful to determine which nerve is affected, and how severely it is damaged or irritated. The test will often clarify where a nerve is actually being compressed – whether it is a spinal nerve in the neck or a peripheral nerve in the shoulder, elbow, forearm, or wrist.
Stingers and transient quadriplegia are often “diagnoses of exclusion,” meaning that other causes should be evaluated for and ruled out before these diagnoses are made. Frequently, patients will have a severe neck strain or herniated disc that will mimic some of the symptoms of a stinger or TQ. It is important for the clinician to conduct a thorough history and clinical examination prior to formulating a diagnosis so as not to misdiagnosis this condition. Imaging studies such as x-rays and MRI are often essential to clarify and confirm the diagnosis.
The treatment of stingers and transient quadriplegia is focused on regaining and improving the strength of the affected extremity(s), as well as the neck and core muscles. An athlete should generally not return to sport until the strength has returned to an adequate, pre-injury level. Patients who are noted to have spinal stenosis should be carefully evaluated by a spine specialist, and return to play criteria should be individualized. At times, surgical decompression may facilitate resolution of the stenosis, improve symptoms, and prevent recurrence. General return-to-play guidelines are listed below.
* Please note – these are only guidelines; each individual athlete must be carefully evaluated by a qualified physician after an injury is sustained, and the decision to allow an athlete to return or not return to sport must be individualized and is ultimately made by the treating and/or team physician.
- No Contraindications to Return to Play **
- Single-level Klippel-Feil deformity/congenital fusion below C2
- Spina bifida occulta
- Resolved stinger or brachial plexus neurapraxia (2 or less)
- Healed herniated disc
- Healed subaxial cervical spine fracture (C3-C7)
- Healed facet fracture
- Healed lamina fracture
- Healed spinous process fracture (clay shoveler’s fracture)
- Healed one-level anterior cervical fusion
- Healed single or multiple level posterior cervical foraminotomy
- Relative Contraindications to Return to Play **
- Resolved transient quadriplegia (1 episode)
- Resolved stinger or brachial plexus neurapraxia (3 or more)
- Non-healed/non-resolved asymptomatic herniated disc or severe foraminal stenosis
- Healed C1 fracture
- Healed C2 or Odontoid fracture
- Any healed subaxial spine fracture with minimal or mild residual displacement, deformity, or decreased range-of-motion
- Healed two-level anterior cervical fusion
- Healed one-level posterior cervical fusion
- Absolute Contraindications to Return to Play or Participation **
- Clinical or radiographic evidence of rheumatoid arthritis, anklosing spondylitis, or diffuse idiopathic skeletal hyperostosis
- Arnold-Chiari malformation
- Os odontoidium or congential odontoid agenesis/hypoplasia
- Klippel-Feil deformity/congenital fusion or anomaly involving C1 and/or C2
- Multiple-level Klippel-Feil deformity/congenital fusion below C2
- C1-C2 hypermobility or instability (ADI > 4 mm)
- Spear tacklers spine deformity
- Transient quadriplegia (2 or more episodes)
- Non-healed/non-resolved symptomatic herniated disc or severe foraminal stenosis
- Cervical myelopathy
- MRI evidence of spinal cord contusion, edema, or abnormality
- Any healed cervical spine fracture/dislocation (lateral mass fracture with subluxation/dislocation)
- Any healed cervical spine fracture or injury with residual instability > 3.5 mm/11°
- Any healed subaxial spine fracture with residual displacement, deformity, or decreased range-of-motion
- C1-C2 fusion
- Three-level (or more) anterior cervical fusion
- Two-level (or more) posterior cervical fusion
- Cervical laminectomy or laminaplasty
** Athletes who are diagnosed with conditions in category I or II should be essentially pain-free, have normal cervical range-of-motion, normal cervical lordosis, and normal strength and sensation before returning to sport. Athletes diagnosed with a condition in category III should generally not be allowed to return to sport, regardless of pain or neurologic status.
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