As the dog-days of summer turn into the cool nights of autumn, our minds turn to football. As an orthopedic surgeon, my thoughts turn to the football players and the injuries that bring them into our offices every week.
Whereas most spinal injuries are minor, there is no more frightening an injury seen on a football field than a traumatic neck injury. The sight of a player lying motionless on the field will send chills down anyone’s spine, much less the trainer and physician assigned to care for that player. The goals of care for that athlete move away from the mundane issues of return to play, to the issues of that young man being able to walk and care for himself for the remainder of his life.
The range of injuries span from the minor sprain to the complete spinal cord injury. Thankfully, these devastating injuries to the cervical spine are relatively rare. This article is a brief overview of a broad, complicated segment of sports injuries. There is a significant amount of ongoing debate regarding the best treatment for various injuries, but fortunately, we do have some good data with regard to the cause, prevention and treatment of cervical spine injuries.
The cervical sprain is a soft tissue injury to the muscle of the neck usually caused by overstretching of the muscle from a lateral blow to the helmet or hyper flexion/ extension of the head from a hit from the front or back. The later of these mechanisms is similar to a whiplash type injury frequently seen in motor vehicle crash victims. Treatment is primarily conservative with rest, gentle stretching and physio-therapy type modalities (ice, heat, ultrasound, etc.). These injuries tend to be self-limited, although severe sprains may take weeks to heal fully.
Athletes with sprains that do not improve with simple care must be evaluated for more significant structural lesions (fractures, disc injuries, etc.). Prevention can consist of use of “cowboy-type” shoulder pad collars and specific resistive type strengthening exercises to strengthen the paraspinal muscles.
Burners are a specific type of injury seen almost exclusively in football players. These injuries are really a stretching injury to the brachial plexus- the cable of nerves that lead from the cervical spinal cord down through the shoulder area into the arm and hand. Burners are caused by a lateral blow to the helmet forcing the ear against the shoulder pad. The affected arm will start to tingle or go completely numb and the player may not be able to move the arm for a variable length of time. My experience with these injuries is that they are much more frequent than any trainer would think because they are usually very transient and the player will frequently not alert the trainer out of fear of being taken out of the game. Thankfully, the burner usually does not lead to permanent neck and/or nerve injury, but frequent episodes should cause the player to be evaluated for structural injuries to the spine itself.
Burners that affect both arms or involve leg symptoms are really not burners at all but a form of transient quadriplegia/quadriparesis. Otherwise known as cervical cord neuropraxia, these are much more serious injuries that should be differentiated at the time of the injury. These injuries involve a direct contusion of the cervical spinal cord-similar to banging an electrical cable causing the signals to be transiently scrambled. These injuries do generally have a good prognosis, but a structural spinal injury needs to be ruled out. These injuries can be seen with increased frequency in athletes with congenital stenosis-patients who are born with less room for the spinal cord in their spinal column than average. In addition, other lesions that can narrow the “canal” can be seen: disc herniation’s, bone spurs, arthritis. Specific treatments for these injuries must be individualized based on the frequency and severity of the quadriparesis, the level of play of the athlete and the underlying cause. The bottom line is that any injury that causes symptoms in both arms and legs must be more fully evaluated. These players may not return to football activities until fully evaluated by a physician.
Finally, we must mention the most devastating of all injuries-the injury that renders the spine highly unstable with associated spinal cord injury. Exhaustive review of the National Football Head and Neck Injury Registry has shown that these injuries invariably occur with direct blows to the crown of the head with the neck in a slightly flexed posture. This is typified by the “spear tackling” seen at all levels of football. Even a fairly innocuous “hit” by today’s football standards to the top of the helmet can cause a highly unstable fracture of the vertebra. Fragments of bone can be forced into the spinal cord causing severe, catastrophic injury. Field care involves immobilization of the injured spine and transport immediately to a medical center prepared to care for such injuries. These injuries invariably involve reconstructive surgery of the injured spinal cord and stabilize the injured segment. Spinal cord injuries can be incomplete-having some sparing of sensation or motion in the legs or complete-having no neurologic activity below the level of injury. The difference in prognosis is huge- whereas incomplete injuries may heal enough to allow the patient to walk and function independently, complete injuries render that patient to a wheelchair permanently with very limited hope of improvement.
Fortunately, we can decrease the incidence of these injuries by outlawing “spear tackling” and by teaching the most junior of football athletes to tackle correctly-with their heads-up, never taking their eyes off the target. Unfortunately, the immediate outlook for patients with complete cord injuries remains bleak. But recent high profile injuries and patients have directed needed attention and money to new treatments such as medications that regenerate nerve cells and stem cell research.