RETURN-TO-PLAY CRITERIA IN ATHLETES WITH TRAUMATIC INJURIES TO THE CERVICAL SPINE.  Current Opinion in Orthopaedics, Vol. 14, No. 3, June 2003.

            David H. Kim, MD            Alexander R. Vaccaro, MD

            Scott C. Berta, MD

ABSTRACT

Of the 10,000 annual cervical spine injuries in the US, approximately 5-10% are sports related.  The number has declined since 1976 when they outlawed headfirst contact in football.  Rates went from 13 cases per million in 1976 to 3 per million in 1991 and 1993.   Defensive football players suffer the greater degree of injuries in football, while alcohol is involved in 40% of the diving injuries.   Gymnastics and wrestling have higher rates of cervical injury, and hockey has injuries due to checking into the boards. 

Stingers are experienced by up to half of all college football players in any given year, and are the result of an impact forcing posterolateral neck extension and ipsilateral neural foramen narrowing.  Symptoms can be either lancinating or burning pain lasting seconds or hours, and weakness may be present and last up to a couple of days.  As single stinger episodes have minimal long-term problems, the return to play criteria is quite liberal.  Once cervical ROM returns to baseline, and there are no pain or strength losses, the player can return.  Carefully examine the deltoid, biceps and spinatii muscle strength, which are the most commonly involved.  Any symptoms that last more than one day should be further evaluated, including MRI to detect stenosis or disc herniation.  Electromyography is more beneficial at the 2-4 week time frame, where mild conduction block is usually seen with persistent problems.  Multiple stinger episodes are associated with persistent weakness and chronic pain syndromes.  Additional coaching and equipment modification is required, and if necessary, position change or cessation of playing that sport.

Burning hand syndrome, which involves both hands and occasionally the feet, should be evaluated for spinal cord injury.  Weakness is often present, and in 50% of the cases, there is a fracture or soft tissue injury.

Transient quadriparesis, or neuropraxia, is temporary paralysis with rapid recovery.  This condition is most affiliated with congenital stenosis of the cervical spine.  MRI is performed to rule out stenosis or other soft tissue conditions.  For those with recovery of their symptoms and no findings on MRI, they can return to play with a warning that there is risk of permanent neurological injury

NO CONTRAINDICATIONS TO RETURN TO PLAY FOR:

·         Healed C1 or C2 fractures with normal cervical ROM

·         Healed subaxial fracture without saggital plane deformity

·         Asymptomatic C7 fracture, or clay shovelers fracture.

RELATIVE CONTRAINDICATION TO RETURN TO PLAY

• After a 2 level anterior or posterior cervical fusion, excluding posterior screw fixation

ABSOLUTE CONTRAINDICATIONS TO RETURN TO PLAY

• After a C1-2 surgical fusion
• After cervical laminectomy
• After a 3 level anterior or posterior fusion
• Radiographic evidence of segmental instability
• Radiographic evidence of distraction/extension cervical injury
• Healed subaxial spine fracture with saggital plane kyphosis or coronal plane deformity.

COMMENTS

Odds are the more involved injuries are going to have adequate physician clearance and work-up to prevent the wrong athlete from playing when he/she should not.  The lower grade injuries, such as the stinger and transient paralysis, may need additional monitoring by the PT to alert the physician if there is any residual dysfunction that would warrant further work-up.