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Cervical Spine Sprain/Strain Injuries: Follow-up

Author: Gerard A Malanga, MD, Founder and Director, New Jersey Sports Medicine Institute; Director of Pain Management, Overlook Hospital; Director of Sports Medicine, Sports Medicine Fellowship Director, Mountainside Hospital; Clinical Chief, Rehabilitation Medicine and Electrodiagnosis, St Michael's Medical Center; Medical Director, Consultant, Horizon Healthcare Worker's Compensation Services, Blue Cross and Blue Shield Worker's Compensation
Coauthor(s): Michael J Mehnert, MD, Associate Physiatrist, The Rothman Institute; Daniel Kim, MD, Staff Physician, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey
Contributor Information and Disclosures

Updated: Mar 31, 2008

Follow-up

Return to Play

Criteria for the patient's return to unrestricted competition include the following^20,21 :

• Minimal or no tenderness
• Full AROM
• Neck strength versus resistance without pain is within normal limits (WNL)
• Posture is WNL
• Neurologic examination is WNL
• Absence of neurologic symptoms

The likelihood of a recurring injury is extremely high if the player returns to action before pain, tenderness, and ROM have returned to normal.

Complications

Long-term complications that may develop from cervical injuries include chronic pain, headaches, depression, permanent loss of cervical ROM, and disability. In patients with chronic symptoms that are unresponsive to a progressive rehabilitation approach, diagnostic zygapophyseal joint injections may help to identify a potentially treatable process, which may respond to radiofrequency denervation treatment in a properly selected patient group.

Prevention

For participants in football or wrestling, strengthening of the muscle groups supporting the cervical spine is imperative.^1,2,3 To guarantee adequate development of strength, power, and endurance, strengthening routines need to include a variety of isometric and isotonic exercises. Emphasis must be placed on strengthening not only the large cervical flexors and extensors, but also the smaller paravertebral muscle groups because they offer the final resistance to forces that may cause dislocation of the vertebrae. Sport-specific drills with emphasis on cervicothoracic spine stability should be included in the athlete’s exercise regimen.

Athletes are advised to add a minimum of 1 cm to their neck circumference. Warm-up of the neck and the cervical spine should be emphasized, especially in contact sports. By performing several repetitions of cervical flexion, cervical extension, lateral bending, and rotation, the athlete can sufficiently warm up the neck. After workouts, while the muscles are warm, stretching to maintain or increase the AROM should be completed. In all AROM, the cervical muscles should be stretched to their limits and held in the stretched position for 30-60 seconds.

In football, a proper shoulder pad should encompass many of the characteristics of a proper cervicothoracic orthosis. Important characteristics of a proper shoulder pad include a modified A-frame shape that fits the athlete's chest and prevents the shoulder pad from rolling during contact.^1,2 Firm, circumferential fixation to the chest is important. Proper fit to the chest is important in evenly distributing the shock to the shoulders over the pad and to the thorax. Better plastics in the outer shell of the pad and improved resistive padding absorb the shock and allow the use of the shoulder in proper blocking and tackling techniques. Improved shoulder protection should allow the player to de-emphasize the use of the head as a blocking and tackling instrument.

After fixing the chest, fix the neck to the chest by the fit of the shoulder pad at the base of the neck. Thick, stiff, comfortable pads at the base of the neck are the key considerations. This lateral support at the base of the neck offers fixation to the cervical spine.

Prognosis

The prognosis for athletic cervical spine sprains and strains is believed to be excellent.

Education

Proper head and neck positioning should be emphasized in all sports. Football players must be taught proper blocking and tackling techniques to avoid the head-first block or tackle, such as spearing, and the use of the head as an offensive weapon, which can increase the potential of severe cervical injury.^1,2 Wrestlers should be instructed to avoid the maneuver of bulling the neck into a hyperextended position while attempting or blocking a takedown because this appears to be associated with the greatest number of neck injuries in wrestling.³

Miscellaneous

Medicolegal Pitfalls

• Precedent exists for legal action against athletic trainers and team physicians who failed to properly treat injured athletes, and those who treated the injured players are legally responsible for their actions. The most difficult athletic injuries to evaluate and manage on the field are those involving the head and cervical spine.^22,23 The risks can be high because of the potential involvement of the nervous system, and as a result, the margin of error is low. The more severe injuries are fortunately the least common; however, a thorough neurologic examination and evaluation of the cervical spine and its ROM is necessary because these should rule out the possibility of a more serious injury.
• Following an acute injury, one should immediately immobilize the athlete's head and neck, maintain an open airway, and make sure the athlete is breathing and has a pulse (ABCs). The safest ways of opening the airway in an athlete with a suspected cervical injury is the jaw-thrust and chin-lift maneuver; the head-tilt method is not considered safe. Extremity neurologic symptoms; severe cervical tenderness; or severe cervical pain at rest, against resistance, or with active motion are all criteria for spinal cord injury transport. When in doubt, always transport the patient as if there is a spinal cord injury present. Logroll the athlete directly onto the spine board with the chief priority of maintaining alignment of the head and neck at all times. To ensure that there is no possibility of motion during transportation, the athlete should be secured with straps once he/she is on the spine board.

Related Medscape topic:
Resource Center Medical Malpractice and Legal Issues

Special Concerns

• A process that should not be performed haphazardly or hastily is managing an unconscious athlete or one suspected of having significant injury to the cervical spine. The best way to prevent actions that could convert a reparable injury into a catastrophe is to be prepared to handle the situation. Preventing further injury is the single most important point to remember. An examiner should always consider that spinal cord injury is a possibility when dealing with an unconscious athlete.

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