Cervical Spine Acute Bony Injuries in Sports Medicine

United States statistics

The incidence of all spinal injuries in the United States has been reported at approximately 10,000 cases per year. Nearly 200,000 people in the United States have a history of spinal injuries. These statistics do not differentiate between injuries with fracture and injuries without fracture.[5, 6, 7]

Sports-related activities represent 10-15% of these injuries, and spinal injuries represent 2-3% of all sports-related injuries. Certain sports (eg, American football, diving, gymnastics, skiing, wrestling, rugby, hang gliding, paragliding, surfing, equestrian events, ice hockey) are more frequently associated with the risk of spinal trauma.[2, 3, 4, 6, 7, 8, 9, 10, 11, 12, 13, 14]

The most common spinal injuries cited in the literature are injuries secondary to contact sports such as football. Nearly 1.2 million high school athletes and 200,000 college and professional athletes participate in football. The National Football Head and Neck Injury Registry contains data on cervical spine injuries as a result of participation in football. A trend can be seen over time, as equipment and helmets improved. The incidence of cervical spine injuries increased until 1976. In that year, antispearing rules were established to prevent the athlete from using the helmet as driving force in tackles. Direct collision created higher axial loads than the neck could withstand, leading to high injury rates. This rule, along with better coaching of blocking and tackling techniques, has resulted in a significant decrease in the number of spinal injuries.[10]

Diving is often cited as another significant cause of cervical spine injuries. Injuries resulting from diving are often associated with devastating outcomes. Diving rules (eg, depth of starting areas) and proper technique have lowered the probability of injury during supervised athletic events. However, unsupervised swimming and diving into shallow water present significant risks. Public awareness of this problem has led to the development of special awareness programs, but the risk of injury remains high.

Leonard et al studied 540 children with cervical spine injuries and found that while motor vehicle crashes accounted for the most common injury in the axial region for children 2 and 2 to 7 years old, sports accounted for as many injuries as motor vehicle crashes (53% being subaxial) in children 8 to 15 years old.[15]  

The human spine serves to provide structural support and bony protection of the spinal cord. The cervical spine consists of 7 bony vertebrae separated by flexible intervertebral discs. They are joined together by an intricate network of ligaments, which helps form the normal lordotic curve of the cervical neck.[16]

The spinal column can be divided into 2 separate columns based on function and injury patterns. The anterior column consists of the bodies of the vertebrae, intervertebral discs, and the anterior and posterior longitudinal ligaments. The function of the vertebral body is to support weight. The posterior column contains the spinal canal and consists of the pedicles, laminae, articulating facets, and transverse and spinous processes. These structures form the vertebral arch, which encloses the vertebral foramen and protects the neural tissues.

The arch is formed by bilateral pedicles that are oriented posteriorly and join 2 laminae. The spinous process arises posteriorly from the vertebral arch. The cervical transverse processes and 4 articular processes also arise from the arch. The cervical transverse processes are unique to the vertebral column with an oval foramen transversarium. The vertebral arteries pass through these foramina. The posterior column also includes a group of ligaments including the supraspinous, infraspinous, interspinous, and nuchal ligaments.

The first 2 cervical vertebrae are atypical in form and function. The next 5 vertebrae are all similar in structure and function. The atlas, C1, is a ring-shaped bone that supports the skull. Two concave, superior articular facets articulate with the occipital condyles. The atlas does not have a body or spinous process. The atlas has an anterior and posterior arch, each with a tubercle and lateral mass. The axis, C2, is the strongest cervical vertebrae. The atlas rotates on 2 large articulating surfaces. The odontoid process (dens) projects superiorly from the C2 body and is the bony structure that the atlas rotates on. The odontoid process is held in place by the transverse ligament of the atlas.

Contact sports, falls, and diving in sports may lead to vertebral stress and fractures. Sports that involving tackling can increase exposure to mechanisms causing fractures.

The prognosis for the athlete is completely dependent on the type and extent of his or her injuries as well as associated problems.

Complications

An extensive list of complications of cervical fractures exists. Neurologic impairment is the most obvious and severe. The neurologic complications may range from paresthesias to complete loss of function. Cervical spinal cord injuries can be devastating because they may involve respiratory function and death. Spinal shock is also challenging to care for in the initial phase of injury. Long-term complications are related to immobilization and loss of function. These complications include skin breakdown, infections, loss of muscle mass, depression, and increased risk of suicide. Halo immobilization is associated with pin-site infections and osteomyelitis. Long-term collar immobilization is associated with skin breakdown.

A strong educational program should be included in all sports, especially contact and high-risk sports. Proper tackling must be taught from the beginning. A community education program should also be encouraged to prevent unsupervised sports injuries. Water and pool safety must be widely encouraged, including emphasis on feet-first water entry and avoidance of chemical impairment while engaging in water sports.

Everyone exposed to athletes (eg, physicians, coaches, trainers, referees, parents) should aid in providing this education. The rules of play for sports should reflect an effort to prevent injury and promote safe play. Paramedics and hospital personnel should be educated in proper care of a patient wearing equipment such as helmets and pads.

For patient education resources, see the Neck Strain, Neck Pain, and Whiplash.

Initially approach every injured athlete with the suspicion of a cervical spine injury. Consider ABCs (ie, airway, breathing, circulation) from the beginning.

Obtain the history before the physical examination or movement of the patient. Include the following in the history:

• The mechanism of the injury defines the possible bony injuries, but this may not be possible to elicit, or it may be multifactorial.

• Determine if the athlete has a history of neck injuries, spinal stenosis, spear tackler's spine, or other abnormalities (see Causes, below).

• Ask the athlete if neck pain is present. Determine location and quality of any pain. Ask if the pain radiates distally or to the extremities.

• Determine if the patient is experiencing paresthesias or weakness.

• Determine if other distracting injuries are present.

• Determine if the athlete is impaired by a head injury or the use of a legal or illicit drug.

Address the patient's ABCs (airway, breathing, and circulation) while protecting the cervical spine.

Palpate the neck, and specifically feel for midline bony pain, muscle spasm, step-off, and crepitus.

Determine if extremity sensation is intact.

Determine if the athlete can move all extremities without deficits.

Determine if the athlete can perform range of motion (ROM) in all directions without pain or symptoms. NOTE: Do not perform passive ROM of the neck.

Determine if head compression elicits pain or symptoms.

Before performing the Spurling maneuver to determine whether pain or symptoms are elicited, exclude the presence of any bony injury or instability first.

The Spurling maneuver is performed by passively forcing the athlete into cervical extension with lateral flexion toward the side of the symptoms. The maneuver reproduces symptoms of recurrent brachial plexus injuries by nerve root compression in the intervertebral foramen.[17]  NOTE: This is an office-based examination to be performed after other injuries have been excluded.

Collision sports are often associated with fractures. The occurrence of fractures increases with poor technique (eg, improper tackling techniques), poor conditioning, and substandard equipment. Previous injury may also predispose the athlete to new injury. The mechanism of injury determines the type of bony injury, and, historically, cervical spine fractures have been categorized by the mechanism of injury.[8, 12, 18, 19]

• Flexion injuries

  • Simple wedge fracture (see the image below)

    • Fracture of the anterosuperior end plate of the vertebral body

    • Associated with posterior ligament disruption, which makes the injury unstable

    • Differs from a burst fracture because no vertical element to the fracture is present

      Child with C6 flexion wedge fracture.

  • Anterior teardrop fracture

    • Teardrop fracture with an anteroinferior vertebral body fragment

    • Unstable fracture associated with complete disruption of ligaments

    • Associated with anterior cord syndrome

  • Clay shoveler's fracture (see the image below)

    • Avulsion of spinous process of the lower cervical vertebrae, usually C7

    • Stable fracture

      Clay shoveler's fracture.

  • Atlantooccipital and atlantoaxial dislocation with fracture (see the image below)

    • High instability

    • High mortality

      Anteroposterior view of atlantooccipital dislocation.

  • Bilateral facet dislocation with fracture (see the image below)

    Bilateral facet fracture/dislocation at C6/C7.

• Flexion with rotation injuries – Unilateral facet dislocation with fracture (The dislocation alone is stable. The fracture may occur at the base of the superior articular mass of the inferior cervical vertebrae, or the fracture may occur at the base of the inferior mass of the superior dislocated vertebrae.)

• Extension with rotation injuries

  • Pillar fracture

    • Vertical or oblique fracture of the articular mass

    • Stable fracture

  • Pediculolaminar fracture

    • Variety of severities

    • Associated ligamentous injuries

• Extension injuries

  • Anterior arch of the atlas (avulsion fracture) – Unstable fracture

  • Posterior arch of the atlas fracture

    • Compression between the axis and occiput

    • High association with other fractures

  • Hangman's fracture (see the image below)

    • C2 pedicles with anterior displacement

    • Common in diving accidents

    • NOTE: The patient may be without neurologic deficit, but this is an unstable fracture

      Lateral view of hangman's fracture.

  • Laminar fracture (see the image below)

    • Subtle fracture associated with spinous process fractures

    • Stable fracture

      C7 lamina fracture.

  • Extension teardrop fracture

    • Anteroinferior vertebral body fracture from an avulsion by the anterior longitudinal ligament

    • Most common at C2

    • Unstable fracture

• Lateral flexion injuries – Uncinate process fracture, resulting in transverse fracture of the base of the uncinate process by the superior vertebral body

• Compression injuries

  • Jefferson fracture (see the image below)

    • The occipital condyles are driven into C1, forcing the lateral masses apart.

    • Often associated with rupture of the transverse ligament

    • Unstable fracture

      Odontoid view of a Jefferson fracture.

  • Burst fracture (see the image below)

    • Axial lode causes the vertebral body to burst.

    • Involves both end plates and may intrude into the spinal canal

    • Unstable fracture

      C4 burst fracture.

  • Spear tackler's spine

    • Associated with use of the head as the initial contact in football

    • Over time, athletes develop cervical stenosis, posttraumatic changes, and loss of cervical lordosis.

    • Traumatic axial compression can cause compression of the anterior column, followed by flexion, resulting in a fracture.

• Other injuries

  • Odontoid fracture

    • Associated with other cervical fractures

    • Type I – At the tip superiorly. The transverse ligament remains intact, and the fracture is stable.

    • Type II – At the junction of the odontoid and the body. This is the most common type of odontoid fracture. See the image below.

      Odontoid type 2 fracture.

    • Type III – Through the superior portion of C2 at the base of the odontoid. See the images below.

      Lateral view of type 3 odontoid fracture.
      Computed tomography scans of odontoid type 3 fracture.

Laboratory studies are not typically useful in the diagnosis of cervical spine injuries.

Plain radiography

Historically providers would obtain plain radiographs when cervical injury is suspected. Plain radiographs are still useful, but are being replaced by the availability and performance of CT.  Two large studies looked at when radiographs should be obtained. The criteria for radiography differ, and some controversy remains regarding which system is better.[20, 21, 22] Keep in mind as well that these studies were not focused on athletes or athletic mechanisms of injury. Use of these guidelines should be taken with precaution in athletes.

According to the National Emergency X-Radiography Utilization Study (NEXUS) study criteria, the patient must exhibit the following criteria in order for the mechanism and dynamics of injury to be considered low risk, and, if any of the below criteria are present, radiographs should be obtained[23] :

• No posterior midline cervical spine tenderness

• No evidence of intoxication

• Normal level of alertness

• No focal neurologic deficit

• No painful distracting injuries

The Canadian C-Spine Rule (CCR) uses more criteria to determine who should undergo radiographs[21, 24, 25] :

• Primary criteria – First, take the following into consideration: (1) patient age older than 65 years, (2) mechanism of injury considered dangerous, and (3) numbness or tingling present in the extremities.

  • A dangerous mechanism of injury would be, for example, a fall from an elevation of 3 feet or higher, a bicycle collision, an axial load to the head (eg, resulting from a dive into an empty swimming pool), or a motor vehicle collision involving high speed, rollover, or ejection.

  • If any of these high-risk factors is present, then the patient is at risk for having a cervical spine injury and neck radiography should be performed.

• Additional criteria: If the patient does not meet any of the above criteria, then the question becomes whether the patient is voluntarily able to actively rotate the neck 45° in each direction.

• NOTE: Before any neck rotation test is performed, at least one of the following low-risk factors must be present: (1) simple rear-end motor vehicle collision, (2) patient ambulatory at any time since injury, (3) delayed onset of neck pain, (4) patient in sitting position in emergency department, or (5) absence of midline cervical spine tenderness. If none of these criteria is met, radiography should be performed.

• Finally, if the athlete is unable to voluntarily rotate to 45° in each direction, radiography should be preformed.

The standard radiographs obtained in a cervical spine series vary slightly by facility. Usefulness of some views in routine radiographic screening has been debated. A large patient study indicated that standard 3-view imaging is reliable for screening trauma patients.[26]

The 3-view series includes cross-table lateral, anteroposterior, and open-mouth odontoid views. Additional radiographic views include oblique views, odontoid tip shots, swimmer's view, and flexion/extension views.[27, 28, 29]

Computed tomography (CT) scanning

Perform CT scanning after plain radiography to further evaluate abnormalities.[30] CT scanning is also useful in the evaluation of areas that are difficult to evaluate or see in plain radiographs, such as the lower cervical spine in very large individuals secondary to body habitus.  CT scanning is often replacing plain radiographs in many facilities.

CT scanning provides much greater visualization of fractures and the capability to form 3-dimensional (3-D) reconstructions of the vertebrae, which may be helpful preoperatively. CT imaging is preferable in the obtunded patient and may facilitate the evaluation of the unstable spine in these patients.[31]

CT scanning has become the study of choice for unconscious patients and for those with abnormal plain radiographs. In some institutions, this imaging modality has replaced plain radiographs for most presentations. There is a greater exposure to radiation with this modality and this should be considered as well.

Magnetic resonance imaging (MRI)

MRI serves best in evaluating the soft structures of the spinal column.

MRI is helpful in the evaluation of ligamentous injuries and neural tissue.

MRI is helpful in the evaluation of spinal stenosis.

MRI assessments after spinal cord injury correlate with patient neurologic status and are predictive of outcome at long-term follow-up.[32]

In patients with persistent midline cervical tenderness and negative CT findings, MRI is not predictive of 12-month outcomes, including long term neck disability and time to return to work.[33]

Bone scanning

Bone scanning may be of assistance in the evaluation of stress fractures, infections, and tumors.

Rehabilitation program

Physical therapy

Treat the site of injury with spinal precautions, and address the ABCs. Immobilize the athlete's neck in neutral position with a cervical collar, towel rolls, or whatever is available. Immobilize the spinal column on a backboard, with the head secured such that the entire column is in neutral position and can be moved en bloc. Transport the athlete to a facility with the ability to stabilize the athlete and to radiographically evaluate the neck.[4, 9, 12]

If a fracture is detected, immediately consult a spinal orthopedic surgeon or neurosurgeon. The consultant should make the recommendations regarding the further stabilization of the fracture if needed. This may include Gardner-Wells tongs, surgical intervention, halo immobilization, a cervical collar, or no intervention. The consultant should be a part of all further decisions regarding rehabilitation, return to play, and long-term prognosis.

The patient should rest and remain immobilized, as directed by the consultant. Some patients with very stable fractures may be able to enter an early strengthening and exercise program.[12, 34]

Occupational therapy

Early occupational therapy may help increase function in those with neurologic deficits.

Medical issues/complications

The cervical spine must always be considered injured until proven otherwise by history and physical or radiologic evaluation.

Establishing the ABCs and searching for other injuries are priorities.

Early consultation of a spinal expert is mandatory for patients with fractures.

Surgical intervention

Surgery may very well be necessary, especially in cases of unstable fractures. The consulting surgeon determines whether surgical intervention is necessary.

Consultations

Consult an orthopedic surgeon or neurosurgeon. Other consultants may be contacted, as determined by the patient's injuries. Early psychologic counseling may also be warranted because these injuries may be devastating to the athlete.

Other treatment

Do not remove helmets and shoulder pads on the field if the athlete has a potential unstable cervical injury or if the patient is unconscious. Remove the face guard with a screwdriver or cutters. Athletes with respiratory compromise should be intubated with the helmet on.[2, 35]

Transport the athlete with helmet and pads in place. The chinstrap should remain attached if possible. No cervical collar should be placed, but the athlete and helmet should be secured to a backboard.

Unless the patient can be clinically cleared, obtain plain radiographs while the protective gear is in place. If the radiographs are inadequate, consider CT scanning with the helmet and pads in place. Caution: The helmet and shoulder pads should be removed by individuals who are trained and qualified in their removal.[36]

Rehabilitation program

Physical therapy

Treatment is determined by the patient's injuries. An exercise and strengthening program may be initiated, as well as a maintenance program for uninvolved areas. At this time, all involved physicians should discuss the type of sports and activities that the athlete will be able to participate in. If a change in sports or activity is needed, plans to encourage the athlete should begin.

Occupational therapy

Occupational therapy is initiated as determined by the injury and neurologic involvement.

Medical issues/complications

Monitor the athlete for signs of depression.

If the athlete is immobilized, monitor for problems such as skin breakdown or deep venous thrombosis (DVT).

Surgical intervention

The consulting surgeon addresses any potential surgical intervention issues (eg, delayed surgical repair, revisions).

Rehabilitation program

Physical therapy

Treatment is determined by the patient's injuries. Continue exercise and strengthening program, as well as the maintenance program for uninvolved areas. Continue to evaluate the type of sports and level of activity that the athlete will be able to participate in. If a change in sports or activity is needed, plans to encourage the athlete should begin.

Medical issues/complications

See the list below:

• Monitor the athlete for signs of depression.

• If the athlete is immobilized, monitor for potential problems such as skin breakdown or DVT.

Surgical intervention

The consulting surgeon addresses any potential surgical intervention issues (eg, delayed surgical repair, revisions).

As with all fractures, pain management should be a primary concern. Often acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID) is prescribed for the acute pain of a fracture. However, additional pain relief may be indicated if the patient does not have relief with acetaminophen or NSAIDs alone. In this case, an opiate may be required, particularly for breakthrough pain. Adjustment of pain medications may be necessary, especially in the acute phase.

Class Summary

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained injuries.

Acetaminophen (Tylenol, Feverall, Tempera, Aspirin Free Anacin, Tylenol-3)

Indicated for mild to moderate pain. DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking PO anticoagulants.

Ibuprofen (Motrin, Ibuprin)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Oxycodone (OxyContin, Percocet, Roxicet, Roxilox, OxyIR, Tylox, Roxiprin)

Indicated for moderate to severe pain.

Hydrocodone and acetaminophen (Vicodin, Margesic, Lortab, Norcet, Lorcet-HD)

Indicated for moderate to severe pain.

Codeine

Indicated for moderate to severe pain. Binds to opiate receptors in the CNS, causing inhibition of ascending pain pathways, altering perception and response to pain.

Class Summary

Corticosteroid agents have anti-inflammatory properties that may be protective in acute spinal cord injuries with neurologic deficits.

Methylprednisolone (Solu-Medrol, Depo-Medrol)

Decrease inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing increased capillary permeability. Indicated for known or suspected spinal cord injury. To be administered within 8 h of injury.

The absolute decision of when to return to play after a cervical spine fracture is dependent on the injury.[12, 19, 34, 37]  Professional athletes, who are more likely to sustain severe injuries and require surgical treatment than high school or college athletes are, typically have a longer wait before they can return to play.[38]

The consulting surgeon should play a large role in determining what type of activity can be performed and when it may begin. Failure to respect the severity of an injury may place the athlete in a position for further injury and possible disability. An athlete with persistent pain or neurologic symptoms certainly should be held from play. This may be frustrating to an athlete. An athlete does not want to be needlessly held from play, but proper evaluation and stabilization is paramount. Various sources indicating contraindications for play are available.

Absolute contraindications for contact and high-risk sports include the following:

• Neurologic symptoms or deficits

• Loss of ROM or pain with ROM

• Acute cervical fracture

• Spear tackler's spine

• Atlantoaxial instability, with or without fracture

• Atlantooccipital instability, with or without fracture

• Limited ROM

• Ligamentous laxity

• Vertebral body fracture with a sagittal segment

• Anterior teardrop fracture

• Fusion of 3 or more vertebrae

• Healed fractures with associated neurologic symptoms

• Fracture with canal involvement

• Odontoid fracture

Relative contraindications for contact and high-risk sports include the following:

• Developmental canal stenosis with history of symptoms

• Healed, nondisplaced Jefferson fracture

• Stable 2-level surgical fusion

• Healed, stable, mildly displaced body fracture without neural ring or sagittal components

• Healed stable neural ring fractures

Indicators that the patient is safe for participation (when asymptomatic with normal findings and pain-free examination) include the following:

• Developmental canal stenosis

• Healed stable compression fracture of body

• Healed spinous process fracture (clay-shoveler's fracture)

• Stable, one-level surgical fusion

• Healed, stable end-plate fracture

Athletes, especially those in contact sports, should participate in neck-strengthening exercises. Encourage education on proper technique and coaching. Rules of play to avoid tackling while leading with the head should be enforced. Additional education for the public should be supported. This should include prevention of diving injuries from shallow pools and natural water sources and avoidance of drinking alcohol while swimming. After the occurence of a cervical fracture, a change of sports or activity modification may be needed to prevent reinjury. Proper rehabilitation may also be necessary.