Targeting Tragedy From the Field to the Operating Room

5/3/2018

Sarah Decker, DO

Summa Akron City Hospital

Family Medicine Residency, PGY-2

Benjamin Burkam, MD, CAQSM

Summa Orthopedic Institute and Sports Medicine

1. Potential outcomes and red flag symptoms in acute spinal injury

2. Medical management to minimize harm to patient

3. Return to play guidelines following spinal trauma/fusion

Objectives

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• Targeting injury at high school football game

• Immediate risk of long-term sequelae

• Injury resulted in surgical intervention

• Adverse outcomes prevented

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Introduction

• 17- year old male

• No significant past medical or surgical history

• Presented with an injury after a head-to-head collision o Running the ball at quarterback position

o Flexed neck as tackled occurred

o Crown of helmet striking oncoming defender’s helmet, creating an axial load to cervical vertebrae

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Case History

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Game Film

• Game immediately stopped

• Stadium went silent

• The player was motionless on field in semi-prone position

• All proper precautions were taken with injury o C-spine stabilized

o EMS on scene

o Patient back-boarded

o Immediately transported to nearest children’s hospital

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Case History

• Initial exam by AT

o Loss of consciousness x 5-10 seconds

• Regained consciousness

o Alert and oriented to person, place and time

• Sensory and motor activity loss

o C5-T1 distribution

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Physical Exam

• Re-assessment by physician

o Approximately 1 minute after injury occurred

o Appropriate grip strength and lower extremity movement

o Noted tenderness to cervical spine palpation

o No cranial nerve deficits

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Physical Exam

1. Transient brachial plexus neuropraxia

2. Cervical spine fracture

3. Mild traumatic brain injury

4. Intracranial hemorrhage

5. Cervical muscle strain and ligamentous sprain

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Differential Diagnosis

• Cervical Spine CT

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Imaging

• Cervical Spine MRI

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Imaging

• Burst fracture and traumatic displaced spondylolisthesis of C5

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Final Diagnosis

• Direct Result o Flexion of cervical spine + compression

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Final Diagnosis: Biomechanics

• Intraoperative

Fluoroscopy

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Imaging

• Red flags initially

o LOC

o Bilateral sensory and motor loss

o Pain in the cervical spine region

• Preliminary diagnosis o C5 spinal cord injury

• Surgical intervention

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Results

• Surgical intervention

o Anterior cervical corpectomy

o Anterior and posterior spinal fusion of C4-6

• Immobilization x 3 months post-operatively

• Complete return of motor and sensory function without residual deficit

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Outcome

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Return to Play: Contraindications

• Initially: No longer eligible to participate in contact sports

• Currently: Cleared for limited contact sports o Playing baseball as a pitcher only

oDesires to water ski this summer

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Return to Play: Decision

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Return to Play: Decision

• Trained sports medicine physicians and athletic trainers

• Prevention of potentially tragic management errors

• Crowd control and protocols in place to prevent social issues interfering o Patient’s father was allowed onto field

o Patient and father adamantly request to return to play

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Discussion

• Preventing a potentially devastating 2nd movement o Any movement of the cervical spine at that time may have resulted in permanent spinal

cord damage

• Long-term neurological deficits can be a potential complication of a significant head or neck injury

• Proper evaluation and stabilization on-field can reduce patient’s risk

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Discussion

• Dailey, et al. High-energy contact sports and cervical spine neuropraxia injuries: What are the criteria for return to participation? Spine. 2010 Oct 1;35(21 Suppl):S193-201.

• Rihn, J.A., Anderson, D.T., Lamb, K. et al. Cervical Spine Injuries in American Football. Sports Medicine, 2009, 39: 697.

• McKeag MD et al. ACSM’s Primary Care Sports Medicine, 2nd edition. 2007. Chapter 24: Head and Neck. Pages 342-355

• Bailes MD, et al. Management of Cervical Spine Injuries in Athletes. Journal of Athletic Training. Vol 42, Jan – March 2007, 126-134. PMD ID: 1896095.

References

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Questions?

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