Head and spine injuries

Head and spine injuriesFormulate an initial management plan for a 16 y/o defensive back with temporary loss of consciousness, neck pain, and upper extremity weakness after a playThe same patient returns 1 week later. He asks when he can return to play

Any athlete with neck pain and altered consciousness must be assumed to have a fractured spine until proven otherwiseAm J Sports Med 1990; 18: 50-7Initial focus is on the ABCs: Airway, Breathing, CirculationJaw thrust method for opening airwayRemoval of helmet should be avoided

If cardiac arrest occurs , cardiopulmonary resuscitation is initiated in the supine positionOnce condition stable, screening neurologic evaluation including level of consciousness, pupillary response, and motor and sensory status.Patient placed on spine board then transferred

ConcussionThe Congress of Neurological Surgeons defined concussion in 1966 as a clinical syndrome characterized by . . . Immediate and transient post-traumatic impairment of neural functions, such as alteration of consciousness, disturbance of vision, equilibrium, etc., due to brainstem involvement

Postconcussion SyndromeOccurs when the symptoms related to the concussion, including headache, fatigue, memory loss, concentration loss, and irritability, persist after initial recovery from the head injury.

Cantu and Colorado Head Injury Grading SystemsGradeCantuColoradoGrade 1 (mild)No LOCPTA < 30 minsConfusion without amnesiaNo LOCGrade 2 (moderate)LOC 30 minsConfusion with amnesiaNo LOCGrade 3 (severe)LOC>5 minsPTA>24 hoursLOCLOC - loss of consciousness; PTA - post traumatic amnesiaReturn-to-play criteriaGrade 1 concussionAthlete should be removed from the contest and examined immediately and at 5-minute intervalsAthlete may return to play if symptoms clear in 15 minutesIf a second grade 1 concussion occurs, the athlete should be removed from participation that day.The athlete must remain asymptomatic for 1 week before being allowed to playReturn-to-play criteriaGrade II concussionAthlete removed from the contest for the day and receive frequent on-site evaluations in addition to next-day evaluation. The athlete must remain asymptomatic for 1 full week at rest and with exertion prior to return to play.CT or MRI is recommended for postconcussive symptoms persisting beyond 1 week. Return-to-play criteriaGrade 3 concussionRequires removal of the athlete from the contest and often transport to the nearest hospital by ambulanceEither 2 fully asymptomatic weeks or 1 asymptomatic week after 1 full month of rest is required before return to play.Second-impact syndrome (SIS)Occurs when an athlete who sustains a head injury then experiences a second head injury before symptoms associated with the first head injury (postconcussive type) have cleared. Metabolic changes occurs after initial injury, increase intracellular calcium, extracellular glutamate and glycolysis resulting in cerebral edema

Since the 1950s, approximately 90% of all traumatic football fatalities have occurred as a result of head or neck injuriesPhys Sportsmed 1996;24(1):35-41Catastrophic neck injuries in footballHelmet-to-helmet or helmet-to body contactHead to spear tackle methodsEducation of coaches to discourage tackling techniques lowered the incidence of neck injuries

Neurapraxia of the cervical cord with transient quadriplegiaOccurs in athletes after forced hyperextension, hyperflexion or axial loading of the cervical spine.Predisposing factors: developmental spinal stenosis, herniated nucleus pulposus, spondylosis will cause narrowing of the AP diameter of the spinal canal.Torg and Pavlov utilized the ratio of vertebral canal width to body size to detect presence of significant spinal stenosis on x-raysRatios less than 0.8 suffered transient neurologic episode.

In separate studies, Herzog and associates and Cantu and colleagues detected a high percentage of false-positive Torg-Pavlov ratio in asymptomatic football players because of their large vertebral body width and suggested that MRI be used to confirm x-ray abnormalitiesMed Sci Sports Exerc 1997, 29(suppl):S233-5Spine 1991: 16(suppl 6): S78-86Return-to-play criteria for developmental cervical spine lesionsAbsolute contraindication for participation in collision sportsSpear-tacklers spine, odontoid abnormalities, atlanto-occipital instability (disruption of alar or transverse ligament)Cervical ligamentous instability documented by more than 3.5 mm. horizontal displacement of adjacent vertebrae or more than 11o of rotation to adjacent vertebra

Relative contraindicationsPersons with a Torg-Pavlov ratio of 0.8 or less with one episode of cervical cord neurapraxia In those with certain fractures that have healed without neurologic deficit in which the athletes regained full pain free range of motionClin J Sport Med 1997:7:273-9Return-to-play criteria for developmental cervical spine lesionsStinger or BurnerTransient neurologic event characterized by pain, paresthesia, and local weakness in an upper limb after a blow to the shoulder or neck. The precipitating event usually involves downward displacement of the shoulder with lateral flexion of the neck.Am J Sports Med 1997: 25: 603-8Stinger or BurnerIn young athletes, the lateral flexion is away from the side of the symptoms, which increases the acromiomastoid distance (stretch mechanism).In older athletes, the head laterally flexes toward the ipsilateral shoulder and creates a pincer mechanism at a foraminal level. EMG studies have demonstrated abnormalities in the roots, cords, trunks, and peripheral nerves of players sustaining theses injuries.