Paraplegia secondary to fracture-subluxation of the thoracic spine sustained playing rugby union football

Fractures of the spinal column during rugby matches of all codes are rare but catastrophic, especially when associated with spinal cord injury. The cervical spine is vulnerable during trauma to the head and neck in contact sports. Spinal injuries reported during rugby matches have almost exclusively involved the cervical region, often with neurological sequelae. This is the first reported case of paraplegia caused by a fracture-dislocation of the thoracic spine resulting from a low velocity rugby union injury.     

Catastrophic spine injuries in sports

Catastrophic spine injuries in sports are rare but tragic events. The sports with the highest risk of catastrophic spinal injuries are football, ice hockey, wrestling, diving, skiing and snowboarding, rugby, cheerleading, and baseball. A common mechanism of injury for all at-risk sports is an axial compression force to the top of the head with the neck slightly flexed. We review common mechanisms of injury and prevention strategies for spine injuries in the at-risk sports.     

Cervical spine injury management in the helmeted athlete

The relative incidence of catastrophic cervical spine injury in sports is low compared to other injuries. However, the potential catastrophic and life-altering consequences of spine injury cause understandable concern regarding the prehospital management and care of the cervical-spine-injured athlete. This is complicated when injured athletes participate in equipment-intensive sports, such as football, where helmets and facemasks are potential barriers to obtaining immediate access to the athlete's airway. Cervical spine injuries in these cases necessitate delicate and precise management, often involving the combined efforts of multiple health-care providers. The outcome of a catastrophic cervical spine injury is dependent on the efficiency of this management process and timeliness of transfer to a controlled environment for diagnosis and treatment.     

Catastrophic cervical spine injuries in the collision sport athlete, part 1: epidemiology, functional anatomy, and diagnosis

Catastrophic cervical spine injuries can lead to devastating consequences for the collision athlete. Improved understanding of these injuries can facilitate early diagnosis and effective on-field management. This article is the first of a 2-part series. The first part reviews the current concepts regarding the epidemiology, functional anatomy, and diagnostic considerations relevant to cervical spine trauma in collision sports. In the second part, to be published later, the principles of emergency care of the cervical spine-injured athlete are reviewed. This article provides a rational approach to the early recognition of the different clinical syndromes associated with catastrophic cervical spine injury. Rapid on-field diagnosis can help to optimize the outcomes of these catastrophic injuries.     

The epidemiology of catastrophic spine injuries in high school and college football

Athletic events have long been identified as a source of catastrophic spinal injuries. One of the most notorious sports has been American football. At both the amateur and professional level, this collision sport is associated with the highest number of direct catastrophic injuries including cervical spine trauma and quadriplegia. Although modifications in the rules of play and education of players and coaches have significantly diminished the rate of quadriplegia, there remains a need to decrease the number of catastrophic spine injuries in football. Further research related to the prevention and management of athletic cervical spine trauma is necessary.     

Spinal injuries in contact sports

Contact and collision sports such as American football expose the athlete to a wide array of potential injuries. Knee injuries garner much of the attention, but spinal injuries are potentially catastrophic and all levels of medical coverage of football must be knowledgeable and prepared to attend to an athlete with a neck injury. Of the other possible spinal conditions, some resolve on their own, others might require conservative therapy, and still others might require surgical intervention. The spectrum of potential injury is wide, yet the medical team must practice and prepare to treat the possible catastrophic neck injury.     

sportspages

Abstract

The incidence of catastrophic cervical spine injury in sports is low compared with other injuries. However, cervical spine injuries necessitate delicate and precise management, often involving the combined efforts of a variety of health care providers. The outcome of a catastrophic cervical spine injury depends on the efficiency of this management process and timeliness of transfer to a controlled environment for diagnosis and treatment. The objective of the National Athletic Trainers' Association (NATA) position statement on the acute care of the cervical spine-injured athlete is to provide the certified athletic trainer, team physician, emergency responder, and other health care professionals with recommendations on how to best manage a catastrophic cervical spine injury in an athlete. Recommendations are based on current evidence pertaining to prevention strategies to reduce the incidence of cervical spine injuries in sport; emergency planning and preparation to increase management efficiency; maintaining or creating neutral alignment in the cervical spine; accessing and maintaining the airway; stabilizing and transferring the athlete with a suspected cervical spine injury; managing the athlete participating in an equipment-laden sport such as football, hockey, or lacrosse; and imaging considerations in the emergency department.     

Roentgen examination of cervical spine injuries in the athlete

The roentgen evaluation of the cervical spine must be performed immediately following the possibility of injury and in such a manner as not to compromise the neurologic status of the patient. Subtle roentgen findings indicating ligamentous injuries must be recognized so that they can be treated prior to developing cervical spine instability. Occult fractures, which may be difficult to diagnose on plain films and require multiple radiographic modalities, must be diagnosed so as to prevent prolonged intractable neck pain. Most importantly, recognizing the mechanism of injury and prevention of cervical spine injuries are critical to prevent catastrophic cervical spine injuries secondary to athletic participation.     

Imaging the cervical spine following rugby related injury

Rugby Union and Rugby League are popular sports with high participation across the world. The high impact nature of the sport results in a high proportion of injuries. Rugby has an association with cervical spine injury which has potentially catastrophic consequences for the patient. Anecdotal evidence suggests that radiographers find it challenging to visualise the cervicothoracic junction on the lateral supine cervical spine projection in broad shouldered athletes. This paper intends to analyse the risk factors for cervical spine injuries in rugby and discuss the imaging strategy in respect to radiography and CT scanning in high risk patient groups such as rugby players who are suspected of suffering a cervical spine injury.     

On-the-field evaluation of an athlete with a head or neck injury

Head and cervical spine sports-related injuries are intimately associated. The on-field evaluation and management of the athlete with these injuries is of paramount importance to stabilize the athlete and prevent further injury. Clinicians need to be aware of the differential diagnoses and consider each possibility based on the mechanism of injury. Although recognition of head and cervical spine injuries has resulted in significant reductions of catastrophic neurological injuries, especially in the cervical spine, further advances to decrease the incidence and long-term sequelae of head and neck injuries are needed. The first step is education of the athlete and the individuals involved in the care of that athlete.     

闭合性颈椎创伤伴椎动脉损伤的临床研究

目的　研究椎动脉损伤在闭合性颈椎创伤中的发病率及其与颈椎损伤机制、类型、损伤程度的相关性 ,观察椎动脉损伤后的临床症状、体征 ,探讨早期正确诊断的方法。　方法　于2 0 0 0年 8月～ 2 0 0 2年 2月间 ,利用颈部动脉磁共振血管造影 (MRA)技术 ,连续观察 4 6例闭合性颈椎创伤患者 ,结合颈椎X线、MRI、CT检查及患者的临床症状、体征综合分析。　结果 4 6例闭合性颈椎创伤中 ,12例 (2 6 % )伴椎动脉损伤。其中 7例为双侧损伤 (4例一侧未显影、一侧狭窄 ,3例双侧狭窄 ) ,5例为单侧损伤 (均为一侧狭窄 ) ;10例椎动脉损伤患者无任何症状 ,2例出现眩晕、恶心呕吐、面部麻木、偏盲等症状。椎动脉损伤与屈曲型损伤及颈椎严重不稳定相关 (P <0 .0 5 ) ,与小关节绞锁、横突孔骨折及脊髓完全性损伤明显相关 (P <0 .0 1)。　结论　椎动脉损伤是闭合性颈椎创伤的较常见并发症 ,其临床症状体征缺乏特异性。颈椎创伤中的颈椎严重不稳定、屈曲型损伤、伴有脊髓完全性损伤、小关节绞锁和 (或 )横突孔骨折应高度怀疑椎动脉损伤。临床医师应对此类损伤有较高的警惕性 ,常规进行颈部动脉MRA检查是最有效的早期正确辅助诊断方法。     

Acute sports-related spinal cord injury: contemporary management principles

Improvements in helmet and equipment design have led to significant decreases in overall injury incidence, but no available helmet can prevent catastrophic injury to the neck and cervical spine. The most effective strategy for preventing this type of injury appears to be careful instruction, training, and regulations designed to eliminate head-first contact. The incidence of football-related quadriplegia has decreased from a peak of 13 cases per one million players between 1976 and 1980 to 3 per million from 1991 to 1993, mostly as a result of systematic research and an organized effort to eliminate high-risk behavior. An episode of transient quadriparesis does not appear to be a risk factor for catastrophic spinal cord injury. Torg reported that 0 of 117 quadriplegics in the National Football Head and Neck Injuries Registry recalled a prior episode of transient quadriparesis, and 0 of the 45 patients originally studied in his transient quadriparesis cohort have subsequently suffered quadriplegia. The significance of developmental spinal stenosis is unclear. Plain radiographic identification of a narrow spinal canal in a player sustaining cervical cord neurapraxia warrants further evaluation by MRI to rule out functional stenosis. The presence of actual cord deformation or compression on MRI should preclude participation in high-risk contact or collision sports.     

Training and equipment to prevent athletic head and neck injuries

Due to the potential for catastrophic neurotraumas and cervical spine injuries in sport, the sports health care professional must take proper measures to prevent such injuries. Strength training of the cervical spine, teaching of proper sporting techniques, and use of protective sports equipment are three primary means of attempting to prevent neurotraumas and cervical spine injuries in sports. There are other avenues to assist in preventing these injuries, such as flexibility programs. The sports health care professional, therefore, must be knowledgeable of the needs of each individual athlete when developing prevention plans.     

Sports-related injury of the pediatric spine

Acute spinal injuries are fortunately rare in pediatric sports but can be catastrophic. Imaging is integral to the diagnosis and care of spinal trauma. Plain radiographs and CT are critical for detecting vertebral fracture, and MR imaging is an essential adjunct for evaluating muscular, ligamentous, and spinal cord injury. Back pain is a common complaint among athletes of all ages. The growing spine has unique weaknesses that result in a higher rate of detectable radiologic abnormalities. Disk pathology is less common in children, and is often uniquely associated with fracture of the ring apophyses. Spondylolysis is far more prevalent in youth athletes than in their adult counterparts, requiring a different approach to imaging for assessment of adolescent back pain.     

Spinal injuries in professional rugby union: a prospective cohort study.

OBJECTIVES: To determine the incidence, severity, nature, and causes of cervical, thoracic, and lumbar spine injuries sustained during competition and training in professional rugby union. DESIGN: A 2 season prospective cohort design. SETTING: Twelve English Premiership rugby union clubs. PARTICIPANTS: Five hundred and forty-six male rugby union players of whom 296 were involved in both seasons. MAIN OUTCOME MEASURES: Location, diagnosis, severity (number of days unavailable for training and matches), and cause of injury: incidence of match and training injuries (injuries/1000 player-hours). RISK FACTORS: Player age, body mass, stature, playing position, use of headgear, and activity and period of season. RESULTS: The incidences of spinal injuries were 10.90 (9.43 to 12.60) per 1000 player match-hours and 0.37 (0.29 to 0.47) per 1000 player training-hours. No player sustained a catastrophic spinal injury, but 3 players sustained career-ending injuries. Overall, players were more likely to sustain a cervical injury during matches and a lumbar injury during training. Forwards were significantly more likely to sustain a spinal injury than backs during both matches (P < 0.01) and training (P = 0.02). During matches, injuries to the cervical (average: 13 days; P < 0.01) and lumbar (13 days; P < 0.01) spine were more severe than injuries to the thoracic (5 days) spine; during training, injuries to the lumbar spine (26 days) were more severe than injuries to the cervical (13 days; P = 0.10) or thoracic (12 days; P = 0.06) spine. A total of 4037 days were lost to competition and training through spinal injuries with lumbar disc injuries sustained during training accounting for 926 days (23%) and cervical nerve root injuries sustained during matches for 621 days (15%). During matches, more injuries were caused by tackles (37%), and during training more injuries were caused by weight-training (33%). CONCLUSIONS: The results showed that rugby union players were exposed to a high risk of noncatastrophic spinal injury during tackling, scrummaging, and weight-training activities; injury prevention strategies, therefore, should be focused on these activities.     

Management of unstable cervical spine injuries in southern Iraq during OP TELIC

INTRODUCTION: Cervical spine fractures and dislocations are uncommon injuries that can have serious neurological consequences. These injuries require adequate stabilisation to prevent further spinal cord injury during transfer between hospitals. Evacuation often requires a combination of road ambulance, helicopter and fixed wing aircraft from military hospitals. This paper outlines the neck injuries sustained during Op Telic and discusses the need for Halo vests to be available at Role 3. METHODOLOGY: The MND(SE) Hospital databases were used to identify all casualties admitted with either a "Cervical" or "Neck" injury. The databases covered the period from 24 March 2003 until 15 April 2004. The diagnoses were categorised into minor and serious cervical spine injuries. We defined a serious cervical spine injury as either a fracture or dislocation. We looked at the discharge letters of all casualties evacuated to a Role 4 hospital to confirm whether the casualties had serious cervical spine injuries. RESULTS: Forty seven casualties were admitted and all were British except three, two Iraqi civilians and one US soldier. Thirty three casualties were returned to their unit for duty, or discharged at the airhead on return to the UK. Fourteen casualties required hospital treatment. There were five serious cervical spine injuries over the study period which included one Hangman's fracture of C2, one flexion compression injury of C5, one flexion compression injury of C7, one unifacetal dislocation and one bifacetal dislocation. CONCLUSIONS: Five casualties were treated at MND(SE) Hospital for serious injuries to the cervical spine. Two patients were transferred without Halo stabilisation after failing to obtain halos in Iraq. One casualty was kept until a Halo was flown out from the UK. RECOMMENDATIONS: All unstable cervical spine fractures should be stabilised with a Halo Vest prior to transfer from Role 3. Halo Rings and Vests should be available at Role 3 facilities.     

Head and neck injuries in college football: an eight-year analysis

The present study documented head and neck injuries in a study group of 342 college football players at a single institution for a period of 8 years. All freshmen players were screened for evidence of: (1) past history of head and neck injuries, and (2) abnormalities of the cervical spine on physical examination and x-ray film. By recording all head injuries and those neck injuries with time loss, incidence rates and patterns of injury incurred in college competition were determined. A total of 175 head and neck injuries were sustained by 100 players over the 8 year period. Those players with abnormal findings on screening examination were twice as likely to have a head or neck injury at some point in their college careers as those players with a normal screening examination. The greater the degree of abnormality on freshman screening examination, the more severe the neck injury in college was likely to be. Twenty-nine percent of all players in the study group sustained a head or neck injury during their college careers. The probability of a subsequent head or neck injury escalated sharply following a single incident. The overall incidence of injury was found to have been dramatically reduced over the 8 years. Influential factors such as legislative rule changes, medical status of recruits, and general coaching philosophies are discussed with regard to injury reduction and prevention of head and neck injuries in college football.     

A scoping review of cervical spine evaluation in standardised clinical concussion evaluation tools

BackgroundIt can be a challenge for clinicians to evaluate trauma that could represent cervical spine injury, concussion, or both. These conditions share common mechanisms of injury and symptom profiles, yet distinct aetiology and management. In the clinical evaluation of concussion, a range of standardised tools are available but the extent to which such tools include cervical spine evaluation is unclear.ObjectiveTo identify a variety of standardised clinical concussion evaluation tools, examine if these tools include cervical spine evaluation, and describe the characteristics of cervical spine evaluation included. To have an informed discussion about how cervical spine evaluation might best be approached after a concussion event.DesignScoping review.MethodA structured literature search was performed in eight databases to identify standardised clinical concussion evaluation tools. Each tool was then reviewed for cervical spine evaluation, and the characteristics of tools including cervical spine evaluation were described.ResultsThe structured search identified 82 standardised clinical concussion evaluation tools. Eleven tools included cervical spine assessment related primarily to the evaluation of red flags and symptoms, just three included physical examination.ConclusionFew standardised clinical concussion evaluation tools include cervical spine evaluation, and even fewer include physical examination. Cervical spine evaluation in concussion may benefit from closer alignment with established approaches to screening for clinically significant cervical spine injuries. In concussion, we advocate for an approach to cervical spine evaluation that includes screening for dangerous mechanisms of injury, neurological deficit, distracting injury and neck pain; and physical examination of neck range of motion and neck tenderness.     

Acute spine injuries in skiers and snowboarders

Skiing and snowboarding are popular winter sports associated with significant traumatic spinal injuries. Despite a decline in most injuries related to these sports over the years, acute injury rates of the spine have remained stable and even increased. Vertebral fractures and spinal cord injuries are the most common serious acute injuries of the spine in skiers and snowboarders. Due to the unique characteristics of each sport, different injury mechanisms are responsible for the majority of injuries. This article reviews injury patterns, injury types, mechanisms of injury, and strategies for prevention of spine injuries in skiers and snowboarders.