Guidelines for return to sport after cervical trauma

RETURN TO ACTIVITY AFTER CERVICAL INJURY

Paul Licina

COLLISION • intentional contact • football, boxing CONTACT • frequent contact • basketball, soccer LIMITED CONTACT • infrequent/inadvertent contact • baseball, volleyball

NONCONTACT • no contact • golf, running

CLASSIFICATION

COLLISION • intentional contact • football, boxing CONTACT • frequent contact • basketball, soccer LIMITED CONTACT • infrequent/inadvertent contact • baseball, volleyball

NONCONTACT • no contact • golf, running

CLASSIFICATION

CERVICAL TRAUMA

• cervical sprain/strain

• burners or stingers

• cervical neuropraxia

• disc herniation

• fracture

• surgery

Morganti et al in questionnaire to

spinal surgeons about return to play

after cervical spine injury found

no consensus in opinion

• no neurological symptoms or signs

• no abnormalities on imaging

• can return to play when

• no neck pain

• full pain-free ROM

• note risk of unrecognised ligamentous injury

CERVICAL SPRAIN/STRAIN

• transient sensory and/or motor loss in one arm

• tingling, burning, numbness

• weakness esp. deltoid and biceps

• due to

• brachial plexus traction

• nerve root foraminal compression

• direct blow at Erb’s point (above clavicle)

• full pain-free ROM

BURNER OR STINGER

• return to sport when

• resolution of neurological symptoms/signs

• full painless ROM

• investigate persistent symptoms or recurrences

BURNER OR STINGER

• syn transient quadriplegia

• after loading of neck

• sensory changes

• numbness, tingling, burning

• with or without motor changes

• weakness, paralysis

• involves BOTH arms and/or BOTH legs

CERVICAL NEUROPRAXIA

• complete return of

• motor function

• full pain-free cervical motion

• transient - resolves quickly

• usually within 15 minutes

• may be residual symptoms up to 48 hrs

• no bony or ligamentous injury on imaging

CERVICAL NEUROPRAXIA

• due to compression of spinal cord

• occurs when canal dynamically narrowed

by neck movement

• usually forced hyperflexion or hyperextension

• commonly associated with canal stenosis

CERVICAL NEUROPRAXIA

Stenosis

• two ways of assessment

• x-ray

• Pavlov/Torg ratio

CERVICAL NEUROPRAXIA

Stenosis

• two ways of assessment

• x-ray

• Pavlov/Torg ratio

CERVICAL NEUROPRAXIA

Stenosis

• two ways of assessment

• MRI

• CSF reserve

• cord shape

CERVICAL NEUROPRAXIA

CERVICAL NEUROPRAXIA

Return to sport

CERVICAL NEUROPRAXIA

Cord Stenosis Previous

Normal No No YES

Normal No Once MAYBE

Normal Mild No MAYBE

Normal Mild Once NO

Normal Severe NO*

Normal Mild Once NO

Normal More NO

Abnormal NO

• common

• acute disc herniation

• absolute contraindication

• can return to play when

• no symptoms

• no neurological deficit

• full pain-free ROM • ?minimum six weeks from

injury

• incidental finding on imaging • as above

DISC HERNIATION

• can return to play if have • spinous process or laminar fracture

• healed vertebral fracture without

instability or malalignment

• after minimum 8 weeks

FRACTURES

• can return to play if have • foraminotomy

• one-level anterior fusion

• may be able to return to play if have • one-level laminectomy

• one-level posterior fusion

• two-level anterior fusion

• cannot return to play if have

• three-level anterior fusion

• C1-2 fusion

• multi level laminectomy

SURGERY

• guidelines exist

• have to be individualised

• severity of original injury

• risk of reinjury • desire of player to return to sport

SUMMARY