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Expert Panel Advises on Return-to-Play for Athletes with Neck Injuries

Posted on: 11/30/1999
If you follow sports at all, you know there's a renewed debate about head and neck injuries on the field. How soon should these players be allowed to return to play? Players who suffer an undiagnosed concussion, compression to the spinal cord or spinal nerve roots, or other neck injury are in danger of long-term consequences. Early diagnosis and treatment may prevent serious complications.

When the symptoms are mild, the athlete may "shake it off" and fail to report it to the coach or trainers. More serious symptoms such as loss of sensation and the use of the arms are harder to mask. One of these conditions affecting the neck is the topic of this article. It is called neuropraxia or cervical cord neuropraxia.

The term neuropraxia describes symptoms of bilateral (affecting both sides) burning, numbness, loss of sensation, and muscle weakness of the arms and hands. The symptoms are caused by pressure on the spinal cord in the cervical spine (neck). It is like having a concussion to the spinal cord (instead of to the brain). The symptoms can last minutes up to hours.

Full recovery is expected -- if the player doesn't go back on the field and experience another high-energy contact injury to the head and/or neck. And if there isn't an undetected fracture of the vertebra or damage to the disc. Only an examination and X-ray, MRI, or CT scan to rule out this type of trauma will answer that question.

The information in this article is meant to help sports officials determine when athletes suffering high-energy contact injuries to the head and neck are safe to return to play. A group of spine surgeons, neurologists, and orthopedic surgeons who specialize in trauma joined together to form a panel to discuss this topic.

After reviewing all the literature already published and examining the data, the panel concluded that there isn't enough high-level evidence to make strong recommendations. They had to rely upon their own clinical expertise and expert opinion in suggesting the following guidelines:

  • X-rays (or other imaging techniques) are required for high-energy contact
    sports injuries before a return-to-play determination can be made
  • Players with transient (temporary) neuropraxia without
    (narrowing of the spinal canal) can return to full sports participation
  • Players with transient neuropraxia (symptoms go away) but with stenosis
    should not be allowed to return to their sport until treatment has resolved the problem.
  • Return to full participation for players with neuropraxia and stenosis may
    require surgical decompression (taking pressure off the spinal cord). The procedure to decompress the spinal cord is usually fusion of the spine at the level of the compression.
  • There are situations when players must be advised not to return to sports.
    This occurs when there are repeated episodes of neuropraxia, persistent stenosis, and of course, permanent disability.

    In all cases, players should not be approved to return to their sport until and unless they have normal neurologic function and pain free (and full) motion. Imaging studies should confirm that there is plenty of room in the spinal canal for the spinal cord (i.e., no more stenosis). And the spine should be stable with no signs of subluxation, dislocation, or hypermobile (excess) motion.

    Keep in mind that football players aren't the only ones susceptible to high-energy injuries affecting the head and neck. Athletes involved in soccer, hockey, snow sports, diving, gymnastics, and rugby are also at risk. We hear about them less because the athletes involved in these sports don't always have the same high-profile media coverage that football players have.

    Rules established in 1975 eliminated certain techniques in football like spear tackling (hitting with the head) and axial loading blocking. Following these new rules helped reduce the number of spinal cord injuries leading to paralysis. Now it's time to address the best way to respond to transient neuropraxia and cervical cord neuropraxia.

    Even though the symptoms may go away in minutes, if there is an underlying stenosis, the spinal cord is still compressed. The danger is that a future episode could result in much more permanent consequences (i.e., paralysis).

    The player could have a congenital stenosis (something he or she was born with). It's important to find that out early on and give the option of treatment to prevent more serious injuries.

    Stenosis can also develop as a result of damage from the injury (change in the alignment of the bones) or as a result of degeneration (wear and tear over time). Children who are not fully developed can have cervical cord neuropraxia because of loose ligaments, immature muscles, and hypermobile (excess movement) joints.

    The panel made note of the fact that cervical cord neuropraxia is a rare problem -- well, at least it appears so from reported cases. It may be this is an injury that is under-reported because it is unrecognized. The symptoms are similar to another transient condition called burners or stingers.

    With burners or stingers, the spinal cord nerve root coming off the spinal cord (not the spinal cord itself) is pinched or compressed. The player experiences the same symptoms of burning, numbness, loss of sensation and/or weakness but in just one arm, not both arms.

    Many coaches, athletic trainers, and other sports officials don't know that bilateral symptoms signal spinal cord injury rather than nerve root impingement. The player might shake off the symptoms and head back onto the field without the necessary evaluation. The panel's recommendations and discussion may help future athletes with cervical cord neuropraxia receive proper care right from the start.

  • References:
    Andrew Dailey, MD, et al. High-Energy Contact Sports and Cervical Spine Neuropraxia Injuries. In Spine. October 2010. Vol. 35. No. 21S. Pp. S193-201.

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