Article topic: Sport-related Cervical Spine Injuries
Author: Hadeel Ayesh.
Editor:  Hamid Ghanem, Inas Jaber.
Reviewer: Ethar Hazaimeh

Keywords: Spinal injuries, athletic injuries, sport, cervical vertebrae. 

 

Introduction

In the sports world, athletes continually push their bodies to extraordinary limits. During their intensely demanding field, the cervical spine, comprising seven vertebrae (C1–C7), can be vulnerable to injury (1).

While cervical spine injuries (CSIs) are relatively uncommon in sports, their occurrence can be devastating and life-changing for the athlete’s health and career. These injuries are not confined to a specific sport. They are more prevalent in high-impact sports such as football, rugby, hockey, and boxing. However, they can also occur in non-contact sports such as cycling, and gymnastics (2,3).

CSIs in athletes have a broad spectrum of severity, ranging from minor soft tissue injuries and muscle strains to life-threatening injuries such as fractures, dislocations, and spinal cord injuries (2,4). The outcome can vary from complete recovery to quadriplegia or even death in the worst cases (4).

This article aims to provide a comprehensive overview of cervical spine injuries, addressing their types, epidemiology, clinical manifestations, prevention strategies, and treatment options.

 

Epidemiology

The incidence of CSIs varies globally by geography, sport, level of competition, and gender. Contact sports like American football, rugby, ice hockey, wrestling, and soccer carry a greater risk of neck fractures and CSIs. Non-contact activities like skiing, cycling, diving, and gymnastics also contribute to this risk. Worldwide, diving is the sport that causes the greatest number of CSIs, accounting for a mean of 35.3% (1,5). In the USA, cycling is the most common cause of cervical fractures in males, while horseback riding leads in females (1).

Although motor vehicle collisions, violence, and falls are the most common causes of spine injuries, Sport-related CSIs account for 15% of all spinal injuries. In the National Football League (2000–2010), CSI was the most common injury (45%) (6). Recent data reports that sports are responsible for 9% of the 12,500 new CSIs annually in the USA (6).

 

Biomechanics

It is crucial to understand the mechanism of CSIs in sports for effective management and prevention. Different mechanisms can lead to cervical injuries, with axial loading being the major one (1,7,8). Axial loading is defined as a sudden force applied to the head or top of the spine that runs along the spinal column (8). This force can lead to hyperflexion and rotation of the spine, which can result in compression, dislocation, or fractures of the spinal vertebra and may result in spinal cord injury (8). The severity of axial load increases when the head is in a flexed position, because the spine’s normal lordotic alignment becomes less stable, which worsens the effect of the axial load (1,7,9,10) (figure1).

Other mechanisms causing CSIs in sports include; hyperflexion, hyperextension, rotational forces, lateral bending, and direct impact on the neck(11,12,13).  Whiplash injury (which results from rapid acceleration and deceleration forces to the cervical spine) can also occur in sports like rugby and football but mostly occurs after motor vehicle accidents (13).

Clinical features

CSIs in sports can present with a wide range of potential signs and symptoms, ranging from relatively mild outcomes to more catastrophic, potentially fatal ones (1). The clinical features include muscle sprain, peripheral nerve injuries, ligamental injuries, cervical vertebral fractures and dislocations, intervertebral disc herniation, cervical stenosis, and cervical spinal cord injury (1,14). The patient may present with neck pain and stiffness, decrease or loss of sensation in the arms and legs, Muscle weakness or paralysis, difficulty breathing, or loss of consciousness (1,15) (Table 1).

CSIs can manifest as a complete or incomplete spinal cord syndrome. The incomplete cord syndrome includes central, anterior, and Brown-Sequard syndromes and cervical cord neurapraxia (Transient quadriplegia) (1,7). These syndromes present with specific motor and sensory deficits according to the level of the injured spinal cord (7,15,16) (Table 2).

For example, in equestrian sports, studies showed that CSIs often result in various paralysis types: 41% experiencing incomplete quadriplegia, 24% complete paraplegia, 19.8% incomplete paraplegia, and fewer cases experiencing complete quadriplegia (17).

Management

The management of CSIs in sports starts with pre-event preparation. It begins with ensuring the availability of medical equipment, readily available Emergency Medical Systems (EMS), and professionally trained medical personnel (25).

On-field management starts with the recognition of a neck injury. The field medical team should pay attention to any suspected injury that could affect the neck (25). Any suspected CSIs in sports need prompt management. Immediate management includes assessing the athlete’s vital signs and hemodynamical stability by applying Basic Life Support (BLS) and advanced trauma life support protocols (ATLS) (12,25). It all starts by securing the airway if compromised and stabilizing the cervical spine by manual in-line stabilization to prevent further catastrophic outcomes (25). Blunt trauma to the neck can compromise the airway and breathing. And if the athlete has no pulse, immediate CPR is needed (25).

After stabilization, assess the presence of any suspected spinal injury by history and physical examination (25). If any signs or symptoms suggest a spinal injury, such as numbness, weakness, significant pain, altered or loss of consciousness, or memory loss, immobilizing the athlete’s neck using a cervical collar is crucial to prevent further movements, followed by immediate transfer to a nearby hospital for further management and evaluation (7, 12).

For athletes who wear helmets with shoulder pads, it is better to leave them in place on-field unless it interferes with medical resuscitation (25,26). If the athlete wears a helmet without shoulder pads, the helmet should be removed to keep the cervical spine in a neutral position and maintain the airway, but the removal should be done by medical personnel or anyone who has experience in helmet removal. An athlete who wears a shoulder pad without a helmet needs cervical spine support in the neutral position (16,25,26).

There are different treatment options available based on the severity of the injury. Minor injuries, such as muscle spasms, may require painkillers or NSAIDs. In cases of minor fractures, a cervical collar may be sufficient. However, more severe fractures often require surgical intervention (1, 7).

The decision to allow an athlete to return to play is highly individualized, requiring a case-by-case evaluation (2,27). Any athlete showing neurological symptoms should not return to play until further evaluation and management (25). A patient can return to play if they have no neck or extremity pain or tightness, no neurological symptoms, including sensory and motor deficits, no headaches or loss of consciousness, and a full pain-free range of motion with a return of strength and activity (25,28,29).

 

Prognosis

The prognosis of SCIs in sports depends on various factors, including the injury type, extent, level, and severity, along with the associated complications (30). Athletes with minor injuries, like muscle sprains or strains that do not impact the spinal cord, have a better prognosis. On the other hand, those with injuries to the spinal cord tend to be more severe (4). Notably, athletes with incomplete spinal cord injuries and without significant comorbidities or medical complications like infection tend to have the best level of improvement and the best recovery outcomes (31).

Effective management of these injuries significantly affects the prognosis, as improper initial management, especially maintaining neck stability, can lead to a much worse prognosis and exacerbate spinal cord damage (4).

 

Conclusion

CSIs in athletes encompass a wide spectrum, ranging from minor muscle sprains to complete paralysis. Paying attention to potential neck injuries during sports is crucial to act quickly and prevent any catastrophic outcomes. Recognizing the athlete’s signs and symptoms, understanding the injury mechanism, and providing the proper intervention are vital to preserving the athlete’s well-being and ensuring their safety in sports.

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