Sports-Related Cervical Spine Injuries

Sports-Related Cervical Spine Injuries

Abstract: Cervical spine injuries are uncommon in children yet can be associated with significant morbidity and mortality. They are primarily seen aft...

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Abstract: Cervical spine injuries are uncommon in children yet can be associated with significant morbidity and mortality. They are primarily seen after blunt trauma. Injuries can occur to bones, ligaments, muscles, spinal cord, nerves, blood vessels, or in some combination of multiple injuries. Prompt recognition and treatment are essential to limit morbidity and mortality. As a result of developing anatomy, children suffer different types and locations of cervical spine injury as compared with adults. Many traumatic cervical spine injuries as well as cervical spinal cord injuries are not apparent on initial radiographs; this presents diagnostic challenges for the clinician. The purpose of this article is to describe the evaluation of the potential cervical spine injured athlete.

Keywords: cervical spine injury; sports; children

Sports-Related Cervical Spine Injuries Holly J. Benjamin, MD, FACSM⁎, David S. Lessman, MD, FAAP†

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ports are the most common cause of cervical spine injuries in children aged 10 to 14 years. 1 After blunt trauma, infants and young children sustain injury primarily to the upper cervical spine (C1-C4), whereas children older than 8 years and adolescents tend to sustain lower cervical injury (C5-C7). 2,3 The injury pattern involves contiguous levels in approximately 60% of patients. 4 Prognosis varies based on the level and grade of the injury. Recovery of neurologic function after severe traumatic spinal cord injury (SCI) occurs with a significantly greater incidence in children than adults, and these improvements can occur over a prolonged postinjury period. 5

ANATOMICAL VARIANTS *Pediatrics and Orthopedic Surgery, Primary Care Sports Medicine, University of Chicago, Chicago, IL; †Pediatric Sports Medicine, Advocate Children's Hospital– Park Ridge, Park Ridge, IL. Reprint requests and correspondence: Holly J. Benjamin, MD, FACSM, Pediatrics and Orthopedic Surgery, Primary Care Sports Medicine, University of Chicago, 5841 S. Maryland Ave, Chicago, IL 60637. [email protected] (H.J. Benjamin), [email protected] (D.S. Lessman) 1522-8401/$ - see front matter © 2013 Published by Elsevier Inc.

Familiarity with anatomical variants is essential for proper image interpretation (Tables 1 and 2). Common variants include pseudosubluxation (Figure 1); absence of cervical lordosis; C3 wedging (Figure 2); prevertebral, predental, and intervertebral widening; and pseudo-Jefferson fracture (Figure 3). 6 The body of C2 fuses with the odontoid process between 3 and 6 years of age. The fusion line, called the subdental synchondrosis (Figure 4), can be confused with a fracture as it can persist until approximately age 11 years. 7 Secondary ossification centers can be seen at the tips of the transverse and spinous processes that persist until early in the third decade of life and may simulate fractures. 8

MEDICAL CONDITIONS PREDISPOSING TO SPINAL INJURY Atlantoaxial and occipitocervical instability related to extreme ligamentous laxity is seen in 10% to 40% of patients with Down

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TABLE 1. Normal anatomical variants of the developing pediatric cervical spine that can misinterpreted as injury. Pseudosubluxation

C2 on C3 or C3 on C4 Seen in up to 40% of children between 1 and 7 years of age Up to 4 mm of step-off in flexion on AP is acceptable Spinolaminar line with 1.5 mm of posterior arch of C1 Should reduce in extension No treatment necessary Seen in midcervical area Seen in up to 14% of children younger than 16 years Should reduce in extension Seen in extension 20% of those between 1 and 7 years of age. Result of nonossified atlas and tip of odontoid Also anterior angulation of odontoid process in as many as 4% Can mimic odontoid fracture Sometimes present until 11 years of age Appears sclerotic unlike true fracture Located well caudal to the base of the odontoid process

Localized kyphosis

Overriding C1 over tip of odontoid (C2)

Persistence of basilar odontoid synchondrosis

syndrome and increases the risk of cervical SCI during sports participation or in the setting of acute trauma. 9 Atlantoaxial rotatory subluxation is also seen in patients with Marfan syndrome. Congenital cervical spinal stenosis can put young people at higher risk for transient quadriplegia after head and neck trauma in sports or other settings. The Torg ratio, a historical a radiographic measure of spinal stenosis, is defined as the measurement of the spinal canal diameter to the vertebral body width (Figure 5). A ratio of 0.8 or less may be indicative of cervical stenosis and therefore a higher risk of neuropraxia. 10 However, more recent studies have shown that although a Torg ratio of less than 0.8 is common, neuropraxia is not. Furthermore, the actual diagnosis of spinal stenosis is made with much greater accuracy with

magnetic resonance imaging (MRI) and is the preferred method of evaluation. Other predisposing factors include history of previous cervical spine injury or cervical spine arthritis, Klippel-Feil syndrome (congenital fusion of 2 cervical vertebrae with possible associated defects including scoliosis, renal anomalies, Sprengel deformity, deafness, and congenital heart disease) (Figure 6), and Larsen syndrome (associated with vertebral hypoplasia and multiple joint dislocations, short fingernails, and flat facies). Any person with a syndrome that is associated with cervical spine abnormalities may be considered to have an increased risk of cervical spine injury.

MECHANISMS OF INJURY TABLE 2. Normal parameters for imaging measurements of cervical spine. Parameter C-1 facet-occipital condylar distance Atlanto-dens interval C2 on C3 pseudosubluxation C3 on C4 pseudosubluxation Retropharyngeal space at C2 Retrotracheal space at C6 Torg ratio (canal to vertebral body) Space available for cord

Normal Value 5 mm 4 mm 4 mm 3 mm 8 mm 14 mm 0.8 14 mm

Axial compression injuries are the most common type seen in sports and predominantly cause vertical compression fractures (Figure 7), intervertebral disc injuries, and ligamentous injuries, typically to C5-C6. 11 Loss of the normal cervical lordosis that occurs when the head is slightly flexed to about 30°, as is seen in head butting maneuvers, significantly reduces the cervical spine's ability to absorb and dissipate compressive force, and therefore, the spine “buckles.” Axial loading is a common cause of catastrophic cervical spine trauma in football, rugby, ice hockey, gymnastics, diving, and trampoline. 12,13 One of the greatest reductions in the incidence of

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Figure 2. Normal wedging of cervical vertebrae, most prominently at C3. With permission, from Radiographics 2003;23:539-60.

associated injury to ligamentous and vascular structures around the spinal cord due to the shear forces exerted during injury. 15,16

EVALUATION

Figure 1. Physiologic pseudosubluxation of C2 on C3. With permission, from Clin Radiol 1999;54:377-80.

catastrophic sports-related cervical spine injuries was seen in the 1970s when spearing and head butting were banned in American football. 14 Flexion injuries cause distraction and stress on the posterior ligamentous structures and can lead to ligament rupture. Resulting spine injuries include vertebral body wedge compression fractures (Figure 7), anterior subluxation (Figure 8), facet dislocations (Figure 9), and spinal cord injuries. Hyperextension injuries may result in ligamentous and muscle strains (“whiplash”) or atlas, laminar, or pillar fractures. Dislocation injuries are less common because a significant rotational force is needed. Fracture dislocation injuries can result in an unstable spine requiring urgent operative stabilization and fixation. There is heightened concern for

In the emergency department (ED) or in the field, children who have symptoms suggestive of spinal injury should have their cervical spine immobilized during initial evaluation and management. The

Figure 3. Pseudo-Jefferson fracture or pseudospread of the atlas on the axis seen on open mouth odontoid radiographs. With permission, from Radiographics 2003;23:539-560.

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Figure 4. Subdental synchondrosis can persist until age 11 years. With permission, from Kim DH, Ludwig SC, Vaccaro AR, Chang JC. Atlas of spine trauma: adult and pediatrics. Philadelphia, PA: Elsevier, 2008; pp. 196-208.

history must be carefully reviewed, and a thorough physical examination be performed to screen for indications for immobilization. High-risk mechanisms of injury that indicate need for prompt cervical spine immobilization and rapid radiographic evaluation are those associated with high force or velocity (falls from heights N 4 ft or 3 times the body length and motor vehicle accidents), diving injuries, blunt traumatic injuries from contact or collision sports (eg, football, hockey, soccer), any significant acceleration-deceleration injury, and the presence of distracting injuries or multiorgan system trauma.

Figure 5. Measurement of Torg-Pavlov ratio (A/B). A, Sagittal spinal canal width measured from the midpoint of the posterior aspect of the vertebral body to the closest point of the opposite spinal lamina. B, Sagittal diameter of the vertebral body measured between the midpoints of the anterior and posterior surfaces. With permission, from Spine J 2013;13(6):605-12.

In the more severely injured child, physical examination findings on initial survey that indicate need for immediate cervical spine immobilization include any alteration in mental status, inability to speak or cooperate with the examination, midline cervical tenderness, decreased range of motion, or other neurologic deficits (transient or persistent). 17,18 Localized cervical spine pain, muscle spasms, and limited neck range of motion constitute the classic triad of symptoms associated with cervical spine injury. The presence of transient symptoms is variable and may consist of paresthesias or localized weakness ranging to quadriplegia. Some patients are asymptomatic despite having suffered a serious injury. In these cases, frequently, there is a history of transient symptoms such as paresthesias and/or weakness, which may indicate an SCI without radiographic abnormality (SCIWORA) or transient burning dysesthesias in the hands and fingers, otherwise known as “burning hands syndrome,”

Figure 6. Congenital fusion of C2 and C3 in Klippel-Feil syndrome. With permission, from Spine 2011; 36(23):e1501-8.

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evaluation is performed. If the mechanism of injury was not high risk and the patient has a normal cervical spine and neurologic examination, then frequently, the cervical collar may be removed. At this time, dynamic maneuvers may then be performed including active and passive range of neck motion and a Spurling's maneuver (neck extension, lateral rotation, and axial compression). If dynamic maneuvers elicit symptoms, then the cervical spine must be restabilized and further evaluation performed.

Cervical Spine Immobilization

Figure 7. Vertebral compression fractures at C5 and C6.

which may indicate central cord contusion due to a significant hyperextension injury. Physical examination of a child with a suspected cervical spine injury should follow advanced trauma life support guidelines and includes assessment of vital signs and the ABCs (airway, breathing, circulation), a thorough neck examination and a complete neurologic examination. Approximately 37% of cervical spine injuries are associated with traumatic brain injury. 1 Vital sign abnormalities, such as apnea or hypoventilation, may be seen from injuries occurring at the levels of diaphragm innervation (C3-C5). Spinal shock can cause hypotension, bradycardia, or temperature instability. A concurrent brain injury can also cause similar symptoms. A complete neurologic examination includes an evaluation of tone, strength, sensation, and reflexes. An isolated sensory deficit that localizes the level of injury is the most common neurologic finding seen. If a cervical collar is in place, it may be removed and the cervical spine manually stabilized during the examination. If any symptoms are present that could indicate a cervical spine injury (localized pain or bony tenderness, muscle spasm, paresthesias, numbness, weakness), the collar must be resecured until radiographic evaluation is completed and a re-

Techniques for cervical spine immobilization in the acute setting, including the sports field, use a rigid immobilization orthosis such as a cervical collar and a rigid spine board. The neck and body are secured with straps. Cervical collars should be appropriately sized and can be used in infants through adults. High cervical collars offer the optimal degree of immobilization by supporting the chin, mastoid process, and the mandible. Contraindications to neutral cervical spine immobilization are limited to airway impairment, massive cervical swelling, and the presence of angulation or significant malalignment of the spine. If the spine can be secured without attempting a reduction in the field and the patient can be stabilized for transport, that is the preferred standard of care. 19,20 One of the goals of spine immobilization is to maintain a neutral spine position, which is defined as “supine without rotating or bending the spinal column.” 21 In young children, where there is a relatively large head-to-torso size ratio, the supine position results in cervical flexion. The use of padding under the shoulders or a specially designed pediatric spine board with a depressed area for the head will help maintain the neutral spine position. Manual stabilization can be performed until an appropriate immobilization device is available and in place. Any maneuver that results in flexion, extension, or traction of the injured neck can worsen the patient's condition. 22 It is estimated that 3 to 25% of patients with an SCI develop neurologic deficits due to manipulation or unrestrained movement during resuscitation, stabilization, and transport. 23-27 The log roll technique is the standard of care for placing an injured patient in the field onto a spine board or to examine or remove them from the spine board when in the ED setting. Removal of the patient from the spine board should be performed as soon as possible to avoid excessive pain or pressure injury.

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This will not compromise cervical spine immobilization if the collar is properly placed and secure. Ideal personnel requirements for log rolling are a minimum of 2 persons for young children and 4 persons for adolescents. Proper field care and evaluation of the patient with an acute neck injury include: (1) immobilization of fractures or obviously injured extremities before log rolling; (2) leaving helmets and pads in place on athletes unless there is airway compromise; 28 (3) straighten and secure legs and arms with straps and padding; (4) secure trunk and pelvis to the board; (5) if the board is too large, fill in gaps with blankets, towels, or padding to ensure secure restraint; (6) secure the patient's head and neck with wedges or rolled towels on the side and tape or straps across the forehead and collar. At all times, the patient should be observed for airway patency. 29,30

Imaging Imaging of the cervical spine should be performed promptly in the setting of suspected injury and should be performed at any time following an acute trauma if symptoms are present (Table 3). The National Emergency X-Radiography Utilization Study (NEXUS) project criteria were defined following a large multicenter prospective study to identify patients who have a low probability of having a cervical spine injury. 31 Five criteria must be met including: (1) no midline cervical tenderness, (2) no focal neurologic

deficit, (3) no alterations in mental status, (4) no intoxication, and (5) the absence of any distracting injury. The presence of all 5 criteria had a sensitivity of 99% (5% confidence interval, 98-99.6%). 31 Radiographic interpretation includes assessment of alignment, bones, cartilage, and soft tissue (Table 4). The anteroposterior (AP) view must be assessed for proper alignment of the spinous processes in the midline. The odontoid (openmouth) view visualizes the dens (odontoid process) and the body of C2 in children 8 years or older. The Waters view is preferred in children younger than age 8 years. The lateral view must include all 7 cervical vertebrae and the C7-T1 junction. The lateral view best visualizes fractures, subluxations, and dislocations as well as alignment, cartilaginous structures, and soft tissue spaces. Any views that require manipulation of an acutely injured patient are difficult to justify in view of the ready availability of cross-sectional imaging. Flexion and extension views may be used if the above 3 views are negative and instability is suspected. The patient must be able to actively flex and extend his/ her own neck without symptoms to safely complete these additional views. If significant pain or other symptoms occur during the imaging process, the rigid cervical orthosis should be secured and the patient re-evaluated.

TYPES OF INJURY Spinal Cord Injury Without Radiologic Abnormality

Figure 8. Subluxation of C5 on C6 due to a gymnastics injury. With permission, from Frontera WR, Herring SA, Micheli LJ, Silver JK. Clinical sports medicine—medical management and rehabilitation. Philadelphia, PA: Saunders, 2007; pp. 331-42.

Spinal cord injury without radiologic abnormality (SCIWORA) should be suspected in patients younger than 8 years who experience blunt trauma and report immediate, usually transient, neurologic symptoms (paresthesias, numbness, or paralysis) and whose radiographs and computed tomography (CT) imaging studies are normal (Table 5). The onset of symptoms in up to 25% of cases may be delayed up to 4 days. 32-34 Up to 61% of patients with a clinical diagnosis of SCIWORA have abnormalities on MRI; therefore, an MRI should be performed when clinical concern for SCIWORA is present. 35 Prompt consultation with a pediatric neurosurgeon is also recommended. The recommended treatment for SCIWORA is usually conservative, with immobilization for 1 to 3 weeks. Decompression is indicated if a distinct lesion can be demonstrated or progressive neurologic deficit occurs.

Fractures Odontoid fractures are common (Figure 10) and can usually be managed by reduction in extension

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laris fractures of C2 caused by hyperextension of the cervical spine. Lateral radiography is helpful in diagnosis, as is CT or MRI. This fracture can be confused with C2 pseudosubluxation, which is a normal variant. 36-38 Hangman fractures may be successfully managed nonoperatively. The Jefferson fracture (Figure 12) is a C1 ring fracture usually caused by an axial loading injury. Fractures occur through the anterior and posterior arches due to the force transmission through the lateral occipital condyles to the lateral masses. If on the odontoid radiograph, there is asymmetry between the lateral aspects of C1 and the odontoid, and if the transverse ligament is intact, then the fracture is more stable. 36 If there is widening of 6 mm or more between the lateral mass of C1 and the odontoid, then the fracture is considered unstable. 27,39,40 All cervical spine fractures or suspected fractures should be evaluated by an orthopedic or neurosurgical specialist familiar with the complex anatomy of the pediatric spine. The remodeling potential of the pediatric spine is greater than that of adults; a pediatric spine fracture that is stable and shows no indication of neurologic compromise may be treated conservatively. Even burst fractures have high remodeling potential, and the fragments in the canal may be left alone if there is no suggestion of neurologic compromise.

Ligamentous Injuries, Subluxations, and Dislocations Figure 9. Bilateral facet dislocations of C4 on C5. With permission, from Radiographics 2003;23:539-560.

and immobilization with a halo or Minerva cast. The os odontoideum almost always represents a nonunion of an odontoid fracture; posterior fusion is recommended if there is pain or instability. Fractures of the lower cervical spine are usually a result of flexion injuries. The vertebral bodies of younger children are normally wedge shaped, sometimes rendering diagnosis difficult. Wedge compression fractures are considered stable and heal well with conservative treatment. Kyphotic deformities that remain after crushing of the epiphyseal plate may also spontaneously progress. Magnetic resonance imaging is recommended to evaluate for associated spinal cord injuries and ligament disruption. 6 The Hangman fracture (Figure 11) is a traumatic spondylolisthesis with associated pars interarticu-

Atlantoaxial injuries to C1-C2 can be caused by ligament disruption, rotatory subluxation, or odontoid separation. Fifty percent of cervical rotation occurs at C1-C2. At C2, approximately equal thirds of the cervical spine diameter is occupied by the spinal cord, the odontoid process, and subarachnoid space. When excess force and rotation is applied to the cervical spine, the odontoid process can injure the spinal cord or adjacent structures. 40,41 Atlantoaxial rotatory subluxation can cause torticollis. The anterior facet of C1 becomes locked on the facet of C2 and limits range of motion. Occasionally, C1-C2 dislocations accompany the injury. These types of injuries are usually diagnosed by alignment abnormalities on lateral radiographs and/or CT. Odontoid fractures in young children occur through the cartilaginous synchondrosis. Lateral radiographs usually demonstrate the fracture and the commonly associated prevertebral swelling. The odontoid usually displaces anteriorly and the dens angles posteriorly. Computed

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TABLE 3. Indications for imaging of the pediatric cervical spine. 17 Key Findings on History and Physical

Images

All of the following are present: *No neck pain *Low-risk mechanism of injury *Absence of distracting injuries *Normal physical examination *No neurologic deficits *No mental status changes Any of the following present: *Headache or head pain *Neck pain, tenderness, or deformity *Injury above the clavicles *Acute neurologic deficit *Abnormal neurologic physical examination *Uncooperative with examination *Altered mental status *Distracting injuries or multisystem trauma *High-risk mechanism of injury Any of the following present: *Inability to adequately visualize C-spine on plain radiographs *Any abnormality noted on radiographs *High index of suspicion for cervical spine injury even with normal plain radiographs All of the following are present: *Normal C-spine imaging either with radiographs or CT *Persistent neck symptoms with movement but not present on palpation Any of the following are present: *Abnormal neurologic examination *High index of suspicion for soft tissue or spinal cord injury *Prolonged LOC N 24 h whose C-spine cannot be otherwise adequately evaluated *Concern for spinal cord injury without radiologic abnormality (SCIWORA)

tomography is helpful for evaluating displacement and diagnosis. 6,36 Posterior ligamentous injuries are inherently unstable, best diagnosed on MRI, and usually require posterior fusion. Facet dislocations are often associated with facet fractures and spinal cord injuries. They are quite unstable, best diagnosed by CT.

Stingers/Burners Rapid and forceful lateral bending of the neck can cause traction injury to the cervical nerve roots or brachial plexus, resulting in neuropraxia (aka “stingers” or “burners”). Stingers may also be caused by direct compression of the brachial plexus or with neck extension and lateral flexion causing compression of the ipsilateral cervical nerve root in the neural foramen. 42 Although American tackle football has the highest prevalence of stingers

None

anteroposterior, lateral, and odontoid cervical radiographs

Computed tomography (CT)

Flexion-extension radiographs (must be performed with collar removed) Magnetic resonance imaging

(reported in as many as 50-65% of collegiate football players over their career), they can occur in other sports as well. 43,44 Brachial plexus traction injuries are more common in younger athletes, whereas cervical nerve root compression is more common in college and professional football players, particularly those who have recurrent or chronic stingers. 45 Recurrent stingers are frequently associated with cervical disk disease, cervical canal stenosis, and neural foraminal stenosis. 45 Symptoms include shooting pain from the neck or shoulder to the hand, parasthesias, numbness, burning, decreased sensation, or motor symptoms such as muscle weakness and transient paralysis that can take minutes, hours, or days to resolve. 46 The most common nerve involvement is at the C5 and C6 levels, leading to weakness of the supraspinatus, infraspinatus, deltoids, and/or biceps muscles. Spurling test and Tinel sign over the supraclavicular fossa may be positive. 47

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TABLE 4. Radiographic evaluation checklist for cervical spine injured patient. Procedure

Evaluation Checklist

Lateral C-spine radiograph Assess alignment

Check radiographic relationships

Antero-posterior and open mouth odontoid views Flexion-extension views

Must see top of T1 Anterior vertebral line Posterior vertebral line Spinolaminar line Spinous process line Atlanto-dens interval Retropharyngeal and retro tracheal spaces Space available for the cord Alignment of lateral masses Odontoid fracture Interpedicular distance Assess ligamentous stability Active range of motion only Physician supervised Fully cooperative patient May need to wait until the first follow-up visit

In the acute setting (eg, on-field evaluation), the medical professional must first establish that there is no injury to the spine, spinal cord, or brain. Headache or altered mental status as well as symptoms extending into other extremities should immediately raise concern for a central nervous system injury. Neck pain, tenderness, muscle spasm, decreased cervical range of motion, and/or persistent neurologic symptoms should raise concern for a cervical spine injury. 48 Spine precautions should be instituted immediately in these circumstances. For a single isolated stinger that resolves rapidly with no sequelae, routine imaging of the cervical spine is not necessary. In athletes with severe neck pain, prolonged symptoms, limited range of motion, weakness, or recurrent injury, it is important to obtain AP, lateral, and oblique radiographs including flexion/extension views to rule out bony foraminal stenosis or ligamentous instability. Although Torg ratio on lateral C-spine radiographs is frequently used to assess for spinal stenosis, several studies have subsequently shown that this method is unreliable. 14,46,49 Magnetic resonance imaging is the best tool for evaluating spinal canal diameter.

TABLE 5. Common cervical spine injuries. Spine Level C1

Injury Jefferson fracture Atlantoaxial subluxation

C2

Odontoid fracture

Stability

Mechanism

Moderately Burst fracture; occurs with axial unstable load or vertebral compression Highly unstable Occurs in patients with Down syndrome, rheumatoid arthritis and other destructive processes Highly unstable Mechanism poorly understood

Hangman's fracture Unstable

Any level

Flexion teardrop injury Bilateral facet dislocations Unilateral facet dislocations

Lower cervical or Clay shoveler's upper thoracic fracture

Sudden deceleration (hanging); hyperextension, as in motor vehicle accidents Highly unstable Sudden, forceful flexion

Highly unstable Flexion or combined flexion/ rotation Unstable Flexion or combined flexion/ rotation

Very stable

Flexion, such as when picking up and throwing heavy loads (such as snow or clay)

Radiographic Findings Displaced lateral aspects of C1 on odontoid view, predental space N 3 mm Asymmetric lateral bodies on odontoid view, increased predental space May be difficult to see on plain films; high clinical suspicion requires CT Bilateral pedicle fracture of C2 with or without anterior subluxation; lateral view required Large wedge off the anterior aspect of affected vertebra; ligamentous instability causes alignment abnormalities Anterior displacement of 50% of one cervical vertebra on lateral views Anterior dislocation of 25-33% of 1 cervical vertebra on lateral views; an abrupt transition in rotation so that lateral view of affected vertebra is rotated; lateral displacement of spinous process on AP view Avulsion of posterior aspect of spinous process; frequently an incidental finding

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Figure 10. Odontoid process fracture in a 9-year-old girl.

Athletes who experience stingers should not return to play until symptoms have resolved completely and muscle strength is full and symmetrical. Most stingers will resolve completely within a couple minutes, in which case, the player may return to the same game. If a patient presents to the ED with persistent symptoms of a stinger, he/she should be advised to rest from contact sports and follow up with the primary care provider or sports medicine specialist. Electromyelograms are sometimes used to monitor neural recovery and assist with return-to-play decisions. Strengthening exercises for the affected muscles are contraindicated and may prolong recovery of nerve function. Patients with recurrent stingers should be evaluated for congenital abnormalities such as spinal stenosis, congenital fusion, intervertebral disc disease, or cervical instability. 14 Some of these conditions may prohibit return to contact sports, due to high risk for permanent neurologic injury. Prevention plays a key role in the management of stingers. Shoulder pads should be checked for an appropriate fit. Some have tried cervical collars to

Figure 11. Jefferson fracture. With permission, from J Pediatr Orthop 2013;33(3):e23-7.

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ation where pediatric radiology, orthopedic, and neurosurgical services are available are preferred. With regard to return to play after any cervical spine injury, clearance must be based on individual evaluation and usually in conjunction with a specialist who understands the risks associated with participation in contact or collision sports. In general, the athlete must be symptom free, have a normal musculoskeletal and neurologic examination, and may have follow-up imaging studies showing resolution of radiographic abnormalities as appropriate.

REFERENCES

Figure 12. Hangman fracture. With permission, from Czervionke LF, Fenton DS. Imaging painful spine disorders. Philadelphia, PA: Saunders, 2011, pp. 280-91.

limit cervical hyperextension, but these have limited effect on lateral flexion of the neck. The use of a cervical collar may also increase neck-down tackling and can put the athlete at risk for a catastrophic neck injury. An off-season program for strengthening the neck muscles is important as well as instruction on proper blocking and tackling techniques.

SUMMARY All cervical spine injuries in athletes are potentially serious, requiring prompt evaluation. Extensive knowledge and understanding of pediatric cervical spine anatomy and development are invaluable in diagnosing injury as well as differentiating the many normal variants that occur. A high index of suspicion must be maintained for underlying instability and soft tissue injuries that frequently accompany cervical spine injuries. Radiographic evaluation and interpretation are complex as is the management of these types of injuries. In the ED and in the field, prompt cervical spine immobilization and thorough evalu-

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