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Sports-Related Neck Injury

September, 2008

Cervical Spine Anatomy

Your neck is part of a long flexible column, known as the spinal column or backbone, which extends through most of your body. The cervical spine (neck region) consists of seven bones (C1-C7 vertebrae), which are separated from one another by intervertebral discs. These discs allow the spine to move freely and act as shock absorbers during activity. The spinal cord, a very vulnerable structure which connects the brain to the body, is located in the middle of the cervical spine, protected by bony structures.

Sports can contribute to neck injuries of varying degrees of severity, including neck fractures and cervical spinal cord injuries (SCIs). A fractured (broken) neck is a very serious matter, but in many cases, the patient can make a full recovery and regain all neurological function. A neck fracture can sometimes lead to a complete SCI, which will result in some degree of paralysis or even death.

Sports-related cervical injuries can be categorized in the following terms:

• Acute cervical sprains/strains including whiplash injury
• Cervical fractures and dislocations
• Nerve root or brachial plexus injuries
• Intervertebral disc injuries
• Cervical stenosis

Fractured or Broken Neck

A neck fracture is a break in one or more of the cervical bones (vertebrae in the neck). A person with a neck injury should not be moved without competent medical care, which should be summoned immediately. It is important to recognize the possibility of a neck fracture. Injuries severe enough to cause head injury or other trauma often also cause neck fracture.

A severe, sudden twist to the neck or a severe blow to the head or neck area can cause a neck fracture. Sports involving violent physical contact carry a greater risk of neck fracture, including football, ice hockey, rugby, and wrestling. Spearing an opponent in football or rugby can cause a broken neck. Neck fractures are also related to several non-contact sports such as skiing, swimming, diving, surfing, power weightlifting, and horseback riding.

Incidence

The U.S. Consumer Product Safety Commission (CPSC) tracks product-related injuries through its National Electronic Injury Surveillance System (NEISS). According to the CPSC, there were an estimated 11,464 neck fractures treated at U.S. hospital emergency rooms in 2007. Of these, an estimated 2,751 were sports-related. The actual incidence of neck injuries may potentially be much higher for two primary reasons. 1). In the 2007 report, the CPSC excluded estimates for product categories that yielded 1,200 injuries or less, those that had very small sample counts, or those that were limited to a small geographic area of the country. 2). Many less severe neck injuries, such as sprains are treated at physician’s offices, immediate care centers, or self-treated.

Included in the sports statistics are not only the sports/recreational activities, but the equipment and apparel used in these activities. For example, swimming-related injuries include the activity as well as diving boards, equipment, flotation devices, pools, and water slides.

• A 10-year-old girl was jumping on a trampoline, tried to do a flip, and landed on her neck. She suffered a compression fracture at C-7.
  
  
• A 17-year-old boy was playing ice hockey and slid backwards into a wall, sustaining an avulsion fracture at C-4.
  
  
• A 21-year-old male without a helmet fell backwards while skateboarding at a skateboarding park, suffering not only a head injury, but a fracture at C4-5.
  
  
• A 27-year-old male without a helmet lost control of his ATV on a remote airfield, flew over the handlebars and sustained a lateral mass fracture at C-1.

Signs and Symptoms of Broken/Fractured Neck

• Pain, which may or may not be severe
• Pain radiating from the neck down to the shoulders and/or arms
• Swelling and bruising
• Tenderness
• Decreased feeling in the arms, legs or body
• Muscle weakness or paralysis of the arms or legs

Cervical SCI

The severity of an injury depends on the part of the spinal cord that is affected. The higher the SCI on the vertebral column, or the closer it is to the brain, the more effect it has on body movement and one's sense of feeling.

• Quadriplegia (a.k.a. tetraplegia) results from injuries to the spinal cord in the cervical (neck) region, with associated loss of muscle strength in all four extremities.

Complete SCI
A complete SCI produces total loss of all motor and sensory function below the level of injury. Nearly 50 percent of all SCIs are complete. Both sides of the body are equally affected. Even in the case of complete SCI, the spinal cord is rarely cut or transected. More commonly, loss of function is caused by a contusion or bruise to the spinal cord or by compromise of blood flow to the injured part of the spinal cord.

Incomplete SCI
In an incomplete SCI, some function remains below the primary level of the injury. A person with an incomplete injury may be able to move one arm or leg more than the other, or may have more functioning on one side of the body than the other.

"Spinal concussions" can also occur. These can be complete or incomplete, but spinal cord dysfunction is transient, generally resolving within one or two days. Football players are especially susceptible to spinal concussions and spinal cord contusions. The latter may produce neurological symptoms including numbness, tingling, electric shock-like sensations, and burning in the extremities. Spinal fracture-dislocation injuries with ligamentous tears cannot be excluded until the opposite is proven

Top 10 Sports Contributing to SCI

• Diving: 1,494 males, 131 females = 1,625
• Bicycling: 260 males, 27 females = 287
• Football: 128 males = 128
• Snow Skiing: 108 males, 13 females = 121
• ATV/ATC: 101 males, 18 females = 119
• Horseback riding: 53 males, 56 females = 109
• Winter sports: 79 males, 20 females = 99
• Other sports: 69 males, 15 females = 84
• Surfing: 82 males, 2 females = 84
• Snowmobiles: 31 males, 5 females = 36

SCI Incidence

• About 89.8 percent of all sports-related SCIs occur in males.
• Diving accidents rank as the fourth leading cause of SCI in males and fifth leading cause in females.
• Sports and recreation-related SCI injuries primarily affect people under age 29.
• Of 24,332 SCI’s reported, a combined total of 3,222 were sports-related: Of these, 2,744 or 85 percent were in males.

Sports-related SCI by age at time of injury

Ages 0-15: 23.8 percent
Ages 16-30: 14.7 percent
Ages 31-45: 6.9 percent
Ages 46-60: 3.4 percent
Ages 61-75: 2.1 percent
Ages 76-98: 0.4 percent

Source: The National Spinal Cord Injury Statistical Center, University of Alabama at Birmingham, NSCISC 2006 Annual Statistical Report.

Signs and Symptoms of SCI

• Extreme pain or pressure in the neck, head or back
• Tingling or loss of sensation in the hand, fingers, feet, or toes
• Partial or complete loss of control over any part of the body
• Urinary or bowel urgency, incontinence, or retention
• Difficulty with balance and walking
• Abnormal band-like sensations in the thorax: pain, pressure
• Impaired breathing after injury
• Unusual lumps on the head or spine

Diagnosis

A neck fracture, as well as a SCI, is a medical emergency. The patient should undergo a full neurological exam as quickly as possible to assess for instability and/or SCI. Diagnosis is made based on the incident, symptoms, a physical examination, and results of radiological tests, including the following:

• Computed tomography scan (CT or CAT scan): A diagnostic image created after a computer reads x-rays; can show the shape and size of the spinal canal, its contents, and the structures around it.
  
  
• Magnetic resonance imaging (MRI): A diagnostic test that produces three-dimensional images of body structures using powerful magnets and computer technology; can show the spinal cord, nerve roots, and surrounding areas, as well as enlargement, degeneration, and tumors.
  
  
• X-ray: Application of radiation to produce a film or picture of a part of the body can show the structure and alignment of the vertebrae and the outline of the joints.

Treatment

Treatment varies depending on the following factors:

• The severity of the fracture
• If there is an associated dislocation or instability
• Which cervical bones are fractured
• Whether there is spinal cord or nerve injury, with muscle weakness or paralysis

A minor (compression) fracture is often treated with a cervical collar or brace worn for six to eight weeks until the bone heals on its own. A more severe or complex fracture may require traction, or surgical interventions including spinal instrumentation (fusion etc) with or without surgical decompression.

Surgical decompression of the spinal cord is often done after an injury occurs, although the timing of this intervention varies widely. Surgery involves the removal of various tissue or bone fragments that are compressing and comprising the spinal cord. Depending on the unique circumstances of the injury, decompression is accomplished through a variety of surgical approaches, including, for example, approaching the compressed cord from either the front (anterior) or back (posterior). Increasingly it has become clear that decompression and stabilization in patients with SCI should be done as soon as medically save and reasonable.

Specific Sports

Cycling

• An estimated 80 percent of fatal bicycle accidents involving motor vehicles among children 14 and younger occur because of the bicyclist's behavior, such as riding into the street without stopping, swerving into traffic, running stop signs, or riding against the flow of traffic.
• A 15-year-old boy without a helmet was riding down a hill, flew off his bike over the handlebars and fractured his neck at C-7.
• A 6-year-old boy without a helmet was riding, fell off and hit his head, suffering not only head injuries but a C-1 fracture.

Football

Neck injuries are usually associated with high-velocity collisions between players, causing acceleration or deceleration of the head on the neck. Acceleration often causes a whiplash type of extension force on the neck, while deceleration often results in flexion forces. Spearing, which has been banned in American football since 1976, happens when a player uses the helmet/head as the first point of contact with another player. Spearing is a significant cause of cervical spine injuries and quadriplegia.

• Cervical-spine injuries are estimated to occur in 10-15 percent of all football players, most commonly in linemen and defensive players.
  
  
• During the 2007 football season there were a total of eight cervical spinal cord injuries with incomplete neurological recovery. Six of the injuries occurred at the high school level and one at the professional level.
  
  
• A majority of catastrophic SCIs occur in games. During the 2007 season, five injuries took place in games, two in practice, and one in a scrimmage game.
  
  
• Nine percent of catastrophic cervical SCIs took place by being tackled.
  
  
• A 17-year-old high school player experienced helmet to helmet collision during scrimmage and continued playing with neck pain. He was subsequently unable to move his neck and was diagnosed with a C-7 fracture.
  
  
• A 14-year-old player was tackled, pulled down by the neck, hitting the ground head first. The other player fell on top of him. He got up in pain and was later diagnosed with a C-4 fracture.
  
  
• During the past 31 years, there have been a total of 278 football players with incomplete neurological recovery related to cervical SCI: 229 high school players; 33 college players; 10 professionals; and six sandlot players. Data indicate a reduction in the number of cervical cord injuries with incomplete neurological recovery when compared to data published in the early 1970s.
  
  
• During the 31-year period from 1977-2007, 193 of the 278 players with cervical SCIs were playing defense.

Sources: National Center for Catastrophic Sport Injury Research, Annual Survey of Catastrophic Football Injuries 1977-2007.

US Consumer Product Safety Commission, National Electronic Injury Surveillance System (NEISS), 2007.

Water Sports

• A 16-year-old boy dove in an above-ground pool in about 4 to 5 feet deep at his friend’s pool party. He suffered an SCI but the extent of his injuries is unknown.
  
  
• A 50-year-old male dove into the pool and hit his head on the bottom. He experienced numbness and was diagnosed with a C-5 fracture with spinal cord impingement.
  
  
• A 49-year-old male was drinking alcohol, dove into 3-5 feet of water in Puget Sound and fractured and dislocated his neck at C-4. He was paralyzed and is still quadriplegic.
  
  
• A 24-year-old male was drinking alcohol with his girlfriend. He dove into the ocean and the water was shallower than anticipated. He suffered a neck fracture, unspecified level.
  
  
• A 28-year-old male dove off the back of a boat, hitting his head on the bottom of the lake, fracturing his neck.

Prevention Tips

Biking

While many cycling injuries are head injuries, the proper usage of SNELL, American National Standards Institute (ANSI) or American Society for Testing and Materials (ASTM)-approved helmets can also help prevent SCI injuries. It is essential that the helmet fit properly and that the helmet strap is closed and tightened so that it doesn’t fall off while riding or if you take a fall. Other SCI cycling prevention tips include:

• Children under age 1 should not be carried on a bicycle, because their necks are not strong enough to withstand a helmet on their heads.
• Bike a minimum of three feet from parked cars, in case a door swings open.
• Do not wear headphones.
• Obey local traffic regulations at all times.
• Never grab onto a moving vehicle to get a "free" ride.
• Use "hand-signs" to indicate the direction of your turns

Football

• Football players should receive adequate preconditioning and strengthening of the head and neck muscles.
• Coaches and officials should discourage players from using the top of their football helmets as battering rams when blocking, hitting, tackling, and ball carrying. Coaches, physicians and trainers should ensure that the players' equipment is properly fitted, especially the helmet, and that straps are always locked.
• Coaches must be prepared for a possible catastrophic SCI. The entire staff must know what to do in such a case, because being prepared and well-informed may make all the difference in preventing permanent disability.
• The rules prohibiting spearing should be enforced in practice and games.
• Ball carriers should be taught to not lower their heads when making contact with the tackler to avoid helmet to helmet collisions.

Skateboarding/In-line Skating

• Inspect your skateboard or skates for any damaged parts and replace them before using again.
• Wear a helmet, fastened securely to your head, every time you skateboard or skate.
• Check the area for rocks, debris, cracks in the pavement or uneven surfaces.
• Wear well-fitting clothing, knee and elbow pads, wrist braces, and gloves.

Swimming/Diving

• Do not dive in water less than 12 feet deep or in above-ground pools. Check the depth and check for debris in the water before diving.
• Follow all rules and warning signs at water parks, swimming pools, and public beaches.
• The first time you go into a body of water, walk into the water.
• Never push or shove somebody into the water and do not allow your children to do so.

General Sports

• Supervise younger children at all times, and do not let them use sporting equipment or play sports unsuitable for their age. Do not let them use playgrounds with hard surface grounds.
• Do not participate in sports when you are ill or very tired.
• Discard and replace sporting equipment or protective gear that is damaged.
• Never slide headfirst when stealing a base.