H EA D A N D S P IN E IN JU R IES

Formulate an initial management

plan for a 16 y/o defensive back with

temporary loss of consciousness,
neck pain, and upper extremity
weakness after a play
The same patient returns 1 week
later. He asks when he can return to
play

 Any athlete with neck pain and

altered consciousness must be

assumed to have a fractured spine
until proven otherwise
Am J Sports Med 1990; 18: 50-7

Initial focus is on the ABCs:

Airway, Breathing, Circulation

Jaw thrust method for opening

airway
Removal of helmet should be

 If cardiac arrest occurs ,

cardiopulmonary resuscitation is
initiated in the supine position
Once condition stable, screening
neurologic evaluation including level
of consciousness, pupillary response,
and motor and sensory status.
Patient placed on spine board then
transferred

Concussion
The Congress of Neurological

Surgeons defined concussion in 1966

as a clinical syndrome characterized
by . . . Immediate and transient
post-traumatic impairment of neural
functions, such as alteration of
consciousness, disturbance of vision,
equilibrium, etc., due to brainstem
involvement

Postconcussion Syndrom e
Occurs when the symptoms related

to the concussion, including

headache, fatigue, memory loss,
concentration loss, and irritability,
persist after initial recovery from the
head injury.

Cantu and Colorado H ead

Injury G rading System s
Grade

Cantu

Colorado

Grade 1 (mild)

No LOC
PTA < 30 mins

Grade 2
(moderate)

LOC <5 mins

PTA>30 mins

Grade 3
(severe)

LOC>5 mins
PTA>24 hours

Confusion
without
amnesia
No LOC
Confusion with
amnesia
No LOC
LOC

LOC - loss of consciousness; PTA - post

traumatic amnesia

Return-to-play criteria
Grade 1 concussion
Athlete should be removed from the

contest and examined immediately and

at 5-minute intervals
Athlete may return to play if symptoms
clear in 15 minutes
If a second grade 1 concussion occurs,
the athlete should be removed from
participation that day.
The athlete must remain asymptomatic
for 1 week before being allowed to play

Return-to-play criteria
Grade II concussion
Athlete removed from the contest for the

day and receive frequent on-site

evaluations in addition to next-day
evaluation.
The athlete must remain asymptomatic
for 1 full week at rest and with exertion
prior to return to play.
CT or MRI is recommended for
postconcussive symptoms persisting
beyond 1 week.

Return-to-play criteria
Grade 3 concussion
Requires removal of the athlete from the

contest and often transport to the

nearest hospital by ambulance
Either 2 fully asymptomatic weeks or 1
asymptomatic week after 1 full month of
rest is required before return to play.

Second-im pact syndrom e (SIS)

Occurs when an athlete who sustains

a head injury then experiences a

second head injury before symptoms
associated with the first head injury
(postconcussive type) have cleared.
Metabolic changes occurs after initial
injury, increase intracellular calcium,
extracellular glutamate and
glycolysis resulting in cerebral
edema

 Since the 1950s, approximately 90%

of all traumatic football fatalities

have occurred as a result of head or
neck injuries
Phys Sportsmed 1996;24(1):35-41

Catastrophic neck injuries in football

Helmet-to-helmet or helmet-to body

contact
Head to spear tackle methods
Education of coaches to discourage
tackling techniques lowered the

 Neurapraxia of the cervical cord with

transient quadriplegia
Occurs in athletes after forced hyperextension,

hyperflexion or axial loading of the cervical

spine.
Predisposing factors: developmental spinal
stenosis, herniated nucleus pulposus,
spondylosis will cause narrowing of the AP
diameter of the spinal canal.

Torg and Pavlov utilized the ratio of

vertebral canal width to body size to

detect presence of significant spinal
stenosis on x-rays
Ratios less than 0.8 suffered transient

neurologic episode.

 In separate studies, Herzog and

associates and Cantu and colleagues

detected a high percentage of falsepositive Torg-Pavlov ratio in
asymptomatic football players
because of their large vertebral body
width and suggested that MRI be
used to confirm x-ray abnormalities
Med Sci Sports Exerc 1997, 29(suppl):S233-5
Spine 1991: 16(suppl 6): S78-86

R eturn-to-play criteria for

developm entalcervicalspine lesions

Absolute contraindication for

participation in collision sports

Spear-tacklers spine, odontoid

abnormalities, atlanto-occipital
instability (disruption of alar or
transverse ligament)
Cervical ligamentous instability
documented by more than 3.5 mm.
horizontal displacement of adjacent
vertebrae or more than 11o of rotation to
adjacent vertebra

R eturn-to-play criteria for

developm entalcervicalspine lesions

Relative contraindications
Persons with a Torg-Pavlov ratio of 0.8 or

less with one episode of cervical cord

neurapraxia
In those with certain fractures that have
healed without neurologic deficit in
which the athletes regained full pain
free range of motion
Clin J Sport Med 1997:7:273-9

Stinger or Burner
Transient neurologic event

characterized by pain, paresthesia,

and local weakness in an upper limb
after a blow to the shoulder or neck.
The precipitating event usually
involves downward displacement of
the shoulder with lateral flexion of
the neck.
Am J Sports Med 1997: 25: 603-8

Stinger or Burner
In young athletes, the lateral flexion is away

from the side of the symptoms, which

increases the acromiomastoid distance
(stretch mechanism).
In older athletes, the head laterally flexes
toward the ipsilateral shoulder and creates
a pincer mechanism at a foraminal level.
EMG studies have demonstrated
abnormalities in the roots, cords, trunks,
and peripheral nerves of players sustaining
theses injuries.