Dr. Martin's notes

Thursday April 13, 2017

The spine and spinal injuries

Spinal injuries

The spine, or vertebral column, encases and provides protection for the spinal cord. Trauma to the spine can produce devastating injuries; these injuries can be fatal, or can cause irreversible spinal cord damage that results in permanent paralysis.

Cervical spine injuries range in severity from minor neck pain to complete paralysis or death. Improper handling and transportation may cause irreparable spinal-cord damage in an athlete who has suffered a cervical spine fracture or dislocation.

Mechanism of injury to the cervical spine can involve vertebrae, facet joints, intervertebral discs, ligaments, muscles, nerve roots, or the spinal cord. The most common mechanism of injury to the neck is forced movement of the head on the cervical spine or excessive motion of the neck.. This may occur when an athlete receives a blow straight to the top or crown of the head, especially when the neck is slightly flexed.

Do not move the athlete except from immediate danger or for basic trauma management. It is estimated that 50% of neurologic injuries are created after the initial traumatic event. A neck injury must be assumed if the athlete is unconscious, has numbness and paralysis, and has neck pain or pain with neck movement. Important questions to ask are:

How did the injury happen?
Are you having any weakness, numbness, or tingling?
Are you feeling any pain?
Have you had a neck injury before?

If the athlete is not breathing, the jaw-thrust technique has been shown to be the safest method for opening the airway in patients with a suspected neck injury. If a football player has a suspected neck injury, do not remove the helmet. If airway access is necessary, the face mask may be cut using a device designed for this purpose.

Immobilization of the cervical spine includes reassuring the athlete and supporting the head and neck in a way that eliminates any movement. Kneel down in front of the athlete's head and, using both hands, hold the head in place until EMS personnel arrive and take over care of the athlete. All injuries of the spine must be evaluated by a physician, who will make the decisions about return to play. The physician may place limits on future participation in certain sports.

Cervical Sprains and Strains
Some of the more common injuries to the neck are cervical sprains and strains. In mild cases, the athlete will express no feelings of weakness or instability. With a moderate sprain and strain, the athlete may have limited motion of the cervical spine, but without radiation of pain or paresthesia (abnormality of sensation). With a more severe injury, the athlete will usually resist moving the neck through a full range of motion. More severe injuries may cause localized pain and muscle spasm, and the athlete may complain of an insecure feeling about the neck.

Any athlete with less than a full, pain-free range of cervical motion, or who has persistent paresthesia or weakness, should be protected and excluded from further athletic activity. These athletes should be referred to a physician for further radiographic and neurologic evaluations.

Cervical Nerve Syndrome
Another common athletic injury to the neck is cervical nerve syndrome. This injury results from forced lateral flexion, which causes the nerve roots to be either stretched or impinged- This is commonly known as a pinched nerve, burner, or stinger, and is characterized by sharp, burning, radiating pain. Athletes may return to athletic activity if all paresthesia has completely subsided; they can demonstrate full muscle strength in the muscles of the upper extremity; and they exhibit full, pain-Free range of cervical motion.

Cervical Fractures and Subluxations
Serious injuries of the cervical spine, such as fractures or dislocations, are not common in athletics, but the potential for this type of an injury is inherent in almost any sport. A spinal cord contusion can cause swelling within the cord, resulting in various degrees of temporary or permanent damage. A spinal cord concussion may cause transitory paralysis and symptoms, but usually there is complete recovery.

The major signs and symptoms that may indicate a serious neck injury include unremitting neck pain, muscle spasms, and evidence of spinal-cord involvement. Spinal-cord involvement may manifest as numbness, loss of sensation, weakness, paresthesia, and partial or complete paralysis of the limbs.

Helmet Management in Suspected Spinal injuries
The first rule of management for an athlete who is on the field with a neck injury is to stabilize the neck. If an injured athlete is breathing and does not require airway management, the helmet should be left on to help support the head and neck. The face mask should be removed, however, because EMS protocols require removal of the mask before transport. There are special tools (trainers angel) designed to snip the plastic clips that hold the face mask onto the helmet.

Thoracic Spine Injuries
Common athletic injuries to the thoracic spine include contusions, sprains, and strains. Serious injuries to the thoracic spine are extremely rare in athletic activities. Fractures or dislocations are unusual because of the spine's stable anatomy in the region. An athlete with a moderate or severe injury may exhibit a very stiff back and may resist any motion or movement of the thoracic spine. The athlete should be referred to a physician for further evaluation.

Lumbar Spine Injuries
The lower back is very susceptible to injury. Occasionally, low back pain is caused by structural defects in the vertebrae or intervertebral discs. All conditions affecting the lumbar spine can be aggravated by various contributing factors, such as inadequate or inappropriate conditioning, inflexibility, congenital anomalies, and poor postural habits.
Common athletic injuries to the lower back are contusions, sprains, and strains.. It is difficult to differentiate between a sprain and a strain in this area.

Spondylolysis
The most common structural defect of the lumbar spine in an athlete is a condition called spondylolysis. Spondylolysis is a defect in the pars interarticularis of the vertebrae. If this defect is bilateral (on both sides), it may allow the vertebra to slip forward on the vertebra or sacrum below—a condition called Spondylolisthesis Spondylolisthesis may develop in athletes who undertake m strenuous exercise or competition. With rest or inactivity, the pain diminishes, only to return again when the activity is resumed. In addition to pain in the lower back, the athlete may complain of pain radiating into the buttocks and upper thighs.

Intervertebral Disc Herniation
In this condition, the nucleus puiposus hemiates through the annulus fibrosus and presses against the spinal cord or the spinal nerve roots. This condition is more common in people in their 30s and 40s, although it can occur in younger athletes as well. The athlete with a ruptured or hemiated disc normally has extreme pain and stiffness in the lower back, pain in the buttocks, and a unique type of radiating leg pain if the compression is severe. This leg pain is usually unilateral (one-sided) and follows the route of the sciatic nerve. Athletes with signs and symptoms of this type must be referred to a physician for further evaluation.

Sacroiliac Injuries
Sacroiliac injuries are usually sprains that occur as a result of acute or chronic trauma. They may result from a single maneuver, twist, or awkward movement, or from overuse associated with poor posture, bad lifting techniques, or strenuous maneuvers repeated many times. Symptoms of a sacroiliac sprain include stiffhess or a consistent soreness of the sacroiliac joint area that is better in the morning but gets worse as the day goes on.