How to assess and treat sports-related spinal cord injury in children

Click here to read about the tips and tricks for recognizing and treating sports-related spine injuries in children.
Last update13th Jan 2021

After spinal trauma, minor neurological complaints without findings or persistent spinal pain is not uncommon. However, any persistent pain in the spine or neurological symptom prohibits the athlete from returning to the sport. Persistent pain or neurological symptoms may indicate a fracture of the spine or actual spinal cord injury and warrant formal medical evaluation.

Sports-related neurological syndromes that can mimic spinal cord injury

Some sports-related syndromes may present similarly to spinal cord injury syndromes, but they are less concerning. Let’s explore four common sports-related injuries that may represent spinal cord injuries:

  1. Stingers or burners
  2. Muscular strain
  3. Bilateral burning hands
  4. Spinal cord neuropraxia

Stingers or burners

A stinger or burner is unilateral paresthesia or dysesthesia in an arm or hand which appears after the athlete’s shoulder has been acutely depressed and their neck laterally flexed­, usually from a fall or tackle. The symptoms are thought to be related to a stretch or traction placed on nerve roots of the brachial plexus and usually resolve rapidly.

The key to recognizing this syndrome is that the symptoms are unilateral. An athlete can return to play (in the same practice) if the symptoms completely resolve and do not return with vigorous exercise. The athlete must also be pain-free in the spine.

Figure 1. A stinger or burner (unilateral paresthesia or dysesthesia in an arm or hand) may result from acute depression of the shoulder and lateral flexion of the neck. A return to play is possible once the symptoms resolve and do not return with vigorous exercise.

Muscular Strain

An athlete may sustain an acute strain of paravertebral muscles during sports play. They will complain of related spinal pain that may be exacerbated by position or movement. Because this will be clinically indistinguishable from a more serious injury, the athlete should not return to play if they have residual pain until formally evaluated by medical professionals. Ideally, they should not return to play until all discomfort has resolved (even if cleared by medical professionals), or else subsequent injury and pain may cause confusion in the evaluation.

Bilateral burning hands

Bilateral burning hands without neurological findings are different from a stinger and may be related to a transient injury of the spinal cord. Do not return this athlete to play.

If the athlete also has neck pain, they should be evaluated at a medical center right away. Ideally, they should be transported on a spine board by an ambulance. If there is no neck pain and the symptoms have resolved, it is acceptable to request a nonemergent spine evaluation with a spinal surgeon or a sports medicine physician.

Figure 2. Bilateral burning hands may be a symptom of a transient spinal cord injury, and return to play is not recommended.

Spinal cord neuropraxia

Spinal cord neuropraxia involves spinal cord symptoms that are transient (e.g., lasting seconds to hours). Spinal cord neuropraxia can show symptoms of paralysis, paresis, diffuse paresthesia, and diffuse dysesthesia. These symptoms may occur in all four limbs (in the case of cervical injuries) or in both lower extremities (in the case of thoracolumbar injuries). The symptoms warrant spinal precautions and urgent transfer to a medical center.

Figure 3. Cervical spinal cord neuropraxia features transient spinal cord symptoms that involve all four limbs whereas thoracolumbar cord neuropraxia features symptoms that involve the lower extremities. With both conditions, a return to play is not recommended.

If the patient has no spinal pain and the symptoms have totally resolved at the scene, they should still undergo urgent evaluation at a medical center, but strict spinal precautions may not be required.

When evaluating a patient with spinal cord neuropraxia in an emergency room, obtain computed tomography (CT) scans of the affected area to rule out a fracture.

Figure 4. Computed tomography (CT) scan of a spinal cord fracture which is possible for symptoms of neuropraxia.

Also, obtain magnetic resonance imaging (MRI) to rule out evidence of spinal cord injury, disc herniation, and extradural hematoma.

You should also obtain lateral cervical flexion-extension x-rays to rule out ligamentous instability. Sometimes, there can be significant movement of one vertebra on another (without fracture). This can be severe enough to compromise the spinal canal and damage the spinal cord.

Figure 5. Flexion-extension x-rays can rule out ligamentous instability in a patient with spinal cord neuropraxia symptoms.

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When is an athlete able to return to sport after a spinal cord injury?

Parents, trainers, and coaches will want to know when it’s safe for an athlete to return to play after a spine injury. It’s important to know when athletes should be forbidden from returning to their sport permanently.

There are nine conditions and situations that prohibit a return to contact or high-risk sports:

  1. Os odontoideum
  2. Multilevel spine fusions
  3. Ligamentous instability
  4. History of spinal cord injury
  5. Atlantoaxial instability or fusion
  6. History of major cervical fracture
  7. Straight or kyphotic cervical spine
  8. Repeated neuropraxia
  9. Chiari malformation with or without a spinal cord syrinx

Os odontoideum

An athlete should not return to contact or high-risk sports if they are found to have os odontoideum. This is a condition where the top of the odontoid process is not fused with the base. This condition is a congenital abnormality that may not be discovered until an athlete undergoes imaging of the spine. It is usually asymptomatic but is prone to instability.

Figure 6. With os odontoideum, the top of the odontoid process is not fused with the base of the vertebrae. This condition is prone to instability and athletes are prohibited from returning to play.

Multilevel spine fusions

If an athlete has a multilevel congenital fusion of the cervical spine (also known as Klippel-Feil syndrome), or if they have undergone previous multilevel surgical fusion of the spine, they should not return to high-risk and contact sports.

Figure 7. The multilevel fusion of the cervical spine, either from Klippel-Feil syndrome or surgical fusion procedures, prohibits a return to high-risk and contact sports.

However, if the athlete only has a single level of congenital or surgical spinal fusion, and has a normal range of motion of the neck without signs or symptoms, they can still participate in their sport.

Figure 8. With a single-level of congenital or surgical cervical fusion, a return to play is possible as long as the athlete has a full range of motion without signs or symptoms.

Ligamentous instability

An athlete should also refrain from high-risk sports if they show ligamentous instability on flexion-extension x-rays. Ligamentous instability may improve over time and should be followed. If it is mild, there is a chance that the patient may be able to return to play. But, seek the opinion of a spinal surgeon first. If it is severe, a cervical fusion may be indicated.

Figure 9. Flexion-extension x-rays can reveal ligamentous instability which prohibits a return to play.

History of spinal cord injury

If the athlete has evidence of a previous spinal cord injury (static neurological findings) or a history of spinal cord injury, they should refrain from high-risk athletics.

Figure 10. Magnetic resonance imaging (MRI) may reveal previous spinal cord injury. This would argue against the return to high-risk activities.

Atlantoaxial instability or fusion

An athlete who has atlantoaxial instability or fusion on imaging, either congenital or surgical, should refrain from high-risk sports.

Figure 11. Both congenital and surgical atlantoaxial fusion or instability are reasons to refrain from high-risk athletic activities.

History of a major cervical fracture

If the athlete’s history includes a major cervical fracture, they should refrain from high-risk sports, even if they are symptom-free. This includes a history of burst fractures, fracture-dislocations, and unilateral or bilateral jumped facet joints.

Figure 12. Magnetic resonance imaging (MRI) showing a major cervical fracture which prohibits a return to high-risk sporting activities.

Straight or kyphotic cervical spine

If the athlete is found to have a straight (alordotic) or kyphotic cervical spine, contact sports are contraindicated. This is particularly a concern if the athlete has a congenitally narrow spinal canal.

Figure 13. Flexion x-ray showing a kyphotic cervical spine, which prohibits a return to contact sports.

Repeated spinal cord neuropraxia

An athlete who has sustained traumatic neuropraxia may eventually return to play after a period of rest (at least two weeks). After two weeks, the athlete can return to play if they have fully recovered and are not showing exclusionary findings on imaging studies. However, if they have experienced repeated episodes of spinal cord neuropraxia, or are found to have spinal stenosis on imaging, they need to refrain from high-risk sports.

Figure 14. If an athlete has experienced repeated spinal cord neuropraxia, they should refrain from high-risk sports.

Congenital narrowing of the cervical canal has not been associated with higher incidents of paralyzing injuries, provided that the patient has maintained cervical lordosis. Therefore, with a total resolution of symptoms under heavy exercise (and no evidence of spinal cord injury), an athlete can return to their sport in a graded fashion after a single incident of neuropraxia.

Figure 15. Congenital cervical stenosis, or a narrowing of the cervical canal, does not prohibit an athlete from participating in high-risk sports as long as they have maintained cervical lordosis and are symptom-free even with vigorous exercise.

Chiari malformation with or without a spinal cord syrinx

Chiari malformation with an associated syrinx or brainstem compression would prohibit a return to high-risk sports. But, an asymptomatic Chiari malformation with no evidence of a syrinx or brainstem compression is not currently considered a contraindication to play. However, there is some controversy regarding this condition.

If your patient with a Chiari malformation participates in a sport, they should be monitored for the development of neurological signs or symptoms, and serial follow-ups should be planned.

Figure 16. A Chiari malformation with an associated syrinx or brainstem compression prohibits participation in high-risk sports.

Spinal cord-related conditions that allow a return to play

There are four spinal cord-related conditions that do not prohibit participation in contact or high-risk sports:

  1. Disc herniations
  2. History of simple fractures
  3. Bifid spinous processes
  4. Spina bifida occulta

Disc herniations and history of simple fractures

A history of a resolved disc herniation (with or without surgery) or healed simple fractures do not prohibit participation in high-risk sports. This is provided that there is no residual pain throughout a full range of motion, no residual deformity, and no structural instability. Healed simple fractures include those of a spinous process, a transverse process, a laminar fracture, or an undisplaced lateral mass or facet fracture.

Figure 17. Resolved disc herniations and healed simple fractures of the spine do not prohibit a return to play as long as there is no residual pain, residual deformity, or structural instability.

Bifid spinous processes and spina bifida occulta

As well, congenital bifid spinous processes and spina bifida do not prohibit participation, as long as there is no evidence of spinal cord tethering.

Figure 18. Congenital bifid spinous processes and spina bifida occulta do not prohibit a return to play provided there is no spinal cord tethering.

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About the author

Gary R. Simonds, MD MHCDS FAANS
Professor at Virginia Tech School of Neuroscience / Virginia Tech Carilion School of Medicine and Program Director for the Division of Neurosurgery at Virginia Tech Carilion Clinic.
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