Jump to content
We need you! See something you could improve? Make an edit and help improve WikSM for everyone.

Cervical Cord Neuropraxia

From WikiSM
(Redirected from Cervical Cord Neurapraxia)


Other Names

  • Transient Brachial Plexus Neuropraxia
  • Transient Brachial Plexus Neurapraxia
  • Burner
  • Burner Syndrome
  • Stinger
  • Dead Arm Syndrome
  • Transient Quadriparesis (TQ)
  • Transient Quadriplegia
  • Cervical Cord Neuropraxia (CCN)
  • Cervical Cord Neurapraxia

Background

  • This page refers to transient neurologic injuries to the cervical spine, often referred to as burner or stinger
    • Technically termed neuropraxia
    • Generally defined as a transient neurological deficit as a result of traction or compression of the upper trunk of the brachial plexus or of a cervical nerve root

Definitions

  • Cervical Cord Neuropraxia (CCN) refers to a transient loss of motor or nerve function of more than one extremity
    • These are often referred to as stingers or burners
  • Transient Quadriparesis (TQ) refers to transient motor or nerve function loss of all 4 extremities
  • Cervical Cord Myelopathy is discussed separately
  • Cervical Radiculopathy is discussed separately

Epidemiology

  • Incidence, prevalence likely under-reported
  • 65% of American football players report experiencing at least one stinger in their lifetime[1]
  • Among Canadian football players, the one year incidence was 26% and lifetime prevalence was 62%[2]
  • Among English rugby players, 72% of players endorsed one of the course of a season[3]
  • Estimated prevalence of 1.3 - 7 per 10,000 football participants[4][5]
  • American Football[6]
    • Green et al: Majority occur due to contact, 36% during tackling and 26% during block
    • 55% during competition and 80% during preseason
    • Most occurred in defensive ends, linebackers and offensive linemen
    • Represents up to 87% of all cases in the US[7]

Pathophysiology

  • Due to traction and/or compression of the brachial plexus or cervical nerve root(s)
  • Cervical neural foramina narrow with neck extension, rotation or sidebending
  • In general, symptoms tend to last less than 15 minutes
    • Can persist up to 48 hours in adults and 5 days in children
  • Recurrence is far more common in adults than children
  • Temporary derangement of axonal permeability is thought to be primary etiology of underlying motor/sensory symptoms[8]
    • Laboratory analysis reveals hyperpolarization, then prolonged depolarization, during which the axon is no longer excitable
    • Transient nature of these physiological changes distinguished neurapraxia from irreversible neurological damage

Etiology

  • Traction injury to the brachial plexus
    • Due to depression of neck, forced sidebending away from the involved side, stretching the brachial plexus
  • Direct blow to the supraclavicular fossa
    • Results in a percussive injury to the upper trunk of the brachial plexus
  • Nerve compression due to hyperextension, and sidebending

Stinger

  • Characterized by transient unilateral burning pain, parasthesia and weakness of a single extremity

Cervical Cord Neuropraxia

  • By definition, acute and transient neurological injury
  • Pattern of injury can be classified as:
    • Upper Only
    • Lower Only
    • Hemiplegia
    • Quadriplegia

Transient Quadriplegia

  • Definition: A form of CCN in which all 4 extremities are affected
  • Etiology
    • Typically occurs following axial load with slight flexion[9]
    • When cervical spine is flexed to about 30°, the cervical spine is straightened allowing forces to be transmitted along the column
    • In neutral position, most energy is dissipated into paracervical musculature

Associated Injuries

Pathoanatomy

Risk Factors

  • Sports
    • American Football
    • Gymnastics (USA)
    • Wrestling (USA)
    • Rugby (Europe)
    • Ice Hockey (Canada)
    • Snow sports
    • Cycling
    • Equestrian
  • "Unsupervised" sports
    • Diving
    • Skiing
    • "sandlot" sports

Differential Diagnosis

Clinical Features

  • General: Physical Exam Neck
  • History
    • Important to clarify history including description of mechanism and symptoms
    • Clarify the presence of weakness, numbness, tingling
    • Most commonly transient unilateral arm tingling that does not clearly follow a dermatomal pattern
    • Resolves in a matter of minutes, typically 15, but can last longer
    • Sensory symptoms can include burning pain, numbness, or tingling
    • Motor exam symptoms can be weakness to complete paralysis
    • Children are more likely to report neck pain, loss of range of motion
  • Physical Exam
    • Normal neck exam
    • Stinger: Unilateral diminished strength (most commonly in C5-C6 tested with biceps, deltoid)
    • As degree of injury increases, deficits can expand to affect all 4 extremities
  • Special Tests

Evaluation

Radiography

  • Standard Cervical Spine films can be used as a screening tool
  • May demonstrate spinal stenosis, fracture
  • Typically normal
  • Torg ratio: cervical canal to the width of the cervical body
    • Used to help define cervical canal stenosis
    • Torg ratio < 0.8 is fairly sensitive (need citation)

MRI

  • Useful to evaluate soft tissue structures
  • Indicated if bilateral (i.e. not a stinger)

CT

  • Useful to better evaluate osseous abnormalities

EMG/NCS

  • Can aid in diagnosis
  • Localize lesion, assess its severity
  • Use in persistent symptoms

Classification

Seddon Classification

  • Grade I: neurapraxia
  • Grade II: axonotmesis
  • Grade III: neurotmesis

Management

Prognosis

  • Most athletes make a full recovery and are able to return to play (need citation)

Nonoperative

  • Acute treatment
    • Patient should be evaluated on sideline with serial exams over subsequent days-to-weeks
  • Long term treatment is aimed at prevention
    • Physical Therapy
    • Protective Equipment including Shoulder pads, Neck Orthosis
    • Consider kerr collar, cowboy collar or bullock collar
    • Football: Improved and proper tackling technique
    • Hockey: 69% reduction in cervical spine injuries from hockey following rule change/penalty increase for checking from behind, boarding[11]
  • Not Indicated
    • Nerve Block
    • Corticosteroid Injection
  • If symptoms are persistent or recurrent, must be worked up for other causes of peripheral neuropathy

Operative

  • Indications
    • Focal lesions, typically seen in older athletes or patients

Rehab and Return to Play

Rehabilitation

  • Neck, Upper back, shoulders[12]
    • Improve flexibility, strength
    • Improve posture

Return to Play

  • Single episode of CCN is not an absolute contraindication for return to sports
  • Patients must have returned to baseline before return to sport
    • If not returning, then they should be held from sport and workup should be escalated
    • Athletes must be counseled on the known and potential risk of return to contact sports
    • Patient should participate in practice before return to games
  • It is not believed that athletes with a single episode of CCN are at increased risk for future, permanent neurologic injury or quadriplegia</ref name="ref2">
    • There are no case reports of athletes with previous CCN returning to play and developing sustained quadriplegia
    • Admittedly, this is based on statistics of small numbers
  • Inclusion Criteria for RTP[13]
    • Complete neurological recovery
    • Full cervical range of motion
    • No evidence of functional stenosis on imaging
    • Regain pre-injury strength
    • No instability
  • Exclusion Criteria for RTP
    • Ligamentous Instability
    • Neurologic symptoms lasting longer than 36 hours
    • Recurrent episodes
    • MRI evidence of cord defect or cord edema
    • Minimal functional reserve

Complications

  • Recurrence
    • Seen in up to 87% college football players[14]
  • Lost play time
  • Permanent neuropathy

See Also

References

  1. ↑ Kuhlman, Geoffrey, FAAFP CAQSM, and Karl B. Fields. "Burners (stingers): Acute brachial plexus injury in the athlete."
  2. ↑ Charbonneau, Rebecca ME, Sonja A. McVeigh, and Kara Thompson. "Brachial neuropraxia in Canadian Atlantic University sport football players: what is the incidence of “stingers”?." Clinical journal of sport medicine 22.6 (2012): 472-477.
  3. ↑ A retrospective study looking at the incidence of 'stinger' injuries in professional rugby union players.
  4. ↑ Torg JS, Guille JT, Jaffe S. Current concepts review: injuries to the cervical spine in American football players. J Bone Joint Surg Am 2002;84:112–22.
  5. ↑ Boden, Barry P., et al. "Catastrophic cervical spine injuries in high school and college football players." The American journal of sports medicine 34.8 (2006): 1223-1232.
  6. ↑ Green, James, et al. "A 6-year surveillance study of “Stingers” in NCAA American football." Research in sports medicine 25.1 (2017): 26-36.
  7. ↑ Torg, Joseph S., et al. "Cervical cord neurapraxia: classification, pathomechanics, morbidity, and management guidelines." Journal of neurosurgery 87.6 (1997): 843-850.
  8. ↑ Clark, Aaron J., Kurtis I. Auguste, and Peter P. Sun. "Cervical spinal stenosis and sports-related cervical cord neurapraxia." Neurosurgical focus 31.5 (2011): E7.
  9. ↑ Torg JS, Pavlov H, Genuario SE, et al.. Neurapraxia of the cervical spinal cord with transient quadriplegia. J. Bone Joint Surg. Am. 1986; 68: 1354–70.
  10. ↑ Parke WW. Correlative anatomy of cervical spondylotic myelopathy. Spine 1988; 13:831–7
  11. ↑ Pluim, Babette M., et al. "Consensus statement on epidemiological studies of medical conditions in tennis, April 2009." British Journal of Sports Medicine 43.12 (2009): 893-897.
  12. ↑ Weinstein, Stuart M. "Assessment and rehabilitation of the athlete with a “stinger”: a model for the management of noncatastrophic athletic cervical spine injury." Clinics in sports medicine 17.1 (1998): 127-135.
  13. ↑ Cantu, Robert C., et al. "Return to play after cervical spine injury in sports." Current sports medicine reports 12.1 (2013): 14-17.
  14. ↑ Sallis, Robert E., Kirk Jones, and William Knopp. "Burners: offensive strategy for an underreported injury." The Physician and sportsmedicine 20.11 (1992): 47-55.
Created by:
John Kiel on 17 June 2019 14:20:05
Authors:
Last edited:
6 October 2022 23:11:40
Categories:
Neurology | Trauma | Neck | Neuropathies | Spine - Cervical | Acute
Retrieved from "https://wikism.org/w/index.php?title=Cervical_Cord_Neuropraxia&oldid=18056"