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Cervical Cord Neuropraxia

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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

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