We need you! See something you could improve? Make an edit and help improve WikSM for everyone.
Cervical Cord Neuropraxia
From WikiSM
Contents
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
- Cervical Spine Stenosis
- Primarily in adults
- Association does not seem to exist in children
- Cervical Disc Disease
Pathoanatomy
- Cervical Spine
- 7 Vertebra
- Cervical canal cross sectional area[10]
- 75% of canals in lower cervical spine
- Less 50% at the level of C1
- Brachial Plexus
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
- Fractures
- Subluxations and Dislocations
- Neuropathic
- Muscle and Tendon
- Pediatric/ Congenital
- Other Etiologies
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
- Spurlings Test: Axial compression may reproduce symptoms
- Tinels Test: May be positive
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
- Internal
- External
- Sports Medicine Review Neck Pain: https://www.sportsmedreview.com/by-joint/neck/
References
- ↑ Kuhlman, Geoffrey, FAAFP CAQSM, and Karl B. Fields. "Burners (stingers): Acute brachial plexus injury in the athlete."
- ↑ 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.
- ↑ A retrospective study looking at the incidence of 'stinger' injuries in professional rugby union players.
- ↑ 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.
- ↑ 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.
- ↑ Green, James, et al. "A 6-year surveillance study of “Stingers” in NCAA American football." Research in sports medicine 25.1 (2017): 26-36.
- ↑ Torg, Joseph S., et al. "Cervical cord neurapraxia: classification, pathomechanics, morbidity, and management guidelines." Journal of neurosurgery 87.6 (1997): 843-850.
- ↑ 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.
- ↑ 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.
- ↑ Parke WW. Correlative anatomy of cervical spondylotic myelopathy. Spine 1988; 13:831–7
- ↑ 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.
- ↑ 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.
- ↑ Cantu, Robert C., et al. "Return to play after cervical spine injury in sports." Current sports medicine reports 12.1 (2013): 14-17.
- ↑ 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: