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Overview of musculoskeletal neck injuries in the child or adolescent athlete

Overview of musculoskeletal neck injuries in the child or adolescent athlete
Literature review current through: Jan 2024.
This topic last updated: Dec 06, 2022.

INTRODUCTION — An overview of musculoskeletal injuries of the neck in the young athlete will be presented here. The anatomy of the cervical spine, the diagnostic approach to the athlete with neck pain or injury, the prehospital management of the athlete with an acute neck injury, and cervical spinal cord and peripheral nerve injuries are discussed separately. (See "Evaluation of the child or adolescent athlete with neck pain or injury" and "Field care and evaluation of the child or adolescent athlete with acute neck injury" and "Overview of cervical spinal cord and cervical peripheral nerve injuries in the child or adolescent athlete".)

FRACTURES — Recreational and sports activities are important causes of spinal fractures associated with neurologic injury. (See "Evaluation of the child or adolescent athlete with neck pain or injury", section on 'Epidemiology'.)

In a review of over 1440 spine fractures treated at two Canadian centers, 14 percent of the fractures, but 23 percent of the injuries with neurologic deficit, were sustained during sporting and recreational activities [1]. Among the 202 fractures that occurred during recreational activity, diving accounted for 21 percent, and snowmobiling, parachuting/skydiving, and equestrian events accounted for 10 percent each. Nearly one-fourth of the fractures were sustained in high-velocity winter sports (eg, snowmobiling, tobogganing, Alpine skiing, and ice hockey). In pediatric-aged patients, 23 percent of cervical spine fractures are sports-related [2].

Atlas (C1) fractures — Axial loading of the cervical spine can cause two types of fractures of the atlas, known as Jefferson fractures: posterior arch fractures and burst fractures [3].

Posterior arch fractures are more common (image 1); with bracing, they typically heal well with fibrous or bony union.

Burst fractures involve disruption of both the anterior and posterior arches, which may allow progressive displacement of the lateral masses of the atlas (image 2 and figure 1), leading to vascular and neurologic compromise [4].

Patients with Jefferson fractures have neck pain and restricted range of motion of the neck, but they usually have a normal neurologic examination. Prompt and careful evaluation is critical to avoid a delay in diagnosis and secondary neurologic compromise.

Open-mouth odontoid views are helpful in establishing the diagnosis. A fracture is suggested by an increased peri-odontoid space and bilateral symmetrical overhang of the lateral masses of the atlas (C1) in relation to the axis (C2). When the transverse diameter of the atlas is 7 mm greater than that of the axis, a transverse ligament rupture should be suspected [4]. (See 'Subluxation and dislocation' below.)

Computed tomography (CT) scans provide excellent detail of the atlas, and are helpful in confirming bony injuries and excluding rupture of the transverse alar ligament (which makes the spine unstable) [5]. In addition, CT scans are recommended in patients in whom C1 fractures are suspected, but whose plain radiographs are normal or inconclusive.

The majority of atlas fractures heal with nonoperative immobilization techniques (eg, a halo brace). However, surgical fusion is occasionally necessary [6].

Axis (C2) fractures

Odontoid fractures — Direct head impact can cause fractures of the odontoid (also called the dens), the toothlike projection from the upper surface of the axis (C2). These fractures can occur at the tip or base of the odontoid. Avulsion fractures of the tip are less common, but more stable, whereas fractures of the base have a higher rate of nonunion with nonsurgical treatment.

Odontoid fractures usually displace anteriorly with posterior angulation of the dens [7]. Displaced odontoid fractures can be identified on lateral radiographs, but nondisplaced fractures and fractures in children may be difficult to visualize. As a general rule, CT scan is recommended in any patient with confirmed or suspected C2 fracture.

Similar to atlas fractures, stable odontoid fractures are usually managed nonsurgically. After 6 to 10 weeks of healing, lateral flexion and extension radiographs should be obtained to verify union [7]. Unstable fractures and those that fail to heal satisfactorily require surgical fusion [8]. The prognosis for complete neurologic recovery is good provided that the initial injury does not compromise the brainstem [9].

Hangman's fracture — The hangman's fracture (spondylolisthesis of C2) is a fracture of the pedicle of the axis, usually resulting from a hyperextension injury. The name is derived from the similar injury suffered during execution-style hangings. Most hangman's fractures result from hyperextension sustained during a motor vehicle accident, but they also occur in diving accidents and headlong falls [10]. Despite marked anterior displacement of C2 on C3, minimal or no spinal cord injury may result if the victim survives the initial injury [9].

Patients with hangman's fractures present with neck pain and often have no neurologic symptoms or signs. Diagnosis is established with radiographs (image 3) and CT.

Most cases can be successfully treated with immobilization with a halo vest. Traction alone should be avoided because it increases the potential for nonunion and more serious neurologic injury [7]. Surgical fusion is indicated if there is nonunion or disruption of the C2-C3 disk [4].

Cervical compression fractures — Vertebral body compression fractures are injuries caused by axial loading with or without cervical flexion or extension. Axial loading occurs when the athlete uses the head in blocking or tackling, or hits the bottom of a body of water after diving into water that is too shallow.

The presenting symptoms of compression fractures depend upon the severity as described below. The presentation of mild fractures (types I and II) may be limited to neck pain and cervical spasm. Depending upon the location of the lesion, more severe fractures (types III-V) can cause respiratory arrest and quadriplegia.

Most compression fractures are identified by plain radiographs and further clarified by CT. Compression fractures may be classified into five types [11]:

Type I injuries are simple wedge compression fractures of the cervical vertebrae (image 4 and image 5 and figure 2). They are stable fractures that heal well with conservative management (8 to 10 weeks in a semirigid cervical collar) [12], usually without neurologic sequelae.

Type II compression fractures are "teardrop," or isolated anterior-inferior vertebral body fractures with intact posterior elements (image 6 and figure 3). The extension teardrop fracture occurs when abrupt neck extension causes the anterior longitudinal ligament to pull the anteroinferior corner away from the remainder of the vertebral body, producing a triangular-shaped fragment (image 7 and figure 4). Like type I injuries, most of these injuries are stable and treated conservatively (8 to 10 weeks in a semirigid cervical collar) [12,13]. However, flexion/extension radiographs should be taken after immobilization to evaluate cervical spine stability. In one study of 27 patients with apparently simple compression fractures, six had cervical spine instability diagnosed on follow-up radiographs [14].

Type III fractures are comminuted burst vertebral body fractures (image 8). The posterior elements remain intact, but bony fragments may be displaced into the spinal medullary canal, resulting in serious neurologic injury. These should be evaluated with CT, and surgical stabilization is needed to prevent late movement of the bone fragments [4]. One variant of this type of fracture is the axial load teardrop fracture. Axial load teardrop fractures must be distinguished from isolated teardrop fractures (described above), which are not usually associated with permanent neurologic sequelae [15].

Types IV and V are complex vertebral fractures involving the posterior elements. They are unstable fractures with a poor prognosis, and often result in quadriplegia.

Cervical spinous process fracture — The spinous process fracture, also called the clay shoveler's fracture, is an avulsion fracture of the tip of the spinous process, most commonly involving C7 (image 9). These injuries were classically seen as a result of vigorous labor and forceful contraction of the shoulder muscles. Now they are more commonly seen following trauma from an assault or motor vehicle accident [9].

Fractures of the spinous process are typically painful. However, unless they involve the base of the spinous process, these fractures are stable and usually heal well spontaneously. Treatment consists of cervical collar immobilization for pain relief. Range of motion is withheld until the fracture site is nontender (usually within four to six weeks), at which time dynamic radiographs can be performed to evaluate cervical spine stability.

Return to play — Recommendations for return to play after a cervical spine fracture are discussed separately. (See "Evaluation of the child or adolescent athlete with neck pain or injury", section on 'Return to play'.)

SUBLUXATION AND DISLOCATION

Cervical vertebral subluxation — Axial compression combined with cervical flexion, which often occurs when a football player "spears" another player with his helmet, can result in cervical vertebral subluxation. The injury occurs to the posterior supporting ligaments, resulting in anterior translation of the superior vertebral body.

The patient may complain of neck pain and stiffness, but usually has no neurologic deficits.

Imaging — Magnetic resonance imaging (MRI) is the imaging modality that best delineates the integrity of ligamentous structures.

Flexion-extension views should be obtained if ligamentous injury is suspected despite normal cervical spine radiographs (three views) and MRI is not rapidly available [16]. (See "Evaluation of the child or adolescent athlete with neck pain or injury", section on 'Radiologic evaluation'.)

In the obtunded patient, flexion-extension (F/E) radiographs perform inadequately in the assessment of blunt cervical spine injury and we do NOT recommend their use [17]. In the alert and cooperative patient, F/E imaging may play a role, particularly if MRI is unavailable. To prevent inadvertent injury to the spinal cord, flexion and extension should be actively performed by the patient in a methodical, slow fashion and only to the point of pain or neurologic symptoms. Findings on flexion-extension views that are consistent with ligamentous injury include [4]:

Motion of the vertebral body relative to its position on the plain lateral view (more than 3.5 mm horizontal displacement between adjacent disks)

Anterior intervertebral disk-space narrowing

Anterior angulation and displacement of the vertebral body

Fanning of the spinous processes

Any patient who has positive findings on flexion/extension views should undergo MRI imaging and neurosurgical consultation. In addition, MRI may show damage to the supporting posterior soft tissues.

Most cases of significant vertebral subluxation require aggressive treatment with posterior cervical fusion to prevent chronic instability and risk of future injury.

Acute atlantoaxial instability — Acute atlantoaxial instability (AAI) is usually the result of trauma that forces the neck into extreme flexion [4]. This causes disruption (or rupture) of the transverse ligament of the odontoid process, allowing the odontoid process to move posteriorly and compress the spinal cord.

The diagnosis of AAI is made on lateral radiographs of the cervical spine when the space between the posterior aspect of the anterior arch of the atlas and the anterior aspect of the odontoid process is greater than 5 mm in children [18] and greater than 3 mm in adults [19]. Acute AAI is an unstable injury that requires definitive treatment (ie, posterior fusion of C1 and C2). Patients are usually immobilized for two to three months after surgery [5].

Down syndrome — AAI in children with Down syndrome is discussed separately. (See "Down syndrome: Clinical features and diagnosis", section on 'Atlantoaxial instability' and "Down syndrome: Management", section on 'Atlantoaxial instability'.)

Atlantoaxial rotary subluxation — Atlantoaxial rotary subluxation (Grisel syndrome) is a common form of torticollis seen in children; it is less common in adults. It usually occurs following minor trauma, head and neck surgery, or an upper respiratory infection [20]. The clinical presentation, evaluation, and treatment of atlantoaxial rotary subluxation are discussed in detail separately. (See "Acquired torticollis in children".)

Facet dislocations — Facet dislocation, occurring with or without a fracture, may be unilateral or bilateral. Most of these injuries occur between C-4 and C-7 [21-23].

Unilateral — Unilateral facet dislocation is usually caused by an axial loading injury with the neck flexed and rotated (image 10). This mechanism results in ligamentous and capsular injury [9]. Facet dislocations that are associated with fractures or that occur at the C3-C4 can cause immediate quadriparesis. Fortunately, most lesions occur lower in the spine and are stable injuries with no neurologic compromise.

Uncomplicated unilateral facet dislocations are identified by a lateral radiograph demonstrating an approximately 30 percent anterior shift of the superior vertebra on the inferior vertebra with a sudden obliquity [9].

Cervical traction should be attempted to reduce the dislocation. This procedure should be performed by a surgeon who is experienced in the treatment of cervical spine fractures. If cervical traction is not successful, operative treatment may be needed.

Bilateral — Bilateral facet dislocation is most often caused by forced flexion that results in severe disruption of the ligaments and capsule (image 11 and image 12). This unstable injury usually results in severe neurologic sequelae, including quadriplegia.

Lateral radiographs demonstrate anterior translation of approximately one-half of the superior vertebra on the inferior vertebral body with no obliquity (image 11). These dislocations can usually be reduced by traction, immobilized in a halo cast, and stabilized by posterior fusion of the involved cervical vertebrae [4].

Return to play — Recommendations for return to play after ligamentous injuries of the cervical spine are discussed separately. (See "Evaluation of the child or adolescent athlete with neck pain or injury", section on 'Return to play'.)

SPEAR TACKLER'S SPINE — Spear tackler's spine, originally described in 1993, is a condition that occurs in football players who habitually tackle using the top of the head as the initial point of contact [24]. Prevention of this condition involves teaching and enforcing proper tackling techniques and should be emphasized.

Spear tackler's spine is identified by the following radiographic changes (on an erect lateral view with the neck in neutral alignment) in a player who uses the spear tackling technique:

Developmental narrowing of the cervical spinal canal

Straightening or reversal of the normal cervical lordotic curve (caused by repeated axial loading and microtrauma to the spinal structures)

Preexisting minor post-traumatic radiographic evidence of injury

Return to play — Spear tackler's spine predisposes the athlete to permanent neurologic injury with continued axial loading [24]. The athlete with spear tackler's spine should be excluded from all contact/collision sports (table 1), unless the condition is reversed (ie, return of normal cervical lordosis) with appropriate physical therapy [25]. The rehabilitation program involves relative rest (including exclusion from all contact/collision sports), modalities such as moist heat and massage, range of motion exercises (including neck and shoulder stretching), and a progressive dynamic and isometric neck strengthening program.

CERVICAL DISC DISEASE — Cervical disc disease is a common cause of neck pain in athletes as well as the general population. The incidence of cervical disc disease increases with age. It typically occurs after the mid-30s, but can occur in younger individuals [26]. In addition, some sports, including football, wrestling, and rugby, increase the incidence of cervical disc problems over the lifetime of the athlete [27,28].

Pathophysiology — There are two main mechanisms by which a cervical disc causes symptoms: acute disc herniation and degenerative disc disease.

Acute disc herniation tends to occur in the younger individual and is more likely to be associated with an identifiable injury. The inciting event may range from a high-impact trauma to simple twisting of the neck during normal daily activities, which causes acute herniation of the nucleus pulposus posterolaterally into the nerve root or spinal cord. The most common areas of disc herniation are the C5-C6 and C6-C7 levels, followed by C4-C5 [29].

The other, more common mechanism of injury is degenerative disc disease. Cervical spondylosis, or narrowing of the neural foramina or spinal canal, results from progressive degeneration of the cervical disc in conjunction with osteophyte formation. These disc changes result in disc space narrowing and bulging or herniation of the degenerative nuclear contents. Secondary osteophytes and spurring at the intervertebral, uncovertebral, and facet joints are caused by the altered mechanics of cervical motion. This process, which is more insidious in onset, tends to occur at the same levels affected by acute disc herniation [29].

The prevalence of degenerative disc disease is about 10 percent in people in their mid-20s, and progresses linearly to 95 to 100 percent by age 70 years [30].

Clinical features — Most patients with acute disc herniation complain of sudden onset of posterior neck pain. Neck pain may be the only presenting symptom, but some patients have referred pain to the shoulder, periscapular area, arm, or hand, depending upon the location of the disc herniation and the nerve roots involved. More classic neurologic symptoms such as numbness, paresthesias, muscle weakness, and diminished reflexes in the distribution of the affected spinal nerve may also be present (table 2). Patients with spinal cord impingement, which is less common, may have gait disturbance, lower-extremity neurologic symptoms and weakness, or loss of normal bowel/bladder function. Patients with degenerative disc disease typically have similar symptoms, but a more insidious onset, than those with acute herniation.

Physical examination usually reveals a combination of spasm, tenderness, and decreased range of motion of the neck. A neurologic examination of the upper and lower extremities should be performed to locate deficits of sensation (figure 5), strength, or reflexes (table 2). The presence of impaired neurologic function helps to localize the lesion. The axial compression and Spurling test (picture 1) may be positive, exacerbating the patient's neurologic symptoms. Although these tests are specific for radiculopathy, they lack sensitivity [29]. (See "Evaluation of the child or adolescent athlete with neck pain or injury".)

Evaluation — Radiographs of the cervical spine, including oblique views, may help to exclude other conditions. In addition, they may provide some clues to the presence of disc disease including disc space narrowing, foraminal narrowing, or osteophytes.

MRI is the study of choice to evaluate cervical disc disease (image 13). It is used to confirm disease when the diagnosis is in question and to plan for invasive treatment such as surgery. MRI abnormalities must be correlated with clinical presentation since MRI evidence of cervical disc disease may be present in asymptomatic individuals [31].

Management — Most cases of cervical disc disease can be managed conservatively. Initial treatment consists of pain management and functional improvement with NSAIDS, moist heat, massage, and relative rest/activity modification.

A soft cervical collar may help by providing partial immobilization and a reminder of activity restrictions. Intermittent traction may be useful if radiculopathy is present, particularly if the distraction test (picture 2) relieves the patient's symptoms.

Once pain and function have improved, the patient should begin a physical therapy program for rehabilitation. Improved range of motion and strength of the neck and shoulder muscles are important to the long-term success of treatment. Selective nerve root injections with anesthetic and steroids under fluoroscopy may be a useful adjunct if physical therapy fails to yield acceptable results.

Indications for surgical treatment of cervical disc disease include severe neurologic symptoms, failure to improve despite appropriate conservative management, or worsening neurologic symptoms during treatment. In the absence of severe neurologic symptoms, surgery is usually not considered until six to eight weeks of conservative management have failed. Surgical options include laminoforaminotomy with limited disc excision or discectomy and fusion. The latter approach has been shown to relieve radicular symptoms in more than 90 percent of patients [32].

Return to play — Return to play for athletes with cervical disc disease depends upon the presence of symptoms and, if surgery was necessary, the level and extent of spinal fusion:

The athlete with symptomatic cervical disc disease must be held out of all contact sports (table 1) until the symptoms have resolved.

The athlete may return to play without restrictions if conservative treatment results in complete resolution of pain, restoration of normal painless range of motion, normal strength, and the athlete has no other contraindication to participation (eg, cervical stenosis or spear tackler's spine) [29].

Athletes with single-level fusion may return to play provided the fusion is solid and the patient is asymptomatic. The exception is high-level fusions (C2-C3, C3-C4), which are inherently less stable and more dangerous.

Patients with multiple level fusions (particularly of three or more levels) and symptomatic patients should not be permitted to return to contact sports (table 1).

MUSCULAR INJURIES

Cervical strain/sprain — Acute strains and sprains of the cervical muscles and ligaments are the most common forms of cervical injury. Isolated strains and sprains do not involve injury to the nerves or bones. They are most often caused by automobile accidents, falls, and injuries sustained in contact-collision sports and recreational activities [33].

Patients with isolated cervical strains or sprains complain of cervical pain without radiation or neurologic symptoms. On examination, they may have limitation of cervical range of motion and muscular spasm or tenderness. The neurologic examination is normal.

Because of the potential for dangerous injury to the cervical spine after trauma to the neck, all neck injuries must be evaluated with diligence and caution. An athlete who has worrisome symptoms or findings on physical examination (table 3) after an acute neck injury should have his or her cervical spine immobilized until radiographic evaluation is complete. (See "Pediatric cervical spinal motion restriction".)

Treatment of the patient with a cervical strain/sprain should be individualized based upon the severity of the patient's symptoms. Initial treatment for pain reduction includes acetaminophen and/or nonsteroidal antiinflammatory drugs (NSAIDs) and modalities, such as moist heat and ultrasound. When pain and range of motion have improved, management should focus on rehabilitation deficits in strength as flexibility. If symptoms persist, further evaluation with magnetic resonance imaging (MRI) may be indicated to evaluate other causes of neck pain such as disc herniation. (See 'Cervical disc disease' above and "Evaluation of the child or adolescent athlete with neck pain or injury", section on 'Neck examination'.)

Return to play — Patients with complaints of neck pain in the absence of other red flags for an unstable cervical spine injury (table 3) should be excluded from play until they are asymptomatic with normal range of motion and strength. Even mildly symptomatic posttraumatic neck pain or decreased range of motion should be evaluated with radiographs including flexion and extension views to rule out significant injury.

Whiplash — Whiplash is a relatively common but still poorly understood neck injury; the incidence is about 4 per 1000 persons [34]. Whiplash has been defined as an acceleration-deceleration injury to the cervical spine most commonly caused by motor vehicle accidents, specifically from rear-end or side impact [35]. Such injuries may also occur in football, hockey, and rugby players. The mechanism of injury seems to be strong compressive and translational forces on the joints and soft tissues, resulting in an abnormal S-shaped movement pattern of the lower cervical spine [36].

Affected patients typically present with head, neck, and upper thoracic pain and decreased range of motion. The symptoms occur at the time of injury, and they may continue to worsen over the following 48 hours. This delayed worsening of symptoms often prompts the patient to seek treatment several days after the injury. They may have cervical muscle spasm, but neurologic signs and symptoms are usually lacking. Symptoms are often out of proportion to objective findings [37].

Some studies suggest that whiplash is more akin to a functional disorder that is often encouraged by economic gains [38,39]. The most common radiographic findings are preexisting degenerative changes or decreased lordosis of the cervical spine secondary to spasm and disuse [40]. Computed tomography (CT) and MRI are generally reserved for patients with neurologic deficit or suspected damage to the spinal cord, discs, bones, or ligaments [41].

Whiplash injuries can be difficult to treat because the injury is often ill-defined and difficult to characterize by physical examination and radiographic evidence. Studies suggest that early treatment can significantly improve both short-term and long-term morbidity [42]. A comprehensive approach with the goals of early pain control and functional improvement seem to work better than the traditional model of immobilization with a soft collar [43]. Such a program would include analgesia with acetaminophen, NSAIDs, modalities such as moist heat, and physical therapy to improve strength and range of motion. In selected patients with physiologically unexplainable chronic pain, consultation with a mental health care provider may be helpful.

POSTURAL SYNDROMES — Poor posture is a common contributing factor for, if not the cause of, nonspecific neck pain in people of all ages. The problematic posture may be occupational (poor office ergonomics), sport-specific (cycling, baseball catchers), caused by muscle imbalance, or simply the result of bad habits.

The patient may complain of periscapular or posterior neck pain that is exacerbated by prolonged static posture. Headaches are a common feature.

On physical examination, typical features of postural syndromes include (picture 3) [44]:

Thoracic kyphosis

Rounded shoulders

Tight pectoral muscles

Restricted shoulder movements

Protruding chin.

In addition to the postural features, the patient often has poor segmental movement of the cervical and thoracic vertebrae. The affected cervical or scapula stabilizing muscles may be tender to palpation and may contain trigger points. Weakness of the periscapular muscles and abnormal scapulothoracic movement may be noted.

Treatment must be individualized, depending upon the clinical features and etiologic mechanism. A comprehensive approach, as outlined below, is helpful in addressing biomechanical causes of neck and upper back pain.

Postural retraining is of the utmost importance. Having the patient concentrate on chin tucks and the "chest out" position will help to improve mechanics and may improve the symptoms. Postural retraining requires consultation with a physical therapist who can demonstrate a therapy program that is designed to be performed by the patient at home each day.

Workplace modifications may be simple and effective.

Physical therapy for mobilization, myofascial release, stretching of the shoulder capsule and pectoral muscles, and neuromuscular retraining will help to improve range of motion and encourage more balanced muscle use patterns.

Taping techniques, demonstrated by a physical therapist, can serve to remind the patient to use the correct muscles while maintaining sound posture.

SUMMARY AND RECOMMENDATIONS

Specific injuries – A variety of musculoskeletal neck injuries may accompany sports participation in the young athlete. Management varies depending upon the specific injury. Potential injuries include:

Cervical spine fractures (see 'Fractures' above)

Cervical spine subluxation or dislocation (see 'Subluxation and dislocation' above)

Spear tackler’s spine (see 'Spear tackler's spine' above)

Cervical disc disease (see 'Cervical disc disease' above)

Muscle injuries (see 'Muscular injuries' above)

Postural syndromes (see 'Postural syndromes' above)

Imaging – Radiologic evaluation of cervical spine injuries in the young athlete is determined by history and physical examination (table 4) and is discussed in detail separately. (See "Evaluation and acute management of cervical spine injuries in children and adolescents".)

Return to play – Athletes with persistent clinical findings after diagnosis of spear tackler’s spine, cervical disc disease, or muscular injuries should be restricted from contact/collision sports (table 1). (See 'Spear tackler's spine' above and 'Cervical disc disease' above and 'Muscular injuries' above.)

Return to play for young athletes with cervical spine fractures, subluxations, or dislocations is discussed separately (table 5 and table 6). (See "Evaluation of the child or adolescent athlete with neck pain or injury", section on 'Return to play'.)

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Topic 6531 Version 14.0

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