a special type of neck injury

Monday, September 14, 2015

Football is a violent sport as witnessed by the length of the injury report every Monday morning. From torn ligaments and broken bones to cuts and scrapes, players accept a fair amount of risk to play a game that they love. Injuries to the brain are becoming less acceptable with concussion being front and center on the field and in the press.

Lorenzo Mauldin of the New York Jets was slow to get up after a play this past weekend, and when he eventually stood, collapsed to the ground, face down and didn’t move. Medical staff converged, finding him unconscious and not moving, and still not moving even after he wakened. There was fear of a head injury and the fear of a damaged spinal cord. The stadium was silent as Mr. Mauldin was immobilized on a board and taken from the field. The good news came after hours in the hospital. Mr. Mauldin had sustained a concussion but his neck was all right.

Most people understand the concept of concussion. The brain is shaken and briefly turns off and then gradually returns to normal. Symptoms may occur immediately or they may be delayed, Symptoms may be dramatic, like being knocked unconscious, or very subtle, like having difficulty concentrating or experiencing changing sleep patterns. Imaging the brain with CT scan or MRI does not usually find any damage.

People also understand broken necks and being paralyzed because of spinal cord injury. The neck attaches the head to the body and allows it to swivel and enjoy the world around it. It is also the conduit where the spinal cord runs inside the spinal canal, attaching the brain to the nerves in the rest of the body. The cervical spine is made up of seven interlocking vertebrae and held stable by a variety of ligaments and muscles. Even with broken bones, if the spinal canal is not compromised, the spinal cord can survived intact and undamaged with no symptoms. However, if the vertebrae fracture in such a way that the spinal canal is narrowed, the spinal cord can be injured and that results in badness. Football players can tolerate the risk of knee injuries but no so much that of being paralyzed.

And then there is SCIWORA: spinal cord injury without radiographic abnormalities. Most often seen in children and adolescents, but also in adults, it is a form of spinal cord injury, where there are signs or symptoms of weakness, paralysis or change in sensation without any evidence of fracture, dislocation, or misalignment of bones on X-ray or CT scan. The symptoms can be transient where the spinal cord stops working and then recovers, almost like the brain that has been concussed. But sometimes there can be permanent damage. SCIWORA was much more of a mystery before MRI but with these scans, some of these injuries may be explained by ligament damage or subtle bleeding into the spinal cord. Many victims though, have no obvious spinal cord injury, even though damage exists because the spinal cord has stopped working.

SCIWORA is a frustrating situation for doctors. Doctors like to make a diagnosis but they also like to fix things. But how can something be fixed, if there is nothing that can be done? The treatment is immobilizing the neck and observation, the watchful waiting to see what nature brings, just like a brain concussion. But when there are some agreement as to how long to keep a concussed player off the field, there is much more caution with the SCIWORA patient: “high risk” activity should be avoided for up to six months.

Mr. Maudlin was discharged from hospital after an overnight stay having suffered “only” a concussion and hopefully his brain will recover quickly. The inability to actually see an injury of the brain or spinal cord remains a frustration for the medical community. The patient knows that it’s there. The doctor knows that it’s there. And the treatment options are the same as in the time of Hippocrates, who wrote: “Healing is a matter of time, but it is sometimes also a matter of opportunity”

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