spinal cord injury

Monday, October 21, 2013

“It kind of just nauseates me when something like that happens. It’s such a violent game sometimes. So many thoughts run through your mind.”   TJ Lang

“That look he had in his eyes, that was something that stuck with me.”  Andrew Quarless

It was the type of football play that makes the highlight reel. As Green Bay Packer receiver, Jermichael Finley, caught a pass running across the middle of the field, he was exploded upon by the defensive back who was trying to dislodge the ball. Both fell to the ground and but this time only one got up. Teammate Andrew Quarless was first to Finley’s: “He couldn’t move at the time…So I just told him, ‘Just stay here, just lay here, don’t move.” Football is a game of speed and finesse but also one of power and violence. In that one moment in Lambeau Field, the violence quieted the crowd.

Most accidents don’t happen in front of 77,000 spectators in the stands and millions more watching on television but when they do, the forces involved in the mechanism of injury are too apparent. Most often, pads and strong muscles can absorb the hit, but if the head is bent just right and the neck flexed at just the wrong angle, the potential for disaster exists. Mr. Finley was immobilized on a backboard and taken off the field by stretcher where waiting ambulance crew transported him to the ER. According to team sources, imaging tests were negative and he was regaining most of his movement. As this is written, he is still being observed in ICU.

The spinal cord connects the brain to the body, and perhaps its most vulnerable point is the neck, the swivel that lets the brain see the world. There are ligaments that help hold the seven cervical vertebrae of the neck in place and their job is to protect the spinal cord along with the large strap muscles of the neck, including the trapezius and sternomastoid. Unfortunately, traumatic forces can overwhelm the protective systems and injury can occur. The vertebra may or may not be fractured; there may or may not be a dislocation; there may or may not be a disc rupture. The spinal cord lives in a very small space and any irritation may cause it to stop working.

When a neck injury is suspected, the first job for bystanders and first responders is to do no harm. If a fracture or dislocation is present, moving the patient may convert a stable injury into an unstable one and that is the reason for the care taken in moving Mr. Finley. He was kept in the position he was found, on his side. A backboard was placed up against him and he was logrolled supine, onto his back, all the while one person has the designated responsibility of not allowing the head to move. This can be challenging because of the helmet and there are special techniques used to remove it. A drill removes the nuts that hold the facemask in place, from below the neck is held stable and the helmet is removed without any flexion of the neck. A hard collar is then placed to keep the neck still. The body is then strapped to the backboard and the patient, collar board and all can be lifted as one unit. This sequence happens thousands of times a day when caring for victims of car wrecks, worksite injuries and other traumas, but rarely witnessed by millions.

There are two considerations for spinal cord injury. First, is there a neurologic deficit, with weakness, paralysis and/or loss of sensation. Second, if there are broken bones in the neck, is the fracture stable or unstable.  There are different parts of the spinal cord that have tracts or pathways that control movement and sensation. Physical examination may help define what part of the cord is injured and at what level the injury has occurred. The higher up the neck that the damage occurs, the more of the body is affected. The 4th cervical vertebra is crucial since this is the level that helps control the muscles that allow us to breathe. If some patients, the spinal cord can be concussed, just like the brain, where it stops working for a few minutes and then regains function. But just like the brain, an injured spinal cord can gradually deteriorate and lose function over many hours. A CT scan may be used to image the bony vertebrae of the neck and MRI can look at the spinal cord and nerve roots directly. Depending upon the situation, one or both test plus other may be required.

Aside from stabilizing any broken bones in the neck or repairing a ruptured disc, there is little that can be done acutely to “fix” a spinal cord injury. Observation and supporting the body, gives the best chance for the patient to recover. Unfortunately, a patient with a complete spinal cord injury has a small chance of complete recovery and it falls to almost zero if he remains paralyzed 72 hours after the injury. Those who have incomplete spinal cord injuries where only part of the pathways have been damaged, have a much better chance of recovery. Making a determination of long term outcomes cannot happen immediately.

There is always risk in life. Safety equipment, from airbags in cars and safety harnesses used by steel workers, does not make us invincible. While motor vehicle crashes account for more than half of spinal cord injuries, more than 7% occur because of injuries on the playing field and proper playing technique may provide the best safety. Leading with the crown of the helmet, with the chin down, puts the neck in a flexed position and increases the risk of neck injury. For that reason USA Football teaches heads up tackling techniques, wanting players to see where they are hitting. Dropping a helmet to deliver a blow on either side of the ball may be courting disaster.

Unlike video games where injuries don’t matter, football is a game of controlled violence played by real people, with families, friends and lives off the field. Prayers that Jermichael Finley will enjoy all of those fully for years to come.

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Attributions: Quarless quotes (espn.com). Lang quotes (jsonline.com)

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