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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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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