Cervical spinal cord injury
Athletes competing in sports rank as the fourth most common cause of spinal column fractures and ranks second in a spinal cord injury after traffic accidents (Bahr, R. & Maehlum, S, 2004).
A cervical spinal cord injury is a catastrophic injury that occurs to the spinal cord between the levels of the first cervical vertebrae (C1) and the seventh cervical vertebrae (C7). The spinal cord is a bundle of nerves that extend from the base of the brain down through the first or second lumbar vertebrae.
Together, the brain and the spinal cord make up the central nervous system. This system is responsible for the transmission of electrical signals to and from the brain from the systems of the body. Sensory nerves transmit information from the body to the brain while motor nerves transmit information from the brain to the muscles.
When a spinal cord injury occurs, this information being transmitted between the brain and the rest of the body ceases. Sensory information (the ability to feel) ceases to exist along with the ability to move the muscles of the body.
When a spinal cord injury occurs within the cervical vertebrae, the athlete may be diagnosed as quadriplegic. This term means that all four limbs may be affected by the spinal cord injury. However, it does not mean that all four limbs do not have some movement.
Depending upon the level of the injury and the corresponding nerves that have been affected, the athlete may be able to have some motor control (activation of muscles) of the shoulder muscles as well as the muscles that flex and extend the elbow.
The higher that the injury occurs within the cervical vertebrae, the more impact the injury will have on the ability for the athlete to feel sensations and move the muscles of the body. Injuries to C2 and C3 may impact the athlete’s ability to breathe on his/her own. Injuries further down at levels C6 and C7 may impact the athlete’s ability to move his/her forearms and hands because these nerves innervate the muscles that control the elbow and wrist.
Classifications of spinal cord injury
Spinal cord injuries can be classified as either complete or incomplete. A complete injury is defined as “a loss of neuromuscular function below the level of the injury that lasts longer than 48 hours” (Bahr, R. & Maehlum, S, 2004).
The spinal cord is comprised of neurons or nerve cells. If the cell body of the neuron is damaged, the neuron will not be able to recover. A complete injury is one in which the breadth of spinal cord is damaged.
An incomplete injury means a partial injury to one or more sections of the spinal cord. These types of injuries may affect certain segments of the body depending on which tract of the cord is damaged.
An injury to the anterior portion may result in paralysis (inability to activate the muscles), and reduced sensitivity to pain and temperature below the injury site.
There is also a spinal cord injury known as a spinal cord concussion. In this case, the spinal cord is concussed within the foramen resulting in temporary paralysis that may last only one to two days. Because the spinal cord does not actually sustain structural damage, once the swelling around the cord decreases, the function of the spinal cord is returned.
Diagnosis of cervical spinal cord injury
With a cervical spine injury, the physician needs to assess the athlete’s neurological status (can the athlete move the fingers and toes). Even if the neurological systems are intact, the athlete may still have suffered from a fracture, dislocation, disc, or ligament injury.
Because of this, an athlete with a suspected spinal cord injury will be maintained in a position of cervical immobilization until x-rays have been taken. It is normal protocol to take x-rays from several angles including frontal and lateral planes.
To determine if there is damage to either the cervical intervertebral discs or ligaments, magnetic resonance imaging (MRI) can be ordered. An MRI is the most sensitive diagnostic tool to view soft tissue structures.
Who gets cervical a spinal cord injury?
In the world of sports, spinal cord injuries occur in high risk sports or those in which athletes use unsafe techniques. Sports that have a higher risk of neck and back injuries include horseback riding, motorized sports (especially snowmobiling), parachuting, hang gliding, paragliding, climbing, ice hockey, bicycling, snowboarding, downhill skiing, and ski jumping (Bahr, R. & Maehlum, S, 2004).
Football is one sport in which cervical spine injuries occur. One of the more common mechanisms for cervical spine injury in the sport of football is “spearing”. Spearing is when an athlete tucks his head and hits another player with the top of his head. Although this maneuver is illegal in football, it continues to occur.
Diving into shallow water or hitting a sand berm while diving through a wave at the beach can cause a cervical spinal cord injury. More than 50% of all fractures/dislocations of the cervical spine are caused by diving accidents during unorganized sport activity (Bahr, R. & Maehlum, S, 2004).
Causes of cervical spinal cord injury
Most cervical spinal cord injuries are the result of axial loading (force directed through the top of the head and through the spine) forcing the head into hyperflexion and/or rotation. This type of mechanism may result in a fracture of dislocation of one or more of the cervical vertebrae.
A fracture of one or more of the cervical vertebrae does not necessarily result in a spinal cord injury unless the fracture or dislocation results in damage to the spinal cord. The spinal cord is housed deep inside the vertebrae in a protective space called the foramen. The spinal cord is protected by bone on all sides, followed by ligaments, and then muscles.
In many neck injuries, the spinal cord is protected because it is housed safely within the foramen. However, if a force is great enough to fracture the surrounding bone of the vertebrae or dislocate one of the vertebrae; the spinal cord can suffer irreparable damage.
The actual mechanism of spinal cord injury may be compression of the head and neck as in a hockey player hitting the sideboard, a diver hitting the bottom of the shallow end of a pool, or a football player lowering his head and using it as a battering ram when hitting an opponent.
A fall from a great height can also be a mechanism of injury for the spinal cord. This can occur when a cheerleader is tossed into the air and lands on her head on a hard surface, a trampoline accident when the individual is inadvertently tossed off a trampoline, or perhaps a snowboarder missing a board landing and landing on his/her head/neck.
Risk factors for cervical spine injury focus on violation of safety rules (spearing), lack of skill of the performer (cheerleading accident), or diving into shallow pools or sand berms in the ocean.
Prevention for cervical spinal cord injury
The cervical spine was designed for mobility so that the head can turn and have a wide range of motion. When mobility is enhanced in a bony structure, stability is weakened.
There are four areas that an athlete can focus on to prevent a serious neck injury. These include strengthening the neck muscles (especially for athletes who compete in contact sports), learning proper technique, learning how to correctly fall, and ensuring that appropriate equipment is used and properly fitted.
All athletes engaged in football need to focus on strengthening the muscles surrounding the neck regardless of the position they play. While linemen focus on strengthening neck musculature, other position players may not feel that it is necessary.
According to Irvin, R., Iversen, D. & Roy, S. (1998), statistics have shown that “the thinner, lighter, and speedier defensive back and wide receiver suffer the greatest incidence of quadriplegia and paraplegia following neck injuries in football”.
There are a number of resistance tools that can be used to strengthen the muscles surrounding the neck including manual resistance (partner-assisted), weighted football helmets, neck harness, and custom-designed resistance devices. The athlete should focus on the following motions:
• Flexion (chin to chest)
• Extension (eyes to ceiling)
• Lateral flexion (ear to shoulder)
• Shoulder shrugs
• Bridging (specific to the sport of wrestling)
Proper technique is another key component in preventing cervical spinal cord injuries. Unfortunately in football, some athletes may get the impression that because they wear a helmet, they can lead and hit with their head. This type of thinking needs to be corrected through education and good mechanics continually taught by informed coaches.
Falling techniques should also be taught to young athletes in sports in which falling from any significant height is a risk factor. This can apply specifically to the sport of cheerleading.
While young athletes are taught to tumble and perform advanced skills, they also need to be taught how to fall correctly so that catastrophic injuries can be avoided.
Athletes need to be taught to tuck and roll using their core body to land on rather than their head and neck. Cheerleaders can be taught to adjust their bodies in flight to prevent landing on their heads. It is a skill that can be taught and practiced.
Equipment is the fourth area of focus to prevent neck injuries. Athletes that are required to wear helmets need to ensure that the helmets are properly fitted, adjusted as needed, and inflated (if air-filled bladders).
Athletes should ensure that their hair is cut and then the helmet is fitted. This ensures that the helmet fits snuggly to the athlete’s head. If an athlete receives a haircut during the season, the helmet should be refitted.
• Check side-to-side fitting by either having the athlete shake their head side to side or holding the face mask and gently applying a side-to-side motion.
• Check the front-to-back fitting by either having the athlete shake their head up and down or by holding the face mask and gently applying an up and down motion.
The helmet should remain secure and snug during these helmet checks. If the helmet slides side-to-side or up and down, then it is too big and needs to be refit.
In football, neck collars can be worn to limit lateral flexion and hyperextension injuries. Helmet-to-shoulder pad straps can also be worn to restrict excessive neck flexion and extension. Along with specific protective equipment that is worn by the athlete, protective equipment that an athlete lands on is also critical to preventing catastrophic injuries.
There is a current push from safety experts in the cheerleading industry (National Cheer Safety Foundation) to ensure that protective mats are used when cheerleaders perform advanced stunts such as basket tosses and pyramids. A recent study published in the Journal of Athletic Training revealed that stunting on grass, rubberized track, and or artificial turf is no safer than stunting on wood floors (Shields, B. & Smith, G., November, 2009).
Emergency treatment for a cervical spinal cord injury
If a cervical injury is suspected, great care must be taken by the coach (if sports medicine personnel are not available) and/or sports medicine personnel to ensure that the injury is not further aggravated by moving the athlete. The athlete should not be moved if the athlete exhibits any of the following signs and/or symptoms:
1. Neck pain
2. Tingling, numbness, burning, or weakness in any limbs
3. Difficulty breathing
5. Difficulty moving any extremities
6. Possible head/brain injury
If any of these symptoms are present, the athlete’s head and neck should be stabilized on the field. The athlete should not be allowed to try to sit up, stand, or walk off the field.
Emergency medical services should be called immediately and the athlete’s vital signs monitored (pulse and respiration). In the event of a catastrophic injury to the spine, the goal of the emergency responders is to also keep the athlete calm through the use of carefully worded conversation (to focus athlete’s attention off of the injury).
If the athlete is wearing a helmet, the helmet should not be removed. The helmet and shoulder pads (football) work together to help stabilize the cervical spine when the athlete is transported.
In the event that the athlete is not breathing, only the facemask should be removed to allow for rescue breathing. The helmet needs to stay in place. Every coach should have a tool that can easily and quickly remove a facemask in the event that rescue breathing needs to be performed. This device should be easily accessible.
Criteria for Return to Activity after a Neck Injury
An athlete who sustains a cervical spinal cord injury will undergo months of rehabilitation and medical treatments in order to regain his/her ability to perform activities of daily living. The athlete will receive therapy from both occupational therapists (focus on activities of daily living) and physical therapists to regain as much motor control as possible.
If a spinal cord injury was a temporary injury as in a spinal cord concussion or the injury was to the ligaments or musculature of the neck, the following criteria can be used to return an athlete to sport:
• No neck tenderness
• Full, pain-free active cervical range of motion
• Pain-free, normal, and full strength of muscles in all directions when tested against resistance.
• Normal and equal strength, sensation, and reflexes in all extremities
• No numbness, tingling, weakness in any extremities
Getting a Second Opinion
A second opinion should be considered when deciding on a high-risk procedure like surgery or you want another opinion on your treatment options. It will also provide you with peace of mind. Multiple studies make a case for getting additional medical opinions.
In 2017, a Mayo Clinic study showed that 21% of patients who sought a second opinion left with a completely new diagnosis, and 66% were deemed partly correct, but refined or redefined by the second doctor.
You can ask your primary care doctor for another doctor to consider for a second opinion or ask your family and friends for suggestions. Another option is to use a Telemedicine Second Opinion service from a local health center or a Virtual Care Service.
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Anderson, M., Hall, S., & Martin. M. (2009). Foundations of Athletic Training: Prevention, Assessment and Management. (4th Ed.). Lippincott Williams and Wilkins: Philadelphia, PA.
Bahr, R. & Maehlum, S. (2004). Clinical Guide to Sports Injuries. Human Kinetics: Champaign, IL.
I rvin, R., Iversen, D. & Roy, S. (1998). Sports Medicine. (2nd Ed.). Allyn and Bacon: Needham Heights, MA.
Shields, B. & Smith, G. (November, 2009). The Potential for Brain Injury on Selected Surfaces Used by Cheerleaders. Journal of Athletic Training 44(6).