BCN #4 Sports Head and Neck Injury - Penney 5.2

What age group has the highest rate of Sports-Related Traumatic Brain Injuries in the ED for both males and females? and what % of that age group account for all sports related ED visits?

1) 10-14 years old 2) 5.1%

Cantu's Concussion Guide: Grade 2

1) Loss of consciousness lasts fewer than 5 min. OR 2) Post-traumatic amnesia lasts longer than 30 min.

A team physician has the primary responsibility of what?

Allowing athletes to participate in a sport or clearing them to return to the playing field after recuperation from an injury

What are the activities associated with the greatest number of TBI-Related ED visits?

Bicycling, Football, Playground activities, Basketball, ATVs

Athlete Head Injuries Trivia:

Differ from head injuries in the general population -> prophylactic protective measures 1) Access to medical care 2) Follow-up available 3) Ability to observe recovery 4) Large at risk population 5) Eyewitness accounts injury

What's on the Horizon: What is the most important key to diagnosing and caring for injured athletes?

Education: Educating 1) trainers 2) coaches 3) parents 4) athletes to the significance of concussions 5) recognition of signs and sxs 6) adherence to guidelines for safe return to play

Dynamics of cord compression...what does extension do?

Extension leads to compression of the spinal cord between the PI portion of the 1st vertebral body and the lamina of vertebra below

True/False: Cervical spinal stenosis is always unilateral

False - It is always bilateral

What sports has injuries that far exceed other sports?

Football - there are 1.5 million football participants per year

Immediate Neurocognitive Effect of Concussion Study:

I) Standardized assessment of concussion (SAC) II) Objective, method to immediately assess MTBI III) Conducted at 5min, 15min, 48hrs, 90days IV) 2385 varsity football players V) Concussion-trauma induced alteration of mental status VI) 91 injuries (3.82%)

What maybe the overriding factor determining whether an athlete will suffer from long-term mental damage?

It may be the presence of Apolipoprotein E epsilon (ApoE4) gene rather than the frequency of concussions

Classification of Burners/Stingers: Grade III

Neurotmesis - disrupt endoneurium (poor prognosis, motor and sensory deficits >1 year) - often requires surgical intervention

Pathology Sports HI: Define rotational acceleration

Rapid turning head results in diffuse shearing forces deep in the brain (Brain Stem - RAS)

What is the TORG ratio?

Ratio = B/A *** < 0.8 = Canal Stenosis

Sports-related cervical injuries account for what % of all spinal cord injuries annually? nearly what % of these result in quadriplegia?

1) 5-10% 2) 92% result in quadriplegia

Athletic knee injury managed what % of time by a physician, while Athletic head injuries are managed what % of the time by physician

1) 72% for knee injury 2) 8% for head injury

Sports Related Head Injury Epidemiology:

1) 750,000 recreational sports injuries/year 2) 300,000 sports related head injuries/year (previous national estimate reports included only those with LOC) 3) However, 2 studies have reported that only 8-19% of SR-TBI involve LOC 4) Extrapolation based on these parameters suggest that 1.6-3.8 million SR-TBI occur/year, including those not treated by health care providers 5) Most mild to moderate in severity 6) Classified as concussions 7) Brain injuries cause death than any other sports injury 8) > 62,000 concussions/year in high school contact sports

What is Second Impact Syndrome?

1) A second or "repeat" mild head injury in a short period of time (hrs,days,weeks) after after an incomplete recovery from the initial concussion - can be catastrophic or fatal - malignant brain swelling after minor head blow - persistence of concussive symptoms - between 1980-1991 there were 29 cases

List the sports with frequent head injuries:

1) Boxing 2) Football 3) Horse-racing 4) Rugby 5) Ice Hockey 6) Soccer 7) Martial Arts

What is the Pathology of the Sports Head Injury?

1) Combination of rotational (angular) and translational (linear) acceleration 2) Force = Mass x Acceleration 3) Rotational Acceleration - rapid turning head results in diffuse shearing forces deep in the brain (Brain Stem - RAS) 4) Translational Acceleration - tensile (pulling apart) plus compressive forces results in skull fractures, torn blood vessels and hematomas

What is a Stinger/Burner?

1) Compressive/traction injuries to multiple roots or brachial plexus 2) Upper roots/trunks stretched by shoulder depression and lateral head flexion away from side 3) Neuropraxia also caused by a direct compression BP itself

Football HI Trivia:

1) Concussions evenly divided between practices and games 2) Only 30% of players do not return to play the same day 3) 35% of concussions in college football had no impact to head 4) Player receiving concussion 4-6X more likely to sustain another 5) High school players sustaining concussion, 20% have multiple concussions

What are the early signs of concussion?

1) Confusion,Disorientation 2) Retrograde amnesia 3) Anterograde amnesia 4) HA 5) Nausea/Vomiting 6) Motor problems, incoordination 7) Dizziness 8) Difficulty carrying-out sequence actions

What are the late signs of concussion?

1) Decreased processing speed 2) Short-term memory impairment 3) Irritability, depression 4) Fatigue, sleep disturbance 5) Feeling of "fogginess"

Sports Related Cervical Spine Injuries Trivia:

1) Each year >1,000,000 students participate in high school football 2) >200,000 in collegiate and professional football 3) Cervical spine injuries occur in 10-15% of football players 4) Estimated 5-10% of 10,000 cervical spine injuries/year are sports related 5) Incidence of spinal cord injuries in football is 1.9/100,000 players a year 6) Most injuries are self-limiting with full recovery

Explain the Magnitude of the Problem:

1) Each year in USA estimated 38 million children and adolescents participate in organized sports 2) Approx. 170 million adults participate in some type of physical activity not related to work 3) Health benefits of these activities are tempered by the risk for injury including TBI 4) CDC estimates that 1.1 million persons with TBI are treated and released from US hospital ED's/year 5) Additional 235,000 are hospitalized for these injuries 6) National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) for period 2001-2005

Cantu's Return to Competition Guidelines: Grade 3 aka Severe

1) First Concussion = May return in one month if asymptomatic for 1 week 2) Second Concussion = Terminate season

Cantu's Return to Competition Guidelines: Grade I aka Mild

1) First Concussion = may return when asymptomatic 2) Second Concussion = may return in 2 weeks if asymptomatic for 1 week 3) Third Concussion = Terminate season

Cantu's Return to Competition Guidelines: Grade 2 aka Moderate

1) First Concussion = may return when asymptomatic for 1 week 2) Second Concussion = may return in 1 month if asymptomatic for 1 week 3) Third Concussion = Terminate season

Athlete Injury Prevention:

1) Following all appropriate safety policies 2) Following the rules of the sport 3) Players, pt.'s, coaches should be aware of the signs and sxs of TBI's and take appropriate action when injury is suspected 4) Protective equipment appropriate for the sport activity -> helmet that fits properly and is worn correctly and consistently 5) "Heads up" tool kit for physicians

What are the activities caused by TBI that account for greater than 7.5% of ED visits?

1) Horseback riding (11.7%) 2) Ice skating (10.4%) 3) ATVs (8.4%) 4) Tobogganing/Sledding (8.3%) 5) Bicycling (7.7%)

Pre-Participation Sports Physical:

1) Hx and physical exam 2) Complete hx and record of all concussions suffered in the past 3) Recording of QEEG, BAER and p300 on all athletes (pre-season) - Brainscope 4) Determination if athlete carries ApoE4 gene 5) Preseason CT scan of the head and C-spine (to determine canal dimensions and rule out spinal stenosis)

What are the main parts of the Standardized assessment of concussion (SAC)?

1) Immediate Memory -> 1 point for each of the 3 word trials 2) Concentration -> 1 point for each - months of the year in reverse order - reverse digits 3) Memory Delayed (recall after 5 min.) -> 1 point for each word

Clinical Signs and Sxs of Burners:

1) Immediate, severe burning pain 2) Prickly paresthesia radiates from supraclavicular area down arm into hand 3) Pain is transient 5-10 min 4) Tenderness supraclavicular area and shoulder weakness for hours-days 5) Most obvious shoulder abduction/extremity rotation weakness

Pitfalls in the ED: Disposition of Concussed Athletes

1) Inadequate discharge instructions 2) Failure to diagnose a concussion due to subtle signs and Sxs 3) Allowing the athlete to RTC too soon 4) Assuming a LOC is needed for a diagnosis of concussion 5) Assuming a HA is necessary for a concussion 6) Failure to image a concussed athlete with LOC or abnormal exam 7) Failure to elicit the # of concussions in season 8) Failing to ask and seek referral

Cantu's Concussion Guide: Grade 3

1) Loss of consciousness lasts longer than 5 min. OR 2) Post-traumatic amnesia lasts longer than 24 hours

Boxing Brain Damage Trivia:

1) Multiple relatively low energy blows over period of time (career) 2) Punch drunk - "dementia puglistica" 3) Exams of former boxers - traumatic encephalopathy 17-50% 4) Risk Factors: NOT # of Technical Knock Outs; they are # of fights and the fighter's age

Cantu's Concussion Guide: Grade 1

1) No loss of consciousness 2) Post-traumatic amnesia lasts fewer than 30 min

What is the diameter of a normal spinal canal? what about a stenotic cana?

1) Normal canal is 15mm (14-23mm) 2) Stenotic canal is < 13mm

Stinger of the Cervical Spine "Negative" Presentations:

1) Normal motion 2) NO tenderness 3) Limited to a single upper extremity

What are the brain damage related boxing risk factors?

1) Number of fights 2) Fighter's age ***NOT the number of technical knockouts

What are the tests for a "sideline evaluation"?

1) Orientation 2) Attention 3) Concentration 4) Memory (immediate/delayed)

What are the red flags of a cervical spine injury?

1) Pain over spinous process 2) Unrelenting neck pain or muscle spasm 3) Abnormal sensation in head, neck, trunk, extremities 4) Loss coordinated movement 5) Paralysis 6) Altered Deep Tendon Reflex (DTR) 7) Mechanism injury violent axial loading, flexion or rotation neck

What is a BrainScope?

1) Real-time functional brain assessment 2) Non-invasive, portable 3) Easy apply, disposable electrodes 4) Automatic spontaneous EEG, BAER's 5) Allows testing even before imaging (often imaging is negative, functional abnormalities occur earlier) 6) Analyses evokes, EEG detecting brainstem or cognitive dysfunction 7) Objective, user independent

What is the Prevention of Second Impact Syndrome?

1) Recognition of and adherence to protocols for return to competition 2) SIS underscores the need to rationally restrict head injured athletes from returning to competition

What's on the horizon besides education?

1) Rule changes-prohibiting high risk blocks, tackles, spearing 2) Improvement in conditioning and protective equipment 3) Design of equipment that allow for improved recognition of concussed athletes 4) Injured professional athletes being identified, treated and managed appropriately

Take Home Message:

1) Sports HIs are common and not benign 2) Earliest signs of concussion are neurocognitive 3) Familiarize with Return to Competition guideline and ADHERE to it 4) Utilize SAC format to assess injured athletes 5) Keep medical records of previous concussions 6) Concussive effects are cumulative 7) If you dont know.....ask?

Describe a Sideline Evaluation:

1) Standardized systematic evaluation 2) Designed for trainers, coaches, physicians 3) Tests: - Orientation - Attention - Concentration - Memory (immediate/delayed)

What does the presence of spinal stenosis mean?

1) The presence of spinal stenosis would heighten the risk of recurrent cervical cord neurapraxia, but player would not be at increased risk of permanent neurologic injury 2) Need for rigorous outcome study 3) "The presence of developmental or spondylitic stenosis, regardless of the degree of canal narrowing, does not result in irreversible cord injury"

What are the Clinical Characteristics of a "Stinger"?

1) Unilateral dysesthetic pain: "Complain lancinating, burning pain down one arm" 2) Dermatomal distribution 3) May have a weakness, most often C5/6 innervated muscles (deltoid, biceps, supraspinatus, infraspinatus) 4) Pain usually resolves <15min. 5) Can have trace abnormal neuro findings for months 6) Strength returns in 24-48 hours

Incidence of Sports Head Injury Trivia:

1) Varies regionally 2) Contact vs Non-contact 3) Organized vs Non-organized 4) Officiated vs Non-officiated 5) Age of population 6) Active injury prevention program

Management of Stingers/Burners:

1) Weakness present -> remove from competition 2) Brachial plexus traction test 3) Strength/function return to normal < 5min. may return to competition 4) Ice massage, sling prn 5) Grade II, III -> no strength training in early rehab 6) ROM exercise in early rehab

Cervical spine injuries occur in what % of football players?

10-15%

Frank Bruno (british heavyweight champ) punch is equal to what?

13 pound wooden mallet swung at 20mph

Football: What % of high school athletes suffer traumatic brain injury?

19%

Football: What % of players sustain concussion per year?

20%

How many cases of Second Impact Syndrome did the National Center for Catastrophic Sports Injury between 1980-1991 find?

29 cases

Cervical hyperextension - infolding ligamentum flavum can lead to what % reduction of the AP diameter of the spinal cord?

30%

Football HI: What % of players do not return to play on the same day of injury?

30%

Football HI: What % of concussions in college football have no impact to the head?

35%

What % of football concussions occur without a blow to the head?

35%

What % of 10,000 cervical spine injuries/year are sports-related?

5-10%

As many as what % of lineman, linebackers and defensive ends have 1 or more Neuropraxias of the nerve roots or Brachial Plexuses per season?

50%

Football: What % of injured high school players return to competition the next day?

70%

Males accounted for approx. what % of Sports Related Traumatic Brain Injury?

70.5%

In the USA, how many football deaths are there per year?

8 football related deaths

What % of Sports Related Traumatic Brain Injury involve loss of consciousness?

8-19%

What % of players with transient quadriplegia also have spinal stenosis?

93%

A delay of even how many hours before formal assessment of neurocognitive status of head injured athletes limits the accuracy of injury severity classifications and predictions of recovery.

A delay of even 24 hours

Football HI: What % of high school players that sustain concussion, sustain multiple?

20%

What % of former boxers have traumatic encephalopathy?

17-50%

What were the results of the Neurocognitive Study?

I) 91 injuries (3.82% sample) II) 76 No LOC, No PTA III) 8 PTA, No LOC IV) 7 LOC with PTA < 1min ***PTA = post traumatic amnesia ***So most varsity football concussions do not have a LOC or PTA but overall they have better SAC scores

True/False: Cervical spinal stenosis sxs are transient, full recovery occurs in minutes to hours

True

True/False: The majority of concussions have no LOC

True

Cervical spinal stenosis is asymptomatic until what?

Until a blow to the forehead, or occiput (hyperextension, hyperflexion)

What college sport has the highest concussion rate?

Women's ice hockey

What are the signs of cervical spinal stenosis?

Immediate motor weakness, sensory changes of arms, legs, both

Who develops Cervical Cord Neuropraxia/Transient Quadraparesis?

A subpopulation with developmental spinal stenosis

What is the definition of concussion?

A trauma induced alteration in mental status, that may or may not involve a loss of consciousness - Latin for concussion is concusses which means "a shaking"

Classification of Burners/Stingers: Grade II

Axonotmesis - produce significant motor and mild sensory deficits (which last 2 weeks) - Epineurium intact

It has also been maintained that a team physician may be negligent for failing to what?

Consult a specialist about an athlete's injury and may be liable for not using recognized and appropriate tests or examinations to gather information necessary to determine the proper treatment of an athlete's injury or illness

The ApoE4 is a susceptibility gene for what?

For late-onset familial and sporadic Alzheimer's disease, which also may be linked with a higher risk of chronic traumatic encephalopathy in boxers - in a prospective investigation there was a strong connection between the presence of the ApoE4 gene and a poor clinical outcome among individuals who had suffered from serious head injuries

What is functional cervical spinal stenosis?

Loss of CSF around the cord, or deformation of the cord

How do you "document" or "image" a cervical spinal stenosis?

MRI, CT, Myelography

Classification of Burners/Stingers: Grade I

Neurapraxia - localized conduction block causing temporary loss sensation and/or loss of motor function - selective demyelination of axon sheath

Concussions result in the immediate impairment of what?

Neurologic function

What is the cervical spine injury most frequently found in football players?

Neuropraxia of the nerve roots or Brachial Plexus

CASE STUDY: Patient suffered a concussion that was likely a Grade I (mild) concussion. However, the pt. remains symptomatic....should the athlete be able to return to practice/play?

No, he should not practice or play until asymptomatic, is symptoms continue the pt. needs a referral

For athletes with cervical cord neuropraxia, a decreased TORG ratio is a risk factor for what?

Recurrent episodes

Pathology Sports HI: Define translational acceleration

Tensile (pulling apart) plus compressive forces results in skull fractures, torn blood vessels and hematomas

What is the one constant feature of concussions?

That they are caused by a direct blow to the head or body with impulsive force transmitted to the head

What is Cervical Spinal Stenosis?

The narrowing of the sagittal diameter of the spinal canal as compared to the diameter corresponding to the vertebral body (TORG ratio)