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Sports-related Neck Injury

Sports-related Neck Injury | American Association of Neurological Surgeons

A Neurosurgeon Explains: Sports-related Neck Injury

Khoi D. Than, MD, FAANS

Playing sports can contribute to neck injuries of varying degrees of severity ranging from relatively minor injuries such as muscle strains to severe life-threatening conditions such as neck fractures and cervical spinal cord injuries. A fractured (broken) neck is a very serious matter, but in many cases, the patient can make a full recovery and regain all neurological functions. A neck fracture can sometimes lead to a complete spinal cord injury, which will result in some degree of paralysis or even death.

While catastrophic cervical injuries do occur in sports, the incidence of fatal cases decreased in the last few decades due to better protective gear, increased awareness, better coaching, and rule changes. Still, these injuries may occur in athletes who participate in contact sports such as American football, soccer, and rugby as well as non-contact sports such as gymnastics and cycling.

Cervical injuries resulting from participation in sports can be divided into the following clinical syndromes:

  • Cervical fractures and dislocations
  • Nerve root or brachial plexus injuries
  • Intervertebral disc lesions
  • Cervical stenosis
  • Acute cervical sprains/strains including whiplash injury
  • Transient quadriplegia

The vertebral column or spine is a part of the axial skeleton and provides paramount structural support for our body. The neck region houses the cervical portion of the spinal column, which consists of seven bones (C1-C7 vertebrae), separated from one another by intervertebral discs. These discs allow the spine to move freely and act as shock absorbers during activity. Along with strong muscles, flexible tendons, and ligaments, the spine allows us to stand upright, bend, and twist. The spinal cord, a very vulnerable nervous tissue that connects the brain to the body, is located in the middle of the cervical spine, protected by bony vertebral structures.

The cervical spine functions to support the weight of the head and to provide flexibility for performing an extensive range of motions with our head. The movement of our head is possible due to the specialization of the first two vertebrae (C1 and C2) which connect directly with the skull. The first vertebrae (C1) or the “atlas” is the topmost vertebrae that allows for nodding or yes motion by articulating along the atlantooccipital joint while the second vertebrae (C2) or the “axis” allows for side-to-side or no motion by pivoting along the atlantoaxial joint.

Cervical Fractures and Dislocation

A cervical fracture is a break in one or more of the cervical bones or vertebrae in the neck. A cervical dislocation refers to a ligament injury in the neck that has caused two or more cervical vertebrae to abnormally separate from one another.

A severe, sudden twist to the neck or a severe blow to the head or neck area can cause a neck fracture. Sports involving violent physical contact carry a greater risk of a neck fracture, including football, ice hockey, rugby, and wrestling. Spearing an opponent in football or rugby can cause a broken neck and so can non-contact activities like gymnastics, if the gymnast misses the high bar during a release and falls. The cervical spine usually absorbs the energy of the collision by dissipating forces through the muscles, the intervertebral discs and the bones along the C-spine curve. However, when the neck is flexed such as in spear tackling, the forces create an abnormal axial load on the support structures, which may lead to a tear in the ligaments or bone. Cervical spine injuries can range from subluxations and dislocations with or without neurologic symptoms to fractures with or without neurologic symptoms.

A person with a neck injury should not be moved without competent medical care, which should be summoned immediately. This is extremely important because proper stability of the cervical spine is crucial to avoid causing any further damage. In situations when a head or neck trauma has occurred, it is important to recognize the possibility of a neck fracture.

  • Localized neck pain, which may or may not be severe
  • Neck stiffness
  • Pain radiating from the neck down to the shoulders and/or arms
  • Swelling and bruising
  • Tenderness
  • Decrease in sensation in the arms, legs or body
  • Muscle weakness or paralysis of the arms or legs
  • Difficulty breathing

The U.S. Consumer Product Safety Commission (CPSC) tracks product-related injuries through its National Electronic Injury Surveillance System (NEISS). According to the CPSC, an estimated 23,720 neck fractures were treated at U.S. hospital emergency rooms in 2018. Of these, an estimated 3194 fractures were related to sports. The actual incidence of neck injuries may potentially be much higher for two primary reasons. First, in the 2018 report, the CPSC excludes data from activities or sports that yield 1,200 injuries or less, from very small sample counts or from locations that are limited to a small geographic area of the country. Additionally, any less severe neck injuries that are treated at a physician’s office, immediate care centers, or self-treated, are also not tracked through this system. The sports statistics include not only the injuries from the sport/recreational activity itself but also any injuries from the equipment and apparel used in these activities. For example, swimming-related injuries include the activity as well as diving boards, equipment, flotation devices, pools, and water slides. Between 2000 and 2015, the number of sporting-related cervical fractures has increased by 30%, driven primarily by a 300% increase in cycling-related injuries. The incidence of injuries in males was 1.7x greater for neck sprains and 3.6x greater for fractures when compared to females. Cycling was the most common cause of cervical fractures in males while horseback riding was the most common cause in females.

Source: US Consumer Product Safety Commission, National Electronic Injury Surveillance System (NEISS), 2018.

Cervical Spinal Cord Injury

A severe neck injury may cause injury to a part of or the entire spinal cord. The degree of symptoms from the spinal cord injury depends  on the part of the spinal cord that is affected. The higher up the injury is on the vertebral column, or the closer it is to the brain, the more effect it has on body movement and one's sense of feeling. Cervical spinal cord injuries are typically the most severe type of spinal cord injuries. They may result in quadriplegia or tetraplegia with associated loss of muscle strength in all four extremities. Based on the extent of the injury, cervical spinal cord injuries can be complete or incomplete.

A complete SCI produces a total loss of all motor and sensory function below the level of injury. Approximately 50% of all spinal cord injuries are complete and affect both sides of the body equally. In the event of a complete SCI, the spinal cord is rarely cut or completely transected. It is more common  than the loss of function caused by a contusion or bruise to the spinal cord or by a compromise of blood flow to the injured part of the spinal cord.

In an incomplete SCI, some residual function remains below the primary level of the injury. A person with an incomplete injury may be able to move one arm or leg more than the other may or may have more functioning on one side of the body than the other.

A spinal concussion can occur which may also be complete or incomplete. In such cases, the spinal cord dysfunction is transient, generally resolving within one or two days. Football players are especially susceptible to spinal concussions and spinal cord contusions. The latter may produce neurological symptoms including numbness, tingling, electric shock-like sensations, and burning in the extremities.

  • Extreme pain or pressure in the neck, head or back
  • Tingling or loss of sensation in the hand, fingers, feet or toes
  • Partial or complete loss of control over any part of the body
  • Urinary or bowel urgency, incontinence or retention
  • Difficulty with balance and walking
  • Abnormal band-like sensations in the thorax: pain, pressure
  • Impaired breathing after injury
  • Unusual lumps on the head or spine

The National Spinal Cord Injury Statistical Center at the University of Alabama tracks comprehensive information regarding SCI, including in-depth data on sports-related SCI.

  • Diving: 1,772 males, 160 females = 1932
  • Bicycling: 496 males, 68 females = 564
  • All Terrain-Vehicle/All Terrain-Cycle (ATV/ATC): 218 males, 37 females = 255
  • Football: 153 males = 153
  • Snow Skiing: 170 males, 19 females = 189
  • Horseback Riding: 76 males, 77 females = 153
  • Winter Sports: 135 males, 30 females = 165
  • Other Sports: 126 males, 29 females = 155
  • Surfing (including body surfing): 140 males, 6 females = 146
  • Wrestling: 94 males, 2 females = 96
  • Trampoline: 68 males, 8 females = 76
  • Gymnastics: 38 males, 21 females = 59
  • Snowmobiles: 48 males, 9 females = 57
  • Field Sports: 44 males, 2 female = 46
  • Hang Gliding: 40 males, 2 females = 42
  • Baseball: 23 males, 1 female = 24
  • Basketball: 15 males = 15
  • Skateboard = 8 males, 1 female = 9
  • Track and field: 6 males = 6
  • An estimated 10.1% of all SCIs are related to sports
  • Of the 33,406 reported SCIs, a combined total of 3,367 were sports-related
  • 3,003 cases occurred in males while 364 cases occurred in females
  • 84.9% of all sports-related SCIs resulted in tetraplegia.
  • Ages 0-15: 24.1%
  • Ages 16-30: 14.2%
  • Ages 31-45: 7.3%
  • Ages 46-60: 4.5%
  • Ages 61-75: 2.8%
  • Ages 76-98: 0.9%

Source: The National Spinal Cord Injury Statistical Center, University of Alabama at Birmingham, NSCISC 2018. Annual Statistical Report and Facts at a Glance, January 2019.

Testing and Diagnosis

Any sports-related neck injury must be managed with a high degree of suspicion for severe conditions, like neck fractures. A neck fracture or a spinal cord injury is a medical emergency. An athlete should not return to the sport or activity until medically cleared and their strength has returned to pre-injury levels. The patient should undergo a full neurological exam as quickly as possible to assess for instability and/or a spinal cord injury. A specialized physician’s diagnosis based on the incident, symptoms, a physical examination, and results of radiological tests, includes one or more of the following:

  • Computed tomography scan (CT or CAT scan): A diagnostic image created after a computer reads X-rays; can show the shape and size of the spinal canal, its contents and the structures around it.

  • Magnetic resonance imaging (MRI): A diagnostic test that produces three-dimensional images of body structures using powerful magnets and computer technology; can show the spinal cord, nerve roots and surrounding areas, as well as enlargement, degeneration and tumors.

  • X-ray: Application of radiation to produce a film or picture of a part of the body can show the structure and alignment of the vertebrae and the outline of the joints.

The treatment options vary depending on the following factors:

  • The severity of the fracture
  • If there is an associated dislocation or instability
  • Which cervical bones are fractured
  • Whether there is spinal cord or nerve injury, with muscle weakness or paralysis

A minor (compression) fracture is often treated with a cervical collar or brace worn for six to eight weeks until the bone heals on its own. A more severe or complex fracture may require traction or surgical interventions, including spinal instrumentation or fusion with or without surgical decompression.

Surgical decompression of the spinal cord is performed after an injury occurs, although the timing of this intervention varies widely. The surgery removes various tissue or bone fragments that are compressing and compromising the spinal cord. Depending on the unique circumstances of the injury, decompression is accomplished through a variety of surgical approaches, including, for example, approaching the compressed cord from either the front (anterior) or back (posterior). Increasingly it has become clear that decompression and stabilization in patients with SCI should be immediate, as soon as medically safe and reasonable.

Cycling-related head injuries are far more common than neck fractures, but it is not infrequent for a patient to incur both a head and neck injury during an accident. Of the estimated 2,692 sports-related neck fractures treated at U.S. hospital emergency rooms in 2009, 536 related to cycling.

An estimated 80% of fatal bicycle accidents involving motor vehicles among children 14 and younger occur  due to the bicyclist's behavior, such as riding into the street without stopping, swerving into traffic, running stop signs, or riding against the flow of traffic.

Source: US Consumer Product Safety Commission, National Electronic Injury Surveillance System (NEISS), 2009.

Football-related head injuries, in particular concussions, are more common than neck fractures; but not infrequent for a player to incur both a head and neck injury during an incident. Of the estimated 2,692 sports-related neck fractures treated at U.S. hospital emergency rooms in 2009, 268 related to football.

Neck injuries are usually associated with high-velocity collisions between players, causing acceleration or deceleration of the head on the neck. Acceleration often causes a whiplash type of extension force on the neck, while deceleration often results in flexion forces. Spearing, which banned in American football since 1976, happens when a player uses the helmet/head as the first point of contact with another player. Spearing is a significant cause of cervical spine injuries and quadriplegia.

  • Cervical-spine injuries estimated to occur in 10-15% of all football players, most commonly in linemen and defensive players.
  • Both past and present data show that the football helmet does not cause cervical spine injuries; rather poorly executed tackling and blocking techniques that are the major problem.
  • During the past 33 years, 307 football players with incomplete neurological recovery related to cervical SCI: 253 high school players; 34 college players; 14 professionals; and 6 sandlot players. Data indicate a reduction in the number of cervical cord injuries with incomplete neurological recovery when compared to data published in the early 1970s.
  • During the 33years from 1977-2009, 216 of the 307 players with cervical SCIs were playing defense.
  • During the 2009 football season, there were nine cervical spinal cord injuries with incomplete neurological recovery. This is a decrease from the 14 cervical spinal cord injuries with incomplete neurological recovery in 2008. Seven of the injuries occurred at the high school level, one at the college level, and one at the professional level.
  • A majority of catastrophic SCIs occur in games. During the 2009 season, five injuries took place in games, two in practice, and two in scrimmage games.
  • Nearly 10% of catastrophic cervical SCIs took place while being tackled.
  • A 47-year-old male was surfing, fell off and possibly hit his head on a sandbar, suffering a compression fracture at C-1 and a thoracic compression fracture at T-1.
  • An 11-year-old boy was riding an inner tube at a water park and was hit, suffering a fatal neck fracture.
  • A 6-year-old boy dove into his backyard built-in swimming pool, hitting his head on the concrete bottom, fracturing his neck at C-2 and C-3.
  • A 32-year-old male was swimming at home, hit his head on the side of the pool, fracturing his neck.

Source: US Consumer Product Safety Commission, National Electronic Injury Surveillance System (NEISS), 2009.

While many cycling injuries are head injuries, the proper usage of SNELL, American National Standards Institute (ANSI) or American Society for Testing and Materials (ASTM)-approved helmets can also help prevent SCI injuries. The helmet must fit properly, and the helmet strap is closed and tightened so that it does not come off while riding or in a fall. Other SCI cycling prevention tips include:

  • Keep children less than a year old off the bicycle.
  • Cycle a minimum of three feet away from parked cars.
  • Do not wear headphones.
  • Obey local traffic regulations at all times.
  • Never hold on to a moving vehicle.
  • Use "hand-signs" to indicate the direction of turns.
  • Football players receive adequate preconditioning and strengthening of the head and neck muscles.
  • Coaches and officials discourage players from using the top of their football helmets as battering rams when blocking, hitting, tackling, and ball carrying.
  • Coaches, physicians, and trainers ensure players' equipment properly fitted, especially the helmet, and that straps are in lock position.
  • Coaches prepared for a possible catastrophic SCI. The entire staff must know what to do in such a case. Being prepared and well informed may make all the difference in preventing permanent disability.
  • Enforcement of rules prohibiting spearing in practice and games.
  • Ball carriers instructed to not lower their heads when making contact with the tackler to avoid helmet-to-helmet collisions.
  • Inspect skateboard or skates for any damaged parts.
  • Always wear a helmet, fastened securely to the head.
  • Check the area for rocks, debris, cracks in the pavement, or uneven surfaces.
  • Wear well-fitting clothing, knee and elbow pads, wrist braces, and gloves.
  • Do not dive in water less than 12 feet deep or in aboveground pools. Check the depth and check for debris in the water before diving.
  • Follow all rules and warning signs at water parks, swimming pools, and public beaches.
  • The first time in a body of water, walk into the water.
  • Never push or shove anyone into the water and do not allow children to do so.
  • Supervise younger children at all times; and do not allow the use of sporting equipment or play sports unsuitable for their age. Do not allow the use playgrounds with hard surface grounds.
  • Do not participate in sports when ill or very tired.
  • Discard and replace damaged sporting equipment or protective gear.
  • Never slide headfirst when stealing a base.

Resources for More Information

National Spinal Cord Injury Statistical Center

Author Information

Nitin Agarwal, MD
Rut Thakkar
Khoi Than, MD

The AANS does not endorse any treatments, procedures, products or physicians referenced in these patient fact sheets. The information provided is as an educational service and not intended to serve as medical advice. Anyone seeking specific neurosurgical advice or assistance should consult his or her neurosurgeon, or locate one in your area through the AANS’ Find a Board-certified Neurosurgeon online tool.

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