Dr. David Carfagno is the principal at Scottsdale Sports Medicine Institute, and a frequent presenter on sports medicine topics around the country.
Concussions and neck injuries are a chronic issue among athletes, particularly in both collegiate and professional football. While their severity is getting more attention today, there are still unique factors that physicians and medical personnel should be aware of.
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Head and Neck Injuries in Sports
A SPORTS MEDICINE PHYSICIANrsquoS PERSPECTIVE
DAVID CARFAGNO DO CAQSMSCOTTSDALE SPORTS MEDICINE
My Life
Team DocFan Team Doc
>
>
Medical Team Progression
INJURY RTP
Sports Medicine Mentality
PT HISTORY RTP COMMUNICATION
Epidemiology of Sports Injuries
Sports injuries rank 2nd highest in terms of cause of injury after home and leisure accidents and rank third in terms of severity after traffic accidents and violence
Approximately 11000 personsday receive treatment in US EDs for injuries sustained during sports recreation and exercise activities
One of every six ED visits for an injury results from participation in sports or recreation
Clin Rehabil 2000 Dec14(6)651-6 CDC Injury Research Agenda 2011
1 Course set up2 Resources3 Staff4 Yourself
PREPARATION
Temporal Awareness
DAY OF WEEK lsquoFRI NIGHT GAMESrsquo
AWARENESS OF CLINICAL SETTINGS
IMPACT ON TEMPORAL DECISIONS FOLLOW UP ETC
Disposition
ADMIT vs DISCHARGE vs TRANSFER TO HIGHER LEVEL OF CARE or SPECIALIZED CARE
IMPORTANCE OF TIMELY DIAGNOSIS
RESOURCES LEVEL 1 CONSULTANTS ANCILLARY TESTING
CASE BASED
Question Concussion
Q The current consensus on concussion in sport recommends neurologic imaging only in situations of prolonged alteration of consciousness focal neurological deficits or worsening symptoms
A True B False
Key Points Importance of effective communication between
members of healthcare team from on-field ED Level 1 Trauma CenterSpecialist
Importance of Expeditious Diagnosis Risk of death (immediate or later) MalpracticeLawsuits
Disposition Clinical suspicion Ongoing assessment
Concussion
18 year old Junior College Football Player sustained a head injury today while playing football
Seen by ATC Team Physician recommended to go to ED for further management
Overview Concussions are an important and common injury for
athletes Challenge is for ED physicians to screen quickly for small
subset of patients with potentially life-threatening intracranial lesions andor increased risk for sequelae while minimizing cost unnecessary testing radiation exposure and admissions
Evaluation management and RTP decision very challenging
Take home message must individualize management and RTP decision
Emerg Med Pract 201214(9)1-24
Definition
Zurich Guidelines 2012
Complex pathophysiological process affecting brain due to traumatic biomechanical forces
Consensus statement 4th International Conference Zurich 2012
Mechanism of TBI
Video Concussion
>
Neuron
Dr Cantu
>
Common Features
Direct blow to head face neck or elsewhere with an ldquoimpulsiverdquo force transmitted to head
Rapid onset of short-lived neurological functional impairment
Maymay not LOC LOC occurs in fewer than 10 with sports-related
concussion
Consensus Statement on Concussion Vienna 2001 Emergency Emerg Med Pract 201214(9)1-24Consensus statement 4th International Conference Zurich 2012
Pathophysiology Neurochemical and neurometabolic changes Increase in glucose and oxidative metabolism Increase in demand for cerebral blood flow
which is reduced Activation of immune inflammatory response Possible shear injury to vessels and neurons May create immediate neuronal depolarization
followed by refractory period of no neural transmission
Monitor for initial few hours following injury or send emergently if change in behavior worsening headache vomiting seizure double vision excessive drowsiness or worsening symptoms
No RTP on day of injury
Sideline Testing
Glasgow Coma Scale (GCS) King-Devick Test Bess Test SCAT 2 Maddocks Questions
King-Devick
Test
Glasgow Coma Scale (GCS)
Basic neurological scale that quantifies level of consciousness
Score ranges from 3 (unconscious) to 15 (alert and oriented)
Most EMS protocols GCS score lt 14 should be transported to Level I or II trauma center
Inverse relationship between GCS score and positive findings on CT
King-Devick Test
Tests for eye saccade (quick simultaneous movements of eyes in same direction)
Uses charts of numbers Charts become
increasingly difficult to read as space between numbers increases
Patientrsquos speed and fluidity of reading used to derive score
K-D Test
>
BESS Testing Postural stability testing
assesses cognitive motor function
Quantifiable modified Romberg test ndash three 20-second balance tests performed on firm and foam surfaces
Postural instability communication between three sensory systems either at central or peripheral level is lost
Clinical J Sports Med 200111182-190
SCAT 2
Calculated for athletegt10 yo Preseason baseline testing can be helpful Calculated based on symptoms physical signs
Detailed neurological exam including Glasgow Coma Scale (GCS) mental status cognitive functioning gait and balance pupillary reflex cranial nerve testing
Progression since time of injury (improvement or deterioration)
Is emergent neuroimaging indicated Rule outtreat hypoxia hypercarbia and hypotension
(associated with poorer outcomes in TBI)
1) Avoid CT scans in low risk patients based on validated decision rules
2) Avoid placing indwelling catheters in stable pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first
Choosing Wiselyrdquoreg campaign during the ACEP13 annual meeting Oct 14-17
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
My Life
Team DocFan Team Doc
>
>
Medical Team Progression
INJURY RTP
Sports Medicine Mentality
PT HISTORY RTP COMMUNICATION
Epidemiology of Sports Injuries
Sports injuries rank 2nd highest in terms of cause of injury after home and leisure accidents and rank third in terms of severity after traffic accidents and violence
Approximately 11000 personsday receive treatment in US EDs for injuries sustained during sports recreation and exercise activities
One of every six ED visits for an injury results from participation in sports or recreation
Clin Rehabil 2000 Dec14(6)651-6 CDC Injury Research Agenda 2011
1 Course set up2 Resources3 Staff4 Yourself
PREPARATION
Temporal Awareness
DAY OF WEEK lsquoFRI NIGHT GAMESrsquo
AWARENESS OF CLINICAL SETTINGS
IMPACT ON TEMPORAL DECISIONS FOLLOW UP ETC
Disposition
ADMIT vs DISCHARGE vs TRANSFER TO HIGHER LEVEL OF CARE or SPECIALIZED CARE
IMPORTANCE OF TIMELY DIAGNOSIS
RESOURCES LEVEL 1 CONSULTANTS ANCILLARY TESTING
CASE BASED
Question Concussion
Q The current consensus on concussion in sport recommends neurologic imaging only in situations of prolonged alteration of consciousness focal neurological deficits or worsening symptoms
A True B False
Key Points Importance of effective communication between
members of healthcare team from on-field ED Level 1 Trauma CenterSpecialist
Importance of Expeditious Diagnosis Risk of death (immediate or later) MalpracticeLawsuits
Disposition Clinical suspicion Ongoing assessment
Concussion
18 year old Junior College Football Player sustained a head injury today while playing football
Seen by ATC Team Physician recommended to go to ED for further management
Overview Concussions are an important and common injury for
athletes Challenge is for ED physicians to screen quickly for small
subset of patients with potentially life-threatening intracranial lesions andor increased risk for sequelae while minimizing cost unnecessary testing radiation exposure and admissions
Evaluation management and RTP decision very challenging
Take home message must individualize management and RTP decision
Emerg Med Pract 201214(9)1-24
Definition
Zurich Guidelines 2012
Complex pathophysiological process affecting brain due to traumatic biomechanical forces
Consensus statement 4th International Conference Zurich 2012
Mechanism of TBI
Video Concussion
>
Neuron
Dr Cantu
>
Common Features
Direct blow to head face neck or elsewhere with an ldquoimpulsiverdquo force transmitted to head
Rapid onset of short-lived neurological functional impairment
Maymay not LOC LOC occurs in fewer than 10 with sports-related
concussion
Consensus Statement on Concussion Vienna 2001 Emergency Emerg Med Pract 201214(9)1-24Consensus statement 4th International Conference Zurich 2012
Pathophysiology Neurochemical and neurometabolic changes Increase in glucose and oxidative metabolism Increase in demand for cerebral blood flow
which is reduced Activation of immune inflammatory response Possible shear injury to vessels and neurons May create immediate neuronal depolarization
followed by refractory period of no neural transmission
Monitor for initial few hours following injury or send emergently if change in behavior worsening headache vomiting seizure double vision excessive drowsiness or worsening symptoms
No RTP on day of injury
Sideline Testing
Glasgow Coma Scale (GCS) King-Devick Test Bess Test SCAT 2 Maddocks Questions
King-Devick
Test
Glasgow Coma Scale (GCS)
Basic neurological scale that quantifies level of consciousness
Score ranges from 3 (unconscious) to 15 (alert and oriented)
Most EMS protocols GCS score lt 14 should be transported to Level I or II trauma center
Inverse relationship between GCS score and positive findings on CT
King-Devick Test
Tests for eye saccade (quick simultaneous movements of eyes in same direction)
Uses charts of numbers Charts become
increasingly difficult to read as space between numbers increases
Patientrsquos speed and fluidity of reading used to derive score
K-D Test
>
BESS Testing Postural stability testing
assesses cognitive motor function
Quantifiable modified Romberg test ndash three 20-second balance tests performed on firm and foam surfaces
Postural instability communication between three sensory systems either at central or peripheral level is lost
Clinical J Sports Med 200111182-190
SCAT 2
Calculated for athletegt10 yo Preseason baseline testing can be helpful Calculated based on symptoms physical signs
Detailed neurological exam including Glasgow Coma Scale (GCS) mental status cognitive functioning gait and balance pupillary reflex cranial nerve testing
Progression since time of injury (improvement or deterioration)
Is emergent neuroimaging indicated Rule outtreat hypoxia hypercarbia and hypotension
(associated with poorer outcomes in TBI)
1) Avoid CT scans in low risk patients based on validated decision rules
2) Avoid placing indwelling catheters in stable pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first
Choosing Wiselyrdquoreg campaign during the ACEP13 annual meeting Oct 14-17
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Team DocFan Team Doc
>
>
Medical Team Progression
INJURY RTP
Sports Medicine Mentality
PT HISTORY RTP COMMUNICATION
Epidemiology of Sports Injuries
Sports injuries rank 2nd highest in terms of cause of injury after home and leisure accidents and rank third in terms of severity after traffic accidents and violence
Approximately 11000 personsday receive treatment in US EDs for injuries sustained during sports recreation and exercise activities
One of every six ED visits for an injury results from participation in sports or recreation
Clin Rehabil 2000 Dec14(6)651-6 CDC Injury Research Agenda 2011
1 Course set up2 Resources3 Staff4 Yourself
PREPARATION
Temporal Awareness
DAY OF WEEK lsquoFRI NIGHT GAMESrsquo
AWARENESS OF CLINICAL SETTINGS
IMPACT ON TEMPORAL DECISIONS FOLLOW UP ETC
Disposition
ADMIT vs DISCHARGE vs TRANSFER TO HIGHER LEVEL OF CARE or SPECIALIZED CARE
IMPORTANCE OF TIMELY DIAGNOSIS
RESOURCES LEVEL 1 CONSULTANTS ANCILLARY TESTING
CASE BASED
Question Concussion
Q The current consensus on concussion in sport recommends neurologic imaging only in situations of prolonged alteration of consciousness focal neurological deficits or worsening symptoms
A True B False
Key Points Importance of effective communication between
members of healthcare team from on-field ED Level 1 Trauma CenterSpecialist
Importance of Expeditious Diagnosis Risk of death (immediate or later) MalpracticeLawsuits
Disposition Clinical suspicion Ongoing assessment
Concussion
18 year old Junior College Football Player sustained a head injury today while playing football
Seen by ATC Team Physician recommended to go to ED for further management
Overview Concussions are an important and common injury for
athletes Challenge is for ED physicians to screen quickly for small
subset of patients with potentially life-threatening intracranial lesions andor increased risk for sequelae while minimizing cost unnecessary testing radiation exposure and admissions
Evaluation management and RTP decision very challenging
Take home message must individualize management and RTP decision
Emerg Med Pract 201214(9)1-24
Definition
Zurich Guidelines 2012
Complex pathophysiological process affecting brain due to traumatic biomechanical forces
Consensus statement 4th International Conference Zurich 2012
Mechanism of TBI
Video Concussion
>
Neuron
Dr Cantu
>
Common Features
Direct blow to head face neck or elsewhere with an ldquoimpulsiverdquo force transmitted to head
Rapid onset of short-lived neurological functional impairment
Maymay not LOC LOC occurs in fewer than 10 with sports-related
concussion
Consensus Statement on Concussion Vienna 2001 Emergency Emerg Med Pract 201214(9)1-24Consensus statement 4th International Conference Zurich 2012
Pathophysiology Neurochemical and neurometabolic changes Increase in glucose and oxidative metabolism Increase in demand for cerebral blood flow
which is reduced Activation of immune inflammatory response Possible shear injury to vessels and neurons May create immediate neuronal depolarization
followed by refractory period of no neural transmission
Monitor for initial few hours following injury or send emergently if change in behavior worsening headache vomiting seizure double vision excessive drowsiness or worsening symptoms
No RTP on day of injury
Sideline Testing
Glasgow Coma Scale (GCS) King-Devick Test Bess Test SCAT 2 Maddocks Questions
King-Devick
Test
Glasgow Coma Scale (GCS)
Basic neurological scale that quantifies level of consciousness
Score ranges from 3 (unconscious) to 15 (alert and oriented)
Most EMS protocols GCS score lt 14 should be transported to Level I or II trauma center
Inverse relationship between GCS score and positive findings on CT
King-Devick Test
Tests for eye saccade (quick simultaneous movements of eyes in same direction)
Uses charts of numbers Charts become
increasingly difficult to read as space between numbers increases
Patientrsquos speed and fluidity of reading used to derive score
K-D Test
>
BESS Testing Postural stability testing
assesses cognitive motor function
Quantifiable modified Romberg test ndash three 20-second balance tests performed on firm and foam surfaces
Postural instability communication between three sensory systems either at central or peripheral level is lost
Clinical J Sports Med 200111182-190
SCAT 2
Calculated for athletegt10 yo Preseason baseline testing can be helpful Calculated based on symptoms physical signs
Detailed neurological exam including Glasgow Coma Scale (GCS) mental status cognitive functioning gait and balance pupillary reflex cranial nerve testing
Progression since time of injury (improvement or deterioration)
Is emergent neuroimaging indicated Rule outtreat hypoxia hypercarbia and hypotension
(associated with poorer outcomes in TBI)
1) Avoid CT scans in low risk patients based on validated decision rules
2) Avoid placing indwelling catheters in stable pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first
Choosing Wiselyrdquoreg campaign during the ACEP13 annual meeting Oct 14-17
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Medical Team Progression
INJURY RTP
Sports Medicine Mentality
PT HISTORY RTP COMMUNICATION
Epidemiology of Sports Injuries
Sports injuries rank 2nd highest in terms of cause of injury after home and leisure accidents and rank third in terms of severity after traffic accidents and violence
Approximately 11000 personsday receive treatment in US EDs for injuries sustained during sports recreation and exercise activities
One of every six ED visits for an injury results from participation in sports or recreation
Clin Rehabil 2000 Dec14(6)651-6 CDC Injury Research Agenda 2011
1 Course set up2 Resources3 Staff4 Yourself
PREPARATION
Temporal Awareness
DAY OF WEEK lsquoFRI NIGHT GAMESrsquo
AWARENESS OF CLINICAL SETTINGS
IMPACT ON TEMPORAL DECISIONS FOLLOW UP ETC
Disposition
ADMIT vs DISCHARGE vs TRANSFER TO HIGHER LEVEL OF CARE or SPECIALIZED CARE
IMPORTANCE OF TIMELY DIAGNOSIS
RESOURCES LEVEL 1 CONSULTANTS ANCILLARY TESTING
CASE BASED
Question Concussion
Q The current consensus on concussion in sport recommends neurologic imaging only in situations of prolonged alteration of consciousness focal neurological deficits or worsening symptoms
A True B False
Key Points Importance of effective communication between
members of healthcare team from on-field ED Level 1 Trauma CenterSpecialist
Importance of Expeditious Diagnosis Risk of death (immediate or later) MalpracticeLawsuits
Disposition Clinical suspicion Ongoing assessment
Concussion
18 year old Junior College Football Player sustained a head injury today while playing football
Seen by ATC Team Physician recommended to go to ED for further management
Overview Concussions are an important and common injury for
athletes Challenge is for ED physicians to screen quickly for small
subset of patients with potentially life-threatening intracranial lesions andor increased risk for sequelae while minimizing cost unnecessary testing radiation exposure and admissions
Evaluation management and RTP decision very challenging
Take home message must individualize management and RTP decision
Emerg Med Pract 201214(9)1-24
Definition
Zurich Guidelines 2012
Complex pathophysiological process affecting brain due to traumatic biomechanical forces
Consensus statement 4th International Conference Zurich 2012
Mechanism of TBI
Video Concussion
>
Neuron
Dr Cantu
>
Common Features
Direct blow to head face neck or elsewhere with an ldquoimpulsiverdquo force transmitted to head
Rapid onset of short-lived neurological functional impairment
Maymay not LOC LOC occurs in fewer than 10 with sports-related
concussion
Consensus Statement on Concussion Vienna 2001 Emergency Emerg Med Pract 201214(9)1-24Consensus statement 4th International Conference Zurich 2012
Pathophysiology Neurochemical and neurometabolic changes Increase in glucose and oxidative metabolism Increase in demand for cerebral blood flow
which is reduced Activation of immune inflammatory response Possible shear injury to vessels and neurons May create immediate neuronal depolarization
followed by refractory period of no neural transmission
Monitor for initial few hours following injury or send emergently if change in behavior worsening headache vomiting seizure double vision excessive drowsiness or worsening symptoms
No RTP on day of injury
Sideline Testing
Glasgow Coma Scale (GCS) King-Devick Test Bess Test SCAT 2 Maddocks Questions
King-Devick
Test
Glasgow Coma Scale (GCS)
Basic neurological scale that quantifies level of consciousness
Score ranges from 3 (unconscious) to 15 (alert and oriented)
Most EMS protocols GCS score lt 14 should be transported to Level I or II trauma center
Inverse relationship between GCS score and positive findings on CT
King-Devick Test
Tests for eye saccade (quick simultaneous movements of eyes in same direction)
Uses charts of numbers Charts become
increasingly difficult to read as space between numbers increases
Patientrsquos speed and fluidity of reading used to derive score
K-D Test
>
BESS Testing Postural stability testing
assesses cognitive motor function
Quantifiable modified Romberg test ndash three 20-second balance tests performed on firm and foam surfaces
Postural instability communication between three sensory systems either at central or peripheral level is lost
Clinical J Sports Med 200111182-190
SCAT 2
Calculated for athletegt10 yo Preseason baseline testing can be helpful Calculated based on symptoms physical signs
Detailed neurological exam including Glasgow Coma Scale (GCS) mental status cognitive functioning gait and balance pupillary reflex cranial nerve testing
Progression since time of injury (improvement or deterioration)
Is emergent neuroimaging indicated Rule outtreat hypoxia hypercarbia and hypotension
(associated with poorer outcomes in TBI)
1) Avoid CT scans in low risk patients based on validated decision rules
2) Avoid placing indwelling catheters in stable pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first
Choosing Wiselyrdquoreg campaign during the ACEP13 annual meeting Oct 14-17
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Sports Medicine Mentality
PT HISTORY RTP COMMUNICATION
Epidemiology of Sports Injuries
Sports injuries rank 2nd highest in terms of cause of injury after home and leisure accidents and rank third in terms of severity after traffic accidents and violence
Approximately 11000 personsday receive treatment in US EDs for injuries sustained during sports recreation and exercise activities
One of every six ED visits for an injury results from participation in sports or recreation
Clin Rehabil 2000 Dec14(6)651-6 CDC Injury Research Agenda 2011
1 Course set up2 Resources3 Staff4 Yourself
PREPARATION
Temporal Awareness
DAY OF WEEK lsquoFRI NIGHT GAMESrsquo
AWARENESS OF CLINICAL SETTINGS
IMPACT ON TEMPORAL DECISIONS FOLLOW UP ETC
Disposition
ADMIT vs DISCHARGE vs TRANSFER TO HIGHER LEVEL OF CARE or SPECIALIZED CARE
IMPORTANCE OF TIMELY DIAGNOSIS
RESOURCES LEVEL 1 CONSULTANTS ANCILLARY TESTING
CASE BASED
Question Concussion
Q The current consensus on concussion in sport recommends neurologic imaging only in situations of prolonged alteration of consciousness focal neurological deficits or worsening symptoms
A True B False
Key Points Importance of effective communication between
members of healthcare team from on-field ED Level 1 Trauma CenterSpecialist
Importance of Expeditious Diagnosis Risk of death (immediate or later) MalpracticeLawsuits
Disposition Clinical suspicion Ongoing assessment
Concussion
18 year old Junior College Football Player sustained a head injury today while playing football
Seen by ATC Team Physician recommended to go to ED for further management
Overview Concussions are an important and common injury for
athletes Challenge is for ED physicians to screen quickly for small
subset of patients with potentially life-threatening intracranial lesions andor increased risk for sequelae while minimizing cost unnecessary testing radiation exposure and admissions
Evaluation management and RTP decision very challenging
Take home message must individualize management and RTP decision
Emerg Med Pract 201214(9)1-24
Definition
Zurich Guidelines 2012
Complex pathophysiological process affecting brain due to traumatic biomechanical forces
Consensus statement 4th International Conference Zurich 2012
Mechanism of TBI
Video Concussion
>
Neuron
Dr Cantu
>
Common Features
Direct blow to head face neck or elsewhere with an ldquoimpulsiverdquo force transmitted to head
Rapid onset of short-lived neurological functional impairment
Maymay not LOC LOC occurs in fewer than 10 with sports-related
concussion
Consensus Statement on Concussion Vienna 2001 Emergency Emerg Med Pract 201214(9)1-24Consensus statement 4th International Conference Zurich 2012
Pathophysiology Neurochemical and neurometabolic changes Increase in glucose and oxidative metabolism Increase in demand for cerebral blood flow
which is reduced Activation of immune inflammatory response Possible shear injury to vessels and neurons May create immediate neuronal depolarization
followed by refractory period of no neural transmission
Monitor for initial few hours following injury or send emergently if change in behavior worsening headache vomiting seizure double vision excessive drowsiness or worsening symptoms
No RTP on day of injury
Sideline Testing
Glasgow Coma Scale (GCS) King-Devick Test Bess Test SCAT 2 Maddocks Questions
King-Devick
Test
Glasgow Coma Scale (GCS)
Basic neurological scale that quantifies level of consciousness
Score ranges from 3 (unconscious) to 15 (alert and oriented)
Most EMS protocols GCS score lt 14 should be transported to Level I or II trauma center
Inverse relationship between GCS score and positive findings on CT
King-Devick Test
Tests for eye saccade (quick simultaneous movements of eyes in same direction)
Uses charts of numbers Charts become
increasingly difficult to read as space between numbers increases
Patientrsquos speed and fluidity of reading used to derive score
K-D Test
>
BESS Testing Postural stability testing
assesses cognitive motor function
Quantifiable modified Romberg test ndash three 20-second balance tests performed on firm and foam surfaces
Postural instability communication between three sensory systems either at central or peripheral level is lost
Clinical J Sports Med 200111182-190
SCAT 2
Calculated for athletegt10 yo Preseason baseline testing can be helpful Calculated based on symptoms physical signs
Detailed neurological exam including Glasgow Coma Scale (GCS) mental status cognitive functioning gait and balance pupillary reflex cranial nerve testing
Progression since time of injury (improvement or deterioration)
Is emergent neuroimaging indicated Rule outtreat hypoxia hypercarbia and hypotension
(associated with poorer outcomes in TBI)
1) Avoid CT scans in low risk patients based on validated decision rules
2) Avoid placing indwelling catheters in stable pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first
Choosing Wiselyrdquoreg campaign during the ACEP13 annual meeting Oct 14-17
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Epidemiology of Sports Injuries
Sports injuries rank 2nd highest in terms of cause of injury after home and leisure accidents and rank third in terms of severity after traffic accidents and violence
Approximately 11000 personsday receive treatment in US EDs for injuries sustained during sports recreation and exercise activities
One of every six ED visits for an injury results from participation in sports or recreation
Clin Rehabil 2000 Dec14(6)651-6 CDC Injury Research Agenda 2011
1 Course set up2 Resources3 Staff4 Yourself
PREPARATION
Temporal Awareness
DAY OF WEEK lsquoFRI NIGHT GAMESrsquo
AWARENESS OF CLINICAL SETTINGS
IMPACT ON TEMPORAL DECISIONS FOLLOW UP ETC
Disposition
ADMIT vs DISCHARGE vs TRANSFER TO HIGHER LEVEL OF CARE or SPECIALIZED CARE
IMPORTANCE OF TIMELY DIAGNOSIS
RESOURCES LEVEL 1 CONSULTANTS ANCILLARY TESTING
CASE BASED
Question Concussion
Q The current consensus on concussion in sport recommends neurologic imaging only in situations of prolonged alteration of consciousness focal neurological deficits or worsening symptoms
A True B False
Key Points Importance of effective communication between
members of healthcare team from on-field ED Level 1 Trauma CenterSpecialist
Importance of Expeditious Diagnosis Risk of death (immediate or later) MalpracticeLawsuits
Disposition Clinical suspicion Ongoing assessment
Concussion
18 year old Junior College Football Player sustained a head injury today while playing football
Seen by ATC Team Physician recommended to go to ED for further management
Overview Concussions are an important and common injury for
athletes Challenge is for ED physicians to screen quickly for small
subset of patients with potentially life-threatening intracranial lesions andor increased risk for sequelae while minimizing cost unnecessary testing radiation exposure and admissions
Evaluation management and RTP decision very challenging
Take home message must individualize management and RTP decision
Emerg Med Pract 201214(9)1-24
Definition
Zurich Guidelines 2012
Complex pathophysiological process affecting brain due to traumatic biomechanical forces
Consensus statement 4th International Conference Zurich 2012
Mechanism of TBI
Video Concussion
>
Neuron
Dr Cantu
>
Common Features
Direct blow to head face neck or elsewhere with an ldquoimpulsiverdquo force transmitted to head
Rapid onset of short-lived neurological functional impairment
Maymay not LOC LOC occurs in fewer than 10 with sports-related
concussion
Consensus Statement on Concussion Vienna 2001 Emergency Emerg Med Pract 201214(9)1-24Consensus statement 4th International Conference Zurich 2012
Pathophysiology Neurochemical and neurometabolic changes Increase in glucose and oxidative metabolism Increase in demand for cerebral blood flow
which is reduced Activation of immune inflammatory response Possible shear injury to vessels and neurons May create immediate neuronal depolarization
followed by refractory period of no neural transmission
Monitor for initial few hours following injury or send emergently if change in behavior worsening headache vomiting seizure double vision excessive drowsiness or worsening symptoms
No RTP on day of injury
Sideline Testing
Glasgow Coma Scale (GCS) King-Devick Test Bess Test SCAT 2 Maddocks Questions
King-Devick
Test
Glasgow Coma Scale (GCS)
Basic neurological scale that quantifies level of consciousness
Score ranges from 3 (unconscious) to 15 (alert and oriented)
Most EMS protocols GCS score lt 14 should be transported to Level I or II trauma center
Inverse relationship between GCS score and positive findings on CT
King-Devick Test
Tests for eye saccade (quick simultaneous movements of eyes in same direction)
Uses charts of numbers Charts become
increasingly difficult to read as space between numbers increases
Patientrsquos speed and fluidity of reading used to derive score
K-D Test
>
BESS Testing Postural stability testing
assesses cognitive motor function
Quantifiable modified Romberg test ndash three 20-second balance tests performed on firm and foam surfaces
Postural instability communication between three sensory systems either at central or peripheral level is lost
Clinical J Sports Med 200111182-190
SCAT 2
Calculated for athletegt10 yo Preseason baseline testing can be helpful Calculated based on symptoms physical signs
Detailed neurological exam including Glasgow Coma Scale (GCS) mental status cognitive functioning gait and balance pupillary reflex cranial nerve testing
Progression since time of injury (improvement or deterioration)
Is emergent neuroimaging indicated Rule outtreat hypoxia hypercarbia and hypotension
(associated with poorer outcomes in TBI)
1) Avoid CT scans in low risk patients based on validated decision rules
2) Avoid placing indwelling catheters in stable pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first
Choosing Wiselyrdquoreg campaign during the ACEP13 annual meeting Oct 14-17
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
1 Course set up2 Resources3 Staff4 Yourself
PREPARATION
Temporal Awareness
DAY OF WEEK lsquoFRI NIGHT GAMESrsquo
AWARENESS OF CLINICAL SETTINGS
IMPACT ON TEMPORAL DECISIONS FOLLOW UP ETC
Disposition
ADMIT vs DISCHARGE vs TRANSFER TO HIGHER LEVEL OF CARE or SPECIALIZED CARE
IMPORTANCE OF TIMELY DIAGNOSIS
RESOURCES LEVEL 1 CONSULTANTS ANCILLARY TESTING
CASE BASED
Question Concussion
Q The current consensus on concussion in sport recommends neurologic imaging only in situations of prolonged alteration of consciousness focal neurological deficits or worsening symptoms
A True B False
Key Points Importance of effective communication between
members of healthcare team from on-field ED Level 1 Trauma CenterSpecialist
Importance of Expeditious Diagnosis Risk of death (immediate or later) MalpracticeLawsuits
Disposition Clinical suspicion Ongoing assessment
Concussion
18 year old Junior College Football Player sustained a head injury today while playing football
Seen by ATC Team Physician recommended to go to ED for further management
Overview Concussions are an important and common injury for
athletes Challenge is for ED physicians to screen quickly for small
subset of patients with potentially life-threatening intracranial lesions andor increased risk for sequelae while minimizing cost unnecessary testing radiation exposure and admissions
Evaluation management and RTP decision very challenging
Take home message must individualize management and RTP decision
Emerg Med Pract 201214(9)1-24
Definition
Zurich Guidelines 2012
Complex pathophysiological process affecting brain due to traumatic biomechanical forces
Consensus statement 4th International Conference Zurich 2012
Mechanism of TBI
Video Concussion
>
Neuron
Dr Cantu
>
Common Features
Direct blow to head face neck or elsewhere with an ldquoimpulsiverdquo force transmitted to head
Rapid onset of short-lived neurological functional impairment
Maymay not LOC LOC occurs in fewer than 10 with sports-related
concussion
Consensus Statement on Concussion Vienna 2001 Emergency Emerg Med Pract 201214(9)1-24Consensus statement 4th International Conference Zurich 2012
Pathophysiology Neurochemical and neurometabolic changes Increase in glucose and oxidative metabolism Increase in demand for cerebral blood flow
which is reduced Activation of immune inflammatory response Possible shear injury to vessels and neurons May create immediate neuronal depolarization
followed by refractory period of no neural transmission
Monitor for initial few hours following injury or send emergently if change in behavior worsening headache vomiting seizure double vision excessive drowsiness or worsening symptoms
No RTP on day of injury
Sideline Testing
Glasgow Coma Scale (GCS) King-Devick Test Bess Test SCAT 2 Maddocks Questions
King-Devick
Test
Glasgow Coma Scale (GCS)
Basic neurological scale that quantifies level of consciousness
Score ranges from 3 (unconscious) to 15 (alert and oriented)
Most EMS protocols GCS score lt 14 should be transported to Level I or II trauma center
Inverse relationship between GCS score and positive findings on CT
King-Devick Test
Tests for eye saccade (quick simultaneous movements of eyes in same direction)
Uses charts of numbers Charts become
increasingly difficult to read as space between numbers increases
Patientrsquos speed and fluidity of reading used to derive score
K-D Test
>
BESS Testing Postural stability testing
assesses cognitive motor function
Quantifiable modified Romberg test ndash three 20-second balance tests performed on firm and foam surfaces
Postural instability communication between three sensory systems either at central or peripheral level is lost
Clinical J Sports Med 200111182-190
SCAT 2
Calculated for athletegt10 yo Preseason baseline testing can be helpful Calculated based on symptoms physical signs
Detailed neurological exam including Glasgow Coma Scale (GCS) mental status cognitive functioning gait and balance pupillary reflex cranial nerve testing
Progression since time of injury (improvement or deterioration)
Is emergent neuroimaging indicated Rule outtreat hypoxia hypercarbia and hypotension
(associated with poorer outcomes in TBI)
1) Avoid CT scans in low risk patients based on validated decision rules
2) Avoid placing indwelling catheters in stable pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first
Choosing Wiselyrdquoreg campaign during the ACEP13 annual meeting Oct 14-17
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Temporal Awareness
DAY OF WEEK lsquoFRI NIGHT GAMESrsquo
AWARENESS OF CLINICAL SETTINGS
IMPACT ON TEMPORAL DECISIONS FOLLOW UP ETC
Disposition
ADMIT vs DISCHARGE vs TRANSFER TO HIGHER LEVEL OF CARE or SPECIALIZED CARE
IMPORTANCE OF TIMELY DIAGNOSIS
RESOURCES LEVEL 1 CONSULTANTS ANCILLARY TESTING
CASE BASED
Question Concussion
Q The current consensus on concussion in sport recommends neurologic imaging only in situations of prolonged alteration of consciousness focal neurological deficits or worsening symptoms
A True B False
Key Points Importance of effective communication between
members of healthcare team from on-field ED Level 1 Trauma CenterSpecialist
Importance of Expeditious Diagnosis Risk of death (immediate or later) MalpracticeLawsuits
Disposition Clinical suspicion Ongoing assessment
Concussion
18 year old Junior College Football Player sustained a head injury today while playing football
Seen by ATC Team Physician recommended to go to ED for further management
Overview Concussions are an important and common injury for
athletes Challenge is for ED physicians to screen quickly for small
subset of patients with potentially life-threatening intracranial lesions andor increased risk for sequelae while minimizing cost unnecessary testing radiation exposure and admissions
Evaluation management and RTP decision very challenging
Take home message must individualize management and RTP decision
Emerg Med Pract 201214(9)1-24
Definition
Zurich Guidelines 2012
Complex pathophysiological process affecting brain due to traumatic biomechanical forces
Consensus statement 4th International Conference Zurich 2012
Mechanism of TBI
Video Concussion
>
Neuron
Dr Cantu
>
Common Features
Direct blow to head face neck or elsewhere with an ldquoimpulsiverdquo force transmitted to head
Rapid onset of short-lived neurological functional impairment
Maymay not LOC LOC occurs in fewer than 10 with sports-related
concussion
Consensus Statement on Concussion Vienna 2001 Emergency Emerg Med Pract 201214(9)1-24Consensus statement 4th International Conference Zurich 2012
Pathophysiology Neurochemical and neurometabolic changes Increase in glucose and oxidative metabolism Increase in demand for cerebral blood flow
which is reduced Activation of immune inflammatory response Possible shear injury to vessels and neurons May create immediate neuronal depolarization
followed by refractory period of no neural transmission
Monitor for initial few hours following injury or send emergently if change in behavior worsening headache vomiting seizure double vision excessive drowsiness or worsening symptoms
No RTP on day of injury
Sideline Testing
Glasgow Coma Scale (GCS) King-Devick Test Bess Test SCAT 2 Maddocks Questions
King-Devick
Test
Glasgow Coma Scale (GCS)
Basic neurological scale that quantifies level of consciousness
Score ranges from 3 (unconscious) to 15 (alert and oriented)
Most EMS protocols GCS score lt 14 should be transported to Level I or II trauma center
Inverse relationship between GCS score and positive findings on CT
King-Devick Test
Tests for eye saccade (quick simultaneous movements of eyes in same direction)
Uses charts of numbers Charts become
increasingly difficult to read as space between numbers increases
Patientrsquos speed and fluidity of reading used to derive score
K-D Test
>
BESS Testing Postural stability testing
assesses cognitive motor function
Quantifiable modified Romberg test ndash three 20-second balance tests performed on firm and foam surfaces
Postural instability communication between three sensory systems either at central or peripheral level is lost
Clinical J Sports Med 200111182-190
SCAT 2
Calculated for athletegt10 yo Preseason baseline testing can be helpful Calculated based on symptoms physical signs
Detailed neurological exam including Glasgow Coma Scale (GCS) mental status cognitive functioning gait and balance pupillary reflex cranial nerve testing
Progression since time of injury (improvement or deterioration)
Is emergent neuroimaging indicated Rule outtreat hypoxia hypercarbia and hypotension
(associated with poorer outcomes in TBI)
1) Avoid CT scans in low risk patients based on validated decision rules
2) Avoid placing indwelling catheters in stable pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first
Choosing Wiselyrdquoreg campaign during the ACEP13 annual meeting Oct 14-17
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Disposition
ADMIT vs DISCHARGE vs TRANSFER TO HIGHER LEVEL OF CARE or SPECIALIZED CARE
IMPORTANCE OF TIMELY DIAGNOSIS
RESOURCES LEVEL 1 CONSULTANTS ANCILLARY TESTING
CASE BASED
Question Concussion
Q The current consensus on concussion in sport recommends neurologic imaging only in situations of prolonged alteration of consciousness focal neurological deficits or worsening symptoms
A True B False
Key Points Importance of effective communication between
members of healthcare team from on-field ED Level 1 Trauma CenterSpecialist
Importance of Expeditious Diagnosis Risk of death (immediate or later) MalpracticeLawsuits
Disposition Clinical suspicion Ongoing assessment
Concussion
18 year old Junior College Football Player sustained a head injury today while playing football
Seen by ATC Team Physician recommended to go to ED for further management
Overview Concussions are an important and common injury for
athletes Challenge is for ED physicians to screen quickly for small
subset of patients with potentially life-threatening intracranial lesions andor increased risk for sequelae while minimizing cost unnecessary testing radiation exposure and admissions
Evaluation management and RTP decision very challenging
Take home message must individualize management and RTP decision
Emerg Med Pract 201214(9)1-24
Definition
Zurich Guidelines 2012
Complex pathophysiological process affecting brain due to traumatic biomechanical forces
Consensus statement 4th International Conference Zurich 2012
Mechanism of TBI
Video Concussion
>
Neuron
Dr Cantu
>
Common Features
Direct blow to head face neck or elsewhere with an ldquoimpulsiverdquo force transmitted to head
Rapid onset of short-lived neurological functional impairment
Maymay not LOC LOC occurs in fewer than 10 with sports-related
concussion
Consensus Statement on Concussion Vienna 2001 Emergency Emerg Med Pract 201214(9)1-24Consensus statement 4th International Conference Zurich 2012
Pathophysiology Neurochemical and neurometabolic changes Increase in glucose and oxidative metabolism Increase in demand for cerebral blood flow
which is reduced Activation of immune inflammatory response Possible shear injury to vessels and neurons May create immediate neuronal depolarization
followed by refractory period of no neural transmission
Monitor for initial few hours following injury or send emergently if change in behavior worsening headache vomiting seizure double vision excessive drowsiness or worsening symptoms
No RTP on day of injury
Sideline Testing
Glasgow Coma Scale (GCS) King-Devick Test Bess Test SCAT 2 Maddocks Questions
King-Devick
Test
Glasgow Coma Scale (GCS)
Basic neurological scale that quantifies level of consciousness
Score ranges from 3 (unconscious) to 15 (alert and oriented)
Most EMS protocols GCS score lt 14 should be transported to Level I or II trauma center
Inverse relationship between GCS score and positive findings on CT
King-Devick Test
Tests for eye saccade (quick simultaneous movements of eyes in same direction)
Uses charts of numbers Charts become
increasingly difficult to read as space between numbers increases
Patientrsquos speed and fluidity of reading used to derive score
K-D Test
>
BESS Testing Postural stability testing
assesses cognitive motor function
Quantifiable modified Romberg test ndash three 20-second balance tests performed on firm and foam surfaces
Postural instability communication between three sensory systems either at central or peripheral level is lost
Clinical J Sports Med 200111182-190
SCAT 2
Calculated for athletegt10 yo Preseason baseline testing can be helpful Calculated based on symptoms physical signs
Detailed neurological exam including Glasgow Coma Scale (GCS) mental status cognitive functioning gait and balance pupillary reflex cranial nerve testing
Progression since time of injury (improvement or deterioration)
Is emergent neuroimaging indicated Rule outtreat hypoxia hypercarbia and hypotension
(associated with poorer outcomes in TBI)
1) Avoid CT scans in low risk patients based on validated decision rules
2) Avoid placing indwelling catheters in stable pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first
Choosing Wiselyrdquoreg campaign during the ACEP13 annual meeting Oct 14-17
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Question Concussion
Q The current consensus on concussion in sport recommends neurologic imaging only in situations of prolonged alteration of consciousness focal neurological deficits or worsening symptoms
A True B False
Key Points Importance of effective communication between
members of healthcare team from on-field ED Level 1 Trauma CenterSpecialist
Importance of Expeditious Diagnosis Risk of death (immediate or later) MalpracticeLawsuits
Disposition Clinical suspicion Ongoing assessment
Concussion
18 year old Junior College Football Player sustained a head injury today while playing football
Seen by ATC Team Physician recommended to go to ED for further management
Overview Concussions are an important and common injury for
athletes Challenge is for ED physicians to screen quickly for small
subset of patients with potentially life-threatening intracranial lesions andor increased risk for sequelae while minimizing cost unnecessary testing radiation exposure and admissions
Evaluation management and RTP decision very challenging
Take home message must individualize management and RTP decision
Emerg Med Pract 201214(9)1-24
Definition
Zurich Guidelines 2012
Complex pathophysiological process affecting brain due to traumatic biomechanical forces
Consensus statement 4th International Conference Zurich 2012
Mechanism of TBI
Video Concussion
>
Neuron
Dr Cantu
>
Common Features
Direct blow to head face neck or elsewhere with an ldquoimpulsiverdquo force transmitted to head
Rapid onset of short-lived neurological functional impairment
Maymay not LOC LOC occurs in fewer than 10 with sports-related
concussion
Consensus Statement on Concussion Vienna 2001 Emergency Emerg Med Pract 201214(9)1-24Consensus statement 4th International Conference Zurich 2012
Pathophysiology Neurochemical and neurometabolic changes Increase in glucose and oxidative metabolism Increase in demand for cerebral blood flow
which is reduced Activation of immune inflammatory response Possible shear injury to vessels and neurons May create immediate neuronal depolarization
followed by refractory period of no neural transmission
Monitor for initial few hours following injury or send emergently if change in behavior worsening headache vomiting seizure double vision excessive drowsiness or worsening symptoms
No RTP on day of injury
Sideline Testing
Glasgow Coma Scale (GCS) King-Devick Test Bess Test SCAT 2 Maddocks Questions
King-Devick
Test
Glasgow Coma Scale (GCS)
Basic neurological scale that quantifies level of consciousness
Score ranges from 3 (unconscious) to 15 (alert and oriented)
Most EMS protocols GCS score lt 14 should be transported to Level I or II trauma center
Inverse relationship between GCS score and positive findings on CT
King-Devick Test
Tests for eye saccade (quick simultaneous movements of eyes in same direction)
Uses charts of numbers Charts become
increasingly difficult to read as space between numbers increases
Patientrsquos speed and fluidity of reading used to derive score
K-D Test
>
BESS Testing Postural stability testing
assesses cognitive motor function
Quantifiable modified Romberg test ndash three 20-second balance tests performed on firm and foam surfaces
Postural instability communication between three sensory systems either at central or peripheral level is lost
Clinical J Sports Med 200111182-190
SCAT 2
Calculated for athletegt10 yo Preseason baseline testing can be helpful Calculated based on symptoms physical signs
Detailed neurological exam including Glasgow Coma Scale (GCS) mental status cognitive functioning gait and balance pupillary reflex cranial nerve testing
Progression since time of injury (improvement or deterioration)
Is emergent neuroimaging indicated Rule outtreat hypoxia hypercarbia and hypotension
(associated with poorer outcomes in TBI)
1) Avoid CT scans in low risk patients based on validated decision rules
2) Avoid placing indwelling catheters in stable pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first
Choosing Wiselyrdquoreg campaign during the ACEP13 annual meeting Oct 14-17
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Key Points Importance of effective communication between
members of healthcare team from on-field ED Level 1 Trauma CenterSpecialist
Importance of Expeditious Diagnosis Risk of death (immediate or later) MalpracticeLawsuits
Disposition Clinical suspicion Ongoing assessment
Concussion
18 year old Junior College Football Player sustained a head injury today while playing football
Seen by ATC Team Physician recommended to go to ED for further management
Overview Concussions are an important and common injury for
athletes Challenge is for ED physicians to screen quickly for small
subset of patients with potentially life-threatening intracranial lesions andor increased risk for sequelae while minimizing cost unnecessary testing radiation exposure and admissions
Evaluation management and RTP decision very challenging
Take home message must individualize management and RTP decision
Emerg Med Pract 201214(9)1-24
Definition
Zurich Guidelines 2012
Complex pathophysiological process affecting brain due to traumatic biomechanical forces
Consensus statement 4th International Conference Zurich 2012
Mechanism of TBI
Video Concussion
>
Neuron
Dr Cantu
>
Common Features
Direct blow to head face neck or elsewhere with an ldquoimpulsiverdquo force transmitted to head
Rapid onset of short-lived neurological functional impairment
Maymay not LOC LOC occurs in fewer than 10 with sports-related
concussion
Consensus Statement on Concussion Vienna 2001 Emergency Emerg Med Pract 201214(9)1-24Consensus statement 4th International Conference Zurich 2012
Pathophysiology Neurochemical and neurometabolic changes Increase in glucose and oxidative metabolism Increase in demand for cerebral blood flow
which is reduced Activation of immune inflammatory response Possible shear injury to vessels and neurons May create immediate neuronal depolarization
followed by refractory period of no neural transmission
Monitor for initial few hours following injury or send emergently if change in behavior worsening headache vomiting seizure double vision excessive drowsiness or worsening symptoms
No RTP on day of injury
Sideline Testing
Glasgow Coma Scale (GCS) King-Devick Test Bess Test SCAT 2 Maddocks Questions
King-Devick
Test
Glasgow Coma Scale (GCS)
Basic neurological scale that quantifies level of consciousness
Score ranges from 3 (unconscious) to 15 (alert and oriented)
Most EMS protocols GCS score lt 14 should be transported to Level I or II trauma center
Inverse relationship between GCS score and positive findings on CT
King-Devick Test
Tests for eye saccade (quick simultaneous movements of eyes in same direction)
Uses charts of numbers Charts become
increasingly difficult to read as space between numbers increases
Patientrsquos speed and fluidity of reading used to derive score
K-D Test
>
BESS Testing Postural stability testing
assesses cognitive motor function
Quantifiable modified Romberg test ndash three 20-second balance tests performed on firm and foam surfaces
Postural instability communication between three sensory systems either at central or peripheral level is lost
Clinical J Sports Med 200111182-190
SCAT 2
Calculated for athletegt10 yo Preseason baseline testing can be helpful Calculated based on symptoms physical signs
Detailed neurological exam including Glasgow Coma Scale (GCS) mental status cognitive functioning gait and balance pupillary reflex cranial nerve testing
Progression since time of injury (improvement or deterioration)
Is emergent neuroimaging indicated Rule outtreat hypoxia hypercarbia and hypotension
(associated with poorer outcomes in TBI)
1) Avoid CT scans in low risk patients based on validated decision rules
2) Avoid placing indwelling catheters in stable pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first
Choosing Wiselyrdquoreg campaign during the ACEP13 annual meeting Oct 14-17
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Concussion
18 year old Junior College Football Player sustained a head injury today while playing football
Seen by ATC Team Physician recommended to go to ED for further management
Overview Concussions are an important and common injury for
athletes Challenge is for ED physicians to screen quickly for small
subset of patients with potentially life-threatening intracranial lesions andor increased risk for sequelae while minimizing cost unnecessary testing radiation exposure and admissions
Evaluation management and RTP decision very challenging
Take home message must individualize management and RTP decision
Emerg Med Pract 201214(9)1-24
Definition
Zurich Guidelines 2012
Complex pathophysiological process affecting brain due to traumatic biomechanical forces
Consensus statement 4th International Conference Zurich 2012
Mechanism of TBI
Video Concussion
>
Neuron
Dr Cantu
>
Common Features
Direct blow to head face neck or elsewhere with an ldquoimpulsiverdquo force transmitted to head
Rapid onset of short-lived neurological functional impairment
Maymay not LOC LOC occurs in fewer than 10 with sports-related
concussion
Consensus Statement on Concussion Vienna 2001 Emergency Emerg Med Pract 201214(9)1-24Consensus statement 4th International Conference Zurich 2012
Pathophysiology Neurochemical and neurometabolic changes Increase in glucose and oxidative metabolism Increase in demand for cerebral blood flow
which is reduced Activation of immune inflammatory response Possible shear injury to vessels and neurons May create immediate neuronal depolarization
followed by refractory period of no neural transmission
Monitor for initial few hours following injury or send emergently if change in behavior worsening headache vomiting seizure double vision excessive drowsiness or worsening symptoms
No RTP on day of injury
Sideline Testing
Glasgow Coma Scale (GCS) King-Devick Test Bess Test SCAT 2 Maddocks Questions
King-Devick
Test
Glasgow Coma Scale (GCS)
Basic neurological scale that quantifies level of consciousness
Score ranges from 3 (unconscious) to 15 (alert and oriented)
Most EMS protocols GCS score lt 14 should be transported to Level I or II trauma center
Inverse relationship between GCS score and positive findings on CT
King-Devick Test
Tests for eye saccade (quick simultaneous movements of eyes in same direction)
Uses charts of numbers Charts become
increasingly difficult to read as space between numbers increases
Patientrsquos speed and fluidity of reading used to derive score
K-D Test
>
BESS Testing Postural stability testing
assesses cognitive motor function
Quantifiable modified Romberg test ndash three 20-second balance tests performed on firm and foam surfaces
Postural instability communication between three sensory systems either at central or peripheral level is lost
Clinical J Sports Med 200111182-190
SCAT 2
Calculated for athletegt10 yo Preseason baseline testing can be helpful Calculated based on symptoms physical signs
Detailed neurological exam including Glasgow Coma Scale (GCS) mental status cognitive functioning gait and balance pupillary reflex cranial nerve testing
Progression since time of injury (improvement or deterioration)
Is emergent neuroimaging indicated Rule outtreat hypoxia hypercarbia and hypotension
(associated with poorer outcomes in TBI)
1) Avoid CT scans in low risk patients based on validated decision rules
2) Avoid placing indwelling catheters in stable pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first
Choosing Wiselyrdquoreg campaign during the ACEP13 annual meeting Oct 14-17
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Overview Concussions are an important and common injury for
athletes Challenge is for ED physicians to screen quickly for small
subset of patients with potentially life-threatening intracranial lesions andor increased risk for sequelae while minimizing cost unnecessary testing radiation exposure and admissions
Evaluation management and RTP decision very challenging
Take home message must individualize management and RTP decision
Emerg Med Pract 201214(9)1-24
Definition
Zurich Guidelines 2012
Complex pathophysiological process affecting brain due to traumatic biomechanical forces
Consensus statement 4th International Conference Zurich 2012
Mechanism of TBI
Video Concussion
>
Neuron
Dr Cantu
>
Common Features
Direct blow to head face neck or elsewhere with an ldquoimpulsiverdquo force transmitted to head
Rapid onset of short-lived neurological functional impairment
Maymay not LOC LOC occurs in fewer than 10 with sports-related
concussion
Consensus Statement on Concussion Vienna 2001 Emergency Emerg Med Pract 201214(9)1-24Consensus statement 4th International Conference Zurich 2012
Pathophysiology Neurochemical and neurometabolic changes Increase in glucose and oxidative metabolism Increase in demand for cerebral blood flow
which is reduced Activation of immune inflammatory response Possible shear injury to vessels and neurons May create immediate neuronal depolarization
followed by refractory period of no neural transmission
Monitor for initial few hours following injury or send emergently if change in behavior worsening headache vomiting seizure double vision excessive drowsiness or worsening symptoms
No RTP on day of injury
Sideline Testing
Glasgow Coma Scale (GCS) King-Devick Test Bess Test SCAT 2 Maddocks Questions
King-Devick
Test
Glasgow Coma Scale (GCS)
Basic neurological scale that quantifies level of consciousness
Score ranges from 3 (unconscious) to 15 (alert and oriented)
Most EMS protocols GCS score lt 14 should be transported to Level I or II trauma center
Inverse relationship between GCS score and positive findings on CT
King-Devick Test
Tests for eye saccade (quick simultaneous movements of eyes in same direction)
Uses charts of numbers Charts become
increasingly difficult to read as space between numbers increases
Patientrsquos speed and fluidity of reading used to derive score
K-D Test
>
BESS Testing Postural stability testing
assesses cognitive motor function
Quantifiable modified Romberg test ndash three 20-second balance tests performed on firm and foam surfaces
Postural instability communication between three sensory systems either at central or peripheral level is lost
Clinical J Sports Med 200111182-190
SCAT 2
Calculated for athletegt10 yo Preseason baseline testing can be helpful Calculated based on symptoms physical signs
Detailed neurological exam including Glasgow Coma Scale (GCS) mental status cognitive functioning gait and balance pupillary reflex cranial nerve testing
Progression since time of injury (improvement or deterioration)
Is emergent neuroimaging indicated Rule outtreat hypoxia hypercarbia and hypotension
(associated with poorer outcomes in TBI)
1) Avoid CT scans in low risk patients based on validated decision rules
2) Avoid placing indwelling catheters in stable pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first
Choosing Wiselyrdquoreg campaign during the ACEP13 annual meeting Oct 14-17
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Definition
Zurich Guidelines 2012
Complex pathophysiological process affecting brain due to traumatic biomechanical forces
Consensus statement 4th International Conference Zurich 2012
Mechanism of TBI
Video Concussion
>
Neuron
Dr Cantu
>
Common Features
Direct blow to head face neck or elsewhere with an ldquoimpulsiverdquo force transmitted to head
Rapid onset of short-lived neurological functional impairment
Maymay not LOC LOC occurs in fewer than 10 with sports-related
concussion
Consensus Statement on Concussion Vienna 2001 Emergency Emerg Med Pract 201214(9)1-24Consensus statement 4th International Conference Zurich 2012
Pathophysiology Neurochemical and neurometabolic changes Increase in glucose and oxidative metabolism Increase in demand for cerebral blood flow
which is reduced Activation of immune inflammatory response Possible shear injury to vessels and neurons May create immediate neuronal depolarization
followed by refractory period of no neural transmission
Monitor for initial few hours following injury or send emergently if change in behavior worsening headache vomiting seizure double vision excessive drowsiness or worsening symptoms
No RTP on day of injury
Sideline Testing
Glasgow Coma Scale (GCS) King-Devick Test Bess Test SCAT 2 Maddocks Questions
King-Devick
Test
Glasgow Coma Scale (GCS)
Basic neurological scale that quantifies level of consciousness
Score ranges from 3 (unconscious) to 15 (alert and oriented)
Most EMS protocols GCS score lt 14 should be transported to Level I or II trauma center
Inverse relationship between GCS score and positive findings on CT
King-Devick Test
Tests for eye saccade (quick simultaneous movements of eyes in same direction)
Uses charts of numbers Charts become
increasingly difficult to read as space between numbers increases
Patientrsquos speed and fluidity of reading used to derive score
K-D Test
>
BESS Testing Postural stability testing
assesses cognitive motor function
Quantifiable modified Romberg test ndash three 20-second balance tests performed on firm and foam surfaces
Postural instability communication between three sensory systems either at central or peripheral level is lost
Clinical J Sports Med 200111182-190
SCAT 2
Calculated for athletegt10 yo Preseason baseline testing can be helpful Calculated based on symptoms physical signs
Detailed neurological exam including Glasgow Coma Scale (GCS) mental status cognitive functioning gait and balance pupillary reflex cranial nerve testing
Progression since time of injury (improvement or deterioration)
Is emergent neuroimaging indicated Rule outtreat hypoxia hypercarbia and hypotension
(associated with poorer outcomes in TBI)
1) Avoid CT scans in low risk patients based on validated decision rules
2) Avoid placing indwelling catheters in stable pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first
Choosing Wiselyrdquoreg campaign during the ACEP13 annual meeting Oct 14-17
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Mechanism of TBI
Video Concussion
>
Neuron
Dr Cantu
>
Common Features
Direct blow to head face neck or elsewhere with an ldquoimpulsiverdquo force transmitted to head
Rapid onset of short-lived neurological functional impairment
Maymay not LOC LOC occurs in fewer than 10 with sports-related
concussion
Consensus Statement on Concussion Vienna 2001 Emergency Emerg Med Pract 201214(9)1-24Consensus statement 4th International Conference Zurich 2012
Pathophysiology Neurochemical and neurometabolic changes Increase in glucose and oxidative metabolism Increase in demand for cerebral blood flow
which is reduced Activation of immune inflammatory response Possible shear injury to vessels and neurons May create immediate neuronal depolarization
followed by refractory period of no neural transmission
Monitor for initial few hours following injury or send emergently if change in behavior worsening headache vomiting seizure double vision excessive drowsiness or worsening symptoms
No RTP on day of injury
Sideline Testing
Glasgow Coma Scale (GCS) King-Devick Test Bess Test SCAT 2 Maddocks Questions
King-Devick
Test
Glasgow Coma Scale (GCS)
Basic neurological scale that quantifies level of consciousness
Score ranges from 3 (unconscious) to 15 (alert and oriented)
Most EMS protocols GCS score lt 14 should be transported to Level I or II trauma center
Inverse relationship between GCS score and positive findings on CT
King-Devick Test
Tests for eye saccade (quick simultaneous movements of eyes in same direction)
Uses charts of numbers Charts become
increasingly difficult to read as space between numbers increases
Patientrsquos speed and fluidity of reading used to derive score
K-D Test
>
BESS Testing Postural stability testing
assesses cognitive motor function
Quantifiable modified Romberg test ndash three 20-second balance tests performed on firm and foam surfaces
Postural instability communication between three sensory systems either at central or peripheral level is lost
Clinical J Sports Med 200111182-190
SCAT 2
Calculated for athletegt10 yo Preseason baseline testing can be helpful Calculated based on symptoms physical signs
Detailed neurological exam including Glasgow Coma Scale (GCS) mental status cognitive functioning gait and balance pupillary reflex cranial nerve testing
Progression since time of injury (improvement or deterioration)
Is emergent neuroimaging indicated Rule outtreat hypoxia hypercarbia and hypotension
(associated with poorer outcomes in TBI)
1) Avoid CT scans in low risk patients based on validated decision rules
2) Avoid placing indwelling catheters in stable pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first
Choosing Wiselyrdquoreg campaign during the ACEP13 annual meeting Oct 14-17
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Video Concussion
>
Neuron
Dr Cantu
>
Common Features
Direct blow to head face neck or elsewhere with an ldquoimpulsiverdquo force transmitted to head
Rapid onset of short-lived neurological functional impairment
Maymay not LOC LOC occurs in fewer than 10 with sports-related
concussion
Consensus Statement on Concussion Vienna 2001 Emergency Emerg Med Pract 201214(9)1-24Consensus statement 4th International Conference Zurich 2012
Pathophysiology Neurochemical and neurometabolic changes Increase in glucose and oxidative metabolism Increase in demand for cerebral blood flow
which is reduced Activation of immune inflammatory response Possible shear injury to vessels and neurons May create immediate neuronal depolarization
followed by refractory period of no neural transmission
Monitor for initial few hours following injury or send emergently if change in behavior worsening headache vomiting seizure double vision excessive drowsiness or worsening symptoms
No RTP on day of injury
Sideline Testing
Glasgow Coma Scale (GCS) King-Devick Test Bess Test SCAT 2 Maddocks Questions
King-Devick
Test
Glasgow Coma Scale (GCS)
Basic neurological scale that quantifies level of consciousness
Score ranges from 3 (unconscious) to 15 (alert and oriented)
Most EMS protocols GCS score lt 14 should be transported to Level I or II trauma center
Inverse relationship between GCS score and positive findings on CT
King-Devick Test
Tests for eye saccade (quick simultaneous movements of eyes in same direction)
Uses charts of numbers Charts become
increasingly difficult to read as space between numbers increases
Patientrsquos speed and fluidity of reading used to derive score
K-D Test
>
BESS Testing Postural stability testing
assesses cognitive motor function
Quantifiable modified Romberg test ndash three 20-second balance tests performed on firm and foam surfaces
Postural instability communication between three sensory systems either at central or peripheral level is lost
Clinical J Sports Med 200111182-190
SCAT 2
Calculated for athletegt10 yo Preseason baseline testing can be helpful Calculated based on symptoms physical signs
Detailed neurological exam including Glasgow Coma Scale (GCS) mental status cognitive functioning gait and balance pupillary reflex cranial nerve testing
Progression since time of injury (improvement or deterioration)
Is emergent neuroimaging indicated Rule outtreat hypoxia hypercarbia and hypotension
(associated with poorer outcomes in TBI)
1) Avoid CT scans in low risk patients based on validated decision rules
2) Avoid placing indwelling catheters in stable pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first
Choosing Wiselyrdquoreg campaign during the ACEP13 annual meeting Oct 14-17
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Neuron
Dr Cantu
>
Common Features
Direct blow to head face neck or elsewhere with an ldquoimpulsiverdquo force transmitted to head
Rapid onset of short-lived neurological functional impairment
Maymay not LOC LOC occurs in fewer than 10 with sports-related
concussion
Consensus Statement on Concussion Vienna 2001 Emergency Emerg Med Pract 201214(9)1-24Consensus statement 4th International Conference Zurich 2012
Pathophysiology Neurochemical and neurometabolic changes Increase in glucose and oxidative metabolism Increase in demand for cerebral blood flow
which is reduced Activation of immune inflammatory response Possible shear injury to vessels and neurons May create immediate neuronal depolarization
followed by refractory period of no neural transmission
Monitor for initial few hours following injury or send emergently if change in behavior worsening headache vomiting seizure double vision excessive drowsiness or worsening symptoms
No RTP on day of injury
Sideline Testing
Glasgow Coma Scale (GCS) King-Devick Test Bess Test SCAT 2 Maddocks Questions
King-Devick
Test
Glasgow Coma Scale (GCS)
Basic neurological scale that quantifies level of consciousness
Score ranges from 3 (unconscious) to 15 (alert and oriented)
Most EMS protocols GCS score lt 14 should be transported to Level I or II trauma center
Inverse relationship between GCS score and positive findings on CT
King-Devick Test
Tests for eye saccade (quick simultaneous movements of eyes in same direction)
Uses charts of numbers Charts become
increasingly difficult to read as space between numbers increases
Patientrsquos speed and fluidity of reading used to derive score
K-D Test
>
BESS Testing Postural stability testing
assesses cognitive motor function
Quantifiable modified Romberg test ndash three 20-second balance tests performed on firm and foam surfaces
Postural instability communication between three sensory systems either at central or peripheral level is lost
Clinical J Sports Med 200111182-190
SCAT 2
Calculated for athletegt10 yo Preseason baseline testing can be helpful Calculated based on symptoms physical signs
Detailed neurological exam including Glasgow Coma Scale (GCS) mental status cognitive functioning gait and balance pupillary reflex cranial nerve testing
Progression since time of injury (improvement or deterioration)
Is emergent neuroimaging indicated Rule outtreat hypoxia hypercarbia and hypotension
(associated with poorer outcomes in TBI)
1) Avoid CT scans in low risk patients based on validated decision rules
2) Avoid placing indwelling catheters in stable pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first
Choosing Wiselyrdquoreg campaign during the ACEP13 annual meeting Oct 14-17
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Dr Cantu
>
Common Features
Direct blow to head face neck or elsewhere with an ldquoimpulsiverdquo force transmitted to head
Rapid onset of short-lived neurological functional impairment
Maymay not LOC LOC occurs in fewer than 10 with sports-related
concussion
Consensus Statement on Concussion Vienna 2001 Emergency Emerg Med Pract 201214(9)1-24Consensus statement 4th International Conference Zurich 2012
Pathophysiology Neurochemical and neurometabolic changes Increase in glucose and oxidative metabolism Increase in demand for cerebral blood flow
which is reduced Activation of immune inflammatory response Possible shear injury to vessels and neurons May create immediate neuronal depolarization
followed by refractory period of no neural transmission
Monitor for initial few hours following injury or send emergently if change in behavior worsening headache vomiting seizure double vision excessive drowsiness or worsening symptoms
No RTP on day of injury
Sideline Testing
Glasgow Coma Scale (GCS) King-Devick Test Bess Test SCAT 2 Maddocks Questions
King-Devick
Test
Glasgow Coma Scale (GCS)
Basic neurological scale that quantifies level of consciousness
Score ranges from 3 (unconscious) to 15 (alert and oriented)
Most EMS protocols GCS score lt 14 should be transported to Level I or II trauma center
Inverse relationship between GCS score and positive findings on CT
King-Devick Test
Tests for eye saccade (quick simultaneous movements of eyes in same direction)
Uses charts of numbers Charts become
increasingly difficult to read as space between numbers increases
Patientrsquos speed and fluidity of reading used to derive score
K-D Test
>
BESS Testing Postural stability testing
assesses cognitive motor function
Quantifiable modified Romberg test ndash three 20-second balance tests performed on firm and foam surfaces
Postural instability communication between three sensory systems either at central or peripheral level is lost
Clinical J Sports Med 200111182-190
SCAT 2
Calculated for athletegt10 yo Preseason baseline testing can be helpful Calculated based on symptoms physical signs
Detailed neurological exam including Glasgow Coma Scale (GCS) mental status cognitive functioning gait and balance pupillary reflex cranial nerve testing
Progression since time of injury (improvement or deterioration)
Is emergent neuroimaging indicated Rule outtreat hypoxia hypercarbia and hypotension
(associated with poorer outcomes in TBI)
1) Avoid CT scans in low risk patients based on validated decision rules
2) Avoid placing indwelling catheters in stable pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first
Choosing Wiselyrdquoreg campaign during the ACEP13 annual meeting Oct 14-17
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Common Features
Direct blow to head face neck or elsewhere with an ldquoimpulsiverdquo force transmitted to head
Rapid onset of short-lived neurological functional impairment
Maymay not LOC LOC occurs in fewer than 10 with sports-related
concussion
Consensus Statement on Concussion Vienna 2001 Emergency Emerg Med Pract 201214(9)1-24Consensus statement 4th International Conference Zurich 2012
Pathophysiology Neurochemical and neurometabolic changes Increase in glucose and oxidative metabolism Increase in demand for cerebral blood flow
which is reduced Activation of immune inflammatory response Possible shear injury to vessels and neurons May create immediate neuronal depolarization
followed by refractory period of no neural transmission
Monitor for initial few hours following injury or send emergently if change in behavior worsening headache vomiting seizure double vision excessive drowsiness or worsening symptoms
No RTP on day of injury
Sideline Testing
Glasgow Coma Scale (GCS) King-Devick Test Bess Test SCAT 2 Maddocks Questions
King-Devick
Test
Glasgow Coma Scale (GCS)
Basic neurological scale that quantifies level of consciousness
Score ranges from 3 (unconscious) to 15 (alert and oriented)
Most EMS protocols GCS score lt 14 should be transported to Level I or II trauma center
Inverse relationship between GCS score and positive findings on CT
King-Devick Test
Tests for eye saccade (quick simultaneous movements of eyes in same direction)
Uses charts of numbers Charts become
increasingly difficult to read as space between numbers increases
Patientrsquos speed and fluidity of reading used to derive score
K-D Test
>
BESS Testing Postural stability testing
assesses cognitive motor function
Quantifiable modified Romberg test ndash three 20-second balance tests performed on firm and foam surfaces
Postural instability communication between three sensory systems either at central or peripheral level is lost
Clinical J Sports Med 200111182-190
SCAT 2
Calculated for athletegt10 yo Preseason baseline testing can be helpful Calculated based on symptoms physical signs
Detailed neurological exam including Glasgow Coma Scale (GCS) mental status cognitive functioning gait and balance pupillary reflex cranial nerve testing
Progression since time of injury (improvement or deterioration)
Is emergent neuroimaging indicated Rule outtreat hypoxia hypercarbia and hypotension
(associated with poorer outcomes in TBI)
1) Avoid CT scans in low risk patients based on validated decision rules
2) Avoid placing indwelling catheters in stable pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first
Choosing Wiselyrdquoreg campaign during the ACEP13 annual meeting Oct 14-17
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Pathophysiology Neurochemical and neurometabolic changes Increase in glucose and oxidative metabolism Increase in demand for cerebral blood flow
which is reduced Activation of immune inflammatory response Possible shear injury to vessels and neurons May create immediate neuronal depolarization
followed by refractory period of no neural transmission
Monitor for initial few hours following injury or send emergently if change in behavior worsening headache vomiting seizure double vision excessive drowsiness or worsening symptoms
No RTP on day of injury
Sideline Testing
Glasgow Coma Scale (GCS) King-Devick Test Bess Test SCAT 2 Maddocks Questions
King-Devick
Test
Glasgow Coma Scale (GCS)
Basic neurological scale that quantifies level of consciousness
Score ranges from 3 (unconscious) to 15 (alert and oriented)
Most EMS protocols GCS score lt 14 should be transported to Level I or II trauma center
Inverse relationship between GCS score and positive findings on CT
King-Devick Test
Tests for eye saccade (quick simultaneous movements of eyes in same direction)
Uses charts of numbers Charts become
increasingly difficult to read as space between numbers increases
Patientrsquos speed and fluidity of reading used to derive score
K-D Test
>
BESS Testing Postural stability testing
assesses cognitive motor function
Quantifiable modified Romberg test ndash three 20-second balance tests performed on firm and foam surfaces
Postural instability communication between three sensory systems either at central or peripheral level is lost
Clinical J Sports Med 200111182-190
SCAT 2
Calculated for athletegt10 yo Preseason baseline testing can be helpful Calculated based on symptoms physical signs
Detailed neurological exam including Glasgow Coma Scale (GCS) mental status cognitive functioning gait and balance pupillary reflex cranial nerve testing
Progression since time of injury (improvement or deterioration)
Is emergent neuroimaging indicated Rule outtreat hypoxia hypercarbia and hypotension
(associated with poorer outcomes in TBI)
1) Avoid CT scans in low risk patients based on validated decision rules
2) Avoid placing indwelling catheters in stable pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first
Choosing Wiselyrdquoreg campaign during the ACEP13 annual meeting Oct 14-17
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Genetics
Jordan et al found Apolipoprotein E (ApoE) E4 assoc w increased severity of chronic TBI (cTBI) in high-exposure boxers
College athletes w ApoE promoter G-219T TT genotype may be at increased risk for having ho concussions
Clin J Sport Med 2008 Jan18(1)10-7
JAMA 1997278(2)136-140
Epidemiology National High School Federation Data 2008-
2010 250 injuries10000 athlete exposures CDC During 2001-2005 an estimated 207830
ED visits annually for concussions and other TBIs related to sports and recreational activities with 65 of TBIs among children aged 5-18 years
Increase in incidence CDC From 2001 to 2009 annual TBI-related ED visits
increased significantly from 153375 to 248418 with highest rates among males aged 10-19 years
MMWR Morb Mortal Wkly Rep 201160(39)1337-42 AJSM January 27 2012 as doi10
Monitor for initial few hours following injury or send emergently if change in behavior worsening headache vomiting seizure double vision excessive drowsiness or worsening symptoms
No RTP on day of injury
Sideline Testing
Glasgow Coma Scale (GCS) King-Devick Test Bess Test SCAT 2 Maddocks Questions
King-Devick
Test
Glasgow Coma Scale (GCS)
Basic neurological scale that quantifies level of consciousness
Score ranges from 3 (unconscious) to 15 (alert and oriented)
Most EMS protocols GCS score lt 14 should be transported to Level I or II trauma center
Inverse relationship between GCS score and positive findings on CT
King-Devick Test
Tests for eye saccade (quick simultaneous movements of eyes in same direction)
Uses charts of numbers Charts become
increasingly difficult to read as space between numbers increases
Patientrsquos speed and fluidity of reading used to derive score
K-D Test
>
BESS Testing Postural stability testing
assesses cognitive motor function
Quantifiable modified Romberg test ndash three 20-second balance tests performed on firm and foam surfaces
Postural instability communication between three sensory systems either at central or peripheral level is lost
Clinical J Sports Med 200111182-190
SCAT 2
Calculated for athletegt10 yo Preseason baseline testing can be helpful Calculated based on symptoms physical signs
Detailed neurological exam including Glasgow Coma Scale (GCS) mental status cognitive functioning gait and balance pupillary reflex cranial nerve testing
Progression since time of injury (improvement or deterioration)
Is emergent neuroimaging indicated Rule outtreat hypoxia hypercarbia and hypotension
(associated with poorer outcomes in TBI)
1) Avoid CT scans in low risk patients based on validated decision rules
2) Avoid placing indwelling catheters in stable pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first
Choosing Wiselyrdquoreg campaign during the ACEP13 annual meeting Oct 14-17
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Epidemiology National High School Federation Data 2008-
2010 250 injuries10000 athlete exposures CDC During 2001-2005 an estimated 207830
ED visits annually for concussions and other TBIs related to sports and recreational activities with 65 of TBIs among children aged 5-18 years
Increase in incidence CDC From 2001 to 2009 annual TBI-related ED visits
increased significantly from 153375 to 248418 with highest rates among males aged 10-19 years
MMWR Morb Mortal Wkly Rep 201160(39)1337-42 AJSM January 27 2012 as doi10
Monitor for initial few hours following injury or send emergently if change in behavior worsening headache vomiting seizure double vision excessive drowsiness or worsening symptoms
No RTP on day of injury
Sideline Testing
Glasgow Coma Scale (GCS) King-Devick Test Bess Test SCAT 2 Maddocks Questions
King-Devick
Test
Glasgow Coma Scale (GCS)
Basic neurological scale that quantifies level of consciousness
Score ranges from 3 (unconscious) to 15 (alert and oriented)
Most EMS protocols GCS score lt 14 should be transported to Level I or II trauma center
Inverse relationship between GCS score and positive findings on CT
King-Devick Test
Tests for eye saccade (quick simultaneous movements of eyes in same direction)
Uses charts of numbers Charts become
increasingly difficult to read as space between numbers increases
Patientrsquos speed and fluidity of reading used to derive score
K-D Test
>
BESS Testing Postural stability testing
assesses cognitive motor function
Quantifiable modified Romberg test ndash three 20-second balance tests performed on firm and foam surfaces
Postural instability communication between three sensory systems either at central or peripheral level is lost
Clinical J Sports Med 200111182-190
SCAT 2
Calculated for athletegt10 yo Preseason baseline testing can be helpful Calculated based on symptoms physical signs
Detailed neurological exam including Glasgow Coma Scale (GCS) mental status cognitive functioning gait and balance pupillary reflex cranial nerve testing
Progression since time of injury (improvement or deterioration)
Is emergent neuroimaging indicated Rule outtreat hypoxia hypercarbia and hypotension
(associated with poorer outcomes in TBI)
1) Avoid CT scans in low risk patients based on validated decision rules
2) Avoid placing indwelling catheters in stable pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first
Choosing Wiselyrdquoreg campaign during the ACEP13 annual meeting Oct 14-17
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
Monitor for initial few hours following injury or send emergently if change in behavior worsening headache vomiting seizure double vision excessive drowsiness or worsening symptoms
No RTP on day of injury
Sideline Testing
Glasgow Coma Scale (GCS) King-Devick Test Bess Test SCAT 2 Maddocks Questions
King-Devick
Test
Glasgow Coma Scale (GCS)
Basic neurological scale that quantifies level of consciousness
Score ranges from 3 (unconscious) to 15 (alert and oriented)
Most EMS protocols GCS score lt 14 should be transported to Level I or II trauma center
Inverse relationship between GCS score and positive findings on CT
King-Devick Test
Tests for eye saccade (quick simultaneous movements of eyes in same direction)
Uses charts of numbers Charts become
increasingly difficult to read as space between numbers increases
Patientrsquos speed and fluidity of reading used to derive score
K-D Test
>
BESS Testing Postural stability testing
assesses cognitive motor function
Quantifiable modified Romberg test ndash three 20-second balance tests performed on firm and foam surfaces
Postural instability communication between three sensory systems either at central or peripheral level is lost
Clinical J Sports Med 200111182-190
SCAT 2
Calculated for athletegt10 yo Preseason baseline testing can be helpful Calculated based on symptoms physical signs
Detailed neurological exam including Glasgow Coma Scale (GCS) mental status cognitive functioning gait and balance pupillary reflex cranial nerve testing
Progression since time of injury (improvement or deterioration)
Is emergent neuroimaging indicated Rule outtreat hypoxia hypercarbia and hypotension
(associated with poorer outcomes in TBI)
1) Avoid CT scans in low risk patients based on validated decision rules
2) Avoid placing indwelling catheters in stable pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first
Choosing Wiselyrdquoreg campaign during the ACEP13 annual meeting Oct 14-17
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
Monitor for initial few hours following injury or send emergently if change in behavior worsening headache vomiting seizure double vision excessive drowsiness or worsening symptoms
No RTP on day of injury
Sideline Testing
Glasgow Coma Scale (GCS) King-Devick Test Bess Test SCAT 2 Maddocks Questions
King-Devick
Test
Glasgow Coma Scale (GCS)
Basic neurological scale that quantifies level of consciousness
Score ranges from 3 (unconscious) to 15 (alert and oriented)
Most EMS protocols GCS score lt 14 should be transported to Level I or II trauma center
Inverse relationship between GCS score and positive findings on CT
King-Devick Test
Tests for eye saccade (quick simultaneous movements of eyes in same direction)
Uses charts of numbers Charts become
increasingly difficult to read as space between numbers increases
Patientrsquos speed and fluidity of reading used to derive score
K-D Test
>
BESS Testing Postural stability testing
assesses cognitive motor function
Quantifiable modified Romberg test ndash three 20-second balance tests performed on firm and foam surfaces
Postural instability communication between three sensory systems either at central or peripheral level is lost
Clinical J Sports Med 200111182-190
SCAT 2
Calculated for athletegt10 yo Preseason baseline testing can be helpful Calculated based on symptoms physical signs
Detailed neurological exam including Glasgow Coma Scale (GCS) mental status cognitive functioning gait and balance pupillary reflex cranial nerve testing
Progression since time of injury (improvement or deterioration)
Is emergent neuroimaging indicated Rule outtreat hypoxia hypercarbia and hypotension
(associated with poorer outcomes in TBI)
1) Avoid CT scans in low risk patients based on validated decision rules
2) Avoid placing indwelling catheters in stable pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first
Choosing Wiselyrdquoreg campaign during the ACEP13 annual meeting Oct 14-17
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Sideline Testing
Glasgow Coma Scale (GCS) King-Devick Test Bess Test SCAT 2 Maddocks Questions
King-Devick
Test
Glasgow Coma Scale (GCS)
Basic neurological scale that quantifies level of consciousness
Score ranges from 3 (unconscious) to 15 (alert and oriented)
Most EMS protocols GCS score lt 14 should be transported to Level I or II trauma center
Inverse relationship between GCS score and positive findings on CT
King-Devick Test
Tests for eye saccade (quick simultaneous movements of eyes in same direction)
Uses charts of numbers Charts become
increasingly difficult to read as space between numbers increases
Patientrsquos speed and fluidity of reading used to derive score
K-D Test
>
BESS Testing Postural stability testing
assesses cognitive motor function
Quantifiable modified Romberg test ndash three 20-second balance tests performed on firm and foam surfaces
Postural instability communication between three sensory systems either at central or peripheral level is lost
Clinical J Sports Med 200111182-190
SCAT 2
Calculated for athletegt10 yo Preseason baseline testing can be helpful Calculated based on symptoms physical signs
Detailed neurological exam including Glasgow Coma Scale (GCS) mental status cognitive functioning gait and balance pupillary reflex cranial nerve testing
Progression since time of injury (improvement or deterioration)
Is emergent neuroimaging indicated Rule outtreat hypoxia hypercarbia and hypotension
(associated with poorer outcomes in TBI)
1) Avoid CT scans in low risk patients based on validated decision rules
2) Avoid placing indwelling catheters in stable pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first
Choosing Wiselyrdquoreg campaign during the ACEP13 annual meeting Oct 14-17
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Glasgow Coma Scale (GCS)
Basic neurological scale that quantifies level of consciousness
Score ranges from 3 (unconscious) to 15 (alert and oriented)
Most EMS protocols GCS score lt 14 should be transported to Level I or II trauma center
Inverse relationship between GCS score and positive findings on CT
King-Devick Test
Tests for eye saccade (quick simultaneous movements of eyes in same direction)
Uses charts of numbers Charts become
increasingly difficult to read as space between numbers increases
Patientrsquos speed and fluidity of reading used to derive score
K-D Test
>
BESS Testing Postural stability testing
assesses cognitive motor function
Quantifiable modified Romberg test ndash three 20-second balance tests performed on firm and foam surfaces
Postural instability communication between three sensory systems either at central or peripheral level is lost
Clinical J Sports Med 200111182-190
SCAT 2
Calculated for athletegt10 yo Preseason baseline testing can be helpful Calculated based on symptoms physical signs
Detailed neurological exam including Glasgow Coma Scale (GCS) mental status cognitive functioning gait and balance pupillary reflex cranial nerve testing
Progression since time of injury (improvement or deterioration)
Is emergent neuroimaging indicated Rule outtreat hypoxia hypercarbia and hypotension
(associated with poorer outcomes in TBI)
1) Avoid CT scans in low risk patients based on validated decision rules
2) Avoid placing indwelling catheters in stable pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first
Choosing Wiselyrdquoreg campaign during the ACEP13 annual meeting Oct 14-17
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
King-Devick Test
Tests for eye saccade (quick simultaneous movements of eyes in same direction)
Uses charts of numbers Charts become
increasingly difficult to read as space between numbers increases
Patientrsquos speed and fluidity of reading used to derive score
K-D Test
>
BESS Testing Postural stability testing
assesses cognitive motor function
Quantifiable modified Romberg test ndash three 20-second balance tests performed on firm and foam surfaces
Postural instability communication between three sensory systems either at central or peripheral level is lost
Clinical J Sports Med 200111182-190
SCAT 2
Calculated for athletegt10 yo Preseason baseline testing can be helpful Calculated based on symptoms physical signs
Detailed neurological exam including Glasgow Coma Scale (GCS) mental status cognitive functioning gait and balance pupillary reflex cranial nerve testing
Progression since time of injury (improvement or deterioration)
Is emergent neuroimaging indicated Rule outtreat hypoxia hypercarbia and hypotension
(associated with poorer outcomes in TBI)
1) Avoid CT scans in low risk patients based on validated decision rules
2) Avoid placing indwelling catheters in stable pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first
Choosing Wiselyrdquoreg campaign during the ACEP13 annual meeting Oct 14-17
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
BESS Testing Postural stability testing
assesses cognitive motor function
Quantifiable modified Romberg test ndash three 20-second balance tests performed on firm and foam surfaces
Postural instability communication between three sensory systems either at central or peripheral level is lost
Clinical J Sports Med 200111182-190
SCAT 2
Calculated for athletegt10 yo Preseason baseline testing can be helpful Calculated based on symptoms physical signs
Detailed neurological exam including Glasgow Coma Scale (GCS) mental status cognitive functioning gait and balance pupillary reflex cranial nerve testing
Progression since time of injury (improvement or deterioration)
Is emergent neuroimaging indicated Rule outtreat hypoxia hypercarbia and hypotension
(associated with poorer outcomes in TBI)
1) Avoid CT scans in low risk patients based on validated decision rules
2) Avoid placing indwelling catheters in stable pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first
Choosing Wiselyrdquoreg campaign during the ACEP13 annual meeting Oct 14-17
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
SCAT 2
Calculated for athletegt10 yo Preseason baseline testing can be helpful Calculated based on symptoms physical signs
Detailed neurological exam including Glasgow Coma Scale (GCS) mental status cognitive functioning gait and balance pupillary reflex cranial nerve testing
Progression since time of injury (improvement or deterioration)
Is emergent neuroimaging indicated Rule outtreat hypoxia hypercarbia and hypotension
(associated with poorer outcomes in TBI)
1) Avoid CT scans in low risk patients based on validated decision rules
2) Avoid placing indwelling catheters in stable pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first
Choosing Wiselyrdquoreg campaign during the ACEP13 annual meeting Oct 14-17
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Maddocks Questions
At what venue are we today Which half is it now Who scored last in this match What did you play last week Did your team win the last game
Evaluation in ED Comprehensive history physical assessment (eg c-
Detailed neurological exam including Glasgow Coma Scale (GCS) mental status cognitive functioning gait and balance pupillary reflex cranial nerve testing
Progression since time of injury (improvement or deterioration)
Is emergent neuroimaging indicated Rule outtreat hypoxia hypercarbia and hypotension
(associated with poorer outcomes in TBI)
1) Avoid CT scans in low risk patients based on validated decision rules
2) Avoid placing indwelling catheters in stable pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first
Choosing Wiselyrdquoreg campaign during the ACEP13 annual meeting Oct 14-17
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Evaluation in ED Comprehensive history physical assessment (eg c-
Detailed neurological exam including Glasgow Coma Scale (GCS) mental status cognitive functioning gait and balance pupillary reflex cranial nerve testing
Progression since time of injury (improvement or deterioration)
Is emergent neuroimaging indicated Rule outtreat hypoxia hypercarbia and hypotension
(associated with poorer outcomes in TBI)
1) Avoid CT scans in low risk patients based on validated decision rules
2) Avoid placing indwelling catheters in stable pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first
Choosing Wiselyrdquoreg campaign during the ACEP13 annual meeting Oct 14-17
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
1) Avoid CT scans in low risk patients based on validated decision rules
2) Avoid placing indwelling catheters in stable pts who can urinate on there own
3) Avoid IV fluids in pt who are mild to moderately dehydrated unless oral rehydration fails first
Choosing Wiselyrdquoreg campaign during the ACEP13 annual meeting Oct 14-17
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Severity of Injury
Related to the burden nature and duration of symptoms
Modifiers (Zurich rsquo09) 1 Age 2 Prior ho concussion 3 Learning disability 4 Headachemigraine history Other risk factors ho neurosurgery
drugalcohol use anticoagulantantiplatelet use hemophilia
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Differential Diagnosis
Acute or subacute subdural hematoma Epidural hematoma (rapid deterioration after a
ldquolucidrdquo interval) Intraparenchymal hemorrhage Diffuse axonal injury or shear injury to white
matter (prolonged LOC and residual deficits) Second Impact Syndrome (SIS) Trauma-induced migraine
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Assessment Modalities
Evoked response potential (ERP) Cortical magnetic stimulation Electroencephalography Biochemical and CSF markers of brain injury
J Neurotrauma 2006 231201-1210
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Neuroimaging CTMRI
Whenever suspicion of intracerebral structural lesion exists1 Prolonged disturbance of conscious state2 Focal neurological deficit3 Worsening symptoms
CTMRI typically interpreted as normal symptoms more often reflect functional rather than structural disturbance
Role of fMRIPET
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Neuropsychological Testing
Evaluate brain-behavior relationships Sensitive in assessment of brain injury Unique contribution in RTP Newer computerized test batteries Validated testing Protocols for using NP as part of ldquoconcussion
planrdquo evolving
Neurosurgery 2004 541073-1078 discussion 8-80
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Neurocognitive Testing
Endorsed as a cornerstone of concussion management by Vienna and Prague Consensuses
imPACT (Immediate Post-concussion Assessment and Cognitive Testing)
Computer-based Compare baseline and post-injury scores
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Management
Physical and cognitive rest until symptoms resolve then graded program of exertion prior to medical clearance and RTP
Activities that require concentration and attention may delay recovery
Curr Sports Med Rep 2004 3316-323Consensus statement 4th International Conference Zurich 2012
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Return to Play (RTP)
All but one US states have active or pending laws on RTP for youth sports and full elimination of same-day RTP after concussive events
Refer to specialist for follow-up care and graduated RTP plan
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Consensus statement 4th International Conference Zurich 2012
Rehabilitation Stage
Functional Exercise
1 No activity Complete rest
bullimPACT testing
2 Light aerobic exercise No resistance
3 Sport-specific exercise
No head impact
4 Non-contact Progressive resistance
5 Full contact Normal training
6 RTP Normal game play
Graduated RTP
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Pharmacology
Management of sleep disturbance anxiety depression
Management of headache vomiting dizziness Before RTP the concussed athlete should not only
be symptom free but avoiding any medications that may mask or modify the symptoms of concussion
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Modifying Factors in Concussion Management
May need additional management considerations
Symptoms signs sequelae temporal threshold
Age co- and premorbidities medication behavior type of sports
Consensus statement 4th International Conference Zurich Nov 2012
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Concussion Resolution Index (CRI)
Internet based neurocognitive assessment tool for use by professionals who manage and monitor sports related concussions
Monitors sports related cognitive sequelae
Takes 25 minutes to administer
Consists of six subtests measuring reaction time object recognition recall
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Post concussion cognitive lingers A retrospective study
College football players showed mild cognitive impairment on the CRI after commonly looked at symptoms subsided
436 Columbia U football players over 11 seasons (2000-2011)
148 had at least one concussion prior to entering college
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Retrospective Study continued
All 436 received baseline CRIrsquos before football started
Total of 647 CRI obtained
70 of the 436 athletes had a concussion
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Retrospective Study Conclusion
Median time between concussions and RTP was 10 days 28 of the 70 concussed cleared to RTP had a decline in
their CRI assessment by 05 units
This is clinically significant impairment identified by cognitive testing
Key Point- DONrsquoT RUSH your players back learn how to test for concussions appropriately and follow the guidelines
Medpage Post-Concussion Cognitive Deficit Lingers Oct 16 2013
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Guidelines amp Consensuses
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Zurich Consensus Statement
Designed to incorporate and expand principles in previous consensuses (Vienna and Prague)
Simple vs complex eliminated Individualized RTP Differentiation of elite vs non-elite RTP Modifiers Same-day RTP only in very specific situations for
adult athlete
Consensus statement 4th International Conference Zurich 2012
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Team Physician Consensus Conference
Symptomatic athlete should not return to play same-day RTP controversial safest course of action hold an athlete
Care of concussed athletes ideally should be managed by healthcare professionals with specific training and experience
Additional considerations in RTP 1 Severity of injury 2 Previous injury (no severity proximity) 3 Significant injury to minor blow 4 Age sport learning disabilities
Collaboration of ACSM AMSSM AOSSM AAOS AAFP AOASM
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Injury Prevention
Helmets and mouth guards 1 Injury rates similar between helmeted and non-
helmeted sports 2 No helmet in any sports prevents concussion 3 Mouth guards do not prevent concussion but prevent
dental injury
BMJ 2005 330281-283
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
How many is too many Influence of gender and genetics on injury risk
severity and outcome Pediatric injury and management paradigms Novel technique testing for biochemical serum
and CSF markers of brain injury Rehabilitation strategies (eg exercise therapy) Novel imaging modality role of fMRIDTI Long term outcomes (eg depressionsuicide) On-field injury severity outcomes Concussion surveillance Protective factors
Future Directions
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Laws of Alaska2011
Source CSHB 15(JUD)
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Section 1
Definition epidemiology causation risks and RTP guidelines
All covered earlier
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Sec 1430142 Prevention and Reporting
Guidelines established by ASAA along with governing body of each school district to educate Coaches Athletes Parents
Guidelines include risks and standards of RTP
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
School provides this information to parentguardian of athletes under 18
Athletes under 18 can not participate in sports without signed verification stating they received the guidelines
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Suspected concussion
Athlete removed from sporting event May not return to play wo being cleared in
writing by qualified person (QP) with certified training
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
QP
Health care provider licensed in the state or exempt from licensure
Person acting under supervision who is licensed in the state
Unpaid QP may not be held liable for civil damages resulting from act or emission of eval unless found negligent or reckless in care
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
School District Immunity Sec 1430143
School district not liable for injury or death caused by concussion by actions of QP if Actioninaction occurred during delivery of service by
district or organization in compliance with AS 1430142
The organization is under contract to provide services Before services the organization provided written
verification of a valid insurance policy Compliance with protocol o prevention and reporting of
concussions required in AS 1430142
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
School District Immunity
Previous slide can not be construed to impair or modify ability of a person to recover damages
Youth organization means publicprivate organization that provides service to youth 18 years of age or younger
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
62
CERVICAL SPINE INJURIES IN SPORTS
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
63
Epidemiology
Roughly 12000 new cases of SCI a year Sports-related events causing approximately
76
Semin Spine Surg 22173-180
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Catastrophic Injury Catastrophic injury- Sport injury that resulted in a
brain or spinal cord injury or skull or spinal fracture
Classification Fatal Serious Complete and incomplete neurological recovery
National Center for Catastrophic Sport Injury Research
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
65
Sometimes you get luckyhellip
>
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
66
And sometimes you donrsquot
>
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
67
Kevin Everett
>
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
68
Kevin Everett
Buffalo Bills TE Fractured C3 and C4 on Sept 9th 2007 Everett could fill nothing below his neck
following impact He was told he would never walk again
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
They were wrong
He started walking again on December 7th 2007
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
70
How do you go from this
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
71
To this
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
How to build success
Recall the hit by Jadeveon Clowney How much time do you think-
Coaches spennt preparing and teaching him He spent practicing basic fundamentals and situational
football Scouting teams spent studying their upcoming
opponent and their style of play
ITS ALL ABOUT PREPAREDNESS
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Success continued Same principles apply to sports medicine Situational preparedness is critical to outcome Our stake are higher more is on the line then just
sporting events
The will to win is important but the will to prepare is vital
Joe Paterno
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
74
Axial loading is the primary mechanism of injury
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
75
Axial Load
J Athl Train 200540(3)155ndash161
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
76
Cervical Spine Injuries
BurnersStringers Strains and Sprains Cervical Spine Fractures Spear Tacklers Spine Herniation and Cervical Disk Disease
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
77
BurnersStingers
Transient sensory andor motor loss involving arms andor legs
2 mechanisms of injuryTraction and compression
Severity determined by amount of time that passes between loss of function and restoration of function
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
78
Traction vs Compression
Bull NYU Hosp Jt Dis 200664(3-4)119-29
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
BurnersStingers
>
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
BurnersStingers Physical Exam
Test for muscle weakness C4-C5 deltoids C5-C6 triceps C6-C7 triceps
Test for sensory loss over biceps (C5) thumb (C 6) and long fingers (C7)
Check reflexs and Spurlingrsquos sign
Tx- Rest until strength and sensation returns RTP Allowed to return when they have normal
neuro exam and full cervical ROM
Netters Sports Med copyright 2010
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
81
Question
The most common cervical injury seen in sports are stingers and burners
True or False
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
82
Sprains and Strains
Most common injury No neurological or osseous injury Cervical xray needed to ro possible fracture Pts return to play when pain is gone ROM is full
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
Traumatic burst fracture from axial load Presents with neck pain and likely neurologic injury Palpate for tendeness check ROM Plain filmsCT are diagnostic Tx unstable injury see spine surgeon RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Cervical Spine Fracture Patterns
C2 Hangmanrsquos Fracture Traumatic spondy from axial load and extension Presents with neck pain instability Palpate for tendeness check ROM Lateral filmsCT are diagnostic Tx immobilize head see spine specialists RTP not likely
Netters Sports Med copyright 2010
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Cervical Spine Fracture Patterns
Burst fractures Traumatic fractures of vertebral body from axial load
with possible retropulsion of fragments into the cord Presentation is similar Palpate for tenderness but loss of sensation or
paralysis requires trauma management which is to be discussed
Tx immobilize head ABCrsquos spine board transport to nearest ER
RTP to be discussed
Netters Sports Med copyright 2010
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Spear Tacklerrsquos Spine
Loss of Lordosis Cervical Stenosis Narrowing of disc
space Preexisting bony or
ligamentous injury seen on studies
Player should not be allowed to RTP
Bull NYU Hosp Jt Dis 200664(3-4)119-29
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
88
Spinal StenosisPlain Radiographs
Measuring canal width accurately and taken in all factors that may change canal width is difficult
Torg Ratio midsagittal diameter to the AP diameter of corresponding vertebral body
-10 is normal 08 consider stenotic most use 07 General consensus is that normal width from C3-
C7 be above 15mm and anything below 13mm AP dimension is stenotic
Bull NYU Hosp Jt Dis 200664(3-4)119-29Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Cervical Stenosis
X-ray MRI
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Torg ratio controversy Herzog found that many athletes had larger than
normal vertebral body width Blackley demonstrated that measurement of
the spinal canal by plain film radiographs is not reliable bc radiographs do not take into account the size and shape of the spinal cord the functional reserve of the spinal canal thepresence of a disc herniation if stenosis results from ligamentous hypertrophy
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Cervical StenosisNFL football players with stenosis Jermichael Finley Jarvis Jones David Wilson Chris Berman Archie Manning
>
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
92
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Defined as the loss of the cerebral spinal fluid (CSF) around the cord or actual cord deformation
Best determined with CT MRI or myelography
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Herniation and Cervical Disc Disease
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
94
Herniation and Cervical Disc Disease
Far less common than lumbar herniation Usually only affects older athletes Two types hard and soft
Bull NYU Hosp Jt Dis 200664(3-4)119-29
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
95
Herniated Cervical disc cont
Tx nonoperative unless myelopathy or progressive neurolgic deficit present
Nonoperative tx includes rest ice NSAIDS immobilization cervical traction and therapeutic injections as needed
RTP when pt regains full function without signs of neurologic complications
Bull NYU Hosp Jt Dis 200664(3-4)119-29
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
96
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
97
Following the Injury
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
98
On Field Initial Evaluation
Every patient suspected of cervical spine injury needs complete physical examination
Immobilize head and neck Assess ABCrsquos
Semin Spine Surg 22173-180
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
99
On field eval continued
Careful attention should be directed towards-neurological complaints-head trauma-headaches-mental status changes-midline spinal paintenderness
Semin Spine Surg 22173-180
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
100
On THE field eval
Following head and neck examination careful motor and sensory exam of extremities should be performed
Semin Spine Surg 22173-180
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
101
Clinical Evaluation Algorithm
Semin Spine Surg 22173-180
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Transfer of supine pt
Lift and slide maneuver used
Causes less motion of C-spine then rolling pt
DOCTOR should be head of injured athlete
Journal of Athletic Training 200944(3)306ndash331
>
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
103
Prone log roll
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Transfer Prone pt Team physician should use
multiple assistants to position pt
DOC at head Minimum of 4 with doc
controlling CS one the torso one the hips and one the legs
Log rolling is initiated by team doc controlling head and cervical spine
Pt should be rolled directly onto spine board
Journal of Athletic Training 200944(3)306ndash331
>
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Log Rolling
Key to successfully maneuvering the injured pthellip
Practice practice practice Donrsquot let the injury be the first time you try to attempt this
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Face-mask removal
Only remove equipment that may obstruct breathing
Tools and techniques that cause least amount of torque should be used
Screwdrivers are preferred over cutting tools Only cut away what can not be removed manually
Journal of Athletic Training 200944(3)306ndash331
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
107
The helmeted patient
Helmeted pts are difficult to collar Once on spine board pt can have sandbags or
foam blocks taped to board for immobilization of c-spine
Vacuum immobilizer can also be used
Journal of Athletic Training 200944(3)306ndash331
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Field to Hospital
Team physician should accompany the injured athlete
Provides Continuity of care Provides ED doc accurate clinical information
regarding pt and injury Allows the sports medicine professional to assist
emergency department personnel during equipment removal
Journal of Athletic Training 200944(3)306ndash331
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
109
ED Eval
Once pt is stable and transferred to the hospital standard diagnostic evaluation of the C-spine should be performed AP lateral and odontoid radiographs of entire cervical
spine including occiputC1 and C7T1 junctions should be obtained
Semin Spine Surg 22173-180
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
110
Plain radiographs vs CT
CT use continues to expand with cervical neck injuries
A diagnostic study showed that CT had higher sensitivity higher specificity and higher positive predictive value over plain films in viewing injury
Semin Spine Surg 22173-180
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
111
Cervical Spine injury and MRI
MRI studies are warranted when suspected ligamentous injury or cervical disc herniation is present
Semin Spine Surg 22173-180
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Cervical Spine injury and MRI
EBMedicinenet bull April 2009
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
113
RTP guidelines
Dependent of context of injury Known risk factors Number of previous injuries Pressure from player coaches and family
members Dependent on each individual pt
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
114
RTP
Generally speaking athletes can RTP when they are asymptomatic have full ROM regain preinjury strength imaging shows no evidence of functional stenosis of
spinal column Normal lordotic curve with no evidence of instability
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
115
Contraindications to RTP
Neurological findings of cervical myelopathy Continued discomfort decreased ROM Following C1-C2 fusion cervical laminectomy or
three level anterior or posterior cervical fusion Increased ligamentous laxiety (gt11degrees) Spear Tacklerrsquos spine
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
116
Conclusion
RTP following injury is complicated and pt specific
No universally accepted RTP criteria Communication is essential from time of injury to
recovery Begins with staff who have educated themselves
on what to do when they encounter these types of injuries
Rehearse correct protocol
Curr Sports Med Rep 2013 Jan-Feb12(1)14-7
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
117
Now back to the video of the kid spearing that would be tackler
USA football was established in 2002 by the NFL and the NFL Players Association
Itrsquos a nonprofit program The program was developed to change the culture
of the sport and the way it has been played with an emphasis on safety
There is a direct correlation between proper technique and decreased injury (this goes for all sports)
Millions of dollars have been donated
Headsupfootballcom
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
118
HEADS UPheadsupfootballcom
>
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
HEADS UP headsupfootballcom
Contact Information
Contact Information
David Carfagno DO CAQSM
Board Certifications Internal Medicine Sports Medicine (CAQ) Ringside Medicine (ABRM)
Medical Director Ironman Arizona Team physician USA Boxing and ATPWTA professional
tennis
10133 N 92nd Street Suite 102Scottsdale AZ 85258Office ndash 4806644615
Email ndash davidcarfagnogmailcom
Head and Neck Injuries in Sports
My Life
Slide 3
Medical Team Progression
Sports Medicine Mentality
Epidemiology of Sports Injuries
Slide 7
Temporal Awareness
Disposition
Question Concussion
Key Points
Concussion
Overview
Definition
Mechanism of TBI
Video Concussion
Neuron
Dr Cantu
Common Features
Pathophysiology
Genetics
Epidemiology
Concussion Signs amp Symptoms
On-fieldSideline Evaluation
Sideline Testing
Glasgow Coma Scale (GCS)
King-Devick Test
BESS Testing
SCAT 2
Maddocks Questions
Evaluation in ED
ldquoChoosing Wiselyrdquo by ACEPrsquos Board of Directors
Severity of Injury
Differential Diagnosis
Complications of TBI
Assessment Modalities
Neuroimaging
Neuropsychological Testing
Neurocognitive Testing
Management
Return to Play (RTP)
Graduated RTP
Pharmacology
Modifying Factors in Concussion Management
Concussion Resolution Index (CRI)
Post concussion cognitive lingers A retrospective study
Retrospective Study continued
Retrospective Study Conclusion
Guidelines amp Consensuses
Zurich Consensus Statement
Team Physician Consensus Conference
Injury Prevention
Future Directions
Laws of Alaska 2011
Section 1
Sec 1430142 Prevention and Reporting
Slide 57
Suspected concussion
QP
School District Immunity
School District Immunity
CERVICAL SPINE INJURIES IN SPORTS
Epidemiology
Catastrophic Injury
Sometimes you get luckyhellip
And sometimes you donrsquot
Kevin Everett
Kevin Everett (2)
They were wrong
How do you go from this
To this
How to build success
Success continued
Axial loading is the primary mechanism of injury
Axial Load
Cervical Spine Injuries
BurnersStingers
Traction vs Compression
BurnersStingers (2)
BurnersStingers (3)
Question
Sprains and Strains
Cervical Fractures
Cervical Spine Fracture Patterns
Cervical Spine Fracture Patterns (2)
Cervical Spine Fracture Patterns (3)
Spear Tacklerrsquos Spine
Spinal Stenosis Plain Radiographs
Cervical Stenosis
Torg ratio controversy
Cervical Stenosis (2)
ldquoFunctionalrdquo Narrowing of the Spinal Canal
Herniation and Cervical Disc Disease
Herniation and Cervical Disc Disease (2)
Herniated Cervical disc cont
Slide 96
Following the Injury
On Field Initial Evaluation
On field eval continued
On THE field eval
Clinical Evaluation Algorithm
Transfer of supine pt
Prone log roll
Transfer Prone pt
Log Rolling
Face-mask removal
The helmeted patient
Field to Hospital
ED Eval
Plain radiographs vs CT
Cervical Spine injury and MRI
Cervical Spine injury and MRI (2)
RTP guidelines
RTP
Contraindications to RTP
Conclusion
Now back to the video of the kid spearing that would be tackler
