Cervical Spine Injuries in Olympic Athletes

Although Olympic athletes are among the best trained and achieve the highest state of physical conditioning, they are still susceptible to sport-related injuries. When these well-conditioned athletes subject their musculoskeletal systems to the extreme physical requirements of Olympic competition, they increase the risk of injury to their cervical spine (Fig.1).

Approximately 10,000 severe cervical spine (neck) injuries occur annually in the United States, with about 1,000 of these injuries resulting from sport-related events. Olympic-level athletes share the rare but potentially catastrophic risk of severe cervical spine injury. For example, in the fall of 2001, German ski coach Markus Anwanda underwent spinal surgery after he sustained spine and head injuries in a collision with World Cup champion Regine Cavagnoud. Tragically, Cavagnoud, a French Olympic hopeful, died from her head injuries two days after the accident.

Many Winter Olympic sporting events have an increased risk of cervical spine injury because of the speed at which the athlete travels and the potential for contact with other athletes or the surrounding terrain. High-velocity events, such as downhill skiing, ski jumping, and toboggan racing, carry a greater risk for cervical spine injury than lower-velocity events, such as ice hockey, figure skating, or curling.

Cervical sprain or strain
The most common cervical condition occurring in the athletic and nonathletic populations is the muscle sprain or ligament strain. Symptoms from cervical sprains or strains include localized (restricted to one area) tightness on one side of the neck that is associated with pain and limited motion in the neck. This condition often becomes noticeable 12 to 24 hours after an injury. This condition is known by many as a "crick" in the neck. It usually subsides with ice or moist heat, gentle stretching exercises, and anti-inflammatory medications, such as aspirin or ibuprofen. Athletes with cervical sprains or strains are rarely limited from returning to their sport.

Cervical facet syndrome
A more serious cervical sprain or strain affects the small facet joints that connect one cervical vertebra to another. Cervical facet injury occurs when the joint capsule and spinal ligaments are stretched and the small muscles that attach to the vertebra are strained (Fig. 2A). Symptoms include localized neck pain; pain that extends to the shoulder, arm, or upper back; limited movement; and, sometimes, headaches. The symptoms often occur immediately after a traumatic injury, such as a sudden neck rotation in a whiplash injury or sideways bending that can occur from a fall. Physical therapy or chiropractic treatments and anti-inflammatory medication or muscle relaxants will usually resolve the symptoms of cervical facet syndrome.

Cervical radiculopathy
Cervical nerve root impingement (pinching of the cervical nerve) results from a disc herniation (a protruding disc) or from a nerve entrapped between bony structures (Fig. 2B). Forced hyperextension (extension beyond normal limits) of the cervical spine or axial (rotation around a straight line) loads can contribute to this condition. Symptoms include localized pain or pain that extends from the neck into an extremity. For example, an injury to a vertebra or disc in your neck could cause pain, numbness, or weakness in your shoulder, arm, or hand. This condition occurs because the nerves that extend from between the cervical vertebrae provide sensation and trigger movement in these areas. An injury near the root of the nerve can cause pain at the end of the nerve, where the sensation is felt. Patients often feel relief by holding the affected extremity over their head, taking pressure off the irritated nerve root. X-rays of the cervical spine rarely show the source of the pain; however, the magnetic resonance imaging (MRI) scan, a test that shows soft tissue, can easily confirm the diagnosis. Cervical traction and a brief dose of oral corticosteroids to reduce inflammation and analgesics to relieve pain are usually effective treatment. Athletes with signs and symptoms of cervical radiculopathy (sensory or motor abnormality), such as numbness or weakness of a limb, are closely monitored by their athletic trainer and physician. Improvement usually occurs within 2 to 3 months in 65% to 70% of patients with cervical radiculopathy. Surgery is reserved for those patients whose symptoms persist beyond this point. Return to sport is possible when the athlete's symptoms resolve and nerve function returns to normal.

Transient quadriplegia
Transient quadriplegia results from a more serious but temporary injury to the cervical spinal cord. Nerve dysfunction can occur in one or both arms, one or both legs, all four extremities, or an arm and leg on the same side of the body. Patients can have numbness or pain, with or without weakness, or complete paralysis. The typical episode of transient quadriplegia lasts less than 15 minutes but can take up to 48 hours to gradually resolve. There is complete return of motor function and sensation and full, pain-free range of motion of the spine. When this dramatic condition occurs, the athlete should be treated with all the precautions for a cervical spine injury, including immobilization of the head and neck and transport to an emergency facility. X-rays and MRI can reveal the presence of a fracture, disc herniation, or congenital (present at birth) narrowing of the central spinal canal. However, the imaging studies are usually normal in transient quadriplegia. Once an athlete has experienced an episode of transient quadriplegia, there is a 40% chance of a second episode. As long as there is no evidence of abnormal motion between the vertebrae or spinal cord compression, athletes are allowed to return to sporting activities without increased risk of permanent nerve injury.

Cervical spine fracture
Athletes with high-energy trauma to the head or neck must be assumed to have a cervical spine injury until proven otherwise. Proper management begins on the scene with examination and treatment of these patients by emergency personnel, such as athletic trainers. Although they are rare, catastrophic cervical spine injuries during athletic events require prompt treatment to prevent further nerve injury and to improve the chances for recovery.

Nearly 50% of patients with acute spinal cord injury have other significant skeletal or organ injuries. The radiographic evaluation of these patients includes x-rays, computed tomography (sectional x-rays), and MRI to confirm the presence of a cervical spine fracture or other injuries and to determine fracture stability. Many cervical spinal fractures are treated with a neck brace, while some patients with unstable injuries and persistent symptoms require surgery.

Return to sport
Most athletes who sustain a minor cervical strain, cervical facet syndrome, or cervical radiculopathy are able to return to competitive sports once their symptoms improve. However, patients with cervical spine fracture with resulting instability, those with congenital narrowing of the cervical spinal canal, and those who have had surgical fusion rarely return to competitive sports because of the risks of reinjury to the cervical spine.

Thomas M. Bernard, Jr., M.D.
Columbus, Georgia

Further Reading:
Vaccaro AR, Watkins B, Albert TJ, Pfaff WL, Klein GR, Silber JS. Cervical spine injuries in athletes: current return-to-play criteria. Orthopedics. 2001;24:699-703.
Corcoran T, Cantu R. Transient quadriplegia. Spineline. 2000;Nov/Dec:11-12. Max J. Prehospital care of the spine-injured athlete. A document from the Inter-Association Task Force for Appropriate Care of the Spine-Injured Athlete. National Athletic Trainers' Association, 1998.