01.05.11

Football Head and Neck Injuries

Posted in Injury at 3:20 PM by Dr. Greathouse

American football is among the most popular sports in the United States with the most potential for serious injury. Players at all ages and skill levels are at significant risk. There has been growing concern recently regarding the long term-risks of repetitive head injuries. A small but stable number of direct and indirect deaths from football occur every year, and players are at risk for significant neurologic and musculoskeletal morbidity. The spectrum of injuries is diverse and is related to both the impact and the playing conditions. Clinicians must be vigilant about the diverse presentations of football injuries as the potential complications of returning to play before a player is safe can be devastating. The T1-weighted MRI shown demonstrates a facet dislocation of C7 on T1, a potential complication of axial loading while tackling.

From 1931 to 2007, the National Center for Catastrophic Sport Injury Research reported 1006 direct and 683 indirect fatalities resulting from participation in organized football (high school, college, and professional) in the United States. Data from the report over the last decade are shown, which demonstrate no significant improvement in mortality despite increased awareness of football injuries. Although sports injury-related deaths are rare, injury to the head or neck is the most common cause of death, followed by heatstroke. Sports-related head injuries result in 21% of all traumatic childhood brain injuries in the United States. (Chart created with information from the National Center for Catastrophic Sport Injury Research.)

A concussion or mild traumatic brain injury is a transient alteration of mental status induced by traumatic biomechanical force, with or without a loss of consciousness. There are over 40,000 concussions suffered every year among high school players. Diagnosis is clinical as routine imaging studies of the brain are typically normal. A brain contusion is a more serious injury associated with localized structural damage and bleeding, often from multiple microhemorrhages, which is readily apparent on CT scans (arrows). They are most commonly found in the frontal and temporal lobes.

In 1994, the National Football League (NFL) initiated a comprehensive clinical and biomechanical research study of mild traumatic brain injury, a study that is ongoing. In 2009, the NFL commission reported that memory-related diseases, like Alzheimer disease, occurred in former NFL players at 19 times the normal rate in men ages 30-49. There is a growing controversy about whether football players are adequately protected from the long-term complications that develop years after they retire. Pathology studies show diffuse brain parenchymal atrophy with advanced Alzheimer disease. Other studies have shown that players who suffered concussions were also more likely to suffer from depression.

Cervical spine injuries are estimated to occur in 10%-15% of football players. A neck sprain commonly occurs as the result of a hyperextension or hyperflexion injury. The result may be injury to cervical muscles, ligaments, intervertebral joints, cervical disks, and nerve roots. Pain may be present immediately after the injury or be delayed for several days. Other symptoms may include shoulder and back pain, numbness or tingling in the upper extremities, headache, and dizziness. Players should not tackle with their head down, as this increases the risk for spine injuries. Straightening of the normal lordotic curve of the cervical spine is commonly found after whiplash injuries, thought to be secondary to spasm or guarding (shown).

Cervical subluxation, dislocation, or fracture occurs when significant axial loading forces are applied to the c-spine. Spearing is when a football player uses his helmet as the first point of contact with another player and is a significant cause of c-spine injuries and quadriplegia. Patients must be assessed anatomically, radiographically, neurologically, and physiologically. The most important initial consideration in a suspected c-spine injury is maintaining immobilization to avoid further injury regardless of current neurologic symptoms. Until stability can be established, all players must have their cervical spine immobilized. Plain x-rays are usually sufficient to diagnose injuries, like jumped facets of C4 on C5 in this x-ray, but in some cases CT, MRI, or both are needed.

Chronic disk changes, such as disk space narrowing, occult fracture, or degenerative changes, are very common among football players. MRI imaging in these patients often reveals disk bulge without obvious herniation. Treatment for these players is conservative.

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