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However, risk cannot be totally eliminated. Natural concerns around the occurrence of such injuries in contact sport have led to calls for the safety of such sports to be improved. In Rugby Union, the Sports Collision Injury Collective—an international group of academics—has recently called for rugby to become a noncontact sport in the under age group.
Hence, to better understand the magnitude of catastrophic cervical injury among elite athletes participating in contact sport, we sought to answer the following questions:. What is the incidence of catastrophic cervical spine injuries CCSIs among elite athletes participating in contact team sports? Does the incidence vary depending on whether the elite athlete is protected shoulder pads and or helmet or unprotected? Information sources: PubMed and Embase were searched for studies published from January 1, to January 29, , and the bibliographies of the included articles were searched.
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The search strategy can be found in the online supplementary material. Inclusion criteria: 1 elite-level athletes aged 17 years or older in a contact team sport rugby, American style football, Gaelic football, hurling, ice hockey, soccer, Australian rules football, lacrosse ; 2 prospective or retrospective longitudinal design that captures injury event and exposure number of people and or time at risk ; 3 studies providing recent estimates at least some data reported during or after the year Exclusion criteria: 1 athletes participating in skiing, wrestling, gymnastics, baseball, swimming, diving, or track and field; 2 noncervical injuries or nonserious or transient cervical injuries; 3 cross-sectional design or study only providing counts; 4 no estimates of incidence during or after the year ; 5 recreational play without inclusion of elite athletes—in cases where data from elite and recreational athletes was combined, we included, noting the mixed population.
Outcomes: Catastrophic outcomes of cervical spine injury included 1 fatality due to traumatic cervical spinal injury; 2 severe nonfatal traumatic cervical spinal injury causing permanent severe functional disability.
Data collection process and items: Data was extracted by a single individual and verified independently by a second using a preestablished data abstraction form. Authors of publications were contacted in cases where data needed confirmation or clarification. The following data items were sought: study design, sport, country, years of data collection, definition of catastrophic injury, data source of injury, data source identifying population at risk, incidence of catastrophic injury, and activity within the sport causing the injury.
Risk of bias evaluation: Each study was evaluated for risk of bias using criteria to judge articles on prognosis. These ratings can be found in the online supplementary material. Analysis and synthesis of results: The incidence rates were recorded as the number of CCSIs per , population at risk per year, or per , player-hours.
In some publications, nonpermanent cervical spine injuries were reported alongside permanent injuries. When possible, only permanent injuries were included.
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However, in some cases it was not always clear whether an injury resulted in permanent neurologic deficit. When this result was unknown, the cases were included and identified as such in the appropriate results table and text. Details about this system can be found in the online supplementary material. We identified 14 studies among 16 publications meeting the inclusion criteria Fig. A list of excluded articles can be found in the online supplementary material. In four rugby studies, data was presented for elite and recreational players together.
Five studies evaluated catastrophic spine injuries based on time at risk for injury during match competition in male elite Rugby Union players during World Cup or season match play Table 2. There was no indication as to whether the cervical dislocation resulted in permanent spine injury. Assuming the case resulted in a CCSI, the incidence rate would be 4. Four studies used annual counts in the denominator from mixed populations of elite and recreational rugby players from Australia, 6 13 France, 1 and South Africa 9 Fig.
The incidence varied between 1. Berry et al compared the injury rate between Australian Union and League players and found a fourfold increase in the rate of tetraplegia comparing Union with League players schoolboy and adult elite and recreational players combined , 6.
Incidence risk of catastrophic cervical spine injury in a mixed population of elite and recreational rugby players. There were no CCSIs in one small study in hurling. Two studies in Rugby Union 1 9 and two studies looking at both Rugby Union and Rugby League 6 13 identified the game activity in which each injury occurred Table 3.
Both studies included elite and recreational athletes. One study in professional football 15 and two studies in American high school or college football 14 16 19 20 21 22 reported the proportions of CCSI by activity Table 4. No studies were identified evaluating the influence of protective gear e. CCSIs are infrequent among athletes participating in elite-level contact team sports Table 5. There is moderate evidence that the rate among elite Rugby Union players is 4. Among a mixed population of elite and recreational rugby players, there is low evidence that the rate ranges from 1.
There are no studies directly evaluating the influence of protective gear on the incidence rate of catastrophic cervical injury. However, the evidence in determining the rate estimates by activity is low. A year-old Division II collegiate defensive back was injured during a practice tackling drill.
He had immediate onset of C6 quadriplegia. His injury radiograph revealed a fracture dislocation of the C5—C6 level Fig. The lateral computed tomography scan at the time of injury showed significant compromise of the spinal canal Fig. The immediate postoperative lateral radiograph revealed good realignment and fixation of the C5—C6 fracture dislocation Fig. However, postoperative T1-weighted magnetic resonance imaging MRI revealed significant cord injury at the level of the fracture dislocation, and the T2-weighted MRI image revealed injury to the cord extending from C4 to C7 Figs.
The lateral cervical radiograph 1 year postoperatively revealed good healing. At that time, he was functioning as a C7-level quadriplegic Fig. Lateral computed tomography scan at the time of injury showed significant compromise of the spinal canal. Immediate postoperative lateral radiograph reveals good realignment and fixation of the C5-C6 fracture dislocation. T1-weighted magnetic resonance image MRI postoperatively reveals significant cord injury at the level of the fracture dislocation. A year-old professional premiership rugby player was bending down at ruck to pick up the ball at breakdown when the opposition forward came through and kneed him accidentally in the head while the head was in the flexed position.
On examination, the patient was found to have a Glasgow Coma Scale rating of 15 with an American Spinal Injury Association Grade B status with a motor score of 8, but some lower extremity sensation. Imaging confirmed a bilateral C5—C6 facet dislocation Figs. After completion of the imaging tests and hemodynamic resuscitation, surgical reduction was planned for the next morning. The patient became increasingly obtunded during the night.
Cranial MRI obtained overnight before the planned surgery showed infarcts in the cerebellum and posterior cortex of the right hemisphere Fig. Clinically the patient fell into a deep coma and despite critical care interventions never recovered brain function. He was declared brain-dead several days later without ever having received spine care. Lateral cervical spine radiograph confirming bilateral C5—C6 facet dislocation.
A, B A prereduction T2-weighted and short tau inversion recovery sequence magnetic resonance imaging with persistent C5—C6 dislocation leading to high-grade cord impingement with cord signal changes and extensive posterior ligamentous injury. A, B Left- and right-sided parasagittal reformatted computed tomography scans confirm bilateral facet dislocation with a left-sided perched facet and a complete dislocation contralaterally. A, B Axial computed tomography and an angiogram show an occluded right-sided vertebral artery from the C5 level rostrally.
A, B Cranial magnetic resonance imaging shows infarcts in cerebellum and posterior cortex of the right hemisphere. Recently, there has been an increased awareness for acute and cumulative head trauma relative to impact sports. The ill effects of repetitive concussive trauma on brain health and its potential association with disorders such as chronic traumatic encephalopathy are being investigated in an unprecedented manner for sports like American football and various forms of rugby, as well as soccer. Despite occasional high-profile cervical spinal cord injuries in these particular sports, there has been no major systematic effort to explore the association of high-impact contact, elite-level sports with CCSIs considering variables such as sports type, position, or age group, nor a more detailed consideration of the effect of protective gear and rule changes on prevention or causation of serious cervical spine injuries.
Given the proximity of the head and the cervical spine, experts have also started questioning the effect of head trauma on the cervical spine. As a foundational study, an international panel of sports medicine and spine surgeon experts who deal with high-impact, elite-level contact sports from eight countries assessed the recent incidence of CCSI in these sports. In addition, the panel attempted to answer whether protective gear had an effect in either preventing or increasing catastrophic cervical injuries. Gear innovations can result in significant decreases in catastrophic injuries when used properly as exemplified by the mandated wear of the head and neck support HANS device for all drivers who participate in elite levels of motorsports such as the National Association for Stock Car Auto Racing NASCAR and Formula One.
This HANS device locks the head to the body during impact. In the time HANS use has been mandated, there have been no deaths from skull base fractures. Similar results have also been seen with the use of omnidirectional suspension used in motorcycle and bicycle helmets to reduce risk of concussion. The NFL is interested in this technology for use in football helmets.
Moreover, those wearing protective gear may use the defensively intended game wear as an offensive impact weapon. The assessment of player position could also allow for some inferences in this regard. In particular, the contrast of American football, with an ever-increasing emphasis on protective gear, and rugby both Union and League , where protective gear is de minimis by intent, also invites a comparison to this end.
In American football, the antispearing rule was implemented in , which outlawed making a tackle or block by leading with the head or face, essentially using the helmet as a weapon. The antispearing rule reduced the incidence of spine injuries from 20 per year during through to 7.
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