Cervical Trauma in a Young Football Player
The patient is a 16-year-old high school football player with a history of neck pain that developed the previous season following a tackle maneuver. Neck pain lasted for a month. He now presents with severe neck pain and transient quadriparesis following a recent tackle.
The patient has restricted neck range of motion but is neurologically intact.
Figure 1. Lateral cervical x-ray
Figure 2A. Flexion x-ray
Figure 2B. Extension x-ray
Figure 3A. Axial CT scan of C2
Figure 3B. Sagittal CT scan shows nonunion of prior Hangman's fracture
Figure 4. Sagittal T2 MRI showing recent ligament injury and possible C2-C3 disc injury
There is nonunion of a prior Hangman's fracture and recent ligament and disc injury.
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C2-C3 anterior discectomy and fusion.
Figure 5A. Postoperative anterior x-ray
Figure 5B. Postoperative lateral x-ray
Figure 6A. Postoperative axial CT scan at C2
Figure 6B. Postoperative sagittal CT scan showing sagittal reconstruction
At 1-year postop, the patient has no neck pain. He has full cervical range of motion.
There is a lingering question: Can he return to playing football?
This case presents an interesting question of return to high impact sports following a C2-C3 ACDF with plating for a non-union of a Type I Hangman's fracture. In short, with a continued incompetent posterior column, my answer is NO.
High impact sports are too risky for this situation. However, much more knowledge and controversy can be garnered from this case.
First, if this had been a fresh fracture on presentation, the ideal treatment would have been direct reduction and trans pars / pedicle screw stabilization of C2. In that case, after fusion was assured, the patient's anatomy would be essentially returned to normal - and, I believe this athlete could return to any form of sports.
Second, what about when the patient did present? Could a trans pars / pedicle screw stabilization have been attempted then? Traditional wisdom says no. However, as long as the patient is thoroughly informed of the possibility that another surgery would be necessary if the fusion failed to occur, I think that could have been attempted. Given his age and the option of utilizing BMP, I think his chances of fusing would actually be quite high. In that case, his anatomy would be returned to normal, a fused segment avoided, and he could return to active sports. If it failed, his only loss would be a second surgery for the anterior fusion.
Each patient, of course, would have to make their own decision regarding risk vs. benefit. In such a young athlete, however, a second operation might be a very reasonable risk to accept, given the potential benefit of near normal anatomy and life style.
The comments made by Dr. Fessler are quite informative. The risk / benefit of direct reduction and trans pars / pedicle screw stabilization in acute management C2 of Type I, Type II and Type IIA (following reduction) is unsettled. Acute screw fixation would have likely returned this athlete to play (if discovered at the time of injury) but, halo immobilization would have likely also obtained the same result.
I felt the associated C2-C3 disc injury, the episode of transient quadriparesis, and the sclerosis of the old fracture site precluded pars / pedicle screw stabilization in acute management.
With a solid fusion between C2 and C3, I felt the risk of injury due to instability was small but there was some increased risk to the present C2-C3 fusion and direct impact to the upper posterior cervical spine. The patient and his parents (following discussion) agreed to restrict activity for collision sports but he continues to play high school basketball and baseball.