Working Diagnosis:
Cervical cord neurapraxia
Congenital cervical canal stenosis

Treatment:
He was discharged from the ER with instructions to follow up with a spine specialist to discuss return to play.

Outcome:
The patient's symptoms resolved. The visiting team physician cleared him for return to contact sports. He finished the football season with no further symptoms.

Author's Comments:
Cervical cord neurapraxia consists of sensory and/or motor changes in two or more extremities. It is believed to be associated with congenital stenosis. The torg ratio on C-spine x-rays is a method used to assess the size of the cervical canal. Current studies have raised concern regarding its validity in athletes with large vertebral bodies. Bilateral upper and/or lower extremity neurologic symptoms should prompt further imaging of the C-spine. Athletes may describe this as a “both arm stinger." No known cases of CCN have led to quadriplegia, though there are rare reports of permanent neurologic symptoms. Recurrent CCN occurs in up to 56% players who return to play. Controversy still exists regarding return to play due to lack of data given low incidence of CCN.

Editor's Comments:
This case highlights the gray area in management of cervical cord neuropraxia, an extremely rare event occurring in 0.17 per 100,000 high school athletes and 2.05 per 100,000 college athletes. The infrequent occurrence of CCN makes data-driven analysis difficult and instead pushes us toward acceptance of expert opinion in the management of these athletes.
A recent meta-analysis summarizes the paucity of data on the controversial subject, concluding there is weak evidence patients with CCN and evidence of cord compromise should be withheld from sport and that there is strong evidence patients without cord compromise should be allowed to return to play. CCN is best imaged with MRI as plain x-ray is unreliable in showing cord stenosis. Reoccurrence of CCN is associated with a decrease in Torg ratio (0.65 vs 0.72), canal diameter (8.7 vs 10.1 mm), and space available for the cord (1.1 vs 2.0 mm). However, none of the 110 athletes in this study experienced permanent sequelae, making it difficult to include these criteria as absolute contraindications to return to play. Based on these imaging critera,it would seem that the patient in our case was safe to return to play.
However, a few absolute contraindications do exist, including demonstrated instability, permanent neurological deficit, return to baseline > 36 hours, various congenital abnormalities, multilevel fusions, basilar invagination, prior laminectomy, and a few other rare conditions. Some of these conditions have documented reports of athletes who returned to play after CCN only to suffer permanent neurologic damage including quadriplegia. Perhaps the most important to our case is permanent neurological deficit, which our patient seems to have based on his decreased sensation to light touch over the left antecubital fossa.
In conclusion, undoubtedly the debate will continue as long as definitive data is absent, but it seems that although the reoccurrence rate is very high, there is little evidence to suggest permanent damage results in return to play for patients with mild stenosis. Nevertheless, expert consensus is to exclude these athletes from return to play. Some data does exist to conclude that patients with instability, permanent neurologic deficit, or slow return to baseline should not be returned to play under any circumstance.

References:
1. Boden, BP. Cervical spine injuries. In: Seidenberg, PH, and Beutler, AI, eds. The Sports Medicine Resource Manual. 1st ed. Philadephia, PA: Saunders Elsevier; 2008: 279-280.
2. Boden, BP, et al. Catastrophic cervical spine injuries in high school and college football players. Am J Sports Med. 2006; 34 (8):1223-1232.
3. Torg, JS., et al. The relationship of developmental narrowing of the cervical spinal canal to reversible and irreversible injury of the cervical spinal cord in football players. J Bone Joint Surg Am. 1996; 78: 1308-14.
4. Torg, JS., et al. Cervical cord neurapraxia: classification, pathomechanics, morbidity, and management guidelines. J Neurosurg. 1997 Dec; 87: 843-850.
5. Brigham, CD., Adamson, TE., Permanent partial cervical spinal cord injury in a professional football player who had only congenital stenosis: A case report. J Bone Joint Surg Am. 2003; 85: 1553-1556.


ADDITIONAL EDITOR REFERENCES
1. Dailey A, Harrop JS, France JC. High-energy contact sports and cervical spine neuropraxia injuries: what are the criteria for return to participation? Spine. 2010 Oct 1;35(21 Suppl):S193-201.

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