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Emergency Department Evaluation: Selected Neurologic Injuries

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Emergency Department Evaluation: Selected Neurologic Injuries

Emergency Department Evaluation: Selected Neurologic Injuries

While a full discussion of neurologic sports injuries is beyond the scope of this article, the January 2000 issue of Emergency Medicine Practice, "Mild Head Trauma: Appropriate Diagnosis And Management," provides an excellent overview. For a complete discussion of cervical spine injuries, see the October 2001 issue of Emergency Medicine Practice, "Cervical Spine Injury: A State-Of-The-Art Approach To Assessment And Management."

Brachial Plexus Injuries

Brachial plexus injuries are common in contact sports, especially football and rugby. A "stinger" or "burner" is classically defined as unilateral burning dysesthesias from the shoulder to the hand, with occasional weakness or numbness in the C5 and C6 distribution.33 The mechanism of injury is usually sudden forced flexion forward or laterally of the cervical spine, resulting in a stretch injury, presumably to the sixth cervical spinal nerve root.

For the vast majority of brachial plexus injuries, the consequences of cervical root strains are minimal. Patients experience pain, numbness, and tingling of the extremity opposite to the direction of lateral bending (i.e., if the head is forced to the left side, the right arm will be affected). Rarely, there can be more severe damage to the nerves. The symptoms typically last minutes but can persist for days to weeks. The unilaterality, brevity, and pain-free range of motion in the athlete can assist in discriminating between a "stinger" and a cervical cord injury.33 Neck pain is usually not a prominent feature in traction injuries.34

ED examination of brachial plexus injuries should include a thorough neurological examination. Compare the strength and sensation to the non-affected side. Additionally, examine the cervical spine and image when indicated. (See the October 2001 issue of Emergency Medicine Practice.) MRI is reserved for patients in whom a cervical spinal cord injury cannot be excluded or an as outpatient test for those with persistent symptoms.34

Rest and NSAID therapy may be helpful. Patients should have a thorough and normal neurological examination before resuming athletic activities. Some may benefit from a short course of physical therapy.34,35

Transient Quadriplegia

Transient quadriplegia most frequently occurs with an axial load injury to the cervical spine, or after hyperextension or hyperflexion.36 Typically, the patient experiences transient upper- and lower-extremity paralysis and numbness, which resolves over a period of minutes. Plain radiographs and computed tomography of the spine, as well as MRI of the spine, are usually normal (but still may be indicated depending on the clinical circumstances, such as cervical spine tenderness, etc.). Before the athlete is allowed to return to play, spinal stenosis must be ruled out, since this is an absolute contraindication for return to training.36 Cervical spinal stenosis can increase the risk of permanent neurologic injury.37,38

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