Rugby injuries to the cervical spine and spinal cord: a 10-year review.

A 10-year review (1987-1996) of injuries sustained to the spine and spinal cord in rugby players with resultant paralysis has been undertaken. This article reviews that the incidence of serious rugby spine and spinal cord injuries in South Africa has increased over the 10-year period reviewed, despite stringent new rules instituted in an attempt to decrease the incidence of these injuries. The mechanisms of injury, as previously reported, remain the same as well as the phases of game responsible for injury of the tight scrum, tackle, rucks, and mauls. Two new observations are reported: the first is related to the occurrence of spinal cord concussion with transient paralysis, and the second is related to the increased incidence of osteoarthritis of the cervical spine in rugby players.

Bodysurfing injuries of the spinal cord.

In a group of 104 patients paralysed as a result of injury while swimming or diving, 3 patients were identified in whom the injury was sustained during bodysurfing. The mechanism of the injury and the clinical and radiological findings in this group differ markedly from the findings in the 101 patients paralysed after diving into shallow water. The 3 patients were significantly older with a mean age of 46 years. No fracture or dislocation of the cervical spine was present, but evidence of osteo-arthrosis was present in all cases. The pattern of spinal cord injury was that of incomplete paralysis consistent with the central cord syndrome. This combination of findings suggests that the mechanism of injury was forced hyperextension of the head and neck due to the surfers having been caught up in turbulent wave action and driven into the sandy sea bottom.

Avascular necrosis of the hip in systemic lupus erythematosus: the role of magnetic resonance imaging.

The value of magnetic resonance imaging (MRI) in the early diagnosis of avascular necrosis (AVN) of the hip in SLE was investigated. Twenty females with severe SLE were studied prospectively. Each underwent 6-monthly X-rays, technetium -99m (Tc-99m) pyrophosphate bone scans and MRI of the hips over a 3-yr period. AVN was diagnosed in five hips of three patients (15%) during the study period. It was confirmed histologically in three hips of two patients who underwent core decompression. Radiological evidence of AVN was present in two patients at diagnosis. One patient developed progressive radiological changes despite core decompression. Bone scintigraphy was abnormal at some stage in all three patients with AVN however failed to detect the early ischaemic stage of AVN. MRI was the most reliable investigation and was able to detect asymptomatic AVN prior to the appearance of radiological or scintigraphic abnormalities.

Spinal cord concussion in rugby players.

During an analysis of a group of 40 rugby players who had sustained cervical spinal cord injury, 9 players were identified who had sustained only transient paralysis. These players showed no radiologic evidence of any injury to the cervical spine. We did a retrospective analysis of the clinical and radiological findings in this group of rugby players. The cervical spine radiographs were analyzed for evidence of spinal stenosis, congenital anomalies, and degenerative disk disease. Using the ratio method of assessment for spinal stenosis, we found spinal canal narrowing maximally at C-3 and C-4 in five of the nine players. In the remaining four players, one showed evidence of osteoarthritic change at two levels while another had congenital fusion of two vertebral bodies. In two players, no radiologic evidence of any abnormality was detected. The mechanism of transient disturbance of the spinal cord function after trauma is discussed here.

A retrospective study of spinal cord injuries in Cape Province rugby players, 1963-1989. Incidence, mechanisms and prevention.

A retrospective study was undertaken to determine aetiological factors for 117 catastrophic neck injuries in rugby players admitted to the Spinal Cord Unit, Conradie Hospital, Cape Town, between 1963 and 1989. Nineteen of these players were known to be dead; the files of another 10 were missing. Questionnaires were sent to the remaining 88 players and 52 responded (59%). Their data were supplemented with information obtained from the medical records of the patients who did not respond. The annual number of admissions increased dramatically after 1976 with 83% of all injuries occurring after that date. A further increase since 1984 contrasts with a falling incidence of these injuries in Britain, Australia and New Zealand. Increased risk of injury was related to the following factors: 98% of injuries occurred in matches and 81% were incurred by adults; 69% of injuries occurred in age-group A team or senior first team players; and 57% of injuries occurred in the tackle situation and 39% in scrums, rucks and mauls. Hooker, centre and flyhalf were the playing positions at greatest risk. Injuries were more common in early season matches and again after the mid-season break. This study confirmed that spinal cord injuries occur under predictable circumstances and are therefore foreseeable and preventable. The high incidence of these injuries in the Cape Province is as unacceptable today as it was when first reported in 1977.

Paralysis due to the high tackle--a black spot in South African rugby.

The high tackle around the neck is illegal but still commonplace in South African rugby. An analysis of 40 rugby players who sustained spinal cord injury during the period 1985-1989 revealed that 8 were injured by a high tackle. The case histories and radiographs of these 8 players were analysed. The majority sustained flexion-rotation injuries after being tackled from the side. Another mechanism of injury was hyper-extension during a tackle from the rear. Disturbingly, 4 of the 8 players sustained complete permanent paralysis. This was consequent upon the orthopaedic injuries sustained--specifically facet dislocations or 'tear-drop' fractures, both injuries carrying with them a high risk of serious spinal cord injury. It is concluded that foul play in the form of the high tackle is still a major cause of serious spinal cord injury in South African rugby.

Catastrophic rugby injuries of the spinal cord: changing patterns of injury.

In reports from the UK and New Zealand, it is noted that the incidence of rugby injuries to the cervical spinal cord has dropped and that the percentage of players injured in the tackle has similarly decreased. In contrast, this does not appear to be the pattern in South Africa and an analysis has therefore been made of 40 rugby players sustaining injuries to the spinal cord during the period 1985 to 1989. The radiological appearances on admission have been correlated with the circumstances of injury, associated orthopaedic injuries and neurological deficits. The tackle was responsible for the majority of injuries, causing more than the scrum. Tackles were also responsible for more cases of complete, permanent quadriplegia than the scrum. The commonest cause of injury in players being tackled was the high tackle around the neck, while the commonest cause of injury in players making the tackle was the dive tackle. This survey has shown that the tackle is now the major cause of spinal cord injury in South African rugby, in contrast to earlier analyses in which the scrum was identified as the most common cause.

Cervical vertebral dislocation in a rugby player with congenital vertebral fusion.

Congenital cervical vertebral fusion is an anomaly which decreases the normal range of spinal movement and predisposes to trauma. The case history of a rugby player with a congenital fusion who sustained permanent quadriplegia after dislocation of the lower cervical spine is presented. The mechanism of injury is discussed. A plea is made for routine radiographic examination of the cervical spines of all rugby players in order to detect the presence of vertebral fusion and other conditions which may predispose to spinal trauma.

Premature onset of degenerative disease of the cervical spine in rugby players.

Rugby players and other individuals with the changes of degenerative disease of the cervical spine are at risk of spinal cord trauma after hyperextension injury. In an attempt to assess whether rugby players are prone to the development of premature degenerative disease, radiographs of the cervical spines of 150 rugby players were compared with a control group of 150 male hospital patients. The study revealed that rugby players showed premature and advanced changes of degenerative disease when compared with the control group. These changes were most marked in the cervical spines of the tight forwards. Rugby players so affected are therefore more likely to present with the symptoms and signs of cervical osteo-arthrosis and are at greater risk of hyperextension injury to the cervical spinal cord.

Rugby injuries of the spine and spinal cord.

This article analyzes the type and circumstances of injury in 50 rugby players who sustained cervical spinal cord injury with paralysis. Specific mechanisms of injury occurring during certain phases of the game are identified as being responsible for the majority of injuries. Each phase of the game is discussed in detail, emphasizing the vulnerability of the cervical spine to certain maneuvers, the dangers of illegal play, and the importance of preventive measures to decrease the incidence of these catastrophic injuries.

Hyperextension trauma in the elderly: an easily overlooked spinal injury.

The diagnosis of hyperextension injury to the cervical spinal cord after a fall is easily overlooked in the elderly. This is because the pattern of neurologic deficit, usually that of the 'central cord syndrome,' is complex and because no radiologic signs of trauma are present apart from changes of cervical spondylosis. The case history of a patient who had delayed onset of paralysis after a fall and in whom the correct diagnosis was initially overlooked is presented. In older patients hyperextension injuries may result in serious damage to the spinal cord due to preexisting weakness of the intervertebral discs, which are fragmented and fissured as a result of degeneration. In such patients, radiologic evidence of spondylosis and a posterior osteophyte at C4/C5 or C5/C6 often go unnoticed. This injury is usually caused by indirect cervical spine trauma resulting from head or face injury. A lateral X-ray view of the area with the patient supine is safe, quick, and inexpensive.

Rugby injuries to the cervical spinal cord sustained during rucks and mauls. Case reports.

Further analysis of a large number of cases of serious cervical spinal cord injury sustained while playing rugby has revealed that these injuries commonly occur during rucks and mauls. Three different mechanisms of injury under these circumstances have been identified and are discussed together with illustrative case reports.

The 'double tackle'--another cause of serious cervical spinal injury in rugby players. Case reports.

The rugby player who is simultaneously tackled by 2 opponents is more susceptible to cervical spinal and spinal cord injury than the player tackled by a single opponent. The reasons for this increased susceptibility are described. Two illustrative case reports are presented.

Rugby injuries of the upper cervical spine. Case reports.

Fractures and dislocations of the upper cervical spine (atlas and axis) differ markedly from those of the lower cervical spine (C3 - C7) because of the unique anatomy and function of these two vertebrae. Case reports of 4 rugby players who sustained serious injuries of the upper cervical spine are presented. The role of the high tackle in causing these injuries is described and the association of head and upper cervical spinal trauma is emphasized. The radiological management of the player with suspected injury is outlined.

Radiological assessment of thoracolumbar spinal injuries.

The vertebrae of the thoracolumbar junction are extremely vulnerable to serious injury. Spontaneous reduction of these unstable fractures or dislocations often occurs, making radiological diagnosis of the full extent of these injuries difficult. The technique of radiological examination applicable is described, and important radiological signs are emphasized. The anatomical factors predisposing the thoracolumbar junction to trauma and the mechanism of injury are briefly described.

Associated sternal and spinal fractures. Case reports.

Fractures of the upper thoracic spine due to flexion-compression trauma may be associated with sternal injuries of a specific type. The sternal or spinal component of such injuries may easily be overlooked, as illustrated by the 2 case reports presented. Sternal injuries due to direct and indirect trauma are described with particular reference to the anatomy of the manubriosternal joint. The importance of routine radiographic examination of the thoracic spine in the presence of sternal injury --and vice versa--is emphasized.

Serious cervical spine injury in the older rugby player. An indication for routine radiological examination.

There appears to be premature onset of cervical spondylosis in the cervical spines of rugby players who are then at increased risk of hyperextension injury to the spinal cord with resultant paralysis. An illustrative case report is presented. The value of and necessity for routine radiological examination of the cervical spines of all rugby players is stressed.