Transcript Slide 1

Umar Khan , MD
SEACSM 2/5/2011
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“My arm keeps getting hurt”
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18 yo male football player with recurrent history of arm pain. Has
been having symptoms off and on since 2007. Symptoms were
bilateral on occasion, but usually down one arm or the other.
Three years ago, playing football while tackling, contact sent
symptoms of pain, numbness and weakness down both arms.
Patient doesn’t remember if he returned to play symptom free,
however that football season, “every impact” he had would
reproduce symptoms (down both arms or either arm). Parents
noted continued weakness in his upper extremities two months
after that football season. He didn’t play in 2008, and in 6/2009
while cutting the grass, patient lifted up his lawnmower and had
numbness and tingling down his left arm.
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In 2009, he played football without any
symptoms, was evaluated for the first time in
2009 before playing.
9/2010, had another episode, affecting his
right arm. He initially stated this was his 1st
episode of the year, however later on repeat
f/u evaluation, he admitted that he would
have symptoms a few times per week, but
“they weren’t bad enough to tell anybody
about it”.
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Unremarkable PMHx, Sx, Fam Hx, Social Hx.
No meds or allergies.
Gen: WN, WD NAD
5’9” 160 lbs
Neck Exam: no ttp along c-spine or paravertebral
muscles, he did have ttp on his right trapezius muscle.
Neck had FROM and full strength in all directions
without symptoms. Spurling’s test was positive
reproducing symptoms on his right and causing right
trapezius pain.
 Neuro exam: CN II-XII intact, DTRs 1+ and symmetric
in his upper and lower extremities, Motor strength
was 5/5 and symmetric in all 4 extremities both
proximal and distal.
 Negative Hoffman’s and inverted BR reflex.
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Recurrent Stingers
Cervical Canal Stenosis
Burning hand syndrome
Malingering
Acute Brachial Neuropathy
Tumor
Cervical Cord Neuropraxia
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Standard Cervical Spine X-Rays, shows no pathology
except for loss of lordosis.
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MRI on 8/10/09: No disk bulging or protrusion
present, normal vertebral body heights. No edema in
the bones or spinal cord. No evidence of foraminal
narrowing or spinal cord stenosis.
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MRI on 10/16/10: Normal cervical spine, C3-C4 level
small bulging disc on the right, also some minimal disc
bulging at C4-C5. No evidence of spinal stenosis. Loss
of lordosis in the cervical spine. SAC 5.5mm
Sagital-diameter spinal-cord, spinal-canal, and
vertebral-body diameter measurments. x =
sagittal spinal-cord diameter, y = sagittal
spinal-canal diameter, z = sagittal vertebralbody diameter.
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Recurrent brachial plexopathy
Spear tackler’s spine.
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Relative Rest, Avoid Contact sports for now
NSAIDS if currently symptomatic
Rehab/PT
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F/U in 3 months. With repeat films to see if
there is return of lordosis of the cervical
spine.
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Once he has lordosis of his cervical spine and
is asymptomatic, and has a normal strength
and full range of motion. Will give him a trial
of activity.
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No Contraindications to Return to Play **
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Single-level Klippel-Feil deformity/congenital fusion below C2
Spina bifida occulta
Resolved stinger or brachial plexus neurapraxia (2 or less)
Healed herniated disc
Healed subaxial cervical spine fracture (C3-C7)
Healed facet fracture
Healed lamina fracture
Healed spinous process fracture (clay shoveler's fracture)
Healed one-level anterior cervical fusion
Healed single or multiple level posterior cervical foraminotomy
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Relative Contraindications to Return to Play **
 Resolved transient quadriplegia (1 episode)
 Resolved stinger or brachial plexus neurapraxia (3 or more)
 Non-healed/non-resolved asymptomatic herniated disc or
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severe foraminal stenosis
Healed C1 fracture
Healed C2 or Odontoid fracture
Any healed subaxial spine fracture with minimal or mild
residual displacement, deformity, or decreased range-ofmotion
Healed two-level anterior cervical fusion
Healed one-level posterior cervical fusion
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Absolute Contraindications to Return to Play or Participation **
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Clinical or radiographic evidence of rheumatoid arthritis, anklosing spondylitis, or diffuse idiopathic skeletal
hyperostosis
Arnold-Chiari malformation
Os odontoidium or congential odontoid agenesis/hypoplasia
Klippel-Feil deformity/congenital fusion or anomaly involving C1 and/or C2
Multiple-level Klippel-Feil deformity/congenital fusion below C2
C1-C2 hypermobility or instability (ADI > 4 mm)
Spear tacklers spine deformity
Transient quadriplegia (2 or more episodes)
Non-healed/non-resolved symptomatic herniated disc or severe foraminal stenosis
Cervical myelopathy
MRI evidence of spinal cord contusion, edema, or abnormality
Any healed cervical spine fracture/dislocation (lateral mass fracture with subluxation/dislocation)
Any healed cervical spine fracture or injury with residual instability > 3.5 mm/11°
Any healed subaxial spine fracture with residual displacement, deformity, or decreased range-of-motion
C1-C2 fusion
Three-level (or more) anterior cervical fusion
Two-level (or more) posterior cervical fusion
Cervical laminectomy or laminaplasty