Head Injury Football Player

Abstract

HISTORY: 17 year-old junior high school football defensive end sustained a concussion while tackling. During an early season football scrimmage, he tackled a player using the spearing technique. Immediately after the game was finished, he had an immediate, intense headache and vomited. There was no motor weakness, impaired sensation, or pain in his neck or upper limbs. Over the next few weeks, he had persistent bi-frontal headaches, radiating from the para-cervical area, usually aggravated by heavy lifting and straining. He had neck pain that was worse in the morning and exacerbated by flexion. Manual therapy helped relieve headaches and neck pain. He had multiple episodes of involuntary loss of stool that occurred in the act of passing gas. PHYSICAL EXAMINATION: Examination revealed moderate tenderness over the facet joints of C1-C2 and C2-C3 on the right side. Normal sensation, strength, and reflexes in the upper and lower limbs. There was full active, pain-free, range of motion with the neck. Spurling's maneuver was provocative of neck pain without radiation bilaterally. Cervical traction relieved his neck pain. Cranial nerves II-XII were normal. DIFFERENTIAL DIAGNOSIS: 1. Concussion with post-traumatic headache 2. Vertebro-basilar insufficiency 3. Cervical spinal cord neuropraxia TEST AND RESULTS: MRI cervical spine without contrast: Cervical vertebral body and disc space height, alignment, marrow signal, and spinal cord is normal. AP diameter of central canal measures 10 mm at C4-C5, while AP diameter of the central canal at C5 measures 16 mm. Torg ratio at C4-C5 measures 60% MRI/MRA Neck and Brain with and without contrast: Left-sided vertebral artery terminates as the left posterior inferior cerebellar artery. Right-sided vertebral artery is strongly dominant. Brain parenchyma is normal FINAL WORKING DIAGNOSIS: 1. Vertebro-basilar insufficiency 2. Cervical spinal stenosis and cord neuropraxia 3. Cervical facet arthropathy, C2-C3 TREATMENT AND OUTCOMES: 1. No clearance to return to football and contact sports. He is still experiencing cervicogenic headaches without a return to premorbid functional level. 2. Excluded neck manipulation and mobilization in treatment program, due to risk of occluding the one good vertebral artery. 3. Hyperbaric oxygen treatment transiently relieved headaches.