Upper Extremity Paresthesias in a High School Football Player

Abstract

HISTORY: A 16 year old male football player presents with recurrent episodes of bilateral arm paresthesias. This first occurred six weeks prior to presentation after he was tackled with his neck axially loaded in a flexed position, and was associated with mild subjective weakness. This lasted a few minutes and resolved spontaneously. This happened four more times with each episode lasting longer in duration. He denied any lower extremity symptoms. One week prior to presentation, he was blocking an opposing player and had a hyperflexion injury which precipitated paresthesias which lasted for hours. He denied any bowel/bladder incontinence or saddle anesthesia. PHYSICAL EXAMINATION: No malalignment or rotational deformity of the neck. No bony tenderness or cervical paraspinal tenderness. Full cervical range of motion in all planes without pain. Spurling test is negative bilaterally. Full motor power in the bilateral upper and lower extremities except for slight weakness in right shoulder abduction and right hand finger abduction. No Hoffman sign present. Sensation intact to light touch bilaterally DIFFERENTIAL DIAGNOSIS: Cervical cord neurapraxia Spinal stenosis Cervical radiculopathy Stinger/Burner Brachial plexopathy Parsonage Turner Syndrome TEST AND RESULTS: Cervical cord neurapraxia without cord contusion in the setting of congenital stenosis of the cervical spine FINAL WORKING DIAGNOSIS: X-rays of the cervical spine showed normal lordosis, proper alignment, preserved intervertebral disc height, and no acute osseous abnormalities. An MRI showed significant central canal stenosis at C3-4, C5-6, and C6-7 with loss of surrounding CSF fluid signal at these levels. Smallest canal diameter is 8mm at C5-6. There was no cord edema noted. TREATMENT AND OUTCOMES: Though a validated risk stratification mechanism or return to play criteria does not presently exist in the literature, the results of the MRI and the progressively increasing duration of symptoms suggest an increased risk of future spinal cord injury with continued participation in contact sports. He does score in the “Moderate risk” category based on the Cervical Spine Injury Rating Scale proposed by Watkins, et al in 1990. He was held from participation and referred to spine surgery to discuss additional treatment options and return to play prognosis.