Fracture-dislocation Of Cervical Spine Research Articles

Surgical treatment for fracture-dislocation of upper cervical spine complicated with vertebral artery injury

Objective To explore the perioperative management and surgical outcomes of fracture-dislocation of the upper cervical spine complicated with vertebral artery injury. Methods We ret-rospectively analyzed the clinical data of 19 patients diagnosed with fracture-dislocation of the upper cervical spine complicated with vertebral artery injury who had been treated at our department from January 2008 through December 2012. They were 14 males and 5 females, aged from 22 to 53 years (mean, 35.2 years). All the patients had fractures of the atlas and/or axis, and disordered atlanto-axial relationship as well. According to Frankel grading system, 8 cases were Grade D and 11 Grade E. The cervical posterior fixation with pedicle screws was adopted for all and hemostasis was conducted for those with bleeding from the broken vertebral artery. Their Frankel grade, Japanese Orthopedic Association (JOA) score and visual analogue scale (VAS) score were compared between preoperation and final follow-up. Results Intraoperative hemor-rhage occurred in 2 patients from the injured vertebral artery. Hemostasis was achieved through direct tamponade with bone wax and gelatin sponge in one and through endovascular intervention after bleeding control by direct tamponade in another. Neither of them presented with symptoms of posterior circulation ischemia after operation. The mean operation time was 153.5 min, and the mean blood loss was 542.1 mL. All the patients were followed up for an average time of 28 months. Bony union was obtained in all after an average time of 13.5 weeks. Follow-ups revealed no ischemic stroke in this series. Symptoms of transient ischemic attack, like transient dizziness and blurred vision, appeared in 2 patients. At the final follow-up, all the patients were assessed as Frankel Grade E. Their mean JOA and VAS scores were significantly improved from 8.1±1.2 and 7.0±1.7 preoperatively to 12.7±1.6 and 1.3±1.2, respectively (P< 0.05). Conclusions An-giography examination is routinely indicated for the patients with fracture-dislocation of the upper cervical spine perioperatively. Preoperative evaluation of the vertebral artery and its adjacent structures and effective intra-operative hemostasis can avoid uncontrollable bleeding during operation, reduce postoperative complications, and improve surgical outcomes. Key words: Cervical; Fractures, bone; Dislocation; Vertebral artery injury

Treatment of combining anterior and posterior approach for lower cervical spine fracture and dislocation with difficult reduction at primary stage

Objective To investigate the clinical effect of the treatment of combining anterior and posterior approach for lower cervical spine fracture and dislocation with difficult reduction by fixation, decompression and bone graft fusion at primary stage. Methods From January 2012 to January 2015, 32 cases patients associated with difficult reduction of articular process interlocking of the lower cervical spine fracture dislocation were treated with primary stage combining anterior and posterior approach surgical treatment, which was anterior resection of intervertebral disc decompression and posterior facet pry dial or replacement after resection, fixed, and then anterior decompression, bone graft fusion and fixation.The operation time blood loss were recorded.Whether trachea during operation, esophagus and accessory nerve injury, dural breakage of cerebrospinal fluid leakage, whether hyponatremia, whether two spinal cord injury or illness and wound healing were observed.Whether loosening or breakage of internal fixation was observed.The fusion of bone graft and whether false joint and nonunion were recorded in the follow up observation.Frankel classification, JOA score, postoperative cervical intervertebral height and horizontal displacement of vertebral body were recorded. Results The average operation time was (3.85+ 0.66) h, average intraoperative bleeding amount was (855.00+ 3.51) ml.There were no intraoperative tracheal and esophageal injury, 2 cases were intraoperative dural breakage of cerebrospinal fluid leakage and appeared 1 case of hyponatremia after surgery 5 days, but all patients were cured.Thirty-two patients were all followed up for 12 to 26 months, with average (18.00±0.55) months.Postoperative Frankel grade, 1 case of grade A, 4 cases of grade B, 7 cases of grade C, 8 cases of grade D, 12 cases of grade E. Postoperative JOA score with average (12.35±0.80) points, improvement rate of JOA score was 55.4% when discharge, postoperative cervical intervertebral height with average (7.25 ± 1.01) mm, the postoperative intervertebral level shift with average (1.22± 0.24) mm.At last follow-up, X-ray examination prompt bone grafting position were obtained bone fusion and internal fixed position good and strong. Conclusion The treatment of combining anterior and posterior approach for lower cervical spine fracture and dislocation with difficult reduction by fixation, decompression and bone graft fusion at primary stage can make the injured segment smooth reduction, early stable, decompression fully so as to improving neural function repair foundation, and also can create the conditions for lower cervical spine fracture dislocation injury rehabilitation. Key words: Joint locking; Cervical fracture and dislocation; Anterior posterior approach; Interbody fusion

Delayed bilateral vertebral artery occlusion after cervical spine injury: a case report.

There are considerable risks for the secondary spinal cord injury and the initial and/or delayed vertebral artery occlusion in cases of cervical fracture dislocation. An 86-year-old man was injured in a car accident and was diagnosed with no fracture or dislocation of the cervical spine by the emergency physician. However, he was transferred to our hospital 3 days later because he had motor weakness that was evaluated to be 32 points (out of 50 points) on the upper limb American Spinal Injury Association (ASIA) motor score and was diagnosed with spontaneously reduced fracture dislocation at C5/6. Magnetic resonance images revealed that the bilateral vertebral arteries were occluded, and there were some microinfarction lesions in the brain. On the first visit to his previous doctor, he was found to have a flow void in the right vertebral artery. This indicated that it was occluded during the waiting period at his previous doctor. On the day of his arrival at our hospital, the patient underwent a C5/6 posterior spinal fusion. Three months after surgery, he recovered to 46 points on the upper extremity ASIA motor score, and blood flow in the left vertebral artery was resumed. Early reduction and stabilization are necessary for cervical spine fracture dislocation; however, it is important not only for the prevention of the secondary injury but also for the reduction of the risk of vertebral artery occlusion.

Effect of anterior distraction and leverage reduction for lower cervical spine fracture and dislocation combined with locked facet

Objective To evaluate the efficacy and safety of anterior distraction and leverage reduction for lower cervical spine fracture and dislocation combined with locked facet. Methods Sixty-one patients with lower cervical spine fracture and dislocation combined with locked facet presenting to hospital between January 2009 and July 2014 were analyzed retrospectively. There were 48 males and 13 females, aged 18-81 years (mean, 48.6 years). Responsible injured segments were C3/4 in eight patients, C4/5 in 15, C5/6 in 23, C6/7 in 11 and C7/T1 in four. A total of 18 patients had unilateral locking of facets and 43 patients bilateral locking of facets. American Spinal Injury Association (ASIA) impairment score was grade A in nine patients, grade B in 13, grade C in 17, grade D in 16 and grade E in six. Under general anesthesia, the patients were performed decompression, reduction and fixation through cervical anterior approach. Postoperative intervertebral height, vertebral horizontal displacement and cervical kyphosis angle and reduction condition were evaluated. Interbody fusion was evaluated using the Bridwell criterion, neurological function using the ASIA score, and spinal cord function using the Japanese Orthopedic Association (JOA) score. Results Complete reduction was achieved in all patients. Fifty-six patients received 3-36 month follow- up (mean, 18 months). A second surgery was required for the postoperative recurrent dislocation in one patient and postoperative delayed union was seen in two patients. No patients had perioperative complications such as incision infection, nerve damage and esophageal injury. All incisions were stage I/first category healed. Cervical physiological curvature and intervertebral height were well maintained. Intervertebral height improved from preoperative 39%-86%[(67.6±14.1)%] to postoperative 89%-109%[(101.2±15.1)%], horizontal displacement of vertebrae improved from preoperative 5.36-11.74 mm [(8.12±1.89)mm] to postoperative 0- 2.56 mm [(1.29±0.29)mm], and Cobb angle improved from preoperative -3°- 26° [(14.3±6.2)°] to postoperative- 13°- 7°[(-3.6±0.7)°] (all P<0.05). Nerve function was improved with no aggravation after operation. JOA score was 0 to 17 points [(13.9±0.7)points] at follow-up versus 0-17 points [(7.3±0.9)points] before operation (P<0.01), and the improvement of spinal cord function was 68% after operation. Conclusion Anterior distraction and leverage reduction effectively improves spinal function, indicating an effective and save method in the treatment of cervical spine fracture dislocation combined with locked facet. Key words: Cervical spine; Dislocation; Zygapophyseal joint; Fracture fixation

EFFECTIVENESS AND SAFETY OF SIMPLY ANTERIOR APPROACH FOR LOWER CERVICAL SPINE FRACTURE DISLOCATION (Allen-Ferguson II OR III TYPE) WITHOUT SPINAL CORD INJURY

To study the effectiveness and safety of simply anterior approach for lower cervical spine fracture dislocation (Allen-Ferguson II or III type) without spinal cord injury. Twenty-five patients with lower cervical spine fracture dislocation (Allen-Ferguson II or III type) without spinal cord injury were treated between June 2013 and June 2015. There were 17 males and 8 females with an average age of 41.2 years (range, 31-57 years). Injury was caused by falling from height in 11 cases, by bruise in 5 cases, by crash of heavy object in 6 cases, and by traffic accident in 3 cases. There were 24 cases of fresh fractures and 1 case of old fracture. According to the Frankel grading criteria, 19 cases were rated as grade E and 6 cases as grade D. The injured levels included C4, 5 in 5 cases, C5, 6 in 14 cases, and C6, 7 in 6 cases. Unilateral locked-facet joint was observed in 9 cases, and bilateral locked-facet joint in 16 cases. The operation time, intraoperative blood loss, and surgical complications were recorded; the Odom standard was used to evaluate the effectiveness. The Cobb angle and D-value (the degree of cervical kyphosis or lordosis) were measured on the X-ray film, the bone graft fusion rate was recorded. The operation was successfully completed in 25 patients; the operation time was 66 to 115 minutes, the intraoperative blood loss was 80 to 220 mL. The postoperative follow-up time was 12 to 36 months (mean, 19.3 months). Postoperative temporary dysphagia occurred in 1 case, and pain at donor site in 2 cases; there were no complications of spinal cord injury, hematoma, hoarse, and esophageal fistula. The nerve function was improved from preoperative grade D to postoperative grade E at 3 months. The X-ray films showed bone graft fusion; there was no loss of intervertebral height or loosening of internal fixation. At 3 months after operation, the effectiveness was excellent in 18 cases, good in 6 cases, and fair in 1 case, and the excellent and good rate was 96.0%. The postoperative Cobb angle and the D value were significantly improved when compared with preoperative ones (P<0.05). Simple anterior approach has the advantages of good effectiveness, small trauma, and fast recovery for treating lower cervical spine fracture dislocation (Allen-Ferguson II or III type) without spinal cord injury.

Vertebral artery injury associated with cervical spine fracture dislocation

Vertebral artery injury associated with cervical spine fracture dislocation

With the Foot to the Neck

Introduction The surgical resolution of a cervical spine fracture dislocation is well known; however, there are certain difficulties when the right instrumentation is not available at the right time. We present an alternative solution for a cervical injury with complete medullary involvement. Patient and Methods: A patient, 45 years old, suffered a fall from a height (tree), arriving at the emergency service with tetraplegia. Imaging study reveals a C6–C7 fracture dislocation. Orthopedic reduction was performed and stabilization occurs in the first 6 hours postaccident. It is reduced manually and stabilized with a compact foot H-plate 2.7. Results The surgical and neurological evolution of the patient was favorable. Currently, the patient is autonomous, has sphincter control, and walks with a cane. Conclusion The management of upper cervical spine fractures presents an interesting challenge given the complexity and possible complications derived from these injuries. Their management is not usually difficult if the proper equipment is available. We present a possible solution when the correct spinal instrumentation is not available that can help solve such injuries with favorable results.

Immediate Reduction Under General Anesthesia and Single-staged Anteroposterior Spinal Reconstruction for Fracture-Dislocation of Lower Cervical Spine

Fracture-dislocation of the lower cervical spine is a severe traumatic lesion, most frequently resulting in tetraplegia. Treatment is usually painful and time consuming. This retrospective study evaluated the clinical curative effect of immediate reduction under general anesthesia and single-staged anteroposterior spinal reconstruction for fracture-dislocation of the lower cervical spine. Twelve cases of traumatic lower cervical spinal fracture-dislocation were retrospectively analyzed from January 2006 to December 2011. The injury level was C4/C5 in 4, C5/C6 in 5, and C6/C7 in 3 patients. The spinal cord function grades according to the American Spinal Injury Association impairment scale (2000 edition amended) before operation were as follows: grade A in 2 cases, grade B in 2 cases, grade C in 5 cases, grade D in 2 cases, and grade E in 1 case. On admission, all patients underwent immediate reduction under general anesthesia and single-staged anteroposterior spinal reconstruction by circumferential fixation/fusion. The spinal cord function grades according to American Spinal Injury Association after operation were as follows: grade A in 1 case, grade B in 1 case, grade C in 3 cases, grade D in 3 cases, and grade E in 4 cases. All 12 patients showed evidence of stability at the instrumented level on the final follow-up examination (mean follow-up, 3.7 y). Immediate reduction under general anesthesia followed by a single-stage combined anteroposterior spinal reconstruction is a safe and reliable way of treating patients with lower cervical spine fracture-dislocations.

Initial Closed Reduction of Cervical Spinal Fracture-Dislocation Injuries

Standards There is insufficient evidence to support treatment standards. Guidelines There is insufficient evidence to support treatment guidelines. Early closed reduction of cervical spine fracture-dislocation injuries with craniocervical traction is recommended to restore anatomic alignment of the cervical spine in awake patients. Closed reduction in patients with an additional rostral injury is not recommended. Patients with cervical spine fracture-dislocation injuries who cannot be examined during attempted closed reduction, or before open posterior reduction, should undergo magnetic resonance imaging (MRI) before attempted reduction. The presence of a significant disc herniation in this setting is a relative indication for a ventral decompression before reduction. MRI study of patients who fail attempts at closed reduction is recommended. Prereduction MRI performed in patients with cervical fracture dislocation injury will demonstrate disrupted or herniated intervertebral discs in one-third to one-half of patients with facet subluxation. These findings do not seem to significantly influence outcome after closed reduction in awake patients; therefore, the usefulness of prereduction MRI in this circumstance is uncertain.

Ideal stabilisation of unstable fracture dislocation of cervical spine in the background of ankylosing spondylitis

Ideal stabilisation of unstable fracture dislocation of cervical spine in the background of ankylosing spondylitis

Decompression via posterior-anterior approach and anterior fixation in treatment of fracturedislocation of the lower cervical spine with bilateral facet joints dislocation

Objective To evaluate the surgical strategy of decompression via posterior-anterior approach and anterior fixation in treatment fracture-dislocation of the lower cervical spine with bilateral facet joints dislocation. Methods This study retrospectively reviewed 37 cases of lower cervical spine fracture with bilateral joints dislocation. There were 21 males and 16 females with an average age of 42 years （19-58）. Distraction-flexion stage 3（DFS 3） were found in 24 cases and DFS 4 in 13 cases. All the cases were diagnosed by X-ray, CT and MRI and confirmed during the surgery. Decompression via posterior-anterior approach and anterior fixation had been adapted as the surgical strategy. The NASCIS and IMSOP standard were applied to definite the level of cervical spinal cord injury. The ASIA grading was used for evaluation the spinal cord function and the recovery rate. The X-ray and CT were used to observe reduction and bone fusion. Results The mean operative time was （4.5：±0.5） h, and the mean amount of blood loss was 360 ml （200-500 ml）. All the incision healed. The two segments fixation was used in 23 cases, 3 segments fixation in 13 cases, and 4 segments fixation in 1 case. The mean follow-up period was 32 months （16-45 months）.Postoperative X-ray and CT showed that bone fusion was achieved in all patients within 4-8 months, without graft displacement, or failure of implants. Spinal cord function did not aggravate, and sensory recovery ranged from 7 to 20 levels （averaged, 12.7）. The ASIA grade were improved with an average of one grade. Conclusion To treat fracture-dislocation of the lower cervical spine with bilateral facet joints dislocation, the posterlor-anterior approach and anterior fixation/fusion was benefit to preservation the cervical spinal cord function and reconstruction biomechanical stability of the cervical spine. Key words: Spinal fractures; Dislocations; Decompression, surgical; Fracture fixation

Vertebral artery injury associated with cervical spine fracture-dislocation: Prevention of distal embolism using coil embolization

Vertebral artery injury associated with cervical spine fracture-dislocation: Prevention of distal embolism using coil embolization

Odebode-Agaja adult cervical traction device

This technical note describes a new simple, cheap and affordable adult cervical traction device that is especially suitable for use in resource-poor third world countries because of its cost-effectiveness. While the widely used imported Gardner-Wells tongs cost over N250,000 (Nigerian) naira (approximately $1630 USD), the new equally effective, durable and locally readily available Odebode-Agaja traction device sells for N35,000 naira (approximately $220 USD). The device does not require scalp incision or skull drilling. It is designed for bedside application in patients with cervical spine injuries, including subluxation and fracture-dislocation of the cervical spine from the atlanto-occipital joint to T1.

Posterior approach for cervical fracture-dislocations with traumatic disc herniation.

In the treatment algorithm for cervical spine fracture-dislocations, the recommended approach for treatment if there is a disc fragment in the canal is the anterior approach. The posterior approach is not common because of the disadvantage of potential neurological deterioration during reduction in traumatic cervical herniation patients. However, reports about the frequency of this deterioration and the behavior of disc fragments after reduction are scarce. Forty patients with traumatic disc herniation were observed. They represented 29.2% of 137 consecutive patients with subaxial cervical spine fracture-dislocations. Surgical planning was performed according to our two-stage algorithm. In the first stage, they were treated with posterior open reduction and posterior spine arthrodesis. In the second stage, anterior surgery was added for cases where neurological deterioration attributed to non-reduced disc fragments on postoperative magnetic resonance imaging (MRI). Neurological deterioration after posterior open reduction was not observed. Furthermore, 25% of total cases and 75% of incomplete paralysis cases improved postoperatively by ≥ 1 grade in the American Spinal Injury Association impairment scale. Reduction or reversal of disc herniation was observed in all cases undergoing postoperative MRI. For local sagittal alignment, preoperative 9.4° kyphosis was corrected to 6.9° lordosis postoperatively. The disc height ratio was 72.4% preoperatively and 106.3% postoperatively. The second stage of our plan was not required after the posterior approach in this series. The incidence of neurological deterioration after posterior open reduction was zero, even in cases with traumatic cervical disc herniation. Favorable clinical and radiological outcomes could be obtained by the first stage alone. Although preparations for prompt anterior surgery should always be made to cover any contingency, the need for them is minimal.

Management of fracture-dislocation of the lower cervical spine with the cervical pedicle screw system

Management of fracture-dislocation of the lower cervical spine with the cervical pedicle screw system

Management of fracture-dislocation of the lower cervical spine with the cervical pedicle screw system.

Usually, cervical pedicle screw fixation has been considered too risky for neurovascular structures. The purpose of this study was to investigate the method and efficacy of the cervical pedicle screw system for fracture-dislocation of the cervical spine because of its rigid fixation. A prospective study was conducted involving 48 patients with cervical spine fracture-dislocation who underwent cervical pedicle screw fixation surgery between January 2003 and January 2007. All patients had various degrees of cord injury, and they were classified according to the American Spinal Cord Injury Association (ASIA) Impairment Scale: 18 cases were grade A, 15 grade B, 10 grade C, and 5 grade D. Six months after the operation, all patients had achieved solid bony fusion and stable fixation of the related segments. Thirty patients with incomplete spinal cord injury improved their ASIA Impairment Scale classification by 1 to 2 grades after the operation. Eighteen patients with complete spinal cord injury had no improvement in neural function. However, nerve root symptoms such as pain and numbness were alleviated to some extent. The cervical pedicle screw system is an effective and reliable method for the restoration of cervical stability. Sufficient pre-operative imaging studies of the pedicles and strict screw insertion technique should be emphasised.

Management of Facet Joint Fracture-Dislocation of the Lower Cervical Spine with Reduction Failure

Purpose: This study examined the obstacles preventing a decrease in a facet joint fracture-dislocation of the lower cervical spine after skeletal traction to determine suitable treatment guidelines. Materials and Methods: This study examined 19 fracture-dislocation cases of the facet joint in the lower cervical spine who failed closed reduction through skeletal traction. The following parameters were analyzed: obstacles preventing reduction, neurological recovery, complications and body to canal ratio of the injured site. Results: The obstacles found on MRI were herniated discs in 17 cases and joint capsule in 2 cases. The surgical decision was based on an analysis of the size and location of the disc, the degree of spinal canal stenosis and damage of the posterior structures. Anterior reduction/fusion and posterior fusion after anterior reduction/fusion, anterior fusion after posterior reduction/fusion and posterior reduction/fusion was performed in 9, 2, 6 and 2 cases, respectively. There was significant neurological recovery at the final follow-up (p=0.000). The body to canal ratio also increased significantly after surgery (p=0.000). Conclusion: For the treatment of unreducible facet joint fracture-dislocation of the cervical spine, pre-reduction MRI is essential for a thorough evaluation of the various underlying pathologies. In addition the surgical methods should be determined according to not only the neurological status, obstacles and pathologic structures preventing reduction, but also the surgeon's experience.

Traumatic fracture-dislocation of C5 on C6 through a previously solid multilevel anterior cervical discectomy and fusion: a case report and review of the literature

Background context Due to the underlying pathology and altered biomechanics, traumatic cervical fractures have been reported in patients with ankylosing spondylitis (AS), diffuse idiopathic skeletal hyperostosis (DISH), ossification of the posterior longitudinal ligament (OPLL), and combination of DISH and OPLL. However, incidence of a fracture-dislocation through a solid multilevel anterior cervical discectomy and fusion (ACDF) construct with no associated underlying pathology of AS, DISH, or OPLL but severe osteopenia has not, to the best knowledge of the authors, been reported in the medical literature. Purpose To report the development of an unstable cervical spine fracture that occurred through a previous multilevel anterior cervical fusion and the challenges associated with the diagnosis and surgical management of these uncommon lesions. Study design/setting A case report and review of the literature. Methods A case report entailing the clinical history, operative management, and postoperative course of a 72-year-old male patient with no known AS, DISH, or OPLL who suffered a cervical spine fracture-dislocation, secondary to a motor vehicle accident, through a previous solid three-level ACDF that was performed 20 years earlier. Results The patient underwent emergent reduction and realignment of the cervical fracture-dislocation, eventual posterior spinal fusion and stabilization with rigid segmental internal fixation, and application of external halo immobilization. At recent follow-up, he has radiographic evidence of fusion and maintenance of sagittal alignment without loss of reduction. Conclusions Multilevel cervical fusion constructs are susceptible to traumatic injuries. Many of the same challenges in the management of the previously fused ACDF patient, who sustains a fracture-dislocation, are similar to those found in the patient with mass-inflammatory conditions or metabolic disorders, such as AS, DISH, or OPLL. In many cases, this includes severe osteopenia, long unstable fusion segments, and difficulties associated with prolonged halo vest immobilization. As a result, preoperative surgical planning should take into consideration the difficulties in achieving fracture reduction, decompression, and proper stabilization.

Management of severe fracture-dislocation of cervical spine with Halifax clamps

Management of severe fracture-dislocation of cervical spine with Halifax clamps

Return-to-play criteria in athletes with traumatic injuries to the cervical spine

Football, diving, gymnastics, and wrestling are among the sports associated most commonly with cervical spine injury. Defensive players and the head-forward position have been associated with an increased risk, and a significant decrease in cervical spine injury has resulted from rule changes banning spearing and other forms of head-first contact. The most frequent mechanism of injury in ice hockey involves a player being driven head-first into the boards, and rules have been instituted to move the action away from the boards. Diving is the recreational activity involved most commonly in cervical spine injury, with alcohol involved in 40% of cases. Stingers are traction or compression injuries to the cervical nerve root or brachial plexus and are typically considered benign injuries that should not prevent return to play once pain and weakness resolve. Bilateral symptoms should prompt evaluation for possible spinal cord injury. The relation between transient quadriparesis in football players and developmental stenosis remains controversial, but the presence of an abnormal Torg ratio does not appear to be predictive of future spinal cord injury. Athletes sustaining multiple episodes of transient quadriparesis or with magnetic resonance imaging evidence of cord injury should be advised to avoid collision sports. Quadriplegia is usually the result of cervical spine fracture–dislocation resulting from a large axial load delivered to the vertex of a player's head. Again, rules prohibiting head-first contact have reduced significantly the incidence of serious spinal cord injury. Cervical spine injury is a potentially catastrophic outcome of sports participation. Systematic data collection and analysis by independent sports and health care organizations have provided much insight into the risk factors and mechanism of injury associated with cervical spine trauma in many sports. This information has allowed a rational approach to injury prevention and has often led to dramatic declines in the incidence of cervical spinal cord injury. One of the most effective interventions has been the institution of specific rules prohibiting head-first contact in American football. Since these rules went into effect in 1976, the incidence of football-related quadriplegia has decreased from 13 cases per million players between 1976 and 1980 to 3 per million cases between 1991 and 1993. The number of basic science and clinical studies directly applicable to the issue of cervical spine injury in athletics has been sparse during the past year. As a result, this expanded review presents data and opinion that has appeared in the literature during the past 4 years.