Cervical Spinal Stenosis with Cord Neuropraxia

CCN follows a high-energy contact-sport mechanism: rugby tackle, American football collision, ice hockey check, diving impact, gymnastics fall, equestrian fall.

Symptoms during the event:

• •Transient bilateral or four-limb sensory disturbance (burning, tingling, numbness, or loss of sensation)
• •Motor weakness ranging from clumsiness to flaccid quadriparesis
• •Distribution typically both upper limbs, both lower limbs, or all four
• •Neck pain may or may not be present
• •Loss of consciousness is NOT a feature of CCN itself - if present, look for concomitant TBI

Recovery is the defining feature: full neurological recovery is the rule, usually within minutes to hours, and by definition complete within 48 hours. Persisting deficit beyond 48 hours redefines the event as structural cord injury.

CCN versus stinger - the critical distinction: a stinger is UNILATERAL upper-limb burning paraesthesia from a brachial plexus or cervical root traction or compression injury, brief, single-limb, with no lower-limb features. CCN is BILATERAL or four-limb, suggests central cord involvement, and demands immobilisation and imaging. Bilateral or four-limb symptoms are NEVER a stinger - misclassification has paralysed players.

Pitchside / on-field examination (PHICIS principles): assume cervical spine injury until proven otherwise. Manual In-Line Stabilisation (MILS) is the absolute first and most important step (NICE NG41, JRCALC, PHICIS). Proceed with ABCDE, oxygen if indicated, IV access. Document time of onset, duration of deficit, distribution, and recovery trajectory. Examine all four limbs systematically (tone, power, sensation, reflexes). Assess respiratory effort and circulation - high cervical cord injury can produce respiratory compromise or neurogenic shock. Coexisting concussion or TBI must be screened for separately; normalisation of limb symptoms does not clear either the cervical spine or the brain.

Pitchside do-not-do checklist: do not let the athlete walk off; do not label bilateral symptoms as a stinger; do not remove protective equipment casually (untrained removal worsens alignment); do not clear for same-day return; do not give routine high-dose methylprednisolone (NICE NG41 advises against); do not rely on the Torg ratio alone.

Differentials: stinger (unilateral upper limb, brief), concussion or TBI (altered consciousness, no limb deficit), cervical fracture or dislocation (persistent pain, deformity, persistent neurology, abnormal imaging), SCIWORA (often persistent paediatric pattern), acute traumatic disc prolapse (persistent unilateral radicular deficit), vertebral artery dissection (posterior circulation symptoms).

The acute imaging pathway in UK adult trauma follows NICE NG41:

• •In adults 16 or over with cervical spine imaging indicated by the Canadian C-spine rule, CT cervical spine is the first-line bony investigation
• •MRI cervical spine is required after CT in any patient with a neurological abnormality attributable to spinal cord injury, even if CT is normal
• •In children under 16 with suspected cervical cord injury or abnormal neurological signs, MRI is the key investigation

After any episode of transient quadriparesis, MRI is therefore mandatory. Plain radiographs (AP, lateral, open-mouth peg) are largely historical or adjunctive in UK adult trauma after a cord-level event.

Imaging the canal anatomy: the Pavlov / Torg ratio (under 0.8) is a classic exam point but has poor specificity in muscular athletes and is not a standalone clearance rule. MRI sagittal canal diameter under 13 mm is a commonly cited threshold but, again, not a standalone return-to-play rule. Functional stenosis - loss of CSF buffer around the cord, cord contact, cord deformation, cord signal change - is more clinically meaningful than absolute numbers.

Flexion-extension views may be considered once acute fracture and instability have been excluded, to assess dynamic instability. Angiography (CT or MR) is for suspected vertebral artery injury.

BOAST documentation standards: record a detailed neurological examination using an ISNCSCI / ASIA chart as early as possible, ideally within 2 hours of admission, and repeat during admission and around interventions. Centres receiving spinal cord injury patients require 24-hour CT and MRI access.

Acute on-field and emergency management - treat as a suspected unstable cervical spine injury:

• •Manual In-Line Stabilisation (MILS) is the absolute first and most important step. A hard collar with blocks and tape may be added per local protocol, but MILS is the priority - modern UK pre-hospital practice (NICE NG41, JRCALC, PHICIS) is more cautious about rigid collar use where it causes agitation or raises intracranial pressure
• •Maintain protective equipment in situ in helmeted sports unless trained removal is required for airway, chest access, CPR, or to achieve neutral cervical alignment. Equipment removal must be performed by trained rescuers; if helmet removal is required, shoulder-pad management must be coordinated to maintain alignment. UK rugby is helmet-free; this principally applies to American football and ice hockey
• •ABCDE assessment with oxygen and IV access
• •Continuous neurological reassessment, documenting motor and sensory function in all four limbs
• •Longboards are for extrication only and not for transport - use a scoop stretcher, vacuum mattress, or local ambulance spinal immobilisation protocol
• •Transfer to a unit capable of CT and MRI cervical spine and with on-call spinal expertise
• •NICE NG41 advises AGAINST methylprednisolone, nimodipine, and naloxone for neuroprotection or prevention of secondary deterioration

After confirmed CCN with full recovery: hospital admission for observation (typically 24-48 hours), cervical MRI, ISNCSCI / ASIA documentation, and spinal surgical opinion for any structural lesion (disc-osteophyte complex, instability, OPLL, cord signal change). Symptomatic analgesia per BNF; short-course NSAID with risk assessment.

Return to contact sport is the critical and often-examined decision. There is no UK-specific guideline; international consensus drives practice. Decisions require shared decision-making with the athlete, family, spinal surgeon, and SEM physician.

Generally accepted contraindications to return to contact sport (consensus):

• •Persistent neurological deficit
• •Persistent T2 cord signal change or myelomalacia
• •Cervical instability
• •Symptomatic OPLL or significant disc-osteophyte cord compression
• •Recurrent CCN episodes
• •Structural canal stenosis with cord deformation on imaging
• •Spear tackler's spine pattern that has not been corrected

Generally permissive (with informed consent and shared decision): single episode, full recovery, normal MRI cord signal, adequate CSF buffer, no instability, no disc-osteophyte cord contact, after spinal surgical and SEM physician review.

Surgical management: decompression (ACDF, posterior laminoplasty, laminectomy with or without fusion) for symptomatic structural stenosis with cord compression, instability, OPLL, or persistent neurology. VTE risk assessment per NICE NG89 post-operatively.

Most athletes with a single CCN episode and full recovery require minimal rehabilitation beyond a graded return to activity. Those with structural lesions, persistent symptoms, or post-operative recovery follow a longer pathway.

Phase 1 - acute recovery and assessment (days to 2 weeks): symptom monitoring, full neurological re-examination, MRI review, cervical range-of-motion work as symptoms allow. Avoid all contact and high-impact activity until decision-making is complete.

Phase 2 - reconditioning (weeks 2-8, dependent on findings): cervical and scapular stabiliser strengthening, postural retraining, aerobic conditioning, sport-specific non-contact training.

Phase 3 - graded return (weeks 8 onward, only if cleared): non-contact drills, limited contact drills with technique modification (head-down tackling, spear tackling, and any extension- or axial-loading positions). Full contact only after spinal surgical and SEM physician sign-off with documented shared decision-making.

Post-operative rehabilitation is surgeon-led: protected cervical movement initially, progressive ROM, scapular and cervical strengthening from around 6 weeks. Return to non-contact aerobic activity often at 3-6 months; return to contact (where considered) often 9-12 months, only after surgical clearance.

Throughout, emphasise tackling and contact technique modification to reduce axial loading and forced extension, the dominant mechanism of CCN.

• •NICE NG41 Spinal injury assessment and initial management (2016): UK pathway for cervical spine imaging in trauma. CT first in adults with neurology, MRI after CT for any neurological abnormality, MRI-first in children under 16. Advises AGAINST methylprednisolone, nimodipine, and naloxone in acute traumatic SCI.
• •BOAST Management of Traumatic Spinal Cord Injury: ISNCSCI / ASIA documentation within 2 hours, 24-hour CT and MRI access at receiving centres, repeated neurological exams during admission.
• •Torg and Pavlov sagittal canal ratio (1986): historical stenosis marker; poor specificity in muscular athletes due to vertebral body hypertrophy.
• •Castro et al. transient quadriparesis series: foundational descriptions of CCN epidemiology and contact-sport return outcomes; inform modern criteria.
• •Cantu and Torg return-to-contact consensus statements: international framework for permissive versus contraindicated criteria after CCN; relied on in UK SEM practice as there is no equivalent UK-specific RTP guideline.
• •World Rugby Spinal Immobilisation guidance: pitchside cervical immobilisation and PHICIS protocols used in UK rugby.

• •CCN = transient BILATERAL or four-limb deficit after a cervical mechanism in an athlete with canal stenosis. Full recovery typically within minutes; defining limit 48 hours. Bilateral or four-limb symptoms are NEVER a stinger.
• •Acute imaging pathway (NICE NG41): CT first in adults with neurology, MRI after CT even if CT is normal. MRI is the key investigation in children under 16.
• •Pavlov / Torg ratio under 0.8 is a classic exam answer but has poor specificity in muscular athletes (vertebral body hypertrophy lowers it falsely). Functional cord effacement and signal change matter more than absolute numbers.
• •MILS is the absolute first step in pitchside cervical management. Longboards are for extrication only, not transport.
• •NICE NG41 advises AGAINST methylprednisolone, nimodipine, and naloxone in acute traumatic SCI. Equipment removal in helmeted sports must be by trained rescuers with coordinated helmet and shoulder-pad management.
• •Generally permissive RTP after CCN: single episode, full recovery, normal MRI cord signal, adequate CSF buffer, no instability, after spinal surgical and SEM review. Persistent cord signal, instability, OPLL with cord compression, recurrent CCN, or uncorrected spear tackler's spine are contraindications.