Head and Neck Articles
Head Injury Concussion
Concussion is the most common form of head injury. We use this term regularly, but what does it really mean and what are the cosequences of a concussion or repetitive concussions. It is most common obviously in contact sports. In North America it would be most common in football but in Canada, hockey would be the most common sport where we see these head injuries. Concussions, especially minor ones were once treated in a fairly cavalier manor as they were not thought to cause permanent damage to the brain. We now know better and treat these injuries with much more respect. A concussion is caused by an acceleration or deceleration force to the brain.
There is a shearing injury to nerve fibers causing damage to these fibers and the brain cells(neurons) which these fibers connect. Immediately the athlete loses some brain function and can not function as normal. The ability to process new information and react to it is particularly bad. The severity and duration of functional impairment is increased with each successive concussion. Also once you have had one concussion the chances of a second one are up to four times as great if you never had a concussion.
The Committee on Head Injury Nomenclature of the Congress of Neurological Surgeons define concussion now as ""a clinical syndrome characterized by immediate and transient posttraumatic impairment of neural function, such as alteration of consciousness, disturbance of vision, equilibrium, etc., due to brain stem involvement."" To simplify matters one of the top neurosurgeons in the United States has come up with a grading system which provides a guideline and only a guideline to grade these injuries and determine when the athlete can go back to play.
GRADE 1: These are the most common and the most mild. The athlete does not lose consciousness. They will report having their ""bell rung"" or not report anything at all. Many will continue to play without even reporting to the coach. They will notice that they are not quite in the game or feel fuzzy. Bystanders may notice that they are not quite doing the right thing because they can not respond to their surroundings as fast or they may forget the plays. They obviously should not be playing. They should be pulled off and examined by a physician. Often they will not seem too bad for the first 10 minutes but then get worse. As they lose their short term memory they will repeatedly ask what happened to them over and over again as they again quickly forget what you have told them. This becomes quite frustrating both for the athlete and the person who is with them. Commonly they will also have a headache and feel light headed or dizzy. If the symptoms persist the athlete certainly can not continue to play and should be checked by a doctor. Generally they will not be able to play contact sports for a week or until all their symptoms have subsided. If the athlete has a second concussion of Grade 1 the same rules apply except they are held back twice as long. A third occurrence would double again the time they were off.
GRADE 2: This is what we call a moderate head injury. The athlete is usually unconscious but less than 5 minutes. While the amnesia would be only short lived for a Grade 1 concussion it may last up to 24 hours with this injury. Because you will have to worry about a serious neck injury as well with this more serious head injury the athlete should only be moved by the appropriate personnel. Then and only then can the athlete be properly removed from the playing surface on a backboard. With an uncomplicated Grade 2 concussion the athlete will be back playing in 1-2 weeks if they do not have any symptoms.
GRADE 3: These are the most severe and the ones we most worry about when the athlete is knocked out for more than 5 minutes. This athlete is transported by ambulance to hospital and evaluated by a neurosurgeon. The most common cause of major problems after a head injury is what we call a sub-dural hematoma where a collection of blood develops which compresses the brain causing damage or even death. This occurs over a slow period of time which is why every patient with a head injury is placed on a head-injury routine where they are woken up every 3 to 4 hours and checked to see if they are okay. There is also a thing called ""Second Impact Syndrome."" This occurs when an athlete goes back to play when there are still symptoms of the concussion.
A subsequent head injury may then cause massive swelling of the brain and the athlete almost always dies. Several athletes die every year in North America from this syndrome. This article only provides a rough guideline to this topic of head injuries. Certain other individual factors may affect your decision of when to or not to play. Some activities such as hang-gliding are more prone to serious head injury than contact sports and thus have to recover longer before returning to their activity. The style of play may have to be modified for the athlete to prevent further injury such as in a rugby player who uses his head to tackle his opponent. Rule changes such as the enforcement of checking from behind in hockey will hopefully prevent some of these injuries. Concussions are serious injuries and must be treated seriously and appropriately.
Doug Gilmour skates across the centre ice neutral zone looking back after passing the puck. A freight train heading east(alias Luke Richardson) hits Gilmour and he crumples to the ice. As Joe Bowen so aptly put it ""Doug Gilmour was seeing stars and he wasn""t even at the Academy Awards."" He had a concussion; the most common head injury in sports. It has been reported that there are over 250,000 concussions in the United States per year in the sport of football alone. While a concussion is usually an accident and not an integral part of most sports it is somewhat the objective in other sports such as boxing. The term concussion means that there is temporary interruption of the brains function. While we used to think and it is still mostly true that the changes are totally irreversible but we know that there may be slight structural damage to the brain especially with repetitive concussions or with the more severe concussions.
A concussion can occur with two types of trauma to the brain. There can be a direct blow to the brain or the brain can be injured by what we call a contrecoup injury. This is when the accelerating brain is banged against a decelerating skull. A blow to the front of the head knocks the head back and the brain is injured when it strikes the back of the skull when it stops moving. The two major symptoms of a concussion are loss of consciousness and loss of memory. We grade concussions on the severity of these symptoms. A first degree concussion is the most common. This is the typical injury where you will say you got your bell rung or saw stars. There is not a loss of consciousness but there is amnesia which lasts for less than 30 minutes after the injury. The athlete will initially not seem too bad but five minutes later the amnesia sets in.
There may also be a brief period of slight mental confusion, dizziness, minimal unsteadiness and a brief loss of judgment. The recovery is quick but some of the symptoms such as headache and mental confusion may persist. An athlete must be pulled from the playing field. Only the minimal of injuries will the athlete be allowed to back into the game. Usually the athlete must be checked by a physician. The athlete can go back to play if and only if they are cleared of ALL symptoms for several days to a week. When an athlete sustains a second Grade 1 concussion then they can not go back to play for at least a week and then only if they are totally symptom free and have been checked by a physician. The major cause of death after a head injury is bleeding that develops in the skull and compresses the brain. This usually develops slowly over several hours. This is why all concussed athletes are put on a ""Head Injury Routine.""
The athlete is awakened every 2-3 hours to make sure they are alright. This is done by someone staying with the athlete. I was told by one athlete that they were alone but set their alarm clock every 2 hours. This would not have helped too much if they were unconscious. A second degree concussion means the athlete was unconscious for up to two minutes and or the amnesia lasted longer than 30 minutes. This is a more severe injury and requires closer observation. The athlete obviously can not continue to play and can not return for at least a week. A second Grade 2 concussion requires one month off competition. The third degree concussion is the most serious and one that no one would miss. The athlete is unconscious for greater than two minutes and/or the amnesia lasts longer than 24 hours.
These athletes are hospitalized for further investigations and can not play for at least one month. The last thing I want to mention is the ""Second Impact Syndrome."" There are several deaths per year in North America from athletes who already have a concussion go back to play sports too soon before all the symptoms of a concussion have resolved. A second blow to the brain causes brain swelling and almost certain death. This is one of the main reasons why we are so careful when we allow our athletes back on to the playing field. Gilmour had a mild concussion and is now back playing. After the Michel Goulet situation last year we will make sure Doug's head protection is adequate and we will be watching him closely like everyone should do after an athlete has suffered this brain injury called a concussion.
Head Injuries In Soccer
While we Canadians often consider hockey as the only real sport in the world, the fact is that soccer is by far the most important sport world wide. Soccer is the number one sport in the majority of countries in the world. The World Cup is the biggest sporting event in the world next to the Olympics. It is a great sport that combines all the attributes of the best athletes. The best players display a combination of speed, skill conditioning and desire. It is a sport that can be played by all people in the world in that it requires only a ball and a field making it accessible to all. It is said to be one of the safest sports in the world, but there are now some concerning reports from one of the fundamental parts of the game. The foot is the prime tool to move the ball, but heading the ball is a very important part of the game. A significant number of goals are scored by the head. The head is the prime part of the body to be used for balls that are in the air.
We consider head injuries to occur in contact sports where the athlete is subjected to significant blows to the head. Boxing is the worst sport for traumatic bran injury and we are all aware of the amount of concussions in hockey and football today. We are now seeing problems in brain injuries in soccer players. The impact on the brain in soccer comes from more repetitive head injury as opposed to the more violent traumas seen in hockey and football. The situation in soccer may be more analogous to the repetitive trauma seen in boxer's. If a soccer player is susceptible to the long term brain problems that a boxer is exposed to this would have a significant impact on the millions of people involved in soccer. Soccer players can have traumatic brain injury by a collision with another player especially when they are competing with another player for a header. In an 1993 study of elite players 89% of players were found to have some history of head injury and 54% reported a history of concussion.
A recent survey of soccer players in Norway has raised even greater concerns. A significant number of symptoms were reported in 128 players who played more than 100 games a year. They compared soccer players to age matched controls who did not [lay soccer and had no history of head injury. They performed tests on all aspects of brain function. This include a detailed interview to look for symptoms of brain trauma as well as a battery of tests. This included EEG evaluation( a measure of bran wave activity), CT scan, neuropsychological testing and MRI scans. The soccer players reported a high incidence of symptoms including headaches, neck pain and dizziness. EEG results showed a much high incidence of abnormal EEG's in soccer players than controls. The abnormal EEG's were more common in players reported symptoms of repetitive head trauma.
CT scans performed on older player who retired an average of 18 years prior showed more atrophy of the brain than normal population. Neuropsychological testing on 37 former players showed some impairment in 81% while controls only demonstrated impairment in 40%. A study in the United States in elite players compared MRI's and only found abnormalities after a history of an acute injury. Soccer is a great sport that can be played anytime and anywhere. Head injuries as a result of repetitive trauma is a concern that must be addressed. The studies done thus far although showing abnormalities have been done a small number of players only at the elite level, and the results have not all been totally convincing of the severity of the problem.
The soccer community must be made aware of the potential for brain trauma from heading the ball. Correct heading technique must be emphasized to limit the amount of trauma imparted to the brain. As in all sports players who sustain any level of a concussion must be seen by qualified medical personal and only returned to play when cleared medically no matter how minor the concussion seem to be. Soccer coaches must be educated that the majority of concussions do occur without loss of consciousness. Let us keep playing soccer but let us also make sure we are doing all we can to avoid causing any problems to our athletes.
It took until the last game of the season when I had to go on to the ice at Maple Leaf Gardens to help an injured player. Cam Russell was involved in an altercation with a Mr. Domi and ended up hitting his unprotected head on the ice. He was immediately unconscious and the medical team responded instantaneously to attend to him. Fortunately, he regained consciousness very quickly. As a precaution that his neck might have been injured we placed him on a backboard with his neck protected and wheeled him off the ice. He was taken immediately to the hospital where a CAT scan of his head revealed no damage. At the star of the third period when he was back in the arena he seemed normal with very little evidence of this serious head injury except for a headache and a small memory loss.
Several years ago we did not hear much about concussions. It seems now that there are more and more concussions and players are out for longer and longer periods of time. We have now heard of several players whose careers have ended from concussions. Nick Kypreos in Toronto, Brett Lindros in New York and Pat Lafontaine's career might be in jeopardy due to repetitive head injuries. There are several theories of why these injuries are on the increase and why they seem to have a longer period of recovery. The players are bigger and hit harder and with all the talk of proper head protection there are players in the NHL not wearing helmets that would pass CSA approval. The NHL Physicians society is looking into the increase in concussions in the league and we hope to have a report out by next year.
We still do not know the major cause of these concussions but we hopefully will be able to shed some light on the issue soon. One of the key factors in the increase in reporting of concussions is simply our awareness of what happens to the brain when it receives a significant blow. It was not long ago the a concussion was regarded as reversible brain trauma. Therefore we did not regard it a serious injury. The brain is made up of delicate interconnected fibres that may suffer damage with internal shear strains and distortions of brain tissue. There is also a fine network of blood vessels that can also be easily torn. When there is significant acceleration of the whole brain there is a period of time when the brain does not function well. In a mid concussion there may be transient confusion only.
A more severe trauma will cause the athlete to have amnesia for events leading up to and after the concussion. An athlete can not return to play until their brain is functioning 100%. The reason for this is two fold. There is a syndrome called ""Second Impact Syndrome"" where an athlete who goes back to play before they are fully recovered receives a second impact to the brain. The brain responds with a diffuse swelling and the result is usually death. Also if the brain is not functioning well the athlete can not process information fast enough to respond to events around him. This not only hampers performance but also makes them more prone to further injury to their head or to another part of their body.
Therefore it is crucial that each athlete is examined carefully to his their individual status to determine when they can go back. The injury to the brain can be accumulative and therefore it is important that we carefully monitor brain function before we even consider a return to play. The reasons players are out for a prolonged period of time or even indefinitely is that they continue to suffer deficits from the head injury. Some of these problems are fatigue, headache, memory loss, dizziness, loss of appetite, apathy, incoordination, irritability and low frustration tolerance, and intolerance of bright lights or loud noises. These symptoms almost always resolve with time but it is those individuals with which they persist that have to retire.
Neck Injuries In Sport
having the extra the protection. A player feels very safe with a helmet and facemask on. This leads to more aggressive play and to play with less regard for their own body. Many physicians and other people involved in sport have responded to these potentially severe tragic injuries. You only have to see one quadriplegic as a result of a sporting injury that even one is too many. There have been several physicians in North America who have taken the crusade to reduce or eliminate these injuries. It is important to understand the mechanism of these injuries to help prevent them. In the United States they have greatly reduced neck injuries by not allowing spearing(using your head) as a method of tackling or blocking.
In Canada Dr. Charles Tator has had a campaign to educate hockey players to not hit from behind. It is important to teach children the consequences of these actions and to learn to avoid these situations. It seems to be working in that the number of serious neck injuries in hockey is decreasing. The main cause of these injuries is diving in to shallow waters and again Dr. Tator's group is bust educating the public to avoid diving in to shallow or unknown waters. The 16 year old player did break his neck. He was operated on that night. He was one of the lucky ones. He fully recovered to have no residual deficits. It is important that we all understand that even sport can have serious consequences. Most, if not all of these are preventable with a little education and a lot of common sense.
Sheila enjoys high school rugby. As she makes a tackle her head is forced to one side. She gets immediate pain shooting down her arm to her fingers. As soon as she really starts to worry about the pain a minute or two later, it goes away as quickly as it came. She shakes her arm a few times to see if it still works and gets back into the game. She has experienced her first burner. In sports that involve tackling and blocking like rugby and football, burner's or stinger's are extremely common. Many athletes will have at least one of these in their career while other's will have a recurrent problem. In high level collegiate football it has been reported that 70% of players will experience at least one burner in their career. Most of them had 3 or 4 in their career. A Burner is a result of stress on the nerve that supplies the arm.
The nerves come from the spinal cord in the neck. The weave together towards the shoulder in what is called the Brachial Plexus. From there the nerves go into the arm and into the various muscles that they supply. When the neck is violently flexed to one side the nerves on one side of the neck are stretched while they are compressed on the other side of the neck. Either of these situations can lead to the Burner Syndrome. it is controversial which one is the most common. Once the nerve is stretched or compressed it sends a shot of pain down the arm. The muscles that are supplied by that particular nerve will not function as well and will be weak. This usually resolves very quickly, but it can last for longer and even be permanent in the more severe cases.
The ones that are at most at risk are the athletes who have recurrent burners especially when they go back to play before they have regained full function in the arm. When the athlete is first examined immediately after an episode they are seen to be leaning towards the side of the injury. There may be pain in the neck region where the nerve was injured. The most dramatic finding is weakness in the arm. Those with recurrent problems may have muscle wasting and chronic weakness. The strength comes back almost immediately in the acute burner syndrome. It is important to rule out any problems in the cervical spine. An injury to the cervical spine and spinal cord can give the exact symptoms but this obviously has much more serious consequences. In the simple Burner Syndrome the athlete can resume play as soon as the pain and numbness goes away and they exhibit full strength in the arm.
The recurrent problems have to be monitored much more closely. Nerve tests are done to determine the exact damage to the nerve and then and only then is a decision made regarding return to competition. In athletes who have had burners we educate them on proper tackling techniques to avoid further trauma to the nerve. The athlete is placed in a therapy program to ensure full range of motion if the neck. A strengthening program is instituted to help protect the neck. Special collars have been very beneficial in football to help reduce the incidence of Burners. Sheila full recovered and never had a recurrence of her Burner. Although many athletes do experience recurrent Burners, the good news is that we rarely see any long term consequences from this very common injury.