Head and Neck Injury - Football

George C. Phillips, MD, FAAP, CAQSM

Clinical Assistant Professor of Pediatrics

University of Iowa Carver College of Medicine

Iowa City, IA

Case History

•      16-year-old male football player

•      Helmet-to-helmet collision during practice six days prior to initial visit in our center

•      Confused and disoriented at the time of injury 

•      Bilateral upper extremity numbness and tingling that lasted 20 minutes

Case History

•      Evaluated on the day of injury at a local emergency department

–   Head CT showed right frontal soft tissue swelling, with normal brain parenchyma

•      Diagnosed with concussion and removed from participation until follow-up at the University of Iowa Sports Medicine Center

Case History

•      At our initial visit, he reported retrograde and post-traumatic amnesia

•      He denied headache, dizziness, blurry vision, confusion, tinnitus, or cognitive/school performance issues

•      He went running the previous day without symptoms

Case History

•      Patient reports a previously unrecognized injury occurring one week prior to the index injury

–   Helmet-to-helmet contact

–   Bilateral upper extremity numbness/tingling

–   Brief loss of vision in left eye

–   Symptoms resolved within 24 hours

Case History

•      No prior head trauma

•      Multiple hand fractures

•      No surgeries

•      Exercise-induced asthma, well-controlled

Physical Examination

•      HEENT, Neck, Pulmonary, Cardiovascular, Abdominal, and Skin exams were unremarkable 

•      No C-spine tenderness

•      Negative Spurling’s maneuver

•      No visual or ocular disturbances

•      Negative Battle sign

Physical Examination

•      Impaired delayed recall (3/5 words)

•      Mild concentration difficulties (6 digits, reverse order of months)

•      Balance impairment (single leg stand with eyes closed) 

•      Fully oriented, immediate memory intact

•      Intact light touch and 2-point discrimination

Differential Diagnosis

•      Complex concussion

•      Spinal cord contusion

•      Cervical spine injury with cord compression

•      Arnold-Chiari malformation

•      Cerebrovascular accident

•      Vascular injury/anomaly to brain stem / spinal cord

Tests and Results

•      Head CT from the day of the index injury

–   Mild soft tissue swelling in right frontal area

–   Normal parenchyma

–   No hemorrhage, ischemia, or hydrocephalus

Tests and Results

•      AP and lateral flexion/ extension views of the C-spine

•      No instability, pre-vertebral soft tissue swelling, fracture or dislocation

•      Mild levoconvex curve of upper thoracic spine

Tests and Results

Tests and Results

•      MRI of the C-spine

•      Normal alignment

•      Normal signal of brainstem, cerebellum, and spinal cord

•      Cerebellar tonsils extend 5 mm below the inlet to the foramen magnum

Tests and Results

Final Working Diagnosis

•      Chiari I Malformation 

•      Concussion

Treatment and Outcomes

•      The athlete was disqualified from contact and collision sports

–   Fortunately, he also had a significant interest in golf

•      Neurosurgical referral was discussed

•      The patient has not returned to our center for any additional visits

Pearls

•      Differences in Chiari malformations

–   Chiari I:  cerebellar tonsils

–   Chiari II:  cerebellar vermis (Arnold-Chiari)

–   Chiari III:  portion of cerebellum within an occipital encephalocele

•      At least 30% of persons with Chiari I with tonsils down 5-10 mm are asymptomatic

•      12 mm down almost always symptoms

Pearls

•      Chiari I and II malformations are associated with syringomelia

–   Chiari I is not associated with myelo-meningocele or other neural tube defects

•      Chiari I can be accompanied by skull abnormalities