Epidural Steroid Injections for the Treatment of Cervical Radiculopathy in Elite Wrestlers: Case Series and Literature Review

Abstract

Background

Elite wrestlers place tremendous stress through their cervical spine. These athletes are at risk for cervical trauma and may develop radiculopathy from recurrent episodes of injury. Team physicians and athletic trainers are faced with the challenge of treating these injuries in such a way as to allow the athlete to safely and expeditiously return to competition. Epidural steroid injections can be a successful complement to a conservative treatment algorithm for these complex injuries.

Study Design

Case Series

Methods

Five upper-level NCAA collegiate wrestlers who experienced symptomatic cervical radiculopathy were identified from an archival review. The majority of the athletes had MRI evidence of cervical disc disease, with corresponding subjective complaints and physical examination findings including pain and weakness that precluded continued competition. All athletes were treated conservatively with initial activity modification, strengthening, rehabilitation, NSAIDs, and, ultimately, cervical epidural steroid injections.

Results

All five athletes successfully returned to competition without negative clinical sequelae or need for operative intervention. The athletes demonstrated subjective improvement in their symptoms and strength, and all were able to return to a high level of competition. The cervical epidural steroid injections were found to be safe, effective, and well tolerated in all of the athletes.

Conclusions

Elite wrestlers with cervical radiculopathy can be effectively and safely managed with a conservative regimen that includes cervical epidural steroid injections, which may allow them to continue to compete at a high level.

Introduction

Collegiate athletes frequently experience high-energy collisions, including blunt force and traction injuries to the cervical spine, cervical nerve roots, and/or brachial plexus. In some cases, this trauma can cause a pinch-stretch neuro-praxia phenomenon known more colloquially as a “burner” or “stinger”. These injuries represent the more benign end of a spectrum that can include catastrophic fractures and permanent neurologic injury. Although “burners” and “stingers” are relatively common in this population, the true pathophysiology of these injuries remains poorly understood¹. These injuries are accompanied by transient shooting pains, numbness, weakness, and paresthesias in the neck and affected extremity. Repetitive injury or large-force single trauma can cause inflammation, vascular insufficiency, or bony or soft-tissue impingement on the cervical nerve roots, leading to persistence of these upper extremity symptoms beyond that expected with simple burners/stingers. This constellation of symptoms is broadly categorized as cervical radiculopathy. These injuries may precipitate severe complaints, but in many cases, respond well to conservative treatment.

These injuries pose a special clinical challenge for physicians and athletic trainers, who are charged with ensuring a safe and expeditious return to sport for the athlete. Accelerated rehabilitation protocols and targeted therapy can facilitate treatment and expedite recovery. This investigation outlines the use of epidural steroid injections (ESI) as an adjunctive therapy in the conservative treatment of collegiate wrestlers with cervical radiculopathy and persistent weakness and pain.

Case Presentation, Workup, and Management

Case 1:

A 22-year old male collegiate wrestler presented with several weeks of right-sided neck pain and increasingly frequent “stingers” radiating down his right upper extremity. Symptoms were exacerbated with a Spurling maneuver and frequently occurred during wrestling. Manual motor testing demonstrated 4/5 strength in the right deltoid and triceps muscles. Due to concern for cervical radiculopathy, magnetic resonance imaging (MRI) was obtained which demonstrated disc protrusion and compression at C3-C4 and C4-C5 (FIGURE 1). As part of his conservative treatment regimen, he underwent an epidural steroid injection centered at C7-T1. He experienced a rapid return to function and was able to return to wrestling with no complaints of pain or dysfunction for the duration of the season. One year later he had a return of symptoms with recalcitrant right-sided neck pain and activity-related “stingers” radiating down the right upper extremity. He underwent a repeat cervical ESI with relief of his symptoms. Four months later he had yet another recurrence of pain associated with new-onset 4/5 weakness in his right deltoid. A repeat MRI confirmed C3-4 bilateral neural foraminal narrowing and right-sided C4-5 neural foraminal narrowing. A third injection was performed and the patient once again returned to full activity.

Figure 1. Sagittal and axial images from MRI demonstrating disc extrusion at C3-C4 with resultant foraminal stenosis and root compression on the right.

Case 2:

A19-year old male competitive wrestler presented with neck pain and left arm weakness associated with increasingly frequent “stingers” involving the left upper extremity. Manual motor testing revealed decreased grip strength and thumb extension strength of the left hand. Subsequent MRI demonstrated evidence of a left sided C6-7 disc extrusion (FIGURE 2). In addition to NSAIDs, the patient was given a short course of oral corticosteroids and referred for rehabilitation. Despite this treatment regimen, he remained symptomatic several weeks later. A repeat physical examination demonstrated 4/5 strength in his left wrist flexors and a positive Spurling test. The patient was then referred for a cervical ESI and he underwent an epidural steroid injection centered at C7-T1. Within a few weeks he experienced complete resolution of his pain and weakness. Three months after his ESI, the patient was cleared to return to full wrestling activity. One year later the patient developed some right-sided radicular symptoms that were less severe than the left side. Repeat MRI demonstrated a stable left-sided C6-7 disk extrusion. The athlete underwent another ESI and was able to return to competition with full resolution of his complaints.

Figure 2. Sagittal and axial MRI images demonstrating disc extrusion and left-sided foraminal compression at C6-C7.

Case 3:

A 22-year old competitive wrestler presented with neck pain, left arm weakness, and numbness, exacerbated by a recent match in which he attempted to turn out of a front headlock. Physical examination findings demonstrated a positive Spurling sign, and 4/5 left deltoid and triceps strength. Subsequent MRI demonstrated a disc osteophyte complex at the C6-7 level on the left side, resulting in moderate to severe narrowing of the neural foramen (FIGURE 3). An interlaminar cervical ESI was performed centered at C7-T1, with symptomatic relief beginning within one week of the injection. By six weeks, the patient had complete resolution of his pain and near-complete restoration of strength, with only a mild discrepancy in comparative strength in the left triceps and wrist flexors. By two months after the injection, his strength deficits had resolved and his activity restrictions were lifted. Several months later, the patient experienced new-onset contralateral radicular symptoms, with pain radiating into the right thumb. Physical examination findings demonstrated mild weakness with wrist extension and elbow flexion. Repeat MRI demonstrated a right-sided C5-6 disc herniation with concomitant impingement at the C5-6 neural foramen. Approximately eight months after his original ESI, the patient underwent a repeat ESI. Symptoms resolved for another four months, but with further competition, the left-sided complaints recurred. Further imaging with MRI showed progressive disc herniation involving the left C6-7 neural foramen. A third ESI was performed. The patient had marked improvement in his strength, with only occasional pain. He requested an additional injection prior to participation in the NCAA championships. Following this injection, the patient was able to successfully participate in competition, and his radiculopathy continues to respond to medical management for several years.

Figure 3. Sagittal and axial images from MRI demonstrating disc extrusion.

Case 4:

A 22-year old collegiate wrestler sustained a traumatic hyperextension-rotation injury during competition when his opponent landed on his head and forced his neck back and to his left. Subsequent to this episode, he experienced increasingly frequent “stingers” when wrestling, describing weakness in his left arm and shoulder as well as pain and numbness that radiated down his left arm and into the hand. Symptoms were reproducible by performing a Spurling test. An MRI demonstrated a diffuse broad-based disk bulge at C7-T1 (FIGURE 4). He underwent an interlaminar ESI centered at C7-T1 with complete resolution of his symptoms and was able to continue competition, without further complaint or dysfunction.

Figure 4. Sagittal and axial images from MRI demonstrating disc extrusion.

Case 5:

A 19 year-old male collegiate wrestler presented with chronic neck and left shoulder pain of two years duration, associated with biceps and wrist extension weakness. He failed conservative and medical management with Gabapentin, NSAIDs and rehabilitative therapy, and continued to have exacerbations of his symptoms during wrestling practice. On exam he was found to have 4/5 strength in left elbow flexion and wrist extension, and left shoulder discomfort with a Spurling maneuver. The patient underwent an interlaminar cervical ESI centered at C7-T1 with complete resolution of his symptoms and was able to return to competition without any further dysfunction.

Discussion

Cervical radiculopathy is a clinical diagnosis in which patients demonstrate sensory and/or motor changes in a distribution specific to an affected cervical nerve root. It is frequently caused by compression of an exiting cervical nerve root. There are a variety of pathological conditions that can result in cervical nerve compression including degenerative cervical spine changes, disc extrusion, and other soft tissue abnormalities. Diagnosis is established by detailed physical exam, and the cause of radiculopathy may be localized with radiographs and advanced imaging². Symptoms are colloquially referred to as “stingers”, and are frequently caused by traction injuries to the brachial plexus, compression of the cervical nerve roots, or a pincer mechanism in which there is some degree of spinal cord compression by the posterior-inferior margin of the superior vertebral body and the anterior-superior portion of the lamina of the vertebra below³. Physical exam findings usually consist of weakness in the deltoid, biceps, and shoulder external rotators.

True brachial plexus injuries are more commonly seen in younger patients who experience a traction injury involving lateral neck flexion away from the affected side and shoulder depression toward the affected side. Although neck pain can accompany the upper extremity symptoms, this is often less prominent. These traction injuries are felt to represent a reversible peripheral nerve neuropraxia, resulting from a temporary physiological block in nerve conduction⁴.

Cervical root lesions are caused by compression of the nerve root or dorsal root ganglion in the intervertebral foramen. Radiographs frequently show evidence of cervical disk disease or stenosis. The injury mechanism is hyperextension with lateral neck flexion, and pathology can be attributed to a combination of factors including inflammatory mediators, angiogenic changes, and intraneural edema². In contrast to traction injuries of the brachial plexus, neck pain is a more prominent clinical finding in cervical root lesions. Furthermore, the presence of a positive Spurling sign and decreased cervical range of motion can assist in differentiating between cervical root lesions and brachial plexopathies.

These symptoms can be severe in athletes with underlying congenital cervical stenosis. Furthermore, wrestlers and other athletes are at risk for the development of disc disease and early degenerative spine changes due to soft tissue trauma and recurrent injury across the cervical spine. Decreased disc height space and degenerative changes at the uncovertebral and zygoapophyseal facet joints has been reported to be responsible for 70-75% of cases of cervical spondylosis, with the remainder attributed to herniated nucleus pulposus (20-25%) or tumors and infections⁵. MRI is recommended for patients who experience severe or persistent neurologic symptoms⁶. EMG studies can be done to further define injuries with persistent or recalcitrant symptoms¹.

The incidence of these injuries in wrestlers remains unknown. Evaluations of football players suggest that one or more stingers were experienced by at least 50% of football players at least once during their careers^7,8. Castro et al reported a 7.7% yearly incidence and a prevalence of 18% of stingers in collegiate football players⁹. These injuries are most common in linemen, defensive ends, and linebackers¹⁰. More generally, it is felt that slightly more than half of the adult population will experience neck and radicular symptoms at some time during their lifetime, although these symptoms rarely progress to fulminant myelopathy. Up to 66% of patients treated with long-term conservative management indicated the persistence of symptoms. Furthermore, 23% of patients who complained of persistent neck pain or radicular symptoms were unable to return to their previous employment².

Cervical radiculpathy can be diagnosed by obtaining a thorough patient history, physical examination, appropriate imaging studies and in some cases electrophysiologic testing that are all concordant. Nonetheless, cervical radiculopathy is a clinical diagnosis and there are no universally accepted criteria for diagnosis¹¹. Treatment is symptom-based, and clinicians must appropriately identify and classify the patient's problems¹², then select the appropriate combination of treatment options including the use of medication, therapeutic modalities, rest, immobilization, patient education, physical therapy, and manual therapies to treat their symptoms. Patients with cervical radiculopathy have a favorable prognosis in the long term, and several conservative treatments appear to be effective in resolving symptoms and improving function. While there is a paucity of high quality prospective research studies to support the use of individual treatment modalities, a multimodal approach can be beneficial in alleviating symptoms. Although the commonly recommended therapies such as immobilization, traction, physical therapy, and manipulation, have not been tested in high quality prospective studies, these therapies can also be beneficial. The approach used must distinguish the acuity of the symptoms and the anatomical sources.

Pharmacotherapy, such as the use of analgesics, corticosteroids, NSAIDS, muscle relaxants, antidepressants, and anticonvulsants can provide some symptomatic relief to athletes. Narcotics can be used in an acute and short-term setting, but prolonged use should be avoided due to addictive and depressive side effects. Antispasmodics and medications used for muscle relaxation also have a role in acute and short-term treatment. These medications can facilitate early rehabilitation and recovery.

Short-term immobilization with a soft collar may reduce symptoms in the acute stages but has not been shown to change the course of the disease process¹³. Cervical traction may relieve nerve root compression and irritation by temporarily enlarging the neural foramen, but there is insufficient evidence to support the use of mechanical traction to treat chronic cases of neck pain with or without radicular symptoms. A gradual progression of gentle range of motion exercises and stretching may be supplemented by use of massage and therapeutic modalities such as heat, ice, and electrical stimulation to decrease symptoms and improve range of motion. As symptoms resolve, a gradual, progressive strengthening program to recondition the musculature may be added as tolerated. While many rehabilitation programs include exercise therapy and modality utilization, there is little clinical research supporting its use. Patient education may help some patients learn to manage their symptoms, though a systematic review did not show that it is of benefit in the treatment of neck pain and radicular arm pain¹⁴.

As suggested by the present investigation, precise, fluoroscopically-guided transforaminal epidural steroid injections have been found to have a favorable role in non-operative treatment of radiculopathy¹⁵. A recent systematic review suggested that the evidence for cervical pain relief with transforaminal epidural steroid injections was moderate¹⁶. These injections, however, have been associated with a reduction in surgical treatment for patients experiencing cervical radiculopathy. In an investigation of epidural steroid injections, patients had a reduction in radicular pain scores, experienced long lasting pain relief, and 5 of the 21 patients studied cancelled and avoided surgery¹⁷. In a retrospective cohort study, Heckmann et al.¹⁸ evaluated the functional outcomes of patients with cervical radiculopathy by comparing patients treated with surgery or conservative care. At an average follow-up of 5.5 years brachalgia was completely or essentially improved in 97% of the conservative care group and 75% in the surgical group. Motor weakness improved in 94% of the conservatively treated patients and 50% of the surgically treated patients. With regard to return to daily activities, 90% of the conservative treatment group versus 67% of the patients in the surgical group did not feel disabled. The authors concluded that patients with radiculopathy can be treated conservatively with good results¹⁸.

Although generally safe, cervical interlaminar epidural steroid injections are performed with some associated complications. Abbasi et al.¹⁹ reviewed the reported incidence of complications and found a rate of complications ranging from 0 to 16.8%. The authors concluded that interlaminar cervical epidural steroid injections are relatively safe procedures. The use of cervical transforaminal injections has largely been abandoned due to to complications related to intravascular injection that have produced spinal cord injury and paraplegia or quadraplegia^20-21. The adverse events associated with these procedures are usually minor and transient in nature, however, major adverse events that have been reported include epidural hematoma, subdural and intradural complications which lead to respiratory depression, moderate hypotension, and sudden apnea with acute cardiovascular collapse, dural puncture headache, neuropathic symptoms, intracranial hypotension, permanent spinal cord injury, intravascular injection, pneumocephalus, venous air embolism, cervical epidural abscess, Cushing's syndrome, and death^22-24. No patients in the present investigation experienced any untoward effects of the injections.

The decision to return an athlete to competition remains complex and controversial. Conservative management of cervical radiculopathy can allow for successful rehabilitation of athletes and can facilitate their return to sport. In order for a patient to return to sport, they must demonstrate full cervical range of motion, normal upper extremity strength, and the athlete must appear healthy with full resolution of their “burner syndrome” symptoms²⁴. Contact athletes should not return to play until the risks of reinjury and permanent dysfunction are minimized. With appropriate diagnosis, treatment, and rehabilitation, athletes can safely return to sport²⁵. Players who experience residual weakness, cervical anomalies, or abnormal imaging or EMG studies should be excluded from contact sports.

Conclusion

Collegiate wrestlers place tremendous stress across their cervical spine and are vulnerable to cervical trauma, which may result in radiculopathy from recurrent episodes of injury. These injuries can be chronic in nature and athletes with recalcitrant symptoms may be forced to end their athletic career. Treatment options for cervical radiculopathy in young competitive athletes include conservative measures such as temporary activity modification, immobilization, strengthening, rehabilitation, and gradual return to activity. Medical management may include NSAIDs, neuromodulators, short burst corticosteroids, and analgesic medications. For patients with focal disease and symptoms that are refractory to conservative and medical management, surgery may be necessary. Unfortunately, return to competition following cervical spine surgery may not be recommended.

Based on the present investigation, elite wrestlers with cervical radiculopathy can be effectively and safely managed with a conservative regimen that includes cervical epidural steroid injections. These injections can be beneficial for athletes with both clinical evidence of cervical radiculopathy and MRI-documented anatomic abnormalities. The duration and effectiveness of cervical ESIs can be variable, but may be definitive in some cases. Team physicians and athletic trainers are faced with the challenge of treating these injuries in such a way as to allow the athlete to safely and expeditiously return to competition. Cervical epidural steroid injections may facilitate a quicker return to competition for some athletes, and the present study suggests this treatment can be well tolerated, safe, and effective in a population of elite wrestlers.