SplintER Series: A Temporary Pain in the Neck

An 18-year-old football player presents to the Emergency Department after an episode of transient numbness, tingling, and inability to move his right upper extremity after making a tackle. He continued playing without recurrence. The above imaging was obtained (Figure 1. Lateral cervical spine x-ray. Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 32505).

What is the most likely diagnosis?

The patient has most likely suffered a “stinger” or “burner”. A stinger is defined as a transient sensory and/or motor loss of one limb. This is a result of either injury to the brachial plexus (via traction causing stretching or compression at Erb’s point by direct trauma) or compression of the nerve roots exiting the cervical spine [1].

Pearl: The most common motor deficit follows the C5 and C6 nerve root distribution which contributes to shoulder abduction, elbow flexion, forearm supination, and wrist extension [1].

What examination findings are expected in the Emergency Department?

None. A stinger typically resolves after several minutes. A thorough history and physical examination must be performed and documented, including a cervical and neurologic examination. If neurological symptoms remain present in the Emergency Department, an alternative diagnosis should be strongly considered.

Pearl: Ask about laterality, number of stingers, and duration of symptoms. Patients with bilateral symptoms, recurrent stingers, or a long duration of symptoms may have underlying structural cervical or plexus pathology such as spinal stenosis.

Is this a common sports injury?

According to the National High School Sports-Related Injury Surveillance System, cervical spine injuries occurred in high school athletes at a rate of ~ 3 per 100,000 athlete exposures. “Nerve injury” occurred 20.5% of the time making it the second most frequent injury behind “muscle injury” (63.1%). Most of the injuries occurred in football followed by wrestling and girls gymnastics [2].

Pearl: According to the NCAA Injury Surveillance Program database, it is estimated that stingers occur in ~2 per 10,000 athlete exposures in American Football [3].

What imaging is indicated in the Emergency Department?

If the patient remains asymptomatic with a negative physical exam, emergent imaging is not necessary.

Pearl: In conjunction with your clinical gestalt, clinical decision tools such as the Canadian C-Spine tool or the NEXUS C-Spine tool can help identify those at low risk for serious injury.

Is it safe for him to continue to play football? What are your recommendations?

If this is his first stinger, it is likely safe for the patient to return to sport given his unilateral and rapid resolution of symptoms. Assuming he has regained full strength and ROM of his cervical spine with no symptoms [1]. However, given there are no clear guidelines and return to sport is largely based on expert opinion, follow up with a Sports Medicine physician and/or Spine physician is appropriate before returning to sports.

Pearl: Additional testing such as x-ray, CT, MRI, and EMG may be performed though should be guided by a physician with clinical experience with this type of injury [4].

Resources & References:

Check out ALiEM’s Paucis Verbis card on cervical spine imaging rules.

Cantu RC, Li YM, Abdulhamid M, Chin LS. Return to play after cervical spine injury in sports. Current Sports Med Rep. 2013;12:14-7. PMID: 23314078
Meron A, McMullen C, Laker SR, Currie D, Comstock RD. Epidemiology of Cervical Spine Injuries in High School Athletes Over a Ten-Year Period. PM R. 2018;10:365-72. PMID: 28919185
Chung AS, Makovicka JL, Hassebrock JD, et al. Epidemiology of Cervical Injuries in NCAA Football Players. Spine. 2019;44:848-54. PMID: 30830045
Standaert CJ, Herring SA. Expert opinion and controversies in musculoskeletal and sports medicine: stingers. Arch Phys Med Rehabil. 2009;90:402-6. PMID: 19254603

Author information

Matthew Negaard, MD

Clinical Assistant Professor
Department of Emergency Medicine
University of Iowa Hospitals and Clinics

Primary Care Sports Medicine Physician
Methodist Sports Medicine (Indianapolis, Indiana)

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