Cervical cord MRI T2 hyperintensity may not affect return to play in contact athletes

Complete symptom resolution, a normal neurological exam and no instability were found to be most critical for return to play decisions.

An MRI finding of T2 hyperintensity in the cervical spinal cord of professional athletes can be used as evidence of cord trauma, but it may not correlate with prognostic values for return to play, based on findings in a recently published study by Joseph C. Maroon, MD, FACS, and colleagues.

The complete resolution of symptoms, no evidence of spinal instability and a clean neurological exam may be more important then the MRI findings in determining whether an elite athlete can resume playing their sport, according to Maroon.

“Clearance for return to play preceded complete resolution of MRI T2 hyperintensity in three of four athletes. Of the athletes that return to contact sport, none as of the date of publication had suffered any further cervical spine injuries. The return to play for this unique group of professional athletes with persistent T2 MRI hyperintensity included, being completely symptom-free, having a normal examination and no evidence of radiographic spinal instability,” Maroon told Spine Surgery Today.

T2 hyperintensity confirmed on MRI

Maroon and colleagues conducted a study of four National Football League (NFL) athletes and one professional wrestler who had prior traumatic neurapraxia and congenitally small cervical canals, multilevel spondylosis/stenosis/disc herniation and focal cord T2 hyperintensity. All these conditions were confirmed by MRI.

Joseph Maroon

Joseph C. Maroon

The four NFL athletes — a defensive tackle, a defensive end, a tight end and a cornerback — were 26 years to 35 years old, with a median age of 31 years. The professional wrestler was 31 years old.

According to the study, the signal abnormalities identified on MRI were seen at C3-4, C4-5 and at the C4 mid-vertebral body. Four of the five athletes underwent single-level anterior cervical discectomy and fusion (ACDF) via a right-side approach, and one athlete was treated nonoperatively.

Criteria for return-to-play

The athletes who underwent ACDF had postoperative AP/lateral and dynamic radiographs taken at 6; weeks, 3, 6, and 9 months and 1 year. To be cleared for return to their sport, the athletes had to have solid arthrodesis of the operative level and a minimum follow-up of 3 months. Solid arthrodesis was determined by the presence of bridging bone across the level without movement on dynamic imaging.

At 3 months of follow-up, Maroon, who is a Spine Surgery Today Editorial Board member, and colleagues found four of the five athletes had partially resolved T2 hyperintensity and one athlete had no change in hypersensitivity.

At 9 months of follow-up, three of the five athletes had completely resolved T2 hyperintensity and four of the five athletes were cleared to return to their sport.

Some cleared before T2 resolution

Investigators found three of the four athletes who were cleared by their physicians to return to play actually returned to play prior to achieving complete resolution of MRI T2 hyperintensity. One athlete retired before returning to his sport, and two of the athletes returned to play and did not experience further episodes of neurapraxia or of cervical spine-related complications.

The investigators noted the presence of persistent cord-related symptoms may be a contraindication for elite athletes to return to play, however, T2 hyperintensity may not be an absolute contraindication if spinal stability is demonstrated.

“Additional observations are needed to confirm this approach due to the small series size reported in the literature thus far,” Maroon said. – by Robert Linnehan

Disclosure: Maroon reports he is the team neurosurgeon for the Pittsburgh Steelers and medical director for World Wrestling Entertainment

An MRI finding of T2 hyperintensity in the cervical spinal cord of professional athletes can be used as evidence of cord trauma, but it may not correlate with prognostic values for return to play, based on findings in a recently published study by Joseph C. Maroon, MD, FACS, and colleagues.

The complete resolution of symptoms, no evidence of spinal instability and a clean neurological exam may be more important then the MRI findings in determining whether an elite athlete can resume playing their sport, according to Maroon.

“Clearance for return to play preceded complete resolution of MRI T2 hyperintensity in three of four athletes. Of the athletes that return to contact sport, none as of the date of publication had suffered any further cervical spine injuries. The return to play for this unique group of professional athletes with persistent T2 MRI hyperintensity included, being completely symptom-free, having a normal examination and no evidence of radiographic spinal instability,” Maroon told Spine Surgery Today.

T2 hyperintensity confirmed on MRI

Maroon and colleagues conducted a study of four National Football League (NFL) athletes and one professional wrestler who had prior traumatic neurapraxia and congenitally small cervical canals, multilevel spondylosis/stenosis/disc herniation and focal cord T2 hyperintensity. All these conditions were confirmed by MRI.

Joseph Maroon

Joseph C. Maroon

The four NFL athletes — a defensive tackle, a defensive end, a tight end and a cornerback — were 26 years to 35 years old, with a median age of 31 years. The professional wrestler was 31 years old.

According to the study, the signal abnormalities identified on MRI were seen at C3-4, C4-5 and at the C4 mid-vertebral body. Four of the five athletes underwent single-level anterior cervical discectomy and fusion (ACDF) via a right-side approach, and one athlete was treated nonoperatively.

Criteria for return-to-play

The athletes who underwent ACDF had postoperative AP/lateral and dynamic radiographs taken at 6; weeks, 3, 6, and 9 months and 1 year. To be cleared for return to their sport, the athletes had to have solid arthrodesis of the operative level and a minimum follow-up of 3 months. Solid arthrodesis was determined by the presence of bridging bone across the level without movement on dynamic imaging.

At 3 months of follow-up, Maroon, who is a Spine Surgery Today Editorial Board member, and colleagues found four of the five athletes had partially resolved T2 hyperintensity and one athlete had no change in hypersensitivity.

At 9 months of follow-up, three of the five athletes had completely resolved T2 hyperintensity and four of the five athletes were cleared to return to their sport.

Some cleared before T2 resolution

Investigators found three of the four athletes who were cleared by their physicians to return to play actually returned to play prior to achieving complete resolution of MRI T2 hyperintensity. One athlete retired before returning to his sport, and two of the athletes returned to play and did not experience further episodes of neurapraxia or of cervical spine-related complications.

The investigators noted the presence of persistent cord-related symptoms may be a contraindication for elite athletes to return to play, however, T2 hyperintensity may not be an absolute contraindication if spinal stability is demonstrated.

“Additional observations are needed to confirm this approach due to the small series size reported in the literature thus far,” Maroon said. – by Robert Linnehan

Disclosure: Maroon reports he is the team neurosurgeon for the Pittsburgh Steelers and medical director for World Wrestling Entertainment