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Stingers: Be aware of the differential diagnosis

Issue: August 2012

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Sports injuries to the head and neck have taken on a higher profile in recent years. Attention has primarily centered on three pathologies: concussions, cord contusions and stingers, which are also referred to as burners. Orthopedic surgeons often serve as team physicians in a variety of settings from middle and high school athletics, through college ranks and into the realm of Olympic and professional sports. In this capacity, stingers/burners are likely to be encountered.

In this Orthopedics Today Round Table, a stellar panel who are well-versed on the issues surrounding head and neck trauma in sports provide readers with critical insights into the pathophysiology, evaluation, treatment and return to play criteria for athletes with stingers/burners.

— David A. Wong, MD, MSc, FRCS(C); and John D. Kelly IV, MD
Moderators

David A. Wong, MD, MSc, FRCS(C): What is a stinger/burner and what are the common mechanisms of injury?

John D. Kelly IV, MD: A stinger/burner is the sudden onset of burning or tingling in one extremity sustained after a blow to the head, shoulder or supraclavicular region. The dyesthethetic pain follows no distinct dermatomal distribution. Weakness may be present and usually involves a C5-C6 dermatomal pattern. Motor deficits, if present, most often affect the deltoid, biceps and/or spinati. Burners present generally following three mechanisms: traction, compression or a direct blow to the supraclavicular fossa.

Perhaps the most common, traction to the plexus, is usually seen with ipsilateral shoulder depression and lateral neck deviation, as seen in “shoulder tackling.” Traction injuries tend to occur in younger, scholastic athletes and in most cases neck pain is not present. Extension/compression burners occur with axial load to an extended neck whereupon the nerve root or dorsal root ganglion is compressed at the neural foramen. Neck pain may be present and extension compression burners occur with more frequency with cervical canal/foraminal stenosis.

The least common mechanism is a direct blow to the supraclavicular fossa (Erb’s point). This plexus contusion may be sustained by a punch, tackle or by an object such as a hockey stick.

Kelly: Is there a sport-specific higher incidence of stingers/burners where team physicians should be particularly vigilant?

Wong: American tackle football has the highest occurrence. Various studies have estimated the incidence in college and professional players to be between 16% and 65%. The next highest incidence is in wrestling. However, all sports where there is potential for head, neck and shoulder trauma have a risk for stingers/burners.

Wong: Compression of Erb’s point by a high stick in hockey or from a direct blow to the shoulder pads in hockey or football has been implicated as a cause of stingers/burners. What and where is Erb’s point in the growing or grown athlete?

Charles “Chip” J. Burke III, MD: Erb’s point is 2 cm to 3 cm above the clavicle. It is the site of the upper trunk of the brachial plexus where the junction of the C5 and C6 roots exit the muscles at the base of the neck. I have seen several ice hockey players with recurrent stingers, but all have been symptomatic from traction/stretch injury. I have not seen a direct blow from a stick produce this injury.

Wong: In your experience, are athletes with stingers/burners more likely to fall into the “walking wounded” category or are they the players out flat on the ice or turf? Can you paint us a picture of the athlete coming to the sideline or bench with a stinger/burner?

Kelly: Burners indeed fall into the “walking wounded” category, and the athlete is usually seen walking off the field holding the affected arm. The lower extremities are spared and one upper extremity is affected. Some athletes respond to a burner by shaking their extremity in hopes of resolving the burning sensation. If the athlete complains of symptoms in more than one extremity, such as both arms or ipsilateral arm and leg, then a cord injury – not a burner – is likely present.

Kelly: Which muscle groups should be examined on the sideline to evaluate a stinger/burner?

Wong: This is a key point. The relevant exam is outlined in Table 1.

  

Wong: Stingers/burners are generally classified grades I to III relating to the neural pathology to the roots and sleeves. Can you give us a broad overview of this classification?

Burke: The classification of this injury depends on the neural pathology that occurs at the time of the injury. Grade I injury is a neuropraxia resulting in a temporary loss of sensation and/or loss of motor function. There is a conduction block preventing the transmission of information. This results in only transient symptoms that may last for minutes or days. Grade II injuries are more significant since axonotmesis is defined as damage to the nerve without disruption. These injuries may produce more significant motor and/or sensory deficits that may last several weeks. It requires regrowth of the injured axon, but full function is usually restored.

The most severe are grade III injuries, defined as neurotmesis, is when there is complete severance of the nerve. These injuries may not fully recover, with symptoms persisting for more than a year. Often they require surgical repair and carry a poor prognosis. See Table 2.

Wong: What are the clinical issues between extension/compression vs. traction mechanisms of stingers/burners?

Kelly: Extension/compression burners are associated with cervical stenosis and thus are more commonly seen in more mature athletes, such as college and professional athletes. The injury is thought to occur at the root or dorsal root ganglion where it exits the neural foramen. Extension and axial loading, as seen in heads-up tackling, present a “perfect storm” for foraminal narrowing. My colleague, David Aliquo, MEd, ATC, and I examined oblique X-rays of athletes who sustained extension burners that demonstrated diminished foraminal height as referenced by the subjacent vertebral body height. Since the zone of injury approximates the cervical spine, neck pain is more commonly seen as compared to the plexus stretch mechanism.

Traction injuries result from lateral neck deviation with concomitant shoulder depression. With the arm adducted at the side, as is usually seen with shoulder tackling, the upper trunk of the lateral cord of the plexus sustains stretch. Thanks to the work of Joseph S. Torg, MD, the NCAA banned spear tackling in 1976. Subsequently, we have fortunately witnessed a dramatic decrease in cervical spine injury but a sharp increase in plexus stretch injuries. Simply stated, shoulder tackling spares the cord but places the plexus at risk for neuropraxic injury.

Wong: Which athletes should be pulled from the game? Who needs further investigation?

Kelly: Fortunately, the symptoms of many stingers/burners resolve in a matter of minutes. Thus, the athlete with resolution of dysesthetic pain and weakness may return to play provided no neck pain is present. Persistent pain and or weakness lasting beyond several minutes mandates prohibition of play. Full painless cervical range of motion must be present as well as no pain with provocative maneuvers.

I attempt to elicit neck pain by applying axial compression to the top of the head as well as asking the athlete to resist pressure applied by my hand to the forehead (forward flexion), lateral skull (lateral deviation) and posterior skull (extension). If an extension/compression burner is suspected, then a Spurling’s test should be performed and must be negative. For plexus injuries, passively deviating from the athlete’s neck while simultaneously depressing the shoulder should not yield any dysesthetic pain.

Radiographs should be obtained whenever any neck pain is present and should include flexion/extension views. The presence of symptoms lingering for more than 2 days to 3 days is justification for MRI to rule out a cervical disc injury. Weakness that lasts more than 2 weeks would be a reasonable indication for an electromyogram.

Kelly: In the last few years, National Hockey League (NHL) arenas went back to softer, less rigid boards and glass partitions around their rinks. Were an increased incidence of stingers/burners and other injuries a factor in this decision?

Burke: This issue was carefully looked at by the NHL Injury Analysis Panel, a committee formed about 10 years ago. The NHL rinks had begun installing seamless glass and stiffer boards to support the increased weight of the glass panels, approximately 940 lbs. per glass panel. The committee looked at injury statistics in rinks with and without the new glass/board systems. The injury rates were higher in all categories, so the NHL produced a standard for deflection/movement of the board/glass system due to impact of the players.

Wong: In the absence of specific pathology, such as a herniated cervical disc, is symptomatic care the essence of treatment?

Kelly: Tincture of time is the essence of care for stingers/burners. The nerve root or plexus must be afforded adequate rest to ensure full recovery. Although this is rare, too soon return to play could conceivably result in chronic dysesthetic pain and permanent weakness. In extreme instances, antineuroleptics, such as gabapentin, may be indicated to ameliorate symptoms during recovery.

Chest-out posturing is encouraged since this position opens foraminal dimensions and may facilitate neural recovery. We encourage our athletes to strengthen trapezial and scapular retraction muscle and paraspinal muscles in hopes of mitigating recurrence. Cowboy collars are an excellent means of limiting extension, but their role in guarding against extreme lateral deviation is more suspect. The clinician must recognize that cowboy collars, horse collars and shoulder pad lifters may serve well to limit neck extension. However, they carry the small risk of facilitating neck down tackling – the at-risk position for catastrophic neck injury.

Finally, we encourage the trainers and coaches to investigate the athlete’s tackling technique to be sure there are no gravely unsafe practices, such as persistent head tackling, present.

Kelly: Can you give us the general criteria for return to play and for ending a player’s season or career?

Wong: There are four key criteria for return to play. First, symptoms must be resolved. Second, on exam the athlete must demonstrate normal strength and sensation. Also on exam, the third issue is full, pain-free range of neck and shoulder motion. Finally, the player must demonstrate the ability to perform sport-specific activities without pain.

In terms of who is out for the season, the criteria are generally the third stinger/burner within the same season even if symptoms resolve quickly.

Permanent cessation of the sport is considered for athletes having persistent symptoms or findings, particularly with the third stinger in the same season or different seasons.

Kelly: A preganglionic root avulsion is the most serious type of stinger/burner that the team surgeon does not want to miss. What are the clinical characteristics?

Burke: This injury represents a severance of the nerve root. It usually results in more severe neurologic symptoms of weakness and loss of sensation. You may find anesthesia above the clavicle and there may even be signs of Horner’s syndrome (ptosis, myosis and anhidrosis). The levator scapulae will be weak and the athlete will be unable to abduct the shoulder through the first 30· of range of motion.

Wong and Kelly: The key take-home points of this Orthopedics Today Round Table are:

• Be aware of the differential diagnosis. Stingers/burners are generally unilateral and upper extremity only. If there is bilateral upper extremity or any lower extremity involvement, then be more suspicious of cord contusion and require additional investigation.
• To return to play, the athlete must be symptom-free, on exam show normal strength and sensation as well as a full, pain-free range of neck and shoulder motion. Also, the athlete must demonstrate sport-specific activity without symptoms.