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Working Diagnosis:
Spinal cord injury without radiographic abnormality (Transient Quadriplegia)

Treatment:
Initial treatment was conservative. No acute surgical intervention was necessary, and no clear indication for corticosteroids or hypothermia protocol was required. Shortly after his admission, he had full return of his upper extremity strength and sensation with residual bilateral lower extremity weakness. Physical therapy was initiated and continued post-discharge.

For several weeks, he continued to experience a gradual return of lower extremity strength. Recovery of balance was more prolonged but eventually improved. Over the next several months he was able to successfully progress to full activities without any deficits.

Outcome:
Following many discussions with his family and our medical team, a mutual decision to no longer play competitive contact sports was reached.

Author's Comments:
This case highlights the importance of proper on-field management. Transient quadriplegia needs to be differentiated acutely from more significant and potentially life threatening injuries. There are various types of mechanisms for this injury, specifically hyperflexion, hyperextension, and axial loading, with hyperflexion being the likely cause of this athlete's injury.

The Torg ratio can be a useful tool for counseling athletes, however overall it is a poor positive predictor of spinal stenosis. MRI provides the most information in regards to spinal cord reserve, spinal stenosis and risk for future injury.

Cervical injuries will forever be a risk when playing high velocity contact sports. Spear tackling was removed in 1976 Case Photo #3, and since then, cervical injuries have decreased. However there still exists a general worry about prevention. Athletes without evidence of risk factors other than prior episodes of transient quadriplegia continue to challenge the sports medical community on how to weigh the risks for future, possibly more serious injury.

Editor's Comments:
This is an excellent case which demonstrates the importance of keeping your differential broad when initially examining the downed athlete. It is imperative to constantly stay vigilent for the most dangerious signs and symptoms, with actions keeping the athlete safe at all times. For example, cervical spine precautions and backboarding were essential in this case but monitoring airway and breathing throughout were also imperative.

Additionally, this case illustrates the point that every injury will not present identically and demonstrates variability from case to case.

Learning how to counsel the athlete, family, and coaches becomes crucial in such cases. Understanding and presenting known facts is important when reviewing the risks of returning to play so that they may make the most educated decision possible.

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