A 19-year-old male collegiate football player presented to the emergency department (ED) with persistent neck pain following an injury at practice. The contact occurred during a blocking drill and reportedly forced his neck into hyperextension. Upon impact, he immediately experienced high cervical neck pain localized to the left side of his neck, although over time this pain became more generalized. The patient was removed from play, and on the sidelines, no weakness or sensory abnormalities were noted on his examination. The pain was exacerbated with palpation at the base of the skull and did not radiate. Cervical range of motion with rotation, flexion, extension, and lateral flexion was limited secondary to pain. The patient had persistent pain later in the evening, not relieved with analgesics and rest, and was ultimately instructed to go the ED for further work- up and evaluation.
In the ED, he had continued complaint of neck pain; however, he remained neurologically intact and denied numbness, paresthesias, or weakness on initial evaluation. Of note though, later that evening in the ED, the patient transiently experienced subjective numbness in his left lateral forearm in an ulnar distribution that later spontaneously resolved. He was an otherwise healthy individual with a medical history significant for one "stinger" in the past that completely resolved. Plain films revealed no acute fracture or dislocation [Figure 1]. A computed tomography (CT) scan of his cervical spine demonstrated absent bony fusion of the anterior midline synchondrosis, as well as the midline posterior arch of the C1 bony ring [Figure 2a-c]. The osseous components had well-developed cortical margins, strongly suggesting that the midline discontinuities were not the result of trauma. The patient additionally underwent magnetic resonance imaging (MRI) of the cervical spine that demonstrated prominent edema in the pre-vertebral soft tissues extending from the level of the clivus to the vertebral body of C5 [Figure 3a]. Images at the level of the C1 bony ring demonstrated edema of the paramedian ventral soft tissues at, above, and below the level of the unfused anterior midline synchondrosis [Figure 3b and c]. No ligamentous disruption was identified.
The patient's overall clinical picture and imaging findings were consistent with a cervical sprain/strain with an incidental finding of a congenital bipartite atlas. Given his persistent neck pain, tenderness, and findings of pre- vertebral soft tissue swelling, the patient was advised to remain in a rigid cervical collar until seen in follow- up 1 week later. He was treated symptomatically with non- steroidal anti-inflammatory drugs (NSAIDs) and a muscle relaxant. He was temporarily removed from contact drills, but was cleared to ride a stationary bike and to do isometric neck strengthening with the athletic training staff, while remaining in the collar. Follow-up 1 week later revealed diminished tenderness and increased range of motion. Flexion/extension radiographs were obtained and demonstrated no evidence of instability or misalignment. The patient was allowed to resume usual activity and his cardiovascular training regimen with symptomatic restrictions. We opted to wait until his MRI findings resolved, prior to resuming contact activity. Repeat MRI of his cervical spine approximately 1.5 months following the injury demonstrated complete resolution of the pre-vertebral swelling and hyperintensity, and an unchanged appearance of the unfused anterior midline synchondrosis. Even after having a discussion with the patient regarding the uncertain future risk for cervical spine injury and was demonstrated understanding the potential consequences, he desired to continue playing. Given the absence of any signs of instability, the patient was cleared to fully return-to-play. He resumed contact activity, both practice and game-time play, without further issues and continues to remain asymptomatic.