Recurrent burner syndrome due to presumed cervical spine osteoblastoma in a collision sport athlete – a case report
© Elias et al. 2007
Received: 23 February 2007
Accepted: 06 June 2007
Published: 06 June 2007
We present a case of a 35-year-old active rugby player presenting with a history of recurrent burner syndrome thought secondary to an osteoblastoma involving the posterior arch of the atlas. Radiographically, the lesion had features typical for a large osteoid osteoma or osteoblastoma, including osseous expansion, peripheral sclerosis and bony hypertrophy, internal lucency, and even suggestion of a central nidus. The patient subsequently underwent an en bloc resection of the posterior atlas via a standard posterior approach. The surgery revealed very good clinical results.
In this report, we will discuss in detail, the presentation, treatment, and return to play recommendations involving this patient.
Differential Diagnosis Radiculopathy versus Stinger
hypersensitivity or numbness
sensory symptoms > motor symptoms
symptoms few minutes
difficult to localize
global transient weakness
tingling, dull, aching
weakness, tingling, burning
Multiple underlying morphological factors exist which have been associated with the incidence of cervical spinal injuries in athletics including congenital or developmental spinal stenoses, congenital fusions, or intervertebral disk herniations or degeneration [3, 4].
Other developmental anomalies that may predispose to subsequent neural compressive injury include spina bifida, Langerhans cell histocytosis (eosinophilic granuloma), exostoses, fibrous dysplasia, and melorheostosis. Additionally, posttraumatic lesions causing osseous enlargement could similarly predispose to later injury.
However, to our knowledge, there have been no reports of a burner syndrome developing through a contact sport injury related to an underlying expansile cervical spine lesion.
We present a case of a rugby player with a unique clinical history of recurrent burners thought to be secondary to an osteoblastoma involving the posterior arch of the atlas. Initially, the condition was felt to most likely reflect previous trauma and a reparative osseous proliferation. After complete imaging evaluation, the lesion was felt to more likely reflect a developmental lesion with bony expansion narrowing the central canal.
In this report, we will detail the presentation, treatment, postsurgical outcome, and return to play recommendations for this patient.
A 35-year-old active rugby player with a one-year history of multiple recurrent stingers or burners in his left upper extremity presented to the senior author for evaluation three weeks following his most recent episode. In that episode, while playing rugby, the patient was involved in a head on collision with another player. The subject was referred to our orthopaedic surgery spine clinic due to a positive L'Hermitte's sign. The patient reported a brief loss of consciousness and states he awoke with a "stiff neck". He also stated that he experienced a burning and tingling pain shooting down his left upper extremity into all five fingers. The pain worsened with activity and was non-dermatomal. His symptoms improved over the subsequent hour after the trauma, and had completely resolved after 48 hours later. He denied any loss of hand or fine finger dexterity or bowel or bladder dysfunction. He also denied any history of fever, chills, weight loss, night pain, nausea or vomiting. He did however admit to intermittent episodes of cervical neck pain, with exacerbation during neck movement, in the interval between the trauma and the office visit, which responded well to nonsteroidal anti-inflammatory medications (NSAIDs).
On physical examination, cervical range of motion was limited to 10 degrees of extension and 45 degrees of rotation with no restriction in active flexion or extension. There were no motor or sensory deficits. Reflexes were equal bilaterally, with no upper motor neuron signs noted. Provocative tests such as flexion, extension and Spurling's sign that were performed were negative or unrevealing.
Plain radiographic evaluation (AP, lateral, flexion, extension cervical radiographs) revealed a mild decrease in cervical lordosis on the neutral lateral view and a hypertrophied, blastic appearance to the posterior arch of the atlas.
Radiographically, the lesion had features typical for a benign tumor such as a large osteoid osteoma or osteoblastoma, including osseous expansion, peripheral sclerosis and bony hypertrophy, internal lucency, and even suggestion of a central nidus. The lesion was greater than 1.5 cm in diameter.
The patient had an uneventful postoperative course and at the latest follow-up, just over one year out of surgery, the patient was doing well without any complaints of neck discomfort or neurologic symptoms. Even so, given the lack of an intact posterior arch of C1, he was advised to refrain from contact sports due to the presence of cervical spinal cord myelomalacia.
Discussion & conclusion
Imaging work up of developmental lesions involving the axial skeleton most frequently includes plain radiographs, followed by CT for assessment of bony matrix and MRI for evaluation of intrinsic spinal cord parenchymal changes and the potential neural compression. With some lesions, bony scintigraphy or PET scanning may be helpful to assess for metabolic activity.
This rugby player's clinical and radiographic findings suggested that the bony lesion involving the posterior elements of the cervical atlas was most compatible with an osteoblastoma, which could directly or indirectly predispose the patient to upper extremity stingers or burner. Although the surgical pathology specimen was determined to be a benign, productive osseous lesion, resection for alleviation of the mass effect on the spinal cord ultimately eliminated the patient's symptoms of the burner syndrome.
Many authors have studied athletes to determine if there are any variables or pre-existing conditions that make one susceptible to "stingers". After evaluating 165 freshman football players, Castro et al. applied the Torg ratio to their cervical imaging studies and found a relationship between the prevalance of burners in those athletes with cervical spinal stenosis. They demonstrated that college athletes with a ratio of less than 0.75 were at an increased risk for recurrent stingers, however the ratio was not related to the initial onset of a stinger .
In another study, Leivitz et al. reported that there is a high incidence of cervical canal stenosis in football players with recurrent burner syndrome .
One of the more difficult answers to determine with these injuries is an appropriate time interval beyond which an athlete can safely return to play following a traumatic cervical peripheral neuropraxia. This is a decision derived from a compilation of factors including the patient's history, severity and chronicity of symptoms, mechanism of injury, objective anatomical injury (based on physical examination or imaging abnormalities), and the athlete's recovery response .
Recommendations for return to play in the setting of sports related "stinger or burner" are generally based on the absence of specific structural abnormalities if imaging studies are available, and the clinical findings and include the following: complete resolution of symptoms, normalization of upper extremity strength to baseline, and normal cervical range of motion . If symptoms persist, a more detailed evaluation including advanced imaging studies (MRI or CT) if not already obtained, should be performed to rule out an occult fracture, physical cord compression (herniated disk), cord parenchymal changes, instability, or structural abnormalities, before returning to play. Advanced cervical disk degeneration has been noted in athletes with chronic recurrent burner syndrome .
Patients with either an osteoblastoma or osteoid osteoma often present with a complaint of intermittent or constant axial spine pain, worst at night, and responsive to aspirin or NSAIDs. In addition to axial pain, neural compression by the tumor may cause clinical manifestations of myelopathy, radiculopathy or a combination of these . As a result, these tumors should generally be considered, although not likely, in the differential diagnosis of young patients with complaints of persistent or recurrent axial pain and radicular symptoms.
While an osteoid osteoma or osteoblastoma involving the spine can often be diagnosed with radiographs, advanced imaging including MRI and/or CT is generally indicated to define the nature and extent of soft tissue involvement or compromise. For example, Raskas et al. reported a 57% incidence of epidural invasion in patients with a documented osteoblastoma .
In summary, the burner syndrome is most often a benign condition commonly experienced by athletes participating in collision sports. Symptoms are typically self-limited, resolving within hours to days. In cases where symptoms fail to resolve, or the patient experiences several recurrent episodes, further clinical and imaging investigation should be performed to exclude possible lesions of the cervical spine.
We conclude that complete en bloc resection of the benign lesion in our case, which turned out to be hypertrophic bone, revealed very good clinical results.
- Leivitz CL, Reilly PJ, Torg JS: The pathomechanics of chronic, recurrent cervical nerve root neurapraxia. The chronic burner syndrome. Am J Sports Med 1997,25(1):73–6.View ArticleGoogle Scholar
- Speer CL, Basset FH: The prolonged burner syndrome. Am J Sports Med 1990,18(6):591–4.View ArticlePubMedGoogle Scholar
- Maroon JC, Bailes JE: Athletes with cervical spine injury. Spine 1996, 21:2294–2299.View ArticlePubMedGoogle Scholar
- Torg JS, Pavlov H, Genuario , Sennet B, Wisneski RJ, Robie BH, Jahre C: Neurapraxia of the cervical spinal cord withtransient quadriplegia. J Bone Joint Surg Am 1986,68(9):1354–70.PubMedGoogle Scholar
- Torg JS: Cervical spinal stenosis with cord neurapraxia and transient quadriplegia. Sports Med 1995,20(6):429–34. ReviewView ArticlePubMedGoogle Scholar
- Castro FP Jr, Ricciardi J, Brunet ME, Bush MT, Whitecloud TS III: Stingers, the Torg ratio and the cervical spine. Am J Sports Med 1997,25(5):603–8.View ArticlePubMedGoogle Scholar
- Vaccaro AR, Klein GR, Ciccoti M, Pfaff WL, Moulton MJ, Hilibrand AJ, Watkins B: Return to play criteria for the athlete with cervical spine injuries resulting in stinger and transient quadriplegia/paresis. Spine J 2002,2(5):351–6.View ArticlePubMedGoogle Scholar
- Vaccaro AR, Watkins B, Albert TJ, Pfaff WL, Klein GR, Silver JS: Cervical spine injuries in athletes: current return-to-play criteria. [Review]. Orthopaedics 2001,24(7):699–703.Google Scholar
- Rushton JG, Mulder DW, Lipscomb PR: Neurologic symptoms with osteoid osteoma. Neurolog 1955, 5:794–797.Google Scholar
- Raskas D, Graziano G, Herzenberg J, Heidelberger KP, Hensinger RN: Osteoid osteoma and osteoblastoma of the spine. J Spinal Disorders 1992,5(2):204–11.View ArticleGoogle Scholar
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