The incidence of reoperation for pseudarthrosis after cervical spine surgery.

INTRODUCTION: Pseudarthrosis after cervical spine surgery represents an underreported and challenging complication. Using a large multi-center surgical database, we sought to: (1) report the incidence of cervical pseudarthrosis, (2) evaluate changes in rates of cervical pseudarthrosis, and (3) describe risk factors for suboptimal outcomes after cervical pseudarthrosis surgery. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2019 was used. The primary outcome was occurrence of a cervical fusion procedure with a prior diagnosis of pseudarthrosis. Fusion for pseudarthrosis was divided into anterior and posterior approaches. Post-operative complications were classified as major or minor. Prolonged LOS was defined as exceeding the 75th percentile for total hospital stay. RESULTS: A total of 780 patients underwent cervical fusion for pseudarthrosis, and a significant increase in rates of surgery for pseudarthrosis was seen (0.25-1.2%, p < 0.001). The majority of cervical pseudarthrosis was treated with a posterior approach (66.5%). Postoperatively, 38 (4.9%) patients suffered a complication and 247 (31.7%) had a prolonged LOS. The three strongest risk factors for complications and extended LOS were > 10% weight loss preoperatively, congestive heart failure, and pre-operative bleeding disorder. CONCLUSION: Results from a large multi-center national database revealed that surgery to treat cervical pseudarthrosis has increased from 2012 to 2019. Most pseudarthrosis was treated with a posterior approach. Reoperation to treat cervical pseudarthrosis carried risk, with 5% having complications and 32% having an extended LOS. These results lay the groundwork for a future prospective study to discern the true incidence of cervical pseudarthrosis and how to best avoid its occurrence.

Sport-related concussions in baseball and softball: do mechanisms of injury affect recovery?

OBJECTIVE: Baseball and softball pose unique risks for sport-related concussion (SRC). Although these are not collision sports, concussions in baseball and softball can nonetheless involve high-speed impacts. In a regional, single-institution cohort of baseball and softball athletes who sustained an SRC, the current study sought to 1) describe the mechanisms of injury that led to SRC, and 2) compare initial symptom burden and recovery metrics across mechanisms, including time to return to learn (RTL), time to symptom resolution, and time to return to play (RTP) by mechanism of injury. METHODS: A retrospective cohort study was performed of baseball and softball athletes 12 to 23 years old who sustained an SRC between November 2017 and April 2022. Mechanisms of injury were divided into two categories: 1) contact mechanism (i.e., what initiated contact with the injured player, such as head-to-ball), and 2) player mechanism (i.e., the action the injured player was performing at the time of injury, such as fielding). The recovery outcomes of time to RTL, symptom resolution, and RTP were compared between mechanisms using bivariate analysis and multivariable regression analysis, controlling for sex, age, time to present to concussion clinic, and initial total symptom score. RESULTS: The sample included 58 baseball and softball players (60.3% female, mean age 16.0 ± 1.9 years). Most SRCs (62.1%) occurred during competition. Head-to-ball (50.0%) was the most common contact mechanism, followed by head-to-head/body (31.0%) and head-to-wall/ground/equipment (17.2%). Fielding (63.8%) was the most common player mechanism, followed by drills (20.7%) and running (13.8%). SRCs sustained in practice had significantly longer RTL (median 10.0 [interquartile range (IQR) 3.3-16.3] vs 4.0 [IQR 2.0-8.0] days; U = 421.5, p = 0.031) and symptom resolution (37.0 [IQR 18.0-90.0] vs 14.0 [IQR 7.0-41.0] days; U = 406.5, p = 0.025) compared with SRCs sustained in competition. Multivariable regression analysis revealed that head-to-wall/ground/equipment contact mechanism was associated with longer RTL (ß = 0.30, 95% CI 0.07-0.54, p = 0.013). CONCLUSIONS: The current study found that SRCs in baseball and softball occurred more often in competition than in practice. Head-to-ball and fielding were the most common contact and player mechanisms, respectively. SRCs sustained in practice were associated with longer time to RTL and symptom resolution, and head-to-wall/ground/equipment was associated with longer RTL in multivariable regression analysis. These results provide empirical data to improve concussion safety in baseball/softball.

Acute psychological symptom profiles in high school athletes following sport-related concussion.

OBJECTIVE: Psychological symptoms following a sport-related concussion may affect recovery in adolescent athletes. Therefore, the aims of this study were to 1) describe the proportion of athletes with acute psychological symptoms, 2) identify potential predictors of higher initial psychological symptoms, and 3) determine whether psychological symptoms affect recovery in a cohort of concussed high school athletes. METHODS: A retrospective cohort study of high school athletes (14-18 years of age) who sustained a sport-related concussion from November 2017 to April 2022 and presented to a multidisciplinary concussion center was performed. The main independent variable was psychological symptom cluster score, calculated by summing the four affective symptoms on the initial Post-Concussion Symptom Scale (PCSS) (i.e., irritability, sadness, nervousness, feeling more emotional). The psychological symptom ratio was defined as the ratio of the psychological symptom cluster score divided by the total initial PCSS score. The outcomes included time to return to learn (RTL), symptom resolution, and time to return to play (RTP). Univariable and multivariable regressions were performed to adjust for demographic factors and health history. RESULTS: A total of 431 athletes (58.0% female, mean age 16.2 ± 1.3 years) were included. Nearly half of the sample (45%) reported at least one psychological symptom, with a mean psychological symptom cluster score of 4.2 ± 5.2 and psychological symptom cluster ratio of 0.10 ± 0.11. Irritability was the most commonly endorsed psychological symptom (38.1%), followed by feeling more emotional (30.2%), nervousness (25.3%), and sadness (22.0%). Multivariable regression showed that female sex (B = 2.15, 95% CI 0.91-3.39; p < 0.001), loss of consciousness (B = 1.91, 95% CI 0.11-3.72; p = 0.037), retrograde/anterograde amnesia (B = 1.66, 95% CI 0.20-3.11; p = 0.026), and psychological history (B = 2.96, 95% CI 1.25-4.70; p < 0.001) predicted an increased psychological symptom cluster score. Female sex (B = 0.03, 95% CI 0.00-0.06; p = 0.031) and psychological history (B = 0.06, 95% CI 0.02-0.10; p = 0.002) predicted an increased psychological symptom ratio. Multivariable linear regression showed that both higher psychological symptom cluster score and ratio were associated with longer times to RTL, symptom resolution, and RTP. CONCLUSIONS: In a cohort of high school athletes, 45% reported at least one psychological symptom, with irritability being most common. Female sex, loss of consciousness, amnesia, and a psychological history were significantly associated with an increased psychological symptom cluster score. Higher psychological symptom cluster score and psychological symptom ratio independently predicted longer recovery. These results reinforce the notion that psychological symptoms after concussion are common and may negatively impact recovery.

Examining for gender differences in return to learn following sport-related concussion in high school student athletes.

OBJECTIVE: Prior studies have investigated associations between gender, symptom resolution, and time to return to play following sport-related concussion (SRC). However, there is a notable gap in research regarding the association between gender and return to learn (RTL) in adolescents. Therefore, this study 1) compared the patterns of RTL between boys and girls who are high school student athletes, and 2) evaluated the possible association between gender and time to RTL after adjusting for covariates. METHODS: A retrospective cohort study of a prospective surveillance program that monitored concussion recovery of athletes in high schools throughout the state of Maine between February 2015 and January 2023 was performed. The primary independent variable was gender, dichotomized as boys and girls. The primary outcome was time to RTL, defined by the number of days for an athlete to return to school without accommodations. Mann-Whitney U-tests were used to compare RTL between the boys and girls. Each athlete's RTL status was dichotomized (i.e., returned vs had not returned) at several time points following injury (i.e., 1, 2, 3, and 4 weeks), and chi-square tests were performed to compare the proportions who achieved RTL between groups. Multivariable linear regression analyses were performed to evaluate the predictive value of gender on RTL. Covariates included age, number of previous concussions, history of learning disability or attention-deficit disorder or attention-deficit/hyperactivity disorder, history of a psychological condition, history of headaches or migraines, initial Sport Concussion Assessment Tool (SCAT3/SCAT5) score, and days to evaluation. RESULTS: Of 895 high school athletes, 488 (54.5%) were boys and 407 (45.5%) were girls. There was no statistically significant difference in median [IQR] days to RTL between genders (6.0 [3.0-11.0] vs 6.0 [3.0-12.0] days; U = 84,365.00, p < 0.375). A greater proportion of boys successfully returned to learn without accommodations by 3 weeks following concussion (93.5% vs 89.4%; χ2 = 4.68, p = 0.030), but no differences were found at 1, 2, or 4 weeks. A multivariable model predicting days to RTL showed that gender was not a significant predictor of RTL (p > 0.05). Longer days to evaluation (ß = 0.10, p = 0.021) and higher initial SCAT3/SCAT5 scores (ß = 0.15, p < 0.001) predicted longer RTL. CONCLUSIONS: In a cohort of high school athletes, RTL did not differ between boys and girls following SRC. Gender was not a significant predictor of RTL. Longer days to evaluation and higher initial symptom scores were associated with longer RTL.

Subclinical, long-term psychological symptoms following sport-related concussion: are athletes more depressed than we think?

INTRODUCTION: In adolescent and collegiate athletes with sport-related concussion (SRC), we sought to evaluate the prevalence and predictors of long-term psychological symptoms. METHODS: A cohort study was conducted of athletes 12-24-year-old diagnosed with SRC between November 2017 and April 2022. Athletes/proxies were interviewed on psychological symptoms (i.e. anger, anxiety, depression, and stress). Participants who scored ≥75th percentile on one or more PROMIS (Patient-Reported Outcomes Measurement System) measures were operationalized to have subclinical, long-term psychological symptoms. Uni/multivariable regressions were used. RESULTS: Of 96 participants (60.4% male), the average age was 16.6 ± 2.6 years. The median time from concussion to interview was 286 days (IQR: 247-420). A total of 36.5% athletes demonstrated subclinical, long-term psychological symptoms. Univariate logistic regression revealed significant predictors of these symptoms: history of psychiatric disorder (OR = 7.42 95% CI 1.37,40.09), substance use (OR = 4.65 95% CI 1.15,18.81), new medical diagnosis since concussion (OR = 3.43 95% CI 1.27,9.26), amnesia (OR = 3.42 95% CI 1.02,11.41), other orthopedic injuries since concussion (OR = 3.11 95% CI 1.18,8.21), age (OR = 1.24 95% CI 1.03,1.48), days to return-to-play (OR = 1.02 95% CI 1.00,1.03), and psychiatric medication use (OR = 0.19 95% CI 0.05,0.74). Multivariable model revealed significant predictors: orthopedic injuries (OR = 5.17 95% CI 1.12,24.00) and return-to-play (OR = 1.02 95% CI 1.00,1.04). CONCLUSIONS: Approximately one in three athletes endorsed long-term psychological symptoms. Predictors of these symptoms included orthopedic injuries and delayed RTP.

Do Sport-Related Concussions Later in the Season Take Longer to Recover From?

OBJECTIVE: In a cohort of high-school football athletes with sport-related concussion (SRC), we sought to investigate the role of seasonality, defined as time of injury during a season, on recovery. DESIGN: Retrospective cohort study. SETTING: Regional sport concussion center. PARTICIPANTS: High-school football athletes ages 14 to 19 -years old who sustained an SRC from 11, 2017 to 04, 2022. INTERVENTION: Athletes were divided into 3 groups based on seasonality: early, middle, and late season. MAIN OUTCOME MEASURES: The primary outcomes were initial Post-Concussion Symptom Scale score and recovery, as defined by time to return-to-learn (RTL), symptom resolution, and return-to-play (RTP). Descriptive statistics, analysis-of-variance, t tests, and multivariable regressions were performed. RESULTS: Of our cohort of 273 high-school football players who sustained an SRC, 97 (35.5%) sustained an SRC during early season, 107 (39.2%) during middle season, and 69 (25.3%) during late season. Compared with late-season concussions, early-season concussions took less days to symptom resolution (early = 11.5 ± 12.9 vs late = 25.5 ± 27.0, P = 0.03), but no differences were found in days to RTL (early = 5.3 ± 4.8 vs late = 7.2 ± 15.8, P = 0.51) and RTP (early = 13.5 ± 11.8 vs late = 23.0 ± 22.8, P = 0.08). Seasonality was not a significant predictor for any recovery metric in multivariable regressions. CONCLUSION: Sport-related concussions occurring in the early third of the season took significantly less time to symptom resolution than those occurring in the later third of the season; however, this was not statistically significant in multivariable analyses. No association was observed between seasonality and time to RTL and RTP. A trend of worse recovery with concussions later in the season may be present.

Risk of Two Sport-Related Concussions in the Same Year: Is the Second Concussion Worse?

OBJECTIVES: 1) Evaluate the frequency of same-year, repeat concussions; (2) assess predictors of sustaining a repeat concussion; and (3) compare outcomes of athletes with repeat concussions with athletes with single concussion. DESIGN: A retrospective, case-control study. SETTING: Regional sports concussion center. PATIENTS: Adolescents sustaining a sport-related concussions (SRC) from November 2017 to October 2020. INDEPENDENT VARIABLES: Participants were dichotomized into 2 groups: (1) athletes with a single concussion; and (2) athletes with repeat concussions. MAIN OUTCOME MEASURES: Between group and within group analyses were completed to look for differences in demographics, personal and family history, concussion history, and recovery metrics between the 2 groups. RESULTS: Of 834 athletes with an SRC, 56 (6.7%) sustained a repeat concussion and 778 (93.3%) had a single concussion. Between group: Personal history of migraines (19.6% vs 9.5%, χ 2 = 5.795, P = 0.02), family history of migraines (37.5% vs 24.5%, χ 2 = 4.621, P = 0.03), and family history of psychiatric disorders (25% vs 13.1%, χ 2 = 6.224, P = 0.01) were significant predictors of sustaining a repeat concussion. Within group: Among those with a repeat concussion, initial symptom severity was greater (Z = -2.422; P = 0.02) during the repeat concussion and amnesia was more common (χ 2 = 4.775, P = 0.03) after the initial concussion. CONCLUSIONS: In a single-center study of 834 athletes, 6.7% suffered a same-year, repeat concussion. Risk factors included personal/family migraine history and family psychiatric history. For athletes with repeat concussions, initial symptom score was higher after the second concussion, yet amnesia was more common after the initial concussion.

Age of First Exposure to Contact Sports Is Not Associated With Worse Later-In-Life Brain Health in a Cohort of Community-Dwelling Older Men.

OBJECTIVE: To evaluate whether early age of first exposure to contact sports (AFE-CS) is associated with worse long-term brain health outcomes. DESIGN: A cross-sectional, survey study of older men with a history of contact sport participation was completed. SETTING: Tertiary care facility. PARTICIPANTS: A cohort of community-dwelling older men dichotomized by using AFE-CS (<12 years vs ≥12 years). INTERVENTIONS: Independent variables included a dichotomized group of AFE-CS (<12 years vs ≥12 years). MAIN OUTCOME MEASURES: Brain health outcomes measured by depression, anxiety, cognitive difficulties, and neurobehavioral symptoms. Endorsements of general health problems, motor symptoms, and psychiatric history were also collected. Age of first exposure groups was compared using t tests, χ2 tests, and multivariable linear regressions, which included the following covariates: age, number of prior concussions, and total years of contact sport. RESULTS: Of 69 men aged 70.5 ± 8.0 years, approximately one-third of the sample (34.8%) reported AFE-CS before age 12 years. That group had more years of contact sports (10.8 ± 9.2 years) compared with those with AFE-CS ≥12 (5.6 ± 4.5 years; P = 0.02). No differences were found after univariate testing between AFE-CS groups on all outcomes (P-values >0.05). Multivariable models suggest that AFE-CS is not a predictor of depression or anxiety. Those in the AFE-CS <12 group had fewer cognitive difficulties (P = 0.03) and fewer neurobehavioral symptoms (P = 0.03). CONCLUSIONS: Those with AFE-CS <12 to contact sports did not have worse long-term brain health outcomes compared with those with AFE-CS ≥12. Individuals with AFE-CS <12 had significantly lower British Columbia Cognitive Complaints Inventory and Neurobehavioral Symptom Inventory scores compared with those with AFE-CS ≥12. CLINICAL RELEVANCE: The benefits of earlier AFE-CS may outweigh the risks of head strikes and result in comparable long-term brain health outcomes.

What are the Protocols and Resources for Sport-Related Concussion Among Top National Collegiate Athletic Association Football Programs? A Cross-Sectional Survey of A5 Schools.

OBJECTIVE: This study summarizes findings from a cross-sectional survey conducted among National Collegiate Athletic Association (NCAA) Division 1 football programs, focusing on sport-related concussion (SRC) protocols for the 2018 season. DESIGN: Cross-sectional survey study. SETTING: 65 football programs within the Autonomy Five (A5) NCAA conferences. PARTICIPANTS: Athletic trainers and team physicians who attended a football safety meeting at the NCAA offices June 17 to 18, 2019, representing their respective institutions. INTERVENTION: Electronic surveys were distributed on June 14, 2019, before the football safety meeting. MAIN OUTCOME MEASURES: Results for 16 unique questions involving SRC protocols and resources were summarized and evaluated. RESULTS: The survey garnered responses from 46 of 65 programs (response rate = 71%). For baseline testing, 98% measured baseline postural stability and balance, 87% used baseline neurocognitive testing, while only 61% assessed baseline vestibular and/or ocular function. Regarding concussion prevention, 51% did not recommend additional measures, while 4% and 24% recommended cervical compression collars and omega-3 supplementation, respectively. In postconcussion treatment, 26% initiated aerobic exercise 1 day postconcussion if symptoms were stable, 24% waited at least 48 hours, 4% waited for the athlete to return to baseline, 11% waited until the athlete became asymptomatic, and 35% determined procedures on a case-by-case basis. CONCLUSIONS: Most institutions assessed postural stability/balance and neurocognitive functioning at baseline and introduced light aerobic exercise within 48 h postconcussion. There was variation in baseline assessment methods and concussion prevention recommendations. These survey findings deepen our understanding of diverse SRC protocols in NCAA football programs.

Examining Acute Symptoms After Sport-Related Concussion in Collegiate Athletes With Preinjury Migraines.

OBJECTIVE: To examine whether a personal history of migraines is associated with worse acute symptom burden after sport-related concussion (SRC). DESIGN: Retrospective cohort study. SETTING: National Collegiate Athletic Association Division III collegiate programs. PARTICIPANTS: Collegiate athletes from a prospective concussion surveillance system between 09, 2014, and 01, 2023. INTERVENTION: Preinjury migraines (yes/no) were self-reported by athletes. MAIN OUTCOME MEASURES: Post-Concussion Symptom Scale (PCSS) were collected within 3 days postinjury. Mann-Whitney U tests compared total PCSS scores and individual symptom scores between athletes with and without preinjury migraines. Chi-squared tests were used to compare proportions of athletes endorsing individual symptoms (ie, item score ≥1) between 2 groups. Multivariable regression analyzed potential predictors of PCSS scores. RESULTS: Of 1190 athletes with SRC, 93 (7.8%) reported a preinjury history of migraines. No significant difference in total PCSS scores was found between athletes with and without preinjury migraines (22.0 ± 16.4 vs 20.5 ± 15.8, U = 48 719.0, P = 0.471). Athletes with preinjury migraines reported greater severity of "sensitivity to light" (1.59 ± 1.59 vs 1.23 ± 1.41, P = 0.040) and "feeling more emotional" (0.91 ± 1.27 vs 0.70 ± 1.30; P = 0.008) and were more likely to endorse "feeling more emotional" (45.2% vs 29.5%, P = 0.002). No differences were found across all other symptoms, including headaches (migraine = 87.1% vs no migraine = 86.3%, P = 0.835). In a multivariable model, a history of migraine was not a significant predictor of acute PCSS scores, but those with a history of psychological disorders (ß = 0.12, P <0 .001) and greater number of days to symptom evaluation (ß = 0.08, P = 0.005) had higher PCSS scores. CONCLUSIONS: Collegiate athletes with a pre-existing history of migraines did not have higher acute symptom burden after SRC.

The clinical utility of dual-energy CT in post-thrombectomy care: Part 2, the predictive value of contrast density and volume for delayed hemorrhagic transformation.

OBJECTIVES: Dual-energy CT allows differentiation between blood and iodinated contrast. This study aims to determine the predictive value of contrast density and volume on post-thrombectomy dual-energy CT for delayed hemorrhagic transformation and its impact on 90-day outcomes. MATERIALS AND METHODS: A retrospective analysis was performed on patients who underwent thrombectomy for anterior circulation large-vessel occlusion at a comprehensive stroke center from 2018-2021. Per institutional protocol, all patients underwent dual-energy CT immediately post-thrombectomy and MRI or CT 24 hours afterward. The presence of hemorrhage and contrast staining was evaluated by dual-energy CT. Delayed hemorrhagic transformation was determined by 24-hour imaging and classified into petechial hemorrhage or parenchymal hematoma using ECASS III criteria. Univariable and multivariable analyses were performed to determine predictors and outcomes of delayed hemorrhagic transformation. RESULTS: Of 97 patients with contrast staining and without hemorrhage on dual-energy CT, 30 and 18 patients developed delayed petechial hemorrhage and delayed parenchymal hematoma, respectively. On multivariable analysis, delayed petechial hemorrhage was predicted by anticoagulant use (OR,3.53;p=0.021;95%CI,1.19-10.48) and maximum contrast density (OR,1.21;p=0.004;95%CI,1.06-1.37;per 10 HU increase), while delayed parenchymal hematoma was predicted by contrast volume (OR,1.37;p=0.023;95%CI,1.04-1.82;per 10 mL increase) and low-density lipoprotein (OR,0.97;p=0.043;95%CI,0.94-1.00;per 1 mg/dL increase). After adjusting for potential confounders, delayed parenchymal hematoma was associated with worse functional outcomes (OR,0.07;p=0.013;95%CI,0.01-0.58) and mortality (OR,7.83;p=0.008;95%CI,1.66-37.07), while delayed petechial hemorrhage was associated with neither. CONCLUSION: Contrast volume predicted delayed parenchymal hematoma, which was associated with worse functional outcomes and mortality. Contrast volume can serve as a useful predictor of delayed parenchymal hematoma following thrombectomy and may have implications for patient management.

The clinical utility of dual-energy CT in post-thrombectomy care: Part 1, predictors and outcomes of subarachnoid and intraparenchymal hemorrhage.

OBJECTIVES: Dual-energy CT allows differentiation between blood and iodinated contrast. We aimed to determine predictors of subarachnoid and intraparenchymal hemorrhage on dual-energy CT performed immediately post-thrombectomy and the impact of these hemorrhages on 90-day outcomes. MATERIALS AND METHODS: A retrospective analysis was performed on patients who underwent thrombectomy for anterior circulation large-vessel occlusion and subsequent dual-energy CT at a comprehensive stroke center from 2018-2021. The presence of contrast, subarachnoid hemorrhage, or intraparenchymal hemorrhage immediately post-thrombectomy was assessed by dual-energy CT. Univariable and multivariable analyses were performed to identify predictors of post-thrombectomy hemorrhages and 90-day outcomes. Patients with unknown 90-day mRS were excluded. RESULTS: Of 196 patients, subarachnoid hemorrhage was seen in 17, and intraparenchymal hemorrhage in 23 on dual-energy CT performed immediately post-thrombectomy. On multivariable analysis, subarachnoid hemorrhage was predicted by stent retriever use in the M2 segment of MCA (OR,4.64;p=0.017;95%CI,1.49-14.35) and the number of thrombectomy passes (OR,1.79;p=0.019;95%CI,1.09-2.94;per an additional pass), while intraparenchymal hemorrhage was predicted by preprocedural non-contrast CT-based ASPECTS (OR,8.66;p=0.049;95%CI,0.92-81.55;per 1 score decrease) and preprocedural systolic blood pressure (OR,5.10;p=0.037;95%CI,1.04-24.93;per 10 mmHg increase). After adjusting for potential confounders, intraparenchymal hemorrhage was associated with worse functional outcomes (OR,0.25;p=0.021;95%CI,0.07-0.82) and mortality (OR,4.30;p=0.023,95%CI,1.20-15.36), while subarachnoid hemorrhage was associated with neither. CONCLUSIONS: Intraparenchymal hemorrhage immediately post-thrombectomy was associated with worse functional outcomes and mortality and can be predicted by low ASPECTS and elevated preprocedural systolic blood pressure. Future studies focusing on management strategies for patients presenting with low ASPECTS or elevated blood pressure to prevent post-thrombectomy intraparenchymal hemorrhage are warranted.

Is contact sport participation associated with chronic traumatic encephalopathy or neurodegenerative decline? A systematic review and meta-analysis.

INTRODUCTION: We sought to evaluate a potential association between contact vs. non-contact sport participation and long-term neurologic outcomes and chronic traumatic encephalopathy (CTE). EVIDENCE ACQUISITION: PubMed/Embase/PsycINFO/CINAHL databases were queried for studies between 1950-2020 with contact and non-contact sports, longitudinal assessment >10 years, and long-term neurologic outcomes in four-domains: I) clinical diagnosis; II) CTE neuropathology; III) neurocognition; and IV) neuroimaging. EVIDENCE SYNTHESIS: Of 2561 studies, 37 met inclusion criteria, and 19 contained homogenous outcomes usable in the meta-analysis. Domain I: Across six studies, no significant relationship was seen between contact sport participation and antemortem diagnosis of neurodegenerative disease or death related to such a diagnosis (RR1.88, P=0.054, 95%CI0.99, 3.49); however, marginal significance (P<0.10) was obtained. Domain II: Across three autopsy studies, no significant relationship was seen between contact sport participation and CTE neuropathology (RR42.39, P=0.086, 95%CI0.59, 3057.46); however, marginal significance (P<0.10) was obtained. Domain III: Across five cognitive studies, no significant relationship was seen between contact sport participation and cognitive function on the Trail Making Test (TMT) scores A/B (A:d=0.17, P=0.275,95% CI-0.13, 0.47; B:d=0.13, P=0.310, 95%CI-0.12, 0.38). Domain IV: In 10 brain imaging-based studies, 32% comparisons showed significant differences between those with a history of contact sport vs. those without. CONCLUSIONS: No statistically significant increased risk of neurodegenerative diagnosis, CTE neuropathology, or neurocognitive changes was found to be associated with contact sport participation, yet marginal significance was obtained in two domains. A minority of imaging comparisons showed differences of uncertain clinical significance. These results highlight the need for longitudinal investigations using standardized contact sport participation and neurodegenerative criteria.

Cervical and Lumbar Disk Replacement in Athletes: Is It Safe to Return to Play? A Systematic Review of the Scientific Literature and Lay Press.

BACKGROUND AND OBJECTIVES: Cervical/lumbar total disk replacements (TDRs) are often performed for degenerative conditions but rarely in athletes. Therefore, we sought to conduct a systematic review of athletes undergoing TDRs of both the scientific literature and lay press, with an emphasis on contact sport athletes. METHODS: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, PubMed/Embase/Cochrane/Scopus/Web of Science databases were queried for all primary literature reporting TDRs in athletes, including both cervical/lumbar disk replacements (CDRs/LDRs). Sports were dichotomized into contact vs limited/noncontact. Because of the public nature of injuries in elite athletes, the lay press was also queried. RESULTS: A total of 488 scientific studies were screened, of which 10 met inclusion criteria. Cervical: seven studies reported CDRs in 53 athletes, of which 7 were professional, 22 semiprofessional, and 24 recreational. Of the seven professional athletes, there was one contact sport athlete (kickboxer). All 7/7 professional and 21/22 semiprofessional athletes successfully returned-to-play at 8-52 weeks without complication. Lumbar: Three studies discussed LDRs in 51 athletes, of which 17 were professional, 6 semiprofessional, and 28 recreational. Of the 17 professional athletes, eight played contact sports (2 boxing, 2 alpine skiing, 2 soccer, judo, rugby). All 17 professional and 6 semiprofessional athletes successfully returned to play at 9-21 weeks. Lay Press: five professional contact sport athletes underwent CDRs, and all returned to play: 3 hockey, 1 mixed-martial arts, and 1 Australian-rules football. CONCLUSION: The scientific literature and lay press revealed 14 professional contact sport athletes who underwent TDR-6 CDRs and 8 LDRs-all with successful return to play. From the little data that exist, it seems that TDR may be safe in elite athletes; however, the small number of patients highlights the major paucity of data on the safety of TDR in elite contact sport athletes.

Do academic accommodations help students recover following sport-related concussion? A retrospective study of 96 youth athletes.

OBJECTIVE: Many schools utilize academic accommodations to help athletes return-to-learn after sport-related concussion, yet little is known about the impact of accommodations on recovery. In a cohort of adolescent athletes with sport-related concussion, the authors sought to 1) describe academic accommodations, 2) determine predictors of receiving accommodations, and 3) determine how accommodations influenced recovery, as defined by days to return-to-learn, symptom resolution, and return-to-play. METHODS: A retrospective survey study was undertaken that included all athletes between the ages of 12 and 24 years who were seen at a regional sport-related concussion center from April 1, 2020, to April 1, 2022. Demographic characteristics, past medical history, injury characteristics, school-related factors, and recovery were collected via a telephone-based survey and from medical charts. The independent variable was the use of academic accommodations by students. The outcome variables included days to return-to-learn, symptom resolution, and return-to-play. Univariable and multivariable logistic regression analyses were performed. RESULTS: Of 300 athletes contacted, 96 consented to participate in this study (mean age ± SD 16.6 ± 2.6 years, 60.4% male). The mean return-to-learn was 9.0 ± 13.2 days. In total, 63.5% of athletes received some kind of school accommodation. The most common accommodations included extra time on tests (46/96 [47.9%] athletes) and extra time for assignments (43/96 [44.8%]), whereas preferential seating in class (0/96 [0.0%]) and reduced workloads (4/96 [4.2%]) were the least commonly used accommodations. Multivariable logistic regression revealed that White race (OR 0.17, 95% CI 0.02-0.71, p = 0.03) and higher initial Post-Concussion Symptom Scale (PCSS) score (OR 1.04, 95% CI 1.01-1.07, p = 0.02) were predictive of receiving accommodations. Univariable models showed that receiving accommodations was not predictive of return-to-learn (ß = 4.67, 95% CI -0.92 to 10.25, p = 0.10), symptom resolution (ß = 24.71, 95% CI -17.41 to 66.83, p = 0.26), or return-to-play (ß = 13.35, 95% CI -14.56 to 41.27, p = 0.35). Regarding other predictors of each outcome, several factors emerged irrespective of accommodations. Multivariable analysis revealed that longer time to return-to-learn was associated with a history of psychiatric illness (ß = 8.00, 95% CI 1.71-14.29, p = 0.02) and initial PCSS score (ß = 0.14, 95% CI 0.06-0.23, p < 0.01). Finally, predictors of days to return-to-play included school personnel who were knowledgeable of concussion (ß = -5.07, 95% CI -9.93 to -0.21, p = 0.04) and higher initial PCSS score (ß = 0.67, 95% CI 0.04-1.29, p = 0.03). CONCLUSIONS: The most common accommodation was extra time on tests/assignments, whereas reduced workload was the least common. White race and greater initial PCSS score were associated with receiving accommodations. Receiving accommodations did not significantly impact days to return-to-learn, symptom resolution, or return-to-play.

Sport-related concussions in wrestling: does mechanism of injury affect recovery?

BACKGROUND: Sport-related concussions (SRC) represent a significant concern for athletes. While popular contact sports such as football and soccer have been the focus of much SRC research, wrestling has received comparatively little attention. The current study aimed to: 1) describe the mechanisms of injury leading to SRC in wrestling; and 2) compare recovery outcomes based on mechanism of injury. METHODS: A retrospective, cohort study of wrestlers aged 12-18 who sustained a concussion between 11/2017-04/2022 was performed. Contact mechanism was defined as what initiated contact with the athlete's head/body. Player mechanism was defined as the activity the injured athlete was performing when the concussion occurred. Recovery outcomes were compared using Mann-Whitney-U Tests and multivariable regression analysis. RESULTS: Seventy-three (age=15.8±1.4 years; boys=73 [100.0%]) wrestlers were included. SRCs occurred more often in competition than in practice (66.2% vs. 33.8%, respectively). Head-to-ground/wall (56.2%) and takedown (58.9%) were the most common contact and player mechanisms, respectively. Bivariate analysis showed that head-to-head/body SRCs had longer time to symptom resolution compared to head-to-ground/wall SRCs (23.0 [14.8-46.5] vs. 14.0 [6.0-30.0] days; U=149.00, P=0.029), though the difference did not persist in multivariable analysis. For player mechanism, non-takedowns SRCs had longer time to symptom resolution than takedown SRCs (15.0 [6.0-24.0] vs. 28.5 [13.0-49.3]; U=166.5, P=0.019), but the difference also did not persist in multivariable analysis. Bivariate analysis revealed no significant difference in RTL between takedown and non-takedown SRCs (3.0 [2.0-6.0] vs. 4.0 [1.5-7.0]; U=484.50, P=0.708); however, in multivariable analysis, takedown SRCs were associated with longer RTL (ß=0.23, 95% CI: 0.02, 9.27; P=0.049). CONCLUSIONS: The current study found that SRCs occurred more commonly during competitions, and head-to-ground/wall and takedown were the most common contact and player mechanism, respectively. SRCs that occurred during takedowns were associated with longer RTL.

Retrospective Case Series of Spinal Cord Neurapraxia in Male Adolescent Athletes: Can These Athletes Return-to-Play?

BACKGROUND AND OBJECTIVES: While spinal cord neurapraxia (SCN) is a documented pathology in athletes, guidance for neurosurgeons evaluating these patients is sparse. Therefore, in a cohort of adolescent athletes with SCN, we sought to (1) review their presentation and management and (2) describe outcomes and return-to-play (RTP). METHODS: A single-center, retrospective case series was conducted to examine adolescent athletes diagnosed with SCN from 2017 to 2022. SCN was defined as an episode of bilateral upper and/or lower extremity weakness/numbness after an impact during sport. Collected variables included demographics, presentation, management, outcomes, and RTP. RESULTS: Six patients were included (mean age = 14.5 ± 2.1 years, 100.0% male). Three American football players sustained tackle injuries, 1 ice hockey and 1 basketball player fell and landed on their head/neck, and 1 weight lifter sustained an axial load of weights to his neck. Motor symptoms ranged from quadriplegia to partial weakness. Full symptom resolution was seen in 6/6 patients: in <1 day for 3 patients, 2-3 days for 2 patients, and 1-2 months for 1 patient. All 6/6 patients received computed tomography of head/cervical spine and MRI of cervical spine, half of whom received computed tomography and MRI of thoracic/lumbar spine. No patient had congenital stenosis or abnormal T2 signal on MRI. Specific RTP recommendations varied. All 6 patients/parents were contacted at a mean of 16.6 ± 2.6 months from the injury. All patients returned to play at a mean of 5.7 ± 3.3 months. All 6 patients returned to their previous sports. Across all patients, no recurrence or neurological sequelae was endorsed in the follow-up period. CONCLUSION: Six athletes with SCN with no imaging abnormalities and full symptom resolution were able to RTP to their previous sport without future consequence. Symptom duration may not be clinically useful in determining the feasibility of RTP. Follow-up studies are warranted in this patient cohort to standardize RTP recommendations.

Does recovery after sport-related concussion vary by time point in a season? A multi-sport investigation.

OBJECTIVE: Seasonality, or the specific point in time within a season in which the injury occurs, may have an impact on the recovery following sport-related concussions (SRCs). In a cohort of high school athletes across multiple sports, the authors sought to investigate the impact of seasonality on 1) concussion frequency, 2) acute symptom presentation (initial Post-Concussion Symptom Scale [PCSS] score), and 3) recovery outcomes, including the time to return to learn (RTL), symptom resolution (SR), and return to play (RTP). METHODS: A retrospective, single-institution, cohort study was conducted with adolescent athletes aged 14-19 years who sustained an SRC between November 2017 and April 2022 and presented to a multidisciplinary specialty concussion clinic. The time from first practice to the end of the regular season was evenly trichotomized into early, middle, and late season. Teams that participated in the playoffs were included in a subanalysis. One-way ANOVA and independent t-tests were used to compare PCSS scores, RTL, SR, and RTP across seasonality. Univariable and multivariable regressions were used to determine predictors for recovery, defined as total days from initial visit to each outcome. RESULTS: Of the 1504 eligible athletes, 620 high school athletes met inclusion criteria; 491 (79.2%) sustained a concussion during the regular season with 73 (14.9%), 136 (27.7%), and 282 (57.4%) concussions occurring in the early, middle, and late seasons, respectively. No differences were seen for initial PCSS score, RTL, SR, or RTP across early-, middle-, and late-season concussions. The initial PCSS score was significantly higher for playoff compared with regular-season concussions (playoffs: 33.4 ± 27.5; regular season: 23.3 ± 22.8; t = -1.979, p = 0.048). A subanalysis of playoff concussions (n = 24) compared with regular-season concussions showed that concussion in the playoffs was associated with a higher initial PCSS score in univariable (ß = 0.093, p = 0.048) and multivariable (ß = 0.112, p = 0.014) analyses. CONCLUSIONS: The majority of concussions occurred during the late-season period. No difference in acute symptoms or recovery outcomes was seen when comparing the three regular season time points. Playoff concussions were associated with significantly increased symptom scores compared with nonplayoff concussions.

Examining the New Consensus Criteria for Traumatic Encephalopathy Syndrome in Community-Dwelling Older Adults.

In 2021, an expert panel of clinician-scientists published the first consensus research diagnostic criteria for traumatic encephalopathy syndrome (TES), a clinical condition thought to be associated with chronic traumatic encephalopathy neuropathological change. This study evaluated the TES criteria in older adults and assessed associations between TES criteria and a history of repetitive head impacts. This cross-sectional, survey-based study examined the symptoms of TES, previous repetitive head impacts, and a variety of current health difficulties. To meet symptom criteria for TES, participants had to report progressive changes with memory, executive functioning, and/or neurobehavioral dysregulation. To meet the criterion for substantial exposure to repetitive head impacts via contact sports, participants reported at least 5 years of contact sport exposure (with 2+ years in high school or beyond). A sample of 507 older adults (mean age = 70.0 years, 65% women) completed the survey and 26.2% endorsed having one or more of the progressive core clinical features of TES. Those who had a significant history of contact sport exposure were not significantly more likely to meet TES criteria compared with those who did not (31.3% vs. 25.3%, p = 0.46). In a binary logistic regression predicting TES status, current depression or anxiety (odds ratio [OR] = 12.55; 95% confidence interval [CI] = 4.43-35.51), history of psychiatric disorders (OR = 2.07, 95% CI = 1.22-3.49), male sex (OR = 1.87), and sleep problems (OR = 1.71, 95% CI = 1.01-2.91) were associated with meeting TES criteria. The sport exposure criterion, age, and current pain were not significantly associated with TES status (ps > 0.05). A significant minority of participants with no history of neurotrauma endorsed symptoms consistent with TES (22.0% of men and 19.8% of women). Nearly 80% of neurotrauma naïve participants with clinically significant anxiety/depression met criteria for TES. In summary, approximately one in four older adults met the symptom criteria for TES, many of whom had no history of repetitive neurotrauma. Mental health problems and sleep issues were associated with TES, whereas having a history of repetitive head impacts in contact sports was not. These data suggest that the new consensus diagnostic criteria for TES may have low specificity and may carry a higher risk of misdiagnosing those with other physical and mental health conditions as having TES.

Acute psychological symptom profiles in high school football players following sport-related concussion.

OBJECTIVE: In a cohort of high school football athletes, the authors sought to 1) describe the proportion of those with acute psychological symptoms postconcussion, 2) determine predictors of more acute psychological symptoms postconcussion, and 3) determine if acute psychological symptoms impact recovery. METHODS: A retrospective cohort study of high school football athletes (14-18 years of age) who sustained a sport-related concussion between November 2017 and April 2022 and presented to a multidisciplinary concussion center was performed. Based on their Post-Concussion Symptom Scale (PCSS) scores at the initial clinic visit, their total psychological symptom cluster score was calculated by summing their scores for the four affective symptoms (irritability, sadness, nervousness, and feeling more emotional). The psychological symptom ratio was defined as the ratio of the psychological symptom cluster score to the total initial PCSS score. Primary outcomes included time to return to learn (RTL), symptom resolution, and return to play (RTP). Uni- and multivariable regression analyses were performed controlling for demographic factors, learning disabilities, attention-deficit/hyperactivity disorder, and personal and/or family history of psychological diagnoses and migraine. RESULTS: A total of 195 male football players (mean age 16.2 ± 1.2 years) were included in the study. About one-third of the sample (n = 70, 35.9%) reported at least one psychological symptom. Of these 70 athletes, their psychological symptom scores were 1 (10.3%), 2 (7.7%), and ≥ 3 (17.9%). Irritability was the most endorsed psychological symptom (25.1%), followed by nervousness (15.9%), feeling more emotional (12.8%), and sadness (11.8%). The multivariable regression model showed that a positive psychological history (B = 2.66, 95% CI 0.74-4.58, p = 0.007) and family psychological history (B = 2.43, 95% CI 0.98-3.88, p = 0.001) were significant predictors of a higher psychological symptom cluster score. Multivariable linear regression analysis showed that a higher psychological symptom cluster score was associated with a longer time to RTP (B = 1.22, 95% CI 0.17-2.264, p = 0.023) but not with time to symptom resolution or RTL. The psychological symptom ratio was not a significant predictor. CONCLUSIONS: In a cohort of male football players, 36% reported at least one psychological symptom, with irritability being most commonly reported. Athletes with a personal and/or family history of psychological disorders experienced more acute psychological symptoms following a sport-related concussion. A higher psychological symptom cluster score was associated with delayed time to RTP but not time to RTL or symptom resolution.