Participation in Contact or Collision Sports in Athletes With Epilepsy, Genetic Risk Factors, Structural Brain Lesions, or History of Craniotomy

Vincent J. Miele, M.D.; Julian E. Bailes, M.D.; Neil A. Martin, M.D.

Disclosures

Neurosurg Focus. 2006;21(4) 

In This Article

Craniotomy

The safety of allowing the return of an athlete to a contact or collision sport following craniotomy has long been debated in neurosurgical and sports medicine circles, and a conservative approach has generally been taken in the past. There have been no controlled studies or patient series on which to base recommendations. In general, there are three primary apprehensions relative to the inherent safety of the cranium to withstand impacts in the postoperative period. These consist of concerns about the strength of the craniotomy flap to withstand direct pressure from blows to the head; the potential fragility of the tissue at the operative site and neovascularity from the healing process; and the alteration of the normal CSF pathways, which will potentially alter the normal "buoyancy" of the brain.

The healing of a craniotomy flap, that is, the integration of the island of bone that has been removed and then restored, occurs circumferentially across the kerf line. This line represents the amount of bone removed by the craniotome. A commonly used criterion in this population is that radiographically demonstrated partial or complete healing of the bone flap must be present as a prerequisite before the athlete can return to play.[5] This commonly occurs within 1 year in nonsmokers. No standardized studies are available in which the effectiveness of newer cranial reconstruction plates at rigid fixation has been evaluated. Similarly, no standardized studies are available to determine the contribution of the recently introduced bone matrix products to more rapid and secure healing of the craniotomy flap.

There are healing and fibrotic reactions that occur after any surgical procedure, and the brain, duramater, and over lying skull and scalp also display a normal pattern of closure and regrowth at the site of excision and the procedure. Although fragility is an inherent concern, it does not appear that there is any unusual or particular aspect to this area that would be prohibitive for safe return to contact or collision sports.

The brain is suspended within the cranium by extensive CSF distribution throughout the subarachnoid space. This space can be focally altered by surgical interventions that lead to scarring and possible restrictions of normal flow and buoyancy. Significant intracranial hemorrhage or parenchymal injury can obliterate the normal CSF pathways by producing scarring. Theoretically, this could affect the brain's buoyancy and result in a loss of cushioning effect, increasing the patient's vulnerability to subsequent injury. Unfortunately, no studies exist regarding scarring of the CSF pathways and consequent decreased buoyancy of the brain and increased susceptibility to concussive forces.

Professional Ice Hockey. A professional hockey player, who had sustained a parenchymal hemorrhage, underwent successful surgery to remove a temporal arteriovenous malformation. He returned to play competitively for several years without sequelae. In addition, fractures of the frontal sinus anterior or posterior wall are known to have occurred in both soccer and ice hockey players who subsequently returned to participation in their respective sport.[63]

Professional Boxing. The return of athletes to the sport of professional boxing at the elite level after craniotomy has been documented.[36,38] Marco Antonio Barrera, one of the best featherweight professional boxers in the world, began to complain of headaches in 1995. In 1997, a neurosurgeon in Mexico City examined him and discovered a cavernous angioma, which was repaired on August 29, 1997. Barrera participated in 16 matches after the surgery, until it became public just weeks before a bout in San Antonio. After numerous examinations and imaging studies, the Texas Boxing Commission gave Barrera permission to participate.

If an athlete is barred from competition in the US, he or she may choose to participate outside of this country. This occurred recently after a boxer (Edwin Valero) was suspended for an abnormality discovered on MR images obtained after he suffered a brain trauma. Venezuelan Boxing Federation medical records indicate that a hematoma was detected in Valero's head and was removed using a drainage procedure. The athlete was then suspended by the New York State Athletic Commission and the Association of Boxing Commissions from competing in the US.[20] After being cleared by doctors in Argentina, Valero resumed his career in the ring outside of the US.

Amateur Soccer. A healthy 16-year-old girl presented with occipital headaches and numbness of the right face and body that had lasted 4 days. Results of a neurological examination were normal. One month previously, a soccer ball had struck her with significant force on the left side of the head. She did not lose consciousness at the time, but she experienced a period of transient disorientation and did not interrupt her play. There was no apparent amnesia. A cranial computed tomography scan revealed a left middle fossa extraaxial hyperdense lesion in the region of the sylvian fissure without a mass effect. In addition, MR imaging revealed a 20-mm-thick chronic SDH in the left frontotemporal convexity in communication with the arachnoid cyst and causing a mass effect. A left temporal craniotomy 3 cm in diameter revealed an arachnoid cyst in the sylvian fissure with a solid clot and subacute subdural fluid, which was drained along with the large chronic SDH. After drainage of the hematoma and fenestration of the cyst wall, underlying poorly developed frontal and temporal opercula consistent with a chronic arachnoid cyst were observed. After a watertight duralclosure was performed, the bone flap was resecured rigidly with titanium plates. The patient did well postoperatively and has remained asymptomatic. A follow-up computed tomography scan obtained 1 month postsurgery demonstrated complete resolution of the chronic SDH and persistent hypodensity in the region of the cyst. Neuroimaging studies obtained the following year demonstrated healing of the kerf lines of the craniotomy, and the athlete was allowed to return to participation and has done so without incident.[62]

Professional Football. A 20-year-old man who played National Collegiate Athletic Association Division I football began to have headaches and feelings of depersonalization. Progression of these symptoms ultimately led to neuroimaging studies, which demonstrated a large right fronto temporal arachnoid cyst. This cyst was successfully removed, and fenestration to the subarachnoid space was performed as well. The following year, 9 months after his craniotomy, he returned to the team for his senior year, in which time he gained 1100 yards and scored 14 touchdowns. He had a brief career in the National Football League, which included scoring two touchdowns. Although he sustained a cerebral concussion at the professional level, it was believed by the athlete—as well as being supported by the results of medical evaluation—that he successfully reentered the sport without direct consequences resulting from his craniotomy.

As recommended in current return-to-play guidelines, athletes who remain symptomatic, with or without provocative testing, should not be allowed to participate until all of these symptoms have completely resolved.[14] Injuries that result in permanent central neurological sequelae should contraindicate a return to contact or collision sports. It has also been suggested that symptomatic neurological or pain-producing abnormalities around the foramen magnum should disallow return to play.[12] Injuries that result in damage to the underlying brain parenchyma and spontaneous subarachnoid hemorrhage from any cause should contraindicate return.

The advisability of allowing athletes to reenter the competitive arena of contact sports after undergoing a craniotomy remains unclear. We commonly discourage return to contact sports in athletes who have suffered parenchymal injuries that required a craniotomy, based solely on experience. We have recently considered rigid cranial fixation not to be an absolute contraindication to later participation in contact sports in an athlete with normal results on neurological examination. We believe that the newer cranial reconstruction plates may confer a major advantage in terms of rigid fixation and the promotion of osteoblastic bridging of the kerf lines in the craniotomy. Similarly, although no standardized studies are available, we believe that the recently introduced bone matrix products may contribute to more rapid and secure healing of the craniotomy flap.

With advances in the diagnosis and management of sports-related head injuries, participation guidelines continue to evolve as our understanding of various conditions improves. Formerly, structural brain lesions were considered to be absolute contraindications to participation in contact or collision sports. These decisions were for the most part based on the opinions of the physicians involved, who wanted to err on the side of caution. Recent in creases in appreciation of the health benefits of sports participation as well as the growing financial rewards for the professional athlete have led to a rethinking of these situations. With the large salary that is possible today for the professional athlete, it is difficult to defend ending a career by arguing that the athlete is at an increased risk of injury when no data exist to support this claim. Obviously, more research is essential to objectify with solid data the reasoning behind ending an athlete's career and possibly his or her only source of income. Thus, athletes with epilepsy, genetic risk factors, structural brain lesions, or a history of craniotomy are often now allowed, with appropriate observation and precautions, to participate in sports formerly denied them.

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