Bob McCown of Sportsnet 590 The Fan became the most interesting man in the world today when he revealed on Sportsnet’s Hockey Central that Sid Crosby has some sort of issue with his C1 and C2 vertebrae. He recently received an MRI and CT scan which apparently revealed previously undiscovered “abnormalities”.

Let’s stop here and define a few things.

 

C1 and C2 Vertebrae:

These are a big deal. C1 is also known as the atlas, because it holds the skull. C2 is known as the axis because it’s what C1 (and therefore the skull) rotate on.

 

AP open mouth x-ray

 

This is my favourite x-ray view – the AP (anterior-posterior) open mouth or odontoid. This is shot exactly how it looks – with your mouth wide open facing the x-ray machine. The point is that you can see C1 and C2, and the odontoid process (aka dens) – the sticky-up bit in the middle of C2 which is what C1 actually rotates around. A look at C1 and C2 from the top should make the relationship pretty clear:

 

See that round outline at the top? That's where the dens fits.

See that pointy bit at the top? That's the dens.

 

You’d have to assume that if Sid had a fracture to his dens, C1 or C2 that had been seen on x-ray, he’d be in a semirigid cervical (neck) collar or a halo (that’s the big contraption that screws into your forehead and holds your head still). The fact that they’ve been letting him skate seems to suggest that’s not currently the case. Not to mention the fact that whatever this “abnormality” is, it was found on MRI (or CT, that’s not been specified – just that he had both studies) well after the original (and subsequent) injury.

 

What’s the big deal about an MRI vs CT?

Different imaging modalities have different purposes – x-rays are good for looking at bones, but they’re one-dimensional. You can see the vetebrae from front to back (the AP view) and the side (the lateral view), but everything is overlapping. CT scans are like really fancy x-rays – they’re great for looking at bone, but also collections of blood or fluid, and organs. They’re also very accurate, as the body is split into thin sections that you can examine one by one. You’re not limited to looking at the vertebrae from just one angle – you’ll get views similar to the x-ray (AP and lateral), as well as an axial view (cross-sections from above). Now as far as soft tissue (for example ligaments) is concerned, CT scans are good, but MRIs are excellent. MRI has much better soft tissue contrast than CT, and has all the same advantages as far as different views are concerned. Generally speaking, you get better bone visualization with CT than with MRI. But with all that having been said, you can see “ghosts” of healed fractures on MRI. Could this be a soft tissue injury? Yes. Could this be an old bone injury? Yes.

 

Relate that to concussions for me, please.

Concussions don’t show up on x-rays, CTs or MRIs. Sid’s original injury was a long time ago, and hockey teams have a lot of money. Sid is a really good hockey player. I’d assume that money + good hockey player = Sid has probably had all of these studies at least once since the original injury to rule out non-concussion issues. It’s pretty much standard that a head injury will get x-rays and a CT scan in the ER. An MRI may be considered down the road if there are persistant symptoms.

 

Yeah, fine, but vertebrae are in the neck and concussions are in the head.

Not so fast, slick. Concussions are notorious for having a wide variety of symptoms affecting just about every part of the body. Sure, headaches, poor balance, mood issues, nausea – we hear about these things all the time. But remember Marc Staal and James Reimer? Staal was said to have headaches due to “neck pressure” and Reimer had “…whiplash-type symptoms…” per Ron Wilson. Both of those players were connected to the term “concussion”. Both of those players had apparent neck issues (and I wrote about Reimer if you’re dying to learn about whiplash). Sometimes concussions and neck issues are almost impossible to separate. It’s not impossible that a neck injury could have been missed because pain may have been attributed to the concussion, and – get ready – no imaging modality is perfect, not to mention you still have to rely on human radiologists to find the problems.

 

Here’s where I speculate wildly!

Crosby passed baseline testing after his re-injury in December. Crosby recently had an MRI. Crosby had an “abnormality” in his C1-C2 vertebrae. His agent has said that he’s safe and it’s treatable. Dr. Robert Bray (a neurological spine specialist) has said the neck issue has healed. Ray Shero has said Crosby will continue to skate and work out. Do you honestly believe that if Crosby had fractured vertebrae they’d be letting him skate? Really? Seriously? No, obviously not. Does this mean there couldn’t have been a fracture in the past? Nope. Elliotte Friedman says Crosby’s agent Pat Brisson used the word fracture. Later Brisson wouldn’t go that far, describing it only as a neck injury. The statements from the Pens and Shero don’t use the word fracture. But there absolutely could have been a fracture at some point, and the agent has flat-out said that’s it. Then he un-said it. Whatever is going on in there, Dr. Spine Expert says it’s okay now. If this was a fracture, it had to have been minor enough to have been missed on any previous imaging studies, not to mention there weren’t any of the typical symptoms you might associate with a broken neck. You know, like not being able to move. I’m willing to believe this could be a healed fracture, but that Brisson has been asked to stop calling it that until the Penguins have it confirmed by yet another set of doctors. They’ve said they’re not going to officially update Crosby’s status until that happens some time this week.

Disclaimer: I AM NOT A NEUROLOGICAL SPINE EXPERT, NOR HAVE I SEEN SID’S FILMS. Smartypants statement: If Sid had a current fracture or serious ligamentous issue, he’d be hard-pressed to get out of the situation without surgery, a halo, or a collar. None of these things are happening right now.

 

Take-home message:

This recent news about Crosby is exactly this: He has a healed C1-C2 “abnormality”. This “abnormality” is being confirmed/reexamined by more doctors. Crosby is still skating and working out. Crosby is not in a halo. Crosby may be back this season. Crosby had a concussion. Crosby had ongoing symptoms that could have been related to a concussion or a neck issue, and the two are often impossible to differentiate. The forces that can cause a concussion can also cause a neck injury. His agent says Crosby is safe.

 

Once more for emphasis: Crosby is safe.

Comments (16)

  1. This might be a good time to highlight the probabilistic nature of medicine, and really of all of our studies (imaging in this case). I think in life as in medicine, a lot of folks go into it expecting a 100%, ironclad, this is the “right” answer. It takes some adjustment to understand that that’s not always the case. If you see your doc and you have flu-like symptoms, you probably have the flu. You might have the plague. But you probably have the flu. He’ll get a good history to see if he can understand the odds a little better, but at the end of the day, he’s just playing the odds.

    Likewise with Sid. Odds are, the injury is X, and it’s having Y effect. The imaging showed Z, which might mean a healed fracture, might mean a soft tissue injury, might mean an overzealous radiologist… at this point, a minor, stable fracture that’s since healed seems like the most likely thing, from what I’ve heard. But I’m just playing the odds.

  2. With this healed facture, depending on how it healed, the dentate ligament (Definition of DENTICULATE LIGAMENT : a band of fibrous pia mater extending along the spinal cord on each side between the dorsal and ventral roots—called also dentate ligament) may be causing a slight torque on the brain stem, thus messing up the proprioception on the body and ears for balance. Which means its back to Carrick. http://richmondhillgachiropractor.com/2012/01/17/concussion-specialist-sidney-crosby-elects-to-see-dr-ted-carrick-a-functional-neurologist-for-care/

  3. Glad somebody appreciates the AP Open Mouth view, those things are the absolute devil to take!

  4. One wonders whether the neck abnormality may have been caused by upper cervical manipulation.

    • I absolutely agree …………. did sid Crosby have upper cervical manipulation at the hands of a chiropractor and did the chiropractor damage the soft tissue (arteries) in Mr. Crosby’s neck causing a bleed and concussion llike symptoms

      • Do you know how rare those things are, 1 in a 2-3 million, and not likely through the hands of a chiropractor. What you are suggesting is that a chiropractor adjusted his neck and caused injury to his blood vessels that only resulted in bleed small enough to only cause concussion like syndrome and not a stroke? And this guy takes hits to his body daily and he is not injured like that? Absurd!

  5. Kelly Chase (ps. Im a hawks fan) commented on NHL.Live…”at some point when you signed up to play hockey…you know your going to be hit.’ …two words for Crosby…Learn how to $%&^n Type…

    • Did you mean body checked? for hit?..i guess he knew that…but i dont think he knew that there was gonna be alot of jealous grown men he be playing against that was jealous of him and made some cheap shots against him…..this is serious…..its not to be joked with….

  6. I feel bad for Sidney no matter what showed up..because i had a bad smack to the head a year ago and got knocked out and my life has never been the same,,,One day it feels like i getting better and then suddenly i am right back at square one…i had just told my husband that Sidney needs to except what happened and try and move forward and put teh injuries behind him….and yet i cant except mine…lol..i know he is a big icon and millions are waiting for him….unlike me….but there are 5 important people who are waiting on me and they feel like millions to me.. ..(children)….I know he love to play hockey again but like i was told one more bad hit to the head could cause me serious problems..no matter how much you have healed………is hockey that important?..you only have one life to live…all the best Sidney in your choices…

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  10. you know your going to be hit.’ …two words for Crosby…Learn how to $%&^n Type…some point when you signed up to play hockey…

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