What’s worse than a concussion? A concussion and a broken neck.

Max Pacioretty of the Montreal Canadiens took a huge hit from Boston’s Zdeno Chara last night that led to him leaving the ice on a stretcher after several minutes of immobility.  Chara knocked Pacioretty into the support post for the glass between the benches, and you can very clearly see his head make contact (go to :46, and be warned – it’s ugly).  Huge hit, scary outcome.  Montreal’s Jacques Martin spoke to the media today to update Pacioretty’s condition:

“Max Pacioretty has a severe concussion, as well as a fracture of the fourth cervical vertebrae, but it’s not displaced,” explained Martin. “Max will remain at the hospital for further observation. There will be no other prognosis for the time being, but he will obviously be out indefinitely. The most important thing for our organization right now is Max’s recovery. We will continue following recommendations from the doctors and of course, Max and his immediate family would appreciate privacy in this matter.”

– Jacques Martin, courtesy of the Montreal Canadiens.

 

A quick word about concussions:

There’s disagreement among experts about how to define ‘concussion’.  In the simplest terms, it’s a temporary loss of brain function as a result of an injury, with no evidence of physical damage on imaging (like a CT scan or MRI).  It’s considered to be a functional, not anatomical state.  It’s known, however, that repeated concussions have cumulative effects in both brain structure and function (see: Probert, Bob).

Concussion severity is graded by the patient’s symptoms, and there are several grading systems in use.  For simplicity’s sake (and because neurologists are smart), I’ll use the American Academy of Neurology‘s system as an example:

• Grade 1: No loss of consciousness, temporary confusion, symptoms resolve within 15 minutes.
• Grade 2: No loss of consciousness, temporary confusion, symptoms last longer than 15 minutes.
• Grade 3: Any loss of consciousness.

The fact that Pacioretty looks to have been knocked out makes his a grade 3 concussion.  Treatment is as you saw it – keeping his spine aligned (by placing him on a backboard and keeping his neck still), and taking him to the hospital for an exam and imaging (x-rays, CT scan, maybe MRI).  The exam and imaging results, not to mention the patient’s symptoms (pain, nausea, dizziness, etc.) after an injury like that determine what happens next.

Well, what did happen next?

In addition to his concussion, Pacioretty was found to have a C4 vertebral fracture.  Plain and simple: He broke his neck.  Your neck is made up of 7 cervical vertebrae.  Bend your head forward and feel the back of your neck.  Feel the bone that sticks way out?  That’s C7.  Now count up to C4.  That’s what he broke.  The fracture is non-displaced, meaning the bone didn’t go anywhere, it just cracked or was crushed.  Vertebrae are complex little critters, with lots of parts and lots of nearby nerves.  The ones in your neck obviously have very important jobs.  The nerves associated with C4 are responsible for sensation just below your collarbones, and they help run some arm/shoulder and neck muscles, not to mention your diaphragm.  You need that to breathe.  Hey, and let’s not forget that your spinal cord runs through your vertebrae.  Has the seriousness of the injury set in yet?

It’s really not possible to know for sure what treatment Pacioretty’s neck will need without knowing the extent of the injury.  It could be as simple as a neck brace for 6-8 weeks or as complex as surgery to fuse vertebrae — putting in rods or plates.  The fact that he was breathing and moving and the the fracture is non-displaced really shouldn’t be downplayed.  That’s all great news.  He could potentially heal with no lasting effects, and obviously that would be the ideal outcome.

So when will he be back?

Go ahead and stop asking.  Not for a long time.  A grade 3 concussion necessitates being out for an absolute minimum of two weeks – that’s assuming he’s free of symptoms.  The likelihood of being symptom-free after a concussion like that?  Ask Savard or Crosby.  But ask quietly, and in a dark room.  Concussions suck.  Recovery sucks.  And now that he’s had one concussion, Pacioretty is at increased risk for future concussions, and for having worse symptoms each time.  Add the broken neck, which could be anywhere from 2 to 6 months, and who knows.

The take-home message:

• Concussion: Potentially very long recovery time, increased risk for future injury.
• C4 fracture: Hopefully an uncomplicated healing process, but potential need for long-term or invasive therapy.
• Potential for return to play: Unknown.  Pacioretty could be fine, or this could be a career-ender.  And it felt really, really gross to even type that out.
• Much respect to the Habs and Bruins medical staff for their handling of Pacioretty’s injury.  It’s obvious in the video that they took incredible care with him.  Nobody wants to make a broken neck or head injury worse.

Did anyone else get a bit misty at Gionta, Hamrlik and Kostitsyn helping load Pacioretty onto the stretcher?  No?  Uhh…  Well then, me neither.

Get well soon, Max.

– Jo