Burners and Stingers | Spine Specialist

An Overview of Burners and Stingers

Burners and stingers are really two names for the same injury; a stretch of the brachial plexus. The brachial plexus is the compilation of the five separate nerves roots that originate in the neck and begins when the radicular nerves leave the neck through the foramen (the holes in the spinal vertebra that these nerves begin from).

These nerves (C5 through T1) originate from the C4-5 interval (C5 nerve) and continue to originate from T1-2 (the T1 nerve). When these nerves exit the neck, they “perform a dance” where the nerves join, blend, branch and then separate. These now mixed nerves transfer through the front of the chest under the collarbone and descend down into the arms.

All sensation and motion from the shoulders to the hands originate from these nerves.

Mechanically, the nerves are secured onto the spinal cord and solidly attach into the upper arm and hands. They act as cables and are fixated by these two separate locations. An abnormal force on the neck and arm can stretch them and nerves do not like to be stretched.

The upper nerves (C5 and C6) have the potential to be stretched more than the lower ones due to their upper location (more motion) and shorter length. This shorter length makes these nerves more susceptible to stretch injury as a shorter nerve has less ability to tolerate stretch.

What are Burners and Stingers?

When the head is laterally flexed (bent to the side) and forward flexed (chin to chest) and the shoulder is depressed (pushed down), this is the perfect combination for this stretch injury, the “stinger”. Nerves are like cables that travel over a pulley (the shoulder). Since these nerves are rigidly fixed to the neck and the arm, when the neck is forced to the opposite side and the shoulder is depressed down, they are severely stretched.

If a nerve is stretched, it may simply recoil to its original length when the stretching force is released. If the stretch is substantial, the nerve may completely snap, similar to the stretch and snap of a rubber band. In general, a nerve can stretch about 6% of its length without injury. Stretching between 6 and 15% will cause temporary damage to the nerve. A stretch of more than 15% of the nerve’s length will cause irreversible damage. No one has yet studied what happens to a nerve that has multiple stretch injuries in this 6-15% zone but clinically, some patients have permanent symptoms with multiple stretch injuries (stingers).

In a stinger, when the nerve cell is injured, generally the membrane of the nerve can be “stunned” (a temporary “concussion” to the nerve). The nerve can also suffer reversible or irreversible damage. The insulation (myelin sheath) can also be damaged. When the nerve cell membrane is “stunned” or damaged, the signal can be blocked which prevents the message from continuing down the nerve. The opposite effect can also occur. Injury to the membrane can cause “leaks” or ions to flow into the nerve at the wrong time, triggering an unintended impulse called an ectopic impulse.

This temporary block of a nerve membrane prevents the message from traveling up to the brain or down the nerve from the brain to the muscle. This would result in numbness of the area served by the nerve and weakness of the muscle supplied by the injured nerve.

What are the Symptoms?

Symptoms are exactly as this disorder is named, burning or stinging down the arm into the hand. This sensation can feel like electrical bolts of lightening.

The arm can feel “dead”. An injured player might return to the bench with the arm hanging by his or her side or this individual might protect their arm with the other hand.

Symptoms typically resolve within minutes of the stretch injury. Repeat injuries can be cumulative which both increase the chance for another injury and could increase the permanent nature of the injury. Multiple injuries could lead to chronic paresthesias (pins and needles), numbness and weakness.

(Click to Enlarge Image) When the head is laterally flexed (bent to the side) and forward flexed (chin to chest) and the shoulder is depressed (pushed down), this is the perfect combination for this stretch injury, the “stinger”. Nerves are like cables that travel over a pulley (the shoulder). Since these nerves are rigidly fixed to the neck and the arm, when the neck is forced to the opposite side and the shoulder is depressed down, they are severely stretched.

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(Please keep reading below for more information on this condition.)

Who gets Burners and Stingers?

Participants in contact sports and sports that allow the participant to travel at a high rate of speed without protection can lead to burners and stingers. Football players are the prototypical athletes who are susceptible to stingers but soccer players and rugby contestants quite commonly suffer from stingers. Skiers and boarders who hit a tree, mountain bikers who impact terrain while descending or surfers with a fall onto a coral reef can injure their brachial plexus.

Treatment Options

Treatment of the stinger injury is initially discontinuation of play and restriction of motion of the injured extremity. Possibly a sling might be considered if the extremity is very weak. Analgesics are used for pain and rest is the main consideration. If the arm does not regain strength and sensation quickly, other diagnoses need to be considered.

Return to Play

Return to play depends upon full resolution of all symptoms and a physical examination that is normal. Persistent symptoms in athletes signal that they should not be allowed to participate in further competition until complete resolution of their symptoms has occurred.

If the athlete has neck stiffness but no longer has arms symptoms, this symptom needs to be addressed to make sure there are no cervical injuries present.

Differential Diagnosis

The stinger needs to be differentiated from a central cord injury by a physician. Central cord injury is a spinal cord injury that produces temporary paralysis that may last only seconds. The differential is that stinger symptoms are found in only one arm and central cord syndrome is found in both upper extremities. Central cord syndrome is also known and “burning hands syndrome” as the back of the hands will “feel on fire”.

The mechanism of the central cord syndrome is an extension injury of the head (bending the head backwards) in the presence of a narrowed spinal canal. This extension motion will narrow the spinal canal and if the canal is already narrowed, will “pinch” the cord. See central cord syndrome on this website for a more detailed description of this disorder.

If there are symptoms on both sides, this injury is not a Stinger or a Burner.

Herniated discs can occasionally mimic a Stinger as there will be pain and numbness in one arm. A careful history and physical will lead to the discovery of single nerve involvement, which is not typical of a Stinger. Herniated disc symptoms generally will not quickly resolve on the field, which means the competitor will not return to immediate play. Motor testing on the bench is sometimes necessary as pain might not start immediately after a herniated disc but weakness will. Hopefully, this individual will then see a spine expert for appropriate diagnosis. An EMG (electrical nerve test) could be considered after three weeks of symptoms that do not resolve in the face of continued weakness.

Although very rare, Stingers need to be differentially diagnosed from nerve avulsion injuries. Nerve avulsions (tearing of the nerve) generally occur with great force or impact mechanisms. I had a patient who was travelling on a motorcycle at 70 mph at night and hit a moose. The force was so great that he actually avulsed his nerves (tore them apart in the shoulder) and had significant weakness of his arm. This should not happen to a contact sports player but I have seen this injury also in a skier vs. tree impact (the tree always wins).

For additional resources on burners and stingers, please contact Dr. Donald Corenman, spine specialist and neck doctor located in the Vail, Aspen, Denver and Grand Junction, Colorado area.

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81 reviews

Eric S

Sep 26, 2021

by Eric S on Donald Corenman, MD, DC

Successful pars repair at 46 years old

Back in November of 2018 (at 46 years old) I came from Vancouver BC to have a pars repair done with Dr. Donald Corenman at the Steadman Clinic in Vail Colorado. I'm finally posting this review nearly three years later in late 2021. The reason I waited so long was I wanted to know the final result before I posted my review. Unfortunately in that time Dr. Corenman has retired. Nevertheless, I want to post this review of Dr. Corenman and his staff at the Steadman Clinic in their excellent treatment of my L5 pars interarticularis.

I fractured my pars at age 42 back in 2014 when rolling on the gym floor, and was denied treatment by the Canadian healthcare system, probably due to my age. First my GP told me there was no surgical option for a pars defect, which was quite incorrect! I tried to live with it, but the symptoms worsened (periodic random spine slippage and weeks of resultant pain after just bending over to tie my shoe, so I eventually learned to mostly squat and hardly bend). When I finally consulted with Canadian spine surgeons, I was told they believed my pars defect had been congenital (since birth). This was absurd, considering I had done extreme martial arts (including jiu jitsu) for years prior, as well as 5 years of reinforcing steel full time in my 20s, probably the hardest job on the back you can find. No pars defect like mine would possibly have allowed this--ergo it was impossible that I had had the defect since birth. I did however have an asymptomatic congenital spina bifida occulta that made me more susceptible to a pars fracture. In 2014 in one instant, I went from having the strongest back people I knew said they'd ever seen, to being unable to safely bend over and tie my shoe without a non-negligible risk of my spine slipping randomly (which would lead to weeks of pain after each occurrence). This was due to the unilateral L5 pars defect, otherwise known as spondylolysis. It was when lying in pain on the floor 4 years later after maybe the 6th spine slippage event post injury, that I had had enough, and resolved to have surgery. If Canada's "universal health care" said no, I would make lemonade from lemons, and find the very best surgeon in the world at pars repairs. That was Dr. Donald Corenman. Dr. Corenman back in 2018 ran a website https://neckandback.com/ that dedicated many pages to the science of every aspect of pars repairs, from eligibility (good discs on MRI), to best surgical techniques (minimal open compared to minimally invasive), best imaging to use (i.e., O-Arm with Stealth imaging vs. older fluoroscopy), the ideal amount of BMP to use and why not use too much or too little, and much more, all to do with pars repairs, pages upon pages of his site just on the pars, with scientific references and his own extensive expert opinion. As a health research statistician, I was very impressed with this. It was in stark contrast to the websites of other spine surgeons which barely gave the pars a word or two, focusing almost exclusively on fusions. I had found the best surgeon in the world for pars repairs, and so after Dr. Corenman personally screened my MRI to ensure my discs were healthy, I booked the surgery.

Being 46 years old at the time of surgery in 2018, with a 4-year-old pars fracture from 2014 combined with a congenital SBO meant my pars fragment was somewhat atrophied, but it was "very solid", said Dr. Corenman in the operative report. Nevertheless, it was challenging with two things to fix, the pars and SBO, and OR time was around 4 hours. Recovery over the following months was guided by a very clear "Spine binder" from the Steadman Clinic with strict rules of "no BLT" (no bending, lifting or twisting), and illustrated physiotherapy guidelines. They even warned patients to avoid fish oil supplements, which could excessively dampen inflammation and hence slow bone healing. They answered many questions I had during months of recovery, with responses coming from the very supportive Lori Fugate (then director of Dr. Corenman's practice), and Ehrich Bean (then physician's assistant at the practice), as well as a couple calls with Dr. Corenman himself after two of the CT scans. Ehrich Bean offered great advice for taking the spine binder conservatively due to the nature of pars repairs vs. fusions. The final post-op CT scan I had was a couple weeks ago at 34 months post-op, and Dr. Corenman had retired, but I got a very positive and informative call from Eric Strauch (current PA at the Steadman Clinic under Dr. Corenman's replacement there, and who had also worked with Dr. Corenman previously). The staff at the Steadman Clinic were extremely supportive all the way through the process. I should mention, the local Canadian spine surgeon did offer me very good post-operative support including antibiotics as needed to deal with a mild surface incision-site infection early on, booking numerous x-rays when I felt something was amiss, as well as booking all four of my post-op CT scans. I am very grateful for that support also.

My final result shows plenty of solid bone across the pars and a healed SBO, with my vertebral body now a solid bone ring instead of being broken at two places as it was pre-op. Does my spine hold up in the real world? You bet! I have recently dug and moved several yards of dirt and sand and gravel by myself (shovel and wheelbarrow!) to fix our water main, pulled roots from the yard, moved several "portable" (these are HUGE) air conditioners up several flights of stairs my myself, and lifted weights. I now run 2 miles (3.2 KM) several times weekly with a hard 100 meter dash in the middle. I bend deeply before each run I go on, with no spine slippage. My spine feels amazing. I can bend over to do exercise, or real word tasks, with no risk of spine slippage.

My sincere thanks to God, Dr. Donald Corenman, Lori Fugate, Ehrich Bean, Eric Strauch, and the Steadman Clinic, as well as the Canadian spine surgeon who offered me excellent post-operative care back in Canada. You have all given me a new lease on life.

Sincerely,
Eric S

Robert S

May 11, 2021

by Robert S on Donald Corenman, MD, DC

Back Fusion Surgery

I had my entire lumbar spine fused in November of 2018. I had scoliosis , with pinched nerves that were so painful I could hardly walk - and standing for more than a few minutes was impossible. Even sitting was painful.
The fusion surgery produced immediate relief! And the recovery was much easier than I expected.
To this day I can do all the activities I love from hiking, to standing in a stream fly fishing to riding my bike long distances - or just walking down the street with my wife.
Kudos to Dr. Corenman and his staff, (including the two Erics) for taking such good care of me!

Leslie R

Jul 9, 2020

by Leslie R on Donald Corenman, MD, DC

TLIF

I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. I was always treated with respect and explained everything throughly, that made it easy for everyone to understand. I highly recommend Dr. Corenman and the Steadman Clinic.

Stingers and Burners