Words

Fight Doctor – Esophageal Tear

Fightland Blog

By Darragh O'Carroll MD

Photo by Mike Roach/Zuffa LLC

There are few words that can send a jolt of adrenaline through a fight doctors body more than “I can’t feel my body” or “my whole body went numb”, the words uttered by Charles Oliveira after he stopped fighting during his main-event bout with Max Holloway. The only thing more alarming would have been no words at all; a fighter unable to talk, or even worse, a fighter unable to breathe.

After studying the replay tape, UFC commentators correctly notice that Oliveira does grab his collarbone area after his first takedown attempt. They are correct to infer that maybe he did suffer a shoulder injury of sorts, as it seemed initially that’s all it was. However the look on Oliveira’s face in combination with him grabbing his neck area suggests a more sinister disease entity than just a shoulder injury, or a “stinger” for that matter. For one, he isn't moving. Lack of movement is always, always, always a red flag. The referee did an excellent job at recognizing Oliveira’s distress. In no way should the fight have continued.

It is tough to infer what Oliveira had said to the ringside doctor and referee at the time of injury, but every precaution was taken. A cervical spine injury would have been the number one injury on the doctor’s mind. His cervical spine was immobilized; he was packaged onto a stretcher and taken to the nearest Emergency Department.

Oliveira did start moving his arms and legs, which only suggests that the motor pathways of his spinal cord were grossly intact. Don't forget the spinal cord does more than allow a human to move, it conducts things like sensation, vibration, and temperature. Just because he was moving somewhat doesn't mean his spinal cord wasn't damaged. Without being there and performing a full neurological exam it is impossible to tell if any other damage was done.

The “injury to his neck” he suffered during training camp certainly could have been a contributing factor. The reports are consistent with either a muscle or ligament injury to his neck. Either injury would put him at risk for further muscular/soft tissue injury and even spinal cord/neck fractures.

The mechanism of injury (severe, rapid and forceful neck flexion) can result in spinal injuries, but also injuries to the arteries traveling through his neck. Injuries to these Carotid and Vertebral arteries can interrupt blood flow to the brain, leading to a stroke and thus causing the paralysis he was alluding to. In the emergency department we usually see vascular injures to the neck associated with 1) seat belt injuries during high speed car accidents 2) hangings or 3) stab or gunshot wounds to the neck.

If I had been the receiving physician at the Emergency Department, the mental leap from hearing “MMA fighter” and “I felt paralyzed” to concern for both spinal and vascular injuries would be very short. An MMA injury could simulate similar types of forces exerted on the neck during a hanging or the seat belt during a car crash, I guess it depends on who's doing the choking.

I am hypothesizing that the Emergency Physician obtained a CT Scan with contrast (the contrast to interrogate the neck arteries) and wasn't suspecting any esophageal injury. An esophageal injury was “accidentally” seen, or in medical terms, was incidental. I could be wrong, but nowhere in any of the reports did Oliveira complain of the typical symptoms or signs of an esophageal injury (tearing throat/chest pain, mid-back pain, spitting up blood, or gagging). It would be very rare to injure the esophagus without injuring other organs first.

The esophagus lies behind the windpipe, in front of the spinal column, and is flanked by a ton of muscle/tendon/ligaments. It’s very protected in there. To be honest, in Oliveira’s case, it would be the last thing I would be worried about.           

Since the esophagus is so protected, it’s rare to be injured during trauma or external forces. An esophagus is usually injured by the severe retching or vomiting that occurs in alcoholics. Less commonly, it can occur in bulimics and pregnant mothers with severe morning sickness.

The classic esophageal injury is the Mallory-Weiss tear, which usually occurs in alcoholics who have vomited so much that they partially rip their esophagus away from where it connects to the stomach, or somewhere close to this connection. They usually have severe lower sternal chest pain, and if that rip goes through a vessel it can be accompanied by mild to profuse bleeding. The Mallory-Weiss tear only goes through 2 of the 3 layers of the Esophagus, sparing the tough outer muscular layer. Treatment depends on the amount of bleeding, and can range from just observation with potent prescription antacids and bland diet to direct visualization with an endoscopic camera and repair via injection, stitches, or rubber bands.

Image via headandneckcancerguide.com

The second and true esophageal emergency is Borhaaves syndrome. In Borhaaves syndrome the esophagus is torn all the way through. This allows stomach contents to leak into the mediastinum (the area where the heart lies) and even between the lungs and the chest wall. This isn't good, even if you “eat clean”, pretend to be vegan, or are on a pre-fight diet—stomach juices in the mediastinum or lungs will undoubtedly cause a massive infection. Without surgery Borhaaves syndrome is almost 100% fatal. If Oliveira hasn't had surgery yet, it’s safe to say he doesn't have Borhaaves syndrome.

My guess is he 1) has a small Mallory-Weiss tear or 2) a pre-existing benign esophageal abnormality that was incidentally picked up on the CT scan. If he continued on with the fight, the likely Mallory-Weiss tear could have gotten bigger due to the intra-thoracic pressure created by the strain of his core muscles. This could have resulted in Oliveira vomiting blood all over the Octagon, or worse progression to Borhaaves Syndrome. Both cases are not pretty.

Oliveira is undergoing additional testing that likely includes an MRI of his head and neck to evaluate his brain, spinal cord and neck ligaments, and swallowing studies/endoscopic camera to examine his esophagus. Without further information, it’s tough to make a recovery prognosis. At the latest, if it is a small esophageal tear, expect him to be training again in 3-6 weeks. 

 

Check out these related stories:

Fight Doc – Rib Injuries

Fight Doctor – The Eye Poke

Fight Doctor – The Groin Strike

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