Traumatic Injuries of the Cervical Spine in the Athlete

History

Football, diving, rugby, and other sports constitute the second most common cause (10%) of catastrophic cervical spine injuries (10,000 annually), after motor vehicle collision (MVC). Football is the most researched of these, with 7 decades of Annual Survey of Football Injury Research (ASFIR) data culminating in a reduction of traumatic quadriplegia incidence from 10 to 1 per 100,000 football participants since outlawing spear tackling in 1976.

First responders to an on-field injury should perform primary and secondary surveys, immobilizing the head while ruling out spine injury and assessing airway, breathing, and circulation. Cardiac defibrillation, neurologic exam, equipment removal, and transport are then performed. The neurologic exam should assess level of consciousness, sensation, and strength.

Immobilization in a cervical collar and rigid spine board is an established historical precedent for transport. New recommendations emphasize limited spinal manipulation. Spine board immobilization is recommended for palpable step-off or spine tenderness, focal neurologic deficit, altered consciousness, or distracting injury. Medication list, allergies, and time of latest oral intake should be communicated.

Physical Examination/on-Field Evaluation

On-field response requires preparation, planning, equipment, and an organized chain of command. First priorities include assessing scene safety and airway patency. Maintain in-line cervical immobilization while assessing airway, breathing, circulation (ABCs). Note airway obstructions, tracheal deviation, and subcutaneous emphysema. Check pulses, and apply pressure over active bleeding. Measure heart rate and blood pressure. Assign level of consciousness (alert, responsive to verbal vs. painful stimuli, unresponsive) or Glasgow Coma Scale. Remove clothing to visualize surface anatomy, noting any deformity, crepitus, abrasions, penetrating trauma, burns, tenderness, lacerations, and swelling.

Spine boarding and equipment removal should be decided upon prior to transport. Some studies support leaving equipment in place until after transport. Even perfect execution engenders a risk of injury. If the helmet or shoulder pads need to be removed, both should be removed to avoid flexion/extension of the cervical spine. Jaw thrust and not head tilt is the appropriate airway access maneuver. Log rolling remains the appropriate technique for prone athletes, to position the spine board beneath them, but fewer cases of iatrogenic neurodeterioration have been documented with newer techniques.

To remove equipment, the team leader stands over the head and stabilizes the C-spine while another provider straddles the patient and cuts down the jersey/shoulder pads and under-arm straps. This also facilitates defibrillator pad placement. Roles are then reversed, holding C-spine from below while two providers pull off the helmet. If three trained providers are not present, facemask removal is an alternative. If quick-release mechanisms are not built-in, cordless screwdrivers or heavy shears may prove instrumental in making bilateral cuts or removing the two screws in the plastic clip affixing the facemask. Chin strap and cheek pad removal facilitate helmet removal while towels are temporarily placed beneath the head to prevent C-spine extension. Shoulder pads can then slide over the head allowing application of a rigid cervical collar.

The sports medicine team may escalate care via emergency medical transport services and communicate injury mechanism, developments, and interventions during on-field management. Intracranial pressure should be monitored by serial neurologic examination. Acuity and resource availability should factor into destination selection for transport. Computed tomography (CT), magnetic resonance imaging (MRI), and spine surgeon availability are important destination determinants. Advanced verbal notice to the receiving facility is helpful.