Catastrophic Cervical Spine Injury

Injury to the spinal cord resulting in temporary or permanent neurologic injury is a rare but potentially catastrophic event during sports competition. Cervical spine trauma is most common in contact and collision sports such as American football, rugby, ice hockey, gymnastics, skiing, wrestling, and diving (Cantu and Mueller, 1999; Carvell et al., 1983; Tator and Edmonds, 1984; Wu and Lewis, 1985). Cervical spinal cord injuries are the most common catastrophic injury in American football and the second leading cause of death attributable to football. The National Center for Catastrophic Sports Injury Research reported that the incidence of cervical spinal cord injury in American football between 1977 and 2001 was 0.52, 1.55, and 14 per 100,000 participants in high school, college, and professional football, respectively (Cantu and Mueller, 2003).

Axial loading is the most common mechanism for catastrophic injury to the cervical spine during sports competition (Torg et al., 1979, 1990). Axial loading occurs when a player strikes another player with the top of the head as the point of initial contact ("spear tackling"). In athletes with cervical spinal stenosis, axial loading followed by forced hyperextension or hyperflexion can further narrow the AP diameter of the spinal canal, resulting in compression of the spinal cord and transient or permanent neurologic changes (Eismont et al., 1984; Penning, 1962; Torg et al., 1993).

Recognition of the axial load mechanism as the major cause of catastrophic cervical spine injury in American football resulted in rule changes that banned "spearing," defined as intentionally striking an opponent with the crown of the helmet, as well as other tackling techniques in which the helmet is used as the initial point of contact. In 1976 the incidence of quadriplegia was 2.24 and 10.66 per 100,000 in high school and college athletes, respectively. In 1977, only 1 year after rule changes that banned spear tackling, the incidence decreased to 1.30 and 2.66 per 100,000 in high school and college athletes (Torg et al., 2002).

On-the-Field Assessment

Medical providers at sporting events must be prepared to assess, stabilize, and transport athletes with suspected cervical spine injuries. Adequate preparation of and anticipation in required personnel and equipment and a well-designed emergency response are critical to the management of catastrophic neck injuries. In general, any athlete with significant neck or spine pain, diminished level of consciousness, or significant neurologic deficits should be immobilized and prepared for transport.

Guidelines for the prehospital care of the spine-injured athlete were established by the Inter-Association Task Force for Appropriate Care of the Spine-Injured Athlete (2001). The initial assessment of an injured athlete begins with a basic assessment of the ABCs and level of consciousness. EMS personnel should be contacted for any concerns regarding basic life support. Unconscious athletes are presumed to have unstable spine injuries until proven otherwise.

The face mask of a protective helmet should be removed as soon as possible, regardless of respiratory status (InterAssociation Task Force, 2001). In football the face mask can be removed with screwdrivers or the loop straps cut with various cutting tools such as pruning shears or a Trainer's Angel (Knox and Kleiner, 1997). Football helmets and chin straps should be left in place. If the helmet is removed from a downed player wearing shoulder pads, the athlete's head will hyperextend, which may result in secondary injury to the cervical spine. If the athlete is not breathing, an adequate airway can be established by the jaw thrust maneuver, which allows opening the airway while maintaining the cervical spine in a stable position. Rarely, assisted ventilation may be necessary.

If transport is indicated, the athlete should be immobilized to a spine board. A supine athlete can be transferred to a spine board using a six-plus person lift technique, with one person responsible for stabilization of the head and neck (Inter-Association Task Force, 2001). To transfer an athlete who is facedown, a logrolling technique is recommended. Transport of a spine-injured athlete should be directed to a trauma center or medical facility with diagnostic and surgical capabilities for spinal injury.

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