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On Field Evaluation of the Injured Athlete

Sports-related injuries are the fourth leading cause of spinal cord injury, accounting for 7.93 percent of all injuries per the National Spinal Cord Injury Center. SCI can occur during any sport, but football has the highest rate of SCI, followed by ice hockey, lacrosse and rugby. Prevalence of SCI has decreased with education on injury prevention. 

Prevention

Advising athletes on proper playing technique, educating medical staff about recognizing a potential SCI and continual evaluation of rules and implementation of changes when appropriate are all measures that have previously decreased cervical injury. One of the most important rule change implementations was performed in 1976 when spear tackling was made illegal (Figure 1). There is a high rate of head and neck injury with spear tackling due to the position of the neck at impact (flexed) and the direction of the force (axial load). After outlawing spear tackling, there was a decrease of SCI from approximately 20 cases per year to approximately seven cases per year. Efforts should be made to identify and prevent at-risk behaviors during sporting events to reduce catastrophic events. The current emphasis on “heads up” tackling has kept injury rates lower.

Figure 1.

Pregame Planning

Optimal outcomes for SCI athletes require a quick and effective response to injury. Proper preparation is essential to this response. The following steps entail proper planning for cervical trauma (Table 1). The tools required to run a cervical trauma are instruments for neurological testing, back board (age appropriate), a cervical collar, tools for removing athletic equipment (sport specific) and advanced airway management supplies/team. It is also important to establish a relationship with a hospital that has an available spine surgeon. A rehearsed protocol for injury can ensure an effective response on game day.

Table 1 - Pregame Planning for SCI
Offseason
  1. Create/practice a sport specific cervical trauma protocol
  2. Annual rehearsals with cervical trauma team
  3. Relationship with local EMS to expedite transport to hospital
  4. Become familiar with new equipment utilized by players
  5. Ensure all tools are available in a known location
  6. Develop protocol to remove equipment safely
  7. Develop relationship with hospital that will accept SCI patients
Game Day
  1. Check inventory of tools and equipment
  2. Establish leader who will run cervical trauma protocol
  3. Ensure all members of team are well-versed on spine trauma protocol
  4. Establish communication between trauma team, EMS and receiving hospital

Initial On-Field Assessment

The medical team should always be attentive to on-field action to identify the mechanism of injury. When approaching the injured athlete, it is important to assess for consciousness and extremity motion. A cervical spine injury is assumed if an athlete exhibits loss of consciousness or has altered mental status. It should be established that only the medical staff are permitted to move an injured athlete. Evaluation of the athlete begins with the standard “ABCDE” trauma protocol, which involves immediate stabilization of the spine in the neutral position (Figure 2). The Glasgow Coma Scale is also used for evaluation and a score less than 8 is associated with cervical spine injury.

Figure 2.

Stabilization and Transport of Injured Athlete

As soon as SCI is suspected, neutral cervical stabilization should occur by the medical staff leader. If a helmet is present it should not be removed. This point remains controversial depending on the resources present. Neutral cervical stabilization is performed by grasping the mastoid processes and cupping the occiput. Under no circumstances should traction be applied to the athlete’s head. A cervical collar should be placed, but this alone is not adequate protection for the cervical spine. The athlete’s head should be moved into the neutral position unless moving the athlete’s head/neck causes increased pain, muscle spasm, loss of neurological function or restriction in range of motion.

A player found in the prone position must be returned to the supine position for evaluation. The proper technique for transitioning the prone patient to supine is the “prone log role technique” (Table 2). The preferred method for transferring supine athletes to a backboard is the “lift and slide technique” due to the theoretical decreased risk of iatrogenic injury to the cervical spine (Table 2).

Table 2 - Rolling Techniques
Prone Log Roll Technique
  • Requires at least four trained personnel
  • Spine maintained in neutral position by team leader using cross armed technique
  • Rescuers synchronously pull athlete towards themselves
  • Fifth rescuer slides back board under athlete during midpoint of roll (if patient stable delay roll until backboard available)
Lift and Slide Technique
  • Requires at least eight trained personnel
  • Less cervical motion compared to log roll and preferred method for transferring supine patient to backboard
  • Spine maintained in neutral position by team leader Three rescuers on either side of athlete synchronously lifting patient six inches off ground Eighth rescuer slides back board under athlete

Assessing the athlete’s cardiovascular status is the first step in the protocol. Identifying cardiac or neurogenic shock allows proper treatment protocols to be initiated in a timely fashion (i.e., fluids, vasopressors, defibrillation). The next step is gaining access to the airway without causing trauma. A jaw thrust can prevent airway obstruction and should be initiated before face mask removal. If conservative airway measures fail, an advanced airway must be established. Head tilt, chin lift and nasopharyngeal airways are to be avoided because they put the athlete at risk for additional injury.

Youth athletes have larger head-to-body ratios, resulting in cervical flexion if placed on a standard backboard. A special backboard with a cut out for the occiput establishes a neutral cervical alignment in this scenario.

Transportation to the hospital can occur via ambulance or helicopter. Both are established as safe without an increase in complication rates. The decision should be based on clinical and logistical factors that allow expedited care. The athlete with an SCI should have a mean arterial pressure supported above >85, and serious consideration should be given to the use of steroids. A recent AO consortium, AO Spine Spinal Cord Injury Guidelines, included a re-analysis of the methylprednisolone issue and the role and timing of decompressive surgery for SCI. The STACIS trial has recommended to consider administering intravenous methylprednisolone within eight hours of injury (particularly in cervical injuries), using the dosing regimen: initial bolus dose of 30 mg/kg followed by an infusion of 5.4 mg/kg/h for 23 hours and early surgery.

Management of Protective Padding

The current recommendation is that the face mask of any player be removed, regardless of clinical status. The helmet and shoulder pads should remain unless they interfere with medical care (i.e., respiratory compromise, improper fitting equipment, need for cardiac defibrillation). The recommended technique to remove face masks is via a cordless screwdriver. There are now quick-release mechanisms of face masks for rapid removal. All existing methods for shoulder pad removal cause head and neck motion. Newer models of shoulder pads separate at the midline, allowing for removal without head motion. If helmet removal is required, it is important to place towels under the occiput to prevent extension of the neck.

Key Points

  1. Reduce the risk of cervical injuries through athlete education programs and continual evaluation of rules.
  2. Prepare for athletic injuries by developing and rehearsing a cervical spine protocol, develop an algorithm.
  3. Spine is stabilized in a neutral position.
  4. Assess circulation and airway of patient and implement necessary treatment in a timely manner.
  5. MAP>85 and strongly consider use of steroids in this narrow subgroup of patients.

Hecht is the chief of spine surgery for the Mount Sinai Health System and chief of spine surgery at the Mount Sinai Hospital. He is an associate professor of orthopedic surgery and of neurologic surgery at the Icahn School of Medicine at Mount Sinai. Hecht is the spine surgical consultant to the New York Jets and New York Islanders, as well as the director of the NFL Spine Care Program for retired players at Mount Sinai (one of five sites across the country). He also directs the acute spinal injury program for the NY Jets and is member of the NFL Brain and Spine Committee. He is the editor of a new textbook, “Spine Injuries in Athletes,” just published by the American Academy of Orthopedic Surgeons and Wolters Kluwer in March 2017.

References

  1. Weir, Tristan et al. “On-Field Evaluation and Transport of the Injured Athlete.” Spine Injuries in Athletes. 1st ed. American Academy of Orthopedic Surgeons, 2017. 32-39. Print.
  2. Fehlings MG, Vaccaro A, Wilson JR, et al: Early versus delayed decompression for traumatic cervical spinal cord injury: Results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS). PLoS One 2012;7(2):e32037.
  3. Del Rossi G, Horodyski M, Powers ME: A Comparison of spine-board transfer techniques and the effect of training on performance. J Athl Train 2003;38(3):204–208.
  4. National Spinal Cord Injury Statistical Center: Fact Sheet: Recent Trends in Causes of SCI. Birmingham, AL, University of Alabama at Birmingham, 2012.