National athletic trainers' association position statement: acute management of the cervical spine-injured athlete

Abstract

Objective: To provide certified athletic trainers, team physicians, emergency responders, and other health care professionals with recommendations on how to best manage a catastrophic cervical spine injury in the athlete.

Background: The relative incidence of catastrophic cervical spine injury in sports is low compared with other injuries. However, cervical spine injuries necessitate delicate and precise management, often involving the combined efforts of a variety of health care providers. The outcome of a catastrophic cervical spine injury depends on the efficiency of this management process and the timeliness of transfer to a controlled environment for diagnosis and treatment.

Recommendations: Recommendations are based on current evidence pertaining to prevention strategies to reduce the incidence of cervical spine injuries in sport; emergency planning and preparation to increase management efficiency; maintaining or creating neutral alignment in the cervical spine; accessing and maintaining the airway; stabilizing and transferring the athlete with a suspected cervical spine injury; managing the athlete participating in an equipment-laden sport, such as football, hockey, or lacrosse; and considerations in the emergency department.

Keywords: catastrophic injuries; emergency medicine; neurologic outcomes.

Figure 1. The prone log-roll push technique. A, Rescuer 1 provides cervical spine stabilization. Rescuers 2 through 4 are positioned on the side the athlete's head is facing. Rescuer 5 is on the opposite side, holding the spine board. B, Rescuers 2 through 4 reach across the athlete and, on command from rescuer 1, carefully roll the athlete away from them by pushing toward rescuer 5, who positions the spine board at a 45° angle beneath the athlete. C and D, Rescuers 2 through 4 slowly lower the athlete as rescuer 5 controls the spine board.

Figure 2. The 6–plus-person lift. A, Rescuer 1 provides cervical spine stabilization. Rescuers 2 through 4 are positioned on one side at the shoulders and thorax, hips, and legs, respectively; rescuers 5 through 7 are positioned similarly on the other side. Rescuer 8 is at the athlete's feet with the spine board. B, On command from rescuer 1, rescuers 2 through 7 lift the athlete approximately 6 inches off the ground, while rescuer 8 slides the spine board beneath the athlete. C, Rescuers 2 through 7 slowly lower the athlete onto the spine board.

Figure 3. Repositioning after transfer to the spine board. A, Rescuer 1 provides cervical spine stabilization. B, The other rescuers straddle the athlete and C, slide the athlete into position on command.

Figure 4. Head immobilization. A, Once the athlete is positioned properly, the rescuer “shimmies” a 4-ft (1.22-m) length of tape under the spine board. B, One side of the tape is pulled across the forehead at the level of the eyebrows, followed by the other side across the first piece.

Figure 5. Long spine-board handle designs. The board in the left hand has a beveled bottom, whereas the board in the right hand has recessed handles.

Figure 6. Face-mask removal. Placing the thumb behind the top loop strap while unscrewing the screw allows the loop strap to be lifted away once the screw is separated from the T-nut on the underside of the helmet. Reprinted with permission from Gale SD, Decoster LC, Swartz EE. The combined tool approach for face mask removal during on-field conditions. J Athl Train. 2008;43(1):14–20.

Figure 7. The backup cutting tool is used to cut away any remaining loop straps.

Figure 8. Quick-release loop-strap attachments. A, The quick-release mechanism is triggered by depressing the button. B, The T-nut is then detached from the inside of the helmet.

Figure 9. Helmet removal. A, Cervical spine stabilization is transferred from the rescuer at the athlete's head to another rescuer, who assumes control from the front. The rescuer at the head grasps the helmet at its sides and B and C, gently removes it from the athlete.

Figure 10. Buckling effect in the cervical column under axial load. Reprinted with permission from Swartz EE, Floyd RT, Cendoma M. Cervical spine functional anatomy and the biomechanics of injury due to compressive loading. J Athl Train. 2005;40(3):155–161.

Figure 11. The instantaneous center of rotation (ICR) for a vertebra is located near the superior aspect of the inferior vertebral body. The inferior vertebra's motion depends on the location of the force vector relative to the ICR. A, Hence, if the lines of force are transmitted anterior to the ICR, the inferior vertebra extends. B, If the lines of force are transmitted posterior to the ICR, the inferior vertebra flexes. Reprinted with permission from Swartz EE, Floyd RT, Cendoma M. Cervical spine functional anatomy and the biomechanics of injury due to compressive loading. J Athl Train. 2005;40(3):155–161.

Figure 12. The Riddell Revolution football helmet (Riddell Sports Inc, Elyria, OH) includes a quick-release attachment system for the face mask. The quick-release system is currently used to attach only the 2 side loop straps, while the top loop straps are secured with the traditional screw and T-nut configuration.