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Diagnosis and management of cervical spine injuries in athletes: the risk of serious injury and permanent damage is high.

Article Excerpt
Cervical spine injuries are common in athletes, particularly those engaged in contact sports. American football and diving are the sports most often associated with these injuries. (1) Although most cervical spine injuries have a benign natural history with limited morbidity, catastrophic spine injuries, along with head injuries, account for 70% of the traumatic deaths and 20% of the permanent disability related to sports. (2) The rate of quadriplegia for high school and college football players in the United States is 0.50 and 0.82 per 100,000, respectively. (3) Participation in tackle football has increased 24% from 1998 to 2007, placing more young athletes at risk for cervical spine injury. (4)

Sports-related cervical spine injuries can affect muscles, ligaments, intervertebral disks, vertebrae, and the neural structures they protect (Table 1). Neck injuries deserve special attention for their potential to affect the spinal cord, potentially resulting in death or crippling permanent disability. The possibility of a catastrophic neurological injury in the setting of an unstable spine fracture necessitates meticulous on-field evaluation. Timely patient evaluation and prevention of further injury are the physician's key objectives. An accurate initial clinical assessment is needed to determine whether a player needs further medical evaluation and care or can return to the game safely. In this article, we survey the spectrum of cervical spine disorders seen in athletes, ranging from muscle strains to spinal cord injury. We emphasize well-organized initial care and identification of conditions that require immediate hospital-level care.

INITIAL ON-FIELD EVALUATION

Preparation is the first step in effective management of on-field injuries. The staff requires education about the nature of cervical spine injuries and the steps in evaluating an injured player so that at the moment of injury the response team executes a plan learned through rehearsal. A spine board, a hard cervical collar, and cardiopulmonary resuscitation equipment must be available. A trained and equipped staff is then ready to take the field to assess a player. (5)

During on-field evaluation, the clinician must suspect a cervical spinal cord injury until it is proved otherwise. On reaching the player, the clinician must control him or her and his position because he may have lost consciousness and, on awakening, routinely will attempt to move. The physician needs to calmly talk to the player and explain what he and his team are doing as they examine him.

First line of action

A player with suspected spine injury is not moved without immobilization unless absolutely necessary to maintain the ABCs--Airway, Breathing, and Circulation. The basic life support survey of ABCs is the first line of action for the response team. A player who must be moved is placed in the supine position with the team holding his head and neck in a neutral position, and then the standard ABC protocol is followed.

Airway assessment begins by removing the mouth guard, if present, and then maintaining an unobstructed airway. (6,7) The jaw thrust technique is the safest approach to opening the airway of an athlete with suspected spinal cord injury. This is performed by placing your fingers behind the angles of the jaw and then pushing the jaw forward or by hooking your fingers under the jaw and pulling forward. The lips are separated to allow breathing through the mouth as well as the nose. These maneuvers are performed without rotating the head.

Moving the jaw forward lifts the tongue and the epiglottis away from the back of the throat and opens the airway. If the jaw thrust does not open the airway, then the head can be tilted backward with care to avoid overextension of the neck. For an athlete who is not wearing a helmet, a cervical collar must be placed on the athlete if there is any evidence of bone or spinal cord involvement. (1)

For players wearing helmets, the facemask should be removed to facilitate airway access. This can be a challenge, because the design of helmets and rusting of bolts from exposure can make one tool more or less effective than another.

Again, staff preparation is crucial. The response team must familiarize themselves with the facemask design that their players use. Most facemasks are secured to the...

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