Spine Stabilization and Transfer

Spine stabilization is essential to prevent further damage and starts during ATLS protocol after a potential spine injury has been identified. To accomplish this the spine is kept in neutral position and alignment with minimal motion. If the athlete’s spine is not in a neutral position when initially approached, it is reasonable to gently move the athlete’s head to create a more anatomic orientation; however, this change in position should cease if the athlete has increased pain or change in neurologic status during movement [13]. One should resist the urge to use distraction or traction as a means of reduction as this has been shown in several studies to lead to further damage [23, 24]. During the on-field evaluation, stabilization in a neutral alignment can be preliminary held manually by medical personnel. This is most effectively done by kneeling above the athlete while facing them and placing both hands under the head, thereby cupping the occiput with the palms and allowing the fingers to grasp over the mastoid processes [25]. This basic management of stabilization should be transitioned to a more definitive stabilization as soon as possible. Use of a hard cervical collar (c-collar) to maintain alignment is routine as it can quickly and easily be applied with minimal motion to the spine.

In the event that transport of the injured athlete is needed, transfer to a spine board is required. Multiple members of the medical team working in unison are needed to maintain stability to the spine and minimize motion. There are two primary techniques of transferring a patient onto a spine board: lift and slide or logroll . For the supine athlete, the National Athletic Trainers’ Association recommends the lift-and-slide technique [26] as it imparts less motion in the axial and coronal planes to the spine [27]. While this technique is preferred, it is not always logistically possible as it requires eight people: one person to take the lead (physician or trainer) and be at the head of the patient; three people should be on each side of the patient at shoulder, pelvis, and leg; and one person must be available to slide the board under the player. The leader will direct the remainder of the team to lift the athlete, in concert, approximately 6 inches. above the ground allowing the final person to slide the spine board beneath the athlete. Subsequently the athlete is lowered to the board in unison at the direction of the leader [28]. To perform the logroll technique , the leader (physician or trainer) should stand at the head of the patient, immobilize the spine as previously discussed, and direct all communication. The remaining assistants (at least three depending on the size of the athlete) should be on the side where the athlete is to roll to. They should reach across the body and securely grab the contralateral side of the athlete. Arms of the assistants should be crossed, thus allowing more stable points of fixation for turning. The leader should give a verbal count to allow for a smooth roll with all participants turning in unison. After the spine board is placed, the athlete may be rolled back onto it at the leader’s direction. In both techniques, it is critically important that all participants take cues from the leader as the team must act in unison when performing the lift or logroll so as not to compromise stability of the spine. Once on the spine board, combinations of supportive straps from the board, foam padding, and blocks should be used to secure the head and shoulders to ensure minimal motion during transport.

Though injuries to the thoracolumbar spine occur with less frequency, the same principles apply during transfer. Limiting motion of the thoracic or lumber spine will mitigate risk for further injury. These areas of the spine should be secured in the spine board such that minimal motion in any plane is allowed. This can be accomplished by appropriately fastening two to three cross body straps around the spinal board. Additional use of towels, foam pads/blocks, and tape can aid in securing the torso.

Considerations for the Injured Athlete in the Prone Position

The injured athlete in the prone position requires unique considerations for evaluation and spinal stabilization. In the prone athlete, the logroll technique should be performed to flip the athlete supine. This allows access to the airway and will enable the examiner to proceed with the evaluation. Ideally in this scenario, logroll can be performed onto a spinal backboard to eliminate the need for additional movement later as this may inevitably be required. However, if the athlete is mentally altered, is unconscious, or has cardiorespiratory compromise, then logroll and assessment should not be delayed if the backboard is not readily available. Conversely, if the athlete is conscious and communicating appropriately with medical personnel, it is reasonable to give pause prior to logroll allowing time for a spinal board to be brought onto the field and appropriately placed.

The logroll technique should be performed as previously described, with some modifications for the prone athlete. The leader should similarly stand at the head of the patient and direct all communication. In the prone athlete, the leader’s arms will start crossed such that when the athlete is flipped supine , the arms will be uncrossed and can maintain stability of the cervical spine in a neutral position throughout the roll [29]. The remaining assistants should follow the same protocol as previously described. All participants should exclusively follow the direction of the leader as the logroll in the prone athlete requires a turn of up to 180° as opposed to 90° in the supine athlete for board placement, creating the opportunity for more motion during movement.

To diminish risk of iatrogenic injury from the roll , terms of the roll should be established prior to moving the athlete. It is our recommendation that turning begins at the command of the leader and is paused at 90°. This will allow a moment for the medical personnel to safely readjust their bodies as needed and ensure smooth, simultaneous transition to the supine position while maintaining spinal alignment. Once supine, the remainder of the evaluation can proceed as previously described.

Considerations for the Athlete in Protective Equipment

The athlete in protective equipment (helmet, face mask, shoulder pads, etc.) also requires special attention, as there may be obstacles to comprehensive assessment. Initial evaluation of airway, breathing, and circulation may be difficult in the helmeted athlete. Again, medical staff must have the appropriate tools and be facile in equipment removal to safely and efficiently provide access to the airway and chest if need be; preparation is paramount as proficiency of medical staff is most important [30–32]. An in-depth understanding of the equipment and implications of equipment removal is also required. Medical personnel should be take inventory prior to each season and ensure familiarity with all types of equipment and manufactures for player equipment.

If there is concern for SCI, the spine must be immediately stabilized by medical personnel in the same manner as if the helmet and other protective equipment were not present. The face mask should be promptly removed using appropriate tools that minimize or eliminate motion to the cervical spine. This mandates one person remains focused on maintaining cervical spine alignment, while a separate individual focuses on face mask removal. Studies have shown a cordless power screwdriver is the most efficient way to remove a face mask from a helmet and also reduces the amount of motion at the spine as compared to other tools [33, 34]. Medical personnel must be aware that there may be multiple points of fixation for the face mask; commonly, the use of a screwdriver for screw removal as well as a cutting tool for attachment loops is required. The helmet and shoulder pads should be left in place as this combination can aid in maintaining spinal stability [35]. Situations that require removal of protective equipment are rare and only indicated if equipment is inhibiting adequate exposure in a timely manner, the spine is inadequately immobilized with the equipment in place, or the equipment is prohibitive to transport for further care. If removal is required, then both helmet and shoulder pads should be removed simultaneously as removing one can negatively affect alignment in the supine athlete as well as cause unnecessary motion to the spine [36–38]. For example, removing a helmet while leaving shoulder pads will enable the head to extend or hyperextend in a resting state; conversely, removing the shoulder pads while keeping the helmet can induce flexion or hyperflexion at the cervical spine.

Once the athlete in protective equipment is on a spinal board, immobilization remains necessary. In this instance, using foam pads, rolled towels or blankets, and tape will aid in restricting motion of the spine as spinal board straps will oftentimes not accommodate the head and shoulders with equipment in place. The use of hard cervical collars are not advised in the helmeted athlete as these rarely fit appropriately over the protective equipment and may cause excessive motion to the spine when applying [39].

Considerations for the Spine-Injured Pediatric Athlete

The pediatric athlete with a possible SCI requires certain nuances in evaluation. Factors related to pregame preparation or initial on-field assessment remains unchanged. Being aware of different types and brands of athletic equipment is important, particularly as there is often even less uniformity in this than older athlete cohorts. Having knowledge of advanced airways in the pediatric population is prudent. A key difference in the pediatric population is in regard to transfer on the spine board. Relative to the adult, children have a larger head to body ratio. This is of particular concern when considering resting position on a backboard during spine stabilization. Without modification to the standard adult spinal board, a child’s head would rest in a flexed position at the cervical spine given this relative mismatch of head to body ratio [40]. Therefore, it is necessary to elevate the body relative to the position of the head. In response to this, pediatric-specific spine boards are available that provide a depression for the occiput or a padding that creates an elevation for the shoulders, thoracic spine, and lumbar spine. These boards are recommended for children 8 years of age and less [41].

Conclusion

Though the incidence of SCI in athletics remains low, these injuries can be catastrophic with significant morbidity and long-term disability. Prevention of these injuries must be the primary focus through sport-specific education, innovation in protective equipment, and rule modifications. Medical personnel must be thoughtful and have a plan in place well before the injury occurs to effectively make an appropriate response. This plan must identify the “who, what, where, and when” questions to efficiently and completely care for the athlete with a spinal injury. For those sports that involve protective equipment, the plan must also account for this, and medical personnel should understand the equipment and be facile in its safe removal. Further, creating an emergency action plan and confirming that all contributors are actively engaged with the plan will help expedite care and save valuable time. Communication is vital to the success of the plan, and annual rehearsals will confirm that all members have a complete understanding of what to do when injuries transpire. Using a team approach will be needed, but the team leaders should take charge and direct the remaining medical personnel to ensure safety in delivery of care to the athlete and to prevent iatrogenic secondary injuries from occurring. Prioritizing spinal stabilization during on-field assessment should be standard, and careful consideration must be given to maintaining spinal stability during maneuvers necessary for resuscitation. While each injury is unique and circumstances surrounding the event change, a well-organized, well-rehearsed, and systematic response will help ensure safe and efficient care for the spine-injured athlete and will mitigate risk of further injury.

Expert’s Opinion

Covering sporting events as a team physician can be exciting, exhilarating, and stressful all at the same time. There is a tremendous amount of pressure on the physician to make decisions regarding diagnosis and treatment following an injury. While the player, coaches, and parents may not have the athlete’s health as a priority, it is the job of the team physician to exercise superior clinical judgment, knowledge, and ability. Team physicians must look out for the well-being of their patients (athletes) and place the needs of the patient first while providing evidence-based care.

Though experience is critical to understanding team doctoring, there are certainly things that can assist the team physician along the way. First, get to know the players before the game. The only way to do this is to spend time with the team. Understanding personalities in addition to having a comprehensive knowledge of each player’s medical history, physical exam, and pertinent imaging findings will help make educated decisions in a timely manner when injuries happen. Second, be prepared. When an injury occurs, events move quickly, and time is of the essence. Practice makes perfect, and the entire team must be present during the practice. Having a rehearsed plan in place with the team allows for shared responsibility in ensuring effective, efficient care is provided for the injured athlete. Knowing where supplies are, who is assigned with certain tasks, and who will lead the encounter can be very helpful in decreasing valuable time lost. Third, be a team physician on the sideline, not a spectator. Team physicians must watch a game anticipating or looking for possible injuries to occur. Often, this means continuing to watch the play after the whistle, taking a step back and more globally observing the game as opposed to watching the ball/puck, identifying environmental or sport-specific factors that may place players at risk and being mindful of those. Even in the exciting final moments of a close game, it is imperative that the team physician put emotions aside and perform the necessary tasks. Fourth, ask for help when needed. Given the heightened awareness of injury in sport, there are often multiple physicians or trainers at any particular event. While one person may be the head physician or trainer, each person has unique skills and experience that may benefit the injured athlete. Using combined knowledge and experience when appropriate can be beneficial. Likewise, each team member on the medical staff should feel comfortable in contributing to and addressing issues. It is everyone’s job on the medical staff to play a role in the care of the injured athlete, and communication strengthens the ability to provide quality care. Lastly, do no harm. To be a team physician is to do the best you can for your patient in the time you have, with what you have.