On-Field Evaluation and Transport of the Injured Athlete

Tristan B. Weir, BS

Michael J. Cendoma, MS, ATC

Ehsan Jazini, MD

Kelley E. Banagan, MD

Steven C. Ludwig, MD

Dr. Banagan or an immediate family member is an employee of Johnson & Johnson; and has received nonincome support (such as equipment or services), commercially derived honoraria, or other non-research–related funding (such as paid travel) from Orthofix. Dr. Ludwig or an immediate family member has received royalties from DePuy, a Johnson & Johnson Company; is a member of a speakers’ bureau or has made paid presentations on behalf of DePuy, a Johnson & Johnson Company, and Synthes; serves as a paid consultant to DePuy, a Johnson & Johnson Company, Globus Medical, K2Medical, and Synthes; has stock or stock options held in ASIP, ISD; has received research or institutional support from AO Spine North America Spine Fellowship Support, Globus Medical, K2M Spine, OMEGA, and Pacira; has received nonincome support (such as equipment or services), commercially derived honoraria, or other non-research–related funding (such as paid travel) from Thieme, QMP; and serves as a board member, owner, officer, or committee member of the American Board of Orthopaedic Surgery, the American Orthopaedic Association, the Cervical Spine Research Society, the Journal of Spinal Disorders and Techniques, and Smiss. Neither of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Jazini and Dr. Weir.

Introduction

According to the National Spinal Cord Injury Statistical Center, sports-related injuries ranked fourth behind vehicular accidents, falls, and violence as the most common causes of spinal cord injury (SCI). Sporting activities accounted for 7.93% of the 4628 cases admitted to sites contributing to the database from September 2005 to May 2012.¹ Although the thoracolumbar spine is susceptible to injury during sports, the focus remains on the cervical spine because of the higher injury incidence and more profound morbidity. All of the 223 SCIs reported in American football between 1977 and 2001 involved the cervical spine.²

American football is associated with the greatest number of catastrophic cervical spine injuries for all sports in the United States.³ Generally, catastrophic cervical spine injuries in American football have declined since the early 1970s. The NATA reports that an average of 7.8 catastrophic cervical spine injuries resulting in incomplete recovery and 6 resulting in quadriplegia were reported in American football between 1997 and 2006.⁴ Alarmingly, double-digit catastrophic cervical spine injuries were reported during three of the four years between 2003 and 2006; only 1999 showed double-digit numbers between 1991 and 2002. As recent as 2015, 14.3% of the direct fatalities reported in American football were attributed to cervical spine fracture.⁵

The risk of catastrophic cervical spine injury in other sports has also been reported. Although American football is associated with the greatest number of catastrophic cervical spine injuries, the incidence of nonfatal, direct catastrophic injuries in ice hockey, lacrosse, men’s hockey, and gymnastics is higher than in American football.³^,⁴

Although severe catastrophic spine injuries are rare in sports, their profound morbidity demands a systematic protocol for injury prevention. On-field stabilization and transport of the injured athlete is essential to minimize or prevent further injury and requires a well-practiced and team-based approach. Sport-specific regulations and proper coaching aid in the primary prevention of SCI, but the initial management of such events begins with preseason planning by the team physician, athletic trainer, and emergency medical services (EMS).⁶ This chapter provides an overview of prevention measures, pregame planning, on-field assessment, stabilization and transfer
techniques, and equipment management concepts that medical personnel should consider when developing an emergency action plan and on-field response protocols for the potentially spine-injured athlete (Video 4-1).

Prevention: Rules, Techniques, and Education

The on-field management of SCI begins by preventing the injury from occurring. Primary prevention of SCI in athletes consists of implementing and enforcing rules, teaching proper technique, and educating athletes and coaches in concepts that promote safety. This is especially important for football and ice hockey because they are the team sports associated with a greater risk of SCI.²

In 1976, an upward trend of fatalities from head and neck trauma in American football led the National Operating Committee on Standards for Athletic Equipment to ban spearing, or using the head as the initial point of contact during blocks and tackles.¹^,⁶ Spearing can result in cervical injury through axial loading and cervical flexion.⁷ In the seasons following the implementation of rules regarding spearing, there was a dramatic decrease in permanent cervical spine injuries, from 20 cases per year before 1976 to only 7.2 cases per year in the 1990s.² However, recent studies show that the incidence of spearing remains high despite implementation of rules banning spearing. Some have argued that rule changes regarding spearing would be more effective at reducing the incidence of spearing if properly enforced.

Educating players, coaches, and officials regarding the rationale for rules regarding spearing and the consequences of such technique is a vital component of any effective prevention program. Educating players and coaches in proper tackling techniques that do not place the head and neck in danger of injury is also a vital component of an effective injury prevention program. The combination of enacting and enforcing appropriate rules and educating players, coaches, and officials is attributed to a reduction in the number of permanent cervical injuries.⁷

Ice hockey has implemented similar guidelines to help reduce the incidence of cervical spine injuries, including penalties for checking players from behind. Checking does not allow players to adequately protect themselves and may lead to head-on collisions against the rink wall.⁸ Education of young players helps to prevent such dangerous occurrences. Studies from the 1980s clearly illustrate a gap in education of youth hockey players because players were unaware of the consequences of checking from behind or leading a check with their head.⁸ The Safety Towards Other Players (STOP) Patch Program requires youth hockey players to wear a STOP symbol on the back of their jerseys as a reminder to avoid checking from behind. Educational programs, along with regulation changes, have a proven track record of promoting player safety and should be continued.⁹

Pregame Planning

Preparation for cervical trauma in the athlete begins in the offseason by creating and practicing a cervical trauma protocol, obtaining the equipment needed for the protocol, and identifying a hospital that can continue the athlete’s care after an injury has occurred. The protocol must be tailored to the specific sport by accounting for variables related to that activity, including the surface of play and the equipment worn by the athletes. It is very important for athletic programs to have an Emergency Action Plan (EAP) developed in conjunction with local EMS.¹⁰

The team medical personnel should become familiar with the type of equipment worn by the players each season because new models of gear may require different tools and techniques to remove padding in the event of an accident. The tools typically required for running a cervical trauma protocol include instruments for neurologic testing, a back board, a cervical collar, tools for removing the athlete’s protective gear, and advanced airway supplies.¹¹

If an athlete sustains an on-field injury, the team physician or athletic trainer typically leads the cervical spine protocol while the other members of the rescue team follow the leader’s commands. The leader should encourage rehearsals with the rescue team at least annually, and each member of the medical team should be versed in her or his role in the protocol.¹² Before each sporting event, the medical team should take inventory of their equipment and review the spine trauma protocol.⁷ This is essential when working with new members from the medical staff because there are variations in protocol from team to team. Communication between the EMS and the rescue team promotes a smooth transition from on-field management to the athlete’s transport to a preplanned hospital that can definitively manage the athlete’s injuries.⁷ Controversy still exists surrounding the timing of definitive treatment for cervical trauma, but the receiving hospital should be able to perform the needed treatment with an available neurosurgeon or orthopaedic spine surgeon.¹³^,¹⁴ Additionally, the athlete’s emergency
contact information should be updated yearly and be easily accessible on the field in the event that a player sustains an injury during a game or practice.¹¹ Sports medicine teams should conduct a “time out” before each athletic event to review of items mentioned earlier to ensure familiarity with medical staff, athletic trainers, EMS, and each team.

Initial Assessment: On the Field

The initial assessment of the athlete begins with on field attentiveness, and the medical staff observing the mechanism of injury (i.e., “spear tackling” or “checking”). Extremity movement and vocalization can be assessed from a distance as the medical team approaches the injured athlete. Athletes with loss of consciousness or altered mental status are assumed to have a cervical spine injury until proven otherwise. For this reason, only the medical staff should be permitted to manipulate the athlete because excessive movement and jostling of the player can lead to primary or secondary injury of the cervical spine.¹⁵ Considerable movement of the athlete may result when equipment needs to be removed from the athlete. During management of an equipment-laden athlete, the medical team will need to consider the appropriateness and timing of equipment removal. This is a decision that each medical team will make while determining a course of action that promotes the safest handling of the injured athlete.

A standard emergency assessment of the athlete’s airway, breathing, circulation, and neurologic function (disability) should be performed to identify any potentially life-threatening injuries, for which EMS must be contacted (Video 4-2).¹⁶ Signs and symptoms that should prompt the rescue team to initiate the cervical spine injury protocol are loss of consciousness, altered mental status, bilateral neurologic symptoms, and focal spine pain or tenderness.¹² A low Glasgow Coma Scale score, especially at or below 8, is associated with cervical spine injury.¹²^,¹⁶ See Figure 4-1 for an algorithm for the on-field assessment of the cervical spine in athletes.¹⁷ After a cervical injury has been ruled out in a conscious athlete, specific symptoms should be elicited, and a physical examination is required, including a neurologic assessment.¹⁶

FIGURE 4-1 Algorithm for the on-field assessment of an athlete’s cervical spine based on neck pain (A) or extremity symptoms (B). HNP = herniated nucleus pulposus. (Reprinted from Banerjee R, Palumbo MA, Fadale PD: Catastrophic cervical spine injuries in the collision sport athlete, part 1: Epidemiology, functional anatomy, and diagnosis. Am J Sports Med 2004;32(4):1077–1087.)

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