Key points

Introduction

Injury to the spine during sporting activities is a rare occurrence that ultimately demands a well-planned and multifaceted approach. These injuries can occur over a wide range of severity, from muscle strains and contusions, fractures, and dislocations, to even catastrophic spine injuries. A catastrophic spine injury is defined as an injury that causes structural distortion of the spinal column associated with the potential for, or actual, spinal cord injury (SCI). Although these injuries affect athletes of all ages, preparation and planning begins before the athlete ever steps out onto the field.

Sport-related injury is the fourth most common cause of SCI (following motor vehicle accidents, falls, and acts of violence) and accounts for approximately 7.8% of injuries since 2015. These traumas are devastating to an athlete and may lead to potentially permanent neurologic compromise or even a fatal outcome. Unlike typical trauma patients, athletes are often wearing helmets and other protective gear, especially in collision sports, which may complicate management of suspected spine injury. Although advances in sporting equipment have helped minimize SCI significantly, these injuries may still occur, demanding proper and expedient care so preparation is paramount. Well-trained medical staff should be present at each sporting event and assigned specific jobs to, not only be vigilant to injury on the field, but also have the skills necessary to evaluate, diagnose, and perform life-saving procedures. In addition, they should be well trained in equipment management and have knowledge of local hospitals capable of handling athletes with such injuries.

It is important for coaches to reinforce safety through practice of proper technique relevant to each sport. This can help minimize high-risk behavior during recreational and competitive play. Ultimately, understanding the epidemiology and mechanisms of SCI is essential to their prevention. The aim of this article was to review the on-field management of SCI from pregame preparation, mechanisms and types of injuries, on-field goals, and ultimately the escalation of an athlete’s care.

Epidemiology

In athletics, there are nearly 12,000 spinal cord injuries each year, which primarily account for the second leading cause of SCI in the first 3 decades of life. ^, The cervical spine is most commonly injured, typically as a result of axial loading and flexion of the neck. Less commonly, injury to the thoracolumbar spine can occur but is usually related to sport-specific degenerative processes. ^, High-risk sports include American football, hockey, rugby, skiing/snowboarding, and equestrian, with hockey accounting for the greatest number of catastrophic spine injuries overall.

American football has gained a lot of attention when considering SCI in athletes. Although accounting for approximately 1% of these injuries, it is responsible for the highest incidence of SCI in the United States and remains under critical review due to the growing number of annual participants at all levels of play. The patterns of spine injury in American football have evolved significantly over time, peaking in the 1960s with introduction of improved helmet design. Athletes were allowed to tackle head first (spear tackling) with the neck in slight flexion making contact with the crown of their head and their opponent. This places significant compressive axial forces through the cervical spine, predisposing the individual to spinal column and cord injury. Between 1971 and 1975, the National Football Head and Neck Injury Registry recorded 259 cases of unstable spine injuries and 99 cases of quadriplegia that were attributed to this aggressive, head-first, tackling. As this danger was recognized, in January of 1976, head-first tackling was banned from high school, collegiate, and National Football Leagues (NFL) and over the following 10 years a 70% decrease in cervical spine injury and quadriplegia was reported.

Similarly, the National Hockey League (NHL) responded to the prevalence of SCI through implementing league rule changes as well. Reports from Canada demonstrated 311 SCIs, 82.8% cervical injuries, in hockey between 1943 and 2005. Many of these injuries were provoked from skating into the boards or being checked from behind. Since 2001, these injuries have substantially decreased as a result of rule modifications now preventing illegal checking. Athletes are now prohibited from checking another athlete from behind, as head-first contact into the board or onto the ice in a forward and flexed position significantly increases their risk of sustaining an SCI. ^, This was later followed in 2010 by the NHL prohibiting lateral or blind-sided checks to the patient’s head and US Hockey raising the age of legal checking from 12 to 14 to minimize injury. Similar to the NFL and NHL, all sports leagues should regularly review and implement rules to improve in-game safety and protection of the athletes.

Congenital anomalies of the spine can also predispose an athlete to SCI on the field. Although such anomalies pose unique challenges to medical professionals due to the lack of unified guidelines, the safety of these athletes in contact sports is unclear. Cervical stenosis has been identified as an important factor in the occurrence of neurologic injury following spine trauma, particularly due to a decreased sagittal canal diameter. ^, Torg and colleagues defined a ratio on radiographic imaging to look at the anterior to posterior diameter of the spinal canal in comparison with the vertebral body and found that the ratio of less than 0.80 predisposed football players to transient neurologic injury. However, this ratio was later found to have a low positive predictive value based on statistical analysis and was not recommended for use in screening athletes.

Aebli and colleagues used MRI to study athletes with SCI and reported that those with such injuries had overall smaller spinal canal diameter. They found that a midsagittal intervertebral disk space diameter of 8 mm was the best measurement and most predictive of SCI after cervical trauma. Overall, studies have shown that even with canal narrowing in high-contact athletes, the incidence of neurologic involvement is relatively small and should not be an absolute contraindication to athletic participation. ^, However, a discussion should be had between athletes and medical providers after one experiences a neurologic injury in conjunction with a congenital abnormality, and they should reconsider further participation in contact sports.

On-field injuries to the spine

There are a wide range of on-field injuries to the spine, and observation and diagnosis are key in the immediate moments after an injury. Although some injuries may require only a short period of rest, most may elicit a permanent injury if not appropriately handled. Therefore, trained medical staff should be cognizant of the mechanism of injury and clinical presentations that follow to properly handle the injured athlete on the field. Injuries range from transient neuropraxias, acute disk herniations, to fractures and dislocations; regardless, if neurologic symptoms present, especially involving bilateral extremities, extreme care in management should be performed.

Stingers/burners

Collision athletes who develop acute neurologic symptoms limited to one upper extremity may be considered to have a transient neuropraxia. These are very common injuries, also known as stingers or burners, that occur in many sports including American football, rugby, hockey, gymnastics, boxing, and weight lifting. In particular, stingers have been reported in as many as 65% of college football players within their careers and in as many as one-third of all rugby players within a single season. Typically this injury occurs as a result of 1 of 3 mechanisms: (1) a traction injury to the brachial plexus as a result of forced contralateral neck sidebending and ipsilateral depression of the shoulder; (2) direct compression to Erb’s point of the brachial plexus; (3) cervical nerve root compression in the neural foramen after extreme extension and sidebending. ^{, ,} Athletes experiencing a stinger will complain of burning pain in the involved extremity with transient motor and sensory deficits in a nondermatomal pattern most commonly affecting the C5-6 nerve roots.

Stingers can last from seconds to hours after insult but usually resolve without intervention. Many times athletes will have complete resolution of symptoms and can be cleared to play when full range of motion and motor strength have occurred. If symptoms persist, the athlete should not be cleared to play. In addition, if any concern for worsening symptoms of neck pain, weakness, involvement of the lower extremity, or clinical suspicion of a catastrophic spine injury, the athlete should be taken to the nearest SCI or trauma center for imaging and frequent neurologic monitoring.

Acute disk herniation

Intervertebral disk herniations are a common cause of neck and back pain. These injuries occur commonly in contact athletes, more so than in the general populations, secondary to repetitive stresses athletes place on their spine, predisposing them to early degenerative processes. From this, injury to the annulus fibrosus allows for herniation of the nucleus pulposus into the spinal canal causing compression on the nerves or spinal cord creating an array of symptoms from transient to permanent neurologic deficits. In high-contact sports, these stresses predispose athletes to cervical disk herniations commonly seen in the C3-4 and C5-6 levels. Particularly in football (lineman and defensive backs) or rugby (front row forwards) there is an especially high incidence of cervical disk herniation due to the mechanics and repetition of their play. In addition, athletes may suffer similar injury to the lower back, where herniations are commonly seen at L4-5 and L5-S1 levels, accounting for 90% of symptomatic cases. Particularly, in football, lineman were found to be at an increased risk of acute disk herniation due to the a culmination of factors such as their training regimen, body weight, and repeated spine hyperextension during play.

On the field, initial neurologic symptoms should prompt emergent immobilization during the primary survey and ultimately escalation of care to ensure any neurologic deficits can be minimized or handled when necessary.

Fractures and dislocations

Fractures to the cervical spine most commonly occur in the subaxial spine with injury patterns predicated on the mechanism of injury. The response to the spine and surrounding soft tissues is dependent on the neck position at the time of impact and can lead to a wide range of injury severity. When the cervical spine is in neutral alignment, the natural lordosis allows the energy of a collision to be distributed throughout the surrounding musculature and ligaments. However, when the spine is in an exaggerated flexion or extension position, reducing the innate lordotic alignment, compressive forces place higher stresses on the bony support predisposing to fractures and dislocations.

Hyperflexion injuries are the most commonly reported neck injuries sustained by athletes. Mechanistically, the cervical spine experiences an axial load while in some degree of flexion, thereby causing compression to the anterior column while the posterior elements experience tension forces creating a “tear-drop” fragment. Although these injuries involve varying degrees of posterior column involvement, they are inherently unstable, and range from posterior ligamentous injury to bilateral facet dislocations. ^,

The second most common injury experienced by athletes is a compressive burst fracture. These injuries occur after a pure axial compression to a neutrally aligned spine, which creates a rise in the intradiskal pressure resulting in failure of both the anterior and middle columns of the vertebral body. If the injury is severe enough, SCI can occur secondary to retropulsion of bony fragments into the spinal canal. Burst fractures can also, and most commonly occur, without neurologic compromise, but this does not preclude immediate spinal stabilization. Again, the severity and ultimate treatment will be dictated by the integrity of the posterior ligamentous complex.

Hyperextension injuries to the spine are rare but result in significant injury. Athletes experiencing a large posterior force to the head will experience failure of the anterior longitudinal ligament and annulus fibrosus. When these injuries are severe, there can be enough force to cause failure of the posterior ligamentous complex leading to posterior translation of the vertebral body into the spinal canal resulting in SCI.

SCI to the upper cervical spine from fractures and dislocations are also rare. Although high-level injury can render a patient reliant on mechanical ventilation indefinitely, oftentimes these injuries do not elicit neurologic compromise. This is twofold, (1) because the space available for the cord at the upper cervical levels is greater than at the subaxial levels, and (2) because the common fracture patterns of the atlas (Jefferson fracture) and axis (traumatic spondylolisthesis), actually expand the diameter available for the spinal cord when they occur. However, injuries of concern include those that render the atlanto-axial joint unstable, transverse ligament injury, and variants of odontoid fractures.

Ultimately, any suspicion of an SCI, whether through observation of the injury or through clinical examination demonstrating neurologic deficits, prompt immobilization and escalation of care are warranted.

Thoracolumbar injuries

Thoracolumbar spine injuries commonly result in benign muscle strains and contusions that respond well to nonoperative management, but these injuries can exist over a wide range including ligamentous instability and fractures. This is because of the innate stability of the thoracolumbar spine is secondary to its surrounding structural support. Injury develops when the extrinsic forces overpower the intrinsic stability of these supporting structures, creating potential for catastrophic injury and neurologic compromise. ^,

Particular injury patterns are often sport-specific, although football and hockey have the highest association with more severe damage to the spine’s structural support; other sports such as in skiing and snowboarding place athletes at a high risk for catastrophic spine injury as well. Gymnasts on the other hand, experience injury through repetitive flexion-extension forces to the posterior elements and can thereby develop stress fractures to the pars interarticularis. Ultimately, traumatic injuries are less commonly seen in these areas of the spine, and are typically related to degeneration from sport-specific activity leading to disk degeneration, herniation, spondylolysis, and others. Regardless of the type of injury, whether cervical or thoracolumbar, management of a suspected SCI should be focused on safe and urgent immobilization and escalation to a higher level of care (this management is discussed in a later section).

Preparing for the game

Before athletes step onto the field, sporting facilities, medical personnel, coaches, and nearby hospitals should collaborate to create protocols designed to effectively manage injured athletes with suspected SCI. First, knowledge of the sporting facility is paramount, all staff should understand routes into and out of sporting facilities to allow timely entrance and departure of emergency medical services (EMS). Although oftentimes the athlete may require up to 6 to 8 people to secure and stabilize a suspected spine injury, it is essential that effective communication occurs. To accomplish this, a lead medical provider should be assigned to run all situations, this individual’s goal is to predesignate jobs to the support staff through organized instructions while EMS is on the way. This job not only spans the time of injury but during pregame preparation, ensuring all appropriate materials are well stocked and easily accessible (eg, backboards, cervical collars, screw drivers, airway management and life support kits, automated external defibrillators [AEDs]), in addition to all ancillary staff being appropriately trained in the use of these tools and equipment management. In emergent situations, the patient may not always be able to communicate to the lead medical provider, so readily available and updated emergency contact information is essential before each event; it may even benefit all parties if families are introduced to the medical staff members at the beginning of each season which may help ease the anxiety in a dire situation.

Ultimately, a suspected catastrophic spine injury will require an escalation of care from the field to a center capable of treating SCIs. Studies have shown that significant neurologic improvement was seen in athletes with SCI when transported directly to these specialty centers rather than to the nearest hospital. Knowledge of such facilities should be predetermined before each game to avoid delay in the athlete’s care. At the time of transportation, a member of the medical staff should be prepared to travel with the athlete to provide historical information and communication with not only the EMS but with the physicians taking over their care.

To ensure success, it would benefit all staff members, local emergency services, and hospitals to meet formally at designated intervals in the preseason period to review injury action plans and protocols. Throughout the season, all sporting event staff would also benefit from holding thorough pregame meetings to review the steps necessary to manage these situations, maximizing efficiency in the event of a serious injury. Preparation is key to successful management of an SCI, and although the treatment is complex, pregame preparation can help promote a safe and effective response.

Initial on-field management

The on-field management of a potential spine injury is critical and begins from the sideline. Seeing the injury first-hand allows the team physician or staff to formulate a differential diagnosis based on the observed mechanism. Extreme care must be taken in the first moments after the injury, as a patient may appear asymptomatic or be positioned in a way that is difficult to examine. It has been reported that up to 25% of SCIs are worsened under the care of medical professionals; although this may be an overestimation, it certainly emphasizes the importance of appropriate and safe management. Therefore, avoidance of excessive movement is prudent, as it minimizes secondary injury to a potentially unstable spinal column. Although it is rare that SCI will present with hemodynamic instability or cardiopulmonary arrest, Banerjee and colleagues ^{, ,} reported 3 presentations experienced by these athletes: (1) impending cardiopulmonary arrest, (2) altered mental status (AMS) with no imminent systemic threat, and (3) normal cardiopulmonary status and normal mentation.

As with any trauma, it is essential to evaluate the patient systemically through the use of basic life support (BLS)/advanced trauma life support (ATLS) algorithms following the “ABCDE sequence.” A primary survey should always be conducted to assess for and rule out life-threatening injuries; first A, for airway management and cervical spine protection; B, breathing; C, circulation; D, disability (evaluating for any obvious neurologic deficits); E, exposure. Any indication of life-threatening or spinal injury should prompt immediate activation of EMS.

Cardiopulmonary compromise on the field can result from numerous etiologies. Although paralysis of the diaphragm may heighten suspicion of SCI; facial fractures, trauma to the trachea or larynx, foreign bodies, pneumothorax, and asthma exacerbations should be considered and managed appropriately if identified. Regardless of the cause, the primary goal is to create a patent airway, ventilate the athlete, and begin cardiopulmonary resuscitation (CPR) if necessary.

In the event of a compromised airway, head tilt maneuvers should be avoided, as they can further propagate SCI. Instead, a jaw thrust maneuver should be used; this technique safely moves the tongue from the back of the throat, avoiding motion to the cervical spine, and permits access to the airway. Ventilation is next provided via a bag-mask ventilation technique, if at this point the patient remains hypoxic, endotracheal intubation may be performed by a trained medical professional, again, remaining cognizant of spinal stability. In the most severe cases, physicians should be capable of performing surgical airways if all other options fail.

After securing an airway and confirming appropriate ventilation, the patient’s circulatory status should be assessed. Diminished pulses and bradycardia or thready pulses and tachycardia may signify neurogenic or hypovolemic shock, respectively, with this, athletes require aggressive fluid resuscitation and strict maintenance of their mean arterial pressure at 85 mm Hg or greater to maintain spinal cord perfusion. At this point, trained medical staff should be prepared to begin CPR and at any point in resuscitative efforts have an AED available in the event of hemodynamic collapse from irregular cardiac rhythms.

Protective padding may prevent efficient CPR or use of AEDs, whereas helmets should remain on the athlete with the chin strap in place if possible, chest pads can be safely removed by cutting straps or laces in the center of the padding near the chest or at the axilla to facilitate chest compressions. If this step is required during emergency stabilization, the medical provider in charge of the spine stabilization must remain cognizant of the aggressive resuscitative maneuver to avoid any changes in neck alignment. Additional challenges may present when an athlete is in a prone position, he or she should first be safely log rolled to the supine position followed by removal of any interfering protective equipment (management of protective equipment and movement of injured athletes is detailed in a later section) again with trained medical staff maintaining a neutral alignment to the cervical spine during the roll and through resuscitative efforts.

Once a patient’s cardiopulmonary status is confirmed to be stable, a thorough assessment of the patient’s level of consciousness should be performed. Physicians again must rely on observation, noting if a patient has any sporadic movements, postures, or even lack of movement, as this may clue one into central nervous system or spinal pathology. Signs of confusion and disorientation usually signify a sustained closed head injury and any signs of AMS should be considered in relation to an SCI until proven otherwise. The Glasgow coma scale (GCS) is a reliable and objective tool that may be used to evaluate an athlete’s level of consciousness. The GCS assigns a score based on verbal cues, eye movement, and motor competency from 0 to 15, where a score of 11 or greater is reported to have a good to excellent prognosis and a score of 7 or less is associated with a poor prognosis. Significant alteration in consciousness should warrant emergent medical evaluation regardless of the cause.

Finally, and most commonly, patients will present with normal mentation and no cardiopulmonary compromise. This does not exclude a catastrophic SCI, so the lead medical provider should maintain hypervigilant until a full evaluation has been performed. As these patients are able to communicate, they should remain motionless as an in-depth history is obtained by the physician. Any indication of neck pain (particularly midline), tenderness, limitations to motion, or bilateral neurologic compromise should warrant immediate immobilization and escalation of care.

Stabilizing the injured spine for transfer

In the event of a spine injury, it is recommended that a patient’s neck be immobilized in neutral alignment before any movement. ^, If the injury has left the athlete’s neck in an alternate position, it is acceptable to slowly correct the alignment of head and neck position to neutral, reassessing frequently, and stopping immediately with any change in pain or neurologic symptoms. To stabilize the athlete’s neck, the physician should be at the head of the athlete where he or she can cradle the occiput using their palms and fingertips to steady the mastoid processes bilaterally to bring the head and neck to the appropriate alignment. The physician can then maintain this position as long as clinically necessary or until transition into a more rigid cervical collar. However, although a rigid cervical collar is effective to most injuries, complete ligamentous disruption requires the addition of continued manual stabilization due to the inherent instability of such injuries.

Once a patient is safely immobilized in an appropriate cervical collar, the next step is to transfer the athlete to a backboard, to not only aid in further immobilization, but to prepare for transfer to the hospital setting. The task of moving an unstable spine should be handled delicately, as transfer to a backboard requires a perfect orchestration from the team leader and staff to move the head, neck, and body as a unit. Two maneuvers have been described to achieve this transfer: the lift and slide and the log roll techniques.

The lift and slide technique has been regarded as the preferred technique by the National Athletic Trainers Association (NATA) and confirmed on cadaveric studies, as it imparts less head and cervical spine motion compared with the log roll technique ( Fig. 1 ). ^, This procedure requires the injured athlete to be lifted off the ground approximately 6 inches in a neutral position permitting placement of the backboard. To accomplish this, a team of up to 8 people are required. In this technique, the team leader takes position at the patient’s head so that he may dictate clear instruction to all assistants. The 6 additional people position themselves at the shoulders, pelvis, and at the lower extremities, 1 on each side of the athlete’s body. The last individual is responsible for sliding the backboard beneath the patient before the athlete being safely lowered down and secured.

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