General Features

Worldwide, diving is the most common cause of acute SCI in sports and recreation. The injuries in diving are almost always to the cervical spine, and there is a high incidence of complete SCI. These injuries occur most often in the setting of unsupervised recreation at the lakeside, the ocean, or in private pools, and less often in a supervised setting such as a pool at a school. Trained divers seldom sustain SCI. With respect to organized sports, football in the United States and hockey in Canada are the team sports with the highest incidence of acute SCI. These sports also cause a high incidence of accelerated degenerative spinal changes that can lead to chronic myelopathy and radiculopathy. In the U.S. and in Canada, registries have been developed that provide systematic reporting of the incidence of SCI related to football and hockey. Major prevention programs have been developed to deal with some of the identified causes of these injuries, such as “clotheslining” and “spearing” in football and hitting from behind into the boards in hockey. Other organized sports with a high incidence of spinal injury or SCI are gymnastics (including the trampoline), wrestling, skiing, hang gliding, mountain climbing, rugby, and horseback riding. Bicycling and motor sports, including snowmobiles, all-terrain vehicles, dirt bikes, and motor cycle racing, also are responsible for large numbers of SCI in specific regions of many countries that have terrain and facilities suitable for these recreational activities.

In almost all types of sports and recreation, approximately 80% of the SCIs are sustained by male participants, and this is true for organized and unorganized activities. Horseback riding is one of the major exceptions in North America, because female participants are affected more often than male participants, likely reflecting the higher numbers of female participants. In sports and recreation, the SCI victims are usually young, with children occasionally affected. Indeed, in such sports as hockey, football, and rugby, teenagers often sustain SCI. In general, children younger than 10 years of age have a lower incidence of SCI but are prone to ligamentous injuries, especially of the upper cervical spine. In contrast, older children have injuries in the middle and lower segments of the cervical spine similar to adults.

Sideline Evaluation

It is safe and best practice to assume that until proved otherwise, all unconscious athletes have an unstable cervical, or other spinal level, fracture or dislocation of the spine. This implies a “no movement” policy for the unconscious player with strict attention directed to immobilization of the neck and back. The one exception to this rule is that the patient may need to be moved to establish an adequate airway and breathing. The same precaution holds for concussed athletes who may not have lost consciousness because they may also have sustained a concomitant spinal injury. Caution is also required in removing the helmet of football or hockey players; in general, it is best to leave the helmet in place until adequate help is available. Once prepared, it is best to remove the helmet and shoulder pads together as a unit to avoid the tendency for extension of the neck if the helmet is removed while the shoulder pads remain in place.

Level, Severity, and Type of Spinal Cord and Spinal Injuries

In general, cervical SCI is much more common in sports and recreation than thoracic or thoracolumbar injury. In certain activities, such as diving, SCIs are almost exclusively cervical. Motor sports, such as those involving all-terrain vehicles and snowmobiles, and horseback riding cause a large number of thoracic and thoracolumbar injuries. Similar to the findings in nonathletic injuries, approximately 60% of SCIs in sports and recreation are incomplete injuries, with American Spinal Injury Association (ASIA) grades of B, C, and D. In some sports, however, notably diving, complete spinal cord injuries occur more often than incomplete injury. SCIs without spinal fracture are frequent in sports and recreation, especially related to acute disc herniations, which can occur at any level of the spinal column.

Many of the sports and recreational injuries of the spine involve a combination of high speed and axial loading, and this is especially true in football and hockey, in which burst fractures and compression fractures frequently occur. The combination of flexion and axial loading, or extension and axial loading, can lead to fracture-dislocation with or without associated disc rupture. Bilateral locked facets in the cervical region with anterior dislocation or fracture-dislocation are common injuries sustained in diving, whereas young gymnasts have a propensity for fractures of the pars interarticularis in the lumbar region. In children, the mechanisms of injury reflect those in adults, although there are significant differences, such as a greater tendency for SCI without fracture or dislocation of the spine.

Overuse spinal injuries accelerate the onset and magnify the severity of such conditions as degenerative disc disease, cervical spondylosis, and spinal osteoarthritis. These conditions may occur at a much earlier age in athletes than in the general population because of repetitive loading of the spine, as in wrestling, weightlifting, and gymnastics. There are several risk factors that make the adolescent spine susceptible to stress fractures manifesting as spondylolysis. The neurologic sequelae of these spinal diseases present as radiculopathy or myelopathy. Activities in which these chronic spinal conditions frequently become significantly symptomatic include running/jogging, tennis, and squash.

Repetitive lifting of heavy weight can also worsen preexisting degenerative spinal conditions. Practitioners should caution participants approaching middle age that high-impact activities may have to be tailored back or abandoned for lower impact or nonimpact activities, such as fast walking or swimming. Similar advice should be given about limiting the amount of weight to be lifted.

Acute Injuries

It is important for physicians associated with sports teams or athletic or recreational events to have the necessary training and equipment to provide first aid safely and effectively. In general, the first aid and subsequent hospital management of the athlete with an acute SCI are identical to the management of other patients with these injuries. There should be preparation for the management of a catastrophic spinal injury, with special attention to airway, breathing, and circulation—the “ABC’s” of resuscitative trauma management. The attending physician or trainer should quickly obtain a thorough history of the injury, inquiring specifically for spinal pain, muscle weakness, and sensory loss, followed by an examination of the nervous system, including assessment of power and sensation. The examiner should gently palpate the entire spine for detection of crepitus, tenderness, or deformity. It is essential to ensure absolute immobilization of the entire spine during examination, and before any required transfers and transport. Effective treatment includes the prevention of secondary injuries, such as pressure sores, and administration of appropriate resuscitative measures. These measures prevent worsening of neurologic deficits or the initiation of a neurologic deficit in persons without an initial deficit who have an unstable spinal injury. There should be complete documentation of any previous injuries, because this information is essential for inclusion in the deliberations regarding return to play.

Helmet removal of injured players requires specific attention in sports like football and hockey sports in which players are also wearing shoulder pads. In these cases, the helmet should not be removed first. If there is a problem with airway management, only the facemask should be removed, and this can be accomplished with heavy wire cutters. Removal of the helmet first in a player wearing shoulder pads may cause extension of the neck because of the thickness of the shoulder pads. In these players, the shoulder pads and helmet should be removed simultaneously while maintaining the neck in axial alignment with the trunk. Spinal injuries in athletes require complete imaging, preferably by a combination of CT and MRI to detect evidence of current and previous injury to the spine and spinal cord, including ligamentous injury, and to detect spinal instability and intracanalicular space-occupying lesions, such as with herniated vertebral discs. MRI is especially useful for the detection of ligamentous injury, disc herniation, and presence of subtle signal changes in the injured cord. The details of management and the choice of surgical versus nonsurgical management are beyond the scope of this article, except that there is a greater tendency toward recommendations for operative fusion in athletes because of the high level of impact forces, especially in contact sports.

Chronic Injuries

The management of athletes with chronic injuries is no different from that of nonathletes with similar injuries, except for the importance of changing to lower impact or nonimpact activities and avoidance of lifting heavy weights.

Acute Injuries

It is important for physicians associated with sports teams or athletic or recreational events to have the necessary training and equipment to provide first aid safely and effectively. In general, the first aid and subsequent hospital management of the athlete with an acute SCI are identical to the management of other patients with these injuries. There should be preparation for the management of a catastrophic spinal injury, with special attention to airway, breathing, and circulation—the “ABC’s” of resuscitative trauma management. The attending physician or trainer should quickly obtain a thorough history of the injury, inquiring specifically for spinal pain, muscle weakness, and sensory loss, followed by an examination of the nervous system, including assessment of power and sensation. The examiner should gently palpate the entire spine for detection of crepitus, tenderness, or deformity. It is essential to ensure absolute immobilization of the entire spine during examination, and before any required transfers and transport. Effective treatment includes the prevention of secondary injuries, such as pressure sores, and administration of appropriate resuscitative measures. These measures prevent worsening of neurologic deficits or the initiation of a neurologic deficit in persons without an initial deficit who have an unstable spinal injury. There should be complete documentation of any previous injuries, because this information is essential for inclusion in the deliberations regarding return to play.

Helmet removal of injured players requires specific attention in sports like football and hockey sports in which players are also wearing shoulder pads. In these cases, the helmet should not be removed first. If there is a problem with airway management, only the facemask should be removed, and this can be accomplished with heavy wire cutters. Removal of the helmet first in a player wearing shoulder pads may cause extension of the neck because of the thickness of the shoulder pads. In these players, the shoulder pads and helmet should be removed simultaneously while maintaining the neck in axial alignment with the trunk. Spinal injuries in athletes require complete imaging, preferably by a combination of CT and MRI to detect evidence of current and previous injury to the spine and spinal cord, including ligamentous injury, and to detect spinal instability and intracanalicular space-occupying lesions, such as with herniated vertebral discs. MRI is especially useful for the detection of ligamentous injury, disc herniation, and presence of subtle signal changes in the injured cord. The details of management and the choice of surgical versus nonsurgical management are beyond the scope of this article, except that there is a greater tendency toward recommendations for operative fusion in athletes because of the high level of impact forces, especially in contact sports.

Chronic Injuries

The management of athletes with chronic injuries is no different from that of nonathletes with similar injuries, except for the importance of changing to lower impact or nonimpact activities and avoidance of lifting heavy weights.