Cervical Spine Injury

Cervical spine injuries ranging from serious to catastrophic can be a cause of sudden death in athletes competing in both contact and non-contact sports.  Although the incidence rate is low this type of injury has a very high fatality rate. There is an estimated 12,000 new cases of cervical spine injury in the US each year, 42% of which are a result of vehicle crashes. Sports constitute about 8% of these cervical spine injuries (~1,000 cases). American football is associated with the highest spine injury among sports, however rule changes have dramatically improved the incidence of spine injuries since the 1970s. Cervical spine injuries are the result of deformation to the cervical spinal column that can cause damage to the spinal cord.  Injury to the C5 vertebrae and higher can be fatal because it may inhibit ventilation controlled by the central nervous system.  24-72 hours after a spinal cord injury has been sustained many complications can be seen which is why immediate recognition and treatment is critical to overall survival of the athlete.

 

How do you prevent cervical spine injuries?

  • Instruct proper tackling technique: no axial loading (spearing, which occurs when the head and neck is flexed between 20-30°and serves as the point of contact).  This is the most common cause of cervical spine injuries in sport.
  • Have medical staff to cover exercise sessions and games
  • Enforce rules for safety
  • Properly fit and maintain protective equipment
  • Use protective equipment that meets safety standards (e.g., NOCSAE for football helmets)
  • Have an EAP (Emergency Action Plan) specifically for cervical spine injuries
  • Continually stay up to date and rehearse skills to manage cervical spine injury
  • Properly identify predisposing conditions (eg: cervical stenosis etc)
  • Have multiple tools/mechanisms to remove protective equipment safely

 

Look for these symptoms in athletes when cervical spine injuries are suspected:

  • Witnessing mechanism of injury
  • Witnessing athlete who remains down or motionless after play
  • Abnormal neurological findings
  • Loss of motion in extremities
  • Cervical spine pain with or with out palpation
  • Cervical spine deformity

 

How do you know if this is a cervical spine injury?

  • Assess breathing/circulatory status (Normal 10-30 breaths per minute)
  • Assess pulse (quality, rate, and rhythm)
  • Assess neurologic status/level of consciousness
  • If conscious, ask patient what symptoms they are experiencing
  • Palpate cervical spine and surrounding musculature
  • Perform upper/lower extremity sensory and motor assessment
  • If assessment reports abnormal finding, prepare for emergency transport

 

Presence of 4 clinical indicators warrants activation of CSI management protocol:

  1. Unconsciousness (or altered consciousness)
  2. Bilateral neurologic complaints/findings
  3. Significant cervical spine pain (with or without palpation)
  4. Obvious spinal column deformity

 

What else could this be?

  • Head injury or concussion
  • Neck sprain/strain
  • Neck spasm
  • Whiplash
  • Brachial plexus injury
  • Cervical disk injury

 

How do you treat an individual with a cervical spine injury?

  • Activate EMS
  • Apply manual cervical spine stabilization (Maintain throughout entire process)\
  • Realign cervical spine to neutral if possible, and apply cervical collar
    • This is not recommended if:
      • Causes increased pain
      • Neurologic symptoms
      • Muscle spasm
      • Airway compromise (jaw thrust maneuver if necessary)
  • Remove protective equipment that hiders access to airway
    • If removal of face mask fails, or immediate treatment requires removal of shoulder pads when the helmet or shoulder pads are removed, the other must also be removed.
    • Lacrosse helmets should be removed in a suspected SCI due to unique structure.
    • Sports with helmet only equipment should have helmet removed to establish neutral alignment.
  • Move athlete onto long spine board (through log roll if patient is prone or lift and slide maneuver) and secure\
  • Secure athlete’s head with blocks to long spine board
  • Monitor vitals/level of consciousness throughout entire process
  • Have member of athletic training staff accompany athlete to hospital

 

When can the individual return to activity?

  • Long term prognosis is directly related to severity of initial tissue damage (recovery may be complete or incomplete)
  • Must be asymptomatic
  • Must have full, pain free cervical spine range of motion
  • Must have normal neurological exam
  • Sport and risk of re-injury must be taken into consideration
  • Return to play should be done on an individual basis

 

Recommended Equipment

  • Spine board/straps
  • Cervical collar
  • Head blocks
  • Electric/cordless screwdriver
  • Trauma Sheers/Backup cutting tools
  • Quick release tool
  • Portable phone
  • Pocket mask
  • Towel
  • AED

References

  1. Bailes JE, Petschauer M, Guskiewicz KM, Marano G. Management of cervical spine injuries in athletes. J Athl Train. 2007;42(1):126-134.
  2. Mueller FO, Cantu RC. Annual Survey of Catastrophic Football Injuries 1977–2009. Chapel Hill, NC: University of North Carolina; 2010.
  3. Mueller FO, Cantu RC. Twenty-Seventh Annual Report, Fall 1982–Spring 2009. Chapel Hill, NC: National Center for Catastrophic Sport Injury Research, University of North Carolina; 2010.
  4. National Spinal Cord Injury Statistical Center. Spinal Cord Injury: Facts and Figures at a Glance. Birmingham, AL: National Spinal Cord Injury Statistical Center, University of Alabama–Birmingham; 2008:2.
  5. National Spinal Cord Injury Statistical Center. The 2007 Annual Statistical Report for the Spinal Cord Injury Model Systems.Birmingham, AL: National Spinal Cord Injury Statistical Center, University of Alabama–Birmingham; 2008.
  6. Swartz EE, Waninger KN. Cervical Spine Injury. In: Casa DJ, ed. Preventing Sudden Death in Sport and Physical Activity. Sudbury, MA: Jones and Bartlett Learning; 2012:129-126. 
  7. Swartz EE, Boden BP, Courson RW, Decoster LC, Horodyski M, Norkus SA, Rehberg RS, Waninger KN. National Athletic Trainers’ Association position statement: acute management of the cervical spine-injured athlete. J Athl Train. 2009;44(3):306-301.
  8. Torg JS. Epidemiology, pathomechanics, and prevention of athletic injuries to the cervical spine. Med Sci Sports Exerc.1985;17:295–303.
  9. Waninger KN, Swartz EE. Cervical spine injury management in the helmeted athlete. Curr Sports Med Rep. 2011;10(1):45-49.