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Cervical Spine Injuries in the Athlete

Key Points

  • Football, ice hockey, rugby, skiing, snowboarding, and equestrian athletes have been identified as being at an increased risk of spinal cord injury. Athletic injuries are the fourth most common cause of spinal cord injury. The risk is small, but such an injury can be devastating to a young player’s career and life.
  • Equipment and rule changes, as well as education of coaches, have helped to reduce the risk of injury.
  • If the space available for the spinal cord is reduced because of a narrow canal, an athlete is at greater risk. Cord compression can be anticipated when the diameter of the midsagittal cervical spinal canal is 10 mm or less.
  • Cervical spine injuries can be classified as either catastrophic or noncatastrophic.
  • Catastrophic injuries can be defined as a structural distortion of the cervical spinal column associated with actual or potential damage to the spinal cord. Such injuries include unstable fractures and dislocations, transient quadriplegia, and acute central disc herniation.
  • The vast majority of injuries are noncatastrophic. These injuries include neuropraxia of the cervical root or brachial plexus (known as a “stinger” or “burner”), paracentral intervertebral disc herniation, stable fractures, spinal ligament injury, and intervertebral disc injury.
  • In football and hockey, the injury vector most frequently associated with cervical spinal cord injury is compression (axial loading).
  • During competition, sports medicine staff should make efforts to monitor play. A visual image of the traumatic event can be useful in attempting to determine both the type and the severity of injury.
  • The initial evaluation follows the ABCDE sequence of trauma care: A, airway maintenance with cervical spine protection; B, breathing and ventilation; C, circulation; D, disability (i.e., neurological status); and E, exposure of the athlete.
  • Regardless of the etiology, the primary objective when respiratory compromise exists is to rapidly identify hypoxia and then intervene by providing proper ventilation for the injured player. This must be accomplished without causing any further injury to the spinal and neurological structures.
  • Protective equipment should be removed before transport only in select cases.
  • Unless an emergency exists that requires removal of the helmet and/or shoulder pads, initial screening radiographs can be obtained with the protective equipment in place. Lateral computed tomography (CT) scout films have been used effectively in this case.

Cervical spine injuries in the athlete continue to present a small but inherent risk and may devastate a young player’s career and life. The injured athlete must be handled cautiously until the extent of skeletal and neurological injury can be defined.

Athletic injuries are the fourth most common cause of spinal cord injury (behind motor vehicle accidents, violence, and falls) and account for approximately 7.5% of the total injuries since 1990. Sports-related spinal cord injuries occur at a much younger age (mean age, 24 years) compared with other causes of this injury.

Furthermore, sports injuries are the second most common cause of spinal cord injury under the age of 30 years. Several sports, including football, ice hockey, rugby , skiing, snowboarding, and equestrian, have been identified as carrying an increased risk for athletes to sustain spinal cord injury. American football and ice hockey, which are the most popular collision sports around the country, account for most these cervical spine injuries.

In addition, these sports have been, perhaps, most influenced by changes in injury and prevention secondary to their popularity and high visibility worldwide.

Defining the spectrum of cervical spine injuries can range from temporary, fully recoverable injuries to permanent, catastrophic injuries. A catastrophic cervical spine injury can be defined as a structural distortion of the cervical spinal column associated with actual or potential damage to the spinal cord.

As mentioned, these catastrophic injuries not only can instantly change an athlete’s life but also leave them with irreversible and devastating neurological consequences. Many advances in protective equipment, including helmet design and modifications in rules of play, have helped to decrease the rate of these injuries in collision sports.

Recognizing and quantifying injury data on a national level have helped to drive several changes in these collision sports; however, this clinical problem challenges the sports medicine physician during early, on-field decision making.

Furthermore, because of the overall low incidence of catastrophic cervical spine injuries, few physicians develop the extensive experience and essential skills that are necessary for the emergency care of cervical spine injuries. Perhaps the single most important primary decision deals with handling of the cervical spinal column on the field and during transport.

Many authors now agree that improper handling of the spine during the early stabilization period can worsen spinal cord dysfunction. An athlete’s cardiac and respiratory status can be significantly compromised with improper management of the cervical spine.

Furthermore, the initial management of a collision sport athlete versus that of a typical trauma victim with an injured cervical spine is very different. Specifically, the protective helmet and shoulder pads worn by the player complicate the medical evaluation and immobilization process during initial management; however, the consensus currently is to leave helmets and shoulder pads in place unless specific circumstances exist. Many clinical scenarios will be reviewed at the end of this chapter.

In this chapter, we will review the epidemiology, functional anatomy, and diagnostic considerations that are relevant to cervical spine trauma in the athlete. We will consider specific injury patterns and clinical syndromes. Although a number of different sports have been associated with spine injuries, we will focus primarily on the collision sports of American football and ice hockey.

The unique aspects of the protective gear (i.e., helmet and shoulder pads) in these sports will be described. We also will provide the reader with a concise protocol for on-field diagnosis and management of the athlete with an injured spine. Finally, we will review initial management of the spine-injured athlete on transfer to the emergency room.

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