Cervical spine alignment in the immobilized ice hockey player. A computed tomographic analysis of the effects of helmet removal

Cervical Spine Injuries in the Ice Hockey Player: Current Concepts in Epidemiology, Management and Prevention

STUDY DESIGN

This review article examines the biomechanics that underly hockey-related cervical spine injuries, the preventative measures to curtail them, optimal management strategies for the injured player and return to play criteria.

OBJECTIVE

Hockey is a sport with one of the highest rates of cervical spine injury, but by understanding the underlying pathophysiology and context in which these injuries can occur, it is possible to reduce their incidence and successfully manage the injured player.

METHODS

Multiple online databases including PubMed, Google Scholar, Columbia Libraries Catalog, Cochrane Library and Ovid MEDLINE were queried for original articles concerning spinal injuries in ice hockey. All relevant papers were screened and subsequently organized for discussion in our subtopics.

RESULTS

Cervical fractures in ice hockey most often occur due to an increased axial load, with a check from behind the most common precipitating event.

CONCLUSIONS

Despite the recognized risk for cervical spine trauma in ice hockey, further research is still needed to optimize protocols for both mitigating injury risk and managing injured players.

On-Field Management of Suspected Spinal Cord Injury

Acute spinal cord injuries in athletes are rare. However, on-field management of such injuries requires a well-planned approach from a team of well-trained medical staff. Athletes wearing protective gear should be handled with care; a primary survey should be conducted to rule out life-threatening injury while concomitantly immobilizing the spine. Treatment with steroids or hypothermia have not been shown to be beneficial, ultimately time to surgery provides the athlete with the best chance of a good outcome.

Consensus Recommendations on the Prehospital Care of the Injured Athlete With a Suspected Catastrophic Cervical Spine Injury

INTRODUCTION

Sports participation is among the leading causes of catastrophic cervical spine injury (CSI) in the United States. Appropriate prehospital care for athletes with suspected CSIs should be available at all levels of sport. The goal of this project was to develop a set of best-practice recommendations appropriate for athletic trainers, emergency responders, sports medicine and emergency physicians, and others engaged in caring for athletes with suspected CSIs.

METHODS

A consensus-driven approach (RAND/UCLA method) in combination with a systematic review of the available literature was used to identify key research questions and develop conclusions and recommendations on the prehospital care of the spine-injured athlete. A diverse panel of experts, including members of the National Athletic Trainers' Association, the National Collegiate Athletic Association, and the Sports Institute at UW Medicine participated in 4 Delphi rounds and a 2-day nominal group technique (NGT) meeting. The systematic review involved 2 independent reviewers and 4 rounds of blinded review.

RESULTS

The Delphi process identified 8 key questions to be answered by the systematic review. The systematic review comprised 1544 studies, 49 of which were included in the final full-text review. Using the results of the systematic review as a shared evidence base, the NGT meeting created and refined conclusions and recommendations until consensus was achieved.

CONCLUSIONS

These conclusions and recommendations represent a pragmatic approach, balancing expert experiences and the available scientific evidence.

Consensus Recommendations on the Prehospital Care of the Injured Athlete With a Suspected Catastrophic Cervical Spine Injury

INTRODUCTION

Sports participation is among the leading causes of catastrophic cervical spine injury (CSI) in the United States. Appropriate prehospital care for athletes with suspected CSIs should be available at all levels of sport. The goal of this project was to develop a set of best-practice recommendations appropriate for athletic trainers, emergency responders, sports medicine and emergency physicians, and others engaged in caring for athletes with suspected CSIs.

METHODS

A consensus-driven approach (RAND/UCLA method) in combination with a systematic review of the available literature was used to identify key research questions and develop conclusions and recommendations on the prehospital care of the spine-injured athlete. A diverse panel of experts, including members of the National Athletic Trainers' Association, the National Collegiate Athletic Association, and the Sports Institute at UW Medicine participated in 4 Delphi rounds and a 2-day nominal group technique meeting. The systematic review involved 2 independent reviewers and 4 rounds of blinded review.

RESULTS

The Delphi process identified 8 key questions to be answered by the systematic review. The systematic review comprised 1544 studies, 49 of which were included in the final full-text review. Using the results of the systematic review as a shared evidence base, the nominal group technique meeting created and refined conclusions and recommendations until consensus was achieved.

CONCLUSIONS

These conclusions and recommendations represent a pragmatic approach, balancing expert experiences and the available scientific evidence.

Ice-man Down: Using Simulation to Practice the Safe Extrication of Collapsed Hockey Players in a Confined Space

Sporting event emergencies are common among both spectators and players, with unique sets of challenges associated with patient extrication in unfamiliar and chaotic environments. It is critical for sports physicians and trainers to deliberately train and prepare for emergent situations with limited resources during athletic events. One of the most difficult, yet commonly encountered challenges is determining when and how to safely remove an injured player's helmet and sporting equipment, particularly if a spinal injury is highly suspected. We created a high-fidelity simulation case to practice the safe extrication of a hockey player who collapses on the bench in the player's box, a space-restricted environment. The patient is a 25-year-old male hockey player who becomes unresponsive after a syncopal episode in the player's box, and subsequently transferred to a medical center for further evaluation. Critical actions include extrication of the player at the scene, diagnosis of syncope, placement of the unconscious player on a backboard with cervical-spine precautions, removal of the player's faceguard, removing the player off the ice, checking the electrocardiogram and glucose level, and transferring the player to a controlled environment. The learning objectives were to identify, evaluate, and manage the reversible causes of syncope, and demonstrate appropriate techniques for the optimal removal of sports equipment. Learner assessment was based on participation in the scenario and debriefing learners after the simulation. Post-simulation debriefing revealed that participants highly appreciated practicing not-so-commonly encountered hockey-related emergencies. Athletic trainers and emergency providers were able to effectively practice their management of the unresponsive hockey player. The participants were also able to deliberately practice their teamwork and communications skills with their peers. Learning points include proper c-spine immobilization techniques in a tight space and indication for gear-removal in an unconscious patient. As hockey continues to gain popularity, this simulation case will prepare athletic trainers and emergency providers to better address the reversible causes for syncope in hockey players, as well as safely and effectively extricate injured players from space-limiting sporting environments.

Cervical spine trauma evaluation

Cervical spine trauma is a relatively rare but catastrophic event in sports. These critical situations depend on sports medicine personnel understanding every aspect of sideline care to ensure a safe and successful evaluation. This involves thorough preparation, vigilant observation of the sporting event to detect the possible mechanism of injury, and initiation of the appropriate action plan when a potentially catastrophic injury is suspected. Sideline management of cervical spine trauma requires the appropriate primary survey, with spine stabilization if necessary, secondary survey for concomitant injury, and, potentially, initiation of full spine stabilization with a spine board. In this chapter, our primary focus is discussion of the sideline evaluation of cervical spine trauma, and sideline practices designed to stabilize the athlete and minimize risk for further injury.

Cervical Spine Alignment in Helmeted Skiers and Snowboarders With Suspected Head and Neck Injuries: Comparison of Lateral C-spine Radiographs Before and After Helmet Removal and Implications for Ski Patrol Transport

OBJECTIVE

Current protocols for spine immobilization of the injured skier/snowboarder have not been scientifically validated. Observing changes in spine alignment during common rescue scenarios will help strengthen recommendations for rescue guidelines.

METHODS

Twenty-eight healthy volunteers (18 men, 10 women) age 47±17 (range 20-73) (mean ±SD with range) underwent a mock rescue in which candidate patrollers completing an Outdoor Emergency Care course performed spine immobilization and back boarding in 3 scenarios: 1) Ski helmet on, no c-collar; 2) helmet on, with c-collar; and 3) helmet removed, with c-collar. After each scenario, a lateral radiograph was taken of the cervical spine to observe for changes in alignment.

RESULTS

Compared with the control group (helmet on, no collar), we observed 9 degrees of increased overall (occiput-C7) cervical extension in the helmet on, with collar group (P < .001), and 17 degrees in the helmet off, with collar group (P < .001). There was increased extension at the occiput-C2 intersegment in the helmet on, with collar group (9 degrees, P < .001) and at both the occiput-C2 (9 degrees, P < .001) and C2-C7 (8 degrees, P < .001) intersegments in the helmet off, with collar group.

CONCLUSION

Ski helmet removal and c-collar application each leads to increased extension of the cervical spine. In the absence of other clinical factors, our recommendation is that helmets should be left in place and c-collars not routinely applied during ski patrol rescue.

Cervical spine motion during football equipment-removal protocols: a challenge to the all-or-nothing endeavor

CONTEXT

The National Athletic Trainers' Association position statement on acute management of the cervical spine-injured athlete recommended the all-or-nothing endeavor, which involves removing or not removing both helmet and shoulder pads, from equipment-laden American football and ice hockey athletes. However, in supporting research, investigators have not considered alternative protocols.

OBJECTIVE

To measure cervical spine movement (head relative to sternum) produced when certified athletic trainers (ATs) use the all-or-nothing endeavor and to compare these findings with the movement produced using an alternative pack-and-fill protocol, which involves packing the area under and around the cervical neck and head with rolled towels.

DESIGN

Crossover study.

SETTING

Movement analysis laboratory.

PATIENTS OR OTHER PARTICIPANTS

Eight male collegiate football players (age = 21.4 ± 1.4 years; height = 1.87 ± 0.02 m; mass = 103.6 ± 12.5 kg).

INTERVENTION(S)

Four ATs removed equipment under 4 conditions: removal of helmet only followed by placing the head on the ground (H), removal of the helmet only followed by pack-and-fill (HP), removal of the helmet and shoulder pads followed by placing the head on the ground (HS), and removal of the helmet and shoulder pads followed by pack-and-fill (HSP). Motion capture was used to track the movement of the head with respect to the sternum during equipment removal.

MAIN OUTCOME MEASURE(S)

We measured head movement relative to sternum movement (translations and rotations). We used 4 × 4 analyses of variance with repeated measures to compare discrete motion variables (changes in position and total excursions) among protocols and ATs.

RESULTS

Protocol HP resulted in a 0.1 ± 0.6 cm rise in head position compared with a 1.4 ± 0.3 cm drop with protocol HS (P < .001). Protocol HP produced 4.9° less total angular excursion (P < .001) and 2.1 cm less total vertical excursion (P < .001) than protocol HS.

CONCLUSIONS

The pack-and-fill protocol was more effective than shoulder pad removal in minimizing cervical spine movement throughout the equipment-removal process. This study provides evidence for including the pack-and-fill protocol in future treatment recommendations when helmet removal is necessary for on-field care.

The effect of laryngoscope handle size on possible endotracheal intubation success in university football, ice hockey, and soccer players

OBJECTIVE

To assess the effectiveness of a standard long-handle laryngoscope and a short-handle laryngoscope on ease of possible intubation in football, ice hockey, and soccer players.

DESIGN

Prospective crossover study.

SETTING

University Sport Medicine Clinic.

PARTICIPANTS

Sixty-two university varsity football (62 males), 45 ice hockey (26 males and 19 females), and 39 soccer players (20 males, 19 females).

INTERVENTIONS

Athletes were assessed for different airway and physical characteristics. Three different physicians then assessed the use of laryngoscopes of different handle sizes in supine athletes who were wearing protective equipment while in-line cervical spine immobilization was maintained.

MAIN OUTCOME MEASURES

The ease of passage of a laryngoscope blade into the posterior oropharynx of a supine athlete was assessed using both a standard long-handle and a short-handle laryngoscope.

RESULTS

Use of a short-handle laryngoscope was easier for all physicians in all sports as compared with a standard-sized laryngoscope. Passage of a laryngoscope blade into the posterior oropharynx of a supine athlete was easiest in soccer players and most difficult in football and ice hockey players for both sizes of laryngoscope. Interference from chest or shoulder pads was a common cause for difficulty in passing the laryngoscope blade into the posterior oropharynx for football and ice hockey players.

CONCLUSIONS

In the rare instances that an endotracheal intubation is to be attempted on an unconscious athlete, a short-handle laryngoscope may provide the best chance for successful intubation.

The assessment of airway maneuvers and interventions in university Canadian football, ice hockey, and soccer players

CONTEXT

Managing an airway in an unconscious athlete is a lifesaving skill that may be made more difficult by the recent changes in protective equipment. Different airway maneuvers and techniques may be required to help ventilate an unconscious athlete who is wearing full protective equipment.

OBJECTIVE

To assess the effectiveness of different airway maneuvers with football, ice hockey, and soccer players wearing full protective equipment.

DESIGN

Crossover study.

SETTING

University sports medicine clinic.

PATIENTS OR OTHER PARTICIPANTS

A total of 146 university varsity athletes, consisting of 62 football, 45 ice hockey, and 39 soccer players.

INTERVENTION(S)

Athletes were assessed for different airway and physical characteristics. Three investigators then evaluated the effectiveness of different bag-valve-mask (BVM) ventilation techniques in supine athletes who were wearing protective equipment while inline cervical spine immobilization was maintained.

MAIN OUTCOME MEASURE(S)

The effectiveness of 1-person BVM ventilation (1-BVM), 2-person BVM ventilation (2-BVM), and inline immobilization and ventilation (IIV) was judged by each investigator for each athlete using a 4-point rating scale.

RESULTS

All forms of ventilation were least difficult in soccer players and most difficult in football players. When compared with 1-BVM, both 2-BVM and IIV were deemed more effective by all investigators for all athletes. Interference from the helmet and stabilizer were common reasons for difficult ventilation in football and ice hockey players.

CONCLUSIONS

Sports medicine professionals should practice and be comfortable with different ventilation techniques for athletes wearing full equipment. The use of a new ventilation technique, termed inline immobilization and ventilation, may be beneficial, especially when the number of responders is limited.

Lacrosse equipment and cervical spinal cord space during immobilization: preliminary analysis

CONTEXT

Removal of the lacrosse helmet to achieve airway access has been discouraged based only on research in which cervical alignment was examined. No researchers have examined the effect of lacrosse equipment on the cervical space available for the spinal cord (SAC).

OBJECTIVE

To determine the effect of lacrosse equipment on the cervical SAC and cervical-thoracic angle (CTA) in the immobilized athlete.

DESIGN

Observational study.

SETTING

Outpatient imaging center.

PATIENTS OR OTHER PARTICIPANTS

Ten volunteer lacrosse athletes (age = 20.7 +/- 1.87 years, height = 180.3 +/- 8.3 cm, mass = 91 +/- 12.8 kg) with no history of cervical spine injury or disease and no contraindications to magnetic resonance imaging (MRI).

INTERVENTION(S)

The lacrosse players were positioned supine on a spine board for all test conditions. An MRI scan was completed for each condition.

MAIN OUTCOME MEASURE(S)

The independent variables were condition (no equipment, shoulder pads only [SP], and full gear that included helmet and shoulder pads [FG]), and cervical spine level (C3-C7). The dependent variables were the SAC and CTA. The MRI scans were evaluated midsagittally. The average of 3 measures was used as the criterion variable. The SAC data were analyzed using a 3 x 5 analysis of variance (ANOVA) with repeated measures. The CTA data were analyzed with a 1-way repeated-measures ANOVA.

RESULTS

We found no equipment x level interaction effect (F(3.7,72) = 1.34, P = .279) or equipment main effect (F(2,18) = 1.20, P = .325) for the SAC (no equipment = 5.04 +/- 1.44 mm, SP = 4.69 +/- 1.36 mm, FG = 4.62 +/- 1.38 mm). The CTA was greater (ie, more extension; critical P = .0167) during the SP (32.64 degrees +/- 3.9 degrees) condition than during the no-equipment (25.34 degrees +/- 2.3 degrees ; t(9) = 7.67, P = .001) or FG (26.81 degrees +/- 5.1 degrees; t(9) = 4.80, P = .001) condition.

CONCLUSIONS

Immobilizing healthy lacrosse athletes with shoulder pads and no helmets affected cervical spine alignment but did not affect SAC. Further research is needed to determine and identify appropriate care of the lacrosse athlete with a spine injury.

Prevalence and characteristics of general and football-specific emergency medical service activations by high school and collegiate certified athletic trainers: a national study

OBJECTIVE

To describe frequency and characteristics of emergency medical services (EMS) activations by certified athletic trainers (ATs) and effects of pre-season planning meetings on interactions between ATs and EMS both generally and specifically during football head/neck emergencies.

DESIGN

Retrospective cross-sectional survey.

SETTING

2009 Web-based survey.

PARTICIPANTS

Athletic trainers (n = 1884; participation rate, 28%) in high school and collegiate settings.

INDEPENDENT VARIABLES

Athletic trainer work setting, AT demographics, history of pre-season planning meetings.

MAIN OUTCOME MEASURES

Proportions and 95% confidence intervals (CIs) estimated the prevalence of EMS activation, planning meetings, and characteristics of AT-EMS interactions (eg, episodes of AT-perceived inappropriate care and on-field disagreements). Chi square tests tested differences (P < 0.05) in proportions. Associations (odds ratio = OR and 95% CI) between work setting, demographics, preseason meetings and fall 2008 1) episodes of AT-perceived inappropriate care, and 2) on-field disagreements were assessed using multivariate logistic regression.

RESULTS

High school ATs activated EMS more frequently than collegiate ATs (eg, fall 2008 EMS activation for football injury, 59.9% vs 27.5%; P < 0.01) and reported fewer pre-season planning meetings (eg, met with EMS to practice, 38.1% vs 55.8%; P < 0.01). During the Fall 2008 football season, high school ATs perceived more episodes of inappropriate care (10.4% vs 3.9%; P < 0.01) and on-field disagreements (5.4 vs 2.2%; P < 0.01) than collegiate ATs. High school work setting was independently associated with episodes of AT-perceived inappropriate care (adjusted OR = 2.76; 95% CI, 1.65-4.62) and on-field disagreements (adjusted OR = 2.33; 95% CI, 1.17-4.64).

CONCLUSIONS

Athletic trainer-EMS interactions are common and sometimes involve AT-perceived episodes of inappropriate care and on-field disagreements between emergency care providers.

National athletic trainers' association position statement: acute management of the cervical spine-injured athlete

OBJECTIVE

To provide certified athletic trainers, team physicians, emergency responders, and other health care professionals with recommendations on how to best manage a catastrophic cervical spine injury in the athlete.

BACKGROUND

The relative incidence of catastrophic cervical spine injury in sports is low compared with other injuries. However, cervical spine injuries necessitate delicate and precise management, often involving the combined efforts of a variety of health care providers. The outcome of a catastrophic cervical spine injury depends on the efficiency of this management process and the timeliness of transfer to a controlled environment for diagnosis and treatment.

RECOMMENDATIONS

Recommendations are based on current evidence pertaining to prevention strategies to reduce the incidence of cervical spine injuries in sport; emergency planning and preparation to increase management efficiency; maintaining or creating neutral alignment in the cervical spine; accessing and maintaining the airway; stabilizing and transferring the athlete with a suspected cervical spine injury; managing the athlete participating in an equipment-laden sport, such as football, hockey, or lacrosse; and considerations in the emergency department.

Summary of the National Athletic Trainers' Association position statement on the acute management of the cervical spine-injured athlete

The incidence of catastrophic cervical spine injury in sports is low compared with other injuries. However, cervical spine injuries necessitate delicate and precise management, often involving the combined efforts of a variety of health care providers. The outcome of a catastrophic cervical spine injury depends on the efficiency of this management process and timeliness of transfer to a controlled environment for diagnosis and treatment. The objective of the National Athletic Trainers' Association (NATA) position statement on the acute care of the cervical spine-injured athlete is to provide the certified athletic trainer, team physician, emergency responder, and other health care professionals with recommendations on how to best manage a catastrophic cervical spine injury in an athlete. Recommendations are based on current evidence pertaining to prevention strategies to reduce the incidence of cervical spine injuries in sport; emergency planning and preparation to increase management efficiency; maintaining or creating neutral alignment in the cervical spine; accessing and maintaining the airway; stabilizing and transferring the athlete with a suspected cervical spine injury; managing the athlete participating in an equipment-laden sport such as football, hockey, or lacrosse; and imaging considerations in the emergency department.

Helmet and shoulder pad removal in football players with unstable cervical spine injuries

Football, one of the country's most popular team sports, is associated with the largest overall number of sports-related, catastrophic, cervical spine injuries in the United States (Mueller, 2007). Patient handling can be hindered by the protective sports equipment worn by the athlete. Improper stabilization of these patients can exacerbate neurologic injury. Because of the lack of consensus on the best method for equipment removal, a study was performed comparing three techniques: full body levitation, upper torso tilt, and log roll. These techniques were performed on an intact and lesioned cervical spine cadaveric model simulating conditions in the emergency department. The levitation technique was found to produce motion in the anterior and right lateral directions. The tilt technique resulted in motions in the posterior left lateral directions, and the log roll technique generated motions in the right lateral direction and had the largest amount of increased instability when comparing the intact and lesioned specimen. These findings suggest that each method of equipment removal displays unique weaknesses that the practitioner should take into account, possibly on a patient-by-patient basis.

Effect of ice hockey helmet fit on cervical spine motion during an emergency log roll procedure

OBJECTIVE

To investigate cervical spine motion during a log roll technique in ice hockey players under different helmet fit conditions.

DESIGN

Prospective counterbalanced design.

SETTING

University research laboratory.

PARTICIPANTS

Eighteen club ice hockey players were recruited to participate in this study.

ASSESSMENT OF RISK FACTORS

A standard emergency log roll was performed 3 times under each of 3 different helmet fit conditions: properly fit, improperly (competition) fit, and helmet-removed.

MAIN OUTCOME MEASUREMENTS

Frontal, sagittal, and transverse plane cervical spine motion were used as outcome measures.

RESULTS

Significantly less sagittal and transverse plane motion occurred during the helmet-removed condition. No differences in frontal plane motion among the 3 conditions were observed.

CONCLUSIONS

Presence of helmet (whether properly fit or not) resulted in increased of sagittal and transverse plane movement. This suggests that when an ice hockey helmet is stabilized, the head within it is not. We recommend the helmet and face shield be removed before performing an emergency prone log roll.

Cervical spine alignment in the youth football athlete: recommendations for emergency transportation

BACKGROUND

Substantial literature exists regarding recommendations for the on-field treatment and subsequent transportation of adult collision-sport athletes with a suspected injury to the cervical spine.

PURPOSE

To develop an evidence-based recommendation for transportation of suspected spine-injured youth football players.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Three lateral radiographs were obtained in supine to include the occiput to the cervical thoracic junction from 31 youth football players (8-14 years). Each child was imaged while wearing helmet and shoulder pads, without equipment, and with shoulder pads only. Two independent observers measured cervical spine angulation as Cobb angle from C1 to C7 and subaxial angulation from C2 to C7. We calculated intraclass correlation coefficients for intraobserver reliability analysis and compared Cobb and C2 to C7 angles between equipment conditions with t tests.

RESULTS

Interobserver analysis showed excellent reliability among measurements. Cobb and subaxial angle measurements indicated significantly greater cervical lordosis while children wore shoulder pads only, compared with the other 2 conditions (no equipment and helmet and shoulder pads) (P <or= .001). There was no statistically significant difference in either Cobb or C2-C7 angles between fully equipped (helmet + shoulder pads) and no-equipment conditions (P >.05).

CONCLUSIONS

Equipment removal for the youth football athlete with suspected cervical spine injury should abide by the "all or none" policy that has been widely accepted for adult athletes. Helmet and shoulder pads should be left in place during emergency transport of the suspected spine-injured youth athlete.

CLINICAL RELEVANCE

Despite differences in head to torso size ratios between youth and adult players, helmet removal alone is not recommended for either during emergency transportation.

Field-side and prehospital management of the spine-injured athlete

Rapid on-field diagnosis and early stabilization can help to optimize the outcomes of spinal injury, which can have devastating consequences. Several basic principles will guide the rescuer through this process. Preinjury planning should include appointing a team leader, assessing the athletes' equipment, acquiring appropriate equipment to facilitate stabilization, and establishing lines of communication to emergency medical services (EMS). When an athlete is down, the team leader should proceed to quickly assess airway, breathing, circulation, level of consciousness, and activation of EMS. This should be followed by stabilization of the head and neck, a coordinated log roll, and ultimately complete spinal immobilization for transport. Specific techniques for stabilizing the cervical spine, removing the facemask, log rolling the athlete, and lifting the athlete, will improve outcome. The helmet and shoulder pads should remain in place during transport unless specific indications require their removal, in which case a specific protocol should be strictly followed.

Catastrophic cervical spine injuries in the collision sport athlete, part 2: principles of emergency care

Catastrophic cervical spine injuries can lead to devastating consequences for the collision athlete. Improved understanding of these injuries can lead to identification of risk factors, early diagnosis, and effective on-field management. This article is the second in a 2-part series. The first part, published in the June 2004 issue, reviewed the current concepts regarding the epidemiology, functional anatomy, and diagnostic considerations relevant to cervical spine trauma in collision sports. In this article, the principles of on-field emergency care of the spine-injured athlete are reviewed. The authors discuss the need for effective pre-event planning, on-field evaluation and management of cervical spine injuries, and the transition of care from the playing field to the emergency room. The protocol for equipment removal, when necessary, is also reviewed. An organized, rapid approach to the management of cervical spine-injured collision athletes can help to optimize the outcomes of these catastrophic injuries.

Management of the helmeted athlete with suspected cervical spine injury

Improper handling of an unstable neck injury may result in iatrogenic neurologic injury. A review of published evidence on cervical management in the helmeted athlete with a suspected spinal injury is discussed. The approach to the neck-injured helmeted athlete and the algorithms for on-field and emergency department evaluations are reviewed. The characteristics of the fitted football helmet allow safe access for airway management, and helmets and shoulder pads should not be initially removed unless absolutely necessary. Prehospital and emergency personnel should be trained in the indications for removal and in proper helmet, shoulder pad, and facemask removal techniques. If required, both helmet and shoulder pads should be removed simultaneously. Radiographs with equipment in place may be inadequate, and the value of computed tomography and magnetic resonance imaging in these helmeted patients has been studied. If adequate films cannot be obtained with equipment in place, helmet and shoulder pads may need to be removed before radiographic clearance. A plan should be formulated to prepare for such unexpected clinical scenarios as cervical spine injuries, and skills should be practiced. Airway and cervical spine management in these helmeted athletes is an area of ongoing research.

MRI is nondiagnostic in cervical spine imaging of the helmeted football player with shoulder pads

BACKGROUND

It is currently recommended that helmet and shoulder pads remain in place during the initial clinical and radiographic evaluation of the helmeted athlete with a potential cervical spine injury. The objective of this prospectively designed, single-subject study was to determine whether MRI may play a role in the initial evaluation and management of the helmeted football player with a cervical spine injury.

METHODS

One male athlete was fitted using equipment (football helmet [Riddell], shoulder pads [Douglas]) worn during the collegiate season at Lehigh University. Standard MRI using a routine clinical 0.7 T high field open MRI scanner (GE Signa System, Milwaukee, WI) was employed for the evaluation using standard clinical parameters (sagittal T1, fast spin echo [FSE] T2, STIR, and axial FSE T2 series). A single board-certified, fellowship-trained neuroradiologist reviewed all series. Studies were evaluated for image clarity and diagnostic capability in this clinical setting.

RESULTS

All standard MRI series were of extremely limited quality, even using sequences and slice selection designed to minimize artifact associated with metals (FSE T2-weighted series). When all MRI series were reviewed as a whole, sufficient evidence was not available to allow clinical decision making.

CONCLUSIONS

The amount and type of metal within the standard football helmet and shoulder pads result in sufficient field inhomogeneity and SKEW artifact to preclude adequate evaluation of the cervical structures, rendering MRI evaluation in this setting not clinically useful. This study shows that current MRI techniques play no role in the clearance of the cervical spine (with currently available brands of helmet and shoulder pads in place) without prior equipment removal or manipulation.