Prevention

1. Individuals responsible for the emergency care of athletes should be familiar with sport-specific causes of catastrophic cervical spine injury and understand the acute physiologic response of the spinal cord to injury. Evidence Category: C

2. Those responsible for the emergency care of athletes should be familiar with safety rules enacted for the prevention of cervical spine injuries and should take actions to ensure that such rules are followed. Evidence Category: C

3. Persons responsible for the emergency care of athletes should be familiar with pertinent protective equipment manufacturers' recommendations and specifications relative to fit and maintenance. Maintaining the integrity of protective equipment helps to minimize the risk of injury. Evidence Category: C

4. Individuals responsible for the emergency care of athletes should educate coaches and athletes about the mechanisms of catastrophic spine injuries, the dangers of head-down contact, and pertinent safety rules enacted for the prevention of cervical spine injuries.30 Evidence Category: C

Planning and Rehearsal

• 5. Those responsible for the care of athletes should be familiar with the National Athletic Trainers' Association position statement on emergency planning in athletics.31 Evidence Category: C

• 6. Planning in advance of events carrying a risk of cervical spine injury should include preparation of a venue-specific emergency action plan. Components of the emergency action plan include appointing a team leader and acquiring appropriate equipment to facilitate stabilization, immobilization, and removal of treatment barriers (ie, sporting equipment). The emergency action plan should also incorporate communication with local emergency medical services and identification of the most appropriate emergency care facility to receive the injured athlete. These groups should be involved in creating the emergency action plan.31 Evidence Category: C

• 7. All individuals responsible for the care of athletes should be involved in regular (at least annual) rehearsals of the emergency action plan, as well as training and practice in the special skills inherent to managing a cervical spine injury. Skills requiring training and regular practice may include manual head and neck stabilization techniques, the multiple methods of transferring injured athletes (eg, log-rolling, lift-and-slide techniques), equipment management (eg, gaining access to the airway or chest), and immobilization methods (eg, long spine board, cervical collar application).31 Evidence Category: C

Assessment

• 8. During initial assessment, the presence of any of the following findings, alone or in combination, heightens the suspicion for a potentially catastrophic cervical spine injury and requires the initiation of the spine injury management protocol: unconsciousness or altered level of consciousness, bilateral neurologic findings or complaints, significant midline spine pain with or without palpation, and obvious spinal column deformity.32–37 Evidence Category: A

Stabilization

• 9. When a potential spine injury is suspected, rescuers should ensure that the cervical spine is in a neutral position and should immediately apply manual cervical spine stabilization. This will minimize motion during the management of the injury.38–42 Evidence Category: B

• 10. Rescuers should not apply traction to the cervical spine, as this may cause distraction at the site of injury. Traction in a cervical spine with ligamentous injury can result in excessive distraction and subluxation that can further compromise the spinal cord.39–41,43–46 Evidence Category: B

• 11. If the spine is not in a neutral position, rescuers should realign the cervical spine to minimize secondary injury to the spinal cord and to allow for optimal airway management. However, the presence or development of any of the following, alone or in combination, represents a contraindication for moving the cervical spine to neutral position40,41: the movement causes increased pain, neurologic symptoms, muscle spasm, or airway compromise; it is physically difficult to reposition the spine; resistance is encountered during the attempt at realignment; or the patient expresses apprehension.32,47–54 Evidence Category: B

Airway

• 12. Rescuers should immediately attempt to expose the airway, removing any existing barriers (eg, protective face masks). Evidence Category: C

• 13. If rescue breathing becomes necessary, the individual with the most training and experience should establish an airway and commence rescue breathing using the safest technique.55–57 Evidence Category: B

• 14. During airway management, rescuers should cause as little motion as possible.39,58 Evidence Category: C

• 15. The jaw-thrust maneuver is recommended over the head-tilt technique, which produces unnecessary motion at the head and in the cervical spine. Advanced airway management techniques (eg, laryngoscope, endotracheal tube) are recommended in the presence of appropriately trained and certified rescuers; these methods have been shown to cause less motion and, therefore, are less likely to worsen neurologic status.55,59–65 Evidence Category: B

Transfer and Immobilization

• 16. Manual stabilization of the head should be converted to immobilization using a combination of external devices (eg, cervical collars, foam blocks), and stabilization of the cervical spine should be continued until a destabilizing injury has been ruled out using appropriate diagnostic testing (imaging). Whenever possible, manual stabilization should be resumed65,66 after the application of external devices.40,67–70 Evidence Category: B

• 17. Individuals responsible for the emergency care of athletes with cervical spine injuries should be prepared to immobilize these athletes with a long spine board or other full-body immobilization device.57,67,69,71 Evidence Category: B

• 18. Although the traditional spine board represents the most common device used for full-body immobilization, devices such as the full-body vacuum splint are more comfortable for athletes, reduce superficial irritation and sores over bony prominences, and may be used in appropriate situations.57,69,71 Evidence Category: B

• 19. For the supine athlete, a lift-and-slide technique (eg, 6–plus-person lift, straddle lift and slide) of transferring the athlete to an immobilization device has been reported to produce less motion at the head and in the cervical spine than the log-roll technique and should be used in appropriate situations.72–75 Evidence Category: B

• 20. For the prone athlete, all potential rescuers must be familiar with the log-roll method of transferring to an immobilization device. Evidence Category: C

Equipment-Laden Athletes

• 21. Because removal of athletic equipment such as helmet and shoulder pads may cause unwanted movement of the cervical spine, removal of helmet and shoulder pads should be deferred until the athlete has been transported to an emergency medical facility, except under specifically appropriate circumstances. The first exception is if the helmet is not properly fitted to prevent movement of the head independent of the helmet. This is imperative, because when the helmet is left in place, it is responsible for securing the head, and, as such, immobilization of the helmet necessarily results in immobilization of the head. The second exception is if the equipment prevents neutral alignment of the cervical spine or airway access. This exception is further addressed in the following recommendations.76,77 Evidence Category: B

• 22. Independent removal of the helmet or shoulder pads in American football and ice hockey is not recommended, because removing one and not the other compromises spinal alignment. Removal of the helmet and shoulder pads in these sports should be considered an all-or-nothing endeavor.54,76–78 Evidence Category: B

• 23. No general recommendation regarding removal of equipment can be made for other sports that require a helmet (with or without shoulder pads) because of considerable variation in the capacity of that equipment to maintain a neutral cervical spine or immobilize the head. The primary acute treatment goals in these sports are to ensure that the cervical spine is properly aligned and that the head and neck are immobilized. Upon observation, if the equipment being worn does not permit the cervical spine to rest in neutral or does not adequately immobilize the head, then removal of one or more pieces of equipment in a safe manner is advisable to achieve neutral alignment or adequate stabilization (or both).79,80 Evidence Category: C

• 24. If the athletic helmet is dislodged during the injury or removed (by either the medical team or the athlete) or if the shoulder pads cannot be easily removed, care must be taken to place padding beneath the head to maintain neutral cervical spine alignment. Evidence Category: C

• 25. A rigid cervical immobilization collar should be placed on the athlete before transfer to a spine board. In equipment-laden sports, this may be difficult or impossible, although a cervical vacuum immobilization device has been shown to limit cervical spine range of motion in the fully equipped football player.81 Evidence Category: C

• 26. Individuals responsible for the emergency care of athletes in equipment-laden sports should be familiar with their team's equipment (external defibrillators) and the tools and techniques required for removal of barriers to treatment (eg, airway management). Evidence Category: C

• 27. Face masks that interfere with the ability to access the airway should be completely removed from the helmet. Evidence Category: C

• 28. Face-mask removal should be initiated once the decision to immobilize and transport has been made. Evidence Category: C

• 29. Rescuers should be aware of, and well trained in, established face-mask removal techniques. The face mask should be removed with the tool and technique that perform the task quickly and with minimal movement and difficulty. A powered (cordless) screwdriver is generally faster, produces less head movement, and is easier to use than cutting tools; it should be the first tool used in attempting to remove a face mask attached with loop straps that are secured with screws. Because it may be impossible to remove the screws, a backup cutting tool, specifically matched to the sport equipment used, should be available. This is referred to as a combined-tool approach.82–87 Evidence Category: B

• 30. To increase the likelihood that all 4 screws can be successfully removed from a football helmet face mask using a cordless screwdriver, athletic trainers, coaches, and equipment managers should ensure that corrosion-resistant hardware is used in the helmet, that helmets are regularly maintained throughout a season, and that helmets undergo regular reconditioning and recertification.82,85 Evidence Category: B

• 31. If the face mask cannot be removed in a reasonable amount of time, then the helmet should be removed from the athlete in the safest manner possible. Helmet style will dictate the technique necessary to safely remove the helmet. A neutral cervical spine position should be preserved during and after this process by removing additional pieces of equipment (eg, shoulder pads) or by placing an object underneath the head (eg, towel, padding) to maintain neutral alignment. Evidence Category: C

Emergency Department Management

• 32. If possible, the team physician or certified athletic trainer should accompany the athlete to the hospital. This provides continuity of care, allows for accurate delivery of clinical information to the emergency department staff, and may allow the sports medicine professional to assist emergency department personnel during equipment removal. Evidence Category: C

• 33. Remaining protective equipment should be removed by appropriately trained professionals in the emergency department environment. Emergency department personnel should make an effort to become familiar with proper athletic equipment removal, seeking education from sports medicine professionals regarding appropriate methods to minimize motion.76,77,88 Evidence Category: C

• 34. Emergency departments should consider implementing guidelines for the use of computed tomography (CT) rather than plain radiographs as the primary diagnostic test for a suspected cervical spine injury in a helmeted athlete. Obtaining plain radiographs adequate for clearance with sport equipment in place is a procedure unsupported by research. A CT may be more sensitive than plain radiographs and is associated with lower rates of missed primary and secondary injuries.89–94 Evidence Category: B

• 35. Emergency department personnel should be aware that magnetic resonance imaging (MRI) is clinically limited for helmeted athletes and may not be suitable as an initial diagnostic tool.95 Evidence Category: B

The Role of Hypothermia Treatment and High-Dose Corticosteroids in the Acute Management of an Athlete With Cervical Spine Injury

• 36. Although the role of hypothermia in the treatment of myocardial infarction and brain injury has been investigated and has shown potential to reduce morbidity, evidence is currently insufficient to justify its use in the acute management of the spine-injured athlete.96,97 Evidence Category: C

• 37. High-dose methylprednisolone for acute spinal cord injury has been used in the initial management of acute spinal cord injury; however, this practice has recently been questioned. One evidence-based analysis of the published literature on methylprednisolone revealed serious flaws in data analysis and conclusions, with no clear support for the use of methylprednisolone in patients with acute spinal cord injury.98 Until additional reliable data are available, the use of high-dose methylprednisolone in this instance remains controversial. When possible, each patient or patient's family should be informed of the risks and benefits of the medication before use. Evidence Category: B

Transfer and Immobilization (Appendix A: Figures 1–5)

• 1. A variety of techniques exist to transfer and immobilize the injured athlete. Rescuers should use the technique that they have reviewed and rehearsed and that produces the least amount of spinal movement.

• 2. To facilitate transfer, the patient's body should be aligned as carefully as possible. Arms should be carefully moved to the sides and legs straightened and positioned together.

• 3. If the athlete is prone, rescuers should inspect the spine before moving him or her.

• 4. If it is necessary to reposition the patient once on the spine board, he or she should not be moved in a perpendicular direction, to avoid shearing and the possibility of spinal column movement. Instead, the patient should be moved in either a cephalad or caudad direction, as deemed necessary by the rescuer controlling the head and neck.

• 5. Selection of appropriate transfer and spine boarding techniques

•  a. The log-roll technique requires 4 to 5 rescuers: 1 to control the head and cervical spine, 2 to 3 to roll the patient on command, and 1 to position the spine board.

•  b. Lift-and-slide technique

•   i. The 6–plus-person lift involves lifting the athlete to allow for spine board placement. This technique is effective in minimizing structural interference that could result in unwanted spinal column movements.

•   ii. The straddle lift-and-slide technique requires only 4 rescuers to lift the body.

•  c. For the supine athlete, the log-roll or lift-and-slide techniques may be used; for a prone athlete, the log-roll technique is the only option. Therefore, all rescuers must be familiar with the log roll.

• 6. Equipment recommendations for spine boarding

•  a. A scoop stretcher with telescoping arms that is hinged on both ends may be used to “scoop” the athlete without having to perform the log roll or lift and slide; however, the device may only be used in this manner if the athlete is in the supine position.

•  b. Vacuum immobilization creates a custom form-fit, full-body splint and has been found to be more comfortable for patients than a standard spine board.57,71 This option may be used on either a supine or a prone athlete, but it may be better suited for the lift-and-slide technique because of its semirigid structure. The large size, however, may make it difficult to slide between the rescuers on either side.

•  c. A short-board system may be useful in immobilizing seated athletes; those with a flexed trunk or awkward positioning; and those affected by equipment barriers, such as the gymnastics or pole-vault pit.

• 7. Head immobilization

•  a. The head should always be the last part of the body secured to the spine board.

•  b. A variety of head-immobilization options exist, including commercial head-immobilization devices, contoured helmet blocks, foam blocks, and towel rolls. Sand bags are not recommended as head-immobilization devices, as their weight is a liability during transfer.

•  c. Once the selected head-immobilization device is placed to stabilize the head, tape or hook-and-loop straps should be used to secure the head to the spine board using 2 separate points of contact, the chin and the forehead,78 to prevent as much head and neck motion as possible.

• 8. A spine board kit should contain all necessary packaging supplies: head-immobilization device, cervical collar, face-mask–removal tools, straps to secure the athlete to the board, wrist straps to secure the athlete's hands together, tape, and various sizes of padding or toweling.

• 9. Rescuers should select the strapping technique with which they are most comfortable and skilled.

• 10. When securing the athlete to the spine board, the arms should be kept free to facilitate a variety of diagnostic and treatment techniques.

• 11. Once the torso is secured to the spine board, the hands may be secured together on top of the body using hook-and-loop wrist straps or tape.

• 12. The athlete should be restrained and secured sufficiently to the spine board that the board may be turned without creating spinal movement, in case, for example, the athlete vomits.

• 13. Some athletes with cervical spine injuries may have concurrent closed head injuries. Therefore, rescuers may encounter combative athletes who resist immobilization. The rescuers should attempt to calm the patient and minimize movement as much as possible based upon the individual circumstances.

• 14. The ambulance should be positioned as close to the scene as possible to minimize transfer on a stretcher over surfaces that may cause body movement.

Equipment-Laden Athletes (Appendix B: Figures 6–9)

• 15. Face-mask removal

•  a. Removing the loop straps from face masks can be a difficult skill and requires extensive practice.

•  b. For a football helmet face mask with 4 attachment locations, the 2 side straps should be removed first, followed by the top straps. This prevents the face mask from rotating down onto the athlete's face or throat during the removal attempt.

•  c. Placing pressure on the underside of the loop strap with the thumb of the other hand while unscrewing can assist in separating the screw from the T-nut.

•  d. If, when attempting to remove the screws from the helmet, 1 or more screws cannot be removed, it is important to continue with the next screw until all screws that can be unscrewed are successfully removed.

•  e. If a backup cutting tool is required, ensure that the tool chosen will successfully cut the loop straps currently being used in the helmets worn by the football team or teams being covered. Not all face-mask removal tools will remove all helmet–loop strap combinations.86

•  f. A screwdriver may not suffice as a backup tool for loop straps secured with a quick-release mechanism rather than a traditional screw and T-nut attachment system. Therefore, an appropriate backup tool should be available to cut away the loop strap should the quick-release system fail.

• 16. Because individual circumstances may dictate removal of an athletic helmet or shoulder pads, athletic trainers and emergency responders should be trained in helmet and shoulder-pad removal. This skill should be rehearsed on a regular basis with the specific equipment used by that team, organization, or facility. Emergency department personnel should also be trained in athletic helmet and shoulder-pad removal.

Prevention

Pathomechanics of Catastrophic Cervical Spine Injury

The highest number of catastrophic cervical spine injuries in the United States occurs in the sport of American football,29,99 and the most common injury mechanism occurs during tackling when the top of the head is used as the point of contact.5,29,30 This mechanism is referred to as an axial load, which can occur in any sport. During axial loading, compressive forces create a buckling effect in the cervical spine.100 This buckling produces large angulations within the cervical spine as a means of releasing the additional strain energy produced by the vertical loading, and this buckling is the causative factor of injury100–102 (Figure 10). This unique buckling effect of the cervical vertebrae, partially explained through the work of Penning103 and Amevo et al,104 is linked to the location of a vertebra's instantaneous center of rotation (ICR). The center of rotation for a particular vertebra is located near the superior aspect of the inferiorly adjacent vertebral body. As the lines of force are transmitted down the cervical column, the vertebra experiences flexion or extension, depending on the location of the force vector relative to the ICR. Hence, if the cervical column is moving into flexion, but the relative orientation of one vertebra to the other causes the force vector to pass behind the ICR, then that vertebra extends103,104 (Figure 11).

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The resultant injury (or injuries) depends on many factors but may be influenced by the velocity of the applied load,102,105 the point of contact on the head relative to the axis of the cervical spine,100,101 the resultant mode of buckling,100,101 and the type of surface with which the head came into contact (ie, solid versus padded).106 A critical factor contributing to the degree of neurologic injury is the extent to which the injury involves the spinal cord. During axial compression or extreme ranges of motion in the cervical spine, the spinal canal experiences transient geometric changes in diameter and height, which may eliminate the space surrounding the spinal cord, potentially resulting in neural tissue damage.47,107 Even if the spinal cord survives insult during the initial injury, its integrity may still be threatened if the osseous and soft tissue structures were injured sufficiently to create instability in the cervical spine.27

Planning and Rehearsal

The effect of creating or rehearsing an emergency plan, or specific skills within an emergency plan, on managing a catastrophic cervical spine injury is not well documented. Previous recommendations to incorporate planning and rehearsal of an emergency action plan appear to be based on expert consensus.31,119,120 Many individuals responsible for the care of athletes with catastrophic cervical spine injuries have already received skills training in on-field techniques as a result of requirements or educational competencies included in obtaining a degree, certification, or license to practice (eg, certified athletic trainer, emergency medical technician, physician). Additionally, many authors investigating or comparing spine-injury management skills require participants to be thoroughly trained and familiar with the procedures before data are collected and analyzed.72,75,86,121

One group73 analyzed the effect of additional training on the performance of transfer skills to an immobilization device and found no differences in proficiency between trained and untrained participants. In contrast, researchers in related fields have reported the beneficial effects of formal education122 and training123 on specific medical skills.

Although the recommendation to create and rehearse an emergency action plan and the skills contained within it is logical from the medical and legal perspectives, the beneficial effects of the rehearsal of the emergency plan or its skills are not established in the literature. No minimum quantity or frequency of rehearsal sessions or type of training can be endorsed.

Assessment

During the initial assessment of an injured athlete suspected of having a potentially catastrophic cervical spine injury, the presence of any or all of the following 4 clinical indicators warrants the activation of the spine-injury management protocol: unconsciousness or altered level of consciousness, bilateral neurologic findings or complaints, significant cervical spine pain with or without palpation, and obvious spinal column deformity. In the presence of any of these findings, the use of spinal injury precautions in the athletic setting have been recommended.33,39,58,119 However, these recommendations are largely based on evidence from research in prehospital and emergency medicine settings rather than athletic settings.

Results from recent research in prehospital and emergency medicine studies have been used to develop and validate criteria for determining selective immobilization and spine clearance protocols in the prehospital setting.34–36,124,125 The most common criteria leading to immobilization in the prehospital setting include unconsciousness, altered mental status, evidence of intoxication, neurologic deficit, long-bone extremity fracture, or cervical, thoracic, or lumbar spine pain.34,35 Domeier et al35 reported that most spine-injured patients (87%) included in a large prospective study presented with more than 1 of the measured clinical findings. The Glasgow Coma Scale has also been identified as a predictor of possible cervical spine injury.36,126 Holly et al36 noted that patients with an initial Glasgow Coma Scale score of 8 or less were more likely to have sustained a cervical injury than those with a score higher than 8. Further, Demetriades et al126 identified an inverse relationship by which a lower Glasgow Coma Scale score correlates with a higher risk of cervical spine injury.

Holly et al36 and Ross et al127 have suggested a link among unconsciousness, mental status, and the possibility of cervical spine injury in trauma patients. Approximately 5% to 7% of patients presenting with unconsciousness and altered mental status had a spinal injury.36,127 In a prospective study of emergency medical services patient charts by Domeier et al,34 37% of spine-injured patients presented with altered mental status. Iida et al37 reported that one-third of all spine-injured patients studied also sustained moderate or severe head injuries. It is important to note, however, that these studies involved mechanisms of injury that included high-velocity impacts (eg, falls, motor vehicle accidents) and were not limited to athletic participation.

Bilateral neurologic findings or complaints, altered mental status, significant midline pain, or obvious spinal column deformity, alone or in any combination, are indicators of potential cervical spine injury and warrant the use of spinal precautions. These criteria are extracted from validated prehospital and emergency medicine spinal clearance protocols, but on a case-by-case basis, other individual or collective signs or symptoms may indicate the presence of a cervical spine injury.

Stabilization

Manual cervical immobilization should be implemented as soon as possible once a cervical spine injury is suspected. The head should be manually stabilized by grasping the mastoid processes bilaterally with the fingertips while cupping the occiput in the hands.46 The rescuer should position his or her hands so the thumbs are pointed toward the face of the injured athlete. This technique ensures that hand placement does not have to be changed with repositioning of the athlete, unless rolling the athlete from a prone to a supine position is required, in which case the rescuer's arms should be crossed before rolling. If the rescuer is alone, it may be appropriate to use the knees to maintain spine stabilization, thus freeing the rescuer's hands to assist with ventilation or to conduct further tests.

Airway

For appropriate management of the spine-injured athlete, the airway should be easily accessible. If the athlete is wearing a face guard that impedes access to the airway, removal of the barrier or insertion of an airway management device is necessary; evidence-based strategies are described in the next section. The airway should be kept open and clear of any obstructions. Potential instability in the cervical spine due to an injury necessitates careful airway management procedures should rescue breathing or introduction of an artificial airway be necessary. In the absence of advanced equipment or training, the airway must be opened using basic techniques that provide cervical spine protection. The jaw-thrust maneuver is recommended over the head-tilt technique, which produces unnecessary motion in the cervical spine. However, the jaw-thrust maneuver may create more motion at the site of injury in the cervical spine than advanced airway maneuvers (ie, esophageal tracheal combitube, laryngoscope endotracheal tube, or laryngeal mask airway).55,63,64 If an airway is compromised, airway management is the treatment priority, and the individual with the most training and experience should apply the safest, most advanced technique available to secure a viable airway and commence rescue breathing.

Patients with potential cervical spine injuries may be treated with the application of a cervical collar or other extrication device. Sports medicine professionals must recognize that it is possible that the application of a semirigid cervical collar may interfere with the ability to open the mouth adequately for certain airway-management techniques,56 possibly requiring the loosening or removal of a previously applied external immobilization device, along with any tape or straps that secure the chin.

Transfer and Immobilization

Manual stabilization of the head and neck is initiated early in the care of the potentially spine-injured athlete. Once the primary survey is complete, the next step in most situations is to transfer manual head and neck stabilization to mechanical head and neck immobilization using an external device or devices. Head and cervical spine immobilization devices splint or brace the head and neck as a unit against the upper torso, typically at the intersection of the base of the neck and shoulders. A log roll has historically been used to transfer the patient to a long spine board for full-body immobilization. Other devices and techniques for transfer and full-body immobilization are available and are discussed in the following sections.

The Equipment-Laden Athlete

Football

In the sport of American football, each player is required to wear a helmet (with a face mask) and shoulder pads. These helmets must be designed and constructed in such a way as to meet specific certification standards imposed by NOCSAE.142 These specifications were devised to protect the wearer from head and facial injuries due to impacts. However, the protective face mask impedes airway access after a potentially catastrophic head or neck injury. Removal of a football helmet created alterations in the position of adjacent cervical vertebrae,77,143 although in a separate study,88 no changes were seen in disc height, cervical vertebrae translation, or space available for the cord. Regardless of the conflicting findings, because the helmet and shoulder pads in football players create neutral alignment of the cervical spine, whenever possible, these items should remain in place and the face mask should be removed in order to access the airway.

The technique used for face-mask removal should be the one that creates the least head and neck motion, is performed most quickly, is the least difficult, and carries the least chance of failure. Early recommendations for face-mask removal were to cut all the loop straps rather than unscrew the hardware holding them in place.119 However, a cordless screwdriver is faster86,144,145 and easier to use,86 and it creates less torque145 and motion86 at the head than do many of the cutting tools commonly used to remove the face mask. Therefore, the cordless screwdriver was recommended for removal of the face mask in place of a cutting tool.86,145 However, relying solely on a screwdriver can result in problems that are not encountered with a cutting tool. Screws may not be able to be removed, and problems with the helmet hardware (eg, screws, T-nuts), such as corrosion and rust, can cause the screw face to shred, allowing the T-nut to spin with the screw while turning or even to become so rusted as to fuse the hardware together, preventing any turning at all.82,85,146

These issues, combined with other issues, such as battery life, led to the early opinion119 that a cordless screwdriver for face-mask removal is not reliable and should not be used as a primary tool, but the reliability of the cordless screwdriver has now been assessed. At several sport equipment reconditioning facilities across the country, face masks were removed from a large sample of high school football helmets (n  =  2584) using a cordless screwdriver. The helmets tested had been used for at least 1 season of play and were at the facilities to be reconditioned. A total of 94% of all screws (9673 of 10 284) were successfully removed. All 4 screws were removed from the face mask with the cordless screwdriver in 84% of the entire sample (2165 successful face-mask removals, out of a possible 2584). Among the 419 failed trials, two-thirds of the helmets only had 1 screw removal failure; the remaining one-third had more than 1 screw fail. A success rate of 84% in face-mask removal from such a large sample of helmets provides evidence that the technique is fairly reliable; data for some individual team helmets within the sample showed 100% success, demonstrating that overall reliability could actually be improved. However, because the face mask could not be removed in 16% of the overall sample, concerns are reasonable.

A prospective study82 incorporating a combined-tool technique to address the possibility of screw removal failure was performed on a Division II football team. The investigators removed face masks from the helmets of players during the course of a full football season. One researcher used a cordless screwdriver to attempt face-mask removal but was also prepared with a backup cutting tool to cut away loop straps associated with any screw removal failures. At the end of the season, the face mask had been successfully removed from 75 of 76 helmets (a success rate of 98%). Five of 6 loop straps associated with screwdriver failure were removed with the backup cutting tool. One trial was classified as a failure because it exceeded the 3-minute time limit for all trials. In a separate study,82 investigators traveled to sport equipment reconditioning facilities to test this technique on used helmets after the football season was complete. Of 300 face-mask removal attempts with the screwdriver, 57 failed, but those face masks were successfully removed with the backup cutting tool. Thus, 100% of the face masks were removed with the combined-tool approach. The evidence from both studies indicates that this technique is reliable.

From the research to date, we can conclude that the cordless screwdriver is the most efficient tool for face-mask removal in helmets with 4 loop straps and screw and T-nut attachments. Because screw failure is a possibility, the combined-tool technique provides the rescuer the added security of a backup cutting tool. The backup cutting tool could be one specifically designed for this task, such as the Trainers Angel (Riverside, CA), FM Extractor (Sports Medicine Concepts Inc, Livonia, NY), or a tool used for other purposes, such as an anvil pruner. However, this backup cutting tool must be appropriately matched to the helmet and loop strap type being used.86

As helmet, face-mask, loop-strap fastener, and tool designs change, so may these specific recommendations. For example, recent changes in the design of the Riddell Revolution football helmet (Riddell Sports Inc, Elyria, OH) include a quick-release attachment system for the face mask. The quick-release system is currently used to attach only the 2 side loop straps, while the top loop straps are secured with the traditional screw and T-nut configuration (Figure 12). Two of the authors (E.E.S. and L.C.D.; unpublished data, 2008) have conducted preliminary research on the quick-release system and found that the average time to remove the face mask was 34.63 ± 14.24 seconds and that the resultant head motion was less than that with a traditional helmet. Regardless of the tool or attachment system, the goal is always to protect the athlete during the management process by minimizing time, motion, and difficulty.

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Face-mask removal precludes the need to remove the helmet and shoulder pads in the prehospital setting. However, there may be situations in which exposure of the head, chest, or body is necessary. As stated earlier, anytime either the helmet or shoulder pads should be removed, rescuers should remove both the helmet and shoulder pads. This practice is followed for several reasons, but most importantly, removal of both the helmet and shoulder pads leaves the cervical spine in neutral alignment.140 Another consideration is that it is much easier to remove the shoulder pads if the helmet has already been removed. Removal of the helmet and shoulder pads using 4 health care providers has been shown88 to be effective in limiting motion in the cervical spine of a healthy volunteer, although, as mentioned earlier, other reports77,143 have provided conflicting results.

Finally, immediate rescue breathing or cardiopulmonary resuscitation may be necessary for the cervical spine–injured football player. In this situation, a pocket mask may be inserted through the face mask and attached to a bag valve mask, allowing the rescuers to ventilate the patient while the face mask is being removed. Ray et al147 conducted a study to compare pocket-mask insertion techniques. Inserting the pocket mask through the face-mask eye hole produced less cervical spine movement than inserting it between the chin and the face mask. Both techniques produced less movement than removing the side loop straps by manual screwdriver and rotating the mask. Yet the face-mask eye-hole technique is not feasible for all types of football face masks (eg, those with a center bar or a shield attachment).

Ice Hockey

In ice hockey, research indicates that players lying supine with the helmet and shoulder pads left in place have neutral cervical spine alignment78,139 and that removing the helmet may alter that alignment.77 As is the case with football and lacrosse helmets, an ice hockey helmet is also reported148 to immobilize the head of an athlete immobilized on a spine board, provided the helmet was applied correctly and securely. These findings indicate that when an ice hockey player may have a cervical spine injury, the helmet should be left in place.

However, anecdotal reports indicate that not all hockey helmets are worn appropriately. Mihalik et al80 investigated head motion created during a prone log roll in hockey players wearing properly fitted helmets, improperly fitted helmets, and no helmets. The smallest amount of head motion occurred when the volunteers wore no helmet at all. With the improperly fitted helmets, the volunteers' heads moved independently, indicating that the rescuers would be unable to secure appropriate head immobilization during the task. The authors80 recommended removal of the ice hockey helmet before performing a prone log roll to limit the motion that might otherwise occur. This does present a dilemma, though, in that removal of the ice hockey helmet may cause undue motion in the cervical spine.77

If an athlete who is wearing a helmet and shoulder pads has a potential cervical spine injury and the helmet does not provide adequate immobilization or cervical spine alignment or if face-mask removal is not possible, the rescuer may need to remove the helmet. If time and personnel allow, the shoulder pads should also be removed. If time or resources do not allow simultaneous removal of the helmet and shoulder pads, then foam padding or a similar article (eg, folded towel) should be placed under the head of the athlete to maintain neutral alignment in the cervical spine.

Lacrosse and Other Equipment-Laden Sports

In supine lacrosse players, equipment may not create the same neutral positioning of the cervical spine as that created in football and ice hockey players.79 As is the case with football helmets, a lacrosse helmet can provide head immobilization when an athlete is immobilized on a spine board, provided the helmet is applied correctly and fitted securely.148 These findings indicate that leaving the equipment in place precludes neutral alignment of the cervical spine. Additionally, in many lacrosse helmets, the face masks are not easily removed. Until we can be certain that lacrosse equipment aligns the cervical spine in a neutral position and that the face mask is easily removed, the lacrosse helmet may need to be removed on the field. At this time, however, no researchers have reported on motion created in the cervical spine during lacrosse helmet removal.

Additional data for lacrosse and many other equipment-laden sports and recreational activities, such as horseback riding, downhill skiing, baseball, softball, and mountain biking, are not available. When dealing with a suspected catastrophic cervical spine injury in athletes in these sports, adhering to the 2 underlying principles of managing the equipment-laden athlete dictates the necessary steps during the management process.

Emergency Department Management

The athletic trainer or team physician should accompany the injured athlete to the hospital for several reasons. This practice provides continuity of care, allows for accurate delivery of clinical information to the emergency department staff, and allows the sports medicine professionals to assist emergency department personnel during equipment removal. Unfortunately, this may be difficult or impossible in some settings. Whether or not the sports medicine professional can accompany the athlete, communication between sports medicine and emergency department staffs during the emergency planning phase is important.

Improved communication between team and hospital personnel can only enhance the care delivered. At a minimum, hospital personnel should understand standards of on-field care for the athlete with a potential spine injury and should receive training regarding the proper approach to equipment removal. We recognize that hospital personnel may be unfamiliar with athletic equipment, including helmets, face masks, shoulder pads, and chest protectors. Sports medicine professionals can be a resource for such information, simultaneously increasing communication and improving collegiality.

The Roles of Hypothermia Treatment and High-Dose Corticosteroids in the Acute Management of Cervical Spine Injury

The exact mechanism of action is unclear, but hypothermia may slow metabolism, decrease the demand for oxygen, and inhibit a cascade of deleterious chemicals, such as inflammatory agents and excitatory amino acids.156,157 Clinical hypothermia has shown promise as a treatment for patients with myocardial infarction, yet potentially deleterious effects (such as sepsis, bleeding, and cardiac arrhythmias) have been demonstrated in patients with brain injury.157 In addition, rewarming may lead to dangerous drops in blood pressure.157

Clinical data on hypothermia as a treatment for brain injury and myocardial infarction are abundant, but few clinical reports have addressed hypothermia for spinal cord injury. Laboratory experiments have shown inconsistent effects, and clinical studies96,97,156,158–162 have been limited by small sample sizes and a lack of controls. Many unanswered questions concerning hypothermia treatment for spinal cord injury remain, including the following: (1) What is the optimal temperature and duration for hypothermia?156 (2) How soon after injury must hypothermia be instituted to be effective? (3) Is regional (epidural versus subarachnoid) or systemic cooling more efficacious? (4) What is the best way to rewarm the body after hypothermia without causing harm? Although regional cooling can lead to faster cooling and fewer systemic effects, technical logistics make this treatment impractical in the management of the on-field athlete. A clinical trial is underway to assess the effects of moderate hypothermia (33°C [92°F]) induced via a cooling catheter placed in the femoral artery immediately after injury. Cooling is maintained for a 48-hour period, followed by slow rewarming of 1°C every 8 hours.163 The catheter has a gauge that allows for temperature monitoring. Despite this clinical trial, hypothermia should be considered an experimental treatment that requires further research before being recommended as a standard component of the on-field spinal cord injury management protocol.

In the early 1990s, the use of high-dose methylprednisolone for the treatment of acute spinal cord injury became the standard of care. Bracken et al164 found that patients with acute spinal cord injury who were treated with high-dose methylprednisolone within the first 8 hours of injury had significant neurologic improvement at the 6-month follow-up compared with a placebo group. The recommended dose of methylprednisolone is an intravenous bolus of 30 mg/kg body weight over 1 hour, followed by infusion at 5.4 mg/kg per hour for 23 hours. One evidence-based review98 of the published literature on methylprednisolone revealed serious flaws in data analysis and conclusions, with no clear support for the use of methylprednisolone in patients with acute spinal cord injury. In fact, several studies98 showed a higher incidence of respiratory and infectious complications with methylprednisolone. Until additional reliable data are available, the use of high-dose methylprednisolone for acute spinal cord injury remains controversial. When possible, each patient or patient's family should be informed about the risks and benefits of the medication before use.