STUDENT-ATHLETE HEALTH & WELFARE Cervical Spine Injury …publicaffairs.vpcomm.umich.edu/wp-content/uploads/sites/... · 2015. 4. 8. · catastrophic cervical spine injury in the

U‐M SA Health & Welfare 4/2/2015

STUDENT-ATHLETE HEALTH & WELFARE

Cervical Spine Injury Training Scenarios Equipment Laden Athlete (e.g. football, ice hockey, men’s lacrosse)-

1. Supine a. Lift & Slide / 6-person lift b. Log Roll

2. Prone

a. Log Roll (Pull Technique) b. Log Roll (Push Technique)

3. Side-lying

4. Helmet off

a. Pack & Fill b. Cervical Collar application c. Shoulder Pad Removal

5. Helmet / Shoulder Pad Removal

a. Ground-based b. Elevated Torso c. Lift & Slide / Levitation d. Log Roll e. Eject

6. AED / Oxygen Administration / BVM

a. Jaw-thrust

7. Advanced Life Support

8. Miscellaneous- a. Ice hockey goalie b. Field Hockey goalie c. Women’s Lacrosse goalie d. Baseball / Softball catcher e. Extreme Sports (winter; summer)

U‐M SA Health & Welfare 4/2/2015

Non-Equipment Laden Athlete-

1. Supine log-roll

2. Supine lift & slide

3. Prone log-roll (push)

4. Prone log-roll (pull)

5. Side-lying log-roll

6. AED / Oxygen Administration / BVM

7. Advanced Life Support

8. Miscellaneous

Miscellaneous-

1. “Spider Strap” application

2. Oxygen Administration

3. Oral airway administration

4. Nasal airway administration

5. Confined Space situation

6. Gymnastics Foam Pit

7. Pole Vault / High Jump student-athlete

8. Seizure / Combative SA

9. Ambulance Operations

National Athletic Trainers’ Association PositionStatement: Acute Management of the Cervical Spine–Injured Athlete

Erik E. Swartz, PhD, ATC*; Barry P. Boden, MD�; Ronald W. Courson, ATC, PT,NREMT-1, CSCS`; Laura C. Decoster, ATC‰; MaryBeth Horodyski, EdD, ATCI;Susan A. Norkus, PhD, ATC"; Robb S. Rehberg, PhD, ATC, CSCS, NREMT#;Kevin N. Waninger, MD, MS, FAAFP, FACSM**

*University of New Hampshire, Durham, NH; 3Uniformed Services University of the Health Sciences, Bethesda, MD,and The Orthopaedic Center, PA, Bethesda, MD; 4University of Georgia Athletic Association, Athens, GA; 1NewHampshire Musculoskeletal Institute, Manchester, NH; IUniversity of Florida, Gainesville, FL; "Quinnipiac University,Hamden, CT; William Paterson University, Wayne, NJ; **St Luke’s Hospital, Bethlehem, PA

Objective: To provide certified athletic trainers, team physi-cians, emergency responders, and other health care profes-sionals with recommendations on how to best manage acatastrophic cervical spine injury in the athlete.

Background: The relative incidence of catastrophic cervicalspine injury in sports is low compared with other injuries.However, cervical spine injuries necessitate delicate andprecise management, often involving the combined efforts of avariety of health care providers. The outcome of a catastrophiccervical spine injury depends on the efficiency of this manage-ment process and the timeliness of transfer to a controlledenvironment for diagnosis and treatment.

Recommendations: Recommendations are based on cur-rent evidence pertaining to prevention strategies to reduce theincidence of cervical spine injuries in sport; emergency planningand preparation to increase management efficiency; maintain-ing or creating neutral alignment in the cervical spine; accessingand maintaining the airway; stabilizing and transferring theathlete with a suspected cervical spine injury; managing theathlete participating in an equipment-laden sport, such asfootball, hockey, or lacrosse; and considerations in theemergency department.

Key Words: catastrophic injuries, emergency medicine,neurologic outcomes

The incidence of spinal cord injury in the UnitedStates is estimated to include 11 000 new cases eachyear.1 Serious spinal injuries have devastating

sequelae, including neurologic impairment and prematuremortality. Sport participation constitutes the fourth mostcommon cause (approximately 7.4%)1 of these injuriesoverall but is the second most common cause for thoseyounger than 30 years of age.2 Since 2000, the majority ofall cervical spine injuries have occurred in individualsbetween the ages of 16 and 30 years.1

American football in the United States is associated withthe greatest number of catastrophic spinal injuries for allUS sports.3 Although catastrophic cervical spine injurieshave decreased compared with the incidence in the early1970s, an average of 7.8 catastrophic cervical spine injurieswith incomplete recovery4 and 6 quadriplegic events5

occurred annually in football alone (data from 1997–2006). Of particular concern is a recent trend of double-digit catastrophic spine injuries in 3 of the 4 years between2003 and 2006; from 1991 to 2002, only data from 1999showed catastrophic spine injuries measuring in the doubledigits.6

Epidemiologic data have established the risk of cata-strophic cervical spine injury in other sports as well. Forexample, an average of 15 catastrophic spine injuries occurannually in ice hockey in Canada and the United States.7

Sports such as skiing,8–13 rugby,14–17 gymnastics,18,19

swimming and diving,20,21 track and field (eg, polevaulting),22 cheerleading,23 and baseball24 all involveactivities that place participants at risk for spine injuries.In fact, the incidence of nonfatal, direct catastrophicinjuries in the sports of lacrosse, gymnastics, and men’sice hockey is higher than that in American football(Table 1).3

Regardless of the sport, proper management andaccurate diagnosis of acute spinal injuries are paramountbecause of the recognized risk of neurologic deteriorationduring and after the initial management of the injury.25,26

Consequently, sports medicine providers must be familiarwith the appropriate acute management guidelines for thecervical spine–injured athlete.

PURPOSE

The purpose of this position statement is to provideathletic trainers, team physicians, emergency responders,and other health care professionals with recommendationsand clinical considerations for managing a major,27

potentially catastrophic28,29 cervical spine injury. A cata-strophic cervical spine injury is defined as ‘‘a structuraldistortion of the cervical spinal column associated withactual or potential damage to the spinal cord.’’28

Journal of Athletic Training 2009;44(3):306–331g by the National Athletic Trainers’ Association, Incwww.nata.org/jat

position statement

306 Volume 44 N Number 3 N June 2009

Specifically, this statement will provide recommenda-tions based on current, rated evidence (Table 2) pertainingto the following:

1. Prevention strategies to reduce the incidence of

cervical spine injuries in sport,

2. Emergency planning and preparation to increase

management efficiency,

3. Maintaining or creating neutral alignment in the

cervical spine,

4. Accessing and maintaining the airway,

5. Stabilizing and transferring an athlete with a suspected

cervical spine injury,

6. Equipment-related issues in sports such as football,

hockey, and lacrosse,

7. Imaging and diagnostic considerations in the emer-

gency department, and

8. The role of hypothermia treatment and high-dose

corticosteroids in the acute management of the

cervical spine–injured athlete.

RECOMMENDATIONS

Based on current research and expert consensus relatedto cervical spine injury, the National Athletic Trainers’

Association provides the following recommendations forprevention and emergency management of the athlete witha suspected catastrophic cervical spine injury.

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


athletes should educate coaches and athletes about the

mechanisms of catastrophic spine injuries, the dangers

Table 1. Combined High School and College Catastrophic Injury Data in Select Sports Derived From the National Center for CatastrophicSport Injury Research, Fall 1982 Through Spring 20073,a

Sport Setting Direct Catastrophic Injuries

Direct Injury Incidence Rates (Nonfatalb)

per 100 000 Population

Males Females

American football (males) High school 603 0.75 NA

College 133 1.89

Gymnastics High school 13 2.08 0.97

College 6 20.07 5.35

Ice hockey High school 19 1.02 0.00

College 12 4.18 0.00

Track and field High school 59 0.12 0.01

College 10 0.34 0.15

Lacrosse High school 9 0.52 0.00

College 11 2.11 2.01

Wrestling (males) High school 58 0.60 NA

College 1 0.00 NA

Cheerleading High school 46 … …

College 23 … …

Abbreviations: NA, not applicable; …, data not available.a Data reprinted with permission of the National Center for Catastrophic Sport Injury Research.b Nonfatal indicates permanent severe disability.

Table 2. Strength of Recommendation Taxonomya

Strength of Recommendation Definition

Patient-oriented evidence

A Recommendation based upon consistent and good-quality patient-oriented evidence (morbidity,

mortality, symptom improvement, cost reduction, and quality of life)

B Recommendation based on inconsistent or limited-quality patient-oriented evidence

C Recommendation based on consensus, usual practice, opinion, disease-oriented evidence

(measures of intermediate, physiologic, or surrogate end points that may or may not reflect

improvements in patient outcomes), or case series for studies of diagnosis, treatment, prevention,

or screening

a Adapted or reprinted with permission from ‘‘Strength of Recommendation Taxonomy (SORT),’’ March 1, 2008, American Family Physician.

Copyright 2008 American Academy of Family Physicians. All Rights Reserved.

Journal of Athletic Training 307

of head-down contact, and pertinent safety rules

enacted for the prevention of cervical spine injuries.30


Planning and Rehearsal

5. Those responsible for the care of athletes should be

familiar with the National Athletic Trainers’ Associa-

tion 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 Cate-

gory: 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 applica-

tion).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 al-

tered 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 reposi-

tion 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 mo-

tion 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 sta-

tus.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 Evi-

dence Category: B


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 Evi-

dence Category: B


18. Although the traditional spine board represents the

most common device used for full-body immobiliza-

tion, 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 transfer-

ring 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 align-

ment 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 recom-

mended, 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 Evi-

dence 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 orremoved (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 orimpossible, although a cervical vacuum immobiliza-

tion device has been shown to limit cervical spine

range of motion in the fully equipped football

player.81 Evidence Category: C


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.


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 securedwith 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 ensurethat 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 Evi-

dence 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. Helmetstyle 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. Evi-

dence Category: C


Emergency Department Management

32. If possible, the team physician or certified athletic

trainer should accompany the athlete to the hospi-

tal. 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.


33. Remaining protective equipment should be removed

by appropriately trained professionals in the emer-

gency department environment. Emergency depart-

ment personnel should make an effort to become

familiar with proper athletic equipment removal,

seeking education from sports medicine professionals

regarding appropriate methods to minimize mo-

tion.76,77,88 Evidence Category: C

34. Emergency departments should consider implement-

ing 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 ade-

quate for clearance with sport equipment in place is a

procedure unsupported by research. A CT may be

more sensitive than plain radiographs and is associat-

ed 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-DoseCorticosteroids in the Acute Management of anAthlete 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 conclu-

sions, with no clear support for the use of methyl-

prednisolone 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

CLINICAL CONSIDERATIONS

Based on expert consensus and current research, theNational Athletic Trainers’ Association provides the fol-lowing special clinical considerations for emergency man-agement of the athlete with a suspected cervical spine injury.

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

1. A variety of techniques exist to transfer and immobi-

lize 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 immobi-

lizing 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 devic-

es, 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, cer-

vical 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 suffi-

ciently 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 immo-

bilization. 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 facemask 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 mecha-

nism rather than a traditional screw and T-nutattachment 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 berehearsed 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.

THE EVIDENCE: BACKGROUND ANDLITERATURE REVIEW

The evidence to support the above-listed recommenda-tions follows. However, we should note that everyemergency situation and every patient are unique and thatindividual circumstances must dictate appropriate actions.Furthermore, the recommendations listed above related tospine-injury management skills and techniques tend to bebased on research results that yielded the least amount ofmotion at the head and neck or the most optimal positionfor the spinal cord. Yet, how much motion or how far fromneutral alignment would result in further injury duringspine-injury management is unknown. Because the ‘‘safe’’amount of motion and degree of alignment are not known,and because the extent of injury in the prehospital stage isnot known, we must strive to create as little motion aspossible and to ensure an optimal position for the spinalcord within the spinal canal (ie, neutral alignment of thespinal column).

Prevention

Pathomechanics of Catastrophic Cervical Spine Injury.The highest number of catastrophic cervical spine injuriesin the United States occurs in the sport of Americanfootball,29,99 and the most common injury mechanism


occurs during tackling when the top of the head is used asthe point of contact.5,29,30 This mechanism is referred to asan axial load, which can occur in any sport. During axialloading, compressive forces create a buckling effect in thecervical spine.100 This buckling produces large angulationswithin the cervical spine as a means of releasing theadditional 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 cervicalvertebrae, partially explained through the work ofPenning103 and Amevo et al,104 is linked to the locationof a vertebra’s instantaneous center of rotation (ICR).The center of rotation for a particular vertebra is locatednear the superior aspect of the inferiorly adjacentvertebral body. As the lines of force are transmitteddown the cervical column, the vertebra experiencesflexion or extension, depending on the location of theforce vector relative to the ICR. Hence, if the cervicalcolumn is moving into flexion, but the relative orientationof one vertebra to the other causes the force vector topass behind the ICR, then that vertebra extends103,104

(Figure 11).The resultant injury (or injuries) depends on many

factors but may be influenced by the velocity of the appliedload,102,105 the point of contact on the head relative to theaxis of the cervical spine,100,101 the resultant mode ofbuckling,100,101 and the type of surface with which the headcame into contact (ie, solid versus padded).106 A critical

factor contributing to the degree of neurologic injury is theextent to which the injury involves the spinal cord. Duringaxial compression or extreme ranges of motion in thecervical spine, the spinal canal experiences transientgeometric changes in diameter and height, which mayeliminate the space surrounding the spinal cord, potentiallyresulting in neural tissue damage.47,107 Even if the spinalcord survives insult during the initial injury, its integritymay still be threatened if the osseous and soft tissuestructures were injured sufficiently to create instability inthe cervical spine.27

Acute Physiologic Response. Although most sportinjuries do not result in complete transection of thecord,108 complete sensory and motor loss can still occur.The outcome largely depends on the degree and duration oftrauma. The histologic response within the spinal cordinvolves both primary injury and a secondary injuryresponse that can lead to destruction of the neural tissue.

Spinal nerve destruction is attributed to both an acutevasospasm within the capillary network and edema-causing traumatic hemorrhagic necrosis within the pro-tective layers of the cord.109 This primary responsecontributes to decreased spinal cord perfusion. Capillaryblood flow is disrupted after rupture of the intramedullaryspinal blood vessels, resulting in gray matter hemorrhage.A build-up of cytotoxic amounts of extracellular calciumand release of norepinephrine from protective storageprovoke cytotoxic responses within neurons.110 Sodium-potassium pump disruption and subsequent cellularmembrane breakdown and lipid peroxidation contributeto neuron hydrolysis at the injury site.111 The sodium-potassium pump is a vital component in the cell’s abilityto repolarize, and cellular membrane destruction allowsfor the influx of extracellular calcium, which becomescytotoxic to the cell.111 The gray matter undergoesprogressive dissolution before the white matter.109 Theseearly changes in the injured spinal cord take place withinthe first 2 hours after trauma.111

Equipment Maintenance. The National Operating Com-mittee on Standards in Athletic Equipment (NOCSAE)was established in 1969 to research injury-reductionstrategies in sports.112 Since that time, NOCSAE has beenrecognized as the authority in equipment standards and thedevelopment of rules for many sport governing bodies. Forexample, the National Collegiate Athletic Associationrequires the use of NOCSAE-certified athletic equip-ment.113 The NOCSAE standards ensure that a helmet isable to withstand a certain degree of impact, andrecertification confirms that used helmets do not fall belowNOCSAE standards.114 Alterations (for example, thedrilling of holes through the helmet shell or the use ofinappropriate or unapproved hardware) may affect thehelmet’s effectiveness.114 Adherence to standards concern-ing the helmet shell and hardware affords sports medicinepersonnel a reasonable degree of assurance that the varietyof equipment they may need to remove in an emergencywill be somewhat limited.

Current recommendations leave the frequency of helmetrecertification to the discretion of the user. Swartz et al85

demonstrated increasing difficulty with face-mask removalas the time from last recertification increased. Therefore, itappears that more regular reconditioning, includingreplacement of all metal hardware, would reduce the

Figure 10. Buckling effect in the cervical column under axial load.Reprinted with permission from Swartz EE, Floyd RT, Cendoma M.Cervical spine functional anatomy and the biomechanics of injurydue to compressive loading. J Athl Train. 2005;40(3):155–161.


likelihood of face-mask removal failure during an emer-gency. The use of corrosion-resistant metal screws alsoincreases the probability of face-mask removal success.85

Regular maintenance and inspection of helmets during aseason can reduce the likelihood that a rescuer willencounter impediments to successful face-mask removal.85

One example is the presence of foreign substancesembedded in the loop-strap screw heads, such as dirt orplastic from other helmets, which prevents the insertion ofthe screwdriver into the screw head. Finally, certifiedathletic trainers should be familiar with equipmentstandards for the sport or sports with which they work,so they can better recognize and correct potential safetyissues.

Education and Rules. Continuing education of certifiedathletic trainers, coaches, officials, and athletes to ensureunderstanding of injury mechanisms may reduce the risk ofcatastrophic injuries. Accepting responsibility for teaching(eg, athletic trainers and coaches), legislating (eg, governingbodies), implementing (eg, athletic trainers, coaches, andathletes), and enforcing (eg, officials) safe alternatives todangerous activities is crucial. For example, axial loadingof the cervical spine is responsible for most quadriplegiccervical injuries in football115,116 and hockey.116,117 Under-standing this concept served as a springboard for rulechanges and education that subsequently reduced theincidence of such injuries. The best examples of theeffectiveness of this approach are the reduction in cervicalspine quadriplegic injuries associated with the banning ofspear tackling in football115,118 and hitting from behind(boarding) in ice hockey.117 Educational multimedia, suchas the Heads Up: Reducing the Risk of Head Injuries in

Football DVD from the National Athletic Trainers’Association (http://www.nata.org/consumer/headsup.html),are available to achieve this purpose.

Planning and Rehearsal

The effect of creating or rehearsing an emergency plan,or specific skills within an emergency plan, on managing acatastrophic cervical spine injury is not well documented.Previous recommendations to incorporate planning andrehearsal of an emergency action plan appear to be basedon expert consensus.31,119,120 Many individuals responsiblefor the care of athletes with catastrophic cervical spineinjuries have already received skills training in on-fieldtechniques as a result of requirements or educationalcompetencies 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-injurymanagement skills require participants to be thoroughlytrained and familiar with the procedures before data arecollected and analyzed.72,75,86,121

One group73 analyzed the effect of additional training onthe performance of transfer skills to an immobilizationdevice and found no differences in proficiency betweentrained and untrained participants. In contrast, researchersin related fields have reported the beneficial effects of formaleducation122 and training123 on specific medical skills.

Although the recommendation to create and rehearse anemergency action plan and the skills contained within it islogical from the medical and legal perspectives, thebeneficial effects of the rehearsal of the emergency planor its skills are not established in the literature. Nominimum quantity or frequency of rehearsal sessions ortype of training can be endorsed.

Assessment

During the initial assessment of an injured athletesuspected of having a potentially catastrophic cervicalspine injury, the presence of any or all of the following 4clinical indicators warrants the activation of the spine-injury management protocol: unconsciousness or alteredlevel of consciousness, bilateral neurologic findings orcomplaints, significant cervical spine pain with or withoutpalpation, and obvious spinal column deformity. In thepresence of any of these findings, the use of spinal injuryprecautions in the athletic setting have been recommend-ed.33,39,58,119 However, these recommendations are largelybased on evidence from research in prehospital andemergency medicine settings rather than athletic settings.

Results from recent research in prehospital and emer-gency medicine studies have been used to develop andvalidate criteria for determining selective immobili-zation and spine clearance protocols in the prehospitalsetting.34–36,124,125 The most common criteria leading toimmobilization in the prehospital setting include uncon-sciousness, altered mental status, evidence of intoxication,neurologic deficit, long-bone extremity fracture, or cervi-cal, thoracic, or lumbar spine pain.34,35 Domeier et al35

reported that most spine-injured patients (87%) included ina large prospective study presented with more than 1 of themeasured clinical findings. The Glasgow Coma Scale hasalso been identified as a predictor of possible cervical spine

Figure 11. The instantaneous center of rotation (ICR) for a vertebrais located near the superior aspect of the inferior vertebral body.The inferior vertebra’s motion depends on the location of the forcevector relative to the ICR. A, Hence, if the lines of force aretransmitted anterior to the ICR, the inferior vertebra extends. B, Ifthe lines of force are transmitted posterior to the ICR, the inferiorvertebra flexes. Reprinted with permission from Swartz EE, FloydRT, Cendoma M. Cervical spine functional anatomy and thebiomechanics of injury due to compressive loading. J Athl

Train. 2005;40(3):155–161.


injury.36,126 Holly et al36 noted that patients with an initialGlasgow Coma Scale score of 8 or less were more likely tohave sustained a cervical injury than those with a scorehigher than 8. Further, Demetriades et al126 identified aninverse relationship by which a lower Glasgow Coma Scalescore correlates with a higher risk of cervical spine injury.

Holly et al36 and Ross et al127 have suggested a linkamong unconsciousness, mental status, and the possibilityof cervical spine injury in trauma patients. Approximately5% to 7% of patients presenting with unconsciousness andaltered mental status had a spinal injury.36,127 In aprospective study of emergency medical services patientcharts by Domeier et al,34 37% of spine-injured patientspresented with altered mental status. Iida et al37 reportedthat one-third of all spine-injured patients studied alsosustained moderate or severe head injuries. It is importantto note, however, that these studies involved mechanismsof injury that included high-velocity impacts (eg, falls,motor vehicle accidents) and were not limited to athleticparticipation.

Bilateral neurologic findings or complaints, alteredmental status, significant midline pain, or obvious spinalcolumn deformity, alone or in any combination, areindicators of potential cervical spine injury and warrantthe use of spinal precautions. These criteria are extractedfrom validated prehospital and emergency medicine spinalclearance protocols, but on a case-by-case basis, otherindividual or collective signs or symptoms may indicate thepresence of a cervical spine injury.

Stabilization

Manual cervical immobilization should be implementedas soon as possible once a cervical spine injury is suspected.The head should be manually stabilized by grasping themastoid processes bilaterally with the fingertips whilecupping the occiput in the hands.46 The rescuer shouldposition his or her hands so the thumbs are pointed towardthe face of the injured athlete. This technique ensures thathand placement does not have to be changed withrepositioning of the athlete, unless rolling the athlete froma prone to a supine position is required, in which case therescuer’s arms should be crossed before rolling. If therescuer is alone, it may be appropriate to use the knees tomaintain spine stabilization, thus freeing the rescuer’shands to assist with ventilation or to conduct further tests.

Traction. Rescuers should not apply traction forces tothe head of the spine-injured athlete during stabilizationand immobilization. Multiple authors39–41,44 have recom-mended against the application of traction during manualin-line stabilization, as movement of the unstable cervicalspine may cause further injury. Cadaver-based studies andresearch investigating spine motion during orotrachealintubation in patients with ligamentous instability demon-strated that traction forces applied during manual in-lineimmobilization created distraction43,45,46 and posteriorsubluxation43 at the site of injury.

Neutral Alignment of the Head and Neck. Medicalprofessionals accept that the cervical spine should beimmobilized in the neutral position or in normal axialalignment, as in the anatomic position.32,39–42 This positionfacilitates airway management procedures and applicationof immobilization devices and reduces spinal cord mor-

bidity that would otherwise result from compromised localcirculation. To achieve a neutral position, the spine mayneed to be manually realigned during the emergencymanagement process.32,39 Contraindications for movingthe cervical spine to neutral include the following: themovement causes or increases pain, neurologic symptoms,or muscle spasm; the movement would compromise theairway40; it is physically difficult to perform the movement;resistance is encountered during the attempt to realign thecervical spine41; or the patient expresses apprehension.

Although no prospective randomized studies have beenconducted to support the above recommendations, evi-dence can be extrapolated from anatomic and airwaymanagement research. Several groups48,52–54,128 have in-vestigated the size of the spinal canal in various positions ofthe cervical spine. Animal-based studies129 demonstratethat the extent of spinal cord neurologic injury increases aspressure is sustained and with increasing levels ofcompression force. Other investigators focused on patientspresenting with radicular symptoms50 or cervical spondy-losis51 and sought to identify dynamic changes in the spinalcanal. Some authors49,130 retrospectively investigated therecords of patients who sustained cervical spine injuries,assessing how these injuries affected the size of the spinalcanal and how that was related to their clinical outcome.Each set of results provides evidence that the optimalposition for the spinal cord is the neutral position.

De Lorenzo et al48 performed MRI on 19 healthyvolunteers to determine the optimal position for cervicalspine immobilization. Participants were positioned inneutral and then in 2 cm and 4 cm of cervical flexion andextension. The angle between the cervical and thoracicspines and the ratio between the spinal canal diameter andspinal cord area were identified. Slight flexion (ie, occiputelevated) produced a 3% increase in the ratio of spinal cordarea to spinal canal at C5 compared with no elevation, and,therefore, these authors48 recommended immobilization ina position of slight flexion. In contrast, Tierney et al54

assessed the effect of head position on the cervical spaceavailable for the cord in volunteers wearing footballequipment. Changes in the sagittal diameter, spinal canal,and spinal cord at the C3–C7 levels were identified onMRI. Increased space was available for the spinal cord at0 cm of cervical flexion compared with 2 cm and 4 cm ofelevation. The space available for the cord was also greatestat the C5–C6 level. The authors54 recommended leaving allequipment on and immobilizing the athlete in neutralwithout any occiput elevation.

Muhle et al52 used whole-body MRI to determine thefunctional changes that occur to the cervical spine andsubarachnoid space during dynamic cervical flexion andextension. Nine angles between 506 of flexion and 306 ofextension were analyzed. Segmental motion, subarachnoiddiameter, and cervical cord diameter were assessed.Decreased ventral subarachnoid space and widened dorsalsubarachnoid space were noted during cervical flexion.Correspondingly, during extension, the ventral spaceincreased, while the dorsal space decreased. In addition,the spinal cord diameter decreased 14% during flexion andincreased 15% during extension. Depending on the locationof the cervical spine injury (ie, dorsal or ventral), theauthors52 contended that movement of the cervical spineaway from neutral may lead to cord compromise.


Ching et al128 investigated the effect of postinjuryposition of the cervical spine on spinal canal occlusionafter inducing burst fractures in 8 cadaver cervical spines.Neutral position was defined as the most central position ofthe spine that preserved normal lordosis. The authors thentested the spine in 8 directions (flexion, extension, right andleft lateral flexion, and 4 intermediate positions). Inaddition, right and left cervical rotation, traction, andcompression were assessed. Compared with the neutralposition, compression, extension, and extension combinedwith lateral flexion increased canal occlusion.128

To identify the relationship between cervical spinesagittal canal diameter and neurologic injury, Eismont etal130 retrospectively reviewed the medical records of 98patients who had sustained closed cervical spine fracturesor dislocations. A correlation between mid-sagittal spinalcanal size and the onset and degree of neurologic deficitwas present. In general, the larger the spinal canaldiameter, the less likely the patient was to suffer aneurologic deficit.130 More recently, Kang et al49 retro-spectively analyzed the records and radiographs of 288patients who had sustained a cervical fracture or disloca-tion over a 30-year period and also identified anassociation between the space available for the cord atthe level of injury and the severity of neurologic deficit.

In conclusion, for proper functioning of the spinal cord,space within the spinal canal must be maintained, both at restand during movement. Neurologic injury results fromsustained mechanical pressure on the cord, which leads toboth anatomic deformation and ischemia.129,131 Persistentmalposition of an abnormal cervical spine may result in cordcompression. If the abnormality is slight, it is likely that themalposition will need to be of greater magnitude andduration to cause harm; as the anatomic derangementincreases, the duration of positional stress required to causeharm is shortened.129 How much space is available for thecord in any potential cervical spine injury is unknown;therefore, the head and cervical spine must be positioned tocreate as much potential space for the spinal cord as possible.

Airway

For appropriate management of the spine-injuredathlete, the airway should be easily accessible. If the athleteis wearing a face guard that impedes access to the airway,removal of the barrier or insertion of an airway manage-ment device is necessary; evidence-based strategies aredescribed in the next section. The airway should be keptopen and clear of any obstructions. Potential instability inthe cervical spine due to an injury necessitates carefulairway management procedures should rescue breathing orintroduction of an artificial airway be necessary. In theabsence of advanced equipment or training, the airwaymust be opened using basic techniques that providecervical spine protection. The jaw-thrust maneuver isrecommended over the head-tilt technique, which producesunnecessary motion in the cervical spine. However, thejaw-thrust maneuver may create more motion at the site ofinjury in the cervical spine than advanced airway maneu-vers (ie, esophageal tracheal combitube, laryngoscopeendotracheal tube, or laryngeal mask airway).55,63,64 If anairway is compromised, airway management is thetreatment priority, and the individual with the most

training and experience should apply the safest, mostadvanced technique available to secure a viable airway andcommence rescue breathing.

Patients with potential cervical spine injuries may betreated with the application of a cervical collar or otherextrication device. Sports medicine professionals mustrecognize that it is possible that the application of asemirigid cervical collar may interfere with the ability toopen the mouth adequately for certain airway-managementtechniques,56 possibly requiring the loosening or removalof 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 initiatedearly in the care of the potentially spine-injured athlete.Once the primary survey is complete, the next step in mostsituations is to transfer manual head and neck stabilizationto mechanical head and neck immobilization using anexternal device or devices. Head and cervical spineimmobilization devices splint or brace the head and neckas a unit against the upper torso, typically at theintersection of the base of the neck and shoulders. A logroll has historically been used to transfer the patient to along spine board for full-body immobilization. Otherdevices and techniques for transfer and full-body immobi-lization are available and are discussed in the followingsections.

Head Stabilization. The capacity of various collars torestrict range of motion in healthy participants and incadaver models has been assessed,70,132–135 with no clearsuperiority of any single device. One researcher136 reportedthat not only did cervical collars provide no support to theinjured cervical spines of cadavers, but in some cases theyactually increased motion at the site of injury. Rather, acombination of padding (eg, foam blocks, towels), rigidcollar application, and taping to a backboard or full-bodysplint is recommended40; this combination approach hasdemonstrated the greatest degree of motion limitation atthe head during active range of motion in healthyvolunteers.67,69,70 These findings, combined with re-ports65,66 that manual cervical spine immobilization issuperior to the use of external devices in reducing cervicalmotion during airway intubation, indicate that manualstabilization should be continued throughout the manage-ment process, whether or not external stabilization devicesare applied.

Transfer and Full-Body Immobilization. Minimizingmovement at the head and neck is a critical factor in thesuccessful management of the spine-injured athlete. Anyequipment or technique that limits movement will allow forthe most effective and safest stabilization of a patient,reducing the potential for secondary injury.67 Currently,emergency medical technicians, paramedics, certified ath-letic trainers, and emergency department personnel typi-cally perform a log roll onto a traditional spine board tostabilize and prepare a patient for transport.40,68

Del Rossi et al72–75 compared the log-roll and lift-and-slide techniques by assessing the spine movement createdduring these tasks in healthy73 individuals and in cadaverswith surgically destabilized cervical spines.72,74,75 Com-pared with the lift-and-slide technique, the log-roll


technique produced greater lateral-flexion motion andgreater axial rotation of the head in healthy volunteers.73

In another study,72 the authors tested cadavers withsurgically destabilized cervical spines at the C5–C6 level(a common site of injury in sport-related cervical spineinjuries137) and found that both techniques created thesame amount of movement at the injured cervical spinelevel. However, only flexion-extension angles were ana-lyzed in that investigation.72 The same authors75 studiedcervical spine movement in multiple planes during the log-roll and lift-and-slide transfer techniques in cadavers withinduced destabilizing injuries. The cadavers were also fittedwith various cervical collars, but regardless of the collarapplied, the log roll created more rotation and lateralflexion than the lift and slide.75 In another study75 ofcadavers with destabilized cervical spines, the log-rolltechnique resulted in more motion than a ‘‘straddle’’ lift-and-slide technique and the 6–plus-person lift-and-slidetechnique in multiple planes of motion.

New devices have been developed to challenge the use ofthe traditional spine board for head and body immobili-zation. One device is described as a vacuum mattress,which conforms and stiffens around a patient’s body whenair is pumped out of the vacuum bag. Several groups havecompared the effectiveness of this vacuum mattress to atraditional spine board and found greater comfort71 andsuperior immobilization with the vacuum mattress.57,69,71

Despite evidence indicating that lift-and-slide techniquesmay be more effective in minimizing motion than the logroll or that the use of a vacuum-immobilization device issuperior to the traditional spine board, no reports indicatethat either the log roll or the traditional spine board hasresulted in further compromise of a spine injury. Therefore,the log-roll technique (which is the only method that can beused in prone patients) and the traditional spine board arestill considered acceptable for transfer and immobilizationof the potentially spine-injured athlete.

The Equipment-Laden Athlete

Equipment and Neutral Cervical Spine Alignment. Anumber of researchers54,76–79,138–141 have investigatedwhether athletic equipment affects cervical spine align-ment. Most have focused on football and how the helmetand shoulder pads may alter the normal lordotic curvatureof the cervical spine.54,76,77,138,140,141 The equipment wornby ice hockey77,78,139 and lacrosse79 athletes has also beeninvestigated.

Numerous authors76,138,140 have used cadavers toidentify the effect of a football helmet and shoulder pads,alone or in combination, on cervical spine alignment.Gastel et al138 obtained lateral radiographs on 8 cadaverspecimens with both intact and unstable C5–C6 segments.Palumbo et al140 also used radiography to identify cervicalspine alignment in 15 cadavers, 8 of which were destabi-lized at the C5–C6 level. Both groups reported similarcervical alignment when comparing full equipment (helmetand shoulder pads) with no equipment and an increase incervical lordosis (approximately 146) when only theshoulder pads were in place.

Donaldson et al76 identified movement in the unstablecervical spines of cadavers during helmet or shoulder-padremoval (or both). Cadaver specimens had cervical spine

instability induced at 1 of 2 levels. Spinal motion wasmonitored constantly with fluoroscopy while 4 trainedindividuals removed the equipment. Maximum displace-ments were identified and compared with the images takenbefore equipment was removed. Removal of the helmetand shoulder pads correlated with decreased spaceavailable for the cord. Helmet removal increased cervicalspine flexion, whereas shoulder-pad removal increasedextension. Approximately 186 of total movement occurredduring equipment removal. Disc height changed 2.3 mm,and the space available for the cord decreased 3.87 mm atthe C5–C6 level. The authors76 concluded that equipmentremoval is a very complex and difficult task that can resultin potentially dangerous cervical spine motion, especiallywhen the cervical spine is unstable.

Prinsen et al77 used fluoroscopy to identify the positionof adjacent vertebrae before, during, and after helmetremoval and cervical collar application in 11 footballplayers. Vertebral position changed during helmet removal,application of a cervical collar, and while the player layhelmet-less on the spine board.77 Swenson et al141

radiographically analyzed cervical spine alignment in 10male volunteers immobilized on a spine board and foundno difference between the no-equipment and full-equip-ment (shoulder pads plus helmet) conditions. However,with the helmet removed, cervical lordosis increasedapproximately 106.141 Using MRI in 12 participants lyingon a spine board, Tierney et al54 found that the greatestspace available for the cord occurred at 06 of elevation withfull equipment. The results of these investigations supportthe recommendation to leave all football equipment on theathlete whenever a cervical spine injury is suspected.

Similar research has been conducted using fluorosco-py,77 CT,139 or traditional radiographs78 in volunteerswearing ice hockey equipment. No differences were notedbetween the no-equipment and full-equipment conditions.With the helmet removed but shoulder pads on, cervicallordosis was greater than in the control or full-equipmentconditions. As in the case of the football player, allequipment should be left on the ice hockey player with asuspected cervical spine injury, provided that the head canbe adequately immobilized and that access to the airway isestablished.

The effect of lacrosse equipment on cervical spinealignment has been investigated by Sherbondy et al,79

who compared cervical angles at the levels of the occiputand C2, C2–C7, and the occiput and C-7 in 16 healthylacrosse players. The cervical angles of the lacrosse playerswere analyzed in 3 conditions: no equipment, fullequipment, and helmet removed. Interestingly, when thelacrosse athletes wore a helmet and shoulder pads (full-equipment condition), lateral CT images revealed anincrease in cervical extension (approximately 66) betweenthe occiput and C7 compared with the no-equipmentcondition. These changes are different than those previ-ously discussed for football and ice hockey players, inwhom the full-equipment conditions left the cervical spinein neutral alignment. With shoulder pads only (helmetremoved), cervical flexion increased 4.76 in the occiput toC2 level when compared with full equipment and 4.46 inthe C2–C7 level when compared with no equipment.79 Theincreased cervical flexion contrasted with the extensionangle noted in football and ice hockey players.


More research is needed regarding the appropriatemanagement of lacrosse equipment, as Sherbondy et al79

only looked at a single combination of helmet and shoulderpads, whereas many types of equipment are available in themarketplace. Based on the rationale already discussedregarding the position of the cervical spine for immobiliza-tion and transport, if the presence of the supine lacrosseathlete’s equipment results in an extended cervical angle, thehelmet and shoulder pads may need to be carefully removedto ensure neutral alignment. However, because we do notknow how much motion occurs during the removal of thelacrosse helmet and shoulder pads, the rescuer may also electto transfer the athlete with appropriately fitting equipmentin place, provided airway access has been established viaface-mask removal.

External Cervical Immobilization Devices. In the equip-ment-laden athlete, applying a cervical immobilizationdevice may be difficult because of the lack of space betweenthe helmet and shoulder pads and may actually becontraindicated as a result of the motion incurred.77

Because the helmet and shoulder pads in some sports (eg,football, ice hockey) provide neutral alignment of thecervical spine, leaving the equipment on without applyinga cervical collar before transfer to a spine board is anacceptable practice. One group81 concluded that a vacuumcervical collar adequately restricted motion in healthyvolunteers wearing football equipment. In any sport, if thehelmet or shoulder pads must be removed to create neutralalignment, a cervical collar should then be appliedimmediately.

Helmet, Face-Mask, and Equipment Removal. Althoughthe benefits of wearing protective equipment in terms ofreducing the number and severity of impact injuries areobvious, the equipment itself may act as a barrier to effectivetreatment of an athlete should an injury occur. Knowinghow to deal with protective equipment during the immediatecare of an athlete with a potential catastrophic cervical spineinjury can greatly influence the outcome. Regardless of thesport or the equipment being used, 2 principles should guidemanagement of the equipment-laden athlete with a potentialcervical spine injury:

1) Exposure and access to vital life functions (airway,

chest for cardiopulmonary resuscitation or use of an

automated external defibrillator) must be established

or easily achieved in a reasonable and acceptable

manner.

2) Neutral alignment of the cervical spine should be

maintained while allowing as little motion as possible

at the head and neck.

Football

In the sport of American football, each player is requiredto wear a helmet (with a face mask) and shoulder pads.These helmets must be designed and constructed in such away as to meet specific certification standards imposed byNOCSAE.142 These specifications were devised to protectthe wearer from head and facial injuries due to impacts.However, the protective face mask impedes airway accessafter a potentially catastrophic head or neck injury.Removal of a football helmet created alterations in theposition 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 thecord. Regardless of the conflicting findings, because thehelmet and shoulder pads in football players create neutralalignment of the cervical spine, whenever possible, theseitems should remain in place and the face mask should beremoved in order to access the airway.

The technique used for face-mask removal should be theone that creates the least head and neck motion, isperformed most quickly, is the least difficult, and carriesthe least chance of failure. Early recommendations forface-mask removal were to cut all the loop straps ratherthan unscrew the hardware holding them in place.119

However, a cordless screwdriver is faster86,144,145 and easierto use,86 and it creates less torque145 and motion86 at thehead than do many of the cutting tools commonly used toremove the face mask. Therefore, the cordless screwdriverwas recommended for removal of the face mask in place ofa cutting tool.86,145 However, relying solely on a screw-driver can result in problems that are not encountered witha cutting tool. Screws may not be able to be removed, andproblems with the helmet hardware (eg, screws, T-nuts),such as corrosion and rust, can cause the screw face toshred, allowing the T-nut to spin with the screw whileturning or even to become so rusted as to fuse the hardwaretogether, preventing any turning at all.82,85,146

These issues, combined with other issues, such as batterylife, led to the early opinion119 that a cordless screwdriverfor face-mask removal is not reliable and should not beused as a primary tool, but the reliability of the cordlessscrewdriver has now been assessed. At several sportequipment reconditioning facilities across the country, facemasks were removed from a large sample of high schoolfootball helmets (n 5 2584) using a cordless screwdriver.The helmets tested had been used for at least 1 season ofplay and were at the facilities to be reconditioned. A totalof 94% of all screws (9673 of 10 284) were successfullyremoved. All 4 screws were removed from the face maskwith the cordless screwdriver in 84% of the entire sample(2165 successful face-mask removals, out of a possible2584). Among the 419 failed trials, two-thirds of thehelmets only had 1 screw removal failure; the remainingone-third had more than 1 screw fail. A success rate of 84%in face-mask removal from such a large sample of helmetsprovides evidence that the technique is fairly reliable; datafor some individual team helmets within the sample showed100% success, demonstrating that overall reliability couldactually be improved. However, because the face maskcould not be removed in 16% of the overall sample,concerns are reasonable.

A prospective study82 incorporating a combined-tooltechnique to address the possibility of screw removalfailure was performed on a Division II football team. Theinvestigators removed face masks from the helmets ofplayers during the course of a full football season. Oneresearcher used a cordless screwdriver to attempt face-mask removal but was also prepared with a backup cuttingtool to cut away loop straps associated with any screwremoval failures. At the end of the season, the face maskhad been successfully removed from 75 of 76 helmets (asuccess rate of 98%). Five of 6 loop straps associated withscrewdriver failure were removed with the backup cuttingtool. 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 reconditioningfacilities to test this technique on used helmets after thefootball season was complete. Of 300 face-mask removalattempts with the screwdriver, 57 failed, but those facemasks were successfully removed with the backup cuttingtool. Thus, 100% of the face masks were removed with thecombined-tool approach. The evidence from both studiesindicates that this technique is reliable.

From the research to date, we can conclude that thecordless screwdriver is the most efficient tool for face-maskremoval in helmets with 4 loop straps and screw and T-nutattachments. Because screw failure is a possibility, thecombined-tool technique provides the rescuer the addedsecurity of a backup cutting tool. The backup cutting toolcould be one specifically designed for this task, such as theTrainers Angel (Riverside, CA), FM Extractor (SportsMedicine Concepts Inc, Livonia, NY), or a tool used forother purposes, such as an anvil pruner. However, thisbackup cutting tool must be appropriately matched to thehelmet and loop strap type being used.86

As helmet, face-mask, loop-strap fastener, and tooldesigns change, so may these specific recommendations.For example, recent changes in the design of the RiddellRevolution football helmet (Riddell Sports Inc, Elyria,OH) include a quick-release attachment system for the facemask. The quick-release system is currently used to attachonly the 2 side loop straps, while the top loop straps aresecured 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 preliminaryresearch on the quick-release system and found that theaverage time to remove the face mask was 34.63 614.24 seconds and that the resultant head motion was lessthan that with a traditional helmet. Regardless of the toolor attachment system, the goal is always to protect theathlete during the management process by minimizingtime, motion, and difficulty.

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

Finally, immediate rescue breathing or cardiopulmonaryresuscitation may be necessary for the cervical spine–injured football player. In this situation, a pocket maskmay be inserted through the face mask and attached to abag valve mask, allowing the rescuers to ventilate thepatient while the face mask is being removed. Ray et al147

conducted a study to compare pocket-mask insertiontechniques. 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. Bothtechniques produced less movement than removing the sideloop straps by manual screwdriver and rotating the mask.Yet the face-mask eye-hole technique is not feasible for alltypes of football face masks (eg, those with a center bar ora shield attachment).

Ice Hockey

In ice hockey, research indicates that players lying supinewith the helmet and shoulder pads left in place have neutralcervical spine alignment78,139 and that removing the helmetmay alter that alignment.77 As is the case with football andlacrosse helmets, an ice hockey helmet is also reported148 toimmobilize the head of an athlete immobilized on a spineboard, provided the helmet was applied correctly andsecurely. These findings indicate that when an ice hockeyplayer may have a cervical spine injury, the helmet shouldbe left in place.

However, anecdotal reports indicate that not all hockeyhelmets are worn appropriately. Mihalik et al80 investigat-ed head motion created during a prone log roll in hockeyplayers wearing properly fitted helmets, improperly fittedhelmets, and no helmets. The smallest amount of headmotion occurred when the volunteers wore no helmet at all.With the improperly fitted helmets, the volunteers’ headsmoved independently, indicating that the rescuers would beunable to secure appropriate head immobilization duringthe task. The authors80 recommended removal of the icehockey helmet before performing a prone log roll to limitthe motion that might otherwise occur. This does present adilemma, though, in that removal of the ice hockey helmetmay cause undue motion in the cervical spine.77

If an athlete who is wearing a helmet and shoulder padshas a potential cervical spine injury and the helmet does notprovide adequate immobilization or cervical spine alignmentor if face-mask removal is not possible, the rescuer may needto remove the helmet. If time and personnel allow, theshoulder pads should also be removed. If time or resourcesdo not allow simultaneous removal of the helmet andshoulder pads, then foam padding or a similar article (eg,

Figure 12. The Riddell Revolution football helmet (Riddell SportsInc, Elyria, OH) includes a quick-release attachment system for theface mask. The quick-release system is currently used to attachonly the 2 side loop straps, while the top loop straps are securedwith the traditional screw and T-nut configuration.


folded towel) should be placed under the head of the athleteto maintain neutral alignment in the cervical spine.

Lacrosse and Other Equipment-Laden Sports

In supine lacrosse players, equipment may not create thesame neutral positioning of the cervical spine as that createdin football and ice hockey players.79 As is the case withfootball helmets, a lacrosse helmet can provide headimmobilization when an athlete is immobilized on a spineboard, provided the helmet is applied correctly and fittedsecurely.148 These findings indicate that leaving the equip-ment in place precludes neutral alignment of the cervicalspine. Additionally, in many lacrosse helmets, the facemasks are not easily removed. Until we can be certain thatlacrosse equipment aligns the cervical spine in a neutralposition and that the face mask is easily removed, thelacrosse helmet may need to be removed on the field. At thistime, however, no researchers have reported on motioncreated in the cervical spine during lacrosse helmet removal.

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

Emergency Department Management

The athletic trainer or team physician should accompanythe injured athlete to the hospital for several reasons. Thispractice provides continuity of care, allows for accuratedelivery of clinical information to the emergency depart-ment staff, and allows the sports medicine professionals toassist emergency department personnel during equipmentremoval. Unfortunately, this may be difficult or impossiblein some settings. Whether or not the sports medicineprofessional can accompany the athlete, communicationbetween sports medicine and emergency department staffsduring the emergency planning phase is important.

Improved communication between team and hospitalpersonnel can only enhance the care delivered. At aminimum, hospital personnel should understand standardsof on-field care for the athlete with a potential spine injuryand should receive training regarding the proper approachto equipment removal. We recognize that hospital person-nel may be unfamiliar with athletic equipment, includinghelmets, face masks, shoulder pads, and chest protectors.Sports medicine professionals can be a resource for suchinformation, simultaneously increasing communicationand improving collegiality.

Equipment Removal and Imaging. Protective equipmentshould be removed by appropriately trained professionalsin the controlled emergency department environment.Previous recommendations78 call for clearance plainradiographs to be taken before equipment removal.Although removal of athletic equipment can cause motionin the cervical spine during the process,76,77 one group88

concluded that it was possible to remove a football helmetand shoulder pads from healthy volunteers withoutcreating significant motion. Two reports93,94 documentedthat obtaining adequate radiographs in healthy, helmeted

football players was difficult. In fact, it is difficult to attainadequate visualization of the full cervical spine even inpatients without equipment.149–152 Missed diagnoses withnegative consequences in nonhelmeted cervical spine–injured patients have been reported; often these conse-quences included delayed diagnoses related to improperradiographic choices or interpretations.152,153 Based on thisevidence and the lack of evidence indicating negativeconsequences caused by equipment removal before radio-graphic imaging, we cannot make a recommendation toperform radiographic imaging with equipment in place.One group93 suggested that ‘‘guidelines for players’ cervicalspine imaging should incorporate procedures for removalof equipment before initial radiographic evaluation’’; thisrecommendation offers an alternative to inaccurate diag-noses based on less-than-optimal radiographic findings.

The advent of readily available multidetector CT hasreplaced the use of plain radiography at many traumacenters, and initial CT evaluation has been recommend-ed89–92 in cases involving acute cervical spine trauma. Notonly is CT more sensitive, but it carries lower rates ofmissed primary and secondary injuries,154 which may spurreconsideration of guidelines for the implementation of CTas the primary diagnostic test for helmeted athletes withsuspected cervical spine injuries. Lateral CT scout filmshave been used with good success in several studies,139,141

and CT films with helmet and shoulder pads in place wereadequate for initial diagnosis and triage.155 Although MRIof acute spinal cord injury in the unhelmeted patientprovides excellent visualization of neurologic and softtissue structures, the amount and type of metal within themodern football helmet results in field inhomogeneity andskew artifact (ie, errors in the image), precluding adequateevaluation of the cervical structures and limiting the valueof MRI in this setting.95

The Roles of Hypothermia Treatment and High-DoseCorticosteroids in the Acute Management of CervicalSpine Injury

The exact mechanism of action is unclear, but hypo-thermia may slow metabolism, decrease the demand foroxygen, and inhibit a cascade of deleterious chemicals, suchas inflammatory agents and excitatory amino acids.156,157

Clinical hypothermia has shown promise as a treatment forpatients with myocardial infarction, yet potentially delete-rious effects (such as sepsis, bleeding, and cardiacarrhythmias) have been demonstrated in patients withbrain injury.157 In addition, rewarming may lead todangerous drops in blood pressure.157

Clinical data on hypothermia as a treatment for braininjury and myocardial infarction are abundant, but fewclinical reports have addressed hypothermia for spinal cordinjury. Laboratory experiments have shown inconsistenteffects, and clinical studies96,97,156,158–162 have been limitedby small sample sizes and a lack of controls. Manyunanswered questions concerning hypothermia treatmentfor spinal cord injury remain, including the following: (1)What is the optimal temperature and duration forhypothermia?156 (2) How soon after injury must hypother-mia be instituted to be effective? (3) Is regional (epiduralversus subarachnoid) or systemic cooling more efficacious?(4) What is the best way to rewarm the body after


hypothermia without causing harm? Although regionalcooling can lead to faster cooling and fewer systemiceffects, technical logistics make this treatment impracticalin the management of the on-field athlete. A clinical trial isunderway to assess the effects of moderate hypothermia(336C [926F]) induced via a cooling catheter placed in thefemoral artery immediately after injury. Cooling ismaintained for a 48-hour period, followed by slowrewarming of 16C every 8 hours.163 The catheter has agauge that allows for temperature monitoring. Despite thisclinical trial, hypothermia should be considered anexperimental treatment that requires further researchbefore being recommended as a standard component ofthe on-field spinal cord injury management protocol.

In the early 1990s, the use of high-dose methylprednis-olone for the treatment of acute spinal cord injury becamethe standard of care. Bracken et al164 found that patientswith acute spinal cord injury who were treated with high-dose methylprednisolone within the first 8 hours of injuryhad significant neurologic improvement at the 6-monthfollow-up compared with a placebo group. The recom-mended dose of methylprednisolone is an intravenousbolus of 30 mg/kg body weight over 1 hour, followed byinfusion at 5.4 mg/kg per hour for 23 hours. One evidence-based review98 of the published literature on methylpred-nisolone revealed serious flaws in data analysis andconclusions, with no clear support for the use ofmethylprednisolone in patients with acute spinal cordinjury. In fact, several studies98 showed a higher incidenceof respiratory and infectious complications with methyl-prednisolone. Until additional reliable data are available,the use of high-dose methylprednisolone for acute spinalcord injury remains controversial. When possible, eachpatient or patient’s family should be informed about therisks and benefits of the medication before use.

CONCLUSIONS

In no other sport injury are the elements of efficientimmediate care, transport, diagnosis, and treatment morecritical to the outcome than in the athlete with a potentiallycatastrophic cervical spine injury. A high level of evidence(ie, prospective randomized trials) on this topic is in mostcases impossible to identify or create. However, therecommendations provided in this position statement arebased on the best currently available evidence and expertconsensus. Technology, equipment, and techniques willundoubtedly evolve, but the primary goals in managing thespine-injured athlete will remain the same: create as littlemotion as possible and complete the steps of the emergencyaction plan as rapidly as is appropriate in order to facilitatetransport to the nearest emergency treatment facility.

ACKNOWLEDGMENTS

We gratefully acknowledge the efforts of Robert C. Cantu,MD; Gianluca Del Rossi, PhD, ATC; Roger Hartl, MD; RobertL. Howard, Jr, MA, ATC; Michael Ryan, PT, ATC, PES; RyanT. Tierney, PhD, ATC; and the Pronouncements Committee inthe preparation of this document.

DISCLAIMER

The National Athletic Trainers’ Association (NATA) publishesits position statements as a service to promote the awareness of

certain issues to its members. The information contained in theposition statement is neither exhaustive nor exclusive to allcircumstances or individuals. Variables such as institutionalhuman resource guidelines, state or federal statutes, rules, orregulations, as well as regional environmental conditions mayimpact the relevance and implementation of these recommenda-tions. The NATA advises its members and others to carefully andindependently consider each of the recommendations (includingthe applicability of same to any particular circumstance orindividual). The position statement should not be relied upon asan independent basis for care but rather as a resource available toNATA members or others. Moreover, no opinion is expressedherein regarding the quality of care that adheres to or differs fromNATA’s position statements. The NATA reserves the right torescind or modify its position statements at any time.

REFERENCES

1. National Spinal Cord Injury Statistical Center. Spinal Cord Injury:

Facts and Figures at a Glance. Birmingham: University of Alabama,

Birmingham; 2006:2.

2. Nobunaga A, Go BK, Karunas RB. Recent demographic and injury

trends in people served by the Model Spine Cord Injury Case

Systems. Arch Phys Med Rehabil. 1999;80(11):1372–1382.

3. Mueller F, Cantu R. National Center for Catastrophic Sport Injury

Research: Twenty-Fourth Annual Report: Fall 1982–Spring 2006.

Chapel Hill: University of North Carolina; 2008.

4. Mueller FO, Cantu RC. Annual Survey of Catastrophic Football

Injuries, 1977–2006. Chapel Hill: University of North Carolina;

2006.

5. Boden BP, Tacchetti RL, Cantu RC, Knowles SB, Mueller FO.

Catastrophic cervical spine injuries in high school and college

football players. Am J Sports Med. 2006;34(8):1223–1232.

6. Mueller FO, Cantu RC. Annual Survey of Catastrophic Football

Injuries, 1977–2005. Chapel Hill: University of North Carolina;

2005.

7. Tator CH, Carson JD, Edmonds VE. Spinal injuries in ice hockey.

Clin Sports Med. 1998;17(1):183–194.

8. Frymoyer JW, Pope MH, Kristiansen T. Skiing and spinal trauma.

Clin Sports Med. 1982;1(2):309–318.

9. Hagel BE, Pless B, Platt RW. Trends in emergency department

reported head and neck injuries among skiers and snowboarders.

Can J Public Health. 2003;94(6):458–462.

10. Keene JS. Thoracolumbar fractures in winter sports. Clin Orthop

Relat Res. 1987;216:39–49.

11. Levy AS, Smith RH. Neurologic injuries in skiers and snowboard-

ers. Semin Neurol. 2000;20(2):233–245.

12. Prall JA, Winston KR, Brennan R. Spine and spinal cord injuries in

downhill skiers. J Trauma. 1995;39(6):1115–1118.

13. Reid DC, Saboe L. Spine fractures in winter sports. Sports Med.

1989;7(6):393–399.

14. McCoy GF, Piggot J, Macafee AL, Adair IV. Injuries of the cervical

spine in schoolboy rugby football. J Bone Joint Surg Br.

1984;66(4):500–503.

15. Scher AT. Catastrophic rugby injuries of the spinal cord: changing

patterns of injury. Br J Sports Med. 1991;25(1):57–60.

16. Scher AT. Rugby injuries to the cervical spine and spinal cord: a 10-

year review. Clin Sports Med. 1998;17(1):195–206.

17. Secin FP, Poggi EJ, Luzuriaga F, Laffaye HA. Disabling injuries of

the cervical spine in Argentine rugby over the last 20 years.

Br J Sports Med. 1999;33(1):33–36.

18. Noguchi T. A survey of spinal cord injuries resulting from sport.

Paraplegia. 1994;32(3):170–173.

19. Silver JR, Silver DD, Godfrey JJ. Injuries of the spine sustained

during gymnastic activities. Br Med J (Clin Res Ed). 1986;293(6551):

861–863.

20. Torg JS. Epidemiology, pathomechanics, and prevention of athletic

injuries to the cervical spine. Med Sci Sports Exerc. 1985;17(3):

295–303.


21. Bailes JE, Herman JM, Quigley MR, Cerullo LJ, Meyer PR Jr.

Diving injuries of the cervical spine. Surg Neurol. 1990;34(3):

155–158.

22. Boden BP, Pasquina P, Johnson J, Mueller FO. Catastrophic

injuries in pole-vaulters. Am J Sports Med. 2001;29(1):50–54.

23. Boden BP, Tacchetti R, Mueller FO. Catastrophic cheerleading

injuries. Am J Sports Med. 2003;31(6):881–888.

24. Boden BP, Tacchetti R, Mueller FO. Catastrophic injuries in high

school and college baseball players. Am J Sports Med. 2004;32(5):

1189–1196.

25. Toscano J. Prevention of neurological deterioration before admis-

sion to a spinal cord injury unit. Paraplegia. 1988;26(3):143–150.

26. Masini M, Alencar MR, Neves EG, Alves CF. Spinal cord injury:

patients who had an accident, walked but became spinal paralysed.

Paraplegia. 1994;32(2):93–97.

27. Cusick JF, Yoganandan N. Biomechanics of the cervical spine 4:

major injuries. Clin Biomech (Bristol, Avon). 2002;17(1):1–20.

28. Banerjee R, Palumbo MA, Fadale PD. Catastrophic cervical spine

injuries in the collision sport athlete, part 1: epidemiology,

functional anatomy, and diagnosis. Am J Sports Med. 2004;32(4):

1077–1087.

29. Mueller FO, Cantu RC. National Center for Catastrophic Sport

Injury Research: Twenty-Second Annual Report, Fall 1982–Spring

2004. Chapel Hill: University of North Carolina; 2005.

30. Heck JF, Clarke KS, Peterson TR, Torg JS, Weis MP. National

Athletic Trainers’ Association position statement: head-down

contact and spearing in tackle football. J Athl Train. 2004;39(1):

101–111.

31. Andersen J, Courson RW, Kleiner DM, McLoda TA. National

Athletic Trainers’ Association position statement: emergency

planning in athletics. J Athl Train. 2002;37(1):99–104.

32. Crosby E. Airway management after upper cervical spine injury:

what have we learned? Can J Anaesth. 2002;49(7):733–744.

33. Sanchez AR II, Sugalski MT, LaPrade RF. Field-side and

prehospital management of the spine-injured athlete. Curr Sports

Med Rep. 2005;4(1):50–55.

34. Domeier RM, Frederiksen SM, Welch K. Prospective performance

assessment of an out-of-hospital protocol for selective spine

immobilization using clinical spine clearance criteria. Ann Emerg

Med. 2005;46(2):123–131.

35. Domeier RM, Swor RA, Evans RW, et al. Multicenter prospective

validation of prehospital clinical spinal clearance criteria. J Trauma.

2002;53(4):744–750.

36. Holly LT, Kelly DF, Counelis GJ, Blinman T, McArthur DL, Cryer

HG. Cervical spine trauma associated with moderate and severe

head injury: incidence, risk factors, and injury characteristics.

J Neurosurg. 2002;96(suppl 3):285–291.

37. Iida H, Tachibana S, Kitahara T, Horiike S, Ohwada T, Fujii K.

Association of head trauma with cervical spine injury, spinal cord

injury, or both. J Trauma. 1999;46(3):450–452.

38. Cantu RC. The cervical spinal stenosis controversy. Clin Sports

Med. 1998;17(1):121–126.

39. Crosby ET. Airway management in adults after cervical spine

trauma. Anesthesiology. 2006;104(6):1293–1318.

40. De Lorenzo RA. A review of spinal immobilization techniques.

J Emerg Med. 1996;14(5):603–613.

41. Gabbott DA, Baskett PJ. Management of the airway and ventilation

during resuscitation. Br J Anaesth. 1997;79(2):159–171.

42. Lennarson PJ, Smith D, Todd MM, et al. Segmental cervical spine

motion during orotracheal intubation of the intact and injured spine

with and without external stabilization. J Neurosurg. 2000;92(suppl

2):201–206.

43. Bivins HG, Ford S, Bezmalinovic Z, Price HM, Williams JL. The

effect of axial traction during orotracheal intubation of the trauma

victim with an unstable cervical spine. Ann Emerg Med. 1988;17(1):

25–29.

44. Ghafoor AU, Martin TW, Gopalakrishnan S, Viswamitra S. Caring

for the patients with cervical spine injuries: what have we learned?

J Clin Anesth. 2005;17(8):640–649.

45. Kaufman HH, Harris JH Jr, Spencer JA, Kopanisky DR. Danger of

traction during radiography for cervical trauma. JAMA. 1982;

247(17):2369.

46. Lennarson PJ, Smith DW, Sawin PD, Todd MM, Sato Y, Traynelis

VC. Cervical spinal motion during intubation: efficacy of stabiliza-

tion maneuvers in the setting of complete segmental instability.


47. Chang DG, Tencer AF, Ching RP, Treece B, Senft D, Anderson PA.

Geometric changes in the cervical spinal canal during impact. Spine.

1994;19(8):973–980.

48. De Lorenzo RA, Olson JE, Boska M, et al. Optimal positioning for

cervical immobilization. Ann Emerg Med. 1996;28(3):301–308.

49. Kang JD, Figgie MP, Bohlman HH. Sagittal measurements of the

cervical spine in subaxial fractures and dislocations: an analysis of

two hundred and eighty-eight patients with and without neurological

deficits. J Bone Joint Surg Am. 1994;76(11):1617–1628.

50. Muhle C, Bischoff L, Weinert D, et al. Exacerbated pain in cervical

radiculopathy at axial rotation, flexion, extension, and coupled

motions of the cervical spine: evaluation by kinematic magnetic

resonance imaging. Invest Radiol. 1998;33(5):279–288.

51. Muhle C, Weinert D, Falliner A, et al. Dynamic changes of the spinal

canal in patients with cervical spondylosis at flexion and extension

using magnetic resonance imaging. Invest Radiol. 1998;33(8):

444–449.

52. Muhle C, Wiskirchen J, Weinert D, et al. Biomechanical aspects of

the subarachnoid space and cervical cord in healthy individuals

examined with kinematic magnetic resonance imaging. Spine.

1998;23(5):556–567.

53. Tierney RT, Maldjian C, Mattacola CG, Straub SJ, Sitler MR.

Cervical spine stenosis measures in normal subjects. J Athl Train.

2002;37(2):190–193.

54. Tierney RT, Mattacola CG, Sitler MR, Maldjian C. Head position

and football equipment influence cervical spinal-cord space during

immobilization. J Athl Train. 2002;37(2):185–189.

55. Aprahamian C, Thompson BM, Finger WA, Darin JC. Experimen-

tal cervical spine injury model: evaluation of airway management

and splinting techniques. Ann Emerg Med. 1984;13(8):584–587.

56. Goutcher CM, Lochhead V. Reduction in mouth opening with semi-

rigid cervical collars. Br J Anaesth. 2005;95(3):344–348.

57. Johnson DR, Hauswald M, Stockhoff C. Comparison of a vacuum

splint device to a rigid backboard for spinal immobilization.

Am J Emerg Med. 1996;14(4):369–372.

58. Banerjee R, Palumbo MA, Fadale PD. Catastrophic cervical spine

injuries in the collision sport athlete, part 2: principles of emergency

care. Am J Sports Med. 2004;32(7):1760–1764.

59. Holley J, Jorden R. Airway management in patients with unstable

cervical spine fractures. Ann Emerg Med. 1989;18(11):1237–1239.

60. Lord SA, Boswell WC, Williams JS, Odom JW, Boyd CR. Airway

control in trauma patients with cervical spine fractures. Prehosp

Disaster Med. 1994;9(1):44–49.

61. Brimacombe J, Keller C, Kunzel KH, Gaber O, Boehler M,

Puhringer F. Cervical spine motion during airway management: a

cinefluoroscopic study of the posteriorly destabilized third cervical

vertebrae in human cadavers. Anesth Analg. 2000;91(5):1274–1278.

62. Criswell JC, Parr MJ, Nolan JP. Emergency airway management in

patients with cervical spine injuries. Anaesthesia. 1994;49(10):900–903.

63. Hauswald M, Sklar DP, Tandberg D, Garcia JF. Cervical spine

movement during airway management: cinefluoroscopic appraisal in

human cadavers. Am J Emerg Med. 1991;9(6):535–538.

64. Donaldson WF III, Heil BV, Donaldson VP, Silvaggio VJ. The

effect of airway maneuvers on the unstable C1–C2 segment: a

cadaver study. Spine. 1997;22(11):1215–1218.

65. Gerling MC, Davis DP, Hamilton RS, et al. Effects of cervical spine

immobilization technique and laryngoscope blade selection on an

unstable cervical spine in a cadaver model of intubation. Ann Emerg

Med. 2000;36(4):293–300.

66. Majernick TG, Bieniek R, Houston JB, Hughes HG. Cervical spine

movement during orotracheal intubation. Ann Emerg Med.

1986;15(4):417–420.


67. Chandler DR, Nemejc C, Adkins RH, Waters RL. Emergency

cervical-spine immobilization. Ann Emerg Med. 1992;21(10):

1185–1188.

68. Dasen KR. On-field management for the injured football player.

Clin J Sport Med. 2000;10(1):82–83.

69. Hamilton RS, Pons PT. The efficacy and comfort of full-body

vacuum splints for cervical-spine immobilization. J Emerg Med.

1996;14(5):553–559.

70. Podolsky S, Baraff LJ, Simon RR, Hoffman JR, Larmon B, Ablon

W. Efficacy of cervical spine immobilization methods. J Trauma.

1983;23(6):461–465.

71. Luscombe MD, Williams JL. Comparison of a long spinal board

and vacuum mattress for spinal immobilisation. Emerg Med J.

2003;20(5):476–478.

72. Del Rossi G, Horodyski M, Heffernan TP, et al. Spine-board

transfer techniques and the unstable cervical spine. Spine.

2004;29(7):E134–E138.

73. Del Rossi G, Horodyski M, Powers ME. A comparison of spine-

board transfer techniques and the effect of training on performance.

J Athl Train. 2003;38(3):204–208.

74. Del Rossi G, Horodyski MH, Conrad BP, Di Paola CP, Di Paola

MJ, Rechtine GR. The 6–plus-person lift transfer technique

compared with other methods of spine boarding. J Athl Train.

2008;43(1):6–13.

75. Del Rossi G, Heffernan TP, Horodyski M, Rechtine GR. The

effectiveness of extrication collars tested during the execution of

spine-board transfer techniques. Spine J. 2004;4(6):619–623.

76. Donaldson WF III, Lauerman WC, Heil B, Blanc R, Swenson T.

Helmet and shoulder pad removal from a player with suspected

cervical spine injury: a cadaveric model. Spine. 1998;23(16):

1729–1733.

77. Prinsen RK, Syrotuik DG, Reid DC. Position of the cervical

vertebrae during helmet removal and cervical collar application in

football and hockey. Clin J Sport Med. 1995;5(3):155–161.

78. Metz CM, Kuhn JE, Greenfield ML. Cervical spine alignment in

immobilized hockey players: radiographic analysis with and without

helmets and shoulder pads. Clin J Sport Med. 1998;8(2):92–95.

79. Sherbondy PS, Hertel JN, Sebastianelli WJ. The effect of protective

equipment on cervical spine alignment in collegiate lacrosse players.

Am J Sports Med. 2006;34(10):1675–1679.

80. Mihalik JP, Beard JR, Petschauer MA, Prentice WE, Guskiewicz

KM. Effect of ice hockey helmet fit on cervical spine motion during

an emergency log roll procedure. Clin J Sport Med. 2008;18(5):

394–398.

81. Ransone J, Kersey R, Walsh K. The efficacy of the Rapid Form

Cervical Vacuum Immobilizer in cervical spine immobilization of the

equipped football player. J Athl Train. 2000;35(1):65–69.

82. Copeland AJ, Decoster LC, Swartz EE, Gattie ER, Gale SD.

Combined tool approach is 100% successful for emergency football

face mask removal. Clin J Sport Med. 2007;17(6):452–457.

83. Gale SD, Decoster LC, Swartz EE. The combined tool approach for

face mask removal during on-field conditions. J Athl Train.

2008;43(1):14–20.

84. Swartz EE, Armstrong CW, Rankin JM, Rogers B. A 3-dimensional

analysis of face-mask removal tools in inducing helmet movement.

J Athl Train. 2002;37(2):178–184.

85. Swartz EE, Decoster LC, Norkus SA, Cappaert TA. The influence

of various factors on high school football helmet face mask removal:

a retrospective, cross-sectional analysis. J Athl Train. 2007;42(1):

11–20.

86. Swartz EE, Norkus SA, Cappaert T, Decoster L. Football

equipment design affects face mask removal efficiency. Am J Sports

Med. 2005;33(8):1210–1219.

87. Swartz EE, Norkus SA, Armstrong CW, Kleiner DM. Face-mask

removal: movement and time associated with cutting of the loop

straps. J Athl Train. 2003;38(2):120–125.

88. Peris MD, Donaldson WF III, Towers J, Blanc R, Muzzonigro TS.

Helmet and shoulder pad removal in suspected cervical spine injury:

human control model. Spine. 2002;27(9):995–999.

89. Hanson JA, Blackmore CC, Mann FA, Wilson AJ. Cervical spine

injury: a clinical decision rule to identify high-risk patients for helical

CT screening. Am J Roentgenol. 2000;174(3):713–717.

90. Li AE, Fishman EK. Cervical spine trauma: evaluation by multi-

detector CT and three-dimensional volume rendering. Emerg Radiol.

2003;10(1):34–39.

91. Schleehauf K, Ross SE, Civil ID, Schwab CW. Computed

tomography in the initial evaluation of the cervical spine. Ann

Emerg Med. 1989;18(8):815–817.

92. Quencer RM, Nunez D, Green BA. Controversies in imaging acute

cervical spine trauma. Am J Neuroradiol. 1997;18(10):1866–1868.

93. Davidson RM, Burton JH, Snowise M, Owens WB. Football

protective gear and cervical spine imaging. Ann Emerg Med.

2001;38(1):26–30.

94. Veenema K, Greenwald R, Kamali M, Freedman A, Spillane L. The

initial lateral cervical spine film for the athlete with a suspected neck

injury: helmet and shoulder pads on or off? Clin J Sport Med.

2002;12(2):123–126.

95. Waninger KN, Rothman M, Heller M. MRI is nondiagnostic in

cervical spine imaging of the helmeted football player with shoulder

pads. Clin J Sport Med. 2003;13(6):353–357.

96. Guest JD, Vanni S, Silbert L. Mild hypothermia, blood loss and

complications in elective spinal surgery. Spine J. 2004;4(2):130–137.

97. Martinez-Arizala A, Green BA. Hypothermia in spinal cord injury.

J Neurotrauma. 1992;9(suppl 2):S497–S505.

98. Hurlbert RJ. The role of steroids in acute spinal cord injury: an

evidence-based analysis. Spine. 2001;26(suppl 24):S39–S46.

99. Boden BP. Direct catastrophic injury in sports. J Am Acad Orthop

Surg. 2005;13(7):445–454.

100. Nightingale RW, McElhaney JH, Richardson WJ, Best TM, Myers

BS. Experimental impact injury to the cervical spine: relating motion

of the head and the mechanism of injury. J Bone Joint Surg Am.

1996;78(3):412–421.

101. Nightingale RW, McElhaney JH, Richardson WJ, Myers BS.

Dynamic responses of the head and cervical spine to axial impact

loading. J Biomech. 1996;29(3):307–318.

102. Nightingale RW, Camacho DL, Armstrong AJ, Robinette JJ, Myers

BS. Inertial properties and loading rates affect buckling modes and

injury mechanisms in the cervical spine. J Biomech. 2000;33(2):

191–197.

103. Penning L. Kinematics of cervical spine injury: a functional

radiological hypothesis. Eur Spine J. 1995;4(2):126–132.

104. Amevo B, Aprill C, Bogduk N. Abnormal instantaneous axes of

rotation in patients with neck pain. Spine. 1992;17(7):748–756.

105. Yoganandan N, Pintar F, Butler J, Reinartz J, Sances A Jr, Larson

SJ. Dynamic response of human cervical spine ligaments. Spine.

1989;14(10):1102–1110.

106. Nightingale RW, Richardson WJ, Myers BS. The effects of padded

surfaces on the risk for cervical spine injury. Spine. 1997;

22(20):2380–2387.

107. Penning L. Some aspects of plain radiography of the cervical spine in

chronic myelopathy. Neurology. 1962;12:513–519.

108. Torg JS. Cervical spinal stenosis with cord neurapraxia and transient

quadriplegia. Sports Med. 1995;20(6):429–434.

109. Osterholm J. The catecholamine hypothesis of spinal cord injury. In:

Wilkins R, ed. The Pathophysiology of Spinal Cord Trauma.

Springfield, IL: Thomas; 1978:41–45.

110. Osterholm J. The histopathology of the wounded spinal cord. In:

Wilkins R, ed. The Pathophysiology of Spinal Cord Trauma.

Springfield, IL: Thomas; 1978:17–28.

111. Osterholm J, Alderman J, Irvin J. The biochemistry of spinal cord

injury. In: Wilkins R, ed. The Pathophysiology of Spinal Cord

Trauma. Springfield, IL: Thomas; 1978:66–87.

112. National Operating Committee for Standards on Athletic Equip-

ment. About NOCSAE: history and purpose. http://www.nocsae.

org/about/history.html. Accessed April 12, 2008.

113. National Collegiate Athletic Association. Football Rules and

Interpretations. Indianapolis, IN: National Collegiate Athletic

Association; 2008:32.


114. National Operating Committee for Standards on Athletic Equip-

ment. Standard Performance Specification for Recertified Football

Helmets. Overland Park, KS: National Operating Committee on

Standards for Athletic Equipment; 2004:1–2.

115. Torg JS, Vegso JJ, O’Neill MJ, Sennett B. The epidemiologic,

pathologic, biomechanical, and cinematographic analysis of foot-

ball-induced cervical spine trauma. Am J Sports Med. 1990;18(1):

50–57.

116. Boden BP, Prior C. Catastrophic spine injuries in sports. Curr Sports

Med Rep. 2005;4(1):45–49.

117. Tator CH, Provvidenza CF, Lapczak L, Carson J, Raymond D.

Spinal injuries in Canadian ice hockey: documentation of injuries

sustained from 1943–1999. Can J Neurol Sci. 2004;31(4):460–466.

118. Torg JS, Vegso JJ, Sennett B, Das M. The National Football Head

and Neck Injury Registry: 14-year report on cervical quadriplegia,

1971 through 1984. JAMA. 1985;254(24):3439–3443.

119. Kleiner DM, Almquist JL, Bailes J, et al. Prehospital Care of the

Spine-Injured Athlete: A Document From the Inter-Association Task

Force for Appropriate Care of the Spine-Injured Athlete. Dallas, TX:

National Athletic Trainers’ Association; 2001.

120. Balady GJ, Chaitman B, Foster C, Froelicher E, Gordon N, Van

Camp S. Automated external defibrillators in health/fitness facilities:

supplement to the AHA/ACSM Recommendations for Cardiovas-

cular Screening, Staffing, and Emergency Policies at Health/Fitness

Facilities. Circulation. 2002;105(9):1147–1150.

121. Swartz EE, Nowak J, Shirley C, Decoster LC. A comparison of head

movement during back boarding by motorized spine-board and log-

roll techniques. J Athl Train. 2005;40(3):162–168.

122. Weller J, Robinson B, Larsen P, Caldwell C. Simulation-based

training to improve acute care skills in medical undergraduates.

N Z Med J. 2004;117(1204):U1119.

123. Martin M, Scalabrini B, Rioux A, Xhignesse MA. Training fourth-

year medical students in critical invasive skills improves subsequent

patient safety. Am Surg. 2003;69(5):437–440.

124. Cooper DJ, Ackland HM. Clearing the cervical spine in unconscious

head injured patients: the evidence. Crit Care Resusc. 2005;7(3):

181–184.

125. Hankins DG, Rivera-Rivera EJ, Ornato JP, Swor RA, Blackwell T,

Domeier RM, Turtle Creek Conference II. Spinal immobilization in

the field: clinical clearance criteria and implementation. Prehosp

Emerg Care. 2001;5(1):88–93.

126. Demetriades D, Charalambides K, Chahwan S, et al. Nonskeletal

cervical spine injuries: epidemiology and diagnostic pitfalls.

J Trauma. 2000;48(4):724–727.

127. Ross SE, O’Malley KF, DeLong WG, Born CT, Schwab CW.

Clinical predictors of unstable cervical spinal injury in multiply

injured patients. Injury. 1992;23(5):317–319.

128. Ching RP, Watson NA, Carter JW, Tencer AF. The effect of post-

injury spinal position on canal occlusion in a cervical spine burst

fracture model. Spine. 1997;22(15):1710–1715.

129. Carlson GD, Gorden CD, Oliff HS, Pillai JJ, LaManna JC.

Sustained spinal cord compression, part I: time-dependent effect

on long-term pathophysiology. J Bone Joint Surg Am. 2003;85(1):

86–94.

130. Eismont FJ, Clifford S, Goldberg M, Green B. Cervical sagittal

spinal canal size in spine injury. Spine. 1984;9(7):663–666.

131. Delamarter RB, Sherman J, Carr JB. Pathophysiology of spinal cord

injury: recovery after immediate and delayed decompression. J Bone

Joint Surg Am. 1995;77(7):1042–1049.

132. Askins V, Eismont FJ. Efficacy of five cervical orthoses in restricting

cervical motion: a comparison study. Spine. 1997;22(11):1193–1198.

133. James CY, Riemann BL, Munkasy BA, Joyner AB. Comparison of

cervical spine motion during application among 4 rigid immobili-

zation collars. J Athl Train. 2004;39(2):138–145.

134. McCabe JB, Nolan DJ. Comparison of the effectiveness of different

cervical immobilization collars. Ann Emerg Med. 1986;15(1):50–53.

135. Rosen PB, McSwain NE Jr, Arata M, Stahl S, Mercer D.

Comparison of two new immobilization collars. Ann Emerg Med.

1992;21(10):1189–1195.

136. Bednar DA. Efficacy of orthotic immobilization of the unstable

subaxial cervical spine of the elderly patient: investigation in a

cadaver model. Can J Surg. 2004;47(4):251–256.

137. Torg JS, Guille JT, Jaffe S. Injuries to the cervical spine in American

football players. J Bone Joint Surg Am. 2002;84(1):112–122.

138. Gastel JA, Palumbo MA, Hulstyn MJ, Fadale PD, Lucas P.

Emergency removal of football equipment: a cadaveric cervical spine

injury model. Ann Emerg Med. 1998;32(4):411–417.

139. Laprade RF, Schnetzler KA, Broxterman RJ, Wentorf F, Gilbert

TJ. Cervical spine alignment in the immobilized ice hockey player: a

computed tomographic analysis of the effects of helmet removal.

Am J Sports Med. 2000;28(6):800–803.

140. Palumbo MA, Hulstyn MJ, Fadale PD, O’Brien T, Shall L. The

effect of protective football equipment on alignment of the injured

cervical spine: radiographic analysis in a cadaveric model.

Am J Sports Med. 1996;24(4):446–453.

141. Swenson TM, Lauerman WC, Blanc RO, Donaldson WF III, Fu

FH. Cervical spine alignment in the immobilized football player:

radiographic analysis before and after helmet removal. Am J Sports

Med. 1997;25(2):226–230.

142. National Operating Committee on Standards for Athletic Equip-

ment. Standard Performance Specification for Newly Manufactured

Football Helmets. Overland Park, KS: National Operating Com-

mittee on Standards for Athletic Equipment; 2003:1–5.

143. Aprahamian C, Thompson BM, Darin JC. Recommended helmet

removal techniques in a cervical spine injured patient. J Trauma.

1984;24(9):841–842.

144. Ray R, Luchies C, Bazuin D, Farrell RN. Airway preparation

techniques for the cervical spine-injured football player. J Athl

Train. 1995;30(3):217–221.

145. Jenkins HL, Valovich TC, Arnold BL, Gansneder BM. Removal

tools are faster and produce less force and torque on the helmet than

cutting tools during face-mask retraction. J Athl Train.

2002;37(3):246–251.

146. Decoster LC, Shirley CP, Swartz EE. Football face-mask removal

with a cordless screwdriver on helmets used for at least one season of

play. J Athl Train. 2005;40(3):169–173.

147. Ray R, Luchies C, Frens MA, Hughes W, Sturmfels R. Cervical

spine motion in football players during 3 airway-exposure tech-

niques. J Athl Train. 2002;37(2):172–177.

148. Waninger KN, Richards JG, Pan WT, Shay AR, Shindle MK. An

evaluation of head movement in backboard-immobilized helmeted

football, lacrosse, and ice hockey players. Clin J Sport Med.

2001;11(2):82–86.

149. Woodring JH, Lee C. Limitations of cervical radiography in the

evaluation of acute cervical trauma. J Trauma. 1993;34(1):32–39.

150. Spain DA, Trooskin SZ, Flancbaum L, Boyarsky AH, Nosher JL.

The adequacy and cost effectiveness of routine resuscitation-area

cervical-spine radiographs. Ann Emerg Med. 1990;19(3):276–278.

151. Gerrelts BD, Petersen EU, Mabry J, Petersen SR. Delayed diagnosis

of cervical spine injuries. J Trauma. 1991;31(12):1622–1626.

152. Davis JW, Phreaner DL, Hoyt DB, Mackersie RC. The etiology of

missed cervical spine injuries. J Trauma. 1993;34(3):342–346.

153. Poonnoose PM, Ravichandran G, McClelland MR. Missed and

mismanaged injuries of the spinal cord. J Trauma. 2002;53(2):314–320.

154. Griffen MM, Frykberg ER, Kerwin AJ, et al. Radiographic

clearance of blunt cervical spine injury: plain radiograph or

computed tomography scan? J Trauma. 2003;55(2):222–227.

155. Waninger KN, Rothman M, Foley J, Heller M. Computed

tomography is diagnostic in the cervical imaging of helmeted football

players with shoulder pads. J Athl Train. 2004;39(3):217–222.

156. Guest JD, Dietrich WD. Spinal cord ischemia and trauma. In:

Tisherman SA, & Sterz F, eds. Therapeutic Hypothermia. Dordrecht,

The Netherlands: Kluwer Academic Publishers; 2005:101–118.

157. Couzin J. Medicine: the big chill. Science. 2007;317(5839):743–745.

158. Yu CG, Jimenez O, Marcillo AE, et al. Beneficial effects of modest

systemic hypothermia on locomotor function and histopathological

damage following contusion-induced spinal cord injury in rats.



159. Chatzipanteli K, Yanagawa Y, Marcillo AE, Kraydieh S, Yezierski

RP, Dietrich WD. Posttraumatic hypothermia reduces polymor-

phonuclear leukocyte accumulation following spinal cord injury in

rats. J Neurotrauma. 2000;17(4):321–332.

160. Green BA, Khan T, Raimondi AJ. Local hypothermia as treatment

of experimentally induced spinal cord contusion: quantitative

analysis of beneficient effect. Surg Forum. 1973;24:436–438.

161. Busto R, Dietrich WD, Globus MY, Ginsberg MD. Postischemic

moderate hypothermia inhibits CA1 hippocampal ischemic neuronal

injury. Neurosci Lett. 1989;101(3):299–304.

162. Green EJ, Pazos AJ, Dietrich WD, et al. Combined postischemic

hypothermia and delayed MK-801 treatment attenuates neurobe-

havioral deficits associated with transient global ischemia in rats.

Brain Res. 1995;702(1–2):145–152.

163. The Miami Project to Cure Paralysis. Clinical trials initiative:

therapeutic hypothermia for acute spinal cord injury and traumatic

brain injury. http://216.235.203.137//Page.aspx?pid5339. Accessed

May 10, 2008.

164. Bracken MB, Shepard MJ, Collins WF, et al. A randomized,

controlled trial of methylprednisolone or naloxone in the treat-

ment of acute spinal-cord injury: results of the Second National

Acute Spinal Cord Injury Study. N Engl J Med. 1990;322(20):

1405–1411.

165. Kwan I, Bunn F. Effects of prehospital spinal immobilization: a

systematic review of randomized trials on healthy subjects. Prehosp

Disaster Med. 2005;20(1):47–53.

166. Mazolewski P, Manix TH. The effectiveness of strapping techniques

in spinal immobilization. Ann Emerg Med. 1994;23(6):1290–1295.

Appendix A. Clinical Considerations in the ManagementProtocol for the Spine-Injured Athlete: Transfer andImmobilization

FULL-BODY IMMOBILIZATION

To achieve full spinal immobilization during on-the-fieldmanagement of an injury, patients are typically transferredand then secured to a long spine board. The task of moving apatient to a spine board can prove challenging, as the headand trunk must be moved as a unit. Spine boarding athletesmay present additional challenges, from the size of theathlete to equipment considerations to athletic venue barriersor obstacles, such as spine boarding an athlete from aswimming pool, a pole-vault pit, or a gymnastics foam pit.

A variety of techniques exist to move and immobilize theinjured athlete. Rescuers should use the technique that theyhave reviewed and rehearsed and are most comfortable withand, most importantly, that produces the least amount ofspinal movement.

SELECTION OF APPROPRIATE TRANSFER ANDSPINE-BOARDING TECHNIQUES

Supine Log-Roll Technique

When transferring an athlete found in the supineposition to a spine board, the supine log-roll techniquemay be used. The rescuer in charge (rescuer 1) providescervical spine stabilization. Ideally, 3 additional rescuersare positioned on 1 side of the athlete, with rescuer 2 at theshoulders and thorax, rescuer 3 at the hips, and rescuer 4 atthe legs. Rescuer 5 is positioned on the opposite side of theathlete with the spine board. Rescuers 2 through 4 reachacross the athlete and, on command from rescuer 1,carefully roll the athlete toward them while rescuer 5

positions the spine board at a 456 angle beneath the athlete.On command, rescuers 2 through 4 slowly lower the athleteas rescuer 5 controls the spine board. Throughout thisprocess, rescuer 1 provides all commands while maintain-ing manual cervical spine immobilization. The supine log-roll technique may also be used for the athlete found in theside-lying position.

Prone Log-Roll Technique

When transferring an athlete found in the prone positionto a spine board, the prone log-roll technique may be used.Two variations to this technique are the prone log-roll pulland prone log-roll push. In the prone log-roll pull, therescuer in charge (rescuer 1) provides cervical spinestabilization, crossing his or her hands initially, so thatwhen the roll is complete, the hands are uncrossed. Ideally,3 additional rescuers are positioned on 1 side of the athlete,with rescuer 2 at the shoulders and thorax, rescuer 3 at thehips, and rescuer 4 at the legs. Rescuer 1 directs the otherrescuers to position themselves on the appropriate side ofthe athlete. In some instances, the athlete may be pronewith the head turned to 1 side. In this case, rescuer 1 directsrescuers 2 through 4 to position themselves on the sideopposite the athlete’s face. Rescuer 5 is positioned on thesame side as the other rescuers, holding the spine board atthe feet of the athlete. Rescuers 2 through 4 reach acrossthe athlete and, on command from rescuer 1, carefully rollthe athlete by pulling toward them. When the athlete ispulled onto his or her side, rescuers 1 through 4 pause whilerescuer 5 carefully slides the spine board between rescuers 2through 4 and the athlete. On command, rescuers 2through 4 slowly lower the athlete as rescuer 5 controlsthe spine board. Throughout this process, rescuer 1provides all commands while maintaining manual cervicalspine immobilization.

It may be difficult for rescuer 5 to slide the spine boardbetween the athlete and rescuers 2 through 4 withouttouching each other’s arms and possibly jeopardizing theirhold on the athlete. To address this issue, an alternativetechnique is the prone log-roll push, shown in Figure 1.

Lift-and-Slide Technique

An alternative to the log roll is the lift-and-slide transfertechnique. Variations include the 6–plus-person lift and thestraddle lift and slide. In contrast to the log roll, in whichthe athlete is rolled to a side-lying position and the spineboard is positioned beneath him or her, with the lift-and-slide technique the athlete is simply lifted off the ground toallow for spine board placement. The premise behind thelift-and-slide technique is that the work of lifting the athleteis handled efficiently by involving 4 to 7 rescuers. Inaddition, this technique avoids rolling the injured athleteover the arm, as well as over possibly bulky protectiveequipment, and, therefore, this technique may be extremelyeffective at minimizing structural interference that couldresult in unwanted spinal column movements.72,73 The lift-and-slide technique may only be used for supine athletes,whereas a prone athlete must be log rolled for transfer to aspine board.

The 6–plus-person lift is shown in Figure 2. A disadvan-tage of this procedure is that it requires 6 additional rescuers.


An alternative lift technique may be used with 3 rescuerswho straddle the athlete rather than lifting from the side;this is referred to as the straddle lift and slide. With thestraddle lift and slide, rescuer 1 provides cervical spinestabilization. Three additional rescuers straddle the athlete,with rescuer 2 at the upper torso, rescuer 3 at the hips andpelvis, and rescuer 4 at the legs. On command from rescuer1, rescuers 2 through 4 lift the athlete approximately6 inches (15.24 cm) off the ground while rescuer 5 slides thespine board beneath the athlete. On command, rescuers 2through 4 slowly lower the athlete onto the spine board.Throughout this process, rescuer 1 provides all commandswhile maintaining cervical spine immobilization.

Other Alternatives for Transfer and Spine Boarding

Another alternative that may be used for transfer or full-body immobilization is the scoop stretcher. A stretcher thatis hinged on both ends and has telescoping arms may beused to ‘‘scoop’’ the athlete without having to log roll or lifthim or her. As with the lift-and-slide technique, the scoopstretcher may only be used on athletes in the supineposition. With the scoop stretcher, the rescuer in charge(rescuer 1) provides cervical spine stabilization. Twoadditional rescuers, rescuers 2 and 3, position the stretcher.Rescuers 2 and 3 first adjust the length of the stretcher tothe athlete using the telescoping arms. Because thestretcher is hinged at both ends, 2 different techniques

may be used. Rescuers 2 and 3 may open both hinges,separating the stretcher into 2 sections. Rescuer 2 positionsthe stretcher from one side, carefully sliding the stretcherbeneath the athlete, while rescuer 3 does the same from theother side. They then work together to align the hinges andreconnect the scoop stretcher. An alternate technique is toopen only one hinge and spread the scoop stretcher open inthe shape of a ‘‘V,’’ position the stretcher at one end of theathlete, and then carefully close it, sliding the stretcherbeneath the athlete and reconnecting the open hinge. Theathlete may be secured to the scoop stretcher itself or, oncethe athlete is on the scoop stretcher, the lift-and-slidetechnique may be used. Rescuers raise the stretcher as aunit from both sides and slide a spine board beneath thescoop stretcher. The athlete may then be secured to thespine board. When using the scoop stretcher, rescuersshould be aware that it may be difficult to close and securethe hinge at the top of the stretcher without interfering withrescuer 1’s maintenance of cervical spine stabilization. Itmay be necessary for a rescuer to assume cervical spinecontrol from the front of the athlete for rescuer 1 to allowfor the top hinge to be secured. Additionally, it may bedifficult to close the hinge(s) on heavier athletes as a resultof their weight or on athletes who are wearing protectivegear, such as shoulder pads.

Another alternative used for transfer or spine boarding isvacuum immobilization. The vacuum-immobilization systemis based upon the same principle as extremity vacuum splints.

Figure 1. The prone log-roll push technique. A, Rescuer 1 provides cervical spine stabilization. Rescuers 2 through 4 are positioned onthe side the athlete’s head is facing. Rescuer 5 is on the opposite side, holding the spine board. B, Rescuers 2 through 4 reach across theathlete and, on command from rescuer 1, carefully roll the athlete away from them by pushing toward rescuer 5, who positions the spineboard at a 456 angle beneath the athlete. C and D, Rescuers 2 through 4 slowly lower the athlete as rescuer 5 controls the spine board.


Originally developed in Europe, the vacuum-immobilizationsystems for the spine are now available in the United States.The system is composed of a large nylon shell filled with tinyStyrofoam (The Dow Chemical Co, Midland, MI) beads.The system is spread out flat, and an air pump is used towithdraw air from the shell, making it semirigid. The athleteis then placed on the system, using either the log-roll or lift-and-slide technique. Air is pumped into the shell and thesystem conforms to the athlete. Then air is again withdrawn,creating a custom, form-fitted, full-body splint. Straps arebuilt into the system to secure the athlete. An advantage ofthe vacuum-immobilization system is athlete comfort,71 as aresult of the softness of the Styrofoam bead shell and thecustom fit, which protects areas of bony prominence (eg,scapula, pelvis) that may develop pain and ischemic injuryfrom prolonged compression on a hard surface, such as astandard spine board. The system also provides support tocontour areas, such as the lumbar spine, buttocks, andpopliteal fossa. Disadvantages are the size of the system,which renders it cumbersome, and the semirigidity of thesystem. The lift-and-slide technique may be better suited forthe vacuum-immobilization system’s semirigidity; however,the large size of the system may make it difficult to slidebetween the rescuers on either side.

Another technique that may be used for transfer or spineboarding is a short-board system such as the KendrickExtrication Device (KED; Ferno, Wilmington, OH).Traditionally used by emergency medical services person-nel for vehicle extrication, the short board may be placed

on a patient who is seated or has a flexed trunk. Thistechnique may be useful in immobilizing athletes positionedawkwardly or where equipment barriers exist, such as in thegymnastics pit or pole-vault pit. A systematic review ofprehospital spinal immobilization by Kwan and Bunn165

showed a reduction in motion reported with the short-boardtechnique compared with cervical-collar immobilization.With the short-board technique, rescuer 1 stabilizes thecervical spine from the front of the patient while rescuer 2positions the short board behind the patient. Straps are usedto secure the short board to the patient’s chest, abdomen,and hip, and the last straps, with or without tape, secure thehead to the board. Once immobilized with the short board,the patient may be extricated and then placed on andsecured to a long spine board.

REPOSITIONING AFTER TRANSFER TO THESPINE BOARD

In many cases, the athlete’s position on the spine boardafter the initial spine-boarding procedure may not be idealfor securing him or her appropriately, particularly whenusing the log-roll technique. Therefore, it may be necessaryto reposition the athlete to assure proper placement. Afterthe initial spine-board placement, rescuer 1 assesses theathlete’s overall position on the spine board. The athleteshould never be moved perpendicular to the long axis ofthe board to avoid shearing and the possibility of spinalcolumn movement. Instead, the athlete should be moved

Figure 3. Repositioning after transfer to the spine board. A, Rescuer 1 provides cervical spine stabilization. B, The other rescuers straddlethe athlete and C, slide the athlete into position on command.

Figure 2. The 6–plus-person lift. A, Rescuer 1 provides cervical spine stabilization. Rescuers 2 through 4 are positioned on one side at theshoulders and thorax, hips, and legs, respectively; rescuers 5 through 7 are positioned similarly on the other side. Rescuer 8 is at theathlete’s feet with the spine board. B, On command from rescuer 1, rescuers 2 through 7 lift the athlete approximately 6 inches off theground, while rescuer 8 slides the spine board beneath the athlete. C, Rescuers 2 through 7 slowly lower the athlete onto the spine board.


cephalad or caudad at an angle, depending on his or herposition on the spine board. When repositioning, rescuer 1provides specific commands: ‘‘On the count of 3, we aregoing to slide the athlete up and to the right … ready … 1… 2 … 3.’’ The rescuers sliding the athlete may eitherstraddle the athlete (Figure 3) or position themselves onboth sides and slide from the sides. Throughout thisprocess, rescuer 1 provides all commands while maintain-ing cervical spine immobilization.

Head Immobilization

A variety of head-immobilization options are availablefor securing the athlete to a spine board, includingcommercial devices, contoured helmet blocks, foam blocks,and towel rolls. Although once used extensively, sand bagsare no longer recommended as head-immobilization devicesbecause of their weight. If the spine board must be turned onits side, the sand bags will move the head laterally,compromising the cervical spine. Rescuers should selectthe head- immobilization technique with which they aremost comfortable and be skilled in the use of that particulartechnique. The head should always be the last part secured tothe spine board. Once the selected head-immobilizationdevice stabilizes the head, either tape or hook-and-loopstraps secure the head to the spine board. Two separatepoints of contact at the chin and the forehead78 should besecured to prevent as much head and neck motion aspossible. The tape or strap at the forehead should be placedat the level of the eyebrows to avoid slipping off the roundedtop of the head. When using tape to secure the forehead, therescuer applies the tape circumferentially for additionalstability. The rescuer tears off a strip of tape approximately4 ft (1.22 m) in length and ‘‘shimmies’’ the tape beneath thespine board, holding a tape end in each hand. One side oftape is pulled across the forehead at the level of theeyebrows, followed by the other side across the first piece(Figure 4). During this process, it may be necessary for arescuer to assume cervical spine control from the front of theathlete for rescuer 1 to allow the head to be properly secured.

Types of Spine Boards and Full-BodyImmobilization Devices

A variety of spine boards and full-body immobilizationdevices exist. The most commonly used device is thestandard spine board. In the past, these boards weretypically wood; however, most spine boards today areconstructed of lighter fiberglass or a similar composite,offering increased strength and durability and easiercleaning, which is particularly important in light ofbloodborne pathogens. Oversize spine boards to accom-modate larger athletes should be considered based uponthe athletic population being covered.

Rigid spine boards may be equipped with nonabsorbentpadding. A patient strapped to spine boards may berestrained for several hours throughout the hospitalemergency department evaluation and diagnostic testingprocess. Areas of bony prominence (eg, scapula, pelvis)may develop pain and ischemic injury from prolongedcompression on a hard surface. Padding may help toreduce this, making the athlete more comfortable.

Most spine boards are the traditional rectangular shapeand have cutouts that serve both as handles and sites to secure

straps. Some spine boards are contoured on the bottom withtapered edges to facilitate placing straps and hands into thecutouts, particularly when the spine board is on a soft surface,such as a grass field, on which the weight of the athlete canpress the spine board into the ground (Figure 5).

Spine-Board Kit

Individuals responsible for the emergency care ofathletes should prepare a spine-board kit to be maintained

Figure 4. Head immobilization. A, Once the athlete is positionedproperly, the rescuer ‘‘shimmies’’ a 4-ft (1.22-m) length of tapeunder the spine board. B, One side of the tape is pulled across theforehead at the level of the eyebrows, followed by the other sideacross the first piece.


with the spine board. This kit should contain necessarysupplies, such as a head-immobilization device, cervicalcollar, face-mask removal tools for sports in which helmetsare worn (ideally on the rescuer’s person during competi-tion), straps to secure the athlete to the board, wrist strapsto secure the athlete’s hands together, tape, and varioussizes of padding or toweling. In many cases, padding maybe necessary for filling in gaps or spaces to maintain properspinal column positioning.

Strapping Options and Techniques

Once the athlete is positioned on the spine board,securing with adequate strapping is essential to minimizeexcess movement during transport and transfers. A varietyof strapping options exist, ranging from tape to thetraditional 3-strap technique (chest, pelvis, and thighs), tospider straps to speed clips. When securing the athlete tothe spine board, the arms should be kept free to facilitate avariety of diagnostic and treatment techniques. Once thetorso is secured to the spine board, the hands may beplaced together on top of the body using hook-and-loopwrist straps or tape.

In strapping the body to the spine board, the rescuersshould use a technique to restrain the athlete as securely aspossible. If the athlete vomits, which may occur with aclosed head injury, the spine board may need to be turnedto the side to allow airway clearance. Proper strapping willminimize lateral movement.

Rescuers should also consider strapping in terms ofambulance transport. With stopping and starting of thevehicle, the athlete may move axially or caudally on theboard if not properly secured: such movement placesadditional stress on the cervical spine. To address this, 2straps may be crossed in an ‘‘X’’ pattern below one axillaand across the body above the opposite shoulder; theprocess is repeated on the other side. Additionally,specifically placed strapping should be added to thetorso to reduce lateral motion on a backboard.166 A 7-strap system provides excellent stabilization on the spineboard:

Straps 1 and 2: ‘‘X’’ at the chest and run across

the shoulders

Strap 3: across chest

Straps 4 and 5: ‘‘X’’ across pelvis

Strap 6: across mid-thighs

Strap 7: across mid-lower legs

MANAGING THE COMBATIVE ATHLETE

As a result of the mechanism of injury, some athleteswith cervical spine injuries may have concurrent closedhead injuries. In this situation, rescuers may encounter acombative athlete who resists immobilization techniques,whether consciously or reflexively. This creates a problemfor the rescuers, who should be aware that attempts tomanually restrain a patient’s head against his or her willmay increase the stresses placed upon the patient’s cervicalspine. Rescuers should attempt to calm the patient andminimize movement as much as possible based upon theindividual circumstances.

Appendix B. Clinical Considerations in the ManagementProtocol for the Equipment- Laden Athlete With a Spine Injury

FACE-MASK REMOVAL

Combined-Tool Approach

In equipment-laden sports, the face mask is secured tothe helmet via loop straps that are screwed into the shell ofthe helmet with a screw and T-nut configuration. Thisarrangement can vary in style or number both within andbetween different types of sports. When the face mask mustbe removed from the helmet, the tool and techniqueselected should be those that create the least head and neckmotion, are the fastest and easiest to use, and that imposethe lowest chance of failure. For football helmets, authorshave reported that a screwdriver, or cordless screwdriver, isfaster,86,144,145 easier to use,86 and creates less torque145 andmotion86 at the head than many of the cutting toolscommonly used to remove the face mask. However, screwremoval can fail, and problems with the helmet hardware(screws, T-nuts), such as corrosion and rust, can cause thescrew face to shred, allowing the T-nut to spin with thescrew while turning or even to become so rusted as to fusethe hardware pieces together, preventing them fromturning at all.85 Therefore, a combined-tool approachprovides the rescuer the added security of using a backupcutting tool, but only when necessary.

In describing the combined-tool approach to face-maskremoval, we use the example of a football helmet face maskthat is attached with 4 separate loop-strap attachments. Werefer to the loop-strap locations under the earholes as theleft side and right side loop strap or screw locations and theloop straps located at the forehead as the left top and righttop loop strap or screw locations.

1. First attempt face-mask removal using a screwdriver.

a. The 2 side loop straps should be removed first. The

top loop straps are then removed. This order

prevents the face mask from rotating down onto

the athlete’s face or throat. Once all the screws are

withdrawn far enough that they are totally

Figure 5. Long spine-board handle designs. The board in the lefthand has a beveled bottom, whereas the board in the right hand hasrecessed handles.


removed from the T-nut holding the face mask in

place on the underside of the helmet shell, the face

mask is simply lifted away, usually with the loop

straps still attached to the face mask.

b. 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

(Figure 6).

c. If, when attempting to remove the screws from the

helmet, 1 or more screws cannot be unscrewed,

skip to the next screw until all screws that can

successfully be unscrewed are removed.

2. Use a backup cutting tool to cut away any remaining

loop strap(s) (Figure 7).

a. Ensure that the cutting tool chosen will success-

fully cut the loop straps of the helmets currently

worn by the football team or teams being covered.

Not all face-mask removal tools will remove all

helmet or loop-strap combinations.86 If the home-

team athletic trainer is the primary caregiver for

the visiting team, he or she should identify the

equipment used by the visitors and have the

appropriate removal tools available.

b. In some traditional helmets with standard loop

straps, the face mask can be rotated to the side,

leaving more of the loop strap exposed for easier

access with the cutting tool. This technique will

not work on all helmet models.

c. The proper technique for cutting loop straps

should be used with the chosen removal tool.

For example, the Trainers Angel removal tool

differs significantly in its cutting mechanism from

the FM Extractor. Removal tools often come with

instructions for their use. These should be followed

and the techniques practiced thoroughly.

d. Loop straps should be cut in such a way as to

ensure that the face mask can easily be lifted away

from the helmet without loop-strap remnants

obstructing removal. Sometimes, more often with

the top loop-strap locations, a complete-thickness

cut can be made through the entire loop strap. In

other cases, it may be necessary to cut a ‘‘window’’

in the loop strap to allow the face-mask bar to be

easily extracted; depending on the type of loop

strap, at least 2 cuts are required.

e. Practicing face-mask removal is extremely important

if cutting loop straps will be the chosen approach, as

removing loop straps from face masks using cutting

tools can be a difficult skill to perform.86

Fortunately, athletic trainers can do much to increasethe chances that a screwdriver will be successful in removinga screw and the face mask from a helmet. Weather-relatedfactors have less effect on successful face-mask removalusing a screwdriver than other factors that are under humancontrol.85 With the use of corrosion-resistant hardware inthe helmet, more regular equipment maintenance, and

annual reconditioning, the chances of all 4 screws beingsuccessfully removed from the helmet increase.

As helmet, face-mask, and tool designs change, so too maythese recommendations. For example, a recently developedface-mask attachment system in football helmets incorpo-rates quick-release loop-strap attachments. To remove theloop straps, the quick-release mechanism is triggered byusing the appropriately sized, pointed end of a tool to depressa button, which detaches the T-nut from the inside of thehelmet (Figure 8). With any current or future developmentsin equipment and design, the goal for face-mask removal willalways be to perform the task in an efficient manner in orderto protect the athlete as much as possible during themanagement process and to do no further harm.

HELMET AND SHOULDER-PAD REMOVAL

Removal of either the helmet or shoulder pads may benecessary when such equipment prevents access to theairway or chest for primary life-support measures. Equip-ment removal may also be necessary if the helmet andshoulder pads do not maintain neutral cervical spine or

Figure 6. Face-mask removal. Placing the thumb behind the toploop strap while unscrewing the screw allows the loop strap to belifted away once the screw is separated from the T-nut on theunderside of the helmet. Reprinted with permission from Gale SD,Decoster LC, Swartz EE. The combined tool approach for face maskremoval during on-field conditions. J Athl Train. 2008;43(1):14–20.


provide adequate immobilization of the head. Equipmentdesign varies considerably, both among and withinequipment-laden sports. This variability requires emergen-cy responders to familiarize themselves with the nuancesinherent in individual helmet and shoulder-pad models.The following are general guidelines offered to facilitate anapproach to helmet and shoulder-pad removal.

1. The chin strap is removed from the helmet. Cutting

away the chin strap is preferable to unsnapping it to

avoid unnecessary movement.

2. Cheek pads should be removed from helmets if they

interfere with the ability to remove the helmet from

the head. Not all cheek pads in all types of helmets

interfere with the ability to remove the helmet, so this

step can be skipped with certain helmets. However,

whether this step is necessary should be determined in

advance. The method for removing cheek pads may

differ based upon the type of helmet:

a. Some cheek pads are snapped into place and may

be detached using a thin, rigid object, such as a

tongue depressor, bite stick, or scissor tip.

b. Some cheek pads are secured with hook-and-loop

straps and may also be removed by sliding a thin,

rigid object between the strap sections.

c. Some cheek pads may require cutting with scissors

for complete removal.

3. If the helmet contains air bladders, the air should be

drained with a deflation needle or blade to loosen the

fit of the helmet and facilitate removal.

4. Before helmet removal, cervical spine stabilization

should be transferred from the rescuer at the head to

another rescuer, who assumes cervical spine control

from the front. The rescuer at the head then grasps

the helmet at the sides and gently removes it from the

athlete. Slightly spreading the helmet from the sides

and rotating the helmet up while sliding it off the

head may facilitate removal. However, these tech-

niques should be practiced in advance to ensure

they enhance, rather than inhibit, helmet removal

(Figure 9).

5. Once the helmet is removed, a cervical collar is placed on

the athlete before the shoulder pads are removed. Padding

may also need to be placed underneath the head to avoid

dropping the head and cervical spine into extension.

Figure 7. The backup cutting tool is used to cut away anyremaining loop straps.

Figure 8. Quick-release loop-strap attachments. A, The quick-release mechanism is triggered by depressing the button. B, The T-nut isthen detached from the inside of the helmet.


6. Any uniform top or jersey worn over the shoulder

pads should be cut away before removing them. Using

scissors, cut along the midline of the jersey, as well asout through each sleeve.

7. Cut through the strings or disconnect or cut through

the plastic buckles in front of the shoulder pads.

8. Be aware of additional equipment that may be

secured to the shoulder pads, such as rib pads or

collars.

9. Remove the shoulder pads using one of the following

techniques or a suitable alternative:

a. A standard technique requires transfer of cervical

spine control from the rescuer at the head to

another rescuer, who assumes cervical spine

control from the front. The rescuer at the head

then carefully removes the shoulder pads bysliding them out from under the athlete.

b. An alternative technique requires cutting the

shoulder pads in the front and, if possible, in the

back to split the pads into 2 sections. This

technique does not require the helmet to be

removed first but must be planned in advance, so

that the cut in the back of the shoulder pads can be

made during a log-roll maneuver. Once bothsections of pads have been cut, simply pull apart

from the sides while the rescuer at the head

maintains cervical spine stabilization.

Address correspondence to National Athletic Trainers’ Association, Communications Department, 2952 Stemmons Freeway, Dallas, TX75247.

Figure 9. Helmet removal. A, Cervical spine stabilization is transferred from the rescuer at the athlete’s head to another rescuer, whoassumes control from the front. The rescuer at the head grasps the helmet at its sides and B and C, gently removes it from the athlete.



Journal of Athletic Training 2004;39(1):101–111q by the National Athletic Trainers’ Association, Incwww.journalofathletictraining.org

National Athletic Trainers’ AssociationPosition Statement: Head-Down Contact andSpearing in Tackle FootballJonathan F. Heck*; Kenneth S. Clarke†; Thomas R. Peterson‡;Joseph S. Torg§; Michael P. Weis\

*Richard Stockton College, Pomona, NJ; † SLE Worldwide, Inc, Fort Wayne, IN (Retired); ‡University of Michigan,Ann Arbor, MI (Retired); §Temple University, Philadelphia, PA; \MCRC Physical Therapy, West Orange, NJ

Jonathan F. Heck, MS, ATC, Kenneth S. Clarke, PhD, Thomas R. Peterson, MD, Joseph S. Torg, MD, and Michael P. Weis,PT, ATC, contributed to conception and design; acquisition and analysis and interpretation of the data; and drafting, criticalrevision, and final approval of the article.Address correspondence to National Athletic Trainers’ Association, Communications Department, 2952 Stemmons Freeway,Dallas, TX 75247.

Objective: To present recommendations that decrease therisk of cervical spine fractures and dislocations in football play-ers.

Background: Axial loading of the cervical spine resultingfrom head-down contact is the primary cause of spinal cordinjuries. Keeping the head up and initiating contact with theshoulder or chest decreases the risk of these injuries. The 1976rule changes resulted in a dramatic decrease in catastrophiccervical spine injuries. However, the helmet-contact rules arerarely enforced and head-down contact still occurs frequently.

Our recommendations are directed toward decreasing the in-cidence of head-down contact.

Recommendations: Educate players, coaches, and officialsthat unintentional and intentional head-down contact can resultin catastrophic injuries. Increase the time tacklers, ball carriers,and blockers spend practicing correct contact techniques. Im-prove the enforcement and understanding of the existing hel-met-contact penalties.

Key Words: catastrophic injuries, cervical spine, head inju-ries, injury prevention, neck injuries, paralysis, quadriplegia

Catastrophic cervical spine injuries (CSIs) resulting inquadriplegia (paralysis of all 4 extremities) are amongthe most devastating injuries in all of sport. In football,

the primary mechanism for these injuries is axial loading thatoccurs, whether intentional or unintentional, as a result ofhead-down contact and spearing. Head-first contact also in-creases the risk of concussion and closed head injury. In 1976,the National Collegiate Athletic Association (NCAA) and theNational Federation of State High School Associations(NFSHSA) changed their football rules to broaden the conceptof spearing to include any deliberate use of the helmet as theinitial point of contact against an opponent. They did this inan effort to reduce the incidence of catastrophic CSIs.

Subsequent data on the occurrence of quadriplegia in or-ganized football dramatically demonstrated that the NCAAand NFSHSA rule changes were successful. The incidence hasremained at a relatively low level, with a mild increase at theend of the 1980s (Figure 1). However, in spite of this accom-plishment, head-down contact still occurs frequently. The hel-met-contact penalties also are not enforced adequately. Clear-ly, a reduction in the incidence of head-down contact andincreased enforcement of the existing rules will further reducethe risk of both paralytic and nonparalytic injuries.

The purpose of this position statement is to (1) provide sci-entifically proven concepts and recommendations to minimizethe risk of catastrophic CSIs in football; (2) clarify that head-

down contact and spearing pose a risk to all positional playersregardless of intent; (3) establish the value and necessity ofongoing educational practices for players, coaches, and offi-cials regarding dangerous and proper playing techniques; and(4) emphasize that increasing safety depends on the partici-pation of sports medicine professionals, coaches, players, of-ficials, administrators, and governing bodies.

RECOMMENDATIONS

The National Athletic Trainers’ Association (NATA) rec-ommends the following regarding head-down contact andspearing in football. These recommendations should be con-sidered by sports medicine professionals, coaches, players, of-ficials, administrators, and governing bodies who work withathletes at risk for cervical spine injuries.

Practices and Concepts

1. Axial loading is the primary mechanism for catastrophicCSI. Head-down contact, defined as initiating contact withthe top or crown of the helmet, is the only technique thatresults in axial loading.

2. Spearing is the intentional use of a head-down contact tech-nique. Unintentional head-down contact is the inadvertentdropping of the head just before contact. Both head-down

102 Volume 39 • Number 1 • March 2004

Figure 1. Incidence of quadriplegia in high school and college athletes. Data from the National Football Head and Neck Injury Registry(1976–1991) and the National Center for Catastrophic Sports Injury Research (1992–present).1–4

Figure 2. Head-down contact poses significant risks of catastroph-ic cervical spine injury. This defensive back (dark jersey) sustainedfractures of his 4th, 5th, and 6th cervical vertebrae. The hit resultedin quadriplegia.

Figure 3. Initiating contact with the shoulder while keeping thehead up reduces the risk of catastrophic injury, as demonstratedby the blocker and potential tackler.

techniques are dangerous and may result in axial loadingof the cervical spine and catastrophic injury (Figure 2).

3. Catastrophic CSI resulting from axial loading is neithercaused nor prevented by players’ standard equipment.

4. Injuries that occur as a result of head-down contact aretechnique related and are preventable to the extent thathead-down contact is preventable.

5. Attempts to determine a player’s intent regarding intention-al or unintentional head-down contact are subjective.Therefore, coaching, officiating, and playing techniquesmust focus on decreasing all head-down contact, regardlessof intent.

6. Catastrophic CSI occurs most often to defensive players.However, all players are at risk. Ball carriers and blockers


Figure 4. Incidence of cervical fractures and dislocations in high school athletes. Data from the National Football Head and Neck InjuryRegistry.

have also become quadriplegics by lowering their heads atcontact. Expanding the concept of head-down contact be-yond tackler spearing and the ‘‘intentional attempt to pun-ish an opponent’’ will decrease the risk of serious injury toplayers in other positions.

7. As emphasized in the college and high school rule books,making contact with the shoulder or chest while keepingthe head up greatly reduces the risk of serious head andneck injury. With the head up, the player can see when andhow impact is about to occur and can prepare the neckmusculature for impact. Even if inadvertent head-first con-tact is made, then the force is absorbed by the neck mus-culature, the intervertebral discs, and the cervical facetjoints. This is the safest contact technique.

8. Each time a player initiates contact with his head down, herisks paralysis. Therefore, increased attention to the fre-quency of head-down contact occurring in games and prac-tices is needed. It is a reasonable conclusion that a reduc-tion in the cause (head-down contact) will further reducethe effect (catastrophic CSI).

9. Data collection on all catastrophic CSIs is important. At-tention to the number of nonparalytic cervical spine frac-tures and dislocations is needed, as each incident has thepotential for paralysis. These data are less reliable and hard-er to obtain than data for paralytic injuries. Both injurytypes require diligent reporting to the National Centerfor Catastrophic Sports Injury Research (mailing address:CB 8700, 204 Fetzer Gymnasium, University of NorthCarolina, Chapel Hill, NC 27599-8700, e-mail:[email protected]).

Rules and Officiating

10. Officials should enforce the existing rules to further re-duce the incidence of head-down contact. A clear discrep-ancy exists between the incidence of head-down/head-firstcontact and the level of enforcement of the helmet-contactpenalties. Stricter officiating would bring more awarenessto coaches and players about the effects of head-downcontact.

11. The current annual education programs for all officialsshould emphasize the purpose of the helmet-contact rulesand the dangers associated with head-down/head-first con-tact. Emphasis should be on the fact that the primary pur-pose of the helmet-contact penalties is to protect the ath-lete who leads with his head. Although the technique isdangerous to both players, it is the athlete who initiateshead-down contact who risks permanent quadriplegia.

12. Not all head-first contacts that result in serious injury areintentional. A major area of concern for officials remainsapplication of the penalties to athletes who unintentionallyinitiate contact with their helmets. Athletic governing bod-ies should address this issue in order to improve penaltyenforcement.

13. Athletic governing bodies should coordinate a protocol todocument and quantify all penalties called through theirorganizations. This will identify the enforcement level ofthe helmet-contact penalties.

14. Athletic governing bodies should periodically survey theirfootball officials regarding their interpretations and per-ceptions of the helmet-contact rules. Existing rules and


Table 1. Available Videos

Title Available From

Prevent Paralysis: Don’t HitWith Your Head 5

See What You Hit 6

Dick Lester, Riddell IncE-Mail: [email protected]: FreeThe Spine in Sports Founda-tionwww.spineinsports.orgCost: Free

Spine Injury Management 7 Human Kineticswww.humankinetics.comCost: $39.95

comments need to specifically include the ball carrier inthe application of these penalties.

15. Those preparing the football rule books should considerrevising the wording ‘‘blocking and tackling techniques’’with ‘‘contact techniques’’ (or similar). This revised word-ing would then include all position players and all typesof contact.

16. A task force of athletic trainers, coaches, team physicians,officials, and league administrators should be developedat all levels of play to monitor rule enforcement and thefrequency of head-down contact by an annual, randomreview of game films.

Education and Coaching

17. The athlete should know, understand, and appreciate therisk of making head-down contact, regardless of intent.Formal team educational sessions (conducted by the ath-letic trainer or team physician or both with the support ofthe coaching staff) should be held at least twice per sea-son. One session should be conducted before contact be-gins and the other at the midpoint of the season. Parentsshould be invited to the first educational session at thehigh school level. Recommended topics are mechanismsof head and neck injuries, related rules and penalties, theincidence of catastrophic injury, the severity and prog-nosis of these injuries, and the safest contact positions.The use of videos such as Prevent Paralysis: Don’t HitWith Your Head,5 See What You Hit,6 or the preventionportion of Spine Injury Management7 should be manda-tory (Table 1). The use of supplemental media and ma-terials are strongly recommended.

18. Correct contact technique should be taught at the earliestorganized level. Pop Warner, Midget, and Pee Wee foot-ball leagues should perpetually emphasize the importanceof coaching and teaching heads-up football.

19. It is crucial that educational programs extend to the tele-vision, radio, and print media for both local and nationalaffiliates regarding the dangers of head-down contact andthe reasons for the helmet-contact rules. This will promoteawareness of these issues and provide extended educationto viewers, listeners, and readers.

20. Initiating contact with the shoulder/chest while keepingthe head up is the safest way to play football. The gamecan be played aggressively with this technique with muchless risk of serious injury (Figure 3). However, it is atechnique that must be learned. To be learned, it must bepracticed extensively. Athletes who still drop their head

just before contact require additional practice time. It isimperative for coaches to teach, demonstrate, and practicethis technique throughout the year for all position players.Specific emphasis should be placed on contact techniquesat least 4 times spread over the entire season. Tacklers,ball carriers, and blockers must receive practice time untilit is instinctive to keep the head up.

21. Initiating contact with the face mask is a rules violationand must not be taught. If the athlete uses poor techniqueby lowering his head, he places himself in the head-downposition and at risk of serious injury.

22. Every coaching staff must display and implement a clearphilosophy regarding the reduction of head-down contact.The head coach should clearly convey this philosophy tothe assistant coaches and the entire team and pursue anenforcement policy during practice. A player’s techniquemust be corrected anytime he is observed lowering hishead at contact. Coaches should also use weekly gamefilm reviews to provide players with feedback about theirhead positions.

23. Athletes should have a year-round supervised neck-strengthening program with appropriate equipment andtechniques. Although the role of strength training is sec-ondary to correcting contact technique in axial-loading in-jury prevention, it provides the strength and endurancerequired to maintain the neck in extension. It also providesprotection against cervical nerve root neurapraxia (burn-ers).

24. Schools, responsible administrators, and the sports medi-cine team should recognize cyclic turnover in coaches andestablish programs that educate new and re-educate exist-ing coaches to appropriate teaching and practicing meth-ods. This will provide a documented and consistent ap-proach to the prevention of these injuries.

HISTORY AND BACKGROUND

In 1931, the American Football Coaches Association com-piled the first Football Fatality Report.8 By 1962, its findingscaused the American Medical Association Committee on Med-ical Aspects of Sports to host a national conference on headprotection for athletes.8 The conference convened the principalauthorities of that era in what was emerging as ‘‘sports med-icine’’ to discuss the current issues involving changes in thefootball helmet and the advent of the football face mask. Thefocus was the rapidly rising fatality rate among high schooland college football players suffering from closed head inju-ries. Football authorities were divided as to whether the newprotective headgear was good for the sport.

Into the 1970s, opinion was more prevalent than scientificdata in addressing these problems. The American Medical As-sociation Committee arrived at a collective expert opinion andencouraged pragmatic scholarly attention to the health andsafety issues within sport. Among the recommendations re-sulting from the 1962 conference were condemning the prac-tice of spearing and the need for research to develop standardsfor football helmets.9 Initially, spearing was defined by rule as‘‘intentionally and maliciously striking the opponent withone’s helmet after the opponent had been downed.’’

After the 1962 conference, Blyth from the University ofNorth Carolina assumed the data collection for the FatalityReport of the America Football Coaches Association.10 Hel-met manufacturers began to sponsor research on impact stan-


dards for helmets, and high school and college rules commit-tees confirmed that spearing was an illegal form of footballcontact after the whistle.

American Medical Association Position Statement

The practice of teaching ‘‘face into the numbers’’ was grow-ing in the 1960s as the helmets evolved and coaches felt thatplayers could therefore better withstand the use of the hel-meted head.8,11,12 ‘‘Face into the numbers’’ was increasinglypopular, because it allowed the blocker or tackler to keep hiseyes forward and neck ‘‘bulled’’ and to move with the oppo-nent, without having the intent to spear.8 In essence, coachesconsidered using the helmet as the primary point of contact asuperior technique.

In 1967, however, the American Medical Association Com-mittee on Medical Aspects of Sports declared, in a groundbreak-ing position statement, its opinion that most spearing was un-intentional and non-malicious, ie, ‘‘inadvertent.’’11 It identifiedthe flaw with teaching ‘‘face-into-the-numbers’’ contact. Ath-letes do not always execute with precision, and the tendency toduck the head at contact is natural. This position statement wasadopted by the NFSHSA as a joint statement in 1968.

Football Helmet Standards

In spite of this timely recognition of unsafe head position,the annual football fatality data reports revealed a continuedrise in frequency during the 1960s.10 Although it was reportedthat the risk of death from football did not exceed the actuarialrisk of death among males of that age in non-football activi-ties,13 the need for helmet design standards became more andmore evident.

Consequently, the helmet manufacturers agreed in 1969 topool their resources through a newly devised interdisciplinaryNational Operating Committee for Safety in Athletic Equip-ment (NOCSAE).8 This committee was charged with the de-velopment of consensus standards for helmets in football byan independent investigator. Hodgson, from Wayne State Uni-versity, was selected as the investigator because of his exten-sive research in this area.14 A safety standard was achieved in1973, and the first helmets were tested on the NOCSAE stan-dard in 1974.12 The NOCSAE standards went into effect forcolleges in 1978 and for high schools in 1980.15 It was com-monly understood that the helmets being produced and usedby the mid-1970s met the NOCSAE standards, and all helmetsbeing worn were, in fact, associated with the same low ratesof clinical concussions.16

The increase in head injury fatalities throughout the 1960sand early 1970s was attributed to the introduction of hardshellhelmets and face masks in the early 1960s, which resulted inplaying techniques that increased exposure of the head to con-tact.1,8 Helmet standards and head injuries received football’spriority attention during this time.8 Similar attention to seriousneck injuries in the 1960s was lacking because the incidenceof nonfatal quadriplegia was not being tracked and thereforewas unknown.

Catastrophic Injury Data

The Annual Football Fatality Report was the only ongoingsource of data into the 1970s. Schneider17 included seriousneck injuries in his landmark survey of catastrophic injuries

in football in the early 1960s. But it was not until the mid-1970s that 2 concurrent and independent studies by Clarke18

and Torg et al19,20 again examined quadriplegia. These datarevealed the increased incidence of paralyzed football players.

The total number of head and neck injuries from 1971 to197519,20 was calculated and retrospectively compared withthe data from 1959 to 1963 compiled by Schneider.17 Thenumber of intracranial hemorrhages and deaths had decreasedby 66% and 42%, respectively. This suggested that the newhelmet standards had been effective in minimizing serioushead injuries. However, the number of cervical spine fractures,subluxations, and dislocations had increased by 204%, and thenumber of athletes with cervical quadriplegia had increased by116%.

Clarke and Torg led the proponents of the spearing rulechanges that were implemented by the NFSHSA and NCAAin 1976. These rule changes preceded the publication of theirdata.18–20 The purpose of the rule changes was to protect thespearer, whether inadvertent or intentional, from neurotrau-ma.5,8,11,12,15,21–25 On the basis of these data, it was concludedthat the improved protective capabilities of the polycarbonatehelmets accounted for a decrease in head injuries but encour-aged playing techniques that used the top or crown of thehelmet as the initial point of contact and put the cervical spineat risk.1

The results of the 1976 rule change are an example of oneof the most successful injury interventions in sport (Figures 1and 4). In the first year after the rule change, the number ofinjuries resulting in quadriplegia in high school and collegeplayers decreased by 53%.1 By 1984, the number dropped by87%. Other than increases in 1988, 1989, and 1990 to the lowteens, these cases have remained in the single digits throughthe most recent years of available data. This decrease is attri-buted to the rule change and to improved coaching techniquesat the high school and college levels.8,12,15,19,23,24,26–34

In order to track nonfatal catastrophic injuries, Torg et al1

established the National Football Head and Neck Injury Reg-istry in 1975, which collected data on CSIs through the early1990s. In 1977, the NCAA initiated funding for a NationalSurvey of Catastrophic Injuries directed by Mueller andBlyth.2–4 In 1982, this project was expanded to include allsports and renamed the National Center for CatastrophicSports Injury Research. Both projects used similar methods ofcollecting data. These sources included coaches, school ad-ministrators, medical personnel, athletic organizations, a na-tional newspaper-clipping service, and professional associates.The collection of these data was crucial in preventing cata-strophic injuries.12

In 1987, a joint endeavor was initiated between the NationalCenter for Catastrophic Sports Injury Research and the sectionon Sports Medicine of the American Association of Neurolog-ical Surgeons. As a result, Cantu became responsible for mon-itoring the collected medical data.2 This project continues tocollect data on these injuries.

Mechanism of Injury

In the early 1970s, several theories existed regarding themechanisms of CSIs and quadriplegia. The theories of hyper-flexion and hyperextension, based on postinjury radiographs,were considered 2 primary causes.1 Forced hyperflexion wasconsidered a primary cause of severe CSI in football and othersports.1,35–57 Hyperextension and the concept of the posterior


Figure 5. (A) Axial loading of the cervical spine (B) first results incompressive deformation of the intervertebral discs. As the energyinput continues and maximum compressive deformation isreached, angular deformation and buckling occur (C). The spinefails in a flexion mode, with resulting fracture, dislocation, or sub-luxation (D and E).

Table 2. Percentage of Plays Involving at Least 1 Head-DownContact Between Tacklers and Ball Carriers During a 1990 HighSchool Season103

Play %

All playsRunning playsKick returnsPass plays

2537387

Table 3. Percentage of Plays Involving Head-Down Contact byHigh School and College Tacklers or Ball Carriers

Position %

Tacklers, film (1990)103

Tacklers, live (1993)101

College tacklers, live (1993)101

Ball carriers, film (1990)103

Ball carriers, film (1989)19

2668

1620

rim of the helmet acting as a guillotine also received attentionas an injury mechanism.58–62 Both of these injury mechanismsreceived acceptance throughout the 1970s.

In contrast to these early theories, Torg et al19,20 determinedthat most cases of permanent quadriplegia occurring between1971 and 1975 were due to head-down contact or direct com-pression to the cervical spine. This resulted from the playerinitiating contact with the top of his helmet. The direct-com-pression or axial-loading concept eventually replaced the nu-merous other inaccurate, theoretic mechanisms of CSI. Theidentification of an accurate mechanism of injury was vitallyimportant to the prevention of these injuries.12,30 This allowedthe development of a precise plan to reduce the incidence ofquadriplegia.8 Axial loading is now accepted as the primarycause of cervical-spine fracture and dislocation in football. Nu-merous studies have supported the role of axial loading20,63–97 incatastrophic CSI and refuted the role of hyperflexion and hyper-extension in these injuries.1,19,23,24,30–32,63–65,68,72,94,98,99

Axial Loading. In the course of contact activity, such asfootball, the cervical spine is repeatedly exposed to danger-ous energy inputs.93 Fortunately, most forces are dissipatedby controlled spinal motion through the cervical paraverte-bral muscles, eccentric contractions, and intervertebraldiscs.19 However, the vertebrae, intervertebral discs, and sup-porting ligamentous structures can be injured when contactoccurs on the top or crown of the helmet with the head, neck,and trunk positioned in such a way that forces are transmittedalong the vertical axis of the cervical spine. In this situation,the cervical spine can assume the characteristics of a seg-mented column. With the neck in the neutral position, thecervical spine is extended as a result of normal cervical lor-dosis (Figure 5). When the neck is flexed to 308, the cervicalspine becomes straight. When a force is applied to the vertex,the energy is transmitted along the longitudinal axis of thecervical spine and is no longer dissipated by the paravertebralmuscles. This results in the cervical spine being compressedbetween the abruptly decelerated head and the force of theoncoming trunk.65 Essentially, the head is stopped, the trunkkeeps moving, and the spine is crushed between the two.When maximum vertical compression is reached, the cervicalspine fails in a flexion mode, with a fracture, subluxation, orfacet dislocation resulting.63 In the laboratory, fracture or dis-

location has occurred with less than 150 ft-lb of kinetic en-ergy.28 A running football player can possess 1500 ft-lb ofkinetic energy.28

Distribution of Serious Injuries

Defensive football players receive the majority of fatalitiesand catastrophic CSIs, accounting for approximately 4 timesthose of offensive players.2–4,12,15,19,20,23 Tackling is the lead-ing cause, followed by being tackled and then blocking.2–4,12,15

By position, defensive backs and special teams players are atthe greatest risk2,3,12,15,16,19,23 with ball-carrier positions, line-backers, and defensive linemen having the next highest inci-dences of serious injury.2,12,15

Each time a player initiates contact with his head down, herisks quadriplegia.2,15,19,22–25,27–33,97,100–106 Each time an ath-lete initiates contact head first, he increases the risk of con-cussion.22,29,101–103,107,108 Although catastrophic injuries haveoccurred to position players at various rates, mechanism ofinjury does not discriminate by position or intent.103,105,107,109

Head-down contact poses a risk to every player who employsthis technique.22,103–105

Incidence of Head-Down Contact

According to Hodgson and Thomas,28 the number of para-lyzed players does not accurately identify the risk of hittingwith the head down. Because of the decrease in catastrophicinjuries since the 1976 rule changes, it is often assumed thathead-down contact rarely occurs. Two authors have examinedthe incidence of head-down contact in the 1990s:22,101,103

twice on film in slow motion and once in live situations. Se-lected data appear in Tables 2 and 3.

One study compared the incidence of head-down contactbetween tacklers and ball carriers before and after the rulechange on the high school level.103 No significant change wasseen in the incidence of head-down contact between the sea-sons. Approximately 20 head-down contacts occurred per teamin a single game. There was 1 head-down contact for every1.8 kick returns. Special teams’ players have been among theleading position players associated with catastrophic injuries.Considering that kicking plays account for only about 7% of


Figure 6. Ball-carrier head-down contact, an often overlooked dan-ger, increases the risk of head and neck injuries.

Table 4. Helmet-Contact Rules and Selected Comments from the2002 National Federation of State High School Associations’Official Football Rules110

Rules

1. Spearing is the intentional use of the helmet in an attempt to punishan opponent.

2. Face tackling is driving the face mask, frontal area, or top of thehelmet directly into the runner.

3. Butt blocking is a technique involving a blow driven directly into anopponent with the face mask, frontal area, or top of the helmet asthe primary point of contact either in close line play or in the openfield.

4. Illegal personal contact occurs when a player intentionally uses hishelmet to butt or ram an opponent.

Points of Emphasis

1. Illegal acts such as spearing, face tackling, and butt blocking shouldalways be penalized.

2. Coaches have the responsibility to teach the proper technique ofblocking and tackling. Officials have the responsibility to penalize allillegal contact.

Shared Responsibility and Football-Helmet Warning Statement

1. The rules against butting, ramming, or spearing the opponent withthe helmeted head are there to protect the helmeted person as wellthe opponent being hit. The athlete who does not comply with theserules is a candidate for catastrophic injury.

2. The teaching of the blocking/tackling techniques which keep the hel-meted head from receiving the brunt of the impact is now requiredby rule and coaching ethics.

Table 5. Helmet-Contact Rules and Comments in the NationalCollegiate Athletic Association’s 2001 Football Rules andInterpretations111

Rules

1. Spearing is the deliberate use of the helmet (including the face mask)in an attempt to punish an opponent.

2. No player intentionally shall strike a runner with the crown or top ofthe helmet.

3. No player intentionally shall use his helmet (including the face mask)to butt or ram an opponent.

Points of Emphasis

1. The NCAA Rules Committee is strongly opposed to tackling andblocking techniques that are potentially dangerous for both the tack-ler/blocker and the opponent.

2. Coaches are reminded to instruct their players not to initiate contactwith any part of their helmets, including the face mask.

Coaching Ethics

The following are unethical practices:1. Using the football helmet as a weapon. The helmet is for the pro-

tection of the players.2. Spearing. Players, coaches, and officials should emphasize the elim-

ination of spearing.

Table 6. Selected 2001 National Collegiate Athletic AssociationPenalty-Enforcement Data from Major Division 1 Conferences114

Penalty Type No. Called

Total penaltiesHoldingFace maskSpearingButting or ramming

20 8373347945178

the plays involving a ball carrier, this play is probably the mostdangerous play in football.

Ball-carrier spearing (Figure 6) is interesting in that defen-sive players were 4 times more likely to hit with their headdown when tackling a head-down ball carrier. It is possiblethat a head-down ball carrier influences a tackler to ‘‘get low-er’’ and use a similar technique.22,103 This coincides well withDrake’s101,102 finding that tacklers were 3 times more likelyto make head-down contact when tackling below the waist.

During the 1990 season, 200 head-down contacts occurredduring one team’s season, and an estimated 2.8 million head-down contacts took place nationally between tacklers and ballcarriers on the high school level. This translated into approx-imately 1 case of quadriplegia for every 251 000 head-downcontacts. Based upon these numbers, a high school shouldhave 1 case of quadriplegia for every 11 000 games.103 Al-though these numbers are rough estimates at best, they dem-onstrate the room for additional improvement in decreasingthe incidence of spearing and head-down contact.

Rules and Officiating

The current helmet-contact rules for high school and collegeare shown in Tables 4 and 5, respectively. In 1976, the highschool rule change defined butt blocking and face tackling andmade them illegal. It was also a ‘‘point of emphasis’’ thatcoaches could no longer teach ‘‘face in the numbers’’ as acontact technique.112 On the collegiate level, the rules wereadapted to make ‘‘deliberate’’ use of the helmet illegal. Also,the rule book included a ‘‘Coaching Ethics’’ statement fromthe American Football Coaches Association that the helmetcannot be used as a primary point of contact in the teachingof blocking and tackling.113 Since 1976, 2 significant changesto the helmet-contact rules have been made. First, in the mid-1980s, the spearing penalty was lessened from an automaticejection to a 15-yard penalty. Second, in the early 1990s, theNCAA made the face mask an official part of the helmet.

Although the rule change is credited with reducing cata-strophic injuries, the role officials have played by enforcingthese rules is questionable (Table 6). To illustrate this, in 2001,college officials called 1 spearing penalty in every 73 games


and 1 butting or ramming penalty in every 156 games. Nospearing penalties were called in 12 of the 20 major Division1 conferences.114 During the 1992 NCAA season, officialscalled 55 spearing penalties (1 in every 21 games) and 16related to butting or ramming.115

On the high school level, officials called an estimated 1spearing penalty in every 20 games.116 During one team’s highschool season, no spearing penalties were called.20 This ap-pears to be the norm rather than the exception. These datacontradict the NFSHSA recommendation that infractions in-volving a safety issue should always be enforced.110,117 At thislevel of enforcement, it is doubtful whether actual penaltieshave decreased the incidence of head-down contact or themechanism of injury.116 If illegal helmet contact is not penal-ized, the message is sent that the technique is acceptable.118

Adequate enforcement of the rules will clearly further reducethe risk of catastrophic injuries.4,12,15,21–23,29–31,101,102,106,115

Surveys of football officials have revealed many inconsis-tencies with regard to the helmet-contact penalties. Footballofficials may not have a uniform understanding of these rules.Fifty percent of New Jersey officials felt that all head-firstcontact was illegal.116 Thirty-two percent felt that the ruleswere difficult to interpret.116 Another 38% were unsure wheth-er the rules were written in a way that allowed easy enforce-ment.116 A survey of college officials found similar resultsregarding the wording of the rules.115 A large number of highschool and college officials believed that determining an ath-lete’s intent made the rules difficult to enforce.

The helmet-contact penalties are unique in football becausethey are the only action penalties that penalize a player for hisown protection.105,109 However, many officials and coacheserroneously perceive the primary purpose of the penalties asprotecting the athlete who gets hit.105,109,115,116 This is reflect-ed by one group’s findings that nearly one third of high schoolplayers did not know that it was illegal to tackle with the topof the helmet or run over an opponent head first.119

Despite the intent of the 1976 rule change to address un-intentional or inadvertent spearing, the primary rule still hasan association with the ‘‘intentional attempt to punish.’’ Thewording of the helmet-contact rules does imply the need forintent.116 On the college level, the rules do not address unin-tentional head-down contact at all. High school rules do ad-dress head-down contact through the penalties for face tack-ling and butt blocking; however, these rules exclude mentionof the ball carrier. Although rules do exist at the high schoollevel, officials may enforce them even less than they enforcethe spearing penalty.116,120 Football’s objective should be toalter athlete behavior to eliminate head-down contact, notmerely to discourage it.121

An appropriate inquiry, which cannot be answered, is,‘‘How many of the approximately 2001 hits resulting in pa-ralysis were flagged at the time of contact?’’ Although a pen-alty flag on a play that involves a head or neck injury cannotprevent that injury, it may prevent one later on.120 In review-ing the video Prevent Paralysis: Don’t Hit With Your Head,football officials did not feel that the rules allowed them topenalize the majority of the hits demonstrated on this film thatresulted in quadriplegia.122 A ‘‘litmus test’’ for the enforce-ment of the helmet-contact rules is their application to actualhits that have resulted in paralysis. There is no better definitionof the type of contact that we must eliminate.

Safest Contact Position

Initiating contact with the shoulder while keeping the headup is the safest contact position.2–4,11,12,15,22,28,49,103,110,123

With the head up, the athlete can see when and how impactis about to occur and can prepare the neck musculature. Thisinformation applies to all position players, including ball car-riers. The game can be played just as aggressively with thistechnique with much less risk of serious injury. Tacklers canstill ‘‘unload’’ a big hit, and ball carriers can still break tack-les.105,109

Conversely, with the head down, the athlete does not havethe advantage of good vision and preparation for the instantof contact. He is likely to receive the full force of the impacton the head instead of the shoulders, chest, or arm. He is moreapt to hit low on the opponent’s body (including the oppo-nent’s hard-driving knees), and exposes his cervical spine toimpact in its most vulnerable position.11 Albright et al124

found that college and high school players had sufficient non-fatal CSIs to warrant concern over the teaching of head-buttingtechniques.

Coaches have expressed that they have taught players totackle correctly, but the players still have a tendency to lowertheir heads just before contact.15,28 It seems that players havelearned to approach contact with their head up, but they needto maintain this position during contact.103–105,109 It is instinc-tive for players to protect their eyes and face from injury bylowering their heads at impact.22,103–105,109 Coaches mustspend enough practice time to overcome this instinct. Playerswho drop their heads at the last instant are demonstrating thatthey need additional practice time with correct contact tech-niques in game-like situations. In addition to teaching correctcontact in the beginning of the season, coaches should putspecific emphasis on this 3 more times throughout the sea-son.21,22,104

The ‘‘See What You Hit’’ concept has gained popularity inrecent years. It is intended to teach athletes to keep their headsup and can be an effective tool. However, caution is requiredto ensure that coaches and athletes do not misinterpret thisslogan as support for initiating contact with the face mask.

Strengthening the neck musculature is an accepted part ofneck-injury prevention.15,29,49,97,100 Although such strength-ening cannot prevent axial loading in the head-down position,it can help athletes keep the head up during contact. Athletesshould have access to some type of neck-strengthening equip-ment, and, ideally, the program should be year round. If thisis not possible, then adequate time (4 to 6 weeks before theseason begins) should be allowed for strength gains. Duringthe season, athletes should continue to lift at least 1 day perweek to maintain their strength levels.125

Litigation

The occurrence of a catastrophic head or neck injury is char-acteristically accompanied by litigation.126–140 The prolifera-tion of litigation for these injuries began in the 1980s. Multi-million-dollar verdicts are now common. Of the $45.8 millionawarded in verdicts between 1970 and 1985, $38.7 millionwas awarded between 1980 and 1985.126,127 Ironically, the lit-igation in football is inversely proportional to the injury sta-tistics. During the time when there was a drastic decrease incatastrophic injuries, litigation increased.126 Any allegation offault can have devastating financial consequences for school


districts, coaches, medical personnel, and equipment manufac-turers.

The increase in litigation had serious effects on the footballhelmet industry. Between 1975 and 1985, 11 of 14 footballhelmet manufacturers left the marketplace.126 This exit fromthe marketplace was due to the cost of defending product li-ability claims126 and not to shortcomings regarding theNOCSAE helmet standards. Dramatic increases in liability in-surance premiums followed the increase in litigation. At thatpoint, many helmet manufacturers became self-insured or ac-cepted the risk of being underinsured. Approximately 40% ofthe helmet price was set aside for product liability.126 Litiga-tion will continue, and medical practitioners will have to de-termine, as the helmet manufacturers did, if they can afford towork in athletics.126 For these individuals and others, the im-plications of the increase in the number of athletic-injury law-suits are obvious. The chance of being named in a lawsuit issignificantly increased, regardless of fault or their role in theinjury.126,127,139

Many steps can be taken to decrease the risk of catastrophicinjuries and being found at fault for these injuries.104,123,127,140

A top priority is to ensure players know, understand, and ap-preciate the risks of making head-first contact in foot-ball.8,104,140 The videos Prevent Paralysis: Don’t Hit withYour Head’’5 and See What You Hit 6 and the prevention sec-tion of Spine Injury Management7 are excellent educationtools. Parents of high school players should also be given theopportunity to view at least one of these videos. Coaches havea responsibility to spend adequate time teaching and practicingcorrect contact techniques with all position players. Everyoneassociated with football has a moral and legal responsibilityto do all in their power to attempt to eliminate head-downcontact from the sport.104,105,109,140

ACKNOWLEDGMENTSWe gratefully acknowledge the efforts of Douglas M. Klei-

ner, PhD, ATC/L, CSCS, FACSM; Frederick O. Mueller, PhD;Robert G. Watkins, MD; and the Pronouncements Committeein the preparation of this document.

DISCLAIMERNATA publishes its position statements as a service to pro-

mote the awareness of certain issues to its members. The in-formation contained in the position statements is neither ex-haustive nor exclusive to all circumstances or individuals.Variables such as institutional human resource guidelines, stateor federal statutes, rules, or regulations, as well as regionalenvironmental conditions, may impact the efficacy and/or re-liability of these statements. NATA advises individuals to care-fully and independently investigate each of its position state-ments (including the applicability of same to any particularcircumstance or individual) and states that such position state-ments should not be relied upon as an independent basis fortreatment but rather as a resource available to its members.Moreover, no opinion is expressed herein regarding the qualityof treatment that adheres to or differs from NATA’s positionstatements. NATA reserves the right to rescind or modify itsposition statements at any time.

REFERENCES1. Torg JS, Guille JT, Jaffe S. Injuries to the cervical spine in American

football players. J Bone Joint Surg Am. 2002;84:112–122.

2. Mueller FO, Cantu RC. Annual survey of catastrophic football injuries:1977–1992. In: Hoerner EF, ed. Head and Neck Injuries in Sports ASTMSTP 1229. Philadelphia, PA: American Society for Testing and Materi-als; 1994:20–27.

3. Mueller FO, Cantu RC. The annual survey of catastrophic football in-juries: 1977–1988. Exerc Sport Sci Rev. 1991;19:261–312.

4. Cantu RC, Mueller FO. Catastrophic football injuries: 1977–1998. Neu-rosurgery. 2000;47:673–675.

5. Torg JS. Prevent Paralysis: Don’t Hit With Your Head [videotape]. Phil-adelphia, PA: Penn Sports Medicine; 1992.

6. See What You Hit [videotape]. Atlanta, GA: Kestrel CommunicationsInc; 2000.

7. Spine Injury Management [videotape]. Champaign, IL: Human Kinetics;2001.

8. Clarke KS. Cornerstones for future directions in head/neck injury pre-vention in sports. In: Hoerner EF, ed. Head and Neck Injuries in SportsASTM STP 1229. Philadelphia, PA: American Society for Testing andMaterials; 1994:3–9.

9. Hard-shelled helmets for athletes, experts say. JAMA. 1962;180:23–24.10. Blyth C, Arnold D. The Thirty-Ninth Annual Survey of Football Fatal-

ities,1931–1970. Chicago, IL: American Football Coaches Association,National Collegiate Athletic Association, and National Federation ofState High School Associations; 1978.

11. American Medical Association Committee on Medical Aspects ofSports. Spearing in Football: Tips on Athletic Training. Chicago, IL:American Medical Association, National Federation of State HighSchool Athletic Associations; 1968:6–7.

12. Mueller FO, Blyth CS. Fatalities from head and cervical spine injuriesoccurring in tackle football: 40 years’ experience. Clin Sports Med.1987;6:185–196.

13. Clarke KS. Calculated risk of sports fatalities. JAMA. 1966;197:894–896.

14. Hodgson V. National Operating Committee on Standards for AthleticEquipment Football Certification Program. Available at: http://www.nocsae.org/nocsae/RESEARCH/Hodgson.htm. Accessed Septem-ber 23, 2002.

15. Mueller FO, Blyth CS, Cantu RC. Catastrophic spine injuries in football.Physician Sportsmed. 1989;17(10):51–53.

16. Clarke KS, Powell, JW. Football helmets and neurotrauma: an epide-miological overview of three seasons. Med Sci Sports. 1979;11:138–145.

17. Schneider RC. Serious and fatal neurosurgical football injuries. ClinNeurosurg. 1964;12:226–236.

18. Clarke KS. A survey of sport-related spinal cord injuries in schools andcolleges, 1973–1975. J Safety Res. 1977;9:140–146.

19. Torg JS, Quedenfeld TC, Moyer RA, Truex R, Spealman AD, NicholsCE. Severe and catastrophic neck injuries resulting from tackle football.J Am Coll Health Assoc. 1977;25:224–226.

20. Torg JS, Truex R Jr, Quedenfeld TC, Burstein A, Spealman A, NicholsCE III. The National Football Head and Neck Injury Registry: reportand conclusions, 1978. JAMA. 1979;241:1477–1479.

21. Heck JF. An analysis of football’s spearing rules. Sideliner J Athl TrainSoc N J. 1993;9:8,9,15.

22. Heck JF. The incidence of spearing by high school football ball carriersand their tacklers. J Athl Train. 1992;27:120–124.

23. Torg JS, Vegso JJ, Sennett B. The National Football Head And NeckInjury Registry: 14-year report on cervical quadriplegia. Clin SportsMed. 1987;6:61–72.

24. Torg JS, Sennett B, Vegso JJ. Spinal injury at the third and fourth cer-vical vertebrae resulting from the axial loading mechanism: an analysisand classification. Clin Sports Med. 1987;6:159–183.

25. Wilberger JE, Maroon JC. Cervical spine injuries in athletes. PhysicianSportsmed. 1990;18(3):57–70.

26. Albright JP, Mcauley E, Martin RK, Crowley ET, Foster DT. Head andneck injuries in college football: an eight-year analysis. Am J SportsMed. 1985;13:147–152.

27. Anderson C. Neck injuries: backboard, bench or return to play. Physi-cian Sportsmed. 1993;21(8):23–34.

28. Hodgson VR, Thomas LM. Play head-up football. Natl Fed News. 1985;2:24–27.


29. Saal JA, Sontag MJ. Head injuries in contact sports: sideline decisionmaking. Phys Med Rehabil. 1987;1:649–658.

30. Torg JS. Epidemiology, pathomechanics, and prevention of athletic in-juries to the cervical spine. Med Sci Sports Exerc. 1985;17:295–303.

31. Torg JS. Epidemiology, pathomechanics, and prevention of football-in-duced cervical spinal cord trauma. Exerc Sport Sci Rev. 1992;20:321–338.

32. Torg JS. Epidemiology, biomechanical and cinematographic analysis offootball induced cervical spine trauma. Athl Train J Natl Athl TrainAssoc. 1990;25:147–159.

33. Torg JS, Sennett B, Vegso JJ, Pavlov H. Axial loading injuries to themiddle cervical spine segment: an analysis and classification of twenty-five cases. Am J Sports Med. 1991;19:6–20.

34. Diehl J. The National Federation: how rules are written. Paper presentedat: National Athletic Trainers’ Association 53rd Annual Meeting andClinical Symposia; June 14–18, 2002; Dallas, TX.

35. Schneider RC. Head and Neck Injuries in Football: Mechanisms, Treat-ment, and Prevention. Baltimore, MD: Williams & Wilkins; 1973.

36. Dolan KD, Feldick HG, Albright JP, Moses JM. Neck injuries in footballplayers. Am Fam Physician. 1975;12:86–91.

37. Funk FJ, Wells RE. Injuries of the cervical spine in football. Clin Or-thop. 1975;109:50–58.

38. Silver JR. Injuries of the spine sustained in rugby. Br Med J (Clin ResEd). 1984;288:37–43.

39. Melvin WJ, Dunlop HW, Hetherington RF, Kerr JW. The role of thefaceguard in the production of flexion injuries to the cervical spine infootball. Can Med Assoc J. 1965;93:1110–1117.

40. Ciccone R, Richman RM. The mechanism of injury and the distributionof three thousand fractures and dislocations caused by parachute jump-ing. J Bone Joint Surg Am. 1948;30:77–97.

41. Ellis WG, Green D, Holzaepfel NR, Sahs AL. The trampoline and se-rious neurologic injuries: a report of five cases. JAMA. 1960;174:1673–1676.

42. Hage P. Trampolines: an ‘‘attractive nuisance.’’ Physician Sportsmed.1982;10(12):118–122.

43. Kravitz H. Problems with the trampoline, I: too many cases of perma-nent paralysis. Pediatr Ann. 1978;7:728–729.

44. Tator CH, Edmonds VE. National survey of spinal injuries in hockeyplayers. Can Med Assoc J. 1984;130:875–880.

45. Tator CH, Ekong CE, Rowed DW, Schwartz ML, Edmonds VE, CooperPW. Spinal injuries due to hockey. Can J Neurol Sci. 1984;11:34–41.

46. Torg JS, Das M. Trampoline-related quadriplegia: review of the literatureand reflections on the American Academy of Pediatrics’ position state-ment. Pediatrics. 1984;74:804–812.

47. Carvell JE, Fuller DJ, Duthie RB, Cockin J. Rugby football injuries tothe cervical spine. Br Med J (Clin Res Ed). 1983;286:49–50.

48. Gehweiler JA Jr, Clark WM, Schaaf RE, Powers B, Miller MD. Cervicalspine trauma: the common combined conditions. Radiology. 1979;130:77–86.

49. Leidholt JD. Spinal injuries in athletes: be prepared. Orthop Clin NorthAm. 1973;4:691–707.

50. Macnab I. Acceleration injuries of the cervical spine. J Bone Joint SurgAm. 1964;46:1797–1799.

51. McCoy GF, Piggot J, Macafee AL, Adair IV. Injuries of the cervical spinein schoolboy rugby football. J Bone Joint Surg Br. 1984;66:500–503.

52. Paley D, Gillespie R. Chronic repetitive unrecognized flexion injury ofthe cervical spine (high jumper’s neck). Am J Sports Med. 1986;14:92–95.

53. Piggot J, Gordon DS. Rugby injuries to the cervical cord. Br Med J.1979;1:192–193.

54. Williams JP, McKibbin B. Cervical spine injuries in rugby union foot-ball. Br Med J. 1978;2:1747.

55. Wu WQ, Lewis RC. Injuries of the cervical spine in high school wres-tling. Surg Neurol. 1985;23:143–147.

56. O’Carroll PF, Sheehan JM, Gregg TM. Cervical spine injuries in rugbyfootball. Ir Med J. 1981;74:377–379.

57. Scher AT. ‘‘Crashing’’ the rugby scrum: an avoidable cause of cervicalspinal injury: case reports. S Afr Med J. 1982;61:919–920.

58. Burke DC. Hyperextension injuries of the spine. J Bone Joint Surg Br.1971;53:3–12.

59. Edilken-Monroe B, Wagner LK, Harris JH Jr. Hyperextension disloca-tion of the cervical spine. AJR Am J Roentgenol. 1986;146:803–808.

60. Forsyth HF. Extension injuries of the cervical spine. J Bone Joint SurgAm. 1964;46:1792–1797.

61. Marar BC. Hyperextension injuries of the cervical spine: the pathogen-esis of damage to the spinal cord. J Bone Joint Surg Am. 1974;56:1655–1662.

62. Alexander E Jr, Davis CH Jr, Field CH. Hyperextension injuries of thecervical spine. AMA Arch Neurol Psychiatry. 1958;19:146–150.

63. Torg JS, Quedenfeld TC, Burstein A, Spealman AD, Nichols CE III.National Football Head and Neck Injury Registry: report on cervicalquadriplegia, 1971 to 1975. Am J Sports Med. 1979;7:127–32.

64. Torg JS, Vegso JJ, O’Neill MJ, Sennett B. The epidemiologic, patho-logic, biomechanical, and cinematographic analysis of football-inducedcervical spine trauma. Am J Sports Med. 1990;18:50–7.

65. Torg JS. Epidemiology, pathomechanics, and prevention of athletic in-juries to the cervical spine. Med Sci Sports Exerc. 1985;17:295–303.

66. Yoganandan N, Sances A Jr, Maiman DJ, Myklebust JB, Pech P, LarsonSJ. Experimental spinal injuries with vertical impact. Spine. 1986;11:855–60.

67. Mertz HJ, Hodgson VR, Thomas LM, Nyquist GW. An assessment ofcompressive neck loads under injury-producing conditions. PhysicianSportsmed. 1978;6(11):95–106.

68. Hodgson VR, Thomas LM. Mechanism of cervical spine injury duringimpact to the protected head. In: Proceedings of the Twenty-FourthStaap Car Crash Conference. Warrendale, PA: Society of AutomotiveEngineers; 1980: 17–42.

69. Sances A Jr, Myklebust JB, Maiman DJ, Larson SJ, Cusick JF, JodatRW. The biomechanics of spinal injuries. Crit Rev Biomed Eng. 1984;11:1–76.

70. Gosch HH, Gooding E, Schneider RC. An experimental study of cer-vical spine and cord injuries. J Trauma. 1972;12:570–576.

71. Maiman DJ, Sances A Jr, Myklebust JB, et al. Compression injuries ofthe cervical spine: a biomechanical analysis. Neurosurgery. 1983;13:254–260.

72. Roaf R. A study of the mechanics of the spinal injuries. J Bone JointSurg Br. 1960;42:810–823.

73. White AA III, Punjabi MM. Clinical Biomechanics of the Spine. Phil-adelphia, PA: Lippincott; 1978.

74. Bauze RJ, Ardran GM. Experimental production of forward dislocationin the human cervical spine. J Bone Joint Surg Br. 1978;60:239–245.

75. Nightingale RW, McElhaney JH, Richardson WJ, Best TM, Myers BS.Experimental impact injury to the cervical spine: relating motion of thehead and the mechanism of injury. J Bone Joint Surg Am. 1996;78:412–421.

76. Kazarian L. Injuries to the human spinal column: biomechanics andinjury classification. Exerc Sport Sci Rev. 1981;9:297–352.

77. Kewalramani LS, Orth MS, Taylor RG. Injuries to the cervical spinefrom diving accidents. J Trauma. 1975;15:130–142.

78. Albrand OW, Corkill G. Broken necks from diving accidents: a summerepidemic in young men. Am J Sports Med. 1976;4:107–110.

79. Albrand OW, Walter J. Underwater deceleration curves in relation toinjuries from diving. Surg Neurol. 1975;4:461–465.

80. Maroon JC, Steele PB, Berlin R. Football head and neck injuries: anupdate. Clin Neurosurg. 1980;27:414–429.

81. Mennen U. Survey of spinal injuries from diving: a study of patients inPretoria and Cape Town. S Afr Med J. 1981;59:788–790.

82. Rogers WA. Fractures and dislocations of the cervical spine: an end-result study. J Bone Joint Surg Am. 1957;39:341–376.

83. Scher AT. Diving injuries to the cervical spinal cord. S Afr Med J. 1981;59:603–605.

84. Scher AT. Injuries to the cervical spine sustained while carrying loadson the head. Paraplegia. 1978;16:94–101.

85. Scher AT. ‘‘Tear-drop’’ fractures of the cervical spine: radiological fea-tures. S Afr Med J. 1982;61:355–356.

86. Scher AT. The high rugby tackle: an avoidable cause of cervical spinalinjury? S Afr Med J. 1978;53:1015–1018.


87. Scher AT. Vertex impact and cervical dislocation in rugby players. S AfrMed J. 1981;59:227–228.

88. Bishop PJ. Impact postures and neck loading in head first collisions: areview. In: Hoerner EF, ed. Head and Neck Injuries in Sports ASTMSTP 1229. Philadelphia, PA: American Society for Testing and Materi-als; 1994:127–141.

89. Burstein AH, Otis JC. The response of the cervical spine to axial load-ing: feasibility for intervention. In: Hoerner EF, ed. Head and NeckInjuries in Sports ASTM STP 1229. Philadelphia, PA: American Societyfor Testing and Materials; 1994:142–153.

90. Pintar FA, Yoganandan N, Sances A JF, Cusick JF. Experimental pro-duction of head-neck injuries under dynamic forces. In: Hoerner EF, ed.Head and Neck Injuries in Sports ASTM STP 1229. Philadelphia, PA:American Society for Testing and Materials; 1994:203–211.

91. Yoganandan N, Pintar FA, Sances A Jr, Reinartz J, Larson SJ. Strengthand kinematic response of dynamic cervical spine injuries. Spine. 1991;16(10 suppl):S511–S517.

92. Yoganandan N, Sances A Jr, Maiman DJ, Myklebust JB, Pech P, LarsonSJ. Experiemental spinal injuries with vertical impact. Spine. 1986;11:855–859.

93. Burstein AH, Otis JC, Torg JS. Mechanisms and pathomechanics ofathletic injuries to the cervical spine. In: Torg JS, ed. Athletic Injuriesto the Head, Neck, and Face. Philadelphia, PA: Lea & Febiger; 1982:139–154.

94. Torg JS, Truex RC Jr, Marshall J, et al. Spinal injury at the level of thethird and fourth cervical vertebrae from football. J Bone Joint Surg Am.1977;59:1015–1019.

95. Allen BL Jr, Ferguson RL, Lehmann TR, O’Brien RP. A mechanisticclassification of closed, indirect fractures and dislocations of the lowercervical spine. Spine. 1982;7:1–27.

96. Jackson DW, Lohr FT. Cervical spine injuries. Clin Sports Med. 1986;5:373–386.

97. Watkins RG. Neck injuries in football players. Clin Sports Med. 1986;5:215–246.

98. Carter DR, Frankel VH. Biomechanics of hyperextension injuries to thecervical spine in football. Am J Sports Med. 1980;8:302–309.

99. Virgin H. Cineradiographic study of football helmets and the cervicalspine. Am J Sports Med. 1980;8:310–317.

100. Cantu RC. Head and spine injuries in the young athlete. Clin SportsMed. 1988;7:459–472.

101. Drake GA. Research provides more suggestions to reduce serious foot-ball injuries. Natl Fed News. November/December 1994;18–21.

102. Drake GA. Catastrophic football injuries and tackling techniques. In:Hoerner EF, ed. Safety in American Football, ASTM STP 1305. Phila-delphia, PA: American Society for Testing and Materials; 1996:42–49.

103. Heck JF. The incidence of spearing during a high school’s 1975 and1990 football seasons. J Athl Train. 1996;31:31–37.

104. Heck JF. Preventing catastrophic head and neck injuries in football.From Gym Jury. 1998;10(1):7.

105. Heck JF. Re-examining spearing: the incidence of cervical spine injuryhides the risks. Am Football Coach. 1999;5(8):52–54.

106. Football-related spinal cord injuries among high school players: Loui-siana, 1989. MMWR Morb Mortal Wkly Rep. 1990;39:586–587.

107. Buckley WE. Concussions in college football: a multivariate analysis.Am J Sports Med. 1988;16:51–56.

108. Cantu RC. Guidelines for return to contact sports after a cerebral con-cussion. Physician Sportsmed. 1986;14(10):75–83.

109. Heck JF. The state of spearing in football: incidence of cervical spineinjuries doesn’t indicate the risks. Sports Med Update. 1998;13(2):4–7.

110. National Federation of State High School Associations. Official FootballRules. Indianapolis, IN: National Federation of State High School As-sociations; 2002.

111. National Collegiate Athletic Association. 2001 Football Rules and In-terpretations. Indianapolis, IN: National Collegiate Athletic Association;2001.

112. National Federation of State High School Associations. Official FootballRules. Elgin, IL: National Federation of State High School Associations;1976.

113. National Collegiate Athletic Association. Football Rules Changes and/or Modifications. Kansas City, MO: National Collegiate Athletic Asso-ciation; January 23, 1976.

114. National Collegiate Athletic Association. 2001 Consolidated NCAA FoulReport. Indianapolis, IN: National Collegiate Athletic Association; 2002.

115. Peterson TR. Roundtable: head and neck injuries in football. Paper pre-sented at: American Society for Testing and Materials’ InternationalSymposium on Head and Neck Injuries in Sports; May 1993; Atlanta,GA.

116. Heck JF. A survey of New Jersey high school football officials regardingspearing rules. J Athl Train. 1995;30:63–68.

117. Lutz R. Good judgment critical in making call. Available at: http://www.mcoa.org/articles/fbp003.html. Accessed July 9, 2002.


119. Lawrence DS, Stewart GW, Christy DM, Gibbs, LI, Ouellette M. Highschool football-related cervical spinal cord injuries in Louisiana: theathlete’s perspective. Available at: http://www.injuryprevention.org/states/la/football/football.htm. Accessed July 15, 2002.


121. Bishop PJ. Factors related to quadriplegia in football and the implica-tions for intervention strategies. Am J Sports Med. 1996;24:235–239.

122. Heck JF. The football official’s role in the prevention of catastrophicneck injuries. Presented at: Southern New Jersey Football OfficiatingAssociation Meeting; September 1994; Audubon, NJ.

123. Kleiner DM, Almquist JL, Bailes J, et al. Prehospital Care of the Spine-Injured Athlete. Dallas, TX: Inter-Association Task Force for Appropri-ate Care of the Spine-Injured Athlete; 2001.

124. Albright JP, Moses JM, Feldick HD, Dolan KD, Burmeister LF. Nonfatalcervical spine injuries in interscholastic football. JAMA. 1976;236:1243–1245.

125. Graves JE, Pollock ML, Leggett SH, et al. Effect of reduced trainingfrequency on muscular strength. Int J Sports Med. 1988;9:316–319.

126. Patterson D. Legal aspects of athletic injuries to the head and cervicalspine. In: Torg JS, ed. Athletic Injuries to the Head, Neck, and Face.2nd ed. St. Louis, MO: Mosey Year Book; 1991:198–209.

127. Patterson D. Legal aspects of athletic injuries to the head and cervicalspine. Clin Sports Med. 1987;6:197–210.

128. Boulet v Brunswick Corporation, 126 Mich App 240 (1982).129. Dibortolo v Metropolitan School District, 440 NE2d 506 Ind Ct App

(1982).130. Gerrity v Beatty, 71 Ill 2d 47 (1978).131. Green v Orleans Parish School Board, 365 So2d 834, 836 La Ct App

(1978).132. Jackson v Board of Education 109, Ill App 3d 716, 441 NE2d 120

(1982).133. Landers v School District #203, 66 Ill App 3d 78, 383 NE2d 645 (1978).134. Low v Texas Tech University, 540 SW2d 297 Tex Supreme Ct (1976).135. Peterson v Multnomah County School District, 669 P2d 387, 393 (1983).136. Stehn v Bernarr Macfadden Foundations, Inc, 434 F2d811 6th Cir (1970).137. Vendrell v School District No 26C, 233 Ore 1 (1962).138. Wissel v Ohio High School Athletic Association, 78 Ohio App 3d 529

(1992).139. Black J. Legal implications for the secondary school athlete. Paper pre-

sented at: National Athletic Trainers’ Association 53rd Annual Meetingand Clinical Symposia; June 14–18, 2002: Dallas, TX.

140. Heck JF, Weis MP, Gartland JM, Weis CR. Minimizing liability risksof head and neck injuries in football. J Athl Train. 1994;29:128–139.

Equipm

ent

113

GUIDELINE 3D

USE OF THE HEAD AS A WEAPON IN FOOTBALL AND OTHER CONTACT SPORTSJanuary 1976 • Revised June 2002

Head and neck injuries causing death, brain damage or paralysis occur each year in football and other sports. While the number of these injuries each year is relatively small, they are devastating occurrences that have a great impact on student-athlete health and well-being. Most of these catastrophic injuries result from initiating contact with the head. The inju-ries may not be prevented due to the forces encoun-tered during collisions, but they can be minimized by helmet manufacturers, coaches, players and officials complying with accepted safety standards and playing rules.

The American Football Coaches Association, empha-sizing that the helmet is for the protection of the wearer and should not be used as a weapon, address-es this point as follows:

1. The helmet shall not be used as the brunt of con-tact in the teaching of blocking or tackling;

2. Self-propelled mechanical apparatuses shall not be used in the teaching of blocking and tackling; and

3. Greater emphasis by players, coaches and officials should be placed on eliminating spearing.

Proper training in tackling and blocking techniques, including a “see what you hit approach,” constitutes an important means of minimizing the possibility of catastrophic injury. Using the helmet as an injury-inflicting instrument is illegal and should be strongly discouraged and penalized by coaches and game offi-cials. This concern is not only in football, but also in other contact sports in which helmets are used (e.g., ice hockey and men’s lacrosse).

Football and all contact sports should be concerned with the prevention of catastrophic head injuries. The rules against butting, ramming and spearing with the helmet are for the protection of the helmeted player and the opponent. A player who does not comply with these rules in any sport is at risk for a catastrophic injury or causing a catastrophic injury.

REFERENCES1. Banerjee R, Palumbo MA, Fadale FD. Catastrophic Cervical Spine

Injuries in the Collision Sport Athlete, Part 1: Epidemiology, Functional

Anatomy, and Diagnosis. Am J Sports Med. (32)4: 1077- 87. 2004.

2. Boden BP, Breit I, Beachler JA, Williams A, Mueller FO. Fatalities in

high school and college football players. Am J Sports Med.

41(5):1108-16. 2013

3. Boden BP, Tacchetti RL, Cantu, RC. Catastrophic Cervical Spine

Injuries in High School and College Football Players. Am J Sports

Med. (34)8:1223-32. 2006.

4. Kleiner, D.M., Almquist, J.L., Bailes, J., Burruss, P., Feurer, H., Griffin, L.Y.,

Herring, S., McAdam, C., Miller, D., Thorson, D., Watkins, R.G., Weinstein,

S. Prehospital Care of the Spine-Injured Athlete: A Document From the

Inter-Association Task Force for Appropriate Care of the Spine-Injured

Athlete. Dallas, National Athletic Trainers’ Association, March, 2001.

5. LaParade RF, Schnetzler KA, Broxterman RJ, Wentorf F, Wendland E,

Gilbert TJ: Cervical Spine Alignment in the Immobilized Ice Hockey

Player: A Computer Tomographic Analysis of the Effects of Helmet

Removal: Am J Sports Med 27: 177-180, 1999.

6. The Spine Injury Management Video Human Kinetics, Champaign,

Illinois.

7. Thomas BE, McCullen GM, Yuan HA: Cervical Spine Injuries in Football

Players: J Am Acad Orthop Surg Sept-Oct; 7 (5), 338-47, 1999.

8. Wojtys EM, Hovda D, Landry G, Boland A, Lovell M, McCrea M, Minkoff

J: Concussion in Sports: Am J Sports Med 27: 676-687, 1999.

RESOURCES

1. NCAA Concussion Fact Sheets and Video

Available at NCAA.org/SSI.

2. Heads Up: Concussion Tool Kit

CDC. Available at www.cdc.gov/ncipc/tbi/coaches_tool_kit.htm.

3. Heads Up Video

NATA. Streaming online at www.nata.org/consumer/headsup.htm.

e.g.,

eo

/

2014

-15

NC

AA

Spo

rts

Med

icin

e H

andb

ook

114

GUIDELINE 3E

HELMET FITTING AND REMOVAL June 1990 • Revised June 2013

Several sports, including football, men’s lacrosse and ice hockey, require wearing tight-fitting, similarly con-structed helmets. The following guidelines, while focused on football, are applicable to periodic evalua-tion, fitting and removal of protective helmets worn in any sport. These guidelines represent minimal stan-dards of care that are designed to assist physicians, coaches, athletic trainers, paramedics, EMTs and hos-pital personnel who care for student-athletes.

Medical coverage of interscholastic and intercollegiate teams entails many routine preventive and acute health care duties for dedicated practicing professionals; however, an occasional, serious, on-the-field, life-threatening head and/or neck injury poses a difficult challenge. It is incumbent upon those individuals assigned to provide medical coverage to be prepared to handle each situation efficiently and expertly.

Proper on-the-field management of head and neck injuries is essential to minimize sequelae, expedite emergency measures and to prepare for transporta-tion. The action of those in attendance must not com-pound the problem. For this reason, clear communica-tion between the medical staff and emergency-trans-portation personnel should be maintained. It is impor-tant that those involved in the medical management of teams engaged in collision and contact sports, and the student-athlete be knowledgeable about the helmet. The student-athlete should be instructed in the fitting, care and use of the helmet. Helmet manufacturer guidelines should be reviewed and followed for proper fitting and care techniques.

The resilient plastic shell is shaped spherically to deflect impacts. Interior suspension pads are designed to match the skull contour to ensure a snug crown fit. Various rigid and removable jaw and brow pads, along with the chin strap, help to hold the sides of the helmet firmly against the mandible and the forehead. When in place, the front edge of the helmet should be positioned about a finger’s breadth above the eyebrows. Pressure on the helmet crown should be dissipated through the interior suspension padding over the top of the head.

The helmet should fit snugly without dependence on the chin strap. The helmet should not twist or slide when an examiner grasps the face mask and attempts to rock or turn the helmet with the wearer resisting the movement.

With a properly fitted helmet, the top of the head is separated from the helmet shell by a uniform, function-

al, shock-absorbing support lining. Daily evaluation of this support mechanism, including cheek and brow pads, for placement and resiliency should be taught to the student-athlete. Helmets that require air inflation should be inflated and inspected daily by the student-athlete. Helmet shells should be examined weekly for cracking and be inspected closely again if the face mask has been bent out of shape. All helmets need to be reconditioned and the attachments of the mask replaced on a yearly basis.

Although the helmet is designed for a stable fit for pro-tection during play, removal of the helmet by others is relatively difficult. In the case of a head or neck injury, jostling and pulling during removal presents high potential for further trauma.

Unless there are special circumstances such as

respiratory distress coupled with an inability to

access the airway, the helmet should never be

removed during the pre-hospital care of the student-

athlete with a potential head/neck injury unless:

1. The helmet does not hold the head securely, such that immobilization of the helmet does not immobi-lize the head;

2. The design of the sport helmet is such that even after removal of the face mask, the airway cannot be controlled or ventilation provided;

3. After a reasonable period of time, the face mask cannot be removed; or

4. The helmet prevents immobilization for transporta-tion in an appropriate position.

When such helmet removal is necessary in any setting, it should be performed only by personnel trained in this procedure.

Ordinarily, it is not necessary to remove the helmet on the field to evaluate the scalp. Also, the helmet can be left in place when evaluating an unconscious student-athlete, an individual who demonstrates transient or persistent neurological findings in his/her extremities, or the student-athlete who complains of continuous or transient neck pain.

Before the injured student-athlete is moved, airway, breathing and circulation (ABCs) should be evaluated by looking, listening and palpation. To monitor breath-ing, care for facial injury, or before transport regardless of current respiratory status, the face mask should be removed by cutting or unscrewing the loops that

Equipm

ent

115

attach the mask to the helmet. These loops may be difficult to cut, necessitating the use of PVC pipe cutters, garden shears or a screwdriver. Those involved in the pre-hospital care of the injured student-athlete should have readily available proper tools for easy face mask removal and should frequently practice removal techniques for face masks and helmets. It should be noted that cold weather and old loops may make cutting difficult. The chin strap can be left in place unless resuscitative efforts are necessary. For resusci-tation, the mouthpiece needs to be manually removed.

Once the ABCs are stabilized, transportation to an emergency facility should be conducted with the head secure in the helmet and the neck immobilized by strapping, taping and/or using lightweight bolsters on a spine board. When moving an athlete to the spine board, the head and trunk should be moved as a unit, using the lift/slide maneuver or a log-roll technique.

At the emergency facility, satisfactory initial skull and cervical X-rays usually can be obtained with the helmet in place. Should removal of the helmet be needed to initiate treatment or to obtain special X-rays, the fol-lowing protocol should be considered:

• With the head, neck and helmet manually stabi-lized, the chin strap can be cut.

• While maintaining stability, the cheek pads can be removed by slipping the flat blade of a screw-driver or bandage scissor under the pad snaps and above the inner surface of the shell.

• If an air cell-padding system is present, it can be

deflated by releasing the air at the external port with an inflation needle or large-gauge hypoder-mic needle.

• By rotating the helmet slightly forward, it should now slide off the occiput. If the helmet does not move with this action, slight traction can be applied to the helmet as it is carefully rocked anteriorly and posteriorly, with great care being taken not to move the head/neck unit.

• The helmet should not be spread apart by the earholes, as this maneuver only serves to tighten the helmet on the forehead and on the occipital regions.

• All individuals participating in this important maneuver must proceed with caution and coordi-nate every move.

If the injured student-athlete, after being rehabilitated fully, is allowed to participate in the sport again, refit-ting his/her helmet is mandatory. Re-education about helmet use as protection should be conducted. Using

the helmet as an offensive, injury-inflicting instru-

ment should be discouraged and places the athlete

and opponents at risk for a catastrophic injury.

SOFT HEADGEAR USE IN NONHELMETED SPORTSWhen considering the use of this optional equipment during practice or permitted competition, athletes and coaches should take the time to read the qualifying statements provided with such a product addressing its limitations, particularly to prevent serious head injuries. If protective soft headgear or headbands are

2014

-15

NC

AA

Spo

rts

Med

icin

e H

andb

ook

116

to be used in a sport then they should be manufac-tured under the guidelines of an accepted standard for that sport.

The NCAA does not view the use of soft headgear products as equipment for the prevention of concus-sion in nonhelmeted sports. As explained below, soft headgear products may be worn in nonhelmeted sports whose rules allow for such optional equipment, but the purpose of that equipment should be for reasons other than concussion prevention. It should be noted that there is no helmet that can prevent a concussion. There continues to be a need for valid scientific evidence that the use of such products decreases the incidence of concussion.

In nonhelmeted sports requiring a medical waiver for the use of such optional equipment, use of soft head-gear as a condition to be medically cleared to play sports is ineffective. Therefore, the NCAA will not provide medical waivers for the use of soft headgear for the prevention of concussion in order to be medi-cally cleared to play sports.

Current design and recommended use of these devices fail to address the proposed primary mecha-nism of concussive injury, that being rotational acceler-ation and deceleration forces acting on the brain. Institutions should refer to equipment standards from NOCSAE, ASTM, HECC and CPSC when considering protective equipment for student-athletes and ensure

the equipment is used for mitigating the risk of injuries for which they are designed.

REFERENCES1. Anderson C: Neck Injuries—Backboard, bench or return to play? The

Physician and Sports Medicine 21(8): 23-34, 1993.

2. Guidelines for Helmet Fitting and Removal in Athletics. Illinois State Medical

Society, 1990. (20 North Michigan Avenue, Chicago, Illinois 60602)

3. Inter-Association Task Force for the Cervical Spine. National Athletic

Trainers’ Association, 2000. (2952 Stemmons Freeway, Dallas, Texas

75247, www.nata.org)

4. AOSSM Helmet Removal Guidelines. The American Orthopaedic

Society for Sports Medicine. (6300 N. River Road, Suite 200,

Rosemont, Illinois 60018 www.sportsmed.org).

5. The Hockey Equipment Certification Council Inc. www.hecc.net.

6. US Lacrosse. www.uslacrosse.org. Lacrosse Helmet Facemask/

Chinguard Removal Hints for Certified Athletic Trainers. US Lacrosse,

2008. Available at www.uslacrosse.org/safety.

7. National Operating Committee on Standards for Athletic Equipment

(NOCSAE). www.nocsae.org.

Documents

STUDENT-ATHLETE HEALTH & WELFARE Cervical Spine Injury …publicaffairs.vpcomm.umich.edu/wp-content/uploads/sites/... · 2015. 4. 8. · catastrophic cervical spine injury in the