Version May 2024
INTRODUCTION — The prehospital evaluation and initial management of the young athlete with an acute neck injury will be discussed here. The approach to the athlete with a complaint of neck pain or injury; overviews of musculoskeletal, cervical spinal cord, and cervical peripheral nerve injuries; and the technique for removal of a motorcycle helmet are presented separately:
●(See "Evaluation of the child or adolescent athlete with neck pain or injury".)
●(See "Overview of musculoskeletal neck injuries in the child or adolescent athlete".)
TERMINOLOGY — For this topic, spinal motion restriction is used in preference to spinal immobilization. Historically, the process of restricting the motion in the spine during emergency medical management was described as "spinal immobilization." More recently, trauma experts have adopted the term "spinal motion restriction" for this process because true immobilization of the spine is unattainable. (See "Pediatric cervical spinal motion restriction", section on 'Definitions'.)
PREPARATION — Severe neck injuries with permanent neurologic sequelae occur rarely among young athletes. Because these injuries are uncommon, most youth team physicians and trainers have little experience managing them [1]. Nonetheless, the management of athletes with potential cervical spine injuries must be a well-coordinated process.
Emergency action plan — Athletic programs should have an emergency action plan developed in conjunction with local emergency medical services (EMS) agencies specific to pre-hospital spine-injury care. The plan should address medical roles and duties of sideline personnel, designate who is responsible for ensuring necessary equipment is immediately available during practice and events, and identify EMS agency and hospital contacts for each event.
Pre-season — Personnel involved in youth team sports, particularly the team physician, must be prepared for the possibility of a cervical spine injury [2]. Adequate preparation and familiarity with individual roles and duties are of paramount importance in avoiding preventable catastrophic injuries [1,3,4].
Preseason simulation of the acute care of the injured athlete can help mitigate the stress and confusion that may arise when a severe injury occurs. Such training should include management of a scenario with practical components such as proper notification of EMS and use of emergency equipment [4]. All members of the interdisciplinary health team should participate.
Pre-event
Equipment — Arrangements should be made to have an ambulance with EMS personnel at the athletic event (particularly football games) or readily available in case an athlete requires urgent transport to a medical facility, whenever possible [3]. In addition, all necessary equipment should be on hand and easily accessible, including:
●A bag-valve-mask for ventilation (with various mask sizes depending upon the age/size of the participating athletes)
●Equipment to safely remove protective gear (eg, face mask, helmet pads, and shoulder pads in football)
●Cervical spine motion restriction (immobilization) devices (see "Pediatric cervical spinal motion restriction")
●A backboard
●A mobile phone to contact EMS
In settings where an onsite ambulance with equipment is not practical, there should be a preplanned ability for sideline personnel to contact and request EMS for concerns.
Ambulance transport — Whenever possible, spine-injured athletes should be transported directly from the field to a medical facility that can deliver immediate stabilization and on-site (or transfer to) definitive care for those with a significant cervical spine injury. Team medical personnel should know how to contact the EMS agency and preferred hospital for each event location, and this information should be reviewed during the medical time-out.
Best practices are for an athlete with a suspected spinal injury to be transported to a designated level 1 or 2 trauma center as quickly and safely as possible [4]. Key capabilities at such centers include:
●An emergency department with board-certified emergency medicine physicians
●In-house trauma team to facilitate emergency evaluation and treatment led by trauma surgeons
●Personnel trained in equipment removal
●Advanced imaging services (24 hours per day, seven days per week)
●Spine surgeon consultation in house or readily available
●Operating room (24 hours per day, seven days per week)
●Critical care monitoring and rehabilitation services
If such a facility is not located within a 30- to 60-minute transport from the event, then transport to the nearest acute care hospital permits initial stabilization prior to transport to a definitive center.
Medical time-out — Sports medicine teams should conduct a pre-event medical time-out before each athletic event (practices and competitions). Before competition, medical personnel from both teams, EMS personnel, and game officials should participate.
The time-out should review:
●Medical roles and duties of sideline personnel
●Available equipment
●Contact numbers for EMS (if not onsite) and hospital notification
FIELD EVALUATION — The prehospital evaluation of young athletes with acute neck injuries includes the following steps [5]:
●Recognition of neck injury
●Cervical spine stabilization and safety
●Notification of emergency medical services (EMS) and immediate treatment of airway, breathing, and circulation in athletes with severe injury to prevent secondary injury
●Evaluation for return to play (ambulatory athletes with neck injury whose signs and symptoms have resolved)
Every patient with concern for an acute neck injury must be assumed to have a serious spinal cord injury until proven otherwise. Failure to adhere to this dictum can result in catastrophic, permanent cervical spine injury [6]. Prehospital personnel who treat patients with potential cervical spine injuries have three priorities:
●Ensure patient survival
●Preserve residual spinal cord function
●Transport the patient safely to an appropriate medical center so that further stabilization and treatment can be initiated as well as definitive evaluation as able
Primary neurologic injury is sustained at the time of impact and is treated at a medical care facility under the direction of appropriate specialists [6]. Secondary neurologic injury results from hypoxia and shock, which increase the degree and extent of the primary injury. Prevention of secondary injury is the primary goal of prehospital and hospital care of the young athlete with acute neck injury.
The hospital care of the unstable pediatric trauma patient and acute spinal cord injury are discussed in detail separately. (See "Trauma management: Approach to the unstable child" and "Acute traumatic spinal cord injury".)
Recognition — The field medical personnel should watch the sporting event carefully so that high-risk neck injuries can be rapidly recognized and treated. Mechanisms of injury associated with severe neck and cervical spine injuries include:
●Axial load to the head (eg, spear-tackle in American football or going directly head-first into the boards in hockey)
●Hyperflexion or hyperextension of the head and neck during a tackle, block, fall, or check
●Direct blow to the neck (ie, clothesline tackle mechanism)
A high index of suspicion for a serious spinal cord injury should be maintained in all unconscious athletes, athletes with neurologic compromise, and any awake athlete who complains of neck pain, even in the presence of an initially normal neurologic examination [7]. As an integral part of resuscitation and before transport, cervical spine motion restriction must be applied and maintained until cervical spine injury is ruled out clinically or radiographically.
Because cervical spine injuries can progress, not all significant injuries may be recognized immediately. Suspicion and recognition of cervical spine injuries in the athlete who walks from the field are discussed below. (See 'Sideline evaluation (ambulatory athletes)' below.)
Spinal motion restriction (immobilization) — In athletes with suspected cervical spine injury, medical field providers should implement spinal motion restriction as soon as possible after injury (algorithm 1):
●Stabilize the cervical spine – The first step involves manual inline cervical spine stabilization to hold the head and neck in a neutral (or current) position (figure 1) [3,8]. No traction should be applied or attempts at neck realignment made. Care must be taken for motion restriction of an obviously deviated cervical spine; it should be stabilized as is without any attempt at straightening [9]. (See "Pediatric cervical spinal motion restriction".)
●Position the patient supine on a spine board – Next, when proper equipment and numbers of field personnel are available, log-roll the athlete into the supine position and onto a padded, rigid spine board for further evaluation and management [10]. Athletes initially in the prone or side position require extra care in maintaining cervical spine stabilization during the log-roll procedure. The log-roll maneuver is discussed in detail separately. (See "Pediatric cervical spinal motion restriction".)
Leave the athlete on the spine board until arrival at the hospital [4].
If adequate numbers of field personnel are not available, then manually stabilize the cervical spine until EMS arrives.
●Determine need to remove helmet and/or shoulder pads – Athletes wearing either a helmet or shoulder pads alone require careful and skilled equipment removal and continued maintenance of inline manual stabilization until properly trained medical personnel can place a rigid cervical collar.
Athletes wearing both a helmet and shoulder pads require simultaneous removal if they interfere with the maintenance of spinal motion restriction or medical resuscitation. Otherwise, we suggest that the helmet and shoulder pads be left in place. (See 'When to remove helmet and/or shoulder pads' below.)
When to remove helmet and/or shoulder pads — In athletes with suspected serious cervical spine injury, whether to maintain the helmet or shoulder pads in place or remove them depends upon whether the equipment interferes with spinal motion restriction or medical resuscitation:
●Helmet without shoulder pads – Helmets that are worn without shoulder pads (eg, batting helmets, bike helmets, motorcycle helmets) should be removed to permit motion restriction of the cervical spine in the neutral position, prevent hyperflexion of the cervical spine when the athlete is in the supine position, and assist with access to the airway as needed. Whenever possible, helmet removal should be performed by a health care provider who has experience and expertise in helmet removal. When the athlete is clinically stable (eg, clear airway with normal breathing and circulation), waiting for EMS personnel to arrive is better than attempted helmet removal by an inexperienced person.
The proper removal of a motorcycle helmet is discussed in more detail separately. (See "Cervical spinal column injuries in adults: Evaluation and initial management", section on 'Helmeted patients'.)
●Shoulder pads without helmet – In some instances, the athlete may have the helmet knocked off but still have shoulder pads in place. These patients require head support to maintain neutral cervical spine alignment during and after the removal of the shoulder pads [4].
●Helmet with shoulder pads (American football, ice hockey, or lacrosse) – For the athlete suspected of serious cervical spine injury, we suggest leaving the helmet and shoulder pads in place during on-the-field care rather than removing them unless they interfere with proper spinal motion restriction or medical resuscitation [11]. To further minimize head motion, towel rolls, foam head blocks, and tape may be used.
Unconscious athletes and awake athletes with respiratory distress should have the face mask removed if there is concern about maintenance of airway and breathing [12]. During face mask removal, one person should stabilize the head and maintain cervical spine motion restriction while a separate person removes the face mask. Tools for face mask removal are brand specific and should be used whenever available [13]. If no such tool is available, the field provider may use heavy-duty trauma shears.
For athletes requiring nasopharyngeal or oropharyngeal airway insertion or bag-mask ventilation to maintain the airway and breathing and for those receiving cardiopulmonary resuscitation (CPR), the field providers should remove the chin strap along with the face mask to facilitate opening the mouth.
Despite our suggestion to keep football helmets and shoulder pads in place on the field, there are certain circumstances in which they should be removed (table 1) [5,7]. If helmet and shoulder pad removal is necessary, those with the highest level of training and experience in removal techniques should participate in equipment removal. Athletic trainers are recognized as the medical professional with the most training and experience in field athletic equipment removal [4].
Because the shoulder pads in American football elevate the player's shoulders in the supine position, removal of the helmet and the shoulder pads must occur at the same time to prevent excessive cervical spinal motion [14]. In general, correct removal requires at least three persons on both sides of the patient and one person stabilizing the cervical spine. The procedure requires precise coordination of steps by all team members throughout the process, with leadership provided by the person providing inline manual cervical spine motion restriction. Tools to remove the shoulder pads, helmet face mask, and helmet pads are specific to the brand of equipment, and the person most experienced with their use should remove the face mask and helmet padding and release the shoulder pads. An approach to simultaneous removal of the helmet and shoulder pads is provided in this video.
Once the helmet and shoulder pads are removed, a spine board is placed under the patient.
Even in patients without a definite indication for helmet and shoulder pad removal, prehospital helmet and shoulder pad removal may sometimes be necessary to provide improved airway management, access to the chest for CPR, and expedited care of the athlete on hospital arrival [4]. The decision to remove equipment before transport should be based on a variety of factors:
•Medical status of the injured athlete
•Type of equipment worn
•Availability of a sufficient number of properly trained onsite rescuers
•Relative training and experience of on-the-field versus emergency room rescuers in equipment removal
Evidence is lacking regarding clinical outcomes of athletes with cervical spine injuries who undergo field removal of equipment compared with those who do not. Based upon a systematic review of 18 studies, most focusing on football equipment and all performed in proxy participants (eg, healthy volunteers, cadavers, or manikins), cervical spine alignment appears to be equivalent for subjects with both helmet and shoulder pads on compared with both helmet and shoulder pads removed [4]. If equipment removal is performed, then simultaneous removal of the helmet and shoulder pads under the direction of well-trained and experienced medical personnel is necessary to prevent excessive cervical spine movement.
Stabilization and transport (severe injury) — Once the cervical spine is immobilized, the initial evaluation of the athlete with acute neck injury should begin with an assessment of the patient's airway, breathing, and circulation (algorithm 1). The goal is to prevent secondary injury caused by hypoxemia or hypoperfusion.
Airway and breathing — Blunt trauma to the anterior neck, particularly when the neck is extended, can result in crush injury to the trachea and larynx. A direct blow to the neck may also precipitate acute laryngospasm.
Symptoms of airway compromise, such as stridor and respiratory distress, may occur immediately following the injury if the airway diameter is significantly reduced. On the other hand, if the airway is not acutely collapsed, the symptoms may be delayed until the onset of edema, which occurs several hours after the injury. Signs of tracheal injury warrant activation of a paramedic EMS ambulance for rapid transport to the nearest acute care facility. Prior to transport, basic care of these athletes includes:
●Remove the mouth guard [1].
●For athletes with patent airways and normal breathing, perform spinal motion restriction as indicated and evaluate the neck and cervical spine.
●For athletes with significant airway obstruction, perform a jaw thrust while avoiding excess spine movement (figure 2). If the jaw thrust maneuver fails to achieve adequate air exchange, place an artificial airway (oropharyngeal or nasopharyngeal airway). (See "Pediatric cervical spinal motion restriction", section on 'Motion restriction during airway management'.)
●For patients with acute laryngospasm, provide reassurance and supplemental oxygen.
●For athletes who are not breathing, establish an airway and begin bag-mask ventilation by properly trained and qualified medical personnel. (See "Basic airway management in children" and "Technique of emergency endotracheal intubation in children".)
Attempts to establish an artificial airway should only be performed by trained and qualified medical providers (eg, paramedics or physicians with advanced airway training and expertise). (See "Evaluation and acute management of cervical spine injuries in children and adolescents", section on 'Airway management' and "The difficult pediatric airway for emergency medicine".)
Circulation — If the athlete lacks a pulse, chest compressions should be initiated (algorithm 2). Shoulder pads may be opened as necessary to provide access for CPR and/or defibrillation [7]. (See "Pediatric basic life support (BLS) for health care providers".)
CPR is a potential indication for helmet and shoulder pad removal. (See 'When to remove helmet and/or shoulder pads' above.)
Spinal shock — Patients with cervical spinal cord injuries may develop spinal shock marked by bradycardia and hypotension. When paramedic-level EMS services are available and initiation of treatment does not unduly prolong transport time, these patients may warrant advanced treatment by advanced EMS personnel (eg, paramedics) per protocol or by online medical control such as atropine or transcutaneous pacing to raise heart rate or vasoactive medications to increase blood pressure. (See "Acute traumatic spinal cord injury", section on 'Cardiovascular complications'.)
Vascular injuries — Although uncommon in sport, vascular injuries of the neck can be difficult to diagnose, which may result in delay of definitive treatment. Thus, a high index of suspicion for such injuries must be maintained in athletes who sustain neck trauma during competition, particularly if there is an expanding hematoma or severe bleeding from a penetrating neck wound. Direct pressure should be applied, and emergency transfer to an appropriate medical facility with vascular surgery and trauma capabilities should be expedited. (See "Penetrating neck injuries: Initial evaluation and management".)
In addition to laceration or rupture of these vessels in high-impact trauma, vessel dissection or thrombotic phenomena can occur as a result of intimal injury after seemingly mild trauma or forceful stretching of the neck [15]. Thus, patients with persistent neck pain warrant urgent medical evaluation to determine the need for advanced diagnostic imaging.
Transfer to ambulance — Once spinal motion restriction is in place and the patient is safely placed on a spine board, the patient is lifted in a coordinated fashion by at least four providers and secured to a stretcher. Whenever possible, it is optimal to place the patient on the ambulance stretcher on the field rather than a separate field stretcher to avoid a second transfer from one stretcher to another when the patient arrives at the ambulance.
In some large stadiums where ambulances do not have direct access to the field, the patient may require transfer by another vehicle to the ambulance. In these situations, field medical personnel should be familiar with the mode of transport and methods of maintaining spinal motion restriction during patient transport from the field to the ambulance.
Sideline evaluation (ambulatory athletes) — Taking a detailed sideline history and performing a careful physical examination are critical in the evaluation of the ambulatory athlete who has sustained an acute neck injury and complains of neck pain.
The history should include:
●Mechanism of injury
●Presence of pain, stiffness, or any neurologic symptoms (eg, numbness or tingling, even if transient)
●Any previous history of neck injuries
●Past medical history of known predisposition to neck injury (eg, congenital cervical spine anomaly or Down syndrome) (see "Approach to neck stiffness in children", section on 'Congenital')
The field examination of an athlete with a possible neck injury should include the following components, performed in the order listed [3]:
●Mental status examination
●Motor and sensory testing
●Neck palpation for cervical tenderness or spasm
At any point during the evaluation, if any signs or symptoms of cervical spine injury are detected (table 2), the examination should be discontinued and cervical spine motion restriction performed. Otherwise, additional field testing includes (see "Evaluation of the child or adolescent athlete with neck pain or injury", section on 'Neck examination'):
●Gentle, resisted neck isometric contractions in the full range of motion (stop if pain develops or resistance is encountered)
●Active range of cervical motion (never perform passive range of motion)
●Repeat evaluation of cervical motion in the sitting or standing position (if originally performed with the athlete in the supine position)
●Axial compression and Spurling test for peripheral nerve impingement (picture 1)
Because cervical spine injuries may evolve with time, the initial clinical picture may be deceptive, particularly in athletes who are ambulatory [1,16]. If the examining physician is unsure of the degree of neck injury, they should keep the athlete out of competition and re-evaluate. It is always safer to err on the side of caution because of the potential for catastrophic harm to the unstable cervical spine.
Although it is unusual for an injured ambulatory athlete who was initially evaluated on the sideline to require full spinal motion restriction, it should be noted that a cervical collar alone does not adequately protect the cervical spine if the athlete has an unstable cervical fracture [17]. Thus, it is best to treat all neck injuries in which the clinical picture is not clear with full motion restriction on a spine board [18]. (See "Pediatric cervical spinal motion restriction".)
RETURN TO PLAY — Athletes with initial concern for acute neck injuries may return to play when they are symptom free and have a normal examination [17,19]. Specifically, the patient should have no neck or extremity pain, no motor or sensory deficits or symptoms, no neck tightness or spasm, and full, pain-free range of cervical motion (actively and against hand resistance). The performance of a sport-specific functional sideline examination may be helpful in this assessment [17].
When performing the assessment, the physician or trainer should ask the player to perform the tasks below but stop promptly if they have return of symptoms. The patient should also undergo a repeat physical examination after participating in the drills:
●Football
•Two 40-yard sideline sprints
•Two 40-yard zig-zag sprints
•Blocking drills with a teammate
●Hockey
•Two sprints half the length of the ice
•Two zig-zags half the length of the ice
•Brief shooting and/or blocking drills with a teammate
If possible, this evaluation should be performed on ice not being used for the competition.
●Lacrosse
•Two 40-yard sideline sprints
•Two 40-yard zig-zag sprints with a stick while feigning passes and shots
●Gymnastics – The evaluation depends upon the event (eg, bars, floor, beam, vault, etc); the gymnast should be able to perform short, limited routines or portions of a routine at less than full speed with minimal difficulty.
●Wrestling – Brief warm-up (jogging, push-ups, etc) followed by brief, light sparring with a teammate.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Cervical spine injury".)
SUMMARY AND RECOMMENDATIONS
●Overview – Severe neck injuries with permanent neurologic sequelae occur rarely among young athletes. Careful planning is necessary to ensure the proper field response and timely transport to definitive care.
●Preparation – Athletic program preparation for severe neck injury during a sporting event includes:
•Development of an emergency action plan in conjunction with local emergency medical services (EMS) agencies (see 'Emergency action plan' above)
•Preseason training of the team's interdisciplinary health providers, including simulation exercises (see 'Pre-season' above)
•Pre-event planning that ensures:
-Availability of necessary equipment (see 'Equipment' above)
-EMS transport onsite or readily available (see 'Ambulance transport' above)
-Medical time-out just prior to the event that includes team medical personnel, EMS providers, and game officials to review roles, responsibilities, and logistics for field stabilization and transport of an injured athlete (see 'Medical time-out' above)
●Field evaluation – Proper field evaluation and management of neck injuries in pediatric athletes require:
•Recognition – Medical providers should suspect a serious spinal cord injury in any unconscious athlete or awake athlete who complains of neck pain and has neurologic symptoms or is unable to walk. Signs and symptoms of spinal cord injury include neck pain, numbness, dysesthetic pain, weakness, limited range of motion, paralysis, respiratory arrest, and loss of consciousness (table 2). (See 'Recognition' above.)
•Cervical spine protection – For patients with an obviously deviated cervical spine, stabilize as is without traction or attempts at straightening. Otherwise, all athletes with a suspected cervical spine injury require spinal motion restriction that is implemented as soon as possible by trained medical field personnel (algorithm 1) (see 'Spinal motion restriction (immobilization)' above):
-Manually stabilize the cervical spine (figure 1).
-While maintaining cervical spine stabilization, log-roll the patient onto a rigid longboard (figure 3).
-For the athlete with a suspected serious neck injury who is wearing a helmet with shoulder pads, we suggest leaving the helmet and shoulder pads in place during on-field care rather than removing them unless they interfere with spinal motion restriction or medical resuscitation (table 1) (Grade 2C). If the helmet and pads remain in place, then the provider should remove the face mask to permit airway access in unconscious athletes and awake athletes with respiratory distress; the chin strap should be cut if oral airway insertion or bag-mask ventilation is necessary. (See 'When to remove helmet and/or shoulder pads' above.)
If equipment removal is performed, simultaneous removal of the helmet and shoulder pads under the direction of well-trained and experienced medical personnel is necessary to prevent excessive cervical spine movement.
●Stabilization – Along with spinal motion restriction, field providers should provide basic support of airway, breathing, and circulation within their scope of practice and assist with transfer of the patient to EMS. (See 'Stabilization and transport (severe injury)' above.)
●Sideline evaluation (ambulatory athletes) – Taking a detailed sideline history and performing a careful physical examination are critical in the evaluation of the ambulatory athlete who has sustained an acute neck injury and complains of neck pain. However, the initial clinical picture may be deceptive, particularly in an athlete who is ambulatory. If the examining physician is unsure of the degree of neck injury, they should keep the athlete out of competition and re-evaluate. (See 'Sideline evaluation (ambulatory athletes)' above.)
●Return to play – Athletes with neck injuries may return to play when they are symptom free and have a normal examination. The performance of a sport-specific functional sideline examination may be helpful in this decision. (See 'Return to play' above.)
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