Prevention and Management of Spine Injuries in Athletes

Peer Reviewed

While increased attention has been given to the safety of athletes who play contact sports, the focus is mostly on concussions with lesser emphasis given to the equally important need for education on preventing and managing spinal cord injuries, Andrew C. Hecht, MD, told attendees at the American Academy of Orthopaedic Surgeons 2018 Annual Meeting held March 6-10 in New Orleans, Louisiana.

“A well thought out emergency action plan (EAP) needs to be developed prior to game day and rehearsed, as well as constant emphasis on prevention of spine injury through teaching proper technique and avoidance of high-risk behavior," said Dr. Hecht, who is Chief of Spine Surgery for The Mount Sinai Health System and Associate Professor of Orthopaedics at the Icahn School of Medicine at Mount Sinai.
Football fumbleAn emergency action plan when put into practice expeditiously can spare catastrophic outcomes. Prevention Is Key
The primary cause of catastrophic cervical spine injuries in athletes is when a force is applied to the top of the head when the neck is partially flexed, which aligns the cervical vertebrae in a straight column. The paraspinal muscles that typically dissipate loads are no longer able to function properly, Dr. Hecht told the audience. Thus, the cervical spine is unable to withstand the compressive force and a fracture or dislocation occurs, he said.

For football players, prevention strategies include educating athletes how to tackle properly, such as playing “heads up” football and not leading a tackle with the head. Similarly, hockey players are instructed to keep their head up and “don’t duck” when hitting the boards or another player.

Develop an Emergency Action Plan
When developing an emergency action plan (EAP) for athletes in the off-season, “understand who the stakeholders are, and recognize common injury patterns and how to treat them so that on game day you have a clear understanding of the members of the team and how to reach EMS and get athletes to the receiving hospital,” Dr. Hecht told the audience. “If you have a plan and act expeditiously, you can make a huge difference in outcomes.” Aspects of pregame planning are shown in the Table.
Table. Pregame Planning for Spine InjuriesAn emergency action plan when put into practice expeditiously can spare catastrophic outcomes. Red flags of spinal cord injury in a conscious patient include bilateral upper or lower extremity symptoms, persistent neck pain (point tenderness or stiffness), any deformity, and fear of moving the head. In addition to assessing vital signs, physicians should palpate the neck and then progress to neurological evaluation (dermatome sensation, myotome-muscle testing). If the evaluations are normal, the athlete can be removed from the field.

For patients who are unconscious, call EMS immediately, assess the airway, and remove the facemask from the helmet while stabilizing the neck. The goal is to identify spinal cord injuries or before the patient is removed from the field, which has been correlated with a more favorable prognosis, Dr. Hecht said. Physicians should assess the potential for an unstable spine and should assume that the spine is unstable until proven otherwise.

Leave Helmet and Pads in Place
“Leave the helmet and pads in place until athletes are in the emergency room,” to avoid secondary injury, Dr. Hecht said. The helmet should only be removed if poor fit effects cervical spine stabilization or if there is no equipment available to adequately remove the facemask.

Prone athletes must be turned supine using rehearsed rolling techniques by a team of at least 5 people. The supine position not only simplifies evaluation and treatment, but also minimizes ischemia to the cervical spine, Dr. Hecht said.

Current recommendations call for immobilization of the head and neck in neutral alignment prior to transfer to an emergency facility.1 Dr. Hecht warned that a stable fracture with no neurological deficits may become an unstable fracture with quadraparesis in a matter of seconds. Thus, the person assigned to maintain stabilization of the head should not relinquish this duty until the patient is completely immobilized.

Once in the hospital, research suggests that the helmet and pads should be removed simultaneously using a team approach the includes athletic trainers to reduce changes in cervical spine alignment.2

Hypothermia
Renewed interest in hypothermia emerged after this technique was used to treat professional football player Kevin Everett, who suffered C3-C4 fracture and dislocation. Hypothermia lowers the core body temperature to 32 to 34°C via local application at the epidural or intradural space or via endovascular cooling. The goals of treatment are to reduce secondary injury from ischemia, edema, and inflammation.

A position statement from the AANS/CNS Joint Sections on Disorders of the Spine & Peripheral Nerves and Neurotrauma & Critical Care suggests that there is not enough evidence available to recommend for or against use of therapeutic hypothermia for acute spinal cord injury.3

What Are the Role of Steroids in Spine Injury?
Dr. Hecht emphasized that athletes are unique from the general spinal injury population in that they receive immediate access to care and typically have an isolated trauma rather than polytrauma as occurs in spinal cord injury from motor vehicle accident or other trauma. Thus, much of the data in the literature showing complications with steroid use in spinal cord injury probably do not apply to athletes.

Recently released guidelines suggest that a 24-hour infusion of high-dose methylprednisolone be offered to adult patients who present within 8 hours of acute spinal cord injury, but not to patients who present 8 or more hours after injury. The guidelines also emphasize the role of early surgery, Dr. Hecht explained. The guidelines were developed under the guidance of AOSpine North America, AOSpine International, and the American Association and Congress of Neurological Surgeons (AACNS).

Conclusion
Dr. Hecht concluded that prevention is key in managing spinal cord injuries in athletes and that all athletic events should have an EAP and emphasized that. An EAP is especially important at the high school level, where team members have less access to trainers and medical personnel on the sidelines, Dr. Hecht said.

Disclosure
Dr. Hecht is a consultant for Zimmer Spine, Medtronic, and Atlas Spine. He has received royalties from Zimmer and Medtronic, is on the NFL Head, Neck and Spine Committee, and is a Spine Surgery Consultant for the NY Jets and NY Islanders.

Updated on: 03/29/18
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Changes in the Care of Head and Neck Injuries in Helmeted Student Athletes
Andrew Hecht, MD
Chief of Spine Surgery
Mount Sinai Health System
New York, NY
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