On-Field Management of Athletic Head and Neck Injuries: Spinal Motion Restriction,Equipment Removal,Patient Transfer,and Spine Boarding Techniques

Abstract

Background:

Although rare, athletic head and cervical spine injuries can be devastating. All health care professionals involved in the on-field care of athletes with these injuries should be aware of updated national guidelines as well as individual institutional practices regarding head and neck immobilization after on-field injuries. Appropriate prehospital management—including evaluation, equipment removal, spine board immobilization, and patient transfer—can mitigate further risk for these injured athletes.

Indications:

The goal of spinal-motion restriction is to reduce spinal instability and prevent further neurologic injury. Indications include blunt trauma with altered level of consciousness, cervical spinal pain or tenderness, or concern for spinal instability, loss of cervical motion, bilateral neurologic complaints, or anatomic deformity of the spine after a sports-related injury.

Technique Description:

This video will describe critical aspects of on-field management of head and neck injuries, featuring a video demonstration of current care concepts and recommended best practices for spinal motion restriction, removal of athletic equipment, and patient transfer techniques for on-field spine boarding. The video demonstrates removal of the helmet and shoulder pads, as well as transfer techniques for athletes in the supine or prone position. The videos also highlight appropriate communication throughout the transfer process, which is paramount to successful stabilization.

Results:

Preinjury preparedness allows health care providers to optimize on-field emergency care safely and efficiently. The appropriate method of spinal-motion restriction is dictated by the athlete's clinical examination, position on the playing field, body position (eg, supine, side-lying, or prone), and the number of rescuers available. Stabilization using more rescuers (≥6) has been shown to minimize spinal motion across an unstable spine injury.

Return to Sport:

Return to sport is managed on a case-by-case basis, determined by the type and the severity of the injury sustained, and by the necessary interventions performed upon transfer to a higher center of care.

Discussion/Conclusion:

Optimizing on-field management of athletic cervical spine injuries with thorough communication and collaborative stabilization techniques can help mitigate the risk of further neurologic compromise in the injured athlete. Understanding various techniques for immobilization, equipment management, and patient transfer will enable health care professionals to provide safe and reproducible care for these injured athletes.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

This video presents the on-field management of presumed or confirmed athletic head and neck injuries, focusing on spinal-motion restriction, athletic equipment removal, patient transfer, and spine boarding techniques. This video is produced by the University of Virginia Orthopaedic Surgery Department in collaboration with the Virginia Athletic Department and the Virginia Athletic Trainers.

The authors of this video all serve as health care providers for collegiate athletics. Otherwise, none of the authors reports disclosures pertinent to this video.

Background

Head and neck injuries can result in life-altering outcomes for athletes. Despite the critical importance of managing these injuries appropriately and efficiently, a recent study demonstrated that many health care providers broadly lack the fundamental knowledge with regard to spine injury management and spine boarding techniques. ⁶

Best Practices and Current Care Concepts

In 2020, the National Athletic Trainers Association released a “Best Practices and Current Care Concepts” publication for care of the spine-injured athlete in football. ³ American football received particular focus, as it is associated with the highest number of catastrophic cervical spine injuries among sports played in the United States. ¹ The document is recommended reading for any sideline providers. This video presents the most current literature and recommendations on the Emergency Action Plan (EAP), spinal-motion restriction, equipment management, and patient transfer.

Clinical Vignette Video

In November 2023, during a game between the University of Virginia and the University of Louisville football teams, running back Perris Jones caught a pass. Subsequently, it sustained a traumatic cervical spine injury after a hit from an opposing player. He reported immediate loss of motor and sensation below the neck. He was evaluated by the team of athletic trainers and physicians, immobilized, placed on a spine board, and transferred to the university trauma center. He underwent an urgent cervical spine decompression and fusion for his injury, and postoperatively has regained full neurologic function. Perris's injury highlights the importance of emergency preparedness when caring for athletes as a sideline provider.

Goals of Current Presentation

Complete immobilization of the cervical spine is not possible in the athletic setting.^3,8 This is often due to athlete distress, positioning on the field or in relation to other players, and equipment complicating evaluation and immobilization. Therefore, principles of spinal-motion restriction are used to reduce motion and limit any further injury to the neurologic and vascular structures during assessment and transfer. These videos demonstrate various equipment removal, spine board application, and patient transfer techniques based on athlete positioning and the number of rescuers available.

Indications

The indications for immobilization with spinal-motion restriction include blunt trauma with altered level of consciousness, spinal pain or tenderness with anatomic deformity, loss of cervical motion, and neurologic complaints with involvement of >o1 limb. ³ Additionally, if there is concern for suspected spinal injury but difficulty ascertaining the severity of the injury, most health providers recommend a conservative approach with preference toward stabilization until further testing is completed.

Technique Description

Initial Management

The EAP is a protocol specific to each event and venue that is routinely reviewed to produce effective and reproducible care in the injury setting. Immediate athlete assessment includes a scene survey to evaluate the athlete's position on the field and the athlete’s prone, lateral, or supine positioning. Equipment may limit this assessment. Upon arrival at the athlete, it is imperative to assess airway, breathing, and circulation immediately. Should the athlete meet any of the spinal-motion restriction indications previously outlined, the head and cervical spine should immediately be stabilized by a predesignated member of the athletic health care team. Athletic emergencies present a unique difficulty with airway management, as athletic equipment can be a significant barrier to access. Emergent on-field removal of helmet and shoulder pads is indicated in the setting of compromised airway, need for cardiopulmonary resuscitation, or placement of medical equipment such as an automated external defibrillator leads.^5,7

Spineboarding and Transfer: General Principles (With Demonstration Videos)

There are several general principles for transfer to the spine board. The first step is maintaining manual in-line stabilization of the spine by the initial or primary rescuer, followed by spinal-motion restriction devices, such as cervical collars, padding/blocks, and spine boards. Effective communication is paramount to successful transfers and appropriate immobilization. The primary rescuer must speak clearly and loudly enough for all members of the team to follow their commands. The transfer technique selected is most dependent on the number of people available for assistance, with studies demonstrating that >6 rescuers involved may minimize the extent of motion across a globally unstable spine.^2,4

The multiperson lift has long been the gold standard for transferring an injured athlete to a spinal-motion restriction board. This technique requires at least 8 rescuers. The primary rescuer provides manual in-line stabilization of the head and cervical spine while 6 rescuers kneel on either side of the injured athlete, positioned at the chest, pelvis, and thighs to assist in the lift. The primary rescuer commands a lift, and in unison, the patient is brought off the ground approximately 6 inches to allow for another rescuer to swiftly slide a spine board into position from the foot end of the athlete. The primary rescuer will communicate when the board is in an appropriate position and the athlete is carefully lowered onto the spinal board. Three rescuers are positioned on either side of the athlete, and cross-link their arms as demonstrated for the safest manipulation of the athlete. Common pitfalls in this method include poorly coordinated movements and uneven distribution of force/strength by the rescuers. Practice as a team is essential for performance during an emergency.

When <8 rescuers are available for assistance, another common technique utilized is the supine log roll. This technique requires at least 5 rescuers, and the primary rescuer is once again positioned at the head of the athlete, providing manual in-line stabilization of the head and cervical spine. Rescuers 2 to 4 assist in rolling the patient, 90° into a side-lying position, while another rescuer wedges the spine board at a 45° angle to the ground underneath the patient. They ensure that the board is centered under the patient and carefully return the patient to the supine position. With fewer rescuers than the multiperson lift, fewer hands are stabilizing the athlete, and there is a higher risk for lateral flexion and axial rotation than a multiperson lift technique. ⁴

For the prone log-roll push method, Rescuer 1 is positioned at the head of the injured athlete, providing in-line stabilization. This is done using a crossed-hand position, preparing the primary rescuer for the normal hand position after the log roll is complete. Three other rescuers are placed on either side of the athlete's body, positioned at the shoulders, pelvis, and knees. A spine board is placed on the posterior side of the patient. At the command of the primary rescuer, the athlete is rolled onto the board in a controlled fashion. For the prone log-roll pull method, the rescuers are on the same side as the spine board, and the spine board is pinned between the thighs of the kneeling rescuers and the prone-positioned patient. On the primary rescuer's command, the rescuers pull the patient onto the spine board. When possible, the prone-log roll push is preferred, as it has been shown to generate less lateral bending than the log-roll pull. ⁴

Equipment Removal: General Principles (With Demonstration Videos)

Current guidelines recommend equipment removal by the provider who is most trained or familiar with the equipment. It is now routinely recognized that the most capable providers are the on-field team. Therefore, equipment removal is recommended rather than deferring to emergency medical technicians or emergency department personnel. At least 2 rescuers will be required for all techniques, with many requiring 4 to 6 rescuers for optimal control of the head, cervical spine, and torso during removal. The jersey should be cut off with trauma shears to maximize visualization and access to the head, neck, and pads. The helmet and shoulder pads are considered a unit, meaning that both are removed or maintained in tandem. Different equipment can force the position of the head into relative flexion or extension, and therefore, it is safest to establish neutral alignment with the removal of all equipment. If there is concern for compromise of the athlete's airway, removal of the facemask in isolation may be indicated. A wide variety of facemasks, helmets, and shoulder pads exist, so knowledge of the specific equipment worn by your team is essential and should be reviewed in the EAP timeout before the event.

For helmet and shoulder pad removal, at least 2 rescuers are required. Commands for removal should be directed by the primary rescuer positioned directly above the athlete's head, who is stabilizing the head and cervical spine. Often, removal of the jersey with trauma shears will aid in full visualization of the cervical spine and head and will simplify access to the shoulder pads.

In situations where fewer rescuers are available, a common strategy is the elevated torso technique, which is demonstrated in this video. The primary rescuer again stabilizes the cervical spine and head initially, but transfers this role to the secondary rescuer positioned anterior to the patient. Next, rescuers 3 and 4 carefully lift the upper torso of the athlete to a level of about 30° of flexion through the waist. The movement in this position is similar to a sit-up. Once in this position, the primary rescuer removes the shoulder pads and helmet while the secondary rescuer maintains cervical spine immobilization, and the side rescuers support the torso. Once the equipment is appropriately removed, the primary rescuer assists with cervical spine and head control as the patient is carefully lowered back down into the supine position.

Finally, a cervical collar is placed, and the athlete is secured to the spine board using the spider straps, which are carefully positioned across the patient’s shoulders, torso, waist, and legs, and then tightened sequentially. Foam blocks and silk tape are used to secure the athlete’s head and cervical spine to the spine board and end the primary rescuer's role of manual spinal immobilization.

Equipment Removal: Other Options

Additionally, a multiperson lift technique is an option where 9 rescuers are positioned around the athlete. The rescuers will lift the patient off the ground to clear the shoulder pads while maintaining neutral spine alignment. Additional rescuers remove the shoulder pads, and then a final rescuer slides the spine board underneath the athlete. The patient is then lowered onto the spine board in unison. The multiperson lift technique is advantageous when larger teams of rescuers are available, particularly when team members work together frequently and are cohesive as a unit.

Discussion/Conclusion

Preinjury preparedness for athletic head and neck injuries is important for optimizing outcomes of on-field management. Sports medicine professionals should be aware of the facilities’ EAP and understand how to use multiple rescue techniques when caring for injured athletes. A collaborative effort of education and practical training will improve care for these injured athletes.