Management of the Helmeted Athlete with Suspected Cervical Spine Injury

Abstract

Improper handling of an unstable neck injury may result in iatrogenic neurologic injury. A review of published evidence on cervical management in the helmeted athlete with a suspected spinal injury is discussed. The approach to the neck-injured helmeted athlete and the algorithms for on-field and emergency department evaluations are reviewed. The characteristics of the fitted football helmet allow safe access for airway management, and helmets and shoulder pads should not be initially removed unless absolutely necessary. Prehospital and emergency personnel should be trained in the indications for removal and in proper helmet, shoulder pad, and facemask removal techniques. If required, both helmet and shoulder pads should be removed simultaneously. Radiographs with equipment in place may be inadequate, and the value of computed tomography and magnetic resonance imaging in these helmeted patients has been studied. If adequate films cannot be obtained with equipment in place, helmet and shoulder pads may need to be removed before radiographic clearance. A plan should be formulated to prepare for such unexpected clinical scenarios as cervical spine injuries, and skills should be practiced. Airway and cervical spine management in these helmeted athletes is an area of ongoing research.

Lacrosse Helmet Facemask Removal

“…Nevertheless, how injury may affect spinal cord space remains unclear. Waninger 4 found that head movement inside a lacrosse helmet is similar to but slightly greater than head movement inside a football helmet. Although these results were not different, the increase in movement may be clinically important.…”

“…3,4 Although some researchers support leaving the helmet and shoulder pads in place until they can be removed in a controlled environment to avoid increasing upper cervical spine flexion due to helmet removal, 5 we still do not know how the helmeted lacrosse athlete with a suspected cervical spine injury should be treated immediately. 6 The lacrosse helmet may need to be removed if neutral cervical alignment cannot be attained, the helmet is fitted improperly, or the facemask cannot be removed easily.…”

The Assessment of Airway Maneuvers and Interventions in University Canadian Football, Ice Hockey, and Soccer Players

“…Available options include simple airway procedures such as a jaw-thrust maneuver; placement of an oral airway to improve ventilation; adjunctive airway devices, such as a bag-valve-mask (BVM), laryngeal mask airway, or Combitube (Kendall Sheridan, Argyle, NY); and, finally, definitive airway control with endotracheal intubation. [1][2][3] In an unconscious athlete, maintaining an adequate airway and assisting ventilation is a timesensitive but often difficult procedure that is potentially lifesaving.…”

“…If the helmet is removed, the head and neck usually fall into an extended position, [4][5][6][7][8][9][10] possibly further complicating an existing cervical spine injury. 11 As such, most experts agree that when a football or ice hockey player has sustained a possible cervical spine injury, either the helmet should be left in place while the face mask or visor is removed 2,3,[12][13][14][15][16][17] or both helmet and shoulder pads should be removed simultaneously. 3 As technology advances, sport equipment evolves.…”

“…11 As such, most experts agree that when a football or ice hockey player has sustained a possible cervical spine injury, either the helmet should be left in place while the face mask or visor is removed 2,3,[12][13][14][15][16][17] or both helmet and shoulder pads should be removed simultaneously. 3 As technology advances, sport equipment evolves. Recently, football and ice hockey helmets have become larger in an effort to provide more protection.…”