Neck Injuries: Urgent Decisions and Actions
John Wiesenfarth, MD, MS; William Briner, Jr, MD
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In Brief: When a neck injury is suspected, the on-site physician must first provide basic trauma care, which includes establishing an airway as necessary, assessing breathing, and checking circulation and neurologic compromise. A few targeted questions during history taking and a directed physical exam will help rule out serious cervical injuries, which are uncommon. More common are minor injuries, such as "burners." Team physicians must also be well-versed in immobilizing and transporting the patient, administering a thorough neurologic exam, and establishing when the athlete can return to competition.
Of the 6,000 to 10,000 spinal cord injuries reported each year, motor vehicle accidents account for 35% to 45%, and falls for 25% to 30% (1). Most of the rest are related to sports, especially football, rugby, ice hockey, soccer, diving, gymnastics, and wrestling (2-4). Nevertheless, catastrophic neck injuries are infrequent in sports, with a prevalence of less than 2/100,000 neck injuries (3). One sport has especially reduced the incidence: Fewer than 10 football players each year have sustained permanent injury to the cervical spinal cord since 1977 (5).
Less serious sports-related neck injuries, in contrast, are fairly common. Moreover, it is often difficult to differentiate a stable neck injury from an unstable one, so physicians must be proficient in assessing and managing all neck injuries. Three priorities must be considered in the emergency medical management of a patient with a spinal cord injury: (1) ensure patient survival, (2) preserve spinal cord function, and (3) allow the highest possible chance for an injured spinal cord to recover.
First, do no harm! Do not move the patient except from immediate danger or for basic trauma management. An estimated 50% of neurologic deficits are created after the initial traumatic insult (6,7). Furthermore, it is difficult to determine immediately if a neck injury is stable or unstable.
If the athlete has fallen on the field, have him or her lie there until a brief initial evaluation is completed (figure 1: not shown). An unstable neck injury must be assumed in the following instances: an unconscious athlete, an awake athlete who has numbness and paralysis, and a neurologically intact athlete who has neck pain or pain with neck movement.
When a neck injury is suspected, institute the ABCDEs of trauma care (airway, breathing, circulation and cervical spine, disability, and exposing an injury for evaluation). Here is a modified version that can be used for possible neck trauma.
Trauma care basics. Airway management is of primary importance. The jaw thrust technique has been shown to be the safest method for opening the airway in patients with suspected neck injury (8). In this technique, the caregiver places his or her fingers behind the angle of both sides of the patient's jaw and lifts up, bringing the mandible forward. If this technique is inadequate, the modified jaw thrust-head tilt, in which the jaw is pulled upward and the head tilted back as little as possible, can be used.
In a football player with a suspected neck injury, do not remove the helmet initially because the jostling may cause severe neurologic complications if the patient has an unstable fracture. If an airway access is necessary, the face mask may be cut using a sharp knife or a device called a Trainer's Angel (Trainer's Angel, Riverside, California). Trained personnel can remove a face mask in less than 30 seconds using a Trainer's Angel.
Breathing problems in a patient with a neck injury may signal more severe injury. For example, apnea may mean that the patient has sustained damage to the brain stem. Once the airway is secure, artificial respiration may be necessary.
In assessing circulation, first check for a carotid pulse. If it is absent, begin chest compressions in accordance with basic life support guidelines. It is important to remember that spinal shock can cause hypotension, paradoxical bradycardia, and warm, dry skin. However, consider all causes of shock in an athlete who might have multiple fractures. A tension pneumothorax, especially in tall, thin athletes, may also cause hypotension with paradoxical bradycardia.
It is also important to gauge cervical tenderness by palpating the spinal processes for tenderness and the paraspinal musculature for tenderness and spasm.
To evaluate disabilities, it is important to perform a motor and sensory assessment (table 1). This can also be done on the sideline. Clinically, there are two classes of spinal cord injury: complete and incomplete. Complete injury renders the patient without motor power or sensation below the level of injury. Incomplete injury leaves the patient with some preserved motor or sensory function. Although rare, a complete injury results in a poor outcome in almost all cases. Spinal shock may appear to be a complete lesion; however, it usually resolves within 24 hours (9).
___________________________________________________________________________ Table 1. Motor and Sensory Innervation of the Cervical Spine Nerve Roots __________________________________________________________________ Root Level Muscles Function Lost Sensory Level ____________________________________________________________________________ C-2 Anterior Neck flexion Occiput vertebral and rotation neck C-3, C-4 Trapezius Shoulder elevation Base of neck C-4 Diaphragm Respiration Shoulder tops C-5, C-6 Biceps Forearm flexion Thumb (C-6) C-7 Triceps Forearm extension Long finger C-8 Flexor digitorum Finger flexion Little finger ____________________________________________________________________________
Finally, if a serious injury is visually obscured, it may be necessary to expose the area by removing clothing or equipment without moving the patient.
History. If the patient is alert, the history is at least as important as the physical exam. History taking can be included during initial trauma management or be done immediately afterward. How the athlete responds to questions can help in further assessing the level of consciousness. If he or she can respond verbally without any problems, chances are the airway is patent. Important questions to ask are:
Most sources agree that severe neck injury is usually accompanied by pain and sometimes neurologic symptoms (10-13). An athlete without pain and neurologic symptoms has a very low probability of having a severe neck injury and therefore can be helped off the field for further evaluation. A patient with neck pain should have his or her cervical spine immobilized and be placed on a backboard for transport to the sideline en route to an emergency facility.
Transportation to the Sideline
It is essential that proper equipment be available for transporting the patient from the field safely. If the clinical picture is unknown, it is best to treat all neck injuries as unstable by immobilizing the neck. If a cervical collar is available, apply it until a cervical-spine injury is ruled out (14). A backboard is necessary to prevent further injury while moving the athlete (figure 2). Once the athlete is on the backboard, immobilize his or her head and torso. Use sandbags or other padding to sandwich the head as it is taped to the backboard (figure 3). Ammonia or smelling salts should be avoided in the dazed or unconscious athlete because a reaction of jerking away from this stimulus may cause neurologic compromise.
Further assessment and initial treatment can be initiated once the patient is on the sideline. If there is time, patients on backboards can be assessed while waiting for emergency transportation.
When an unstable injury is possible, it is important to determine the nature and severity of the injury and have the patient further evaluated at an appropriate medical facility. Stable cervical sprains and strains, in contrast, rarely require extensive treatment and generally resolve without incident. All possible neck injuries, however, require a thorough neurologic examination off the field.
The sideline neurologic exam includes a quick assessment of motor, sensory, and reflex pathways. Have the patient move his or her fingers and toes. Assess grip strength by having the athlete squeeze your fingers with each hand simultaneously; be alert for asymmetry. Look for asymmetry when the athlete dorsiflexes and plantar flexes his or her feet. Check for gross sensation in the upper extremities by simultaneously touching similar parts of each arm. If the situation allows, check for reflexes and for asymmetry of reflexes.
Also, assess the cranial nerves. Nerves II through XII should be quickly assessed in all patients who have acute neck injuries. This evaluates brain stem function. Finally, active range of motion (ROM) should be included so that the patient can stop if the movement becomes painful. A patient who is asymptomatic and has full ROM can usually return to play.
The most common neurologic cervical injury is a unilateral neurapraxia of the cervical nerve roots and brachial plexus, often called a "burner." Key historical features of this condition are quick recovery from the resulting paresthesia or weakness in the extremities, accompanied by full ROM without pain. Return to activity is permitted when the paresthesia has subsided and full muscle strength and full, pain-free ROM have returned (15,16). Neurapraxias that are multiple or bilateral may warrant further diagnostic workup. If this is an athlete's first neurapraxia or if the condition involves the lower extremities, he or she needs a full workup and should not return to play.
The best way to handle cervical spine injuries is to be prepared for them. It is important to have a game plan, with all equipment inspected and readily accessible, and all personnel involved trained to use it. Communication among all members of the emergency medical team should be established before the competition. Transportation to an emergency medical facility should be immediately available as well. Proper preparation can go a long way in avoiding serious long-term sequelae.
The authors thank Scott Raub, DO, for his assistance in preparing this manuscript.
Dr Wiesenfarth is a resident in the Department of Emergency Medicine at William Beaumont Hospital in Royal Oak, Michigan. Dr Briner is the director of the Primary Care Sports Medicine Fellowship at Lutheran General Hospital in Park Ridge, Illinois. He is a fellow of the American College of Sports Medicine. Dr Howe is a team physician at Western Washington University in Bellingham, Washington, and a member of the editorial board of The Physician and Sportsmedicine. Address correspondence to John Wiesenfarth, MD, MS, Dept of Emergency Medicine, William Beaumont Hospital, 3601 W 13 Mile Rd, Royal Oak, MI 48073.