Sideline Evaluation of Neck Pain
When Is It Time for Transport?
Robert R. Haight, MD; Brian J. Shiple, DO
THE PHYSICIAN AND SPORTSMEDICINE - VOL 29 - NO. 3 - MARCH 2001
In Brief: Both ambulatory and nonambulatory athletes with neck pain require careful evaluation for possible cervical spine injury. The fact that an athlete is ambulatory should not lull the physician into a false sense of security—we offer a case study of a high school football player that makes this point dramatically—and the decision to return a player to the game should not be taken lightly. Symptoms such as neck pain, numbness, loss of range of motion of the neck, paralysis, or loss of consciousness require immediate action to prevent further, and possibly permanent, cervical spinal cord damage.
For the physician on the sideline, the literature regarding the evaluation of athletes who are down on the field and suspected of having a cervical spine injury is far more clear than it is regarding players who leave the field under their own power and then complain of neck pain. We review both situations.
A 16-year-old male football player developed neck pain after an open-field tackle during a game. He walked off of the field without assistance, removed his helmet, and was observed rubbing his posterior neck from across the field by the medical team. He was first evaluated by the athletic trainer, who found normal results from a neurologic examination, mild tenderness over C-5 posteriorly, and full cervical range of motion. The patient denied severe pain and wanted to return to play.
Initial evaluation. The physician covering the game evaluated the patient approximately 10 minutes later. On further questioning, the athlete said he struck the ball carrier "in the numbers" using the top of his helmet with his neck slightly flexed. He also admitted to a few seconds of paresthesias in all four extremities immediately postcontact. He denied any severe pain, apprehension, or radicular symptoms and was still eager to return to play.
Physical examination revealed no acute distress, normal neurologic findings, mild-to-moderate tenderness over the C-5 spinous process, no change in pain or radiculopathy with resisted cervical range of motion, and a normal cervical range of motion that did not increase his pain. An axial compression test increased the pain at the C-5 spinous process but produced no radicular symptoms. A "no-return-to-play" status was established.
Progression of findings, reevaluation, and treatment. While the physician was writing a referral note, the patient was observed to have increased neck stiffness and pain with lateral rotation as he watched the game. Reevaluation at approximately 30 minutes postinjury confirmed a decreased and painful range of motion. The patient was asked to wait on the bench until the ambulance arrived, while the physician left to deal with another emergency. When the ambulance arrived, the athlete was placed in a Philadelphia collar and walked to the ambulance by the paramedics.
In the emergency department, anteroposterior and lateral cervical radiographs (figure 1) showed a C-5 fracture with inferior angulation and a step-off of C-4 onto C-5, reversal of lordosis, and anterior compression of C-5. Computed tomography (figure 2) showed an incomplete sagittal fracture of the body of C-5, a transverse fracture of the right lamina propria of C-5, and minimal anteroposterior narrowing of the C-5 canal diameter. The patient was transferred to a hospital "downtown," where he was placed in a halo vest for 4 months.
He recovered without any deficits and was restricted from collision sports by his neurosurgeon. He played varsity basketball 1 year after his injury.
This player's injury highlights several aspects of diagnosing cervical spine injury that we will discuss in this review article: axial loading, assessment of physical signs and symptoms, immobilization, and return-to-play decisions.
Axial loading. The mechanism of injury was classic for axial loading, which should raise suspicion when an athlete presents with neck pain. The significance of paresthesias in all four extremities lasting for a few seconds is unclear since this does not fit any of the low-velocity, trauma-induced neurologic syndromes described in the literature, and thus is not helpful in establishing a diagnosis.
Symptom assessment. The lack of neurologic symptoms other than the extremely brief paresthesias and the negative neurologic examination does not rule out a serious cervical spine injury. Mild-to-moderate tenderness over the C-5 spinous process could indicate soft-tissue injury or fracture. A full range of motion that does not increase the patient's neck pain is unusual for a fracture but does not rule it out. The fact that the pain was increased by axial compression favors the diagnosis of a fracture.
Immobilization. Cervical spasm in this case was protective and helps account for his favorable outcome. However, optimal management would have included immobilization of the patient by placing him supine and manually stabilizing his cervical spine until the ambulance arrived.
Return to play. The decision to not allow the athlete to return to play, in spite of his resistance, probably prevented permanent neurologic injury. Continued neck pain alone is enough to forbid further participation. When the patient developed a decreased and painful cervical range of motion, the diagnosis of fracture became a serious consideration.
As noted, this athlete was restricted from collision sports but played basketball. Some sources suggest that a vertebral body fracture with a sagittal component or a vertebral body fracture with an associated posterior arch fracture represents an absolute contraindication to further participation in contact activities (1,2).
Axial loading is the major mechanism responsible for cervical spine injuries in tackle football. The greatest risk of sustaining a cervical spine injury resulting in permanent quadriplegia is in defensive backs who use their heads as the initial point of contact (3). In the neutral position, the cervical spine assumes its normal lordotic curve. This allows forces applied to the cervical spine to be more effectively dissipated by the paravertebral musculature and intervertebral disks via controlled motion. With the neck flexed to 30°, the lordotic curve is lost, and the cervical spine acts as a segmented column. Under this condition, compressive forces cannot be dissipated and may result in fracture, dislocation, or both (4).
The National Football Head and Neck Injury Registry was started in 1975 to define a possible increase in catastrophic football neurotrauma (4). Torg (4) compared his data with Schneider's (5) data from 1959 to 1963. (Data from these studies are summarized in table 1.) The observed increase in fractures, dislocations, and quadriplegia from 1971 to 1976 was assumed to be due to the development of techniques using the head as the initial point of contact. As a result, the National Collegiate Athletic Association and the National Federation of State High School Associations adopted antispearing rules in 1976. By 1987, football-related cervical spine injuries and quadriplegia had decreased dramatically (4).
The case study detailed earlier is an excellent example of axial loading related to spear tackling. Recognizing this improper technique should raise the clinician's suspicion for a serious neck injury. It should be reemphasized that this maneuver is illegal and therefore may be symptomatic of a failure in enforcement of the rules and education of the players and coaches.
Preparation beforehand is the key to optimal injury management. Sideline medical personnel should be trained and rehearsed in stabilizing an athlete with a cervical spine injury. The necessary equipment, including an ambulance in the case of football, should be available. Arrangements should be made in advance with a facility that is competent to handle athletic injuries of the head and neck.
Field Care of the Downed Athlete
In any athlete suspected of having a cervical spine injury, the prevention of further injury is the single most important objective (6). The shoulder pads, helmet, and chin strap should not be removed. According to Cantu (7), "The chin strap serves as a halter and the ear holes and/or immediately adjacent edge of the helmet as a site for attachment of neutral traction." The first step is to hold the head and neck in neutral position to immobilize them. Then, in the following order, assess respiration, circulation, and level of consciousness (8). If the athlete is breathing, remove the mouth guard and maintain an airway. If the athlete is not breathing, logroll him or her (figure 3) into the supine position and establish an airway.
Prior to transportation, the face mask should be removed from all athletes who may have cervical spine injuries (9,10). This may be accomplished by using a Trainer's Angel (Trainer's Angel, Riverside, California), an electric or manual screwdriver, bolt cutters, or another cutting tool. A manual or electric screwdriver induces less cervical motion (if the facemask mounting screws are well maintained) than the Trainer's Angel during face mask removal (11).
For expediency, a CPR mask with a one-way air valve (11,12) or "rescue breather" can be used to provide ventilation until the face mask is removed from the helmet. An airway is best established via the jaw-thrust technique. Smelling salts should never be used on unconscious athletes (13,14).
If there is no pulse, begin cardiopulmonary resuscitation (CPR). If the patient is breathing and has a pulse, a neurologic examination should follow, with attention to the level of consciousness, pupillary response to light, response to pain, posturing, and muscle tone. If the patient is face down when the ambulance arrives, logroll him or her onto a spine board. Once the patient is on the spine board, the head should be immobilized with sandbags and tape or straps and the body should be secured to the board to prepare for transportation.
Evaluating the Upright Athlete
The evaluation of an ambulatory player, such as in our case study, is based on a careful history and physical exam. Ideally, the conscious patient, like the unconscious patient, should be examined at the site of injury. A history should include the mechanism of injury, presence of any cervical pain, and presence of any neurologic symptoms, including loss of consciousness, weakness, paresthesias, or pain, and any previous neck injury.
The physical exam of a conscious player with a possible neck injury should consist of the following elements, in this order:
The examination should cease once the physician has detected any signs of cervical spine injury, and immobilization and transport should be initiated. Continuing the examination might create or worsen a neurologic deficit or cause further panic in the athlete.
Immobilize or Not?
In assessing the athlete who comes to the sidelines with neck pain, the problem is to separate the injuries requiring immobilization and further evaluation from those that do not. This is made especially difficult by the fact that the incidence of severe cervical injuries is low while the incidence of less serious injuries is relatively high.
The physician should also keep in mind that the initial clinical picture is often deceptive (6). An article from 1959 (15) commented, "We have been amazed at the number of patients we have seen who complained chiefly of a crick in the neck following an apparently trivial injury to the neck and who were proved to have fracture dislocations of the cervical spine without neurologic deficit." In a 1984 symposium (16), Torg commented that an athlete who sustains a significant injury may be able to walk off the field. At the time of injury, there is no way short of obtaining appropriate x-rays to determine the presence of an unstable fracture (17). According to Vegso and Torg (8), when patients have neck pain after trauma but are ambulatory, conscious, and without obvious neurologic deficit, significant spinal injury must still be suspected.
Feldick and Albright (18) reported that cervical spine x-rays done as a part of the University of Iowa's preparticipation examination for freshman football players revealed evidence of previous injury in 35 of 108 men. This implies that forces sufficient to create structural injury are encountered with significant frequency in football.
There is no uniform algorithm for evaluating the ambulatory athlete on the sideline. The clinician is forced to rely on the literature, which seems at times to be vague, divergent, and incomplete in regard to the patient with cervical pain on the sidelines. Table 2 is our attempt to summarize the literature (8,13,14,19-28). The physician must therefore maintain a high index of suspicion and order radiographic evaluation to differentiate an unstable injury from a routine cervical sprain if any doubt exists (23). It's best to err on the side of caution since the consequences are potentially catastrophic. Also, caution should be taken not to confuse a serious neck injury with a "burner" (see "Distinguishing 'Burners' From Serious Injuries," above).
Until the predictive value of signs and symptoms of serious cervical injury is better established, clinicians will have to make decisions based on their ideas of the convergence of expert opinions. We have attempted to characterize the literature in the algorithm in figure 5. Some authors seem to recommend treating all sports-related neck pain as serious, while others specify treating neck pain at rest, moderate-to-severe pain, or severe pain only. There is agreement for the most part that any persistent neurologic symptom should be assumed to indicate a serious neck injury. Wiesenfarth and Briner (14) comment that there is a very low probability of having a severe neck injury in an athlete without pain and neurologic symptoms.
|Some authors simply state that cervical tenderness should lead to immobilization and transportation, while others specify a degree or site of tenderness. Anderson (13) classifies tenderness as a cause of great concern if it is severe, localized over the cervical vertebrae, or associated with neurologic symptoms or severe spasm. In contrast, isolated tenderness over the paraspinal muscles or spinous processes is classified as low risk if no other concerns are present. Fourré (23) states that athletes with bony cervical spine injuries often have intense neck pain and tenderness over the spine and may or may not have neurologic deficits.
There appears to be agreement that a significantly decreased cervical range of motion or spasm is worrisome and should lead to immobilization and further workup. In the fully conscious athlete, a cervical fracture or cervical spinal cord injury is usually accompanied by rigid cervical muscle spasm and pain (17). Often, unstable cervical spine injuries without neurologic deficit may present with only a decrease in cervical range of motion, possibly because an emotional football player may have a distorted perception of pain (28).
Anderson (13) recommends backboarding for patients who have significant neurologic symptoms, even if symptoms are transient, without neck manipulation and without attempting range of motion. Watkins (28) commented, "'Numb all over' may be a loss of consciousness, a transitory quadriplegia, or nothing. Usually, if it last 1 to 5 seconds and there are no residual symptoms, the player walks off. Transient symptoms (meaning seconds to several minutes in duration) are reasonably common. A one-time episode is seldom worked up." In an analysis of 63 patients who sustained acute cervical spine injuries while participating in organized sports reported by Bailes et al (29), 18 athletes had temporary neurologic symptoms. None had radiologic evidence of vertebral body fracture or spinal column instability. The duration of symptoms ranged from 10 minutes to 5 days.
The American Academy of Pediatrics' Sports Medicine: Health Care for Young Athletes (19) states: "The experienced team physician or athletic trainer will not send every athlete with a neck injury to the emergency room on a spine board. Many will be stabilized in a stiff cervical collar and sent for radiographs by car, or even diagnosed as having muscle strains without x-rays."
It is unusual for an injured athlete who was initially evaluated on the sideline to need full immobilization (13); however, a cervical collar alone is never considered adequate protection if the physician suspects an unstable cervical fracture (13). It is best to treat all neck injuries as unstable by immobilizing the neck if the clinical picture is unknown (14).
Also, the sideline physician's responsibility does not end once the athlete leaves the site of injury. The team physician should communicate the patient's condition to the emergency department prior to the patient's arrival.
Guidelines for Return to Play
Choices for disposition of injured athletes extend beyond return to play or immobilization and treatment for a suspected fracture. The physician can also keep them out of play and reevaluate them. In fact, it is much simpler to decide which athletes should be removed from play than which athletes require further workup. Watkins (28) recommended that athletes should not return to play with residual numbness, tingling, dysesthesias, weakness, or pain radiating into the arm.
Anderson (13) stated, "Guidelines for return to play are clear: A player must have a normal neurologic exam with emphasis on full, pain-free cervical range of motion (actively and against hand resistance) and normal sensation, strength, and reflexes. Axial head compression is an additional sideline maneuver that, if painful, should prevent return to competition." Anderson also recommended a sport-specific "functional" sideline evaluation to verify that the athlete is able to return to play safely.
Cantu (30) recommends that prior to return to play, the athlete should have no neck tenderness or spasm, neck or arm pain, numbness, paresthesias, or weakness, either at rest, with full range of motion, or on axial compression. The consensus seems to be that only those players with absolutely no neurologic symptoms or neck pain and completely negative neurologic and cervical examinations may return to play.
Helmet and Shoulder Pad Removal
In sports like football, very rarely should the helmet and shoulder pads be removed by medical personnel before cervical spine x-rays are obtained to rule out fracture or instability. Some authors (31) have suggested that the equipment must be removed to treat a player in cardiac arrest and that performing defibrillation with the shoulder pads in place may be ineffective and hazardous to the operator. A task force organized by the National Athletic Trainers' Association stated that access for CPR and defibrillation can be obtained by opening the front of the shoulder pads. The task force also states that the helmet should not be removed unless: (1) the helmet and chin straps do not hold the head securely, (2) the airway cannot be controlled after face mask removal, (3) face mask removal cannot be accomplished in a reasonable time period, or (4) it prevents immobilization (9,10).
When an injured player removes his or her helmet prior to medical evaluation, applying a cervical collar and removing the shoulder pads prior to spine board immobilization would be prudent. Studies using cadavers (32) have shown that neutral alignment is disrupted by removing either the helmet or shoulder pads alone, and it has been shown by quantitative radiographic assessment using normal subjects (33) that removal of the helmet alone alters neutral cervical alignment.
Many emergency medical personnel believe that the helmet should be removed from any injured athlete based on Emergency Medical Services trauma protocols for motorcycle accident victims, which advocate helmet removal for airway management and to complete the trauma survey (34,35). In such a situation, it is important to maintain control and insist that the helmet remain in place while an optimal immobilization procedure is followed.
In looking back on the case study reported earlier in light of a review of the literature, a number of points are illustrated. First, prevention is important. The athlete in our case study sustained his injury as the result of an illegal tackling technique. Second, the option to remove the athlete from play should be carefully considered. In this case, it was probably the critical factor that saved him from permanent neurologic injury. Third, the ambulatory athlete with neck pain deserves serious evaluation and may require reexamination to establish a diagnosis. Fourth, the fact that the athlete is ambulatory should not lead the physician to a false sense of security.
Distinguishing 'Burners' From Serious Injuries
A "burner" (or "stinger") typically involves an immediate onset of burning pain radiating from the supraclavicular area down the arm that frequently resolves in minutes (1). Burners should not be considered if the symptoms involve both arms or either lower extremity. A burner is not synonymous with a brachial plexus neurapraxia. It is a syndrome that may result from a number of pathologies. Proposed mechanisms include lateral neck flexion with shoulder depression (contralateral brachial plexus traction) and lateral neck flexion with rotation and extention (ipsilateral nerve root compression). Therefore, in football the mechanism of injury is often not helpful in excluding a cervical spine fracture.
When there are persistent symptoms or associated neck pain, it is best not to consider a burner until the other possibilities have been excluded. In the presence of any of the signs or symptoms of a cervical spine injury, the athlete should be treated as outlined in the main text. The key to the nature of the lesion is the brevity of the symptoms in the presence of a full pain-free range of motion (2). A ruptured cervical disk should be suspected if the athlete sustains "burnerlike" symptoms but the pain, numbness, or weakness persists, especially if it is accompanied by neck pain and spasm (3). Disagreement exists about how many burner episodes must occur in an athlete to necessitate further evaluation. Athletes should definitely not return to play until all symptoms have resolved and the physical examination shows no abnormalities.
Dr Haight is an independent contractor in eastern Pennsylvania. Dr Shiple is the director of the Primary Care Sports Medicine fellowship and the division chief of Sports Medicine in the Department of Family Practice at Crozer-Keystone Health System in Springfield, Pennsylvania. Address correspondence to Brian J. Shiple, DO, Primary Care Sports Medicine, 1260 E Woodland Ave, Suite 200, Springfield, PA 19064.