In sports medicine, football injuries are discussed all of the time. Football players can injure just about anything while playing the game. Fortunately, most things will not cause significant morbidity in the long run. Even when dealing with knee ligament tears or severe shoulder problems that may sideline players for months, they almost always eventually recover and the injuries generally aren’t life threatening.
Unfortunately, a small percentage of football injuries do leave players disabled for life. The vast majority of these injuries involve the cervical spine. This column has previously focused on “minor” neck injuries treated in the outpatient setting. But, due to the severity and magnitude of injury, it is reasonable to discuss the more severe neck injuries even though they are fairly rare.
Lets begin with a brief review of the anatomy of the cervical spine. There are seven vertebrae that form the cervical portion of the vertebral column. There is a normal curvature of the cervical spine that is not pathological in most cases. The spinal cord begins at a large hole in the bottom of the skull called the foramen magnum and continues through the neck. As the cord descends through the neck, it is protected by the cervical vertebra. At each level of the C-spine, peripheral nerves come off of the cord.
If the integrity of the bony C-spine is lost, the protection of the cord will be lost. Furthermore, the fractured and/ or fragmented bone may in fact injure the spinal cord. Once the spinal cord is damaged, the possibility exists that recovery will never come. That’s not to say that everyone with a C-spine injury or even a fracture will be a quadriplegic, but that possibility exists in many cases.
In football, the primary mechanism for fracturing the cervical spine is axial loading. This means that a force is applied to the top of the head, which is transmitted to the cervical spine. The result of this force is that of a compression fracture. For this reason, it is extremely important that spearing be discouraged. Also in the realm of prevention, we might consider the role of neck support in football. It is a common practice to outfit players with neck rolls or cowboy collars. Although the theoretical advantage of these protective devices is obvious, it has not been proven that they reduce the incidence of neck fracture. Their primary role is in treating the minor neck injury such as a cervical strain or brachial plexus strain.
If a football player does suffer a neck injury and is being evaluated by the coaches or trainers on the field, it is vitally important that the neck not be moved at all. Recall that if there is a cervical fracture, the protection of the spinal cord is gone. Only trained professionals should be responsible for transporting players with a suspected neck injury to an emergency department. Also, unless there is a serious and life threatening problem that mandates otherwise, the helmet and shoulder pads should be left in place. There is good evidence available from several studies that in the absence of at least three to four trained professionals acting deliberately and in concert, removal of the helmet and shoulder pads violates the integrity of the cervical spine.
Although head injury is not the focus of this column, it should be remembered that anyone who injures their head should be suspected of having a neck injury as well. In all cases, a trained professional should evaluate any player with a suspected C-spine injury. These may be certified athletic trainers, paramedics or physicians. The threshold for immobilization and transport to an emergency department should be very low.
It is important that for all football games that EMS be nearby. It is the custom of most school districts to have an ambulance present at the game site. However, if this is not possible, it is crucial that trained EMS and/or sports medicine personnel; are on site to manage any emergency situations that arise.