The medical team that is caring for athletes should understand the importance of identifying and proper care for the neurologically injured athlete. Approximately 70% of trauma-related deaths and 20% of the disability that is related to sports injuries are as a result of head and neck injuries [1•]. Sports with a high incidence of cervical spine injuries include diving, surfing, and skiing [1•]. In a recent study looking at catastrophic injuries in baseball, 41 incidents of catastrophic injuries were found between 1982 and 2002. Of these catastrophic injuries, eight cervical injuries were found . A protocol should in place at every practice and sporting event for emergency management of these injuries, should they occur.
The team physician should be outfitted with the proper equipment to handle these injuries, including airway supplies. In an unconscious athlete one has to assume that there is a cervical spine injury, using proper techniques such as the log roll, back board, and use of a cervical collar to move and transport the patient. One should always be prepared for airway emergencies by carrying a device to remove facemasks if the athlete is unconscious and not breathing. Checking the ABCs (airway, breathing, and circulation) is always recommended as a first line of defense.
Cervical spine injuries can range from mild to devastating. The mild injuries are much more common, but one must always be prepared for the devastating injuries. Catastrophic neck injuries occur at a rate of two in 100,000 neck injuries . In an unconscious athlete one must assume cervical spine injury and must first evaluate the ABCDEs (ABCs in addition to disability and environment/exposure) of trauma care while keeping the cervical spine stable. In football players a protocol to remove facemasks should be in place in the case of an airway emergency. A trainer's angel or other device for removing a facemask from a football helmet should be in a medical bag for football game coverage. These injuries are seen most commonly in football, but can be seen in other sports such as diving, rugby, and wrestling. The protocol should include not moving the patient until the cervical spine is cleared by either pain-free evaluation of the cervical spine in a conscious patient along with active (never passive) flexion and extension of the neck, or log roll protocol onto a spine board and application of a cervical collar. Always evaluate the ABCs first, and as long as the patient is breathing and is cardiovascularly stable, the patient with a cervical spine injury can be moved off the field. In a conscious athlete that complains of neck pain with or without numbness or weakness, the athlete should be treated as having a serious injury. It is important not to move the athlete until evaluation is complete, because it is estimated that 50% of neurologic deficits are created after the initial trauma [4,5]. Injuries that can be found in an athlete with a cervical spine injury range from mild musculotendonous injuries to serious cervical spine injuries.
Acute Cervical Sprain or Strain
Cervical strain injuries are frequently seen in contact sports. With more severe sprains or strains the athlete may complain of pain immediately after injury, but more frequently the pain and stiffness begins later. These injuries are never associated with neurologic deficits. A strain is associated with a partial or complete tear of a muscle and a sprain is associated with the partial or complete tear of a ligament. In an acute injury cervical instability needs to be ruled out. These injuries can be associated with decreased range of motion in all directions and paraspinous muscle tenderness. Athletes should not be cleared to play contact sports unless they have pain-free range of motion.
Cervical Instability and Fractures of the Cervical Spine
Cervical instability and fractures account for the largest number of football causalities involving the cervical spine. In a study by Cantu and Mueller  looking at catastrophic football injuries from 1977 to 2001, 176 out of 233 of these injuries were caused by fracture/dislocation of the cervical spine. Although the largest number was seen prior to 1975 before the spear tackle was made illegal, these injuries can still occur. Cervical instability is caused by ligament disruption and injury that can occur with or without fracture. These ligaments support the vertebral bodies and may include the infraspinous ligament and the anterior and posterior longitudinal ligaments. Kang et al.  and Torg et al.  identified the C3-C4 as the most common area of dislocation to result in quadriplegia.
Cervical instability usually presents with neck pain which is exacerbated by extension and flexion. The neurologic examination may be completely normal. Regardless of the neurologic examination care must be taken with these athletes, because ligamentous injuries whether there is a fracture or not can result in neurologic deficits from mild weakness to complete quadriplegia.
Stingers (burners) are brachial plexus injuries that are seen very commonly in sports such as football. These injuries result from trauma to the neck or shoulder area resulting in pain, numbness, or weakness on the affected side. These injuries are unilateral and almost never affect the lower extremities. The weakness may last as long as several days. The pain can range from seconds to hours. The general consensus is that the C5-C6 nerve root is the most commonly affected. In addition the deltoid, biceps, and spinatus muscles are the most commonly affected [9•].
There are three main mechanisms of injury that occur. First is the stretch or traction injury that occurs with the head being forced away from the symptomatic side along with shoulder depression. These injuries are usually seen in younger athletes without degenerative changes of the spine or cervical stenosis. The second mechanism is usually seen in older athletes with extension of the neck, which causes a compression at the neural foramen. These injuries are usually associated with some degree of degenerative disk disease or arthritis. Lastly a direct blow to the brachial plexus may occur . It is very important that an athlete with a stinger should be evaluated immediately after injury. Both an examination of the cervical spine and a full neurologic examination of the upper extremities should be performed. If there is any weakness or burning of the affected side the athlete should not be allowed to return to play. These are very common injuries, especially in football and many times the players will not notify anyone after they occur.
Cervical Cord Neuropraxia
Cervical cord neuropraxia results from cervical spinal cord injury that is usually transient in nature, which can be associated with sensory and motor changes. These episodes can involve both arms, both legs, or all four extremities. Sensory changes can range from numbness and tingling to complete loss of sensation. There can also be a burning sensation. Motor changes can range from weakness to complete paralysis. The symptoms can be short-lived from 10 to 15 minutes, but may last as long as 36 hours.
There are three mechanisms of injury are commonly seen in transient quadriplegia. These mechanisms include cervical hyperextension, hyperflexion, or axial loading [11•,12,13]. Neck pain is normally not associated with these episodes, except some burning paresthesias.
There is an incidence of 1.3 per 10,000 athletes . These injuries are typically associated with cervical stenosis, which can either be congenital or acquired. Transient quadriplegia may also be associated with vascular and metabolic disorders. Individuals at higher risk for these injuries include those with developmental cervical stenosis, kyphosis, congenital fusion, cervical instability, or disc protrusion. Torg et al.  found a strong relationship between spinal canal diameter in relationship to vertebral body size (ratio < 0.8) and an episode of cervical neuropraxia. However, there was a very low predictive value (0.2%) of the spinal canal to vertebral body ratio, therefore the ratio alone should not be used for screening.
Any athlete that has experienced an episode of cervical cord neuropraxia should be removed from that event, despite full recovery occurs during that event. Even if the symptoms are transient and completely resolve, the athlete should have a full radiographic examination to access risks of further injury. These athletes should not be allowed to return to play until a full evaluation has taken place by a physician familiar with these types of injuries. If the neurologic symptoms persist cervical manipulation should be avoided at the time of evaluation. In addition a cervical orthosis should be applied and athlete should be transported to nearest medical facility if the neurologic deficits do not clear.
Sideline evaluation of neck injuries can be clinically challenging. Due to the significant mortality associated with these injuries, it is important for the medical team to be prepared. It is vital that the team have a protocol in place for cervical spine injuries and airway emergencies. The most important point is never let an athlete who has experienced a neck injury play when they are still symptomatic. It is always better to sit the athlete out rather than risk further injury.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance, •• Of major importance
1.• Ghiselli G, Schaadt G, McAllister D: On-the-field evaluation of an athlete with a head or neck injury.Clin Sports Med
Good review article concerning acute management of head and neck injuries.
2. Boden B, Tacchetti R, Mueller F: Catastrophic injuries in high school and college baseball players.Am J Sports Med
3. Torg JS, Vegso JJ, O'Neill MJ, et al.
: The epidemiological, pathological, biomechanical, and cinematographic analysis of football-induced cervical spine trauma.Am J Sports Med
4. Torg JS, Wiesel S, Rothman R: Diagnosis and management of athletic injuries in the cervical spine and spinal cord.Athletic Injuries to the Head, Neck, and Face.
Edited by Torg JS. Philidelphia: Lea & Febinger; 1982:182–209.
5. Wiesenfarth J, Briner: Neck injuries: urgent decisions and actions.Phys Sportsmed
6. Cantu RC, Mueller FO: Catastrophic spine injuries in American football, 1977–2001.Neurosurgery
7. Kang JD, Figgie MP, Bohlman HH: Sagital measurement of the cervical spine in subaxial fractures. An analysis of two hundred and eighty-eight patients with and without neurological deficits.J Bone Joint Surg Am
8. Torg JS, Truex Jr RC, Marshall J, et al.
: Spinal injury at the level of the 3rd and 4th cervical vertebrae from football.J Bone Joint Surg Am
9.• Shannon B, Klimkiewicz: Cervical burners in the athlete.Clin Sports Med
Good review article concerning diagnosis, treatment, and prevention of cervical burners.
10. Kuhlman GS, McKeag DB: The “burner”: a common nerve injury in contact sports.Am Fam Phys
11.• Torg JS: Cervical spinal stenosis with cord neuropraxia: evaluations and decisions regarding participations in athletes.Curr Sports Med Rep
Good review article summarizing cervical spinal cord neuropraxia and cervical spinal stenosis.
12. Torg JS, Gennario SE, et al.
: Neuropraxia of the cervical spine cord with transient quadriplegia.J Bone Joint Surg
13. Torg JS, Fay CM: Cervical spinal stenosis with cord neuropraxia and transient quadriplegia.Athletic Injuries to the Head, Neck, and Face,
edn 2. Edited by Torg JS. St. Louis: Mosby-Year Book; 1991.
14. Torg JS, Naranja RJ Jr, Pavlov H, et al.
: The relationship of developmental narrowing of the cervical spinal canal to reversible and irreversible injury of the cervical spinal cord in football players.J Bone Joint Surg Am