In the United States, sports are among the leading causes of catastrophic cervical spine injury (CSI), defined as “a structural distortion of the cervical spinal column associated with actual or potential damage to the spinal cord.”1 There are more than 250 new sport-related CSIs each year.2 The risk of injury varies among sports. Ice hockey players are among those at highest risk of CSIs.3 Football is the sport associated with the largest number of CSIs due to the high levels of participation, with more than 1.5 million participants from the middle school through professional levels.3 Nearly one-quarter of CSIs in children younger than 15 years are sport related, and 85% of sport-related CSIs result in tetraplegia.2 Appropriate prehospital care of athletes with suspected CSIs can mitigate the significant and long-lasting impacts such injuries have on the health, finances, and quality of life of injured athletes and their families.4
There are a number of special organizational and equipment considerations pertaining to optimizing the prehospital care of athletes with suspected CSIs. State and local emergency medical service statutes and guidelines vary. Community sports clubs, high schools, and intercollegiate and professional organizations differ in the available resources, skill levels, and training of rescuers to protect and care for injured athletes. The size of the athlete, weather conditions, space restrictions, and equipment, although important to consider, may not be modifiable. Despite these disparities in resources, providing evidence-based prehospital CSI care is essential for optimizing postinjury outcomes. The development of a set of best-practice recommendations may help organizations without resources to advocate for the additional support needed to provide high-quality care.
The Spine Injury in Sport Group (SISG) was developed to address the evidence that emerged after the 2015 Inter-Association Task Force on Pre-Hospital Care of the Spine-Injured Athlete.5 The SISG met in Atlanta, Georgia, on March 2 to 3, 2019, attended by 20 health care professionals with expertise in emergency medicine, sports medicine, neurologic surgery, orthopedic surgery, neurology, physiatry, athletic training, and research, to review the current literature and discuss evidence-based medicine, best practices, and different options available for the prehospital care of athletes with suspected CSIs. Eleven members had previously served on the Inter-Association Task Force.
The goals of this project were to develop conclusions by summarizing the available evidence and achieve consensus where limited evidence existed and then make recommendations on key concepts of care for athletes with suspected CSIs, with a focus on athletes wearing protective equipment. The target audience includes athletic trainers, emergency responders, sports medicine and emergency physicians, and others caring for athletes with suspected CSIs. The structure of the article is as follows: The “Methods” section describes the processes involved in (1) developing the scope of the systematic review, (2) the systematic review itself, and (3) building of consensus around conclusions and recommendations. The “Results” section describes (1) the specific questions addressed in the review, (2) the findings of the review, and (3) the conclusions and recommendations based on those findings. For ease of reference, the conclusions and recommendations are presented as Table 1. Additional details on phases of the project are available as a Web supplement (Supplemental Digital Content, http://links.lww.com/JSM/A240).
To achieve the multifaceted goals of the project, the National Athletic Trainers' Association, the National Collegiate Athletic Association, and the Sports Institute at UW Medicine engaged the Harborview Injury Prevention and Research Center (HIPRC) as an independent, objective research partner. The HIPRC is an interdisciplinary research center with well-established expertise in injury research, including the use of consensus group methods.6–13 To address the priorities of the SISG (ie, consensus recommendations on a shared evidence base), the HIPRC research team chose the RAND/UCLA appropriateness method14 in combination with a systematic literature review. The RAND/UCLA method combines elements of the Delphi and nominal group technique (NGT) approaches for achieving consensus. The 3 stages of the project were (1) identification of the key research questions using a modified Delphi process,15 (2) a systematic review to assess available evidence, and (3) an NGT in-person meeting16 to achieve consensus on the conclusions and recommendations regarding the prehospital care of the spine-injured athlete. These stages are described in the following section.
Stage 1: Delphi Process
The research group used a Web-based modification of the Delphi method of expert consensus building15 to collect expert opinion and achieve consensus on the target audience, population, and sport for the guidelines and questions for the systematic review. Twenty-one (100%) members of the SISG participated in at least 2 of 4 rounds of iterative online questionnaires over a 2-month period of time. Rounds 1 and 2 (October 2018 and November 2018) focused on defining the audience, population, and sports for the guidelines. Rounds 3 and 4 (December 2018 and January 2019) generated questions to be addressed in the systematic review. A full description of the Delphi process, including consensus scores, appears in the Supplemental Material (Supplemental Digital Content, http://links.lww.com/JSM/A240).
Stage 2: Systematic Review
Key terms for the systematic review were based on the 8 questions selected by panelists during the Delphi process. A trained health sciences research librarian consulted on the terms and search process. Six research databases (PubMed, SPORTDiscus, CINAHL, Web of Science, Embase, and Scopus) and 2 journal archives (Journal of Athletic Training and American Journal of Sports Medicine) were searched between mid-December 2018 and mid-January 2019. Each data source was queried using identical key words: (injury) AND (spine OR spinal OR vertebrae OR cervical) AND (triage OR stabilization OR assessment OR treatment OR immobilization OR motion restriction OR care OR screening) AND (sport OR athlete OR athletics) AND (Emergency Medical Services OR sports medicine OR prehospital OR emergency medicine) AND (equipment OR gear OR helmet). Search results were limited to English-language articles with abstracts available. Articles published at any time were included. Two strategies were used to maximize search results. First, related words, equivalent subjects, and full-text searches were conducted when data sources offered those options. Second, we included all studies involving a comparison or control group and did not exclude quasi-experimental or nonrandomized studies.
Two authors (B.M.M., K.M.C.) screened all potential articles, first by titles and then by abstracts using Rayyan software [Qatar Computing Research Institute (Data Analytics), Doha]17 and prespecified exclusion criteria (see Supplemental Digital Content, http://links.lww.com/JSM/A240) to ensure a blinded review. Any disagreements were resolved through consensus. One author (B.M.M.) then reviewed the full text of selected articles, whereas another (K.M.C.) hand-searched the references of selected articles for relevant studies that may have been overlooked. When the systematic review identified no relevant articles for a particular question, the 2013 Congress of Neurological Surgeons guidelines18,19 for the management of acute cervical spine and spinal cord injuries were considered as a “backstop” resource summarizing non–sport-specific spinal injury-care evidence related to prehospital cervical spine immobilization (chapter 2) and transportation (chapter 3). Additional details on the systematic review protocol, including inclusion and exclusion criteria and summary tables, are provided in the Supplemental Material (Supplemental Digital Content, http://links.lww.com/JSM/A240).
Stage 3: The Nominal Group Technique Consensus Meeting
Results of the systematic review, including reference lists of relevant articles and draft conclusions for each research question, were presented for discussion at the in-person SISG meeting in March of 2019. Questions regarding equipment were divided into subquestions so that conclusions and recommendations regarding face masks could be discussed separately from those regarding helmets and shoulder pads. Draft conclusions were altered and new conclusions were proposed. Using a confidential web-based voting system, participants scored conclusions on a 1 to 9 scale, where 1 represented strong disagreement and 9 represented strong agreement. Conclusions with a mean score <5 were dropped, and those with a mean score >7 were adopted. Conclusions scoring between 5 and 7 were discussed and further votes conducted until consensus was reached. After agreeing on evidence-based conclusions, the group proposed, discussed, and voted on recommendations on the basis of those conclusions using the same confidential scoring process.
Stage 1: Delphi Process
All SISG members responded to at least 1 round of the Delphi process; response rates for each round ranged from 71% (round 1) to 90% (rounds 2 and 3). Participants were given 10 to 20 days to respond (depending on the demands of the respective round) and were provided with 1 reminder e-mail. Respondents indicated that sports at all levels (middle school, high school, college, and professional) should be included in the guidelines and that the user audience should include athletic trainers (ATs), team physicians, paramedics or emergency medical technicians, leagues, and coaches (Supplemental Table 1, Supplemental Digital Content, http://links.lww.com/JSM/A240). Because spine injuries without equipment can be handled under local emergency medical services guidelines, it was determined that the systematic review and consensus recommendations would focus on sports involving helmets and body-worn protective gear. Twenty suggested key research questions were condensed into a final set of 8 questions (The questions are reproduced in their original form [Table 2]).
Stage 2: Systematic Review
Through the comprehensive search strategy, we identified 1544 publications to be screened (Figure). After title, abstract, and full-text screening, 49 articles were included in the final review (see Supplemental Figures 1 and 2, Supplemental Digital Content, http://links.lww.com/JSM/A240). The levels of evidence20 of the included articles varied substantially. Only 1 study was described as a randomized controlled trial (level of evidence 2); a majority of articles involved quasi-experimental designs without randomization (level of evidence 3). A single systematic review was also included. Most articles focused on football (78%) or players in the supine position (84%) and did not involve randomization in the study design (see Supplemental Tables 2 and 3, Supplemental Digital Content, http://links.lww.com/JSM/A240). Proxy participants took the place of potentially injured athletes in all research. Healthy volunteers participated in a majority of studies (n = 35, 71%), although cadavers and manikins were also studied. Key information and relevance to the specific research questions were extracted from all 49 articles. Sixteen articles were deemed not relevant to the specific research questions. Summary findings, including the number of relevant studies identified, are provided in this section. Tables with individual study characteristics and results are available in the Supplemental Material (see Supplemental Tables 4–10, Supplemental Digital Content, http://links.lww.com/JSM/A240). Conclusions and recommendations are available in Table 1.
Question 1: What facilities are associated with the best outcomes for an athlete with a suspected CSI? No relevant sport-related articles addressing this question were identified by the systematic review (N = 0). In the absence of specific sports-related evidence, the Congress of Neurological Surgeons guidelines19 recommend transport to a specialized, acute spine-injury treatment center whenever possible.
Question 2a: Are outcomes after CSI likely to be better when face masks are removed before transport? In the systematic review, we found that multiple techniques and removal tools exist; these differ in the time required for removal and the resulting induced motion. No studies directly examined patient outcomes. Studies (N = 4) compared the insertion of a pocket mask with face-mask removal or face-mask removal prior to helmet removal.21–24 Helmet removal induces significantly more cervical spine motion than does face-mask removal alone. Motion is reduced but time is increased if the face mask is removed before the helmet, although this provides better access to the airway.
Question 2b: Are outcomes after CSI likely to be better when the helmet/shoulder pads are removed before transport? The systematic review identified studies22,24–40 (N = 18) of both static cervical alignment and dynamic cervical motion during immobilization in American tackle football, ice hockey, and lacrosse players. No studies directly examined patient outcomes. Comparisons of alignment and motion were made between participants wearing full equipment (helmet and shoulder pads), wearing shoulder pads but no helmet, and wearing no equipment. Studies27,28,31–34,36,40 involving American tackle football and ice hockey equipment did not indicate statistically significant differences in either static cervical alignment or dynamic cervical motion when comparing participants wearing full equipment with participants wearing no equipment. Removal of the football or ice hockey helmet alone, without removing shoulder pads, resulted in cervical alignment that was statistically significantly different from alignment when not wearing any equipment, with greater cervical lordosis seen when only the helmet is removed.33–35 However, authors of studies26,38,39 of lacrosse players (N = 3) disagreed on the difference in cervical alignment between full equipment and no equipment. According to the results of cadaver studies,28,37 removing only the helmet may lead to more angular displacement in injured spines than is suggested by healthy model studies. For skiers, helmet removal caused significant changes in cervical extension.29 In the “Discussion” section, we describe in more detail, the limitations of these types of comparisons.
Question 3a: What criteria should be considered when deciding to remove face masks with a suspected CSI? To identify which criteria should be considered, we looked for studies that examined the influence of personal and situational characteristics on face-mask-removal decisions. Through the systematic review, we found studies (N = 7) comparing both pocket-mask insertion with face-mask removal (n = 3) and face-mask removal with helmet removal (n = 2) as well as equipment and rescuer characteristics.22,23,41–45 Only 4 criteria were specifically tested for their influence on face-mask removal: equipment design, lighting conditions, hand size of the rescuer, and grip strength of the rescuer. Specific helmet and face-mask designs affect the time for removal and the motion involved in all airway-access techniques, with no clearly superior design. Lighting conditions, hand size, and grip strength of the rescuer were not found to be significant factors affecting successful removal.45
Question 3b: What criteria should be considered when deciding to remove helmet/shoulder pads with a suspected CSI? In the systematic review (N = 9), we found that equipment design influenced speed and motion involved in removal (Refs. 22, 23, 25, 26, 30, 39, 42, 46, and 47). Deflating helmet bladders did not seem to decrease motion or the difficulty of helmet removal, but it did increase removal time.42 In contrast to football and ice hockey, in which cervical alignment is closer to neutral when the equipment is on the athlete, in lacrosse, equipment removal may lead to a more neutral alignment. There is no evidence that helmet fit (proper or improper) is a significant factor in cervical spine immobilization.26,30 Heavier athletes not wearing helmets or shoulder pads experienced less motion on a rigid spine board than when immobilized with vacuum devices.25 Removing ice hockey helmets before the prone log-roll technique may reduce cervical spine motion.30
Question 4: What method of transfer and spinal-motion restriction is associated with the best outcomes for athletes with suspected CSIs, in both the supine and prone position? Conducting the systematic review (N = 4), we found that some methods of transfer may involve less cervical spine motion.25,48–50 Using cadavers, the researchers of 1 study48 showed that the log-roll push involved less lateral motion than the log-roll pull from the prone into the supine position. Authors of another cadaver study49 reported that a lift-and-slide technique involved less cervical spine motion than the log roll when starting from a supine position, whereas an 8-person lift involved less motion than the lift-and-slide or log-roll technique. Transfer with either full-body vacuum immobilization or a rigid spine board for athletes in full equipment involved similar amounts of sagittal and frontal angular cervical spine motion, measured as angular motion normalized by time to peak motion (degrees/second).25 Volunteer athletes did not report a significantly different level of perceived comfort or sense of security during transfer when immobilized with full-body vacuum immobilization or with a rigid spine board.25
Question 5: What formal training in the emergency care of an athlete with an on-field suspected CSI is required and recommended? Through the systematic review, we determined that whereas pretest training on the techniques studied is included as part of most study protocols, there is very limited research (N = 3) into the content or frequency of training itself.22,27,46 Frequent training reinforcement and practice can improve speed and reduce head motion.46
Question 6: When immobilizing the head and neck, is it better to leave the head in the position in which it is found or apply gentle axial distraction to align the head with the cervical spine? In the systematic review, we identified no studies that addressed this question, nor was it addressed in the Congress of Neurological Surgeons guidelines.18
Question 7: How many trained personnel does it take to remove a face mask/helmet/shoulder pads on the field? Through the systematic review, we found that whereas face-mask removal processes typically involve 1 to 2 people, researchers have not formally compared techniques or outcomes on the basis of the number of people involved in removing the face mask, and only 1 study51 compared other equipment-removal techniques. Personnel required for removal vary according to the removal technique and the specific athletic equipment being removed.
Question 8: Once the athlete with a suspected CSI is moved from the field to the ambulance stretcher, should the spinal-motion restriction equipment be removed before transport or on arrival at the emergency department? In the systematic review, we identified no studies directly addressing this question. The Congress of Neurological Surgeons guidelines19 consider limiting spinal motion during transport essential. However, all transport may necessitate measures to optimize oxygenation and pulmonary function.
Stage 3: The Nominal Group Technique Consensus Meeting
Over the course of 2 days, 20 members of the SISG suggested, discussed, and voted on 22 conclusions and 45 recommendations in total. A summary of those conclusions (based on the findings of the systematic review) and recommendations for each question are provided in Table 1. On a scale from 1 (strong disagreement) to 9 (strong agreement), the mean consensus score among conclusions was 8.24. The mean consensus score among recommendations was 8.01. Full consensus scores for each conclusion and recommendation are included in the Supplemental Material (see Supplemental Table 11, Supplemental Digital Content, http://links.lww.com/JSM/A240).
This project aimed to develop evidence-based guidelines for the prehospital care of the athlete with a suspected CSI. These conclusions and recommendations are intended to provide a structure for conversations around implementing guidelines for prehospital care that are appropriate for the resources, setting, and needs of each care team. A companion article52 provides more specific information on current best practices for each stage of on-field assessment, emergency care, and transfer of an athlete with a suspected CSI, including emergency action planning, medical time outs, and prehospital versus hospital equipment removal. This article, in contrast, is intended to give readers a more thorough understanding of the underlying issues and questions that should be addressed and the available evidence, even as the specific approaches and practices will vary on the basis of sport, age, level of play, equipment condition, and other varying characteristics of facilities where athletes are at risk of CSIs. It is our intention that these recommendations will be relevant for every type of athletic facility, from small rural high schools with a single coach and volunteer emergency medical services personnel to professional leagues, because best practices for all such organizations include a plan for the prehospital care of an athlete with a suspected CSI as part of their emergency medical action plan. Facilities and medical personnel involved in definitive care for athletes with suspected CSIs may also find these recommendations valuable because prehospital care directly affects hospital care.
A variety of approaches have previously been taken to address the need for standard guidance on prehospital care when an athlete has a suspected CSI. Previously published guidelines have been widely but not universally adopted, and there are important limitations to consider given the established literature. Because the nature of sports, the demographics of athletes, and injury-care science have changed over time, it is important to review and address changes in all 3 areas. These conclusions and recommendations are based not only on the collective expertise of a highly qualified group of health care professionals but also on a systematic assessment of the available evidence. The consensus-based approach and strictly defined protocol of the literature review were designed to enhance objectivity and reduce bias. Consensus approaches such as the Delphi and NGT are particularly valuable when available evidence is limited and results are mixed. First establishing the areas of agreement (such as the intended audience) and having a shared evidence base available for reference led to productive discussion. Confidential scoring ensured that participants felt comfortable expressing disagreement. Iterative discussion after each round of scoring addressed concerns in real time. Although it remains to be seen how our systematic, consensus-based approach influences the adoption of these recommendations, many participants expressed satisfaction with the strategy as a whole. This approach is also intended to serve as a model for future projects, so that recommendations can be updated as additional evidence becomes available.
The systematic review process highlighted many limitations in the evidence base for a number of the research questions included in this study. A CSI is a rare event, and most studies rely on proxy participants (healthy volunteers, cadavers) and proxy measures (spine alignment, motion, time to equipment removal) that are assumed to be relevant to suspected CSI events. It is unknown how well these proxies represent the reality of an athlete with a suspected CSI. It is not known, for example, what degree of cervical motion in any plane is safe if an individual has a CSI. It is also important to acknowledge the small numbers of participants involved in each study, which may have resulted in studies that were insufficiently powered to detect clinically relevant differences between comparison groups. “No significant difference” should not be interpreted as “no meaningful difference.”
Even limited to those sports that involve helmets and body-worn protective gear, there is a great deal of heterogeneity among athletes at risk of a suspected CSI. However, many studies included in the review were limited to American tackle football and examined a very limited number of equipment designs. It is unknown how generalizable the results of these studies are to other equipment designs or other sports or the exact influence of specific equipment design elements on study results. Similarly, most healthy volunteers involved in these studies were young men. In particular, there is a notable lack of studies involving female and adolescent athletes. Most investigations were conducted under laboratory conditions, which may not represent conditions during practice or competitive play.
Although our review protocol may have excluded some relevant studies, it is clear that insufficient research exists on this subject. For several questions, we were unable to identify any relevant studies meeting our review criteria. We encourage researchers and funders to explore the gaps we have identified, including sport-specific studies of athletes of various ages and sizes and personnel with varying backgrounds and levels of training.
Athletes, especially those who play sports involving substantial amounts of head and torso protection, are a patient group with unique challenges for health care professionals. Leaving protective equipment in place can affect ambulance transport and hospital-care protocols. The removal of protective equipment is made more challenging by variations in equipment design. The transfer of kinetic energy between players at speed and other physical elements of injury circumstances are quite different from other mechanisms of CSIs. Underlying health, height and weight, and prior injuries of an athlete with a suspected CSI may be substantially different from those of an average patient, and these factors can all affect injury presentation and management.
The devastating consequences of CSIs and the long-term costs that ensue mandate that appropriate resources be devoted to development of a stronger, more rigorous evidence base for the care of athletes with suspected CSIs. Given the resources available in sports, especially at the collegiate and professional levels in the United States, such investment is both feasible and appropriate.
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