New Guidelines for Athletic Spine Injuries

Source: The Sports Institute at UW Medicine

On September 26, 2015 when Devon Gale joined his Southern University teammates on the football field to play against University of Georgia, he had no idea how dramatically his life would change in just one moment, in just one tackle from the opposing team. A fractured C6 vertebrae may have left him paralyzed from the waist down, but he credits the sports medicine team on the field that day for saving his life.

Southern University’s Lovie Tabron, ATC and University of Georgia’s senior associate athletic director Ron Courson, ATC, PT, NRAEMT were on the field involved in his care. When Gale realized he couldn’t feel his lower extremities, the University of Georgia staff activated its C-spine emergency action plan. And through the quick action of his pre-hospital care team, Gale was stabilized and safely transported to the hospital without worsening the injury.

Tabron and Courson are now members of the Spine Injury in Sports Group (SISG) which has teamed up with the National Athletic Trainers Association (NATA) to create consensus recommendations on pre-hospital care for athletes with a spine injury.

“It was evident through the harmonious movements of the University of Georgia staff that their Emergency Action Plan had been practiced over and over again. Utilizing best practices like the protocols being released today were the difference between life and death for Devon,” Tabron, who is now a sports medicine coordinator at the University of Georgia, said during a press conference announcing the release of the new guidelines.

“He had a C-6 burst so any extra movement could have caused bone fragments to compromise his spinal cord so I don’t share lightly that education and practice is truly lifesaving.”

Traumatic spinal cord injuries have a high rate of morbidity and mortality. In the U.S., sports are the fourth leading cause of this type of injury. There are more than 250 new sports-related spinal injuries each year, especially in tackle football.

An Evolving Process

These aren’t the first guidelines created for spine injury care of athletes. It is an evolving process with new research always coming out and changes in emergency medical care protocols being made in some locations.

A coordinated action plan like the one implemented when Gale got injured is what the NATA is recommending in their new consensus guidelines created to help sports medicine teams across the country provide the best pre-hospital care for their athletes who suffer a spine injury on the field.

“Spine injury is a catastrophic event that happens in a moment and can affect the quality of life for that athlete forever,” NATA President Tory Lindley, MA, ATC said. “It takes a team of educated, collaborated and rehearsed health care professionals working in concert to ensure the best possible outcomes for the patient.”

Both the consensus recommendations and the research process behind the best practices are published in two publications in the Journal of Athletic Training. “Best Practices and Current Care Concepts in Prehospital Care of the Spine-Injured Athlete in American Tackle Football Players” outlines best practices and practical applications while “Consensus Recommendations on the Prehospital Care of the Injured Athletes with a Suspected Catastrophic Cervical Spine Injury” outlines the Delphi Method process.

The Consensus Process

The Spine Injury in Sports Group includes 11 physicians, 9 athletic trainers and 2 emergency medical technicians. The University of Washington Harborview injury Prevention and Research Center helped complete the systematic review and Delphi study on which the best practices are based.

The consensus process took place in three stages: the Delphi Method, the systematic review of all current research on spine injury, and the Nominal Group Technique (NGT) Consensus Meeting.

“The Delphi Method is a combination of web-based and in-person techniques to get a group of diverse strong opinions into agreement. What it really means is we took several months to develop and refine the research questions through multiple rounds of surveys,” Brianna Mills, a research scientist at Haborview Injury Prevention and Research Center said.

Ultimately the group identified 8 research questions. Next Mills and her colleagues at the University of Washington Harborview Injury Prevention and Research Center conducted a systemic review on current research on spine injury that included 1,544 studies, 49 of which were included in the final review.

The SISG group then met in person in Atlanta, Georgia, March 2 and 3, 2019 and used the evidence gathered to create and refine conclusions and recommendation until a consensus was reached.

“Over the course of 2 days, 20 members of the SISG suggested, discussed and voted on 22 conclusions and 45 recommendations in total. We worked our way up from agreeing on what the questions were to agreeing on what the answers were,” Mills said.

Key Recommendations and Best Guidelines Practices

The key recommendations and best practices are:

1. Athletic programs should have an emergency action plan (EAP) developed in conjunction with local emergency medical services agencies specific to pre-hospital spine-injury care. Best practices are for an athlete with a suspected spinal injury to be transported to a designated Level 1 or 2 trauma center as quickly and safely as possible. The EAP should be reviewed by all parties annually.

• • The NATA and the members of SISG advise that an athletic trainer or other sports medicine provider always be present at high-risk activities. But if they can’t be, sports administrators should have procedures in place to implement the EAP.
  • The role of the sports medicine team consists of the following:
    1. Establishing and controlling scene safety
    2. Activating the Emergency Medical Service system
    3. Directing Emergency Medical Service to the scene, and
    4. Initiating and directing care of the injured athlete.
  1. Sports medicine teams should conduct a pre-event medical time out before each athletic event (practices and competitions). Participating in these “time outs” should include medical personnel from both teams, Emergency Medical Service personnel and game officials.
  • • “A medical time out is an opportunity before an event or practice to sit down and go over what conditions have changed,” Co-chair of SISG and Clinical Associate Professor, Department of Emergency Medicine, University of South Carolina School of Medicine-Grenville, Jim Ellis, M.D., FACEP [Fellow of the American College of Emergency Physicians], said. “Are we practicing at a different site? Has there been a change in route because of construction on a college campus or at a facility? All critical components to talk about in medical time out before an event or practice.”
    • He added, “You have to be collaborative in these types of situations and communication is critical. Education is also critical. And practice, practice, practice.”
    1. When feasible, those with the highest level of training and experience in removal techniques should participate in equipment remova
    2. Removal of the helmet and shoulder pads can occur in the emergency room or on the field. There are potential advantages to on-field removal prior to transport to the hospital, such as improved airway management, access to the chest for CPR and expedited care of the athlete.
    • • “The question of equipment removal is at the heart of the situation. You look at a player down on the field and there are shoulder pads and helmets and it is not necessarily intuitive how to get these things off while protecting the cervical spine. It is a perishable skill,” said Stanley A. Herring, M.D., co-chair of SISG and senior medical advisor and co-founder of The Sports Institute at UW Medicine.
      • The decision to remove equipment before transport, according to best practices, should be based on a variety of factors, such as the medical status of the injured athlete, type of equipment worn, number of onsite rescuers and training and experience of the on-the-field and emergency room rescuers in equipment removal.
      1. If the spine board is used in the care of an athlete with a suspected cervical spine injury, non-athlete data recommends that time on the board be minimized, however, the board is left in place for transport to the hospital.
      2. If feasible, spine-injured athletes should be transported to a medical facility that can deliver immediate and definitive care in the event the athlete has a significant cervical spine injury. This includes: an emergency department with certified emergency medicine physicians; personnel trained in equipment removal; advanced imaging services; spine surgeon consultation in house or readily available; 24/7 operating access; and critical care monitoring and rehabilitation services.

      One of the most important steps when dealing with a spine injury is to stabilize the head and the spine to reduce spinal motion and prevent harm to the spinal cord, especially during transport to the medical facility.

      “Athletic health care professionals rarely perform on-field spinal-motion restriction (SMR) and must therefore practice at least annually to minimize skill decay. Interprofessional collaboration and education may improve knowledge and clinical skills in this area,” the SISG group wrote in “Best Practices and Current Care Concepts in Prehospital Care of the Spine-Injured Athlete in American Tackle Football”.

      “I have enacted emergency protocols for the pre-hospital care of a spine-injured athlete several times during my career and have seen first-hand the monumental and lasting effects that it can have on both the athlete and family,” Courson who is also a co-chair of SISG said. “My experience has driven home the paramount importance of having rehearsed and evidence-based protocols ready to implement.”

      He added though that, “It is important to emphasize that this is not a one-size fit all protocol but are options that can be adapted to a wide variety of needs. Every spine injury is different.”

      The Sports Institute at UW Medicine created an accompanying training film to illustrate the guidelines and best practices. “The care of the spine-injured athlete is dependent upon the collaboration of medical professionals from athletic trainers to EMTs/paramedics, team and emergency physicians and beyond. It was deemed critical that in addition to the articles, we created a high-quality visual component to allow for efficient and effective training across disciplines,” explained Dr. Herring.

      Today Gale now assistant coach of the Jefferson High School football team in Jefferson, Georgia, is a strong advocate of having an athletic trainer on site at games and practices at all levels of sports, and for educating medical professionals on C-spine care.