11.1 Cervical Spine Trauma, Equipment Removal & Spine Boarding

Quick Answer: After trauma, treat unresponsiveness, bilateral neurologic findings, midline cervical pain, or obvious deformity as a catastrophic cervical spine injury (CSI) until proven otherwise. Hold manual in-line stabilization (MILS) — no traction. Remove the face mask before transport with a cordless screwdriver plus a backup cutting tool. If the athletic trainer (AT) is trained and enough rescuers are present, remove the helmet and shoulder pads together before transport so emergency medical services (EMS) receive a neutral spine in a rigid collar. Never pull the helmet and leave the pads.

Practice Analysis, 8th Edition (PA8) Domain III, task 0303, asks the AT to manage cervical-spine injury, hemorrhage, and other emergent conditions. This section is the CSI half of that task. Catastrophic CSI is uncommon, but American football still accounts for the largest U.S. sport total because of participation volume; ice hockey and men's lacrosse carry high per-athlete risk. The 2009 NATA position statement (Acute Management of the Cervical Spine–Injured Athlete, Swartz et al., Journal of Athletic Training 44(3):306–331), the 2015 Inter-Association Task Force executive summary (Appropriate Care of the Spine-Injured Athlete), and the 2020 Spine Injury in Sport Group (SISG) consensus (Mills et al., JAT 55(6):563–572) are the documents the exam and the sideline both use. Older “leave the equipment on for the emergency department” teaching is not current when a trained on-field team is present.

When to start the spine protocol

NATA 2009 recommendation 8 (Evidence Category A) is still the recognition rule. During the initial assessment, any one of the following — alone or in combination — requires the spine-injury management protocol:

• Unconsciousness or altered level of consciousness after trauma (including a helmet-to-helmet hit, spearing, a shallow-water dive, or a fall from height).
• Bilateral neurologic findings or complaints (numbness, tingling, weakness, or burning in both arms, both legs, or all four limbs). Unilateral “stinger” or burner patterns are different — they are usually a brachial-plexus or nerve-root traction/compression injury — but bilateral symptoms are cord until proven otherwise.
• Significant midline spine pain with or without palpation.
• Obvious spinal column deformity.

A conscious athlete who says “I cannot feel my legs,” an athlete who remains down after a collision, and an athlete who walked two steps then collapsed with midline neck pain all trigger the same first move: stop the contest, control the head, and do not sit them up.

Manual in-line stabilization — not traction

NATA 2009: once CSI is suspected, rescuers ensure the cervical spine is in a neutral position and immediately apply manual cervical spine stabilization. Hands take the helmet (or the occiput and mandible if the athlete is unequipped) so the head cannot nod, rotate, or tilt. Traction must not be applied to the cervical spine (NATA 2009, Evidence Category B). Pulling “to lengthen the neck” can distract an unstable segment.

If the neck is not already neutral, trained rescuers may gently realign it so the airway stays patent — but only in a cooperative athlete, and they must stop if any of the following appear (NATA 2009 / 2020 SISG):

• Pain caused or increased by movement
• Neurologic symptoms or deterioration
• Muscle spasm
• Airway compromise
• Physical difficulty or resistance to repositioning
• Apprehension expressed by the patient

If realignment is abandoned, stabilize in the position found. Alignment should be sufficient to keep a patent airway; circulation, airway, and breathing (CAB) outrank a perfectly straight radiograph.

Face-mask removal for the airway

Airway access is established before transport. SISG 2020 is explicit: in athletes with suspected CSI, airway access should be established before transport, and American tackle football face masks should be removed before transport whether or not the athlete is currently apneic. Hardware fails, loop straps corrode, and some youth helmets do not release — so the AT brings more than one method.

NATA 2009 recommendation 29 describes the combined-tool approach (Evidence Category B):

1. A powered (cordless) screwdriver is generally faster, produces less head movement, and is easier than cutting tools. It is the first tool for a face mask attached with loop straps and screws.
2. Because screws seize or strip, a backup cutting tool matched to the equipment (trainer's angel, FM Extractor, pruning shears designed for the strap, or the manufacturer's quick-release system) must be on the sideline.
3. Corrosion-resistant hardware, in-season maintenance, and regular recertification/reconditioning make screwdriver success more likely.

Command comes from the rescuer at the head who is holding MILS. Typical order for a four-strap football mask: side straps first, then top straps, so the mask cannot rotate down onto the throat. If the plan is to remove the entire helmet next, the face mask may not need to come off first — helmet removal itself opens the airway — but if the athlete is transporting with equipment still on, the face mask comes off regardless of current respiratory status.

Jaw-thrust, not head-tilt/chin-lift, is the airway maneuver that protects the neck. Pocket masks and bag-valve devices must seal on the face once the mask is gone. If the athlete needs chest access for cardiopulmonary resuscitation (CPR) or an automated external defibrillator (AED), the jersey and the front of the shoulder pads are cut; compressions and defibrillation outrank leaving equipment photogenic.

Equipment removal: all or none

This is the highest-yield equipment item on the exam.

Older teaching (NATA 2009 equipment-laden section): leave the helmet and shoulder pads in place for transport except when the helmet is so loose the head moves inside it, the equipment prevents neutral alignment, or the equipment blocks airway or chest access.

Current consensus (2015 Inter-Association Task Force; 2020 SISG; 2020 NATA Best Practices for American tackle football): when feasible, protective equipment is removed before transport by the people who actually know the hardware — usually the on-field AT — so the emergency department receives an athlete in a properly fitted rigid cervical collar with a neutral spine. Advantages listed by NATA Best Practices (2020) include improved airway management, chest access for CPR/AED, and expedited hospital care.

The decision is not automatic. SISG 2020 leaves helmet and shoulder-pad removal to trained personnel at the scene, considering athlete height and weight, sport, equipment make/model/condition, number of trained rescuers, immobilization devices available, and — always first — CAB. Trained personnel should remove helmet and shoulder pads from athletes with compromised CAB or a decreased level of consciousness. If fewer than three experienced rescuers are present, equipment stays until enough trained hands arrive.

All or none is non-negotiable. Removing a football, ice hockey, or men's lacrosse helmet while leaving the shoulder pads lets the head drop into extension relative to the thorax and can malalign an unstable cervical spine. Cervical alignment is statistically equivalent with both on versus both off; it is not equivalent with helmet-off/pads-on. If the athlete is found with the helmet already off and the pads still on, support the head (towel pack, pad, or hands) to restore neutral alignment, then remove the pads or keep the head packed until both can come off.

Never helmet-only is the classic trap.

How the pair actually comes off

Commands stay with the rescuer stabilizing the head.

1. Cut the jersey with trauma shears. Cut the front of the shoulder pads and any neck roll attachments so the chest is exposed.
2. A second rescuer takes anterior cervical control (hands under the pads onto the mandible/occiput or the front of the neck) so the head person can let go briefly.
3. Helmet first: ear pads or cheek pads are loosened or removed if the design requires it; the helmet is expanded laterally and slid off in line with the cervical axis — not levered into extension.
4. Shoulder pads next, as a unit with the helmet decision: flat-torso method (at least two trained people for the pads; more for a large athlete) or torso-tilt (at least four trained people). Torso-tilt should not be used when thoracic or lumbar injury is also suspected.
5. Apply a rigid cervical collar once the equipment is off, then transfer.

If the team is not trained or EMS protocol forbids field removal, transport with equipment in place after face-mask removal, and send an AT who knows the hardware with the athlete.

Transfer and “boarding”

The goal is spinal motion restriction (SMR), not a particular brand of board. SISG 2020:

• Highest priority during any transfer is maintaining cervical alignment.
• For suspected CSI, use an 8-person lift-and-slide for supine athletes and a log-roll–push (not log-roll–pull) for prone athletes when feasible. The 8-person lift-and-slide produces less spinal movement than a log roll in the research the consensus used.
• A full-length rigid spine board and full-body vacuum immobilization are equivalent for cervical immobilization. A scoop stretcher is an acceptable device for minimizing motion in supine patients.
• If a cervical collar is placed, it stays on during transport.
• If a long board is used, time on the board should be minimized (pressure injury, pain, respiratory restriction). Once the athlete is safely on the ambulance stretcher, extrication devices may be removed if enough trained people can keep SMR. Rigid boarding is not automatically mandatory when a scoop, vacuum mattress, and a trained team can restrict motion.

Log rolling a fully equipped football player still has a role when the athlete is prone or when lift-and-slide staffing is impossible. The medical professional in charge chooses the technique the team has actually rehearsed.

Combined airway and spine, destination, and rehearsal

CAB plus MILS are simultaneous, not sequential in a way that drops either. Jaw-thrust, face-mask removal, and oxygen happen while the head is held. If the athlete is in cardiac arrest, expose the chest — pads and jersey are cut — because defibrillation and compressions will not wait for a perfect log roll.

SISG 2020: transport a suspected CSI athlete to a designated Level I or II trauma center as expeditiously and safely as possible. Venue emergency action plans (EAPs) name that hospital, the gate EMS will use, and who rides with the athlete.

Training is scenario-based, includes the interdisciplinary team (AT, team physician, EMS, coaches for crowd control), and is rehearsed at least annually at each venue. A pre-event medical time-out confirms who holds the head, who cuts the jersey, who has the screwdriver and the cutting tool, and which transfer the crew will use tonight.

Exam trap: pulling the helmet off a downed football player and leaving the shoulder pads, or sitting an athlete up for a concussion exam before the cervical spine has been conceptually cleared.