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Abstract & Commentary
Synopsis: There is a need for carefully monitored helmet and shoulder pad removal by at least three and preferably four trained people.
Source: Donaldson WF, et al. Helmet and shoulder pad removal from a player with suspected cervical injury. A cadaveric model. Spine 1998;23(16):1729-1733.
This study by donaldson and colleagues identifies the risk of cervical position change even when using the current guidelines of the National Athletic Trainers Association (NATA) for helmet and pad removal. In this study, two types of cervical instability were experimentally produced and cervical position was evaluated fluoroscopically during helmet and pad removal. In the first experiment, a transverse base of dens osteotomy was performed to create C1-C2 instability in three cadavers. Thereafter, video fluoroscopy was done while the helmet and shoulder pads were removed by personnel trained in the technique recommended by NATA. "In cadavers with C1-C2 instability, the mean change in angulation was 5-47° and space available for cord was 3.91 mm." With pad removal, space available for cord was 2.64 mm in the C1-C2 instability model. Similarly, in three cadavers, C5-C6 instability was created by a posterior cervical release and helmet and shoulder pad removal was done under fluoroscopy. As seen in alantoaxial instability, helmet and pad removal created abnormal cervical motion at the C5-C6 level. In these segments, space available for cord was decreased to 3.87 mm and flexion-extension occurred. In helmet removal, flexion was 9.32° and shoulder pad removal extended the neck 8.95° for an approximate total of 18°. Donaldson et al conclude that there is a need for carefully monitored helmet and shoulder pad removal by at least three, and preferably four, trained people. Unfortunately, they made no suggestions to improve safe equipment removal. Clearly, they desire to educate clinicians on the limitations of the current technique of helmet and shoulder pad removal. In a commentary on this article, J. P. Albright, MD recommends continuing the use of NATA guidelines as reasonable.
The gravity and frequent inevitability of cervical injuries makes this new study an important area of debate. On-the-field removal of helmet and shoulder pads in a suspected cervical injury is not recommended. The current recommendation of on-the-field removal of a face mask only still stands. Shoulder pad and helmet removal should be performed in a supervised environment, ideally in an emergency room. Transfer of the athlete with helmet (taped to a backboard) and pads in place is recommended. Airway management is primary, and quick-cut tabs on modern helmets allow the face mask to be flipped up for management of the athlete’s airway. However, controversy now exists on the process of helmet and shoulder pad removal in the controlled medical setting. One shortcoming of this study is its basic model—the cadaver. Flexion-extension studies of cervical injuries (plain radiographs) are useful and safe when performed in an awake patient under his or her own control. The risk of helmet and shoulder pad removal noted in the cadaver model may be lessened in an awake patient with cervical muscular control. Certainly, in an unconscious patient, this information is even more important and signifies the appropriate risk. Helmet and pad removal in a suspected cervical injury is best performed with three or four trained personnel, in a well-controlled medical facility, with an alert and communicating patient. This review acknowledges that there are different guidelines, and a consensus of on-the-field management is in progress but still requires further clarification.