Management of the helmeted athlete with suspected cervical spine injury

American Journal of Sports Medicine

Volumn 32, Issue 5, 2004, Pages 1331-1350

  Waninger, Kevin N ^a,b  

^a ST LUKE S HOSPITAL   (United States)

^b NONE   (United States)

Author keywords

Cervical spine; Football; Helmet removal; Ice hockey; Injury; Sports; Trauma

Indexed keywords

AIRWAY; ALGORITHM; ARTICLE; BIOMECHANICS; CERVICAL SPINAL CORD INJURY; CERVICAL SPINE INJURY; CERVICAL SPINE RADIOGRAPHY; CLINICAL EXAMINATION; COMPUTER ASSISTED TOMOGRAPHY; HELMET; HUMAN; IMMOBILIZATION; PATIENT POSITIONING; PATIENT TRANSPORT; PRACTICE GUIDELINE; PRIORITY JOURNAL; SPORT INJURY;

AIRWAY OBSTRUCTION; ATHLETIC INJURIES; CERVICAL VERTEBRAE; EMERGENCY TREATMENT; EQUIPMENT DESIGN; HEAD PROTECTIVE DEVICES; HUMANS; SPINAL INJURIES;

EID: 3242813651     PISSN: 03635465     EISSN: None     Source Type: Journal    
DOI: 10.1177/0363546504264580     Document Type: Article

References (192)

1. Advanced Trauma Life Support for Doctors. American College of Surgeons, Committee on Trauma. Chicago: American College of Surgeons; 1997.
2. Allen K. Lions' Brown bruises spine. USA Today. December 22-23, 1997.
3. Almquist JL. Spine injury management: a comprehensive plan for managing the cervical spine-injured football player. Sports Med Update. 1998;13:8-11.
4. Almquist JL, Kleiner DM. A survey of the techniques to be employed for the on-the-field management of a football player with a suspected spine injury [abstract]. J Athl Train. 2002;37(suppl 2):S85-S86.
5. Almquist JL, Rehberg RS, Kleiner DM. An assessment of the response time prior to facemask removal [abstract]. J Athl Train. 2000;35(suppl 2):S61.
6. Anderson C. Neck injuries: backboard, bench, or return to play? Phys Sportsmed. August 1993;21:23-34.
7. Anderson JC, Courson RW, Kleiner DM, et al. National Athletic Trainers' Association position statement: emergency planning in athletics. J Athl Train. 2002;37:99-104.
8. Andrish JT, Bergfeld JA, Romo LR. A method for the management of cervical spine injuries in football: a preliminary report. Am J Sports Med. 1977;5:89-92.
9. Angotti DD, Hoenshel RW, Kleiner DM. The most efficient technique for using the FM extractor [abstract]. J Athl Train. 2000;35(suppl 2):S60.
10. Aprahamian C, Thompson BM, Darin JC. Recommended helmet removal techniques in a cervical spine injured patient. J Trauma. 1984;24:841-842.
11. Bailes JE, Maroon JC. Management of cervical spine injuries in athletes. Clin Sports Med. 1989;8:43-57.
12. Benson BW, Mohtadi NGH, Rose MS, et al. Head and neck injuries among ice hockey players wearing full face shields vs half face shields. JAMA. 1999;282:2328-2332.
13. Berge J, Marque B, Vital JM, et al. Age-related changes in the cervical spines of front-line rugby players. Am J Sports Med. 1999;27:422-429.
14. Bishop PJ. Factors related to quadriplegia in football and the implications for interventional strategies. Am J Sports Med. 1996;24:235-239.
15. Bishop PJ, Norman RW, Kozey JW. An evaluation of football helmets under impact conditions. Am J Sports Med. 1984;12:233-236.
16. Block JJ, Kleiner DM, Knox KE. Football helmet facemask removal with various tools and straps [abstract]. J Athl Train. 1996;31(suppl 2):S11.
17. Bond GR, Christoph RA, Rodgers BM. Pediatric equestrian injuries: assessing the impact of helmet use. Pediatrics. 1995;95:487-489.
18. Brandenburg MA, Archer P. Survey analysis to access the effectiveness of the bull touch helmet in preventing head injuries in bull riders: a pilot study. Clin J Sport Med. 2002;12:360-366.
19. Branfoot T. Motorcyclists, full-face helmets, and neck injuries: can you take the helmet off safely, and if so, how? J Accid Emerg Med. 1994;11:117-120.
20. Brown A, Armstrong CW, Rankin J, et al. Observed hand placement patterns of certified trainers while using various facemask removal tools [abstract]. J Athl Train. 2001;36(suppl 2):S69.
21. Budassi SA. Helmet removal from injured patients. J Emerg Nurs. 1981;7:290.
22. Burney RE, Waggoner R, Maynard FM. Stabilization of spinal injury for early transfer. J Trauma. 1989;29:1497-1499.
23. Caro DA, Kleiner DM. Athletic spine injuries, emergency medicine physicians, and video training [abstract]. J Athl Train. 2002;37(suppl 2):S85.
24. Casazza BA, Rossner K. Baseball/lacrosse injuries. Phys Med Rehabil Clin N Am. 1999;10:141-157.
25. Caswell SV, Deivert RG. Lacrosse helmet designs and the effects of impact force. J Athl Train. 2002;37:164-171.
26. Ching RP, Thompson DC, Thompson RS, et al. Damage to bicycle helmets involved with crashes. Accid Anal Prev. 1997;29:555-562.
27. Committee on Sports Medicine and Fitness. Safety in youth ice hockey: the effects of body checking (RE9835). Pediatrics. 2000;105:657-658.
28. Coon ME, Chan SB. Investigation into the relationship between intracranial injury and cervical spine injury in pediatric sports trauma [abstract]. Ann Emerg Med. 2003;42:S87.
29. Curran C, Dietrich AM, Bowman MJ, et al. Pediatric cervical spine immobilization: achieving neutral position? J Trauma. 1995;39:729-732.
30. Dansen KR. On-field management of the injured football player [letter to the editor]. Clin J Sport Med. 2000;10:82-83.
31. Davidson RM, Burton JH, Snowise M, et al. Football protective gear and cervical spine imaging. Ann Emerg Med. 2001;38:26-30.
32. Davis JW, Phreaner DL, Hoyt DB, et al. The etiology of missed cervical spine injuries. J Trauma. 1993;34:342-346.
33. DeLorenzo RA, Olson JE, Boska M, et al. Optimal positioning for cervical immobilization. Ann Emerg Med. 1996;28:301-308.
34. Del Rossi G, Horodyski M, Powers ME. A comparison of spine-board transfer techniques and the effect of training on performance. J Athl Train. 2002;38:204-208.
35. Denegar C, Saliba E. On the field management of the potential cervical spine injured football player. J Athl Train. 1989;24:108-111.
36. Domeier RM, Evans RA, Swor RA, et al. Prehospital clinical findings associated with spinal injury. Prehosp Emerg Care. 1997;1:11-15.
37. Domeier RM, Evans RA, Swor RA, et al. Prospective validation of prehospital spinal clearance criteria. Acad Emerg Med. 1997;6:643-646.
38. Donaldson WF, Lauerman WC, Heil B, et al. Helmet and shoulder pad removal from a player with suspected cervical spine injury: a cadaveric model. Spine. 1998;23:1729-1733.
39. Ducker TB, Salcman M, Daniell HB. Experimental spinal cord trauma, III: therapeutic effect of immobilization and pharmacological agents. Surg Neurol. 1978;10:71-76.
40. Ensch CA, Kleiner DM, Tillman MD. The effect of tool familiarity on facemask removal [abstract]. J Athl Train. 2001;36(suppl 2):S68.
41. Feld F. Management of the critically injured football player. J Athl Train. 1993;28:206-212.
42. Feld F, Blanc R. Immobilizing the spine injured football player. J Emerg Med Serv. 1987;12:38-40.
43. Finch CF, McIntosh AS, McCrory PM. What do under 15-year-old schoolboy rugby union players think about protective headgear? BrJ Sports Med. 2001;35:89-94.
44. Fine KM, Vegso JJ, Sennett B, Torg JS. Prevention of cervical spine injuries in football: a model for other sports. Phys Sportsmed. October 1991;19:54-63.
45. Fischer MP, Rehberg RS, Kleiner DM, et al. Attention about football equipment removal of procedures from EMT-B students [abstract]. J Athl Train. 2002;37(suppl 2):S85.
46. Fischer RP. Cervical radiographic evaluation of alert patients following blunt trauma. Ann Emerg Med. 1984;13:905-907.
47. Fourre M. On-site management of cervical spine injuries. Phys Sportsmed. April 1991;19:53-56.
48. Fuchs EJ, Haung CH, Bryant JE, et al. Facemask removal time of four facemask extrication devices [abstract]. J Athl Train. 1996;31(suppl 2):S38.
49. Funk FJ, Wells RE. Injuries of the cervical spine in football. Clin Orthop. 1975;109:50-58.
50. Gallup DA, Boker JR, Hartz L. Helmet types and removal. Emerg Med Serv. 1981;10:91-92.
51. Gastel JA, Palumbo MA, Hulstyn MJ, et al. Emergency removal of football equipment: a cadaveric cervical spine injury model. Ann Emerg Med. 1998;32:411-417.
52. Gieck J, McCue FC. Fitting of protective football equipment. Am J Sports Med. 1980;8:192-196.
53. Godwin SA, Kleiner DM, Norton CE. The ability of physicians to perform endotracheal intubation with a football helmet, face mask, and chin strap. 2003 Southeastern Regional Meeting of the Society for Academic Emergency Medicine; April 11-13, 2003; Jacksonville Beach, Fla.
54. Gooding MR, Wilson CB, Hoff JT. Experimental cervical myelopathy: effects of ischemia and compression of the canine spinal cord. J Neurosurg. 1975;43:9-17.
55. Gorden JA, Straub SJ, Swanik CB, et al. Effects of football collars on cervical hyperextension and lateral flexion [abstract]. J Athl Train. 2001;36(suppl 2):S71.
56. Greenstein JS, Kleiner DM. Guidelines for the pre-hospital management of the spine-injured athlete. J Sports Chiropract Rehabil. 2000;14:105-110.
57. Grimard G, Nolan T, Carlin JB. Head injuries in helmeted child bicyclists. Inj Prev. 1995;1:21-25.
58. Hafen BQ, Karren KJ. Helmet removal. In: Prehospital Emergency Care and Crises Intervention. Englewood Cliffs, NJ: Prentice Hall; 1992:285-288.
59. Haight RR, Shiple BJ. Sideline evaluation of neck pain: when is it time for transport. Phys Sportsmed. March 2001;29:45-62.
60. Hall MC, Decoster LC, Norkus SA, et al. Comparison of four popular tools for number of cuts required, correlated with time, and success in first attempt to remove a football facemask [abstract]. J Athl Train. 2002;37(suppl 2):S37.
61. Hanson JA, Blackmore CC, Mann FA, et al. Cervical spine injury: a clinical decision rule to identify high-risk patients for helical CT screening. Am J Roentgenol. 2000;174:713-717.
62. Hart CM, McGuine TA. Football helmet fitting errors for high school grade levels. J Athl Train. 1995;29(suppl 2):S159-S160.
63. Hastings RH, Kelley SD. Neurologic deterioration associated with airway management in a cervical spine-injured patient. Anesthesiology. 1993;78:580-583.
64. Heck JF. The incidence of spearing by high school football ball carriers and their tacklers. J Athl Train. 1992;27:120-124.
65. Heck JF. The incidence of spearing during a high school's 1975 and 1990 football seasons. J Athl Train. 1996;31:31-37.
66. Herzenberg JE, Dedrick DK, Phillips WA. Emergency transport and positioning of young children who have an injury of the cervical spine: the standard backboard may be dangerous. J Bone Joint Surg Am. 1989;71:15-22.
67. Hoenshel RW, Angotti DD, Kleiner DM. An objective evaluation of the FM extractor [abstract]. J Athl Train. 2000;35(suppl 2):S61.
68. Hoenshel RW, Pearson DB, Kleiner DM. The technique most commonly employed with the FM extractor [abstract]. J Athl Train. 2001;36(suppl 2):S70.
69. Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med. 2000;343:94-99.
70. Holland AJ, Roy GT, Gob V, et al. Horse-related injuries in children. Med J Aust. 2001;175:609-612.
71. Huston RL, Sears J. Effect of protective helmet mass on head and neck dynamics. J Biomech Eng. 1981;103:18-23.
72. Irvin WS, Bowman LS. Inconsistencies in the treatment of football neck injuries. J S C Med Assoc. 2000;96:345-347.
73. Iselborn AJ, Kleiner DM, Pearson DB. The amount of spine movement that occurs with football helmet removal [abstract]. J Athl Train. 2001;36(suppl 2):S72.
74. Jacobs C, Rozea G, Horodyski MB. Football collars increase cervical extension during immobilization [abstract]. J Athl Train. 2001;36(suppl 2):S68.
75. Jenkins HL, Valovich TC, Arnold BL, et al. Removal tools are faster and produce less force and torque on the helmet than cutting tools during face-mask retraction. J Athl Train. 2002;37:246-251.
76. Jones MD. Cineradiographic studies of the collar-immobilized cervical spine. J Neurosurg. 1960;17:633-637.
77. Josefson D. US call for mandatory skiing helmets. BMJ. 1998;316:172.
78. Kennedy MA. Athletic trauma [abstract]. Med Sci Sports Exerc. 1997; 29:S211.
79. Kleiner BM, Miller GL. Endotracheal intubation vs Combitube insertion: implications for athletic protective equipment [abstract]. 2003 Southeastern Regional Meeting of the Society for Academic Emergency Medicine; April 11-13, 2003; Jacksonville Beach, Fla.
80. Kleiner BM, Miller GL. The influence of a football face mask and chin strap on endotracheal intubation [abstract]. Med Sci Sports Exerc. 2002;35(suppl 5):S102.
81. Kleiner DM. Attitudes and knowledge about removing athletic protective equipment in the prehospital setting [abstract]. 2002 Southeastern Regional Meeting of the Society for Academic Emergency Medicine; April 12-14, 2002; Jacksonville Beach, Fla.
82. Kleiner DM. Facemask removal vs facemask retraction [abstract]. J Athl Train. 1996;31(suppl 2):S32.
83. Kleiner DM. Football helmet facemask removal. Athletic Ther Today. 1996;1:11-14.
84. Kleiner DM. Prehospital care of the spine-injured athlete: monograph summary. Clin J Sport Med. 2003;13:59-61.
85. Kleiner DM, Almquist JL, Bailes J, et al. Prehospital Care of the Spine-Injured Athlete: A Document From the Inter-Association Task Force for Appropriate Care of the Spine-Injured Athlete. Dallas, Texas: National Athletic Trainers' Association; March, 2001.
86. Kleiner DM, Almquist JL, Hoenshel RW, et al. The effects of practice on facemask removal skills [abstract]. J Athl Train. 2000;35(suppl 2):S60.
87. Kleiner DM, Bozeman WP, Caro D, et al. Knowledge of football equipment removal guidelines among attendees of a regional emergency medicine meeting [abstract]. 2002 Southeastern Regional Meeting of the Society for Academic Emergency Medicine; April 12-14, 2002; Jacksonville Beach, Fla.
88. Kleiner DM, Godwin SA, Norton CE. Laryngeal mask airway (LMA) insertion and football equipment [abstract]. 2003 Southeastern Regional Meeting of the Society for Academic Emergency Medicine; April 11-13, 2003; Jacksonville Beach, Fla.
89. Kleiner DM, Greenwood LD. The influence of hand size and grip strength on the ability to remove a football helmet facemask [abstract]. J Athl Train. 1997;32(suppl 2):S50.
90. Kleiner DM, Knox KE. An evaluation of the techniques used by athletic trainers when removing a facemask with a Trainers Angel [abstract]. J Athl Train. 1995;30(suppl 2):S7.
91. Kleiner DM, Pearson DB, Hoenshel RW, et al. Certified athletic trainers, Combitube insertion, and football equipment [abstract]. J Athl Train. 2002;37(suppl 2):S38.
92. Kleiner DM, Pollak AN. Dos & don'ts of football helmet removal. JEMS. July 2001;26:37-48.
93. Kleiner DM, Sonnenberg RJ. The influence of temperature on the ability to cut the football helmet facemask loop-strap attachment [abstract]. J Athl Train. 1999;34(suppl 2):S84.
94. Knight KL. Editorial: removing football helmet facemasks. J Athl Train. 1992;27:197.
95. Knox KE, Kleiner DM. A description of how chin straps are attached to high school football helmets [abstract]. J Athl Train. 2000;35(suppl 2):S62.
96. Knox KE, Kleiner DM. The effectiveness of EMT shears for face mask removal [abstract]. J Athl Train. 1996;31 (suppl 2):S17.
97. Knox KE, Kleiner DM. The efficiency of tools used to retract a football face mask. J Athl Train. 1997;32:211-215.
98. Kraus JF, Anderson BD, Mueller CE. The effectiveness of a new touch football helmet to reduce head injuries. J Sch Health. 1970;40:496-500.
99. LaPrade RF, Schnetzler K, Boxterman RJ, et al. Cervical spine alignment in the immobilized ice hockey player: a computed tomographic analysis of the effects of helmet removal. Am J Sports Med. 2000;28:800-803.
100. Lawrence DW, Stewart GW, Christy DM, et al. High school football-related cervical spine injuries in Louisiana: the athlete's perspective. J La State Med Soc. 1997;149:27-31.
101. Lennarson PJ, Smith D, Todd MM, et al. Segmental cervical spine motion during orotracheal intubation of the intact and injured spine with and without external stabilization. J Neurosurg. 2000;92:201-206.
102. Li AE, Fishman EK. Cervical spine trauma: evaluation by multidetector CT and three-dimensional volume rendering. Emerg Radiol. 2003;10:34-39.
103. Long SE, Reid SE, Sweeney HJ, et al. Removing football helmets safely. Phys Sportsmed. October 1980;8:119.
104. Martin V. Football rules seek to curb head blocking. Phys Sportsmed. March 1976;4:23-24.
105. McGuine TA, Hart C, Nass SJ. Football helmet fitting in Wisconsin high schools [abstract]. J Athl Train. 1995;30:S39.
106. McGuine TA, Nass SJ. Evaluation of football helmet fit in high school football players [abstract]. Med Sci Sports Exerc. 1994;26:S13.
107. McGuine TA, Nass SJ. Football helmets: are they fitted properly? A survey of high school football coaches' knowledge and policies for fitting football helmets [abstract]. Med Sci Sports Exerc. 1995;27:S53.
108. McIntosh AS, Janda D. Evaluation of cricket helmet performance and comparison with baseball and ice hockey helmets. Br J Sports Med. 2003;37:325-330.
109. McSwain NE. Techniques of helmet removal from injured patients. Bull Am Coll Surg. 1981;66:19-21.
110. McVey R, Gruber D, Hodges J. Neck pain in a collegiate football player [abstract]. J Athl Train. 2001;36(suppl 2):S70.
111. Metz CM, Kuhn JE, Greenfield ML. Cervical spine alignment in immobilized hockey players: radiographic analysis with and without helmets and shoulder pads. Clin J Sport Med. 1998;8:92-95.
112. Meyer RD, Daniel WW. The biomechanics of helmets and helmet removal. J Trauma. 1985;25:329-332.
113. Miller GL, Kleiner DM. Esophageal tracheal Combitube intubation and football equipment [abstract]. Med Sci Sports Exerc. 2002;35(suppl 5):S102.
114. Mower WR, Hoffman JR, Pollack CV, Zucker MI, Browne BJ, Wolfson AB. Use of plain radiography to screen for cervical spine injuries. Ann Emerg Med. 2001;38:1-7.
115. Muckart DJ, Bhagwanjee S, van der Merwe R. Spinal cord injury as a result of endotracheal intubation in patients with undiagnosed cervical spine fractures. Anesthesiology. 1997;87:418-420.
116. Mueller FO, Cantu RC. Annual survey of catastrophic football injuries (1977-2002) [National Center for Catastrophic Sport Injury Research Web site]. 2003. Available at: www.unc.edu/depts/nccsi.
117. National Collegiate Athletic Association. Guideline 4-F: guidelines for helmet fitting and removal in athletes. In: Schluep C, ed. 2003-2004 NCAA Sports Medicine Handbook. 16th ed. Indianapolis, Ind: National Collegiate Athletic Association; 2003:79-81.
118. Neifeld GL, Keene JG, Hevesy G, et al. Cervical injury in head trauma. J Emerg Med. 1988;6:203-207.
119. Nelson DE, Rivara FP, Condie C. Helmets and horseback riders. Am J Prev Med. 1994;10:15-19.
120. Nypaver M, Treloar D. Neutral cervical spine positioning in children. Ann Emerg Med. 1994;23:208-211.
121. Osberg JS, Schneps SE, Di Scala C, et al. Skateboarding: more dangerous than roller-skating or in-line skating. Arch Pediatr Adolesc Med. 1998;152:985-991.
122. O'Sullivan PT, Decoster LC, Swartz EE. Comparison of football facemask retraction and removal times [abstract]. J Athl Train. 2002;37(suppl 2):S37.
123. Palumbo MA, Hulstyn MJ, Fadale PD, et al. The effect of protective football equipment on alignment of the injured cervical spine: radiographic analysis in a cadaveric model. Am J Sports Med. 1996;24:446-453.
124. Patel MN, Rund DA. Emergency removal of football helmets. Phys Sportsmed. October 1994;22:57-58.
125. Pearl AJ, Mayer PW. Neck motion in the high school football player: observations and suggestions for diminishing stresses on the neck. Am J Sports Med. 1979;7:231-233.
126. Pearson D, Gearhart T, Horodyski M, et al. A comparison of the effectiveness of helmet fit during immobilization in youth and professional ice hockey players [abstract]. Med Sci Sports Exerc. 2000;15:298-299.
127. Pearson DB, Hoenshel RW, Almquist JL, et al. The anvil prunner vs the modified PVC pipe cutter [abstract]. J Athl Train. 2001;37(suppl 2):S38.
128. Pearson DB, Hoenshel RW, Kleiner DM. An evaluation of the Bike loop-strap vs the Schutt loop-strap [abstract]. J Athl Train. 2001;36(suppl 2):S69.
129. Peris MD, Donaldson WF, Towers J, et al. Helmet and shoulder pad removal in suspected cervical spine injury human control model, Spine. 2002;27:995-998.
130. Pettersen JA. Does rugby headgear prevent concussions? Attitude of Canadian players and coaches. Br J Sports Med. 2002;36:19-22.
131. Podolsky S, Baraff LJ, Simon RR, et al. Efficacy of cervical spine immobilization methods. J Trauma. 1983;23:461-465.
132. Prinsen RKE, Syrotuik DG, Reid DC. Position of the cervical vertebrae during helmet removal and cervical collar application in football and hockey. Clin J Sport Med. 1995;5:155-161.
133. Putnam LA. Alternative methods for football helmet face mask removal. J Athl Train. 1992;27:170-172.
134. Quencer RM, Nunez D, Green BA. Controversies in imaging acute cervical spine trauma. Am J Neuroradiol. 1997;18:1866-1868.
135. Quinn DI. Dissecting the rugby tackle: do shoulder pads contribute to cervical spine injuries? Med J Aust. 1998;169:501-502.
136. Quinn TM. Touchdown! Immobilization of the professional football player. Emerg Med Serv. October 2001;30:71-75.
137. Quinn TM, Miller GL, Kleiner DM. Attitudes about football equipment removal procedures among fire rescue personnel [abstract]. Med Sci Sports Exerc. 2002;35(suppl 5):S103.
138. Ransone J, Kersey R, Walsh K. The efficacy of the rapid form cervical vacuum immobilizer in cervical spine immobilization of the equipped football player. J Athl Train. 2000;35:65-69.
139. Ray R. Helmets and face masks [letter to the editor]. J Athl Train. 1992;27:294.
140. Ray RR, Luchies C, Abfall MK, et al. Cervical spine motion in football players during three airway exposure techniques. J Athl Train. 2002;37:172-177.
141. Ray R, Luchies C, Bazuin D, et al. Airway preparation techniques for the cervical spine-injured football player. J Athl Train. 1995;30:217-221.
142. Redden WW, Kleiner DM, Holcomb WR. The effects of gender, hand size, and grip strength on the ability to remove a football helmet facemask [abstract]. J Athl Train. 1998;33(suppl 2):S43.
143. Rehberg RS. Facemask removal tools come in all shapes, styles. NATA News. 1999;8:8-9.
144. Rehberg RS, Kleiner DM, Knox KE. A description of how chin straps are attached to high school football helmets in New Jersey [abstract]. J Athl Train. 2002;37(suppl 2):S38.
145. Reynen PD, Clancy WG. Cervical spine injury, hockey helmets, and facemasks. Am J Sports Med. 1994;22:167-170.
146. Roberts WO. Hitting in amateur ice hockey: not worth the risk. Phys Sportsmed. November 1999;27:35.
147. Robey JM. Contribution of design and construction of football helmets to the occurrence of injuries. Med Sci Sports Exerc. 1972;4:170-174.
148. Sanville M, Hoenshel RW, Angotti DD, et al. The sharpness of face-mask removal tools and performance [abstract]. J Athl Train. 2000;35(suppl 2):S60.
149. Scher AT. Rugby injuries to the cervical spine and spinal cord: a 10-year review. Clin Sports Med. 1998;17:195-205.
150. Schleehauf K, Ross SE, Civil ID, et al. Computed tomography in the initial evaluation of the cervical spine. Ann Emerg Med. 1989;18:815-817.
151. Schneider RC, Reifel E, Crisler HO, et al. Serious and fatal football injuries involving the head and spinal cord. JAMA. 1961;177:362.
152. Schriger DL, Larmon B, LeGassick T, et al. Spinal immobilization on a flat backboard: does it result in neutral position of the cervical spine. Ann Emerg Med. 1991;20:878-881.
153. Segan RD, Cassidy C, Bentkowski J. A discussion of the issue of football helmet removal in suspected cervical spine injuries. J Athl Train. 1993;28:294-305.
154. Shaffer MA, Doris PE. Limitation of the cross-table lateral view in detecting cervical spine injuries: a retrospective study. Ann Emerg Med. 1981;10:508-513.
155. Silloway KA, McLaughlin RE, Edrich RC, et al. Clavicular fractures and acromioclavicular joint locations in lacrosse: preventable injuries. J Emer Med. 1985;3:117-121.
156. Slucky AV, Potter HG. Use of magnetic resonance imaging in spinal trauma: indications, techniques, and utility. J Am Acad Orthop Surg. 1998;6:134-145.
157. Smith M, Bourn S, Larmon B. Ties that bind: immobilizing the injured spine. J Emerg Med Serv. 1987;4:28-35.
158. Springer BL, Kleiner DM. Effectiveness of video training emergency medicine physicians on athletic spine injuries [abstract]. Med Sci Sports Exerc. 2002;35:S220.
159. Stenger J, Lawton EA, Wright J, et al. Mouthguards: protection against shock to head, neck, and teeth. J Am Dent Assoc. 1964;69:273-281.
160. Stephenson A, Horodyski MB, Meister K, et al. Cervical spine alignment in the immobilized ice hockey player: radiographic analysis before and after helmet removal [abstract]. J Athl Train. 1999;34:S27.
161. Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001;286:1841-1848.
162. Surace AF, Goldfuss AJ, Hauth JM, et al. Effect of selected tools on facemask removal and head motion [abstract]. J Athl Train. 2000;35(suppl 2):S62.
163. Swartz EE, Armstrong CW, Rankin JM, et al. A 3-dimensional analysis of face-mask removal tools in inducing helmet movement. J Athl Train. 2002;37:178-184.
164. Swartz E, Norkus S. Riddell helmet research continues [letter to the editor]. NATA News. 2003;3:62.
165. Swartz EE, Norkus SA, Armstrong CW, et al. Face-mask removal: movement and time associated with cutting of the loop straps. J Athl Train. 2003;38:120-125.
166. Swenson TM, Lauerman WC, Donaldson WF, et al. Cervical spine alignment in the immobilized football player: radiographic analysis before and after helmet removal. Am J Sports Med. 1997;25:226-230.
167. Tarazi F, Dvorak MFS, Wing PC. Spinal injuries in skiers and snow-boarders. Am J Sports Med. 1999;27:177-180.
168. Tierney RT, Maldjian C, Mattacola CG, et al. Cervical spine stenosis measures in normal subjects. J Athl Train. 2002;37:190-193.
169. Tierney RT, Mattacola CG, Sitler MR, et al. Head position and football equipment influence cervical spinal cord space during immobilization. J Athl Train. 2002;37:185-189.
170. Torg JS. Epidemiology, pathomechanics, and prevention of football-induced spinal cord trauma. Exerc Sport Sci Rev. 1992;20:321-338.
171. Torg JS, Ramsey-Emrhein JA. Management guidelines for participation in collision activities with congenital, developmental, or postinjury lesions involving the cervical spine. Clin J Sport Med. 1997;7:273-291.
172. Torg JS, Vegso JJ, O'Neill MJ, et al. The epidemiologic, pathologic, biomechanical, and cinematographic analysis of football-induced cervical spine trauma. Am J Sports Med. 1990;18:50-57.
173. Torg JS, Vesgo JJ, Torg E. Prevent Paralysis: Don't Hit With Your Head [video production]. Philadelphia, Pa: University of Pennsylvania Sports Medicine Center and the National Federation of State High School Association; 1992.
174. Trupianoi TP, Sampson ML, Weise MW. Fracture of the first cervical vertebrae in a high school player: a case report. J Athl Train. 1997;32:159-162.
175. Van Camp LA, Vanderschot PM, Sabbe MB, et al. The effect of helmets on the incidence and severity of head and cervical spine injuries in motorcycle and moped accident victims: a prospective analysis based on emergency department and trauma center data. Eur J Emerg Med. 1998;5:207-211.
176. Veenema K, Greenwald R, Kamali M, et al. The initial lateral cervical spine film for the athlete with a suspected neck injury: helmet and shoulder pads on or off? Clin J Sport Med. 2002;12:123-126.
177. Vegso JJ, Lehman RC. Field evaluation and management of head and neck injuries. Clin Sports Med. 1987;6:1-15.
178. Vieson M, Wimer JW. Attitudes about football helmet removal procedures from students in a paramedic education classroom [abstract]. J Athl Train. 1998;33(suppl 2):S61.
179. Virgin H. Cineradiographic study of football helmets and the cervical spine. Am J Sports Med. 1980;8:310-317.
180. Waeckerle JF, Kleiner DM. Protective athletic equipment and cervical spine imaging [editorial]. Ann Emerg Med. 2001;38:65-67.
181. Waninger KN. The efficacy of the rapid form cervical vacuum immobilizer in cervical spine immobilization of the equipped football player [letter to the editor]. J Athl Train. 2001;36:361-362.
182. Waninger KN. On-field management of potential cervical spine injury in helmeted football players: leave the helmet on! Clin J Sport Med. 1998;8:124-129.
183. Waninger KN. On-field management of the injured football player [response to letter to the editor]. Clin J Sport Med. 2000;10:82-83.
184. Waninger KN, Richards JG, Pan WT, et al. An evaluation of head and cervical spine movement in backboard-immobilized helmeted football, lacrosse, and ice hockey players. Clin J Sport Med. 2001;11:82-86.
185. Waninger KN, Rothman M, Foley J, et al. Evaluation of the adequacy of CT in the cervical spine imaging of the American Football Player with helmet and shoulder pads on. Abstract presented at: Annual Meeting of the American Society of Spine Radiology; February 19-23, 2003; Scottsdale, Ariz; Pennsylvania Radiological Society Scientific Exhibits, Hershey, Pa, 2003.
186. Waninger KN, Rothman M, Heller M. Evaluation of the adequacy of MRI in the cervical spine imaging of the American football player with helmet and shoulder pads on. Clin J Sport Med. 2003;13:339-343.
187. Watt GM, Finsc CF. Preventing equestrian injuries: locking the stable door. Sports Med. 1996;22:187-197.
188. Wetzler MJ, Akpata T, Laughlin W, et al. Occurrence of cervical spine injuries during the rugby scrum. Am J Sports Med. 1998;26:177-180.
189. White AA, Johnson RM, Panjabi MM, et al. Biomechanical analysis of clinical stability in the cervical spine. Clin Orthop. 1975;109:85-95.
190. Wilson BD. Protective headgear in rugby union. Sports Med. 1998;25:333-337.
191. Winters JE. Commentary: role of properly fitted mouthguards in prevention of sport-related concussion. J Athl Train. 2001;36:339-341.
192. Zeal JA, Kleiner DM, Pearson DB, et al. The effects of modifying the standard loop-strap arrangement on face mask removal [abstract]. J Athl Train. 2002;37(suppl 2):S87-S88.