Chapter 10: The Head, Neck, and Spine

EDUCATIONAL OBJECTIVES

The learner should, at the completion of the chapter, be able to perform the following:

Student athletic trainers are not responsible for stabilizing or transporting severely injured athletes. The student athletic trainers' responsibilities in emergency situations include:
  1. Becoming aware of the causes of serious injuries
  2. Making sure equipment and the playing area are safe
  3. Recognizing signs of serious injury
  4. Alerting the athletic trainer, coach and team physician of potential dangers
  5. Implementing a detailed plan to handle emergency transport.
ANATOMY

For our purposes, we will consider the head in two parts: the cranium, which encases the brain, and the face. The brain is protected from trauma by the bones of the skull. Other bones of the head include the mandible, or jaw, and the bones of the face. The head has excellent blood supply from the body.

Seven cervical vertebra makeup the bones of the neck. The cervical spine, with its attached ligaments and muscles, is adequate to support the head, which weighs about fourteen pounds. Other structures in the neck are the larynx, trachea, muscles, nerves, and blood vessels. The neck is a very fragile region of the body, in which injuries can occur to the seven cervical vertebrae. The cervical section of the spine is by far the most flexible, allowing flexion, extension, rotation and lateral bending of the neck and head. A list of the muscles in the head and neck region is located in the anatomy section of this chapter.

The neck is seldom injured in daily activities, including sports. However, those injuries that do occur to the neck have the potential to cause paralysis and even death. When the cervical vertebrae are fractured, dislocated or sprained, permanent spinal cord damage can occur. The spinal cord transmits impulses that control all voluntary and involuntary movements of the body. Muscles allow the head, neck, and spine to move in different movement patterns. Listed next is a brief outline of the anatomy for the head, neck and spine.

HEAD, NECK AND SPINE ANATOMY

Bones

  1. Cranial (frontal, parietal-2, temporal-2, occipital, sphenoid, ethmoid)
  2. Facial (nasal-2, maxillary-2, zygoma-2, mandible, lacrimal-2, palatine-2, inferior turbinate-2, vomer)
  3. Ear Ossicles
  4. Hyoid
  5. Cervical Vertebrae (7)
  6. Thorax Vertebrae (12)
  7. Lumbar Vertebrae (5)
  8. Sacral Vertebrae (5)
  9. Coccyx Vertebrae (4 fused)
Joints

Head

  1. Temporomandibular Joint
  2. Atlantoccipital Joint
Neck and Spine
  1. Atlantoaxial Joint
  2. Intervertebral Joints
Range of Motion
Head and Neck
Flexion: touch chin to chest
Extension: look at ceiling
Rotation: movement around an axis in an angular motion
Lateral Bending: touch ear to shoulders
Protraction: anterior (forward) movement of shoulders or chin
Retraction: posterior (backward) movement of shoulders or chin
Elevation: superior (upward) movement of shoulders or head
Depression: inferior (downward) movement of shoulders or head

Spine
Flexion: anterior (forward) movement of the spine
Extension: posterior (backward) movement of the spine
Lateral Bending: lateral (sideward) movement of the spine
Rotation: rotational (twisting) movement of the spine

Anatomical Planes
Sagittal Plane: bisecting body into right and left halves
Frontal Plane: bisecting the body into front and back halves
Transverse Plane: bisecting body into upper and lower halves

Muscles

1. Digastricus
2. Erector spinae
3. Geniohyoideus
4. Levator scapulae
5. Longus capitis
6. Longus coli
7. Mylohyoideus
8. Oblicuus capitis superior
9. Obliquus capitis inferior
10. Omohyoideus
11. Platysma
12. Rectus capitis anterior
13. Rectus capitis lateralis
14. Rectus capitis posterior major
15. Rectus capitis
16. Posterior minor
17. Scalenus anterior
18. Scalenus medius
19. Scalenus posterior
20. Semispinalis
21. Capitis
22. Splenius capitis
23. Sternocleidomastiod
24. Sternohyoideus
25. Sternothyroideus
26. Stylohyoideus
27. Thyrohyoideus
28. Trapezius

Neurological Evaluation: Cranial Nerves
 
 
 
Nerve Nerve Type  Function
#1 - Olfactory  Sensory Sense of smell
#2 - Optic  Sensory Vision
#3 - Oculomotor Motor Control of extrinsic eye muscles
#4 - Trochlear Motor Control of extrinsic eye muscles
#5 - Trigeminal Sensory/Motor Sensation of facial region and movement of jaw muscles
 #6 - Abducens Motor Control of lateral eye movements
#7 - Facial Sensory/Motor Control of facial movements, taste, and secretion of tears and saliva
#8 - Vestibulocochlear Sensory Hearing and equilibrium
#9 - Glossopharyngeal Sensory/Motor Taste, control of tongue and pharynx, secretion and saliva
#10 - Vagus Sensory Taste, sensation to the pharynx, larynx, trachia, and bronchioles
#11 - Accesssory Motor Control of movement of the pharynx, larynx, head and shoulders
#12 - Hypoglossal Motor Control of tongue movements
Dermatomes

Myotomes When determining strength of myotomes, provide resistive force.

EVALUATION OF HEAD INJURIES

The athlete sustaining a head injury may recover from the initial trauma and have all signs of recovery, and then suddenly show signs of deteriorating conditions. If the arteries surrounding the brain have been torn, signs and symptoms may be present within minutes, while rupturing of veins may not produce symptoms for days. Therefore, any athlete sustaining a head injury should be evaluated by a physician, monitored for 24 hours, and carefully evaluated on a regular basis for at least one week. Brain injury as a result of external trauma can be classified into three primary categories of intracranial hemorrhaging: epidural, subdural, and intracerebral.

Intracranial Hemorrhaging

Epidural--If the arteries located in the dural membrane are torn, a hematoma (blood clot) will rapidly accumulate, usually in a specific area, due to the epidural covering lying in close association to the skull. The athlete who shows all signs of recovery (the "lucid interval") soon demonstrates signs of a serious head injury. Immediate medical referral for physician evaluation is required.

Subdural--When the veins connecting the dura membrane to the brain are ruptured, hemorrhaging may spread over a much greater area and, therefore, signs may develop at a slower rate. It may take hours or days to develop symptoms of brain damage. Immediate medical referral for physician evaluation is required.

Intracerebral--Bleeding within the brain usually has a fast onset and will require immediate hospitalization to avoid complication. Immediate medical referral for physician evaluation is required.

Secondary conditions may also arise as a result of a head injury. A cerebral edema is localized swelling at the injury site, may be evident within 12 hours, and is characterized by headache and occasional seizures. Seizures may occur immediately following a head injury or within a 24-hour period of time. For the athlete having a seizure, make sure the victim's airway is opened, he/she is safe from further harm, and turn the head to the side to allow saliva and blood to drain. Migraine headaches are an attack of severe headaches accompanied by partial blindness in the field of vision and loss of sensation in the limbs and/or face.

A Concussion is defined as a shaking of the brain. Forceful blows to the head, or even to other parts of the body can cause this shaking. A player does not have to suffer a loss of consciousness to have suffered a concussion. Concussions can occur in football, wrestling, gymnastics, basketball, or any sport where hard contact is made, either with another player, equipment or the ground. Even though a single blow can cause a concussion, the accumulated effects of numerous minor blows can also cause a concussion.

When the brain is traumatized, internal hemorrhage can occur. However, the brain has very little room to swell because of the encasing skull. This internal hemorrhage (bleeding) can not be controlled with applications of cold packs and elevation. Besides the original tissue damage from the concussion, additional damage is possible from the internal hemorrhage, which has no outlet or area in which to expand. This pressure on the brain will affect the central nervous system, causing various reactions in the body. In reviewing literature, grades, levels, and stages are commonly utilized methods for classifying head concussions. For this text, concussions are classified as mild, moderate, or severe, depending on the amount of damage done to the brain. Each classification of injury may produce any or all of the following signs.

1. Mild concussion symptoms: No loss of consciousness, post-traumatic anmesia less than thirty minutes, mental confusion, unsteadiness, ringing in the ears, minor dizziness, dull headache, rapid recovery from all symptoms. The team physician and certified athletic trainer will decide whether the athlete may return to play.
It is recommended that no athlete be permitted to participate as long as he or she has a headache or any other symptoms caused by a blow to the head. Before return to active participation, the athlete must be asymptomatic and have medical approval. If symptoms worsen, immediate medical referral is recommended.

2. Moderate concussion symptoms: Loss of consciousness less than five minutes in duration or post-traumatic amnesia lasting longer than thirty minutes but less than twenty-four hours in duration. Additonally, inability to remember events that occurred before losing consciousness, nausea, dizziness, ringing in the ears, disturbance of balance, and frequent headaches are common symptoms associated with moderate concussion. Immediate medical referral and physician evaluation is required. The athlete should not be permitted to re-enter practice or competition. Continuous observation for 24 hours to be aware of worsening symptoms is essential.

3. Severe concussion symptoms: Loss of consciousness for more than five minutes or post-traumatic amnesia lasting longer than twenty-four hours. Additionally, lack of response to painful stimuli in the extremities, possible wandering eye movements, severe retrograde amnesia, inequality of pupil size, possible convulsions along with other symptoms associated with moderate concussions exist in patients who have suffered sever concussion. Emergency personnel should transport an athlete with a severe concussion to the hospital. As with all head injuries, the ambulance crew will also assume there is a neck injury. In caring for an athlete who has suffered a concussion, quick action is mandatory. It must be stressed again that the athletic trainer or coach should always suspect that the athlete has suffered a neck injury in addition to the concussion.

Regardless of the severity of the concussion, a physician must examine the athlete to determine when activity may be resumed. The coach should obtain a signed statement from the physician before the athlete is allowed to return to activity.

EVALUATION FORMAT

The first purpose of an evaluation is to determine if a serious injury has occurred. The evaluation format of History, Observation, Palpation and Special Tests are thoroughly covered in Chapter 2 and Chapter 6. Listed below is an abbreviated version of this format.

History: Questions should include mechanism of injury, location of pain, sensations experienced, and previous injury.

Observation: Compare the uninvolved to the involved anatomical structure and look for bleeding, deformity, swelling, discoloration, scars, and other signs of trauma.

Palpation: Using bilateral comparison, palpate neurological, circulatory, and anatomical structures, and assess for potential fractures.

Special Tests: Special tests assess disability to ligament, muscle, tendon, accessory anatomical structures, inflammatory conditions, range of motion, and pain or weakness in affected area.

ASSESSMENT TESTS

A physician MUST evaluate all injuries to the head, neck and spine. The purpose of a thorough evaluation is to enable the allied health professional to properly assess the severity of the injury and to make recommendations regarding treatment and possible return to participation. Listed below is an outline of potential evaluation techniques utilized in the evaluation of head, neck and spine injuries.

Vital Signs

Pulse: heart rate
Respiratory Rate: breathing rate
Respiratory Effort: effort and pattern of breathing
Blood Pressure: contraction and relaxation of heart
Pupils: accommodate to sensory input (light, stimula, etc)
Memory: ability to recall facts, situations

Neurological

Sensory: assess sensory nerves through touch (dermatomes)
Motor: assess motor nerves through movement (myotomes)

Head Concussion

Glasgow Coma Scale

Romberg: test for propriception/balance
Stork Stand: test for propriception/balance
Heel/Toe Walking: test for propriception/balance
Finger to Nose: test for hand/eye coordination
Memory: ability to recall facts, situations
Eye Tracking: ability of eyes to move
Peripheal Vision: ability to view objects in various planes
Pupilary Reflex: accommodate to sensory input (light, stimula, etc)

Bone Integrity

Palpation: touching of anatomical structures (physical inspection)
Distraction: light/mild traction to suspect injured anatomical structures
Compression: light/mild compression to suspect injured anatomical structures

Special Tests

Valsalva Test: test to increase intrathecal pressure
Swallowing Test: swallow test to determine is pain causes cervical spine discomfort
Adson Test (Halstead): test used to determine the state of the subclavian artery.

REFERRAL TO A PHYSICIAN IS CRITICAL WHEN SERIOUS INJURY OCCURS TO THE HEAD, NECK, AND/OR SPINE. IF ANY OF THESE SITUATIONS EXISTS, IMMEDIATE REFERRAL IS CRITICAL:

COMMON INJURIES

Cervical Fractures and Dislocations: The mechanism of injury is any force that compresses, hyperflexes, hyperextends or rotates the neck beyond its normal range of motion. These movements can occur in any sport, most commonly in high contact sports such as diving, football, and gymnastics. Symptoms of cervical fracture or dislocation include:

Pain in the cervical region or back
Paralysis below the site of the fracture
Numbness, tingling, or burning sensation in the extremities
Muscle spasm and swelling
Decreased limb strength
Deformity in the cervical area
History of potential serious injury mechanism Any history of forced flexion or hyperextension, whiplash, forced rotation, or a hard head-on blow should alert the certified athletic trainer or coach to the possibility of a fracture or dislocation of the cervical vertebrae. Prevention of neck injuries depends a great deal on the athlete using safe and proper techniques. Neck strength and flexibility, as well as proper protective equipment, can also help prevent neck injuries. If a cervical injury is suspected, emergency medical help should be summoned quickly and the athlete should be stabilized. Never allow removal of a football helmet from a player with a possible neck injury. Also, remember that the athlete may not have neck pain with a neck injury.

Cervical Nerve Stretch Syndrome (Brachial Plexus): A cervical injury often seen in football is the stretching of one or more of the brachial plexus nerves. This nerve group begins in the neck and innervates the upper extremities. A common name for this injury is a "burner" or "stinger." When the brachial plexus becomes stretched or contused, a burning sensation is produced that extends from the point of injury into the arm. A temporary loss of function and some numbness of the arm may also result. The mechanism of injury is usually forced lateral movement of the head. An athlete who has suffered from cervical nerve stretch syndrome must be removed from competition and checked by a physician. Even though symptoms may disappear rapidly, an examination is needed to rule out a more serious injury. Medical clearance by the physician must be obtained before further athletic participation is permitted.

Back Injuries: The most common back injuries are strains, sprains and contusions. Sudden forceful twisting movement, a direct blow, improper mechanics, or a lack of flexibility often causes these injuries. If a serious injury is suspected, highly qualified medical personnel (emergency medical personnel) should transport the athlete for evaluation. Mishandling of a vertebral fracture can cause spinal cord damage, resulting in paralysis. Chronic back sprains and strains are common with individuals who have physically active lifestyles. There are very few movements in sports that do not use the muscles of the back in some degree of flexion, extension, lateral bending, or rotation. When the back muscles are injured, all of the movements that we have just mentioned will produce some degree of discomfort in the athlete. Even the maintenance of normal posture can be uncomfortable. Any injury to the back should be treated conservatively with protection, rest, and medical evaluation. The sports medicine team may use ice or heat.

Epistaxis (Nosebleed): Usually the result of a direct blow, a nosebleed is a common injury in athletics. Concussion is also a consideration when there is a direct blow to the nose area. There are many first aid methods, which can stop the bleeding quickly. One method is to have the athlete sit up, pinching the affected nostril(s) closed. A cold pack should be held over the nose. The athlete's head should be tilted forward. Tilting the head back will cause the blood to drip into the throat. Bleeding should stop within five minutes. If the bleeding does not stop after using this method, the use of a rolled-up sterile gauze pad can be used to plug the nose. The use of a cold pack should be reapplied.

Eyeball Contusion: All injuries to the eyes must be taken seriously. If the contusion is severe enough, vision could be affected permanently. Concussions are also a consideration when there is a sharp blow to the eye area. Fortunately, most eye contusions are minor. Capillary bleeding can produce discoloration, or the familiar "black eye." Despite swelling of tissue, the vision remains normal in minor contusions. Signs of more serious contusions include blurred, double or spotty vision, and pain. Blood in the eye is also an indication of serious injury. In such cases, both eyes should be patched to reduce movement, a cold pack should be applied, and the athlete should be taken for physician evaluation. Note: chemical cold packs should never be used around the eyes because of' the danger of the pack leaking.

Foreign Body in the Eye: When a foreign object gets into a person's eye, the natural response is to rub the eye. However, rubbing the eye can cause two problems. First, the object may scratch the eye, creating greater discomfort and damage. Second, the object may become embedded in the tissue of the eye, making it more difficult to remove. In removing a foreign body from the surface of the eye:

Dental Injuries: Most dental injuries and conditions can be painful or distracting, but generally do not require emergency treatment. Simple first aid measures should be adequate until the athlete can see a dentist. A dentist should be part of the sports medicine program. Reviewing first aid and emergency treatment procedures with the dentist in the off-season will help the athletic trainer and coach be prepared for common dental problems. A mouthpiece will reduce the incidence of concussion and dental injuries by cushioning the teeth from the shock of blows to the jaw. Mouthpieces are effective in reducing occurrence of dental injuries. Athletes in other contact sports, such as basketball and field hockey, could also benefit from wearing protective mouthguards. Mouthpieces should be comfortable so athletes will wear them. The coach or student athletic trainer should inspect them regularly for wear. Worn mouthpieces must be replaced immediately to help prevent dental injuries.

REHABILITATION

Sending an athlete back to competition before healing is complete leaves the player susceptible to further injury. The best way to determine when healing is complete is by the absence of pain during stressful activity and by the return of full range of motion and strength, power and endurance to the affected muscle group. Prior to the beginning of any rehabilitation exercise program, the athletic trainer should consult with the sports medicine team to establish an individual program tailored for that individual athlete and the specific injury to be rehabilitated. The following list of exercises can be used as rehabilitative or preventive exercises.

Range of Motion Exercises

Head and Neck

Flexion and Extension
Rotation
Lateral Bending
Protraction and Retraction
Elevation and Depression

Spine

Flexion and Extension
Lateral Bending
Rotation

Torso

Sagittal Plane Movement
Transverse Plane Movement
Frontal Plane Movement

Strengthening Exercises

Head/Neck

Shoulder Shrugs

Shoulder/Upper Arm

Non-gravity pendular movements
Shoulder wheel
Towel routine
Swimming
Light throwing
Rowing
Push-ups
Military press

Back

Pelvis Tilt (prone and supine)
Back Flexion Exercises
Back Extension Exercises
Included in any rehabilitation protocol is the following:

PREVENTIVE/SUPPORTIVE TECHNIQUES

Taping and wrapping techniques utilized for prevention and support of head, neck and spine are minimal. Listed next are preventive/supportive techniques for the thorax and low back, which provide support to the head, neck and spine.

Taping Techniques for the Thorax and Low Back

Rib
Low Back

PROTECTIVE DEVICES

The use of protective devices is beneficial, if they are properly selected, used in the appropriate setting, correctly fitted, properly applied, and used within the rules and guidelines of the specific sport. Consultation with an equipment specialist and certified athletic trainer is highly encouraged. Listed below are various protective devices that are commercially available to use as an adjunct or replacement to taping or wrapping procedures.

Head
Chin straps: solid and flexible
Ear muffs
Ear plugs
Eyeshields Guards and Goggles
Face Shields and Masks - must meet National Operating Committee on the Safety of Athletic Equipment (NOCSAE) regulations.
Helmet - Football, Batting, Lacrosse, Cycling and Ice Hockey must meet NOCSAE Regulations.
Head Gear: boxing, fencing headgear, hockey, wrestling
Intra-oral Tooth Protector
Mouth Pieces - Stock, mouth formed, custom made (single, double, lip cover)
Nose guards
Nose plugs
Polycarbonate Eyewear - lightweight, scratch and impact resistant
Rubber Caps for football helmets
Ski mask
Sun Glasses
Throat guard - attaches to face protector

Neck
Cervical collars
Neck roll
Neck collar
Neck straps
Throat protector

MUSCULOSKELETAL CONDITIONS/DISORDERS

Listed below are conditions/disorders that affect the head, neck, and/or spine. Define and review these conditions using a medical dictionary.
Head/Face

  • Cauliflower Ear
  • Conjunctivitis (pink eye)
  • Corneal Abrasion
  • Deviated Septum
  • Gingivitis
  • Keratitis
  • Orbital Blowout Fracture
  • Otitis Externa
  • Otitis Media
  • Pericoronitis
  • Peridontitis
  • Stye
  • Temporomandibular Joint Dysfunction
  • Tooth Fracture/Dislocation
    • Spinal Column
  • Nerve Root Compression
  • Spinal Cord Injury
  • Spondylitis
  • Spondylosis
  • Spondylolysis
  • Spondylolisthesis
    • References

    American Academy of Orthopaedic Surgeons (1991). Athletic Training and Sports Medicine (2nd ed.). Park Ridge, IL: AAOS.

    American Red Cross (1996) Responding to Emergencies (2nd ed.). St. Louis: Mosby Lifeline.

    Anderson M. and Hall S. (1995) Sports Injury Management Baltimore: Williams and Wilkins.

    Arnheim D. & Prentice, W. (1997) Principles of Athletic Training (9th ed.). St. Louis: McGraw-Hill.

    Booher, J. & Thibodeau, G. (1994). Athletic Injury Assessment. St. Louis: Times Mirror/Mosby College.

    Cantu, R. (1986) Guidelines for returning to contact sports after a cerebral concussion. Physician and SportsMedicine 14(10: 75

    Cantu, R.C. (1994) Minor Head Injuries in Sports: Proceeding of Mild Brian Injury in Sports Summit Washington, D.C., 12-16

    Daniels L & Worthingham C (1986) Muscle Testing: Techniques of Manual Examination. Philadelphia: W.B. Saunders, 5th ed., 1986.

    Donnelly, J. (1990) Living Anatomy Champaign, Human Kinetics

    Gallaspy J. and May D. (1995) Signs and Symptoms of Athletic Injuries St. Louis: Mosby.

    Gennarelli, T (1991) Cerebral concussions and diffuse brain injuriesAthletic injuries to the head, neck, and face St. Louis: Mosby

    Hoppenfield, S. (1976) Physical Examination of the Spine and Extremities New York: Appleton, Century, and Crofts.

    Kissane, J. (1990) Anderson's Pathology (vol 1, 9th ed.) St. Louis: Mosby.

    Mellion, M., Walsh, W. & Shelton, G. (1992) The Team Physician's Handbook. Philadelphia: Hanley & Belfus.

    Norkin & White (1985) Measurement of Joint Motion: A Guide to Goniometry Philadelphia: F.A. Davis Co..

    Parcel, G. (1990) Basic Emergency Care of the Sick and Injured. (4th ed.) St. Louis: Mosby.

    Porth, C. (1994) Pathophysiology. Philadelphia: Lippincott.

    Prentice, W. (1994) Rehabiliation Techniques in Sports Medicine. St. Louis: Mosby.

    Stone R. & Stone J. (1997) Atlas of Skeletal Muscles (2nd ed.) Dubuque: McGraw Hill.

    Tu, HK, Davis, LF, & Nique, TA. (1990) Maxillofacial injuriesThe team physician's handbook Philadeplhia: Hanley and Belfus

    Vegso, J & Torg, J (1991) Field evaluation and management of intracranial injuries Athletic injuries to the head, neck, and face St. Louis: Mosby

    Williams, P. & Warwick, R. (1980) Gray's Anatomy (36th ed.) Philadelphia: W.B. Saunders.

    Wright K. & Whitehill W. (1996) The Comprehensive Manual of Taping and Wrapping Techniques Gardner: Cramer Products

    Review Questions - Chapter 10

    Completion:

    1. The first seven vertebrae are known as the __________ _________.

    2. The brain is protected from trauma by the bones of the __________.

    3. A __________ is defined as a shaking of the brain.

    4. __________ is commonly referred to as a nosebleed.

    5. When the brachial plexus becomes stretched or contused, a _______ ________ is felt.

    6. Conjunctivitis is commonly referred to as __________ __________.

    7. When evaluating a possible neck fracture __________ is not always a factor.

    8. An athlete with a head injury should be monitored at least __________ hours and carefully evaluated regularly for at least __________ week.

    9. A person does not have to suffer a loss of __________ to have suffered a concussion.

    10. Pressure on the brain will affect the __________ __________ system, causing various reactions of the body.

    Short Answer:

    1. Name the three primary categories of intracranial hemorrhaging:
     

    2. List all components of a comprehensive rehabilitation program:
     

    3. Identify and define the three types of concussions.
     

    4. What are the symptoms of a cervical fracture or dislocation?
     
     


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