title: Maintaining neutral sagittal cervical alignment after football helmet removal during emergency spine injury management.
abstract: METHODS
  Descriptive laboratory study.
  
  
  OBJECTIVE
  To determine whether the placement of padding beneath the occiput after helmet removal is an effective intervention to maintain neutral sagittal cervical spine alignment in a position comparable with the helmeted condition.
  
  
  BACKGROUND
  Current on-field recommendations for managing football athletes with suspected cervical spine injuries call for face mask removal, rather than helmet removal, because the combination of helmet and shoulder pads has been shown to maintain neutral cervical alignment. Therefore, in cases when helmet removal is required, recommendations also call for shoulder pad removal. Because removal of equipment causes motion, any technique that postpones the need to remove the shoulder pads would reduce prehospital motion.
  
  
  METHODS
  Four lateral radiographs of 20 male participants were obtained (age = 23.6 ± 2.7 years). Radiographs of participants wearing shoulder pads and helmet were first obtained. The helmet was removed and radiographs of participants with occipital padding were obtained immediately and 20 minutes later and finally without occipital padding. Cobb angle measurements for C2-C6 vertebral segments were determined by an orthopedic spine surgeon blinded to the study's purpose. Intraobserver reliability was determined using intraclass coefficient analysis. Measurements were analyzed using a 1×4 repeated-measures analysis of variance and post hoc pairwise comparisons with Bonferroni correction.
  
  
  RESULTS
  Intraobserver analysis showed excellent reliability (intraclass correlation = 1.0; 95% confidence interval [CI], 0.999-1.0). Repeated-measures analysis of variance detected significant differences (F(3,17) = 13.34; P < 0.001). Pairwise comparisons revealed no differences in cervical alignment (all measurements reported reflect lordosis) when comparing the baseline helmeted condition (10.1° ± 8.7°; 95% CI, 6.0-14.1) with the padded conditions. Measurements taken after removal of occipital padding (14.4° ± 8.1°; 95% CI, 10.6-18.2) demonstrated a significant increase in cervical lordosis compared with the immediate padded measurement (9.5° ± 6.9°; 95% CI, 6.3-12.7; P = 0.011) and the 20-minute padded measurement (6.5° ± 6.8°; 95% CI, 3.4-9.7; P < 0.001).
  
  
  CONCLUSIONS
  Although face mask removal remains the standard, if it becomes necessary to remove the football helmet in the field, occipital padding (along with full body/head immobilization techniques) may be used to limit cervical lordosis, allowing safe delay of shoulder pad removal.
authors.affiliation: New Hampshire Musculoskeletal Institute, Manchester, NH 03101, USA. Laura@nhmi.net
authors.forename: Laura C
authors.initials: LC
authors.lastname: Decoster
authors.forename: Matthew F
authors.initials: MF
authors.lastname: Burns
authors.forename: Erik E
authors.initials: EE
authors.lastname: Swartz
authors.forename: Dinakar S
authors.initials: DS
authors.lastname: Murthi
authors.forename: Adam E
authors.initials: AE
authors.lastname: Hernandez
authors.forename: James C
authors.initials: JC
authors.lastname: Vailas
authors.forename: Linda L
authors.initials: LL
authors.lastname: Isham
mesh_terms: D000328:Adult; D002574:Cervical Vertebrae / Q000000981:diagnostic imaging / Q000293:injuries*; D005538:Football / Q000293:injuries*; D006260:Head Protective Devices; D006801:Humans; D007103:Immobilization / Q000379:methods*; D008297:Male; D011859:Radiography; D013124:Spinal Injuries / Q000000981:diagnostic imaging / Q000628:therapy*