According to the National Spinal Cord Injury Statistical Center, approximately 12,000 new cases of spinal cord injuries occur each year, with sports-related events causing approximately 7.6% of the injuries.
Historically, much attention has been placed on football as a high-risk sport, but during the past decade, ice hockey, diving, and other sports have drawn their share of attention. Overall, the number of catastrophic cervical spine injuries resulting from contact sports has been decreasing since the latter part of the 1970s, primarily because of modifications in playing habits and adoption of rules to decrease the potential for injury. 
Although the incidence of catastrophic cervical spine injuries is lower in association with football compared with gymnastics and ice hockey, football is still associated with the largest number of overall catastrophic cervical spine injuries because of the large numbers of participating athletes. From a historical perspective, between 1945 and 1994, nearly 85% of all football-related fatalities resulted from head and cervical spine injuries. The greatest numbers of those injuries occurred between 1965 and 1974, with a dramatic decrease during the next 2 decades.4 Since the 1970s, nonfatal cervical spine injuries have also been decreasing, largely because of laws prohibiting unsafe defensive plays, such as spearing (ie, use of the vertex of the helmet as a point of contact in tackling).
Although football-related spine injuries seem to be more highly publicized in the North American press, Canadian ice hockey is associated with a greater incidence of cervical spine injuries compared with American football. Most ice hockey injuries result from checking (striking an opponent from behind), which can result in the attacked player sliding and striking his or her head against the surrounding ice rink.
Initial Evaluation
On-Field Assessment Although the vast majority of sports-related cervical spine injuries are sprains, every patient with a suspected injury requires a complete physical examination of the cervical spine (Fig. 1).
Figure 1 On-field assessment clinical algorithm.
Every athlete should be assessed as though an unstable cervical spine injury is present. The head and spine should be immobilized immediately, and a standard sequence for treating all trauma patients should begin with an assessment of airway, breathing, circulation, disability, and neurological status. Careful attention should be directed to any signs of head trauma, complaints of headaches, or changes in mental status.
Considering that the vast majority of patients are conscious, assessment should focus on the presence of spinal tenderness, restricted range of motion, and any neurological deficits before the athletes are sent to the sidelines. Athletes with any of the aforementioned symptoms should be immobilized on a backboard and transferred to a hospital with protective gear (helmets and shoulder pads) in place for further evaluation.
Cervical Immobilization and Patient Transfer
Athletes with neck tenderness, limitations in cervical motion, or evidence of neurological symptoms should have the cervical spine immobilized in a neutral alignment with spine precautions.
Cervical spine immobilization in the supine patient should be performed carefully, avoiding any traction and distraction. While the physician cups the occiput with his or her hands, the mastoid processes should be held bilaterally by use of the fingertips, with gradual alignment of the cervical spine into a neutral position.11 The reasons for maintaining a neutral alignment have been evaluated indirectly by anatomic and biomechanical studies of cervical spine fractures. 11,12 When placed in a neutral position, the cervical spinal canal has less risk of canal occlusion compared with positions in extension.12 Although the goal is to keep the spine in a neutral position, manual adjustments should not be performed if the patient reports increasing pain and/or spasms or if a change in the neurological examination findings is noted during attempts at placing the cervical spine in neutral position.13 A 2-piece cervical collar should then be applied. These patients can be stabilized in a position of comfort until transfer to the nearest hospital. Patients should be immobilized on a long spine board during the transfer process.
This portion of the on-field management of spinal cord injury patients should proceed carefully with multiple assistants. For athletes in the prone position, the primary survey should begin before moving the patient. If the patient is helmeted, one person should stabilize the cervical spine by placing one hand on each side of the helmet while another examines the patient.