Working Diagnosis:
ASIA class C spinal cord injury with C4/5 fracture dislocation with C5 vertebral body burst fracture.

Treatment:
Taken to the operating room with neurosurgery a few hours following the injury.

Operative Management:
Stage I
1. C4-5 and C5-6 anterior cervical discectomy
2. C5 100% complete corpectomy
3. Open reduction of C4 on C5 fracture dislocation
4. C4-C6 anterior cervical arthrodesis with 29 mm and Niko strut
5. C4-6 anterior cervical instrumentation with 34 mm extend plate and screws
6. Use of intraoperative microscope for microdissection
7. Use of intraoperative fluoroscopy

Stage II
1. C4-C6 posterior lateral instrumentation with ellipse screws and rods
2. C4-6 posterior lateral arthrodesis using 20 cc cancellous chips and 30 cc DBM putty
3. Left C4-5 foraminotomy and partial facetectomy for open reduction of locked facet

Outcome:
He was taken to surgery a few hours after the injury occurred. He remained in the hospital for 5 days working with physical and occupational therapy prior to discharge to a rehab facility. He continued to regain his strength and sensation and was able to run onto the field with his teammates in his Aspen collar without other assistance one month following the injury. He has continued progressing and has overall had a promising recovery from a significant injury.

Author's Comments:
This case highlights the importance of having a well-defined Emergency Action Plan (EAP) and discussing key points of this plan with staff from both home and away programs during the pregame medical timeout. Identifying who will take charge of certain high-risk situations such as cardiac arrest, airway management, and how spinal cord injuries will be managed helps maintain order and allows for rapid assessment and treatment of the athletes without compromising athlete safety. In this case, the athlete was rapidly assessed on the field and the appropriate emergency action plan was initiated. The athlete was then transported following spine boarding by EMS to the emergency room. He was also accompanied by a home team physician familiar with the receiving hospital system as well as members of the away team medical staff.

Editor's Comments:
The importance of an EAP as well as being able to technically initiate proper cervical spine precautions is highlighted in this case. It is important to consider that a player who is down may be positioned awkwardly or the location on the field of play may provide additional challenge to delivering safe and expedient care. Prepare your team to adapt techniques to these situations. Additionally, the case exemplifies the importance of the multidisciplinary team for treatment as well as return to play decisions.

References:
Chan CW, Eng JJ, Tator CH, Krassioukov A; Spinal Cord Injury Research Evidence Team. Epidemiology of sport-related spinal cord injuries: A systematic review. J Spinal Cord Med. 2016 May;39(3):255-64. Epub 2016 Feb 18.

Rihn JA, Anderson DT, Lamb K, Deluca PF, Bata A, Marchetto PA, Neves N, Vaccaro AR. Cervical spine injuries in American football. Sports Med. 2009;39(9):697-708. PMID: 19691361

Weir, Tristan et al. "On-Field Evaluation and Transport of the Injured Athlete." Spine Injuries in Athletes. 1st ed. American Academy of Orthopedic Surgeons, 2017. 32-39.

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