Environmental Laws & Compliance Chapter Summary

LIVING WITH THE EARTH
CHAPTER 13
ENVIRONMENTAL LAWS
& COMPLIANCE
Page
Objectives for this Chapter
A student reading this chapter will be able to:
1. Discuss how a law is made and describe the system of
environmental laws.
2. List and describe the major components of the major federal
environmental laws including: RCRA, CERCLA, EPCRA,SARA
Title III, Pollution Prevention Act, CAA, CWA, SDWA,
stormwater regulations, pesticide regulations, and underground
storage tank regulations.
3. Describe and discuss the major components of environmental

compliance.
The Making of a Law
Bill is first introduced into house and senate;
Referred to subcommittee for review and support;
90% fail at this level
Recommended bills are brought forward for hearings and
comment;
Committee meets to mark up (discuss) bill and vote on it;
If still found favorable, bill is sent to full chamber;
The Making of a Law (cont.)
The bill is then sent to the Rules committee of House where a
time limit is set for debate and other rules are set.
The bill is also sent to the Senate where unrelated riders may be
attached to a popular bill.
House and Senate usually make changes in the bill before
passing, and the different versions are sent to a conference
committee for resolution.
BILL
SENATE

HOUSE
Rules committee
BILL
BILL
Senate version
House version
CONFERENCE COMMITTEE
The Making of a Law (cont.)
If a resolution is accepted and the same version is approved by
both House and Senate, the bill moves forward to the President
who may sign or veto it.
Congress can override a veto by 2/3rds majority, but this is
difficult to do.
CONFERENCE COMMITTEE

BILL
SENATE
HOUSE
If both Chambers approve final version, the bill is sent forward
to the president
Veto?
Sign?
PRESIDENT
Page
Common Themes Among Environmental Laws
EIGHT GENERIC COMPLIANCE OBLIGATIONS
1. Notification requirements
2. Discharge or waste controls
3. Process controls and pollution prevention
4. Product controls
5. Regulation of activities

6. Safe transportation requirements
7. Response and remediation requirements
8. Compensation requirements
Environmental Laws are Part of a System
ENVIRONMENTAL LAW ENCOMPASSES ALL THE
ENVIRONMENTAL PROTECTION THAT COMES FROM:
U.S. CONSTITUTION AND STATE CONSTITUTIONS
FEDERAL AND STATE STATUTES AND LOCAL
ORDINANCES
REGULATIONS PUBLISHED BY FEDERAL, STATE AND
LOCAL AGENCIES
PRESIDENTIAL EXECUTIVE ORDERS
COURT DECISIONS INTERPRETING THESE LAWS
THE COMMON LAW
Executive Orders
These are orders issued by the president and require federal
facilities to comply and provide leadership in protecting the
environment. More than 18 executive orders have been issued
since 1970.

Common Law
A body of rules and principles that pertain to the government
and the security of persons and property.
Basic rules originally developed in England and then brought to
American Colonies.
Under Common Law
Tort
A private wrong or wrongful act for which the injured party can
bring forth a a civil action.
Nuisance
Trespass
Negligence
Resource Conservation and Recovery Act (RCRA)

The Resource Conservation and Recovery Act (RCRA) was
passed as an amendment in 1976 to the SWDA originally
promulgated in 1965.
There are three subchapters. Subchapter C establishes a system
for controlling hazardous waste from the point of generation to
the ultimate disposal.
RCRA: Two main
concepts are addressed
(1) the dangers posed to human health and the environment by
improper waste disposal and
(2) the conservation of valuable energy and resources. (Title 40
Part 260 et seq. of the Code of Federal Regulations contains the
RCRA regulations)
Defining Waste Under RCRA
Hazardous waste
LISTED: Listed in the CFR,Title 40, Part 261
CHARACTERISTIC: Not listed but meeting certain criteria for

ignitability, corrosivity, reactivity, or toxicity.
Hazardous Waste
Generator Criteria
More than 100 kg
Less than 100 kg
Large Quantity Generator
Small Quantity Generator
Conditionally Exempt Generator
More than 1000 kg

Page
Tracking Hazardous Waste (Fig 13.1)
Tracking is accomplished by using a paper trail created by
shipping manifests called the Uniform Hazardous Waste
Manifest.
Other Requirements Under RCRA
Accurate record keeping
Proper labeling, shipping
Comprehensive Environmental Responsibility, Compensation
and Liability Act (CERCLA) or (Superfund)

Steps in Superfund: Find, Prioritize, and Clean
Identification of sites contaminated with hazardous substances.
Setting priorities for cleanup is based on the National Oil and
Hazardous Substance Pollution Contingency Plan (National
Contingency Plan; 40 Code of Federal Regulations part 300).
Steps in Superfund: Find, Prioritize, and Clean
Identification of those parties responsible for site
contamination. “Potentially responsible parties” and
“responsible parties” identified by EPA and state agencies can
be required to finance cleanup activities, either directly or
through reimbursement of federal Superfund expenditures.
Emergency Planning and Community Right-to-Know (SARA
Title III)
In response to the Bhopal, India disaster, US federal, state, and
local governments created a variety of laws to improve accident
prevention and emergency response planning activities by
chemical-handling facilities and local governments.

Emergency Planning and Community Right-to-Know (SARA
Title III)
"Right-to-Know" laws increased public access to information
about the storage and use of hazardous chemicals. MSDS
(Material Safety Data Sheets) on hazardous chemicals in the
workplace must be made available to employees in the
workplace.
Transportation of Hazardous Materials
DOT regulates the transportation of hazardous wastes and
materials.
Packaging, labeling and construction requirements are defined
under HTMA and must now meet United Nations UN)
recommendations.
Pollution Prevention and Improved Waste Management
Programs
The Pollution Prevention
Act of 1990

Source reduction" is the deliberate decrease in the amounts of
hazardous substances which enter the environment via
recycling, treatment or disposal.”
Pollution Prevention and Improved Waste Management
Programs
Source reduction must be reported by facilities generating over
a certain amount of toxic emissions during the previous
calendar year.
Toxic Substances Control Act (TSCA)
TSCA mandates that manufacturers of chemicals develop safety
and health data on chemicals and mixtures.
Requires the USEPA to regulate chemical substances and
mixtures that present an unreasonable risk of injury to health
and the environment.
PCBs, Asbestos, CFCs, Dioxins
Regulation of Underground Storage Tanks
The federal UST law is a component of the Hazardous and Solid

Waste Amendments of 1984 (HSWA) under the Resource
Conservation and Recovery Act (RCRA).
A UST is any tank or underground piping connected to the tank
that has a minimum of 10% of its volume located underground
(Fig 13-4).
Regulation of Underground Storage Tanks
must have spill and overfill protection;
new USTs and associated piping must have leak detection
provisions;
new petroleum USTs may continue to be single-lined (primary
containment only), whereas USTs containing other hazardous
substances must be double-lined .
Pesticide Regulation
The basic national framework for pesticide control is provided
by the Federal Insecticide, Fungicide, and Rodenticide Act
(FIFRA)
The USEPA uses the authority under FIFRA to collect
information necessary to register and control the "active
ingredients" in pesticides, while state and local agencies control
the registration and actual use of the pesticides themselves.

Air Quality Control
National framework for protecting air quality was created by the
Federal Clean Air Act (CAA), and amendments.
1990 Amendments to
Clean Air Act
Title I—Provisions for Attainment and Maintenance of the
NAAQS.
Emissions standards for new and modified sources of air
contaminants are set by the USEPA.
Other Related Programs Established Under Recent Air Quality
Regulations:
Ozone, Particulates
1990 Amendments to
Clean Air Act

Title II—Provisions Relating to Mobile Sources.
Vehicle Emissions Requirements
Inspection/Maintenance Requirements
Reformulated Gasoline Requirement
1990 Amendments to
Clean Air Act
Title III—Hazardous Air Pollutants
A list of 189 toxic air pollutants for which emissions must be
reduced is included in this law.
Area-wide control strategies must be formulated by the USEPA
by the year 2000
1990 Amendments to
Clean Air Act
Title IV regulates the sources of acid deposition.
Emissions of SO2 and NOx from fossil fuel-fired electric utility
plants are the leading cause of acid deposition.

1990 Amendments to
Clean Air Act
Title V—Permits.
For the first time, a nationwide program of air emissions
permits had been established by the 1990 amendments.
1990 Amendments to
Clean Air Act
Title VI—Stratospheric Ozone Protection.
A complete production phaseout of ozone-depleting chemicals
(especially CFCs and halons) is required by Title VI.

CFCs
Chlorine
Ozone
1990 Amendments to
Clean Air Act
Title VII—Provisions Relating to Enforcement.
The Amendments contain a broad array of provisions which
brings the law up to date to with the other major environmental
statutes and thus makes the law more readily enforceable.

Water Quality Control
Goals of the Clean Water Act are to eliminate the discharge of
pollutants into surface waters and to achieve water quality
which "provides for the protection and propagation of fish,
shellfish and wildlife," and "for recreation in and on the water.”
Water Quality Control
The second major focus is that of water quality-based controls.
The discharger applies the required technology-based standards
to the facility through application of a comprehensive
permitting scheme known as the National Pollutant Discharge
Elimination System (NPDES).
Stormwater
The runoff and pollutants enter storm drains and are then
discharged into receiving waters.
November 16, 1990, the USEPA published a final rule in the
Federal Register (55 CFR 47990) that contains permit

requirements for stormwater discharges.
Stormwater
Oil and Hazardous Substance Spill and Reporting Requirements.
CWA contains specific provisions regulating the handling of oil
and hazardous substances.
Compliance Strategies
There are criminal penalties for non-compliance with
environmental health and safety programs.
The most effective protection against aggressive enforcement
and other efforts to assess liability is aggressive compliance.
Environmental law compliance is a responsibility of everyone.
Demonstrate a concern for compliance by providing appropriate
education and training.

Prevention of violations and minimization of liability through
aggressive implementations of environmental objectives.
Periodic "audits" to verify compliance and identify areas that
can be improved upon.
Trends in Regulatory Compliance
The USEPA has developed target strategies, based on the
quantity and severity of toxic materials discharged, emitted or
disposed of by a facility as reported under the Community-
Right-to-Know Act.
The USEPA will likely focus on repeated violations and
evidence of suspicious self-reporting.
a
a
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ASSESSING HUMAN RISK - Moore
LIVING WITH THE EARTH
CHAPTER 12
ASSESSING HUMAN RISK
1. Define risk and discuss the uncertainties associated with
environmental risk.
2. Discuss the characteristics of risk.
3. Define risk analysis and describe the tools used to perform
risk analysis.
4. Explain the concepts of dose, extrapolation, and acceptable

daily intakes (ADI).
5. List and discuss the process of risk analysis including hazard
identification, dose-response assessment, exposure assessment,
and risk characterization.
6. Outline and discuss the major components of risk
management and risk communication.
INTRODUCTION
Risk can be of a financial, personal, social, health, and
environmental nature.
The word “Risk” describes a range of activities, situations and
concepts, from drinking a glass of red wine daily to skydiving
and extreme skiing, to chemical exposure.

INTRODUCTION
Risk is commonly used to describe types of people or situations.
Risk-taker
Risk-free
A comparison of some of life’s risks are shown in Figure 1.
Fig.
12-1
INTRODUCTION
People accept certain risks because they enjoy the benefit they
receive from the behavior or activity.
Some people seek out extraordinarily high levels of risk,
engaging in skydiving, bungee jumping, rock and ice climbing
and other extreme sports (Fig. 12-2).

Fig. 12-2
Some risks are voluntary
Environmental Risk
A central factor of environmental risk is that it is usually
involuntary.
People do not choose to ingest chemical pollutants such as
pesticides or industrial solvents in their food and water or
undergo workplace exposures to dangerous chemicals.
Risk Characteristics
Risk can be defined as the likelihood of an unwanted occurrence
coupled with an element of uncertainty about when the risk
might occur.

Risk Characteristics
Many environmental risks have the characteristics of unknown
and dread, they cause people anxiety and concern about the
consequences of exposure to the risk.
Development of Risk Analysis
Risk analysis is the process of reviewing information on a
hazard to characterize that hazard’s impact on human health.
Risk analysis allows public groups to make informed decisions
and weigh the risks and benefits in their community.
The Process of Risk Analysis
A review of scientific studies
An understanding of the properties of a risk,

An assessment of levels of human exposure and dose
A conclusion about the likelihood, impact and extent of a risk.
Tools of Risk Analysis
Risk analysis employs several scientific disciplines in its goal
to characterize a risk (Fig. 12.3).
Fig.
12-3
Tools of Risk Analysis
Toxicology
Toxicologists study chemicals to determine their physiological
and health impacts on humans.

Regulatory toxicology aims at guarding the public from
dangerous chemical exposures.
Toxicology
Studies can delineate both the lower and upper limits of a
chemicals potency
Endpoints
NOEL,
NOAEL,
LOAEL
Dose
Toxicologists use different doses to elicit different animal
responses.
Animals receiving doses above the threshold amount will begin
to show adverse effects and some animals will die (Fig. 12.4).

Fig.
12-4
Dose
LD50
ED50
Maximum Tolerated Dose (MTD)
Exposure Studies
Acute, two weeks
Subchronic, 5-90 days
Long term or Chronic, up to two years

Extrapolation
In risk analysis, the term extrapolation refers to the use of
animal data to predict human response to chemical exposure.
Extrapolation
The results from high-dose, short duration studies are used to
extrapolate human response to the longer term, lower level
exposures we generally receive.
Acceptable Daily Intakes
The purpose of toxicology studies is often to establish an
acceptable level of exposure or dose of a substance that is
considered “safe”.
This level, which poses little risk, is termed the acceptable daily
intake (ADI).

Epidemiology
Epidemiology is the study of the distribution and determinants
of disease frequency in the human population.
Epidemiology
Study Types
Cross-sectional
Cohort
Case Control
Clinical Trials
In clinical drug trials, individuals volunteer to be exposed to a
substance or to ingest a drug, and are assessed for their health
response.

The Process of Risk Analysis
The process of risk analysis has four steps (Fig. 12-5):
hazard identification;
dose-response evaluation;
exposure assessment; and
risk characterization.
Fig. 12-5
Hazard Identification
The initial step in risk analysis, hazard identification, involves
identifying chemicals that present a risk to human health.
This step entails performing a qualitative assessment of a
chemical’s potential for negative health impacts on humans.

Dose-Response Assessment
The next step, dose-response evaluation, provides a quantitative
view of the risk.
This step also involves a review of scientific studies and data.
In this case, the magnitude of response is correlated with the
dose (Fig, 12-6).
Fig.
12-6
Exposure Assessment
The purpose of the exposure assessment is to measure or
estimate a person’s level of exposure.
Exposure is different from dose in that exposure refers to the
amount of a substance in the environment, while dose is the
level of a substance actually taken in by an organism.

Exposure Assessment
Dose can be influenced by many factors, such as how the
substance enters the body, whether absorbed through the skin,
ingested with food, or inhaled (Fig 12-7).
Fig.12-7
Risk Characterization
Risk characterization provides a picture of the risk that
addresses its severity, likelihood, and consequences.
The risk characterization includes an estimate of the negative
effects to exposed individuals, such as the number of cases of
cancer or deaths per 100,000 people (Fig. 12-8).

Fig. 12-8
Limitations of Risk Analysis
Limitations of risk analysis include uncertainty, variability, and
effect of multiple exposures.
Despite these limitations, risk assessment is still a valuable tool
for exploring and understanding the risks of the modern world.
Risk Management
Risk management involves merging the results of risk analysis
with various social factors, such as socioeconomic conditions,
political pressures, and economic concerns (Fig. 12-9).

Fig. 12-9
Risk Management
Three avenues of risk management are:
educational;
economic; and
regulatory
Risk Management
Risk management generally involves comparing the risk to some
other factor such as the cost, or reducing the risk or the benefit
gained from the risk (Fig. 12-10).

Fig.
12-10
Risk Management
The “best” course of action is not always the one that reduces
the most risk, but rather, is the most economically feasible
option, reducing the greatest amount of risk per dollar spent.
Risk Communication
The goal of risk communication is to effectively relay risk
information developed through risk analysis to various
interested groups.

Risk Communication
Methods of risk communication include public hearings,
emergency hotlines, information pamphlets.
Risk Communication
Risk communication can be challenging, as it requires
addressing people’s different risk perceptions, biases, scientific
knowledge, educational backgrounds, even race and gender.
Risk Communication
Translating technical terminology into comprehensible
terminology can increase risk communication (Fig. 12-11).

Fig. 12-11
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at: https://www.researchgate.net/publication/277961886
Cervical Spine Injuries in Sports
Article · January 2015
DOI: 10.5005/jp-journals-10017-1057
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Lindsay T Kleeman et al
58
DOJ
1Lindsay T Kleeman MD, 2Michael A Gallizzi MD MS, 3Daniel
J Blizzard MD MS, 4Melissa M Erickson MD
ABSTRACT
Injuries to the cervical spine in athletes are rare but potentially
devastating outcomes resulting from involvement in sports
activities. New rules and regulations implemented by national
sports organizations have helped to decrease the rate of
cervical spine and spinal cord injuries sustained by athletes.
A basic understanding of cervical spine anatomy, physical
examination and spine precautions is necessary for any physi-
cian evaluating athletes on the field to determine if transfer to
higher level of care is needed. It is particularly important to
know the syste matic protocol for spine immobilization, neuro-

logic exam and helmet removal in a patient with a suspected
cervical spine injury. While cervical strain is the most common
cervical spine injury, physicians should be familiar with the
presentation for other injuries, such as Burner’s syndrome
(Stinger), cervical disk herniation, transient quadriplegia and
cervical spine fractures or dislocations. Special consideration
is needed when evaluating patients with Down syndrome as
they are at higher risk for atlantoaxial instability. Determination
of when an athlete can return to play is patient-specific with
early return to play allowed only in a completely asymptomatic
patient.
Keywords: Athlete, Cervical, Cervical spine, Sports, Sports
injury, Management.
Kleeman LT, Gallizzi MA, Blizzard DJ, Erickson MM. Cervical
Spine Injuries in Sports. The Duke Orthop J 2015;5(1):58-62.
Source of support: Nil
Conflict of interest: None
InTRoDuCTIon
Athletic injuries account for approximately 10% of all
cervical spine injuries in the United States.1 Cervical spine
injury has been reported in football, soccer, wrestling,
basketball, trampoline, sledding, baseball, hockey, water
sports, diving and rugby with the majority occurring
in collision sports.2,3 Injuries range from transient
radiculopathies to permanent, complete spinal cord
injury. Here, we review the incidence and management
of a variety of cervical spine injuries that can be seen
among athletes.
Review ARticle

1-4Department of Orthopaedic Surgery, Duke University
Medical
Center, Durham, NC, USA
Corresponding Author: Lindsay T Kleeman, Department of
Orthopaedic Surgery, Duke University Medical Center, Box
3000
Durham, NC 27710, USA, Phone: 919-684-3170, e-mail:
lindsay.
[email protected]
10.5005/jp-journals-10017-1057
InCIDEnCE
The sports associated with the highest rates of spine
injuries include football, ice hockey, wrestling, driving,
skiing, snowboarding, rugby, cheerleading and baseball.4
The majority of these spine injuries involve axial forced
applied to the head with the head in slight flexion.
Football has been associated with the highest number of
spine injuries; however, the actual rate of spine injuries
in higher in gymnastics and hockey.
Rates of devastating spine injuries in contact sports,
particularly football, have decreased dramatically due
to improved equipment, medical care, rule changes,
and coaching. In 1976, the National Collegiate Athletic
Association (NCAA) banned the intentional striking of
an opponent with the crown of the helmet (spearing) in
football. In 1978, the National Operating Committee of
Safety of Athletic Equipment (NOCSAE) implemented
the football helmet standard for collegiate football which
was subsequently implemented at the high school level
2 years later. As of 1976, the rate of quadriplegia was

2.24/100,000 players in high school and 10.66/100,000
in college.5 From 1989 to 2002, the overall incidence
of quadriplegia dropped to 0.82/100,000 at the college
level and 0.5/100,000 at the high school level. While not
completely understood, the discrepancy in quadriplegia
incidence is likely due to bigger, faster and stronger
players at the college level. Despite the rule changes,
spear-tackling continues to be the most common cause of
quadriplegia with defensive players being at the greatest
risk for this injury. There is a continued focused effort in
player education on proper tackling technique to further
reduce incidence in cervical quadriplegia.6
Ice hockey has one of the highest rates of cervical
spine injuries. The majority injuries occur at the C5-7
levels and result from body-checking when the head
is tilted downward.4 During the 1980s, the incidence of
spine injuries in ice hockey significantly increased as
checking became a more accepted part of the game. In
1994, the International Ice Hockey Federation established
that checking or pushing from behind qualifies as a
penalty. This rule change has led to lower spine injury
rates. Further, changes including padded boards are
being assessed to help further decrease the rate of spine
injury among ice hockey players.
Wrestling has the highest rate of catastrophic injuries
to cervical spine.4 The rate of catastrophic injury is around
The Duke Orthopaedic Journal, July 2014-June 2015;5(1):58-62
59

DOJ
1 per 100,000 high school and collegiate wrestlers, most
commonly occurring with a takedown of an opponent.
Injury prevention is currently focused on education
by coaches and referees on safe rolling techniques
and discouragement from ‘slams,’ or takedowns with
excessive force.
Though there remains potential for improvement in
equipment in many other sports, the primary focus of
cervical spine injury prevention remains legislation of
new rules or amendments to current rules and education
on proper playing technique.
AnAToMy AnD MEChAnICS
The cervical spine consists of seven cervical vertebrae.
The occiput, atlas and axis comprise the ‘upper cervical
spine’. The atlanto-occipital articulation accounts for
50% of cervical flexion-extension motion. The atlanto-
axial articulation accounts for 50% of cervical rotation
motion. The ‘lower cervical spine’ includes C3 through
C7. Progressing down the spinal column, the diameter
of the bony canal gradually narrows as the diameter of
the spinal cord widens, thus reducing the space available
for the cord in the inferior cervical spine.
Cervical stenosis is defined as a canal diameter that
is less than 13 mm or a Pavlov ratio (cervical canal dia-
meter/vertebral body width) less than 0.8 on a lateral
radiograph.2 In neutral position, the overall alignment
of the cervical spine is lordotic. When engaging in colli-
sion sports, the majority of force is dissipated by the
paravertebral musculature. If the neck is flexed, however,
lordosis is reduced and the cervical sagittal alignment

becomes straight. If a tackle is made in this position (spear
tackling), the axial load is absorbed by the spine causing
compression of the cervical spine, which can result in
catastrophic spine injury.6 The majority of cervical spine
injuries sustained by athlete results from an axial force
when the spine is in a flexed position.
Particularly at the high school level, special consi-
deration should be given to the pediatric cervical
spine. Children have more horizontally oriented facets,
increased capsular and ligamentous laxity, and their
paracervical musculature is not fully developed, all
of which leads to a relative hypermobility. However,
children tend to recover faster and sustain less disabling
injuries than adults.7
Physical Examination including
Provocative Maneuvers
The examination of an awake and alert patient with
neck pain after an injury should begin with palpation
of the spinous processes and paracervical musculature.
Active range of motion is evaluated in flexion, extension,
lateral flexion (both directions) and rotation. A complete
sensorimotor evaluation of the extremities is performed
with attention toward any sensory deficits that occur in
dermatomal distributions. Biceps, brachioradialis and
triceps deep tendon reflexes should be tested. Spurling’s
maneuver should be assessed. This is tested by applying
axial load to spine with patient’s head turned toward side
of interest. This maneuver narrows the vertebral foramen,
reproducing radicular symptoms. Controlled separation
of the head and shoulder can be used to reproduce
symptoms of a traction injury to the brachial plexus.

Cervical Spine Injuries
Cervical Strain
Paraspinal muscle strain and cervical ligament sprain
are the most common cervical spine injuries in athletes.
Direct blows or rapid eccentric muscle contraction can
cause strains of the muscle. Forced flexion of the head
and neck can cause ligamentous sprains or capsular
injures of the facets. Patients will present with localized
pain without radiation or neurologic deficit and range
of motion may be limited secondary to pain. When an
athlete complains of acute pain after a contact injury,
a cervical collar should be prophylactically placed as
further work-up is initiated. Anteroposterior, lateral
and odontoid radiographs should be obtained initially
and lateral flexion/extension radiographs can be used
to assess for instability. The mainstay of treatment is
immobilization and anti-inflammatories until pain
resolves. The collar can be discontinued and the patient
can return to play once full, painless range of motion is
demonstrated.
Burners Syndrome (Stinger)
Burners syndrome is condition marked by temporary
burning and weakness in a single upper extremity, most
commonly occurring at the C5 and C6 distribution. The
mechanism is due to a traction injury to the brachial
plexus in younger athletes and compression of the upper
cervical roots in adult athletes. The cervical foramina
are narrowed transiently when the cervical spine is
forced into hyperextension alone or in combination with
lateral flexion or shoulder elevation to the affected side
resulting in transient radiculopathy. Athletes complain
of a transient paralysis with a burning sensation that

radiates from the shoulder to the fingertips. Full recovery
normally returns within 10 minutes. The athlete can be
allowed to return to play once symptoms resolve and
they are assessed to have a normal cervical spine and
upper extremity sensorimotor exam. Athletes should be
60
restricted from play if they have had more than three
episodes, cervical stiffness and tenderness, persistent
weakness or both upper extremities are involved. These
athletes should undergo formal imaging and examination
to rule-out potential anatomical variations or pathology
that pose an increased potential for permanent injury.
Once these entities are ruled out, the athlete should
undergo a period of rest and upper extremity strength
rehabilitation.7
Intervertebral Disk Herniation
Acute disk herniations result from an axial load that
rapidly increases intradiscal pressure. The nucleus
pulposus is extruded through the annulus fibrosus into
the spinal canal or neuroforamen, compromising the space
available for the spinal cord or nerve roots. The resulting
cord injury can be either transient or perma nent. The
athlete may present with paralysis of all four extremities,
loss of pain and temperature sensation, posterior neck
pain and/or paraspinal spasm.2 Patients may also present
with anterior cord syndrome. Magnetic resonance
imaging (MRI) is the gold-standard for diagnosis of a
herniated disk.

Transient Quadriplegia
Neurapraxia of the cervical cord can result in transient
quad riplegia. Hyperextension can cause infolding or
bunching of the ligamentum flavum creating a dynamic
narrowing of the canal. Hyperflexion can cause a pincer
effect between the lamina of the cranial vertebra and
the endplate of the caudal vertebra. Brief compression
of the cord creates a ‘postconcussive’ effect on the cord.2
Athletes with cervical stenosis may be predisposed to
transient quadriplegia. A Pavlov/Torg ratio of less than
0.8 was found in 93% of football players with transient
quadriplegia. The recurrence rate in football players has
been reported as high as 56%.8
Athletes present with pain, burning and tingling
bila terally that is thought to be due to local compression
or contusion of the cord. Symptoms can be in the upper
extre mities, lower extremities or both with variable pene-
tration of motor deficits. The symptoms are temporary
with complete recovery usually occurring within
15 minutes, but in some recovery may take up to 48 hours.
Congenital Anomalies and Down Syndrome
Congenital anomalies change the structural integrity of
the cervical spine, predisposing an athlete to catastrophic
injury. Klippel-Feil syndrome is a failure of segmentation
characterized by fusion of two or more vertebrae. With an
increasing number of fused segments, fewer motion seg-
ments can dissipate applied loads, inherently increasing
the risk of injury at the remaining mobile segments.
Odontoid hypoplasia can result in atlantoaxial instability
placing the athlete at risk of spinal cord injury from a

variety of mechanisms.
Athletes with Down syndrome have hypermobile
occipito cervical and atlantoaxial articulations. Atlantoaxial
instability is defined as an atlantodens interval (ADI) of
5 mm or more and is seen in 10 to 30% of Down syndrome
patients.9 Some athletic organizations, including the
special olympics, require lateral flexion-extension
radiographs to screen athletes with Down syndrome prior
to participation in high-risk sports, such as gymnastics
and contact sports. An athlete with an atlantodens
inter val greater than 5 mm, but less than 10 mm, is
restricted from high-risk sports. Patients with progressive
instability, myelopathy or an ADI greater than or equal
to 10 mm warrant evaluation for surgical stabilization.7
Unstable Fractures and Dislocations
Upper cervical spine fractures or dislocations rarely cause
spinal cord injury due to greater space available cord in
the cervical spine. Most fractures and dislocations occur
in the lower cervical spine. In a compressive-flexion
injury, axial force and a bending moment result in shor-
tening of the anterior column. This is often referred to
as a ‘teardrop’ injury and is frequently associated with
spinal cord injury. When the injury is purely compressive,
an axial load causes failure of the endplate resulting in
a burst fracture. Retropulsion of bony fragments often
results in spinal cord compromise. Flexion-distraction
injury results in facet dislocation.
A range of neurologic deficits are possible in athletes
with unstable fractures, dislocations or both. However,
athletic spinal cord injuries are most often incomplete.
Central cord syndrome, where upper extremity weakness
is more pronounced than lower extremity weakness, is

the most common pattern.10 A variant of this, ‘burning
hands’ syndrome, is a condition whereupon dysesthesias
occur both hands without sensorimotor loss.11
Permanent Neurologic Deficits
Permanent deficits occur most commonly with fractures
and dislocations. Increased risk for permanent neurologic
damage is associated with ‘spear tackler’s spine.’ Torg
described this entity as follows:
• Narrowed cervical canal (a Pavlov/Torg ratio of <0.8
at 1 or more levels).
• Persistent reversal of the normal cervical lordosis.
• Concomitant pre-existing post-traumatic radiographic
abnormalities of the cervical spine.
Permanent neurologic injury occurred in 4 of 15
cases identified with spear tackler’s spine. Athletes with
The Duke Orthopaedic Journal, July 2014-June 2015;5(1):58-62
61
DOJ
a diagnosis of ‘spear tackler’s spine’ are restricted from
collision sports.6
On-field Management of a Player with a
Suspected neck Injury

Immobilization
When a spine injury is suspected, the athlete should
be removed from play after manual cervical spine
stabi li zation or placement of a cervical collar with the
spine in neutral position. If the spine is not in a neutral
position, it should be realigned to neutral for optimal
airway management. Contraindications’ placement of
the spine in a neutral position include increased pain
from movement, neurologic symptoms, muscle spasm
or airway compromise, any difficulty repositioning the
spine, resistance encountered or patient apprehension.12
The facemask should be removed prior to transport.13 It is
important to know whether a wire cutter, screwdriver or
both are needed to remove the facemask. Both tools need
to be a part of the sideline medical supplies at football
games. Before the athlete is moved, airway, breathing and
circulation should be assessed. Once these are stabilized,
the athlete is transferred onto a spine board taking care
to move the head and trunk as a unit in logroll fashion.
Taping or strapping the helmet to the backboard for
transportation effectively immobilizes the athlete’s head.
Helmet Removal
The helmet and shoulder pads should remain in place
during the initial clinical and radiographic assessment.
According to NCAA guidelines,12 the helmet should not
be removed on the field when there is the potential of
a head or neck injury unless there are specific circum-
stances, such as respiratory distress coupled with an
inability to access the airway or one of the following:
• The helmet does not adequately immobilize the head.
• Airway cannot be controlled due to design of the
helmet.

• The facemask cannot be removed after a reasonable
amount of time.
• The helmet prevents immobilization in an appropriate
position.
X-rays should be obtained with the helmet and
shoulder pads in place. If plastic or metal prevents ade-
quate visualization of the cervical spine, the helmet and
shoulder pads may be removed, although some recom-
mend bypassing triage and proceeding directly to CT
scan.14 Follow the ‘all or none’ policy in both youth and
adults where both the helmet and shoulder pads are left
on or removed at the same time.15
Removal of the helmet and shoulder pads should be
performed with two people, with one person immobi-
lizing the head and neck at all times.16 The second
person begins with removal of the facemask followed
by the chin strap. The cheek/jaw pads are removed next
by using scissors under the pads and twisting to loosen
them. The exception is with the Riddel Revolution helmet
where the pads must be deflated with an 18 gm needle
prior to removal. Next, the air inflation system is deflated
using one of the external ports with an 18 gm needle or
air pump needle. The assistants switch places with the
second person assuming head immobilization using one
hand to hold the mandible and the other hand underneath
the occiput. The first person places a thumb in each
earhole of the helmet and curls their fingers underneath
the helmet edges, removing the helmet by gently rotating
it off the head taking care not to pull laterally. This should
be performed simultaneously with pad removal to avoid
the head from falling into hyperextension. If unable to
perform simultaneously, the head must be immobilized

at all times for staged removal of the helmet and shoulder
pads. A cervical collar should be placed following
removal of equipment.16
Return to Play
The majority of the studies regarding return to play after
sustaining a cervical spine injury are class III evidence.
Most recommendations are made on an individual basis
and based on clinical judgment.16 In general, patients
who are completely pain free with full range of motion
and strength may be eligible for return to play if no other
injuries are present. However, potential cervical spine
injuries should be handled on a case-by-case basis and
involve thorough evaluation by a trained physician to
make the determination.
SuMMARy
Cervical spine injuries can be potentially devastating
injuries to athletes and should be treated systematically
a nd usi ng ever y precaut ion necessar y. Thorough
evaluation should be performed of all suspected injuries
maintained cervical spine immobilization, return to play
should be based determined on an individual basis with
only completely asymptomatic patients cleared for early
return.
REfEREnCES
1. Vaccaro AR, Klein GR, Ciccoti M, et al. Return to play
criteria
for the athlete with cervical spine injuries resulting in stinger
and transient quadriplegia/paresis. Spine 2002;2(5):351-356.

62
2. Banerjee R, Palunbo MA, Fadale PD. Catastrophic cervi-
cal spine injuries in the collision sport athlete, part 1:
epidemiology, functional anatomy and diagnosis. Am J
Sports Med 2004;32(4):1077-1087.
3. Chang SK, Tominaga GT, JH W, Weldon EJ, Kaan KT. Risk
factors for water sports-related cervical spine injuries. J
Trauma 2006;60(5):1041-1046.
4. Boden BP, Tacchetti RL, Cantu RC, Knowles SB, Mueller
FO.
Catastrophic cervical spine injuries in high school and college
football players. Am J Sports Med 2006;34(8):1223-1232.
5. Mueller FO, Cantu RC. The annual survey of catastrophic
football injuries: 1977-1988. Exerc Sport Sci Rev 1991;19:261-
312.
6. Torg JS, Sennett B, Pavlov H, Leventhal MR, Glasgow SG.
Spear
tackler’s spine. An entity precluding participation in tackle
football and collision activities that expose the cervical spine
to axial energy inputs. Am J Sports Med 1993;21(5):640-649.
7. Herman MJ. Cervical spine injuries in the pediatric and
adolescent athlete. Instr Course Lect 2006;55:641-646.
8. Torg JS, Ramsey-Emrhein JA. Management guidelines
for participation in collision activities with congenital,
developmental, or post-injury lesions involving the cervical
spine. Clin Sports Med 1997;16(3):501-530.

9. Winell J, Burke SW. Sports participation of children with
Down syndrome. Orthop Clin North Am 2003;34(3):439-443.
10. Maroon JC, Abla AA, Wilberger JI, Bailes JE, Sternau LL.
Central cord syndrome. Clin Neurosurg 1991;37:612-621.
11. Wilberger JE, Abla AA, Maroon JC. Burning hands
syndrome
revisited. Neurosurg 1986;19(6):1038-1040.
12. Swartz EE, Boden BP, Courson RW, et al. National athletic
trainers’ association position statement: acute management
of the cervical spine-injured athlete. J Athl Train 2009;44(3):
306-331.
13. Waninger KN. Management of the helmeted athlete with
suspected cervical spine injury. Am J Sports Med 2004;
32(5):1331-1350.
14. Waeckerle JF, Kleiner DM. Protective athletic equipment
and
cervical spine imaging. Ann Emerg Med 2001;38(1):65-67.
15. Treme G, Diduck DR, Hart J, Romness MJ, Kwon MS, Hart
JM. Cervical spine alignment in the youth football athlete:
recommendations for emergency transportation. Am J Sports
Med 2008;36(8):1582-1586.
16. Agulnick MA, Grossman M. Spinal Injuries. In: Bono CM,
Garfin SR, editors. Orthopaedic Surgery Essentials: Spine
Surgery. Philadelphia: Lippincott Williams and Wilkins; 2004.
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https://www.researchgate.net/publication/277961886

Answer the following questions below.
Due Wednesday July 31, 2019
In deciding on the starting time for an upcoming summer
marathon, what prior meteorologic information would be most
valuable and why? (100 WORDS)
Please provide at least100 word responsesto EACHof the
following 4questions from the chapter reading above on
biomechanics of the spine: (ARTICLE IN LINK)
1) What are the postural consequences of having extremely
weak
abdominal muscles?
2) Weight training is used in conjunction with conditioning for
numerous
sports. What would you advise regarding spinal posture during
weight training?
3) What exercises strengthen the muscles on the anterior,
lateral, and
posterior aspects of the trunk?
4) Compare and contrast the major muscles that serve as
agonists during
performances of straight-leg and bent-knee sit-ups. Should
situps
be prescribed as an exercise for a low back pain patient?
Explain
why or why not.
Then after reading the article on Cervical Injuries in Sports,
please write a 350 word response to the article. (ARTICLE IN
LINK) Your responses about the article can talk about:1) what
you learned from the article 2)what you found interesting about
the article 3) any experience you have in your current or past
job of dealing with neck/spine injuries that the articles talk
about, 4) any prior spine/neck you may have experienced that

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