SPINAL INJURIES ON THE SLOPES - 2 - LITERATURE REVIEW


The first page on spinal injuries looked at the basic anatomy of the spine, the mechanisms of spinal injury and what to do if one occurs on the slopes. Click here if you missed it. This second page will specifically look at the incidence and pattern of spinal injuries seen as a result of snow sports. This is basically an evidence-based review of the literature up to June 2008, with a few of my own thoughts thrown in for good measure. Spinal injuries are, thankfully, pretty rare on the slopes. However, when they do occur (as happened to Silvano Beltrametti in Val D'Isere in 2001), the results can be simply devastating - resulting either in death or long term and significant disability and there is growing evidence to suggest that they are increasing in number.

The current generation of skiers, snowboarders and skiboarders have at their disposal better equipment than ever - allowing them to push the limits of their ability like never before. The potential for spinal injury is certainly there, and as jumps and half pipes get ever bigger we must all be aware of the potential for spinal injuries occurring.

So, you might ask, why do I devote a whole two pages of this website to a group of injuries that I admit are pretty rare in the big scale of snow sports injuries? The reason is simple - they may be rare, but when they happen they can be life-changing injuries. As page 1 explained, in the centre of the spine runs the spinal cord - a fairly squidgy and easily damaged structure that carries within it the nerves that transmit both sensation and function (movement) to and from the various areas of the body. If other structures within the spine are damaged (e.g. broken bones) - the real worry is that the nerves within the spinal cord will be damaged too. Unfortunately, unlike many other types of tissue, nerve tissue does not repair and once damage is done it is usually permanent.

If damage occurs at a particular level in the spinal cord, this damage prevents any nerve messages being transmitted upwards from (even undamaged) nerves lower down the cord. In addition, the spinal bones get stronger as you go down the spine so the bones in the cervical spine are quite fragile and relatively easy to break. For both these reasons, the higher the damage occurs, the worse the resulting disability is. This is demonstrated in the diagram to the left. The blue bits indicate those parts of the body that can no longer function because of damage to the spinal cord at a higher level. You can clearly see that injury high up in the neck results in total paralysis below the neck (tetra/quadraplegia). Even damage much lower down can completely paralyse both legs (paraplegia). Important? Worth knowing about? I think so.

The rest of this page will review the literature on the topic of spinal injuries as a result of skiing and snowboarding.

   

Literature review on spinal injuries amongst skiers and snowboarders


The following twelve articles are reviewed in this section - click on the paper you wish to see

  1. Cervical Spinal Fractures in Alpine Skiers. Kip & Hunter 1995
  2. Spine and Spinal Cord Injuries in Downhill Skiers. Prall et al. 1995
  3. Spinal Cord Injury and Snowboarding - The British Columbia Experience. Koo & Fish 1999
  4. Spinal Injuries in Skiers and Snowboarders. Tarazi et al. 1999
  5. Neurologic Injuries in Skiers and Snowboarders. Levy & Smith 2000
  6. Traumatic Paraplegia in Snowboarders. Seino et al 2001
  7. Spinal Injuries in Snowboarders: Risk of Jumping as an Integral Part of Snowboarding. Yamakawa et al 2001
  8. Alpine Skiing, Snowboarding and Spinal Trauma. Floyd 2001
  9. Multiple Spine Fractures in an Adolescent Snowboarder: Case Report. Richards et al 2001
  10. An international review of head and spinal cord injuries in alpine skiing and snowboarding. Ackery A et al. 2007
  11. Severe spinal injuries in alpine skiing and snowboarding: a 6-year review of a tertiary trauma centre for the Bernese Alps ski resorts, Switzerland. Franz T et al. 2008
  12. Acute spine injuries in skiers and snowboarders. Kary JM. 2008
  13. Overview of all the findings - Mike Langran 2008


i. Cervical Spine Fractures in Alpine Skiers

This paper looked at all the cervical spine (neck) fractures that occurred as a result of alpine skiing in the Aspen/Snowmass area between May 1987 and April 1992. 18 such injuries were seen, giving a yearly incidence of 3.6 fractures (estimated at 0.1% of all skiing injuries). The mean age of casualties was 40.8 years and 89% were male. A third of the injuries were relatively minor and only required conservative treatment. However, one injury killed the person involved and two were left paralysed in all 4 limbs.  Those accidents resulting in the most severe injuries usually occurred as a result of a collision with a static object ( a tree or a snow fence).

Reference

Kip P and Hunter RE. Cervical Spinal Fractures in Alpine Skiers. Orthopedics 1995; 18(8): 737-741


ii. Spine and Spinal Cord Injuries in Downhill Skiers

This paper reviewed the spinal injuries seen as a result of skiing at a level I trauma centre in Denver, Colorado over an 11 year period. There were 126 injuries occurring at an overall rate of 1injury every one million skier days. The male to female ratio was 3.4 to 1 and the average age of casualties was 32.5 yrs. One in five injuries involved the spinal cord - this was most likely with cervical spine injuries. The commonest mechanism of injury to the spine was a fall; one third of those injured had sustained multiple injuries. The authors observed that those injured were skiing at or below their skill level, but that excess speed was the main factor in virtually all the accidents that occurred.

Reference

Prall JA et al. Spine and spinal cord injuries in downhill skiers. J Trauma 1995;39(6): 1115-1118
 
     
iii. Spinal Cord Injury and Snowboarding - The British Columbia Experience

This was a small review of 10 cases of snowboarding spinal injuries admitted to Vancouver Hospital in 1997-98. All but one of the snowboarders described their ability level as 'expert' with an average of 6.25yrs experience. 90% were male and the average age was 22.4yrs. Only one cervical injury was seen, the majority involved the lower thoraco-lumbar spine. Most injuries were caused by compression and half the injured snowboarders had damage to the spinal cord. The main mechanism of injury was a failed jump or a fall from a significant height (up to 25 feet). The authors commented on the lack of associated injuries, particularly to the limbs (there was only one associated wrist fracture). They postulated that the inability to break a fall with an outstretched limb may have contributed to the spinal injury as the forces have to be absorbed by the skeleton. They urged snowboarders to consider proper instruction before trying to learn potentially hazardous jumping techniques by trial and error. In one snowboarder's case, his trial lead to him being left with two paralysed legs.

Reference

Koo DW & Fish WW. Spinal cord injury and snowboarding - the British Columbia experience. J Spinal Cord Medicine. 1999; 22(4): 246-251


 
iv. Spinal Injuries in Skiers and Snowboarders

Tarazi and colleagues (again from Vancouver Hospital) reported on a series of spinal injuries treated between 1994 and 1996. 34 skiers and 22 snowboarders were included. They calculated that spinal injuries occurred at a rate of 0.01 injuries per 1000 skier days and 0.04 injuries per 1000 boarder days. The mean ages were 34.5yrs (skiers) and 22.4yrs (boarders). 70% of the skiers and all the snowboarders were male. Intentional Jumps (>2 metres) was the cause of injury in 20% of skiers and 77% of boarders. The main cause of injury amongst skiers was a fall (59%). Nearly half of all injuries in both groups involved the cervical spine. Again, compression was the main mechanism of damage to the spine. Two casualties died as a result of their injuries. Tarazi comment on the fact that the incidence of spinal injuries in their study was 10x that seen by Prall et al (above). They believe that their study contained more accurate information on the actual skiing and snowboarding populations involved and that Prall et al may not have reported on all the spinal injuries that occurred during the time of their study. Not surprisingly, they also advise snowboarders to seek professional instruction before attempting jumps. 

Reference

Tarazi F et al. Spinal injuries in skiers and snowboarders. Am J Sports Med. 1999; 27(2): 177-180

     
v. Neurologic Injuries in Skiers and Snowboarders

This comprehensive review by Stewart Levy (a Denver neurosurgeon) and Richard Smith reviews both head and spinal injuries amongst skiers and snowboarders. They quote a spinal injury rate of 0.075 injuries per 1000 skier or boarder days. They make the point though that, amongst serious snow sports injuries, spinal injuries are third commonest after head and abdominal injuries and may lead to permanent disability. They go on to report their own series of 187 serious spinal injuries seen between 1988 and 1998. 74% of casualties were male with a mean age of 31.6 yrs. Injured snowboarders were significantly younger than injured skiers. The distribution of injuries along the spine was cervical (30%), thoracic (32%), lumbar (32%) and sacral (6%). Again, cervical injuries were more likely to be associated with spinal cord damage and disability. They also found that the more serious injuries were associated with multiple injuries - usually involving the head. They found that simple falls accounted for 52% of spinal injuries in skiers and 55% of snowboarders. 16% of snowboarders were injured as the result of a jump compared to 9% of skiers.

They made the very interesting observation that skiers tended to fall forwards and were thus more likely to injure the cervical spine whereas snowboarders were more likely to fall backwards or sustain hard landings either on both feet or on the buttocks resulting in thoracic or lumbar injuries (lower down the spine).

Reference

Levy AS & Smith RH. Neurologic Injuries in Skiers and Snowboarders. Seminars in Neurology. 2000; 20(2): 233-245

 
vi. Traumatic Paraplegia in Snowboarders

Seino and colleagues in this paper report on a small series of 6 snowboarders who sustained serious spinal injuries resulting in nerve damage between 1996 and 1999. All were male with an average age of 23.7 yrs. The primary mechanism in each case was a backwards fall from an intentional jump. Unfortunately, all casualties were left permanently paralysed.

Reference

Seino H et al. Traumatic Paraplegia in Snowboarders. Spine 2001; 26(11): 1294-1297

     
vii. Spinal injuries in snowboarders: Risk of jumping as an integral part of snowboarding

This was a small review of 10 cases of snowboarding spinal injuries admitted to Vancouver Hospital in 1997-98. All but one of the snowboarders described their ability level as 'expert' with an average of 6.25yrs experience. 90% were male and the average age was 22.4yrs. Only one cervical injury was seen, the majority involved the lower thoraco-lumbar spine. Most injuries were caused by compression and half the injured snowboarders had damage to the spinal cord. The main mechanism of injury was a failed jump or a fall from a significant height (up to 25 feet). The authors commented on the lack of associated injuries, particularly to the limbs (there was only one associated wrist fracture). They postulated that the inability to break a fall with an outstretched limb may have contributed to the spinal injury as the forces have to be absorbed by the skeleton. They urged snowboarders to consider proper instruction before trying to learn potentially hazardous jumping techniques by trial and error. In one snowboarder's case, his trial lead to him being left with two paralysed legs.

Reference

Yamakawa H, Murase S, Sakai H et al. Spinal injuries in snowboarders: Risk of jumping as an integral part of snowboarding. J Trauma. 50: 1101-1105, 2001
 
             
viii. Alpine Skiing, Snowboarding and Spinal Trauma

Floyd conducted a 10 yr review of spinal injuries at a major (but unspecified) ski resort in the USA from 1986-1996. 41 patients with spinal fractures or dislocations were identified - 29 men and 12 women. Men were on average 9 yrs younger than women (32 vs 41 yrs). 12 patients had injuries at two or more levels in the spine. There were 12 cervical, 25 thoracic and 20 lumbar injuries. ¼ of all cervical injuries were associated with neurological problems at some stage, compared to only 4% of those with thoracic injuries. None of the lumbar injuries were associated with nerve damage. Cervical spine injuries were related to a landing onto  the head, with a flexion-hyperextension (whiplash-type) mechanism, often with a head plant into snow. 23 of the thoracic injuries were compression injuries resulting from a fall directly onto the upper or lower back. Typically, these patients reported suddenly losing control, becoming airborne, and landing in an uncontrolled manner.  85% of the lumbar injuries occurred in the same way. 9% of casualties required surgery. Floyd calculated that 1 significant spinal injury occurred once every 100,000 skier days. A permanent neurological deficit after a spinal injury was much rarer, occurring only once every 9 million skier days

Reference

Floyd T. Alpine skiing, snowboarding and spinal trauma. Arch Orthop Trauma Surg. 2001; 121: 433-6

 
ix. Multiple spine fractures in an adolescent snowboarder: Case Report

Not a case series this one, but a report of a 15yr old male snowboarder who descended a slope and went off a 7 metre (21 foot) jump. He fell feet first from the cliff and landed in a semiflexed position on his buttocks and back. He had immediate pain in his lower back but denied any symptoms of nerve damage. On admission to hospital he was tender over his lower cervical, lower thoracic and lumbar spine. A complete neurological examination was normal. In total, he broke 9 vertebrae (yes, nine!). These were compression fractures at C5 & C7, anterior wedge fractures from T10 to L3 and a burst fracture of L5. At 6 months follow up, this lucky lad was deemed to have made a full recovery!

Reference

Richards DP et al. Multiple spine fractures in an adolescent snowboarder: Case Report. J Trauma. 2001; 50(4): 730-732

 
x. An international review of head and spinal cord injuries in alpine skiing and snowboarding

This important paper is a meta analysis of all papers and references on the subject of head and spinal injuries in skiers and snowboarders published between January 1990 and December 2004. 24 relevant articles, from 10 different countries, were identified. The conclusion from them all is that the incidence of traumatic brain injury (TBI)  and spinal cord injury (SCI) in skiing and snowboarding is increasing. The increases coincide with the development and acceptance of acrobatic and high-speed activities on the mountains. There is evidence that helmets reduce the risk of head injury by 22–60%. Head injuries are the most common cause of death among skiers and snowboarders, and young male snowboarders are especially at risk of death from head injury.

Reference

Ackery A et al. An international review of head and spinal cord injuries in alpine skiing and snowboarding. Injury Prevention 2007;13:368-375



xi. Severe spinal injuries in alpine skiing and snowboarding: a 6-year review of a tertiary trauma centre for the Bernese Alps ski resorts, Switzerland.

This study was set in a tertiary trauma referral centre in Bern Switzerland and looked at all adults (>16 yrs old) admitted with a spinal injury between 1 July 2000 and 30 June 2006. A total of 728 patients injured from snow sports were identified. Severe spinal injuries (defined as spinal fractures, subluxations, dislocations or concomitant spinal cord injuries) were found in 73 patients (17 female, 56 male).  The majority of severe spinal injuries (n = 63) were related to skiing. Fatal central-nervous injuries and transient or persistent neurological symptoms occurred in 28 patients (23 skiers, 5 snowboarders). None of the snowboarders suffered from persistent neurological sequelae. Snowboarders with severe spinal injuries (n = 10) were all male (p<0.05), and were significantly younger than skiers (p<0.001). The most commonly affected site was the lumbar spine. However, 39 patients (53.4%) suffered from injury pattern at two or more levels. The authors conclude that advances in technology and slope maintenance mean that skiers and snowboarders can progress to higher skill levels and faster speeds more rapidly than ever before. They recognise the efforts that have been focused on reducing extremity injuries in snow sports, but feel that until recently very little attention has been given to spinal injury prevention on the slopes. They suggest encouraging the use of spine protectors, participation on appropriate runs for ability level, proper fit and adjustment of equipment, and taking lessons with the goal of increasing ability and learning hill etiquette.

Reference

Franz T et al. Severe spinal injuries in alpine skiing and snowboarding: a 6-year review of a tertiary trauma centre for the Bernese Alps ski resorts, Switzerland. BJSM 2008; 42(1): 55-58




  
xii. Acute spine injuries in skiers and snowboarders.

The final paper (by publication date) in this series reinforces the latest information on spinal injuries in snow sports - that whilst they are still thankfully relatively rare, they are also on the increase. In general, the paper concludes that skiers usually suffer acute serious spinal injuries from falls or collisions at high speeds, whereas snowboarders are frequently injured from failing attempted jumps. More specifically, snowboarders seem more likely to suffer thoracolumbar spine injuries from the way they fall after jumps. There is some evidence to suggest that when injuring their spines, snowboarders tend to fall backwards whereas skiers fall forwards. Kary states "This can lead to snowboarders falling in such a way as to apply axial loading through the spine, resulting in the commonly reported anterior compression fractures. In addition, landing in an uncontrolled manner after a jump may result in a direct blow to the upper or lower back, resulting in a transverse or spinous process fracture. Collisions on the slopes also can be significant contributors to spinal injuries. Skiers tend to suffer from more cervical spine injuries related to falling forward after losing control and skiing at excessive speeds." Finally, Kary makes the point that "concomitant injuries and multilevel fractures are common. It is imperative that a thorough examination and work-up is performed in the evaluation of an injured skier or snowboarder to avoid missing an injury."

Reference

Kary, JM. Acute spine injuries in skiers and snowboarders. Current Sports Medicine Reports 2008; 7(1): 35-38.
 

Overview of all these papers


So to summarise all these papers

  • Spinal injuries are very rare, but can have devastating consequences
  • They tend to occur in young males (but remember young males predominate on the slopes)
  • Spinal injuries tend to follow a pattern of excess speed, losing control and a bad landing from a jump
  • Cervical injuries are more likely to be associated with long term nerve damage. They frequently are associated with the head impacting onto something (snow or another object)
  • Thoracic and lumbar injuries are less likely to be associated with nerve damage and result from the spine being compressed, usually as a result of a landing directly onto the lower back and/or buttocks

If you're going to jump - get some professional instruction and take care!