Sports-Related Cervical Spine Fracture and Spinal Cord Injury

A Review of Nationwide Pediatric Trends

Haddy Alas, BS; Katherine E. Pierce, BS; Avery Brown, BS; Cole Bortz, BA; Sara Naessig, BS; Waleed Ahmad, MS; Michael J. Moses, MD; Brooke O'Connell, MS; Constance Maglaras, PhD; Bassel G. Diebo, MD; Carl B. Paulino, MD; Aaron J. Buckland, MBBS, FRACS; Peter G. Passias, MD


Spine. 2021;46(1):22-28. 

In This Article

Abstract and Introduction


Study Design: Retrospective cohort study.

Objective: Assess trends in sports-related cervical spine trauma using a pediatric inpatient database.

Summary of Background Data: Injuries sustained from sports participation may include cervical spine trauma such as fractures and spinal cord injury (SCI). Large database studies analyzing sports-related cervical trauma in the pediatric population are currently lacking.

Methods: The Kid Inpatient Database was queried for patients with external causes of injury secondary to sports-related activities from 2003 to 2012. Patients were further grouped for cervical spine injury (CSI) type, including C1–4 and C5–7 fracture with/without spinal cord injury (SCI), dislocation, and SCI without radiographic abnormality (SCIWORA). Patients were grouped by age into children (4–9), pre-adolescents (Pre, 10–13), and adolescents (14–17). Kruskall-Wallis tests with post-hoc Mann-Whitney U's identified differences in CSI type across age groups and sport type. Logistic regression found predictors of TBI and specific cervical injuries.

Results: A total of 38,539 patients were identified (12.76 years, 24.5% F). Adolescents had the highest rate of sports injuries per year (P < 0.001). Adolescents had the highest rate of any type of CSI, including C1–4 and C5–7 fracture with and without SCI, dislocation, and SCIWORA (all P < 0.001). Adolescence increased odds for C1-4 fracture w/o SCI 3.18×, C1–4 fx w/SCI by 7.57×, C5–7 fx w/o SCI 4.11×, C5–7 w/SCI 3.63×, cervical dislocation 1.7×, and cervical SCIWORA 2.75×, all P < 0.05. Football injuries rose from 5.83% in 2009 to 9.14% in 2012 (P < 0.001), and were associated with more SCIWORA (1.6% vs. 1.0%, P = 0.012), and football injuries increased odds of SCI by 1.56×. Concurrent TBI was highest in adolescents at 58.4% (pre: 26.6%, child: 4.9%, P < 0.001), and SCIWORA was a significant predictor for concurrent TBI across all sports (odds ratio: 2.35 [1.77–3.11], P < 0.001).

Conclusion: Adolescent athletes had the highest rates of upper/lower cervical fracture, dislocation, and SCIWORA. Adolescence and SCIWORA were significant predictors of concurrent TBI across sports. The increased prevalence of CSI with age sheds light on the growing concern for youth sports played at a competitive level, and supports recently updated regulations aimed at decreasing youth athletic injuries.

Level of Evidence: 3


The past decade has seen a rise in public awareness toward prevention of traumatic pediatric sports injuries. Over 44 million children participate in organized sports and recreational activities in the United States each year, and one-quarter of all pediatric cervical spine injuries presenting to the emergency department can be traced back to sports.[1–3] Pediatric patients are more susceptible to cervical spine injury (CSI) than adults—indeed, up to 80% of pediatric spine injuries occur in the cervical region compared to 30% in adult spinal trauma.[4] Mortality rates have ranged widely in the literature from 3% to 28%, with higher rates typically reported in younger children with atlantoaxial injuries.[5]

A child's age is associated with key developmental milestones in terms of anatomy, cognition, and behavioral changes. Younger children have a greater head to body ratio and thus a higher fulcrum of motion at the cervicocranial junction.[6] This, coupled with a relatively underdeveloped paraspinal musculature, puts younger children at greater risk for high-level cervical trauma and spinal cord injury without radiographic abnormality (SCIWORA).[7–9] On the contrary, older children and adolescents have more strength, mobility, and a higher rate of participation in high-velocity sports which may predispose them to more dangerous mechanisms of injury.[10]

Cervical spine injuries have been associated with numerous sports and recreational activities, including football, soccer, swimming, diving, and ice hockey.[11–14] Contact sports can result in cervical spinal cord injury (SCI) directly via blows to the neck or indirectly via accelerating or decelerating forces from impacts to the head and torso. Cervical spine injuries secondary to hyperflexion, extension, or compressive mechanisms are well-recognized across sport types (especially American football), resulting in cervical fracture with or without SCI, cervical dislocation, SCIWORA, and/or traumatic brain injury (TBI).[13]

The present study utilizes the largest inpatient pediatric database in the United States to describe the incidence of sports-related cervical spine injuries across age groups, ranging from children to adolescents. We aimed to quantify the rate and location of various types of cervical injuries, including fractures of the upper cervical spine (C1–4), fractures of the subaxial cervical spine (C5–7), cervical dislocation, and cervical SCIWORA. We also analyzed rates and predictors of concurrent TBI per CSI type, and we compared rates of injuries across different sports by category.