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


Patient Sample

A total of 12,039,432 discharges for pediatric patients aged 0 to 20 in the KID database were initially queried. Of this cohort, 38,539 patients (mean age: 12.76 years, 24.5% female) between the ages of 4 and 17 had an ICD-9-CM E-code pertaining to external causes of injury from a sports-related activity, including American football, other team sports, individual sports, winter sports, water sports, climbing sports, martial arts, and others (SDC).

Of these patients, 20.1% were Children, 28.5% were pre-adolescents, and 51.4% were adolescents. Adolescents had a significantly lower percentage of females (18.0%) compared to children (34.4%) and pre-adolescents (21.1%) (P < 0.001). There were no differences in rates of sports-related injuries within each respective race's age groups (P = 1.00); however, Whites had higher rates of sports injuries per age group compared to other ethnicities.

Adolescents had the highest rate of sports-related injuries by E-code for the years of 2003, 2009, and 2012 compared to other age groups (P < 0.001). Rates of sports-related injuries increased in children from 11.7% in 2003 to 26.9% in 2012, but decreased in pre-adolescents (31.9%–26.7%) and adolescents (56.4%–46.4%) over the same period. Pre-adolescents and adolescents had significantly higher rates of specific comorbidities, including skeletal dysplasia (P = 0.001) and vitamin deficiency (P = 0.017) but not sickle cell anemia (P = 0.314).

CSI Type Across all Sports

Across all age groups, there were 468 (% total = 1.2%) cervical fractures associated with sports-related activities of any type. Of these fractures, 184 (% total = 0.48%) were C1–4 fractures without spinal cord injury (SCI), 45 (% total = 0.12%) were C1–4 fractures with SCI, 181 (% total = 0.47%) were C5–7 fractures without SCI, and 58 (% total = 0.15%) were C5–7 fractures with SCI. In addition, 83 patients had cervical spine dislocation (0.22%), and 415 patients (1.1%) had cervical cord injury without evidence of radiographic abnormality (SCIWORA).

Adolescents had the highest rate of CSI among age groups, including the highest rate of upper (C1–4) cervical fracture with and without SCI, subaxial (C5–7) fracture with and without SCI, cervical dislocation, and cervical SCIWORA (all P < 0.001, Table 1). Adolescents also had the highest rate of TBI (3.83%) compared to pre-adolescents (1.75%) and children (0.98%) (P < 0.001).

Age Group as a Predictor of CSI

Logistic regression found age group to be a significant predictor for increased odds of CSI arising from sports-related mechanisms. Compared to children or pre-adolescents, adolescence (having an age between 14 and 17) increased odds for C1–4 fracture without SCI by a factor of 3.18 (OR: 3.18 [2.23–4.54], P < 0.001), C1–4 fracture with SCI by a factor of 7.57 (OR: 7.57 [2.98–19.19], P < 0.001), C5–7 fracture without SCI by a factor of 4.11 (OR: 4.11[2.83–5.97], P < 0.001), C5–7 fracture with SCI by a factor of 3.63 (OR: 3.63 [1.92–6.85], P < 0.001), cervical dislocation by a factor of 1.7 (OR: 1.70 [1.19–2.42], P = 0.004), and cervical SCIWORA by a factor of 2.75 (OR: 2.75 [2.29–3.31], P < 0.001) (Table 2, Table 3 and Table 4) Compared to adolescents, children and pre-adolescents trended relatively lower odds (OR < 1) of CSI across all sports.

Sport Type as a Predictor of CSI

The most common sport categories including team sports, individual sports, winter sports, water sports, and martial arts were compared for types of CSI (Table 5). Cervical fractures (both upper and subaxial) tended to occur in disproportionately higher rates when injured via winter sports (1.8% vs. 1.1%, P < 0.001) or water sports (5.5% vs. 1.1%, P < 0.001). Water sport injuries also trended higher rates of cervical dislocation (0.4% vs. 0.2%, P = 0.324), although this did not reach statistical significance. Martial arts injuries had significantly lower rates of cervical SCIWORA (0.6% vs. 1.3%, P < 0.001) and cervical dislocation (0.1% vs. 0.2%, P = 0.039) compared to other sports injuries, whereas team sports injuries were associated with lower rates of cervical fracture (0.5% vs. 1.1%, P < 0.001) overall.

American tackle and flag football injuries rose from 5.83% in 2009 to 9.14% in 2012 (P < 0.001) and were associated with a significantly higher rate of cervical SCIWORA (1.6% vs. 1.0%, P = 0.012) than non-football injuries. Football injuries also increased odds of SCIWORA by a factor of 1.56 (OR: 1.56 [1.11–2.20], P = 0.011) compared to injuries of any other sport type.

Subanalysis of Concurrent TBI With CSI

Across all sports-related injuries and age groups, TBI had a prevalence of 6.6%. Concurrent TBI was found to co-present with cervical SCIWORA at a significantly higher rate than other mechanisms of sports injury (14.0% vs. 6.5%, P < 0.001). SCIWORA was a significant predictor for concurrent TBI across all sports (OR: 2.35 [1.77–3.11], P < 0.001). Concurrent TBI with cervical dislocation (2.4%, P = 0.857) or cervical fracture (6.7%, P = 0.178) did not co-present at disproportionally higher rates compared to other sports injuries.