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

Disclosures

Spine. 2021;46(1):22-28.

Conclusion

The present study investigated national trends in sports-related cervical spine injuries over the span of nearly a decade, and found that adolescent age increases risk for cervical spine fractures between C1–4 and subaxial (C5–7) segments, cervical dislocation, and cervical SCIWORA. Cervical SCIWORA was most associated with a concurrent TBI compared to other types of cervical injuries. American football injuries predicted greater odds of cervical SCIWORA compared to any other sport, whereas winter and water sports injuries were most associated with cervical fracture. The increased prevalence of cervical spine injury with age sheds light on the growing concern for youth sports played at a highly competitive level. Our findings support recently updated regulations aimed at decreasing life-threatening injuries in youth athletics and recreation.

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No funds were received in support of this work.

Relevant financial activities outside the submitted work: grants

Table 1. Univariate Analysis of Demographics and Cervical Injury Type
	Children (Age 4–9)	Pre-adolescent (Age 10–13)	Adolescent (Age 14–17)	P
Demographics
Total sports injuries (N)	7737	10,989	19,813
Mean age, y	6.71	11.86	15.62
Sex (%F)	34.4%	21.1%	18.0%	*<0.001
Race (%)
White	52.5%	60.6%	62.5%	1.000
Black	11.9%	14.9%	14.9%	1.000
Hispanic	25.7%	17.1%	15.4%	1.000
Asian/Pacific Islander	3.6%	2.2%	2.3%	1.000
Other	6.3%	5.1%	5.0%	1.000
Year
2003 (N=10,908)	1276 (11.7%)	3482 (31.9%)	6150 (56.4%)	*<0.001
2009 (N=9109)	1487 (16.3%)	2554 (28.0%)	5068 (55.6%)	*<0.001
2012 (N=18,522)	4974 (26.9%)	4953 (26.7%)	8595 (46.4%)	*<0.001
Total hospital charges	$25,898.73	$24,613.16	$28,760.41	*<0.001
Comorbidities
Skeletal dysplasia	30	49	43	*0.001
Sickle cell anemia	2	2	10	0.314
Vitamin deficiency	7	7	35	*0.017
Cervical injury type
C1–4 fracture w/o SCI	18 (0.23%)	22 (0.20%)	144 (0.73%)	*<0.001
C5–7 fracture w/o SCI	14 (0.18%)	20 (0.18%)	147 (0.74%)	*<0.001
C1–4 fracture with SCI	4 (0.05%)	1 (<0.01%)	40 (0.20%)	*<0.001
C5–7 fracture with SCI	4 (0.05%)	8 (0.07%)	46 (0.23%)	*<0.001
Dislocation	12 (0.16%)	11 (0.10%)	60 (0.30%)	*0.001
SCIWORA	18 (0.23%)	101 (0.92%)	296 (1.49%)	*<0.001
TBI	377	673	1477	*<0.001

SCI indicates spinal cord injury; SCIWORA, spinal cord injury without radiographic abnormality; TBI, traumatic brain injury.

Table 2. Multivariate Analysis for Cervical Fractures Across Age Groups for all Sports
Age Group	C1–4 Fracture w/o SCI (N)	% Total	Odd Ratio	Lower CI	Upper CI	P
Children	18	9.78%	0.458	0.281	0.747	*0.002
Pre-adolescent	22	11.96%	0.362	0.231	0.566	*<0.001
Adolescent	144	78.26%	3.181	2.233	4.531	*<0.001
Total	184	100%
Age Group	C1–4 Fracture With SCI (N)	% Total	Odd Ratio	Lower CI	Upper CI	P
Children	4	8.89%	0.388	0.139	1.084	0.071
Pre-adolescent	1	2.22%	0.057	0.008	0.413	*0.005
Adolescent	40	88.89%	7.574	2.989	19.196	*<0.001
Total	45	100%
Age Group	C5–7 Fracture w/o SCI (N)	% Total	Odd Ratio	Lower CI	Upper CI	P
Children	14	7.73%	0.333	0.193	0.574	*<0.001
Pre-adolescent	20	11.05%	0.310	0.195	0.494	*<0.001
Adolescent	147	81.22%	4.109	2.829	5.970	*<0.001
Total	181	100%
Age Group	C5–7 Fracture With SCI (N)	% Total	Odd Ratio	Lower CI	Upper CI	P
Children	4	6.90%	0.295	0.107	0.813	*0.018
Pre-adolescent	8	13.79%	0.401	0.190	0.845	*0.016
Adolescent	46	79.31%	3.629	1.922	6.853	*<0.001
Total	58	100%

CI indicates confidence interval; SCI, spinal cord injury.

Table 3. Multivariate Analysis for Cervical Dislocations Across Age Groups for all Sports
Age Group	Cervical Dislocation (N)	% Total	Odd Ratio	Lower CI	Upper CI	P
Children	12	14.5%	0.657	0362	1.19	0.168
Pre-adolescent	11	13.3%	0.390	0.210	0.726	*0.003
Adolescent	60	72.3%	1.70	1.19	2.42	*0.004
Total	83	100%

CI indicates confidence interval.

Table 4. Multivariate Analysis for Cervical Cord Injury Across Age Groups For all Sports
Age Group	Cervical SCIWORA (N)	% Total	Odd Ratio	Lower CI	Upper CI	P
Children	18	4.3%	0.229	0.143	0.368	*<0.001
Pre-adolescent	101	24.3%	1.03	0.83	1.29	0.766
Adolescent	296	71.3%	2.75	2.29	3.31	*<0.001
Total	415	100%	2.09	1.78	2.46	*<0.001

CI indicates confidence interval; SCIWORA, spinal cord injury without radiographic abnormality.

Table 5. χ ² Analyses for Specific Cervical Injuries Across Sport Type
Total Injuries by Sport	Any Cervical Fracture, N (%)	P (χ²)	Cervical Dislocation, N (%)	P (χ²)	SCIWORA N (%)	P (χ²)	Total Cervical Injuries
American football (N=2223)	17 (0.7%)	0.559	5 (0.2%)	0.596	36 (1.6%)	*0.012	58
Team sports (N = 4629)	25 (0.5%)	*<0.001	8 (0.2%)	0.613	57 (1.2%)	0.287	90
Individual sports (N = 2711)	25 (0.9%)	0.344	5 (0.2%)	1.000	8 (0.3%)	*<0.001	38
Winter sports (N = 2627)	46 (1.8%)	*0.002	3 (0.1%)	0.378	10 (0.4%)	*<0.001	59
Water sports (N = 471)	26 (5.5%)	*<0.001	3 (0.4%)	0.270	5 (1.1%)	1.000	34
Martial arts (N = 10,599)	120 (1.1%)	0.917	14 (0.1%)	*0.039	60 (0.6%)	*<0.001	194