Objective: To analyse the epidemiological data, injury pattern, clinical features and mechanisms of severe spinal injuries related to alpine skiing and snowboarding.
Study design: A six-year review of all adult patients with severe spinal injuries sustained from alpine skiing or snowboarding.
Setting: Tertiary trauma centre in Bern, Switzerland.
Patients and methods: All adult patients (over 16 years of age) admitted to a tertiary trauma centre from 1 July 2000, through 30 June 2006, were reviewed using a computerised database. From these records, 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 clinical features of these patients were reviewed with respect to epidemiological factors, mechanism of injury, fracture pattern, and neurological status.
Results: 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.
Conclusions: With advances in technology and slope maintenance, skiers and snowboarders progress to higher skill levels and faster speeds more rapidly than ever before. Great efforts have been focused on reducing extremity injuries in snow sports, but until recently very little attention has been given to spinal injury prevention on the slopes. Suggestions for injury prevention include 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.
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Head, neck and spinal injuries are among the most devastating injuries associated with recreational sports. Alpine skiing and snowboarding may result in high-energy falls or collisions with other skiers, obstacles or equipment, resulting in significant trauma. Orthopaedic injuries sustained in alpine snow sports have been reviewed extensively, with spinal injuries comprising between 1% and 17% of all injuries.1–4 Traditionally, spinal injuries in alpine skiing have been less common than in snowboarding, but this disparity is likely to diminish with the recent trend of incorporating snowboarding moves into skiing.5 Although there are many reports in the literature describing ski injuries, data on spinal trauma resulting from snow sports, especially from snowboarding, are very limited. The increasing number of sports-related injuries, in combination with an increasing amount of medical data available and rising costs of health care, prompted our institution to look for ways to cooperate with major insurance companies in order to become more efficient in patient treatment, injury prevention, and data management. To deal as efficiently as possible with our own data, a comprehensive electronic medical database has been used by the Department of Emergency Medicine as well as the Department of Orthopedic Surgery. Through the current years of practice, the authors noticed a marked increase of prevalence of spinal injuries, both from alpine skiing and snowboarding. The aim of this study is to document the characteristics of snow sports-related spinal trauma admissions to the Inselspital Bern, the tertiary trauma centre for the top-level ski resorts of the Bernese Alps and parts of the Valais, Switzerland, over a six-year period (2000–6).
PATIENTS AND METHODS
The Department of Emergency Medicine and the Department of Orthopedic Surgery at the university hospital of Bern are the only referral centres for severe spinal trauma in this region. They serve a population of about 1.5 million and provide a 24-h on-call service. All adult patients (over 16 years of age) admitted to our tertiary trauma centre from 1 July 2000, through 30 June 2006, were reviewed using a computerised database (Qualicare Office, Medical Database Software, Qualidoc AG, Bern, Switzerland). As that medical database allows instantaneous retrieval of past diagnostic reports, discharge summaries, other text documents, patients’ laboratory results, or radiographs, the authors were able to retrospectively analyse the diagnostic results, and therapeutic procedures. From these records, a total of 728 patients (250 female, 478 male) injured from snow sports were identified. 573 patients (78.7%; 202 female, 371 male) sustained injuries from alpine skiing, and 155 patients (21.3%; 48 female, 107 male) sustained injuries from snowboarding. Among those 728 patients, a total of 140 (50 female, 90 male) suffered from any kind of spinal injuries.
Severe spinal injuries were found in 73 patients (17 female, 56 male). Severe spinal injuries were defined as spinal fractures, subluxations, dislocations or concomitant spinal cord injuries. Patients suffering from transient symptoms such as concussion, temporary sensory disorders of less than two minutes’ duration, back pain and lumbago were not included. Only those patients who were injured while participating in alpine skiing or snowboarding were included. Ice skaters, snowmobilers and people involved in mountain accidents were not reviewed. The patients with severe spinal injuries were referred from all ski resorts in the Bernese Alps (for example, Eiger-Jungfrau region, Schilthorn, Wengen, Adelboden ski resorts) and the eastern parts of the Valais (for example, ski resorts of Zermatt and Saas-Fee), for which Inselspital Bern is the tertiary trauma centre.
Age, gender, date of injury, type of injury and initial neurological symptoms for all patients were obtained from the database of the Department of Emergency Medicine. Further information about fracture type, operative and conservative treatment, and outcome were derived from a similar computerised database of the Department of Orthopaedic Surgery.
For statistical analysis the χ2 test was used. Probability values less than 0.05 were considered to indicate statistical significance.
During the ski seasons 2000/1 through 2005/6, a total of 73 adult patients (17 female, 56 male) with severe spinal injuries were referred to the Department of Emergency Medicine at Inselspital Bern, Switzerland. The majority of those severe spinal injuries (n = 63; 86.3%) were related to alpine skiing, whereas only 10 severe spinal injuries (13.7%) were associated with snowboarding. The characteristics of patients with severe ski-related spinal injuries (SSKSI), and severe snowboard-related spinal injuries (SSBSI) are shown in table 1. The median age of snowboarders with severe spinal injuries was significantly younger than skiers—22.5 years versus 40.0 years (p<0.001). All snowboarders with severe spinal injuries were male (p<0.05). At least half of the 10 SSBSI resulted from jumping while snowboarding; only one snowboarder had a collision with an obstacle (no further information available for the remaining four patients). The majority of SSKSI resulted from falling forwards or collisions with obstacles or other skiers; only two skiing injuries were associated with jumping.
With regard to severe spinal injuries in 73 patients, 39 patients (53.4%) suffered from injury pattern at two or more levels. Twenty four patients (32.9%) were injured at two levels, eight patients (11.0%) at three levels, and seven patients (9.6%) at more than three levels. A total of 148 spinal fractures, subluxations, or dislocations were diagnosed in 73 patients. The most common site of injury was the lumbar spine (n = 55 fractures), followed by the thoracic spine (n = 51), the cervical spine (n = 41) and the sacrum (n = 1). That is especially true for the snowboarders group, with 60.0% of fractures (9 out of 15 fractures) located in the lumbar spine (fig 1). Additionally, the solitary sacrum fracture was diagnosed in a snowboarder. Overall, transverse or spinous process fractures were the most common fracture type (n = 60), followed by anterior thoraco-lumbar compression fractures, and thoraco-lumbar burst fractures.
The 41 severe cervical spine injuries included eight fracture dislocations C6/7 (fig 2), one fracture dislocation C7/T1, and one fracture dislocation C4/5. There were another nine fractures of the vertebrae C5 to C7 without dislocation. Common cervical injuries included transverse and spinous process fractures of the lower segments (n = 17). Fractures of the upper cervical spine were rare (for example, one hanged-man fracture of the axis, one atlanto-occipital dissociation combined with additional type II odontoid fracture according to the classification of Anderson/d’Alonzo).
Of the 51 severe thoracic spine injuries, the majority were transverse process fractures (n = 21), most of which resulted from a direct fall on the upper or lower back. Most of the compression fractures were diagnosed in T10 to T12 (n = 10). Nine burst fractures involved T12 (n = 5), T8 (n = 2), T9 (n = 1), and T11 (n = 1). However, two fracture dislocations of T3/4 and T6/7, respectively, resulted in paraplegia.
Sixteen of the 55 severe lumbar spine injuries were burst fractures, involving L1 (n = 11), L2 (n = 1), L3 (n = 3) and L4 (n = 1). Compression fractures were diagnosed in L1 (n = 8), L2 (n = 6) and L3 (n = 1) (fig 3). Twenty two of the lumbar injuries were transverse process fractures. One patient sustained a traumatic spondylolysis L5/S1. The sacrum fracture seen in a young snowboarder consisted of a longitudinal split in the lateral mass as well as a fracture dislocation of the coccyges.
Central nervous injuries, and transient neurological symptoms (more than two minutes’ duration), or persistent neurological symptoms occurred in 28 patients (5 snowboarders, 23 alpine skiers). None of the injured snowboarders suffered from persistent neurological sequelae. Two accidents in alpine skiers were fatal: a 39-year-old female sustained severe multiple injuries of central nervous system, spine (unstable fracture of C5), thorax, abdomen, pelvis and extremities after a fall from a height of more than 20 m offside the ski-run. A 36-year-old male died from severe cranial injuries after hitting his head on a stone when falling at the end of the ski run. He also sustained severe thoracic trauma, and severe spinal trauma with multiple fractures of the upper thoracic spine.
A 48-year-old male with severe head injury, atlanto-occipital dissociation, and odontoid fracture initially survived after neurosurgical intervention and dorsal cervico-occipital stabilisation (C0-2). Severe cerebral injury and its sequelae, however, determined the further course (permanent need of nursing).
Quadriplegia occurred in three alpine skiers: a 78-year-old male with fracture dislocation C6/7 resulting from a fall, a 43-year-old male with fracture dislocation C6/7 resulting from a fall, and a 49-year-old male with pre-existing spinal stenosis C4/5 suffering from incomplete quadriplegia after sustaining a sudden forced hyperextension of his neck. Another fracture dislocation C6/7 in a 19-year-old male resulted in Brown-Sequard syndrome.
Paraplegia resulted in two alpine skiers: a 75-year-old male with fracture dislocation of T4/5 resulting from a fall, and a 49-year-old male with fracture dislocation of T6/7, severe thorax trauma, and transverse process fractures L1-5 resulting from a fall, respectively. Unilateral sensomotoric or sensory deficits of the upper extremities were seen in four patients with articular process fractures of C6. Persistent sensory deficits of the lower extremities occurred in four patients with burst-split fractures L1 (n = 3) and L2. In the remaining seven of 28 patients presenting with neurological symptoms, initial sensory deficits (more than two minutes’ duration) resolved completely without any intervention.
Among the 73 patients with severe spinal injuries, a total of 40 patients (54.8%) had to undergo surgery. In the SSBSI group, five out of 10 snowboarders needed internal fixation of the spine, while the injuries of the remaining five patients could be treated non-operatively. All thoraco-lumbar burst fractures (n = 4) as well as a cervical fracture dislocation C6/7 required operative treatment. In three SSBSI patients, a second operation (two-staged stabilisation dorsally and ventrally) was necessary. In the SSKSI group, 35 out of 63 alpine skiers (55.6%) needed surgical intervention, including 11 cervical injuries, 7 fracture dislocations or burst fractures at the thoracic spine, and 17 anterior compression fractures or burst fractures of the lumbar spine. Seventeen skiers underwent two or more operations at the spine.
Associated injuries were found in 27 of 73 patients (37.0%) with severe spinal trauma, including 22 patients (34.9%) in the SSKSI group, and five patients (50.0%) in the SSBSI group, respectively. Combinations of spinal and cerebral injuries were seen in 23.3% of all patients (n = 17; 14 alpine skiers, 3 snowboarders). Extremity injuries were diagnosed in 12 patients (16.4%) involving 11 alpine skiers, and only one snowboarder (table 2).
Alpine skiing and snowboarding continue to gain in popularity, attracting a more heterogeneous group of participants in recent years. Overall, injuries seem to occur at a rate of approximately 4–8 per 1000 skier-days in both of these alpine sports.5 6 In 1991, the incidence of serious injuries, requiring referral to a tertiary trauma centre, has been estimated at 0.02 per 1000 participant days in alpine skiing, and 0.03 per 1000 participant days in snowboarding, respectively.7 Over the past decade, the rate of severe injuries has increased to about 0.07 per 1000 skier-days.8–10 Neurological injuries have been reported to be the leading cause of death and disability in skiing and snowboarding accidents, despite accounting for only a small fraction of injuries overall.4 Head injuries make up 3% to 15% of all skiing and snowboarding related injuries, and spinal injuries constitute 1% to 17% of reported snow sports injuries.1–4
As with other causes of spinal trauma, more than half of the patients in our study (53.4%) suffered from spinal injury pattern at more than one segment. These injuries were often contiguous fractures of the spinous or transverse processes. Moreover, combinations of spinal and cerebral injuries were seen in 23.3% of all patients (n = 17; 14 alpine skiers, 3 snowboarders). This emphasises the necessity to diligently search for multiple fractures and associated cerebral injuries when examining patients with spinal trauma.
The overall incidence of spinal fracture or fracture dislocation has been reported to be 0.01 per 1000 skier-days and 0.04 per 1000 snowboarder-days.11 12 Recent epidemiological studies show certain similarities to our findings in that snowboarders are significantly younger than those sustaining skiing-related injuries, and are predominantly male.7 8 13 Data from our medical centre confirmed these observations: SSBSI patients were an average of 22.5 years old versus 40.0 years old for SSKSI patients (p<0.001). While all SSBSI patients were male (p<0.05), the SSKSI population was more heterogeneous having a broader age range and less disparity in gender.
The injury patterns of snowboarders differed considerably from alpine skiers, as did the severity of neurological sequelae. Our results showed that at least half of the SSBSI involved jumping, whereas there were few SSKSI associated with jumps. Recent studies on snowboarding-related spinal injuries indicate that snowboarders are at greater risk of falling backward from intentional jumps, and thus sustaining axial loading injuries.7 11 14 Consistent with this, the most commonly affected site of injury in snowboarders were the lumbar spine and the sacrum (fig 1). In the SSKSI group, falls were the most frequent cause of injury. Additionally, all fatal injuries and all traumata with persistent neurological sequelae occurred in alpine skiers. The severity of the injuries and mortality might be explained by the generally faster speed obtained by skiers, a higher likelihood of collision as a result of the higher speed, and the tendency to fall forward. Blunt head trauma has been reported to be the leading cause of death in snow sports.4 15
In contrast to previous reports, our study suggests that alpine skiers run the risk of severe spinal injuries with neurological sequelae. Conventionally, the incidence of spinal injuries in snowboarding has been reported to be significantly greater than in alpine skiers.10 16 17 However, this disparity seems to diminish because of higher velocities obtained with carving skis, a higher likelihood of collisions, and the recent trend of incorporating snowboarding moves into skiing. On the other hand, protective equipment (helmets, spine protectors) seems to be more accepted among snowboarders than by skiers. Great efforts have been focused on reducing extremity injuries in snow sports, but until recently very little attention has been given to spinal injury prevention on the slopes. Prevention programmes should probably be focused on safe skiing and snowboarding practices, avoidance of collisions, development of terrain parks and appropriate trails, and recommendations for the proper maintenance of equipment. While helmet use for skiing and snowboarding is increasingly encouraged, the promotion of spine protectors might be a feasible prevention method.
What is already known on this topic
The incidence of serious injuries in snow sports has perceptibly increased over the past decade.
Neurological injuries are the leading cause of death and disability in skiing and snowboarding accidents.
Previously, the incidence of spinal trauma in snowboarding has been reported to be greater than in alpine skiing.
What this study adds
This six-year retrospective review of a tertiary trauma centre in Switzerland discusses the epidemiological data, injury pattern, and mechanisms of severe spinal injuries related to alpine skiing and snowboarding.
Our study suggests that snowboarders sustaining spinal injuries are significantly younger than those sustaining skiing-related injuries, and are predominantly male.
The spinal injury patterns of snowboarders and alpine skiers are rather different. Alpine skiers sustain more severe cervical spinal injuries with persistent neurological consequences. Spinal injuries at more than one segment are considerably frequent.
Competing interests: None.