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Objective: To examine CrossFit-related injuries based on sex and age., Design: Retrospective case series., Setting: A tertiary-level pediatric sports medicine clinic., Participants: CrossFit athletes., Main Outcome Measures: CrossFit-related injuries by sex (males vs females) and age groups (≤19 years vs >19 years) using a χ analysis with P = 0.05, odds ratio (OR), and 95% confidence interval (95% CI)., Results: Among injured CrossFit athletes, female athletes sustained lower extremity injuries more frequently than male athletes (P = 0.011; OR, 2.65; 95% CI, 1.25-5.65). In observed CrossFit injuries, shoulder injuries were more frequently observed in male athletes compared with female athletes (P = 0.049; OR, 2.79; 95% CI, 0.98-7.95). Additionally, a greater proportion of CrossFit athletes aged 19 years and younger suffered trunk/spine injuries than those older than 19 years (P = 0.027; OR, 2.61; 95% CI, 1.10-6.21) in injured CrossFit athletes., Conclusions: The current results indicated sex- and age-specific susceptibility to CrossFit-related injuries based on body parts and diagnoses. The presented information may be useful to develop a safer exercise program, especially for pediatric and adolescent CrossFit participants.

Background: There is a paucity of data defining safe transport protocols for children treated with hip spica casting. Although restraint devices for casted children are available, all federally mandated testing uses a noncasted anthropomorphic test device (ATD or crash dummy). The purpose of this study was to evaluate current restraint options in simulated frontal crash testing using a casted pediatric ATD to determine injury risk to the head, cervical spine, chest, and pelvis., Methods: Using a 3-year-old ATD, dynamic crash sled tests simulating frontal crash were performed in accordance with government safety standards. The ATD was casted in a double-leg spica and the following restraint devices were tested: a seat designed for spica casted children, a restraint vest-harness, a traditional booster seat, and 2 traditional forward-facing car seats., Results: Although the presence of the cast increased many of the injury metrics measured, all seats passed current federal guidelines for the head and chest. No single seat performed best in all metrics. The greatest magnitude of neck loading and second-highest head injury criterion values were observed for the booster seat. The vest-harness produced the highest head injury criterion and the chest compression exceeded proposed federal limits., Conclusions: The results suggest safe transport in commercially available seats is possible with the child properly restrained in a correctly fitting seat. However, parents should not assume a child restraint system is appropriate for use just based on fit as, for example, seats with harnesses outperformed an easy to fit booster seat., Clinical Relevance: Each child and the position of the child's cast are unique and discharge planning involves consideration of safe transportation. Although this study suggests several seats used to transport spica casted children pass the federal head and chest injury prevention requirements, it is important to recognize that some children may still require emergency vehicle transport.

Importance: This study highlights the unnecessarily high suspicion for cervical spine injury among study providers and shows that cervical CT scans were more likely in patients who arrived to the emergency department wearing a cervical collar, even when clinically cleared for suspicion of cervical spine injury by the emergency department provider., Objective: To determine if patients with a cervical collar were more likely to undergo cervical spine imaging than those who arrived to the emergency department without a collar., Design: Adult trauma patients at a level 1 trauma center over 4 months (n = 1,438) were stratified by acuity (1,2, or 3), mechanism, and known injury cephalad to clavicles, defined as pain, wounds, or hematomas. Cervical spine imaging findings were recorded., Results: 975 patients (67.8%) had cervical CT scans. Twenty-six (1.81%) sustained a fracture or ligamentous injury, all with known injury cephalad to clavicles. 161 (11.2%) patients without injury cephalad to clavicles all had a negative cervical CT. Category 1 patients with gunshot wounds with injury cephalad to clavicles were more likely to have CT if they arrived with a collar versus without (66.7% vs 14.3%, p = 0.027). Category 2 and 3 patients with injury cephalad to clavicles after motor vehicle collision (MVC) (88.2% vs 69.6%, p = 0.011), low energy falls (88.3% vs 59.4%, p < 0.0001), and assault (86.0% vs 37.1%, p < 0.0001) underwent cervical CT more frequently if they arrived wearing a collar. Category 2 and 3 trauma patients without injury cephalad to clavicles were also more likely to undergo CT when wearing a collar after MVC (66.3% vs 21.4%, p = 0.001), low energy fall (81.8% vs 35.3%, p = 0.016), and pedestrian vs MVC (55.6% vs 12.5%, p = 0.04)., Conclusion: Certain trauma patients were more likely to undergo cervical CT if they arrived wearing a cervical collar. No conscious patients without complaints proximal to the clavicles had cervical injury., Competing Interests: Declaration of Competing Interests The authors have no conflicts of interest related to this work. This study was not externally funded., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Recent field data analyses have shown that lumbar spine fractures occurred more frequently in late model vehicles than the early ones in frontal crashes. Therefore, the objective of this study was to investigate risk factors associated with lumbar spine fractures in frontal crashes. Parametric simulations were conducted using a set of validated vehicle driver compartment model, restraint system model, and a HIII mid-size male crash test dummy model. Risk factors considered in the study included occupant seating posture, crash pulse, vehicle pitch angle, seat design, anchor pre-tensioner, dynamic locking tongue, and shoulder belt load limiter. ANOVA and ANCOVA were used to test the statistical significance (p < 0.05). Simulation results showed that all the factors that reduced the risk of submarining increased the lumbar spine forces, indicating a direct conflict between submarining and lumbar spine fractures. Among all the factors selected, seat structure is the most significant factor in determining the lumbar spine force (p < 0.001). Crash pulse severity, time at which the peak crash deceleration reached, and pitch angle are also crucial for lumbar spine force. Specifically, increase in vehicle pitch angle increased lumbar spine force, but reduced injury measures to other body regions; while a crash pulse with early peak produced greater lumbar spine force than that with a late peak. On average, more reclined posture increased the lumbar spine force compared to upright posture, and decreases in the coefficient of friction between the pelvis and the seat cushion reduced the lumbar spine force. However, they are not statistically significant. This study provided better understanding of effects from design countermeasures to reduce occupant lumbar spine injuries in new generation of vehicle models., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Pediatric cervical spine injuries (CSI) are rare but potentially devastating sequelae of blunt trauma. Existing protocols to evaluate children at risk for CSI frequently incorporate computed topography (CT) and magnetic resonance imaging (MRI); however, the clinical value of performing both remains unclear., Methods: Single-center retrospective review of pediatric trauma patients who underwent both CT and MRI of the cervical spine between 2001 and 2015. Based on radiographic findings, CT and MRI results were grouped into one of three categories: no injury, stable injury, or unstable injury. Radiographic instability was defined by disruption of two or more contiguous spinal columns while radiographic stability was defined by any other acute cervical spine abnormality on imaging. Clinical instability was defined by the need for surgical intervention (halo or spinal fusion), with the remaining patients, including children discharged in a cervical collar, considered clinically stable., Results: In total, 221 children met inclusion criteria, with a median age of 9 (interquartile range, 3-14). The Glasgow Coma Scale (GCS) score of the cohort was 9 (interquartile range, 4-15). Thirty-three (14.9%) children had clinically unstable injuries, requiring surgical intervention. Among the 160 (72.4%) children with no injury on CT, MRI identified no injury in 84 (52.5%) cases, a stable injury in 76 (47.5%) cases, and an unstable injury in none. Among the 21 children with stable injuries on CT, MRI findings were concordant in 17 (81.0%) cases. In four (19.0%) cases, a spinal column injury was identified on CT and appeared to be stable, but later deemed unstable on MRI. Forty (18.1%) patients had an unstable injury on CT with 100% MRI concordance., Conclusion: In pediatric trauma patients suspected of having a CSI, a normal cervical spine CT is sufficient to rule out a clinically significant CSI as no child with a normal cervical CT was found to be radiographically or clinically unstable., Level of Evidence: Diagnostic Test, level III.

A short cut review was carried out to establish whether patients presenting to the emergency department after a near drowning should have cervical spine immobilisation. A search of the literature found only three studies directly relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that cervical spine injuries are rare in drowning and near drowning unless there is a history of diving or a fall or signs of trauma. Cervical spine immobilisation should be reserved for cases where there is a reasonable suspicion of a spinal injury., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: There is uncertainty regarding the efficacy of ski helmets in preventing traumatic injury. We investigated the relationship between helmet use, injury types, and injury severity among skiers and snowboarders., Methods: The trauma registry at a Northeast American College of Surgeons Level I trauma center was queried by International Classification of Diseases Codes-9th or 10th Revision for skiing and snowboarding injury between 2010 and 2018. The primary exposure was helmet use and primary outcome was severe injury (Injury Severity Score >15). We performed univariate and multivariable logistic regression to assess for injury types and severity associated with helmet use., Results: Seven hundred twenty-one patients (65% helmeted, 35% unhelmeted) met inclusion criteria. Helmet use doubled during the study period (43% to 81%, p < 0.001), but the rate of any head injury did not significantly change (49% to 43%, p = 0.499). On multivariable regression, helmeted patients were significantly more likely to suffer severe injury (odds ratio [OR], 2.01; 95% confidence interval [CI], 1.30-3.11), intracranial hemorrhage (OR, 1.81; 95% CI, 1.10-2.96), chest injury (OR, 1.66; 95% CI, 1.05-2.61), and/or lumbosacral spine injury (OR, 1.84; 95% CI, 1.04-3.25) than unhelmeted patients. Helmeted patients were half as likely to suffer cervical spine injury (OR, 0.51; 95% CI, 0.30-0.89) and a third as likely to sustain skull fracture and/or scalp laceration (OR, 0.30; 95% CI, 0.14-0.64). More patients who hit a stationary object were helmeted compared with those who fell from standing height onto snow (70% vs. 56% respectively, p < 0.001). After adjustment, hitting a stationary object was the injury mechanism most significantly associated with severe injury (OR, 2.80; 95% CI, 1.79-4.38)., Conclusion: Helmeted skiers and snowboarders evaluated at a Level I trauma center were more likely to suffer severe injury, including intracranial hemorrhage, as compared with unhelmeted participants. However, they were less likely to sustain skull fractures or cervical spine injuries. Helmeted patients were also more likely to hit a stationary object. Our findings reinforce the importance of safe skiing practices and trauma evaluation after high-impact injury, regardless of helmet use., Level of Evidence: Prognostic and epidemiological, level IV.

Introduction: Exercise-related injuries (ERIs) are a common cause of nonfatal emergency department and hospital visits. CrossFit is a high-intensity workout regimen whose popularity has grown rapidly. However, ERIs due to CrossFit remained under investigated., Methods: All patients who presented to the main hospital at a major academic center complaining of an injury sustained performing CrossFit between June 2010 and June 2016 were identified. Injuries were classified by anatomical location (eg, knee, spine). For patients with spinal injuries, data were collected including age, sex, body mass index (BMI), CrossFit experience level, symptom duration, type of symptoms, type of clinic presentation, cause of injury, objective neurological examination findings, imaging type, number of clinic visits, and treatments prescribed., Results: Four hundred ninety-eight patients with 523 CrossFit-related injuries were identified. Spine injuries were the most common injuries identified, accounting for 20.9%. Among spine injuries, the most common location of injury was the lumbar spine (83.1%). Average symptom duration was 6.4 months ± 15.1, and radicular complaints were the most common symptom (53%). A total of 30 (32%) patients had positive findings on neurologic examination. Six patients (6.7%) required surgical intervention for treatment after failing an average of 9.66 months of conservative treatment. There was no difference in age, sex, BMI, or duration of symptoms of patients requiring surgery with those who did not., Conclusions: CrossFit is a popular, high-intensity style workout with the potential to injure its participants. Spine injuries were the most common type of injury observed and frequently required surgical intervention.

Introduction: Road traffic accidents (RTAs) are the most frequent cause of traumatic spinal injuries (TSIs), which account for up to 33.6% of all spinal fractures. The Kingdom of Saudi Arabia (KSA) is one of the countries which has high rates of SCIs and bears the economic burden of that situation., Methods: 120 patients were included in this study, using a stringent set of inclusion and exclusion criteria. The patients were followed-up from the point of triage to admission and discharge. We analysed the clinical notes of the patients to determine the severity of their traumatic spinal injuries, the neurosurgical management carried out, and other prognosticating factors such as blood transfusion and the Glasgow Coma Scale (GCS). The data collected was analysed anonymously, and the confidentiality of all participants was respected., Results: Most of the patients were young adults and adolescents under the age of 40 (n = 96). There was a male preponderance of 84.1%. With respect to spinal injury stratification, 55 patients had cervical spine fractures, 10 patients had cervical lacerations, 85 patients had thoracolumbar spinal fractures, and 10 patients had thoracolumbar spinal lacerations. 35 patients had other fractures documented. All 120 patients were followed up to assess the management of their traumatic spinal injuries. 66.6% (n= 80) of all patients were managed conservatively, whereas the remaining 33.3% (n=40) were managed surgically., Conclusion: Trauma is an important cause of spinal injuries (TSIs), and untreated TSIs may lead to poor clinical outcome, especially if the cervical region is involved., Competing Interests: The authors declare no competing interests., (© Khalid Hadi Aldosari et al.)

Background: High rates of pneumonia and death have been reported among elderly patients with rib fractures. This study aims to identify patterns of injury and risk factors for pneumonia and death in elderly patients with rib fractures., Methods: A retrospective multicenter observational study was performed using data registered in the national trauma registry between 2008 and 2015 in the South West Netherlands Trauma region. Data regarding demographics, mechanism of injury, pulmonary and cardiovascular history, pattern of extra-thoracic and intrathoracic injuries, ICU admission, length of stay, and morbidity and mortality following admission were collected., Results: Eight hundred eighty-four patients were included. Median age was 76 years (P 25 -P 75 70-83). 235 patients (26.6%) were 81 years or older. Moderate or worse extra-thoracic injuries were present in 456 patients (51.6%), of whom 146 (16.6%) had severe head injuries and 45 (5.1%) severe spinal injuries. Median ISS was 9 (P 25 -P 75 5-18). The rate of pneumonia was 10% (n = 84). Ten percent of patients (n = 88) died. Risk factors for in-hospital mortality included age (OR 3.4; p = 0.003), presence of COPD (OR 1.3; p = 0.01), presence of cardiac disease (OR 2.6; p = 0.003), severe or worse head (OR 3.5; p < 0.001), abdominal (OR 6.8; p = 0.004) and spinal injury (OR 4.6; p = 0.011) by AIS, number of rib fractures (OR 2.6; p = 0.03), and need for chest tube drainage (OR 2.1; p = 0.021)., Conclusions: Pneumonia and death occur in about 10% of elderly patients with rib fractures. Apart from the severity of thoracic injuries, the presence and severity of extra-thoracic injuries and cardiopulmonary comorbidities are associated with poor outcome.

Introduction: Alpine winter sports have become increasingly popular over recent decades, with a similar increase in accident incidence. This review provides an overview of the most recent literature concerning spinal injury epidemiology, mechanisms, patterns and prevention strategies in the context of alpine winter sports., Material and Methods: The PubMed, Cochrane Library, and EMBASE databases were searched using the keywords spine injury, alpine injury, spine fracture, skiing injuries, snowboard injuries. 64 published studies in English and German met a priori inclusion criteria and were reviewed in detail by the authors., Results: There are various mechanisms of injury in alpine winter sports (high speed falls in skiing, jumping failure in snowboarding) whilst regionality and injury severity are broadly similar. The thoracolumbar spine is the most common region for spinal injury. Spinal cord injury is relatively rare, usually accompanying distraction and rotation type fractures and is most commonly localised to the cervical spine. Disc injuries seem to occur more commonly in alpine winter sport athletes than in the general population., Discussion: Despite awareness of increasing rates and risks of spinal injuries in alpine winter sports, there has been little success in injury prevention.

Steel rod impalements, mostly experienced by construction workers due to falls from heights, are known entities, but only some individuals unfortunately suffer spinal cord injury. The management of the spine involved injuries is challenging due to the lack of guidelines, various clinical presentations resulting from different trajectories, and high risk of infection. We report a case of steel rod impalement involving the spinal canal and review the literature to enhance the management strategies and to identify the risk factors for possible complications, particularly infection. A 37-year-old male construction worker presented to our emergency department due to falling onto a concrete reinforcing steel rod that penetrated through his perineum to the L4 vertebra. Examination revealed paralysis and sensory loss of the left foot. The rod was removed in the operating room (closed removal) under general anesthesia, followed by laparotomy. Rectal laceration was primarily repaired, and colostomy was performed. In a separate session, laminectomy was performed. At 3 months post-discharge, the patient was ambulatory with armrest based on the same motor examination performed on presentation This case is a good example of careful preoperative planning, multidisciplinary involvement, and appropriately sequenced interventions resulting in an acceptable outcome for an injury with high morbidity and mortality and demonstrates the feasibility and potential benefits of closed removal of the rod in an operating room just before laparotomy. The presence of an intestinal perforation increases the infection risk, but infections can still be prevented in this setting. Shorter time intervals between the incidence and surgery may reduce the infection rate.

Introduction: This study evaluates characteristics and risk factors of traumatic spinal injuries (TSIs) treated at a trauma center in Abuja, Nigeria. TSIs are a global concern. They are frequently disabling, leading to economic, workforce, and quality of life strain. Little is known of the epidemiology of TSIs in Nigeria., Methods: Data were collected from National Hospital Abuja's trauma registry on 3025 patients treated at the hospital between 2014 and 2017. Patient characteristics were compared between spinal and nonspinal injury groups. Multiple logistic regression was used to identify risk factors of TSIs., Results: 15% (452) of all injuries were spinal. Road traffic crashes were a significantly greater cause of spinal (77.4%) than nonspinal (59.4%) injuries (p<0.0001). Pedestrians were involved in 19% (356) of total crashes, occupying a significantly larger proportion of spinal (18.6%) than nonspinal (10.6%) injuries (p<0.0001). Three variables were modeled as risk factors of crash-related TSIs: mode of transportation, age, and gender. Only mode of transportation demonstrated statistical significance, with involvement as a pedestrian showing an adjusted odds ratio of 1.38 (95% confidence interval: 1.03-1.85, p=0.0329)., Conclusion: Determining characteristics and risk factors of TSIs is an essential step in addressing this health concern in Nigeria. Crashes are a significant cause of TSIs, and a quarter of TSI patients involved in a crash are pedestrians. Involvement in a crash as a pedestrian is associated with high risk of TSI. These results can help guide both the development of spinal injury prevention policies and the allocation of resources., Competing Interests: The authors declare no competing interests.

Head collisions in sport can result in catastrophic injuries to the cervical spine. Musculoskeletal modelling can help analyse the relationship between motion, external forces and internal loads that lead to injury. However, impact specific musculoskeletal models are lacking as current viscoelastic values used to describe cervical spine joint dynamics have been obtained from unrepresentative quasi-static or static experiments. The aim of this study was to develop and validate a cervical spine musculoskeletal model for use in axial impacts. Cervical spine specimens (C2-C6) were tested under measured sub-catastrophic loads and the resulting 3D motion of the vertebrae was measured. Specimen specific musculoskeletal models were then created and used to estimate the axial and shear viscoelastic (stiffness and damping) properties of the joints through an optimisation algorithm that minimised tracking errors between measured and simulated kinematics. A five-fold cross validation and a Monte Carlo sensitivity analysis were conducted to assess the performance of the newly estimated parameters. The impact-specific parameters were integrated in a population specific musculoskeletal model and used to assess cervical spine loads measured from Rugby union impacts compared to available models. Results of the optimisation showed a larger increase of axial joint stiffness compared to axial damping and shear viscoelastic parameters for all models. The sensitivity analysis revealed that lower values of axial stiffness and shear damping reduced the models performance considerably compared to other degrees of freedom. The impact-specific parameters integrated in the population specific model estimated more appropriate joint displacements for axial head impacts compared to available models and are therefore more suited for injury mechanism analysis., Competing Interests: The authors have declared that no competing interests exist.

A 68-year-old man presented with back pain after falling from a ladder and was found to have anterolisthesis of thoracic vertebrae T11-12 with secondary focal aortic injury and disruption of the aortic wall. This was successfully repaired using thoracic endovascular aortic repair (TEVAR) followed by spinal fusion with excellent result.

Introduction: "Blobbing" is a modern outdoor activity where a participant sits on the end of a partially inflated air bag ("blobber") and is launched into the water when another participant jumps onto the air bag from a platform on the opposite side ("jumper"). This is the first study to evaluate the injury patterns associated with blobbing., Patients and Methods: A retrospective data analysis was conducted based on 86 patients who sustained blobbing injuries between January 2011 and December 2016. The date of birth, gender, day of injury, diagnosis, body region of trauma, and treatment were recorded for the patients. Treatment was subclassified into conservative or surgical treatment. The position of the participant was recorded as either a jumper or a blobber., Results: One-third of the patients sustained a spine injury, which was the most common body part injured. The most frequent type of injury was cervical spine distortion. All shoulder (n = 9), elbow (n = 3), hand (n = 2), knee (n = 3), and foot (n = 12) injuries occurred in jumpers, whereas all ear (n = 6) and lung (n = 5) injuries occurred in blobbers. Head (n = 5) and spine (n = 33) injuries were distributed in jumpers and blobbers. Sixty-nine patients were treated with conservative treatment. Three ankle fractures and two spine fractures were treated with immediate surgical treatment. Twelve patients were treated with conservative treatment but were referred for potential surgery at their hospital at home., Conclusion: Both jumpers and blobbers were prone to injuries. More severe injuries with the potential for surgical treatment occurred in jumpers, presumably because of bad landings. This analysis of the injury patterns in blobbers might lead to the introduction of protective gear and changes in the behavior of participants in order to reduce the risk of injury., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background/aim: Reconstruction of spinal soft tissue defects is challenging, especially when neural structures or prosthetic material are exposed. They should be covered with well-vascularized tissue such as paraspinal perforator flaps., Materials and Methods: This is a retrospective study of soft tissue reconstructions with paraspinal perforator flaps from 2011 to 2018. The technique is described and risk factors for poor wound healing were assessed. Postoperative complications are reported., Results: Twenty patients with a mean age of 63.65 years were included. Defects had an average size of 47 cm 2 and were mainly located in the lumbosacral region (9 patients). Twelve patients suffered from infection following spinal stabilization, seven of whom were diagnosed with osteomyelitis, two patients presented with pressure sore and one patient experienced wound dehiscence. One partial flap necrosis with a lumbar defect occurred, which required revision surgery. No total flap loss occurred. Stable, closed wounds were achieved at their final follow-up., Conclusion: Perforator paraspinal flaps are suitable for immediate reconstruction of spinal defects., (Copyright© 2019, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Introduction: traumatic spinal fracture is a painful and disabling injury associated with poor long-term functional outcome. The objective of the present study was to assess the frequency of spinal fractures in road traffic accident (RTA) victims, their management, mortality rate and associated injuries. This study reveals and adds useful insights to the literature from Kingdom of Saudi Arabia (KSA) in terms of incidence of RTA-related spinal fractures, including their management and mortality rate., Methods: a cross-sectional study was conducted at King Khalid Hospital and Prince Sultan Center for Health Services (KKH & PSCHS) in AlKharj, KSA from September 2016 to June 2017. A total of 120 patients suffering from spinal/vertebral fractures due to RTAs were included in this study. The data was collected from patients' charts, including age, gender, region or distribution of the spinal fracture, associated fractures, number of fractures, degrees of shock, admission to intensive care unit (ICU), treatment modalities, along with the management of spinal fractures, days of hospital stay, referral and discharges or deaths., Results: the mean age of patients was 29.21. The most common anatomic region of the fracture was the cervical region (35%). Injuries associated with traumatic spinal fracture were predominated by clavicular fractures. More than half of the victims (58.30%) had a cervical brace applied before leaving the hospital. 29.20% patients required posterior stabilization with pedicle screws. Anterior corpectomy, grafting and plating was done to 4.30% patients., Conclusion: traumatic spinal fractures require prompt diagnosis and timely management in order to improve the outcome., Competing Interests: The authors declare no competing interests.

Background: Head-first impacts with an aligned cervical spine cause some of the most severe types of injuries due to the risk of fractures and associated spinal cord injury. Sports, such as football, mountain biking and horseback riding, contribute to the incidence of spinal cord injury but there is potential to reduce the risk of these injuries through a helmet-mounted device., Methods: A novel device, the Pro-Neck-Tor mechanism, was incorporated into a commercial football helmet and tested in head-first impact experiments. The Pro-Neck-Tor connects an inner and outer helmet shell, which upon head-first impact of a certain load, induces motion of the head away from the path of the following torso. Impacts were performed onto three impact surface angles with a flexion-inducing Pro-Neck-Tor mechanism., Findings: Based on averaged data, the Pro-Neck-Tor provided a significant and consistent reduction in peak compressive neck forces compared to the unmodified football helmet in the conditions tested. In some impact conditions, the Pro-Neck-Tor increased the peak sagittal plane neck bending moments and impulse over that observed for the unmodified helmet., Interpretation: The Pro-Neck-Tor with flexion escape is capable of lowering axial neck forces in head-first impacts compared to a conventional helmet by guiding the cervical column away from an aligned posture and into an eccentric loading scenario which published studies suggests frequently leads to no injury or to a less severe injury. Continued development and testing of the device are needed to optimize the altered neck loading and to drive the design toward a commercial configuration., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

The battlefield treatments of spinal and spinal cord injury vary from civilian settings. However, there is no unified battlefield treatment guidelines for spine trauma in PLA. An expert consensus is reached, based on spine trauma epidemiology and the concepts of battlefield treatment combined with the existing levels of military medical care in modern warfare. Since the specialized treatment for spine trauma are no significant difference between civilian settings and modern war, the first aid, emergency treatment and early treatment of spine trauma are introduced separately in three levels in this consensus. In Level I facilities, the fast and accurate evaluation of spine trauma followed by fixation and stabilization are recommended during the first-aid stage. Re-evaluation, further treatment for possible hemorrhagic shock, dyspnea and infection are recommended at Level II facilities. At Level III facilities, it is recommended to strengthen the intensive care and the prevention of urinary system and lung infection for the wounded with severe spinal injury, however, spinal surgery is not recommended in a battlefield hospital. The grading standard for evidence evaluation and recommendation was used to reach this expert consensus.

Background: Although rare, spinal injuries associated with abuse can have potentially devastating implications in the pediatric population. We analyzed the association of pediatric spine injury in abused children and determined the anatomic level of the spine affected, while also focusing on patient demographics, length of stay, and total hospital charges compared with spine patients without a diagnosis of abuse., Methods: A retrospective review of the Kids' Inpatient Database was conducted from 2000 to 2012 to identify pediatric patients (below 18 y) who sustained vertebral column fractures or spinal cord injuries. Patients with a documented diagnosis of abuse were identified using ICD-9-CM diagnosis codes. Our statistical models consisted of multivariate linear regressions that were adjusted for age, race, and sex., Results: There were 22,192 pediatric patients with a diagnosis of spinal cord or vertebral column injury during the study period, 116 (0.5%) of whom also had a documented diagnosis of abuse. The most common type of abuse was physical (75.9%). Compared with nonabused patients, abused patients were more likely to be below 2 years of age (OR=133.4; 95% CI, 89.5-198.8), female (OR=1.67; 95% CI, 1.16-2.41), and nonwhite (black: OR=3.86; 95% CI, 2.31-6.45; Hispanic: OR=2.86; 95% CI, 1.68-4.86; other: OR=2.33; 95% CI, 1.11-4.86). Abused patients also presented with an increased risk of thoracic (OR=2.57; 95% CI, 1.67-3.97) and lumbar (OR=1.67; 95% CI, 1.03-2.72) vertebral column fractures and had a multivariate-adjusted mean length of stay that was 62.2% longer (P<0.001) and mean total charges that were 52.9% higher (P<0.001) compared with nonabused patients. Furthermore, 19.7% of all pediatric spine patients under 2 years of age admitted during the study period belonged to the abused cohort., Conclusions: Spine injuries are rare but can be found in the pediatric population. With an additional documented diagnosis of abuse, these injuries affect younger patients in the thoracolumbar region of the spine, and lead to longer lengths of stay and higher hospital costs when compared with nonabused patients. Because of these findings, physicians should maintain a higher level of suspicion of abuse in patients with spine injuries, especially patients under 2 years of age., Level of Evidence: Level III evidence-a case-control study.

Background: Subaxial cervical spine injuries may be treated with either nonoperative stabilization or surgical fixation. The subaxial injury classification (SLIC) provides 1 method for suggesting the degree of necessity for surgery. In the current study, we examined if the SLIC score, or other preoperative metrics, can predict failure of nonoperative management., Methods: We performed a retrospective chart review to identify patients who presented with acute, nonpenetrating, subaxial cervical spine injury within our health system between 2007 and 2016. Patient demographics, medical comorbidities, injuries, and treatments were collected. Logistic regression analysis was used to determine potential predictors of failure of nonoperative management., Results: During the study period, 40 patients met the inclusion criteria. A small subset of patients failed nonoperative management (n = 5, 12.5%). The mean SLIC score was 3.9 ± 1.9; however, 14 (35%) patients had scores >4. Neither total SLIC score (P = 0.68) nor SLIC subscores (morphology [P = 0.96], discoligamentous complex [P = 0.83], neurologic status [P = 0.60]) predicted failure of nonoperative treatment. Time to evaluation/treatment did predict failure of nonoperative management. Evaluation within 8 hours of injury was a negative predictor of failure (odds ratio = 0.03, P = 0.001) and evaluation 24 hours or more after injury was a positive predictor of failure (odds ratio = 66.00, P < 0.001). We created a modified SLIC score on the basis of these findings, which significantly predicted failure of nonoperative management (P = 0.044)., Conclusions: Management of subaxial spine injuries is complex. In our cohort, SLIC scoring did not adequately predict odds of failure of nonoperative management. Time to evaluation, however, did. We created a modified SLIC score that significantly predicted failure of nonoperative management., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: To compare self-extraction with and without a cervical collar in subjects at low risk of cervical spine injuries., Material and Methods: Simulation study analyzing biomechanical data from inertial sensors to detect misalignment of the cervical spine during self-extraction with and without a cervical collar., Results: Misalignment was a mean (SD) 3.12 (34.62) degrees greater during self-extraction with a Stiffneck collar in place (95% CI, -15.33 to 21.57 degrees; P=.7234) than during extraction without a collar. Misalignment was also greater, by 5.95 (31.76) degrees, with an X-collar in place (95% CI, -10.98 to 22.87; P=.4654) than without a collar. The between-collar comparison of differences showed that misalignment was 2.83 (12.10) degrees greater with the X-collar (95% CI, -3.62 to 9.27 degrees; P=.3650)., Conclusion: Misalignment of the cervical spinal column is similar during self-extraction with or without a cervical collar in place.

Background: Although several investigations have examined the epidemiology of cervical spine injuries in sports, few studies have analyzed the nationwide incidence and sex-specific epidemiology of cervical spine injuries., Method: The National Electronic Injury Surveillance System database, which collects information on patients presenting to the emergency department at 100 hospitals across the United States, was queried for neck sprains and cervical fractures associated with sporting activities from 2000-2015., Result: A total of 26,380 neck sprains and 1166 fractures were identified. Compared with females, the incidence for injuries in males was 1.7 times greater for neck sprains and 3.6 times greater for fractures (P < 0.0001). Football was the most common cause of cervical sprains in males, followed by cycling and weightlifting/aerobics. Females sustained most neck sprains in weightlifting/aerobics, trampoline, and cheerleading. From 2000 to 2015, the incidence of neck sprains from aerobics increased from 15.5 to 25.3 per million person-years (P < 0.0001). Similarly, the incidence of cervical fractures from cycling increased from 0.67 to 2.7 per million (P < 0.0001). For males, cycling was the most common cause of fracture, followed by diving/swimming and football. For females, horseback riding was most common, followed by cycling and diving/swimming., Conclusions: Football is the leading cause of cervical sprains in the United States. The most common cause of cervical fracture in men is cycling, while in women it is horseback riding. The incidence of sport-related cervical fractures has increased by 35% from 2000 to 2015, which has been driven by an increase in cycling-related injuries., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Up to 4% of adults with blunt trauma suffer cervical spine injury. Clinicians who evaluate trauma patients can use validated clinical decision tools to assess whether patients are at risk for these injuries. Beyond these tools, imaging (most often CT) remains the mainstay of evaluation. Further challenges exist when patients have persistent pain or cannot be evaluated clinically. This article reviews the evidence available to assist clinicians in evaluating adults for significant cervical spine injury after blunt trauma.

Study Design: This was a retrospective case series at a single institution., Objective: The study was performed to investigate the characteristics of spinal injuries in survivors of suicidal jumping., Summary of Background Data: Spinal fracture/dislocation is associated with high-energy trauma such as that induced by motor vehicle accidents. Survivors of suicidal jumping sometimes sustain spinal injuries. However, the characteristics of such spinal injuries are unclear., Methods: We identified 87 survivors of suicidal jumping who sustained spinal injuries from 2007 to 2016 in our institution. We compared the demographic data, radiological findings, neurological status, associated injuries, treatments, and mental health conditions between these 87 survivors and 204 non-suicidal patients with spinal injury., Results: Suicidal jumpers were predominantly female (67%) and 10 years younger than non-suicidal patients. Mental health problems, mainly schizophrenia and depression, were diagnosed in 77% of suicidal jumpers. Neurological damage from spinal trauma was generally less severe in suicidal jumpers than in non-suicidal patients. Most spinal injuries in suicidal jumpers were located in the thoracic or lumbar spine region (85%). Among comorbid injuries, extremity injuries were highly associated with spine injury in suicidal jumpers. Nearly 70% of suicidal jumpers exhibited extremity injury in contrast to 33% of non-suicidal patients. Approximately, 25% of suicidal jumpers underwent surgical treatment. Surgical treatment was similarly performed on suicidal jumpers and non-suicidal patients regardless of the discrepancy in neurological damage between these two groups., Conclusion: Spinal injuries in suicidal jumpers differed from spinal injuries in non-suicidal patients with regard to sex, age, mental health condition, injury location, neurologic damage, and associated injuries. Most survivors of suicidal jumping were young female patients with mental health problems. They tended to have thoracic and lumbar spine trauma rather than cervical trauma with less severe neurological deficits and a higher incidence of accompanying limb injury., Level of Evidence: 3.

Purpose: Long-term side effects of the treatments are common in survivors of irradiated pediatric brain tumors. Ionizing radiation in combination with surgery and chemotherapy during childhood may reduce vertebral height and bone mineral density (BMD), and cause growth failure. The aim of this study was to evaluate the late consequences of tumor treatments on vertebrae in survivors of childhood brain tumors., Methods: 72 adult survivors (mean age 27.8 years, standard deviation 6.7) of irradiated childhood brain tumor were studied by spinal magnetic resonance imaging (MRI) for vertebral abnormalities from the national cohort of Finland. Patients were treated in five university hospitals in Finland between the years 1970 and 2008. Subject height and weight were measured and body mass index (BMI) was calculated. The morphology and height/depth ratio of the vertebrae in the middle of the kyphotic thoracic curvature (Th8) and lumbar lordosis (L3) were examined. Vertebrae were analyzed by Genant's semiquantative (SQ) method and spinal deformity index (SDI) was calculated. BMD was measured by using dual X-ray absorptiometry., Results: 4.2% (3/72) of the patients had undiagnosed asymptomatic vertebral fracture and 5.6% (4/72) of patients had radiation-induced decreased vertebral body height. Male patients had flatter vertebrae compared with females. Patient age at the time of irradiation, BMI and irradiation area correlated to vertebral morphology differentially in males and females. BMD had no association with the vertebral shape. Patients who had received craniospinal irradiation were shorter than the general population., Conclusion: Childhood brain tumor survivors had a high number of vertebral abnormalities in young adulthood. Irradiation was associated with abnormal vertebral morphology and compromised final height. Male gender may predispose vertebrae to the side effects of irradiation., Competing Interests: The authors have declared that no competing interests exist.

This study was designed to assess the utility of using a measure of dynamic spine stability in an unfatigued, rested state as a predictor of dynamic spine stability in a challenged, fatigued state. Participants completed three trials (Day 1: Rested, Fatigued; Day 2: Recovery) during which the dynamic stability of the spine was assessed over 30 repeated flexion/extension motions using maximum finite-cycle Lyapunov exponents. Multiple sets of dynamic trunk extensions were performed to fatigue the trunk extensor muscles. Across the sample population, an increase in dynamic spine stability when fatigued was observed, as well as a moderate correlation between the level of dynamic stability when rested and a stabilizing response when fatigued. Further analysis of the data on a person-by-person basis revealed three distinct responses in which participants either stabilized, destabilized or had no change in dynamic spine stability when fatigued. Therefore, the mean response of the sample population did not adequately represent the true, meaningful response of individuals within the population. These results illustrate the importance of considering individualized responses when examining dynamic stability measures, and provide preliminary evidence that suggests that individual injury risk cannot be completely captured by measures taken in an unchallenged, rested state., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Although spinal injuries in fish have been associated with electric stimuli applied during electrofishing and electrotrawling, bone fracture and repair in the axial skeleton have yet not been studied. To study this, we radiographed a group (n = 64) of individually tagged farmed cod twice, with a 1-year interval (∼36 cm at first and ∼ 50 cm at second inspection). The study focus was on the neural and haemal spines. These structures are un-paired and are not covered by other bones laterally, making them useful for radiological studies on axial skeletal fracture in live fish. At the first examination, four animals showed radiological changes in their neural and haemal spines. Two animals had fractures, and two had callus formations. One year later, at the second radiological examination, the fractures had developed into calluses or into normal morphology, and calluses either remained as calluses or had developed into normal morphology. A further 14 animals that were all normal at the first inspection had developed changes in their neural and haemal spines, both fractures and callus formations. This is the first record of spontaneous bone fracture in fish; the fractures observed occurred under normal farming conditions and were not induced. The results show that cod have a functional fracture healing mechanism in their neural and haemal spines. The findings are discussed in relation to fish hyperostosis., (© 2018 John Wiley & Sons Ltd.)

Objective: To determine role of lordosis in cervical spine injuries using a novel competing risk analysis model., Methods: The first subgroup of published experiments (n = 20) subjected upright human cadaver head-neck specimens to impact loading. The natural lordosis was removed. The second (n = 21) and third (n = 10) subgroups of published tests subjected inverted specimens to head impact loading. Lordosis was preserved in these 2 subgroups. Using axial force and age as variables, competing risks analysis techniques were used to determine the role of lordosis in the risk of bone-only, ligament-only, and bone and ligament injuries., Results: Bony injuries were focused more at 1 level to a straightened spine, and ligament injuries were spread around multiple levels. Age was not a significant (P < 0.05) covariate. A straightened spine had 3.23 times higher risk of bony injuries than a lordotic spine. The spine with maintained lordosis had 1.14 times higher risk of ligament injuries, and 2.67 times higher risk of bone and ligament injuries than a spine without lordosis (i.e., preflexed column)., Conclusions: Increased risk of bony injuries in a preflexed spine and ligament injuries in a lordotic spine may have implications for military personnel, as continuous use of helmets in the line of duty affects the natural curvature; astronauts, as curvatures are less lordotic after missions; and civilian patients with spondylotic myelopathy who use head protective devices, as curvatures may change over time in addition to the natural aging process., (Published by Elsevier Inc.)

Cervical spine injuries can occur in military scenarios from events such as underbody blast events. Such scenarios impart inferior-to-superior loads to the spine. The objective of this study is to develop human injury risk curves (IRCs) under this loading mode using Post Mortem Human Surrogates (PMHS). Twenty-five PMHS head-neck complexes were obtained, screened for pre-existing trauma, bone densities were determined, pre-tests radiological images were taken, fixed in polymethylmethacrylate at the T2-T3 level, a load cell was attached to the distal end of the preparation, positioned end on custom vertical accelerator device based on the military-seating posture, donned with a combat helmet, and impacted at the base. Posttest images were obtained, and gross dissection was done to confirm injuries to all specimens. Axial and resultant forces at the cervico-thoracic joint was used to develop the IRCs using survival analysis. Data were censored into left, interval, and uncensored observations. The Brier score metric was used to rank the variables. The optimal metric describing the underlying response to injury was associated with the axial force, ranking slightly greater than the resultant force, both with BMD covariates. The results from the survival analysis indicated all IRCs are in the "fair" to "good" category, at all risk levels. The BMD was found to be a significant covariate that best describes the response of the helmeted head-neck specimens to injury. The present experimental protocol and IRCs can be used to conduct additional tests, matched-pair tests with the WIAMan and/or other devices to obtain injury assessment risk curves (IARCs) and injury assessment risk values (IARVs) to predict injury in crash environments, and these data can also be used for validating component-based head-neck and human body computational models.

Objective: The aim of this study was to ascertain potential factors associated with cervical spine injuries in children injured during sports and recreational activities., Methods: This is a secondary analysis of a multicenter retrospective case-control study involving children younger than 16 years who presented to emergency departments after blunt trauma and underwent cervical spine radiography. Cases had cervical spine injury from sports or recreational activities (n = 179). Comparison groups sustained (1) cervical spine injury from other mechanisms (n = 361) or (2) other injuries from sports and recreational activities but were free of cervical spine injury (n = 180)., Results: For children with sport and recreational activity-related cervical spine injuries, common injury patterns were subaxial (49%) and fractures (56%). These children were at increased odds of spinal cord injury without radiographic abnormalities compared with children with cervical spine injuries from other mechanisms (25% vs 6%). Children with sport and recreational activity-related trauma had increased odds of cervical spine injury if they had focal neurologic findings (odds ratio [OR], 5.7; 95% confidence interval [CI], 3.5-9.4), had complaints of neck pain (OR, 3.1; 95% CI, 1.9-5.0), were injured diving (OR, 43.5; 95% CI, 5.9-321.3), or sustained axial loading impacts (OR, 2.2; 95% CI, 1.3-3.5). Football (22%), diving (20%), and bicycle crashes (11%) were the leading activities associated with cervical spine injury., Conclusions: In children injured during sports and recreational activities, focal neurologic findings, neck pain, axial loading impacts, and the possibility of spinal cord injury without radiographic abnormality should guide the diagnostic evaluation for potential cervical spine injuries. Certain activities have a considerable frequency of cervical spine injury, which may benefit from activity-specific preventive measures.

Background: Conventional intubation of the trachea and consequent prone positioning of anesthetized patients with cervical spine instability may result in secondary neurological injury. Historically, flexible fiberoptics used to be the chief choice for patients presenting with cervical spine instability surgery with difficult airway. Recently, the rigid optical stylets have shown promise in assisting difficult intubations., Purpose: The aim of the present study was to compare the efficacy of Shikani optical stylet (SOS) with the flexible fiberscope for awake intubation in patients with cervical spine instability., Patients and Methods: In total, 60 adult patients diagnosed with cervical instability or at risk of secondary cervical injury, who were planned for awake intubation and/or self-positioning prone, were registered in this study and were randomly categorized into 2 equal groups (30 patients each), a fiberoptic group and an SOS group, followed by assessment of coughing and gagging during intubation, time to successful intubation, number of attempts for successful intubation, and hemodynamic parameters., Results: As regards time to successful intubation, statistically significant differences were detected between the 2 studied groups, with the fiberoptic group having significantly longer intubation time than the Shikani group, whereas no statistically significant differences were recorded between the 2 groups with regard to the first-attempt success, the mean heart rate value, the mean arterial blood pressure, coughing, and occurrence of complications., Conclusion: This study validates the efficacy of both SOS and flexible fiberoptic bronchoscope for awake oral intubation in patients with cervical spine instability. SOS has been found to be more effective in reducing time to intubation.

Study Design: Retrospective cohort study., Objective: To identify patient characteristics and associated injuries in those sustaining a spine fracture from personal watercraft (PWC) usage., Summary of Background Data: There are few studies regarding PWC use and injuries, and even more scarce are studies evaluating PWC usage and spine injuries. Identifying high-risk actions and individuals can help to effectively treat them, reduce mortality, and possibly avoid certain spine fractures., Methods: Retrospective analysis of 142 patients admitted from the emergency department with PWC-related injuries at a single-level I trauma center from January 1, 2004 to May 1, 2017. Twenty-six (18.3%) sustained a spine fracture, totaling 71 fractures. Statistical analysis was used to investigate the patient characteristics, specific mechanisms of injury, injury severity score (ISS), and associated injuries. Patients expiring (12) had incomplete evaluations and were excluded from most reported results., Results: Spine fractures were not associated with age, race, or sex, but were associated with a higher ISS, intensive care unit length, in-patient length of stay, cerebral injury, and abdominal/genitourinary (GU) injury. There were 8 cervical fractures, 22 thoracic fractures, 33 lumbar, and 8 sacral fractures. Axial load injuries were associated with vertebral body fractures and specifically burst fractures. Being a driver or passenger did not influence likelihood of a spine fracture, but did correlate with abdominal/GU injury. Five (19.2%) of patients with spine fractures required eight spine surgeries during admission. Mortality was associated with females, severe systemic injuries (ISS ≥ 15), direct collision mechanism of injury, and the spring season., Conclusion: PWC usage may result in spine fractures with a moderate percentage requiring orthopedic surgery. Additional studies should examine how hull or seat modifications can lessen the risk of axial loads leading to spine fractures. PWC patients with spine fractures should also be evaluated for abdominal/GU and cerebral injuries at presentation., Level of Evidence: 4.

Rationale: Traumatic bilateral facet dislocation in the lumbar (L) spine has rarely been reported. All reported cases were presented with acute facet dislocation. However, we present the first case of delayed bilateral facet dislocation at L4-5., Patient Concerns: A 34-year-old woman presented with back pain after a head-on collision. The patient was treated conservatively for 3 months with rigid orthosis and activity restriction. Even after this conservative treatment, she continued to suffer from persistent back pain that radiated down her left leg and a progressively kyphotic posture., Diagnoses: Initial imaging studies revealed a fracture of the left L5 superior articular process with a posterior ligament complex (PLC) injury. Subsequent radiographs showed the locked facet dislocation with kyphotic changes., Interventions: The patient underwent surgical reduction and fusion, and the operative findings revealed the L4-5 bilateral facet dislocation and rupture of the PLC at the index level., Outcomes: After surgical reduction and fusion at L4-5 by posterior interbody fusion, we achieved a satisfactory clinical outcome., Lessons: Injury of the PLC in the lower lumbar region deserves careful attention for the development of sequelae. The anatomic transition from lordosis to kyphosis, in the lumbosacral region may be related to this type of injury.

Introduction: Cycling has seen a large increase in popularity worldwide over the last number of years. This has been linked to an increase in the number of road traffic accidents involving cyclists. Participation in cycling as part of competitive sport and endurance events has seen particular growth., Aim: To examine patients referred with spinal trauma related to cycling and to assess whether the growing popularity of cycling and particularly competitive cycling is linked to an increase in spinal trauma., Methods: A retrospective analysis was carried out of a prospectively maintained database of referrals to a national referral centre for spinal trauma over a 4-year period (2010-2013). Data were further analysed for years 2012-2013, as there were incomplete data for years 2010-2011., Results: Spinal injuries involving cyclists increased by 200% from 2010 to 2013. In comparison those involving cars only increased by 29% and motorcycles reduced by 68%. From 2012 to 2013 there were 24 cyclist trauma referrals. The most common level injured was cervical spine (71%). Five patients (20.8%) had neurological deficit with 12.5% complete paralysis ASIA A disability score. The spinal fixation rate was 29.1%, 16.6% were managed with a HALO device. In total, 25% of patients were injured whilst training on a racer style bicycle, including all of the patients with complete spinal cord injury., Conclusion: There has been a significant increase in spinal trauma due to cycling accidents over this four year period. Competitive cycling has been a factor in the most severely injured patients. Increased public awareness campaigns for those participating in cycling for sport may be warranted., (Copyright © 2017 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

This study was to investigate the fracture risk of irritable bowel syndrome (IBS) in comparison with non-IBS group. Our results found that IBS group has increased risk for fracture, in particular of the spine, forearm, hip, and hand., Introduction: Patients with IBS might also be at increased risk of osteoporosis and osteoporotic fractures. Up to now, the association between IBS and the risk of fractures at different anatomic sites occurrences is not completely clear. We conducted a population-based cohort analysis to investigate the fracture risk of IBS in comparison with non-IBS group., Methods: We identified 29,505 adults aged ≥ 20 years with newly diagnosed IBS using the Taiwan National Health Insurance Research Database in 2000-2012. A comparison group was constructed of patients without IBS who were matched according to gender and age. The occurrence of fracture was monitored until the end of 2013. We analyzed the risk of fracture events to occur in IBS by using Cox proportional hazards regression models., Results: Patients with IBS had a higher incidence of osteoporotic fractures compared with the non-IBS group (12.34 versus 9.45 per 1000 person-years) and an increased risk of osteoporotic fractures (adjusted hazard ratio [aHR] = 1.27, 95% confidence interval [CI] = 1.20-1.35). Site-specific analysis showed that the IBS group had a higher risk of fractures for spine, forearm, hip, and hand than did the non-IBS group. With further stratification for gender and age, a higher aHR value for osteoporotic fractures in the IBS group was seen across all age groups in males, but seen in elderly females. In addition, female, elderly, low income, hypertension, coronary artery disease, cerebrovascular disease, and depressive disorders as independent osteoporotic fracture risk factors in IBS patients., Conclusions: The IBS is considered as a risk factor for osteoporotic fractures, particularly in female individuals and fracture sites located at the spine, forearm, hip, and hand.

Background: The present study aimed to find out if possible differences in early military flight career +Gz exposure level could predict permanent flight duty limitations (FDL) due to spinal disorders during a pilot's career., Methods: The study population consisted of 23 pilots flying with Gz limitation (max limitation ranging from +2 Gz to +5 Gz) due to spinal disorders and 50 experienced (+1000 flight hours) symptomless controls flying actively in operative missions in the Finnish Air Force. Data obtained for all subjects included the level of cumulative Gz exposure measured sortie by sortie with fatigue index (FI) recordings and flight hours during the first 5 yr of the pilot's career., Results: The mean (± SD) accumulation of FI in the first 5 yr of flying high-performance aircraft was 8.0 ± 1.8 among the pilots in the FDL group and 7.7 ± 1.7 in the non-FDL group. There was no association between flight duty limitations and early career cumulative +Gz exposure level measured with FI or flight hours., Discussion: According to the present findings, it seems that the amount of cumulative +Gz exposure during the first 5 yr of a military pilot's career is not an individual risk factor for spinal disorders leading to flight duty limitation. Future studies conducted with FI recordings should be addressed to reveal the relationship between the actual level of +Gz exposure and spinal disorders, with a longer follow-up period and larger sample sizes.Honkanen T, Sovelius R, Mäntysaari M, Kyröläinen H, Avela J, Leino TK. +Gz exposure and spinal injury-induced flight duty limitations. Aerosp Med Hum Perform. 2018; 89(6):552-556.

Purpose: This study examines non-accidental trauma (NAT) fatalities as a percentage of all injury fatalities and identifies injury patterns in NAT admissions to two level 1 pediatric trauma centers., Methods: We reviewed all children (<5years old) treated for NAT from 2011 to 2015. Patient demographics, injury sites, and survival were obtained from both institutional trauma registries., Results: Of 4623 trauma admissions, 557 (12%) were due to NAT. However, 43 (46%) of 93 overall trauma fatalities were due to NAT. Head injuries were the most common injuries sustained (60%) and led to the greatest increased risk of death (RR 5.1, 95% CI 2.0-12.7). Less common injuries that increased the risk of death were facial injuries (14%, RR 2.9, 95% CI 1.6-5.3), abdominal injuries (8%, RR 2.8, 95% CI 1.4-5.6), and spinal injuries (3%, RR 3.9, 95% CI 1.8-8.8). Although 76% of head injuries occurred in infants <1year, children ages 1-4years old with head injuries had a significantly higher case fatality rate (27% vs. 6%, p<0.001)., Conclusion: Child abuse accounts for a large proportion of trauma fatalities in children under 5years of age. Intracranial injuries are common in child abuse and increase the risk of death substantially. Preventing NAT in infants and young children should be a public health priority., Type of Study: Retrospective Review., Level of Evidence: II., (Copyright © 2018. Published by Elsevier Inc.)

Introduction: Horse-related injuries account for one quarter of all paediatric sports fatalities. It is not known whether the pattern of injury spectrum and severity differ between children injured whilst mounted, compared with those injured unmounted around horses. We aimed to identify any distinctions between the demographic features, spectrum and severity of injuries for mounted versus unmounted patients., Patients and Methods: Trauma registry data were reviewed for 505 consecutive paediatric patients (aged<16years) admitted to a large paediatric trauma centre with horse-related injuries over a 16-year period. Patients were classified into mounted and unmounted groups, and demographics, injury spectrum, injury severity, and helmet usage compared using odds ratios and Wilcoxon rank-sum tests., Results: More patients (56%) were injured in a private setting than in a sporting or supervised context (23%). Overall, head injuries were the most common horse-related injury. Mounted patients comprised 77% of the cohort. Mounted patients were more likely to sustain upper limb fractures or spinal injuries, and more likely to wear helmets. Unmounted were more likely to be younger males, and more likely to sustain facial or abdominal injuries. Strikingly, unmounted children had significantly more severe and critical Injury Severity Scores (OR 2.6; 95% CI 1.5, 4.6) and longer hospital stay (2.0days vs 1.1days; p<0.001). Unmounted patients were twice as likely to require intensive care or surgery, and eight times more likely to sustain a severe head injury., Conclusions: Horse-related injuries in children are serious. Unmounted patients are distinct from mounted patients in terms of gender, age, likelihood of personal protective equipment use, severity of injuries, and requirement for intensive or invasive care. This study highlights the importance of vigilance and other safety behaviours when unmounted and around horses, and proposes specific targets for future injury prevention campaigns, both in setting of organised and private equestrian activity., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

OBJECTIVE There has been no successful study of trends in population-based incidences of pediatric spinal injury in the United States. The goal of the current study was to develop robust data to correct this deficiency in contemporary trauma epidemiology. METHODS Discharges coded for spinal injury were extracted from the Kids' Inpatient Database for 1997, 2000, 2003, 2006, 2009, and 2012 for patients younger than 18 years. Childhood was defined as ages 0 through 14 years and adolescence as ages 15, 16, and 17 years. Denominator population data were taken from the website of the US Census. Annual incidences were estimated for hospitalization for spinal injury, spinal cord injury (SCI), and hospital death with spinal injury. Mechanistic and anatomical patterns of injury were studied. RESULTS The annual population-based incidences of hospitalization for spinal injury, SCI, and death with spinal injury trended downward from 1997 to 2012 for children and adolescents in the United States. Rates of SCI and death fell faster than overall hospitalization rates, suggesting lower thresholds for admission or greater diagnostic sensitivity to minor injuries over time. The incidence of hospitalization for spinal injury was roughly 8 times greater for adolescents than for children, and the incidence of SCI was roughly 6 times greater. Motor vehicle crash predominated among mechanisms for both children and adolescents, but penetrating injuries and sport injuries were more commonly associated with SCI. Lumbosacral injuries predominated in both children and adolescents, but injuries of the cervical spine were more commonly associated with SCI. CONCLUSIONS Further research is needed to identify the cause or causes of the observed decline in injury rates. Epidemiological data can inform and support prevention efforts.

Background: Traumatic spinal injury (TSI) results from injury to bony, ligamentous, and/or neurologic structures of the spinal column and can cause significant morbidity and mortality. The global burden of TSI is poorly understood, so we performed a systematic review and meta-analysis to estimate the global volume of TSI., Methods: We performed a systematic review through PubMed, Embase, and Cochrane Databases on TSI studies reported from 2000 to 2016. Collected data were used to perform a meta-analysis to estimate the annual incidence of TSI across World Health Organization regions and World Bank income groups using random-effect models. Incorporating global population figures, the annual worldwide volume of TSI was estimated., Results: A total of 102 studies were included in the systematic review and 19 studies in the meta-analysis. The overall global incidence of TSI was 10.5 cases per 100,000 persons, resulting in an estimated 768,473 [95% confidence interval, 597,213-939,732] new cases of TSI annually worldwide. The incidence of TSI was higher in low- and middle-income countries (8.72 per 100,000 persons) compared with high-income countries (13.69 per 100,000 persons). Road traffic accidents, followed by falls, were the most common mechanism of TSI worldwide. Overall, 48.8% of patients with TSI required surgery., Conclusions: TSI is a major source of morbidity and mortality throughout the world. Largely preventable mechanisms, including road traffic accidents and falls, are the main causes of TSI globally. Further investigation is needed to delineate local and regional TSI incidences and causes, especially in low- and middle-income countries., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: In spinal instrumentation surgeries, surgical site infection (SSI) is one of the complications to be avoided. However, spinal instrumentation surgeries have a higher rate of SSI than other clean orthopedic surgeries. The purpose of this study was to investigate the risk factors for SSI following spinal instrumentation surgeries and contribute to the prevention of SSIs by identifying high-risk patients., Methods: Records of 431 patients who underwent spinal instrumentation surgeries from 2011 to 2014 with a minimum follow-up period of 90 days were retrospectively reviewed. Associations of SSI with various preoperative, operative, and postoperative factors were statistically analyzed with univariate and stepwise multivariate logistic regression analysis., Results: Deep or superficial SSIs were observed in 15 patients (3.5%). Univariate analysis revealed significant association of SSI with diabetes mellitus (odds ratio [OR] 4.7, 95% confidence interval [CI] 1.5-14.4; p = 0.012) and serum albumin ≤3.5 g/dl (OR 3.35, 95% CI 1.1-10.38, p = 0.012). The number of regular medications prescribed in patients with SSI (8.2 ± 5.4) was significantly more than that in patients without SSI (3.8 ± 4.4) (p = 0.001), and the cut-off value of the number of medications was 7, as derived from receiver operating characteristics analysis. Multivariate analysis revealed that the number of regular medications ≥7 was an independent risk factor significantly associated with SSIs (OR 7.3, 95% CI 2.3-24.0, p = 0.001)., Conclusions: Our study demonstrated that an important risk factor for SSI after spinal instrumentation surgery was number of regular medications ≥7. Number of regular medications is a simple and valuable risk index for SSI, which reflects the influence of medications and comorbidities., (Copyright © 2018 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Background and Aims: Catastrophic cervical spine injuries are rare in rugby union but require close monitoring. The aim of this study was to analyse the incidence of severe cervical spine injuries and determine the impact of a national prevention programme and new scrum rules implemented by the French Rugby Union., Methods: A prospective study was performed between 2006 and 2013 including all players affiliated to the French Rugby Union. All cervical spine injuries resulting in death, tetraplegia or a permanent neurological deficit were included. Prevention programmes were implemented from 2007 to 2013 and a change in scrum rules in 2010. To measure the impact of rule changes, results between 2006-2010 and 2010-2013 were compared using a Poisson regression., Results: Altogether, 31 injuries were observed and the mean annual incidence was 1.6 per 100 000 players. There were significantly more injuries in senior players compared to junior players (3.5 vs 0.6 per 100 000 players; CI 95% (2.1 to 4.9) vs (0.1 to 1.0)). Incidence decreased from 1.8 in 2006 to 1.0 per 100 000 players in 2013 (p<0.0001). After 2010, there were significantly fewer injuries during scrums (p=0.02). In contrast, there were significantly more injuries in backs during 2010-2013 compared to 2006-2010 (p=0.003)., Conclusions: The incidence of catastrophic cervical spine injuries has declined in French Rugby Union. The implementation of specific prevention programmes and scrum law changes has notably resulted in a decrease in scrum injuries in forwards. This prospective study should be continued to monitor the future progression of injuries and adapt prevention programmes accordingly., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Objective: The objective of this study was to determine the influence of age and injury mechanism on cervical spine tolerance to injury from head contact loading using survival analysis., Methods: This study analyzed data from previously conducted experiments using post mortem human subjects (PMHS). Group A tests used the upright intact head-cervical column experimental model. The inferior end of the specimen was fixed, the head was balanced by a mechanical system, and natural lordosis was removed. Specimens were placed on a testing device via a load cell. The piston applied loading at the vertex region. Spinal injuries were identified using medical images. Group B tests used the inverted head-cervical column experimental model. In one study, head-T1 specimens were fixed distally, and C7-T1 joints were oriented anteriorly, preserving lordosis. Torso mass of 16 kg was added to the specimen. In another inverted head-cervical column study, occiput-T2 columns were obtained, an artificial head was attached, T1-T2 was fixed, C4-C5 disc was maintained horizontal in the lordosis posture, and C7-T1 was unconstrained. The specimens were attached to the drop test carriage carrying a torso mass of 15 kg. A load cell at the inferior end measured neck loads in both studies. Axial neck force and age were used as the primary response variable and covariate to derive injury probability curves using survival analysis., Results: Group A tests showed that age is a significant (P < .05) and negative covariate; that is, increasing age resulted in decreasing force for the same risk. Injuries were mainly vertebral body fractures and concentrated at one level, mid-to-lower cervical spine, and were attributed to compression-related mechanisms. However, age was not a significant covariate for the combined data from group B tests. Both group B tests produced many soft tissue injuries, at all levels, from C1 to T1. The injury mechanism was attributed to mainly extension. Multiple and noncontiguous injuries occurred. Injury probability curves, ±95% confidence intervals, and normalized confidence interval sizes representing the quality of the mean curve are given for different data sets., Conclusions: For compression-related injuries, specimen age should be used as a covariate or individual specimen data may be prescaled to derive risk curves. For distraction- or extension-related injuries, however, specimen age need not be used as a covariate in the statistical analysis. The findings from these tests and survival analysis indicate that the age factor modulates human cervical spine tolerance to impact injury.

Most emergency medical service personnel rely on one of two techniques to extricate motor vehicle crash victims; the Rapid Extrication Maneuver (REM) or the Kendrick Extrication Device (KED). The purpose of this study was to compare pre- and postextrication neurological outcomes between these two techniques. A retrospective review was conducted of all adult patients with a vertebral column injury resulting from motor vehicle collision and admitted to a Level I trauma center between January 1, 2003 and December 31, 2010. Standardized pre- and postextrication neurological examinations were reviewed for all patients. More than half of patients (N = 81) were extricated using the KED (53.1%, n = 43) and 46.9 per cent (n = 38) were extricated with the REM. Except for the thoracic Abbreviated Injury Score, no differences between groups emerged related to the Glasgow Coma Scale score, Injury Severity Score or Abbreviated Injury Score. There were no pre- and postextrication changes for motor to all extremities and sensation to all extremities using either method. The results of this study suggest that the REM and the KED are equivalent in protecting the patient from neurologic injury after motor vehicle collision.

Purpose: To evaluate the zonal differences in risk and pattern of pedicle screw perforations in adolescent idiopathic scoliosis (AIS) patients., Methods: The scoliosis curves were divided into eight zones. CT scans were used to assess perforations: Grade 0, Grade 1(< 2 mm), Grade 2(2-4 mm) and Grade 3(> 4 mm). Anterior perforations were classified into Grade 0, Grade 1(< 4 mm), Grade 2(4-6 mm) and Grade 3(> 6 mm). Grade 2 and 3 (except lateral grade 2 and 3 perforation over thoracic vertebrae) were considered as 'critical perforations'., Results: 1986 screws in 137 patients were analyzed. The overall perforation rate was 8.4% after exclusion of the lateral perforation. The highest medial perforation rate was at the transitional proximal thoracic (PT)/main thoracic (MT) zone (6.9%), followed by concave lumbar (6.7%) and convex main thoracic (MT) zone (6.1%). The overall critical medial perforation rate was 0.9%. 33.3% occurred at convex MT and 22.2% occurred at transitional PT/MT zone. There were 39 anterior perforations (overall perforation rate of 2.0%). 43.6% occurred at transitional PT/MT zone, whereas 23.1% occurred at concave PT zone. The overall critical anterior perforation rate was 0.6%. 5/12 (41.7%) critical perforations occurred at concave PT zone, whereas four perforations occurred at the transitional PT/MT zone. There were only two symptomatic left medial grade 2 perforations (0.1%) resulting radiculopathy, occurring at the transitional main thoracic (MT)/Lumbar (L) zone., Conclusion: Overall pedicle perforation rate was 8.4%. Highest rate of critical medial perforation was at the convex MT zone and the transitional PT/MT zone, whereas highest rate of critical anterior perforation was at the concave PT zone and the transitional PT/MT zone. The rate of symptomatic perforations was 0.1%.