Cervical Spine Injuries in Ocean Bathers: Wave-related Accidents

Cervical spine immobilisation is only required in drowning patients at high risk of axial loading of the spine

OBJECTIVES

Wave forced impacts are known to result in cervical spine injuries (CSI) and approximately 20% of drownings in Australia occur at the beach. The most common mechanism of injury in studies examining the frequency of CSI in drowning patients is shallow water diving. The aim of the present study was to determine what proportion of CSIs occurring in bodies of water experienced a concomitant drowning injury in a location where wave forced impacts are likely to be an additional risk factor.

METHODS

Electronic medical records at the Sunshine Coast Hospital and Health Service EDs, Queensland Ambulance Service case records and Surf Life Saving Queensland data between 1 January 2015 and 21 April 2021 were manually linked. Outcomes recorded included victim demographics, scene information, hospital course and patient disposition.

RESULTS

Ninety-one of 574 (15.9%) CSIs occurred in a body of water with risk of drowning. However, only 4 (4.3%) had a simultaneous drowning injury, representing 0.8% (4/483) of drowning presentations. Ten (10.9%) patients reported loss of consciousness, including the four with drowning. The principal mechanism of CSI was a wave forced impact (71/91, 78%). Most injuries occurred at the beach (79/91, 86.8%). Delayed presentation was common (28/91, 31%). A history of axial loading was 100% sensitive when indicating imaging.

CONCLUSIONS

The combination of CSI and drowning is uncommon. Cervical spine precautions are only required in drowning patients with signs or a history, or at high risk of, axial loading of the spine. This paper supports the move away from routine cervical spine precautions even in a high-risk population.

Cervical spine injuries occurring at the beach: epidemiology, mechanism of injury and risk factors

Objective

Surf zone injuries include cervical spine injuries (CSI). Risk factors for CSI have not been extensively investigated. The objective was to examine risk factors associated with diagnosed CSI that occurred in a beach setting.

Methods

This retrospective case series used manually linked data from Sunshine Coast Hospital and Health Service Emergency Departments, Queensland Ambulance Service, Surf Life Saving Queensland (SLSQ), and Bureau of Meteorology data from 01/01/2015-21/04/2021. Variables included victim demographics, mechanism of injury, scene information, and patient course.

Results

Seventy-nine of the 574 (13.8%) confirmed CSI occurred at the beach. Local residents and visitors were injured equally. Females represented a minority (12.7%) of those diagnosed with CSI but were a higher proportion of suspected spinal incidents reported to SLSQ (45%). Surfers were more likely to be injured through shallow water diving than swimmers (27.6% vs 2.2%). Females were more likely to be injured by shallow water diving than males (30.0% vs 8.7%). Visitors were more likely to be injured swimming and local residents surfing (68.2% vs 77.8% respectively). CSI occurred most commonly (40.0%) with a below average ocean wave height (0.75-1.25 m) and were most likely (45.3%) to occur in the second half of the outgoing tide. One beach had a statistically significant greater incidence of spinal incidents (OR 3.9, 95% CI: 2.1-7.2) and of CSI (OR 10.7, 95% CI: 1.5-79.5).

Conclusions

Risk factors for CSI at the beach include male sex, smaller wave height and an outgoing tide. Shallow water diving among surfers and females should be addressed urgently.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13810-9.

Beach Breaking Waves and Related Cervical Spine Injuries: A Level One Trauma Center Experience and Systematic Review

OBJECTIVE

To analyze cervical spine injuries resulting from recreational activity in shallow ocean water amidst high energy breaking waves.

METHODS

Single-center 10-year review of patients who sustained cervical injuries at the beach in Long Island, New York. A systematic review following the PRISMA guidelines was also performed.

RESULTS

Nineteen patients (age 17-79 years) sustained cervical injury from high energy breaking waves while in shallow beach water. Six patients dove into a wave; 6 patients were struck by a large wave while standing upright; and 7 tumbled in the waves while engaged in non-specified recreational activity. All 7 patients with Subaxial Cervical AO Spine Injury Score (AO-SIS) scores higher than 10 had cervical spine injury with cord signal change and required operative management. Diving mechanism, AO-SIS score > 10, and cord signal change all predicted significant disability or death at 12 months (p<0.01). The present study and 7 additional studies reporting on 534 patients (mean age: 45.4 years) were analyzed. Within reported literature, most patients (94.2%) sustained a spinal cord injury. On long-term follow up, an estimated 64.8% of patients had permanent neurological injury and 12.5% had permanent quadriplegia.

CONCLUSIONS

We offer the first description of cervical injuries sustained in water-related recreational activity using the AOSpine scoring system. The morphology of injuries varied significantly and appeared to depend upon body position and wave kinetic energy. Patients presenting with cervical injury in this setting and yielding AO-SIS scores higher than 10 are likely to have poor functional recovery.

Posterior fusion for fragility type 2 odontoid fractures

OBJECTIVE

The purpose of this study was to evaluate the outcomes of elderly patients with type 2 odontoid fractures treated with an instrumented posterior fusion.

METHODS

Ninety-three consecutive patients older than 65 years of age in whom a type 2 odontoid fracture had been treated with a variety of C1-2 posterior screw fixation techniques were retrospectively reviewed.

RESULTS

The average age was 78 years (range 65-95 years). Thirty-seven patients had an additional fracture, 30 of which involved C1. Three patients had cervical spinal cord dysfunction due to their injury. All patients had comorbidities. The average total hospitalization was 9.6 days (range 2-37 days). There were 3 deaths and 19 major complications, the most common of which was pneumonia. No patient suffered a vertebral artery injury. Imaging studies were obtained in 64 patients at least 12 months postsurgery (mean 19 months). Fusion was assessed by dynamic radiographs in all cases and with a CT scan in 80% of the cases. Four of the 64 patients did not achieve fusion (6.25% overall). All patients in whom fusion failed had undergone C1 lateral mass fixation and C2 pars (1/29, 3.4%) or laminar (3/9, 33.3%) fixation.

CONCLUSIONS

Instrumented posterior cervical fusions may be performed in elderly patients with acceptable morbidity and mortality. The fusion rate is excellent except when bilateral C2 translaminar screws are used for axis fixation.

Early Predictors of Near-Shore Spinal Injuries Among Emergency Department Patients

BACKGROUND

Spinal injuries (SIs) can pose a significant burden to patients and family; delayed surgical intervention, associated with interhospital transfer, results in worse outcomes.

OBJECTIVE

This study aimed to identify early patient-centered factors associated with risk for near-shore SIs to assist clinicians with expeditious medical decision-making.

METHODS

We performed a multicenter retrospective study of all adults transported from Ocean City, Maryland to two emergency departments (EDs) and one regional trauma center for evaluation of suspected SIs from 2006 to 2017. Outcomes were any SI and any spinal cord injury (SCI). Multivariable logistic regression was performed for association of environmental and clinical factors with outcomes.

RESULTS

We analyzed 278 records, 102 patients (37%) were diagnosed with any SI and 41 (15%) were diagnosed with SCIs. Compared with patients without SI, patients with SI were more likely to be older (48 vs. 39 years), male (90% vs. 70%), with pre-existing spinal condition (62% vs. 33%), and injury caused by diving (11% vs. 2%). Multivariable logistic regression showed age (odd ratio [OR] 1.07; 95% confidence interval [CI] 1.04-1.11), diving (OR 3.5; 95% CI 3-100+), and wave height (OR 4.5; 95% CI 1.35-15.2) were associated with any SI, and a chief complaint of extremity numbness or tingling (OR 5.73; 95% CI 1.2-27.9) was associated with SCI.

CONCLUSIONS

We identified older age, diving, and higher wave height as risk factors for any SI and symptoms of numbness and tingling were associated with SCIs. Clinicians should consider expediting these patients' transfers to a trauma center with neurosurgical capability.

Correlation of history and physical examination with imaging in traumatic near-shore aquatic head and spinal injury

OBJECTIVE

It remains unclear whether clinicians can rely on specific symptoms and signs to detect or exclude serious head and spinal injury sustained during near-shore aquatic activities. Our study investigated patients' history of present illness (HPI) and physical examination (PE) for their utility in detecting serious head and spinal injury.

METHODS

We conducted a multicenter retrospective comparative analysis of adult patients who were transported from the beach in Ocean City, Maryland, to three nearby emergency departments for possible spinal injury from 2006 through 2017. Patients suspected to have any spinal injury from beach activities were eligible. We excluded patients who could not verbalize their symptoms or with insufficient emergency department records. We compared components of each patient's HPI and PE with radiologic evidence of spinal injury. We calculated sensitivity, specificity, and negative and positive likelihood ratios (LRs).

RESULTS

We analyzed 278 patients with suspected spinal injury. Midline spinal tenderness was associated with increased likelihood of thoracic (LR+ 2.6) and lumbar spinal fractures (LR+ 3.5). HPI complaints of paralysis (LR+ 13.9) and sensory loss (LR+ 5.8) had strong associations with spinal cord injuries. Weakness found through PE was also associated with spinal cord injury (LR+ 5.3).

CONCLUSIONS

We identified several components of the clinical evaluation that had clinically significant association with spinal injuries from beach-related trauma. While prospective studies are needed to confirm our observations, clinicians may consider these high-risk features in patients with beach-related trauma and adjust testing and level of care appropriately.

Delaware coast Delaware surf zone injury demographics

INTRODUCTION

Beaches are a popular destination for recreation activities. Surf zone injuries (SZI) can occur resulting from a variety of in-water activities. Little is known regarding the sustained injury types, or demographics of injured persons and activities leading to injuries.

METHODS

This study examines the distribution of SZI types, activities and populations occurring on Delaware Beaches as recorded by a local level III trauma center (Department of Emergency Medicine at Beebe Healthcare in Lewes, Delaware).

RESULTS

There were 2021 injuries over the eight study years (2010-2017). The relative demographics of the injured population are similar despite fluctuating injury totals (mean [SD], 253.1 [104.4]). Non-locals (n=1757) were 6.7 times more likely to be injured as their local (n=264) counterparts (RR, 2.62; 95% CI, 2.08-3.31). Males (n=1258) were 1.7 times more likely to be injured than their female (n=763) counterparts (RR, 1.29; 95% CI, 1.21-1.37). Serious injuries, defined as patients requiring admission to a trauma service, represented 9.1% (n=184) of injuries. Fatal SZI (n=6) were categorized as serious injuries. Wading (50.1%) was found to be the dominant activity associated with injury followed by body surfing (18.4%), and body boarding (13.3%).

CONCLUSION

To the authors' knowledge, this study is one of the first to investigate long-term trends in SZI data, injury activity, and demographics. Better understanding of the characteristics of injuries will allow for improved awareness techniques, targeted at populations with higher injury rates.

Spinal Cord Injuries in Wave-Riding Sports: The Influence of Environmental and Sport-Specific Factors

Spinal cord injury is a nonfatal, catastrophic consequence of wave-riding sports. With surfing at the core, a multitude of activities have evolved that attempt to harness the power of ocean waves. The unique qualities of each wave-riding sport, in combination with the environmental factors of the ocean, define the risk for potential injuries. As wave-riding sports have become more advanced, athletes continue to push physical barriers. Taller waves are attempted while incorporating aerial maneuvers, all without protective equipment.

Epidemiology of Aquatic and Recreational Water Sport Injuries: A Case-Control Analysis

The purposes of the current investigation are to evaluate the epidemiology of water sport injuries at a coastal tertiary trauma center and to determine the association of these activities with spinal column injury and to determine whether aquatic trauma injuries differ significantly from those that occur terrestrially. A retrospective review of a consecutive series of 105 patients with aquatic-based mechanisms of injury admitted to a Level II trauma center over a 3-year period, as well as a matched control cohort with terrestrial-based mechanisms of injury, was conducted. Patients were treated at a Level II trauma center from January 1, 2008, to December 31, 2010. All patients received a full trauma work-up on arrival. Patients were identified retrospectively from a prospectively collected database (N=5298). Eligible patients were identified from billing/coding data as having mechanisms of injury related to an aquatic setting. Patients were evaluated using standard trauma protocols. Spinal column and cord injury occurrence and differences between groups were reviewed. Personal watercrafts accounted for the majority of injuries (n=39). Cervical (33.3%), closed-head (25.7%), and thoracolumbar (21.9%) injuries accounted for the majority of injury types. The cervical spinal column and the spinal cord were at an increased risk of injury in the aquatic injury cohort (P<.0001). The current data show the high incidence of spinal column and cord injuries in this patient population relative to controls. Practitioners who care for trauma patients near an aquatic environment should be aware of the high prevalence of these injuries, with proper spinal cord preservation protocols in place to optimize outcome.

Diagnosis and management of traumatic cervical central spinal cord injury: A review

Background:

The classical clinical presentation, neuroradiographic features, and conservative vs. surgical management of traumatic cervical central spinal cord (CSS) injury remain controversial.

Methods:

CSS injuries, occurring in approximately 9.2% of all cord injuries, are usually attributed to significant hyperextension trauma combined with congenital/acquired cervical stenosis/spondylosis. Patients typically present with greater motor deficits in the upper vs. lower extremities accompanied by patchy sensory loss. T2-weighted magnetic resonance (MR) scans usually show hyperintense T2 intramedullary signals reflecting acute edema along with ligamentous injury, while noncontrast computed tomography (CT) studies typically show no attendant bony pathology (e.g. no fracture, dislocation).

Results:

CSS constitute only a small percentage of all traumatic spinal cord injuries. Aarabi et al. found CSS patients averaged 58.3 years of age, 83% were male and 52.4% involved accidents/falls in patients with narrowed spinal canals (average 5.6 mm); their average American Spinal Injury Association (ASIA) motor score was 63.8, and most pathology was at the C3-C4 and C4-C5 levels (71%). Surgery was performed within 24 h (9 patients), 24–48 h (10 patients), or after 48 h (23 patients). In the Brodell et al. study of 16,134 patients with CSS, 39.7% had surgery. In the Gu et al. series, those with CSS and stenosis/ossification of the posterior longitudinal ligament (OPLL) exhibited better outcomes following laminoplasty.

Conclusions:

Recognizing the unique features of CSS is critical, as the clinical, neuroradiological, and management strategies (e.g. conservative vs. surgical management: early vs. late) differ from those utilized for other spinal cord trauma. Increased T2-weighted MR images best document CSS, while CT studies confirm the absence of fracture/dislocation.

Medical illnesses and injuries encountered during surfing

Surfing is an exciting sport enjoyed in many coastal communities around the globe. Participants are prone to various conditions ranging from acute injuries to conditions borne from chronic environmental exposure. Lacerations, contusions, sprains, and fractures are the common types of acute traumatic injury. Injury from the rider's own surfboard is the prevailing mechanism of injury. Interaction with marine animals may lead to injury through envenomation. Although jellyfish stings are common, no definitive treatment strategy has been proven most effective in dealing with such stings. Exposure to jellyfish and other nematocyst-containing larvae can cause a reaction known as seabather's eruption. Stingrays and coral reefs present further hazards to the surfboard rider. Infection of wounds is often seen and should be treated with fluoroquinolones or third-generation cephalosporins to cover Vibrio species, along with Staphylococcus and Streptococcus species. Otologic sequelae of surfing include auditory exostoses, ruptured tympanic membrane, and otitis externa.