Traumatic spine injuries suffered by skiers and snowboarders can be devastating and potentially cause death or permanent disability. The overall rate of injuries related to skiing and snowboarding has been reported at 1.5 to 6 per 1000 skier days (1-7). Spinal injuries account for 1%-14% of all injuries (2,4-6,8-19). Despite this relatively low percentage of all injuries, spine injuries are the third most common cause of critical injury in severe skiing injuries (1). The popularity of these winter sports continues to remain high with an estimated 200 million participants worldwide and 12 million in the United States (2,20). Sports medicine physicians should be aware of the common injury patterns, injury types, and strategies for injury prevention related to the spine in skiers and snowboarders.
Historically, injury rates among U.S. skiers were reflected by data collected by Earle et al. in the 1950s (21). An incidence rate of 7.6 injuries per 1000 skier days was reported from their study. Over the ensuing years, incidence rates for ski injuries have decreased to between 1.5 and 3 injuries per 1000 skier days (1-4,7,22,23). However, during this same time, spine injury rates have remained fairly consistent and in some cases even risen. Prall et al. reported an incidence rate of 0.001 spinal injuries per 1000 skier days between the years of 1982 and 1993 (15). During the 9-yr period from 1983 to 1992, Davidson and Laliotis found cervical spine injury rates increased from 0.02 to 0.04 injuries per 1000 skier days, while back injury rates increased from 0.05 to 0.09 per 1000 skier days (4). Deibert et al. found a one- to fourfold increase in spinal injuries among children and adolescents during a recent 20-yr period (23). More recently, over a 6-yr period from 2000 to 2006, Franz et al. found 20% of all skiing and snowboarding injuries presenting to a tertiary trauma center were spine injuries (24). These data represent a trend toward higher rates of spine injuries when compared with older studies. In an effort to explain this apparent trend, several authors have noted an increase in spinal injuries with the increased popularity of snowboarding (10,12,13,17,25). Although snowboarding has been present in the United States since the 1970s, the sport really began to grow in the 1980s. The Winter Olympic Games in 1998 were the first to include snowboarding and have likely contributed to further growth in its popularity. Pino and Colville may have been the first to report on the unique pattern of injuries sustained by snowboarders (18). They found that 8% of snowboarding injuries involved the neck or back and were due primarily to impact with the slope. Subsequently, Abu-Laban reported a higher percentage of spinal injuries in snowboarders (12%) versus skiers (4%) (13). These findings have been substantiated by more recent studies (10,12,17,25). However, in studies done at trauma centers, where more severe injuries may be seen, spinal injury rates seem to be similar or increased in skiers versus snowboarders (1,8,9,24). Prall et al. found that a higher percentage of skeletal injuries of the spine occurred in skiers versus snowboarders (24% vs 5%) (9). The recent data from Franz et al. indicate that the majority of severe spinal injuries seen at a trauma center are related to skiing, including spinal fractures, subluxations, dislocations, or spinal cord injuries (24). Regardless, spinal injuries occur in both snowboarders and skiers. The unique features of each sport lead to varying types of spinal injuries.
INJURY TYPES AND CHARACTERISTICS
Reports of spinal injury types can vary from author to author in the literature depending upon region, size of catchment area, and type of medical practice. There are definite trends and characteristics noted among various large-scale studies looking at spinal injuries in skiers and snowboarders. Tarazi et al. noted that the majority of spinal injuries were fractures. Burst fractures were most common, followed by anterior compression fractures. Fractures of the thoracolumbar spine were most common, with T-12 and L-1 accounting for the majority. The C-7 vertebra was most commonly fractured in the cervical spine. Snowboarders were noted to have a higher incidence of sacral fractures. Neurologic injuries accompanied 24% of skier's and 9% of snowboarder's injuries (25). Prall et al. reported similar results. Most spinal injuries were fractures and commonly involved C-6, T-12, and L-1. Compression fractures were more common than burst fractures. Neurologic injury accompanied 17% of fractures with the C5-6 region most common. Cervical spine injuries were more likely to be isolated, while thoracolumbar injuries were more likely to be associated with injuries of the thorax and abdomen (15). In a series of 187 serious spinal injuries, reported by Levy and Smith, the distribution of injuries was evenly distributed among the cervical, thoracic, and lumber regions. However, snowboarders experienced more thoracic/lumbar injuries than cervical injuries compared with skiers. Neurologic injuries were highly associated with cervical spine injuries and subsequently decreased with thoracic then lumbar spine injuries (1). A large Japanese study by Yamakawa et al. with more than 300 spinal injuries found no significant difference between skiers and snowboarders related to the location of spinal fractures. Fractures of the lumbar spine were most common, followed by thoracic then cervical spine fractures. Anterior compression fractures were the most common, followed by transverse process fractures. Snowboarders were found to have a higher incidence of transverse process fractures. There were more neurologic injuries in snowboarders than skiers, most commonly affecting the cervical spine, but the difference was not significant (12). Franz et al. reported a similar distribution of spinal fractures with lumbar vertebral fractures most common, followed by the thoracic spine, and the cervical spine. A total of 60% of fractures were located in the lumbar spine among snowboarders. Transverse or spinous process fractures were more common than anterior compression or burst fractures. Approximately 38% of patients in this study suffered some type of neurologic injury, with cervical spine injuries being the most common. Skiers experienced more neurologic injuries than snowboarders (24). A study by Wakahara et al. emphasizes several important points regarding neurologic injuries of the spinal cord in snowboarders. In their series of 18 snowboarders, the most commonly affected spinal cord level was the thoracolumbar junction, usually accompanied by a burst fracture with anterior dislocation. Very few cervical spinal cord injuries with fracture were identified. Additionally, more than 80% of the thoracolumbar spinal cord injuries were associated with complete or near-complete (except sensory) deficits (16). These findings correlate well with a previous case series of snowboarding spinal cord injuries by Koo and Fish. Most of their patients suffered compression or burst fractures of the thoracolumbar spine associated with a 50% rate of complete or near-complete neurologic deficits (26). Donald et al. from New Zealand also published similar findings regarding location and type of spinal fractures. However, the incidence of spinal cord injury was much lower than the previously mentioned studies. The authors relate this to the triage system in place, which sends all patients with neurologic deficits directly to a spinal injuries unit, bypassing their hospital (17).
MECHANISM OF INJURY
Agreement seems to exist among authors regarding the most common mechanisms of injury in skiers and snowboarders. In general, skiers usually suffer acute serious spinal injuries from falls or collisions at high speeds, whereas snowboarders are frequently injured from failing attempted jumps (1,11,12,16,17,24-26). More specifically, snowboarders seem more likely to suffer thoracolumbar spine injuries from the way they fall after jumps. Nakaguchi et al. demonstrated that the majority of snowboarders fall backwards; conversely, skiers tend to fall forwards (27). This can lead to snowboarders falling in such a way as to apply axial loading through the spine, resulting in the commonly reported anterior compression fractures. In addition, landing in an uncontrolled manner after a jump may result in a direct blow to the upper or lower back, resulting in a transverse or spinous process fracture. Collisions on the slopes also can be significant contributors to spinal injuries. Skiers tend to suffer from more cervical spine injuries related to falling forward after losing control and skiing at excessive speeds (15,27). Fatigue is known to play a role in skiing and snowboarding injuries with more injuries occurring in the second half of the day in most studies.
There are several conclusions to be drawn from these studies. First, skiers and snowboarders alike experience serious acute spine injuries, most commonly fractures of the thoracolumbar region. Snowboarders may be at higher risk for thoracolumbar spine fractures. Fracture types may be burst, anterior compression, transverse, or spinous process fractures. Second, neurologic injury may frequently be associated with acute spinal fracture, especially with cervical spine fractures. Snowboarders may be at higher risk for thoracolumbar neurologic injury. Third, first-time skiers and snowboarders have been found to have a higher incidence of emergent injuries (8,12,28). One exception may be the experienced skier or snowboarder who is attempting dangerous jumps, which may lead to acute serious spinal injury. Fourth, it appears snowboarders are more likely to sustain acute spinal injuries from failure of an attempted jump, whereas falls at high speeds are usually the cause of serious spinal injury in skiers. Nonetheless, as jumps and aerial maneuvers become increasingly more common among skiers, the incidence of injury from failed jumps may increase. Finally, concomitant injuries and multilevel fractures are common. It is imperative that a thorough examination and work-up is performed in the evaluation of an injured skier or snowboarder to avoid missing an injury.
EVALUATION AND MANAGEMENT
Initial evaluation of an acutely injured skier or snowboarder should consist of an accurate history obtained from the patient or a reliable bystander who observed the injury mechanism. Obviously, all spinal precautions should be taken if assessment is taking place on the slopes and the extent of injury is unknown. Initial evaluation and management of acute cervical spine injuries has been detailed extensively (29,30). A thorough physical examination including a comprehensive neurologic exam is necessary based upon the frequent incidence of multiple injuries in skiing and snowboarding trauma. Initial diagnostic imaging should consist of radiographs detailing the affected areas of the spine. Multiple views may be needed to fully visualize the bony anatomy including anterior-posterior, lateral, and oblique views. Further imaging is usually needed to accurately identify the vertebral fractures commonly associated with skiing and snowboarding injuries. Computed tomography (CT) provides excellent images of the bony spine, helps identify the spatial anatomy of fractures, and aids in guiding management decisions. Magnetic resonance imaging (MRI) is extremely useful in visualizing the soft tissues of the spine. In patients who have suffered acute trauma of the spine with associated neurologic deficits, it can provide excellent images of the spinal cord, intervertebral discs, and nerve roots. Individuals with acute spinal cord injuries should be transported immediately to a tertiary trauma center where appropriate treatment can be initiated. High-dose methylprednisolone steroid therapy has been demonstrated to improve neurologic outcomes up to 1 yr post-injury if given within 8 h of injury (31-33). Novel therapies including induction of hypothermia and stem cell treatments have shown promise in the management of acute spinal cord injuries and may become the standard of care in the future. Management of vertebral fractures depends on the type, severity, location, and displacement. Options include surgical fixation, bracing, kyphoplasty, and rehabilitation.
Injury prevention strategies for reducing the incidence of acute spinal injuries and lessening their severity when they do occur should be a priority. Despite the difficulty of changing risk-taking behavior in skiers and snowboarders, which might decrease injury, there have been various strategies proposed. Very few of these strategies have undergone rigorous study to evaluate their effectiveness. Skiers and snowboarders should be educated about the various known risk factors for spinal injury, such as fatigue or alcohol contributing to poor decision-making and decreased coordination. Individuals should ski or snowboard under control, reduce speed when appropriate, and not attempt advanced moves unless properly trained or coached. They should use appropriately fitted equipment and consider the use of spine protectors, especially for snowboarders. Helmets are known to clinically reduce the incidence of head injuries but have been implicated by some in contributing to cervical spine injuries due to their weight. Macnab et al. evaluated these contentions in a study of skiers and snowboarders under 13 yr of age and found no increased incidence of cervical spine injuries (34). Ski resorts can help reduce injury by designing and maintaining their slopes with injury prevention as a priority (35). Slopes should be groomed appropriately, runs should not be overcrowded, and obstacles should be clearly marked and padded. Creation of dedicated terrain parks along with teaching of safe jumping techniques could potentially decrease spinal injuries, especially among snowboarders.
It is clear that although spinal injuries make up a small percentage of injuries sustained by skiers and snowboarders, their critical nature and associated disability make them important to consider. Research into the various patterns, types, and mechanisms of injury has helped elucidate critical factors related to spine injuries. As these sports continue to evolve, finding innovative ways to prevent spine injuries will be imperative. Further research in this area should continue to identify risk factors associated with traumatic spinal injuries and focus upon rigorously evaluating interventions aimed at prevention so that more individuals can enjoy skiing and snowboarding safely.
1. Levy, A.S., and R.H. Smith. Neurologic injuries in skiers and snowboarders. Semin. Neurol.
2. Hunter, R.E. Skiing injuries. Am. J. Sports Med.
3. Boden, B.P., and C. Prior. Catastrophic spine injuries in sports. Curr. Sports Med. Rep.
4. Davidson, T.M., and A.T. Laliotis. Alpine skiing injuries: a nine-year study. West. J. Med.
5. Bladin, C., P. Giddings, and M. Robinson. Australian snowboard injury data base study: a four-year prospective study. Am. J. Sports Med.
6. Sutherland, A.G., J.D. Holmes, and S. Myers. Differing injury patterns in snowboarding and alpine skiing. Injury.
7. Langran, M., and S. Selvaraj. Snow sports injuries in Scotland: a case-control study. Br. J. Sports Med.
8. Davidson, T.M., and A.T. Laliotis. Snowboarding injuries: a four-year study with comparison with alpine ski injuries. West. J. Med.
9. Prall, J.A., K.R. Winston, and R. Brennan. Severe snowboarding injuries. Injury.
10. Ferrera, P.C., D.P. McKenna, and E.A. Gilman. Injury patterns with snowboarding. Am. J. Emerg. Med.
11. Floyd, T. Alpine skiing, snowboarding, and spinal trauma. Arch. Orthop. Trauma Surg.
12. Yamakawa, H., S. Murase, H. Sakai, et al
. Spinal injuries in snowboarders: risk of jumping as an integral part of snowboarding. J. Trauma.
13. Abu-Laban, R.B. Snowboarding injuries: an anlysis and comparison with alpine skiing injuries. Can. Med. Assoc. J.
14. Reid, D.C., and L. Saboe. Spine fractures in winter sports. Sports Med.
15. Prall, J.A., K.R. Winston, and R. Brennan. Spine and spinal cord injuries in downhill skiers. J. Trauma.
16. Wakahara, K., K. Matsumoto, H. Sumi, et al
. Traumatic spinal cord injuries from snowboarding. Am. J. Sports Med.
17. Donald, S., D. Chalmers, and J.C. Theis. Are snowboarders more likely to damage their spines than skiers? Lessons learned from a study of spinal injuries from the Otago skifields in New Zealand. N. Z. Med. J.
18. Pino, E.C., and M.R. Colville. Snowboard injuries. Am. J. Sports Med.
19. Shorter, N.A., P.E. Jensen, B.J. Harmon, et al
. Skiing injuries in children and adolescents. J. Trauma.
21. Earle, A.S., J.R. Moritz, and G.B. Saviers. Ski injuries. JAMA.
22. Warme, W.J., J.A. Feagin, P. King, et al
. Ski injury statistics, 1982 to 1993, Jackson Hole Ski Resort. Am. J. Sports Med.
23. Deibert, M.C., D.D. Aronsson, R.J. Johnson, et al
. Skiing injuries in children, adolescents, and adults. J. Bone Joint Surg. Am.
24. Franz, T., R.M. Hasler, L. Benneker, et al
. Severe spinal injuries in alpine skiing and snowboarding: a six-year review of Tertiary Trauma Center for the Bernese Alps Ski Resorts, Switzerland. Br. J. Sports Med.
25. Tarazi, F., M.F.S. Dvorak, and P.C. Wing. Spinal injuries in skiers and snowboarders. Am. J. Sports Med.
26. Woo, D.W., and W.W. Fish. Spinal cord injury and snowboarding: the British Columbia experience. J. Spinal Cord Med.
27. Nakaguchi, H., T. Fujimaki, K. Ueki, et al
. Snowboard head injury: prospective study in Chino, Nagano, for two seasons from 1995 to 1997. J. Trauma.
28. O'Neill, D.F., and M.R. McGlone. Injury risk in first-time snowboarders versus first-time skiers. Am. J. Sports Med.
29. Banerjee, R., M.A. Palumbo, and P.D. Fadale. Catastrophic cervical spine injuries in the collision sport athlete, part 1: epidemiology, functional anatomy, and diagnosis. Am. J. Sports Med.
30. Banerjee, R., M.A. Palumbo, and P.D. Fadale. Catastrophic cervical spine injuries in the collision sport athlete, part 2: principles of emergency care. Am. J. Sports Med.
31. Bracken, M.B., M.J. Shepard, T.R. Holford, et al
. Administration of methylprednisolone for 24 or 48 h or tirilazad mesylate for 48 h in the treatment of acute spinal cord injury. Results of the Third National Acute Spinal Cord Injury Randomized Controlled Trial. National Acute Spinal Cord Injury Study. JAMA.
32. Bracken, M.B. Steroids for acute spinal cord injury. Cochrane Database Syst. Rev.
2: 2002, doi:10.1002/14651858.CD001046.
33. Bracken, M.B., M.J. Shepard, W.F. Collins, et al
. A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury. Results of the Second National Acute Spinal Cord Injury Study. New Engl. J. Med.
34. Macnab, A.J., T. Smith, F.A. Gagnon, et al
. Effect of helmet wear on the incidence of head/face and cervical spine injuries in young skiers and snowboarders. Inj. Prev.
35. Koehle, M.S., R. Lloyd-Smith, and J.E. Taunton. Alpine ski injuries and their prevention. Sports Med.