Cervical Fractures Jump 35% in Five Years! Why?

With warmer weather coming soon, more people will be out and about enjoying outdoor activities including cycling. And according to a new study, “Incidence of Cervical Spine Injuries Sustained During Sporting Activities,” recently presented at the 2018 Annual Meeting of the American Academy of Orthopaedic Surgeons in New Orleans, Louisiana, orthopedic doctors should be prepared to see more cervical fractures in their offices come spring and summer.

Sports-related cervical injuries generally are categorized as acute cervical sprains/strains including whiplash injury, cervical fractures and dislocations, nerve root or brachial plexus injuries, intervertebral disc injuries and cervical stenosis.

Cycling’s Impact on the Body

J. Mason DePasse, M.D., an orthopedic trauma surgery fellow at Brown University in Boston, and colleagues found in their study that the 35% increase in sports-related cervical fractures between 2000 and 2015 is directly linked to a rise in cycling injuries.

Using the National Electronic Injury Surveillance System (NEISS) database which includes data from 100 U.S. hospitals, DePasse and colleagues identified 27,546 patients who sustained a neck injury during a sporting activity.

The team used SAS 9.4 for analysis and built algorithms involving string recognition and automated text analysis that went through the over 50,000 patient cases. Patients were selected based on specific criteria, including association with recreational activity, diagnosis code indicating fracture or strain/sprain, and body part indicating neck region. Weighted estimates of each injury were calculated and compared by sport, while incidence rates were calculated by age and sex utilizing U.S. census data.

“Our diverse team helped us to streamline our research, work faster and ask better questions,” said DePasse in a release. “When we—the orthopaedic surgeons—first looked at the problem, we thought it was impossible due to the sheer volume of cases. However, one of our team members—who is a medical student and previously worked as an analyst—said it could be done. When you have people with cross training and diverse backgrounds, you can often discover a different way of approaching problems.”

For men, the most common cause of cervical fracture was due to cycling while in women, the most common cause was horseback riding. Football was the most common cause of cervical spine injury in the U.S., with most of these injuries being sprains.

In total, there were 26,380 neck sprains and 1,166 fractures, representing a weighted estimate of 926,235 neck sprains and 37,416 fractures. The estimated injury incidence was 191.5 (182.9-200.2) neck sprains and 7.7 (7.0-8.5) fractures per million person-years. Compared to females, the incidence for injuries in males was 1.7 times greater for neck sprains and 3.6 times greater for fractures (p< 0.001 for both).

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 sport increased from 6.5 to 8.8 per million (p=0.005), and the incidence of fractures from cycling increased from 0.67 to 2.7 per million (p<0.0001) over the same interval.

Overall, the number of neck sprains decreased by 33% from 2000 to 2015, but there was a 66% increase in sprains that were sustained during weightlifting and aerobic exercise.

In addition, sporting-related cervical fractures increased by 35% in the same time period. This increase was largely due to a 300% increase in cycling related injuries.

When it came to neck sprains, the most common causes were football, weightlifting/aerobics, cycling, trampoline and diving/swimming. For men the most common cause of sprains was football. When it came to fractures in men, most were caused by cycling followed by diving/swimming and football.

For women, most neck sprains occurred during weightlifting/aerobics, trampoline and cheerleading. Cervical fractures in women, on the other hand, occurred more during horseback riding followed by cycling and diving/swimming.

“Cervical spine injury is a substantial cause of morbidity and mortality, and, as far as injuries go, one of the more devastating injuries that we as orthopaedic surgeons can treat,” said DePasse.

“There isn’t much data available on spine/neck injuries in recreational activities and sports. The most recent paper we quoted was from 1991 and looked only at 63 male patients.”

He explained that the problem is that while it is known that sporting activities are the fourth most common cause of cervical spine injury, previous studies were primarily based off of media reports which led to underreporting.

“In our study, we were able to sort through more than 50,000 cases by utilizing data analytics, which would have been nearly impossible to sift through by hand. The biggest takeaway was that cycling is the number one cause of neck fractures, which suggests we may need to investigate this in terms of safety,” he added.

The researchers also noted that while football still remains the main cause of cervical injuries in the U.S., these injuries are mostly sprains and the overall incidence of football-related injuries has decreased. They pointed to better protective equipment and safety rules as the reasons why.

“What Is Cyclist Neck?”

What is it about cycling that makes riders more at risk for cervical spine injuries like cervical fractures? One study, “Cyclist Neck ‘The Prevalence of Cervical Spine Degeneration in Cyclists Using Different Handlebars” published in the Journal of Fractures and Sprains in October 2016 points to the phenomenon of “cyclist neck” as the cause of a lot of the problems with cervical spine injuries in cyclist.

In this study, the researchers examined 100 male bicyclists from the L.I. Bicycle Club, Huntington Bicycle Club and Suffolk Bicycling Riders Association whose ages ranged from 35 to 42 years old for evidence of degenerative cervical spine disease. All the riders rode at least twice per week for a minimum two hours per ride for at least 10 years.

Fifty of the cyclists used drop (bull whip) handlebars while the other half used standard flat (upright) handlebars. With the drop handlebars, the rider flexes his lumbar spine forward and extends his cervical spine (c-spine) to get an aerodynamic advantage. Unfortunately, the c-spine being forced into hyper-extension (35 to 45 degrees) for long periods causes stress on the cervical spine.

In total, 30% of the cyclists had X-ray evidence of c-spine degeneration. In the drop handlebars group, 46% of them had evidence of degeneration, which is an increased prevalence of 53%.

The researchers recommended that cyclists should be warned of the possible risks of using drop handlebars versus standard handlebars.

Orthopedic doctors should also talk about proper form with their patients. Cyclists need to look forward with their eyes not by stretching with their neck so they are not lifting their head up higher than it needs to be. Cyclists also need to make sure their bike is positioned appropriately to fit their body. For cyclists who buy their bike from a friend or a secondhand store, there is not trained professional there to adjust the bike for them. Preventing exercises that strengthening trapezius muscles and cervical spine during regular workouts off the bike can also prevent a lot of stress on the cervical spine.

Effectively Treating Cervical Fractures

Treatment for cervical fractures depends on the nature and severity of the injury. Minor and non-displaced fractures are treated with a brace or some type of immobilization. For more severe fractures or when the spine is unstable, some type of surgery is usually required; surgical treatments usually involves posterior cervical fusion and small metal screws and rods to stabilize the spine. Some patients are eligible though for anterior decompression and fusion with or without metal plate and screws. Surgical treatment of unstable cervical fractures, particularly those associated with spondyloarthropathy and deformities that alter function, are particularly challenging for spinal surgeons.

The study, “Incidence of Cervical Spine Injuries Sustained During Sporting Activities,” was previously presented at the December 2017 Cervical Spine Research Society Annual Meeting.

For more information from the 2018 AAOS Conference, click here.