Incidence of Head and Spine Injuries
Death due to head injuries is the second-leading sport-related cause of death in American football. It accounted for 62 football deaths (0.26/100,000 participants) between 1990 and 2010.34 One can see the evolution of player safety in high school and college football by examining the average number of deaths from head trauma. Between 1945 and 1975, there were an average of 9.5 deaths/year. A spike in deaths occurred between 1965 and 1969, when the average increased to 17.5 deaths/year.35 The number of deaths from brain injuries dropped dramatically in the 1980s, primarily due to new standards for safety equipment and rule changes, such as no spearing and the fair catch. Helmet technology has continued to improve since 1978, when certification of equipment by the National Operating Committee on Standards for Athletic Equipment became required at the collegiate level, followed by the high school level in 1980.
Sport is the fourth most common cause of spinal injury in the United States, followed by motor vehicle accidents, violence, and falls.36 In football, there have been 269 cases of permanent neurological injuries related to spinal cord injuries over the past 30 years. Of those, 70% were defensive players in the process of blocking or tackling. The mechanism of injury most associated with spinal cord injuries is spearing37 (Figure 7-3).
The rate of cervical spine injuries has decreased dramatically.35,37-40 From 1977 to 2002, the incidence of cervical spine injury went from 2.24/100,000 players and 10.66/100,000 players in high school and college, respectively, to .33/100,000 players and 1.33/100,000 players, respectively.39 The incidence of cervical spine injuries increases with higher levels of play. Collegiate players are 1.5 times more likely than high school players to suffer a catastrophic spine injury.39 Over the past 11 seasons in the National Football League, there have been 2208 injuries involving the spine and axial skeleton. Of those, 987 (44.7%) involved the cervical spine, resulting in missed time of approximately 80 days/injury.41 At the youth level, evidence is not as well documented, but based on the available data, spine injuries in youth athletes account for 7% to 10% of injuries.42
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Other collision sports have similar incidences of spinal injuries to American football. Rugby has an incidence of anywhere from 1 to 2/100,000 to 10/100,000 players, but recent evidence suggests that the incidence is 1.73 cervical spinal injuries/100,000 players/year.43 In addition, ice hockey has an incidence rate of 2 to 5/100,000 player-hours.44
Figure 7-3. Teaching proper tackling techniques at the youth football level.
Epidemiological data analyzing catastrophic injuries has shown that 63.3% and 71.2% of direct catastrophic injuries occurring in female athletes occur in cheerleaders at the high school and college level, respectively. Of the 183 catastrophic injuries occurring in female athletes at the high school and college levels from 1982 to 2012, 120 (65.5%) of them occurred in cheerleaders and 19.3% involved the head or neck.1 The rate of catastrophic injuries in cheerleaders per 100,000 athletes is 5 times higher in collegiate than high school cheerleaders.45 Seventy-five percent of the catastrophic injuries occurring in cheerleaders are the result of a fall.1 Furthermore, Boden et al45 examined the relationship between catastrophic injuries in cheerleaders and the surface on which they were performing. Results indicate that hard, nonimpact, absorbing surfaces (concrete, asphalt, and gym floors) were a factor in 72% of the catastrophic injuries.46
Gymnastics is the second leading cause of catastrophic injury in female athletes,1 and of 38 reported cases of accidents involving gymnasts, 35 involved the cervical spine.47 Analyzing injuries that resulted in paralysis between 1985 and 1997, 10% of the sport-related accidents occurred in gymnastics.48 Catastrophic head and spine injuries are also prevalent in diving, typically due to individuals diving into shallow water (1 to 2 m deep). Diving accidents account for 7% to 9.5% of all catastrophic spine injuries.49-51 Males are at a much greater risk than females for diving-related cervical spine injuries.49 When combined with gymnastics, diving accounts for 14.5% of catastrophic spine injuries.48