Broken necks from diving accidents: a summer epidemic in young men OTMAR W. ALBRAND, M.D., F.A.C.S., AND GUY CORKILL, M.D., F.A.C.S. From the Department of Sacramento, California

Neurological Surgery, University

Four years (1970 to 1973) of experience in the management of fractured cervical spine from diving accidents is examined with reference to clinical ogy,

prognosis,

and

radiolsocioeconomic

findings,

aspects.

Duringspine

the past 4 years, 22 patients with and spinal cord injuries caused diving into shallow water were admitted a university medical center. These

cervical

by to

patients comprised approximately

15 per

This

study was funded by the Department of Neurosurgery, University of California, DavisSacramento Medical Center.

Dr. Albrand is a practicing neurosurgeon who did his medical training in Guatemala and his residency in neurosurgery in the United States. He is a Diplomate of the Board of Neurological Surgeons of the United States and an Assistant Professor with the University of California at Davis in Sacramento. He is currently in private practice at the Denison Medical and Surgical Clinic, Denison, Texas. Dr. Corkill is an English trained neurosurgeon currently in academic practice with the University

of California at Davis in Sacramento ate Professor. Address requests for

reprints M.D., F.A.C.S., Department

of

Associ-

Guy Corkill, Neurological

4301 X Street, Sacramento, Califor95817.

Surgery, nia

to:

as

of

California, Davis-Sacramento Medical Center,

cent of the

patients admitted to the center with cervical spine injuries, in contrast to the majority, which were associated with motor vehicle accidents. The location of the medical center near popular water resorts, swimming pools, rivers, lakes, and reservoirs probably caused the relatively high percentage of diving injury admissions (Table I). A review of the literature reveals little material relating directly to spinal cord injuries caused by diving, in contrast to the literature on underwater swimming. Burke, in 1972, reported on 52 injuries resulting from diving accidents. In 1964, Landrgot et al analyzed 50 injuries of the cervical spine resulting from physical training or sport and found that the most frequent serious injury occurred from diving into shallow water.22 Piotrowski, in 1965, observed the radiologic findings in five such patients,3 whereas Laursen studied 11 patients with fractures of the cervical spine sustained by diving into shallow water and emphasized the need for prevention to combat the increasing incidence of this injury.4 The personality of the victim is perhaps exemplified by Burke’s case of a young man who dived off a notice board warning swimmers not to dive beI cause of the shallowness of the water. Each summer five or six such patients were brought to the university center. A profile patient was a 25-year-old man in extremely good physical condition who, 107

TABLE I

Common Location of Diving

Injury

without checking the depth of the water, dived into shallow water, never deeper than 1.52 meters (five feet). He was rescued from drowning by bystanders, only to found to be permanently tetraplegic in many instances. The associated head injury was usually mild and, indeed, only three of these pateints sustained scalp lacerations or worse. MANAGEMENT

SKELETAL INJURIES

Holdsworth and Cheshire classified the mechanism of injury by analyzing the bony fractures and probably ligamentous tears of the vertebral column as seen on plain xray.5, 6 Skeletal injuries seen radiographically consisted mainly of burst or wedge fractures. The majority of the force of impact appears to have been expended in the C5 body. The saggital diameter of the cervical canal narrows below the second cervical vertebra,’ whereas the cord width increases. Cervical canal encroachment attributable to dislocation might therefore be expected to vary pari passu with neurologic deficit. Of the 14 patients with severe permanent neurologic deficit, 11had significant canal narrowing radiologically. In contrast, of the remaining eight patients with neurologic deficit who recovered, only one was found to have measurable radiologic narrowing of his

canal. diagnosis was suspected, the spinal patients were placed on a Stryker frame and NEUROLOGIC INJURIES AND SUBSEQUENT sandbags were placed laterally in contact with their heads. After portable x-rays were COURSE obtained confirming the diagnosis, Crutch- Frankel et al’s classification$(Table II) field or Vinke tongs were applied to the head deserves careful study and is useful in deand traction was instituted. Patients early in scribing the eventual status relative to the the series received lumbar puncture and the initial neurologic impairment. Ten patients (group A, Table II) sustained Queckenstedt test to establish the presence of subarachnoid block. Later patients had total loss of function below the level of myelograms with introduction of Pan- injury. Seven of these patients had signifitopaque through the intervertebral foramen cant radiographic narrowing of the spinal at the C2-C3 interspace. This modified canal. Besides the complete tetraplegia and myelogram is quickly performed, requires complete sensory loss, most of them had minimal mobilization of the patient, and initially at least impairment of autonomic yields significant information when subar- function characterized by bradycardia, low achnoid block, herniated disc, or swelling of blood pressure, hyperthermia or hypothe spinal cord is suspected. In the presence thermia, and absent bulbocavernosus of a block or disk prolapse, operation was reflexes. One patient with a C3-C4 dislocaundertaken, provided that the patient was in tion was pulled from the water conscious but a stable condition. Decompression by the at the hospital required intubation and venanterior approach was followed by fusion tilatory assistance. Despite the therapeutic using either the Cloward or the Smith- efforts, he lapsed into coma and died 48 hr Robinson technique. Patients who were poor after admission. Although most of these surgical candidates initially had surgery patients survived the acute stage of the delayed until their condition was stable. We injury, none of them improved. believe that early fusion facilitates early Four patients (group B) were classified in mobilization and rehabilitation of the this category owing to preservation of some patients. There were no complications of sensory function which was usually posterior column preservation or sacral dermatomal fusion or fusion failures. As

108

soon as

the

TABLE II

Distribution of 22 Patients tial and Final Conditions,

by

Ini-

with the

exception of the single death already described. The average hospitalization for all patients in this series was 6 A and B requiring 8 weeks and groups C and D requiring 4 weeks of

weeks, groups

hospitalization. DISCUSSION

The

physical disabilities of tetraplegia are so devastating and permanent that, with present knowledge of the problem, efforts are best directed toward prevention. The increased incidence of diving accident-related tetraplegia in the summer season is clear, as is the factor of proximity to shallow water. The victim is often reckless, owing to relative youth and robust physical attributes. Warning signs erected in the shallow parts of rivers might reduce accident frequency.

a Grid with two letters of the alphabet, the first related to the neurologic deficit on admission and the second to the neurologic deficit at discharge as described by Frankel et al. A total neurological deficit below fracture; B some dorsal column or sacral sensory sparing; C marked sparing of motor and sensory function; D slight neurologic deficit; E normai neurologic function. =

=

=

The unskilled diver does not lock his thumbs when he dives headfirst into the water, and on impact the arms are spread apart by the force of the water and the head is left unprotected. Water has an eventual dampening effect on the speed of the fall, but only after some 1.52 meters (5 feet) or so of

entry. Once

injury

to

the

spinal

cord has

oc-

=

curred, attention should be directed toward

=

These patients had total motor loss and their autonomic systems were damaged as in group A. Because the autonomic efferent system is located in the gray matter deep in the lateral funiculus, evidence of injury to it indicates the severity of the lesion. As in group A, none of these patients

sparing.

protecting the individual from further neurologic damage. Attainment of these goals will necessitate intensive education of the

public, particularly young adults, with regard to the danger of diving. Emphasis should be placed on the proper handling of the injured and the effect on prognosis. In particular, dangers of repeated diving into pools while intermittently drinking require emphasis. Attention should further be directed to the dangers of changing light conditions, especially with regard to visible un-

improved. Six patients (groups C and D) had varying degrees of incomplete spinal cord injury ranging from tetraplegia immediately after derwater rocks which become invisible the injury and subsequent recovery to only owing to lengthening shadow patterns as paresthesia in all of the extremities with evening approaches. subsequent recovery. Those are grouped under the letters C and D of the Frankel classification, and all advanced to E, or good functional recovery. Two patients had no neurologic deficit from the outset and are grouped under E despite cervical spine fractures. In no group did patients become worse after admission,

SUMMARY cases of diving injuries in young reviewed. Narrowing of the cervical canal and loss of autonomic function had a poor prognosis. The vertebra most likely to be involved was C5, which was usually

Twenty-two men are

109

t

fractured in a burst or wedge manner. In injuries in which there was complete or near complete loss of neurologic function on initial examination, there was no recovery. The importance of prevention in medicine is well established, but where no cure exists prevention becomes of paramount importance. This is nowhere

more

true than in this

devastating injury to the young males of our population. The need for publicity aimed at preventive measures by state and local agencies and news media in relationship to this problem cannot be overemphasized.

fracture-dislocations of the

spine. J Bone Joint

Surg 45B:-6-20, 1963 6. Cheshire DJE: The stability of the cervical spine following the conservative treatment of fractures and fracture-dislocations. Paraplegia 7:193-203, 1969 7. Wolf BS, Khilnani M, Malis L: The sagittal diameter of the bony cervical spinal canal and its significance in cervical spondylosis. J Mount Sinai Hosp 23:283-292, 1956 8. Frankel HL, Hancock DO, Hyslop G, et al: The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. Part I. Paraplegia 7:179-192, 1969 EDITORIAL COMMENT

REFERENCES

1. Burke DC: Spinal cord injuries from water sports. Med J Aust 2:1190-1194, 1972 2. Landrgot B, Ledinsky Q, Suchan J: Injuries to the cervical spine caused by jumping into the water. Plzendky Lekarsky Sbornik 23 :107110, 1964 3. Piotrowski W.: Kopfsprungverletzungen der Halswirbelsaule. Langenbecks Arch Klin Chir 313:575-579, 1965 4. Laursen B: Diving accidents. Fractures of the cervical spine sustained by diving into too shallow water. Ugeskr Laeger 131: 122, -1 1121 1969 5. Holdsworth FW: Fractures, dislocations, and

The authors should be commended for emphasizing this serious problem. It is important in treating these injuries that one recognize the fact that there is instability posteriorly as well as anteriorly and that when anterior decompression and fusion is performed, adequate immobilization’ in a halo cast or Minerva jacket or combined anterior and posterior fusion should be accomplished in order to produce stability and prevent the development of kyphosis which may occur secondary to collapse in the inadequately stabilized spine.

Announcement

Purgatory Colorado Medical Ski Symposium Durango, Colorado March 18, 19, 1977 Sponsor: Albuquerque Academy of Family Physicians, tion credit Contact:

Phone:

110

of Family 2650 Yale Blvd., S.E., Suite 105 Albuquerque, New Mexico 87106 505-247-0539

Albuquerque Academy

Physicians

4 hours

continuing

educa-