Injuries in Skiers and Snowboarders in British Columbia
Hentschel, Walter Hader, Michael Boyd
Background: At the Vancouver General Hospital Neurosurgical
Service there have been a significant number of seriously brain
injured snowboarders, seemingly out of proportion to the number
of skiers. The purpose of this study was to determine whether
snowboarders suffered more serious head injuries than skiers
in the Vancouver catchment area. Methods: The
British Columbia Trauma Registry was searched for patients incurring
head injuries while skiing or snowboarding on British Columbia
mountains during the period from January 1992 to December 1997.
Patients were included if they were admitted to hospital and
underwent neurosurgical consultation. Results:
A total of 40 skiers and 14 snowboarders met the above criteria.
Of the skiers, 15% sustained a severe head injury by Glasgow
Coma Score, another 30% sustaining moderate head injuries, while
29% of snowboarders had a severe injury and 36% a moderate injury.
A concussion was present in 60% of the skiers and 21% of the
snowboarders. Snowboarders suffered an intracranial hemorrhage
in 71% of the cases compared to 28% of the skiers. A craniotomy
was performed acutely in 10% of skiers and in 29% of snowboarders.
Three deaths occurred as a direct result of head injury, one
while snowboarding. All but one of the surviving skiers were
able to return home, whereas four of 13 surviving snowboarders
required additional inpatient rehabilitation or transfer to
another acute hospital for ongoing care. Conclusions:
Snowboarders suffer more significant head injuries compared
to skiers in this series and are much more likely than skiers
to require an intracranial procedure. In our opinion, this indicates
that additional safety measures, in particular the use of mandatory
helmets, should be considered by ski areas and their patrons.
Traumatismes crâniens chez les skieurs et les adeptes
de la planche à neige en Colombie-Britannique. Introduction:
Le service de neurochirurgie du Vancouver General Hospital a
reçu un nombre adeptes de la planche à neige souffrant
de blessures sérieuses à la tête hors de
proportion avec celui des skieurs présentant de telles
blessures. Le but de cette étude était de déterminer
si les adeptes de la planche à neige avaient plus de
blessures sérieuses à la tête que les skieurs
dans la région desservie par Vancouver. Méthodes:
Le registre des traumatismes de la Colombie-Britannique a été
consulté pour identifier les patients qui avaient subi
des blessures à la tête en ski ou en planche à
neige dans les centres de sports d'hiver de la Colombie-Britannique
pendant la période de janvier 1992 à décembre
1997. Les patients étaient inclus dans l'étude
s'ils étaient admis à l'hôpital et avaient
eu une consultation en neurochirurgie. Résultats:
Au total, 40 skieurs et 14 adeptes de la planche à neige
rencontraient les critères décrits ci-haut. Parmi
les skieurs, 15% avaient subi une blessure sévère
à la tête selon le score GCS et 30% avaient subi
une blessure modérée, par rapport à 29%
des adeptes de la planche à neige qui avaient subi des
blessures sévères et 36% des blessures modérées.
60% des skieurs et 21% des adeptes de la planche à neige
avaient subi une commotion cérébrale. Les adeptes
de la planche à neige avaient subi une hémorragie
intracrânienne dans 71% des cas par rapport à 28%
des skieurs. Une crâniotomie a été effectuée
en urgence chez 10% des skieurs et 29% des adeptes de la planche
à neige. Trois patients sont décédés
de leurs blessures à la tête, dont un adepte de
la planche à neige. Tous sauf un des skieurs survivants
ont pu retourner chez eux, alors que quatre des 13 adeptes de
la planche à neige survivants ont eu besoin de réhabilitation
additionnelle pendant leur séjour à l'hôpital
ou d'un transfert à un autre hôpital de soins aigus.
Conclusions: Dans cette série de cas, Les
adeptes de la planche à neige ont subi plus de blessures
sévères à la tête que les skieurs
et sont plus susceptibles que les skieurs d'avoir besoin d'une
intervention intracrânienne. À notre avis, ceci
indique que des mesures de sécurité additionnelles,
surtout quant au port obligatoire du casque, devraient être
considérées par les centres de ski et leurs clients.
J. Neurol. Sci. 2001; 28: 42-46
have been several reports in recent years that have studied
and compared injuries sustained while downhill skiing[1,2]
or snowboarding.[3-9] Some have concentrated on central
nervous system injuries in skiers and snowboarders;[10-12]
however, only one has specifically addressed the severity of
head injuries in this population.
Columbia (BC) has become a major destination for skiers and
snowboarders during the last several years resulting in an increased
number of persons skiing each year. Concurrent with this, there
has been a perceived increase in the quantity and severity of
ski and snowboarding injuries admitted to the five Vancouver
area hospital neurosurgical services. The purpose of this study
was to determine the number and severity of ski and snowboard
related head injuries requiring neurosurgical management in
the Vancouver area and to compare these two groups.
trauma database (BC Trauma Registry) was searched for patients
who suffered head injuries while skiing or snowboarding on the
five local BC mountains during the period from January 1992
to December 1997. Patients were included in this study if they
met the following criteria: 1) suffered a head injury that required
neurosurgical consultation, 2) the injury occurred while skiing
or snowboarding, 3) the injury occurred on a BC mountain and
4) the patient was admitted to one of the five centers in Vancouver
with a neurosurgical service. The hospital record was reviewed
for information regarding circumstances of the injury, initial
Glasgow Coma Score (GCS), CT scan results, injuries sustained,
treatments provided and condition on discharge.
initial GCS score was taken to be the score that was first recorded
after appropriate initial resuscitation. This was usually obtained
by the attending mountain physician or by trained ambulance
personnel. Head injuries were classified as either being minor
(GCS 14-15), moderate (GCS 8-13), or severe (GCS <8). A concussion
was felt to have occurred when a patient sustained a mild head
injury with a normal CT scan of the head, with or without associated
skull fractures. The outcomes were recorded as the patient's
status at the time of discharge from hospital.
the ski areas do not record the relative proportion of skiers
and snowboarders and thus an estimate of 70% skiers and 30%
snowboarders was made by the main resort areas reported in the
study for use in the calculation of head injury rates.
patients, 40 skiers and 14 snowboarders were included in the
study (see Table
1). The age range was 9-73 years. Snowboarders had a younger
median age (22 years) compared to skiers (32 years). Eleven
patients (20%) were female (14% of snowboarders, 23% of skiers).
The most common mechanism of injury was a fall on the mountain.
Injuries sustained while jumping occurred in six skiers and
two snowboarders. There were a total of 8,728,095 skier and/or
snowboarders at the two main ski areas included in this study
during the reported time period. The head injury rates at these
areas were 0.005 per 1000 for skiers and 0.004 per 1000 for
snowboarders. The other ski areas were not included in this
calculation due to the small numbers contributed by these locations.
Five skiers and two snowboarders were specifically recorded
as not wearing helmets, the rest were unspecified.
concussion was the most common injury among skiers, occurring
in 24 (60%) of these patients, compared to only three (21%)
in the snowboarding group (see Table
2). There were 10 severe head injuries, occurring in six
(15%) skiers and four (29%) snowboarders. Seventeen patients
had a moderate head injury, including 12 (30%) of the skiers
and five (36%) of the snowboarders. Another 27 patients had
mild head injuries, found in 22 (55%) skiers and five (36%)
snowboarders. The average GCS score for skiers was 12 and for
snowboarders it was 11. Fourteen (35%) of the skiers had skull
fractures, four linear, eight basal, and two depressed. A higher
incidence of fractures was present in the snowboarders with
nine (64%) skull fractures, two linear, five basal, and two
most common single intracranial pathology was diffuse axonal
injury, demonstrated by shear hemorrhages and cerebral edema,
occurring in 13 (24%) patients in total. Ten (25%) of the skiers
and three (21%) of the snowboarders sustained such an injury.
Twenty-one (39%) patients, 11 (28%) skiers and 10 (71%) snowboarders,
had a hemorrhagic lesion on CT scan (other than a shear hemorrhage).
The most common such lesion was a cerebral contusion, being
present in 12 (22%) patients, with a further nine (17%) having
epidural hematomas, four (7%) having subdural hematomas and
four (7%) with traumatic subarachnoid hemorrhages. Note that
different types of hematoma may have been present in a single
patient. See Table 2 for a breakdown of the head injuries.
eight craniotomies were performed, four (10%) in skiers and
four (29%) in snowboarders (see Table
3). In skiers, craniotomies were performed for one epidural
hematoma, one depressed skull fracture, and one intracerebral
contusion. One further craniotomy was performed for a CSF leak
resulting from a basal skull fracture. Two snowboarders required
a craniotomy to evacuate an epidural hematoma and another two
required operation for depressed skull fractures. Two snowboarders
had insertion of an external ventricular drain for intracranial
pressure (ICP) management and one had burr holes for a chronic
subdural hematoma. Two significantly debilitated patients, one
in each group of patients, required tracheostomy and gastric
tube insertions. Table 3 lists the other procedures performed
on these patients.
skiers died from their head injuries, one from a severe diffuse
head injury and another from a large epidural hematoma. Two
other patients died with what appeared to be minor head injuries
(on CT scan), one from massive cerebral infarction secondary
to bilateral carotid dissections with occlusion, and the other
from anoxic injury secondary to respiratory arrest with abdominal
and thoracic trauma. A fifth skier, with a high complete cervical
cord injury, died after a prolonged stay in hospital when his
ventilator was disconnected at his request (he had initially
sustained a mild head injury). The one snowboarder who died
suffered a severe head injury resulting in brain death.
but three (92%) of the injured skiers (including the two patients
who suffered fatal head injuries) were able to return home,
with only one requiring further inpatient rehabilitation (see
the three patients who died of nonhead injury related causes
were excluded from this analysis. However, only nine (64%) of
the snowboarders were able to return home directly on discharge,
while 4 (29%) required ongoing inpatient rehabilitation. Most
(83%) of the surviving skiers were neurologically normal upon
leaving hospital, compared to only 54% of the snowboarders.
Mild dysfunction included symptoms of 'postconcussion syndrome',
persistent headaches, significant fatigue and mild concentration
or memory problems. Patients with significant impairment had
difficulties with the basic activities of daily living. Three
snowboarders had significant impairment on discharge whereas
none of the skiers did.
the hospital stay and intensive care unit stays were longer
for the snowboarders with an average stay of 20.4 days on the
ward and 11.8 days in the ICU while for skiers it was 6.6 days
and 4.7 days, respectively. One patient in each group with a
very prolonged stay artificially inflated both groups' averages.
of head injuries
injuries associated with recreational skiing and snowboarding
are uncommon but represent a significant cause of morbidity
and mortality. There has only been one previous report looking
specifically at head injuries in snowboarders and skiers.
Most studies to date have only addressed head injuries as a
subgroup of a larger multiple trauma population concerning snowboard
and ski related injuries. Prall et al, who reported
on severe snowboarding injuries, found intracranial hemorrhages
in 25% of snowboarders and 31% of skiers out of the patients
who had head injuries, none of which required an ICP monitor
or a craniotomy. His patient population consisted of patients
requiring referral to a level I trauma center and thus would
be expected to include the most severely head injured patients.
From his data, it can be calculated that the head injury rate
in skiers and snowboarders was 0.008 and 0.016 per 1000, respectively.
Our reported head injury rates are expected to be lower than
this due to the restricted population in this study. What is
quite different about our data is the much higher incidence
of snowboarder intracranial hemorrhage (71% vs. 25%). Another
study found 16 intracranial hemorrhages in 88 head injured downhill
skiers, for an incidence of 18%.11 Their patient population
was quite similar to the one that we are reporting upon, with
selection criteria including requirement for neurosurgical consultation
and admission to hospital.
a study by Myles et al that included all central
nervous system injuries, there was a total of 88 head injuries
over a five year period. He reported 70 (80%) of these injuries
as concussions, which he defined as a "transient loss of consciousness
due to an impact". Prall et al reported a similar
concussion rate of 65% in snowboarders and 46% in skiers. Contrary
to his findings, skiers in our series were noted to have a concussion
60% of the time while only 21% of the snowboarders sustained
a concussion, the rest sustaining a more serious injury.
fractures occurred nearly twice as often as in skiers. Intracranial
hemorrhages occurred 2.5 times more frequently in snowboarders
than in skiers. Although some of these did not require surgical
intervention, the fact that 29% of snowboarders and only 10%
of skiers required a craniotomy lends further support to the
more serious nature of snowboarder injuries. There were no skiers
who had an intracranial pressure monitoring device placed, while
two snowboarders required external ventricular drainage for
management of raised ICP. A study from Japan found a significantly
higher incidence of major head injury (defined as a positive
CT scan) in snowboarders (6.3% of all head injuries) compared
with skiers (1.3%).
that our patient population is so highly selected to represent
the most severely head injured but surviving patients, it is
difficult to compare with most previous studies. Our findings
suggest that snowboarders suffered more serious brain injuries
than did skiers during the time period included in this study.
Most other authors have found that skiers and snowboarders suffer
relatively similar head injuries in terms of the severity.[3,8]
Prall et al found that snowboarders had a somewhat
higher incidence of head injuries (54% compared to 40% in skiers)
but most of the injuries in snowboarders were concussions and
skiers actually suffered the more significant head injuries
by a small margin. It may be that these prior studies either
were not able to analyze enough skier and snowboarder head injuries
specifically and thus were not able to identify a difference
between the two groups, or it may be that our study has identified
a more recent trend in the pattern of injury in these groups.
This may be reflective of the rapidly increasing popularity
possible reasons for snowboarders having more serious brain
injuries than skiers are multiple. Firstly, the snowboarding
population is perhaps already preselected by being younger,
more likely male, more adventurous, and more likely to engage
in potentially dangerous activities. The second reason, which
we were not able to address in this study but has been previously
reported, is that snowboarders are more likely to be beginners
and thus more likely to be injured.[3,9,13] The third
reason, for which we have no proof, is that the mechanics of
snowboarding predispose one to head injuries.
of the study
small retrospective study precludes any statistical analysis
and the potential for incomplete data is inherent. Stringent
criteria for entry into this study may exclude a significant
number of head injured skiers and snowboarders and therefore
underestimate true head injury rates. Several reasons exist
to explain the seemingly disproportionate number of seriously
injured snowboarders as compared to skiers. It is possible that
skiers suffer more serious fatal head injuries, do not survive
long enough to reach hospital and therefore escape analysis
through hospital data bases. Alternatively, a younger snowboarder
with a more mild head injury such as concussion, may not seek
medical attention, and therefore only the most serious head
injuries would result in referral, neurosurgical consultation,
and admission. Age and sex are confounding variables in this
study. However, in this observational study, we feel that rather
than invalidate the observations, younger age and male sex further
define the population at risk.
fact that no patient was recorded to have been wearing a helmet
at the time of injury does not, of course, mean that no helmets
were worn at the time of injury. However, in our experience,
helmet use during this time period would be quite uncommon for
the ski areas reported in this study.
with head injuries in this series had more serious intracranial
injuries, required an intracranial procedure at a much higher
rate, had overall longer hospital and intensive care unit stay,
and had worse functional outcomes than did skiers during the
same time period. In our opinion, serious consideration needs
to be given to this matter given that snowboarding is becoming
increasingly popular. Increased awareness through education
as well as mandatory helmets and/or lessons prior to undertaking
these potentially dangerous activities may help to reduce the
number of serious head injuries.
thank Sharon Kasic, Manager, and Dr. Richard Simons, Medical
Director, of the BC Trauma Registry as well as Susan Sirett
of VGH medical records for their help in obtaining the data
for the patients in this study.
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the Division of Neurosurgery, Department of Surgery, University
of British Columbia, Vancouver Hospital and Health Sciences
Center, Vancouver, British Columbia, Canada
Received March 29, 2000. Accepted in final form November
Reprint requests to: Stephen Hentschel, Department of
Surgery, Division of Neurosurgery, 3rd Floor, 910 West
10th Avenue, Vancouver, BC V5Z 4E3 Canada
J. Neurol. Sci. 2001; 28: 42-46