Background: Sports-related cervical spine injuries (CSI) are devastating traumas that can result in permanent disability and death. However, there is a paucity of literature on catastrophic CSI sustained in young athletes who require surgical intervention. The objectives of this study were to review injury characteristics, management, and outcomes in pediatric patients who sustained an operative CSI during youth sports. Methods: This was a retrospective review of patients treated at a Level 1 pediatric trauma center for CSI (2004-2019). Children <18 years old who sustained a sports-related CSI which required operative treatment were identified. All patients received modern cervical spine instrumentation and fusion. Clinical, surgical, hospital admission, and radiographic data were analyzed. The American Spinal Cord Injury Association classification (ASIA) was used to stratify spinal cord injuries (SCI). Comparisons were made between patients with and without SCI. Results: Twenty-nine patients (25 males) sustained an operative CSI over a 15-year period. Mean age at surgery was 14.5 ±2.88 years (range, 6.4-17.8 years). Sporting activities were football (n=8; 28%), wrestling (n=7; 24%), gymnastics (n=5; 17%), diving (n=4; 14%), trampoline (n=2; 7%), hockey (n=1; 3%), snowboarding (n=1; 3%), and biking (n=1; 3%). Mechanisms included hyperflexion (n=19; 65%), axial loading (n=8; 28%), and hyperextension (n=2; 7%) injuries. There were 23 predominantly bony (79%) and six ligamentous (21%) defects: six C1-C2 injuries (21%) and 23 C3-C7 injuries (72%). Ten patients (34%) had traumatic cervical disc herniation on CT/MRI. Seven boys (24%) with subaxial CSI sustained SCI: ASIA A (n=3; 10%), ASIA B (n=3; 10%), ASIA C (n=0; 0%), ASIA D (n=1; 3%). Three children had cord contusion (n=2; 7%) or myelomalacia (n=1; 3%) without neurological deficits. The risk of SCI increased with age (15.8 vs. 14.1 years; p=0.03) and axial loading mechanism (71% vs. 14%; p=0.003). Instrumentation included anterior (n=9; 31%), posterior (n=15; 52%), and circumferential (n=5; 17%) fusions. No intraoperative complications or new neurological deficits were seen. Two incomplete SCI improved one ASIA grade and one SCI two ASIA grades. Complications related to SCI included: three patients with prolonged mechanical ventilation requiring tracheostomy, three pneumonia, two autonomic instability, and one urinary sepsis. Two quadriplegic patients required posterior spinal fusion for paralytic scoliosis. The risk of complication was greatest for SCI (p=0.001). At median follow-up of 32 months (IQR, 14-52 months), 24/26 patients (92%) with available imaging had clinical/radiographic fusion. Conclusion: Overall, a mean of two children annually sustained a sports-related cervical spine injury that required surgical intervention at our high-volume Level 1 pediatric trauma center for CSI. Age- and gender discrepancies were found. Hyperflexion injuries often had a good prognosis; however, older male athletes who sustained an axial loading CSI in contact sports were at greatest risk of SCI, complications, and permanent disability.

Operative cervical spine injuries sustained in youth sports cohort characteristics (n=29)