- University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA
- Department of Neurosurgery, University of Rochester Medical Center, 601 Elmwood Avenue, Box 670, Rochester, NY 14642, USA
- Case Western Reserve University, School of Law, 11075 East Blvd, Cleveland, OH 44106, USA
Anthony L. Petraglia
Department of Neurosurgery, University of Rochester Medical Center, 601 Elmwood Avenue, Box 670, Rochester, NY 14642, USA
DOI:10.4103/2152-7806.134074Copyright: © 2014 Plog BA. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Plog BA, Pierre CA, Srinivasan V, Srinivasan K, Petraglia AL, Huang JH. Neurologic injury in snowmobiling. Surg Neurol Int 06-Jun-2014;5:87
How to cite this URL: Plog BA, Pierre CA, Srinivasan V, Srinivasan K, Petraglia AL, Huang JH. Neurologic injury in snowmobiling. Surg Neurol Int 06-Jun-2014;5:87. Available from: http://sni.wpengine.com/surgicalint_articles/neurologic-injury-snowmobiling/
Background:Snowmobiles are increasingly popular recreational, all-terrain utility vehicles that require skill and physical strength to operate given their inherent maneuverability, acceleration, and top speed capabilities. These same characteristics increase the risk of injury with the operation of these vehicles, particularly neurological injury. We characterize our series of 107 patients involved in snowmobiling accidents.
Methods:From January 2004 to January 2012, all snowmobiling-related injuries referred to our regional trauma center were reviewed. Information had been recorded in the hospital's trauma registry and medical records were retrospectively reviewed for data pertaining to the injuries, with particular emphasis on neurological injuries and any associated details.
Results:A total of 107 patients were identified. Ninety percent of injured riders were male. The mean age was 34.4 years (range 10-70), with 7% younger than age 16. The mean Injury Severity Score was 12.0 ± 0.69 (range 1-34). Although not documented in all patients, alcohol use was found in 7.5% of the patients and drug use found in one patient. Documentation of helmet use was available for only 31 of the patients; of which 13% were not helmeted. Causes included being thrown, flipped, or roll-over (33%), striking a stationary object (27%), being struck by a snowmobile (9%), striking another snowmobile (5.5%) or a car, train, or truck (5.5%), being injured by the machine itself (9%), other (2%) or unspecified (18%). Head injuries occurred in 35% patients, including concussion, subarachnoid hemorrhage, subdural hematoma, contusion, and facial/skull fracture. Spinal fractures occurred in 21% of the patients. Fractures to the thoracic spine were the most common (50%), followed by the cervical (41%) and lumbar (36%) spine. There were also three brachial plexus injuries, one tibial nerve injury, and one internal carotid artery dissection. Average length of stay was 4.98 ± 0.56 days. Disposition was home (78%), home with services (12%), rehabilitation placement (9%), and one death. Details regarding other systemic injuries will also be reviewed.
Conclusions:Snowmobiles are a significant source of multi-trauma, particularly neurological injury. Neurosurgeons can play key roles in advocating for neurological safety in snowmobiling.
Keywords: Brain injury, neurological sports medicine, snowmobile, spine injury, trauma, traumatic brain injury
In 1923, Joseph-Armand Bombardier introduced the first prototype of the snowmobile in Valcourt, Quebec, Canada.[
In 2004, Carr et al. published a comprehensive 10-year retrospective review of neurologic injury and death resulting from all-terrain vehicle crashes in West Virginia.[
As recreational all-terrain vehicle use in West Virginia has become greatly popular, so too has the sport of snowmobiling in many cold-weather climates including Upstate New York.[
The present study is a retrospective review of trauma registry data, as well as patient records at the University of Rochester Medical Center in Rochester, New York between January 2004 and January 2012 identifying snowmobile-related injuries. Given the long winter season in Western New York State, and the increasing participation in the sport of snowmobiling among the patient population our level I trauma center serves, we sought to characterize injury in terms of patient demographics, mechanism of injury, spectrum of neurologic and nonneurologic injury, and disposition and patient outcomes. We also reviewed the literature to determine if common risk factors for snowmobile use were shared by our study, and if so what regulatory or legislative action has or could be taken to alleviate this risk and improve the safety of this popular winter pastime.
This study involves the retrospective review of trauma registry data for both adults and children less than 18 years of age who were referred for treatment at the University of Rochester Medical Center in Rochester, New York with snowmobile-related injuries between January 2004 and January 2012. This time frame was used to adequately assess trends and evaluate outcomes surrounding snowmobile-related injury across many winter seasons. The University of Rochester Medical Center Research Subjects Review Board approved this study (RSRB00039900). Information obtained from trauma registry data as well as from patient records from the University of Rochester Medical Center system, including Strong Memorial Hospital and Highland Hospital, was retrospectively reviewed for data pertaining to the injuries, with particular emphasis on neurological injuries and any associated details.
Data acquired regarding these patients with snowmobile-related trauma included patient demographics, mechanism of snowmobile injury including helmet-use status, spectrum of neurologic injury, spectrum of nonneurologic injury, and disposition and outcomes following hospital stay. Types of neurologic injury were classified as spinal, head, peripheral nerve, and vascular injuries. Types of nonneurologic injury were classified as orthopedic, abdominal, or thoracic in origin. Each injury was counted individually, and if there were multiple injuries within a single patient each injury was counted independently. The objective severity of injuries was evaluated with the Injury Severity Score (ISS). Using this system, the injuries from seven different body regions (head, neck, abdomen, pelvis, thorax, extremities, and external tissues) were standardized and scored from minor (1 point) to critical (5 points).[
Snowmobile registration and statewide injury data were obtained from the New York State Office of Parks, Recreation, and Historical Preservation (OPRHP).
A total of 107 snowmobile-related trauma patients were identified. In agreement with other mechanisms of trauma, 90% of riders injured due to snowmobile-related incidents were male. The mean age was 34.4 years (range 10-70), with 7% younger than age 16 [
Statewide registration information was obtained from the New York Office of Parks, Recreation, and Historical Preservation for the last 13 years [
Of the trauma registry data and patient records reviewed, documentation of helmet use was available for only 31 of the 107 patients; of which 13% were not helmeted. Again, although not documented in all patients, ethanol use was found in 7.5% of the patients where blood alcohol content was recorded, and drug use found in one patient where the data was available.
Mechanisms of injury
Most snowmobile-related injuries encountered could be attributed to one of several mechanisms including being thrown from the snowmobile or having the snowmobile flip or roll-over [n = 35 (33%)], striking a stationary object [n = 29 (27%)], being struck by a snowmobile [n = 10 (9%)], striking another snowmobile [n = 6 (5%)], striking a car, train, or truck [n = 6 (5%)], being injured by the machine itself [n = 10 (9%)], other [n = 2 (2%)], or unspecified [n = 19 (18%)]. In none of the incidents reviewed was falling through ice or drowning attributed as the causal etiology of injury [
Spectrum of neurologic and nonneurologic injury
Neurologic injuries were categorized and head injuries occurred in 36% of patients (n = 39 patients). The most common injury was concussion [n = 33 (31%)]. Other cranial vault injuries included subarachnoid hemorrhage [n = 2 (2%)], subdural hematoma [n = 1 (1%)], intraparenchymal hemorrhage [n = 2 (2%)], and facial/skull fractures [n = 9 (8%)] [
Details regarding nonneurologic systemic injuries were also reviewed and were broken into three categories including orthopedic, abdominal, and thoracic injuries. The spectrum of orthopedic injury included upper extremity [n = 17 (16%)], lower extremity [n = 6 (34%)], and hip and pelvis [n = 6 (6%)]. Abdominal injury was predominantly to the solid organs of the peritoneal cavity and retroperitoneal cavities including the liver [n = 4 (4%)], the spleen [n = 13 (12%)], the kidneys [n = 2 (2%)], and other [n = 2 (2%)]. Lastly, thoracic trauma contributed greatly to the morbidity associated with snowmobile-related accidents and included pneumothorax and hemothorax [n = 20 (19%)], pulmonary contusion [n = 17 (16%)], rib fractures [n = 31 (29%)], clavicle fracture [n = 12 (11%)], and scapula fracture [n = 3 (3%)] [
Disposition and patient outcomes
Average length of stay (LOS) due to snowmobile trauma-related admission was 4.98 ± 0.56 days. Disposition was home in 78% of patients, home with services in 12% of patients, to a dedicated rehabilitation facility in 9% of patients, and there was one death in this series of 107 patients [
This study's 107 snowmobile-related traumas represented approximately 3% per year of the total state's snowmobile traumas, and less than 1% of total registrations per year in the region, when extrapolated over the prior 10 years. While this is a very small number in any given year, in aggregate, it represents a continuing problem, and the state's numbers show a continuing trend of injuries each season. State law requires all accidents involving personal injury to be reported to OPRHP and 14 fatalities were reported to the state in the 2012–2013 year. These are 14 lives that could have potentially been saved with proper training, education, and safety equipment.
The patient demographics of the present study are in accordance with data from similar series of recreation-related trauma.[
There have been many prior studies evaluating the incidence, type, mechanism, and outcomes of pediatric snowmobile-related trauma.[
As head injuries are the leading cause of snowmobile-associated morbidity and mortality among pediatric populations, it is reassuring to know that New York State requires anyone driving or riding on a snowmobile, regardless of age, to be wearing an approved safety helmet while on public lands.[
The AAP has stated that there is insufficient scientific evidence that operator safety education courses adequately educate children as a strategy of snowmobile-related injury prevention.[
Since 43% of snowmobile-related incidents occur on privately owned property,[
The present study was also able to demonstrate that head injuries occurred in 35% of patients with the spectrum including concussions, intracranial hemorrhages, and facial/skull fractures. Spinal injuries were also contributory in 21% of the patients evaluated. Legislation in New York State currently mandates that all operators and riders of snowmobiles on public land wear an approved safety helmet.[
Multiple studies recognize lack of helmet use, exceeding safe operating speeds, operating under poor lighting or trail conditions, and operating under the influence of ethanol or drugs as the leading modifiable risk factors responsible for snowmobile-related morbidity and mortality.[
Currently, anyone who is a minimum 18 years old may operate a snowmobile in New York State without any other qualification, and it is only recommended that all operators complete a recognized snowmobile safety course.[
Finally, while neurosurgeons are most focused on injuries to the central and peripheral nervous system, it is important to highlight the other the nonneurologic injuries associated with snowmobiling. In this study, thoraco-abdominal solid organ and nonspinal orthopedic injuries were seen in patients in isolation and in combination with injuries to the nervous system. While it is certainly tempting to focus on obvious cranial or spinal injuries, the principles of trauma management should not be forgotten, and a complete trauma survey must be undertaken on every trauma patient. Neurosurgeons should follow their institutional policies for trauma management (either by the emergency room physician or a dedicated trauma surgery service) and ensure that potentially life-threatening injuries are managed first before attention is turned to the secondary survey and the nervous system.
In our study, 19% of patients presented with a pneumothorax or hemothorax and chest tube placement. These can be rapidly fatal if not recognized early and treated. Twenty percent of patients had injuries to intraabdominal solid organs, which require close observation, and in some cases, surgical repair; three patients required a splenectomy, one patient needed a small bowel resection, and another required a colectomy with colostomy creation. While cranial injuries can be significant causes of morbidity and mortality, following trauma protocols and performing necessary radiographic studies or procedures before rushing to treat the neurosurgical injury can ensure other life-threatening injuries are not ignored or missed.
Snowmobiles are a significant source of multi-trauma, particularly neurological injury, in both adult and pediatric populations. Young adult males are a particularly high risk demographic for snowmobile-related injury, and more needs to be done to target this population for injury prevention strategies. Additionally, greater effort should be devoted toward policy, which brings current New York State snowmobile legislation in line with the AAP position statement on snowmobile use in children and adolescents, that this new legislation be applied universally to not only public but also private lands, and that there be a greater effort by law enforcement to ensure that these laws are being adhered to by all riders, especially children. Furthermore, regardless of age, competency thresholds for snowmobile operation must be made more stringent, and there must be increased efforts to strengthen and enforce legislation surrounding helmet use, speed limits, and operation under the influence of ethanol or drugs.
As physicians with extensive experience in nervous system trauma, and often the ones who treat injuries resulting from snowmobile accidents, neurosurgeons can play powerful roles in shaping educational programs and legislative action as in other sports (e.g., football). Neurosurgeons can use their patient data to promote safe riding practices within their communities and play key roles in advocating for neurological safety in snowmobiling.
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