Pediatric sports-related traumatic brain injury in United States trauma centers

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OBJECTIVE

Traumatic brain injury (TBI) in children is a significant public health concern estimated to result in over 500,000 emergency department (ED) visits and more than 60,000 hospitalizations in the United States annually. Sports activities are one important mechanism leading to pediatric TBI. In this study, the authors characterize the demographics of sports-related TBI in the pediatric population and identify predictors of prolonged hospitalization and of increased morbidity and mortality rates.

METHODS

Utilizing the National Sample Program of the National Trauma Data Bank (NTDB), the authors retrospectively analyzed sports-related TBI data from children (age 0–17 years) across 5 sports categories: fall or interpersonal contact (FIC), roller sports, skiing/snowboarding, equestrian sports, and aquatic sports. Multivariable regression analysis was used to identify predictors of prolonged length of stay (LOS) in the hospital or intensive care unit (ICU), medical complications, inpatient mortality rates, and hospital discharge disposition. Statistical significance was assessed at α < 0.05, and the Bonferroni correction (set at significance threshold p = 0.01) for multiple comparisons was applied in each outcome analysis.

RESULTS

From 2003 to 2012, in total 3046 pediatric sports-related TBIs were recorded in the NTDB, and these injuries represented 11,614 incidents nationally after sample weighting. Fall or interpersonal contact events were the greatest contributors to sports-related TBI (47.4%). Mild TBI represented 87.1% of the injuries overall. Mean (± SEM) LOSs in the hospital and ICU were 2.68 ± 0.07 days and 2.73 ± 0.12 days, respectively. The overall mortality rate was 0.8%, and the prevalence of medical complications was 2.1% across all patients. Severities of head and extracranial injuries were significant predictors of prolonged hospital and ICU LOSs, medical complications, failure to discharge to home, and death. Hypotension on admission to the ED was a significant predictor of failure to discharge to home (OR 0.05, 95% CI 0.03–0.07, p < 0.001). Traumatic brain injury incurred during roller sports was independently associated with prolonged hospital LOS compared with FIC events (mean increase 0.54 ± 0.15 days, p < 0.001).

CONCLUSIONS

In pediatric sports-related TBI, the severities of head and extracranial traumas are important predictors of patients developing acute medical complications, prolonged hospital and ICU LOSs, in-hospital mortality rates, and failure to discharge to home. Acute hypotension after a TBI event decreases the probability of successful discharge to home. Increasing TBI awareness and use of head-protective gear, particularly in high-velocity sports in older age groups, is necessary to prevent pediatric sports-related TBI or to improve outcomes after a TBI.

ABBREVIATIONSCCI = Charlson Comorbidity Index; ED = emergency department; FIC = fall or interpersonal contact; GCS = Glasgow Coma Scale; ICD-9 = International Classification of Diseases, Ninth Revision; ICU = intensive care unit; ISS = Injury Severity Score; LOS = length of stay; NSP = National Sample Program; NTDB = National Trauma Data Bank; TBI = traumatic brain injury.

Abstract

OBJECTIVE

Traumatic brain injury (TBI) in children is a significant public health concern estimated to result in over 500,000 emergency department (ED) visits and more than 60,000 hospitalizations in the United States annually. Sports activities are one important mechanism leading to pediatric TBI. In this study, the authors characterize the demographics of sports-related TBI in the pediatric population and identify predictors of prolonged hospitalization and of increased morbidity and mortality rates.

METHODS

Utilizing the National Sample Program of the National Trauma Data Bank (NTDB), the authors retrospectively analyzed sports-related TBI data from children (age 0–17 years) across 5 sports categories: fall or interpersonal contact (FIC), roller sports, skiing/snowboarding, equestrian sports, and aquatic sports. Multivariable regression analysis was used to identify predictors of prolonged length of stay (LOS) in the hospital or intensive care unit (ICU), medical complications, inpatient mortality rates, and hospital discharge disposition. Statistical significance was assessed at α < 0.05, and the Bonferroni correction (set at significance threshold p = 0.01) for multiple comparisons was applied in each outcome analysis.

RESULTS

From 2003 to 2012, in total 3046 pediatric sports-related TBIs were recorded in the NTDB, and these injuries represented 11,614 incidents nationally after sample weighting. Fall or interpersonal contact events were the greatest contributors to sports-related TBI (47.4%). Mild TBI represented 87.1% of the injuries overall. Mean (± SEM) LOSs in the hospital and ICU were 2.68 ± 0.07 days and 2.73 ± 0.12 days, respectively. The overall mortality rate was 0.8%, and the prevalence of medical complications was 2.1% across all patients. Severities of head and extracranial injuries were significant predictors of prolonged hospital and ICU LOSs, medical complications, failure to discharge to home, and death. Hypotension on admission to the ED was a significant predictor of failure to discharge to home (OR 0.05, 95% CI 0.03–0.07, p < 0.001). Traumatic brain injury incurred during roller sports was independently associated with prolonged hospital LOS compared with FIC events (mean increase 0.54 ± 0.15 days, p < 0.001).

CONCLUSIONS

In pediatric sports-related TBI, the severities of head and extracranial traumas are important predictors of patients developing acute medical complications, prolonged hospital and ICU LOSs, in-hospital mortality rates, and failure to discharge to home. Acute hypotension after a TBI event decreases the probability of successful discharge to home. Increasing TBI awareness and use of head-protective gear, particularly in high-velocity sports in older age groups, is necessary to prevent pediatric sports-related TBI or to improve outcomes after a TBI.

Sports-related traumatic brain injury (TBI) is an important public health concern that is increasingly in the spotlight of both the lay press and the general public. Recent estimates suggest that 300,000 to 3.8 million sports-related TBIs occur in the United States annually,11,17,32,40,49 resulting in more than 500,000 emergency department (ED) visits and over 60,000 hospitalizations.31,44 In children older than 1 year, TBI is the leading cause of death and disability,27 and roughly 60%–80% of sports-related TBI ED visits are by pediatric patients—predominantly adolescents.27,30,31 Of great concern are the evolutions of postconcussion symptoms that persist for weeks to months after the injury event. These symptoms include prodromal symptoms such as headaches (65%–93%), fatigue (55%–82%), and dizziness (32%–75%), as well as specific neurocognitive and neuropsychiatric deficits such as difficulty concentrating (30%–57%), forgetfulness (34%–42%), and depression (17%–24%).13,21,40 The persistence of these symptoms raises the risk not only for extended time away from play, but also for second-impact syndrome38,54 and possibly for chronic traumatic encephalopathy.13,36,38 Thus, persistent postconcussion symptoms have long-term implications for disability and mortality rates.43

Most athletic endeavors involve some risk for TBI. The highest-risk sports are those that involve interpersonal contact and collisions such as football, hockey, rugby, wrestling, and boxing.29,41 Although there have been several investigations into TBI among collegiate and professional athletes,9,36,53 a much smaller number of studies has characterized the morbidity and mortality rate profiles of sports-related TBI in younger athletes.12,47 Furthermore, few studies have focused on TBIs incurred outside of organized athletics, for example, during equestrian events, skiing, or even normal playground activities.15,18,24–26,48

Therefore, the field of pediatric sports-related TBI requires more focused study. Extrapolating from the literature on TBI in adults to that in children is insufficient not just because the injury mechanisms are different between these 2 age groups, but also because age-dependent changes in biomechanical properties, intracranial water content, intracranial blood volume, and overall myelination within the CNS put the pediatric patient at greater risk for posttraumatic brain edema.3,4,16,19,42,51 Efforts are therefore needed to characterize the mechanisms and morbidity and mortality rates of pediatric sports-related TBI in US trauma centers.

Here, we use the National Sample Program (NSP) of the National Trauma Data Bank (NTDB), a prospective registry established with the purpose of informing trauma care and outcome analyses in the United States (https://www.facs.org/quality-programs/trauma/ntdb). We retrospectively analyzed data from 3046 pediatric sports-related head injuries collected from 2003 to 2012 to characterize the demographics, mortality rates, length of stays (LOSs) in the hospital and intensive care unit (ICU), inpatient complications, and discharge disposition of children with sports-related TBI. The analysis was grouped by the type of sports incident leading to the injury; these incidents included fall or interpersonal contact (FIC) and equestrian and related sports, roller sports, skiing/snowboarding, and aquatic sports injuries. Our aim was to analyze and report the demographics of sports-related TBI in the pediatric population and to identify characteristics among patients and sports that influence overall morbidity and mortality rates in this age group.

Methods

The methods we used in this study are very similar to those used in the study by Winkler et al., which also appears in this issue of Neurosurgical Focus.56 To aid readers, we provide detailed descriptions in both papers.

In this study, we used data in the NSP of the NTDB from pediatric patients (age 0–17 years) treated in the ED for sports-related TBI during a 10-year period (from 2003 to 2012). The NSP for each year consists of a stratified sample of 100 NTDB-participating hospitals, based on US census region, trauma care designation, and NTDB reporting status. The NTDB drew hospitals from the sampling universe of 453 Level I or II trauma centers using the probability-proportional-to-size-sampling-without-replacement method of Levy and Lemeshow. A previous review determined that the sample size of 100 hospitals can be extrapolated to represent the national patient distribution.56 Detailed data qualification, selection, cleaning, and standardization algorithms have been previously reported.45 Because the NSP of the NTDB is a fully deidentified data set without the 18 federal Health Insurance Portability and Accountability Act identifiers, the current study was classified as being exempt from institutional review board review.

Of 1,490,076 incidents contained in the overall NSP sample, data from 3711 pediatric individuals who sustained a TBI were extracted as defined by the International Classification of Diseases, Ninth Revision (ICD-9) codes 800–801.99, 803–804.99, and 850–854.19 as previously described (Fig. 1).5,6,34 The subgroup with sports-related mechanisms of injury was included in the present analysis on the basis of ICD-9 E-codes and stratified into the following 5 categories: FIC, roller skate/skateboard (roller sports), skiing/snowboarding, equestrian and related sports, and aquatic sports (Table 1). The ICD-9 E-codes in the NTDB do not identify individual sports, and the relative contributions of individual sports to each category are therefore unknown. The data from patients with known sex (variable name “gender”), ED Glasgow Coma Scale (GCS) score (variable name “edgcstotal”), and hospital discharge disposition (variable name “dischdisp” in NTDB 2003–2006 and “hospdisp” in NTDB 2007–2012) were extracted (n = 3049). Patients who were noted to have died before hospital admission (variable name “eddisp” = “died” or “died in ED,” n = 2), had penetrating TBI (variable name “injurytype” = “penetrating,” n = 1), or both were excluded, yielding a final sample of 3046 cases.

FIG. 1.
FIG. 1.

Flow chart depicting the extraction of the study data set from the NSP of the NTDB.

TABLE 1.

Summary of extracted sports-related ICD-9 E-codes

Type of Sports Injury & CodeICD-9 E-Code DescriptionNo. of Incidents
FIC1444
  886.0Fall on same level from collision, pushing, or shoving, by or w/other person in sports196
  917.0Striking against or struck accidentally by objects or persons in sports566
  917.5Striking against or struck accidentally by object in sports w/subsequent fall682
Roller skate/skateboard806
  885.1Fall from roller skates46
  885.2Fall from skateboard760
Ski/snowboard318
  885.3Fall from skis124
  885.4Fall from snowboard194
Equestrian/related sports427
  828.2Accident involving animal being ridden injuring rider of animal424
  828.9Accident involving animal being ridden injuring unspecified person3
Aquatic sports51
  831.4Accident to watercraft causing other injury to water skier7
  831.5Accident to watercraft causing other injury to swimmer0
  832.4Other accidental submersion or drowning in water transport accident injuring water skier3
  832.5Other accidental submersion or drowning in water transport accident injuring swimmer1
  833.4Fall on stairs/ladders in water transport injuring water skier0
  833.5Fall on stairs/ladders in water transport injuring swimmer0
  883.0Accident from diving or jumping into water (swimming pool)24
  910.0Accidental drowning & submersion while water-skiing0
  910.1Accidental drowning & submersion while engaged in other sport or recreational activity w/diving equipment2
  910.2Accidental drowning & submersion while engaged in other sport or recreational activity w/o diving equipment14

Demographic and clinical variables of interest were extracted to include age, sex, race, health insurance status, medical history, mechanism of injury, scalar and stratified Injury Severity Score (ISS), ED discharge disposition, medical complications, hospital mortality rate, hospital discharge status, hospital and ICU LOSs, and number of days on ventilator. Medical comorbidities and complications were coded as present/absent, and the Charlson Comorbidity Index (CCI) was calculated with the standard comorbidity weights, as previously described.8,55

In considering age-dependent differences in TBI pathophysiology, developmental milestones, and recovery profiles,3,4,16,19,42,51 we grouped patients by age into 3 categories: 0–6 years, 7–13 years, and 14–17 years. These age brackets were determined by further considering representations of typical stages in the educational system (preschool, primary and middle school, and secondary or high school) and the increasing incidence of TBI with age.27,30,31 Participation in sports activities is often dictated by their availability at school; therefore, those in secondary or high school were separated from primary or middle school students to maximize homogeneity within each age group. Demographic and clinical variables that were missing from the NSP or marked as not known or not recorded were coded as “unknown.”

Analysis of mortality rates included all patients with a known hospital discharge status (n = 3046). An analysis of hospital discharge to home included all patients with a known hospital discharge status, excluding death (n = 3023); these patients were dichotomized to “home, with or without services” versus “skilled nursing facility, rehabilitation, or other form of higher level care.” Hospital LOS analysis included all patients who were alive at discharge (n = 3023), excluding 1 outlier LOS of 356 days (final n = 3022). An ICU LOS analysis included all patients who were alive at discharge (n = 3023), were admitted to the ICU or operating room (n = 1227), and had known or recorded ICU LOS (n = 1129), excluding 2 outlier ICU LOSs of 59 and 81 days (final n = 1127). Analysis of the length of time on mechanical ventilation included all patients who were alive at discharge (n = 3023) and were admitted to the ICU or operating room (n = 1227), and whose length of time on mechanical ventilation was known or recorded (n = 425), excluding 4 outlier values of 59, 66, 175, and 216 days on ventilation (final n = 421).

Statistical Analysis

Descriptive variables are presented as mean and SEM unless specified otherwise for continuous variables and as proportions for categorical variables. Group differences were assessed for statistical significance with ANOVA for continuous variables and with Pearson's chi-square test for categorical variables. For analyses with individual cell counts < 5, Fisher's exact test was used in place of the chi-square test. Categorical outcome variables (presence of any inpatient medical complication, mortality rate, and hospital discharge to home) were assessed with binary logistic regression. Continuous outcome variables (hospital and ICU LOSs and days on ventilator) were assessed with linear regression. All multivariable analyses were conducted with multivariable regression adjusted for the category of injury (FIC, roller sports, skiing/snowboarding, equestrian and related sports, and aquatic sports), demographic and clinical variables (age, sex, race, health insurance, ED GCS score, stratified ISS, and CCI score).

Odds ratios with 95% CIs are reported for all logistic regression models, and mean increase or decrease values with 95% CI are reported for all linear regression models. Statistical significance was assessed at α = 0.05. The Bonferroni correction for multiple comparisons was applied in the 5 outcome analyses (presence of any medical complication, mortality rate, discharge to home, and hospital and ICU LOSs; α = 0.05 divided by 5), yielding a statistical significance threshold of p = 0.01. All analyses were performed with SPSS version 22 (IBM Corporation).

Results

Patient Demographics and Injury Characteristics

During the 10-year period chosen for this study (2003–2012), 54,713 incidents resulting in TBI in children were recorded in the NSP. Of these, 3046 patient events were the result of sports-related mechanisms of injury, and these events were included in this study. After adjustment for sample weighting, these data represented 11,614 incidents nationally, and sports-related TBIs accounted for 5.6% of pediatric TBI in US trauma centers. The mean age (± SD) of the cohort was 13.3 ± 3.5 years (Table 2). Most of the patients were boys (76.1%), and white was the most represented racial group (72.7%).

TABLE 2.

Demographic data and injury characteristics of 3046 pediatric patients with sports-related TBI*

VariableValue
Mean age in yrs (SD)13.3 (3.5)
M/F ratio (%)2317 (76.1):729 (23.9)
Mean CCI score (SD)0.06 (0.27)
Race
  White2214 (72.7)
  Black248 (8.1)
  Asian or Pacific Islander90 (3.0)
  Native American18 (0.6)
  Other247 (8.1)
  Unknown229 (7.5)
Health insurance
  Private/commercial1400 (46.0)
  Medicare/Medicaid306 (10.0)
  Government/other362 (11.9)
  Self-pay/unbilled202 (6.6)
  Unknown776 (25.5)
Coagulopathy
  No3043 (99.9)
  Yes3 (0.1)
Injury mechanism
  FIC1444 (47.4)
  Roller skate/skateboard806 (26.5)
  Ski/snowboard318 (10.4)
  Equestrian/related sports427 (14.0)
  Aquatic sports51 (1.7)
ED SBP
  ≥90 mm Hg2809 (92.2)
  <90 mm Hg121 (4.0)
  Unknown116 (3.8)
ED GCS score
  3–8256 (8.4)
  9–12136 (4.5)
  13–152654 (87.1)
ISS
  0–81292 (42.4)
  9–15552 (18.1)
  16–24710 (23.3)
  25–75126 (4.1)
  Unknown366 (12.0)
ED disposition
  Home81 (2.7)
  Observation48 (1.6)
  General ward1174 (38.5)
  Telemetry-monitored units135 (4.4)
  ICU1102 (36.2)
  OR146 (4.8)
  Transfer15 (0.5)
  Other/unknown345 (11.3)

OR = operating room; SBP = systolic blood pressure.

The age range of the patients was 0–17 years.

Data represent number of patients (%), unless indicated otherwise.

The range of the CCI score is 0–8.

The most prevalent injury category was FIC (47.4%) followed by roller sports (26.5%), equestrian and related sports (14%), skiing/snowboarding (10.4%), and aquatic sports (1.7%) (Table 2). The mean ISS was 10.0 ± 7.1, and the median GCS score was 15 (interquartile range 14–15). Mild TBI (GCS score of 13–15) accounted for 87.1% of all head injuries, and 4.5% and 8.4% of TBIs were moderate (GCS score of 9–12) and severe (GCS score of 3–8), respectively. Injuries led to hospital admission in nearly 84% of ED visits—with patients being admitted to a general ward most frequently (38.5%), followed by ICU (36.2%), operating room (4.8%), and telemetry-monitored units (4.4%).

The number of sports-related TBI events increased with age in this pediatric cohort; adolescents (14–17 years) contributed to approximately 60% of all events (Fig. 2). When we analyzed sports-related mechanism as a function of age, several trends emerged. Injuries from FIC represented the largest proportion of sports-related TBI in all age groups, and the proportion of TBIs due to FIC increased with age. Traumatic brain injuries due to roller sports showed an age-dependent increase from children 0–6 years old to those of older age. In contrast, equestrian and related sports showed an age-dependent decrease in contribution to TBI. Traumatic brain injury due to aquatic sports was the smallest contributor in all age groups, and TBI due to aquatic sports or skiing/snowboarding showed no significant age-specific trends (Fig. 2).

FIG. 2.
FIG. 2.

Demographics of sports-related TBI by age and sports mechanism of injury. Left: Graph depicting the number of sports-related TBI events in each of the 3 pediatric age groups. Right: Graph depicting the proportions of sports-related TBI attributed to FIC, roller skating/skateboarding, skiing/snowboarding, equestrian and related sports, and aquatic sports in the 3 pediatric age groups.

Hospital LOS and Medical Complications

Across sports-related injury mechanisms, the mean hospital LOS was 2.68 ± 0.07 days; patients admitted to the ICU or operating room spent on average 2.73 ± 0.12 days and 1.96 ± 0.19 days in the ICU and on mechanical ventilation, respectively. Multivariable linear regression identified several statistically significant predictors for prolonged hospital LOS in sports-related TBI, including moderate or severe TBI; an ISS of 9–15, 16–24, 25–75, or unknown; and roller sports–related TBIs (Table 3). Comparing the sports mechanism of injury, we found that roller sports were associated with statistically significantly prolonged hospital LOS compared with FIC (mean increase 0.54 days, 95% CI 0.25–0.83 days, p < 0.001). Aquatic sports TBI showed a statistically nonsignificant trend toward prolonged hospital LOS compared with FIC (mean increase 1.12 days, 95% CI 0.2–2.03 days, p = 0.017) after multiple comparisons correction (significance threshold p = 0.01). Additional multivariable analyses indicated that moderate or severe TBI and an ISS of 16–24, 25–75, or unknown also were significant predictors of increased ICU LOS (p < 0.001) (Table 4). No statistically significant association was observed between injury mechanism and the duration of ICU stay.

TABLE 3.

Multivariable linear regression of predictors of LOS in the hospital after pediatric sports-related TBI

ParameterBSEM95% CIp Value*
Injury mechanism
  FICReferenceNANANA
  Roller skate/skateboard0.50.20.2 to 0.8<0.001
  Ski/snowboard0.20.2−0.2 to 0.60.221
  Equestrian/related sports0.20.2−0.2 to 0.60.250
  Aquatic sports1.10.470.20 to 2.00.017
Age in yrs
  0–6ReferenceNANANA
  7–13−0.10.3−0.6 to 0.50.817
  14–170.30.3−0.2 to 0.80.303
Sex
  MaleReferenceNANA
  Female0.00.2−0.3 to 0.30.905
Race
  WhiteReferenceNANANA
  Not white0.140.1−0.1 to 0.40.315
Health insurance
  Private/commercialReferenceNANANA
  Medicare/Medicaid0.20.3−0.2 to 0.60.400
  Government/other−0.40.2−0.8 to −0.00.044
  Self-pay/unbilled−0.20.2−0.6 to 0.30.537
  Unknown−0.10.2−0.3 to 0.20.737
ED SBP
  ≥90 mm HgReferenceNANANA
  <90 mm Hg0.00.3−0.8 to 0.40.475
  Unknown−0.20.3−0.6 to 0.60.938
ED GCS score
  13–15ReferenceNANANA
  9–121.40.30.9–2.0<0.001
  3–85.00.24.5–5.4<0.001
ISS
  0–8ReferenceNANANA
  9–150.80.20.5–1.1<0.001
  16–241.50.21.2–1.8<0.001
  25–756.30.35.6–6.9<0.001
  Unknown1.60.21.2–2.0<0.001
CCI score (per-unit increase)0.50.20.1–0.90.018

NA = not applicable.

The statistical significance threshold was set at p = 0.01 because we investigated 5 outcomes in the primary analysis.

TABLE 4.

Multivariable linear regression of predictors of LOS in the ICU after pediatric sports-related TBI

ParameterBSEM95% CIp Value*
Injury mechanism
  FICReferenceNANANA
  Roller skate/skateboard0.30.2−0.2 to 0.80.213
  Ski/snowboard−0.20.4−0.9 to 0.60.695
  Equestrian/related sports0.50.4−0.2 to 1.20.132
  Aquatic sports1.00.7−0.4 to 2.40.150
Age in yrs
  0–6ReferenceNANANA
  7–13−0.40.5−1.4 to 0.60.444
  14–17−0.10.5−0.9 to 1.00.899
Sex
  MaleReferenceNANANA
  Female−0.10.3−0.7 to 0.40.624
Race
  WhiteReferenceNANANA
  Not white−0.10.2−0.5 to 0.40.818
Health insurance
  Private/commercialReferenceNANANA
  Medicare/Medicaid−0.30.3−1.0 to 0.30.326
  Government/other−0.80.3−1.5 to −0.20.016
  Self-pay/unbilled−0.80.4−1.7 to 0.00.059
  Unknown−0.40.3−0.9 to 0.20.182
ED SBP
  ≥90 mm HgReferenceNANANA
  <90 mm Hg0.80.8−0.8 to 2.40.332
  Unknown−1.10.7−2.5 to 0.20.098
ED GCS score
  13–15ReferenceNANANA
  9–121.50.40.7 to 2.3<0.001
  3–83.20.32.6 to 3.7<0.001
ISS
  0–8ReferenceNANANA
  9–150.70.30.0 to 1.30.040
  16–241.10.30.5 to 1.6<0.001
  25–755.60.44.8 to 6.5<0.001
  Unknown1.70.31.0 to 2.4<0.001
CCI score (per-unit increase)0.20.3−0.5 to 0.80.573

The statistical significance threshold was set at p = 0.01 because we investigated 5 outcomes in the primary analysis.

In total, 65 patients (2.1% overall) had a medical complication during their hospital stay: 38 had pneumonia, 25 acute respiratory distress syndrome, 8 decubitus ulcers, 7 coagulopathy, 4 cerebrovascular accidents, and 1 each had cardiac arrest, deep venous thrombosis, and urinary tract infection; no cases of acute kidney injury, renal failure, myocardial infarction, or pulmonary embolism were observed. The rates of any medical complication for the sports categories were as follows: FIC 1.1%, roller skating/skateboarding 2.6%, skiing/snowboarding 2.2%, equestrian and related sports 4.4%, and aquatic sports 3.9%.

Univariate analysis confirmed statistically significantly higher rates of medical complications in TBIs resulting from equestrian and related sports and significantly lower rates of medical complications from FIC events (p < 0.05). Multivariable logistic regression analysis indicated that moderate or severe TBI and an ISS of 25–75 or unknown were statistically significant predictors of medical complications (Table 5). This analysis also showed that no sports-specific mechanism of injury was significantly associated with increased rates of medical complications.

TABLE 5.

Multivariable logistic regression of predictors of complications after pediatric sports-related TBI

ParameterOdds Ratio (95% CI)p Value*
Injury mechanism0.457
  FICReferenceNA
  Roller skate/skateboard1.0 (0.4–2.1)0.918
  Ski/snowboard1.4 (0.5–4.1)0.492
  Equestrian/related sports2.2 (0.8–5.5)0.112
  Aquatic sports0.8 (0.1–4.5)0.798
Age (yrs)0.132
  0–6ReferenceNA
  7–130.5 (0.2–1.8)0.322
  14–171.1 (0.3–3.5)0.880
Sex0.207
  MaleReference
  Female0.6 (0.3–1.3)
Race0.875
  WhiteReferenceNA
  Not white1.1 (0.5–2.1)
Health insurance0.814
  Private/commercialReferenceNA
  Medicare/Medicaid1.0 (0.4–2.5)0.959
  Government/other0.6 (0.2–1.7)0.322
  Self-pay/unbilled0.6 (0.2–2.0)0.418
  Unknown0.9 (0.4–1.9)0.762
ED SBP0.419
  ≥90 mm HgReferenceNA
  <90 mm Hg2.2 (0.6–7.5)0.224
  Unknown0.7 (0.1–3.5)0.645
ED GCS score<0.001
  13–15ReferenceNA
  9–1213.0 (4.0–42.8)<0.001
  3–853.7 (22.9–126.0)<0.001
ISS<0.001
  0–8ReferenceNA
  9–152.1 (0.6–8.0)0.259
  16–243.3 (1.1–9.8)0.028
  25–758.8 (3.1–25.5)<0.001
  Unknown5.8 (1.9–17.8)0.002
CCI score (per-unit increase)0.9 (0.3–2.9)0.880

The statistical significance threshold was set at p = 0.01 because we investigated 5 outcomes in the primary analysis.

Mortality Rates and Discharge Disposition

There were 23 deaths in the cohort, corresponding to a mortality rate of 0.8% (Table 6). All deaths occurred in patients with severe TBI as evidenced by an ED GCS score of 3–8. Similarly, 19 of the 23 deaths occurred in those with an ISS of 25–75, suggesting severe extracranial injury. Univariate analysis indicated a statistically nonsignificant trend of dissimilar mortality rates across the sports categories (p = 0.041); however, a post hoc analysis indicated a higher mortality rate in TBI from equestrian and related sports. The small number of deaths and concentration of all events in more severe injury categories precluded a multivariable analysis.

TABLE 6.

Hospital mortality distribution after pediatric sports-related TBI*

VariableAliveDeadp Value
Injury mechanism0.041
  FIC1438 (99.6)6 (0.4)
  Roller skate/skateboard798 (99.0)8 (1.0)
  Ski/snowboard317 (99.7)1 (0.3)
  Equestrian/related sports420 (98.4)7 (1.6)
  Aquatic sports50 (98.0)1 (2.0)
Age (yrs)0.342
  0–6171 (98.8)2 (1.2)
  7–131042 (99.0)10 (1.0)
  14–171810 (99.4)11 (0.6)
ED GCS score<0.001
  3–8233 (91.0)23 (9.0)
  9–12136 (100.0)0 (0.0)
  13–152654 (100.0)0 (0.0)
ISS<0.001
  0–81292 (100.0)0 (0.0)
  9–15552 (100.0)0 (0.0)
  16–24709 (99.9)1 (0.1)
  25–75107 (84.9)19 (15.1)
  Unknown363 (99.2)3 (0.8)
All3023 (99.2)23 (0.8)

The data represent number of patients (%); row percentages are shown. The statistical significance threshold was set at p = 0.01 because we investigated 5 outcomes in the primary analysis.

We next shifted our analysis focus to survivors. Overall, 89.4% of the pediatric patients ultimately returned home, and 10.6% of the patients were discharged to rehabilitation or skilled nursing facilities. Broken down by the sports categories causing the TBI, rates of return to home were as follows: FIC 90.8%, roller sports 90.0%, skiing/snowboarding 84.2%, equestrian and related sports 88.3%, and aquatic sports 80.0%. Univariate analyses indicated a significantly lower rate of return to home in both skiing/snowboarding and aquatic sports groups (p < 0.05), whereas patients with FIC injuries returned home at a significantly higher rate. Multivariable regression analysis identified several predictors of decreased odds of returning to home, including ED hypotension, moderate or severe TBI, and an ISS of 16–24 or 25–75 (Table 7). With regard to sports category, only skiing/snowboarding injuries were associated with a trend toward lower odds of returning home (p = 0.011), which was nonsignificant after correction for multiple comparisons (at a significance threshold of p = 0.01).

TABLE 7.

Multivariable logistic regression of predictors of hospital discharge disposition to home after pediatric sports-related TBI

ParameterOdds Ratiop Value*
Injury mechanism0.051
  FICReferenceNA
  Roller skate/skateboard1.1 (0.8–1.5)0.665
  Ski/snowboard0.6 (0.4–0.9)0.011
  Equestrian/related sports0.9 (0.6–1.4)0.580
  Aquatic sports0.5 (0.2–1.3)0.171
Age (yrs)0.157
  0–6ReferenceNA
  7–130.7 (0.4–1.4)0.363
  14–170.6 (0.3–1.1)0.117
Sex0.602
  MaleReference
  Female1.1 (0.8–1.6)
Race0.033
  WhiteReferenceNA
  Not white0.7 (0.5–1.0)
Health insurance<0.001
  Private/commercialReferenceNA
  Medicare/Medicaid1.3 (0.8–2.1)0.274
  Government/other0.8 (0.5–1.1)0.165
  Self-pay/unbilled0.7 (0.4–1.1)0.115
  Unknown1.9 (1.3–2.8)0.001
ED SBP<0.001
  ≥90 mm HgReferenceNA
  <90 mm Hg0.05 (0.03–0.07)<0.001
  Unknown1.6 (0.6–3.8)0.314
ED GCS score<0.001
  13–15ReferenceNA
  9–120.3 (0.2–0.5)<0.001
  3–80.2 (0.1–0.2)<0.001
ISS<0.001
  0–8ReferenceNA
  9–150.6 (0.4–0.9)0.020
  16–240.5 (0.4–0.8)<0.001
  25–750.2 (0.1–0.2)<0.001
  Unknown0.9 (0.6–1.5)0.684
CCI score (per-unit increase)0.8 (0.5–1.2)0.315

The statistical significance threshold was set at p = 0.01 because we investigated 5 outcomes in the primary analysis.

Discussion

Sports-related TBI in the pediatric population is presently one of the most widely discussed neurosurgical topics in the public discourse. With the intense public and media scrutiny of TBI in professional sports, parents are increasingly concerned about encouraging their children to participate in both contact and noncontact sports. Unfortunately, the large, population-based observational studies that are necessary to inform this conversation are scarce in the scientific literature. Previous studies have described the incidence of sports-related TBI in adult ED populations.10,23,46 Similarly, a large study in the Pediatric Emergency Care Applied Research Network, conducted between 2004 and 2006, recently reported that the overall incidence of sports-related TBI was 1%, with significant variation by type of sports.20 However, the characteristics of inpatient hospital LOS, complications, discharge, and mortality rates in a large, nationally representative cohort have yet to be described.

One obstacle to such an analysis is the paucity of nationwide epidemiological statistics on inpatient complications and acute outcomes after sports-related TBI in children. The NTDB, although not set up specifically for tracking sports-related TBIs, is well suited for this analysis because of its large overall sample. From 2003 to 2012, we identified more than 3000 cases that fit our inclusion criteria, and we subsequently could characterize the demographic profiles, hospital and ICU LOSs, medical complications, mortality rates, and discharge dispositions across various categories of injury mechanism in pediatric sports-related TBI. To our knowledge, this study is the first in the English literature to characterize predictors of acute outcomes in pediatric sports-related TBI across sports disciplines and pediatric age groups.

Age and Sports-Related TBI

Overall, our data showed that sports-related TBI events dramatically increased with older age, a finding consistent with previous epidemiological studies.27,31,50 We found that that the rate of TBI due to roller sports significantly increased at age 7, and comprised over a quarter of TBIs in ages 7–17 years. This relationship between injury and age likely reflects how mobility and balance, both key components of roller sports, reach a threshold at this point in development that allows children to pursue this sport. This trend is present across many sports categories; indeed, sports activities become more systematic in the community starting in middle childhood.28 Interestingly, TBI from equestrian and related sports bucked this trend; it showed a marked decrease in contribution to overall TBI with increasing age. Although we do not have a definite explanation for this finding, we hypothesize that this decrease may reflect the changing interests of children as they mature. Additionally, although we refer to this category as “equestrian and related,” within the ICD-9 coding, this category is called “rider of animal.” As such, these injuries may also result from encounters between small children and pets. Thus, it is unsurprising that the incidence of these injuries declines with increasing age.

In our study, we observed a significant increase in FIC in the high school age group compared with their younger counterparts. It is likely that high school athletics contributed to this difference. More than 7 million US high school students play sports, and a nationwide representative study in 2008 estimated that 2.5 per 10,000 injury exposures of high school athletes result in concussion.35 Sports injuries show a substantial increase at age 13 and range from 20 to 33 per 100,000 exposures in those 13–16 years old.2 Protective devices such as helmets are known to decrease rates of TBI;7 however, the rate of helmet use is lower among older teens than among younger children.52 Thus, the combination of increased exposure and decreased use of protective wear drive the overall increase in TBI among older children.

Inpatient Complications

The overall rate of medical complications was 2.1% in our study, with GCS scores and ISSs being independent predictors of increased complication rates. This observed rate among children is relatively low compared with that of adults, a finding we attribute to the better overall health of and fewer preinjury comorbidities among the pediatric trauma patients.27 With the exception of respiratory disease (4.6% prevalence)—likely attributable to childhood asthma—the rates of all other comorbidities ranged from 0.0%–0.3% in our pediatric cohort. Although sports injury mechanism was not an independent predictor of complication rates in the multivariable analysis, we note that the highest rate of complications was observed after equestrian-related TBI, and the lowest was observed after FIC-associated TBI. The likelihood of higher velocities and forces involved in causing animal-riding injuries compared with those in ground-level interpersonal contact may contribute to this higher complication rate.

LOS and Discharge Disposition

Similar to complication rates, hospital and ICU LOSs were both strongly predicted by GCS scores and ISSs in the ED. The sports injury mechanism was an independent predictor of hospital LOS, driven by the prolonged hospital LOS observed in roller sports compared with FIC. A statistically nonsignificant trend of prolonged hospital LOS was observed in aquatic sports compared with FIC. No significant differences were observed in ICU LOS across the sports mechanisms of TBI; we surmise that this lack of a difference resulted from an overall low rate of medical comorbidities or complications in this age group and also from small sample sizes.

Similarly, neither age group nor category of injury predicted the likelihood of discharge to home. However, in a subgroup analysis, we did find that compared with FIC, skiing/snowboarding injuries approached statistical significance for decreased odds of discharge to home (OR 0.58, 95% CI 0.38–0.88). Again, we highlight the need for improved compliance with helmet use for sports in general and high-velocity sports in particular.22,33 Patients with no known or unrecorded health insurance status had higher odds of being discharged to home than those with private or commercial insurance. Although it is possible that this disparity reflected a lack of available rehabilitation resources for the uninsured, it may also be due to the speedy discharge of patients with minor injuries before health insurance information was fully collected.

Mortality Rates and Sports-Related TBI

The overall mortality rate in children due to TBI of any cause has been estimated to be at 2.5%; previously identified predictors of poor recovery in children include age younger than 4 years, cardiopulmonary resuscitation, multisystem trauma, hypotension and hypoxia, hyperventilation and hyperglycemia, and intracranial pressure.27 In our study, 0.8% of the patients died, and in all the TBI had been classified as severe (with a GCS score of 3–8). Twenty (87%) of the 23 deaths were graded as severe or critical systemic trauma by the ISS, and the 3 remaining deaths had an unknown ISS. Although the mortality rate observed in our study was lower than the average for overall pediatric TBI, it is yet unknown whether this trend is typical of sports-related pediatric TBI. Not surprisingly, in our study, mortality rate was driven by the severity of TBI as graded by presenting GCS score and the overall trauma severity as graded by the ISS.

Of note, for mortality rates, the sports injury mechanism varied across the 3 age groups: animal riding led to both of the deaths recorded for the youngest age group, whereas FIC and roller sports caused most of the deaths in the 2 older age groups. This variation likely reflects the aforementioned overall age-dependent shift away from equestrian sports and toward organized athletics and roller sports.

Limitations

Despite the large size of our cohort, one limitation was the relatively low number of deaths in this sample. As a result, a multivariable analysis of predictors of mortality rates was not feasible. Future works in larger sample populations with greater heterogeneity of cause of death are needed to create such a model.

It is possible that the mortality rates due to certain sports mechanism are underreported in the NTDB overall because this database includes only patients triaged to a Level I or Level II trauma center. Deaths that occur in the field, in rural areas, or at community hospitals are therefore not included in the NTDB. Most likely, this limitation would cause an underestimation of the mortality rate, particularly after equestrian sports–related injuries, which are more likely to take place outside of major metropolitan centers. Furthermore, the NTDB fails to capture the countless mild TBIs that are never reported because either they are too minor to require medical attention or they are managed in community hospitals and do not require referral to a Level I or Level II trauma center. Last, our analysis did not include those injuries incurred through mechanisms that fall outside the coding parameters of the NTDB. We therefore expect that our analysis of sport-related TBI did not estimate its true prevalence, which is likely several times that of our reported number of injuries.

Conclusions

In pediatric sports-related TBI, the severity of extracranial injury and low admission GCS scores were the strongest predictors of acute medical complications, prolonged hospital and ICU LOSs, in-hospital mortality rate, and failure to discharge to home. Acute hypotension in the ED was found to be detrimental to successful discharge to home. The injury mechanism of roller sports was an independent predictor of prolonged hospital LOS after TBI in the pediatric population. Use of protective headgear, particularly during high-velocity sports in older age groups, is necessary to improve outcomes after pediatric sports-related TBI. Understanding the characteristics of sports-related TBI in terms of complication, morbidity, and mortality rates could help focus public awareness efforts on preventing these debilitating injuries.

Acknowledgments

We acknowledge the use of the NSP in this study as follows: Committee on Trauma, American College of Surgeons, NTDB NSP 2003–2012, Chicago, IL. The content reproduced from the NTDB NSP remains the full and exclusive copyrighted property of the American College of Surgeons. The American College of Surgeons is not responsible for any claims arising from works based on the original data, text, tables, or figures.

References

  • 1

    American College of Surgeons: National Trauma Data Bank (NTDB) National Sample Program Arrival Year 2012 (January 2013). Instructional Manual (https://www.facs.org/~/media/files/quality%20programs/trauma/ntdb/ntdbmanual2012.ashx) [Accessed March 4 2016]

  • 2

    Agran PFWinn DAnderson CTrent RWalton-Haynes L: Rates of pediatric and adolescent injuries by year of age. Pediatrics 108:E452001

  • 3

    Aldrich EFEisenberg HMSaydjari CFoulkes MAJane JAMarshall LF: Predictors of mortality in severely head-injured patients with civilian gunshot wounds: a report from the NIH Traumatic Coma Data Bank. Surg Neurol 38:4184231992

  • 4

    Bauer RFritz HHarald F: Pathophysiology of traumatic injury in the developing brain: an introduction and short update. Exp Toxicol Pathol 56:65732004

  • 5

    Bekelis KMissios SMackenzie TA: Prehospital helicopter transport and survival of patients with traumatic brain injury. Ann Surg 261:5795852015

  • 6

    Bowman SMMartin DPSharar SRZimmerman FJ: Racial disparities in outcomes of persons with moderate to severe traumatic brain injury. Med Care 45:6866902007

  • 7

    Buller DBAndersen PAWalkosz BJScott MDCutter GRDignan MB: The prevalence and predictors of helmet use by skiers and snowboarders at ski areas in western North America in 2001. J Trauma 55:9399452003

  • 8

    Charlson MEPompei PAles KLMacKenzie CR: A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40:3733831987

  • 9

    Collins MWGrindel SHLovell MRDede DEMoser DJPhalin BR: Relationship between concussion and neuropsychological performance in college football players. JAMA 282:9649701999

  • 10

    Coronado VGHaileyesus TCheng TABell JMHaarbauer-Krupa JLionbarger MR: Trends in sports- and recreation-related traumatic brain injuries treated in US emergency departments: the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) 2001–2012. J Head Trauma Rehabil 30:1851972015

  • 11

    Daneshvar DHNowinski CJMcKee ACCantu RC: The epidemiology of sport-related concussion. Clin Sports Med 30:117vii2011

  • 12

    Echlin PSTator CHCusimano MDCantu RCTaunton JEUpshur REG: Return to play after an initial or recurrent concussion in a prospective study of physician-observed junior ice hockey concussions: implications for return to play after a concussion. Neurosurg Focus 29:5E52010

  • 13

    Eisenberg MAMeehan WP IIIMannix R: Duration and course of post-concussive symptoms. Pediatrics 133:99910062014

  • 14

    Gardner AIverson GLMcCrory P: Chronic traumatic encephalopathy in sport: a systematic review. Br J Sports Med 48:84902014

  • 15

    Gassner RTuli THächl OMoreira RUlmer H: Cranio-maxillofacial trauma in children: a review of 3,385 cases with 6,060 injuries in 10 years. J Oral Maxillofac Surg 62:3994072004

  • 16

    Gefen AGefen NZhu QRaghupathi RMargulies SS: Age-dependent changes in material properties of the brain and braincase of the rat. J Neurotrauma 20:116311772003

  • 17

    Gessel LMFields SKCollins CLDick RWComstock RD: Concussions among United States high school and collegiate athletes. J Athl Train 42:4955032007

  • 18

    Gilliam JMJones PJField WEKraybill DBScott SE: Farm-related injuries among Old Order Anabaptist children: developing a baseline from which to formulate and assess future prevention strategies. J Agromed 12:11232007

  • 19

    Giza CCMink RBMadikians A: Pediatric traumatic brain injury: not just little adults. Curr Opin Crit Care 13:1431522007

  • 20

    Glass TRuddy RMAlpern ERGorelick MCallahan JLee L: Traumatic brain injuries and computed tomography use in pediatric sports participants. Am J Emerg Med 33:145814642015

  • 21

    Grubenhoff JAKirkwood MWDeakyne SWathen J: Detailed concussion symptom analysis in a paediatric ED population. Brain Inj 25:9439492011

  • 22

    Hagel BEPless IBGoulet CPlatt RWRobitaille Y: Effectiveness of helmets in skiers and snowboarders: case-control and case crossover study. BMJ 330:2812005

  • 23

    Haring RSCanner JKAsemota AOGeorge BPSelvarajah SHaider AH: Trends in incidence and severity of sports-related traumatic brain injury (TBI) in the emergency department, 2006–2011. Brain Inj 29:9899922015

  • 24

    Hendricks KJAdekoya N: Non-fatal animal related injuries to youth occurring on farms in the United States, 1998. Inj Prev 7:3073112001

  • 25

    Hendricks KJMyers JRLayne LAGoldcamp EM: Household youth on minority operated farms in the United States, 2000: exposures to and injuries from work, horses, ATVs and tractors. J Safety Res 36:1491572005

  • 26

    Hubler CLHupcey JE: Incidence and nature of farm-related injuries among Pennsylvania Amish children: implications for education. J Emerg Nurs 28:2842882002

  • 27

    Kannan NRamaiah RVavilala MS: Pediatric neurotrauma. Int J Crit Illn Inj Sci 4:1311372014

  • 28

    Keenan HTBratton SL: Epidemiology and outcomes of pediatric traumatic brain injury. Dev Neurosci 28:2562632006

  • 29

    Koh JOCassidy JDWatkinson EJ: Incidence of concussion in contact sports: a systematic review of the evidence. Brain Inj 17:9019172003

  • 30

    Lam WHMacKersie A: Paediatric head injury: incidence, aetiology and management. Paediatr Anaesth 9:3773851999

  • 31

    Langlois JARutland-Brown WThomas KE: The incidence of traumatic brain injury among children in the United States: differences by race. J Head Trauma Rehabil 20:2292382005

  • 32

    Langlois JARutland-Brown WWald MM: The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil 21:3753782006

  • 33

    Macpherson AKTo TMMacarthur CChipman MLWright JGParkin PC: Impact of mandatory helmet legislation on bicycle-related head injuries in children: a population-based study. Pediatrics 110:e602002

  • 34

    Majidi SSiddiq FQureshi AI: Prehospital neurologic deterioration is independent predictor of outcome in traumatic brain injury: analysis from National Trauma Data Bank. Am J Emerg Med 31:121512192013

  • 35

    Marar MMcIlvain NMFields SKComstock RD: Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med 40:7477552012

  • 36

    McCrea MGuskiewicz KMMarshall SWBarr WRandolph CCantu RC: Acute effects and recovery time following concussion in collegiate football players: the NCAA Concussion Study. JAMA 290:255625632003

  • 37

    McCrory PMeeuwisse WHKutcher JSJordan BDGardner A: What is the evidence for chronic concussion-related changes in retired athletes: behavioural, pathological and clinical outcomes?. Br J Sports Med 47:3273302013

  • 38

    McCrory PRBerkovic SF: Second impact syndrome. Neurology 50:6776831998

  • 39

    McKee ACCantu RCNowinski CJHedley-Whyte ETGavett BEBudson AE: Chronic traumatic encephalopathy in athletes: progressive tauopathy after repetitive head injury. J Neuropathol Exp Neurol 68:7097352009

  • 40

    Meehan WP IIId'Hemecourt PComstock RD: High school concussions in the 2008–2009 academic year: mechanism, symptoms, and management. Am J Sports Med 38:240524092010

  • 41

    Powell JWBarber-Foss KD: Traumatic brain injury in high school athletes. JAMA 282:9589631999

  • 42

    Prins MLHovda DA: Developing experimental models to address traumatic brain injury in children. J Neurotrauma 20:1231372003

  • 43

    Rose SCWeber KDCollen JBHeyer GL: The diagnosis and management of concussion in children and adolescents. Pediatr Neurol 53:1081182015

  • 44

    Schneier AJShields BJHostetler SGXiang HSmith GA: Incidence of pediatric traumatic brain injury and associated hospital resource utilization in the United States. Pediatrics 118:4834922006

  • 45

    Schoenfeld AJBelmont PJ JrSee AABader JOBono CM: Patient demographics, insurance status, race, and ethnicity as predictors of morbidity and mortality after spine trauma: a study using the National Trauma Data Bank. Spine J 13:176617732013

  • 46

    Selassie AWWilson DAPickelsimer EEVoronca DCWilliams NREdwards JC: Incidence of sport-related traumatic brain injury and risk factors of severity: a population-based epidemiologic study. Ann Epidemiol 23:7507562013

  • 47

    Sim ATerryberry-Spohr LWilson KR: Prolonged recovery of memory functioning after mild traumatic brain injury in adolescent athletes. J Neurosurg 108:5115162008

  • 48

    Smith GAScherzer DJBuckley JWHaley KJShields BJ: Pediatric farm-related injuries: a series of 96 hospitalized patients. Clin Pediatr (Phila) 43:3353422004

  • 49

    Sosin DMSniezek JEThurman DJ: Incidence of mild and moderate brain injury in the United States, 1991. Brain Inj 10:47541996

  • 50

    Stocchetti NConte VGhisoni LCanavesi KZanaboni C: Traumatic brain injury in pediatric patients. Minerva Anestesiol 76:105210592010

  • 51

    Thibault KLMargulies SS: Age-dependent material properties of the porcine cerebrum: effect on pediatric inertial head injury criteria. J Biomech 31:111911261998

  • 52

    U.S. Consumer Product Safety Commission: National Bike Helmet Use Survey (http://www.cpsc.gov/en/Media/Documents/Research--Statistics/Technical-Reports/Sports--Recreation/Other-Sport-Injury-/National-Bike-Helmet-Use-Survey/?utm_source=rss&utm_medium=rss&utm_campaign=Other+Sports+Technical+Reports+) [Accessed February 17 2016]

  • 53

    Warden DLBleiberg JCameron KLEcklund JWalter JSparling MB: Persistent prolongation of simple reaction time in sports concussion. Neurology 57:5245262001

  • 54

    Wetjen NMPichelmann MAAtkinson JLD: Second impact syndrome: concussion and second injury brain complications. J Am Coll Surg 211:5535572010

  • 55

    Winkler EAYue JKBirk HRobinson CKManley GTDhall SS: Perioperative morbidity and mortality after lumbar trauma in the elderly. Neurosurg Focus 39:4E22015

  • 56

    Winkler EAYue JKBurke JFChan AKDhall SSBerger MS: Adult sports-related traumatic brain injury in United States trauma centers. Neurosurg Focus 40:4E42016

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Tarapore, Yue, Winkler, Dhall, Berger, Manley. Acquisition of data: Tarapore, Yue, Winkler, Dhall, Berger, Manley. Analysis and interpretation of data: all authors. Drafting the article: all authors. Critically revising the article: Tarapore, Yue, Winkler, Dhall, Berger, Manley. Reviewed submitted version of manuscript: Tarapore, Yue, Winkler, Dhall, Berger, Manley. Statistical analysis: Tarapore, Yue, Winkler. Administrative/technical/material support: Tarapore, Yue, Winkler, Burke, Chan. Study supervision: Tarapore, Yue, Winkler, Berger, Manley.

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Article Information

INCLUDE WHEN CITING DOI: 10.3171/2016.1.FOCUS15612.

Correspondence Phiroz E. Tarapore, San Francisco General Hospital, 1001 Potrero Ave., Bldg. 1, Rm. 101, San Francisco, CA 94110. email: taraporep@neurosurg.ucsf.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Flow chart depicting the extraction of the study data set from the NSP of the NTDB.

  • View in gallery

    Demographics of sports-related TBI by age and sports mechanism of injury. Left: Graph depicting the number of sports-related TBI events in each of the 3 pediatric age groups. Right: Graph depicting the proportions of sports-related TBI attributed to FIC, roller skating/skateboarding, skiing/snowboarding, equestrian and related sports, and aquatic sports in the 3 pediatric age groups.

References

1

American College of Surgeons: National Trauma Data Bank (NTDB) National Sample Program Arrival Year 2012 (January 2013). Instructional Manual (https://www.facs.org/~/media/files/quality%20programs/trauma/ntdb/ntdbmanual2012.ashx) [Accessed March 4 2016]

2

Agran PFWinn DAnderson CTrent RWalton-Haynes L: Rates of pediatric and adolescent injuries by year of age. Pediatrics 108:E452001

3

Aldrich EFEisenberg HMSaydjari CFoulkes MAJane JAMarshall LF: Predictors of mortality in severely head-injured patients with civilian gunshot wounds: a report from the NIH Traumatic Coma Data Bank. Surg Neurol 38:4184231992

4

Bauer RFritz HHarald F: Pathophysiology of traumatic injury in the developing brain: an introduction and short update. Exp Toxicol Pathol 56:65732004

5

Bekelis KMissios SMackenzie TA: Prehospital helicopter transport and survival of patients with traumatic brain injury. Ann Surg 261:5795852015

6

Bowman SMMartin DPSharar SRZimmerman FJ: Racial disparities in outcomes of persons with moderate to severe traumatic brain injury. Med Care 45:6866902007

7

Buller DBAndersen PAWalkosz BJScott MDCutter GRDignan MB: The prevalence and predictors of helmet use by skiers and snowboarders at ski areas in western North America in 2001. J Trauma 55:9399452003

8

Charlson MEPompei PAles KLMacKenzie CR: A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40:3733831987

9

Collins MWGrindel SHLovell MRDede DEMoser DJPhalin BR: Relationship between concussion and neuropsychological performance in college football players. JAMA 282:9649701999

10

Coronado VGHaileyesus TCheng TABell JMHaarbauer-Krupa JLionbarger MR: Trends in sports- and recreation-related traumatic brain injuries treated in US emergency departments: the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) 2001–2012. J Head Trauma Rehabil 30:1851972015

11

Daneshvar DHNowinski CJMcKee ACCantu RC: The epidemiology of sport-related concussion. Clin Sports Med 30:117vii2011

12

Echlin PSTator CHCusimano MDCantu RCTaunton JEUpshur REG: Return to play after an initial or recurrent concussion in a prospective study of physician-observed junior ice hockey concussions: implications for return to play after a concussion. Neurosurg Focus 29:5E52010

13

Eisenberg MAMeehan WP IIIMannix R: Duration and course of post-concussive symptoms. Pediatrics 133:99910062014

14

Gardner AIverson GLMcCrory P: Chronic traumatic encephalopathy in sport: a systematic review. Br J Sports Med 48:84902014

15

Gassner RTuli THächl OMoreira RUlmer H: Cranio-maxillofacial trauma in children: a review of 3,385 cases with 6,060 injuries in 10 years. J Oral Maxillofac Surg 62:3994072004

16

Gefen AGefen NZhu QRaghupathi RMargulies SS: Age-dependent changes in material properties of the brain and braincase of the rat. J Neurotrauma 20:116311772003

17

Gessel LMFields SKCollins CLDick RWComstock RD: Concussions among United States high school and collegiate athletes. J Athl Train 42:4955032007

18

Gilliam JMJones PJField WEKraybill DBScott SE: Farm-related injuries among Old Order Anabaptist children: developing a baseline from which to formulate and assess future prevention strategies. J Agromed 12:11232007

19

Giza CCMink RBMadikians A: Pediatric traumatic brain injury: not just little adults. Curr Opin Crit Care 13:1431522007

20

Glass TRuddy RMAlpern ERGorelick MCallahan JLee L: Traumatic brain injuries and computed tomography use in pediatric sports participants. Am J Emerg Med 33:145814642015

21

Grubenhoff JAKirkwood MWDeakyne SWathen J: Detailed concussion symptom analysis in a paediatric ED population. Brain Inj 25:9439492011

22

Hagel BEPless IBGoulet CPlatt RWRobitaille Y: Effectiveness of helmets in skiers and snowboarders: case-control and case crossover study. BMJ 330:2812005

23

Haring RSCanner JKAsemota AOGeorge BPSelvarajah SHaider AH: Trends in incidence and severity of sports-related traumatic brain injury (TBI) in the emergency department, 2006–2011. Brain Inj 29:9899922015

24

Hendricks KJAdekoya N: Non-fatal animal related injuries to youth occurring on farms in the United States, 1998. Inj Prev 7:3073112001

25

Hendricks KJMyers JRLayne LAGoldcamp EM: Household youth on minority operated farms in the United States, 2000: exposures to and injuries from work, horses, ATVs and tractors. J Safety Res 36:1491572005

26

Hubler CLHupcey JE: Incidence and nature of farm-related injuries among Pennsylvania Amish children: implications for education. J Emerg Nurs 28:2842882002

27

Kannan NRamaiah RVavilala MS: Pediatric neurotrauma. Int J Crit Illn Inj Sci 4:1311372014

28

Keenan HTBratton SL: Epidemiology and outcomes of pediatric traumatic brain injury. Dev Neurosci 28:2562632006

29

Koh JOCassidy JDWatkinson EJ: Incidence of concussion in contact sports: a systematic review of the evidence. Brain Inj 17:9019172003

30

Lam WHMacKersie A: Paediatric head injury: incidence, aetiology and management. Paediatr Anaesth 9:3773851999

31

Langlois JARutland-Brown WThomas KE: The incidence of traumatic brain injury among children in the United States: differences by race. J Head Trauma Rehabil 20:2292382005

32

Langlois JARutland-Brown WWald MM: The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil 21:3753782006

33

Macpherson AKTo TMMacarthur CChipman MLWright JGParkin PC: Impact of mandatory helmet legislation on bicycle-related head injuries in children: a population-based study. Pediatrics 110:e602002

34

Majidi SSiddiq FQureshi AI: Prehospital neurologic deterioration is independent predictor of outcome in traumatic brain injury: analysis from National Trauma Data Bank. Am J Emerg Med 31:121512192013

35

Marar MMcIlvain NMFields SKComstock RD: Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med 40:7477552012

36

McCrea MGuskiewicz KMMarshall SWBarr WRandolph CCantu RC: Acute effects and recovery time following concussion in collegiate football players: the NCAA Concussion Study. JAMA 290:255625632003

37

McCrory PMeeuwisse WHKutcher JSJordan BDGardner A: What is the evidence for chronic concussion-related changes in retired athletes: behavioural, pathological and clinical outcomes?. Br J Sports Med 47:3273302013

38

McCrory PRBerkovic SF: Second impact syndrome. Neurology 50:6776831998

39

McKee ACCantu RCNowinski CJHedley-Whyte ETGavett BEBudson AE: Chronic traumatic encephalopathy in athletes: progressive tauopathy after repetitive head injury. J Neuropathol Exp Neurol 68:7097352009

40

Meehan WP IIId'Hemecourt PComstock RD: High school concussions in the 2008–2009 academic year: mechanism, symptoms, and management. Am J Sports Med 38:240524092010

41

Powell JWBarber-Foss KD: Traumatic brain injury in high school athletes. JAMA 282:9589631999

42

Prins MLHovda DA: Developing experimental models to address traumatic brain injury in children. J Neurotrauma 20:1231372003

43

Rose SCWeber KDCollen JBHeyer GL: The diagnosis and management of concussion in children and adolescents. Pediatr Neurol 53:1081182015

44

Schneier AJShields BJHostetler SGXiang HSmith GA: Incidence of pediatric traumatic brain injury and associated hospital resource utilization in the United States. Pediatrics 118:4834922006

45

Schoenfeld AJBelmont PJ JrSee AABader JOBono CM: Patient demographics, insurance status, race, and ethnicity as predictors of morbidity and mortality after spine trauma: a study using the National Trauma Data Bank. Spine J 13:176617732013

46

Selassie AWWilson DAPickelsimer EEVoronca DCWilliams NREdwards JC: Incidence of sport-related traumatic brain injury and risk factors of severity: a population-based epidemiologic study. Ann Epidemiol 23:7507562013

47

Sim ATerryberry-Spohr LWilson KR: Prolonged recovery of memory functioning after mild traumatic brain injury in adolescent athletes. J Neurosurg 108:5115162008

48

Smith GAScherzer DJBuckley JWHaley KJShields BJ: Pediatric farm-related injuries: a series of 96 hospitalized patients. Clin Pediatr (Phila) 43:3353422004

49

Sosin DMSniezek JEThurman DJ: Incidence of mild and moderate brain injury in the United States, 1991. Brain Inj 10:47541996

50

Stocchetti NConte VGhisoni LCanavesi KZanaboni C: Traumatic brain injury in pediatric patients. Minerva Anestesiol 76:105210592010

51

Thibault KLMargulies SS: Age-dependent material properties of the porcine cerebrum: effect on pediatric inertial head injury criteria. J Biomech 31:111911261998

52

U.S. Consumer Product Safety Commission: National Bike Helmet Use Survey (http://www.cpsc.gov/en/Media/Documents/Research--Statistics/Technical-Reports/Sports--Recreation/Other-Sport-Injury-/National-Bike-Helmet-Use-Survey/?utm_source=rss&utm_medium=rss&utm_campaign=Other+Sports+Technical+Reports+) [Accessed February 17 2016]

53

Warden DLBleiberg JCameron KLEcklund JWalter JSparling MB: Persistent prolongation of simple reaction time in sports concussion. Neurology 57:5245262001

54

Wetjen NMPichelmann MAAtkinson JLD: Second impact syndrome: concussion and second injury brain complications. J Am Coll Surg 211:5535572010

55

Winkler EAYue JKBirk HRobinson CKManley GTDhall SS: Perioperative morbidity and mortality after lumbar trauma in the elderly. Neurosurg Focus 39:4E22015

56

Winkler EAYue JKBurke JFChan AKDhall SSBerger MS: Adult sports-related traumatic brain injury in United States trauma centers. Neurosurg Focus 40:4E42016

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