injury (1987) 18,329-332 Printed in Great Britain 329

Unstable cervical spine injuries in rugby-a 20-year review

Priscilla Williams and B. McKibbin

Department of Traumatic and Orthopaedic Surgery, University of Wales College of Medicine, Cardiff

Summary A study of a well-defined group of rugby players was under- taken in Wales to determine whether there has been an increase in the number of serious neck injuries during the past 20 years. None such occurred until a single incident in 1964 and not again until 1974. Since then the injuries have con- tinued at a steady rate of about two per year.

The mechanism of the injuries was analysed but no single factor could be identified as being responsible for this sudden increase although tactics in the scrummage played an import- ant part. The importance of flexion injuries is emphasized but it is likely that not all the responsible factors have yet been identified.

INTRODUCTION SINCE the late 1970s there has been an increasing interest in the occurrence of serious neck injuries in rugby football, as evidenced by the number of reports published in the medical literature from all over the rugby playing world (Scher, 1977; Williams and McKib- bin, 1978; Burry and Gowland, 1981). There is a wide- spread feeling that these injuries have increased in number quite sharply over this period, particularly in young players (Hoskins, 1979; Carve11 et al., 1983; Silver, 1984).

If there has indeed been such an increase it is clearly important to attempt to identify the reason for it in the hope of reversing the trend, but before embarking upon premature speculation and proposing simple solu- tions it is necessary to establish that there has been an increase. There is certainly a prima facie case that this is so but most reviews have been retrospective, recording admissions to specialist spinal centres, whose cases are referred from large but variable catchment areas and which cannot therefore provide absolute figures. One of the difficulties with retrospective studies is that with the passage of time memories fade and records dis- appear; this alone is bound to account for some of the apparent increase.

Because of these considerations it was decided to carry out a further review in Wales over a 20-year period from 1964. This study consisted of two parts. The first was confined to patients injured while playing for clubs affiliated to the Welsh Rugby Union (WRU), the purpose being to study the incidence of the con- dition in this well-defined group. This part of the study was confined to those with spinal cord injuries because

This work was supported by a grant from the International Rugby Football Board.

these patients are normally treated in one central unit, where figures are therefore likely to be reliable.

The second part consisted of an analysis of all serious neck injuries sustained during the study period. This was done with the hope that, should a true increase be identified, some light might be shed on the underlying cause.

MATERIAL The first part of the study was confined to playel;s in clubs affiliated to the Welsh Rugby Union who sus- tained injury of the cervical spinal cord during matches in the period 1964-1984. This yielded a population of approximately 30000 of schoolboys, youths and senior players.

Patients were identified from the records of the Welsh Spinal Injuries Unit in Cardiff. All cases of serious spinal cord injury in South and West Wales are normally transferred to this unit but enquiries were also made of the units at Oswestry and Southport who may accept patients from North and Mid-Wales.

The second part of the study included all cases of serious neck injury, whether accompanied by paralysis or not, which had been sustained in rugby games during the same 20-year period. These were identified from the records at the Cardiff Royal Infirmary, which is the largest accident centre in South Wales and which acts as the centre for all forms of spinal injury, including those subsequently transferred to the Welsh Spinal Injuries Unit.

For the purposes of this part of the study a serious neck injury was defined as one showing sufficient insta- bility either to damage the cord or to require surgical stabilization.

METHOD OF ASSESSMENT All players who were treated in Cardiff from Septem- ber 1982 to December 1984 for a serious injury of the neck were interviewed (PW) after any necessary opera- tion had been carried out and their progress was fol- lowed until the end of 1984, by when they had either been discharged or were still inpatients in the Rehabili- tation Unit. Details were recorded, using a question- naire based on that used in New Zealand (Burry and Gowland, 1981). The data recorded included the date of injury and time in the game at which the accident occurred. The position of the player was noted, together with the occurrence in which the incident occurred, i.e. strum/tackle, ruck/maul, and in each case

330 Injury: the British Journal of Accident Surgery (1987) Vol. 18/No. 5

Tab/e 1. Summary of all injuries

Total injuries 30 (Spinal cord injuries, 16 complete, 7 incomplete}

Average age of player 22 (Range 16-361 Phase of game, strum 12 (strum COilapSe = 9)

(strum lifted = 2) (clashed strum = I)

Tackle 9 (tackler = 31 (tacklee = 6)

Ruc~maul 9 In all, strum injuries =40% injuries to ball carrier =43% Injuries to tackler =17%

Date of injury Before end of Ott= 17 (63%) Before end of Dee = 23 (85%)

Time into game 1st quarter = 56% 4th quarter = 21% Training = 13% Other = 10%

Average neck size 15.8 inches

Average weight 12st 61bs

Type of player Top club=3 Average club = 18 Youth=3 School=6

Position of player, prop=10 (tight head=51 (loose-head = 5)

Hooker=3 Centre=4 Flanker=5 Serum half= 1 Fly half=2 Lock=4 Forward=74% Front row=48%

a detailed account of each individual accident was taken from the player.

Patients who had been interviewed in an earlier study (Williams and McKihhin, 1978) had their details trans- ferred to the standard questionnaire and were brought up to date by telephone interviews.

The players injured during the remaining years were traced either through the records at the Welsh Spinal Injuries Unit or through Welsh Rugby Union insurance records.

RESULTS Thirty players sustained serious injuries of the neck during the 20 years of the study and the mechanism of injury was clearly described in 3Y of these; the other died instantaneously. The details are summarized in Table I. Twenty-three of these also had injuries of the spinai cord.

incidence Eighteen patients satisfied the criteria for inclusion in

Tab/e II. Summary of all injuries

the first part of the study in that they had all suffered important damage to the spinal cord while playing for clubs affiliated to the WRU. During the Z&year period before 1YhS there were only two recorded injuries of the neck with involvement of the spinal cord. During the study period no injury occurred until 1Y66 and then not again until 1974. The incidence over the remaining years is set out in Tobk II, where it can be seen that since lY76 the injuries have continued at an average rate of about two per year.

Mode of injury (all patients) Forty per cent of injuries were in strums the remainder were equally divided between tackles (30 per cent) and the ruckimaul (30 per cent) Tub/e I.

Nature of the bony injury (a# patients) With the exception of two pptients who did not suffer damage to the spinal cord ~11 the injuries were either dislocations or subluxatiows; although there were frac- tures of the vertebral bony in some of these they were verv small. The c~)mmo~est level was CSl6.

?:hcre appears to be a relationship between the level of injury and the player’s age. The group studied spans 30 vears but when the average ages are analysed with respect to the level of the lesion it appears that as a player gets older, the lower part of the neck becomes more prone to damage (Q. I).

CASE REPORTS Case 1 A M-year-old P.E. teacher who had been playing first-class rugby for over IO years; he gave a graphic account of his injury. This occurred in July 1975 when he was generally tit after an intensive gymnastics course during the summer hut probably not specially fit for front row rugby. The ground was very hard and when the strum collapsed after packing down very low the inexperienced second row kept on pushing and his head rolled onto his chset. the vertex being restrained by contact with the opposite front row. He eventually felt some- thing ‘go’ and he immediately became tetrapiegic. He was later found to have sustained a complete dislocati(~n at CM. There has been no recovery.

Case 2 A 27-year-old accountant who had played first XV rugby for a good club side for 4 years. His injury also occurred during a training session. slightly later in October 1979, where he was at his usual position of loose head prop. The strum collapsed and the lock behind him, who usually played in another position. kept on pushing. His neck became more tiexed until there was a sudden loss of sensation and movement below the shoulder level. He was taken to hospital, where a radiograph showed a fracture dislocation at C4/5 which was reduced by traction within 3 hours of injury, following which he under- went posterior cervical fusion. He subsequently recovered and is now able to jog and play badminton as well as return to work. There is residual weakness of the left hand and hyper- aesthesia and motor loss on the lateral aspect of his left leg.

Year No. of patients Total

lncideffce of spinai cord injury in dense Rugby U~;o~ Players from 79661984 ‘66, . . ‘74, ‘75, ‘76, ‘77, ‘78, ‘79, ‘80, ‘81, ‘82, ‘83, ‘84

1 1 0 1 1 4 2 2 - 2 2 2 18

Williams and McKibbin: Cervical spine injuries in rugby 331

26

1

c3-4 C5-6 C7-Tl

level of cervical lesion Fig. 1. Graph showing the relationship between the level of cervical injury and the patient’s age.

Case 3 A 20-year-old man was playing his fourth season in top club rugby. He had been playing strum half for 10 years and was injured during a club game in November 1981. He mistimed a tackle and ended up in a sitting position when one of his own pack, having successfully tackled an opponent, landed on top of his back, forcing his head onto his chest. He felt a click and immediately lost sensation and movement below shoulder level. A radiograph showed a subluxation of C.5 on 6, which was eventually treated by posterior cervical fusion. Following this he made a complete recovery and went back to playing top class rugby within 9 months, against medical advice.

Case 4 A 15year-old schoolboy whose injury was not stabilized until one year afterwards. He had been in a strum that collapsed and had been treated with a surgical collar at another casualty

department. He came to the Cardiff Royal Infirmary only after suffering a severe wound of the face while playing football. Radiographs showed an avulsion fracture of the spinous process of C2, with instability of C2/3 shown by flexion and extension views. He was treated by posterior fusion.

DISCUSSION This study supports the proposition that there has been an increase in the number of serious neck injuries associated with playing rugby football in Wales in re- cent years and particularly since 1974. Young players have shared in this increase but not disproportionately so.

The total number is small but the victims are derived from a well-defined group of players and therefore accord with the findings in all the other studies in the United Kingdom indicating that there is sufficient evi- dence of a trend to cause concern.

An attempt was made to go back earlier than 1962 but the records were too unreliable. Nevertheless, the fact that only two patients with injury of the spinal cord can be identified during the whole 20 years before the present study is surely noteworthy.

During the period of study when records were avail- able there was only one injury in the first decade. A

sudden increase appears to have occurred in 1974 and once established the number has not risen. During the period 1974-1978 inclusive there were six complete tetraplegias, including one death, in a rugby playing population of 33000 whereas in the series from New Zealand over the same 5-year period there were 16 complete tetraplegias, again including one death from a playing population of 200000; when corrected to the same population of players there are in New Zealand only half the number of tetraplegias found in Wales (Burry and Gowland, 1981).

It might have been anticipated that, since the in- crease in these injuries occurred in 1974 and has re- mained fairly constant since, some single factor might explain this. However, in spite of a detailed analysis none has emerged. If there had been some change in laws or technique of play one might have expected this to affect a particular phase of the game, whereas, in fact, all phases appear to be equally affected.

Certain types of play became more popular in the mid-seventies, including deliberately collapsing the strum and placing emphasis on the ruck which, if incorrectly set up, resulted in multiple pile-ups. Changes in the laws have since been introduced to avoid this and it remains to be seen whether this will reduce the incidence of serious injuries of the neck. The limi- ted evidence to date (Table II) suggests that while the incidence is not increasing it has not reverted to the pre- 1974 level.

Injuries in strums call for a separate comment be- cause these appear to follow a more set pattern than in other phases of the game. The proportion of these among the total injuries is remarkably constant, being 35 per cent in the New Zealand series (Burry and Gowland, 1981) while in South Africa Scher (1977) reported 40 per cent and Silver (1984) 38 per cent in Britain. The incidence in the present series was 44 per cent. The injury involves predominantly players in the front row and the characteristic injury of flexion accompanied by restraint of the vertex decribed by Williams and McKibbin in 1978 is well illustrated by Cases I and 2. This injury is particularly serious because it frequently leads to dislocations of both facets which are usually associated with transection of the cord (Scher, 1977). Nine of the 12 injuries in strums in this series suffered severe injury of the spinal cord.

Most of the injuries in strums occurred early in the season, only one occurring after the New Year. This, coupled with the finding that many injuries were sustained during the first quarter of the game or in training (Table I), suggests that injury is more likely to occur if packs are not used to each other and are uncertain of their combined course of action in the event of a collapsed strum.

Injuries sustained during tackles and in the rucW maul are inevitably more varied in their mechanism but even so, the effect of violent flexion predominated, as in Case 3. In these cases the element of restraint of the vertex is often absent and the amount of damage to the spinal cord therefore may be less severe. There was no instance of extension injury.

Particular attention was paid to the younger patients in the series, 7 were under the age of 18. Of these, a similar proportion (75 per cent) sustained serious spinal

332 injury: the British Journal of Accident Surgery (1987) Vol. 18/iNo. 5

cord injury as in the total group (70 per cent). Their injuries did not appear to be of a different type from those of the older players although they tended to be higher up the neck (Cusr 41. It has frequently been suggested that increase in these injuries in young play- ers is due to the recent development of a ‘win at all costs’ attitude but the fact remains that the increase has affected all grades of player. including those in top clubs (CUSPS f, 2 and 4). It is hardly to be supposed that the desire to win in these latter was any less marked prior to 1974.

In spite of being able to locate the increase in ;I specific year (1974) it has not been possible to identify any one factor which was responsible for the increase. which has affected all phases of the game. Multiple factors must therefore be involved and it is by no means certain that ah have yet been identified. However, as in other series, the strum is the place where most injuries occur and these are of the most serious nature. The mechanism of injury in these cases is almost invariably flexion combined with restraint of the vertex, hexion also predominates with injuries sustained in other phases of the game. increasing the awareness of players

and referees to the dangers of this mechanism appears to be the most important single contribution that can be made in the hope of preventing this still rare but devastating injury.

REFERENCES Burry H. c‘. and Gowland H. (19X1) Cervical injury foot-

hall---ii New Zealand survey. Rr. f. ~~p~~f,~ MP~. 15. 56.

<~arvrll .l. E., Fuller D. J., Duthie R. B.. et ai. (19X3) Ru#\: football injuries to the cervical spine. Br. Med. .I. i. 49.

lloskins T. W. (1979) Rugby injuries to the cervical spine in schoolboys. Practitioner 223. 36.5.

Scher A. 7‘. (1977) Rugby injuries to the cervical spinal cord. s. nf;. h&d. .I. 51. 473.

Silver J. R. (1’184f Injuries of the spine sustained in rugby. RI-. MmT J. i, 37.

Williams J. P. R. and McKibbin B. (197X) Cervical spine injurim in rugby football. Br. Med. J. ii, 1747.

Paper accepted 4 December IYXh

Requests for reprints should hr uddrrssed to: B. McKibhin, Department of Traumatic and Orthopaedic Surgery, University of Wales College of Medicine. Cardiff.