Fatal Cervical Spine Injury From Diving Accident.

Spinal cord injuries result after diving into shallow water, often after incautious jumps head first into water of unknown depth during recreational or sport activities. Mortality is generally due to upper cervical trauma. The authors present a case of a diving-related death in a young woman who underwent medicolegal investigations. The measured water depth at the supposed dive site was 1.40 m. Postmortem radiology and autopsy revealed fractures of the body and the posterior arch of the fifth cervical vertebra, a fracture of the right transverse process of the sixth cervical vertebra and hemorrhages involving the cervical paraspinal muscles. Neuropathology showed a posterior epidural hematoma involving the whole cervical region and a symmetric laceration of the spinal cord located at the fourth and fifth cervical vertebra level, surrounded by multiple petechial hemorrhages. Toxicology revealed the presence of ethanol in both blood and urine samples. The death was attributed to cervical spine fracture (C5-C6), spinal cord contusion, and subsequent drowning. This case highlights the usefulness of postmortem radiology, examination of the deep structures of the neck, toxicology, neuropathology, and a detailed research of signs of drowning to formulate appropriate hypotheses pertaining to the cause and mechanism of death.

Related papers:

title: Cervical spine injuries from diving accident: a 10-year retrospective descriptive study on 64 patients.
abstract: Ninety percent of the lesions resulting from diving injuries affect the cervical spine and are potentially associated with spinal cord injuries. The objective is to determine the most frequent lesion mechanisms. Evaluate the therapeutic alternatives and the biomechanical evolution (kyphotic deformation) of diving-induced cervical spine injuries. Define epidemiological characteristics of diving injuries.



A retrospective analysis over a period of 10 years was undertaken for patients admitted to the Department of Neurosurgery of Montpellier, France, with cervical spinal injuries due to a diving accident. Patients were re-evaluated and clinical and radiological evaluation follow-ups were done.



This study included 64 patients. Cervical spine injuries resulting from diving predominantly affect young male subjects. They represent 9.5% of all the cervical spine injuries. In 22% of cases, patients presented severe neurological troubles (ASIA A, B, C) at the time of admission. A surgical treatment was done in 85% of cases, mostly using an anterior cervical approach.



This is a retrospective study (type IV) with some limitations. The incidence of diving injuries in our region is one of the highest as compared to reports in the literature. Despite an increase of our surgical indications, 55% of these cases end up with a residual kyphotic deformation but there is no relationship between the severity of late vertebral deformity and high Neck Pain and Disability Scale (NPDS) scores.

title: A 10-year review of sports-related spinal injuries
abstract: IntroductionThe incidence of traumatic spinal cord injury varies in different countries from 2.5 to 57.8 per million per annum, with sport accounting for 8–12.7% of these injuries. Spinal injuries associated with recreational sport often result in long-term permanent disability in otherwise active individuals.Materials and methodsThe aetiology, pattern and mechanism of the 196 sports-related spinal injuries treated in the National Spinal Injuries unit in Ireland from 1993 to 2003 is reviewed in this article.ResultsSports-related spinal injuries accounted for 11% of all spinal injury admissions. There were 145 (74%) males and 51 (26%) females, with an average age of 30.2 years (range 14–72 years). The most common sport responsible for a spinal injury was equestrian events (41.8%), rugby (16.3%), diving (15.3%), Gaelic football and hurling (9.6%), cycling (4.2%), and miscellaneous (12.7%). Injury distribution was cervical spine (118 patients, 60%), thoracic (41 patients, 21%), lumbar spine (37 patients, 19%). In 18 patients (9.25%) more than one region was affected. In 78 patients (40%) more than one vertebral level was affected. On admission 71 patients (36%) had a neurological deficit with 46 patients (65%) incomplete and 25 (35%) complete, of which 6 patients (23%) were paraplegic and 19 (77%) were tetraplegic.ConclusionSport is an important cause of spinal injury among young people in Ireland. This study contributes to our understanding of these injuries aetiology, pattern and mechanism of injury and allows constructive recommendations for injury prevention and management.

title: Medicolegal aspects of athletic cervical spine injury.
abstract: Approximately 10,000 Americans suffer catastrophic cervical spinal cord injuries each year. Most are caused by automobile accidents; however, many of these crippling injuries are related to participation in sports. This article evaluates the legal aspects of neck injury resulting from participation in a number of athletic events, including football, wrestling, gymnastics, snow skiing, ice hockey, diving, and surfing.

title: Diving injuries of the cervical spine in amateur divers.
abstract: Diving injuries are the cause of potentially devastating trauma, primarily affecting the cervical spine.



Our purpose was to describe our experience with diving injuries treatment.



Retrospective review.



Twenty patients with diving injuries.



Using the American Spinal Injury Association (ASIA) impairment scales as the primary outcome measure, the patients' neurological status before and after treatment was assessed. In this way we were able to draw conclusions about neurological improvement or deterioration in response to conservative or operative treatment.



We retrospectively reviewed 20 patients with diving injuries of the cervical spine who were admitted to our institute over a 34-year period from 1970 until 2004.



The typical patient profile was of a young, healthy, athletic male who suffered an injury to the cervical spine after diving into shallow water. The number of cases corresponds to 2.6% of all admitted cervical spine injuries. All injures occurred between May and September. The most commonly fractured vertebrae were C5 and C6. Four patients were treated operatively and 16 conservatively. The indications for surgical treatment were posttraumatic instability and persistent neurological deficit. The mean follow-up of the patients was 17 years. Five patients died within the first month of their hospitalization and 1 patient died 1 year after his injury. Of the 14 patients who were available for follow-up 5 years past injury time, 6 improved neurologically and 8 remained unchanged in relation to their neurology upon admission. Of the 11 patients who were available for follow-up 10 years past injury time, 9 remained neurologically unchanged, 1 deteriorated, and 1 improved in relation to their neurology in the 5-year follow-up.



Diving injuries of the cervical spine demonstrate high mortality and morbidity rates. Recovery depends on the severity of the initial neurological damage. Conservative treatment is justified in specific patients and can lead to improvement of the initial neurological deficit.

title: Aetiology and Occurrence of Diving Injuries
abstract: SummaryThis paper examines multifaceted aspects of diving entries into water which are the cause of many critical injuries (costed at $A150 million) and therefore have important safety ramifications. Wedge and compression fractures are most commonly found in the cervical area of the spine with off-centre impacts with the pool or sea bottom. Diving-related injuries range from 2.3 in a South African study to 21% of spinal cord injuries in Poland. Alcohol and diving do not mix because of diminished awareness and information processing.Children aged under 13 years suffer fewer cervical injuries (1 to 4%), but complication rates are relatively high for this group. Sports trauma (diving-related in particular) is one of the more prevalent causes of spinal cord injury in children aged 6 to 15 years. The highest incidence occurs among those aged 10 to 14, followed by the group aged 5 to 9 years. This contradicts the common perception that 15- to 19-year-olds comprise the highest risk group. Boys are more frequently injured, and swimming pools are more common as an injury location then is the case with adults.The role played by water depth has not been conclusively ascertained; technique, and therefore education, appear to be more important considerations in injury prevention. Although 89% of injuries occur in water <1.52m, injuries are rare in water of 0.46 to 0.61m. Care with pool design to avoid sudden depth changes and the resultant ‘spinal wall’ is necessary. Minimum depth values for diving vary from 1 to 1.52m.Velocities and angles of entry are considered to ascertain the body’s decelerative capacity upon entry. The scoop, racing start dive has been shown to require at least 1.22m of water even when practised by trained divers; the risks involved must therefore be weighed against the fact that it may be no faster than more conventional dives. While it may be safe to perform kneeling and crouching dives into shallower water, standing dives by untrained divers require a greater margin of error.Lack of education is an issue which needs to be addressed and this paper makes recommendations for safety practices such as steering up to the surface, head protection with the arms and only diving when absolutely necessary.

title: Cervical spine injuries resulting from diving accidents in swimming pools: outcome of 34 patients
abstract: Cervical spine injuries after diving into private swimming pools can lead to dramatic consequences. We reviewed 34 patients hospitalized in our center between 1996 and 2006. Data was collected from their initial admission and from follow-up appointments. The injuries were sustained by young men in 97% (mean age 27) and the majority happened during the summer (88%). Fractures were at C5–C7 in 70%. American Spinal Injury Association class (ASIA) on admission was A for 8 patients, B for 4, C for 4, D for 1, and E for 17. There were 23 surgical spine stabilizations. Final ASIA class was A for 6 patients, B for 1, C for 3, D for 5, and E for 18. The mean duration of hospitalization was 21.3 days in our neurosurgical center (mean overall cost: 36,000 Euros/patient) plus 10.6 months in rehabilitation center for the 15 patients admitted who had an ASIA class A to C. Mean overall direct cost for a patient with class A is almost 300,000 Euros, compared to around 10,000 Euros for patients with class D and E. In addition, a profound impact on personal and professional life was seen in many cases including 11 divorces and 7 job losses. Dangerous diving into swimming pools can result in spinal injuries with drastic consequences, including permanent physical disability and a profound impact on socio-professional status. Moreover, there are significant financial costs to society. Better prevention strategies should be implemented to reduce the impact of this public health problem.

title: Diving injuries of the cervical spine.
abstract: From 1975 to 1986, 2435 patients were admitted to the Northwestern University-Midwest Regional Spinal Cord Injury Unit. Of these, 220 patients (9.0%) had documented neck fractures from diving accidents, representing the largest series of acute diving injuries yet analyzed. The average age of these patients was 21 years, and males predominated. Two hundred twelve patients (96.4%) were admitted within 48 hours of injury. Associated injuries were rare: none had intracranial mass lesions or systemic injuries, and only nine were near-drowning victims who required endotracheal intubation. The most common levels of injury were C-5 (140 fractures) and C-6 (85 fractures), with 70 patients having fractures at more than one level. Neurological injury was sustained in 154 (70.0%) patients, while 66 (30.0%) patients were neurologically intact. One hundred forty-seven (66.8%) patients underwent posterior cervical fusion, and anterior fusion was performed in 36 (16.4%), allowing for early ambulation and an average hospital stay of 17 days. Hospitalization was relatively uncomplicated, with urinary tract infection in 121 (55.0%), pneumonia in nine (4.1%), and deep vein thrombosis in 24 (10.9%). Long-term follow up averaged 5 years and was obtained in 160 (72.7%) patients. Sixteen (10.0%) improved neurologically, five (3.1%) deteriorated, and 139 (86.9%) were unchanged. Notably, this large study shows that diving accidents occur in a young, healthy population who sustain essentially no other associated intracranial or systemic injuries and have few serious hospital complications. Such patients may be mobilized early in their care after either internal or external stabilization. Subsequent long-term neurological improvement can be expected to occur in about 10% of patients. The importance of water safety and injury prevention is stressed.

title: Spine trauma due to diving: main features and short-term neurological outcome
abstract: This is a retrospective study.The aim of this study is to examine the main features and short-term neurological outcomes associated with injuries to the spine due to diving into water in a Latin American country.Salvador, Brazil.A total of 1324 subjects were admitted with spinal trauma between 1991 and 2006 (inclusive). Subjects aged between 14 and 65 years who sustained diving injuries corresponded to 10.6% (N=140) of the cases.Neurological status was determined by the Frankel Functional Scale (FFS) on admission and discharge. The FFS was secondarily converted to the American Spinal Injury Association impairment scale.This study is a patient record database review that examines demographic and injury-related characteristics, details of hospital treatment and neurological status at the time of discharge.Males (N=129) outnumbered females (N=11) in a proportion of 12:1 (mean age: 28.62 years). The cervical spine region was the most affected area (92.1%) and 45% of the cases presented with tetraplegia. On admission, neurologically complete lesions accounted for 32.1% of the overall cases and 45.7% were neurologically intact. The mean length of stay (7.7 weeks) did not differ with regard to treatment option (P=0.83). During hospitalization, patients with incomplete neurological impairment had shorter lengths of stay and showed more neurological improvement than those with complete lesions (P=0.26 and 64.5 versus 2.2%, P<0.0001).Conclusion:Diving spine injuries have a high tetraplegia rate. Neurological recovery and shorter length of stay are associated with incomplete lesions.

title: Effect of Spinal Cord Injury on the Respiratory System: Basic Research and Current Clinical Treatment Options
abstract: Spinal cord injury (SCI) often leads to an impairment of the respiratory system. The more rostral the level of injury, the more likely the injury will affect ventilation. In fact, respiratory insufficiency is the number one cause of mortality and morbidity after SCI. This review highlights the progress that has been made in basic and clinical research, while noting the gaps in our knowledge. Basic research has focused on a hemisection injury model to examine methods aimed at improving respiratory function after SCI, but contusion injury models have also been used. Increasing synaptic plasticity, strengthening spared axonal pathways, and the disinhibition of phrenic motor neurons all result in the activation of a latent respiratory motor pathway that restores function to a previously paralyzed hemidiaphragm in animal models. Human clinical studies have revealed that respiratory function is negatively impacted by SCI. Respiratory muscle training regimens may improve inspiratory function after SCI, but more thorough and carefully designed studies are needed to adequately address this issue. Phrenic nerve and diaphragm pacing are options available to wean patients from standard mechanical ventilation. The techniques aimed at improving respiratory function in humans with SCI have both pros and cons, but having more options available to the clinician allows for more individualized treatment, resulting in better patient care. Despite significant progress in both basic and clinical research, there is still a significant gap in our understanding of the effect of SCI on the respiratory system.

title: Pattern of sports- and recreation-related spinal cord injuries in Beijing
abstract: Retrospective study.To determine the characteristics of sports- and recreation-related (SR-related) spinal cord injuries (SCIs) in Beijing.Beijing, China.A review of the complete medical records of 57 consecutive SR-related SCI patients referred to four general hospitals and two rehabilitation institutions was carried out. Patients were injured between 1993 and 2006. The variables studied included demography, sports and recreation characteristics, diagnoses and outcome.There were 44 males and 13 females with a ratio of 3.3:1. The mean age was 24.49±11.92 years. In 37 patients (64.9%), water sports was the single most commont cause. Of them, injury because of diving was seen in 34, which constituted 59.6% of the total. Other types of sports and recreation accounted for 35.1%. Level of cord lesion was cervical in 89.5% and thoracic in 10.5% of the injured. The lesion of C4 alone constituted 45.6% of the total. The ratio of complete to incomplete lesion was 1.2:1. In all, two patients died, and one with an injury at the C4 level recovered completely. Of the other 54 survivals, 48 (89%) remained tetraplegic and six remained paraplegic (11%). The main underlying cause was the lack of safety awareness, safety regulations and their implementation.SR-related SCI was most commonly seen among young male adults, predominantly as a result of diving accidents. There was a significant increase in sports injuries, other than those caused by diving, in later years. Successful prevention programs of other countries are being adopted in Beijing in recent years, hence an improvement in safety is expected in the years to come.This work was sponsored by Funding Project for Academic Human Resources Development in Institutions of Higher Learning Under the Jurisdiction of Beijing Municipality(2007) and Funding Project for Science and Technology Development of Beijing Municipality(km200710029003).