Winter is here…Where is your helmet?

hs2Kristopher G. Hooten, MD (left)
Major United States Army
Fellow in Pediatric Neurosurgery at Duke University Medical Center
Durham, NC 

Kimberly B. Hoang, MD (right)
Resident in Neurological Surgery at Duke University Medical Center
Durham, NC

Winter is here. Where is your helmet? As the temperatures drop, neurosurgeons unfortunately also see an increase in devastating injuries secondary to winter sports, such as ice-skating, skiing, snowboarding, sledding and snowmobiling. Notably, traumatic brain injury (TBI) remains the leading cause (approximately 20 percent) of death and disability for winter sports enthusiasts, and many of these traumatic injuries are preventable.1

skiWhile many states have mandatory two-wheeled vehicle helmet laws, only one state (New Jersey) legally mandates helmet use for youth skiers and snowboarders. A few other states have pending legislation, but helmet regulation in this field is hardly the norm. Many general parallels have been made between winter sports-related head injuries and those sustained on two-wheeled vehicles, such as bicycles, particularly regarding mechanism and speeds of injury.2 Over the past decade, the movement for bicycle helmet safety has gained national focus with a cooperative campaign between the AANS and the ThinkFirst National Injury Prevention Foundation. Perhaps the next logical step is for the neurosurgery community to take the same position on helmet policies for winter sports.

A growing body of literature supports the efficacy of helmets in mitigating TBI and spine trauma. In 2006, Sulheim et al. demonstrated a 60 percent reduction in the risk of head injury for skiers and snowboarders with the use of helmets.3 More recently, a 2012 evidence-based review by the Eastern Association for the Surgery of Trauma Injury Control Violence Prevention Committee in the Journal of Trauma and Acute Care Surgery recommended that all recreational skiers and snowboarders should wear safety helmets, citing Level I evidence. Helmet use demonstrated a significant reduction in the risk of head injury and did not increase the rates of cervical spine injury, neck injury or, interestingly, risk compensation behavior.4 In the pediatric realm, Milan et al. recently reported helmeted skiers and snowboarders had lower injury severity and head acute injury severity scores in their recent single-institution findings at a Level 1 pediatric trauma center.5

snowDespite these and other similar studies, opposition remains regarding the mandated used of helmets and concerns regarding helmet efficacy linger — especially among participants and the general public. Milan et al. report that in injuries sustained in Colorado during winter sports, winter enthusiasts from out of state were less likely to be wearing a helmet and more likely to be severely injured.5 Even within the scientific community, the evidence remains mixed regarding the efficacy of helmet use in the winter sports subgroup. Recent studies from two groups (Hasler et al. and Baschera et al.) cite an increased use of helmets in their populations with no decrease in severe TBI among snowboarders and/or snowboarders.6, 7 Clearly further study is needed in larger cohorts to understand the efficacy of helmet use better. Beyond outcomes or biomechanical standpoints, further research is required to understand the fundamental relationship between risk-taking behavior and helmet use.

Ideally, this type of understanding will guide future design to minimize injury, regardless of whether helmet use is legally mandated. Injury patterns are notably different between skiers and snowboarders, suggesting a potential for sport specific design changes in the future.8, 9 In 2012, Hoshizaki and others biomechanically compared different types of currently used winter helmets with bicycle helmets using a monorail drop apparatus. Bicycle helmets provided superior protection to winter helmets, and the kind of helmet significantly affected the risk of brain injury.10  This has obvious implications for helmet design, highlighting the likely need for the industry to tailor helmet design based on the stress forces exerted on the brain. Specifically, rapid deceleration and rotation/torsion within the skull or against fixed tissue at impact should be addressed in winter helmet design carefully. It is possible this may be sport specific. Another area of novel innovation involves mild internal jugular vein compression to mitigate the “slosh” effect in the brain during a trauma.11 Regardless, communication between researchers and industry is clearly necessary to advance brain safety in a meaningful way.

Ultimately, the injury prevention movement must be driven by both science and common sense. Education, prevention, research and advocacy in this at-risk population deserve our efforts and attention as medical providers. Education of our youth can be an excellent first target group. Lids on Kids, an organization backed by the National Ski Areas Association to increase the safety in winter sports, is a leader in this effort. Clearly, additional study is needed to define the efficacy and optimal design of our protective equipment. However, this winter when you go outside to enjoy the snow and ice, we strongly encourage you to be safe and remember your helmet!

References:

  1. Ackery, A., Hagel, B.E., Provvidenza, C. and Tator, C.H. (2007). An international review of head and spinal cord injuries in alpine skiing and snowboarding. Injury prevention: journal of the International Society for Child and Adolescent Injury Prevention 13, 368-375.
  2. Juang, D., Feliz, A., Miller, K.A. and Gaines, B.A. (2010). Sledding injuries: a rationale for helmet usage. The Journal of trauma 69, S206-208.
  3. Sulheim, S., Holme, I., Ekeland, A. and Bahr, R. (2006). Helmet use and risk of head injuries in alpine skiers and snowboarders. Jama 295, 919-924.
  4. Haider, A.H., Saleem, T., Bilaniuk, J.W., Barraco, R.D. and Eastern Association for the Surgery of Trauma Injury ControlViolence Prevention, C. (2012). An evidence-based review: efficacy of safety helmets in the reduction of head injuries in recreational skiers and snowboarders. The journal of trauma and acute care surgery 73, 1340-1347.
  5. Milan, M., Jhajj, S., Stewart, C., Pyle, L. and Moulton, S. (2017). Helmet use and injury severity among pediatric skiers and snowboarders in Colorado. Journal of pediatric surgery 52, 349-353.
  6. Hasler, R.M., Baschera, D., Taugwalder, D., Exadaktylos, A.K. and Raabe, A. (2015). Cohort Study on the Association Between Helmet Use and Traumatic Brain Injury in Snowboarders From a Swiss Tertiary Trauma Center. World neurosurgery 84, 805-812.
  7. Baschera, D., Hasler, R.M., Taugwalder, D., Exadaktylos, A. and Raabe, A. (2015). Association between head injury and helmet use in alpine skiers: cohort study from a Swiss level 1 trauma center. Journal of neurotrauma 32, 557-562.
  8. Sacco, D.E., Sartorelli, D.H. and Vane, D.W. (1998). Evaluation of alpine skiing and snowboarding injury in a northeastern state. The Journal of trauma 44, 654-659.
  9. Fukuda, O., Takaba, M., Saito, T. and Endo, S. (2001). Head injuries in snowboarders compared with head injuries in skiers. A prospective analysis of 1076 patients from 1994 to 1999 in Niigata, Japan. The American journal of sports medicine 29, 437-440.
  10. Hoshizaki, B., Vassilyadi, M., Post, A. and Oeur, A. (2012). Performance analysis of winter activity protection headgear for young children. Journal of neurosurgery. Pediatrics 9, 133-138.
  11. Sindelar, B., Bailes, J., Sherman, S., Finan, J., Stone, J., Lee, J., Ahmadian, S., Zhou, Y., Patel, V. and Smith, D. (2016). Effect of Internal Jugular Vein Compression on Intracranial Hemorrhage in a Porcine Controlled Cortical Impact Model. Journal of neurotrauma.
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