Epidemiology of Traumatic SCI

Sports and Recreation

There were 100 different studies reporting data on sporting activities as a cause of SCI including both organized sports and recreational activities (Table 9). 34 studies provided frequencies of SCI due to a specific sporting activity. The majority of studies were conducted in North America (Canada N=10; United States N=28) and Europe (N=24), and fewer reports were from Asia (N=16), Oceania (N=14), Africa (N=6) and South America (N=2). 16 studies reported on the frequency of SCI resulting from more than one specific sporting activity.

Studies reporting on sporting accidents as one cause of SCI among others include proportions ranging from a low of 0.2% in Tianjian, China (Ning et al. 2011) to a high of 23.8% in Russia (Silberstein and Rabinovich 1995). In the majority of these papers the proportion ranged between 7% and 16% (N=32 studies). Major sources of variation are likely due to differences in reporting techniques, inclusion criteria, and each study’s definition of sports. Some studies fail to define the sporting activities considered for their estimates of SCI due to sports. For example, in the United States, several studies (Acton et al. 1993; Calancie et al. 2005; Cosar et al. 2010; McCammon and Ethans 2011) reported the frequency of SCI due to diving separately while other studies include diving in their overall estimates of SCI due to sporting accidents.

The frequency of SCI due to sports is relatively low in China. Recent reports indicate SCIs due to sporting accidents range from 0.2% (Ning et al. 2011) to 1.1% (Li et al. 2011; Hua et al. 2013). A reason for the relatively low frequency is that individuals in China are less active in sports that could lead to a SCI (e.g. skiing, diving, rugby) than individuals in countries where sports participation is higher (Ning et al. 2011; Li et al. 2011). Ning et al. (2011) speculate however that as China’s society develops, changes in lifestyle will lead to more participation in high-risk sports that could lead to an increase in the number of sport-related SCIs.

Spinal cord injuries due to diving are commonly reported around the world, and their proportion is highest in Australia (9.4%) (Ring et al. 1986), Brazil (9.3%) (da Paz et al. 1992), and Finland (9.2%) (Dahlberg et al. 2005). Studies from the USA, Canada, and Japan also reported frequencies of SCI due to diving as high as 8.5% (Acton et al. 1993), 2.4% (McCammon and Ethans 2011) and 1.3% (Shingu et al. 1995), respectively. In a recent study focused on SCIs due to shallow-water diving in South Africa, Vlok et al. (2010), reported increasing numbers of SCIs from 2003 to 2009. The occurrences of injuries were most common during summer holidays, and among young males who consumed alcohol.

In South America, Africa, and Oceania, rugby was reported as a leading sports-related cause of SCI. In 16 studies examining SCI due to rugby, the incidence was as high as 4.6 per 10,000 player hours in South Africa (Jakoet and Noakes 1998), and the prevalence ranged from 1.7 (Rugby League) to 6.8 (Rugby Union) per 100,000 players in Australia between 1995 and 2003 (Berry et al. 2006). Hermanus et al. (2010) reported an increasing frequency of SCIs due to playing rugby in the South African Rugby Union between 1980 and 2007. The highest frequency of SCI was reported to be in 2006. Forwards sustained 76% of all SCIs, club players 60%, and those age 17 years had the highest number of SCIs (Hermanus et al. 2010). Other major causes of sports related SCI include skiing/snowboarding (N=7), ice hockey (N=4) and horseback riding (N=2). A report from the United States identifies skimboarding as a new cause of SCI, especially among young males (Collier et al. 2010). The authors’ note that as the sport increases in popularity and more extreme maneuvers are performed, that associated risk of SCI with the sport will likely increase (Collier et al. 2010)

Table 9. Sports and Recreation

Canada

Author Year N of study population	Geographic region	Inclusion/ exclusion criteria Study	Study population	Injury features	Cause: %(n of cases)
Lenehan et al. 2012 N=930	British Columbia, Canada	1995-2004 Hospital admissions to level 1 trauma center were prospectively collected using a locally designed spine database	Males = 80% Median: 35 years	Cervical: 45.1% Thoracic: 24.5% L/S: 20.9% Unspecified: 9.5%	Sports: 17.9%
McCammon and Ethans 2011 N=553	Manitoba, Canada	1981-1985, 1998- 2002, 2003-2007 Inclusion criteria: survival to hospital admission with TSCI, or outpatient referral to an SCI rehabilitation specialist. Exclusion criteria: congenital causes of paralysis such as spina bifida or cerebral palsy as well as acquired paralysis from multiple sclerosis or Guillan-Barre syndrome.	75.8% male Mean Age: 1981-1985: 29.0 years 1998-2002: 35.3 years 2003-2007: 39.8 years	1981-1985: Cervical: 46.2% Thoracic:33.0% Lumbar: 20.9% Sacral:0.0% 1998-2002: Cervical:45.0% Thoracic:33.3% Lumbar: 21.6% Sacral:0.0% 2003-2007: Cervical:51.3% Thoracic:34.9% Lumbar:12.5% Sacral:1.3%	Sports: 81-85: 13.6% 98-02: 2.0% 03-07: 5.2%
Pickett et al. 2006 N=151	London, Ontario, Canada	1997-2006 Admissions to hospital in London, Ontario with SCI.	Male=74.2% Mean age = 42.2 ± 20.9 (9-96) years Mortality=12 (8%)	Cervical=75% Thoracic= 10% Lumbar=9% Junctional=6% Complete=35% Incomplete=65%	Sports: 9.3% (n=14)
Tator et al. 2004 N=271	Canada	1943-1999 Survey results from physicians and other sources reporting spinal or spinal cord injury in hockey players. Exclusion Criteria: Minor spinal injuries such as strains, sprains or whiplash.	Males=97% Mean age =20.6 (11-50) years	Known features (n=236): Cervical =83.5% Thoracic=5.1% ThoracoLumbar=5.9% Lumbo-sacral=5.5% Complete=58 (21%) Incomplete=58 (21%) Transient neurological symptoms=43 (16%) Root injury only=26 (10%) No neurological deficit=60 (22%) Unknown=26 (10%)	Ice hockey: 100% (n=271)
Tator et al. 1991 N=117	Canada and USA Canada=110 USA=6 Unknown=1	1966-1987 Survey results from physicians and other sources reporting spinal or spinal cord injury in hockey player. Exclusion Criteria: Minor spinal injuries such as strains, sprains, flexionextension injuries and whiplash.	Males=96% Mean age=21 (11-47) years Mortality=5 (4%)	Cervical=93 (80%) Thoracic=3 (3%) Thoracolumbar=7 (6%) Lumbosacral=6 (5%) Unknown=8 (7%) Complete=29 (25%) Incomplete=32 (27%) Root injury only=12 (10%) No neurological deficit=28 (24%) Unknown=16 (14%)	Ice Hockey: 100% (n=117)

USA

Author Year N	Geographic region	Inclusion/exclusion criteria	Study population	Injury features	Cause (%) / sample
Devivo et al. 2011 N=45,442	USA	1935-2008 Persons who were treated at either a SCI Model System or a Shriners Hospital SCI unit	Males= 79.2% Mean age at injury= 32.5 years	19.8% C1-4 32.6% C 5-8 45.4% Paraplegic 2.2% Normal	Sports: 10.3% (n=4,681)
Collier et al. 2010 N=3	Shepherd Center, Atlanta, USA.	Admission to the spinal cord injury rehabilitation center and experienced traumatic SCI during skimboarding.	100% (n=3) males mean age: 19.7 years	Case 1: motor incomplete (AIS C) cervical (C4-C5) SCI Case 2: sensory incomplete (AIS B) C4 SCI Case 3: C3-C4 AIS A SCI	Sports: (skiboarding) (100%)
NSCISC 2010 N=26852	USA	1973-2009 26 federally funded Model SCI Care Systems and National SCI Database	Male= 80.8% (1973-2009) Mean age at injury = 40.2 years (2005- 2009)	2005-2009 Tetraplegia = 55.2% Paraplegia = 44.4 % Complete Tetraplegia = 16.9% Incomplete tetraplegia = 38.3% Complete Paraplegia = 22.9% Incomplete Paraplegia = 21.5%	Sports: 7.9% (n=2,121)
Macciocchi et al. 2008 N= 298	Southeastern USA	2004-2005 All patients admitted for traumatic SCI between the ages 16- 59. Excluded if unable to speak English.	Males=79% Mean age =28.7±10.1 years. 74% of all eligible patients.	C1-4 ASIA A-C, n=9 C1-4 ASIA D, n=5 C5-8 ASIA A-C, n=30 C5-8 ASIA D, n=6 T1-8 ASIA A-C, n=26 T1-8 ASIA D, n=2 T9-12 ASIA A-C, n=15 T9-12ASIA D, n=3 L1-S3 ASIA A-C, n=5	Sports: 13% (n=39)
Fassett et al. 2007 N=412	Philadelphia, Pennsylvania, USA	1978-2005 Treated in Delaware Valley Regional Spinal Cord Injury Center at Thomas Jefferson University Hospital	≥70 years old. No further demographics given.	High quadriplegic (C4 and above)=42% Paraplegic=22% ASIA A ~ 45% ASIA B ~ 13% ASIA C ~ 15% ASIA D ~ 24%	Diving: 1% (n=4)
Boden et al. 2006 N=196	USA	1989-2002 Catastrophic cervical injuries in high school and collegiate football programs reported to National Center for Catastrophic Sports Injury Research	Male=100% 150 (76.5%) high school and 46 (23.5%) collegiate. Average age at injury=17 (range 14-28) years	93 (48.2%) permanent neurologic deficit, 100 (51.8%) no residual neurologic deficits 16 (8.2%) C1/C2 level 17 (8.6%) incomplete	American Football: Prevalence: Per 100,000 players: 1.10 in high school 4.72 in college
Injury Prevention Service, Oklahoma Department of Health 2006 SCI=2312	Oklahoma, USA	1988-2003 Admissions to Oklahoma hospitals with SCI due to sports; Patients who died at scene.	Football: Males=100% Ages 15-24 years=68% No mortality	Incomplete tetraplegia=44 Incomplete paraplegia=9	Football: 2.3% (n=53)
Injury Prevention Service, Oklahoma Department of Health 2006 SCI=2312	Oklahoma, USA	1988-2003 Admissions to Oklahoma hospitals with SCI due to sports; Patients who died at scene.	Diving: Males=86.4% Ages 15-24 years=53% Females=12 Mortality=3	Complete tetraplegia=35 Incomplete tetraplegia=47 Incomplete paraplegia=3	Diving: 3.8% (n=88)
Injury Prevention Service, Oklahoma Department of Health 2006 SCI=2312	Oklahoma, USA	1988-2003 Admissions to Oklahoma hospitals with SCI due to sports; Patients who died at scene.	Horseback Riding: Males=66.7% Mortality=2	Complete paraplegia=1 Incomplete tetraplegia=15 Incomplete paraplegia=15	Horse riding: 1.4% (n=33)
Calancie et al. 2005 N=229	Dade County, Florida, USA	Acute traumatic spine and/or spinal cord injury admitted to Jackson Memorial Hospita	Male = 74.6% Average age at injury =40.0±17.5 years 15 were children	ASIA A = 32.8% (75) ASIA B = 4.8% (11) ASIA C = 24.0% (55) ASIA D = 31.5% (72) ASIA E = 7.0% (7.4) Fractures: Cervical = 62% T1-T10 = 15% (35) T11-L4 = 19% (44) Non-fractures: Cervical = 3% (7) Complete = 32.8%	Diving: 5.2% (n=12)
Calancie et al. 2005 N=229	Dade County, Florida, USA	Acute traumatic spine and/or spinal cord injury admitted to Jackson Memorial Hospital	Male = 74.6% (175) Female = 24% (54); Average age at injury=40.0±17.5 years 15 were children	ASIA A = 32.8% (75) ASIA B = 4.8% (11) ASIA C = 24.0% (55) ASIA D = 31.5% (72) ASIA E = 7.0% (7.4) Fractures: Cervical = 62% T1-T10 = 15% (35) T11-L4 = 19% (44) Non-fractures: Cervical = 3% (7) Complete = 32.8%	Sports: 3.5% (n=8) Bicycle 2.6% (n=6) Water-related 2.6% (n=6)
National Spinal Cord Injury Statistical Center 2005 N=23,683	USA	2000-2005 National Spinal Cord Injury Database from 25 Model SCI Care Systems	Males=79.6% Average age of injury=37.6 years 62.9% Caucasian 22% African American 12.6% Hispanic 51.8% single	Incomplete tetraplegia (34.5%) Complete tetraplegia (18.4%) Incomplete paraplegia (17.5%) Complete paraplegia (23.1%)	Sports: 8.9% (n=2108)
Cantu and Mueller 2003 N=223	USA	1977-2001 All permanent cervical spinal cord injury collected at national level from all organized football Programs National Center for Catastrophic Sports Injury Research	Males=100% 183 high school, 29 college, 7 professional, 4 sandlot 71% playing defense 69% tackles	Fracture/dislocation = 176 (79%) Cord contusion = 31 (14%) Acute disc rupture = 11 (5%)	American Football: Prevalence: Per 100,000 players: 1991-2001 0.52 in high school 1.55 in college 14 in professional
National Spinal Cord Injury Statistical Center 2000 N=19648	USA	1973 -1990’s 24 federally funded Model SCI Care Systems and National SCI Database	Males=81.7% 55% within 16-30 years old, mean age at injury is 31.8 years	Tetraplegia = 51.7% Paraplegia = 46.7 % Complete Tetraplegia = 18.5% Incomplete tetraplegia = 29.5% Complete Paraplegia = 27.9% Incomplete Paraplegia = 21.3%	Sports: 7.1% (n=1395)
Nobunaga et al. 1999 N=25,054	USA	1973-1998 Admissions to a Model Spinal Cord Injury Care System within 365 days of injury	Males=81.5% Mean age =32.3±15.8 years.	Complete tetraplegia=44.0% Incomplete tetraplegia=45.1% Complete paraplegia=5.4% Incomplete tetraplegia=4.9%	Sports: 11.1% (n=2781)
Price et al. 1994 N=376	Oklahoma, USA	1988-1990 SCI cases in Oklahoma statewide multilevel surveillance system Exclusion Criteria: Non Oklahoma residents; patients who died at scene; injuries to nerve roots or spinal plexus.	Males=80% 15-19 years=66 (18%) 20-29 years=110 (29%) 30-59 years=145 (39%) ≥60 years =43 (11%) Mortality=30 (8%)	Complete tetraplegia=55 (15%), Incomplete tetraplegia=157 (42%) Complete paraplegia=59 (16%), Incomplete paraplegia=105 (28%)	Sports: 11.1% (n=42) Diving (43%) Horse riding (19%) Football (17%) Other (21%)
Thurman et al. 1994 N=223	Utah, USA	1989-1991 Utah residents with SCI in Statewide reporting system of the Utah Department of Health, Bureau of Epidemiology.	Males=76% Median age=29 years	128 (57%) tetraplegia 95 (43%) paraplegia 41 (18%) fatal 21 (9%) died before hospital admission 110 (49%) Frankel A/B/C 46 (21%) Frankel D 25 (11%) returned to full neurological function	Diving: 4.9% (n=11)
Thurman et al. 1994 N=223	Utah, USA	1989-1991 Utah residents with SCI in Statewide reporting system of the Utah Department of Health, Bureau of Epidemiology	Males=76% Median age=29 years	128 (57%) tetraplegia 95 (43%) paraplegia 41 (18%) fatal 21 (9%) died before hospital admission 110 (49%) Frankel A/B/C 46 (21%) Frankel D 25 (11%) returned to full neurological function	Sports: (excluding diving) 10.8% (n=24)
Woodruff and Baron 1994 N=150	West Virginia, USA	1985-1988 Data collected during the West Virginia Spinal Cord Injury Registry, includes only injured patients surviving until hospitalization	Male= 82% Majority of individuals were between 15-24.	56% tetraplegia 44% paraplegia	Sports: 8% (n=12)
Acton et al. 1993 N=644	Arkansas, USA	1980-1989 Arkansas residents in Arkansas State Spinal Cord Commission registry. Exclusion Criteria: Lesions caused by degenerative disease; people who died at scene.	Males=80% Mean age males=32.4 years Mean age females=35.4 years	Tetraplegia=61 Paraplegia=9	Diving: 8.5% (n=55)
Acton et al. 1993 N=644	Arkansas, USA	1980-1989 Arkansas residents in Arkansas State Spinal Cord Commission registry. Exclusion Criteria: Lesions caused by degenerative disease; people who died at scene.	Males=80% Mean age males=32.4 years Mean age females=35.4 years	Tetraplegia=61 Paraplegia=9	Sports: 11.3% (n=73) Prevalence: 6.15/million/yr (males) 0.53/million/yr (females)
DeVivo et al. 1992 N=6563	USA	Admissions to Spinal Cord Injury Care Systems within 1 year of injury from: 1978-1980 N=17841981-1983 N=13911984-1986 N=1433	Mean age=28.4 years Males=82.4% Females=17.6%Males=82.7% Mean age=30.5 yearsMales=84.5% Mean age=31.2 years	Frankel grade at discharge: Complete=51.8% Sensory=13.7% Motor nonfunctional=7.2% Motor functional=25.9% Recovered=1.4%Frankel grade at discharge: Complete=57.2% Sensory=11.7% Motor nonfunctional=7.8% Motor functional=22.5% Recovered=0.8%Frankel grade at discharge: Complete=48.6% Sensory=16.2% Motor nonfunctional=11.0% Motor functional=23.5% Recovered=0.6%	Sports: 15.0% (n=268)Sports: 13.7% (n=191)Sports: 14.4% (n=206)
Goebert et al. 1991 N=59	Hawaii, USA	1987-1989 Traumatic injury Patient at the Rehabilitation Hospital of the Pacific	Male=84.7% Mean age =20.2 years 0-15years=5.2% 16-30 years=44.8% 31-45 years=25.9% 46-60 years= 12.1% 61-90 years=12.1%	High Tetraplegia (C1- 4)=16.2% Low Tetraplegia (C5- 8)=45.9% High Thoracic (T1- 6)=18.9% Low Thoracic (T7- 12)=10.8% Lumbar (L1-5)=8.1% Frankel Grades: Complete (A)=50.8% Motor functional (D)=35.6%	Sports: 19.0% (n=11) Diving: (64%) Surfing: (9%)
Tator et al. 1991 N=117	Canada and USA Canada=110 USA=6 Unknown=1	1966-1987 Survey results from physicians and other sources reporting spinal or spinal cord injury in hockey player. Exclusion Criteria: Minor spinal injuries such as strains, sprains, flexionextension injuries and whiplash.	Males=96% Mean age=21 (11-47) years Mortality=5 (4%)	Cervical=93 (80%) Thoracic=3 (3%) Thoracolumbar=7 (6%) Lumbosacral=6 (5%) Unknown=8 (7%) Complete=29 (25%) Incomplete=32(27%) Root injury only=12 (10%) No neurological deficit=28 (24%) Unknown=16 (14%)	Ice Hockey: 100% (n=117)
Torg et al. 1990 N=979	USA	1976-1987 National Football Head and Neck Injury Registry Note: Rules prohibiting head first tackling and blocking introduced in 1976	(n=720): Male= 100% No details given.	Cervical spine fractures/subluxations /dislocations=720 158 (21.9%) of these injuries resulted in tetraplegia.	American Football: 73.5% (n=720) Prevalence: Per 100,000 players/1987 SCI: 2.3 Tetraplegia: 0.73
Ditunno et al. 1985 N=56	Philadelphia, USA	Traumatic onset of SCI, aged 16-50 without brain trauma.	Males=94.3% 53% of the subjects were between 20-29 years of age.	Not given.	Sports: 14% (n=8)
Griffin and Opitz 1985 N=154	Olmsted County, Minnesota, USA	1935-1981 Medical recordslinkage system of the Rochester Project at the Mayo Clinic, periodic multi-centre surveys	Males=72% 153 White, 1 Black	56.5% (n=87) cervical 31.8% (n=49) thoracic 9.1% (n=14) lumbar 2.6% (n=4) sacral	Sports: 7.8% (n=12)

Europe

Author Year N of study population	Geographic region	Inclusion/ exclusion criteria	Study population	Injury features	Cause: %(n of cases)
Alshahri et al. 2012 N=307	Riyadh, Saudi Arabia	2003 to 2008 Traumatic SCI, admitted to Riyadh Military Hospital in Saudi Arabia	Males = 88% Mean age=29.5 years	Complete tetra = 21% Incomplete tetra = 31% Complete para = 29% Incomplete para = 18%	Diving: 1% (n=3)
Knutsdottir 2012 N=207	Iceland	1975-2009 Patients admitted to Landspitali University Hospital	Males: 72% Mean Age: 38 years	Cervical: 57% Thoracic/Lumbar: 43%	Sports: 18.8%
Cosar et al. 2010 N TSCI=127	Turkey	Patients with traumatic SCI who participated in an inpatient rehabilitation program at a tertiary research hospital from 1996-2008.	67.7% (n=86) male mean age 37.81±13.65 years	36 (28.3%)-tetraplegic (C4-T1) 76 (59.8%)-paraplegic (T2–T12) 15 (11.8%) had conus–cauda equina (L1–S4) injury	Sports: (non-diving) (0.6%) n=1
Hagen et al. 2010 N=336	Norway (2 counties: Hordaland and Sogn og Fjordane)	Patients who suffered a TSCI from 1952- 2001 and lived in Hordaland or Sogn og Fjordane	Male to female ratio was 4:7:1 % of women varied from 6.9- 24.4%	Complete (41.4%) Incomplete (58.6%) Cervical (52.4%) Thoracic (29.5%) Lumbar/sacral (18.2%)	Sports: (8.6%) n=29 swimming 2.7% skiing 3.9% Other 2.1%
Bohu et al. 2009 N=37	France	1996-2006 French Rugby Union seasons All permanently disabling cervical spine injuries	Males=100% 21 adults over 21 years, 12 juniors 17-21 years. Average age at injury = 25.1 years	ASIA A (n=27, 73%) ASIA B (n=4, 11%) ASIA C (n=5, 14%) ASIA D (n=1, 3%)	Rugby: 100% (n=37) Prevalence: Per 100,000 players: 2.1 from 1996-1997 1.4 from 2005-2006
Ahoniemi et al. 2008 N=1647	Finland	1976-2005 Register survey; Medical records from registers of Käpylä Rehabilitation Centre	Males= 83% Mean age of injury (M/F): 1976-1985: 34.7/35.8 1986-1995: 36.7/38.3 1996-2005: 42.4/40.4	50.6% tetraplegia 49.4% paraplegia	Diving: 6.6% (n=109)
Franz et al. 2008 N=73	Bern, Switzerland	2000-2006 Admissions >16 years to hospital with severe spinal injuries Exclusion Criteria: Transient neurological symptoms excluded (<2 mins)	Skiing (n=63): Males=73% Median age=40 years Mortality=2 (3%) Snowboarding (n=10) Males=100% Median age=22.5 years	Tetraplegia=5 Paraplegia=3 No persistent neurological deficits=7 No persistent neurological deficits	Skiing: 86.3% (n=63) Snowboarding: 13.7% (n=10)
Dahlberg et al. 2005 N=152	Helsinki, Finland	January 1, 1999 cross-section date Adult citizens (18 years or more) who had permanent sensory or motor deficits (ASIA A–D). ASIA-E cases were excluded	Male=76% Average age of injury=47.9 years	Data only for 121 subjects: 46% (n=56) tetraplegia 54% (n=65) paraplegia 57% (n=69) incomplete 43% (n=52) complete	Diving: 9.2% (n=14)
Pagliacci et al. 2003 N=684	Italy	1997-1999 Rehabilitation admissions to 32 institutions in Italy with traumatic SCI.	Males = 80% Mean age=38.5 (11-94) years.	ASIA Scores: A=346 (50%) B=72 (10%) C=149 (22%) D=94 (14%) E=12 (2%)	Sports: 7.9% (n=54)
Schmitt and Gerner 2001 N=1,016	Heidelberg, Germany	1985-1997 All traumatic SCI at Orthopedic Department at the University of Heidelberg	Male = 83% Average age for sports accident =26.8, range (9- 52) years.	Sport accidents Complete para n=18 Incomplete para n=16 Complete tetra n=21 Incomplete tetra n=14	Sports: (excluding diving) 6.8% (n=69)
Karacan et al. 2000 N=581	Turkey	1992 Nation-wide survey of SCI admissions to medical institutions. Exclusion Criteria: Patients who died before hospitalization.	Males=71% Mean age=35.5±15.1 years.	Cervical=31.7% Thoracic=26.6% Lumbar=25.1% Tetraplegia=87 (32%) Paraplegia=394 (68%)	Diving: 1.2% (n=7)
Ravaud et al. 2000 N=1668	France	1995-1996 Self-administered questionnaire survey at 35 specialized Rehabilitation Centres	Males=93% Mean age at injury=22.2 years	4.9% C1-C2 22.1% C3 40.4% C4 17.3% C5 12.5% C6 2.8% C7-C8 63.1% complete	Diving: 6.5% (n=108)
Ravaud et al. 2000 N=1668	France	1995-1996 Self-administered questionnaire survey at 35 specialized Rehabilitation Centres	Males = 94% Mean age of injury=26.2 years	6% C1-C2 20.9% C3 32.8% C4 25.7% C5 14.2% C6 0.4% C7-C8 52.5% complete	Sports: 15.8% (n=264)
van Asbeck et al. 2000 N=126 (specific data for 113)	Netherlands	1994 Patients with SCI in National Registration system and with obtainable medical records. Exclusion Criteria: Spinal contusions with no or temporary neurological symptoms.	Males = 77% <20 years=15 (13%) 21-30 years=28 (25%) 31-60 years=36 (32%) >61=34 (30%) Mortality=18 (16%)	Complete tetraplegia =26 (23%) Incomplete tetraplegia =39 (34%) Complete paraplegia =29 (26%) Incomplete paraplegia =19 (17%)	Sports: 8.8% (n=10)
Molsa et al. 1999 N=16	Finland and Sweden	1980-1996 Ice hockey related SCI. Excluded transient neurological deficits	Males=100% Mean age =21.2 years	Tetraplegia n=10 Paraplegia n=6	Ice Hockey: 100% (n=16) Prevalence 0.011 per 1000 hockey players
Caldana and Lucca 1998 N=127	Veneto, Italy	1994-1995 New cases of traumatic spinal cord injury and nontraumatic spinal cord disease treated in regional hospitals (small hospitals excluded)	Male = 83.5% Average age (male) = 39.8 years old Average age (female) = 36 years old	Cervical=62 (21 were complete) Thoracic=29 (25were complete) Thoracolumbar (T12-L1)=18(11) Caudal=14(3) Unidentified=1	Sports: 1% (n=8)
Aung and Masry 1997 N=219	Great Britain	1985-1988 New traumatic admissions to the Midlands Centre for SCI	Male = 79% Average age (male) = 35.5 years. Average age (female) = 44.2 years.	Cervical n=116 Thoracic n=73 Lumbar n=30	Sports: 7.3% (n=16)
Exner and Meinecke 1997 N= 22,212	Germany	1976-1996 All traumatic and nontraumatic SCI	72% male	62% paraplegic 38% tetraplegic	Diving: 4% (n=856)
Exner and Meinecke 1997 N= 22,212	Germany	1976-1996 All traumatic and nontraumatic SCI	72% male	62% paraplegic 38% tetraplegic	Sports: 4% (n=853)
Soopramanien 1994 N=412 (SCI=270)	Bucharest, Romania	1992-1993 SCI patients admitted to Dr Gh. Marinescu Hospital	Male=77% 0-40 years =41.3% 41-90 years =58.7% 37.6%labourer 8.7% farmer 18.2% retired	158 cervical 81 thoracic 36 lumbar 47% incomplete Frankel grade A n=134 Frankel grade B n=24 Frankel grade C n=25 Frankel grade D n=73 Frankel grade E n=150	Diving: 7% (n=29)
GarciaReneses et al, 1991 N=1010	Spain	1984-1985 Every traumatic and non traumatic SCI patient in specialized Spanish hospitals	Male = 72.4% Mean age = 41.8 ± 1.2 years.	Sensory-motor Incomplete SCI = 49% Complete SCI= 38%	Sports: 4% (n=40)
BieringSorensen et al. 1990 N=268	Kingdom of Denmark (Denmark, Greenland, Faroe Islands)	January 1975- December 1984 Admission to national specialized rehabilitation hospitals	Male=76.9% 40% within 15-24 years old	Cervical = 136 Thoracic = 76 Lumbar = 56 Complete tetraplegia = 22% Incomplete tetraplegia = 29% Complete paraplegia = 26% Incomplete paraplegia = 23%	Diving: 6% (n=15)
Pedersen et al. 1989 N=27	Greenland	1965-1986 Admissions to rehabilitation hospital in Hornback with traumatic SCI; Patients injured in Greenland.	Males=74% Mean age=33.5 (14-50) years.	Sports: Incomplete tetraplegia n=1	Sports: 3.7% (n=1)

Asia

Author Year N of study population	Geographic region	Inclusion/ exclusion criteria	Study population	Injury features	Cause: %(n of cases)
Hua et al. 2013 N=561	China	Retrospective review of individuals who were treated at The General Hospital of Chinese People’s Armed Police Forces	Males = 79.9% Mean Age = 31.85 years	Not Specified	1.1%
Ibrahim et al. 2013 N=292 (traumatic and non)`	Kuala Lumpur, Malaysia	2006-2009 Admitted to the Department of Rehabilitation Medicine, Hospital Kuala Lumpur	Males = 77% Mean age = 39 years	Tetraplegia: 37% (108) Paraplegia: 63% (180)	Traumatic: Sports: 2%
Wang et al. 2013 N=761	Anhui Province, China	All patients admitted to two hospitals within Anhui Province, China between January 2007 and December 2010.	Males = 77.3% Mean age = 45 years	Cervical (46.3%) Thoracic (20.4%) Lumbrosacral (33.3%)	Other (sports and assault): 8.1%
Wu et al. 2012 N=143	Tianjin, China	Patients admitted to Tianjin Medical University General hospital with diagnosis of tSCI	Mean age 54.6 years Male:Female = 5:1	ASIA A = 5.6% ASIA B = 16.8% ASIA C = 18.9% ASIA D = 58.7%	Sports: 4.2%
Li et al. 2011 # of patients: N=1079 data collected: N=264	Beijing, China	Patients with acute TSCI admitted to civilian or military hospitals during Jan 1- Dec 31 2002	200 male (76%) Mean age: 41.7 years Range: 6-80 years	Cervical (4.9%) Thoracic (28%) Thoracolumbar, lumbar and lumbosacral (66%)	Sports: (1.1%) n=3
Ning et al. 2011 N=869	Tianjin, China	All patients with TSCI aged 15 or older admitted to tertiary hospitals in Tianjin from Jan 1, 2004- Dec 31, 2008	738 male (84.9%) Mean age (sd) 46.0 (14.2)	Cervical (71.5%) Thoracic (13.3%) Lumbar (15.1%) Sacral (0.1%)	Sports: (0.2%) n=2
Ye et al. 2009 N=57	Beijing, China	1993-2006 Admission to 6 institutions in Beijing with SCI due to sports and recreation.	Males=77% Mean age =24.5 ±11.9 years Mortality=2 (3.5%)	ASIA A=32 (56%) ASIA B=19 (33%) ASIA C= 5 (9%) ASIA D= 1 (2%) Ratio of complete to incomplete: 1:2.1	Sports: 100% (n=57) Water sports (65%) Gymnastics (9%) Ball game (7%) Casual play (5%) Dancing (5%) Other (9%)
Shrestha et al. 2007 N=149	Eastern region, Nepal	2001-2004 Admission to hospital in Dharan with cervical spinal injury.	Males= 80% Mean age=40 (6- 88) years Mortality=6 (4%)	Frankel levels: A=54 (36%) B=20 (13%) C=22 (15%) D=19 (13%) E=34 (23%)	Sports: 2.0% (n=3)
Yamakawa et al. 2001 N=324 SCI=26	Okumino skiing area, Gifu prefecture, Japan	1988-2000 Admissions with ski or snowboard related spinal injuries to hospital in Okumino ski area.	Males=67% Mean age= 26.7 (4-62) years Beginner=27 (31%) Intermediate/ Expert=59 (69%)Males=68% Mean age=22.3 (11-46) years Beginner=105 (44%) Intermediate/ Expert=133 (56%)	Cervical=7 Lumbar=2Cervical=14 Thoracic=2 Lumbar=1	Skiing: (n=86) (SCI=9) Prevalence: SCI 0.42/100,000 Spinal Injury 5.73/100,000 visitsSnowboarding: (n=238) (SCI=17) Prevalence: SCI 0.69/100,000 Spinal Injury 0.073/100,000
Chen et al. 1997 SCI=1,586	Taiwan	1992-1996 113 hospitals (11 medical centers, 50 regional general hospitals, 52 local general hospitals)	Male = 75% Average age of injury=46.1 years	49.9% cervical 13.3% thoracic 34.6% lumbar 6.6% (n=105) died after treatment	Sports: 1.2% (n=19)
Otom et al. 1997 N=151	Jordan	1988-1993 Royal Jordanian Rehabilitation Centre (RJRC) King Hussein Medical Centre (KHMC)	Males = 85.4% Average age of injury=33 years	Cervical=31.8% (n=48) Thoraco-lumbar= 68.2% (n=103) Frankel A= 53.6% (n=81) Frankel B = 10% (n=15) Frankel C =22.5% (n=34) Frankel D= 13.9% (n=21)	Sports: 2.6% (n=4)
Shingu et al. 1995 N=9752	Japan	1990-1992 Survey of nationwide institutions assumed to accept SCI patients. Exclusion criteria: Patients only receiving outpatient services in this period	Males=80.4% Mean age=48.6±19.1 (0.92-96) years	Frankel levels: A=2518 (25.8%) B=1208 (12.4%) C=1984 (20.3%) D=1761 (18.1%) E=2242 (23.0%) Unknown=39 (0.4%) Cervical=7317 (75.0%) Below cervical=2408 (24.7%) Unknown=27 (0.3%) Complete=61.1%	Skiing: 0.7% (n=71) Rugby: 0.7% (n=67) Diving: 1.2% (n=114) Sports: 5.4% (n=528)
Silberstein and Rabinovich 1995 N=196	Novosibirsk, Russia	1989-1993 All in patients with SCI admitted to the Department of SCI. Nerve root or plexus injury was excluded.	Males = 93.4% Mean age =34.7 years.	Cervical spine C1-2 n=15 C3-7 n=81 Thoracic T1-12 n=54 Lumbar L1-5 n=46	Sports: 23.8% (n=47)
Shingu et al. 1994 N=3465	Japan	1990 Survey of nationwide institutions assumed to accept SCI patients; Exclusion criteria: Traumatic cervical syndrome cases and extradural nerve root; Patients only receiving outpatient services in this year or who obtained injury abroad	Male (overall) =81.2% Mean age (sports) =26.1 years	Cervical=158 (87%) Below cervical=24 (13%)	Skiing: 0.6% (n=20) Rugby: 0.7% (n=24) Diving: 1.3% (n=44) Sports: 5.3% (n=182)
Lan et al. 1993 N=99	Hualien county, Taiwan	1986-1990 Treatment of traumatic SCI in 4 hospitals in Hualien county. Exclusion Criteria: People who died before hospitalization; nontraumatic SCI; patients with transient paralysis; non residents of Hualien.	Males= 80% Mean age (males)=44 years Mean age (females)=46 years Mortality=10 (10%)	Complete tetraplegia=2 Incomplete tetraplegia=2 Incomplete paraplegia=2	Sports: 6.1% (n=6)
Chen et al. 1985 N=560	Taipei, Taiwan	1978-1981 All record from general hospitals in Taipei. Included all spinal cord lesion with or without vertebral injury	Males = 86% Mean age = 35.9 (range 20-49) years.	Incomplete Paraplegia n=118 Complete paraplegia n=180 Incomplete Tetraplegia n=117 Complete Tetraplegia n=145 Death n=31	Sports: 3.7% (n=21)

Oceania

Author Year N of study population	Geographic region	Inclusion/exclusion criteria	Study population	Injury features	Cause: % (n of cases)
Middleton et al. 2012 N=324	New South Wales, Australia	January 2004 to June 2008, Data from Ambulance Service of New South Wales	Males = 85% Mean age = 42 years	Not Specified	Sports: 8.3% Water-related: 13.3%
Quarrie et al. 2007 N=77	New Zealand	1976-2005 Spinal injury claims due to rugby in Accident Compensation Corporation database Note: Mandatory education program for rugby players started in 2001.	No details	No details	Rugby: 100% (n=77) Prevalence: Per 100,000 players Scrum related: 1.4 (1996-2000) 0.2 (2001-2005) Other related 1.3 (1996-2000) 1.1 (2001-2005)
Berry et al. 2006 N=54	New South Wales, Australia	1986-2003 rugby seasons Acute cervical spinal cord injury resulting in tetraplegia and admission to NSW spinal units Australian Spinal Cord Injury Register (ASCIR)	Males=100% 89% adults Median age 24 (range 15-38) years	Complete tetra (n=24, 44%) Incomplete tetra (n=30, 56%)	Rugby Union: 57.4% (n=31): Prevalence: Per 100,000 players: 9.2 from 1986-1991 6.8 from 1995-2003
Carmody et al. 2005 N = 52	Australia	1997-2002 All acute, Football related SCI (lasting) from 6 SCI units that were major referral centers for SCI	Males = 100% 45 adults, 7 schoolboys. Average age at injury=24.4 (RU), 25.9 (RL), 23.4 (ARF), 26.0 (soccer)	Frankel grade A n=12 Frankel grade B n=1 Frankel grade C n=2 Frankel grade D n=24 Frankel grade E n=11	Rugby: 66% (n=34) Australian Football 26% (n=14) Soccer 8% (n=4) Prevalence: Per 100,000 players: Rugby: 4.7 8.7 cases per year of football-related SCI
Roe et al. 2003 N=34	New South Wales, Australia	1976-1996 Admissions to 2 SCI units in Sydney due to horse riding.	Males=62% Mean age= 39.3±18.4 years Mean years of riding experience= 25.7±21.8	Cervical=15 (44%) Thoracic=8 (24%) Lumbro-sacral=11 (32%) Complete=13 (38%) Incomplete=21 (62%)	Horse riding: 100% (n=34)
Spinecare Foundation 2003 N = 80	Queensland and New South Wales, Australia	1986-1996 All acute, Football related SCI (lasting) from 6 SCI units that were major referral centers for SCI	Males = 100% Average age at injury =23.5 (15- 49) years; 62 adults, 18 schoolboys.	C4/5 or C5/6 n=38 Frankel grades A B C n=42 Frankel grade D n=24 Frankel grade F n=8 37 complete 43 incomplete T11 n=1 Deaths n=6	Rugby: 100% (n=80) Prevalence: Per 100,000 players: 5.9 7.3 cases per year of rugby related SCI
O’Connor 2002 N = 265	Australia	1998-1999 Australian Spinal Cord Injury Register (ASCIR) for persons 15 years and older. All adult SCI cases are reported to the ASCIR Transient neural deficits were excluded.	76 % male No other demographics given	C4 n=47 C5 n=45 C6 n=22 L1 n=30 T12 n=17 Incomplete tetraplegia n=101 Incomplete paraplegia n=64 Complete tetraplegia n=51 Complete paraplegia n=48	Sports: 5% (n=13)
Rotem et al. 1998 N=115	New South Wales (NSW), Australia	1984-1996 Admission to 2 SCI units in Sydney with cervical spinal injuries from rugby union and league football. Exclusion Criteria: Patients transferred from outside NSW	Males = 100% Median age = 22 (14-37) years Mortality=2 (2%)	Complete tetraplegia: 26 (46%) C2-3=1 C3-4=2 C4-5=14 C5-6=6 C6-7=3 Complete tetraplegia: 23 (39%) C3-4=2 C4-5=8 C5-6=6 C6-7=6 Unknown level=1	Rugby Union: 48.7% (n=56) Prevalence: Tetraplegia/ 10,000/player/year 1.2 (1984-87) 0.3 (1988-91) 0.5 (1992-96) Rugby League: 51.3% (n=59) Prevalence: Tetraplegia/ 10,000/player/year 0.2 (1984-87) 0.2 (1988-91) 0.1 (1992-96)
Maharaj 1996 N=75	Fiji	1985-1994 Medical records of spinal cord paralysis patients admitted to the Medical Rehabilitation Unit at Tamavua Hospital	Males = 87% Mean age=38.3 (6-76) years 10 (13%) female 45 (60%) Fijian 26 (35%) Indian	Tetraplegia = 53% (n=40) Paraplegia=47% (n= 35) Complete = 61% (n= 46) Incomplete=39% (n= 29)	Sports: 20% (n=15)
Dixon et al. 1993 N=164	New Zealand	1988 SCI cases in Health Services Statistics files.	Males=73.2% Males aged 15- 29 years=46%	C1-C4=49 (30%) C5-C7=30 (18%) T1-T6=19 (12%) T7-T12-19 (12%)	Sports: 11% (n=18)
Ring et al. 1986 N=202	New South Wales, Australia	1977-1978 Admissions to New South Wales hospitals with spinal injury; death certificates that involved spinal injury. 99% of cases had neurological involvement.	Males=81% ≤1 years=2 (1%) 2-14 years=13 (6%) 15-24 years=84 (42%) 25-44 years=58 (29%) 45-64 years=30 (15%) ≥65 years=15 (7%) Mortality=69 (39%)	Glasgow Outcome Scale: Severe disability=98(49%) Moderate disability=19(9%) Good recovery=13(6%) Not recorded=3(1%)	Diving/ Swimming: 9.4% (n=19)
Ring et al. 1986 N=202	New South Wales, Australia	1977-1978 Admissions to New South Wales hospitals with spinal injury; death certificates that involved spinal injury. 99% of cases had neurological involvement.	Males=81% 15-24 years=84 (42%) 25-44 years=58 (29%) 45-64 years=30 (15%) ≥65 years=15 (7%) Mortality=69 (39%)	Glasgow Outcome Scale: Severe disability =98(49%) Moderate disability =19(9%) Good recovery =13(6%) Not recorded =3(1%)	Sports (excluding diving): 9.4% (n=19)

Africa

Author Year N of study population	Geographic region	Inclusion/ exclusion criteria	Study population	Injury features	Cause: %(n of cases)
Hermanus et al 2010 N=183	South Africa	1980-2007 Data from an inventory of rugbyrelated SCIs that occurred in South Africa	All Male Mean age= 21 years Weight range= 70-79 kg Median height= 179cm	C4/C5- 38% C5/C6- 31%	Rugby specific: n=183
Vlok et al. 2010 N=46	South Africa	All patients admitted to ASCI unit at Groote Schur Hospital from April 19, 2003 – Feb 8, 2009 with diving related injuries	91% male mean age: 23 years old	Neurological status: 25 incomplete, 13 complete, 8 had no neurological fallout C4 & C5 most common	Shallow Water Diving: Sea (20) Swimming pools (13) Rivers (7) Tidal pools (4) Location unknown (2)
Obalum et al. 2009 N=468	Lagos, Nigeria	1992-2006 Registrars at the emergency room and wards from the Lagos University Teaching Hospital (receives the majority of SCI patients in Lagos)	Males= 70.1% 66.2% were ages 40 years and below. Peak age incidence = 21-30 years.	ASIA A n=230 ASIA B n=45 ASIA C n=36 ASIA D n=41 ASIA E n= 34 Death n=82 Lumbar n=278 Cervical n=142 Thoracic n=48	Sports: 1.7% (n=8)
Noakes et al. 1999 N=67	Western Cape, South Africa	1990-1997 All rugby related SCI at the SC Unit at Conradie Hospital.	Males= 100% 54 adults 13 schoolboy rugby players	32% C4/5 42% C5/6 8% death 48% tetraplegia 35% recovery	Rugby: 100% (n=67)
Jakoet and Noakes 1998N=416 SCI=1	South Africa	1995 Played in the Rugby World Cup	No information provided	Ligament/joint injuries = 34%(Neck (including SCI) =4%) Lacerations=27% Muscle/contusions =24% Fractures/ Dislocations=11 Concussions=3	Rugby: 0.24% (n=1)Incidence: 4.5/10,000 player hours
Kew et al. 1991 N=117	Cape Province, South Africa	1963-1989 Major SCI unit in South Africa; rugby listed as cause of SCI	Males = 100% 81 adults, 36 schoolboys. No other demographics given.	C3/C4 n=4 C4/C5 n=43 C5/C6 n=38 C6/C7 n=11 T1-18 n=6 >T8 n=1	Rugby: 100% (n=117) 21.3% scrum 17.9% ruck and maul 20.5% tackling 29.9% tackled 1.7% foul play 0.9% line out 7.7% unknown

South America

Author Year N of study population	Geographic region	Inclusion/ exclusion criteria	Study population	Injury features	Cause: %(n of cases)
Secin et al. 1999 N=18	Argentina	1977-1997 All rugby reported cervical injuries in Argentina. Injuries could be permanent or transient.	Mean age =22 (range 15-27) years. No other demographics given.	Complete recovery n=2 Tetraplegia n=15 Death = 1	Rugby: 100% (n=18) 61.1% scrum 16.7% tackling 11.1% tackled 11.1% maul 0.9 cases per year of rugby related SCI
da Paz et al. 1992 N=1255 (SCI=108)	Brazil	1988 36 public hospitals from 7 Brazilian capitals (represents 6.2% of all hospitals and 9.2% of the total hospital bed capacity	Males = 80.6% Mean age=30.3 (range 6-56) years 5.6% high education	Complete = 94 (87.0%) Paraplegia = 61 (64.9%) Quadriplegia = 33 (35.1%)	Diving: 9.3% (n=10)