In the early 1980s, staff in Australian hospital spinal units became aware of a serious increase in the incidence of young football players in both codes of rugby -- union and league -- admitted with serious or permanent cervical spinal cord injury.

By 1983 the two spinal units in Sydney were admitting 10 or more young players in a season.¹ By 1984, I had introduced the Spinal Awareness and Prevention Program at the Royal North Shore Hospital, Sydney, for audiovisual presentation to schoolchildren in independent and public schools in New South Wales. Lecturers in this program, themselves disabled from spinal cord injury, highlighted how spinal cord injury could occur. By 1987, documentation from injured players had been presented in a report to the International Rugby Board, and changes to the scrum formation had been recommended.

In 1987, in a review of 107 footballers in Australia who had suffered a spinal cord injury between 1960 and 1985, scrummaging in rugby union was identified as particularly dangerous, with illegal tackles (eg, "spear tackling" -- with a player being driven head-first into the ground, or a "stiff-arm" impact to a player's head and neck) identified as the most serious problem in rugby league.² Administrators of both codes had already acknowledged these problems, particularly in "schoolboy" football. There were also lectures by sports medicine specialists to coaches and selectors of teams, with identification of the particular danger for young players in their mid teens beginning to participate in a contact sport.

During the second half of the 1980s, coaches for both schoolboy and more senior grades of rugby union and rugby league were emphasising adequate preparation for the game and careful selection of players for particular positions of play, and encouraging the reporting of injuries. Some heads of independent schools in Sydney were initially reluctant to accept that many boys are genetically and psychologically destined to be unsuitable for participation in competitive contact sport! Some administrators were reluctant to consider changes of rules necessary to reduce the forces generated on the necks and shoulders of players involved in scrums and mauls and to ensure the absolute necessity of playing according to the rules.

In 1997, Armour et al confirmed an increased frequency of serious spinal cord injuries in rugby union and league players over the 20-year period 1976 to 1995 in New Zealand.³ One hundred and forty-one players were admitted to New Zealand's two spinal injury units, and 47 remained permanently paralysed. The authors noted that, although studies of cervical spinal cord injury in rugby football had been presented to medical and rugby authorities within the previous five years, no action appeared to have been taken to reduce the unacceptable incidence of this grave injury.

Professor Timothy Noakes, from Cape Town, South Africa, lamented in an editorial in the British Medical Journal in 1995 that "nearly 20 years after the BMJ first drew attention to the issue, we still do not know the true incidence of either spinal cord or cervical injuries in rugby players in any rugby-playing country".⁴ He emphasised that changes in rules of the game and player preparation could not be supported without sufficient accurate epidemiological data. More recently, Scher reported that the incidence of serious rugby spinal injuries in South Africa had not decreased over the past 10 years, with an average of 5.4 players per year admitted to one of the world's largest spinal cord injury centres, in Cape Town.⁵

Of interest, therefore, is the finding of Rotem et al, reported in this issue of the Journal, of a "small but significant decline in the number and approximate incidence of cases [of permanent neurological deficits leading to tetraplegia] associated with rugby union but no change in rugby league", from their survey of the spinal units at Royal North Shore Hospital and Prince Henry's Hospital.⁶ Further collection of data will allow a more detailed study of the statistics and will, one hopes, confirm the apparent trend towards reduction in injury incidence. In the 18 months since the New Zealand Rugby Union instituted compulsory nationwide safety seminars for coaches early in 1996, no cases of spinal cord injury from scrums have been reported in that country, although one player sustained tetraplegia in a tackle.³ During 1997, the spinal unit at Royal North Shore Hospital had no admissions of patients with serious cervical spinal cord injury from playing either rugby union or league (Dr Sue Rutkowski, Medical Director, personal communication), although this encouraging statistic could be a continuation of the variability seen in Rotem et al's study.

In 1995, the National Health and Medical Research Council released a handbook⁷ with Guidelines for prevention and management of head and neck injuries in football. Compiled by medical specialists with knowledge and interest in neurotrauma from sporting injuries, this useful guide should be in the hands of all referees, umpires, coaches and players. The handbook highlights important first-aid principles and assessment of injured players before returning them to play, to prevent aggravation of a potentially serious injury. The laws for under-19 players, with the 1993 variations (such as rules eliminating "crotch binding" in scrums) introduced to rugby union in New South Wales, must also be maintained.

The cost to the community of spinal cord injuries cannot be overemphasised. In Australia, 300 new patients with spinal cord injuries are expected every year; the lifetime cost is one million dollars for each paraplegic casualty and five million dollars for a tetraplegic casualty, as confirmed by awards in Australian courts. Our pessimism should be balanced by remembering Davidson's 1987 findings that, among 1444 schoolboys injured in interschool rugby from 1969 to 1986, there were two clinically "serious" injuries -- a skull fracture and a fracture dislocation of the cervical spine. The "severe" injury rate was 14 per 10 000 player-hours, or 0.12 per 100 player-games.⁸

Rotem et al have confirmed the impression of a reduction in the incidence of spinal cord injury in some contact sports following rule changes, as well as increasing our understanding of how cervical spinal cord injury occurs. Further epidemiological studies are essential for the adequate re-assessment of rule changes and of techniques to prepare players for contact sports. We must also further our knowledge of how injuries occur, and remain in close consultation with physicists, sports medicine clinicians and biomedical engineers. There must be no complacency in the future. Continuing vigilance is imperative to avoid the devastating personal and societal costs.

John D Yeo, AO
Associate Professor, and Consultant in Spinal Injuries
Royal North Shore Hospital, Sydney, NSW

1. Yeo JD, Walsh J. Prevention of spinal cord injuries in Australia. Paraplegia 1987; 25: 221-224.
2. Taylor TKF, Coolican MRJ. Spinal cord injuries in Australian footballers, 1960-1985. Med J Aust 1987; 147: 112-118.
3. Armour KS, Clatworthy BJ, Bean AR, et al. Spinal injuries in New Zealand rugby and rugby league -- a 20-year survey. N Z Med J 1997; 110: 462-465 .
4. Noakes T, Jakoet I. Spinal cord injuries in rugby union players. BMJ 1995; 310: 1345-1346.
5. Scher AT. Rugby injuries to the cervical spine and spinal cord -- a 10-year review. Clin Sports Med 1998; 17: 195-206.
6. Rotem T, Lawson JS, Wilson SF, et al. Severe cervical spinal cord injuries related to rugby union and league football in New South Wales, 1984-1986. Med J Aust 1998; 168: 379-381.
7. Newcombe R, et al. Football injuries of the head and neck. National Health and Medical Research Council Report, January 1995. Canberra: AGPS, 1995.
8. Davidson RM. Schoolboy rugby injuries, 1969-1986. Med J Aust 1987; 147: 119-120.
9. Lewis CS. The problem of pain. London: Collins Fontana Books, 1940: 141.

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