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With an estimated 300 million people riding roller coasters in the United States every year, the overall injury risk is low.1 Nonetheless, ED physicians should keep the possibility in mind in cases in which there are inexplicable symptoms consistent with head injury, suggested the investigators in a 2018 review published in the Journal of Emergency and Trauma Care.1 They recommended asking about amusement park visits in the previous 3 months, as some findings have shown that “patients tend to minimize these events and avoid them during the medical interview, and other authors have reported cases where the onset of symptoms is 2 months after” the park visit.
As summer approaches, many children in the United States look forward to that warm-weather tradition of visiting amusement parks. Meanwhile, emergency department (ED) physicians prepare for the inevitable increase in patients seeking care for related injuries. From 1990 to 2010, an average of 4423 US children age ≤17 presented to the ED every year for treatment of injuries resulting from amusement park rides, with a mean patient age of 8.73.2
The vast majority of these injuries occurred between May and September, with an average rate of 20 per day, according to study results published in 2013 in Clinical Pediatrics.3 The most frequent injury sites were the head and neck, comprising 28% of injuries, and soft tissue injuries were the most common type (29%). Although the majority of these incidents resulted from falling in, on, off, or against an amusement park ride, numerous case studies over the years have described neurologic injuries that appear to have occurred in the absence of any impact.
Rates of hospitalization (1.5% annually) and death (4.5 per year) associated with amusement park rides, including roller coasters, are relatively low.2,4 However, the “neurologic complications after roller-coaster rides can be potentially catastrophic,” according to a 2016 case report published in Pediatrics.4 “Some of the rare complications that have been described include dissection of vertebral artery and internal carotid artery with or without concomitant stroke, intraparenchymal hemorrhage, subdural hemorrhage, and posttraumatic migraine,” the investigators noted.
The researchers described a rare case of a spinal cord infarction (SCI) due to fibrocartilaginous embolism (FCE) that occurred in a 12-year-old girl with hemoglobin SC disease (HbSC) after riding a roller coaster.5 Several hours following the ride, she experienced new-onset neck pain and predominant left-sided weakness, which prompted a visit to the ED. After emergency treatment and subsequent rehabilitation, the patient regained some physical function and mobility, albeit with continued left hemiparesis, spasticity of the right upper and lower extremities, and limited motion of the right upper extremity.
The investigators noted that numerous spinal cord injuries caused by roller coaster rides have been reported, including 656 injuries that occurred in a 19-month period in 932,000 rides on 1 roller coaster in Texas.5 While most of these injuries were classified as mild, 39 were severe and primarily involved herniations of the cervical nucleus pulposus.4 “Given this, it is reasonable that our patient’s cervical nucleus pulposus could have herniated and ejected into the blood supply of her anterior spinal cord during the roller-coaster ride,” they wrote.5
In a case study published in April 2019 in Pediatric Emergency Care, physicians at the University of Southern California in Los Angeles described a teenage patient who was diagnosed with subdural hematoma when she presented to the pediatric ED with new-onset seizures and hemiplegia 2 days after riding a roller coaster.7 “The acceleration and G forces of roller coasters are hypothesized to cause enough stress and shearing forces that are thought to directly cause subdural hemorrhage,” the researchers wrote. “Advances in roller coaster technology may surpass the passenger’s physical capacity for acceleration and rotary forces, and we may see an increased number of medical complications after these rides.” Thus, they recommend that clinicians “consider amusement park thrill rides as a possible cause of subdural hematomas in previously healthy patients with new neurologic complaints.”
Findings from a 2009 study suggest that head motions during roller coaster rides typically confer a very low risk for traumatic brain injury (TBI), and a 2017 study found that brain strain rates during roller coaster rides were similar to those observed during running and lower than those that occur during soccer headers.8.9 The researchers in the 2017 study mentioned recently published case reports of brain injuries related to roller coasters: 7 subdural hematomas, 2 subarachnoid hemorrhages, and multiple concussions. These types of injuries are “thought to be mostly caused by excessive mechanical deformations of the bridging veins causing subdural hematoma, of aneurysms causing subarachnoid hemorrhage, and of the parenchymal brain tissue itself causing concussion,” they explained.8
Some cases involved individuals with a pre-existing medical condition that may have made them more susceptible to injury. For example, patients with Chiari I malformation or connective tissue disorders such as Ehlers-Danlos or Marfan syndrome could experience an “exacerbation of symptoms due to whiplash — especially with the head turned since we know that on the football field, rotational acceleration presents a higher risk, even in the absence of a head injury,” Gerald Grant, MD, endowed professor and chief of pediatric neurosurgery at Stanford University Medical Center in California, told Neurology Advisor. “If there is a history of neck strain, roller coaster rides can be problematic since the strain on the neck during the ride is quite extreme, especially with the older roller coasters that have less padding and a less secure harness.”
It should also be noted that, in some case reports, patients had repeated the ride multiple times during the park visit, for instance, 13 times for a patient with macular hemorrhage and 11 times for a patient with subdural hematoma).9 “Going back on the roller coaster with no break in between can be troubling, since symptoms can be delayed after getting off the ride, and the forces are cumulative over time,” said Dr Grant.
There is a dearth of evidence regarding the long-term sequelae of neurologic injuries related to roller coaster rides. Further research is needed in this area.
References
1.Nam CBY, Pablo AS, Elena SV. Non-fatal injuries associated with riding roller coaster. J Emerg Trauma Care. 2018;3:1.
2. Thompson MC, Chounthirath T, Xiang H, Smith GA. US pediatric injuries involving amusement rides, 1990-2010. Clinical Pediatrics. 2013; 52(5):433-440.
3.Nationwide Children’s. New study finds 20 children a day during the summer are treated in US emergency departments for amusement ride-related injuries. www.nationwidechildrens.org/newsroom/news-releases/2013/05/new-study-finds-20-children-a-day-during-the-summer-are-treated-in-us-emergency-departments-for. Published May 1, 2013. Accessed April 5, 2019.
4. Levenson MS. Amusement ride-related injuries and deaths in the United States: 2004 update. Bethesda, Maryland. Consumer Product Safety Commission. www.cpsc.gov/PageFiles/108566/amus2004.pdf. 2004. Accessed April 10, 2019.
5. Ryan Eid, Ashok Raj, Darren Farber, Vinay Puri, Salvatore Bertolone. Spinal cord infarction in hemoglobin SC disease as an amusement park accident. Pediatrics. 2016; 138(3).
6. Freeman MD, Croft AC, Nicodemus CN, Centeno CJ, Elkins WL. Significant spinal injury resulting from low-level accelerations: a case series of roller coaster injuries. Arch Phys Med Rehabil. 2005; 86(11):2126-2130.
7.Tseng P, Kearl YL, Ansari A. Roller coaster-induced subdural hematoma in a previously healthy teenager. Pediatr Emerg Care. 2019; 35(4):e76-e78.
8. Pfister BJ, Chickola L, Smith DH. Head motions while riding roller coasters: implications for brain injury. Am J Forensic Med Pathol. 2009; 30(4):339-345.9.
9. Kuo C, Wu LC, Ye PP, Laksari K, Camarillo DB, Kuhl E. Pilot findings of brain displacements and deformations during roller coaster rides.J Neurotrauma. 2017; 34(22):3198-3205.
