Injury, Int. J.

Care Injured 48 (2017) 1093–1097

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

The impact of helmet use on outcomes after a motorcycle crash

Desmond Khor, Kenji Inaba* , Alberto Aiolfi, Samantha Delapena, Elizabeth Benjamin,
Kazuhide Matsushima, Aaron M. Strumwasser, Demetrios Demetriades
Division of Acute Care Surgery and Surgical Critical Care, LAC + USC Medical Center, CA, USA

A R T I C L E I N F O A B S T R A C T

Background: Helmet use in a motorcycle collision has been shown to reduce head injury and death. Its
Keywords: protective effect on the cervical spine (C-spine), however, remains unclear. The objective of this study
Helmet
was to explore the relationship between helmet use and C-spine injuries.
Cervical spine
Motorcyclist
Method: Retrospective National Trauma Data Bank (NTDB) study. All motorcycle collisions between 2007
Motorcycle collisions and 2014 involving either a driver or passenger were included. Data collected included demographics,
Trauma vital signs, Abbreviated Injury Scale (AIS), Injury Severity Score (ISS) and specific injuries. The primary
outcome was the prevalence of C-spine injuries. Secondary outcomes included were overall mortality,
ventilation days, intensive care unit length of stay (LOS), total hospital LOS, and in-hospital
complications.
Results: A total of 270,525 patients were included. Helmets were worn by 57.6% of motorcyclists. The non-
helmeted group was found to have a higher incidence of head injury with head AIS > 2 (27.6% vs 14.8%,
p < 0.001). Univariate analysis showed a higher prevalence of C-spine injuries in the non-helmeted group
(10.4% vs 9.4%, p < 0.001), with a higher proportion of severe C-spine injuries with AIS > 2 (3.2% vs 2.6%,
p < 0.001). Additionally, traumatic brain injury (TBI) was found to be two times higher in the non-
helmeted group (20.7% vs 10.9%, p < 0.001). Multiple logistic regression showed helmet use to be an
independent protective factor against mortality (OR = 0.832, 95% CI 0.781–0.887, p < 0.001). Although
statistically significant in univariate analysis, helmet use was not associated with C-spine injuries after
adjusting for relevant covariates. However, helmet use reduced the risk of severe head injuries by almost
50% (OR = 0.488, 95% CI 0.475–0.500, p < 0.001).
Conclusions: Helmet use reduces the risk of head injury and death among motorcyclists; however, no
association with C-spine injuries could be detected.
© 2017 Elsevier Ltd. All rights reserved.

Introduction evidence, there are still a number of states without a mandatory

There were 8.4 million motorcyclists documented in the United
States in 2014, with 13 percent of all motor vehicle crash fatalities
involving motorcyclist riders [1]. The fatality rate for motorcycle or
scooter riders is even more pronounced in developing countries. In
Malaysia, for example, motorcycle-related fatalities accounted for
greater than 50 percent of the total road traffic accident fatalities
[2].
Helmet use has been shown in several studies to reduce the risk
of head injury and death [3,4]. A reduction in traumatic brain
injuries by 67% has also been estimated by the United States
National Highway Traffic Safety Administration [5]. Despite this
* Corresponding author at: Division of Trauma and Surgical Critical Care,
University of Southern California, LAC + USC Medical Center, 2051 Marengo Street,
Inpatient Tower, C5L100, Los Angeles, CA 90033, USA.
E-mail address: kenji.inaba@med.usc.edu (K. Inaba).
helmet law. Only 19 states and the District of Columbia have a
universal helmet law in place. In another 28 states, only certain
motorcyclists are required to wear a helmet. There is no helmet law
in three other states [6].
The data supporting the impact of helmet use on cervical spine
injury remain controversial [7]. The Goldstein study, for example,
showed an increased risk of neck injuries in helmeted motorcy-
clists [8]. A possible mechanism suggested for this is that helmets
exert a significant mass effect on the head, further increasing
flexion and extension of the neck upon collision, increasing the risk
of neck injuries.
However, several studies have shown no increased risk or even
a reduction in cervical spine injury with helmet use [9–13].
Therefore, the objective of this study was to address the conflicting
data in the published literature and explore the relationship
between helmet use and cervical spine injuries using the largest

http://dx.doi.org/10.1016/j.injury.2017.02.006
0020-1383/© 2017 Elsevier Ltd. All rights reserved.
1094 D. Khor et al. / Injury, Int. J. Care Injured 48 (2017) 1093–1097

available trauma database in the United States. We hypothesized 80.0%

that helmet use will not increase the risk of cervical spine injuries.
75.0%

Methods 70.0%

Helmet use in percentages

65.0%
After Institutional Review Board approval, a retrospective
American College of Surgeons National Trauma Data Bank (NTDB) 60.0%

study was conducted. The NTDB remains the full and exclusive 55.0%
copyrighted property of the American College of Surgeons. The
50.0%
American College of Surgeons is not responsible for any claims
arising from works based on the original Data, Text, Tables, or 45.0%
Figures. It consists of trauma registry data voluntarily submitted by
40.0%
trauma centers throughout the United States. All cases between 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
2007 and 2014 involving a road traffic motorcycle collision with Year
either a driver or passenger were included in the study (E-code
Fig. 1. Trend of helmet use at the time of injury over the years 2007–2014.
810-819, series 0.2 and 0.3). Non-traffic motorcycle collisions were
excluded from the study. Injury to the cervical spine (C-spine) was
The NHM group was found to have more motorcyclists with a
identified using the Abbreviated Injury Scale (AIS) code, which
head AIS > 2 (27.6% vs 14.8%, p < 0.001). The unadjusted analysis
included bony and non-bony injury, cord syndrome, nerve root
also showed a higher prevalence of C-spine injuries in the NHM
injury, ligamentous injury, disc herniation, dislocation and strain.
group compared to the HM group (10.4% vs 9.4%, p < 0.001). They
The data collected included helmet use at the time of injury,
had a higher proportion of severe C-spine injuries with AIS > 2
demographics, vital signs upon arrival in the emergency depart-
(3.2% vs 2.6%, p < 0.001). C-spine fractures were also more
ment (ED), alcohol and illegal drug intoxication, regional AIS (head,
common in the NHM group (7.6% vs 6.2%, p < 0.001). There were
spine, neck, thorax, and abdomen), Injury Severity Score (ISS),
no differences in other C-spine injury types between HM and NHM
specific injuries, and procedures performed within 24 h. The
groups. Additionally, traumatic brain injury (TBI) was found to be
primary outcome measure was the prevalence of C-spine injuries.
two times higher in the NHM group (20.7% vs 10.9%, p < 0.001). The
Secondary outcomes included overall mortality, ventilation days,
NHM group was more likely to undergo craniectomy and
intensive care unit (ICU) length of stay (LOS), total hospital LOS,
intracranial pressure monitoring within 24 h (1.6% vs 0.4%, p
and in-hospital complications.
< 0.001, and 1.0% vs 0.4%, p < 0.001, respectively).
All variables were compared between the helmeted (HM) and
Hospital outcomes comparing HM and NHM groups are
non-helmeted (NHM) group. Categorical data were reported as
presented in Table 2. There were no differences in ventilation
percentages, and continuous data were reported as medians with
days, ICU LOS, or hospital LOS between groups. Overall mortality
interquartile ranges (IQR). Continuous variables were also dichot-
was higher in the NHM group (3.9% vs 2.5%, p < 0.001). The HM
omized using clinically relevant cutoff points. Pearson’s chi
group was less likely to develop a complication compared to the
squared test or Fisher's exact test were used to compare
NHM group (8.8% vs 10.6%, p < 0.001). An unadjusted comparison
proportions for categorical variables while Mann-Whitney U test
of mortality, overall complications, C-spine injury, and TBI
was used to compare medians for continuous variables. A direct
between HM and NHM groups is shown in Fig. 2.
fitting logistic regression model was used to identify independent
After including significant covariates into a logistic regression
risk factors for mortality and C-spine injuries. Each result was
model, helmet use was found to be an independent protective
presented as an odds ratio (OR) with 95% confidence interval (CI).
factor against mortality (OR = 0.832, 95% CI 0.781–0.887, p
Multicollinearity testing was performed to identify any correlation
< 0.001). Male gender, age  65, hypotension, GCS < 9, and AIS >
between covariates. The accuracy of the test was calculated using
2 (head, neck, abdomen, and thorax) were all associated with a
the area under the curve with 95% CI. Variables with p-value < 0.05
significant increase in the risk for mortality (Table 3). Our analysis
were considered significant. All analyses were performed using
demonstrated no association between helmet use and C-spine
SPSS for windows version 20.0 (SPSS Inc. Chicago, IL).
injuries (Table 4); however, helmet use was shown to reduce the
risk of severe head injuries (head AIS > 2) by almost 50%
Results
(OR = 0.488, 95% CI 0.475–0.500, p < 0.001) after adjusting for
gender, age, vital signs upon arrival, alcohol use, illegal drug use,
A total of 270,525 patients were identified during the study
and other body region injuries (Table 5).
period. Helmets worn at the time of injury were documented in
155,877 (57.6%) motorcyclists. Overall, the trend of helmet use
Discussion
among motorcyclists remain constant from 2007 to 2014 (Fig. 1).
Median age was 41 (IQR 27-52), 6946 (2.6%) patients were less than
Riding a motorcycle places the rider at high risk for sustaining
16 years, 234,360 (87.0%) were male, and 252,180 (93.2%) were
injuries and death compared to being within an enclosed vehicle
drivers. Alcohol screening was positive in 48,376 (21.3%) while
[1]. Helmet use was introduced as a passive protection measure,
illegal drugs were found to be positive in 32,794 (16.1%) patients.
designed to protect the head during collision. In most countries,
Overall, 84,776 (31.4%) patients had an ISS > 15, and C-spine
the use of helmets has been made compulsory [14].
injuries were seen in 9.8% of the population (26,557 patients).
In the United States, however, there is no universal helmet law.
Demographic and injury characteristics for HM and NHM
Helmet laws are regulated by the state government. Only 19 states
motorcyclists are shown in Table 1. NHM motorcyclists were more
and the District of Columbia have a mandatory helmet law in place.
likely to be less than 16 years old (3.3% vs 2.1%, p < 0.001), have a
States with selective helmet laws may require minor riders, for
GCS less than 9 (13.9% vs 7.6%, p < 0.001), be hypotensive (4.4% vs
example, to use a helmet, while leaving adults to decide whether or
3.8%, p < 0.001), be tachycardic (7.9% vs 6.4%, p < 0.001), and test
not to wear a helmet. One of the concerns expressed by opponents
positive for alcohol use (28.8% vs 15.8%, p < 0.001) and illegal drugs
of a mandatory helmet law is that the use of a helmet will increase
(17.2% vs 15.3%, p < 0.001). The age, gender, race, number of riders,
the risk of a C-spine injury.
and ISS did not differ between groups.
 D. Khor et al. / Injury, Int. J. Care Injured 48 (2017) 1093–1097 1095

Table 1
Characteristics of motorcycle patients with/without helmet use.

Total (+) Helmet ( ) Helmet p-value

(n = 270,525) (n = 155,877) (n = 114,648)

Demographics
Gender, male 234,360 (87.0%) 136,528 (87.6%) 97,832 (86.1%) <0.001
Age, years 41 (27–52) 41 (27–53) 41 (28–51) <0.001
Age  65 13,852 (5.1%) 8768 (5.6%) 5084 (4.4%) <0.001
Age  16 (underage) 6946 (2.6%) 3213 (2.1%) 3733 (3.3%) <0.001
Race <0.001
Asian 3185 (1.2%) 2162 (1.5%) 1023 (0.9%)
African American 24,734 (9.6%) 14,101 (9.5%) 10,633 (9.9%)
White 207,675 (81.0%) 120,495 (81.2%) 87,180 (80.8%)
Rider 252,180 (93.2%) 146,727 (94.1%) 105,453 (92.0%) <0.001

ED findings
SBP < 90 mmHg 10,769 (4.1%) 5881 (3.8%) 4888 (4.4%) <0.001
HR > 120 bpm 18,610 (7.0%) 9807 (6.4%) 8803 (7.9%) <0.001
GCS < 9 26,969 (10.3%) 11,619 (7.6%) 15,350 (13.9%) <0.001
Alcohol screen 48,376 (21.3%) 20,508 (15.8%) 27,796 (28.8%) <0.001
Illegal drug use 32,794 (16.1%) 17,723 (15.3%) 15,071 (17.2%) <0.001

Abbreviated Injury Scale >2

Head 54,712 (20.2%) 23,050 (14.8%) 31,662 (27.6%) <0.001
Spine 12,848 (4.7%) 7386 (4.7%) 5462 (4.8%) 0.755
Neck 1375 (0.5%) 744 (0.5%) 631 (0.6%) 0.008
Thorax 81,682 (30.2%) 49,694 (31.9%) 31,988 (27.9%) <0.001
Abdomen 18,643 (6.9%) 11,720 (7.5%) 6923 (6.0%) <0.001
C-spine 7712 (2.9%) 4090 (2.6%) 3622 (3.2%) <0.001

Injuries
ISS 10 (5–17) 10 (5–17) 10 (5–18) <0.001
ISS > 15 84,776 (31.4%) 46,743 (30.0%) 38,033 (33.2%) <0.001
TBI 40,715 (15.1%) 16,962 (10.9%) 23,753 (20.7%) <0.001
Brachial plexus 993 (0.4%) 698 (0.4%) 295 (0.3%) <0.001
Vertebral artery 688 (0.3%) 363 (0.2%) 325 (0.3%) 0.010
Cervical spine 26,557 (9.8%) 14,598 (9.4%) 11,959 (10.4%) <0.001
Fracture 18,423 (6.8%) 9712 (6.2%) 8711 (7.6%) <0.001
Nerve root injury 165 (0.1%) 113 (0.1%) 52 (0.0%) 0.005
Strain 6437 (2.4%) 3938 (2.5%) 2499 (2.2%) <0.001
Ligamentous injury 869 (0.3%) 466 (0.3%) 403 (0.4%) 0.017
Disc herniation 368 (0.1%) 207 (0.1%) 161 (0.1%) 0.595
Dislocation 1381 (0.5%) 741 (0.5%) 640 (0.6%) 0.003
Cord syndrome
complete C1–C3 (lac/contusion) 272 (0.1%) 149 (0.1%) 123 (0.1%) 0.343
complete C4–C8 (lac/contusion) 435 (0.2%) 234 (0.2%) 201 (0.2%) 0.106
contusion-incomplete syndrome 2803 (1.0%) 1577 (1.0%) 1226 (1.1%) 0.143
laceration-incomplete syndrome 161 (0.1%) 86 (0.1%) 75 (0.1%) 0.280

Procedures, within 24 h
Craniectomy 2542 (0.9%) 671 (0.4%) 1871 (1.6%) <0.001
ICP monitoring 1858 (0.7%) 685 (0.4%) 1173 (1.0%) <0.001
C-spine fusion 729 (0.3%) 417 (0.3%) 312 (0.3%) 0.819
C-spine fusion (general) 2394 (0.9%) 1356 (0.9%) 1038 (0.9%) 0.330
Halo placement 403 (0.1%) 218 (0.1%) 185 (0.2%) 0.152

C-spine: cervical spine; ICP: intracranial pressure; TBI: traumatic brain injury; ISS: injury severity score; SBP: systolic blood pressure: HR: heart rate.

The purpose of this study was to study the relationship between
motorcycle helmet use and C-spine injury. The data available prior
to this study has had conflicting results, likely due to the small
sample size. In the Crompton study, 40,890 patients from NTDB
were included, with a helmet being worn by 77% of riders. The
prevalence of C-spine injury was 3–5% [4]. In the present study of
greater than 270,000 patients, C-spine injury occurred in 10%.
There was a lower prevalence of helmet use among motorcyclists
compared to several previously reported series [4,16]. This is likely
due to the different data capture time frames, reflecting changes in
the participating institutions and usage patterns. However, this
also varies widely in the literature with Hooten et al. showing a
52.5% prevalence of helmet use [15]. According to the National
Highway Safety Administration, helmets were used by approxi-
mately 60% of fatally injured motorcyclists [1], similar to the
results seen in our dataset.
This study has demonstrated several important findings. First,
helmet use was found to reduce mortality and is protective against
severe head injuries. This is consistent with previously published
studies [4,11], with the largest study being a Cochrane review done
by Liu et al. in the United Kingdom. Examining 61 observational
studies, they demonstrated a reduction in the risk of death by 42%
and head injury by 69% [3]. Secondly, C-spine injuries were found
to be slightly higher in the NHM group using univariate analysis.
While this difference reached statistical significance, this is likely
not clinically relevant. More importantly, after adjusting for other
potential covariates in the multivariate logistic analysis, there was
no significant association between helmet use and C-spine
injuries. This supports the findings of multiple smaller studies
[12,13,15,17,18].
In contrast to this, Goldstein et al. demonstrated an increased
risk of neck injury with helmet use [8]. They theorized that
1096 D. Khor et al. / Injury, Int. J. Care Injured 48 (2017) 1093–1097

Table 2
Outcome comparison between motorcycle patients with/without helmet.

Total (+) Helmet ( ) Helmet p-value

(n = 270,525) (n = 155,877) (n = 114,648)

Mortality 8304 (3.1%) 3825 (2.5%) 4479 (3.9%) <0.001

Ventilation daysa 4 (2–11) 4 (2–11) 4 (2–11) 0.618
ICU stay, daysa 3 (2–8) 3 (2–7) 3 (2–9) <0.001
Hospital length of staya 4 (2–8) 4 (2–7) 4 (2–8) <0.001

Complicationsb
Overall 16,304 (9.6%) 8658 (8.8%) 7646 (10.6%) <0.001
ARDS 4355 (2.6%) 2397 (2.4%) 1958 (2.7%) <0.001
Cardiac arrest with CPR 1003 (0.6%) 533 (0.5%) 470 (0.7%) 0.004
Deep vein thrombosis 4057 (2.4%) 2240 (2.3%) 1817 (2.5%) 0.002
Pulmonary embolism 1681 (1.0%) 1038 (1.1%) 643 (0.9%) 0.001
Pneumonia 9094 (5.3%) 4587 (4.7%) 4507 (6.3%) <0.001
Unplanned intubation 1451 (0.9%) 751 (0.8%) 700 (1.0%) <0.001

ARDS: acute respiratory distress syndrome; CPR: cardiac pulmonary resuscitation; ICU: intensive care unit.
a
Include only patients without mortality (n = 262,221).
b
Include only patients with hospital length of stay >2 days (n = 170,119).

Fig. 2. Unadjusted comparison of mortality, overall complications, C-spine injuries and traumatic brain injury (TBI) with p < 0.001 in helmeted and non-helmeted
motorcyclist.

helmets exert a mass effect and put extra weight on the driver’s
Table 3
Multivariable analysis showing independent risk factors for mortality. head, which increases the flexion-extension of the neck upon
collision. However, Rice et al. showed that there is a protective
Mortality
effect of helmet use in preventing neck injury (RR 0.63, 95% CI
adj p OR 95% CI for OR 0.40–0.99) [11]. Other contemporary retrospective studies have
Gender, male <0.001 1.231 (1.114–1.360) also shown a reduced risk of C-spine injuries with helmet use
Age  65 <0.001 2.533 (2.265–2.832) [4,10].
Age  16 (underage) <0.001 0.404 (0.293–0.556) This study also demonstrated a higher in-hospital complication
Helmet use <0.001 0.832 (0.781–0.887)
rate, especially pneumonia, in the NHM group. This is likely due to
SBP < 90 mmHg <0.001 2.021 (1.863–2.193)
HR > 120 bpm <0.001 1.942 (1.804–2.090) the higher rate of head injuries in this group. Head injured patients
GCS < 9 <0.001 14.082 (12.987–15.270) with low GCS were more likely to be intubated and immunocom-
Alcohol <0.001 0.860 (0.801–0.923) promised [19,20], therefore putting this patient population at
Drugs <0.001 0.721 (0.642–0.809)
higher risk for nosocomial pulmonary infections.
Head AIS > 2 <0.001 3.032 (2.809–3.272)
Spine AIS > 2 0.306 1.092 (0.923 1.293)
This is also the most comprehensive and largest study sample
Neck AIS > 2 <0.001 1.253 (1.037–1.514) size to date, including 270,525 patients over an eight-year span,
Thorax AIS > 2 <0.001 1.902 (1.779–2.034) decreasing the risk of a type II error. We selectively used AIS pre-
Abdomen AIS > 2 <0.001 2.197 (2.024–2.385) dot codes for more reliable injury identification, rather than the
C-spine AIS > 2 0.059 1.211 (0.993–1.478)
NTDB International Classification of Diseases, 9th Revision (ICD-9)
Multicollinearity test was checked before doing multivariable analysis. codes, which potentially include comorbidities and complications.
AUROC = 0.931 (95% CI = 0.928–0.934)
There are several limitations to our study despite its large
C-spine: Cervical spine; AIS: Abbreviated Injury Scale; adj p: adjusted p-value; OR:
odd ratio; CI: confidence interval.
sample size. The primary weakness would be related to the
retrospective nature of this study. Also, we lacked information on
 D. Khor et al. / Injury, Int. J. Care Injured 48 (2017) 1093–1097 1097

Table 4 DK, KI and AA formed the study design.

Multivariable analysis showing independent risk factors for cervical spine injury.
Data collection done by DK and SD.
C-spine Injury DK and AA analyzed the data.
adj p OR 95% CI for OR
DK, AA, KI, EB, and DD interpreted the data.
DK and KI wrote the manuscript.
Gender, male 0.851 1.004 (0.959–1.052)
Age  65 <0.001 1.136 (1.063–1.213)
SD, KM, AMS, EB, KI and DD critically reviewed the manuscript.
Age  16 (underage) <0.001 0.598 (0.520–0.688)
Helmet use 0.285 1.017 (0.986–1.050) Acknowledgement
SBP < 90 mmHg <0.001 1.354 (1.265–1.450)
HR > 120 bpm <0.001 1.168 (1.107–1.232)
None.
GCS < 9 <0.001 1.469 (1.400–1.542)
Alcohol <0.001 1.367 (1.319–1.416)
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DK and AA did the literature search.