• Narayan Yoganandan, Anjishnu Banerjee, Nicholas DeVogel, Frank A Pintar, and Jamie L Baisden.
• Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA; Center for NeuroTrauma Research, Medical College of Wisconsin, Milwaukee, Wisconsin, USA. Electronic address: yoga@mcw.edu.
• World Neurosurg. 2018 Nov 1; 119: e962-e967.

ObjectiveTo determine role of lordosis in cervical spine injuries using a novel competing risk analysis model.MethodsThe first subgroup of published experiments (n = 20) subjected upright human cadaver head-neck specimens to impact loading. The natural lordosis was removed. The second (n = 21) and third (n = 10) subgroups of published tests subjected inverted specimens to head impact loading. Lordosis was preserved in these 2 subgroups. Using axial force and age as variables, competing risks analysis techniques were used to determine the role of lordosis in the risk of bone-only, ligament-only, and bone and ligament injuries.ResultsBony injuries were focused more at 1 level to a straightened spine, and ligament injuries were spread around multiple levels. Age was not a significant (P < 0.05) covariate. A straightened spine had 3.23 times higher risk of bony injuries than a lordotic spine. The spine with maintained lordosis had 1.14 times higher risk of ligament injuries, and 2.67 times higher risk of bone and ligament injuries than a spine without lordosis (i.e., preflexed column).ConclusionsIncreased risk of bony injuries in a preflexed spine and ligament injuries in a lordotic spine may have implications for military personnel, as continuous use of helmets in the line of duty affects the natural curvature; astronauts, as curvatures are less lordotic after missions; and civilian patients with spondylotic myelopathy who use head protective devices, as curvatures may change over time in addition to the natural aging process.Published by Elsevier Inc.

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