Golf cart-related neurosurgical injuries

Abstract

Background
Head and spine injuries sustained following golf cart accidents have been rarely analyzed. This study aimed to describe a series of patients sustaining golf cart injuries requiring neurosurgical management for head or spine injuries.

Methods
The University of Puerto Rico Neurosurgery database was used to retrospectively identify and investigate patients who sustained a golf cart-related injury requiring a neurosurgical evaluation during 15 years.

Results
The analysis identified 25 patients with golf cart-related injuries requiring neurosurgical management with a median age of 16 (interquartile range 13–34). Seventeen patients (68%) were female. The primary mechanism of injury was ejection from the cart in 84% of the patients ( n = 21). The most frequent head injury was a skull fracture in 80% of patients ( n = 20). Intracranial hemorrhage was present in 76% of patients ( n = 19), with brain contusions ( n = 16, 64%) being the most common. Eighteen patients (72%) were admitted for surgery or neurological monitoring. The median hospital length of stay among hospitalized patients was 5.5 days. Ten patients (40%) were admitted to the intensive care unit (ICU) with a median stay of 8.5 days. Four patients (16%) required surgery for their injuries. At discharge, 80% of patients ( n = 20) had a good outcome.

Conclusion
This study showed that children and adolescents are at high risk for golf cart-related neurosurgical injuries. This form of transportation can produce considerable neurological injuries, the primary mechanism of injury being ejection from the cart. Approximately three-quarters of the patients need hospital admission, with half requiring an ICU stay.

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Original Article
Golf cart-related neurosurgical injuries
Annelisse Torres-Urquia, Orlando De Jesus
Department of Surgery, Section of Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico, United States.
E-mail: Annelisse Torres-Urquia-annelisse.torres@upr.edu; *Orlando De Jesus-drodejesus@aol.com
INTRODUCTION
e use of golf carts has expanded in the past decades from its classic use on golf courses to
an everyday mode of transportation in resorts, gated communities, and even open roads. is
augmented use has increased the incidence of golf cart-related injuries.[8,11,12] Most patients
involved in a golf cart-related accident experience mild traumatic bruises, lacerations, long bone
fractures, and simple skull fractures; however, signicant spinal and brain injuries can occur.[3,4,7,8]
Some patients with severe brain injury or spinal fractures require urgent surgical intervention.
Injuries can result from cart ejection, a cart overturned, or being struck by a cart.[3,12] It has been
reported that approximately two-thirds of golf cart-related hospitalizations are secondary to head
or neck injuries.[3] Brain injuries are more prominent among children, who are more susceptible
to developing traumatic brain injuries (TBIs) than adults.[3] e presence of a TBI or an abdominal
injury in a child is associated with prolonged hospitalization.[3,5,12] is predisposition in children
ABSTRACT
Background: Head and spine injuries sustained following golf cart accidents have been rarely analyzed. is
study aimed to describe a series of patients sustaining golf cart injuries requiring neurosurgical management for
head or spine injuries.
Methods: e University of Puerto Rico Neurosurgery database was used to retrospectively identify and
investigate patients who sustained a golf cart-related injury requiring a neurosurgical evaluation during 15years.
Results: e analysis identied 25patients with golf cart-related injuries requiring neurosurgical management
with a median age of 16 (interquartile range 13–34). Seventeen patients (68%) were female. e primary
mechanism of injury was ejection from the cart in 84% of the patients (n = 21). e most frequent head injury
was a skull fracture in 80% of patients (n = 20). Intracranial hemorrhage was present in 76% of patients (n = 19),
with brain contusions (n = 16, 64%) being the most common. Eighteen patients (72%) were admitted for surgery
or neurological monitoring. e median hospital length of stay among hospitalized patients was 5.5days. Ten
patients (40%) were admitted to the intensive care unit (ICU) with a median stay of 8.5days. Four patients (16%)
required surgery for their injuries. At discharge, 80% of patients (n = 20) had a good outcome.
Conclusion: is study showed that children and adolescents are at high risk for golf cart-related neurosurgical
injuries. is form of transportation can produce considerable neurological injuries, the primary mechanism of
injury being ejection from the cart. Approximately three-quarters of the patients need hospital admission, with
half requiring an ICU stay.
Keywords: Golf cart, Neurosurgery, Pediatric, Traumatic brain injury
www.surgicalneurologyint.com
Surgical Neurology International
Editor-in-Chief: Nancy E. Epstein, MD, Professor of Clinical Neurosurgery, School of Medicine,
State U. of NY at Stony Brook.
SNI: Trauma
Editor
Naveed Ashraf, M.S., M.B.B.S.
University of Health Sciences; Lahore, Pakistan Open Access
*Corresponding author:
Orlando De Jesus,
Department of Surgery, Section
of Neurosurgery, University of
Puerto Rico, San Juan, Puerto
Rico, United States.
drodejesus@aol.com
Received: 14March 2024
Accepted: 06June 2024
Published: 28 June 2024
DOI
10.25259/SNI_185_2024
Quick Response Code:

Torres-Urquia and De Jesus: Golf cart neurosurgical injuries
Surgical Neurology International • 2024 • 15(222) | 2
establishes the importance of monitoring the prevalence of
golf cart accidents in this population.[3,5,12]
Head and spine injuries sustained by golf cart accidents
are usually underreported, as only patients requiring
management at an emergency department (ED) are included
in the reports. is study aimed to describe and analyze
a series of patients sustaining golf cart injuries requiring
neurosurgical management for head or spine injuries.
MATERIALS AND METHODS
e University of Puerto Rico Neurosurgery database, which
has been stored daily in Excel soware since 2004, was used
to identify patients who sustained a golf cart-related injury
requiring a neurosurgical evaluation during 15years from
July 1, 2008, to June 30, 2023. e database was queried
in August 2023 to retrieve information for the study. All
patients who sustained a golf cart-related injury requiring
a neurosurgical evaluation were included in the study. No
patients were excluded from the study. For each identied
patient, basic demographics were collected, including age and
gender. In addition, the following variables were investigated:
mechanism of injury (ejection, rollover, and pedestrian),
injuries received, Glasgow coma scale (GCS) score at arrival,
days of hospitalization, days at the intensive care unit (ICU),
surgery performed, and outcome on discharge using the
modied Rankin scale (mRS) score. A good outcome was
dened as a mRS score of 0–3. Descriptive statistics were
used to report frequency, median value, and interquartile
range (IQR). is study was reviewed and approved by the
Institutional Review Board of the participating institution
(protocol 2308131225). Due to the study’s retrospective
nature, informed consent was not required.
RESULTS
e retrospective analysis identied 25 patients with golf
cart-related injuries requiring neurosurgical management
during the 15 years from July 1, 2008, to June 30, 2023.
eir ages ranged from 4 to 69, with a median age of 16
(IQR = 13–34) [Table 1]. Seventeen patients (68%) were
female. e primary mechanism of injury was ejection from
the cart in 84% of the patients (n = 21), followed by a rollover
in 8% (n = 2), and being hit by a cart as a pedestrian in 8%
(n = 2). Forty percent (n = 10) of the accidents occurred in
the 11–20 age group [Figure 1]. e most frequent injury
was a skull fracture in 80% of patients (n = 20) [Table 2].
An intracranial hemorrhage occurred in 76% of patients
(n = 19). Brain contusions (64%, n = 16) were the most
frequent nding among intracranial hemorrhages. One
patient had a contusion at the cerebellar hemisphere. An
acute subdural hematoma occurred in 44% of the patients
(n = 11). At the initial neurosurgical evaluation, the GCS
Table1: Patient demographics and characteristics (n=25).
Vari ab l e n (%)
Gender
Female 17 (68)
Male 8 (32)
Age
0–18 14 (56)
>18 11 (44)
Mechanism of injury
Ejection 21 (84)
Rollover 2 (8)
Pedestrian 2 (8)
Table2: Distribution of all golf cart-related neurosurgical injuries,
with most patients presenting multiple injuries.
Type of injury %
Skull fracture 80
Brain contusion 64
Acute subdural hematoma 44
Subarachnoid hemorrhage 20
Otorrhea 20
Epidural hematoma 12
Vertebral fracture 4
Pneumocephalus 4
Scalp hematoma 4
score varied from 4 to 15 with a median of 14 (IQR 12–15).
Eight percentages of the patients had a GCS of 3–8, 24% had
a GCS of 9–12, and 68% had a GCS of 13–15.
Eighteen patients (72%) were admitted for surgery or
neurological monitoring, while 7 (28%) were discharged
from the ED aer being observed for 1 day. e median
hospital length of stay among admitted patients was 5.5days
(IQR 3–16; range 2–40). Ten patients (40%) were admitted
to the ICU with a median stay of 8.5 days (IQR 4–14;
range 1–23). Four patients (16%) required surgery for their
Figure 1: Age distribution among patients sustaining golf cart
neurosurgical injuries.

Torres-Urquia and De Jesus: Golf cart neurosurgical injuries
Surgical Neurology International • 2024 • 15(222) | 3
injuries. Among them, two had a decompressive craniectomy
and were readmitted a few months later for a cranioplasty.
At discharge, 80% of patients (n = 20) had a good outcome.
Among the patients with poor outcomes, one died. Surgery
was not performed on this patient due to the catastrophic
nature of the injuries on arrival.
ree patients (12%) returned to the ED for reevaluation.
One patient showed worsening symptoms and required
surgery for an expanding subacute subdural hematoma. e
other two patients developed post-traumatic seizures that
were controlled with oral medications at the ED and did not
require admission. One of the patients experienced seizures
1 week aer discharge, while the other experienced them
3months later.
DISCUSSION
Most golf cart accidents occur on golf courses; however,
some occur in resorts, residential areas, or farms.[2-4,12] Our
study focused on neurosurgical injuries following golf cart
accidents. We found that ejection from the cart was the
primary mechanism of injury among the 25patients. More
than half of the accidents involved children and adolescents,
with predominance in the 11–20 age groups. Golf cart-
related injuries aer being ejected from a golf cart have been
reported to occur in 38–80% of the patients.[2,3,12] National
studies have demonstrated that ejection from a golf cart is the
most frequent cause of injury in adults and children.[3,12] Our
cohort’s most frequent mechanism of injury in our sample
was consistent with these prior studies. Researchers have
thought that the increased rate of ejections is secondary to
the vehicle’s design.[5] Golf carts lack seatbelts, and the hip
restraints are not large enough to prevent passengers from
falling o. In addition, hip restraints can increase head
injuries by acting as a pivot, causing the head to crash rst
into the ground when the passenger is ejected over the hip
restraint. Moreover, most children sit forward while riding
as a passenger, and the hip restraints do not provide any
protection. Children are almost 1½ times more likely to be
injured aer being ejected than patients of all other ages.[3] It
has been noted that ejected patients are more likely to sustain
an injury to the head or neck than patients injured by all other
mechanisms.[3] Compared to adults, golf cart-related head
and neck injuries involving children occur more frequently at
homes, farms, or on the road.[3,5,10,12] Adults are more likely to
be injured at a sports or recreational facility.[3,12]
Recently, Horvath et al. documented an increase in head and
neck injuries aer a golf cart accident, demonstrating that
they were the most frequent body location for injuries.[3]
is increase in head and neck injuries could be explained
by the development of faster carts and the augmented use by
the pediatric population, factors associated with accidents
secondary to ejection from the cart.[5] It has been shown that
in several pediatric cases, the accident occurred while the
child was driving the golf cart.[5]
Simpson et al. found that most patients with a golf cart-related
injury sustained mild TBIs with good outcomes, which they
ascribe to the low speed of the cart.[8] In our study, skull
fractures (80%) were the most frequent type of injury, closely
followed by intracranial hematomas (subdural, contusions,
subarachnoid, and epidural hemorrhages). Our results are
consistent with previous studies, which have shown that the
most frequent intracranial injuries include skull fractures,
contusions, subdural hematomas, and subarachnoid
hemorrhages.[4,8] Golf cart-related TBIs in children are
2–3times more frequent than in adults.[3,5] In the pediatric
population, slightly over half of the injuries occurred while
riding as a passenger.[10,11] Tracy et al. demonstrate that skull
fractures were more frequent in younger children, while
orthopedic injuries were more frequent in older children.[11]
Compared to adults, head-and-neck injuries in children are
more frequent aer being ejected from the cart.[3,5,12] Leg and
foot injuries are more common in adults while getting out of
the cart or aer being struck by the cart compared to those
injuries in children.[3,12] Passaro et al. found that in a non-golf
course setting, more than half of the injured individuals were
ejected from a golf cart.[6] ey also noted that 40% of injured
adults were known to have been drinking alcohol before the
accident.[6] e inuence of alcohol could not be analyzed
for our study as most adult patients did not have laboratory
values for alcohol levels.
In their analysis, Simpson et al. reported that 87% of patients
had a good outcome at discharge.[8] In our investigation, 80%
of patients had a good outcome. In the study by Simpson
etal., the mean presenting GCS score was 13, with only one
patient (4%) developing a seizure disorder.[8] Our patient’s
initial median GCS score was 14. Two patients (8%) in our
cohort developed post-traumatic seizures. One patient
experienced early seizures, while the other experienced late
seizures.
e incidence of golf cart accidents in Puerto Rico is
unknown as no investigations have been previously done.
ese accidents do not have to be reported to the police
or the transportation department. Contrasting the results
of golf-cart accidents noted in our cohort with comparable
accident-type scenarios in which a cabin does not protect,
the occupant may provide helpful information. However,
few reports exist in Puerto Rico of comparable transport
such as an all-terrain vehicle (ATV), motorcycle, or bicycle.
In the study by Acosta and Rodriguez, motorcycle accidents
occurred twice as frequently as ATV accidents.[1] ey found
that the number of patients younger than 17years involved
in ATV accidents was signicantly higher than in motorcycle
accidents. e percentage of patients with head injuries
aer ATV accidents was signicantly higher compared to

Torres-Urquia and De Jesus: Golf cart neurosurgical injuries
Surgical Neurology International • 2024 • 15(222) | 4
motorcycles. For ATV accidents, half of the injuries involved
the head region. e 20% mortality secondary to ATV
accidents was slightly higher than for motorcycle accidents;
however, there was no statistical signicance.[1] Although
golf cart accidents may resemble ATV accidents because
they involve a younger population and have an elevated
frequency of head injuries, they are much rare, with less
morbidity.
Individuals must develop more awareness of the injuries that
can be sustained while riding golf carts. Community safety
guidelines must be implemented to reduce the incidence
of these injuries. Several authors have suggested rigorous
safety regulations during golf cart driving, including a stricter
minimum legal age for adolescents or children operating the
cart to reduce the number of inexperienced operators.[3-5,7
0] In our study, a substantial number of injuries occurred in
children; for this reason, we agree with the previous authors’
recommendations. Golf carts are not prepared for the secure
transportation of children, and their use for transporting
children should be dissuaded. Children and adolescents without
a driver’s license should not operate a golf cart. Adult drivers
transporting children should operate golf carts at low speeds,
braking slowly and avoiding sharp turns to reduce the risk of
passenger ejection. e use of rear-facing cart seats should
be banned in children and adolescents as they are associated
with high rates of passenger ejection. Golf carts used for
transportation in resorts, gated communities, and open roads
should include seat belt safety equipment as they eectively
reduce ejection from the cart.
Limitations
is study contains several limitations. First, the study
design was retrospective and observational, which may
be subject to bias or errors. Second, the institution where
the study was performed is a trauma level I hospital;
therefore, only those cases with major trauma involving
a golf cart accident were referred to. Finally, the study
involved the population of Puerto Rico, which may limit
the generalizability of the ndings to other populations or
countries where golf cart use varies and may impact the
incidence of golf cart accidents.
CONCLUSION
is study showed that children and adolescents in our
population are at high risk for golf cart-related neurosurgical
injuries. is form of transportation can produce considerable
neurological injuries, the primary mechanism of injury being
ejection from the cart. Approximately three-quarters of the
patients need hospital admission, with half requiring an ICU
stay. However, the outcome in most patients is good.
Ethical approval
e research/study was approved by the Institutional Review
Board at the University of Puerto Rico Medical Sciences
Campus, number 2308131225, dated August 31, 2023.
Declaration of patient consent
Patients’ consent not required as patients’ identities were not
disclosed or compromised.
Financial support and sponsorship
Nil.
Conicts of interest
ere are no conicts of interest.
Use of articial intelligence (AI)-assisted technology for
manuscript preparation
e authors conrm that there was no use of articial
intelligence (AI)-assisted technology for assisting in the
writing or editing of the manuscript and no images were
manipulated using AI.
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How to cite this article: Torres-Urquia A, De Jesus O. Golf cart-related
neurosurgical injuries. Surg Neurol Int. 2024;15:222. doi: 10.25259/
SNI_185_2024
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