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J Neurosurg Pediatr. 2020 Jan 3:1-14. doi: 10.3171/2019.10.PEDS19377. [Epub ahead of print]

Primary prevention of road traffic accident-related traumatic brain injuries in younger populations: a systematic review of helmet legislation.

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1Division of Neurosurgery, Texas Children's Hospital, Houston.
2Department of Neurosurgery, Baylor College of Medicine, Houston, Texas.
3Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago; and.
4Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.



Road traffic accidents are the most frequent cause of severe traumatic brain injury (TBI), particularly among young populations worldwide. Helmets are proven to prevent injuries; however, estimates of helmet compliance are low globally. Surgical/critical care management of TBI is often used to treat these injuries, but primary prevention should be recommended. A key component in promoting TBI prevention among pediatric and young populations is through helmet legislation. The authors investigated helmet policies for motorcycles and bicycles globally to provide recommendations for how related legislation may impact TBI and guide advocacy in pediatric neurosurgery.


The authors conducted a systematic review of helmet laws and/or policies by using the National Library of Medicine PubMed and SCOPUS databases. Additional articles were identified using citation searches of key publications. Abstracts from articles of all sources were read and selected for full-text review. Details of relevant full articles were extracted and analyzed for the following: bibliographic data, study aim, design and duration, study participants, intervention characteristics, and intervention effect data.


Of 618 search results, 53 full-text articles were analyzed for recommendations. Helmet legislation is associated with increased helmet use among bicyclists and decreased road traffic accident-related head injuries and fatalities among motorcyclists and bicyclists. Laws are more effective if comprehensive and inclusive of the following: both primary riders and passengers, all age groups, all modes of transportation made safer by helmets, a proper use clause, and standardized helmet quality measures. Cultural, socioeconomic, and infrastructural circumstances are important as well, and legislation must consider enforcement mechanisms with penalties significant enough to incentivize behavioral changes, but proportional to community socioeconomic status.


Compulsory use laws are the optimal primary intervention; however, concurrent programs to support financial access to helmets, change cultural attitudes, increase health literacy, and improve road infrastructure will augment legislative benefits. Pediatric neurosurgeons are caretakers of children suffering from TBI. Although extensive study has explored the surgical management of TBI, the authors believe that primary prevention is instrumental to improving outcomes and reducing injury. All helmet laws are not equal; based on these findings, a comprehensive, context-specific approach is the key to success, especially in resource-limited countries.


HICs = high-income countries; LMICs = low- and middle-income countries; RCT = randomized controlled trial; RTA = road traffic accident; TBI = traumatic brain injury; UI = uncertainty interval; advocacy; bicycle; head injury; helmet; motorcycle; neurosurgery; pediatric; public health; trauma; traumatic brain injury


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