SAN DIEGO (Reuters Health) - While people riding in the back seat of a car without a seat belt are less likely to sustain life-threatening injuries during a crash than unrestrained drivers and front-seat passengers, they are at greater risk for brain damage, a new study finds.

The results challenge the common belief that rear seat belts aren't important, said study author Dr. Lewis Kaplan of the MCP/Hahnemann University Hospital in Philadelphia.

``When people put people in the back seat of their cars, they have to be just as vigilant about belting them in as they are for front-seat passengers and children,'' Kaplan told Reuters Health.

But that is often not the case, despite the awareness brought to the issue when Princess Diana was killed in a car crash in Paris in 1997. She was in the back seat and was not wearing a seat belt; neither was the driver or her companion, Dodi Fayed, also in the back. Only her bodyguard, who was buckled up in the front passenger seat and had an air bag, survived.

Kaplan said that after Diana's death, he looked through the medical literature to see if there were studies on the risks to rear passengers, and found very little information. So he and his colleagues began collecting data on people treated for crash injuries at his hospital between November 1998 and November 2000.

Of 152 cases involving both front and rear riders, 79% of rear-seat passengers and 63% of front-seat drivers or passengers were not wearing seat belts at the time of the crash, Kaplan reported here Sunday at a meeting of the Society of Critical Care Medicine.

When the researchers looked at injury patterns, they found--as expected--that unrestrained front riders were most likely to require lengthy stays in the intensive care unit: an average of 104 days, compared with a dozen or fewer for the other study groups.

That's because the crash impact is usually much greater in the front of the vehicle, and drivers and front-seat passengers often sustain multiple severe injuries, including internal organ and spinal cord damage, the researchers explained.

But, surprisingly, the study found that unrestrained rear passengers were the most likely to sustain brain injuries--65% did, compared with 61% of unrestrained front-seat riders, 43% of rear restrained riders and 43% of front restrained riders.

Despite the often-greater impact in the front, air bags can help protect against brain injury, Kaplan explained. In addition, the steering column frequently keeps drivers from hitting their heads on the windshield. But rear passengers, who are typically in tighter spaces, often hit their heads on the seat in front of them, the side post or the side window, he said.

Another unexpected finding was that rear passengers wearing seat belts were most likely to sustain orthopedic injuries, such as fractures of the arms, ribs and collarbone. In the study, 43% of rear restrained passengers had orthopedic injuries--more than twice as many as the other groups studied. A big factor is that many cars don't come with shoulder restraints in addition to lap belts in the back, Kaplan said, particularly for the middle passenger position. As a result, the upper body can be propelled forward or sideways during an accident.

Still, the risk of fracture is no reason to forgo a seat belt, Kaplan stressed. ``You recover from orthopedic injuries pretty readily but brain injuries can cause lasting impairment,'' he said.

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