Return to Play After Cervical Disc Surgery

Timelines for Return to Different Sports Types After Eight Cervical Spine Fractures in Recreational and Elite Athletes: A Survey of the Association for Collaborative Spine Research

STUDY DESIGN

Prospective cross-sectional survey.

OBJECTIVE

To identify timelines for when athletes may be considered safe to return to varying athletic activities after sustaining cervical spine fractures.

BACKGROUND

While acute management and detection of cervical spine fractures have been areas of comprehensive investigation, insight into timelines for when athletes may return to different athletic activities after sustaining such fractures is limited.

METHODS

A web-based survey was administered to members of the Association for Collaborative Spine Research that consisted of surgeon demographic information and questions asking when athletes (recreational vs elite) with one of 8 cervical fractures would be allowed to return to play noncontact, contact, and collision sports treated nonoperatively or operatively. The third part queried whether the decision to return to sports was influenced by the type of fixation or the presence of radiculopathy.

RESULTS

Thirty-three responses were included for analysis. For all 8 cervical spine fractures treated nonoperatively and operatively, significantly longer times to return to sports for athletes playing contact or collision sports compared with recreational and elite athletes playing noncontact sports, respectively (P< 0.05), were felt to be more appropriate. Comparing collision sports with contact sports for recreational and elite athletes, similar times for return to sports for nearly all fractures treated nonoperatively or operatively were noted. In the setting of associated radiculopathy, the most common responses for safe return to play were "when only motor deficits resolve completely" and "when both motor and sensory deficits resolve completely."

CONCLUSIONS

In this survey of spine surgeons from the Association for Collaborative Spine Research, reasonable timeframes for return to play for athletes with 8 different cervical spine fractures treated nonoperatively or operatively varied based on fracture subtype and level of sporting physicality.

Return to Play for Cervical and Lumbar Spine Conditions

Although the safety of contact sports has improved over the years, participation in any sport always carries a risk of injury. When cervical or lumbar spine injuries do occur, prompt diagnosis is essential, and athletes must be held out of the sport if indicated to prevent further harm and allow for recovery. This article highlights some of the most common cervical spine pathologies (stinger/burners, strain, stenosis/cord neuropraxia, disc herniation, and fracture/instability) and lumbar spine pathologies (strain, disc degeneration, disc herniation, fracture, spondylolysis/spondylolisthesis, and scoliosis) encountered in sports and reviews the associated return to play guidelines and expectations for each condition.

Return-to-Play Outcomes in Elite Athletes After Cervical Spine Surgery: A Systematic Review

CONTEXT

Return-to-play (RTP) outcomes in elite athletes after cervical spine surgery are currently unknown.

OBJECTIVE

To systematically review RTP outcomes in elite athletes after anterior cervical discectomy and fusion (ACDF), cervical disc replacement (CDR), or posterior foraminotomy (PF) surgery.

DATA SOURCES

EMBASE, PubMed, Cochrane, and Medline databases from inception until April 2020. Keywords included elite athletes, return to play, ACDF, foraminotomy, and cervical disc replacement.

STUDY SELECTION

Eligible studies included those that reported RTP outcomes in elite athletes after cervical spine surgery.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Data were extracted by 2 independent reviewers.

RESULTS

The primary outcomes of interest were rates and timing of RTP. Secondary outcomes included performance on RTP. A total of 1720 studies were initially screened. After inclusion criteria were applied, 13 studies with a total of 349 patients were included. A total of 262 (75%) played football, 37 (11%) played baseball, 19 (5%) played rugby, 10 (3%) played basketball, 10 (3%) played hockey, 9 (3%) were wresters, and 2 (1%) played soccer. ACDF was reported in 13 studies, PF in 3 studies, and CDR in 2 studies. The majority of studies suggest that RTP after surgical management is safe in elite athletes who are asymptomatic after their procedure and may lead to higher rates and earlier times of RTP. There is limited evidence regarding RTP or outcomes after CDR or multilevel surgery.

CONCLUSION

The management and RTP in elite athletes after cervical spine injury is a highly complex and multifactorial topic. The overall evidence in this review suggests that RTP in asymptomatic athletes after both ACDF and PF is safe, and there is little evidence for decreased performance postoperatively. Surgical management results in a higher RTP rate compared with athletes managed conservatively.

Guidelines for Rehabilitation and Return to Play After Cervical Surgery in a General Athletic Population: A Delphi Analysis

OBJECTIVE

Decisions concerning the rehabilitation process and return to play (RTP) after cervical spine surgery in a general sporting population can be difficult and may be influenced by several factors. Moreover, no clear guidelines for this are currently available. The aim of this study was to create tentative guidelines for rehabilitation and RTP after cervical surgery in a general sporting population.

DESIGN

Five-step Delphi analysis.

SETTINGS

Primary, secondary, and tertiary medical practitioners.

PARTICIPANTS

Panel of Belgian neurosurgeons, orthopedic surgeons, physiotherapists, and physical and rehabilitation medicine practitioners.

ASSESSMENT

Round 1 (R1) was a brainstorm phase. A comprehensive list of answers from R1 was validated in round 2 (R2). In round 3 (R3), experts ranked these items in a chronological order. Contraindications and criteria to start each rehabilitation step were linked in round 4 (R4). In round 5 (R5), panelists ranked theses about contraindications and criteria on a 5-point Likert scale.

MAIN OUTCOME MEASURES

Theses scoring ≥10% "oppose" or "strongly oppose" were rejected.

RESULTS

The response rate was 100% (n = 15) for R1, 93% (n = 14) for R2, 73% (n = 11) for R3, 53% (n = 8) for R4, and 67% (n = 10) for R5. In R5, 25 theses on absolute and relative contraindications and criteria were endorsed.

CONCLUSIONS

This Delphi analysis resulted in contraindications and criteria for the rehabilitation process and RTP after cervical surgery in a general athletic population. Tentative guidelines and timetable are proposed. Key messages from these guidelines are (1) Rehabilitation should start before surgery with education; (2) Rehabilitation should be patient-tailored; and (3) An unstable arthrodesis is an absolute contraindication for RTP.

Return to Golf, Tennis, and Swimming After Elective Cervical Spine Surgery

Background

After surgery for degenerative cervical spine problems, most patients hope to return to non-competitive sports and other leisure activities. Limited data are available to counsel patients about return to play (RTP) in non-competitive sports after cervical surgery.

Methods

Participants had cervical surgery for degenerative diagnoses from April 1, 2007, to April 1, 2018. Demographic data were collected, and participants were asked to complete a survey regarding sports participation before and after cervical surgery. 

Results

Of the 73 participants who responded to the study, the majority (81.1%) were able to return to one or multiple hobby sports after elective spine surgery. RTP rates at 12 months for golf, tennis, and swimming were 67.6%, 31.2%, and 81.6%, respectively. Younger age and lack of preoperative motor deficit were significant predictors of return to swimming after surgery. After surgery, 54.3% of golfers reported similar or improved levels of play. 

Conclusions

After elective cervical spine surgery, the majority of hobby athletes can expect to return to athletics. The majority of golfers returned to play with similar or improved frequency and quality of play compared to preoperative levels. Future prospective studies will further elucidate factors predicting RTP after different types of elective cervical surgeries.

Updated Return-to-Play Recommendations for Collision Athletes After Cervical Spine Injury: A Modified Delphi Consensus Study With the Cervical Spine Research Society

BACKGROUND

Previous studies have attempted to establish return-to-play (RTP) guidelines in collision sport athletes after cervical spine injury; however, recommendations have been limited by scant high-quality evidence and basic consensus survey methodologies.

OBJECTIVE

To create relevant clinical statements regarding management in collision sport athletes after cervical spine injury, and establish consensus RTP recommendations.

METHODS

Following the modified Delphi methodology, a 3 round survey study was conducted with spine surgeons from the Cervical Spine Research Society and National Football League team physicians in order to establish consensus guidelines and develop recommendations for cervical spine injury management in collision sport athletes.

RESULTS

Our study showed strong consensus that asymptomatic athletes without increased magnetic resonance imaging (MRI) T2-signal changes following 1-/2- level anterior cervical discectomy and fusion (ACDF) may RTP, but not after 3-level ACDF (84.4%). Although allowed RTP after 1-/2-level ACDF was noted in various scenarios, the decision was contentious. No consensus RTP for collision athletes after 2-level ACDF was noted. Strong consensus was achieved for RTP in asymptomatic athletes without increased signal changes and spinal canal diameter &gt;10 mm (90.5%), as well as those with resolved MRI signal changes and diameter &gt;13 mm (81.3%). No consensus was achieved in RTP for cases with pseudarthrosis following ACDF. Strong consensus supported a screening MRI before sport participation in athletes with a history of cervical spine injury (78.9%).

CONCLUSION

This study provides modified Delphi process consensus statements regarding cervical spine injury management in collision sport athletes from leading experts in spine surgery, sports injuries, and cervical trauma. Future research should aim to elucidate optimal timelines for RTP, as well as focus on prevention of injuries.

Controversies in the Management of Cervical Spine Conditions in Elite Athletes

Cervical spine injuries in elite athletes can have detrimental consequences, which makes return to play for professional athletes after cervical spine injury controversial. Although most athletes can return to sport under some circumstances, such as single-level anterior cervical diskectomy and fusion for cervical disk herniation, return to play after cervical disk arthroplasty and multilevel fusion for cervical disk herniation remains controversial. Allowing athletes to return to play after a finding of cervical stenosis and in the incidence of pseudarthrosis remains unclear. This review provides a systematic framework to guide return-to-play decision-making in common cervical conditions in elite athletes. [Orthopedics. 2019; 42(4):e370-e375.].