Return to Play in Athletes Receiving Cervical Surgery: A Systematic Review

Guidelines for returning to activity after spinal deformity surgery

Returning to activity after spinal deformity surgery is vital for patient recovery and long-term health, yet there is significant variability in postoperative protocols among surgeons worldwide. This paper aims to define guidelines for returning to activity across diverse patient groups: early onset scoliosis (EOS), adolescent idiopathic scoliosis (AIS), young adults, adult spinal deformity (ASD), elite athletes, and general sports participants. This paper provides guidelines to foster a unified approach to postoperative care, improving outcomes and ensuring patients can safely and effectively resume their activities. This paper represents the proceedings of an SRS educational CME webinar. A summary of recommendations for each patient group is included aiming to enhance surgeon practice and patient care through standardized postoperative protocols.

Discrepancies in recommendations for return to regular activities after cervical spine surgery: A survey study

Background

The recommended timing for returning to common activities after cervical spine surgery varies widely among physicians based on training background and personal opinion, without clear guidelines or consensus. The purpose of this study was to analyze spine surgeons' responses about the recommended timing for returning to common activities after different cervical spine procedures.

Methods

This was a survey study including 91 spine surgeons. The participants were asked to complete an anonymous online survey. Questions regarding their recommended time for returning to regular activities (showering, driving, biking, running, swimming, sedentary work, and nonsedentary work) after anterior cervical decompression and fusion (ACDF), cervical disc replacement (CDR), posterior cervical decompression and fusion (PCDF), and laminoplasty were included. Comparisons of recommended times for return to activities after each surgical procedure were made based on surgeons' years in practice.

Results

For ACDF and PCDF, there were no statistically significant differences in recommended times for return to any activity when stratified by years in practice. When considering CDR, return to non-sedentary work differed between surgeons in practice for 10 to 15 years, who recommended return at 3 months, and all other groups of surgeons, who recommended 6 weeks. Laminoplasty surgery yielded the most variability in activity recommendations, with earlier recommended return (6 weeks) to biking, non-sedentary work, and sedentary work in the most experienced surgeon group (>15 years in practice) than in all other surgeon experience groups (3 months).

Conclusions

We observed significant variability in surgeon recommendations for return to regular activities after cervical spine surgery.

Anterior Cervical Discectomy and Fusion in Professional Athletes: Allograft Versus Autograft

STUDY DESIGN

Level III-retrospective study.

OBJECTIVE

The aim was to evaluate the effect method of bone grafting and contract status have on outcomes in a cohort of professional athletes treated with anterior cervical discectomy and fusion (ACDF).

SUMMARY OF BACKGROUND DATA

The choice of graft-type in ACDF is controversial, with current reports limited to smaller cohorts.

MATERIALS AND METHODS

Retrospective analysis of 54 professional athletes treated with single level ACDF for cervical disc herniation, cervical fracture, or transient paraparetic event.

RESULTS

A case series of professional athletes with ACDF by the senior surgeon were evaluated, 39 with structural iliac crest autograft and 15 with allograft. All autograft patients had confirmed bony fusion, whereas 13/15 allograft patients had a confirmed bony fusion. Each of these players (2/15, 13.3%) was delayed for clearance for return to play by 1 season. In total, 43/50 players (88%) returned to professional play; 25/27 (92.6%) of them "self-employed" and 18/23 (78.2%) "league-contracted."

CONCLUSIONS

Surgical treatment of cervical pathology in the professional athlete with structural iliac crest autograft results in high union and return to play rates. Use of allograft resulted in a 13.3% increased rate of missing an additional season. Self-employed athletes returned to play 1 season earlier than league-contracted athletes on average.

Quality assessment of systematic reviews of surgical treatment of cervical spine degenerative diseases: an overview

OBJECTIVE

To gather all systematic reviews of surgical treatment of degenerative cervical diseases and assess their quality, conclusions and outcomes.

METHODS

A literature search for systematic reviews of surgical treatment of degenerative cervical diseases was conducted. Studies should have at least one surgical procedure as an intervention. Included studies were assessed for quality through Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) and Assessment of Multiple Systematic Reviews (AMSTAR) questionnaires. Quality of studies was rated accordingly to their final score as very poor (<30%), poor (30%-50%), fair (50%-70%), good (70%-90%), and excellent (>90%). If an article reported a conclusion addressing its primary objective with supportive statistical evidence for it, they were deemed to have an evidence-based conclusion.

RESULTS

A total of 65 systematic reviews were included. According to AMSTAR and PRISMA, 1.5% to 6.2% of studies were rated as excellent, while good studies counted for 21.5% to 47.7%. According to AMSTAR, most studies were of fair quality (46.2%), and 6.2% of very poor quality. Mean PRISMA score was 70.2%, meaning studies of good quality. For both tools, performing a meta-analysis significantly increased studies scores and quality. Cervical spondylosis studies reached highest scores among diseases analyzed. Authors stated conclusions for interventions compared in 70.7% of studies, and only two of them were not supported by statistical evidence.

CONCLUSION

Systematic reviews of surgical treatment of cervical degenerative diseases present "fair" to "good" quality in their majority, and most of the reported conclusions are supported by statistical evidence. Including a meta-analysis significantly increases the quality of a systematic review.

Return to Football after a Cervical Disk Arthroplasty: A Case Report

Introduction

Symptomatic cervical spine disk hernations in high-level athletes are traditionally treated with anterior cervical disk fusion (ACDF) after failed conservative management. Unfortunately, an ACDF comes with decreased mobility and only a return to sport 73.5% of the time. In high-level athletes, mobility and range of motion can be critical to their long-term success. This case report will discuss the successful treatment of a C6-C7 disk herniation with a cervical disk replacement (CDR).

Case Report

This is a 23-year-old football player whom had a left paracentral C6-C7 disk herniation causing foraminal stenosis. He had significant triceps muscle wasting and weakness and he was not able to participate in football secondary to his symptoms. After failing 6 weeks of conservative, he underwent a CDR. At 8 weeks postoperatively, he was cleared for football and return to sport without complications.

Conclusion

The CDR provides high-level athletes the ability to return to contact sports safely. In this unique case, we present a division one football player with a symptomatic cervical herniated disk that was treated with a CDR and return to sport without any limitations or complications. The CDR was able to treat symptoms, improve strength and motion, and ultimately allow the player to return to football. More studies need to be performed, but ultimately CDR in athletes can get them back on the field, improve their cervical range of motion, and decrease their risk of adjacent segment disease in the long run when compared to the cervical fusion.

Cervical Disc Herniations, Radiculopathy, and Myelopathy

The key to successful treatment of elite athletes is optimizing the medical care at every step: injury prevention and sport-specific training; comprehensive history and physical examination; high-quality and complete diagnostic studies; accurate diagnosis; control and completion of rehabilitation program; minimally invasive, safe, and effective surgeries; risk assessment for return to sport; guided and gradual return to sport; and continued rehabilitation and exercise program after return to sport.

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.

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.].