Return to Play in Football Players Following Traumatic Cervical Spine Injury: ExpertOpinions from NFL Spine Surgeons

Introduction: The cervical spine is the most common site of traumatic axial skeletal injuries in
the American football player. Despite potential catastrophic outcomes, high-quality return to play
(RTP) guidelines for spinal injuries are lacking. Here we gathered insights from NFL team
physicians to determine best practices in treatment of professional football players.

Methods: An electronic online survey was distributed to all NFL team physicians specializing in
the management of spine injuries. The survey covered five vignettes, including cases on cervical
radiculopathy, myelopathy, facet fracture, facet dislocation, and neck pain after a tackle with
MRI changes. Participants were asked about management options and criteria to clear players for
RTP.

Results: A total of 26 physicians from 21 teams responded. Anterior surgery was preferred for
cervical radiculopathy and myelopathy (73% and 88%, respectively), with pluralities favoring no
bracing. A rigid cervical orthosis was preferred by 68% of experts for the facet fracture, but
single segment ACDF was preferred by 56% for a facet dislocation. Common criteria to clear
players with radiculopathy for RTP included normal exam (85%), fusion (58%), and pain-free
range of motion (50%), while contraindications included significant stenosis (35%), instability
(31%), multi-level fusion (27%), and cord signal change (23%). Similar results were observed
for the cervical myelopathy player. Additional criteria for RTP in players with facet fractures or
dislocations included evidence of fracture healing (32% and 24%, respectively) and normal
flexion-extension radiographs (24% and 32%, respectively). Finally, resolution of MRI findings
and abnormal signal change was required by 36% of experts for the player with acute neck pain.

Conclusion : Professional football players sustaining spine injuries require resolution of
symptoms, pain-free range of motion, and evidence of healing fracture if present prior to RTP.
The insights from this study can inform development of standardized guidelines.