Cervical spine injuries are, unfortunately, a common problem for athletes who participate in contact sports such as football, hockey, or rugby. One of the most challenging roles for the physician team that cares for elite athletes is the decision making regarding cervical spine injuries and return to play considerations.
Recently, AAOS Now convened a group of spine surgeons who care for elite and professional athletes to discuss this issue. Moderating the discussion and presenting a series of case studies was Andrew C. Hecht, MD, chief of spine surgery, associate professor of orthopaedic and neurosurgery, and director of the spine center at Mount Sinai Hospital, New York City. Joining him were the following:
- Alexander Vaccaro, MD, PhD, the Richard H. Rothman Professor and chairman, department of orthopaedic surgery and professor of neurosurgery at Thomas Jefferson University in Philadelphia
- Wellington K. Hsu, MD, the Clifford C. Raisbeck Distinguished Professor of Orthopaedic Surgery at Northwestern Medicine in Chicago
- Andrew Dossett, MD, a spine surgeon at the W.B. Carrell Memorial Clinic, in Dallas
- Robert G. Watkins III, MD, codirector of the Marina Spine Clinic and a member of the Association of Professional Team Physicians
Dr. Hecht: Let’s discuss some challenging management scenarios, beginning with a professional football player with a C4/5 posterolateral disk herniation with weakness in his deltoid who has exhausted all conservative care. What kind of surgery would you perform?
Dr. Vaccaro: I would perform an anterior cervical decompression and fusion (ACDF), using an allograft bone and a cervical plate. I would allow him to return to play 6 to 9 months after that procedure, after he has completed rehabilitation and has full range of motion and his strength back.
Dr. Watkins: My recommendation is a one-level anterior cervical fusion using allograft and a plate. I use a cortical allograft packed with autogenous cancellous bone from the iliac crest.
I would not recommend a total disk replacement. I think the unknown factors of artificial disk replacement preclude its use in high performance athletes and certainly not in those in sports that potentially involve head contact, including National Basketball Association (NBA), National Hockey League, and Major League Baseball players.
I would not perform a foraminotomy and posterior disk excision. The potential risk of instability and reherniation is too high in this athlete.
Dr. Dossett: I would also perform an ACDF with autologous iliac crest graft and a plate.
Dr. Hecht: I agree with the ACDF with allograft and instrumentation. I would not do a foraminotomy or disk replacement in a football player with a disk herniation. Would total disk replacement in this scenario be appropriate for a player in any other sport?
Dr. Vaccaro: If the player were involved in a noncontact sport, I would perform a disk replacement, if the patient preferred it after I explained the risks and benefits. In athletes involved in a sport that involves significant contact, I would avoid disk replacement.
Dr. Hsu: Although both foraminotomy and ACDF have been successful for National Football League players, they both have their challenges. ACDF can lead to adjacent segment degeneration and ultimately a two-level fusion that is currently incompatible with return to play.
Posterior foraminotomies also lead to problems because it’s been shown that up to 50 percent of professional athletes may require surgery at that index level in their lifetimes. ACDF probably has better long-term results in football players, but total disk arthroplasty is not indicated at this time.
Dr. Hecht: Do you think a CT scan that shows definitive fusion is needed before you would allow this athlete to return to contact sports, even if he is asymptomatic?
Dr. Vaccaro: I would always get a CT scan in a professional athlete, primarily as documentation. If a CT scan taken at 10 months after surgery showed a nonhealed union, and the athlete had good isometric strength and symmetric range of motion, I would tell that athlete that significant contact may disrupt a stable, nonhealed fusion, and he may become symptomatic, which may affect his ability to play. If he agreed and understood that, I would allow him to return to play. But, I would document it thoroughly.
Dr. Watkins: I don’t think it is imperative that a patient have a radiographic solid fusion before returning to play. An asymptomatic patient with full range of motion, full strength and conditioning, after completing a rehabilitation program for his sport, could return to play.
Dr. Hsu: I would say that a CT scan is definitely indicated. I know a number of physicians don’t necessarily agree with that. But certainly knowing that someone has a pseudarthrosis before returning to the field is important.
Dr. Hecht: Let’s expand on the situation. The player had an ACDF and he has no motion on flexion/extension films, but his CT scan shows a nonunion, with haloing around the screws of the anterior cervical plate and radiolucent lines. However, he’s completely asymptomatic. Would you let him return to contact sports?
Dr. Watkins: A patient with an obvious nonunion who is completely asymptomatic and passes all of his conditioning and sport-specific training may return to play. He is at risk of becoming symptomatic at the operated level, just as he is at risk at becoming symptomatic at the adjacent level. Part of the problem at times is trying to sort out whether symptoms are at an adjacent level or the prior operated level.
Dr. Vaccaro: In contact sports, the potential exists that neck pain may develop and the player may experience a symptomatic pseudarthrosis that may limit range of motion. At that point, the player has to decide whether to return to play or not. He’s not at risk of a catastrophic neurologic deficit.
He may or may not be at risk for development of arm discomfort, which can be seen due to inflammation associated with pseudarthrosis. I would clearly document this and the patient would have to sign off to return to play. If he became concerned, he could opt to not return to contact sports or to have additional surgery. I would supplement posteriorly to allow the anterior fusion to eventually heal over time. I would allow that patient to return to sports.
Dr. Dossett: I’d say this: if the player had a cervical procedure other than an anterior autograft, and a symptomatic nonunion developed, I’d go back in anteriorly with an autograft.
Dr. Hecht: If I had a patient with a nonunion autograft or allograft, I would almost universally use a posterior approach, unless there was an adjacent segment problem with radiculopathy. If it was just the index level, I would treat that posteriorly. The union rate has been shown to be nearly 99 percent with a posterior augmentation of an anterior fusion. Despite the posterior dissection, athletes can return to play without limitation.
Dr. Watkins: If the patient has an anterior nonunion, I would generally recommend a posterior fusion. If the complex becomes solidly fused, I would clear him to return to play.
Dr. Hecht: What about the player who has a two-level ACDF? Is this still a relative contraindication for returning to play in collision contact sports?
Dr. Dossett: My personal belief is that an athlete with a two-level cervical fusion should not play collision sports, because the next injury that requires surgery dramatically reduces cervical function.
Dr. Watkins: My opinion is that a two-level cervical fusion is a contraindication to return to a head contact sport. Even in a noncontact sport, such as professional baseball, the problem in letting an athlete return after a two-level fusion is the increased risk of adjacent level injury. Then you have a young guy with a three-level neck problem. That is not good for his health and future outside of his professional sport.
If it’s possible to sort out which is the symptomatic level when an adjacent level has degenerative changes, we would recommend fusing only the symptomatic level. If the adjacent level becomes symptomatic, the patient should definitely retire.
Dr. Vaccaro: I’m not as afraid to let an athlete with a healed two-level ACDF return to football. I agree that range of motion may be decreased, but I’m not sure how significant that decreased range of motion is. I agree also that, if junction disease develops, a three-level fusion would not allow a return to play.
Dr. Hecht: I would let him go back to playing, even with a two-level ACDF but counsel him that symptoms may develop and force him to stop playing. What about a football player who has recurring stingers? You’re sure they’re stingers, but an MRI shows congenital cervical stenosis.
Dr. Dossett: Those are unrelated conditions, and the risk doesn’t impact each other. Once the player can demonstrate normal range of motion, resistance with isometrics and all kinds of combinations thereof, and has a normal neurologic examination, he can return to play.
Dr. Hsu: The physical exam and the history are important as many of the reported symptoms can be mixed up with a transient cord neurapraxia episode. These are separate entities. If everybody with that scenario was held out, I think half the league would probably be affected.
Dr. Vaccaro: When I see patients with multiple stingers, I tell them that many studies have shown that the more stingers you have, the greater the likelihood of future chronic neck pain and referred arm discomfort from symptomatic degenerative disease as they age.
Dr. Hecht: What about a patient who has a cervical cord neurapraxia (CCN)? Let’s look at two possible scenarios—one in which the patient has no congenital stenosis or herniation of any kind and one in which he has stenosis. So, a player with congenital cervical stenosis has his first episode of a CCN. How many episodes would you allow?
Dr. Hsu: In my opinion, it is not safe for that player to return to a collision sport, because that incident is a harbinger for a permanent neurologic injury from a spinal cord injury. I think that player should have the cord decompressed before returning to the field. If more than one level is affected, he should not return to play, as we’ve already established.
Dr. Vaccaro: If a player has a transient CCN in the setting of cervical stenosis, I would strongly argue to keep that patient from playing. It could predispose the individual to a future spinal cord neurapraxia.
If the patient has no evidence of congenital spinal stenosis, he would have to complete a thorough rehab program, demonstrate symmetrical motion and normal strength before I would allow him to return to sports. After a second episode, I would counsel against return.
Dr. Watkins: I think the equivocal factor is the severity of the episode. It varies from mild quadriparesthesia that goes away immediately, to being transported off the field with a spinal cord injury and being paralyzed for 1 hour to 6 hours, hospitalized, and having burning upper extremity symptoms for months after the episode. This can become a chronic problem. I would take all the appropriate measurements and evaluate for a spinal column injury such as ligamentous disruption, disk herniation, or lateral mass fracture. If the episode is mild and transitory, and the cervical stenosis is not significant, I would allow the patient to return to professional football. A second episode would disqualify him from the sport.
Unfortunately, when the patient comes to you, the history is often somewhat confusing. The patient may attempt to deny having significant symptoms. The history from the team’s healthcare providers is very important.
Under the scenario of congenital stenosis without degenerative change, transitory minor episode, I would let the player return. If he has a significant spinal cord injury with residual symptoms, I would not let him return.
Dr. Hecht: Is there a role for laminoplasty in an athlete with congenital cervical stenosis who has had a cord neurapraxia?
Dr. Hsu: I know of one NBA player who returned to play after a laminoplasty. I think a laminoplasty is consistent with return to play, even in a collision sport, as long as a CT scan demonstrates complete healing on the hinge side.
Dr. Watkins: We performed a laminoplasty on a top-level NCAA basketball player after a history of seven or eight transitory episodes that the player was not sure were happening—until the last significant one. His healthcare providers were not sure what was happening. We returned him to play with full confidence. I think he is at greater risk for a fracture-dislocation, but in professional basketball, the chance of that occurring is remote, to say the least.
Dr. Vaccaro: If I saw someone with a history of a cervical spinal cord neurapraxia who had a laminoplasty, and the hinged side healed, I would clear that athlete to play, as long as I didn’t see any cord atrophy or edema.
However, if I saw the patient up front with a spinal cord injury, I would take a more pessimistic approach because there are too many “ifs.” Would I be able to operate and be successful? Would there be a risk of a C5 palsy? Will I be sure that the CT scan confirms adequate healing of the hinge side or be deceived due to volume averaging? With all these variables, I would say that it’s probably not a good idea to return to sports.
Dr. Hecht: What about the player who has cord neurapraxia and a disk herniation? Once the disk herniation was addressed, we would let him return to play, but what if there was a small spot of myelomalacia in the cord? Would you let the athlete return to play, assuming he has painless range of motion and is neurologically normal?
Dr. Watkins: If the patient has an area of myelomalacia and a disk herniation, we would treat him with an ACDF. If the patient has a residual area of myelomalacia and a solid fusion, I would not let him return to professional football.
Dr. Vaccaro: No, I know what myelomalacia represents and I probably would not let him play.
Dr. Hsu: I would let him play, as long as the amount of space around that myelomalacia was significant and he had a normal canal. I don’t see any reason why the myelomalacia would prevent him from playing, if it were treated successfully.
One or more of the roundtable participants reported potential conflicts of interest. For complete disclosure information, visit www.aaos.org/disclosure