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 consensuswas achieved for RTP in asymptomatic athletes without increased signal changes and spinal canal diameter >10 mm (90.5%), as well as those with resolved MRI signal changes and diameter>13mm(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.