Compared with other sports the rate of cervical spine injuries in football is relatively low. However as one of our radiology reviews illustrates, these injuries do occur and can be difficult to manage. There is also a lack of evidence to guide return to play decisions. This FastFact reviews a Delphi consensus study published in Neurosurgery that aimed to provide guidelines to assist with this process.1.
A Delphi consensus study involving more than one hundred spine surgeons (members of the Cervical Spine Research Society or NFL team physicians) was conducted to evaluate return to play (RTP) decisions in athletes playing collision sport (like American football). After three question rounds the authors were able to establish eight RTP recommendations with strong consensus, three with weak consensus and two with no consensus. Two factors that the group considered to be very important for decision making, were the presence (or absence) of cervical stenosis and/or T2 hyperintensity within the cord.
One of the key recommendations of the group is that asymptomatic players, who do not have evidence of canal stenosis or T2 signal changes, should be allowed to return to all sport. Where a player was found to have a canal diameter in the ‘absolute stenosis’ range (defined as being <10mm) it is suggested that RTP decisions are less clear-cut and should be individualised. Where a player has had a solid fusion following either a cervical fracture (compression, burst or facet fractures) or a single level anterior cervical discectomy and fusion (ACDF) they should also be allowed to return to play as long as they are asymptomatic and have a radiologically normal cord. There was no consensus about whether a player could safely return after a two level ACDF. A final point that is worth noting is that there was strong consensus among the group that athletes who had been treated for a significant cervical spinal injury (with the exception of a stinger) should have an MRI prior to returning to competitive collision or contact sport.
Clearly football involves less contact than collision sports like NFL or rugby. For this reason, it seems likely that these recommendations would be generalisable to football and could guide RTP decisions in our sport.
To learn more about the assessment and management of injuries to the cervical spine complete the “Cervical Spine” module in the FIFA Diploma in Football Medicine.
1.Schroeder GD, Canseco JA, Patel PD et al. Updated Return-to-Play Recommendations for Collision Athletes After Cervical Spine Injury: A Modified Delphi Consensus Study With the Cervical Spine Research Society. Neurosurgery, nyaa308, https://doi-org.ezproxy.aut.ac.nz/10.1093/neuros/nyaa308