Return to Play after Cervical Spine Injuries: A consensus of Opinion

Editorial Review

Return to Play after Cervical Spine Injuries: A consensus of Opinion

John C. France Michael Karsy, JamesS. Harrop, Andrew T. Dailey

Global Spine J 2016;792-797

JACO Editorial Reviewer: Thomas Mack DC, FACO

Published: March 2017

Journal of the Academy of Chiropractic Orthopedists

March 2017, Volume 14, Issue 1

The original article copyright belongs to the original publisher. This review is available from: http// © 2017 (Mack) and the Academy of Chiropractic Orthopedists. This is an Open Access article which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Author’s Abstract:

Study Design: Survey.

Objective: Sports-related spinal cord injury (SCI) represents a growing proportion of total SCI’s but lacks evidence or guidelines to guide clinical decision-making on return to play (RTP). Our objective is to offer the treating physician a consensus analysis of expert opinion regarding RTP that can be incorporated with the unique factors of a case for clinical decision-making.

Methods: Ten common clinical scenarios involving neurapraxia and stenosis, atlantoaxial injury, subaxial injury, and general cervical spine injury were presented to 25 spine surgeons from level 1 trauma centers for whom spine trauma is a significant component of their practice. We evaluated responses to questions about patient RTP, level of contact, imaging required for clinical decision, and the time to return for each scenario. The chi-square test was used for statistical analysis, with p <0.05 considered significant.

Results: Evaluation of the surgeons’ responses to these cases showed significant consensus regarding return to high-contact sports in cases of cervical cord neuropraxia without symptoms of stenosis, surgically repaired herniated disks, and nonoperatively healed C1 ring or C2 hangman’s fractures. Greater visibility was found in recommendations for patients showing persistent clinical symptomatology.

Conclusion: This survey suggests a consensus among surgeons for allowing patients with relatively normal imaging and resolution of symptoms to return to high-contact activities;; however, patients with cervical stenosis or clinical symptoms continue to be a challenge for management. This survey may serve as a basis for future clinical trials and consensus guidelines.

JACO Editorial Summary:

  1. This is an original, well written and researched article published April, 2016 in Global Spine Injury.
  2. Sports related spinal cord injury (SCI) lacks empirical data regarding decision making on return to play (RTP). This article presents an expert opinion consensus on RTP for treating physicians.
  3. Return to sport (RTP) has no universally accepted guideline. There is not any currently accepted criteria, decisions are mainly subjective and poorly validated.
  4. Consensus opinion regarding RTP ma provide better evidence than individual case reports or small case series regarding opinions about returning to sport activity.
  5. Twenty-five spine surgeons in the Spine Trauma Study Group (STSG) who considered spine trauma to be a significant component of their practice, all from separate level 1 spine trauma centers were surveyed.
  6. Parameters included: Level of contact, sport, cervical neurapraxia and stenosis. Atlantoaxial cervical injury with or without fusion, subaxial cervical injury with or without fusion.
  7. Scenario ‘keywords’ included: Spine, trauma, spinal cord injury, imaging, canal dimensions, congenital stenosis and cord signal changes. Sudden onset paresthesia resolving with on-field evaluation, resolving within a few hours. Fracture with operative and non-operative treatment.
  8. Full clinical recovery was defined as minimal to no neck pain, return of full or near full range of motion, and return of normal motor and sensory function.
  9. There were no differences between orthopedic and neurosurgeons, so data was analyzed as one group, which is consistent with previous finding from this group of fellowship trained spine surgeons regarding evaluation of cervical dislocation injuries.
  10. The case scenarios set forth do not cover the entire gamut of potential cervical injuries but they were thought to include a broad representation of the common injury patterns may be made. Although the study will not completely answer the questions about RTP, it establishes a reasonable consensus of expert surgical opinion with substantial expertise to guide the treating physician involved in similar case scenarios.


Recently, chiropractic has played a more significant role in athletic evaluation and treatment of injury during sport. Often, chiropractic physicians are actively involved in a multi-disciplinary approach to athletic care. Today, youth and young adults involved in contact sport has grown linearly with the increased population in the United States. When evaluation and treatment is rendered in-office, determining return to play (RTP) may have been difficult due to lack of literature and studies. Without evidence, expert guidance is often relied on for navigating such difficult decisions. This article provides clinical decision guidelines using a consensus developed by surgeons in the Spine Trauma Study Group. Chiropractors engaged in athletic injury, particularly contact resulting in cervical spine injury, may find this article helpful in developing protocol for return to play (RTP).