Return to Play Guidelines After Cervical Spine Injuries in American Football Athletes

A Literature-Based Review

Peter R. Swiatek, MD; Tejas S. Nandurkar, MS; Joseph C. Maroon, MD; Robert C. Cantu, MD; Henry Feuer, MD; Julian E. Bailes, MD; Wellington K. Hsu, MD


Spine. 2021;46(13):886-892. 

In This Article

Abstract and Introduction


Study Design: Literature-based review.

Objective: We sought to evaluate clinical and case studies related to return to play (RTP) after cervical spine injuries in elite American football athletes and to formulate guidelines to help health care practitioners manage these conditions.

Summary of Background Data: American football athletes are at unique risk of cervical spine injury and appropriate case-by-case management of cervical spine injuries is necessary for these athletes. Despite this need, no standardized guidelines exist for RTP after cervical spine injury.

Methods: Observational or case-based articles relating to RTP after cervical spine injury in American football athletes were curated from PubMed/EMBASE databases. Primary literature published before December 1, 2019 involving National Football League (NFL) or National Collegiate Athletic Association (NCAA) athletes met inclusion criteria.

Results: The data acquisition process yielded 28 studies addressing cervical spine injuries and RTP in American football athletes. Stingers/burners were the most common injury and placed athletes at higher risk of a more severe re-injury. Transient quadriplegia, cervical stenosis, cervical disc herniation (CDH), and cervical fractures have a more significant impact on the long-term health and career longevity of the American football athlete. As such, the literature offers some guidance for management of these athletes, including average time for RTP in patients treated nonoperatively, thresholds involving cervical stenosis, and postoperative recommendations after spinal decompression and/or fusion surgery.

Conclusion: Elite American football athletes are at high risk for cervical spine injury due to the nature of their sport. The decision to allow these athletes to return to play should involve an understanding of the average RTP time, the potential risks of recurrence or re-injury, and individual characteristics such as position played and pathology on imaging.

Level of Evidence: 3


The incidence, management, and outcomes after cervical spine injuries are of major interest for athletes participating in American football. From 2000 to 2010, nearly 1000 National Football League (NFL) athletes suffered a cervical spine injury, accounting for 45% of all their spinal injuries in that timespan.[1] Additionally, collegiate football athletes suffered nearly 7500 cervical spine injuries from 2009 to 2014.[2] There are a variety of diagnoses within this group with each type associated with a different degree of severity, disability, and ability to participate in practices and games. Given the significance of its impact on American football player participation and performance, health care professionals need to be aware of the available literature and opinions as it pertains to diagnosis, treatment, and proper management of these injuries.

Despite the prevalence of these conditions, there do not exist any standardized consensus guidelines for return to play. Many of the pertinent treatises for treatment in this population are based upon expert opinion only. Given the variety and complexity of cervical spine injuries that can affect players, it is likely that an algorithm that incorporates general guiding principles, the best available evidence, and consensus opinion amongst experts may be most appropriate for treatment of these players. The purpose of this study is to propose a set of evidence-based guidelines for return to play after cervical spine injury in American football athletes based upon a comprehensive literature review.