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


An initial search was conducted using the MEDLINE database (PubMed, U.S. National Institutes of Health, National Library of Medicine) and the EMBASE (Elsevier, the Netherlands). Articles listed for publication by December 1, 2019 met the inclusion criteria. We used keywords to identify those sources aimed at discussing return to play after cervical spine injury in American football athletes. The Boolean logic query is as follows: ("cervical spine injury" OR "brachial plexus" OR "cervical injury" OR "cervical injuries" OR "cervical strain" OR "cervical sprain" OR "stinger" OR "burner" OR "cervical stenosis" OR "cervical cord neuropraxia" OR "transient quadriplegia" OR "cervical disc herniation" OR "Spear tackler's spine" OR "cervical fracture" OR "acdf" OR "anterior cervical discectomy and fusion") AND ("NFL" OR "National Football League" OR "football") AND ("return to play" OR "rtp" OR "return to competition" OR "return to contact" OR "return-to-play").

Manual searches using the above keywords were also performed to identify additional papers discussing RTP in American football athletes with cervical injuries (Figure 1). Only articles published in English were included. Two independent reviewers completed an initial screening based upon review or title and abstracts. The final set of articles for full-text review were determined based upon the following set of inclusion: (1) discusses American football athletes participating at the NFL or National Collegiate Athletic Association (NCAA) levels, (2) includes at least one type of cervical spine injury or condition, (3) provides a detailed discussion of RTP after cervical injury. Exclusion criteria included qualitative literature reviews and purely editorial-based or opinion articles. Publications with minimal or no discussion of RTP were excluded. Additionally, studies focusing on sports other that professional or collegiate football, such as rugby or high school sports, were excluded.

Figure 1.

Study selection process. Source: PubMed, EMBASE, published or electronically available prior to December 1, 2019. Note: 1. Reasons for exclusion include no full text available (n = 13), unrelated topics (n = 32), high school football players only or rugby players only (n = 20), letter or opinion articles (n = 4), or literature reviews (n = 45). RTP indicates return to play.

Patient and Public Involvement

Individual patients were not directly involved in the completion of this work; instead, this work represents a review of previously published data. Research questions were formulated based upon the need for more appropriate and evidence-based guidelines for treatment of cervical spine injuries in American football athletes.