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


A total of 28 publications met the inclusion criteria for this study (Supplementary Table 1, The pertinent injuries discussed included strains/sprains (n = 4 studies), stingers/burners (n = 7 studies), stenosis (n = 19 studies), disc herniation (n = 14 studies), and fractures (n = 6 studies).

For strains/sprains (n = 4 studies), these injuries comprised nearly 37% of all cervical spine injuries in NFL athletes[1] from 2000 to 2010 and 55% of collegiate football players from 2009 to 2014.[2] Strains/sprains appear to be self-limited and have been associated with minimal time away from play. For NFL athletes, strains and sprains have been associated with 6 and 10 days mean loss of playing time, respectively.[1] Similarly, more than 90% of collegiate football athletes suffering strains/sprains lost fewer than 7 days of play.[2]

Stingers/burners (n = 7 studies) were the most common cause of cervical spine injury in elite American football athletes, accounting for 46%[1] and 65%[2] of all cervical injuries in NFL and collegiate athletes, respectively. NFL athletes with stingers/burners with persistent symptoms experienced an average of 15 days of playing time missed[1] and 97% of collegiate athletes with stingers/burners missed fewer than 21 days of playing time.[2]

Transient quadriplegia (n = 19 studies) occurred in 7.3 per 10,000 professional football players and is closely associated with the presence of congenital cervical stenosis, which puts the player at risk with extreme flexion and extension of the cervical spine.[3–10] Historically, Torg et al[11] suggested RTP recommendations for NFL athletes based upon 0.8 vertebral canal-to-body ratio on plain radiographs and presence of symptoms. However, in a CT-based evaluation of 80 NFL athletes, Herzog et al[12] demonstrated that nearly 50% of asymptomatic players had abnormal canal-to-body ratios, despite having average spinal canal measurements on advanced imaging. These data challenge the specificity for the usage of this test in this patient population. More recent studies have identified the sagittal MRI as the most appropriate screening tool to diagnose cervical stenosis.[13,14] For example, the term "congenital cervical stenosis" has recently been specifically defined as a patient less than 50 years of age with mid-sagittal canal diameters of less than 10 mm at multiple sub-axial cervical levels measured at the pedicle on MRI T2 imaging.[15] Furthermore, Aebli et al[16] recently reported that a sagittal canal diameter of less than 8 mm may increase the risk of spinal cord injury with minor trauma to the neck.[16] MRI evaluation can also lead to the qualitative diagnosis of stenosis, or "functional cervical spinal stenosis," that grades severity by the loss of protective cerebrospinal fluid (CSF) around the spinal cord.[6]

Cervical disc herniations (CDH) (n = 14 studies), from 2000 to 2010, accounted for 5.8% of cervical spine injuries in NFL athletes resulting in an average of 85 days of lost practice and game activity.[17] Proportionately fewer collegiate football players, approximately 2%, suffered CDH from 2009 to 2014 and nearly 30% of these athletes lost more than 3 weeks of play.[2] From a position perspective, this injury has been most commonly reported in both linebackers and defensive backs, accounting for 18% and 16% of all CDH cases in NFL athletes, respectively. Furthermore, performance outcomes after surgical treatment may be worse for players of these positions than others.[18] In general, after a single-level surgery for CDH, postoperative outcomes are favorable, with 72% successfully returning to play for an average of 29 games over a 2.8-years period, while only 46% of NFL players treated nonoperatively successfully returned to play for an average of 15 games over a 1.5 years period.[19,20] Maroon et al[21] demonstrated in a smaller case series that 80% were able to return to play approximately 9 months after anterior cervical discectomy and fusion (ACDF).[22]

While some experts have suggested that NFL and other American football players suffering CDH in the upper cervical spine (C2–4) should not return to collision sports after ACDF due to the catastrophic risk of adjacent segment disease in the upper cervical region,[23] Mai et al[18] found no significant difference in RTP for NFL athletes treated surgical for upper (C2–4) versus lower (C4–T1) CDH. Because NFL athletes are more prone to developing upper cervical (C3–4) pathology compared with the general population,[1,17,24,25] the decision-making process for these types of conditions are pertinent. Rates of adjacent segment disease in post-ACDF NFL athletes have been reported to be comparable to that of the general population.[18,26] Finally, American football athletes who undergo surgical management of CDH with foraminotomy have a higher return-to-play rate and shorter recovery time, but are at higher risk of requiring reoperation.[18,27]

A total of 18 cervical fractures (n = 6 studies) were reported in the NFL between 2000 and 2010.[1] According to Rodts et al,[28] cervical fractures were associated with a 120-day recovery period before RTP. Specific treatment of these injuries depends upon fracture pattern and stability, but with regard to collegiate football, Chung et al[2] reported a total of 114 cervical spine fractures from 2009 to 2014 that were all treated nonoperatively.