Cervical disc replacement in athletes: a modified Delphi Consensus Survey of expert opinion

Scott L Zuckerman¹, Jacob Jo², Grant H Rigney³, Julian E Bailes⁴, Christopher M Bonfield⁵, Robert C Cantu⁶, Patrick C H Chan⁷, Andrew M Cordover⁸, Domagoj Coric⁹, Hank Feuer¹⁰, Raymond J Gardocki¹¹, Andrew C Hecht¹², Wellington K Hsu¹³, Jacob R Joseph¹⁴, Ronald A Lehman Jr¹⁵, Allan D Levi¹⁶, Susan M Liew¹⁷, Philip K Louie¹⁸, Steven C Ludwig¹⁹, Joseph Maroon²⁰, Vincent J Miele²⁰, Jeff Mullin²¹, Venu M Nemani²², Frank M Phillips²³, Sheeraz Qureshi²⁴, K Daniel Riew²⁵, Myron A Rogers¹⁰, Rick C Sasso²⁶, Gabriel A Smith²⁷, Jay D Turner²⁸, Alexander R Vaccaro²⁹, Robert G Watkins 4th³⁰, Nicholas Theodore², David O Okonkwo²⁰, Allen K Sills⁵, Gavin A Davis³¹

Affiliations

¹ Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA. Electronic address: scott.zuckerman@vumc.org.
² Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, MD, USA.
³ Department of Neurosurgery, Harvard Medical School, Boston, MA, USA.
⁴ Department of Neurosurgery, NorthShore University Health System, University of Chicago Pritzker School of Medicine, Chicago, IL, USA.
⁵ Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
⁶ Neurosurgery Service, Emerson Health, Concord, MA, USA.
⁷ Department of Neurosurgery, The Alfred Hospital and Monash University, Melbourne, Australia.
⁸ Andrews Sports Medicine and Orthopaedic Center; American Sports Medicine Institute, Birmingham, AL, USA.
⁹ Atrium Health Spine Center of Excellence, Bermuda Run, NC, USA.
¹⁰ Cabrini Hospital, Melbourne Australia and Department of Neurosurgery, Austin Hospital, Melbourne, Australia.
¹¹ Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
¹² Department of Orthopaedic Surgery Mount Sinai Health System and Icahn School of Medicine, New York, NY, USA.
¹³ Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
¹⁴ Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA.
¹⁵ Department of Orthopaedic Surgery, Columbia University, New York, NY.
¹⁶ Department of Neurosurgery, University of Miami, Miami, FL, USA.
¹⁷ Department of Orthopaedic Surgery, The Alfred, Melbourne, Australia.
¹⁸ Center for Neurosciences and Spine, Virginia Mason Medical Center, Seattle, WA, USA.
¹⁹ Department of Orthopaedic Surgery, University of Maryland Medical Center, Baltimore, MD, US.
²⁰ Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
²¹ Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA.
²² Center for Neurosciences and Spine, Virginia Mason Franciscan Health, Seattle, WA, USA.
²³ Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA.
²⁴ Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA.
²⁵ Department of Neurological Surgery, Weill Cornell Medical Center, Och Spine Hospital, New York, NY, USA.
²⁶ Department Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
²⁷ Case Western Reserve University School of Medicine, Cleveland, OH, USA.
²⁸ Barrow Neurological Institute, Phoenix, AZ, USA.
²⁹ Department of Orthopaedics, Thomas Jefferson University and The Rothman Institute, Philadelphia, PA, USA.
³⁰ Cedars Sinai Marina Del Rey Hospital, CA, USA.
³¹ Department of Neurosurgery, Austin Health and Cabrini Health, Melbourne, Victoria, Australia.

PMID: 40339994
DOI: 10.1016/j.spinee.2025.05.009

Free article

Cervical disc replacement in athletes: a modified Delphi Consensus Survey of expert opinion

Scott L Zuckerman et al. Spine J. 2025.

Free article

. 2025 May 6:S1529-9430(25)00234-7.

doi: 10.1016/j.spinee.2025.05.009. Online ahead of print.

Authors

Affiliations

¹ Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA. Electronic address: scott.zuckerman@vumc.org.
² Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, MD, USA.
³ Department of Neurosurgery, Harvard Medical School, Boston, MA, USA.
⁴ Department of Neurosurgery, NorthShore University Health System, University of Chicago Pritzker School of Medicine, Chicago, IL, USA.
⁵ Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
⁶ Neurosurgery Service, Emerson Health, Concord, MA, USA.
⁷ Department of Neurosurgery, The Alfred Hospital and Monash University, Melbourne, Australia.
⁸ Andrews Sports Medicine and Orthopaedic Center; American Sports Medicine Institute, Birmingham, AL, USA.
⁹ Atrium Health Spine Center of Excellence, Bermuda Run, NC, USA.
¹⁰ Cabrini Hospital, Melbourne Australia and Department of Neurosurgery, Austin Hospital, Melbourne, Australia.
¹¹ Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
¹² Department of Orthopaedic Surgery Mount Sinai Health System and Icahn School of Medicine, New York, NY, USA.
¹³ Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
¹⁴ Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA.
¹⁵ Department of Orthopaedic Surgery, Columbia University, New York, NY.
¹⁶ Department of Neurosurgery, University of Miami, Miami, FL, USA.
¹⁷ Department of Orthopaedic Surgery, The Alfred, Melbourne, Australia.
¹⁸ Center for Neurosciences and Spine, Virginia Mason Medical Center, Seattle, WA, USA.
¹⁹ Department of Orthopaedic Surgery, University of Maryland Medical Center, Baltimore, MD, US.
²⁰ Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
²¹ Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA.
²² Center for Neurosciences and Spine, Virginia Mason Franciscan Health, Seattle, WA, USA.
²³ Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA.
²⁴ Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA.
²⁵ Department of Neurological Surgery, Weill Cornell Medical Center, Och Spine Hospital, New York, NY, USA.
²⁶ Department Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
²⁷ Case Western Reserve University School of Medicine, Cleveland, OH, USA.
²⁸ Barrow Neurological Institute, Phoenix, AZ, USA.
²⁹ Department of Orthopaedics, Thomas Jefferson University and The Rothman Institute, Philadelphia, PA, USA.
³⁰ Cedars Sinai Marina Del Rey Hospital, CA, USA.
³¹ Department of Neurosurgery, Austin Health and Cabrini Health, Melbourne, Victoria, Australia.

PMID: 40339994
DOI: 10.1016/j.spinee.2025.05.009

Abstract

Background context: The safety and efficacy of cervical disc replacement (CDR) for spinal disorders in contact sport athletes is unclear. Current research is limited and highlights mixed results regarding return-to-sport (RTS) among athletes with CDR.

Purpose: We sought to perform a modified Delphi consensus survey of expert opinion on CDR in athletes.

Study design/setting: A cross-sectional, modified Delphi consensus survey of different scenarios regarding RTS for athletes with CDR was conducted among a panel of expert spine surgeons.

Patient/respondent sample: An international panel of 34 spine surgeons involving both neurosurgeons and orthopedic surgeons with sport expertise was identified.

Outcome measures: Consensus regarding return to any level of sport as defined above was queried as the main outcome measure, with consensus defined a-priori at ≥70%.

Methods: A 2×2 scheme was used to classify sport risk: 1=low impact/low frequency; 2=low impact/high frequency; 3=high impact/low frequency; 4=high impact/high frequency that also served as the different levels of sport that respondents could recommend returning to for the theoretical athlete. Descriptive statistics were performed with survey respondent data to generate the percentages of respondents recommending return to each level of sport for all scenarios.

Results: Of the 34 sports spine surgeons invited to participate (55.9% neurosurgeons and 44.1% orthopedic surgeons), all completed nine questions as part of a larger survey. Regarding radiculopathy, consensus was achieved that CDR is an acceptable treatment for cervical radiculopathy in a high impact/high frequency athlete for one-level disease (73.5%). However, only 58.8% responded that they would offer a CDR in this scenario. Regarding spinal cord compression, consensus was not achieved that CDR is an acceptable treatment for a high impact/high frequency forces athlete for one-level disease with cord compression with/without myelopathy (47.1%). The most common reasons behind not offering a CDR included certainty of the anterior cervical discectomy and fusion (ACDF), safety concerns (eg, adequacy, efficacy, stability), and lack of data/evidence. Postoperatively, following a one-level CDR for myelopathy or radiculopathy, 57.6% of participants responded that they would advise the athlete may return to high impact/high frequency sport, whereases following a two-level CDR, only 23.5% of all participants responded they would advise the same. For one-level CDR, the most endorsed timelines for return to practice were 6 weeks (26.5%) and 3 months (26.5%) and for games was 3 months (41.2%). For two-level CDR, the most endorsed timeline for return to practice was 3 months (26.5%) and for games was 3 months (41.2%).

Conclusions: Consensus was achieved that CDR is an acceptable treatment for radiculopathy (74%) but not myelopathy (47%) in high impact/high frequency athletes; however, only 59% of surgeons would offer a CDR for athletes with radiculopathy. Reasons for CDR hesitancy were certainty of outcomes with ACDF, safety concerns, and lack of long-term data. Although consensus was reached for some indications herein, this study highlights the ongoing heterogeneity in the use of CDR for contact sport athletes and concerns regarding its safety. Future research should focus on gathering primary data on safety, durability, and long-term efficacy of CDR among athletes of different sports.

Keywords: Arthroplasty; Athlete; Return-to-sport; Spine surgery; Total disc replacement.

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Conflict of interest statement

Declaration of competing interest The authors would like to declare the following potential conflicts of interest: Scott L. Zuckerman has no funding or other related conflicts of interest to disclose. Jacob Jo has no funding or other related conflicts of interest to disclose. Grant H. Rigney has no funding or other related conflicts of interest to disclose. Julian E. Bailes has no funding or other related conflicts of interest to disclose. Christopher M. Bonfield serves as an unaffiliated neurotrauma consultant to the National Football League. Robert C. Cantu has no funding or other related conflicts of interest to disclose. Patrick C.H. Chan has no funding or other related conflicts of interest to disclose. Andrew M. Cordover has no funding or other related conflicts of interest to disclose. Domagoj Coric has no funding or other related conflicts of interest to disclose. Hank Feuer has no funding or other related conflicts of interest to disclose. Raymond J. Gardocki has received royalties and provided consulting services for Accelus and has received royalties from Spineology. He has provided consulting services for Accelus, Joimax, and Arthrex. Andrew Hecht has received royalties from: Atlas Spine and has provided consulting services for Orthofix. Wellington K. Hsu has no funding or other related conflicts of interest to disclose. Jacob R. Joseph has no funding or other related conflicts of interest to disclose. Ronald A. Lehman, Jr. has no funding or other related conflicts of interest to disclose. Allan D. Levi has no funding or other related conflicts of interest to disclose. Susan M. Liew has no funding or other related conflicts of interest to disclose. Philip K. Louie has provided consulting services to: Alphatec, Augmedics, Depuy-Synthes, Globus, and Viseon. Dr. Louie has received research funding from: AO Spine and the Cervical Spine Research Society. Steven C. Ludwig receives IP royalties from Atlas Spine, receives Stock/stock options from Alphatec Spine, MDC and Nuvasive, is a paid consultant for Nuvasive, and receives research support from AO Spine North America Spine Fellowship Support, Baxter, Nuvasive, and OMEGA. Additionally, Steven Ludwig is a board/committee member for American Academy of Orthopaedic Surgeons (AAOS), American Board of Orthopaedic Surgery, Inc., American Orthopaedic Association (AOA), Cervical Spine Research Society (CSRS), Lumbar Spine Research Society (LSRS), and Society for Minimally Invasive Spine Surgery (SMISS). He is on the Editorial/Governing Board of Contemporary Spine Surgery, and the Spine Journal. Joseph Maroon has no funding or other related conflicts of interest to disclose. Vincent J. Miele has no funding or other related conflicts of interest to disclose. Jeff Mullin serves as a consultant to Nuvasive, SI Bone, and Medtronic. Venu M. Nemani serves as a consultant for Medtronic, Alphatec, and SeaSpine, and he has received speaking fees from Medtronic and Augmedics. Frank M. Phillips has no funding or other related conflicts of interest to disclose. Sheeraz Qureshi has no funding or other related conflicts of interest to disclose. K. Daniel Riew receives royalties from Biomet, Happe Spine (Expected, none at present), and Nuvasive (Expected). Dr. Riew owns stock in Amedica, Axiomed, Benvenue, Expanding Orthopedics, Osprey, Paradigm Spine, Spinal Kinetics, Spineology, Vertiflex, and Happe Spine. Dr. Riew serves as a consultant for Happe Spine (nonfinancial) and Nuvasive, has received travel reimbursement from Nuvasive, and serves on the scientific advisory board for Nuvasive and the Board of Directors for Global Spine Journal (nonfinancial). Myron A. Rogers has no funding or other related conflicts of interest to disclose. Rick C. Sasso receives royalties from Medtronic and Nuvasive. Gabriel A. Smith has no funding or other related conflicts of interest to disclose. Jay D. Turner has no funding or other related conflicts of interest to disclose. Alexander R. Vaccaro receives royalties from Stryker, Globus, Medtronic, Atlas Spine, Alphatech Spine, SpinWave, Spinal Elements, Elsevier, Jaypee, Taylor Francis/Hodder and Stoughton, and Thieme. Dr. Vaccaro has stock or stock options in Accelus, Advanced Spinal Intellectual Properties, Atlas, Avaz Surgical, AVKN Patient Driven Care, Cytonics, Deep Health, Dimension Orthotics LLC, Electocore, Flagship Surgical, FlowPharma, Rothman Institute and Related Properties, Globus, Harvard MedTech, Innovative Surgical Design, Jushi (Haywood), Nuvasive, Orthobullets, Parvizi Surgical Innovation, Progressive Spinal Technologies, Sentryx, Stout Medical, and ViewFi Health. Dr. Vaccaro is a consultant for Stryker, Globus, Spinal Elements, Accelus, and Ferring Pharmaceutical. Robert G. Watkins has no funding or other related conflicts of interest to disclose. Nicholas Theodore receives royalties from Globus Medical, owns stock in Globus Medical, is a consultant for Globus Medical, and has served on the scientific advisory board for Globus Medical. David O. Okonkwo has received royalties from Globus, Highridge Medical, NuVasive, and Zimvie, serves as a consultant for NuVasive, and has received travel or lodging fees from Nuvasive. Allen K. Sills serves as a salaried employee of the National Football League. He has no other disclosures related to any devices or companies involved in spine surgery. Gavin A. Davis serves on the scientific advisory committee for the 6th International Conference on Concussion in Sport and is an honorary member of the Australian Football League Concussion Scientific Committee. He is a section editor for Sport and Rehabilitation, Neurosurgery, and has attended meetings organized by sporting organizations, including the National Football League, National Rugby League, International Ice Hockey Federation, International Olympic Committee, and Fédération Internationale de Football Association; however, he has not received any payment, research funding, or other monies from these groups other than for travel costs.

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Cervical disc replacement in athletes: a modified Delphi Consensus Survey of expert opinion

Affiliations

Cervical disc replacement in athletes: a modified Delphi Consensus Survey of expert opinion

Authors

Affiliations

Abstract

Conflict of interest statement

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