Return-to-Sport Recommendations in Athletes Requiring Cervical Spine Surgery: A Modified Delphi Consensus Survey of Expert Opinion

Scott L Zuckerman^{1

2}, Michael White, Grant H Rigney³, Jacob Jo⁴, Julian E Bailes⁵, Christopher M Bonfield¹, Robert C Cantu⁶, Patrick C H Chan⁷, Andrew M Cordover⁸, Domagoj Coric⁹, Hank Feuer¹⁰, Raymond J Gardocki², Andrew C Hecht¹¹, Wellington K Hsu¹², Jacob R Joseph¹³, Ronald A Lehman Jr¹⁴, Allan D Levi¹⁵, Susan M Liew¹⁶, Philip K Louie¹⁷, Steven C Ludwig¹⁸, Joseph Maroon¹⁹, Vincent J Miele¹⁹, Jeff Mullin²⁰, Venu M Nemani²¹, Frank M Phillips²², Sheeraz Qureshi²³, K Daniel Riew²⁴, Myron A Rogers²⁵, Rick C Sasso²⁶, Gabriel A Smith²⁷, Jay D Turner²⁸, Alexander R Vaccaro²⁹, Robert G Watkins 4th³⁰, Nicholas Theodore⁴, David O Okonkwo¹⁹, Allen K Sills¹, Gavin A Davis³¹

Affiliations

¹ Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
² Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
³ Department of Neurosurgery, Harvard Medical School, Boston, MA, USA.
⁴ Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, MD, USA.
⁵ Department of Neurosurgery, NorthShore University Health System, University of Chicago Pritzker School of Medicine, Chicago, IL, 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 Department of Neurological Surgery, Indiana University School of Medicine and Goodman Campbell Brain and Spine, Indianapolis, IN, USA.
¹¹ Department of Orthopaedic Surgery Mount Sinai Health System and Icahn School of Medicine, New York, NY, USA.
¹² Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
¹³ Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA.
¹⁴ Department of Orthopaedic Surgery, Columbia University, New York, NY.
¹⁵ Department of Neurosurgery, University of Miami, Miami, FL, USA.
¹⁶ Department of Orthopaedic Surgery, The Alfred, Melbourne, Australia.
¹⁷ Center for Neurosciences and Spine, Virginia Mason Medical Center, Seattle, WA, USA.
¹⁸ Department of Orthopaedic Surgery, University of Maryland Medical Center, Baltimore, MD, US.
¹⁹ Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
²⁰ Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA.
²¹ Center for Neurosciences and Spine, Virginia Mason Franciscan Health, Seattle, WA, USA.
²² Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA.
²³ Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA.
²⁴ Department of Neurological Surgery, Weill Cornell Medical Center, Och Spine Hospital, New York, NY, USA.
²⁵ Cabrini Hospital, Melbourne Australia and Department of Neurosurgery, Austin Hospital, Melbourne, Australia.
²⁶ Department Orthopedic 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: 40838273
DOI: 10.1097/BRS.0000000000005464

Return-to-Sport Recommendations in Athletes Requiring Cervical Spine Surgery: A Modified Delphi Consensus Survey of Expert Opinion

Scott L Zuckerman et al. Spine (Phila Pa 1976). 2025.

. 2025 Aug 21.

doi: 10.1097/BRS.0000000000005464. Online ahead of print.

Authors

Affiliations

¹ Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
² Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
³ Department of Neurosurgery, Harvard Medical School, Boston, MA, USA.
⁴ Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, MD, USA.
⁵ Department of Neurosurgery, NorthShore University Health System, University of Chicago Pritzker School of Medicine, Chicago, IL, 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 Department of Neurological Surgery, Indiana University School of Medicine and Goodman Campbell Brain and Spine, Indianapolis, IN, USA.
¹¹ Department of Orthopaedic Surgery Mount Sinai Health System and Icahn School of Medicine, New York, NY, USA.
¹² Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
¹³ Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA.
¹⁴ Department of Orthopaedic Surgery, Columbia University, New York, NY.
¹⁵ Department of Neurosurgery, University of Miami, Miami, FL, USA.
¹⁶ Department of Orthopaedic Surgery, The Alfred, Melbourne, Australia.
¹⁷ Center for Neurosciences and Spine, Virginia Mason Medical Center, Seattle, WA, USA.
¹⁸ Department of Orthopaedic Surgery, University of Maryland Medical Center, Baltimore, MD, US.
¹⁹ Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
²⁰ Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA.
²¹ Center for Neurosciences and Spine, Virginia Mason Franciscan Health, Seattle, WA, USA.
²² Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA.
²³ Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA.
²⁴ Department of Neurological Surgery, Weill Cornell Medical Center, Och Spine Hospital, New York, NY, USA.
²⁵ Cabrini Hospital, Melbourne Australia and Department of Neurosurgery, Austin Hospital, Melbourne, Australia.
²⁶ Department Orthopedic 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: 40838273
DOI: 10.1097/BRS.0000000000005464

Abstract

Study design: Modified Delphi consensus survey.

Objective: To survey expert opinion on postoperative return-to-sport (RTS) decisions in athletes requiring cervical spine surgery.

Summary of background data: Postoperative sport participation recommendations for athletes requiring cervical spine surgery are lacking, and management of these athletes remains challenging.

Methods: A cross-sectional, modified Delphi consensus survey investigating RTS decisions in athletes requiring various cervical spine operations was undertaken. A panel of neurosurgery/orthopedic spine surgeons with sport expertise was identified from the United States and Australia. Single and multi-level cervical spine surgical conditions studied included: anterior cervical discectomy and fusion (ACDF), cervical laminectomy and laminoplasty, posterior cervical fusion, occipito-cervical fusion, C1 fracture, and C1-C2 fusion. A 2×2 scheme was used to classify sport risk based on impact forces and frequency: low impact/low frequency, low impact/high frequency, high impact/low frequency, and high impact/high frequency. Consensus was a-priori defined at ≥70%. Descriptive statistics were performed.

Results: Of the 34 sports spine surgeons invited (56% neurosurgeons and 44% orthopedic surgeons), survey completion was 100%. Consensus was achieved to recommend return to high impact/high frequency sport for individuals with 1-level ACDF, 1-level cervical laminectomy, 1-level posterior cervical fusion, and for a healed C1 fracture treated with open reduction and internal fixation. For individuals with a healed occipito-cervical fusion, consensus was achieved to recommend return to low impact/low frequency sport.

Conclusions: Consensus was achieved to recommend return to high impact/high frequency sport after surgical treatment of a variety of cervical pathologies in athletes. Certain situations received consensus recommendations to return to low impact/low frequency sport, while many others did not reach a consensus. These results provide useful data that can help spine surgeons navigate challenging postoperative RTS decisions.

Keywords: amatuer; athlete; cervical; cervical spine injury; delphi; professional; return-to-play; return-to-sport; spine surgery; survey study.

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Conflict of interest statement

Conflicts of Interest and Sources of Funding: The authors report no sources of funding for the manuscript. The authors report the following conflicts of interest: 1. Scott L. Zuckerman has no funding or other related conflicts of interest to disclose. 2. Jacob Jo has no funding or other related conflicts of interest to disclose. 3. Grant H. Rigney has no funding or other related conflicts of interest to disclose. 4. Julian E. Bailes has no funding or other related conflicts of interest to disclose. 5. Christopher M. Bonfield serves as an unaffiliated neurotrauma consultant to the National Football League. 6. Robert C. Cantu has no funding or other related conflicts of interest to disclose. 7. Patrick C.H. Chan has no funding or other related conflicts of interest to disclose. 8. Andrew M. Cordover has no funding or other related conflicts of interest to disclose. 9. Domagoj Coric has no funding or other related conflicts of interest to disclose. 10. Hank Feuer has no funding or other related conflicts of interest to disclose. 11. 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. 12. Andrew Hecht has received royalties from: Atlas Spine and has provided consulting services for Orthofix. 13. Wellington K. Hsu has no funding or other related conflicts of interest to disclose. 14. Jacob R. Joseph has no funding or other related conflicts of interest to disclose. 15. Ronald A. Lehman, Jr. has no funding or other related conflicts of interest to disclose. 16. Allan D. Levi has no funding or other related conflicts of interest to disclose. 17. Susan M. Liew has no funding or other related conflicts of interest to disclose. 18. 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. 19. 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. 20. Joseph Maroon has no funding or other related conflicts of interest to disclose. 21. Vincent J. Miele has no funding or other related conflicts of interest to disclose. 22. Jeff Mullin serves as a consultant to Nuvasive, SI Bone, and Medtronic. 23. Venu M. Nemani serves as a consultant for Medtronic, Alphatec, and SeaSpine, and he has received speaking fees from Medtronic and Augmedics. 24. Frank M. Phillips has no funding or other related conflicts of interest to disclose. 25. Sheeraz Qureshi has no funding or other related conflicts of interest to disclose. 26. 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). 27. Myron A. Rogers has no funding or other related conflicts of interest to disclose. 28. Rick C. Sasso receives royalties from Medtronic and Nuvasive. 29. Gabriel A. Smith has no funding or other related conflicts of interest to disclose. 30. Jay D. Turner has no funding or other related conflicts of interest to disclose. 31. 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. 32. Robert G. Watkins has no funding or other related conflicts of interest to disclose. 33. 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. 34. 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. 35. 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. 36. 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. 37. Scott L. Zuckerman has no funding or other related conflicts of interest to disclose. 38. Jacob Jo has no funding or other related conflicts of interest to disclose. 39. Grant H. Rigney has no funding or other related conflicts of interest to disclose. 40. Julian E. Bailes has no funding or other related conflicts of interest to disclose. 41. Christopher M. Bonfield serves as an unaffiliated neurotrauma consultant to the National Football League. 42. Robert C. Cantu has no funding or other related conflicts of interest to disclose. 43. Patrick C.H. Chan has no funding or other related conflicts of interest to disclose. 44. Andrew M. Cordover has no funding or other related conflicts of interest to disclose. 45. Domagoj Coric has no funding or other related conflicts of interest to disclose. 46. Hank Feuer has no funding or other related conflicts of interest to disclose. 47. 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. 48. Andrew Hecht has received royalties from: Atlas Spine and has provided consulting services for Orthofix. 49. Wellington K. Hsu has no funding or other related conflicts of interest to disclose. 50. Jacob R. Joseph has no funding or other related conflicts of interest to disclose. 51. Ronald A. Lehman, Jr. has no funding or other related conflicts of interest to disclose. 52. Allan D. Levi has no funding or other related conflicts of interest to disclose. 53. Susan M. Liew has no funding or other related conflicts of interest to disclose. 54. 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. 55. 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. 56. Joseph Maroon has no funding or other related conflicts of interest to disclose. 57. Vincent J. Miele has no funding or other related conflicts of interest to disclose. 58. Jeff Mullin serves as a consultant to Nuvasive, SI Bone, and Medtronic. 59. Venu M. Nemani serves as a consultant for Medtronic, Alphatec, and SeaSpine, and he has received speaking fees from Medtronic and Augmedics. 60. Frank M. Phillips has no funding or other related conflicts of interest to disclose. 61. Sheeraz Qureshi has no funding or other related conflicts of interest to disclose. 62. 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). 63. Myron A. Rogers has no funding or other related conflicts of interest to disclose. 64. Rick C. Sasso receives royalties from Medtronic and Nuvasive. 65. Gabriel A. Smith has no funding or other related conflicts of interest to disclose. 66. Jay D. Turner has no funding or other related conflicts of interest to disclose. 67. 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. 68. Robert G. Watkins has no funding or other related conflicts of interest to disclose. 69. 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. 70. 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. 71. 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. 72. 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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Return-to-Sport Recommendations in Athletes Requiring Cervical Spine Surgery: A Modified Delphi Consensus Survey of Expert Opinion

Affiliations

Return-to-Sport Recommendations in Athletes Requiring Cervical Spine Surgery: A Modified Delphi Consensus Survey of Expert Opinion

Authors

Affiliations

Abstract

Conflict of interest statement

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