Guidelines for Return to Play in Collision Sports after Cervical Spine Injury or after Discovery of Cervical Spine Lesions

*(Note: this article is probably too technical for the average reader.)

The respected orthopedist, Joe Torg, has recently published some comprehensive recommendations for return to play in collision sports (such as football) after the discovery of congenital, developmental, or post-injury lesions of the cervical spine.(1) These guidelines are based on personal experience as well as on scientific data, since not enough good data exists on many of the risks associated with some of these conditions. The following is some of the highlights:

CONGENITAL CONDITIONS

1. Odontoid anomalies
The presence of odontoid agenesis, odontoid hypoplasia, or os odontoidium is an absolute contraindication for participation in collision sports such as football.

2. Atlanto-occipital Fusion
Absolute contraindication for participation in collision sports.

3. Klippel-Feil Anomaly
A type I lesion involving mass fusion of both the cervical and the upper thoracic vertebrae is an absolute contraindication.
A type II lesion involving fusion of 1 or 2 interspaces at C3 and below in an individual with full cervical range of motion and an absence of occipito-cervical anomalies, instability, disc disease, or degenerative changes should present no contraindication.

DEVELOPMENTAL CONDITIONS

1. Developmental Stenosis
Developmental narrowing of the cervical spinal canal (a Torg ratio of less than or equal to 0.8) with no instability does not predispose individuals to permanent neurological injury and is not a contraindication for participation.
Developmental narrowing of the cervical canal with one episode of cervical cord neuropraxia is a relative contraindication.
Episodes of cervical cord neuropraxia with intervertebral disc disease and/or developmental changes is a relative contraindication.
An episode of cervical cord neuropraxia associated with MRI evidence of cord defect or cord edema is a relative/absolute contraindication.
An episode of cervical cord neuropraxia associated with ligamentous instability, symptoms of neurologic findings lasting longer than 36 hr and/or multiple episodes is a relative/absolute contraindication

2. Spear Tackler's Spine
This is a clinical entity defined by Torg in a previous paper(2), marked by (a) developmental stenosis of the cervical canal, (b) straightening or reversal of the cervical lordotic curve, (c) preexisting posttraumatic x-ray abnormalities of the c spine, (d) documentation of having employed spear tackling techniques. Spear tackler's spine is an absolute contraindication to participation in collision sports.

3. Spina Bifida Occulta
This is no contraindication for participation.

TRAUMATIC CONDITIONS OF THE UPPER CERVICAL SPINE

1. Atlanto-axial Instability
Absolute contraindication for participation in collision sports.

2. Atlanto-axial Rotatory Fixation (medically defined)
Absolute contraindication for participation in collision sports.

3. Fractures
Acute fractures--absolute contraindication for participation in collision sports.
Healed non-displaced Jefferson fractures, type I and type II odontoid fractures and healed lateral mass fractures of C2 are a relative contraindication, provided that patient has full, pain free range of motion and no neurologic findings.

4. C1/2 Fusion
Absolute contraindication for participation in collision sports.

TRAUMATIC CONDITIONS OF THE MIDDLE AND LOWER CERVICAL SPINE

1. Ligamentous Injuries
Instability as demonstrated by more than 3.5 mm displacement of one vertebra in relation to another or greater than 11 degrees rotation as demonstrated on lateral x-rays is an absolute contraindication. Less than this amount of instability is a relative contraindication.

2. Fractures
Acute--absolute contraindication for participation in collision sports.
Relative contraindications apply to the following healed stable fractures in individuals who are asymptomatic, neurologically normal and have a full, pain free range of motion:
(a) stable displaced vertebral body compression fracture w/out a saggital component
(b) stable fractures involving the posterior neural ring

Absolute contraindications apply with the following:
(a) vertebral body fx w/ a sagittal component
(b) vertebral body fx w/ or w/out displacement but w/ associated posterior arch fxs and/or ligamentous laxity
(c) comminuted fxs of the vertebral body with displacement into the canal
(d) any fx w/ associated pain, neurologic findings, and limited ROM
(e) healed displaced fxs involving the lateral masses w/ resulting facet incongruity.

3. Disc Injury
Acute disc herniation is an absolute contraindication.
Healed disc herniation treated conservatively or w/ discectomy and fusion as long as there is a solid fusion, there are no symptoms, no neurological findings, and full ROM.
Treated disc disease w/ residual instability is a relative contraindication.


Summary by Ben Weitz, D.C., C.C.S.P., C.S.C.S.

References:

1. Torg JS, Ramsey-Emrhein JA. Management guidelines for participation in collision activities with congenital developmental, or postinjury lesions involving the cervical spine. Clinical Journal of Sport Medicine. 1997; 7:273-291.
2. Torg JS, et al. Spear tackler's spine: an entity precluding participation in tackle football and collision activities that expose the cervical spine to axial energy inputs. Am Journal of Sports Medicine. 1993; 21: 640-9.