Spine and Sports: A Roundtable Discussion

Andrew C. Hecht, MD

Alexander R. Vaccaro, MD, PhD, MBA

Wellington Hsu, MD

Robert G. Watkins, MD

Andrew Dossett, MD

Dr. Dossett or an immediate family member has stock or stock options held in Alphatec Spine. Dr. Hecht or an immediate family member has received royalties from Zimmer; serves as a paid consultant to Medtronic Sofamor Danek, Stryker, and Zimmer; has stock or stock options held in Johnson & Johnson; and serves as a board member, owner, officer, or committee member of the AAOS, Musculoskeletal Transplant Foundation, the American Journal of Orthopedics, the Global Spine Journal, the Journal of Spinal Disorders and Techniques, the Orthopaedic Knowledge Online Journal, and Orthopedics Today. Dr. Hsu or an immediate family member has received royalties from Stryker; is a member of a speakers’ bureau or has made paid presentations on behalf of AONA; serves as a paid consultant to AONA, Bacterin, Bioventus, CeramTec, Globus, Graftys, Lifenet, Medtronic Sofamor Danek, Relievant, Rti, SI Bone, and Stryker; has received research or institutional support from Medtronic; and serves as a board member, owner, officer, or committee member of the AAOS, the Cervical Spine Research Society, the Journal of Spinal Disorders and Techniques, the Lumbar Spine Research Society, and the North American Spine Society. Dr. Vaccaro or an immediate family member has received royalties from Aesculap/B. Braun, Globus Medical, Medtronic, and Stryker; serves as a paid consultant to DePuy, A Johnson & Johnson Company, Ellipse, Expert Testimony, Gerson Lehrman Group, Globus Medical, Guidepoint Global, Innovative Surgical Design, Medacorp, Medtronic, Orthobullets, Stout Medical, and Stryker; has stock or stock options held in Advanced Spinal Intellectual Properties, Avaz Surgical, Bonovo Orthopaedics, Computational Biodynamics, Cytonics, Dimension Orthotics, LLC, Electrocore, Flagship Surgical, FlowPharma, Gamma Spine, Globus Medical, In Vivo, Innovative Surgical Design, Location-Based Intelligence, Paradigm Spine, Prime Surgeons, Progressive Spinal Technologies, Replication Medica, Rothman Institute and Related Properties, Spine Medica, Spinology, Stout Medical, and Vertiflex; has received nonincome support (such as equipment or services), commercially derived honoraria, or other non-research–related funding (such as paid travel) from Elsevier, Jaypee, Taylor Francis/Hodder and Stoughton, and Thieme; and serves as a board member, owner, officer, or committee member of AO Spine, the Association of Collaborative Spine Research, Clinical Spine Surgery, Flagship Surgical, Innovative Surgical Design, Prime Surgeons, and the Spine Journal. Dr. Watkins Sr. or an immediate family member has received royalties from Medtronic Sofamor Danek; is a member of a speakers’ bureau or has made paid presentations on behalf of Aesculap/B. Braun, Amedica, and RTI Surgical; serves as a paid consultant to Aesculap/B. Braun, Amedica, and RTI Surgical; serves as a board member, owner, officer, or committee member of the Journal of Neurosurgery and the Spine.

Spine injuries are, unfortunately, a common problem for athletes who participate in contact sports such as football, hockey, and rugby. One of the most challenging roles for the physician team that cares for elite athletes is the decision making regarding spine injuries and return to play considerations. In this chapter, a group of spine surgeons who care for elite and professional athletes discuss this issue. Moderating the discussion and presenting a series of case studies was Andrew C. Hecht, MD, chief of spine surgery, associate professor of orthopaedic and neurosurgery, and director of the spine center at Mount Sinai Hospital, New York City. Dr. Hecht is the spine surgeon for the NY Jets and NY Islanders professional teams and sits on the NFL Brain and Spine Committee. He is also spine surgical consultant for the USTA. Joining him were the following:

Alexander R. Vaccaro, MD, PhD, MBA the Richard H. Rothman Professor and chairman, department of orthopaedic surgery and professor of neurosurgery at Thomas Jefferson University in Philadelphia.
Dr. Alexander Vaccarro is spine surgeon for the Philadelphia Eagles.
Wellington K. Hsu, MD, the Clifford C. Raisbeck, distinguished professor of orthopaedic surgery at Northwestern Medicine in Chicago. Dr. Wellington Hsu is spine surgeon for Northwestern University.
Andrew Dossett, MD, a spine surgeon at the W.B. Carrell Memorial Clinic, in Dallas. Dr. Drew Dossett is Spine surgeon for the Dallas Cowboys.
Robert G. Watkins III, MD, co-director of the Marina Spine Clinic and a member of the Association of Professional Team Physicians, in Marina Del Rey, California. Dr. Robert Watkins is Spine Surgeon is member of the NFL Brain and Spine Committee, and spine surgical consultant for numerous professional and collegiate teams.

Dr. Hecht: Let’s discuss some challenging management scenarios, beginning with a professional football player with a C4 to C5 posterolateral disk herniation with weakness in his deltoid who has exhausted all conservative care. What kind of surgery would you perform?

Dr. Vaccaro: I would perform an anterior cervical decompression and fusion (ACDF) using an allograft bone and a cervical plate. I would allow him to return to play 6 to 9 months after that procedure after he has completed rehabilitation and has full range of motion (ROM) and his strength back.

Dr. Watkins: My recommendation is a one-level anterior cervical fusion using allograft and a plate. I use a cortical allograft packed with autogenous cancellous bone from the iliac crest.

I would not recommend a total disk replacement. I think the unknown factors of artificial disk replacement preclude its use in high-performance athletes, and certainly not in those in sports that potentially involve head contact, including those playing in the National Basketball Association (NBA), National Hockey League (NHL), and Major League Baseball (MLB) players.

I would not perform a foraminotomy and posterior disk excision. The potential risk of instability and reherniation is too high in this athlete.

Dr. Dossett: I would also perform an ACDF with autologous iliac crest graft and a plate.

Dr. Hecht: I agree with the ACDF with allograft and instrumentation. I would not do a foraminotomy or disk replacement in a football player with a disk herniation. Would total disk replacement in this scenario be appropriate for a player in any other sport?

Dr. Vaccaro: If the player were involved in a noncontact sport, I would perform a disk replacement if the patient preferred it after I explained the risks and benefits. In athletes involved in sports that involve significant contact, I would avoid disk replacement.

Dr. Hsu: Although both foraminotomy and ACDF have been successful for National Football League players, they both have their challenges. ACDF can lead to adjacent segment degeneration and ultimately a two-level fusion that is currently incompatible with return to play.

Posterior foraminotomies also lead to problems because it’s been shown that up to 50% of professional athletes may require surgery at that index level in their lifetimes. ACDF probably has better long-term results in football players, but total disk arthroplasty is not indicated at this time.

Dr. Hecht: Even though there is adjacent segment degeneration after ACDF (2.9%/year), there is also an overlooked rate of adjacent segment degeneration after foraminotomy (1.8%/year). I would not perform a cervical disk replacement in any athlete with a risk of contact or collision. The success rate after ACDF is so high that I do not see any good reason to introduce this yet unknown risk of device failure in contact sports.

Dr. Hecht: Do you think a CT scan that shows definitive fusion is needed before you would allow this athlete to return to contact sports even if he is asymptomatic?

Dr. Vaccaro: I would always get a CT scan in a professional athlete, primarily as documentation. If a CT scan taken at 10 months after surgery showed a nonhealed union and the athlete had good isometric strength and symmetric ROM, I would tell that athlete that significant contact may disrupt a stable, nonhealed fusion, and he may become symptomatic, which may affect his ability to play. If he agreed and understood that, I would allow him to return to play. But, I would document it thoroughly.

Dr. Watkins: I don’t think it is imperative that a patient have a radiographic solid fusion before returning to play. An asymptomatic patient with full ROM and full strength and conditioning, after completing a rehabilitation program for his sport, could return to play.

Dr. Hsu: I would say that a CT scan is definitely indicated. I know a number of physicians don’t necessarily agree with that. But certainly knowing that someone has a pseudarthrosis before returning to the field is important.

Dr. Hecht: I would document a healed fusion with CT in an athlete returning to contact sports. The gold standard today is not motion on flexion-extension
radiographs but fusion on coronal and sagittal reconstructed CT scans. I would be less concerned with a tennis player than an athlete involving collision and contact.

Dr. Hecht: Let’s expand on the situation. The player had an ACDF, and he has no motion on flexion-extension films, but his CT scan shows a nonunion, with haloing around the screws of the anterior cervical plate and radiolucent lines. However, he’s completely asymptomatic. Would you let him return to contact sports?

Dr. Watkins: A patient with an obvious nonunion who is completely asymptomatic and passes all of his conditioning and sport-specific training may return to play. He is at risk of becoming symptomatic at the operated level, just as he is at risk at becoming symptomatic at the adjacent level. Part of the problem at times is trying to sort out whether symptoms are at an adjacent level or the prior operated level.

Dr. Vaccaro: In contact sports, the potential exists that the player may develop neck pain and experience a symptomatic pseudarthrosis that may limit ROM. At that point, the player has to make a decision, if he wants to go back or not. He’s not at risk of a catastrophic neurologic deficit.

He may or may not be at risk for developing arm discomfort, which can be seen due to inflammation associated with pseudarthrosis. I would clearly document this, and the patient would have to sign off to return to play. If he became concerned, he could opt to not return to contact sports or to have additional surgery. I would supplement posteriorly to allow the anterior fusion to eventually heal over time. I would allow that patient to return to sports.

Dr. Dossett: I’d say this: If the player had a cervical procedure other than an anterior autograft and a symptomatic nonunion developed, I’d go back in anteriorly with an autograft.

Dr. Hecht: If I had a patient with a nonunion autograft or allograft, I would almost universally use a posterior approach unless there was an adjacent segment problem with radiculopathy. If it was just the index level, I would treat that posteriorly. The union rate has been shown to be nearly 99% with a posterior augmentation of an anterior fusion. Despite the posterior dissection, athletes can return to play without limitation. The union rate is statistically significantly lower with revision anterior approaches for anterior nonunions, but the outcomes are similar once fused. Both approaches would be acceptable.

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