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

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 9 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 2-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 2-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.