A call to arms: the absence of standardized return to play guidelines for professional rugby union players after cervical spine surgery.

Cervical spine injuries in elite rugby union, while infrequent, carry a disproportionately high risk for players. The nature of collisions in rugby creates unique biomechanical stresses on the cervical spine, heightening the risk of catastrophic injury. Injuries vary across a spectrum from transient neuropraxia ('stingers') to structural injuries requiring surgical intervention. Despite the gravity of these injuries, there remains no standardized, evidence-based return to play (RTP) protocol for rugby players after cervical spine surgery. A thorough literature review was undertaken to systematically analyze the existing literature on RTP outcomes for rugby players after surgical intervention for a cervical spine injury, and to clarify deficiencies in clinical practice. The most common procedures undertaken are anterior cervical discectomy and fusion, cervical disc arthroplasty, and posterior foraminotomy. Each procedure has unique biomechanical implications for RTP. A consensus is that caution is urged in multilevel fusions, occipitocervical involvement, and injuries crossing the cervicothoracic junction due to loss of movement and increased strain on adjacent segments. However, there is no consensus about the timeline for safe RTP after surgery. Additionally, considerations of neuromuscular conditioning and the assessment of sarcopenia in determining a safe time to return to play are of the essence. If unaddressed, deconditioning, especially of deep cervical musculature, may predispose athletes to hardware failure or recurrent injury. Thus, a multidisciplinary approach is essential. Rugby has shown leadership in the management of concussion yet lacks a comparable framework for cervical spine injury, a condition with arguably more devastating long-term outcomes. Drawing on consensus guidelines from American football and orthopaedic spinal literature, this paper calls for a multidisciplinary, rugby-specific RTP protocol that integrates surgical, biomechanical, neuromuscular, and imaging criteria. Such guidelines would enhance player safety and provide clarity for clinicians navigating complex decisions about return to play. This is a clinical and fiscal imperative given the potential for career-ending injury and significant economic consequences.