Patients frequently ask when they can return to driving after cervical spine surgery, and surgeons have to make recommendations without much evidence supporting their advice. There are a handful of studies looking at this, and most make recommendations based on driver reaction time, a metric that evaluates a specific, focused factor that probably does not capture overall driving ability.1 Given the lack of evidence on this topic, Dr. Moses and colleagues performed a survey of Cervical Spine Research Society (CSRS) meeting attendees to determine practice patterns and see if a consensus exists on the topic. In addition to evaluating return to driving, they also evaluated recommendations for post-operative cervical collar use, which would likely impact decisions about return to driving. They had 71/98 surveys they handed out completed, and 80% of respondents were orthopaedic spine surgeons (20% neurosurgeons). In general, most surgeons allowed patients to return to driving between 2 and 6 weeks, with 2 weeks being the most common response (40%) following 1 or 2 level ACDF or disk replacement. Six weeks was the most common response for > 2 level ACDF (52%) or laminectomy and fusion (60%). About 40% of surgeons recommended less than 2 weeks of driving restriction following foraminotomy or disk replacement. In terms of collar use, there was also a broad range of practices. Following single-level ACDF, 42% used no collar, 27% used a hard collar, and 31% used a soft collar. Of those who used a collar, 40% used it for 2 weeks and 36% for 6 weeks. For > 2 level ACDF, 23% used no collar, 68% used a hard collar, and 10% used a soft collar. The majority (57%) kept the collar in place for 6 weeks. Similar bracing patterns were reported for laminectomy and fusion. Following foraminotomy and disk replacement, approximately 2/3 of surgeons used no collar, and under 10% used a hard collar. Surgeons with over 15 years of practice experience were more likely to allow patients to return to driving in under 2 weeks following > 2 level ACDF and laminectomy and fusion (47% vs. 24%).
The authors have done a nice job administering a survey on a topic on which there is very little literature to guide practice. In these situations, consensus is likely the best way to determine best practice patterns. Not surprisingly, given the lack of evidence on this topic, there was no clear consensus and a wide variation in practice. When deciding about return to driving, one must consider reaction time, range of motion, pain severity, and judgment. All of these impact driving ability, and cervical spine surgery, collar use, and opioid medication can adversely affect these factors. There is one RCT that demonstrated no advantage to collar use following one level ACDF, but no data looking at other procedures.2 The authors point out that driving while wearing a cervical collar or while taking narcotic pain medication likely put the patient and the surgeon who approved return to driving in legal jeopardy. Both factors almost certainly have a negative effect on driving performance. The most concerning finding in the paper is that 28% of surgeons allow patients to drive while taking opioids, and 31% allow driving in a cervical collar. It seems as though these practices should be changed in order to promote driver safety and reduce legal exposure. This survey has the same limitations of all survey studies, the most important of which is potential limited generalizability to the entire population of spine surgeons. However, the authors reported a 70% response rate, which is relatively good, and this group of surgeons at CSRS likely have practices that mirror those of the greater spine surgeon community. The most important finding of this study is the wide variation in practice, as would be expected given the lack of evidence on the topic. It would be helpful if professional societies could issue guidelines on collar use and return to driving as these issues come up after every surgery, and it would be nice to inform patients that our recommendations are based on something (slightly) more solid that our individual opinions. Such guidelines could also provide some legal cover, provided they are followed.
Please read Dr. Moses's article on this topic in the October 15 issue. Does this change how you view collar use and return to driving following cervical spine surgery? Let us know by leaving a comment on The Spine Blog.
Adam Pearson, MD, MS
Associate Web Editor
1. Alhammoud A, Alkhalili K, Hannallah J, Ibeche B, Bajammal S, Baco AM. Driving Safety after Spinal Surgery: A Systematic Review. Asian Spine J 2017;11:319-27.
2. Campbell MJ, Carreon LY, Traynelis V, Anderson PA. Use of cervical collar after single-level anterior cervical fusion with plate: is it necessary? Spine (Phila Pa 1976) 2009;34:43-8.