What is the recommended treatment for spinal cord stenosis in wrestlers?

Management of Spinal Cord Stenosis in Wrestlers

For wrestlers with cervical spinal stenosis, return-to-play decisions must be based on spinal canal diameter measurements, presence or absence of T2-signal changes on MRI, and symptom resolution, with absolute stenosis (<10 mm) generally contraindicating return to wrestling unless specific criteria are met. 1

Initial Assessment and Imaging

When evaluating a wrestler with suspected cervical stenosis:

• Obtain MRI with T2-weighted sequences to assess both canal diameter and presence of cord signal changes 1
• Measure spinal canal diameter on sagittal MRI images, as this is the critical determinant for return-to-play decisions 1
• Assess for any T2-signal hyperintensity changes, which indicate edema, inflammation, or in chronic cases, neurodegeneration and demyelination 1
• Evaluate for any fractures, dislocations, or ligamentous instability that would require different management 2, 3

Key stenosis definitions:

• Absolute stenosis: spinal canal diameter <10 mm 1
• Relative stenosis: spinal canal diameter <13 mm 1

Return-to-Play Algorithm After Transient Neurological Symptoms

Scenario 1: Asymptomatic with NO T2-Signal Changes

• Canal diameter >10 mm (no stenosis): Return to wrestling is recommended 1
• Canal diameter <10 mm (absolute stenosis): Individual case-by-case evaluation required 1

Scenario 2: Initial T2-Signal Changes That Have RESOLVED

• Canal diameter >13 mm (no stenosis): Return to wrestling is allowed 1
• Canal diameter 10-13 mm (relative stenosis): Case-by-case evaluation required 1
• Canal diameter <10 mm (absolute stenosis): Should NOT return to wrestling 1

Scenario 3: PERSISTENT T2-Signal Changes

• Canal diameter >13 mm: Individual evaluation for return to wrestling can be considered 1
• Canal diameter <13 mm: Return to wrestling is contraindicated 1

Surgical Management Considerations

If surgical intervention becomes necessary:

For 1- or 2-level pathology:

• Anterior cervical discectomy and fusion (ACDF) is the standard approach 2
• Athletes with solidly fused 1- or 2-level ACDF and no T2-signal changes can return to wrestling (84.4% strong consensus) 1
• Athletes with 1-level ACDF with continued MRI changes but solid fusion can return on a case-by-case basis 1

For 3+ level pathology:

• 3-level ACDF patients should NOT return to wrestling, even without MRI changes 1
• Multi-level ACDF patients should not return to play 1

Posterior cervical fusion:

• Return-to-play decisions should be made case-by-case 1
• Extensive posterior fusion (C2-T2) carries significant risks including nerve root palsies, hardware failure, and reduced neck mobility 4

Critical Pitfalls to Avoid

• Do not rely on plain radiographs alone - MRI is essential as cervical disc herniation causing spinal cord injury can occur without bony involvement 2
• Do not treat asymptomatic findings - the presence of stenosis alone without symptoms does not require intervention or disqualification 1
• Do not assume resolution of T2-signal changes is required - some evidence suggests asymptomatic athletes with normal neurologic exams and no instability can return to play despite persistent T2 changes, though this remains controversial 1
• Do not ignore the Torg-Pavlov ratio - a ratio ≤0.8 indicates stenosis and warrants careful evaluation 1

Special Considerations for Wrestlers

• Wrestling carries high risk for catastrophic spinal injuries due to axial compression forces to the head 5
• Certain head-holds and techniques are particularly prone to causing cervical spine injuries 6
• Athletes with prior cervical spine pathology should undergo screening MRI before returning to competitive wrestling (78.9% strong consensus) 1
• Even with appropriate surgical management and rehabilitation, the decision to return to wrestling must weigh the risk of permanent quadriplegia against athletic participation 7, 6