- shows torg ratio small.jpg - shows torg ratio.jpg
  • Cervical stenosis may be 
    • congenital
    • acquired (traumatic, degenerative)
  • Associated conditions
    • Spear tackler's spine
      • a syndrome of cervical stenosis caused by repetitive microtrauma and improper tackling techniques
      • is considered a contraindication to return to play
  • Prognosis
    • cervical stenosis places a patient at increased risk for  radiculopathy/myelopathy/SCI even from minor trauma or cervical spondylosis
      • therefore congenital cervical stenosis is an important consideration in the athlete
  • Absolute cervical stenosis
    • defined as canal diameter < 10mm
  • Relative cervical stenosis
    • defined as canal diameter of 10-13mm
  • Radiographs
    • recommended views
      • ap, lateral, flexion/extension views of cervical spine
    • radiographic risk factors for neurologic involvement on lateral radiograph include
      • canal diameter of < 13mm (normal is ~17mm)
      • Torg-Pavlov ratio (canal/vertebral body width) of < 0.8 (normal is 1.0)  
        • Torg ratio is technique dependent, not predictive, and not accurate in large athletes
  • MRI
    • study of choice to evaluate soft tissue anatomy and neural impingement
  • Somatosensory evoked potentials
    • may help identify cord compromise in absolute stenosis
  • Nonoperative
    • observation with possible activity restrictions
      • indications
        • patients without neurologic symptoms
      • contraindications to return to play (controversial)
        • loss of the CSF around the cord or deformation of the spinal cord documented by MRI
          • especially with
            • history of multiple episodes of transient quadriparesis
            • bilateral extremity symptoms 
        • spear tackler's spine
        • Torg ratio of <0.8 alone is not considered a contraindication to return to play 
  • Operative
    • surgical decompression and stabilization
      • indications
        • radiculopathy
        • myelopathy
        • in some cases surgery may be indicated as a prophylactic measure

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Questions (1)

(OBQ05.81) 21-year-old college football player sustains transient loss of motor function in his arms after a collision. Which of the following is an absolute contraindication to return to play? Review Topic


Anterior cervical diskectomy and fusion for one level disk herniation




Torg ratio of less than 0.8 with no other neurologic symptoms




Cord signal changes in the MRI




Frequent episodes of stingers when he was in high school




Chronic neck and back pain



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The Torg ratio is the ratio of the spinal canal/vertebral body. Torg and Pavlov stated that a ratio under 0.8 corresponded to severe spinal stenosis. However, subsequent studies have shown the incidence of spinal stenosis (using a Torg ratio of 0.8 as a definition) to be 49% in asymptomatic professional football players. Kim et al also found that the presence of an abnormal Torg ratio does not appear to be predictive of future spinal cord injury.

Ladd and Scranton argue that spinal stenosis cannot be defined by bone measurements alone; they claim “functional” spinal stenosis is more accurately defined as a loss of the CSF around the cord or deformation of the spinal cord documented by CT myelography or MRI. Cantu advises that in the setting of “functional” spinal stenosis, a return to contact or collision sports should be contraindicated. Kim et al argue that athletes sustaining multiple episodes of transient quadriparesis or bilateral extremity symptoms with MRI evidence of cord injury should be advised to avoid contact/collision sports.

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