Assessment Of Lumbar Spinal Stenosis Research Articles

Clinical assessment and management of lumbar spinal stenosis: clinical dilemmas and considerations for surgical referral.

Lumbar spinal stenosis is the leading indication for spine surgery in older adults. Surgery is recommended in clinical guidelines if non-surgical treatments have been provided with insufficient benefit. The difficulty for clinicians is that the current number of randomised controlled trials is low, which creates uncertainty about which treatments to provide. For non-surgical clinicians this paucity of data leads to a clinical dilemma of whether to continue managing the patient or refer to a spine surgeon. This Viewpoint aims to provide an update on the assessment of lumbar spinal stenosis, treatment recommendations, indications for referral to a spine surgeon, and current clinical dilemmas facing non-surgical clinicians and spinal surgeons.

Assessment of Lumbar Spinal Stenosis as a Risk Factor for Development of Sleep Disorder: The Locomotive Syndrome and Health Outcome in Aizu Cohort Study (LOHAS).

Insomnia has been reported to coexist with various musculoskeletal disorders. Although lumbar spinal stenosis (LSS) is the most frequently operated on spinal disease, the causal relationship between LSS and development of sleep disorders remains unclear due to lack of longitudinal studies. This study aimed to determine whether LSS was a risk factor for developing new sleep disorders, primarily insomnia, using a prospective cohort of community residents. This study was a prospective cohort study. Participants aged ≥65 years from the "Locomotive Syndrome and Health Outcomes in Aizu Cohort Study (LOHAS)" conducted in 2008 formed our study population. LSS was diagnosed using the self-administered, self-reported history questionnaire, a validated diagnostic support tool for LSS. Sleep disorder was investigated using a questionnaire during the 2-year follow-up. The impact of LSS on sleep disorder onset was analyzed after adjusting for potential confounders, such as age, sex, obesity, hypertension, diabetes, depression, and smoking habits, using propensity score matching. Of the 489 participants who were followed up for two years, 38 (7.8%) had newly developed a sleep disorder in 2010. After adjusting for confounding factors, a comparison of 133 participants each in the control and LSS groups showed significantly higher frequency of new-onset sleep disorders (19 [14.3%] in the LSS group versus 6 [4.5%] in the control group). LSS was found to be an independent risk factor for sleep disorders.

339 The Glasgow Lumbar Spinal Stenosis Scale: An Individualised Measurement Formula for the Radiological Assessment of Lumbar Spinal Stenosis

Abstract Background Lumbar spinal stenosis (LSS) is a common spinal problem. Currently there is no universally accepted quantitative approach to the radiological measurement of LSS. Quantitative descriptions do exist, but these are unidimensional and do not consider normal variation in anatomy. We propose a universal and individualised measurement system for the quantitative radiological assessment of lumbar spinal stenosis. Method A retrospective case series of patients who had undergone surgery for symptomatic lumbar spinal stenosis over a 3-year period. Pre-operative T2 weighted lumbar spine MRI were analysed. Each patient had the degree of lumbar canal stenosis quantified using our approach. Results Our novel formula for the quantitative radiological assessment of LSS is two dimensional, repeatable, and presented as a percentage, to correct for the individual patient. The surface area of the canal at the level of stenosis is measured (mm2). The adjacent 2 levels are then measured and averaged. The calculation becomes (A-S/A) x 100 = R, where S is the canal surface area at the stenosed level, A is the average canal surface area of the two levels adjacent to the level of interest and R is the relative degree of lumbar spinal canal stenosis expressed as a percentage. Conclusions This novel quantitative measurement formula for the radiological assessment of lumbar canal spinal stenosis is quick and simple to calculate and most importantly adjusts for the individual patient’s normal or degenerative anatomy. This new measurement tool will need validation against specific clinical and operative criteria in the future.

The glasgow lumbar spinal stenosis scale: an individualised measurement formula for the radiological assessment of lumbar spinal stenosis

Background Lumbar spinal stenosis (LSS) is a common and important spinal surgical problem. Currently there is no universally accepted quantitative approach to the radiological measurement of LSS. LSS can be described qualitatively with reference to facet and ligamentous hypertrophy, lack of perineural or intraforaminal fat, and reduced CSF around the cauda equina. Quantitative descriptions do exist e.g., lumbar canal antero-posterior diameter, but these are unidimensional and do not consider normal variation in anatomy. We propose a universal and individualised measurement system for the quantitative radiological assessment of lumbar spinal stenosis. Methods A retrospective case series of patients who had undergone surgery for symptomatic lumbar spinal stenosis over a 3 year period. Pre-operative lumbar spine MRI were analysed. Each patient had the degree of lumbar canal stenosis quantified using our novel approach. Results Our novel formula for the quantitative radiological assessment of lumbar spinal stenosis is two dimensional, repeatable and presented as a percentage, to correct for the individual patient. The surface area of the lumbar spinal canal at the level of stenosis is measured in mm2 plus the adjacent 2 levels which are then averaged. The calculation then becomes (A-S/A) x 100 = R, where S is the canal surface area at the stenosed level in mm2, A is the average canal surface area of the two levels adjacent to the level of interest and R is the relative degree of lumbar spinal canal stenosis expressed as a percentage. Measurements are calculated using axial T2 weighted images. Conclusions This novel quantitative measurement formula for the radiological assessment of lumbar canal spinal stenosis is quick and simple to calculate and most importantly adjusts for the individual patient’s normal or degenerative anatomy. This new measurement tool will need validation against specific clinical and operative criteria in the future.

Preoperative Assessment of Neural Elements in Lumbar Spinal Stenosis by Upright Magnetic Resonance Imaging: An Implication for Routine Practice?

IntroductionLumbar spinal stenosis (LSS) is a kinetic-dependent disease typically aggravating during spinal loading. To date, assessment of LSS is usually performed with magnetic resonance imaging (MRI). However, conventional supine MRI is associated with significant drawbacks as it does not truly reflect physiological loads, experienced by discoligamentous structures during erect posture. Consequently, supine MRI often fails to reveal the source of pain and/or disability caused by LSS.The present study sought to assess neural dimensions via MRI in supine, upright, and upright-hyperlordotic position in order to evaluate the impact of patient positioning on neural narrowing. Therefore, radiological measures such as neuroforaminal dimensions, central canal volume, sagittal listhesis, and lumbar lordosis at spinal level L4/5 were extracted and stratified according to patient posture.Materials and methodsOverall, 10 subjects were enclosed in this experimental study. MRI was performed in three different positions: (1) 0° supine (SP), (2) 80° upright (UP), and (3) 80° upright + hyperlordotic (HY) posture. Upright MRI was conducted utilizing a 0.25T open-configuration scanner equipped with a rotatable examination bed allowing for true standing MRI. Radiographic outcome of upright MRI imaging was extracted and evaluated according to patient positioning.ResultsUpright MRI-based assessment of neural dimensions was successfully accomplished in all subjects. Overall, radiographic parameters revealed a significant decrease of neural dimensions from supine to upright position: Specifically, mean foraminal area decreased from SP to UP by 13.3% (P ≤ 0.05) as well as from SP to HY position by 21% (P ≤ 0.05). Supplementation of hyperlordosis did not result in additional narrowing of neural elements (P ≥ 0.05). Furthermore, central canal volume revealed a decrease of 7% at HY and 8% at UP compared to SP position (P ≥ 0.05). Assessment of lumbar lordosis yielded in a significant increase when assessed at HY (+22.1%) or UP (+8.7%) compared to SP (P ≤ 0.05).ConclusionsOur data suggest that neuroforaminal dimensions assessed by conventional supine MRI are potentially overestimated in patients with LSS. Especially, in patients having occult disease not visualized on conventional imaging modalities, upright MRI allows for a precise, clinically relevant, and at the same time non-invasive evaluation of neural elements in LSS when neural decompression is considered.

Surgeon Reliability for the Assessment of Lumbar Spinal Stenosis on MRI: The Impact of Surgeon Experience

Treating surgeon's visual assessment of axial MRI images to ascertain the degree of stenosis has a critical impact on surgical decision-making. The purpose of this study was to prospectively analyze the impact of surgeon experience on inter-observer and intra-observer reliability of assessing severity of spinal stenosis on MRIs by spine surgeons directly involved in surgical decision-making. Seven fellowship trained spine surgeons reviewed MRI studies of 30 symptomatic patients with lumbar stenosis and graded the stenosis in the central canal, the lateral recess and the foramen at T12-L1 to L5-S1 as none, mild, moderate or severe. No specific instructions were provided to what constituted mild, moderate, or severe stenosis. Two surgeons were "senior" (>fifteen years of practice experience); two were "intermediate" (>four years of practice experience), and three "junior" (< one year of practice experience). The concordance correlation coefficient (CCC) was calculated to assess inter-observer reliability. Seven MRI studies were duplicated and randomly re-read to evaluate inter-observer reliability. Surgeon experience was found to be a strong predictor of inter-observer reliability. Senior inter-observer reliability was significantly higher assessing central(p<0.001), foraminal p=0.005 and lateral p=0.001 than "junior" group.Senior group also showed significantly higher inter-observer reliability that intermediate group assessing foraminal stenosis (p=0.036). In intra-observer reliability the results were contrary to that found in inter-observer reliability. Inter-observer reliability of assessing stenosis on MRIs increases with surgeon experience. Lower intra-observer reliability values among the senior group, although not clearly explained, may be due to the small number of MRIs evaluated and quality of MRI images.Level of evidence: Level 3.

Qualitative Grading on Magnetic Resonance Imaging as a Tool for Decision Making in Lumbar Spinal Stenosis

IntroductionSeveral parameters exist for assessment of lumbar spinal stenosis (LSS) but none has shown to be an absolute criteria for defining the condition. Moreover these parameters lack clinical...

Management Protocol of Patients with Lumbar Spinal Stenosis, using the Qualitative Grading as a Tool

Objectives: Several parameters exist for assessment of lumbar spinal stenosis (LSS) but these parameters lack clinical correlation. To formulate a protocol for management of these group of patients using the qualitative grading as a tool. Materials and methods: A prospective study was undertaken using the qualitative grading on magnetic resonance imaging (MRI) to assess the clinical outcome of LSS at a single level. Irrespective of the grade every patient underwent a minimum 3 months period of conservative management after which depending on the oswestry disability index (ODI) and visual analog scale (VAS) for pain he was grouped into success or failure and the failed patients were advised for decompression surgery at the involved level. These patients were then further assessed after a period of 3 months after surgery. A decrease in ODI by 10 points and a 20 points decrease in VAS was considered as a success. Results: Out of the 90 patients, there were 61 failures in conservative group, out of these 57 were operated of which only nine did not match the success criteria, while the other four either refused surgery or were lost to follow-up. In grades A1 to 3, only two patients failed conservative trial while from A4 to D, there was a gradual decline in success of conservative trial. Conclusion: Qualitative grading is a useful tool in LSS and correlates with the clinical outcome and to decision making of these patients.

Radiologic Assessment of Lumbar Spinal Stenosis and its Clinical Correlation

Radiologic Assessment of Lumbar Spinal Stenosis and its Clinical Correlation

Clinical value of transcranial magnetic stimulated motor evoked potentials in assessment of lumbar spinal stenosis.

Objective To evaluate the clinical usefulness of assessing transcranial magnetic stimulated motor evoked potentials (MEP) in lumbar spinal stenosis (LSS).Methods Twenty-three LSS patients, consisting of 12 males and 11 females were enrolled.The mean age was 67.9 years(52-83 years).The average duration of symptoms was 31.5 months(3 months to 10 years).Twelve patients were associated with degenerative spondylolisthesis.Fourteen patients had bilateral and 9 patients had unilateral leg symptoms.The number of involved disc levels was one in 15 cases, two in 7 cases and three in 1 case.All patients were associated with neurogenic intermittent claudication (NIC).The mean walking distance of NIC and the minimal cross-sectional area (mCSA) of the dural sac was 302.1 m and 0.4 cm2, respectively.The preoperative data of MEP latency (MKPLT) recorded in both sides of adductor hallucis (AH), clinical symptoms, Japanese Orthopaedic Association (JOA) scores for low back pain, visual analogue scale (VAS) for back pain, leg pain and numbness were evaluated.Results The mean MEPLT were (42.1±2.8) ms.The mean JOA score, VAS scores for back pain, leg pain and numbness were 15.9±4.8, 6.0±2.9, 7.7±1.9 and 7.3±3.0, respectively.MEPLT was related to the walking distance (r=-0.455, P<0.05), limb symptoms (bilateral or unilateral symptoms, r=0.545, P<0.05) and VAS-numbness (r=0.605, P<0.05), but was not related to diagnosis (with/without degenerative spondylolisthesis), affected disc levels, duration of symptoms, JOA scores, VAS for back pain and leg pain.MEPLT was significantly delayed in patients who showed a walking distance less than 500 m (P<0.05).Conclusion MEP is useful in LSS assessment.It can reflect the subjective severity of motor disturbance and predict the neurological deficit prior to appearance. Key words: Lumbar vertebrae; Spinal stenosis; Evoked potentials, motor

Clinical value of motor evoked potentials with transcranial magnetic stimulation in the assessment of lumbar spinal stenosis

The objective of this study was to evaluate the clinical usefulness of assessing motor evoked potentials (MEP) in lumbar spinal stenosis (LSS). Twenty-three LSS patients were enrolled. The preoperative data of MEP latency (MEPLT), clinical symptoms, Japanese Orthopaedic Association (JOA) scores for low back pain, visual analogue scale (VAS) for back pain, leg pain and numbness, walking distance and the minimal cross-sectional area (mCSA) of the dural sac were evaluated. The mean MEPLT was 42.1 +/- 2.8 ms. Fourteen patients had bilateral leg symptoms. The mean walking distance and mCSA were 302.1 +/- 302.8 m and 0.4 +/- 0.2 cm(2), respectively. The mean JOA score and VAS scores for back pain, leg pain and numbness were 15.9 +/- 4.8, 6.0 +/- 2.9, 7.7 +/- 1.9 and 7.3 +/- 3.0, respectively. MEPLT was related to the walking distance, limb symptoms and the VAS for numbness. MEPLT was significantly delayed in patients who showed a walking distance less than 500 m. MEP is useful in LSS assessment. It can reflect the subjective severity of motor disturbance and predict the neurological deficit prior to appearance.