Central Spinal Canal Stenosis Research Articles

Lumbar Dorsal Root Ganglion Pulsed Radiofrequency for Spinal Stenosis with an Atypical Fluoroscopic Neurogram: A Case Study

Background: We present a case of an atypical fluoroscopic neurogram pattern for complex chronic axial low back pain during a lumbar dorsal root ganglia (DRG) pulsed radiofrequency stimulation. Case Report: A 70 year old female with a history of complex chronic axial low back pain with radicular leg pain. Initially her pain was described as intermittent, burning, and sharp with an intensity of 9/10 on the Numeric Rating Scale (NRS). This pain worsens with ambulation, lumbar extension, turning, weight bearing and spinal loading activities. MRI imaging noted lumbar anterolisthesis, moderate to severe central spinal stenosis, and mild bilateral neural foraminal space narrowing. From these findings, her pain is likely secondary to components of sacroiliac (SI) joint dysfunction, lumbar facetogenic pain, lumbar radiculitis, and spinal stenosis with neurogenic claudication. A multimodal and multidisciplinary rehabilitation approach involving minimally invasive interventional procedures and medication management was implemented with varying pain relief. She responded to L5 transforaminal epidural nerve root injections, SI joint prolotherapy, and sacral lateral branch radiofrequency ablation. She completed bilateral L5 DRG pulsed radiofrequency stimulation, which did not provide radicular pain relief. We performed a unilateral L4 DRG pulsed radiofrequency stimulation, which revealed an atypical L4 fluoroscopic neurogram pattern. At the 3 month follow up she reported the pain severity to have a NRS between 7-8/10. At 4 months, the pain severity was reported to have a NRS between 4-6/10 with subjective improvements with her daily activities. Conclusion: In a normal transforaminal epidural fluoroscopic neurogram, the anteroposterior view should demonstrate contrast spread medially around the pedicle and laterally following the exiting nerve root. In the case of this patient the combined anatomical presentation of anterolisthesis, central spinal canal stenosis, and circumferential disc bulging are all potential reasons for insufficient contrast passage resulting in the atypical neurogram.

Comparison of ligamentum flavum thickness between central and lateral lesions in a patient with central lumbar spinal canal stenosis.

Thickened ligamentum flavum has been considered as a major cause of central lumbar spinal canal stenosis (CLSCS). Previous studies have demonstrated that ligamentum flavum thickness (LFT) is correlated with aging, degenerative spinal stenosis, and disc degeneration. Thus, hypertrophy of the ligamentum flavum is a major cause of CLSCS, and measurement of LFT has been considered a morphologic parameter in the diagnosis of CLSCS. To our knowledge, comparison of LFT between central and lateral lesions has not been reported. In addition, no research has analyzed best clinical cutoff values of central ligament flavum thickness (CLFT) and lateral ligament flavum thickness (LLFT). This study aimed to compare CLFT with LLFT in patients with CLSCS and further compare the CLFT and LLFT findings between the 2 groups to analyze LFT variation. Both CLFT and LLFT samples were collected from 101 participants with CLSCS and from 103 participants in the control group who underwent lumbar magnetic resonance imaging without evidence of CLSCS. Axial T2-weighted lumbar magnetic resonance scans were acquired at the L4 to 5 facet joint level from each participant. Average CLFT value was 2.25 ± 0.51 mm in the control group and 4.02 ± 0.74 mm in the CLSCS group. Average LLFT value was 2.50 ± 0.51 mm in the control group and 3.38 ± 0.66 mm in the CLSCS group. CLSCS patients had significantly higher CLFT and LLFT (both P < .001). Regarding the validity of both CLFT and LLFT as predictors of CLSCS, a receiver operating characteristic estimation revealed that the most suitable cutoff value for CLFT was 3.10 mm, with sensitivity of 95.0%, specificity of 94.2%, and an area under the curve of 0.97. The best cut-off value of LLFT was 2.92 mm, with sensitivity of 78.2%, specificity of 77.7%, and area under the curve of 0.87. We have 4 important new findings: The mean CLFT is significantly lower than that of the mean LLFT in the normal control group; CLFT and LLFT are both significantly associated with CLSCS; Increase rate of CLFT is faster than that of LLFT in the CLSCS group; and CLFT is a more sensitive measurement parameter to predict CLSCS than LLFT.

[Early-effectiveness of unilateral biportal endoscopic laminectomy in treatment of two-level lumbar spinal stenosis].

To analyze the early effectiveness of unilateral biportal endoscopy (UBE) laminectomy in the treatment of two-level lumbar spinal stenosis (LSS). The clinical data of 98 patients with two-level LSS treated with UBE between September 2020 and December 2021 were retrospectively analyzed. There were 53 males and 45 females with an average age of 59.9 years (range, 32-79 years). Among them, there were 56 cases of mixed spinal stenosis, 23 cases of central spinal canal stenosis, and 19 cases of nerve root canal stenosis. The duration of symptoms was 1.5- 10 years, with an average of 5.4 years. The operative segments were L 2, 3 and L 3, 4 in 2 cases, L 3, 4 and L 4, 5 in 29 cases, L 4, 5 and L 5, S 1 in 67 cases. All patients had different degrees of low back pain, among of which 76 cases were with unilateral lower extremity symptoms and 22 cases were with bilateral lower extremity symptoms. There were 29 cases of bilateral decompression in both segments, 63 cases of unilateral decompression in both segments, and 6 cases of unilateral decompression and bilateral decompression of each segment. The operation time, intraoperative blood loss, total incision length, hospitalization stay, ambulation time, and related complications were recorded. Visual analogue scale (VAS) score was used to assess the low back and leg pain before operation and at 3 days, 3 months after operation, and at last follow-up. The Oswestry disability index (ODI) was used to evaluate the functional recovery of lumbar spine before operation and at 3 months and last follow-up after operation. Modified MacNab criteria was used to evaluate clinical outcomes at last follow-up. Imaging examinations were performed before and after operation to measure the preservation rate of articular process, modified Pfirrmann scale, disc height (DH), lumbar lordosis angle (LLA), and cross-sectional area of the canal (CAC), and the CAC improvement rate was calculated. All patients underwent surgery successfully. The operation time was (106.7±25.1) minutes, the intraoperative blood loss was (67.7±14.2) mL, and the total incision length was (3.2±0.4) cm. The hospitalization stay was 8 (7, 9) days, and the ambulation time was 3 (3, 4) days. All the wounds healed by first intention. Dural tear occurred in 1 case during operation, and mild headache occurred in 1 case after operation. All patients were followed up 13-28 months with an average of 19.3 months, and there was no recurrence or reoperation during the follow-up. At last follow-up, the preservation rate of articular process was 84.7%±7.3%. The modified Pfirrmann scale and DH were significantly different from those before operation ( P<0.05), while the LLA was not significantly different from that before operation ( P=0.050). The CAC significantly improved ( P<0.05), and the CAC improvement rate was 108.1%±17.8%. The VAS scores of low back pain and leg pain and ODI at each time point after operation significantly improved when compared with those before operation, and the differences between each time points were significant ( P<0.05). According to the modified MacNab criteria, 63 cases were excellent, 25 cases were good, and 10 cases were fair, with an excellent and good rate of 89.8%. UBE laminectomy is a safe and effective technique with little trauma and fast recovery for two-level LSS and the early effectiveness is satisfactory.

Efficacy and safety of percutaneous transforaminal endoscopic surgery (PTES) compared with MIS-TLIF for surgical treatment of lumbar degenerative disease in elderly patients: A retrospective cohort study.

To evaluate the efficacy and safety of PTES for surgical treatment of lumbar degenerative disease (LDD) including lumbar disc herniation, lateral recess stenosis, intervertebral foraminal stenosis and central spinal canal stenosis in elderly patients compared with MIS-TLIF. From November 2016 to December 2018, 84 elderly patients (>70years old) of single-level LDD with neurologic symptoms underwent the surgical treatment. 45 patients were treated using PTES under local anesthesia in group 1 and 39 patients treated using MIS-TLIF in group 2. Preoperative, postoperative back and leg pain were evaluated using Visual analog scale (VAS) and the results were determined with Oswestry disability index (ODI) at 2-year follow-up. All complications were recorded. PTES group shows significantly less operation time (55.6 ± 9.7 min vs. 97.2 ± 14.3 min, P < 0.001), less blood loss [11(2-32) ml vs. 70(35-300) ml, P < 0.001], shorter incision length (8.4 ± 1.4 mm vs. 40.6 ± 2.7 mm, P < 0.001), less fluoroscopy frequency [5(5-10) times vs. 7(6-11) times, P < 0.001] and shorter hospital stay[3(2-4) days vs. 7(5-18) days, P < 0.001] than MIS-TLIF group does. Although there was no statistical difference of leg VAS scores between two groups, back VAS scores in PTES group were significantly lower than those in MIS-TLIF group during follow-ups after surgery (P < 0.001). ODI of PTES group was also significantly lower than that of MIS-TLIF group at 2-year follow-up (12.3 ± 3.6% vs. 15.7 ± 4.8%, P < 0.001). Both PTES and MIS-TLIF show favorable clinical outcomes for LDD in elderly patients. Compared with MIS-TLIF, PTES has the advantages including less damage of paraspinal muscle and bone, less blood loss, faster recovery, lower complication rate, which can be performed under local anesthesia.

Results of surgical treatment of degenerative stenosis of the lumbar spine in elderly and old patients

Aim. To evaluate the results of surgical treatment in older patients with lumbar spinal stenosis.Materials and methods. The study is based on the results of a comprehensive examination and surgical treatment of 20 patients who were hospitalized in the neurosurgery department of the SI NMC “Shifobakhsh” in the Department of Neurosurgery and Combined Trauma of the ATSMU with stenosis of the lumbar spine with various options for the clinical course. Assessment of the neurological status in degenerative spinal disease was conducted using a visual analog scale (VAS.)Results. When comparing subgroups, it was noted that decompressive interventions show the best results for lumbar spinal stenosis in the older age group.Conclusion. The use of differentiated microsurgical decompression techniques in older patients with degenerative lateral and central spinal canal stenosis provides an improvement in quality of life.

Evaluation of Lumber Spine Stenosis on Magnetic Resonance Imaging Correlating with Its Clinical Manifestation

Lumber spine stenosis (LSS) is one of the major reasons of spinal surgery all over the globe. Despite using standard Diagnostic tools for LSS, the clinical and imaging findings often do not correlate. Over past years, the central spinal canal stenosis is assumed to be the diagnoses of lower back pain, while other anatomical stenosis (i.e lateral recess stenosis) not gaining as much attention. This fact assumed to be the reason for failed back surgery. In this context numerous studies in past have done. The aim of this study is to verify the clinical manifestation of LSS correlation to its Diagnostic find. To evaluate the lumbar spine stenosis on magnetic resonance imaging &amp; correlating with its clinical manifestations. The duration of study was three months. Study was done at Lahore General Hospital, Pakistan. A cross-sectional analytical study included 120 patients. According our study the patients comes with lumber spine stenosis at different levels. At L4L5 presents 39 (32.5%) patients, 47(39.2%) patients reveal at the level of L5S1, 14 (11.7%) patients at L2L3, and only 3 (2.5%) patients appear at the level of L1L2, 19 (15.8%) patients show stenosis at L3L4 Then we correlate the pain intensity with all lumber spine levels and the results are 35 (29.2%) patients are absent and 85 (70.8%) presents at the level of L4L5. On the level of L5S1 pain intensity is absent in 81 (67.5%) patients, &amp; present in 39 (32.5) patients. On the level of L2L3 106 (83.5%) absent and 14 (11.7%) patients are present pain intensity. On the level of L1L2 117 (97.5%) absent of pain intensity and only 3 (2.5%) patients are present with pain intensity. The study concluded that the clinical manifestation of lumber spine stenosis to devise the management plan for the patient for better diagnoses in magnetic resonance imaging in LSS. Keywords: Lumber spine stenosis, manifestation, MRI DOI: 10.7176/JHMN/90-10 Publication date: June 30 th 2021

Decompression of Lumbar Central Spinal Canal Stenosis Following Minimally Invasive Transforaminal Lumbar Interbody Fusion.

This was a retrospective clinical series. The objective of this study was to evaluate radiologic changes in central spinal canal dimensions following minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) with placement of a static or an expandable interbody device. MIS-TLIF is used to treat lumbar degenerative diseases and low-grade spondylolisthesis. MIS-TLIF enables direct and indirect decompression of lumbar spinal stenosis, with patients experiencing relief from radiculopathy and neurogenic claudication. However, the effects of MIS-TLIF on the central spinal canal are not well-characterized. We identified patients who underwent MIS-TLIF for degenerative lumbar spondylolisthesis and concurrent moderate to severe spinal stenosis. We selected patients who had both preoperative and postoperative magnetic resonance imaging (MRI) and upright lateral radiographs of the lumbar spine. Measurements on axial T2-weighted MRI scans include anteroposterior and transverse dimensions of the dural sac and osseous spinal canal. Measurements on radiographs include disk height, neural foraminal height, segmental lordosis, and spondylolisthesis. We made pairwise comparisons between each of the central canal dimensions and lumbar sagittal segmental radiologic outcome measures relative to their corresponding preoperative values. Correlation coefficients were used to quantify the association between changes in lumbar sagittal segmental parameters relative to changes in radiologic outcomes of central canal dimensions. Statistical analysis was performed for "all patients" and further stratified by interbody device subgroups (static and expandable). Fifty-one patients (age 60.4 y, 68.6% female) who underwent MIS-TLIF at 55 levels (65.5% at L4-L5) were included in the analysis. Expandable interbody devices were used in 45/55 (81.8%) levels. Mean duration from surgery to postoperative MRI scan was 16.5 months (SD 11.9). MIS-TLIF was associated with significant improvements in dural sac dimensions (anteroposterior +0.31 cm, transverse +0.38 cm) and osseous spinal canal dimensions (anteroposterior +0.16 cm, transverse +0.32 cm). Sagittal lumbar segmental parameters of disk height (+0.56 cm), neural foraminal height (+0.35 cm), segmental lordosis (+4.26 degrees), and spondylolisthesis (-7.5%) were also improved following MIS-TLIF. We did not find meaningful associations between the changes in central canal dimensions relative to the corresponding changes in any of the sagittal lumbar segmental parameters. Stratified analysis by interbody device type (static and expandable) revealed similar within-group changes as in the overall cohort and minimal between-group differences. MIS-TLIF is associated with radiologic decompression of neural foraminal and central spinal canal stenosis. The mechanism for neural foraminal and central canal decompression is likely driven by a combination of direct and indirect corrective techniques.

Clinical and radiological results of indirect decompression after anterior lumbar interbody fusion in central spinal canal stenosis.

Whereas the benefits of indirect decompression after lateral lumbar interbody fusion are well known, the effects of anterior lumbar interbody fusion (ALIF) have not yet been verified. The purpose of this study was to evaluate the clinical and radiological effects of indirect decompression after ALIF for central spinal canal stenosis. In this report, along with the many advantages of the anterior approach, the authors share cases with good outcomes that they have encountered. The authors performed a retrospective analysis of 64 consecutive patients who underwent ALIF for central spinal canal stenosis with instability and mixed foraminal stenosis between January 2015 and December 2018 at their hospital. Clinical assessments were performed using the visual analog scale score, the Oswestry Disability Index, and the modified Macnab criteria. The radiographic parameters were determined from pre- and postoperative cross-sectional MRI scans of the spinal canal and were compared to evaluate neural decompression after ALIF. The average follow-up period was 23.3 ± 1.3 months. All clinical parameters, including the visual analog scale score, Oswestry Disability Index, and modified Macnab criteria, improved significantly. The mean operative duration was 254.8 ± 60.8 minutes, and the intraoperative bleeding volume was 179.8 ± 119.3 ml. In the radiological evaluation, radiological parameters of the cross-sections of the spinal canal showed substantial development. The spinal canal size improved by an average of 43.3% (p < 0.001) after surgery. No major complications occurred; however, aspiration guided by ultrasonography was performed in 2 patients because of a pseudocyst and fluid collection. ALIF can serve as a suitable alternative to extensive posterior approaches. The authors suggest that ALIF can be used for decompression in central spinal canal stenosis as well as restoration of the foraminal dimensions, thus allowing decompression of the nerve roots.

Magnetic Resonance Evaluation of Lumbar Disc Degenerative Disease as an Implication of Low Back Pain: A Prospective Analysis.

The main objectives of this study are MR characterization of disc degeneration and sequelae, analysis of lumbar disc degeneration patterns in patients with low back pain, and evaluation of the extent of involvement. This unique study evaluates the number of discs involved and the Modic changes at prolapsed, degenerated nonprolapsed, and at nondegenerated, nonprolapsed levels. A prospective, magnetic resonance imaging-based radiological study. A total of 1000 whole spine and lumbosacral spines were subjected to MRI examination, including spin echo with T1, T2, and STIR sequences. The Modic classification, Pfirrmann disc classification method, Borenstein criteria for central spinal canal stenosis, and Weishaupt Classification for Facet Degeneration were used for evaluation. The commonest level of disc degeneration was L4-L5 (41.2%) and the commonest type was disc protrusion (69.4%). Disc height reduction was common at L5-S1 level (32.2%). Multidisc involvement is the commonest presentation (38.2%) followed by contiguous double level (34.7%) with disc bulges frequently reported at L3-L4 (27.2%) and L4-L5 (26.9%) levels. Majority of discs (56.1%) demonstrated Modic changes at prolapsed levels. Spondylolisthesis was commonly reported at L5-S1 level (87.5%) and was mostly associated with lumbar canal stenosis (38.4%). Posterior osteophytes were frequent at L3-L4 (31.1%) and L5-S1 (31.1%) levels. D12-L1 was least affected (4.1%) in lumbar disc degenerative disease. The clinicians evaluated multiple variables associated with intervertebral disc degeneration and its sequelae such as lumbar canal stenosis and found the evaluation methods to be simple and practical in evaluating lumbar spine degeneration and simple communication.

X-RAY AND MAGNETIC RESONANCE IMAGING FEATURES IN PATIENTS WITH ACQUIRED LUMBAR SPINAL STENOSIS

Background: Lumbar spinal stenosis often associates with chronic pain described the abnormal narrowing of the lumbar spinal canal, resulting in compression of neural elements within the central spinal canal or the lateral recesses or the root canals or coordinate with each other. The purpose of this study was to describe and compare the plain X-ray and magnetic resonance imaging features of lumbar canal stenosis. Materials and methods: This was a cross-sectional study of 78 patients with an acquired lumbar spinal canal between October 2017 and May 2018. Results: The X-rays confirmed osteophytes in 92.3%, endplate sclerosis in 88.5% and disc space narrowing 62.8%. On MRI, 213 lumbar levels were lumbar spinal canal stenosis, 181 lumbar levels were evaluated for the grade of central spinal canal stenosis. Conclusions: X-ray examination has limitations in a diagnosis of lumbar spinal stenosis but also serves as a diagnostic aid. MRI is well diagnosed as spinal pathology as well as lumbar spinal stenosis. Key words: Lumbar spinal, Lumbar spinal stenosis, Magnetic resonance imaging (MRI), X-ray, Grading

Динамическая межостистая фиксация при спинальном поясничном стенозе: компромисс или вариант решения?

Introduction Currently, there is no single concept of interspinous process stabilization. Some authors consider the procedures to be a trade-off for the elderly population with vague morphological changes and neurogenic claudication whereas others do not support the practice, and still others offer it as an alternative to conservative and conventional surgical treatment for lumbar spinal stenosis (LSS). Material and methods The study included 22 patients with LSS. The patients were followed for 6 months. The clinical outcomes measures were neurological assessment, the Wong-Baker pain rating scale, Oswestry Disability Index (ODI). Radiographic evaluation and statistical analysis were also used. Surgical treatment included distraction laminoplasty and placement of interspinous dynamic fixator. Results Interspinous dynamic fixation and distraction laminoplasty resulted in regression of neurological deficiency and did not lead to deterioration of segmental and local imbalance. Clinical assessment of pain, radicular motor and sensory deficit and intermittent neurogenic claudication was performed. Morphological evaluation showed relative central spinal canal stenosis, foraminal stenosis and enduring degenerative spondylolisthesis (grades I and II). Conclusion Interspinous dynamic fixation is the method of choice for patients with lumbar spinal stenosis in presence of specific morphological and clinical manifestations.

Unilateral approach for microchannel percutaneous bilateral decompression of lumbar spinal stenosis

Objective To evaluate the clinical outcomes and operative techniques of microscopic bilateral decompression for lumbar spinal canal stenosis via the unilateral paramedian approach with tubular retractor system. Methods A retrospective study was conducted to analyze 35 patients with central lumbar spinal canal stenosis who were admitted to Department of Neurosurgery, Affiliated Union Hospital, Fujian Medical University from November 201l to May 2015. Bilateral spinal canal decompression was performed using microchannel percutaneous system through unilateral paraspinal approach and under intraoperative electroneurophysiological monitoring (IOEM). Data including surgical incision, operation time, blood loss volume and IOEM were analyzed. Creatine kinase(CK-MM) levels were measured 1 day before surgery and l day, 3 day as well as 5 days postoperatively. The Japanese Orthopedic Association (JOA) and Visual Analog Scale (VAS) scores were documented at l day preoperatively, and postoperatively at day 1, day 3, day 5, month 1, month 3, month 6 and month 12 months . Lumbar magnetic resonance imaging, computed tomography (CT), and X-ray scan were conducted preoperatively and at 1 month, 6 month and the last follow-up postoperatively. Results The operations were all successfully accomplished with no cases of nerve injury, cerebrospinal fluid leakage (CSFL), postoperative infection or death. The surgical incisions measured 1.5-1.8 cm, the operations lasted 65-110 min, and blood loss volumes were estimated between 8 to 35 ml. The CK-MM level was increased to(461.2±32.6)IU/ml 1 day post-op. with a statistically significant difference compared with pre-op. (P 0.05). At the 12-month follow-up, the JOA score was elevated from (13.4±3.7) to (28.1±0.8)(P<0.05) and the VAS score decreased from (6.9±1.1) to (0.4±0.5)(P<0.05). Postoperative examination of MRI indicated sufficient nerve decompression.No lumbar spinal instability or scoliosis was observed. Conclusion Microscopic bilateral decompression through microelectrode percutaneous approach seems effective for central lumbar spinal canal stenosis with sufficient nerve decompression and less injuries of paraspinal muscles, facet joints, spinous processes and ligaments. This technique offers the advantage of postoperative stability and preserved lumbar mobility. Key words: Lumbar vertebrae; Spinal stenosis; Microsurgery; Unilateral approach; Bilateral decompression

Aneurysmal bone cyst of thoracic spine in polyostotic fibrous dysplasia causing acute myelopathy

Background: Fibrous dysplasia affecting the spine is considered an uncommon entity in polyostotic fibrous dysplasia and aneurysmal bone cysts occurring in this setting is rare. Although, these are benign conditions, they may present with acute cord compression and fractures which necessitate emergency treatment. Clinical course: Our patient is a 38-year-old Egyptian male who presented to the Emergency Department with a 2-week history of increasing pain over the thoracolumbar spine with acute bilateral lower limb weakness and difficulty walking. There was no history of trauma or fever. Physical examination revealed significant sensory loss below the level of the umbilicus with paraparesis of bilateral lower limbs. X-rays revealed large expansile lesion over the mid thoracic vertebrae and multiple expansile lesions involving the ribs. Subsequent CT and MRI showed features of multiple areas of polyostotic fibrous dysplasia with secondary cystic degeneration and aneurysmal bone cysts formation, worst at T6-7 complicated with severe central spinal canal stenosis, cord compression. The patient underwent urgent spinal cord decompression with laminectomy at T6 and T7 and hemilaminectomy at T4 and T5 with aneurysmal cyst curettage and fat graft placement and subsequent physiotherapy and rehabilitation with complete resolution of motor and sensory deficits. Discussion: This case highlights the presentation of benign, non-malignant, non-infectious, and non-traumatic acute spinal cord compression in the Emergency Department. This case also showcases classical radiological images of a rare combination of polyostotic fibrous dysplasia of the spine with subsequent cystic degeneration and aneurysmal bone cyst formation causing acute spinal cord compression.

Decompression surgery for lumbar spinal canal stenosis in octogenarians; a single center experience of 121 consecutive patients

Introduction: With increasing age, ubiquitous degeneration processes lead to a narrowing of the spinal canal. Degenerative lumbar spinal stenosis (DLSS) causes functional disability and is associated with back and lower extremity pain in older individuals. The goal of this study was to determine if decompression surgery can be performed safely and provide a stable benefit in our octogenarian patient population.Methods: In this retrospective study, 121 patients over the age of 80 (mean age: 82.7 years SD: 2.4 years) with the diagnosis of central spinal canal stenosis who underwent posterior decompression surgery without fusion for DLSS between January 2006 and August 2013 were followed up from November to December 2013. Peri- and post-operative complications were recorded. Walking distances and visual analogue scale (VAS) scores were determined before surgery and at follow up time (mean follow up time 36 months). Patient’s satisfaction with treatment was documented with the overall satisfaction degree scale in Zurich Claudicatio Questionnaire (ZCQ).Results: The peri-operative complication rate was 6.6% with five dural tears, two wound infections and one epidural haematoma. Four patients required revision surgery (three re-decompression and one secondary spondylodesis). Walking distance improved from 147 meters (SD ±110 m) to 340 m (SD ±170 m) p < .001. Pain improved with change of the VAS scores from 7.2 (SD ±1.2) to 4.5 (SD ±1.0), p < .001. The overall satisfaction scale in ZCQ was 2.2 at follow up.Conclusion: A minimal surgical intervention, namely decompression, improves walking ability, decreases pain and has marginal potential for complications in patients with DLSS who are over 80 years old.

Role of Diffusion Tensor MR Imaging in Degenerative Cervical Spine Disease: a Review of the Literature.

In the article we review the current role of diffusion tensor imaging (DTI), a modern magnetic resonance (MR) technique, in the diagnosis and the management of cervical spondylotic myelopathy (CSM), the most serious complication of degenerative cervical spine disease (DCSD). The pathogenesis of DCSD is presented first with an emphasis placed on the pathological processes leading to myelopathy development. An understanding of the pathophysiological background of DCSD is necessary for appropriate interpretation of MR images, both plain and DTI. Conventional MRI is currently the imaging modality of choice in DCSD and provides useful information concerning the extent of spondylotic changes and degree of central spinal canal stenosis; however its capability in myelopathy detection is limited. DTI is a state of the art imaging method which recently has emerged in spinal cord investigations and has the potential to detect microscopic alterations which are beyond the capability of plain MRI. In the article we present the physical principles underlying DTI which determine its sensitivity, followed by an overview of technical aspects of DTI acquisition with a special consideration of spinal cord imaging. Finally, the scientific reports concerning DTI utility in DSCD are also reviewed. DTI detects spinal cord injury in the course of DCSD earlier than any other method and could be useful in predicting surgical outcomes in CMS patients, however technical and methodology improvement as well as standardization of acquisition protocols and postprocessing methods among the imaging centers are needed before its implementation in clinical practice.

SP0018 How to Use MRI in Low Back Pain

Back pain is an important problem that affects two-thirds of adults at some time in their lives. One of the leading causes of functional incapacity is spinal degeneration, which is...

Cervical Stenosis in a Patient with Arthrogryposis: Case Report

Study Design Case report. Objective Amyoplasia-type arthrogryposis is a rare congenital disease that presents as multiple contractures involving various areas of the body. To the authors' knowledge, there have been no reports of adults with amyoplasia in the current literature. We report a case of an adult patient with cervical stenosis in the setting of amyoplasia. Patients and Methods A 48-year-old patient with amyoplasia and over 30 previous orthopedic reconstructive surgeries presented with neck pain radiating down his left shoulder and into the fingers, dysesthesia in his fingertips, and left-sided periauricular headache. A diagnosis of central spinal canal stenosis and bilateral foraminal stenosis at C3–C7 with radiculopathy was made based on computed tomography scans. Because of a prior right-side sternocleidomastoid muscle transfer, a left-side C3–C4, C5–C7 anterior cervical discectomy and fusion procedure was performed. Results The patient experienced significant improvement in symptoms that was transient. Symptoms returned to preoperative values after 1 year, despite significant and persistent improvement in stenosis. Conclusions Both amyoplasia and cervical stenosis can manifest in neurologic symptoms. Distinguishing the causing pathology can be challenging. The radiographic improvement of cervical stenosis in a patient with amyoplasia is not always associated with long-standing pain relief.

Diagnostic Advancement of Axial Loaded Lumbar Spine MRI in Patients With Clinically Suspected Central Spinal Canal Stenosis

Case series study. To define diagnostic advancement of L-spine magnetic resonance with axial loading device in patients with clinically suspected central spinal canal stenosis, and to show a relationship of facet joint instability with aggravated central spinal canal stenosis in axial loaded studies. Although the axial loading device has been used for several years, there have been few reports about the usefulness of the axial loading device in clinical settings. Also, there has been no report about the relationship between facet arthrosis and dynamic central spinal canal stenosis. Lumbar magnetic resonance image (MRI) with axial loading device was obtained in 54 patients. Axial images were evaluated with attention to (1) gross change of central spinal canal stenosis, (2) findings of facet joint, including arthrosis, effusion, effacement of effusion, and (3) formation of ventral synovial cyst after axial loading. In addition, dural sac cross-sectional area was measured in L3-L4, L4-L5, and L5-LS1 levels to quantify the change of stenosis. Changes of neural foraminal stenosis, curvature, and spondylolisthesis were evaluated with sagittal images. With a use of axial loading device, the additional diagnosis of severe central spinal canal stenosis was made in 13 patients (25%) in both gross interpretation and quantitative study (dural sac cross-sectional area <75 mm). The significant decrease of dural sac cross-sectional area was demonstrated in 22 patients (42%). The significant decrease was related to facet joint effusion and effacement of effusion. Measurable advancement in diagnosis of severe central spinal canal stenosis was possible with axial loaded MRI. Patients with facet joint instability had a tendency to show significant changes in the central spinal canal area. 4.

Transforaminal Hypertonic Saline for the Treatment of Lumbar Lateral Canal Stenosis: A Double-Blinded, Randomized, Active-Control Trial

Background: Degenerative lumbar spinal stenosis is one of the most common causes of chronic lower back pain and radiculopathy. Spinal stenosis is anatomically classified as central and lateral spinal canal stenosis. Many treatment modalities and techniques, including surgery and epidural injection, have been used to manage the pain. However, the effect of hypertonic saline injection via the transforaminal approach has not yet been studied. Objectives: The aim of this study is to determine the effect of adding hypertonic saline to conventional transforaminal epidural steroid injections (TFEI) to provide pain relief for chronic radiculopathy patients secondary to lateral canal spinal stenosis. Study Design: A double-blind, randomized, active-control trial. Setting: An interventional pain management practice in a hospital, Republic of Korea. Methods: Two groups: the hypertonic group received hypertonic saline combined with triamcinolone and the control group received normal saline combined with triamcinolone. A total of 68 patients were randomly allocated into either 2 groups by a computergenerated randomization program. Twenty-seven patients in the hypertonic group and 26 patients in the control group were assessed. A total of 53 patients were included in this analysis. Outcome measures were taken at baseline, one, 2, 3, 4, and 6 months postprocedure. The primary outcome measures included the numerical rating scale (NRS) and the proportion of substantial responders. The secondary outcome measures included the Oswestry disability index (ODI), the proportion of substantial and moderate responders, and patient satisfaction. Results: Transforaminal epidural injection of steroids, with or without the addition of 10% hypertonic saline, was effective and provided significant pain relief with the improvement of functional outcome within 4 months. The addition of hypertonic saline was superior in efficacy compared with conventional TFEI at 3 months follow-up. The differences in the absolute pain scores did not demonstrate statistical significance between the 2 groups. The reduction in pain intensity from the baseline was greater in the hypertonic group and demonstrated higher rates of satisfaction. The use of hypertonic saline also extended the duration of significant pain relief to 6 months compared with baseline. Limitations: The lack of placebo group and small sample size. Conclusion: Superior short-term pain relieving efficacy, but limited long-term effects of hypertonic saline, when added to TFEIs. Key words: Chronic pain, lumbar radiculopathy, lateral canal, spinal stenosis, transforaminal, epidural steroid injections, hypertonic saline, local anesthetic

Spontaneous Spinal Subdural Hematoma Concurrent with Cranial Subdural Hematoma

A 39-year old female presented with chronic spinal subdural hematoma manifesting as low back pain and radiating pain from both legs. Magnetic resonance imaging (MRI) showed spinal subdural hematoma (SDH) extending from L4 to S2 leading to severe central spinal canal stenosis. One day after admission, she complained of nausea and severe headache. Computed tomography of the brain revealed chronic SDH associated with midline shift. Intracranial chronic SDH was evacuated through two burr holes. Back pain and radiating leg pain derived from the spinal SDH diminished about 2 weeks after admission and spinal SDH was completely resolved on MRI obtained 3 months after onset. Physicians should be aware of such a condition and check the possibility of concurrent cranial SDH in patients with spinal SDH, especially with non-traumatic origin.