Neural Foraminal Narrowing Research Articles

When can we Kick (Some) Humans “Out of the Loop”? An Examination of the use of AI in Medical Imaging for Lumbar Spinal Stenosis

AbstractArtificial intelligence (AI) has attracted an increasing amount of attention, both positive and negative. Its potential applications in healthcare are indeed manifold and revolutionary, and within the realm of medical imaging and radiology (which will be the focus of this paper), significant increases in accuracy and speed, as well as significant savings in cost, stand to be gained through the adoption of this technology. Because of its novelty, a norm of keeping humans “in the loop” wherever AI mechanisms are deployed has become synonymous with good ethical practice in some circles. It has been argued that keeping humans “in the loop” is important for reasons of safety, accountability, and the maintenance of institutional trust. However, as the application of machine learning for the detection of lumbar spinal stenosis (LSS) in this paper’s case study reveals, there are some scenarios where an insistence on keeping humans in the loop (or in other words, the resistance to automation) seems unwarranted and could possibly lead us to miss out on very real and important opportunities in healthcare—particularly in low-resource settings. It is important to acknowledge these opportunity costs of resisting automation in such contexts, where better options may be unavailable. Using an AI model based on convolutional neural networks developed by a team of researchers at NUH/NUS medical school in Singapore for automated detection and classification of the lumbar spinal canal, lateral recess, and neural foraminal narrowing in an MRI scan of the spine to diagnose LSS, we will aim to demonstrate that where certain criteria hold (e.g., the AI is as accurate or better than human experts, risks are low in the event of an error, the gain in wellbeing is significant, and the task being automated is not essentially or importantly human), it is both morally permissible and even desirable to kick the humans out of the loop.

Efficacy of Marma Chikitsa in pain management of Cervical Spondylosis - A Single Case Study

Cervical spondylosis is a chronic degenerative condition of the cervical spine that affects the vertebral bodies and intervertebral discs of the neck as well as the contents of spinal canal. It is characterized by neck pain radiating to shoulders, arms, head and person is unable to perform daily routine work. Patient aged 47 years came to our institute with the complaint of headache, pain and stiffness in cervical region & pain is radiated to hand, tingling sensation in hand, restricted movement of cervical spine for 6 month. He was diagnosed as case of cervical spondylosis. MRI of cervical spine suggested protrusion at C5-C6 level causing anterior thecal sac compression & bilateral moderate neural foraminal narrowing with left exiting nerve compression. In this case study effect of Marma Chikitsa in pain management of cervical spondylosis is evaluated. This case study shows that pain in cervical spondylosis may be successfully managed by Marma Chikitsa.

Evaluation of the Diagnostic Utility of Spinal Magnetic Resonance Imaging in Low Back Pain Patients

Introduction: Low back pain secondary to degenerative disc disease is a condition that affects young to middle-aged persons with peak incidence at approximately 30-39 years. Magnetic Resonance Imaging (MRI) is the standard modality for detecting disc pathology. This study is being conducted to review the pattern of spinal degenerative diseases in patients referred to our institution. Methods: A retrospective study was conducted at Gandaki Medical College Teaching Hospital & Research Centre (GMCTHRC) from January 2018 to April 2018 with approval from the Institutional Review Committee of Gandaki Medical College Teaching Hospital and Research Centre. The MRI findings were noted i.e. disc desiccation, disc bulge (diffuse, symmetrical and asymmetrical), disc protrusion, neural foramen narrowing, traversing nerve root compression, exiting nerve root compression and posterior annular ligament tear. Results: Out of 98 patients enrolled in the study mean age being 41 years. Disc bulge as most common finding seen in 89 (90.8%) followed by protrusion 50 (51.1%) neural foraminal narrowing (NFN) 72 (73.4%) traversing nerve roots (TNR) compression 58 (59.1%) and exiting nerve root (ENR) compression 22 (22.4%). Conclusions: The study shows that degenerative disc diseases remain the cause of morbidity in the most productive years of life (30-40 years). Large volumes of MRIs performed for this condition represent a significant economic and healthcare burden in a developing country like Nepal.

Unexplained back pain and sciatica: the added value of upright dynamic MRI of the lumbar spine in cases of clinical/radiological mismatch

BackgroundDegenerative disease of the lumbar spine is one of the most prevalent pathologies worldwide, and MRI is the gold standard imaging modality that helps to assess soft tissue and bony abnormalities and elicit causes of neural compression. It is not uncommon in the daily practice to have patients presenting with neurological symptoms during standing or walking while MRI fails to detect lesion that explains their clinical picture. The aim of this study was to detect changes that appear on dynamic weight-bearing MRI of the lumbar spine that was hidden on conventional supine MRI and to correlate them with the clinical situation.MethodologyNinety patients with back pain were enrolled in the study, they did conventional and dynamic MRI of the lumbar spine. We compared findings in both modalities as regard alignment, ligamentum flavum buckling, foraminal narrowing and neural compression.ResultsDynamic MRI showed neural compression in 87% of patients in comparison to supine MRI, ligamentum flavum buckling was reported in 80%, neural foraminal narrowing was seen in 24%, exaggeration of the lumbar lordoisis in 10% and exaggeration of the already existing disc protrusion was documented in 60% of the included patients.ConclusionsUpright dynamic MRI has added to supine MRI in problem solving cases with clinical radiological mismatch. The results indicated changes in the spine alignment, neural compression and spinal canal stenosis. Since the examination is non-invasive, it could be used in the preoperative planning of patients with degenerative lumbar spine disease.

Tarlov cysts in back pain patients: prevalence, measurement method and reporting points.

Determining the prevalence of Tarlov cysts in low back pain patients. The picture archiving & communication system (PACS) & hospital information system (HIS) of a corporate hospital were retrospectively analyzed to determine the percentage of Tarlov cysts among patients undergoing spinal MRI for back pain over 3 years (January 2017 to December 2019). 384 patients had undergone spinal MRI for back pain over the study period, and 25 of them (6.51%) had Tarlov cysts. Vast majority (15 cases) showed cysts located at S2/S3 level, and few were found at S1/S2 and other levels. Single cysts were found in most (=18) of the cases, while 7 cases of multiple / bilateral cysts were found. Cyst dimensions were higher in craniocaudal than anteroposterior or transverse directions. In case of multiple cysts, one or two cysts were noted as dominant, having higher dimensions than the others. The study data revealed no gender or age predilection. We conclude that including the entire sacrum with a T2 sagittal sequence in all MRI for low back pain can increase detection of Tarlov cysts, and thereby provide more data for further analysis. We propose the concept of one "dominant" cyst when there are multiple Tarlov cysts. We recommend that diameter or size of Tarlov cysts be specified to their craniocaudal dimension. We also suggest reporting points for contextual structured reporting, viz. presence or absence of bony scalloping, neural foraminal narrowing, nerve root compression or extraforaminal extension.

Importance of neural foraminal narrowing in lumbar spine fractures of low AIS severity

Objective In recent years, based on injuries predicted using machine learning, there have been efforts to reduce imaging performed on trauma patients. While useful, such efforts do not incorporate results from studies investigating the pathophysiology of traumatic events. The objective of this study was to identify potentially symptomatic vertebral foramen narrowing in the presence of minor to moderate (AIS ≤ 2 levels of severity) thoracolumbar fractures sustained in motor vehicle crashes (MVCs). Methods Hospital records and images of patients admitted to a Level One trauma center between the years 2014 and 2018 with the diagnosis of thoracolumbar fracture were reviewed. Spinal injuries were scored using the AIS v2015. In addition, the geometry of the neural foramina, particularly the height of the foramina and intervertebral disk at the posterior region, were measured using reconstructed sagittal computed tomography (CT) images. The criteria for foraminal narrowing were associated with <15 mm for the foraminal height and <4 mm for the height of the posterior disk. Results 24 patients with MVCs associated thoracolumbar fractures, who met both the clinical and imaging criteria for radiculopathy and foraminal narrowing without spinal cord injury, were considered for the present clinical study. 54% of the total lumbar fracture cases reported were rated as AIS 2 injuries. AIS ≥ 3 cases reported 50% narrowing of foramen, which was expected. However, it was surprising to note that the AIS 2 cases also sustained foraminal stenosis, narrowing ranging from 13% to 20%. Conclusions Low severity (AIS ≤ 2) injuries were often found to be associated with foraminal narrowing leading to clinical complaints. While the present clinical study cannot determine if narrowing existed prior to the trauma, they were certainly asymptomatic prior to the trauma. The present findings emphasize the need for detailed imaging in all instances of thoracolumbar trauma, as clinically significant nerve compression may occur even with modest vertebral body injury.

Correlation Between Intravascular Injection Rate, Pain Intensity, and Degree of Cervical Neural Foraminal Stenosis During a Cervical Transforaminal Epidural Block.

PurposeCervical transforaminal epidural blocks (CTEBs) are useful for the treatment of cervical radicular pain. However, during CTEBs, inadvertent intravascular injection can introduce particulate steroids into the bloodstream, thus leading to serious complications. Moreover, the risk factors associated with intravascular injection during CTEBs have not been identified. Cervical neural foraminal stenosis (CNFS) is a form of neural foraminal narrowing and a common cause of cervical radicular pain. In this study, we aimed to identify whether there is a correlation between the incidence of intravascular injection during CTEB, pain intensity, and the degree of CNFS.Patients and MethodsA total of 126 patients were recruited. The patients were classified into two subgroups (group M and group S) based on the routine cervical T2-weighted axial magnetic resonance imaging (MRI) findings. Group M (n = 63) consisted of moderate CNFS patients, while group S (n = 63) consisted of severe CNFS patients. The occurrence of intravascular injection during CTEB was established using real-time fluoroscopy. The intravascular injection was determined by the spreading of the contrast medium through the vascular channel during the injection. Additionally, pain intensity was scored using a Numeric Rating Scale (NRS) before the procedure and 1 month after the procedure.ResultsThere was no significant difference in the incidence of intravascular injection during CTEB between group M and group S (41.3% vs 39.7%, respectively; p = 0.99) and in the NRS scores before and 1 month after CTEB. However, both groups showed a significant decrease in the NRS scores at 1 month after the procedure compared with that before the procedure.ConclusionThe degree of CNFS does not affect the incidence of intravascular injection during CTEB. Regardless of whether patients have moderate or severe CNFS, caution should be exercised during CTEB procedures.

Weight-bearing MRI of the Lumbar Spine: Spinal Stenosis and Spondylolisthesis.

Symptoms of degenerative lumbar spinal stenosis include back pain, radiculopathy, claudication, and muscular fatigue that tend to be predominant in the standing position or during walking. Lumbar spondylolisthesis is also a well-known cause of spinal stenosis, lateral recess, and neural foraminal narrowing that tends to become more severe in the upright position. This indicates a functional positional component of both spinal stenosis and spondylolisthesis. Lumbar spinal stenosis and spondylolisthesis are typically evaluated by magnetic resonance imaging (MRI) performed in the supine position with a pillow under the patient's lower limbs that slightly flexes the lumbar spine and ameliorates symptoms. Because these two entities tend to be aggravated in the upright position, it seems rational to also consider performing diagnostic imaging in these patients in the upright position. This article reviews the use of weight-bearing MRI for lumbar spinal stenosis and spondylolisthesis.

Evaluation of spine MRIs in athletes participating in the Rio de Janeiro 2016 Summer Olympic Games

Background/aimIn high-level Olympic athletes, many spinal pathologies arise from overuse, while others are the result of acute injury. Our aim is to analyse the epidemiology of spinal pathologies detected on...

A Case of AL Amyloidosis

Case: 45 year old lady presented with anorexia, weakness for last one year and development of deformity in her spine for last one and half years following fracture. On clinical examination she had mild bilateral pedal edema, kyphoscoliosis, tenderness over rib cage on left side. MRI spine showed diffuse marrow edema in D5 D6 D7 D9 D10 and L4 vetrbral bodies and posterior elements with subtle decrease in anterior height and associated paraspinal muscle edema seen. There was osteophytic bulge with ligamentum flavum thickening at c4-c5 and c5-c6 levels causing spinal canal and bilateral neural foraminal narrowing with nerve root impingement. Blood tests showed Hb-16.5, calcium-7.5, serum albumin-1.2, and globulin-4. Urinary albumin +++. Urinary 24hr protein was 7.81 gram. On skeletal survey no lytic lesion was found. Whole body scan showed abnormal tracer uptake involving multiple dorsal and lumber vetebrae, sternum multiple ribs on either side anteriorly. Serum electrophoresis revealed biclonal IgG and IgA and lambda light chain paraproteins. On bone marrow examination there were 50% plasma cells

MRI of the cervical spine with neck extension: is it useful?

Standard MRI of the cervical spine is performed in a different anatomical position to that utilised for traditional contrast myelography. Those well practised in myelography are familiar with the considerable changes in configuration of the bony and soft tissues of the cervical spine that may occur with changes in the degree of neck flexion and extension. We set out to compare the findings in a select group of patients with myeloradiculopathy who had undergone myelography and MRI in both standard and neck-extended positions. These findings were correlated with the clinical status. 29 patients underwent myelography with CT (CTM) and MRI in neutral and neck-extended positions. The imaging was assessed for the degree of cord compression and neural foraminal narrowing, quantified using a simple grading scheme suitable for routine clinical practice. The degree of neck extension was assessed using an angular measurement. For both CTM and MRI, scanning with the neck extended significantly increases the severity of cord compression compared with the standard supine position, to a degree similar to that shown during conventional prone myelography. The degree of perceived cord compression is related to the degree of neck extension achieved. Correlation of standard MRI findings and the clinical level of radiculopathy is poor. This correlation improves when the neck is extended. The most appropriate position for routine MRI of the cervical spine in degenerative disease remains unknown, but in selected patients imaging with the neck extended may provide important additional information.

Use of a multimodal conservative management protocol for the treatment of a patient with cervical radiculopathy

Objective The purpose of this study is to describe and discuss the treatment of a cervical disk herniation using a sequential multimodal conservative management approach. Clinical Features A 40-year-old man had complaints of headache and severe sharp neck pain radiating to his left shoulder down to his arm, forearm, and hand. Results of electromyography/nerve conduction studies were abnormal. Magnetic resonance imaging revealed a large disk protrusion at C5-C6 with indentation of the thecal sac and a spur at the posterior margin. Moderate left neural foraminal narrowing was present at C5-C6 with narrowed intervertebral disk space at C5-C6 and C6-C7. Intervention and Outcome High-velocity, low-amplitude chiropractic manipulation; electrotherapy; ice; and exercise were used for treatment. The Neck Disability Index was used as a primary and electromyography/nerve conduction studies as a secondary outcome measurement. Based on the Neck Disability Index, there was an overall 89.65% symptoms improvement from the baseline. Conclusions This case study demonstrated possible beneficial effects of the multimodal treatment approach in a patient with cervical radiculopathy.

Epidural Corticosteroid Injections as a Possible Cause of Menorrhagia: A Case Report

A 47-year-old female was referred for evaluation of chronic lower back pain. A magnetic resonance imaging of her lumbar spine revealed a broad-based disc herniation at L4-L5 with bilateral neural foraminal narrowing. A decision was made to treat her with bilateral L4-5 transforaminal epidural steroid injections. Following moderate pain relief, the procedure was repeated. Several days after each injection, the patient experienced unusually heavy and painful menstrual bleeding. We postulate that the introduction of exogenous corticosteroids directly into the neuraxial space can initiate a negative feedback loop on the hypothalamic-pituitary-ovarian axis. As a result, this may lead to decreased levels of circulating hormones, resulting in episodes of menorrhagia in the premenopausal population.

Neck Pain in Recreational Bicyclist/Walker

HISTORY: 54-year-old female athlete with congenital hip dysplasia status post bilateral hip replacement. During her rehab for recent hip surgery, she developed right shoulder tendonitis and neck pain. The pain is dull aching with numbness without radiation. She recalls that as a teenager she had difficulty turning her head due to “possible congenital neck disorder”. She denies any weakness, gait abnormalities, or cauda equina symptoms. Past Medical HISTORY: Menopausal, hypertensive cardiomyopathy, glaucoma, hearing loss. Meds: female hormones. PHYSICAL EXAMINATION: VS: normal. Bi-pedal, upright gait. Quad weakness noted in the right leg consistent with her postoperative status. Significant decrease neck ROM. ROM of shoulders is symmetric. Her strength is excellent except for mild weakness of external rotation. She has normal arm and leg reflexes, without clonus and with normal response to pin, light touch and vibration. A dextrolumbar levothoracic curvature and forward head posture is noted with level pelvis in standing posture. Her cervical and thoracic musculature is extremely tight. Her hairline is low. DIFFERENTIAL DIAGNOSIS: Myofascial pain DJD Facet Arthropathy Spondylolisthesis Spondylolysis Herniated disc Klippel-Feil deformity TEST AND RESULTS: Cervical spine: Fusion between C5 and T1 with a right hemivertebra at C2-C4. There is extensive facet disease with hypertrophic facet and uncovertebral arthropathy. CT without contrast: There are multiple congenital anomalies with fusion at the C2-3, C4-5, and C7-T1 levels, a butterfly shaped vertebral body at the C4 level and a hemivertebral body at C7. There is a defect in the left lamina at C2. There is fusion of bilateral C2-3 and C4-5 facet joints. There is approximately 4 mm anterolisthesis of C5 on C6 facet joint space. Uncovertebral spurring, right greater than left causing moderate right C6 neural foraminal narrowing. There is no focal disc her herniation at any level. FINAL WORKING DIAGNOSIS: Klippel-Feil Syndrome TREATMENT AND OUTCOMES: No spinal instability was present on flexion/ extension views of the cervical spine. The patient had marked reduction in cervical rotation upright that largely improved in the supine, relaxed position suggesting a significant myofascial component to her neck pain. She was treated with a combination of physical therapy directed at improving her forward head posture in conjunction with acupuncture directed at release of her trapezius, levator scapulae, splenii, and middle and posterior scalene musculature. After altering her physical therapy regimen in conjunction with 3 sessions of acupuncture, her neck and shoulder pain were quiescent.

Vertebral Fracture in a Pre-Menopausal Ballet Dancer

HISTORY - A 45 year-old Caucasian ballet dancer arrives at clinic with complaints of back pain. Initially seen and diagnosed with sacroiliitis, she underwent physical therapy, responded well and was discharged pain free. Two weeks following discharge from physical therapy she resumed dancing, but within a week, similar symptoms recurred. She returned, eight days after discharge from PT. Her pain was described as a burning, near the right sacroiliac joint. She denied numbness, tingling, or gait disturbance, but reported pain with ambulation. We referred the patient for a lumbar spine MRI, returned her to PT, and prescribed ice, NSAIDS, and relative rest. She was to return in two weeks. PHYSICAL EXAM - Gait normal. Palpation of PSIS revealed a right-sided tilt. There was mild right-sided SI joint tenderness. Straight-legged test and faber test was negative bilaterally. No leg length discrepancy. Neuro and vascular exams were normal. Plantar/dorsiflexion, flexion/extension of quads and hamstrings were normal bilaterally. Skin - normal. Flexion/extension of the lumbar spine normal, with no pain elicited. DIFFENTIAL DIAGNOSIS Sacroiliitis Paraspinal lumbar muscle strain Degenerative disc disease Spondylolisthesis Spinal stenosis Annulus herniation Vertebral Fracture TESTS AND RESULTS Lumbar spine xrays Minimal degenerative changes, bone island in right ilium, no fractures Lumbar spine MRI Abnormal signal intensity of inferior endplate in L4 vertebral body, with a 15% loss of stature. Loss of disc height, disc desiccation and circumferential disc bulging at the lowest 3 lumbar levels. Posterior annular tear, L3-L4. Hypertrophic degenerative changes in L4-L5 and L5-S1 facet joints bilaterally. Mild bilateral L4 and left L5 neural foraminal narrowing. Bone Mineral Analysis Normal, T-score 0, Z-score 0.6 right hip; T-score −0.3, Z-score 0.1 in lumbar spine. FINAL WORKING DIAGNOSIS L4 Vertebral fracture TREATMENT AND OUTCOMES On her return, we discussed the results of her MRI. A thorough dietary and family history was taken, all of which were unremarkable. She denied history of any fractures, reported daily supplement of calcium, and normal dietary calcium intake. The patient progressed well through therapy, and wanted to participate in a week-long ballet camp. We discussed the risks, and advised her as long as she stayed pain-free we felt should could continue low impact dance maneuvers. We discouraged participating in routines requiring jumps or hyperextension. At the onset of any pain, she was to stop participation immediately

Cervical spondylosis: contrast-enhanced magnetization transfer prepulsed 3D turbo field echo MR imaging.

Magnetic resonance (MR) imaging of the cervical spine with axial, low flip angle three-dimensional (3D) gradient-echo sequences is limited by long acquisition times and also by increased sensitivity to extrinsic and intrinsic magnetic field inhomogeneity, magnetic susceptibility differences, chemical shifts, and cerebrospinal fluid pulsatility. We attempted to assess the performance of gadolinium-enhanced, magnetization transfer (MT) prepulsed 3D fast gradient-echo sequences in demonstrating spondylotic changes of the cervical spine. Twenty patients with known cervical spine spondylosis were prospectively imaged in the axial plane using two gradient-echo-based MR techniques: 3D fast field echo (FFE) and gadolinium-enhanced, MT prepulsed, segmented turbo field echo (TFE). An average of 58 neural foramina on the 3D FFE images and 47 neural foramina on the contrast-enhanced TFE images were judged to be narrowed. The degree of neural foraminal narrowing was significantly less on the contrast-enhanced TFE images compared with the FFE images (P <0.001). Contrast-enhanced, MT prepulsed, segmented 3D TFE MR imaging has potential for ameliorating some of the limitations encountered in the more widely used gradient-echo techniques.

Three-Dimensional CT Imaging in Postsurgical “Failed Back” Syndrome

One hundred consecutive patients with postsurgical "failed back" syndrome (PSFBS) without fusion and 100 patients with PSFBS with fusion were evaluated with direct CT, two-dimensional (2D) multiplanar, and three-dimensional (3D) imaging. In the patients with and without fusion, 3D images were found to best display the following: the surgical procedure and its extent, lateral neural foraminal narrowing, and fractures of the posterior elements. The 3D images enabled optimal demonstration of fusion: solidity, pseudarthrosis, incorporation of transverse processes and facet joints, and transitional syndrome. In the patients without fusion, 3D images provided improved appraisal of surgical results in 31%; it showed additional fracture(s) in 9%, better displayed lateral neural foraminal narrowing in 42%, and showed additional posterior element fractures in 11% as compared to axial and 2D multiplanar reconstructed (MPR) scans. Three-dimensional imaging uncovered incomplete fusion in 17%, transitional syndrome in 13%, and pseudarthrosis in 6%. Thus, the 3D imaging provided additional information over the direct axial and MPR images (2D images) in 56 of 100 patients without fusion and 76 of 100 patients with fusion. At our institution, this imaging modality is now routinely performed in this patient population.