Severe Central Stenosis Research Articles

Effects of the Severity of Stenosis on Clinical Outcomes of Indirect Decompression Using Oblique Lumbar Interbody Fusion.

Background: No consensus has been reached regarding the efficacy of indirect decompression through oblique lumbar interbody fusion (OLIF) in severe lumbar spinal stenosis (LSS). This study investigated the impact of preoperative magnetic resonance imaging (MRI)-based grading of central and foraminal stenosis on OLIF outcomes in LSS patients and identified risk factors for postoperative clinical dissatisfaction. Methods: We retrospectively reviewed LSS patients who underwent OLIF with a minimum 1-year follow-up. Clinical scores obtained preoperatively and at 3, 6, 12, and 24 months postoperatively were analyzed using the substantial clinical benefit (SCB) framework. The severity of central and foraminal stenosis in the initial MRI was assessed through qualitative grading systems. Results: Among the 145 patients, with a mean follow-up of 33.7 months, those with severe central stenosis showed a significantly higher proportion of patients achieving SCB in the visual analog scale for leg pain (94.5% versus 83.1%; p = 0.044) at one year postoperatively than those without. However, those with severe foraminal stenosis showed significantly higher Oswestry Disability Index (ODI) scores (p = 0.024), and lower walking ability scores in the Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) (p = 0.004) at one year postoperatively than those without. The presence of a foraminal osteophyte of the superior articular process (SAP) was a significant risk factor responsible for not achieving SCB in ODI and walking ability in JOABPEQ at one year postoperatively (odds ratio: 0.20 and 0.22, respectively). Conclusions: After OLIF, patients with severe central stenosis showed clinical outcomes comparable to those without. The improvement in ODI and walking ability in JOABPEQ was limited in patients with severe foraminal stenosis. Surgeons should consider direct decompression in cases with the presence of foraminal osteophytes of SAP.

Synchronous Low-Grade Central Osteosarcoma and Ewing Sarcoma: A Rare Case Report.

A 23-year-old female patient presented with radicular back pain, perineal numbness, and urinary retention. The patient was diagnosed with cauda equina syndrome and magnetic resonance imaging (MRI) of the spine revealed an enhancing osseous lumbar lesion causing severe central stenosis. A core needle biopsy of the lumbar spine showed microscopic features compatible with a small round blue cell tumor. CD99 and FLI1 were positive in the tumor cells. Next-generation sequencing demonstrated a EWSR1::FLI1 fusion. Given these findings, the spine lesion was diagnosed as Ewing sarcoma. The patient underwent surgical decompression of L2. On further workup, an MRI revealed an ill-defined enhancing mass of the right distal femur. This area was biopsied, demonstrating a fibro-osseous lesion with osteoblast proliferation containing nuclear atypia, low mitotic activity, and SATB2 positivity, diagnosed as low-grade central osteosarcoma (LGCOS). The patient underwent resection, which showed a classic LGCOS by histomorphology. Although fluorescence in-situ hybridization study for MDM2 gene amplification was negative, the overall findings are most consistent with LGCOS. These neoplasms are considered to be synchronous due to the presentation of each entity within 6 months. Considering the aggregate yearly incidence of Ewing sarcoma (approximately 1 case per 750 000 per year) and LGCOS (approximately 1 case per 10 million per year), the aggregate yearly probability of developing both of these genetically unrelated tumors in a single individual is 1 per 7.5 trillion per year, and it is likely such an event has never happened in the past.

Exploring the impact of mild-to-moderate foraminal stenosis at L5−S1 on clinical outcomes following L4−5 posterior lumbar interbody fusion

BACKGROUND CONTEXTPatients scheduled for L4−5 PLIF often have FS at L5-S1. However, data on the clinical and radiographic outcomes of cases with mild-to-moderate L5−S1 FS are lacking, which may affect clinical outcomes or require additional surgery after L4−5 fusion. PURPOSETo evaluate the clinical and radiographic outcomes of L4−5 PLIF in patients with and without mild-to-moderate L5−S1 FS, with a primary focus on the association between L5−S1 FS and postoperative clinical outcomes including back pain, leg pain, and scores on the oswestry disability index (ODI) and EuroQol 5-dimension (EQ-5D). STUDY DESIGNRetrospective comparative study. PATIENT SAMPLEA retrospective review of patients who underwent L4−5 PLIF from 2014 to 2018. The patients were divided according to the presence of mild-to-moderate FS at L5−S1. OUTCOME MEASURESClinical assessment included the pain visual analog scale (VAS), ODI, and EQ-5D score. Radiographic assessments included spinopelvic parameters and grades for central and foraminal stenosis. METHODSClinical outcomes were assessed using validated outcome measures at preoperative, 6-month, 12-month, and 36-month follow-up visits. Radiographic evaluations were performed using preoperative and postoperative radiographs. Foraminal stenosis was assessed qualitatively using MRI with a grading system from none to severe and quantitatively by measuring changes in the foraminal area on CT. RESULTSAmong 186 patients, 55 were categorized as the FS group and 131 as the non-FS group. The FS group was older (p=0.039) and had more severe central stenosis at L5−S1 (p=0.007) as well as more severe FS at both L4−5 and L5−S1 (both p<0.001). Preoperative disc height (p<0.001), C7-S1 sagittal vertical axis (p=0.003), lumbar lordosis (p=0.005), and pelvic incidence–lumbar lordosis mismatch (p=0.026) were more aggravated in the FS group. The FS group showed inferior clinical outcomes at the final follow-up in terms of back pain (p=.010) and ODI score (p=.003). CONCLUSIONThe presence of mild-to-moderate FS at L5–S1 was associated with more aggravated sagittal balance in terms of smaller preoperative disc height, larger sagittal vertical axis, smaller lumbar lordosis, and larger pelvic incidence–lumbar lordosis mismatch. Patients with L5−S1 FS also had poorer clinical outcomes including back pain and ODI score after L4−5 PLIF. Patients with L5−S1 FS need to be carefully examined before L4−5 fusion considering their adverse outcomes due to underlying degenerative changes.

The Implication of Preoperative Central Stenosis on Patient-Reported Outcomes After Lumbar Decompression Surgery

To assess the impact of central stenosis severity on patient-reported outcomes after lumbar decompression. Patient diagnosis, demographics, and surgical characteristics were collected via query search and manual chart review of electronic medical records. The inclusion criteria were posterior lumbar decompressions from 2014-2020, with accessible MRI reports. As previously validated by Lee et al., central stenosis was determined on magnetic resonance imaging and graded as none, mild, moderate, or severe. Patients were dichotomized into two groups to improve statistical power for comparisons: none or mild central stenosis and moderate or severe central stenosis. PROMs were compared between cohorts at one year postoperatively. Statistical significance was set at p < 0.05. On bivariant analysis, no significant differences were noted between cohorts with regard to preoperative, one-year postoperative, and ΔPROMs. In addition, no significant difference in the number of patients attaining minimal clinically important difference (MCID) for each PROM was noted between cohorts. With the exception of MCS-12, all intragroup preoperative to postoperative PROMs indicated significant improvement (all p<0.05) after lumbar decompression surgery. Multivariate regression identified moderate or severe central canal stenosis as a significant independent predictor of improvement in VAS-back (estimate=-1.464, p=0.045). We demonstrate that patients with moderate or severe central spinal stenosis may have more improvement in back pain than those with mild or no central stenosis after lumbar spine decompression surgery.

Relationship between Time Elapsed Since Pain Onset and Efficacy of Pain Relief in Patients Undergoing Lumbar Percutaneous Epidural Adhesiolysis.

The aim of this study was to investigate the relationship between pain duration and pain relief after epidural adhesiolysis. Patients with low back pain who underwent lumbar epidural adhesiolysis were enrolled. A clinically significant reduction in pain score was defined as a ≥30% reduction at 6-month follow-up evaluation. Variables were compared based on pain duration categories. Changes in pain scores and pain outcome were also compared. Logistic regression analysis was conducted to identify factors associated with pain relief after adhesiolysis. A total of 169 patients, including 77 (45.6%) patients with a favorable pain outcome, were included for analysis. Patients with a pain duration ≥3 years reported lower baseline pain scores and showed more frequent severe central stenosis. Pain scores significantly decreased over time after the procedure except in patients with a pain duration ≥3 years. Most patients who experienced pain for ≥3 years showed poor pain relief (80.8%), unlike other pain duration categories (pain duration <3 months=48.1%, 3 months-1 year=51.8%, 1-3 years=48.6%). A pain duration ≥3 years and lower baseline pain score were independent factors associated with an unfavorable pain outcome. Pain lasting ≥3 years prior to lumbar epidural adhesiolysis was associated with worse outcomes in terms of pain relief. Therefore, this intervention should be considered early before pain chronification in patients with low back pain.

When does CT myelography add value beyond MRI for lumbar degenerative disease?

Background ContextIn patients with lumbar spinal stenosis, it is crucial for clinicians to identify all symptomatic levels. Prior studies have demonstrated that CT myelography has a greater sensitivity in revealing stenosis (94.4%) compared to MRI (75.9%). However, this is an invasive test that should be used judiciously. No study has identified subgroups of patients that do or do not benefit from this additional invasive testing. PurposeThe objective of this study was to identify subgroups of patients with lumbar stenosis for whom CT myelogram could be expected to provide additional information following an MRI scan. Study DesignRetrospective chart review. Patient SampleConsecutive series of patients with lumbar degenerative disease seen at a single multisurgeon tertiary spine center. Outcome measuresDegree of stenosis on MRI or CT myelo. MethodsMedical records were reviewed to collect standard demographic and surgical data and patient diagnoses. MRI and CT myelo obtained within 6 months of each other in patients >45 years old with a diagnosis of central stenosis, spondylolisthesis or degenerative scoliosis were reviewed. Each lumbar level was recorded as mild, moderate, or severe based on the radiologist's report. Fisher exact test was performed with change in recorded severity of stenosis from MRI to CT myelo as the primary outcome of interest. ResultsOf 269 patients, 207 (80%) had at least one level of moderate or severe central stenosis on MRI and 62 had mild or no stenosis on MRI. Of the 207, 139 (67%) had multilevel stenosis and 68 (33%) had single level stenosis. CT myelo identified a greater proportion of additional stenotic levels in patients with multilevel stenosis (80/139, 58%) compared to patients with single-level stenosis (27/68, 40%, p=.018). In 62 patients with a clinical diagnosis of lumbar stenosis but no moderate to severe stenosis on MRI, CT myelogram identified three additional stenotic levels (3/65, 5%, p=.836). ConclusionSCT myelography is not as useful in providing additional information in patients with no stenosis or single level stenosis as compared to patients with multilevel stenosis.

Predictors of indirect neural decompression in minimally invasive transpsoas lateral lumbar interbody fusion.

An advantage of lateral lumbar interbody fusion (LLIF) surgery is the indirect decompression of the neural elements that occurs because of the resulting disc height restoration, spinal realignment, and ligamentotaxis. The degree to which indirect decompression occurs varies; no method exists for effectively predicting which patients will respond. In this study, the authors identify preoperative predictive factors of indirect decompression of the central canal. The authors performed a retrospective evaluation of prospectively collected consecutive patients at a single institution who were treated with LLIF without direct decompression. Preoperative and postoperative MRI was used to grade central canal stenosis, and 3D volumetric reconstructions were used to measure changes in the central canal area (CCA). Multivariate regression was used to identify predictive variables correlated with radiographic increases in the CCA and clinically successful improvement in visual analog scale (VAS) leg pain scores. One hundred seven levels were treated in 73 patients (mean age 68 years). The CCA increased 54% from a mean of 0.96 cm2 to a mean of 1.49 cm2 (p < 0.001). Increases in anterior disc height (74%), posterior disc height (81%), right (25%) and left (22%) foraminal heights, and right (12%) and left (15%) foraminal widths, and reduction of spondylolisthesis (67%) (all p < 0.001) were noted. Multivariate evaluation of predictive variables identified that preoperative spondylolisthesis (p < 0.001), reduced posterior disc height (p = 0.004), and lower body mass index (p = 0.042) were independently associated with radiographic increase in the CCA. Thirty-two patients were treated at a single level and had moderate or severe central stenosis preoperatively. Significant improvements in Oswestry Disability Index and VAS back and leg pain scores were seen in these patients (all p < 0.05). Twenty-five (78%) patients achieved the minimum clinically important difference in VAS leg pain scores, with only 2 (6%) patients requiring direct decompression postoperatively due to persistent symptoms and stenosis. Only increased anterior disc height was predictive of clinical failure to achieve the minimum clinically important difference. LLIF successfully achieves indirect decompression of the CCA, even in patients with substantial central stenosis. Low body mass index, preoperative spondylolisthesis, and disc height collapse appear to be most predictive of successful indirect decompression. Patients with preserved disc height but severe preoperative stenosis are at higher risk of failure to improve clinically.

Indirect Lumbar Decompression Combined With or Without Additional Direct Posterior Decompression: A Systematic Review.

Study Design:Systematic review.Objective:Indirect decompression via lateral lumbar interbody fusion (LLIF) can ameliorate central and foraminal lumbar stenosis. In severe central stenosis, additional posterior direct decompression is utilized. The aim of this review is to synthesize existing literature on these 2 techniques and identify significant differences in outcomes between isolated indirect decompression via LLIF and combined indirect decompression supplemented with direct posterior decompression.Methods:A database search algorithm was utilized to query MEDLINE, COCHRANE, and EMBASE to identify literature reporting adult decompression study groups that involved an oblique or lateral fusion approach through September 2020. Improvement in outcomes measures and complication rates were pooled and tested for significance.Results:A total of 110 publications were assessed with 15 studies meeting inclusion criteria, including 557 patients and 1008 levels. Mean age was 63.1 years with BMI of 27.5 kg/m2. For the combined indirect and direct decompression cohort, lumbar lordosis (LL) increased 133.9%, from 22.8o to 48.7o, while the indirect decompression cohort LL increased 8.9%, from 41.9o to 45.5o. Difference in LL improvement between cohorts was insignificant (P > .05). Oswestry Disability Index (ODI) decreased from 36.5 to 19.4 in the combined indirect and direct decompression cohort, and from 44.4 to 23.1 in the indirect decompression cohort. ODI reduction was insignificant (P = .053).Conclusions:Prior studies of both indirect decompression as well as combined indirect and direct decompression of lumbar spine stenosis are limited by small samples, heterogeneous populations, and lack of direct comparisons. Both procedures result in improved function and pain postoperatively with direct decompression restoring more lordosis in patients with worse preoperative alignment.

The association between clinical symptoms of lumbar spinal stenosis and MRI axial imaging findings.

Purpose: In diagnosing lumbar spinal stenosis (LSS), Magnetic Resonance Imaging (MRI) is appropriate to confirm the presence of anatomical stenosis of the spinal canal or compression of the nerve roots. However, it is known that morphological LSS is often present in asymptomatic subjects. There is still controversy about the relationship between anatomical LSS and symptomatic LSS. The aim of this study was to assess the association between qualitative imaging findings on MRI of the lumbar spine and symptomatic LSS. Patients and methods: This was a cross-sectional study of 239 volunteers from an epidemiological survey that included 1,862 participants in total. MRI of the lumbar spine was evaluated in four categories: morphological grading of central stenosis and lateral recess stenosis, presence of the sedimentation sign, and severity of facet joint effusion. The relationship between these morphological evaluations and typical LSS symptoms as assessed by the self-administered, self-reported history questionnaire for lumbar spinal stenosis (LSS-SSHQ) was investigated by multiple logistic regression analysis. Results: The odds ratio of the most severe central stenosis to no stenosis was 15.5 (95%CI: 1.4-164.9). Only the most severe central stenosis was associated with typical LSS symptoms, but not all cases with typical LSS symptoms were due to severe central stenosis. Conclusion: Extreme severe central stenosis was strongly related to typical LSS symptoms. However, although subjects with severe central stenosis showed symptoms suggestive of LSS, these subjects did not always show typical LSS symptoms.

Full endoscopic unilateral laminotomy for bilateral decompression of the cervical spine: surgical technique and early experience.

Full-endoscopic decompression surgery has been shown to be safe and efficacious in the lumbar spine, while its role remains to be determined in the cervical spine. We describe the utility of cervical endoscopic unilateral laminotomy for bilateral decompression (CE-ULBD) in a series of elderly patients with severe central stenosis, significant medical comorbidity, and existing cervical deformity. A prospectively collected spine surgery registry at the University of Washington was retrospectively queried for patients with cervical spondylotic myelopathy receiving CE-ULBD. Demographic data, operative details, imaging, and patient reported outcomes, including visual analogue scale (VAS) for neck and upper extremity pain, Nurick grade, and the modified Japanese Orthopedic Association (mJOA) score, were reviewed. Description of the surgical technique is provided. Descriptive statistics were calculated. From 2014 through 2018, 10 patients with an average age of 70.2±5.0 years underwent CE-ULBD for symptomatic upper cervical stenosis due to ligamentum flavum buckling. Half of these patients had one stenotic segment, the other half had two stenotic segments. The most commonly affected segment was C3/4 (5/10 patients). Average length of surgery was 128±18.4 minutes. Average length of stay was 1.2±0.2 days. Average clinical follow-up time was 22.0±4.7 months; clinical outcomes at most recent follow-up were improved via both the Nurick grade (1.2±0.4, P<0.01) and modified Japanese Orthopedic Association (14.6±1.0, P<0.001) compared with pre-operative values. One patient experienced a transient loss of motor evoked potentials intraoperatively, but there were no cases of permanent neurological deficit. Severe central cervical stenosis is a safe and viable target for full-endoscopic decompression via an interlaminar approach.

A retrospective comparison of laminectomy and unilateral fenestration with foraminotomy on outcome of patients with lumbar spinal stenosis

Abstract Background: Neural decompression for lumbar spinal stenosis (LSS) can be performed, besides conventional lumbar laminectomy, by many other surgical techniques. Objective: The goal of this study is to analyze the results of laminectomy versus unilateral fenestration and foraminotomy with bilateral neural decompression in LSS patients. Methods: A number of 58 patients with lumbar spinal stenosis were divided into two groups: group A (no.=22) consists of patients that underwent a laminectomy procedure and group B (no.=36) of cases where unilateral fenestration with foraminotomy was used. Outcome was assessed at 1, 6 and 12 months postoperatively. Two parameters were evaluated: level of pain with the VAS (Visual Analogue Scale) score and the ODI (Oswestry Disability Index) scale for functional improvement. Results: The level of pain was reduced in both patient groups. Cases in group A maintained higher levels of back pain in the first postoperative month versus group B. Improvement was faster for those operated by unilateral approach. At 6 months and 1 year follow-ups, VAS values were very similar. All patients presented functional recovery evaluated with the ODI scale, that showed continuous improvement at 6 months and 1 year. Conclusions: Bilateral decompression by unilateral approach is an efficient method that represents the first option of treatment for patients with lateral lumbar spinal stenosis with unilateral or predominantly unilateral symptoms. For patients with severe central stenosis, classic laminectomy remains the first surgical choice.

Visually assessed severity of lumbar spinal canal stenosis is paradoxically associated with leg pain and objective walking ability.

BackgroundLumbar spinal stenosis (LSS) is the common term used to describe patients with symptoms related to the anatomical reduction of the lumbar spinal canal size. However, some subjects may have a markedly narrowed canal without any symptoms. This raises the question of what is the actual role of central canal stenosis in symptomatic patients. The purpose of this study was to compare radiological evaluations of LSS, both visually and quantitatively, with the clinical findings of patients with LSS.MethodsEighty patients [mean age 63 (11) years, 44% male], with symptoms severe enough to indicate LSS surgery, were included in this prospective single-center study. Lumbar magnetic resonance imaging was performed and one experienced neuroradiologist classified patients into three groups: 0 = normal or mild stenosis, 1 = moderate stenosis, and 2 = severe stenosis. In addition, the same observer measured the minimal dural sac area level by level from the inferior aspect of L1 to the inferior aspect of S1. The association between radiological and clinical findings were tested with Oswestry Disability Index, overall visual analog pain scale, specific low back pain, specific leg pain, Beck Depression Inventory, and walking distance on treadmill exercise test.ResultsIn the visual classification of the central spinal canal, leg pain was significantly higher and walking distance achieved was shorter among patients with moderate central stenosis than in patients with severe central stenosis (7.33 (2.29) vs 5.80 (2.72); P = 0.008 and 421 (431) m vs 646 (436) m; P = 0.021, respectively). Patients with severe stenosis at only one level also achieved shorter walking distance than patients with severe stenosis of at least two levels. No correlation between visually or quantitatively assessed stenosis and other clinical findings was found.ConclusionsThere is no straightforward association between the stenosis of dural sac and patient symptoms or functional capacity. These findings indicated that dural sac stenosis is not the single key element in the pathophysiology of LSS.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2474-15-348) contains supplementary material, which is available to authorized users.

Preoperative MRI findings predict two-year postoperative clinical outcome in lumbar spinal stenosis.

PurposeTo study the predictive value of preoperative magnetic resonance imaging (MRI) findings for the two-year postoperative clinical outcome in lumbar spinal stenosis (LSS).Methods84 patients (mean age 63±11 years, male 43%) with symptoms severe enough to indicate LSS surgery were included in this prospective observational single-center study. Preoperative MRI of the lumbar spine was performed with a 1.5-T unit. The imaging protocol conformed to the requirements of the American College of Radiology for the performance of MRI of the adult spine. Visual and quantitative assessment of MRI was performed by one experienced neuroradiologist. At the two-year postoperative follow-up, functional ability was assessed with the Oswestry Disability Index (ODI 0–100%) and treadmill test (0–1000 m), pain symptoms with the overall Visual Analogue Scale (VAS 0–100 mm), and specific low back pain (LBP) and specific leg pain (LP) separately with a numeric rating scale from 0–10 (NRS-11). Satisfaction with the surgical outcome was also assessed.ResultsPreoperative severe central stenosis predicted postoperatively lower LP, LBP, and VAS when compared in patients with moderate central stenosis (p<0.05). Moreover, severe stenosis predicted higher postoperative satisfaction (p = 0.029). Preoperative scoliosis predicted an impaired outcome in the ODI (p = 0.031) and lowered the walking distance in the treadmill test (p = 0.001). The preoperative finding of only one stenotic level in visual assessment predicted less postoperative LBP when compared with patients having 2 or more stenotic levels (p = 0.026). No significant differences were detected between quantitative measurements and the patient outcome.ConclusionsRoutine preoperative lumbar spine MRI can predict the patient outcome in a two-year follow up in patients with LSS surgery. Severe central stenosis and one-level central stenosis are predictors of good outcome. Preoperative finding of scoliosis may indicate worse functional ability.

Associations between radiographic lumbar spinal stenosis and clinical symptoms in the general population: the Wakayama Spine Study

Many asymptomatic individuals have radiographic lumbar spinal stenosis (LSS), but the prevalence of symptoms among individuals with radiographic LSS has not yet been established. The purpose of this study was to clarify the association between radiographic LSS and clinical symptoms in the general population. In this cross-sectional study, data from 938 participants (308 men, 630 women; mean age, 66.3 years; range, 40-93 years) were analyzed. The severity of radiographic LSS, including central stenosis, lateral stenosis, and foraminal stenosis, was assessed by mobile magnetic resonance imaging and rated qualitatively. Assessment of clinical symptoms was based on the definition of symptomatic LSS in the North American Spine Society guideline. We found that 77.9% of participants had more than moderate central stenosis and 30.4% had severe central stenosis. Logistic regression analysis after adjustment for age, sex, body mass index, and severity of radiographic LSS showed that severe central stenosis was related to clinical symptoms. However, only 17.5% of the participants with severe central stenosis were symptomatic. Although radiographic LSS was common in our cohort, which resembled the general Japanese population, symptomatic persons were relatively uncommon.

Degenerative lumbar spinal stenosis: correlation with Oswestry Disability Index and MR Imaging

Because neither the degree of constriction of the spinal canal considered to be symptomatic for lumbar spinal stenosis nor the relationship between the clinical appearance and the degree of a radiologically verified constriction is clear, a correlation of patient's disability level and radiographic constriction of the lumbar spinal canal is of interest. The aim of this study was to establish a relationship between the degree of radiologically established anatomical stenosis and the severity of self-assessed Oswestry Disability Index in patients undergoing surgery for degenerative lumbar spinal stenosis. Sixty-three consecutive patients with degenerative lumbar spinal stenosis who were scheduled for elective surgery were enrolled in the study. All patients underwent preoperative magnetic resonance imaging and completed a self-assessment Oswestry Disability Index questionnaire. Quantitative image evaluation for lumbar spinal stenosis included the dural sac cross-sectional area, and qualitative evaluation of the lateral recess and foraminal stenosis were also performed. Every patient subsequently answered the national translation of the Oswestry Disability Index questionnaire and the percentage disability was calculated. Statistical analysis of the data was performed to seek a relationship between radiological stenosis and percentage disability recorded by the Oswestry Disability Index. Upon radiological assessment, 27 of the 63 patients evaluated had severe and 33 patients had moderate central dural sac stenosis; 11 had grade 3 and 27 had grade 2 nerve root compromise in the lateral recess; 22 had grade 3 and 37 had grade 2 foraminal stenosis. On the basis of the percentage disability score, of the 63 patients, 10 patients demonstrated mild disability, 13 patients moderate disability, 25 patients severe disability, 12 patients were crippled and three patients were bedridden. Radiologically, eight patients with severe central stenosis and nine patients with moderate lateral stenosis demonstrated only minimal disability on percentage Oswestry Disability Index scores. Statistical evaluation of central and lateral radiological stenosis versus Oswestry Disability Index percentage scores showed no significant correlation. In conclusion, lumbar spinal stenosis remains a clinico-radiological syndrome, and both the clinical picture and the magnetic resonance imaging findings are important when evaluating and discussing surgery with patients having this diagnosis. MR imaging has to be used to determine the levels to be decompressed.

The Longitudinal Assessment of Imaging and Disability of the Back (LAIDBack) Study: baseline data.

Prospective cohort study of randomly selected Veterans Affairs (VA) outpatients. To determine the prevalence of magnetic resonance imaging (MRI) findings in the lumbar spine among persons without current low back pain or sciatica and to examine which findings are related to age or previous back symptoms. Previous studies of patients without low back pain have not explored the possible association of various MRI findings to past symptoms. We randomly selected an age-stratified sample of subjects without low back pain in the past 4 months from clinics at a VA hospital. We collected information on demographics, comorbidity, functional status, and quality of life. MR images were obtained using a standardized protocol through each of the five lumbar disc levels. Of 148 subjects, 69 (46%) had never experienced low back pain. There were 123 subjects (83%) with moderate to severe desiccation of one or more discs, 95 (64%) with one or more bulging discs, and 83 (56%) with loss of disc height. Forty-eight subjects (32%) had at least one disc protrusion and 9 (6%) had one or more disc extrusions. Many MR imaging findings have a high prevalence in subjects without low back pain. These findings are therefore of limited diagnostic use. The less common findings of moderate or severe central stenosis, root compression, and extrusions are likely to be diagnostically and clinically relevant.

Gd-DTPA enhanced MR of the lumbar spinal canal in patients with claudication.

The purpose of this work was to study the findings on intravenous gadolinium-enhanced MRI of the lumbar spinal canal in patients with clinically suspected neurogenic claudication. A prospective gadolinium-enhanced MR evaluation of seven adult patients presenting with clinical claudication thought to be related to the lumbosacral spine was undertaken. Of seven consecutive enhanced conventional SE MRI examinations of the lumbosacral spine in patients presenting with lower extremity claudication, five patients (71.4%) revealed abnormal intrathecal enhancement on MR at and extending craniad from the level(s) of severe spinal stenosis. Each of the seven patients (100%) showed relatively severe central stenosis of the lumbar spinal canal. The enhancement pattern was linear, curvilinear, punctate, and/or diffuse in configuration. Two of the five patients with intrathecal enhancement also showed similar abnormal intrathecal enhancement extending caudal to the severely stenotic levels. The clinically significant intrathecal enhancement on intravenous gadolinium-enhanced MRI identified above the level of a severely stenotic lumbar spinal canal hypothetically might represent enhancement of dilated, obstructed venous structures serving the cauda equina. More likely, however, the major factor in such enhancement at, above, and/or below the stenosis signals blood-nerve barrier breakdown associated with mechanical injury, inflammatory response, and wallerian degeneration/regeneration of axons within chronically compressed nerve roots.