Severe Lumbar Spinal Stenosis Research Articles

Application of perfusion bone cement screw in lumbar degenerative disease with osteoporosis

To observe the early clinical effect of perfusion bone cement screw for lumbar degenerative diseases with osteoporosis. The clinical data of 28 patients with lumbar degenerative diseases combined with moderate to severe osteoporosis treated by posterior lateral graft fusion with perfusion of bone cement screws from June 2015 to June 2017 were retrospectively analyzed. There were 9 males and 19 females, aged from 55 to 86 years old with an average of 76 years. Anteroposterior, oblique, and dynamic radiography were performed before operation, and the diagnosis was confirmed by CT, MRI and dual energy X-ray absorptionmetry(DXA). All the patients had moderate to severe lumbar spinal stenosis, including 16 cases with degenerative scoliosis, 12 cases with degenerative lumbar spondylolisthesis, and 16 cases with lumbar disc herniation. According to Jikei grade of osteoporosis, 9 cases were grade II and 19 cases were grade III. Visual analogue scale (VAS) and Japanese Orthopaedic Association (JOA) score were used to assess the improvement of lumbar leg pain, and neurological function. Imaging data were used to observe the circumstance of pedicle loosening, prolapse, breakage and bone cement leakage, and comprehensively evaluate the fusion. The hospital stay was from 10 to 14 days with an average of 12 days; the operative time was 100 to 150 min with an average of 120 min;the blood loss was 200 to 600 ml with an average of 350 ml (for operations more than 3 vertebral segments, blood filtration recovery was intraoperatively used);the postoperative drainage volume was 150 to 600 ml with an average of 300 ml, no allogeneic blood was used in all the patients. Bone cement of 2 to 3 ml were injected into each vertebral body, and bone cement leakage occurred in 2 cases during injection, both of which were paravertebral vessel leakage, and there was no evidence of intravertebral leakage. The injection of bone cement was terminated in a timely manner without serious complications such as nerve injury, bone cement toxicity, and vascular embolization and pulmonary embolism. According to the fusion criteria by X-ray, 18 cases achieved strong bone fusion, and 10 cases were inaccurate fusion, but no pseudarthrosis occurred in the fusion segment. No screw loosening, prolapse or fracture were found, and postoperative VAS, JOA scores were significantly improved. Perfusion bone cement screw technique can obtain satisfactory effect in treating lumbar degenerative diseases with osteoporosis.

Percutaneous Unilateral Biportal Endoscopic Spine Surgery Using a 30-Degree Arthroscope in Patients With Severe Lumbar Spinal Stenosis: A Technical Note.

Unilateral biportal endoscopic surgery (UBESS) for severe lumbar central canal stenosis (LCCS) remains challenging. To describe the use of UBESS with a 30-degree arthroscope in patients with severe LCCS. Working and viewing portals were created in each unilateral paravertebral area at the target interlaminar level. After ensuring the visual field with a 30-degree arthroscope, effective tissue removal was possible through safe access to the bilateral hypertrophic yellow ligament with minimal osteotomy. The authors evaluated 58 patients and analyzed the clinical outcomes using the visual analog scale, Macnab criteria, and self-predicted walking distance. The visual analog scale scores for low back and leg pains decreased from 7.1 to 1.9 and from 7.9 to 1.6, respectively, at 18 months after the procedure. According to the Macnab criteria, "excellent," "good," and "fair" results were obtained in 51.7%, 41.4%, and 6.9% subjects, respectively. Before surgery, the subjects could walk a mean of 305.8±468.1 m. After surgery, 43.1% of the patients could walk for >1 hour, whereas the remaining patients could walk 1521.8±1831.1 m. UBESS using a 30-degree arthroscope can be an efficient and safe intervention in patients with severe LCCS.

Research progress on nerve root sedimentation sign of lumbar spinal stenosis

To summarize the research progress on the nerve root sedimentation sign of lumbar spinal stenosis. The recent domestic and foreign literature in recent years was reviewed. The definition, classification, and mechanism of nerve root sedimentation sign and the relation of nerve root sedimentation sign to diagnosis and treatment of lumbar spinal stenosis were summarized. Nerve root sedimentation sign is a phenomena which is found in MRI images of lumbar spine. Its mechanism is mainly increased intraoperative epidural pressure. There are two types of classification and the classification in which nerve root sedimentation sign is classified into "positive" and "negative" is widely applied. It has high sensitivity and specificity in differential diagnosis patients with severe lumbar spinal stenosis and patients with nonspecific low back pain. As for treatment, the nerve root sedimentation sign is related to the surgical disc levels. However, it's not sure if the nerve root sedimentation sign is related to surgical outcome. In addition, a positive sedimentation sign turns negative after sufficient surgical decompression and a new positive sedimentation sign after sufficient decompression surgery could be used as an indicator of new stenosis in previously operated patients. For lumbar spinal stenosis, the nerve root sedimentation sign can be applied as an auxiliary diagnostic indicator, as a guidance for deciding the operated disc levels, and as a postoperative indicator for evaluating the effectiveness.

Clinical evaluation of minimally invasive transforaminal lumbar interbody fusion for severe lumbar spinal stenosis

To investigate the clinical results and complication prevention of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in the treatment of single-segment severe lumbar spinal stenosis (LSS). The clinical data of 112 patients with severe LSS treated with MIS-TLIF between January 2010 and January 2017 were retrospectively analyzed. There were 43 males and 69 females, aged 52-81 years, with an average age of 65.3 years. The disease duration ranged from 4 to 126 months, with an average of 10.5 months. Clinical manifestations: 104 cases of low back pain, 91 cases of nervous intermittent claudication of both lower limbs, 21 cases of unilateral nerve root pain and/or numbness, and 5 cases of cauda equina nerve injury. The 112 cases were all severe central spinal stenosis, including 32 cases with lateral recess stenosis, 20 cases with foramen stenosis, 9 cases with ossification of ligamentum flavum, 38 cases with disc herniation; 14 cases with two complications and 5 cases with three. Stenosis segment: L 3, 4 in 6 cases, L 4, 5 in 89 cases, and L 5, S 1 in 17 cases. Surgical methods included bilateral decompression through bilateral approach (60 cases), bilateral decompression through unilateral approach (15 cases), and unilateral decompression (37 cases). The operation time, intraoperative blood loss, visual analogue scale (VAS) score of low back pain and leg pain, Oswestry disability index (ODI) score, fusion rate, and surgical complications were recorded. At last follow-up, the lumbar fusion was evaluated by Bridwell method, grades Ⅰ and Ⅱ were expressed as fusion. The operation time was 83-186 minutes (mean, 126.8 minutes), and the intraoperative blood loss was 65-630 mL (mean, 163.1 mL). All the 112 patients were followed up 25-49 months, with an average of 35.1 months. The VAS score of low back pain and leg pain and ODI score at each time point after operation were significantly improved when compared with preoperative scores ( P<0.05). There was no significant difference between the VAS score of low back pain and leg pain and ODI score at the other time points except 1 month after operation ( P<0.05). At last follow-up, 2 cases of cauda equina nerve injury recovered and 3 cases partially recovered. According to Bridwell classification criteria, 58 cases were grade Ⅰ, 47 cases were grade Ⅱ, and 7 cases were grade Ⅲ. The fusion rate was 93.8%. Perioperative complications included 5 cases of incision complications (superficial infection in 3 cases, hematoma formation in 2 cases), 19 cases of internal fixator complications (intraoperative end plate fracture in 8 cases, fusion cage sinking in 11 cases at last follow-up), and 15 cases of neurological complications (dural sac tear in 10 cases, transient neurological symptoms of lower extremities aggravated in 5 cases). MIS-TLIF treatment of single-level severe LSS can achieve good clinical results, while there is a risk of serious complications. Full understanding of the clinical and imaging features of the disease and reasonable and careful operation are helpful to control the occurrence of cauda equina nerve damage.

Desflurane for management of decompressive laminectomy in a patient with hereditary spastic paraplegia: a case report

BackgroundHereditary spastic paraplegia (HSP) is a rare, genetic neurodegenerative condition. Thus far, ideal anesthetic management is not established for patients with HSP; therefore, careful selection and dosage of anesthetic agents is required.Case presentationA 54-year-old woman with HSP, who was diagnosed with severe lumbar spinal canal stenosis, underwent decompressive laminectomy to relieve her back pain. Preoperatively, she experienced slight difficulty in walking independently; however, she exhibited no other dysfunction. Anesthesia was maintained with desflurane after tracheal intubation. Rocuronium and sugammadex were used for neuromuscular blockade and reversal, respectively, with neuromuscular monitoring equipment. The patient showed uneventful postoperative recovery without signs of neurological deterioration after extubation.ConclusionsOur successful experience in this case implies that, for patients with neuromuscular diseases, including HSP, desflurane may be an option for anesthetic management; moreover, careful assessment (e.g., medical condition, bispectral index, and train-of-four) should be performed prior to administration of anesthesia.

Qualitative versus quantitative lumbar spinal stenosis grading by machine learning supported texture analysis—Experience from the LSOS study cohort

Purpose: To investigate and compare the reproducibility and accuracy of qualitative ratings and quantitative texture analysis (TA) in detection and grading of lumbar spinal stenosis (LSS) in magnetic resonance imaging (MR) scans of the lumbar spine.Materials and methods: From a nationwide multicenter and multidisciplinary lumbar stenosis outcome study (LSOS) register 82 patients, undergoing MR scans of the lumbar spine due to clinical indication of spinal claudication, with a single level central or lateral severe LSS were included. In total 343 transaxial T2-weighted images of the lumbar spine were included from one to five levels (L1 to S1) per patient. One expert radiologist serving as reference standard rated LSS grade according to a standard four-point (normal to severe) as well as to an eight-point Schizas grading scale. DICOM data were then rescaled to a defined pixel size. Two independent readers performed qualitative ratings analogous to expert reader in addition to TA of spinal canals by manually placing two regions of interest (ROI) per image reflecting qualitative scales: (1) dural sac only (2) inner contour of the spinal canal including epidural fat and bilateral recesses. Interreader agreements of qualitative and quantitative parameters were assessed by Cohen’s Kappa (κ) and intraclass correlation (ICC), respectively. TA feature reduction was performed by ICC threshold > 0.75. Remaining features were analyzed with machine learning algorithms (Weka 3 tool) for correlation with LSS grades using 10-fold cross validation.Results: Qualitative ratings showed only moderate reproducibility for both LSS classification systems but high correlation with cut-off cross-sectional area (CSA) <130mm² for severe spinal stenosis. In quantitative TA of both ROIs, machine learning analysis with a decision tree classifier revealed higher performances for LSS grading compared to qualitative assessments using the reference CSA cut-off, respectively.Conclusion: Qualitative LSS grading independent of classification system shows moderate reproducibility. TA with machine learning offers highly reproducible quantitative parameters that increase accuracy for severe LSS detection with minor impact of grading score and CSA border definition.

Factory and construction work is associated with an increased risk of severe lumbar spinal stenosis on MRI: A case control analysis within the wakayama spine study.

BackgroundTo explore the association of MRI‐diagnosed severe lumbar spinal stenosis with occupation.MethodsOccupational data were collected by questionnaire and all participants underwent spine MRI scans using the same protocol. Central lumbar spinal stenosis (LSS) was graded qualitatively. Those with severe LSS (>two‐thirds narrowing) were compared with the controls with lesser degrees of stenosis or no stenosis.ResultsData were available for 722 subjects, mean age 70.1 years. 239 (33%) cases with severe LSS were identified. Factory/construction workers had an almost four‐fold increased risk of severe LSS after adjustment for age, sex, smoking, and walking speed amongst those aged <75 years (OR 3.97, 95%CI 1.46‐10.85). Severe LSS was also associated with squatting ≥1 h/day (OR 1.76, 95%CI 1.01‐3.07) but this association became non‐significant after adjustment.ConclusionFurther research is needed but this study adds more evidence that occupational factors are associated with an increased risk and/or severity of degenerative disease of the lumbar spine.

Outcomes of surgical management of severe lumbar spinal canal stenosis

Background: Lumbar Spinal Canal Stenosis (LSCS), requiring surgical intervention is a common presentation in Orthopaedic practice in Nigeria. Although it is well established that surgery is very effective in relieving the symptoms of this condition, there is a paucity of reports of surgical treatment outcomes of LSCS in Nigeria. Objective: The study aims to report the early outcomes of surgical treatment of LSCS in the study centre. Methods: Prospective Observational Pretest and Post-test Study at a single centre, the University of Medical Sciences Teaching Hospital, located in Ondo State in Southwest Nigeria, West Africa. The study was done between January 2015 and June 2017. Preoperative and postoperative data collected from 32 patients with a diagnosis of LSCS who had Decompressive Laminectomy with or without instrumented fusion were analyzed for relief of symptoms: pain, functional wellbeing and general health status using Visual Analogue Scale (VAS) for back and leg pain, Oswestry Disability Index (ODI) and Short Form 36 (SF 36). Results: Excellent to good pain relief was reported by 31 (96.9%) and 30 (93.8%) of the patients for leg and back pain respectively at 6 months, 1 (3.1%) reported a fair outcome for leg pain while 2 (6.2%) reported fair outcome for back pain. No patient had a poor pain relief outcome. Functional outcome and general health status were also excellent/good for 28 (87.5%) and 29 (90.6%) respectively. There was no mortality or major cardiorespiratory event recorded. However, there was a minor complication rate of 68.8% (22 patients). These include dural tears 16 (50%), deep vein thrombosis 1 (3.1%), postoperative neurological weakness 2 (6.2%), wound infection 20 (62%), wound dehiscence 10 (31%), reoperation 6 (18.6%). The outcome at 24 weeks was unaffected by these minor complications. Conclusion: Although associated with early perioperative minor complications, Spine surgery is an effective and safe therapeutic option for the relief of LSCS symptoms with short term good clinical outcomes.

Clinical outcomes of minimally invasive transforaminal lumbar interbody fusion for lumbar degenerative disease at more than 5 years follow-up: a review of 832 patients

Objective To observe the mid-and long-term clinical efficacy of minimally invasive transforaminal lumbar interbody fusion for the treatment of single-segment lumbar degenerative diseases. Methods Retrospective analysis of the clinical data of 832 patients with lumbar degenerative disease treated with single-segment MIS-TLIF surgery from 2007 to 2013, 443 males and 389 females; aged 23-82 years, mean 56.4±18.7 years old. All cases were divided into revision surgery group, severe lumbar spinal stenosis group, moderate to severe lumbar spondylolisthesis group and general case groups (as a control) for comparative analysis. Efficacy evaluation indicators include Oswestry disability index (ODI), visual analog scale (VAS), intervertebral fusion rate, and complications. Results All patients were followed up for 62 to 93 months, with an average of 79.2±18.6 months. One month after operation, the VAS score of low back pain in the severe spinal stenosis group 2.9±0.5 and the moderate to severe spondylolisthesis group 3.8±1.1 were both significantly higher than the general case group 1.6±0.6, and the difference was statistically significant. The VAS score of leg pain was high in the moderate to severe slip group 2.6±0.7, but the difference was not statistically significant. The ODI value was significantly higher in the moderate to severe spoiler group 28.8±6.9% than in the general case group 22.1±6.4%. In the 2 years after the operation, the vas of lower back pain was divided into 2.4±0.9, compared with the general case group 1.7±0.5, and the difference was statistically significant; the ODI group of severe spinal stenosis and moderate-severe spondylolisthesis were 17.9%±3.4% and 19.4%±4.9%, respectively, which was higher than the general case group 11.3%±3.3%, and the difference was statistically significant. In the last follow-up, the VAS scores 2.3±0.8 and 2.6±1.1 of the severe vertebral canal stenosis group and the moderate-severe spondylolisthesis group were respectively higher than that of the general case group 1.6±0.7, and the difference was statistically significant; the ODI group of severe vertebral canal stenosis and moderate-severe spondylolisthesis were 18.3%±11.1% and 19.6%±12.1, higher than the general case group 11.8%±9.7%, the difference was statistically significant. The incidence of mid- and long-term complications (intervertebral non-fusion, adjacent segment disease) was not statistically significant among the four groups. Conclusion MIS-TLIF treatment of lumbar degenerative diseases can obtain good medium and long-term clinically effect. For complex diseases such as revision, severe degeneration and moderate to severe spondylolisthesis, MIS-TLIF did not increase the incidence of medium and long-term complications. Key words: Lumbar vertebrae; Surgical procedures, minimally invasive; Spinal fusion

The nerve root sedimentation sign in diagnosis of lumbar spinal stenosis

The nerve root sedimentation sign is a magnetic resonance (MR) sign, shown to be present in central lumbar spinal stenosis. The lack of sedimentation of the nerve roots to the dorsal part of the dural sac is consistent with the positive nerve root sedimentation sign. To validate the reliability of the nerve root sedimentation sign in diagnosis of different grades of lumbar spinal canal stenosis. This study was a retrospective review of 101 consecutive MR imaging (MRI) studies obtained on patients with clinically suspected lumbar canal stenosis. Based on the minimum anteroposterior (AP) diameter of the dural sac the study sample was classified into two groups: a group with morphological lumbar spinal stenosis; and the group of patients free from stenosis (AP > 12 mm). Patients with stenosis were further subclassified based on its severity: severe stenosis (AP ≤ 10 mm); and moderate stenosis (AP > 10 mm to ≤ 12 mm). Positive sedimentation sign was identified in 81% of patients with severe lumbar spinal stenosis and 14% of patients with moderate stenosis. No patients without lumbar spinal stenosis had a positive nerve root sedimentation sign. Of patients with a positive nerve root sedimentation sign, 89% presented with neurological claudication. The nerve root sedimentation is a useful tool for identification of patients with both severe clinical and morphological lumbar spinal stenosis; however, its performance in the diagnosis of patients with moderate morphological spinal stenosis is poor.

Expansive Suspension Laminoplasty Using a Spinous Process-Splitting Approach for Lumbar Spinal Stenosis: Surgical Technique and Outcomes Over 8 Years of Follow-up.

Introduction:To maximize the benefits of posterior decompression for severe multilevel lumbar spinal stenosis, we refined the expansive laminoplasty technique using a spinous process–splitting approach. This study tests the hypothesis that the surgical benefit of adequate decompression with posterior element preservation is maintained in the long term, over 8 years of follow-up.Methods:Fifty-eight patients were followed up yearly for 8 years. Eight patients having nonlumbar spine surgery or Parkinson disease were excluded. The noninferiority of the 8-year versus peak-year outcomes was tested, with margins of 5 points for the Oswestry disability index and 1 point for the numeric rating scales (NRSs).Results:In the 50 patients available for follow-up, the peak values of the mean improvements from baseline within the first 7 years were 35.8, 5.7, 5.9, and 2.8 points for the Oswestry disability index, low back pain NRS, leg pain NRS, and leg numbness NRS, respectively. The 95% lower confidence limits for the differences between the mean improvements from baseline at 8 years and the peak year were within the noninferiority margins for each scale.Conclusion:Our technique was associated with substantial improvement from baseline for each scale. The initial improvements in function and symptoms were maintained for 8 years.

Urinary incontinence due to lumbar spinal stenosis causing disability and lowering quality of life.

Lumbar spinal stenosis may lead to urinary inconsistence and can have a negative impact on the quality of life. The aim of the study was to assess the incidence of urinary incontinence and quality of life in female patients with spinal canal stenosis comparing to control group. The study population consisted of 50 women diagnosed with severe lumbar spinal canal stenosis. Their mean age was 55.32 ± 12.97 years. The clinical control group consisted of 30 women who did not suffer from any spine disorders. Their mean age was 54.87 ± 12.01 years. There was no difference between both groups regarding age, weight, BMI and number of parity. The women diagnosed with clinical and radiographic symptoms of spinal canal stenosis filled out an anonymous questionnaire, ODI, ICIQ-UI-SF, and ICIQ-LUTSqol questionnaires. We found urinary incontinence in 56% of women with lumbar spinal canal stenosis and in 43% of clinical control group. We also found a statistically significant correlation between duration of lumbar stenotic symptoms, the SLR sign, number of deliveries and the intensity of urinary incontinence. Urinary incontinence in women with lumbar spinal canal stenosis is significantly different from the control group. Leakage of urine happened more frequently, the amount of urine leaked was greater, and the general impact on everyday life is harsher, as compared to the clinical control group.

Surgical strategy and relevant problems about degenerative spinal deformity

As the complicated and three-dimensional deformity, degenerative spinal deformity is common in middle-aged and elderly patients, which often accompanies with severe lumbar spinal stenosis and corresponding symptoms, high surgical difficulties and risks in perioperative periods. The aims of the surgery are removing decompression of spinal cord and nerve root, ending the process of deformity and rebuilding spinal balance. Recently, relevant problems of sagittal balance in degenerative spinal deformity have attracted more and more attention. Proper use of orthopedic technique and correct choice of upper and lower instrumented vertebra play a key role in deformity correction and improvement of postoperative symptoms.

Factors associated with lumbar spinal stenosis in a large-scale, population-based cohort: The Wakayama Spine Study.

ObjectivePatients with lumbar spinal stenosis (LSS) who have radiographically similar degrees of stenosis may not necessarily exhibit equivalent symptoms. As part of a cross-sectional study, we examined factors associated with symptomatic LSS (sLSS) in the general population of Japan.MethodsWe evaluated 968 participants (men, 319; women, 649) between 2008 and 2010. Orthopedic surgery specialists diagnosed sLSS using interview results, medical examinations, and imaging findings. LSS was radiographically graded using a 4-level scale. Additionally, we examined basic anthropometry, smoking habits, alcohol consumption, ankle-brachial index values (ABI), and glycosylated hemoglobin (HbA1c) levels. We grouped patients with moderate and severe radiographic LSS, and compared the indicated factors on the basis of the presence/absence of sLSS. Data were evaluated using multiple logistic regression analyses.ResultsRadiographically, 451 participants had moderate and 288 severe stenosis. Clinically, 92 participants were diagnosed with sLSS, including 36 with moderate and 52 with severe stenosis. In the moderate stenosis group, participants with sLSS had significantly higher rates of diabetes mellitus (DM) and lower ABIs than did non-LSS participants. Although sLSS participants tended to be older (p = 0.19), there were no significant differences in the sex distribution, body mass index values, or in the percentages of participants who were drinkers/smokers. In the severe stenosis group, there were no differences in any of the evaluated factors. Multiple logistic regression showed that DM (odds ratio [OR], 3.92; 95% confidence interval [CI], 1.52–9.34]) and low ABI (1 SD = 0.09; OR, 1.36; 95% CI, 1.04–1.81) were significantly associated with LSS in the moderate stenosis group.ConclusionsDM and low ABIs are significantly associated with sLSS in patients with moderate radiographic stenosis. Neither factor is associated with sLSS in patients with severe stenosis. Notably, the effects of intrinsic factors on symptomology may be masked when anatomic stenosis is severe.

Introduction to Special Series: Deconstructing chronic low back pain in the older adult: shifting the paradigm from the spine to the person.

Over the past decade, the estimated prevalence of low back pain (LBP) among older adults (typically defined as those ≥age 65) has more than doubled ⇓, and the utilization of advanced spinal imaging (e.g., computerized tomography (CT), magnetic resonance imaging [MRI]) and procedures guided by this imaging (e.g., epidural corticosteroids, spinal surgery) have continued to skyrocket ⇓. Treatment outcomes, however, have not improved apace. Why? Part of the answer lies in the fact that treatment may in part be misdirected. This issue of Pain Medicine contains the first in a series of articles on how to systematically and comprehensively rethink our approach to evaluating and designing management for older adults with chronic low back pain (CLBP). The series is entitled “Deconstructing Chronic Low Back Pain in the Older Adult: Step-by-Step Evidence and Expert-Based Recommendations for Evaluation and Treatment” and the article in this issue focuses on hip osteoarthritis (OA), an important potential contributor to CLBP in older adults. To understand how we might attempt to improve the care of older adults with CLBP, let us start by examining current approaches. Management of patients with CLBP often begins with a search for the cause of pain using spinal imaging. The vast majority of people with CLBP do not require imaging because they do not have “red flag” pathology, that is, serious disorders such as cancer or infection that require urgent treatment ⇓. Spinal imaging in the older adult who does not have red flags on history or physical examination will almost certainly reveal “abnormalities.” Imaging evidence of lumbar degenerative disc and facet disease is nearly ubiquitous in older adults, even those who are pain-free ⇓. An estimated 20% of older adults without neurogenic claudication have moderate to severe lumbar spinal stenosis on magnetic resonance imaging ⇓. …

Diagnostic value of the nerve root sedimentation sign, a radiological sign using magnetic resonance imaging, for detecting lumbar spinal stenosis: a meta-analysis.

This study aimed to determine the diagnostic value of the nerve root sedimentation sign, a relatively new radiological sign using magnetic resonance imaging, for diagnosing lumbar spinal stenosis. The literature search was based on PUBMED, EMBASE, Cochrane Library, Google Scholar, and the Chinese Biomedical Literature Database up to March 2014. A total of 120 articles were identified. Seven studies involving 1,182 patients were included. The quality of the methodology of the seven studies was good. Overall, the pooled weighted value showed that the sedimentation sign had moderate sensitivity of 0.80 [95 % confidence interval (CI) 0.77-0.83] and high specificity of 0.96 (95 % CI 0.94-0.98). The area under the curve was 0.76. Subgroup analysis showed that the degree of morphological spinal stenosis was responsible for the heterogeneity. In the patients with severe morphological lumbar spinal stenosis, the sedimentation sign had even higher sensitivity and specificity: 0.899 (95 % CI 0.87-0.92) and 0.99 (95 % CI 0.98-1.00), respectively. The area under the curve was 0.96. In the patients with lumbar spinal stenosis without definition of morphological stenosis, there was a notable threshold effect and significant heterogeneity. The area under the curve was 0.63. Current evidence suggests that the sedimentation sign has high sensitivity and specificity for diagnosing severe lumbar spinal stenosis. Its performance in diagnosing moderate and mild spinal stenosis, however, has yet to be corroborated in properly designed studies.

Concomitant combined degenerative compression of the spinal cord and cauda Equina: A report on three cases

We report on three cases with concomitant combined degenerative compression of the spinal cord and cauda equina which were diagnosed and operated in a single stage. The first case presents left-sided paramedian disc herniations at L1-2 and L4-5 levels, combined with concurrent degenerative spinal stenosis. The second case includes right-sided paramedian disc herniation at Th12-L1 level in combination with severe degenerative lumbar spinal stenosis at L3-4 level. The third case describes advanced degenerative compression at Th7-8 level with concurrent central spinal stenosis at L4-5 level. We have discussed the clinical presentation of concurrent combined symptomatic degenerative compression of the spinal cord and cauda equinа which can deceive the physician and lead to omitted diagnosis of the thoracic compression. In an attempt to avoid misdiagnosis of thoracic degenerative compression, it is necessary to perform thorough neurological examination of the spinal cord motor and sensory functions. In addition, further MRI examination of upper spinal segments is needed, if previous studies of the lumbar spine fail to provide reasonable explanation for the existing neurological symptoms.

Risk factors and incidence for peripheral arterial disease in patients with typical lumbar spinal stenosis.

ObjectiveIntermittent claudication (IC) is a typical symptom of peripheral arterial disease (PAD) and lumbar spinal stenosis (LSS). In order to prevent misdiagnosis of vascular disease, it is important to know the incidence of and risk factors for PAD in patients with LSS. Therefore, the aim of our study was to evaluate the incidence of and risk factors for PAD in patients with typical and severe LSS who underwent spinal surgical treatment.MethodsThe occurrence of PAD was examined retrospectively in 171 consecutive patients with LSS and severe IC who underwent surgical treatment at our hospital from June 2012 to June 2013. Data were collected on background characteristics (sex, age) and known risk factors for PAD, such as hypertension, diabetes mellitus, smoking, hyperlipidemia, stroke, and ischemic heart disease.ResultsOf the 171 patients enrolled, 7 had an abnormal ankle-brachial index (ABI). Computed tomography angiography (CTA) was performed in these patients, and a final diagnosis of PAD was established for all 7 patients. The incidence of PAD in all patients with LSS was 4.1%(7 of 171). Stroke and ischemic heart disease were significantly more common in the LSSPAD group compared with the LSS group. Multiple logistic regression analyses with a forced-entry method revealed that age and stroke (p<0.05) were independent risk factors for PAD.ConclusionTo prevent misdiagnosis of fatal PAD, we recommend ABI be assessed in patients with LSS and history of stroke.

Nerve Root Sedimentation Sign for the Diagnosis of Lumbar Spinal Stenosis

Retrospective review of magnetic resonance images. Examine the diagnostic accuracy, discriminative ability, and reliability of the sedimentation sign in a sample of patients with clinically diagnosed lumbar spinal stenosis (LSS), low back pain (LBP), and vascular claudication, and in asymptomatic controls. The nerve root sedimentation sign (SedSign) was recently described as a new diagnostic test for LSS; however, the degree to which this sign is sensitive and specific in diagnosis of LSS is unknown. All LSS images were obtained from subjects who had clinically diagnosed LSS confirmed on imaging by a spine specialist. The other images were obtained from people with LBP but no LSS, people with severe vascular claudication, and asymptomatic participants. Three blinded raters independently assessed the images. A positive sign was defined as the absence of nerve root sedimentation at the level above or below the level of maximum stenosis. Images from 148 subjects were reviewed (67 LSS, 31 LBP, 4 vascular, and 46 asymptomatic). Intrarater reliability for the sign ranged from κ= 0.87 to 0.97 and inter-rater reliability from 0.62 to 0.69. Sensitivity ranged from 42% to 66%, and specificity ranged from 49% to 78%. Sensitivity improved to a range of 60% to 96% when images with only a smallest cross-sectional area of the dural sac less than 80 mm were included. The sign was able to differentiate (P = 0.004) between LSS and asymptomatic controls but not between LSS and LBP or between LSS and vascular claudication. The SedSign was shown to have high intrarater reliability and acceptable inter-rater reliability. The Sign appears most sensitive in defining severe LSS cases, yet may not aid in the differential diagnosis of LSS from LBP or vascular claudication, or add any specific diagnostic information beyond the traditional history, physical examination, and imaging studies that are standard in LSS diagnosis. 4.

The natural clinical course of lumbar spinal stenosis: a longitudinal cohort study over a minimum of 10 years

BackgroundLittle is known about the short- and long-term prognoses of conservative treatment of lumbar spinal stenosis (LSS). Furthermore, there are no reports in the literature that investigate the relationship between longitudinal imaging changes and clinical symptoms in patients with LSS. This longitudinal cohort study aimed to clarify the morphologic changes and role of conservative treatment in LSS. MethodsThis study included 34 patients with leg or low back pain who had received a diagnosis of LSS by magnetic resonance imaging (MRI). The patients’ average age was 58years at the initial examination. All participants received conservative treatment with or without medication for over 10years. The clinical course was assessed by using the Japanese Orthopaedic Association scoring system, a visual analog scale for back or leg pain, and symptomatic Johnsson’s classification. Additionally, patients’ dural sac cross-sectional area was measured on axial MRI. ResultsOne patient could not be contacted and four others died during this investigation. After an average follow-up of 11.1years, symptoms improved in approximately 30% of patients, remained unchanged in 30%, and worsened in 30%. The dural sac cross-sectional areas in both the worsened and unchanged groups were significantly smaller than that of the improved group (P<0.05). In the worsened group, the average area at the initial examination was <50mm2. Some patients underwent surgery during this observation, and had severe narrowing (<40mm2) of the area at the initial examination. ConclusionsThis study showed that clinical symptoms of LSS did not develop in more than 60% of patients who received conservative treatment, which was dependent on the severity of LSS. In patients with severe LSS and a dural sac cross-sectional area <50mm2, the clinical course may deteriorate with conservative treatment, and surgery should be considered at an early stage.