Severity Of Lumbar Spinal Stenosis Research Articles

Performance of Artificial Intelligence in Diagnosing Lumbar Spinal Stenosis: A Systematic Review and Meta-analysis.

The present study followed the reporting guidelines for systematic reviews and meta-analyses. Therefore, we conducted this study to review the diagnostic value of AI for various types of LSS and the level of stenosis, offering evidence-based support for the development of smart diagnostic tools. Artificial intelligence (AI) is currently being utilized for image processing in clinical practice. Some studies have explored AI techniques for identifying the severity of lumbar spinal stenosis (LSS) in recent years. Nevertheless, there remains a shortage of structured data proving its effectiveness. Four databases (PubMed, Cochrane, Embase, and Web of Science) were searched until March 2024, including original studies that utilized deep learning and machine learning models to diagnose LSS. The risk of bias (RoB) of included studies was assessed using QUADAS-2. The accuracy in the validation set was extracted for a meta-analysis. The meta-analysis was completed in R4.4.0. A total of 48 articles were included, with an overall accuracy of 0.885 (95% CI: 0.860-0907) for dichotomous tasks. Among them, the accuracy was 0.892 (95% CI: 0.867-0915) for deep learning (DL) and 0.833 (95% CI: 0.760-0895) for machine learning (ML). The overall accuracy for LSS was 0.895 (95% CI: 0.858-0927), with an accuracy of 0.912 (95% CI: 0.873-0.944) for DL and 0.843 (95% CI: 0.766-0.907) for ML. The overall accuracy for central canal stenosis was 0.875 (95% CI: 0.821-0920), with an accuracy of 0.881 (95% CI: 0.829-0.925) for DL and 0.733 (95% CI: 0.541-0.877) for ML. The overall accuracy for neural foramen stenosis was 0.893 (95% CI: 0.851-0.928). In polytomous tasks, the accuracy was 0.936 (95% CI: 0.895-0.967) for no LSS, 0.503 (95% CI: 0.391-0.614) for mild LSS, 0.512 (95% CI: 0.336-0.688) for moderate LSS, and 0.860 for severe LSS (95% CI: 0.733-0.954). AI is highly valuable for diagnosing LSS. However, further external validation is necessary to enhance the analysis of different stenosis categories and improve the diagnostic accuracy for mild to moderate stenosis levels.

Severity of lumbar spinal stenosis does not impact responsiveness to exercise-based rehabilitation.

Spine pain is a prevalent and costly condition affecting up to 85% of individuals throughout their lifetime, and spinal stenosis is one of the most debilitating sources of spine pain. Although conservative management is the first line of treatment for spinal stenosis, severe cases often are directly referred to surgical intervention due to the belief that conservative strategies delay necessary treatment. However, there are no studies supporting the premise that individuals with more severe stenosis respond poorly to conservative management. The purpose of this study was to compare improvements in pain, disability, strength, medication usage, and patient goals in response to an exercise-based physical therapy program across 1,806 individuals with mild, moderate, or severe lumbar spine stenosis. Participants demonstrated significant improvements in all variables of interest (p<0.001), and 11.5% of participants reported cessation of narcotic use with treatment. There were no significant differences in treatment response across mild, moderate, or severe stenosis groups for any outcome (p>0.546). Exercise-based rehabilitation is as beneficial in the short term for individuals presenting for nonoperative care with severe stenosis compared to their milder counterparts. Future research is needed to evaluate long term durability and cost effectiveness of rehabilitation in this patient population.

Correlation between Preoperative MRI Parameters and Oswestry Disability Index in Patients with Lumbar Spinal Stenosis: A Retrospective Study.

Background and Objectives: Lumbar spinal stenosis (LSS) is a degenerative condition posing significant challenges in clinical management. Despite the use of radiological parameters and patient-reported outcome measures like the Oswestry Disability Index (ODI) for evaluation, there is limited understanding of their interrelationship. This study aimed to investigate the correlation between preoperative MRI parameters and ODI scores in patients with LSS undergoing surgical treatment. Materials and Methods: A retrospective analysis was conducted on 86 patients diagnosed with LSS over a 5-year period. Preoperative MRI measurements, including the cross-sectional area of the psoas muscle, lumbar canal stenosis, neural foramina area, and facet joint osteoarthritis, were assessed. ODI scores were collected preoperatively and at a 1-year follow-up. Statistical analyses were performed using IBM SPSS Statistics software (version 26). Results: Weak to moderate correlations were observed between certain MRI parameters and ODI scores. The initial ODI score had a weak positive correlation with the severity of lumbar canal stenosis according to Schizas criteria (rho = 0.327, p = 0.010) and a moderate negative correlation with the relative cross-sectional area of the psoas muscle (rho = -0.498, p = 0.000). At 1-year follow-up, the ODI had a weak negative correlation with the relative cross-sectional area of the psoas muscle (rho = -0.284, p = 0.026). Conclusions: While the severity of LSS showed a weak correlation with initial ODI, it was not a predictor of 1-year postoperative ODI. Furthermore, although the cross-sectional area of the thecal sac, the sagittal area of the neural foramen, and the grade of facet joint osteoarthritis influence the imagistic severity, none of them correlate with ODI. These findings underscore the need for a comprehensive model that integrates multiple imaging and clinical parameters for a holistic understanding of LSS and its functional outcomes.

Predicting postoperative outcomes in lumbar spinal fusion: development of a machine learning model

BACKGROUND CONTEXTDegenerative lumbar spondylolisthesis (DLS) is a prevalent spinal disorder, often requiring surgical intervention. Accurately predicting surgical outcomes is crucial to guide clinical decision-making, but this is challenging due to the multifactorial nature of postoperative results. Traditional risk assessment tools have limitations, and with the advent of machine learning, there is potential to enhance the precision and comprehensiveness of preoperative evaluations. PURPOSEWe aimed to develop a machine-learning algorithm to predict surgical outcomes in patients with degenerative lumbar spondylolisthesis (DLS) undergoing spinal fusion surgery, only using preoperative data. STUDY DESIGNRetrospective cross-sectional study. PATIENT SAMPLEPatients with DLS undergoing lumbar spinal fusion surgery. OUTCOME MEASURESThis study aimed to predict the occurrence of lower back pain (LBP) ≥4 on the numeric analogue scale (NAS) 2 years after surgery. LBP was evaluated as the average pain patients experienced at rest in the week before questioning. NAS ranges from 0 to 10, 0 representing no pain and 10 representing the worst pain imaginable. METHODSWe conducted a retrospective analysis of prospectively enrolled patients who underwent spinal fusion surgery for degenerative lumbar spondylolistheses at our institution in the United States between January 2016 and December 2018. The initial patient characteristics to be included in the training of the model were chosen by clinical expertise and through a literature review and included demographic characteristics, comorbidities, and radiologic features. The data was split into a training and validation datasets using a 60/40 split. Four different machine learning models were trained, including the modern XGBoost model, logistic regression, random-forest, and support vector machine (SVM). The models were evaluated according to the area under the curve (AUC) of the receiver operating characteristics (ROC) curve. An AUC of 0.7 to 0.8 was considered fair, 0.8 to 0.9 good, and ≥ 0.9 excellent. Additionally, a calibration plot and the Brier score were calculated for each model. RESULTSA total of 135 patients (66% female) were included. A total of 38 (28%) patients reported LBP ≥ 4 after 2 years, representing the positive class. The XGBoost model demonstrated the best performance in the validation set with an AUC of 0.81 (95% CI 0.67–0.95). The other machine learning models performed significantly worse: with an AUC of 0.52 (95% CI 0.37–0.68) for the SVM, 0.56 (95% CI 0.37–0.76) for the logistic regression and an AUC of 0.56 (95% CI 0.37–0.78) for the random forest. In the XGBoost model age, composition of the erector spinae, and severity of lumbar spinal stenosis as were identified as the most important features. CONCLUSIONSThis study represents a novel approach to predicting surgical outcomes in spinal fusion patients. The XGBoost demonstrated a better performance compared with classical models and highlighted the potential contributions of age and paraspinal musculature atrophy as significant factors. These findings have important implications for enhancing patient care through the identification of high-risk individuals and modifiable risk factors. As the incorporation of machine learning algorithms into clinical decision-making continues to gain traction in research and clinical practice, our insights reinforce this trajectory by showcasing the potential of these techniques in forecasting surgical results.

Relationship between lumbar spinal stenosis and axial muscle wasting

BACKGROUND CONTEXTAlthough the effect of lumbar spinal stenosis (LSS) on the lower extremities is well documented, limited research exists on the effect of spinal stenosis on the posterior paraspinal musculature (PPM). Similar to neurogenic claudication, moderate to severe spinal canal compression can also interfere with the innervation of the PPM, which may result in atrophy and increased fatty infiltration (FI). PURPOSEThis study aims to assess the association between LSS and atrophy of the PPM. STUDY DESIGNRetrospective cross-sectional study. PATIENT SAMPLEPatients undergoing MRI scans at a tertiary orthopedic center for low back pain or as part of a preoperative evaluation. OUTCOME MEASURESThe functional cross-sectional area (fCSA) and percent fatty infiltration (FI) of the PPM at L4. METHODSLumbar MRIs of patients at a tertiary orthopedic center indicated due to lower back pain (LBP) or as a presurgical workup were analyzed. Patients with previous spinal fusion surgery or scoliosis were excluded. LSS was assessed according to the Schizas classification at all lumbar levels. The cross-sectional area of the PPM was measured on a T2-weighted MRI sequence at the upper endplate of L4. The fCSA and fatty infiltration (FI) were calculated using custom software. Crude differences in FI and fCSA between patients with no stenosis and at least mild stenosis were tested with the Wilcoxon signed-rank test. To account for possible confounders, a multivariable linear regression model was used to adjust for age, sex, body mass index (BMI), and disc degeneration. A subgroup analysis according to MRI indication was performed. RESULTSA total of 522 (55.7% female) patients were included. The median age was 61 years (IQR: 51–71). The greatest degree of moderate and severe stenosis was found at L4/5, 15.7%, and 9.2%, respectively. Stenosis was the least severe at L5/S1 and was found to be 2% for moderate and 0.2% for severe stenosis. The Wilcoxon test showed significantly increased FI of the PPM with stenosis at any lumbar level (p<.001), although no significant decrease in fCSA was observed. The multivariable regression model showed a significant increase in FI with increased LSS at L1/2, L2/3, and L3/4 (p=.013, p<.01 and p=.003). The severity of LSS at L4/5 showed a positive association with the fCSA (p=.019). The subgroup analysis showed, the effect of LSS was more pronounced in nonsurgical patients than in patients undergoing surgery. CONCLUSIONSIn this study, we demonstrated a significant and independent association between LSS and the composition of the PPM, which was dependent on the level of LSS relative to the PPM. In addition to neurogenic claudication, patients with LSS might be especially susceptible to axial muscle wasting, which could worsen LSS due to increased spinal instability, leading to a positive feedback loop.

The Relationship between the Severity of Lumbar Spinal Stenosis and Levels of Vitamin D and Parathyroid Hormone

Background: It is known that parathyroid hormone (PTH) and vitamin D have a wide variety of effects on bone metabolism. However, the levels of PTH and vitamin D in patients with lumbar spinal stenosis (LSS) have not been adequately investigated in the literature. Objective: The objective of this study was to investigate the relationship between PTH and vitamin D levels and the severity of stenosis in patients with LSS. Materials and Methods: This retrospective observational study included consecutive patients who presented to the Neurosurgery outpatient clinic with chronic leg pain and low back pain and were diagnosed with LSS between January 2019 and July 2022. Patients were categorized into three groups based on their vitamin D and parathyroid hormone status. Group 1: High parathyroid hormone and Low vitamin D levels; Group 2: Normal parathyroid hormone and low vitamin D levels; Group 3: Normal parathyroid hormone and vitamin D levels. There were 17 (37%), 10(22%), and 19(41%) subjects in groups I, II, and III, respectively. Results: The mean age of the groups with a total of 46 patients I, II and III were 62.2±11, 58.3±6, and 63.2±6.4 years, respectively (p=0.553). Sex of the study groups was not statistically different, either (p=0.079). Spinal canal AP diameter (p=0.002) and ligamentous interfacet distance (p=0.008) were significantly different in study groups. Vitamin D positively correlated with Spinal canal AP diameter (r=0.56, p&lt;0.001) and ligamentous interfacet distance (r=0.51, p=0.003), while PTH was inversely correlated with them (r=-0.33, p=0.020), ( r=-0.47, p=0.007) . Conclusion: Vitamin D is significantly correlated with the diameters of spinal canal AP and ligamentous interfacet distance. PTH is negatively correlated with the diameters of spinal canal AP and ligamentous interfacet distance. Keywords: Lumbar spinal stenosis, Vitamin D, Parathyroid hormone, Neurogenic claudication, Low back pain, Ligamentous interfacet distance.

Retracted: Relationship between Severity of Lumbar Spinal Stenosis and Ligamentum Flavum Hypertrophy and Serum Inflammatory Factors.

[This retracts the article DOI: 10.1155/2022/8799240.].

Relationship between Severity of Lumbar Spinal Stenosis and Ligamentum Flavum Hypertrophy and Serum Inflammatory Factors.

Objective This study is aimed at investigating the correlation between lumbar spinal stenosis (LSS) severity, ligamentum flavum hypertrophy, and the upregulation of inflammatory markers. Methods From March 2019 and May 2022, eighty-five inpatients with LSS were enlisted as the study's research group, while sixty-five patients hospitalized for lumbar intervertebral disc herniation over the same time period served as the study's control group. Moreover, mild, moderate, and severe subgroups of patients were created within the research population based on their LSS severity. The ligamentum flavum thickness and the positive expression rates of TNF-α, TGF-β1, and IL-1α were compared between the study group and the control group. The levels of TNF-α, TGF-β1, and IL-1α that were found to be positively expressed were compared between the mild, moderate, and severe groups. Patients with LSS had their ligamentum flavum thickness and their positive expression rates of TNF-α, TGF-β1, and IL-1α analyzed using Spearman correlation analysis. We evaluated the diagnostic utility of the positive expression rates of IL-α1, TGF-β1, and TNF-α and ligamentum flavum thickness in distinguishing the severity of LSS using a receiver operating characteristic (ROC) curve. Results The rates of both lower limb pain (40.00%) and intermittent claudication (80.00%) in the LSS group were higher than those in the lumbar disc herniation group (15.38%, 12.31%), with statistical significance (P < 0.05). However, no substantial disparity was observed in left lower limb pain, right lower limb pain, low back pain, lower limb sensation, muscle strength, and reflex abnormalities between the two groups (P > 0.05). Positive expressions of TGF-β1, TNF-α, and IL-1α and thicker ligamentum flavum were more prevalent in the LSS group than in the lumbar intervertebral disc herniation group. All indexes were significantly (P < 0.05) higher in the moderate stenosis group than in the severe stenosis group. Additionally, the thickness of the ligamentum flavum and the positive expression rates of TNF-α, TGF-β1, and IL-1α were higher in the mild and moderate stenosis groups than in the severe stenosis group. The expression levels of TNF-α, TGF-β1, and IL-1α were favorably linked with ligamentum flavum thickness (P < 0.05). ROC curve analysis showed that the thickness of ligamentum flavum, the expression of IL-1α, the expression of TGF-β1, and the expression of TNF-α could effectively diagnose mild, moderate, and severe LSS (P < 0.05). Conclusion Ligamentum flavum hypertrophy and positive expression rates of IL-1α, TGF-β1, and TNF-α are closely linked to LSS, which can effectively identify mild, moderate, and severe LSS.

MRI grading of spinal stenosis is not associated with the severity of low back pain in patients with lumbar spinal stenosis

BackgroundAlthough lumbar spinal stenosis (LSS) often coexists with other degenerative conditions, few studies have fully assessed possible contributing factors for low back pain (LBP) in patients with LSS. The purpose of this study was to identify factors associated with the severity of LBP in patients with LSS.MethodsThe patients with neurogenic claudication caused by LSS, which was confirmed by magnetic resonance imaging (MRI) were included in this cross-sectional study. Data included ratings of LBP, buttock and leg pain, and numbness on a numerical rating scale (NRS), 36-item Short-Form Survey (SF-36) scores, muscle mass measured by bioelectrical impedance analysis, and radiographic measurements including lumbopelvic alignment and slippage. The severity of LSS, endplate defects, Modic endplate changes, intervertebral disc degeneration, and facet joint osteoarthritis were evaluated on MRI. Spearman correlation and multivariate linear regression analyses were used to examine the factors associated with the severity of LBP (NRS score).ResultsA total of 293 patients (135 male and 158 female, average age 72.6 years) were analyzed. LBP was moderately correlated with buttock and leg pain, and buttock and leg numbness. Significant but weak correlations were observed between LBP and body mass index, appendicular and trunk muscle mass, all domains of SF-36, pelvic tilt, total number of endplate defects and Modic endplate changes, and summary score of disc degeneration grading, but not severity or number of spinal stenoses. In the multivariate regression analysis, age, female sex, trunk muscle mass, diabetes, NRS buttock and leg pain, NRS buttock and leg numbness, SF-36 vitality, pelvic tilt, and total number of endplate defects were associated with the severity of LBP.ConclusionsTrunk muscle mass, lumbopelvic alignment, and endplate defects, but not severity of stenosis are partly associated with severity of LBP, but buttock and leg pain and buttock and leg numbness have strongest relationships with LBP in patients with LSS.

Endplate defects, not the severity of spinal stenosis, contribute to low back pain in patients with lumbar spinal stenosis

BACKGROUND CONTEXTIt is controversial whether lumbar spinal stenosis (LSS) itself contributes to low back pain (LBP). Lower truncal skeletal muscle mass, spinopelvic malalignment, intervertebral disc degeneration, and endplate abnormalities are thought to be related to LBP. However, whether these factors cause LBP in patients with LSS is unclear. PURPOSETo identify factors associated with LBP in patients with LSS. STUDY DESIGN/SETTINGCross-sectional design. PATIENT SAMPLEA total of 260 patients (119 men and 141 women, average age 72.8 years) with neurogenic claudication caused by LSS, as confirmed by magnetic resonance imaging (MRI). OUTCOME MEASURESRatings of LBP, buttock and leg pain, and numbness on a numerical rating scale (NRS), 36-Item Short Form Survey (SF-36) scores, muscle mass measured by bioelectrical impedance analysis, and radiographic measurements including slippage and lumbopelvic alignment. The severity of LSS, endplate defects, Modic endplate changes, intervertebral disc degeneration, and facet joint osteoarthritis were assessed on MRI. METHODSThe presence of LBP was defined as an NRS score ≥3. The demographic data, patient-reported outcomes, and radiological and MRI findings were compared between patients with and without LBP. Multivariate logistic regression analysis was used to identify the factors that were independently associated with the presence of LBP. RESULTSThere were significant differences between patients with and without LBP for buttock and leg pain and numbness on the NRS, general health on the SF-36, presence of endplate defects, presence of Modic changes, disc degeneration grading, and disc height grading (all p < .05). Multivariate logistic regression analysis showed significant associations between LBP and diabetes (OR 2.43; 95% CI 1.07–5.53), buttock and leg numbness on the NRS (OR 1.34; 95% CI 1.17–1.52), general health on the SF-36 (OR 0.97; 95% CI 0.95–0.99), and the presence of erosive endplate defects (OR 3.04; 95% CI 1.51–6.11) (all p < .05). CONCLUSIONSThese results suggest that LBP in patients with LSS should be carefully assessed not only for spinal stenosis but also clinical factors and endplate defects.

High Expression of Lysophosphatidic Acid Induces Nerve Injury in LSS Patients via AKT Mediated NF-κB p65 Pathway.

Lumbar spinal stenosis (LSS) is a spinal degenerative disease, complicated with nerve injury. Lysophosphatidic acid (LPA), a kind of glycerophospholipid molecule is elevated in the initial stages of neural injury. This research aimed to investigate the patho-mechanism of nerve injury caused by LPA in LSS patients. Twenty-five LSS patients and fifteen idiopathic scoliosis patients (without neurological symptoms) were recruited from Xianyang Central Hospital of Shanxi Province. We measured the concentration of LPA in cerebrospinal fluid samples of all subjects. Different concentrations (0.1, 1, and 10 mol/L) of LPA were used to stimulate Rat Neurons-spinal cord (RN-SC) cells. The effects of LPA on cell injury was detected by MTT and LDH (lactate dehydrogenase) assay. Cell apoptosis was determined by FCM (flow cytometry) and TUNEL staining. The changes in the expression of key proteins involved in Akt mediated NF-κB p65 pathway intervened by LPA were determined by western blot. RN-SC cells were pretreated with JSH-23 (NF-κB inhibitor) before LPA exposure, followed by cell apoptosis measurement. The concentration of LPA in LSS patients was notably higher than that in control patients (p < 0.01). The level of LPA was positively correlated with the severity of LSS. LPA treatment induced RN-SC cells displaying oval or rounded cell body with degenerated protrusion dose dependently. In addition, LPA decreased RN-SC cell viability and promoted cell apoptosis in a dose-dependent manner. LPA initiated Akt phosphorylation, IKB phosphorylation, and NF-κB nuclear translocation in a dose-dependent manner. However, JSH-23 (NF-κB inhibitor) pre-treatment prevented effects of LPA. The high levels of LPA induced nerve injury by reducing the viability of RN-SC cells and promoted cell apoptosis through Akt mediated NF-κB p65 signaling pathway. LPA might be a new therapeutic target for relieving nerve injury in LSS patients.

Association between fatty infiltration of paraspinal muscle, sagittal spinopelvic alignment and stenosis grade in patients with degenerative lumbar spinal stenosis

IntroductionSagittal balance and fatty infiltration of paraspinal muscle are important factors in patients with lumbar spinal stenosis (LSS) that may affect patients’ quality of life. Sagittal spinopelvic parameters and fatty infiltration may be associated with the severity of LSS. The purpose of this study was to test the hypothesis that severity of fatty infiltration correlates with severity of LSS and with sagittal pelvic alignment independent of age. MethodsAge and body mass index (BMI) were extracted. Fatty infiltration was rated according to Goutallier classification and the severity of LSS was graded according to Schizas at five intervertebral disc levels. Overall fatty infiltration was computed as average fatty infiltration (aFI) and severity of LSS was defined as the highest severity of LSS of all segments. The sagittal spinopelvic parameters pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL) and PI-LL were measured. Associations among parameters were assessed using Spearman correlation coefficients adjusted for age (α = 0.05). Results165 LSS patients with a median age of 69 years were included. All parameters correlated with age (R>0.162, P<0.05) except BMI and LL (R<0.007, P>0.05). aFI correlated with PI, PT and PI-LL before (R>0.371, P<0.05) and after (R>0.180, P<0.05) adjusting for age. Severity of LSS correlated with PI, PT and PI-LL before (R>0.187, P<0.05) but not after (R<0.130, P>0.05) adjusting for age. aFI correlated with severity of LSS before (R=0.349, P<0.05) but not (R=0.114, P>0.05) after adjusting for age. ConclusionsThe correlation of aFI with sagittal spinopelvic parameters indicates that there might be a relationship between muscle characteristics and the sagittal alignment. Sagittal spinopelvic parameters and fatty infiltration of paraspinal muscles are not associated with radiological severity of LSS. Whether they are associated with clinical manifestation of LSS remains to be investigated.

The relationship between the grading of lumbar spinal stenosis and pain improvement after caudal epidural steroid injection.

Objective: This study aimed to determine the relation of severity of lumbar spinal stenosis and pain improvement after caudal epidural injection.&#x0D; Material and Methods: 70 patients of neurogenic claudication were included from July 2019 to June 2020. MRI lumbosacral spine was done of all patients to categorize the degree of spinal stenosis on T2-W axial. All patients were given caudal epidural steroid injection as a day case procedure. Follow-up was done at 3 &amp; 8 weeks and pain improvement was assessed by using Ronald satisfaction score.&#x0D; Results: Mean age was 37.9 ± 7.8 years. 48.6% patients were male and 51.6% were female. The improvement was observed in 28 patients (40%) at 3 weeks and in 46 patients (65.7%) at 8 weeks. There was no statistically significant relationship between lumbar&#x0D; spinal stenosis and pain improvements at 3 weeks (p value 0.30) and 8 weeks (p value 0.32).&#x0D; Conclusion: The grade of lumbar spinal stenosis has no significant effect on pain improvement after caudal epidural steroid injection.&#x0D; Keywords: LSS (Lumbar spinal stenosis), caudal epidural steroid injection (ESI), neurogenic claudication, MRI (Magnetic resonance imaging), T2W (T2 weighted) images.

Lysophosphatidic acids and their substrate lysophospholipids in cerebrospinal fluid as objective biomarkers for evaluating the severity of lumbar spinal stenosis

Lysophospholipids (LPLs) are known to have potentially important roles in the initiation and maintenance of neuropathic pain in animal models. This study investigated the association between the clinical severity of lumbar spinal stenosis (LSS) and the cerebrospinal fluid (CSF) levels of LPLs, using human samples. We prospectively identified twenty-eight patients with LSS and fifteen controls with idiopathic scoliosis or bladder cancer without neurological symptoms. We quantified LPLs from CSF using liquid chromatography-tandem mass spectrometry. We assessed clinical outcome measures of LSS (Neuropathic Pain Symptom Inventory (NPSI) and Zurich Claudication Questionnaire (ZCQ)) and categorized patients into two groups according to their severity. Five species of lysophosphatidic acid (LPA), nine species of lysophosphatidylcholine (LPC), and one species of lysophosphatidylinositol (LPI) were detected. The CSF levels of all species of LPLs were significantly higher in LSS patients than controls. Patients in the severe NPSI group had significantly higher LPL levels (three species of LPA and nine species of LPC) than the mild group. Patients in the severe ZCQ group also had significantly higher LPL levels (four species of LPA and nine species of LPC). This investigation demonstrates a positive correlation between the CSF levels of LPLs and the clinical severity of LSS. LPLs are potential biomarkers for evaluating the severity of LSS.

Radiologic Evaluation Of Lumbar Spinal Stenosis: The Integration Of Sagittal And Axial Views In Decision Making For Minimally Invasive Surgical Procedures.

Radiologic findings in combination with clinical symptoms are critical in the diagnosis and evaluation of the severity of lumbar spinal stenosis (LSS) as well as the need for surgical treatment. Dynamic radiographs, computerized tomography (CT), and magnetic resonance imaging (MRI) each provide different but interrelated pieces of information in the patient with lumbar spinal stenosis. Making a treatment decision based only on one of the radiographic studies may negatively affect the treatment outcome. Minimal procedures are predicated on identifying and performing surgery on a limited segment of the lumbar spinal canal affected by the stenosis compared to what occurs during open surgery where the judgment of the spine surgeon often expanded the decompression area based on real-time intra-operative findings correlated with radiologic findings of stenosis. As newer, less invasive procedures are gaining acceptance for surgical treatment of spinal stenosis with symptomatic claudication, radiologic studies become more critical in selecting the correct procedure since there may be no or minimal surgical visual confirmation of the pathology. This article will review how the finding of spinal deformity and motion, canal dimensions, viewed in multiple planes and the presence of facet fluid impact treatment decisions. Differences in these abnormal radiologic findings can affect the selection of surgical procedures ranging from open decompression with pedicle fixation, decompression with interlaminar stabilization, minimally invasive lumbar decompression, and percutaneous interspinous implants providing distraction without decompression. With the development of less invasive procedures, lumbar spinal stenosis is being evaluated and treated not only by spine surgeons but also by interventional pain and neuroradiology physicians that may not be totally familiar with the complexity of the pathology and neuro-radiology of LSS. Each radiologic study provides different information. The goal of this report is to provide a framework for the use of studies such as plain X-rays, dynamic films, MRI, and CT scans as well as the importance of different views, and how to use them in evaluating the abnormal radiologic anatomy seen with LSS and in selecting the most appropriate procedure.

Diffuse idiopathic skeletal hyperostosis is associated with lumbar spinal stenosis requiring surgery.

Factors related to the onset and progression of lumbar spinal stenosis (LSS) have not yet been identified. Diffuse idiopathic skeletal hyperostosis (DISH) increases mechanical loading on the non-fused lumbar levels and may therefore lead to LSS. This cross-sectional study aimed to identify associations between LSS and DISH. This study included 2363 consecutive patients undergoing surgery for LSS and 787 general inhabitants without symptoms of LSS as participants of the population-based cohort study, Research on Osteoarthritis/Osteoporosis Against Disability. Standing whole-spine radiographs were used to diagnose DISH based on the criteria proposed by Resnick and Niwayama. The prevalence of DISH showed a significant step-wise increase among asymptomatic inhabitants without radiographic LSS, asymptomatic inhabitants with radiographic LSS, and patients with LSS requiring surgery (14.4, 21.1, and 31.7%, respectively; p<0.001). The distribution of DISH was similar between the groups, but the lower thoracic and upper-middle lumbar spine regions were more frequently involved in patients with LSS requiring surgery. Multivariate analysis indicated that DISH was an independent associated factor for LSS requiring surgery (adjusted odds ratio 1.65; 95% confidence interval 1.32-2.07) after adjustment for age, sex, body mass index, and diabetes mellitus. Among patients with LSS requiring surgery, a higher occurrence of stenosis at the upper lumbar levels and multi-level stenosis were observed in patients with DISH requiring surgery than in patients without DISH. In conclusion, DISH is independently associated with LSS requiring surgery. The decrease in the lower mobile segments by DISH may increase the onset or severity of LSS.

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

Introduction Several parameters exist for assessment of lumbar spinal stenosis (LSS) but none has shown to be an absolute criteria for defining the condition. Moreover these parameters lack clinical correlation to help physicians to decide on the plan of management. Aim To assess the clinical relevance of the qualitative grading described for LSS and to formulate a protocol for management of these group of patients. Materials and Methods A prospective study was undertaken between the period of 2014–15 using the qualitative grading based on T2 weighted MRI1 to assess the clinical outcome of 83 patients with clinical signs and symptoms suggestive of lumbar spinal stenosis at a single level to divide them into 7 morphological categories A 1–4,B, C, and D. Patients with more than two level stenosis, congenital stenosis, instability, having undergone previous surgery, other neurological disease were excluded. The diagnosis and the qualitative grading was done by a Senior surgeon not part of the study. Irrespective of the grade every patient underwent a minimum three month period of conservative management after which depending on the Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS) for pain was grouped into success or failure and the failed patients were advised for decompression surgery in form of laminectomy at the involved level. These patients were further grouped into success or failure after a period of three months after surgery. A 15 point decrease in ODI and a VAS scale of less than 5 on admission into the study was considered as a success. Results Out of the 83 patients there were 57 failure in conservative group while out of these 50 were operated of which only 10 did not match the success criteria, while the other 7 either refused surgery or were lost to follow up. As per the grading in types A1 and 2 only 2 patients out of 17 failed conservative trial while in all the other grades from A3 to D there was a gradual decline in success of conservative trial. In patients with grades C and D all patients failed conservative trial and required surgery. In comparison for grades A3 to D operative outcome had a significantly better outcomes as measured by the Chi-square test with p-value &lt; 0.05 considered significant. Conclusion We conclude that the qualitative grading can be used as a tool for decision making in LSS. Patients with grade A4, B, C and D should be advised for an early surgery to achieve a good functional outcome as there was a high incidence of failure of conservative management in these patients. While in patients with grade A1 to A3 a conservative management is to be recommended. Reference Schizas C, Theumann N, Burn A, et al. Qualitative grading of severity of lumbar spinal stenosis based on the morphology of the dural sac on magnetic resonance images. Spine 2010;35(21):1919–1924

Is There an Association Between Radiological Severity of Lumbar Spinal Stenosis and Disability, Pain, or Surgical Outcome?: A Multicenter Observational Study.

Observational multicenter study. To evaluate if the severity of lumbar spinal stenosis (LSS) on magnetic resonance imaging (MRI) correlates with preoperative disability, pain, or surgical outcomes. Surgeons use the morphological appearance of LSS on MRI for clinical decision making. However, the associations between radiological severity of LSS and disability, pain, or surgical outcomes remain unclear. Evaluation of severity of LSS on preoperative MRI according to the Schizas morphological classification. Patient and treatment data were retrieved from the Norwegian Registry for Spine Surgery. Preopertaive outcome measures were Oswestry disability index (ODI) and numeric rating scale (NRS) scores for back and leg pain. Postopertive outcome measures were ODI and NRS scores for back and leg pain at 1 year, changes in ODI and NRS scores after treatment, duration of surgery, length of hospital stay, and perioperative complications. Of 202 patients included, 7 were found to have mild stenosis, 38 had moderate stenosis, 108 had severe stenosis, and 49 had extreme stenosis. The radiological severity of LSS was not linked to preoperative ODI (P = 0.089), NRS back pain (P = 0.273), or NRS leg pain (P = 0.282) scores. There were no differences in ODI (P = 0.933), NRS back pain (P = 0.652), or NRS leg pain (P = 0.912) scores after 1 year. The radiological severity of stenosis was not associated with change in ODI (P = 0.494), NRS back pain (P = 0.235), NRS leg pain (P = 0.790), duration of surgery (P = 0.661), length of hospital stay (P = 0.739), or perioperative complication rates (P = 0.467). Among patients who underwent decompressive surgery for LSS, radiological severity of stenosis was not associated with preoperative disability and pain, or clinical outcomes 1 year after surgery. In this patient group, the radiological severity of LSS has no clear clinical correlation and should therefore not be overemphasized in clinical decision making. 2.

Elevated levels of phosphorylated neurofilament heavy subunit in the cerebrospinal fluid of patients with lumbar spinal stenosis: preliminary findings

Background contextThe phosphorylated neurofilament heavy subunit (pNfH) is an axon fiber structural protein that is released into the cerebrospinal fluid (CSF) after nerve damage. Although the previous studies have reported elevated CSF levels of pNfH in various neurological diseases, including amyotrophic lateral sclerosis, these levels have not been examined in patients with spinal stenosis. PurposeThe purpose of this study was to investigate the CSF levels of pNfH in patients with lumbar spinal stenosis (LSS) and to examine the relationship between CSF levels of pNfH and the severity of LSS. Study designThis is a prospective observational study. Patient sampleWe included consecutive patients with LSS who were undergoing myelography for preoperative evaluation. The CSF samples from patients with idiopathic scoliosis were used as the controls. Outcome measuresPhysiological measures: CSF levels of pNfH were measured using an enzyme-linked immunosorbent assay. The Zurich Claudication Questionnaire (ZCQ) and the Numerical Rating Scale (NRS) for sciatic pain were used to assess the clinical severity of LSS, and patients were grouped into tertiles according to their symptom severity and pain grading. Axial magnetic resonance imaging was used to evaluate the morphological severity of LSS, and patients were classified into three groups based on their morphological grading (using the CSF/rootlet ratio). MethodsAnalysis of variance was used to examine the relationship between the CSF levels of pNfH and the severity of LSS. ResultsThirty-three patients with LSS were included (13 men and 20 women and mean age 73.2 [range 58–88] years). Most patients (n=32) were positive for pNfH in their CSF (mean 1,344 [149–9,250] pg/mL), whereas all control subjects were negative for pNfH in their CSF. Regarding the association with clinical severity, patients in the third tertiles of ZCQ and NRS tended to have higher levels of pNfH compared with the other groups. There was no association between the CSF level of pNfH and the morphological severity of LSS. ConclusionsThis study detected elevated pNfH levels in the CSF of patients with LSS. Patients with severe clinical symptoms were more likely to exhibit high levels of pNfH. Our results indicate the potential usefulness of pNfH as a biomarker for compressive spinal disorders.

Correlation Between Severity of Lumbar Spinal Stenosis and Lumbar Epidural Steroid Injection

Lumbar spinal stenosis (LSS) is a narrowing of the spinal canal that causes mechanical compression of the spinal nerve roots. The compression of these nerve roots can cause leg pain, as well as neurogenic claudication. Lumbar epidural steroid injections have commonly been used in patients with LSS. The aim of our study was to determine the relationship between the severity of LSS using a grading system (grade 1 = mild stenosis with separation of all cauda equina; grade 2 = moderate stenosis with some cauda equina aggregated; grade 3 = severe stenosis with none of the cauda equina separated) and the subject's response to computed tomography-guided lumbar epidural steroid injection (CTG-LESI) and to evaluate the short-term effectiveness. Forty-seven consecutive patients with degenerative LSS were enrolled in this prospective study. All subjects underwent lumbar spine magnetic resonance imaging. Two radiologists independently graded lumbar central canal stenosis based on T2-weighted axial images. All CTG-LESI were performed in the procedure room. Outcome measures were obtained using the 5-point patient's satisfaction scale at 2 and 8 weeks post-treatment. To evaluate the outcome, we divided the patients into two groups according to their response to the treatment. Improvement (including reports of slightly improved, much improved, and no pain) was observed in 37 patients (78.7%) at 2 weeks and 36 patients (77.6%) at 8 weeks after the procedure. There was no statistically significant correlation between pain relief and age. The grade of LSS appears to have no effect on the degree of pain relief associated with CTG-LESI. However, CTG-LESI seems to provide effective short-term pain relief due to LSS.