Tandem Stenosis Research Articles

0034: Carotid Interpretation Criteria. How to Choose What You Use

The first criteria for estimation of carotid stenosis were developed by the Strandness group at the University of Washington in the 1980s. Others proposed different criteria around the same time. The major carotid surgery trials of the 1990s (NASCET, ECST and ACAS) prompted the development of CDUS criteria to match the 70% and 60% ICA diameter reducing stenosis cut-offs used in these trials. It is to be remembered that these trials used differing methods for estimating stenosis. B mode measurement of stenosis has improved substantially on modern duplex scanners. In 1988 Gray-Weale proposed a classification of carotid plaques on the basis of their echogenicity. Recently interest has returned to plaque characterization with measurement of Gray scale median and other features in an attempt to identify the “vulnerable carotid plaque” and better select asymptomatic patients who might benefit from intervention. The diagnosis of ICA occlusion is important clinically but is not 100% accurate with any of the available imaging modalities. Anatomic information regarding abnormal height of the bifurcation (high or low), the distal extent of the plaque, the diameter of the distal ICA and the presence of tortuosity or kinking of the vessels is also important information and may prompt additional imaging. Care is required in the interpretation of the CDUS and application of standard criteria in a variety of circumstances including contralateral high-grade ICA stenosis or occlusion; elevated CCA velocities and proximal stenosis; tandem ICA stenosis; altered cardiac output states and valvular heart disease, and the presence of intracranial disease. Standard criteria are employed for restenosis follow-up after CEA. Dimensions of the patched bulb should be recorded for serial follow-up. Different criteria with higher cut-off velocities for restenosis and B mode assessment of stent apposition are required following carotid stenting (CAS). A number of consensus panel criteria for carotid stenosis have been developed including the Society of Radiologists in Ultrasound Carotid Stenosis Consensus Conference Criteria (2002) and in Australia, the ASUM criteria (1999). Ideally individual vascular laboratories should validate the criteria they use with the results of alternative imaging modalities and operative pathology. The reality however is that this is increasingly difficult with a reduction in the use of conventional angiography and the dispersion of comparative imaging between CTA, MRA and angiography, each of which has its own inherent limitations for stenosis measurement. This presentation will discuss carotid interpretation criteria with particular emphasis on how the information assists the practicing clinician.

Vertebral artery ostial stent placement for atherosclerotic stenosis in 72 consecutive patients: clinical outcomes and follow-up results

The study's purpose is to report the technical and clinical outcomes of a patient cohort that underwent vertebral artery ostium stent placement for atherosclerotic stenosis. We retrospectively analyzed a prospectively collected database of neurointerventional procedures performed at a single center from 1999 to 2005. Outcome measures included recurrent transient neurological deficits (TNDs), stroke, and death. Kaplan-Meier analysis was used to estimate stroke- and/or death-free survival at 12 months. Cox proportional hazard was used to identify risk factors for recurrent vertebrobasilar ischemic events. Seventy-two patients with 77 treated vertebral ostial lesions were included. The 30-day stroke and/or death rate was 5.2% (n = 4), although no event was directly related to the vertebral ostium stent placement. Three procedure-related strokes were secondary to attempted stent placement at other sites (one carotid artery and two basilar arteries), and the one death was secondary to the presenting stroke severity. The mean clinical follow-up time available for 66 patients was 9 months. There were 14 TNDs (21%), two strokes (3%), and two deaths (3%) recorded in the follow-up. Recurrent vertebrobasilar ischemic events occurred in nine patients (seven TNDs and two strokes). No recurrent stroke and/or deaths were related to the treated vertebral ostium. Stroke- and/or death-free survival rate (including periprocedural stroke and/or death) was 89 +/- 5% at 12 months. No vascular risk factor was significantly associated with recurrent vertebrobasilar ischemic events. Vertebral artery ostium stent placement can be safely and effectively performed with a low rate of recurrent stroke in the territory of the treated vessel. Patients who also underwent attempted treatment of a tandem intracranial stenosis appeared to be at highest risk for periprocedure stroke.

The role of indirect extracranial-intracranial bypass in the treatment of symptomatic intracranial atheroocclusive disease

The optimal treatment of medically refractory intracranial atheroocclusive disease remains unclear. The EC-IC Bypass Study Investigators found that patients with internal carotid and middle cerebral artery (ICA and MCA) occlusion received no benefit from direct superficial temporal artery to MCA bypass, and that patients with ICA occlusion and MCA stenosis may have actually fared worse after surgery, perhaps in part due to flow reversal in critical perforator-bearing segments. Although the results of recent investigations have suggested that direct bypass may be beneficial in a subgroup of patients with hemodynamic failure secondary to unilateral ICA occlusion, similar data do not exist for patients with hemodynamic failure from other intracranial stenoocclusive diseases. Indirect bypass via encephaloduroarteriosynangiosis offers a surgical alternative that may avoid rapid flow reversal while providing additional flow to at-risk, distal vascular territories. Twelve patients with medically resistant hemodynamic failure from intracranial atheroocclusive disease underwent indirect vascular bypass. Eight patients had ICA occlusion and coexistent MCA stenosis, 1 patient had tandem ICA stenoses and MCA stenosis, 1 patient had tandem ICA and MCA occlusion, 1 patient had ICA and posterior cerebral artery occlusion and an ischemic hemisphere supplied via a proximal superficial temporal artery branch, and 1 patient had poor donor arteries and severe medical comorbidities that precluded the use of general anesthesia. Patient evaluation included clinical assessment of neurological status, CT scanning, MR imaging, digital subtraction angiography, and transcranial Doppler ultrasonography with CO(2) reactivity, or SPECT with acetazolamide challenge. Patient records were reviewed and patients were interviewed for outcome assessment, including transient ischemic attack (TIA), cerebral infarction, change in cerebral perfusion, graft patency, and functional level according to the modified Rankin scale. Kaplan-Meier cumulative failure curves for the primary end point of cerebral infarction were used to compare these patients to a control group of 81 patients derived from the literature who received medical management for severe symptomatic hemodynamic failure. Eleven patients underwent encephaloduroarteriosynangiosis and 1 patient received bur holes with dural and arachnoid incisions; the mean length of follow-up was 51.2 +/- 40.1 months. Five patients had decreased perfusion on follow-up despite graft patency, and 10 patients suffered new infarctions or TIAs during the follow-up period. Five patients (42%) suffered infarctions within 1 year of surgery. A meta-analysis of 4 studies of patients with symptomatic ICA occlusion and severe hemodynamic failure who underwent medical treatment revealed a new infarction rate of 30% in the first year after entry into the study. There was no significant difference between patients with severe hemodynamic failure who underwent surgery and those in the medically treated control group (log-rank test, p = 0.179). The authors found that indirect bypass does not promote adequate pial collateral artery development and appears to be of limited utility in patients with symptomatic ICA or MCA stenoocclusive disease and secondary hemodynamic failure. Rates of postoperative TIAs or cerebral infarctions after indirect bypass in this patient population do not differ from previous reports in patients who received medical management only.

Safety of Angioplasty and Stenting Without Thrombolysis for the Treatment of Early Ischemic Stroke

Strokes from large-vessel atherosclerotic occlusions or severe stenoses are often resistant to re-canalization with thrombolytic agents. As in acute coronary syndromes, angioplasty and stenting for stroke may be used to achieve timely reperfusion with possibly less risk for hemorrhagic complications. From a prospectively collected database, we have retrospectively reviewed cases of patients presenting acutely with an ischemic stroke or subacutely with fluctuating ischemic deficits due to a large-vessel atherosclerotic stenosis and who were treated with angioplasty and stenting without thrombolytics. Endpoints were reperfusion based on the Thrombolysis in Myocardial Infarction (TIMI) score, procedural complications, parenchymal hematoma formation leading to neurologic decline, and 30-day clinical improvement based on the National Institutes of Health Stroke scale (NIHSS). Nine patients with a mean age of 70 +/- 9 years and mean NIHSS of 18.3 +/- 5.0 were treated. Culprit stenotic lesions were located in the extracranial internal carotid artery (ICA) origin (2), intracranial ICA (2), tandem stenosis in the extra- and intracranial ICA (3), and middle cerebral artery (2). Eight patients were treated with angioplasty and adjunctive stenting; one of these patients also required snaring of thrombus from the middle cerebral artery. One patient was treated with angioplasty of an intracranial ICA stenosis alone. TIMI 3 reperfusion was achieved in 8 (88.9%) patients. The mean 30-day improvement in the NIHSS was 15.5 +/- 5.6. Six patients had a NIHSS of 0 or 1 at 30 days. One patient died due to reasons unrelated to stroke or interventional procedure. There were no significant complications or parenchymal hemorrhages. In appropriately selected patients with ischemic deficits due to large artery atherosclerotic stenoses, angioplasty with adjunctive stenting can be safely performed. Such interventions may improve outcome without the use of thrombolysis.

Long-Term Outcome of Tandem Stenting for Stenoses of the Intracranial Vertebrobasilar Artery and Vertebral Ostium

Patients with symptomatic atherosclerotic stenosis of the intracranial vertebrobasilar artery (VBA) have a poor prognosis, and those with coexistent intracranial and extracranial stenoses have worse outcomes despite medical therapy. Our aim was to study the long-term outcome of patients with symptomatic atherosclerotic tandem stenoses at the intracranial VBA and the vertebral artery ostium (VAO) after elective stent placement. Ten consecutive patients (mean age, 65.3 years) with this condition underwent elective stent placement at our institution between September 2001 and December 2007. Technical success was defined as stent placement of both VAO and intracranial VBA stenoses with complete stent coverage of the lesions, residual stenosis of < or = 30%, and good antegrade blood flow. The study end point was a composite of any stroke or death within 30 days and ischemic stroke in the VBA territory after 30 days. Technical success was obtained in 9 of 10 patients without any stroke or death within 30 days. During a median follow-up duration of 32 months, 1 patient had a fatal ischemic stroke in the VBA territory at 4 months, and the other 9 patients were free from stroke recurrence. Thus, the annual stroke rate in VBA territory (including any stroke or death within 30 days) was 3.8%. This pilot study shows that elective stent placement for patients with symptomatic atherosclerotic tandem stenoses at the intracranial VBA and VAO has an acceptable long-term outcome and may be considered as an alternative to medical therapy.

The value of 3D-CT angiographic assessment prior to carotid stenting

Anatomic suitability for carotid artery stenting (CAS) is determined by arteriography, but this has a discrete stroke risk. We evaluated the use of multidetector CT angiography with three-dimensional reconstruction (3D-CTA) as a noninvasive screening tool for prospective CAS patients. Between 2003 and 2006, 90 CAS procedures were performed by vascular surgeons at our institution. At the discretion of the operating surgeon, 59 of the potential candidates for CAS underwent screening 3D-CTA of the aortic arch and carotid arteries. Results were used in patient selection and then analyzed retrospectively to determine clinical utility. Analysis of 3D-CTA data by the operating surgeon allowed stratification of patients into four groups: (1) appropriate for CAS via femoral approach (n = 37, 63%); (2) appropriate for CAS with transcervical access due to adverse arch anatomy (n = 2, 3%); (3) borderline anatomy for CAS (n = 5, 9%); or (4) not appropriate anatomy for CAS (n = 15, 25%). Group 1 had 100% technical success with one minor stroke. Group 2 had successful transcervical CAS without stroke. Group 3 patients underwent arteriography but CAS was aborted in four out of five cases for the same reason that had been identified by 3D-CTA (internal carotid artery [ICA] tortuosity n = 2, ICA string sign with distal disease n = 2). The one failure in group 3 was the result of a previously placed common carotid stent extending into an already unfavorable aortic arch. Group 4 patients underwent endarterectomy (n = 7) or continued medical management (n = 8) instead of CAS (without arteriography) because of the following reasons, cited alone or in combination: common carotid tandem stenosis n = 5, difficult arch anatomy n = 2, ICA tortuosity n = 2, extreme lesion calcification or length n = 4, ICA string sign or occlusion n = 3, concomitant intracranial disease n = 2, and stenosis overestimated by duplex n = 3. The overall 30-day stroke rate, on an intention to treat basis, for patients that underwent preprocedural 3D-CTA was 2.3% (one major [NIH stroke scale >3] and one minor stroke). In our initial experience, 3D-CTA reconstruction of the aortic arch and carotid arteries significantly influenced the plan for CAS in 37% of patients. Patients with clear anatomic contraindications to CAS can be excluded without the risks of arteriography. 3D-CTA further facilitates the CAS procedure by anticipating potential procedural. The cost-effectiveness and potential impact of this imaging modality on CAS outcomes deserve further study.

Tandem High-grade Stenoses in the Innominate and Right Internal Carotid Arteries Diagnosed with Carotid Duplex Ultrasound

Peak systolic velocity criteria for assessing the severity of internal carotid artery (ICA) stenosis may be inadequate in the setting of a critical proximal lesion. A 54-year-old man with a history of panvascular atherosclerosis presented for re-evaluation of known carotid stenosis. Carotid duplex ultrasound was performed by using B-mode ultrasound (Philips) with color and pulsed Doppler. Velocities within the innominate artery were markedly increased (PSV 553 cm/sec; EDV 211 cm/sec), consistent with high-grade stenosis. Waveforms in the right subclavian and common carotid (CCA) arteries were poststenotic in appearance, and velocity in the distal right CCA was very low (PSV 39 cm/sec). There was an additional step-up in velocity in the proximal right ICA with extensive homogeneous plaque visualized (right ICA PSV 210 cm/sec; EDV 115 cm/sec). Although the ICA lesion did not meet peak systolic velocity or end diastolic velocity criteria for &gt;80% stenosis in our laboratory, the lesion was interpreted as an 80–99% lesion on the basis of the markedly increased ICA/CCA ratio (ICA/CCA ratio 5.38). The left subclavian artery had low, monophasic flow and was likely occluded near its origin with filling from a retrograde vertebral artery. The patient was referred for percutaneous intervention. Angiography confirmed a 99% stenosis of the innominate artery and a 90% stenosis of the right ICA in its proximal portion. The left subclavian artery was occluded. The left CCA arose from a bovine aortic arch. The innominate and right ICA lesions were treated successfully with balloon angioplasty and stenting. Duplex ultrasound is an outstanding diagnostic tool for the evaluation of extracranial carotid and innominate lesions. In the setting of tandem lesions, critical stenosis of the ICA may be missed with reliance on traditional PSV criteria alone. In such cases, interpretation of secondary criteria, particularly the ICA/CCA ratio, is crucial to establish an accurate diagnosis.

Carotid endarterectomy with simultaneous retrograde common carotid artery stenting: Technical Considerations

Carotid endarterectomy with simultaneous retrograde common carotid artery stenting (CEA-RCCAS) is performed with increasing frequency to treat tandem common and internal carotid artery stenoses. Technical details are not clearly delineated in the literature. Our procedure aims to maximize procedural ease and cerebral protection. Although the need for the endovascular component being performed first, followed by shunt placement, and the use of short wires and sheaths has been advocated, we describe the avoidance of shunt placement and the use of long sheaths to facilitate the procedure using local anesthesia and cervical blockade. Use of local anesthesia, avoidance of a shunt, and use of a long sheath may increase the procedural applicability and safety in some patients. CEA-RCCAS permits safe simultaneous treatment of tandem common and internal carotid artery stenoses. The use of technical adjuncts described here will permit further expansion of the procedure to allow additional patients to be treated in this hybrid fashion.

Percutaneous saphenous vein graft intervention with sequential embolic protection devices: Complementing lesion anatomy with embolic protection device

Saphenous vein graft (SVG) percutaneous coronary intervention (PCI) carries unique technical challenges requiring the utilization of embolic protection devices (EPDs) to reduce the adverse events associated with distal embolization. Distal embolization is a common and almost ubiquitous consequence of SVG PCI due to the soft and friable nature of the SVG lesions. We describe a case of revascularizing a SVG with tandem stenoses employing the use of two different EPDs that complemented their respective lesion's location within the SVG.

Stenting of Symptomatic Basilar and Vertebral Artery Stenosis in Patients Resistant to Optimal Medical Prevention: The Lyon Stroke Unit Experience

Intracranial angioplasty stenting may be an efficient therapy in patients with intracranial atherosclerotic symptomatic vertebrobasilar artery stenosis unresponsive to optimal medical therapy. We present our experience in this setting. Results: The study included 12 cases (8 men, 4 women), with an age range of 43–78 years (mean 62.6 years). Intracranial stenosis that resulted in qualifying stroke or transient ischemic attack involved the vertebral artery (n = 4), lower basilar artery (n = 1) and mid basilar artery (n = 5). Tandem stenosis included the intracranial vertebral artery and basilar artery (n = 1) and both intracranial vertebral arteries (n = 1). The degree of stenosis ranged between 70 and 90% in the basilar and vertebral arteries. Angioplasty + stenting was performed in all lesions. A successful procedure resulting in 30% of residual stenosis was found in 14 vessels. A periprocedural adverse event occurred in 1 case and was related to a brain hemorrhage. The mean patient follow-up was 15 ± 3 months; 10 patients remained symptom free. All patients underwent a percutaneous endovascular balloon angioplasty and stent placement. Conclusions:This study supports the safety and the potential efficiency of stent-assisted angioplasty in patients resistant to optimal prevention. Randomized larger prospective trials are needed to confirm the benefit of this approach.

Single-staged sequential endovascular stenting in patients with in tandem carotid stenoses

Background and purpose: Simultaneous stenoses at the origin of the internal carotid artery and the carotid siphon, also known as 'in tandem stenoses', are not uncommon. However, the clinical importance of this condition is still a subject of controversy. Surgical and endovascular approaches have been proposed to manage symptomatic patients who fail antithrombotic therapy.Methods: We present a series of eight patients with symptomatic in tandem carotid artery stenoses treated by sequential endovascular stent-assisted angioplasty. In all the cases, the intracranial stenosis was equal to, or greater, than the extracranial stenosis.Results: Procedural success, defined as residual stenosis of less than 30% in extracranial and intracranial lesions, was obtained in all the cases. No patient sustained myocardial infarction, stroke or transient ischemic attack (TIA) during the procedure or hospital stay. During a mean clinical follow-up of 12 ± 3.4 months (range: 7–20 months), there were no neurological events and on angiographic follow-up after 6 months, no patient presented in-stent de novo stenosis.Conclusion: Endovascular stent-assisted angioplasty appears to be a valid alternative for selected patients with symptomatic in tandem carotid stenoses that are refractory to medical treatment. In most of the cases, the characteristics of intracranial stenoses determine the feasibility of the procedure.

Tandem stenosis: a cadaveric study in osseous morphology

Background Tandem stenosis is the occurrence of concurrent cervical and lumbar stenosis. The prevalence has been estimated to be from 5% to 25%. Symptomatic tandem stenosis can present with a confusing scenario of both neurogenic claudication and myelopathy symptoms. Purpose The purpose of this study was to determine 1) the prevalence of anatomic tandem stenosis in a cadaveric population, 2) if there was an associative relationship between lumbar and cervical stenosis, and 3) the positive predictive values of stenosis in one area for stenosis in the other. Study design We obtained 440 skeletally mature skeletons and examined the cervical and lumbar spines from the Hamann Todd Collection in the Cleveland Museum of Natural History. Methods For the cervical spine, we measured the mid-sagittal canal diameter using digital calipers for every level from C3 through C7. The minimum full central sagittal diameter was recorded for each level. For the lumbar spine, we measured the minimum full mid-sagittal canal diameter for every level from L1 through L5, using digital calipers. Stenosis was defined as a mid-sagittal canal diameter of less than 12 mm at at least one level. After analysis of this data, a second analysis was performed after correcting the data for contemporary body size and radiographic manifestation. Results The prevalence of tandem stenosis ranged from 0.9% to 5.4% in this population. The association of cervical and lumbar stenosis was found to be statistically significant (p<.05). Stenosis in one part of the spine positively predicts for stenosis in the other area of the spine 15.3% to 32.4% of the time. Conclusion Tandem stenosis should be considered when evaluating a patient with mixed claudication and myeloradiculopathy symptoms.

Treatment of tandem spinal stenosis

Treatment of tandem spinal stenosis

Tandem spine stenosis: Clinical assessment and therapeutical management

Tandem spine stenosis: Clinical assessment and therapeutical management

Combined (Tandem) Lumbar and Cervical Stenosis

Cervical and lumbar spinal stenosis frequently coexist in patients presenting with clinical manifestations of one of these conditions. It is important for the clinician to be aware of the possibility that asymptomatic cervical stenosis, or symptomatic myelopathy from spinal cord compression, may be present in a patient presenting with symptoms of lumbar spinal stenosis. In general, symptomatic cervical stenosis should be addressed surgically before operating on lumbar stenosis. This article examines the incidence of tandem stenosis and management strategies for dealing with it.

Massive stroke in a patient with pituitary apoplexy, cervical carotid artery stenosis and hypotension

We report a case of massive cerebral infarct in the early stage of pituitary apoplexy. The case is unique because the stroke was delayed and occurred only after the patient developed severe arterial hypotension superimposed on a tandem internal carotid artery stenosis by both the sellar mass on the siphon and an unknown homolateral atheromatous cervical lesion. Illustrated with MRI and specifically by diffusion-weighted imaging, this case reinforces the idea that a low apparent diffusion coefficient in a non-enhancing sellar mass may indicate the presence of pituitary apoplexy and help in the early adequate management of such patients.

Intraoperative perfusion computerized tomography scanning for management of intracranial stent placement in a patient with tandem intracranial stenoses

The authors describe the novel use of cerebral perfusion computerized tomography studies to evaluate the effectiveness of internal carotid artery stent placement in a man with symptomatic transient ischemic attacks caused by tandem stenoses of the internal carotid and middle cerebral arteries.

Primary Stenting of Intracranial Atherosclerotic Stenoses

To determine the feasibility and safety of stenting intracranial atherosclerotic stenoses. In 12 patients the results of primary intracranial stenting were evaluated retrospectively. Patient ages ranged from 49 to 79 years (mean 64 years). Six patients presented with stenoses in the anterior circulation, and six had stenosis in the posterior circulation. One patient presented with extra- and intracranial tandem stenosis of the left internal carotid artery. Three patients presented with acute basilar thrombosis, caused by high-grade basilar stenoses. Intracranial stenoses were successfully stented in 11 of 12 patients. In one patient the stent could not be advanced over the carotid siphon to reach the stenosis of the ophthalmic internal carotid artery. Follow-up digital subtraction angiographic studies were obtained in two patients who had presented with new neurologic signs or symptoms. In both cases the angiogram did not show any relevant stenotic endothelial hyperplasia. In one patient, after local thrombolysis the stenosis turned out to be so narrow that balloon angioplasty had to be performed before stent deployment. All three patients treated for stenosis-related basilar thrombosis died due to brainstem infarction that had ensued before the intervention. Prophylactic primary stenting of intracranial stenoses of the anterior or posterior cerebral circulation can be performed with a low complication rate; technical problems such as stent flexibility must still be solved. Local thrombolysis followed by stenting in stenosis-related thrombotic occlusion is technically possible.

Technical challenges in a program of carotid artery stenting

Successful carotid artery stenting (CAS) involves gaining access to the common carotid artery, characterizing and crossing the lesion, deploying an anti-embolic device and stent, and retrieving the anti-embolic device. These steps are critical determinants of the complexity of the procedure. The frequency with which technical challenges are encountered during CAS is ill-defined. The purpose of this investigation was to review the incidence and types of technical challenges encountered during CAS and determine their effect on outcome. Data were prospectively collected for 194 consecutive CAS procedures (177 patients) and separated into group 1, standard CAS technique, and group 2, procedures with technical challenges requiring modifications to the technique. Technical challenges were defined as difficult femoral arterial access (aortoiliac occlusive disease), complex aortic arch anatomy (elongated or bovine arch, deep takeoff of the innominate artery, tandem stenoses (CCA, innominate artery), difficult internal carotid artery anatomy (tortuosity, high-grade stenosis), and circumferential internal carotid artery calcification. The incidence of technical challenges, types of technical modifications required, and effect on outcomes were determined. Fifty technically challenging situations (26%) were encountered in 194 CAS procedures (group 2), which required advanced technical skills. Standard methods were used in the other 144 procedures (group 1, 74%). No significant differences in 30-day stroke and death rates were noted between the groups (group 1, 3.1%; group 2, 2.0%; P = .564). Twenty-six percent of the procedures required a modification in the standard technique for successful CAS. Circumferential calcification and severe tortuosity continue to be relative contraindications to CAS. Recognition of these technical challenges and increasing facility with the methods to manage them will enable expanded use of CAS without increased morbidity and mortality.

Poster 75: Concurrent (tandem) cervical and lumbar spinal stenosis: a 10-year review of 54 hospitalized patients

Objective: To determine the prevalence of simultaneous cervical and lumbar spinal stenosis, that is, tandem spinal stenosis based on a 10-year review of hospital admissions. Design: A retrospective study of 460,964 hospital admissions. Setting: A 940-bed academic community hospital. Participants: A base population of 54 patients with tandem spinal stenosis. Intervention: Not applicable. Main Outcome Measures: Patients presented with multiple complaints including, among others, neurogenic claudication, progressive gait disturbances, as well as neurologic signs of both upper- and lower-motoneuron dysfunction. Since 1964, when tandem spinal stenosis was first described, estimates as to its prevalence have varied widely from a low of 5% to a high of 28%. Results: 54 (.012%) cases of tandem spinal stenosis were identified in 460,964 patient admissions during a 10-year period. Of this number, 36 (66.7%) were men and 18 (33.3%) were women. 51 (94.4%) were older than 51 years of age. For all ages, the incidence rate of tandem spinal stenosis in this series was 12 per 100,000. Conclusion: With tandem spinal stenosis the symptoms of either the cervical and/or the lumbar clinical complaints are usually preeminent. Only after the primary pathology is treated does the secondary problem become evident, that is, a decompressive lumbar laminectomy unmasks Babinski reflexes as the first clinical sign of a previously occult cervical spinal stenosis. Although significant tandem spinal stenosis occurs relatively infrequently, in this series (>1%) its potential for interfering with patient recovery should not be overlooked.