Lumbar spinal stenosis diagnosis

Lumbar spinal stenosis diagnosis

Diagnosing lumbar spinal stenosis or herniated intervertebral disc is usually helpful only in potential surgical candidates 1).

Boden et al., performed magnetic resonance imaging on sixty-seven individuals who had never had low back pain, sciatica, or neurogenic claudication. The scans were interpreted independently by three neuro-radiologists who had no knowledge about the presence or absence of clinical symptoms in the subjects. About one-third of the subjects were found to have a substantial abnormality. Of those who were less than sixty years old, 20 per cent had a herniated nucleus pulposus and one had spinal stenosis. In the group that was sixty years old or older, the findings were abnormal on about 57 per cent of the scans: 36 per cent of the subjects had a herniated nucleus pulposus and 21 per cent had spinal stenosis. There was degeneration or bulging of a disc at at least one lumbar level in 35 per cent of the subjects between twenty and thirty-nine years old and in all but one of the sixty to eighty-year-old subjects. In view of these findings in asymptomatic subjects, they concluded that abnormalities on magnetic resonance images must be strictly correlated with age and any clinical signs and symptoms before operative treatment is contemplated 2).


Results of a survey suggested that there are no broadly accepted quantitative criteria and only partially accepted qualitative criteria for the diagnosis of lumbar spinal stenosis. The latter include disk protrusion, lack of perineural intraforaminal fat, hypertrophic facet joint degeneration, absent fluid around the cauda equine, and hypertrophy of the ligamentum flavum 3).

There is still no widely accepted diagnostic or classification criteria for the diagnosis of Lumbar spinal canal stenosis LSS and as a consequence studies use widely differing eligibility criteria that limit the generalizability of reported findings 4).

There are no universally accepted radiographic definitions for the diagnosis of central, lateral recess and foraminal stenosis.


Most studies of Lumbar central canal spinal stenosis diagnosis (LCCSS) rely on criteria published by Verbiest et al. 5). He defined relative spinal stenosis as a diameter between 10 and 12 mm whereas absolute stenosis was a diameter less than 10 mm. This method has been criticized for ignoring the trefoil shape of the LSS and the intrusion of ligamentum flavum and disc material in degenerative stenosis 6).

Magnetic resonance imaging

Magnetic resonance imaging (MRI) is most commonly used for the clinical assessment of degenerative LCCSS. LCCSS is a quantitative diagnosis that is made when the measurement of an individual is outside the range of normal. Thus, the criteria for LCCSS should be compared from an analysis of a normative distribution of measurements 7) 8)

In a meta-analysis, CT and MRI were found to have similar accuracy for the assessment of central stenosis 9).

By using a combination of magnetic resonance imaging (MRI) and computed tomography (CT) of the lumbar spine, it is possible to distinguish between spinal stenosis caused by bone compression and specific soft tissue epidural intraspinal lesions that cause localized spinal canal stenosis and neural compression. Examples include facet cysts and yellow ligament hypertrophy 10).

Because imaging findings of lumbar spinal stenosis (LSS) may not be associated with symptoms, clinical classification criteria based on patient symptoms and physical examination findings are needed 11).

Magnetic resonance imaging (MRI) has replaced myelography, now considered an old-fashioned technique. In selected cases with multilevel lumbar spinal stenosis, functional myelography revealed the highest precision in reaching a correct diagnosis. It resulted in a change in the surgical approach in every fifth patient in comparison with the MRI and proved most helpful, especially in elderly patients 12).

Cross sectional area

Narrowing of the lumbar dural sac cross sectional area (DSCSA) and spinal canal cross-sectional area (SCCSA) have been considered major causes of lumbar central canal spinal stenosis (LCCSS). DSCSA and SCCSA were previously correlated with subjective walking distance before claudication occurs, aging, and disc degeneration. DSCSA and SCCSA have been ideal morphological parameters for evaluating LCCSS.

To evaluate lumbar central canal spinal stenosis (LCCSS) patients, pain specialists should more carefully investigate the dural sac cross-sectional area (DSCSA) than spinal canal cross-sectional area (SCCSA) 13).

Schonstrom et al. showed that neurogenic claudication due to LSS was better defined by the cross-sectional area (CSA) of the dural sac, but that the CSA of the lumbar vertebral canal was unrelated to that of the dural sac 14). From in vitro 15) and in situ 16) studies, the authors postulated that constrictions above the critical size 70 to 80 mm2 would be unlikely to cause symptoms and signs of cauda encroachment. Subsequently, conflicting results have been published concerning the relationship between symptom severity and dural CSA. Even after axial loading, no statistically significant correlations were found in some studies 17). However, in another study, the use of the minimal CSA of the dural sac in central stenosis was found to be correlated with neurogenic claudication assessed measuring the maximum tolerated walking distance 18).

Electrodiagnostic studies

Patients with symptoms, physical examination and imaging findings consistent with LSS do not require additional testing. Although there is little evidence in the literature, electrodiagnostic evaluation is used in some patients with symptoms and findings that are equivocal or conflicting with imaging results and in whom procedures are being considered. Electrodiagnostic criteria for stenosis have been proposed:(47) mini-paraspinal mapping with a one side score > 4 (sensitivity 30%, specificity 100%), fibrillation potential in limb muscles (sensibility 33%, specificity 88%), absence of tibial H-wave (sensitivity 36%, specificity 92%). Better sensitivity was found for a composite limb and paraspinal fibrillation score (sensitivity 48%, specificity 88%) 19).

Diagnostic Screening

Jensen et al. developed a self-administered diagnostic screening questionnaire for lumbar spinal stenosis (LSS) consisting of items with high content validity and to investigate the diagnostic value of the questionnaire and the items.

The screening questionnaire was developed based on items from the existing literature describing key symptoms of LSS. The screening questionnaire (index test) was to be tested in a cohort of patients with persistent lumbar and/or leg pain recruited from a Danish publicly funded outpatient secondary care spine clinic with clinicians performing the reference test. However, to avoid unnecessary collection of data if the screening questionnaire proved to be of limited value, a case-control design was incorporated into the cohort design including an interim analysis. Additional cases for the case-control study were recruited at two Danish publicly funded spine surgery departments. Prevalence, sensitivity, specificity and diagnostic odds ratio (OR) were calculated for each individual item, and AUC (area under the curve) was calculated to examine the performance of the full questionnaire.

A 13-item Danish questionnaire was developed and tested in 153 cases and 230 controls. The interim analysis was not in favour of continuing the cohort study, and therefore, only results from the case-control study are reported. There was a positive association for all items except the presence of back pain. However, the association was only moderate with ORs up to 3.3. When testing the performance of the whole questionnaire, an AUC of 0.72 was reached with a specificity of 20% for a fixed sensitivity of 95%.

The items were associated with LSS and therefore have some potential to identify LSS patients. However, the association was not strong enough to provide sufficient accuracy for a diagnostic tool. Additional dimensions of symptoms of LSS need identification to obtain a reliable questionnaire for screening purposes 20).

References

1)

Deyo RA, Bigos SJ, Maravilla KR. Diagnostic imaging procedures for the lumbar spine. Ann Intern Med. 1989 Dec 1;111(11):865-7. Review. Erratum in: Ann Intern Med 1989 Dec 15;111(12):1050. PubMed PMID: 2530926.
2)

Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990 Mar;72(3):403-8. PubMed PMID: 2312537.
3)

Mamisch N, Brumann M, Hodler J, Held U, Brunner F, Steurer J; Lumbar Spinal Stenosis Outcome Study Working Group Zurich. Radiologic criteria for the diagnosis of spinal stenosis: results of a Delphi survey. Radiology. 2012 Jul;264(1):174-9. doi: 10.1148/radiol.12111930. Epub 2012 May 1. PubMed PMID: 22550311.
4)

Genevay S, Atlas SJ, Katz JN. Variation in eligibility criteria from studies of radiculopathy due to a herniated disc and of neurogenic claudication due to lumbar spinal stenosis: a structured literature review. Spine (Phila Pa 1976). 2010 Apr 1;35(7):803-11. doi: 10.1097/BRS.0b013e3181bc9454. Review. PubMed PMID: 20228710; PubMed Central PMCID: PMC2854829.
5)

Verbiest H. Pathomorphologic aspects of developmental lumbar stenosis. Orthop Clin North Am. 1975 Jan;6(1):177-96. PubMed PMID: 1113966.
6)

Eisenstein S. The trefoil configuration of the lumbar vertebral canal. A study of South African skeletal material. J Bone Joint Surg Br. 1980 Feb;62-B(1):73-7. PubMed PMID: 7351439.
7)

Chatha DS, Schweitzer ME. MRI criteria of developmental lumbar spinal stenosis revisited. Bull NYU Hosp Jt Dis 2011;69:303–7.
8)

Premchandran D, Saralaya VV, Mahale A. Predicting lumbar central canal stenosis—a magnetic resonance imaging study. J Clin Diagn Res 2014;8:RC01–4.
9)

Kent DL, Haynor DR, Larson EB, Deyo RA. Diagnosis of lumbar spinal stenosis in adults: a metaanalysis of the accuracy of CT, MR, and myelography. AJR Am J Roentgenol. 1992 May;158(5):1135-44. PubMed PMID: 1533084.
10)

Jacobson RE, Granville M, Hatgis DO J. Targeted Intraspinal Radiofrequency Ablation for Lumbar Spinal Stenosis. Cureus. 2017 Mar 10;9(3):e1090. doi: 10.7759/cureus.1090. PubMed PMID: 28413736; PubMed Central PMCID: PMC5388364.
11)

Genevay S, Courvoisier DS, Konstantinou K, Kovacs FM, Marty M, Rainville J, Norberg M, Kaux JF, Cha TD, Katz JN, Atlas SJ. Clinical classification criteria for neurogenic claudication caused by lumbar spinal stenosis. The N-CLASS criteria. Spine J. 2017 Oct 12. pii: S1529-9430(17)31052-5. doi: 10.1016/j.spinee.2017.10.003. [Epub ahead of print] PubMed PMID: 29031994.
12)

Morgalla M, Frantz S, Dezena RA, Pereira CU, Tatagiba M. Diagnosis of Lumbar Spinal Stenosis with Functional Myelography. J Neurol Surg A Cent Eur Neurosurg. 2018 Jan 18. doi: 10.1055/s-0037-1618563. [Epub ahead of print] PubMed PMID: 29346832.
13)

Lim YS, Mun JU, Seo MS, Sang BH, Bang YS, Kang KN, Koh JW, Kim YU. Dural sac area is a more sensitive parameter for evaluating lumbar spinal stenosis than spinal canal area: A retrospective study. Medicine (Baltimore). 2017 Dec;96(49):e9087. doi: 10.1097/MD.0000000000009087. PubMed PMID: 29245329; PubMed Central PMCID: PMC5728944.
14)

Schonstrom NS, Bolender NF, Spengler DM. The pathomorphology of spinal stenosis as seen on CT scans of the lumbar spine. Spine (Phila Pa 1976). 1985 Nov;10(9):806-11. PubMed PMID: 4089655.
15)

Schönström N, Bolender NF, Spengler DM, Hansson TH. Pressure changes within the cauda equina following constriction of the dural sac. An in vitro experimental study. Spine (Phila Pa 1976). 1984 Sep;9(6):604-7. PubMed PMID: 6495030.
16)

Schönström N, Hansson T. Pressure changes following constriction of the cauda equina. An experimental study in situ. Spine (Phila Pa 1976). 1988 Apr;13(4):385-8. PubMed PMID: 3406845.
17)

Lohman CM, Tallroth K, Kettunen JA, Lindgren KA. Comparison of radiologic signs and clinical symptoms of spinal stenosis. Spine (Phila Pa 1976). 2006 Jul 15;31(16):1834-40. PubMed PMID: 16845360.
18)

Ogikubo O, Forsberg L, Hansson T. The relationship between the cross-sectional area of the cauda equina and the preoperative symptoms in central lumbar spinal stenosis. Spine (Phila Pa 1976). 2007 Jun 1;32(13):1423-8; discussion 1429. PubMed PMID: 17545910.
19)

Genevay S, Atlas SJ. Lumbar spinal stenosis. Best Pract Res Clin Rheumatol. 2010 Apr;24(2):253-65. doi: 10.1016/j.berh.2009.11.001. Review. PubMed PMID: 20227646; PubMed Central PMCID: PMC2841052.
20)

Jensen RK, Lauridsen HH, Andresen ADK, Mieritz RM, Schiøttz-Christensen B, Vach W. Diagnostic Screening for Lumbar Spinal Stenosis. Clin Epidemiol. 2020;12:891-905. Published 2020 Aug 19. doi:10.2147/CLEP.S263646

Cauda equina syndrome due to intradural lumbar disc herniation

Cauda equina syndrome due to intradural lumbar disc herniation

Intradural lumbar disc herniation is rare, with an incidence of 0.3%-1%, but has been well reported in the literature. Transdural migration of the disc penetrating both ventral and dorsal dura is extremely rare, and there is a dearth of literature in the pathophysiology and surgical management of transdural herniation. Lack of knowledge on this type of presentation can cause intraoperative surprises and inadvertent cauda equina root injuries and lead to prolonged operative time. 1).

Diagnosis

Intradural disc prolapse remains a diagnostic dilemma as it is very difficult to diagnose all the cases preoperatively. The presence of MRI findings of mass effect in the form of displacement of the traversing nerve roots due to large central disc with crumble disc sign were suggestive of early evidence of intradural disc herniation. Y sign in ventral dura due to splitting of ventral dura and arachnoid mater by disc material was a good diagnostic sign to suspect intradural extra-arachnoid disc. The presence of hypointense structure inside the dura with no continuity with the adjacent intervertebral disc on MRI was highly suggestive of an intradural disc, in patients having the large central disc on MRI, especially at L4-L5 levels, should raise suspicion of intradural herniation of disc. 2).


Ducati et al. described five cases of this pathology and review the literature as well as some considerations about the difficulties in the preoperative diagnostic issues and the surgical technique.

They concluded that for intradural disc herniations the diagnosis is mainly intraoperative, and the surgical technique has some special aspects 3).


A female patient with lumbosciatic pain who developed an incomplete cauda equina syndrome. An asymmetric discopathy of the L2-L3 space and a gas bubble with disc material within the spinal canal was noticed in the radiologic explorations. The literature and the authors’ experience are reviewed with the aim of confirming the frequency of intradural herniation in association with gas in the spinal canal.

A laminoarthrectomy of the involved space was performed followed by direct intradural examination, which revealed a disc fragment that was excised. An instrumented L2-L3 arthrodesis was performed. Postoperative evolution was satisfactory. To date, the authors have found this association in 2% of the patients with intraspinal gas.

The potential presence of an intradural disc herniation must always be considered when performing an open discectomy on a patient whose CT scan study shows the presence of epidural gas. This association is particularly striking given the relative rarity of intradural herniations and intraspinal gas. In the event that no clear disc herniation was found, an intradural examination may be indicated to justify clinical signs and symptoms or previous radiologic studies 4).

Treatment

Intradural exploration and/or transdural sequestrectomy avoids traction on already compromised nerve roots and is often safer than extradural sequestrectomy. The onset of bladder paralysis is a most important indication for immediate surgery. The cases presented show that there is a highly significant difference in the outcome of those cases operated on within 24h of bladder paralysis compared to those operated on after this period 5).

Case series

Sharma et al. presented a case series of six cases of intradural disc herniation at L4-L5 level diagnosed on the basis of intraoperative findings.

All the cases, on preoperative magnetic resonance imaging (MRI) were reported as having diffuse annular bulge with large posterocentral extrusion. The study comprised patients in age group of 30-60 years. Four cases out of six presented with cauda equina syndrome. In three cases, cauda equina was associated with sudden deterioration in the power of lower limb muscle groups.

They suspected that intradural herniation of disc was synchronous with cauda equina syndrome in these cases, which was very well documented in one of the cases. On retrospective analysis, MRI findings of mass effect in the form of displacement of the traversing nerve roots due to large central disc with crumble disc sign were suggestive of early evidence of intradural disc herniation. Y sign in ventral dura due to splitting of ventral dura and arachnoid mater by disc material was a good diagnostic sign to suspect intradural extra-arachnoid disc. The presence of hypointense structure inside the dura with no continuity with the adjacent intervertebral disc on MRI was highly suggestive of an intradural disc.

Intradural disc prolapse remains a diagnostic dilemma as it is very difficult to diagnose all the cases preoperatively. The presence of above-mentioned radiological signs on MRI in patients having the large central disc on MRI, especially at L4-L5 levels, should raise suspicion of intradural herniation of disc. 6).


Ducati et al. described five cases of this pathology and review the literature as well as some considerations about the difficulties in the preoperative diagnostic issues and the surgical technique.

They concluded that for intradural disc herniations the diagnosis is mainly intraoperative, and the surgical technique has some special aspects 7).

Case reports

Intradural lumbar disc herniation is rare, with an incidence of 0.3%-1%, but has been well reported in the literature. Transdural migration of the disc penetrating both ventral and dorsal dura is extremely rare, and there is a dearth of literature in the pathophysiology and surgical management of transdural herniation. Lack of knowledge on this type of presentation can cause intraoperative surprises and inadvertent cauda equina root injuries and lead to prolonged operative time. Pedaballe et al. reported 1 such case, described the surgical experience, and discussed the pathological mechanisms and signs.

A 30-year-old woman presented to outpatient clinic with chronic cauda equina syndrome due to massive L4-L5 disc herniation. L4-L5 decompression and transforaminal lumbar interbody fusion were planned. Unexpectedly, however, surgery revealed a transdural herniation, which was effectively managed with laminectomy, extension of durotomydiscectomy, repair of both dorsal and ventral dura, and interbody fusion, but at the expense of prolonged surgical time.

Transdural herniation of a lumbar disc is very rare presentation. It can be effectively managed with laminectomy, extension of durotomydiscectomy and repair of both dorsal and ventral dura. It can be diagnosed by magnetic resonance imaging preoperatively only if read with suspicion of such presentation. 8).


A 56-year-old man who developed cauda equina syndrome after several episodes of severe Valsalva maneuver.

The patient was found to have developed subacute urinary retention and leg weakness. Magnetic resonance imaging findings were concerning for an unusual-appearing lesion extending cranially at L2-3. Urgent decompression via an L2 laminectomy, exploration, and subsequent discectomy was performed. The patient recovered exceptionally well, regaining bladder function and ultimately being able to ambulate without assistance.

Cranially extending intrathecal disc herniations are a rare phenomenon and exceptionally uncommon above L3. The clinician should have a high level of suspicion for herniation when looking at the clinical and historical information consistent with such a diagnosis even in the presence of ambiguous imaging findings 9)


Nagaria et al. presented a case with intermittent symptoms and signs of cauda equina compression. They were unable to find in the literature, any previously described cases of intermittent cauda equina compression from a herniated intradural disc fragment leading to a “floppy disc syndrome” 10).


A 73-year-old male presented with a rare dorsally sequestrated lumbar disc herniation manifesting as severe radiating pain in both leg, progressively worsening weakness in both lower extremities, and urinary incontinence, suggesting cauda equina syndrome. Magnetic resonance imaging suggested the sequestrated disc fragment located in the extradural space at the L4-L5 level had surrounded and compressed the dural sac from the lateral to dorsal sides. A bilateral decompressive laminectomy was performed under an operating microscope. A large extruded disc was found to have migrated from the ventral aspect, around the thecal sac, and into the dorsal aspect, which compressed the sac to the right. After removal of the disc fragment, his sciatica was relieved and the patient felt strength of lower extremity improved 11).


Mailleux et al. described a case of anterior transdural L4-L5 disc herniation presenting as a partial cauda equina syndrome without related back pain or history of back pain. MRI allowed presurgical diagnosis showing an irregular intradural mass that did not enhance. That lack of enhancement could be related to the fact that the disc herniation was relatively recent 12).


A female patient with lumbosciatic pain who developed an incomplete cauda equina syndrome. An asymmetric discopathy of the L2-L3 space and a gas bubble with disc material within the spinal canal was noticed in the radiologic explorations. The literature and the authors’ experience are reviewed with the aim of confirming the frequency of intradural herniation in association with gas in the spinal canal.

A laminoarthrectomy of the involved space was performed followed by direct intradural examination, which revealed a disc fragment that was excised. An instrumented L2-L3 arthrodesis was performed. Postoperative evolution was satisfactory. To date, the authors have found this association in 2% of the patients with intraspinal gas.

The potential presence of an intradural disc herniation must always be considered when performing an open discectomy on a patient whose CT scan study shows the presence of epidural gas. This association is particularly striking given the relative rarity of intradural herniations and intraspinal gas. In the event that no clear disc herniation was found, an intradural examination may be indicated to justify clinical signs and symptoms or previous radiologic studies 13).


A 59 year-old man with ILDH. It was the only case of ILDH among 960 patients surgically treated, during the period 1989-1996. Clinically the patient demonstrated an acute cauda equina syndrome. The diagnosis was established by radiculograms, which showed a total block at the L3-L4 level. There was a 3 days time interval between the diagnosed syndrome itself and the operation. At surgery the L3-L4 level was intact, whereas dense adhesions were found between the L4-L5 disc and the dura. Root retraction to expose the nucleus pulposus mass was impossible. A laminectomy of the L4 was undertaken. An incision was made in the dura and arachnoid, revealing an extruded discal mass, lying between the roots of the cauda equina. It was carefully removed. The state of the patient at follow-up 1 year after surgery was unsatisfactory. The patient has moderate flaccid paraparesis, bladder dysfunction improved. The prognosis appeared to be linked to the preoperative duration of symptoms 14)


One case of intradural lumbar disc herniation at the L3-L4 disc level with cauda equina syndrome is reported. Myelo-CT demonstrated an intradural tumor-like lesion with complete block. An intradural fragment of sequestrated disc material was found intraoperatively. Accurate preoperative diagnosis of the intradural nature of the disease and prompt surgical treatment resulted in a smooth recovery 15).


A case of intradural disk herniation at L4-5 observed in a patient with longstanding low back pain and sciatica due to a herniated disk. After having undergone various surgical procedures for this disorder, the patient developed a multiradicular syndrome of the cauda equina 16)

References

1) , 8)

Pedaballe AR, Mallepally AR, Tandon V, Sharma A, Chhabra HS. An Unusual Case of Transdural Herniation of a Lumbar Intervertebral Disc: Diagnostic and Surgical Challenges. World Neurosurg. 2019 Aug;128:385-389. doi: 10.1016/j.wneu.2019.05.103. Epub 2019 May 20. PubMed PMID: 31121367.
2) , 6)

Sharma A, Singh V, Sangondimath G, Kamble P. Intradural Disc a Diagnostic Dilemma: Case Series and Review of Literature. Asian J Neurosurg. 2018 Oct-Dec;13(4):1033-1036. doi: 10.4103/ajns.AJNS_55_17. PubMed PMID: 30459862; PubMed Central PMCID: PMC6208249.
3) , 7)

Ducati LG, Silva MV, Brandão MM, Romero FR, Zanini MA. Intradural lumbar disc herniation: report of five cases with literature review. Eur Spine J. 2013 May;22 Suppl 3:S404-8. doi: 10.1007/s00586-012-2516-4. Epub 2012 Sep 27. Review. PubMed PMID: 23014741; PubMed Central PMCID: PMC3641279.
4) , 13)

Hidalgo-Ovejero AM, García-Mata S, Gozzi-Vallejo S, Izco-Cabezón T, Martínez-Morentín J, Martínez-Grande M. Intradural disc herniation and epidural gas: something more than a casual association? Spine (Phila Pa 1976). 2004 Oct 15;29(20):E463-7. Review. PubMed PMID: 15480124.
5)

Dinning TA, Schaeffer HR. Discogenic compression of the cauda equina: a surgical emergency. Aust N Z J Surg. 1993 Dec;63(12):927-34. PubMed PMID: 8285904.
9)

Tempel Z, Zhu X, McDowell MM, Agarwal N, Monaco EA 3rd. Severe Intradural Lumbar Disc Herniation with Cranially Oriented Free Fragment Migration. World Neurosurg. 2016 Aug;92:582.e1-582.e4. doi: 10.1016/j.wneu.2016.06.024. Epub 2016 Jun 16. PubMed PMID: 27318310.
10)

Nagaria J, Chan C, Kamel M, McEvoy L, Bolger C. Episodic cauda equina compression from an intradural lumbar herniated disc: a case of ‘floppy disc’. J Surg Case Rep. 2011 Sep 1;2011(9):6. doi: 10.1093/jscr/2011.9.6. PubMed PMID: 24950507; PubMed Central PMCID: PMC3649298.
11)

Kim JS, Lee SH, Arbatti NJ. Dorsal extradural lumbar disc herniation causing cauda equina syndrome : a case report and review of literature. J Korean Neurosurg Soc. 2010 Mar;47(3):217-20. doi: 10.3340/jkns.2010.47.3.217. Epub 2010 Mar 31. PubMed PMID: 20379476; PubMed Central PMCID: PMC2851086.
12)

Mailleux R, Redant C, Milbouw G. MR diagnosis of transdural disc herniation causing cauda equine syndrome. JBR-BTR. 2006 Nov-Dec;89(6):303-5. PubMed PMID: 17274584.
14)

Bayassi S. [Intradural lumbar disk herniation (ILDH). Case report and literature review]. Neurol Neurochir Pol. 1998 Sep-Oct;32(5):1295-301; discussion 1301-2. Polish. PubMed PMID: 10463243.
15)

Fang CM, Huang TJ, Chen WJ, Lee ST, Hsu RW. Intradural lumbar disc herniation–a case report. Changgeng Yi Xue Za Zhi. 1994 Sep;17(3):297-300. PubMed PMID: 7954013.
16)

Borgogno G, Fontanella C, La Camera V. [Herniated intradural lumbar disk: a clinical case]. Arch Putti Chir Organi Mov. 1991;39(1):87-91. Italian. PubMed PMID: 1842495.

Lumbar spinal stenosis risk factors

Lumbar spinal stenosis risk factors

Risk factors for the disease include some comorbidities such as obesity or smoking, daily habits such as an active lifestyle, but also genetic factors that are not completely elucidated yet 1).

Lumbar spinal stenosis (LSS) is frequently observed in obese patients and the elderly especially due to the aging of the spine.

Increased Spinal inclination angle (SIA) and Body Mass Index BMI might be the most relevant risk factors for LSS 2).

DM and low ankle-brachial index values (ABI)s 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 3).


Kitab et al., performed a re-analysis of data from their previously reported prospective MRI-based study, stratifying data from the 709 cases into 3 age categories of equal size (instead of the original < 60 vs ≥ 60 years). Relative lumbar spinal canal dimensions, as well as radiological degenerative variables from L1 to S1, were analyzed across age groups in a multivariate mode. The total degenerative scale score (TDSS) for each lumbar segment from L1 to S1 was calculated for each patient. The relationships between age and qualitative stenosis grades, TDSS, disc degeneration, and facet degeneration were analyzed using Pearson’s product-moment correlation and multiple regression.

Multivariate analysis of TDSS and spinal canal dimensions revealed highly significant differences across the 3 age groups at L2-3 and L3-4 and a weaker, but still significant, association with changes at L5-S1. Age helped to explain only 9.6% and 12.2% of the variance in TDSS at L1-2 and L2-3, respectively, with a moderate positive correlation, and 7.8%, 1.2%, and 1.9% of the variance in TDSS at L3-4, L4-5, and L5-S1, respectively, with weak positive correlation. Age explained 24%, 26%, and 18.4% of the variance in lumbar intervertebral disc (LID) degeneration at L1-2, L2-3, and L3-4, respectively, while it explained only 6.2% and 7.2% of the variance of LID degeneration at L4-5 and L5-S1, respectively. Age explained only 2.5%, 4.0%, 1.2%, 0.8%, and 0.8% of the variance in facet degeneration at L1-2, L2-3, L3-4, L4-5, and L5-S1, respectively.

Age at presentation correlated weakly with degeneration variables and spinal canal morphometries in LSS segments. Age correlated with upper lumbar segment (L1-4) degeneration more than with lower segment (L4-S1) degeneration. The actual chronological age of the patients did not significantly correlate with the extent of degenerative pathology of the lumbar spinal stenosis segments. These study results lend support for a developmental contribution to LSS 4).

References

1)

Bagley C, MacAllister M, Dosselman L, Moreno J, Aoun S, El Ahmadieh T. Current concepts and recent advances in understanding and managing lumbar spine stenosis. F1000Res. 2019 Jan 31;8. pii: F1000 Faculty Rev-137. doi: 10.12688/f1000research.16082.1. eCollection 2019. Review. PubMed PMID: 30774933; PubMed Central PMCID: PMC6357993.
2)

Hirano K, Imagama S, Hasegawa Y, Muramoto A, Ishiguro N. Impact of spinal imbalance and BMI on lumbar spinal canal stenosis determined by a diagnostic support tool: cohort study in community‑living people. Arch Orthop Trauma Surg. 2013 Nov;133(11):1477-82. doi: 10.1007/s00402-013-1832-4. PubMed PMID: 23959069.
3)

Maeda T, Hashizume H, Yoshimura N, Oka H, Ishimoto Y, Nagata K, Takami M, Tsutsui S, Iwasaki H, Minamide A, Nakagawa Y, Yukawa Y, Muraki S, Tanaka S, Yamada H, Yoshida M. Factors associated with lumbar spinal stenosis in a large-scale, population-based cohort: The Wakayama Spine Study. PLoS One. 2018 Jul 18;13(7):e0200208. doi: 10.1371/journal.pone.0200208. eCollection 2018. PubMed PMID: 30020970; PubMed Central PMCID: PMC6051614.
4)

Kitab S, Habboub G, Abdulkareem SB, Alimidhatti MB, Benzel E. Redefining lumbar spinal stenosis as a developmental syndrome: does age matter? J Neurosurg Spine. 2019 May 17:1-9. doi: 10.3171/2019.2.SPINE181383. [Epub ahead of print] PubMed PMID: 31100722.
WhatsApp WhatsApp us
%d bloggers like this: