Natural Course and Diagnosis of Lumbar Spinal Stenosis: WFNS Spine Committee Recommendations

Untreated symptomatic lumbar spinal stenosis and health-related quality of life: the locomotive Syndrome and Health Outcome in Aizu Cohort Study (LOHAS)

PURPOSE

This study compared health-related quality of life (HRQoL) between untreated and conservatively treated patients with symptomatic lumbar spinal stenosis (LSS) using data from the Locomotive Syndrome and Health Outcome in Aizu Cohort Study.

METHODS

We retrospectively analyzed HRQoL using the SF-12 survey in patients diagnosed with symptomatic LSS via a self-reported history questionnaire. LSS treatment history was confirmed through physician interviews. The study included untreated (UTG) and conservatively treated patients (CTG). One-to-one nearest-neighbor propensity score matching compared patients receiving and not receiving conservative treatment. Propensity scores were calculated using background data: age, sex, height, weight, smoking, difficulty walking 100 m, urinary incontinence during walking, comorbidities, musculoskeletal disease treatment history, and questionnaires (depression screening, low back pain-specific QoL, self-efficacy regarding falls, physical activity assessment, and the 2008 SF-12).

RESULTS

In 2008, 376 patients were diagnosed with symptomatic LSS. At the 1-year follow-up, 251 were untreated, 144 received conservative treatment, and 11 underwent lumbar spinal surgery. Before matching, overall HRQoL was lower in the CTG than in the UTG at baseline and 1-year follow-up. Mental health scores in the CTG significantly decreased at the 1-year follow-up. After matching, the median change in mental health scores was significantly lower in the CTG than in the UTG.

CONCLUSION

At baseline and the 1-year follow-up, HRQoL was lower in the CTG compared to the UTG. Additionally, there was no apparent QoL deterioration in the UTG during the 1-year follow-up, even when patients followed their natural medical consultation behaviors.

Artificial intelligence for segmentation and classification in lumbar spinal stenosis: an overview of current methods

PURPOSE

Lumbar spinal stenosis (LSS) is a frequently occurring condition defined by narrowing of the spinal or nerve root canal due to degenerative changes. Physicians use MRI scans to determine the severity of stenosis, occasionally complementing it with X-ray or CT scans during the diagnostic work-up. However, manual grading of stenosis is time-consuming and induces inter-reader variability as a standardized grading system is lacking. Machine Learning (ML) has the potential to aid physicians in this process by automating segmentation and classification of LSS. However, it is unclear what models currently exist to perform these tasks.

METHODS

A systematic review of literature was performed by searching the Cochrane Library, Embase, Emcare, PubMed, and Web of Science databases for studies describing an ML-based algorithm to perform segmentation or classification of the lumbar spine for LSS. Risk of bias was assessed through an adjusted version of the Newcastle-Ottawa Quality Assessment Scale that was more applicable to ML studies. Qualitative analyses were performed based on type of algorithm (conventional ML or Deep Learning (DL)) and task (segmentation or classification).

RESULTS

A total of 27 articles were included of which nine on segmentation, 16 on classification and 2 on both tasks. The majority of studies focused on algorithms for MRI analysis. There was wide variety among the outcome measures used to express model performance. Overall, ML algorithms are able to perform segmentation and classification tasks excellently. DL methods tend to demonstrate better performance than conventional ML models. For segmentation the best performing DL models were U-Net based. For classification U-Net and unspecified CNNs powered the models that performed the best for the majority of outcome metrics. The number of models with external validation was limited.

CONCLUSION

DL models achieve excellent performance for segmentation and classification tasks for LSS, outperforming conventional ML algorithms. However, comparisons between studies are challenging due to the variety in outcome measures and test datasets. Future studies should focus on the segmentation task using DL models and utilize a standardized set of outcome measures and publicly available test dataset to express model performance. In addition, these models need to be externally validated to assess generalizability.

Effect of Acupuncture on Neurogenic Claudication Among Patients With Degenerative Lumbar Spinal Stenosis : A Randomized Clinical Trial

BACKGROUND

Acupuncture may improve degenerative lumbar spinal stenosis (DLSS), but evidence is insufficient.

OBJECTIVE

To investigate the effect of acupuncture for DLSS.

DESIGN

Multicenter randomized clinical trial. (ClinicalTrials.gov: NCT03784729).

SETTING

5 hospitals in China.

PARTICIPANTS

Patients with DLSS and predominantly neurogenic claudication pain symptoms.

INTERVENTION

18 sessions of acupuncture or sham acupuncture (SA) over 6 weeks, with 24-week follow-up after treatment.

MEASUREMENTS

The primary outcome was change from baseline in the modified Roland-Morris Disability Questionnaire ([RMDQ] score range, 0 to 24; minimal clinically important difference [MCID], 2 to 3). Secondary outcomes were the proportion of participants achieving minimal (30% reduction from baseline) and substantial (50% reduction from baseline) clinically meaningful improvement per the modified RMDQ.

RESULTS

A total of 196 participants (98 in each group) were enrolled. The mean modified RMDQ score was 12.6 (95% CI, 11.8 to 13.4) in the acupuncture group and 12.7 (CI, 12.0 to 13.3) in the SA group at baseline, and decreased to 8.1 (CI, 7.1 to 9.1) and 9.5 (CI, 8.6 to 10.4) at 6 weeks, with an adjusted difference in mean change of -1.3 (CI, -2.6 to -0.03; P = 0.044), indicating a 43.3% greater improvement compared with SA. The between-group difference in the proportion of participants achieving minimal and substantial clinically meaningful improvement was 16.0% (CI, 1.6% to 30.4%) and 12.6% (CI, -1.0% to 26.2%) at 6 weeks. Three cases of treatment-related adverse events were reported in the acupuncture group, and 3 were reported in the SA group. All events were mild and transient.

LIMITATION

The SA could produce physiologic effects.

CONCLUSION

Acupuncture may relieve pain-specific disability among patients with DLSS and predominantly neurogenic claudication pain symptoms, although the difference with SA did not reach MCID. The effects may last 24 weeks after 6-week treatment.

PRIMARY FUNDING SOURCE

2019 National Administration of Traditional Chinese Medicine "Project of building evidence-based practice capacity for TCM-Project BEBPC-TCM" (NO. 2019XZZX-ZJ).

A propensity-matched study of patients with symptomatic lumbar spinal stenosis opting for surgery versus not

Introduction

Although most surgeons treating patients with lumbar spinal stenosis (LSS) believe that surgical treatment is superior to conservative measures, systematics reviews have concluded that no solid evidence support this.

Research question

To compare change at 1-year of walking ability, health-related quality of life, leg and back pain in patients with symptomatic LSS referred to a spine surgery clinic who opted for surgery and those who did not.

Material and methods

The study included 149 operated and 149 non-operated patients seen by spine surgeons and diagnosed with LSS. The non-operated patients were propensity-matched to a cohort retrieved from the Danish national spine registry. Matching was done on demographics and baseline outcome measures. The outcomes was walking improvement measured by item 4 of the Oswestry Disability Index, EQ-5D-3L, global assessment (GA) of back/leg pain, back and leg pain on the Visual Analogue Scale and the Short Form 36 transition item 2.

Results

Less than half of the non-operated reached MCID on EQ-5D-3L, VAS pain legs or VAS pain back where 2/3 of the operated did. The largest difference was VAS back pain where 27.5% of the non-operated reached an MCID of 12 points compared to 71.8% in the operated group.

Discussion and conclusion

Surgical treated patients improved better than non-operated on all outcome measures. However, further research is required to compare the effectiveness of surgical decompression with non-operative care for LSS patients.

Psoas muscle index and psoas muscle density are associated with functional status in patients with degenerative lumbar spinal stenosis

BACKGROUND

The factors affecting lumbar spinal function in patients with degenerative lumbar spinal stenosis (DLSS) are still unclear.

OBJECTIVE

This study explored psoas major muscle morphology in patients with DLSS and its association with their functional status.

METHODS

A retrospective study was conducted on 288 patients with DLSS and 260 control subjects. Psoas major muscle evaluation included three morphometric parameters at the L3/4 disc level: psoas major index (PMI), muscle attenuation, and psoas major morphological changes (MPM). The association between psoas major morphology and functional status was assessed using the Oswestry disability index (ODI).

RESULTS

Both female and male patients with DLSS had a higher PMI and lower muscle attenuation. PMI and muscle attenuation were inversely correlated with age in the DLSS group. After multivariable analyses, the PMI and psoas major muscle attenuation were positively correlated with patients' functional status.

CONCLUSION

The PMI and muscle attenuation were positively correlated with functional status in patients with DLSS. These findings have important implications for physiotherapy programs of postoperative rehabilitation and conservative management of DLSS.

Machine Learning Predicts Decompression Levels for Lumbar Spinal Stenosis Using Canal Radiomic Features from Computed Tomography Myelography

BACKGROUND

The accurate preoperative identification of decompression levels is crucial for the success of surgery in patients with multi-level lumbar spinal stenosis (LSS). The objective of this study was to develop machine learning (ML) classifiers that can predict decompression levels using computed tomography myelography (CTM) data from LSS patients.

METHODS

A total of 1095 lumbar levels from 219 patients were included in this study. The bony spinal canal in CTM images was manually delineated, and radiomic features were extracted. The extracted data were randomly divided into training and testing datasets (8:2). Six feature selection methods combined with 12 ML algorithms were employed, resulting in a total of 72 ML classifiers. The main evaluation indicator for all classifiers was the area under the curve of the receiver operating characteristic (ROC-AUC), with the precision-recall AUC (PR-AUC) serving as the secondary indicator. The prediction outcome of ML classifiers was decompression level or not.

RESULTS

The embedding linear support vector (embeddingLSVC) was the optimal feature selection method. The feature importance analysis revealed the top 5 important features of the 15 radiomic predictors, which included 2 texture features, 2 first-order intensity features, and 1 shape feature. Except for shape features, these features might be eye-discernible but hardly quantified. The top two ML classifiers were embeddingLSVC combined with support vector machine (EmbeddingLSVC_SVM) and embeddingLSVC combined with gradient boosting (EmbeddingLSVC_GradientBoost). These classifiers achieved ROC-AUCs over 0.90 and PR-AUCs over 0.80 in independent testing among the 72 classifiers. Further comparisons indicated that EmbeddingLSVC_SVM appeared to be the optimal classifier, demonstrating superior discrimination ability, slight advantages in the Brier scores on the calibration curve, and Net benefits on the Decision Curve Analysis.

CONCLUSIONS

ML successfully extracted valuable and interpretable radiomic features from the spinal canal using CTM images, and accurately predicted decompression levels for LSS patients. The EmbeddingLSVC_SVM classifier has the potential to assist surgical decision making in clinical practice, as it showed high discrimination, advantageous calibration, and competitive utility in selecting decompression levels in LSS patients using canal radiomic features from CTM.

Deep-learning reconstruction for the evaluation of lumbar spinal stenosis in computed tomography

To compare the quality and interobserver agreement in the evaluation of lumbar spinal stenosis (LSS) on computed tomography (CT) images between deep-learning reconstruction (DLR) and hybrid iterative reconstruction (hybrid IR). This retrospective study included 30 patients (age, 71.5 ± 12.5 years; 20 men) who underwent unenhanced lumbar CT. Axial and sagittal CT images were reconstructed using hybrid IR and DLR. In the quantitative analysis, a radiologist placed regions of interest within the aorta and recorded the standard deviation of the CT attenuation (i.e., quantitative image noise). In the qualitative analysis, 2 other blinded radiologists evaluated the subjective image noise, depictions of structures, overall image quality, and degree of LSS. The quantitative image noise in DLR (14.8 ± 1.9/14.2 ± 1.8 in axial/sagittal images) was significantly lower than that in hybrid IR (21.4 ± 4.4/20.6 ± 4.0) (P < .0001 for both, paired t test). Subjective image noise, depictions of structures, and overall image quality were significantly better with DLR than with hybrid IR (P < .006, Wilcoxon signed-rank test). Interobserver agreements in the evaluation of LSS (with 95% confidence interval) were 0.732 (0.712-0.751) and 0.794 (0.781-0.807) for hybrid IR and DLR, respectively. DLR provided images with improved quality and higher interobserver agreement in the evaluation of LSS in lumbar CT than hybrid IR.

Correlation of psoas major muscle morphology with function and clinical symptoms in patients with symptomatic multilevel lumbar spinal stenosis

OBJECTIVE

This study was performed to quantify the morphological characteristics of the psoas major muscle in patients with symptomatic multilevel degenerative lumbar spinal stenosis (SMLSS) and assess the correlations of these morphological characteristics with function and clinical symptoms.

METHODS

One hundred fourteen patients diagnosed with SMLSS (≥ 3 segments) were included. The patients' presenting symptoms were assessed with the Oswestry Disability Index (ODI), and visual analogue scale (VAS) scores were recorded. The morphology of the psoas major was evaluated at the L3/4 intervertebral disc level in three ways: by measuring (i) the psoas muscle mass index (PMI); (ii) the mean muscle attenuation (Hounsfield units, HU); and (iii) the morphologic change of the psoas major (mean ratios of the short axis to the long axis of the bilateral psoas major).

RESULTS

Men had a higher PMI than women (p = 0.001). Patients with severe disability had a significantly lower PMI (p = 0.002) and muscle attenuation (p = 0.001). The PMI and muscle attenuation were significantly higher in the patients with no or mild back pain (both p < 0.001). In the univariable and multivariable analyses, a greater HU value was associated with a higher functional status as assessed by the ODI (p = 0.002), and a higher PMI was associated with less severe back pain as measured by the VAS score (p < 0.001).

CONCLUSION

This study showed that muscle attenuation of psoas major positively correlated with the functional status and PMI negatively correlated with low back pain severity in patients diagnosed with SMLSS. Future prospective studies are needed to evaluate whether improvement in such muscle parameters through physiotherapy programs can alleviate the clinical symptoms and improve the functional status of patients with SMLSS.

The current state of radiodiagnostics of degenerative changes in the lumbar spine (literature review)

Examination of the spine using radiological methods remains the most frequently conducted study in the outpatient practice of almost any radiologist. In most cases, changes in the spine are degenerative and dystrophic in nature. These changes in the spine are the leading cause of loss of activity among adults and the elderly, and cover a wide range of age-related structural changes. It is of great importance to understand the possibilities and limitations of radiological methods of diagnostics. The description of morphological changes observed in degenerative and dystrophic changes requires the use of unified terminology and classifications among clinicians and radiologists.The aim. To present modern concepts in the assessment of degenerative changes of the spine using radiological methods. A description of the standardized international nomenclature of intervertebral disc pathology and current classifications of spinal canal stenosis are presented.Material and methods. For literature search, we used electronic databases MEDLINE (PubMed), eLibrary, EMBASE and Cochrane Library with a selection of sources published from 2000 to 2021. We analyzed the works devoted to the diagnosis of degenerative changes in lumbar spine and to degenerative stenosis.Conclusion. The key to productive communication between physicians is the uniformity or standardization of terminology and definitions used. It is important that the protocol of description, its terms, semantic expressions be uniform and understandable to specialists who are involved in the diagnosis and treatment of the spine. Magnetic resonance imaging is a valuable method in the diagnosis of degenerative changes of the spinal column, but it has its limitations.

Relationship between Lower Limb Pain Intensity and Dynamic Lumbopelvic-Hip Alignment in Patients with Degenerative Lumbar Spinal Canal Stenosis: A Cross-Sectional Study

STUDY DESIGN

This cross-sectional study was conducted in a single hospital.

PURPOSE

To clarify the relationship between lower limb pain intensity and dynamic lumbopelvic-hip alignment in patients with lumbar spinal canal stenosis (LSS), using a three-dimensional (3D) motion analysis system.

OVERVIEW OF LITERATURE

Although it is well known that leg symptoms have a close relationship with posture in patients with LSS, the relationship under dynamic conditions, such as gait, remain unclear.

METHODS

Thirty patients with LSS scheduled for spine surgery participated in this study. Lower limb pain was assessed using the Visual Analog Scale (VAS), and the patients were divided into two groups based on the mean scores (patients with scores above and below the mean were classified as the high-VAS and low-VAS groups, respectively). The kinematics of the spine, pelvis, and hip joints during gait were then measured using a 3D motion analysis system. Student paired t -tests were used to compare the angles of the spine, pelvis, and hip during gait between the two groups.

RESULTS

Compared to those in the low-VAS group, the spine was significantly extended and bent toward the more painful lower limb side, and the pelvis was significantly anteriorly tilted among individuals in the high-VAS group.

CONCLUSIONS

Patients with LSS experiencing severe pain in their lower limb tend to keep the spine in a more extended position, bend laterally toward the painful side, and have an anteriorly tilted pelvic posture. The dynamic spinal and pelvic alignment was closely related to the intensity of the lower limb pain.

Correlation between lumbar spinal canal magnetic resonance imaging grading systems and parameters in lumbar spinal canal compromise

Background

There is a need to assess how commonly used classification systems of intervertebral disc degeneration reflect the compromise of neural elements. This study aims to explore the relationship between lumbar discs degenerative diseases using the Pfirrmann and the Combined Task Forces (CTF) of the North American Spine Society (NASS) grading systems as well as qualitative and quantitative grades of lumbar spinal stenosis. This retrospective cohort study included adult patients undergoing non-contrast MR imaging of lumbosacral spine. The radiological assessment included the Pfirrmann grading system, Van Rijn classification, Combined Task Force (CTF) classification, measurement of the cross-sectional area of the dural sac, mid-sagittal antero-posterior diameter of the thecal sac, the degree of dural sac compression at disc level, lateral recesses heights, and intervertebral foramina diameters. The degree of stenosis of the spinal canal and intervertebral foramina was assessed.

Results

One hundred patients were included in the study. At all levels, Pfirrmann grades had a moderate, significant, positive correlation with the severity of stenosis of the central and lateral spinal canals as well as foraminal stenosis. The grades of lumbar spinal canal and foraminal stenosis had a significant positive correlation with degree of disc displacement as assessed by CTF classification and had a significant negative correlation with the quantitative lumbar spinal canal and foraminal measures.

Conclusions

There is a good correlation between Pfirrmann classification, CTF classification of NASS, qualitative grading and quantitative measures of lumbar spinal canal that reflects the severity of lumbar spinal canal stenosis and nerve root compression.

Impact of Preoperative Total Knee Arthroplasty on Radiological and Clinical Outcomes of Spinal Fusion for Concurrent Knee Osteoarthritis and Degenerative Lumbar Spinal Diseases

Concurrent knee osteoarthritis (KOA) and degenerative lumbar spinal disease (LSD) has increased, but the total knee arthroplasty (TKA) effect on degenerative LSD remains unclear. The aim of this study was to retrospectively analyze to compare radiological and clinical outcomes between spinal fusion only and preoperative TKA with spinal fusion for the patients with concurrent KOA and degenerative LSD. A total of 72 patients with concurrent KOA and degenerative LSDs who underwent spinal fusion at less than three levels were divided in two groups: non-TKA group (n = 50) and preoperative TKA group (n = 22). Preoperative lumbar lordosis (LL) was significantly lower in the preoperative TKA group than the non-TKA group (p < 0.05). Significantly higher preoperative pelvic incidence (PI), PI/LL mismatch, and pelvic tilt (PT) occurred in preoperative TKA group than non-TKA group (all p < 0.05). There was significant improvement of postoperative Oswestry Disability Index and leg Visual Analog Scale in the preoperative TKA group (all p < 0.01). Preoperative TKA could be a benefit for in proper correction of sagittal spinopelvic alignment by spinal fusion. Therefore, preoperative TKA could be considered a preceding surgical option for patients with severe sagittal spinopelvic parameters in concurrent KOA and degenerative LSD.

How people with lumbar spinal stenosis make decisions about treatment: A qualitative study using the Health Belief Model

OBJECTIVE

Surgery rates for lumbar spinal stenosis (LSS) have increased despite inherent risks, high reoperation rates, and a lack of evidence for benefit over conservative treatment. Scant research has investigated how people make decisions about treatment, which may help clinicians better support patients during the course of care. The purpose of the present study was to explore the beliefs of people with LSS and how they make decisions about treatment.

DESIGN

Cross-sectional qualitative study.

METHODS

Semi-structured individual interviews were conducted with participants who had LSS (based on diagnostic imaging and recent symptoms). Transcribed interview data was analyzed using directed content analysis informed by the Health Belief Model.

RESULTS

Twelve patients (mean age 75.3 years, range 63-87 years, 9 female, 6 with previous LSS surgery) participated. The Health Belief Model appeared useful for explaining decisions about treatment. Perceived threat of LSS was higher in those who had surgery. Patients who decided on surgery perceived themselves as more susceptible to surgery, often because of pathoanatomical beliefs. These patients had lower perceived control over symptoms and the treatment decision itself. Although patients saw benefit in conservative treatment because of its lower risk and ability to foster self-management, many had no or poor education and reported previous experiences with ineffective conservative treatment.

CONCLUSION

Patients with LSS make decisions about treatment by weighing the perceived threat of LSS against the perceived barriers and benefits of conservative treatment. Consistent and nonthreatening educational messages from clinicians may help these patients during their decision-making process.

Degenerative Lumbar Spine Stenosis Consensus Conference: the Italian job. Recommendations of the Spinal Section of the Italian Society of Neurosurgery

In the modern era evidence-based medicine, guidelines and recommendations represent a key-point of daily activity. The Spinal Section of the Italian Society of Neurosurgery introduced some recommendations regarding Degenerative Lumbar Spine Stenosis based on those of the Spine Committee of World Federation of Neurosurgical Societies, revising them on the basis of Italian common practice. In June 2019, a Committee of 21 spine surgeons met in Rome to validate the recommendations of the WFNS. Furthermore, they decided to review the ones that did not reach a consensus to create Italian Recommendations on Degenerative Lumbar Spine Stenosis. A literature review of the last ten years was performed and the statements were voted using the Delphi method. Forty-one statements were discussed, and 7 statements were voted again to reach a consensus with respect to those of the WFNS. A total of 40 statements reached a consensus, of which 36 reached a positive consensus and 4 a negative consensus, while no consensus was reached in 1 case. Conservative multimodal therapy, tailored on the patient, is a reasonable and effective first option choice for the treatment of LSS patients with tolerable moderate symptoms. Surgical treatment is reserved for symptomatic patients non-responding to conservative treatment or with neurological deficits. The best surgical technique to use depends on personal experience; modern MISS techniques are equivalent to open decompressive surgery with some advantages and higher cost-effectiveness. Fusion surgery and mobility preserving surgery only have a marginal role in the treatment of DLSS without instability.