Is there a Correlation Between Degree of Radiologic Lumbar Spinal Stenosis and its Clinical Manifestation?

Changes in the Concentration Profile of Selected Micro- and Macro-Elements in the Yellow Ligament Obtained from Patients with Degenerative Stenosis of the Lumbo-Sacral Spine

Background/Objectives: Degenerative lumbo-sacral spinal stenosis is characterized by spinal canal narrowing, often linked to ligamentum flavum hypertrophy. This study evaluated the elemental composition of ligamentum flavum tissue in DLSS patients compared to healthy controls. Methods: This study involved 180 patients diagnosed with degenerative lumbo-sacral spinal stenosis and 102 healthy controls. Ligamentum flavum samples were analyzed for concentrations of magnesium (Mg), calcium (Ca), phosphorus (P), zinc (Zn), copper (Cu), iron (Fe), sodium (Na), potassium (K), manganese (Mn), and lead (Pb) using inductively coupled plasma optical emission spectrometry (ICP-OES). Statistical analyses were conducted using Student's t-test, ANOVA, and Pearson's correlation, with a significance threshold of p < 0.05. Results: The study group exhibited significantly elevated levels of Mg (p < 0.001), Ca (p = 0.014), and P (p = 0.006), along with reduced concentrations of Zn (p = 0.021) and Cu (p = 0.038) compared to controls. No statistically significant differences were observed for Na, K, Mn, or Fe (p > 0.05). Elemental imbalances were more pronounced in individuals with higher body mass index (BMI) and varied by gender. Pain intensity demonstrated a significant correlation with Zn (p = 0.012) and Na (p = 0.045), but no consistent associations with Mg, Ca, or P. Conclusions: Altered Mg, Ca, P, and Zn levels in ligamentum flavum suggest their involvement in degenerative lumbo-sacral spinal stenosis pathophysiology. These elements may serve as potential biomarkers and therapeutic targets for mitigating spinal canal narrowing.

Evaluation of the Concentration of Selected Elements in the Serum of Patients with Degenerative Stenosis of the Lumbosacral Spine

In humans, 23 elements have been shown to have biological activity. The purpose of this study was to evaluate the concentrations of iron (Fe), zinc (Zn), sodium (Na), potassium (K), magnesium (Mg), phosphorus (P), and calcium (Ca) in the serum of patients diagnosed with lumbar degenerative stenosis when compared to the concentrations of those elements in the serum of healthy volunteers. The study group consisted of 60 patients who were diagnosed with degenerative stenosis of the lumbosacral spine and who qualified for hemilaminectomy. The control group included 60 healthy volunteers without degenerative spinal stenosis. The clinical specimens studied had sera collected from both groups. The quantitative analysis of the selected elements revealed statistically significant (p < 0.05) lower concentrations of Zn (740 ± 110 µg/L vs. 880 ± 160 µg/L) and Mg (22,091 ± 4256 µg/L vs. 24,100 ± 4210 µg/L) in the serum of the patients from the study group when compared to the controls. By contrast, K (16,230 µg/L ± 1210 µg/L vs. 13,210 µg/L ± 1060 µg/L) and Fe (141.87 µg/L ± 11.22 µg/L vs. 109.1 µg/L ± 26.43 µg/L) levels were significantly higher in the study group compared to the controls (p < 0.05). No statistically significant changes were detected in the concentrations of the assessed micronutrients and macronutrients in both sexes in either the study group, the control group, or those based on body mass index (p > 0.05). In the serum samples from the study group, the strongest correlations were noted between the concentrations. In the study group, we showed a significant relationship between the levels of Fe/Zn (r = 0.41), Fe/Na (r = 0.41), Fe/P (r = 0.55), Zn/P (r = 0.68), Zn/K (r = 0.48), Zn/Ca (r = 0.94), Mg/Ca (r = 0.79), and Na/K (r = 0.67). We showed that only Mg concentration varied statistically significantly with the severity of pain (p < 0.05). These findings suggest that the assessment of Fe, Zn, Mg, and K concentrations can be helpful in predicting the onset of degenerative changes in the spine.

Influence of frailty status on the health-related quality of life in older patients with chronic low back pain: a retrospective observational study

PURPOSE

Understanding the influence of frailty on health-related quality of life (HRQoL) in older individuals experiencing chronic low back pain can provide valuable insights into the impact of frailty. Therefore, the aim of our study is to assess how different frailty statuses among older outpatients with chronic low back pain affect their HRQoL.

METHODS

Patients aged 60 and above with chronic low back pain were recruited from March 2022 to February 2023. Frailty was assessed via the frailty phenotype questionnaire, and HRQoL was evaluated using the EQ-5D-5L. Multiple regression models were used to explore the influence of frailty status on the EQ-5D-5L index and EQ-VAS. Logistic regression was used to determine odds ratios for the impact of frailty status on belonging to the lowest EQ-5D-5L index quartile.

RESULTS

A total of 1,054 participants were classified into robust (29.8%), pre-frail (47.7%), and frail (22.5%) groups. Frailty was significantly associated with declining HRQoL. Pre-frail and frail statuses were inversely linked to the EQ-5D-5L index, with significantly higher odds of scoring in the lowest quartile compared to robust individuals. Stratification analysis identified sex as an effect modifier, emphasizing a more substantial association between frailty and the lowest EQ-5D-5L index quartile in female patients.

CONCLUSIONS

A significant association exists between frailty and reduced HRQoL in patients with chronic low back pain. This association was predominant in female patients. Furthermore, considering the dynamic nature of frailty, early detection and effective interventions targeting pre-frailty are essential to delaying the transition to full frailty and improving HRQoL.

1. Lumbosacral radicular pain

INTRODUCTION

Patients suffering lumbosacral radicular pain report radiating pain in one or more lumbar or sacral dermatomes. In the general population, low back pain with leg pain extending below the knee has an annual prevalence that varies from 9.9% to 25%.

METHODS

The literature on the diagnosis and treatment of lumbosacral radicular pain was reviewed and summarized.

RESULTS

Although a patient's history, the pain distribution pattern, and clinical examination may yield a presumptive diagnosis of lumbosacral radicular pain, additional clinical tests may be required. Medical imaging studies can demonstrate or exclude specific underlying pathologies and identify nerve root irritation, while selective diagnostic nerve root blocks can be used to confirm the affected level(s). In subacute lumbosacral radicular pain, transforaminal corticosteroid administration provides short-term pain relief and improves mobility. In chronic lumbosacral radicular pain, pulsed radiofrequency (PRF) treatment adjacent to the spinal ganglion (DRG) can provide pain relief for a longer period in well-selected patients. In cases of refractory pain, epidural adhesiolysis and spinal cord stimulation can be considered in experienced centers.

CONCLUSIONS

The diagnosis of lumbosacral radicular pain is based on a combination of history, clinical examination, and additional investigations. Epidural steroids can be considered for subacute lumbosacral radicular pain. In chronic lumbosacral radicular pain, PRF adjacent to the DRG is recommended. SCS and epidural adhesiolysis can be considered for cases of refractory pain in specialized centers.

A neural network model for detection and classification of lumbar spinal stenosis on MRI

OBJECTIVES

To develop a three-stage convolutional neural network (CNN) approach to segment anatomical structures, classify the presence of lumbar spinal stenosis (LSS) for all 3 stenosis types: central, lateral recess and foraminal and assess its severity on spine MRI and to demonstrate its efficacy as an accurate and consistent diagnostic tool.

METHODS

The three-stage model was trained on 1635 annotated lumbar spine MRI studies consisting of T2-weighted sagittal and axial planes at each vertebral level. Accuracy of the model was evaluated on an external validation set of 150 MRI studies graded on a scale of absent, mild, moderate or severe by a panel of 7 radiologists. The reference standard for all types was determined by majority voting and in case of disagreement, adjudicated by an external radiologist. The radiologists' diagnoses were then compared to the diagnoses of the model.

RESULTS

The model showed comparable performance to the radiologist average both in terms of the determination of presence/absence of LSS as well as severity classification, for all 3 stenosis types. In the case of central canal stenosis, the sensitivity, specificity and AUROC of the CNN were (0.971, 0.864, 0.963) for binary (presence/absence) classification compared to the radiologist average of (0.786, 0.899, 0.842). For lateral recess stenosis, the sensitivity, specificity and AUROC of the CNN were (0.853, 0.787, 0.907) compared to the radiologist average of (0.713, 0.898, 805). For foraminal stenosis, the sensitivity, specificity and AUROC of the CNN were (0.942, 0.844, 0.950) compared to the radiologist average of (0.879, 0.877, 0.878). Multi-class severity classifications showed similarly comparable statistics.

CONCLUSIONS

The CNN showed comparable performance to radiologist subspecialists for the detection and classification of LSS. The integration of neural network models in the detection of LSS could bring higher accuracy, efficiency, consistency, and post-hoc interpretability in diagnostic practices.

A new comprehensive MRI classification and grading system for lumbosacral central and lateral stenosis: clinical application and comparison with previous systems

PURPOSE

The purpose of our study was to provide a novel schematized and comprehensive classification of causes and severity grading system for lumbosacral stenosis.

MATERIALS AND METHODS

The MRI system proposed consisted of a severity grading scale for central and lateral (recess and foramen) stenosis, together with a schematized indication of the main causes of the disease (disc, arthritis, epidural lipomatosis, and their combinations). The system was applied to a cohort of patients from a single Institution in the last 2-years. Two radiologists evaluated all the MRIs to determine intra- and inter-observer reliability according to Cohen Kappa (Kc, for non-ordered categorical variables) and weighted Kappa (Kw, for ordered variables). Two orthopaedic surgeons clinically evaluated all patients and provided a schematic grading system with a central and lateral stenosis clinical score (CS-CS and LS-CS). Associations between ordinals were tested with chi-square test and measured with the Goodman and Kruskal's gamma index (Gi, with 95% confidence interval [95% CI]). Lastly, the most used previous MRI systems were applied, and their performances were compared to the new system proposed.

RESULTS

One hundred and twelve patients were included (55 females-mean age 63.3 ± 10.7 years). An almost perfect intra-observer agreement for the assessment of central stenosis, foramen stenosis, and lateral recess stenosis was found (Kw = 0.929, 0.928, and 0.924, respectively). The inter-observer agreement was almost perfect for central stenosis and foramen stenosis and substantial for lateral recess stenosis (Kw = 0.863, 0.834, and 0.633, respectively). Whatever the aetiologies involved in central and lateral stenosis, the intra-observer agreement was perfect (all Kc = 1), whereas the inter-observer agreements were almost perfect for arthritis (Kc = 0.838) and lipomatosis (Kc = 0.955) and substantial for disc (Kc = 0.691) regarding central stenosis. The inter-observer agreement for the causes of lateral stenosis was lower and variable, ranging from perfect (lipomatosis) to fair (disc, Kc = 0.224). The grading system revealed a strong association with CS-CS for both readers, with GI = 0.671 (95% CI 0.535-0.807) and 0.603 (95% CI = 0.457-0.749), respectively. The association with MRI grading and LS-CS was moderate for foraminal stenosis and for the concomitant presence of foraminal and lateral recess stenosis, with Gi = 0.337 (95% CI 0.121-0.554) and Gi = 0.299 (95% CI 0.098-0.500), respectively. A weak association was found between lateral recess grading alone and LS-CS with Gi = 0.102 (95% CI 0.193-0.397). The new grading systems showed higher Gi for associations with clinical symptoms, compared with previous ones, both for CS-CS and LS-CS.

CONCLUSIONS

A standardized visual grading system for lumbar spinal stenosis that takes into account all of the major contributing factors-including disc, arthritis, and lipomatosis, for the central canal, lateral recess, and neural foramina could be a useful and practical tool for defining the stenosis, lowering inter-observer variability, and directing the various treatment options.

An Artificial Intelligence-Based Support Tool for Lumbar Spinal Stenosis Diagnosis from Self-Reported History Questionnaire

OBJECTIVES

Symptomatic lumbar spinal stenosis (LSS) leads to functional impairment and pain. While radiologic characterization of the morphological stenosis grade can aid in the diagnosis, it may not always correlate with patient symptoms. Artificial intelligence (AI) may diagnose symptomatic LSS in patients solely based on self-reported history questionnaires.

METHODS

We evaluated multiple machine learning (ML) models to determine the likelihood of LSS using a self-reported questionnaire in patients experiencing low back pain and/or numbness in the legs. The questionnaire was built from peer-reviewed literature and a multidisciplinary panel of experts. Random forest, lasso logistic regression, support vector machine, gradient boosting trees, deep neural networks, and automated machine learning models were trained and performance metrics were compared.

RESULTS

Data from 4827 patients (4690 patients without LSS: mean age 62.44, range 27-84 years, 62.8% females, and 137 patients with LSS: mean age 50.59, range 30-71 years, 59.9% females) were retrospectively collected. Among the evaluated models, the random forest model demonstrated the highest predictive accuracy with an area under the receiver operating characteristic curve (AUROC) between model prediction and LSS diagnosis of 0.96, a sensitivity of 0.94, a specificity of 0.88, a balanced accuracy of 0.91, and a Cohen's kappa of 0.85.

CONCLUSIONS

Our results indicate that ML can automate the diagnosis of LSS based on self-reported questionnaires with high accuracy. Implementation of standardized and intelligence-automated workflow may serve as a supportive diagnostic tool to streamline patient management and potentially lower health care costs.

Influence of radiological factors, psychosocial factors, and central sensitization-related symptoms on clinical symptoms in patients with lumbar spinal canal stenosis

BACKGROUND

No study to date has concurrently evaluated the impact of radiological factors, psychosocial factors, and central sensitization (CS) related symptoms in a single lumbar spinal canal stenosis (LSS) patient cohort.

OBJECTIVE

To investigate the associations between these factors and clinical symptoms in LSS patients.

METHODS

We recruited 154 patients with LSS scheduled for surgery. Patient-reported outcome measures and imaging evaluation including clinical symptoms, psychosocial factors, CS-related symptoms, and radiological classifications. Spearman's rank correlation coefficient and multiple regression analyses were employed.

RESULTS

Spearman's correlation revealed CS-related symptoms positively correlated with low back pain (r= 0.25, p< 0.01), leg pain (r= 0.26, p< 0.01), and disability (r= 0.32, p< 0.01). Pain catastrophizing positively correlated with leg pain (r= 0.23, p< 0.01) and disability (r= 0.36, p< 0.01). Regression analysis showed that pain catastrophizing was associated with disability (β= 0.24, 95%CI = 0.03-0.18), and CS-related symptoms with low back pain (β= 0.28, 95%CI = 0.01-0.09). Radiological classifications were not associated with clinical symptoms.

CONCLUSION

Our findings suggest that psychosocial factors and CS-related symptoms, rather than radiological factors, seem to contribute to clinical symptoms in patients with LSS.

Balancing ability of patients with lumbar spinal canal stenosis

PURPOSE

To determine the relationship between postural sway and the severity of lumbar spinal canal stenosis as well as the effect on postoperative improvement.

METHODS

Stabilometry was performed before and 6 months after surgery in 52 patients (29 men and 23 women; mean age, 74.1 ± 7.8 years) who underwent decompression surgery for lumbar spinal canal stenosis. The environmental area (EA; the area surrounding the circumference of the stabilogram) and locus length per EA (L/EA) were evaluated. The patients were divided into moderate (n = 22) and severe (n = 30) groups according to the severity of canal stenosis. Patient characteristics and parameters were compared between the groups before and after surgery, including the visual analog scale (VAS) score for leg pain, Oswestry Disability Index (ODI), EA, and L/EA. In addition, factors affecting EA and L/EA were evaluated using multiple regression analysis.

RESULTS

Age (p = 0.031), preoperative EA (p < 0.001), preoperative L/EA (p = 0.032), and sagittal vertical axis (p = 0.033) were significantly different between groups. The VAS score and ODI significantly improved postoperatively in both groups (p < 0.001). The EA significantly improved postoperatively only in the severe group (p < 0.001), whereas the L/EA did not significantly improve in either group. Multiple regression analysis showed that only the severity of canal stenosis was significantly associated with preoperative EA (p = 0.030), whereas age (p = 0.040) and severity of canal stenosis (p = 0.030) were significantly associated with preoperative L/EA. Diabetes was significantly associated with postoperative EA (p = 0.046) and L/EA (p = 0.030).

CONCLUSION

The severity of canal stenosis affected abnormal postural sway, which improved after decompression surgery.

Early-stage chronic venous disorder as a cause of leg pain overlooked for lumbar spinal disease

Leg pain can be caused by both lumbar spinal disease and chronic venous disorder (CVD) of leg veins, but their clinical differences have not been thoroughly investigated. This study aimed to determine the incidence of CVD among patients visiting a spine center for leg pain. A total of 196 cases underwent ultrasound examination with a diagnosis rate were 85.7% (168 cases). CVD-diagnosed cases were divided into two groups based on the severity of lumbar spinal disease. The Clinical grades, symptom areas, and symptom types were compared. The differences in symptom improvements with vasoactive medication were also assessed. The most common symptom area was calf then the foot in CVD, while calf then thigh in lumbar spinal disease. Tingling-paresthesia was the most common symptom type for both, with pain and cramping similarly common in CVD and pain more common than cramping in lumbar spinal disease. Considering that the majority of CVD cases (78.6%) had minor cutaneous changes and almost half of cases (41.7%) had refluxes only in tributaries, significant differences in symptom improvement in CVD-dominant group suggested that early-stage venous reflux is a symptomatic disease and a possible cause of leg pain and other symptoms.

The Implication of Preoperative Central Stenosis on Patient-Reported Outcomes After Lumbar Decompression Surgery

OBJECTIVE

To assess the impact of central stenosis severity on patient-reported outcomes after lumbar decompression.

METHODS

Patient diagnosis, demographics, and surgical characteristics were collected via query search and manual chart review of electronic medical records. The inclusion criteria were posterior lumbar decompressions from 2014-2020, with accessible magnetic resonance imaging reports. As previously validated by Lee et al., central stenosis was determined on magnetic resonance imaging and graded as none, mild, moderate, or severe. Patients were dichotomized into 2 groups to improve statistical power for comparisons: none or mild central stenosis and moderate or severe central stenosis. Patient-reported outcome measures (PROMs) were compared between cohorts at 1 year postoperatively. Statistical significance was set at P < 0.05.

RESULTS

On bivariate analysis, no significant differences were noted between cohorts with regard to preoperative, 1-year postoperative, and delta PROMs. In addition, no significant difference in the number of patients attaining minimal clinically important difference (MCID) for each PROM was noted between cohorts. With the exception of mental score of the Short Form-12 survey, all intragroup preoperative to postoperative PROMs indicated significant improvement (all P < 0.05) after lumbar decompression surgery. Multivariate regression identified moderate or severe central canal stenosis as a significant independent predictor of improvement in visual analog scale back (estimate = -1.464, P = 0.045).

CONCLUSIONS

We demonstrate that patients with moderate or severe central spinal stenosis may have more improvement in back pain than those with mild or no central stenosis after lumbar spine decompression surgery.

Comparison of the Tubular Approach and Uniportal Interlaminar Full-Endoscopic Approach in the Treatment of Lumbar Spinal Stenosis: Our 3-Year Results

BACKGROUND

To report the long-term results of patients with lumbar spinal stenosis (LSS), for whom we applied the tubular and endoscopic approaches and previously published the short-term results.

METHODS

A multicenter, prospective, randomized, double-blind study was carried out to evaluate 2 groups of patients with LSS who underwent microsurgery via a tubular retractor with a unilateral approach (T group) and bilateral spinal decompression using uniportal interlaminar endoscopic approaches (E group). Dural sac cross-sectional and spinal canal cross-sectional areas were measured with the patients' preoperative and postoperative magnetic resonance images. The visual analog scale, Oswestry Disability Index, and Japanese Orthopedic Association scores in the preoperative period and the first, second, and third years after surgery were evaluated.

RESULTS

Twenty patients met the inclusion criteria for the research (T group; n = 10, E group; n = 10). The groups' visual analog scale (respectively; P = 0.315, P = 0.529, and P = 0.853), Oswestry Disability Index (respectively; P = 0.529, P = 0.739, and P = 0.912), and Japanese Orthopedic Association (respectively; P = 0.436, P =0.853, and P = 0.684) scores from the first, second, and third postoperative years were quite good compared with the preoperative period, but there was no statistically significant difference. A significant difference was found in the E group, with less blood loss (P < 0.001).

CONCLUSIONS

The long-term results of the patients with LSS treated with tubular and endoscopic approaches were similar and very good. Bilateral decompression with minimally invasive spinal surgery methods can be completed with less tissue damage, complications, and blood loss with the unilateral approach.

Correlation between clinical scoring systems and quantitative MRI parameters in degenerative lumbar spinal stenosis

Background

Many quantitative MRI parameters and clinical scores have been used patients with lumbar spinal stenosis (LSS). However, the correlation between clinical scores and MRI parameters is not very clear. The objective of the study was to find out the correlation between commonly used clinical scoring systems and quantitative MRI parameters.

Methods

Eighty two patients (more than 40 years) with clinical and radiological characteristics of degenerative LSS completed 10 clinical questionnaires which included Oswestry disability index (ODI), Swiss spinal stenosis (SSS) questionnaire, Quebec pain disability scale (QPD), Visual analogue scale (VAS), modified Japanese orthopaedic association scale (mJOA), Pain disability index (PDI), Short form health survey (SF-36), Self-paced walking test (SPWT), Euro quality of life-5D (EQ-5D) and Neurogenic claudication outcome score (NCOS). Lumbosacral MRIs were performed and 8 quantitative parameters namely transverse & AP diameter of dural sac (TDD, APDD), anteroposterior diameter of spinal canal (APDS), ligamentous interfacet distance (LID), mid-sagittal diameter of thecal sac (MSDT), cross-sectional area dural sac (CSAD), lateral recess depth and angle (LRD, LRA) were measured at the maximum stenotic level at the level of the disc. The clinical and radiological parameters were then statistically analysed.

Results

There were 51 females and 31 males in the study with a mean age of 53.0253.02 ± 9.18 years. NCOS score had a moderate correlation with CSAD, LID and TDS (p<0.05,0.7>r ≥ 0.3). MSDT showed a moderate negative correlation with SSS, VAS, ODI and QPD (p<0.05,0.7>r ≥ 0.3). LRD had a moderate negative correlation with ODI and VAS score (p<0.05,0.7>r ≥ 0.3). LRA had a moderate correlation with the EQ-5D and ODI (p<0.05,0.7>r ≥ 0.3). The CSAD had a moderate negative correlation with PDI (r = -0.383, p = 0.000). For all other comparisons, there was poor or no correlation. MRI parameters showed poor or no correlation with most of components of SF-36 score.

Conclusions

A poor correlation or no correlation was noted for most of the MRI parameters when compared to commonly used clinical scores. Hence, poor MRI's don't necessarily mean poor clinical scores in LSS. The role of MRI parameters should be supplementary and overreliance on them in LSS management should be avoided.

Magnitude of Dural Tube Compression Still Does Not Show a Predictive Value for Symptomatic Lumbar Spinal Stenosis for Six-Year Follow-Up: A Longitudinal Observation Study in the Community

Background: Lumbar spinal stenosis (LSS) is a clinical syndrome based on anatomic narrowing of the spinal canal. It is well known that anatomic narrowing of the spinal canal is essential for manifestation, but not all of them cause symptoms. There are many studies assessing the relationship between dural tube compression on MRI and clinical symptoms; however, most of them are cross-sectional. The purpose of this study was to reveal the magnitude of dural tube compression’s influence on the presence or development of LSS symptoms at the six-year follow-up and the occurrence of surgery during the follow-up period or not in the community setting. Methods: This was a longitudinal observational study of 459 participants who were assessed for typical LSS symptoms, and whose Roland–Morris Disability Questionnaire and numerical rating scale of leg pain and numbness was recorded using a questionnaire and conventional MRI of the lumbar spine. Typical LSS symptoms were judged using an LSS diagnostic support tool, which was a self-administered, self-reported history questionnaire (LSS-SSHQ). After six years, 232 subjects (follow-up rate 50.5%) were followed-up with typical LSS symptoms using LSS-SSHQ by mail. The relationship between the magnitude of dural tube compression evaluated by dural tube cross-sectional area (DCSA) in the initial assessment and the time course of typical LSS symptoms for the six-year duration were analyzed. In addition, predictors of the presence of typical LSS symptoms at the six-year follow-up were assessed. Furthermore, we investigated the relationship between typical LSS symptoms and DCSA during the initial assessment of patients who underwent surgery during the follow-up period. A multivariate logistic regression analysis was performed for statistical analysis. Results: (1) Severe dural tube compression did not show that LSS symptoms continued after six years. (2) Severe dural tube compression could not detect development of LSS-symptoms and surgery during the six-year period. Conclusion: Severe dural tube compression could not detect typical LSS symptom development and occurrence of surgery during the six-year period.

Probability for surgical treatment in patients with lumbar spinal stenosis according to the stenotic lesion severity: a 5-10-year follow-up study

BACKGROUND

We aimed (1) to clarify difference in the natural history of lumbar spinal stenosis (LSS) with respect to surgical treatment according to severity of stenosis on magnetic resonance imaging (MRI) using qualitative grading system and (2) to estimate surgical probabilities depending on radiological severity.

METHODS

With the design of retrospective observational study, a total of 1,248 patients diagnosed with LSS between 2011 and 2014 at our hospital were followed up for the mean duration of 7.7 years (5.17-9.8 years). We investigated severity of central and foraminal stenoses on initial MRI using qualitative grading system and whether surgical treatment was performed. Logistic regression models were used to identify risk factors for surgery.

RESULTS

During the mean follow-up period of 7.7 years, grade 3 maximal central stenosis showed the highest percentage of surgical treatment (57.9%-62.3%) with no significant difference in surgical probabilities according to concomitant foraminal stenosis. Surgical probabilities in grade 2 and 3 maximal foraminal stenosis, were 22.2%-62.3% and 33.3%-57.9%, respectively, depending on concomitant central stenosis. Maximal central stenosis of grades 1, 2, and 3 (odds ratio [OR]: 1.79, 2.21, and 6.26, respectively), and maximal foraminal stenosis of grades 2 and 3 (OR: 2.22 and 2.12, respectively) were significant risk factors for surgical treatment.

CONCLUSIONS

The high grades of maximal central and foraminal stenoses were risk factors for surgical treatment. Surgical probabilities were 57.9%-62.3% in grade 3 maximal central stenosis, 22.2%-62.3% and 33.3%-57.9%, respectively, in grade 2 and 3 maximal foraminal stenosis during the mean follow-up period of 7.7 years. These results indicate that the natural history of LSS differs according to grade of maximal central and foraminal stenoses.

Computed Tomographic Epidurography in Patients with Low Back Pain and Leg Pain: A Single-Center Observational Study

This study was conducted to analyze the findings and benefits of computed tomography (CT) epidurography in patients with low back and leg pain and compare these findings with those of magnetic resonance imaging (MRI) images. In total, 495 intervertebral discs from 99 patients with low back and leg pain who underwent percutaneous epidural adhesiolysis (epidural neuroplasty or percutaneous adhesiolysis) were examined. The axial views of CT epidurography were classified into six types to examine each intervertebral disc: round type, ellipse type, spike type, Benz mark, incomplete block, complete block, and non-contrast. MRI images were graded from A to D using the Schizas classification. Notably, 176 images were round-type and ellipse-type axial views, and 138 were spike-type and Benz-mark views; Schizas classification Grades A and B were observed in 272 and 47 MRI images, respectively. The incomplete block and complete block axial images did not significantly differ in CT epidurography and Schizas classification Grades C and D. The images showing Benz marks existed only at the L4/5 and L5/S intervertebral levels and only in 14.7% of patients. The ratio of normal shadows differed between MRI images and CT epidurography. Therefore, CT epidurography may enable a detailed evaluation of the epidural space.

Reliability of preoperative MRI findings in patients with lumbar spinal stenosis

Background

Magnetic Resonance Imaging (MRI) is an important tool in preoperative evaluation of patients with lumbar spinal stenosis (LSS). Reported reliability of various MRI findings in LSS varies from fair to excellent. There are inconsistencies in the evaluated parameters and the methodology of the studies. The purpose of this study was to evaluate the reliability of the preoperative MRI findings in patients with LSS between musculoskeletal radiologists and orthopaedic spine surgeons, using established evaluation methods and imaging data from a prospective trial.

Methods

Consecutive lumbar MRI examinations of candidates for surgical treatment of LSS from the Norwegian Spinal Stenosis and Degenerative Spondylolisthesis (NORDSTEN) study were independently evaluated by two musculoskeletal radiologists and two orthopaedic spine surgeons. The observers had a range of experience between six and 13 years and rated five categorical parameters (foraminal and central canal stenosis, facet joint osteoarthritis, redundant nerve roots and intraspinal synovial cysts) and one continuous parameter (dural sac cross-sectional area). All parameters were re-rated after 6 weeks by all the observers. Inter- and intraobserver agreement was assessed by Gwet’s agreement coefficient (AC1) for categorical parameters and Intraclass Correlation Coefficient (ICC) for the dural sac cross-sectional area.

Results

MRI examinations of 102 patients (mean age 66 ± 8 years, 53 men) were evaluated. The overall interobserver agreement was substantial or almost perfect for all categorical parameters (AC1 range 0.67 to 0.98), except for facet joint osteoarthritis, where the agreement was moderate (AC1 0.39). For the dural sac cross-sectional area, the overall interobserver agreement was good or excellent (ICC range 0.86 to 0.96). The intraobserver agreement was substantial or almost perfect/ excellent for all parameters (AC1 range 0.63 to 1.0 and ICC range 0.93 to 1.0).

Conclusions

There is high inter- and intraobserver agreement between radiologists and spine surgeons for preoperative MRI findings of LSS. However, the interobserver agreement is not optimal for evaluation of facet joint osteoarthritis.

Trial registration

www.ClinicalTrials.gov identifier: NCT02007083, registered December 2013.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04949-4.

The association between clinical symptoms of lumbar spinal stenosis and MRI axial imaging findings

Purpose:

In diagnosing lumbar spinal stenosis (LSS), Magnetic Resonance Imaging (MRI) is appropriate to confirm the presence of anatomical stenosis of the spinal canal or compression of the nerve roots. However, it is known that morphological LSS is often present in asymptomatic subjects. There is still controversy about the relationship between anatomical LSS and symptomatic LSS. The aim of this study was to assess the association between qualitative imaging findings on MRI of the lumbar spine and symptomatic LSS.

Patients and methods:

This was a cross-sectional study of 239 volunteers from an epidemiological survey that included 1,862 participants in total. MRI of the lumbar spine was evaluated in four categories: morphological grading of central stenosis and lateral recess stenosis, presence of the sedimentation sign, and severity of facet joint effusion. The relationship between these morphological evaluations and typical LSS symptoms as assessed by the self-administered, self-reported history questionnaire for lumbar spinal stenosis (LSS-SSHQ) was investigated by multiple logistic regression analysis.

Results:

The odds ratio of the most severe central stenosis to no stenosis was 15.5 (95%CI: 1.4-164.9). Only the most severe central stenosis was associated with typical LSS symptoms, but not all cases with typical LSS symptoms were due to severe central stenosis.

Conclusion:

Extreme severe central stenosis was strongly related to typical LSS symptoms. However, although subjects with severe central stenosis showed symptoms suggestive of LSS, these subjects did not always show typical LSS symptoms.

Reliability and Validity of the Boston Bedside Quantitative Sensory Testing Battery for Neuropathic Pain

OBJECTIVE

Recent studies suggest that sensory phenotyping may provide critical information for the diagnosis and management of patients with chronic neuropathic pain (NP). However, many formal quantitative sensory testing (QST) paradigms require expensive equipment, a dedicated location, and substantial time commitments on the part of patient and examiner, highlighting the need for a convenient and portable "bedside" QST battery. We developed and tested a bedside QST battery in a sample of patients with chronic NP.

METHODS

Participants (N = 51) attended two in-person visits over approximately two weeks, during which they underwent QST using both laboratory-based equipment and simple, easily accessible bedside tools. Participants also completed questionnaires about their daily pain and NP symptoms.

RESULTS

Test-retest reliability estimates were highly statistically significant and did not differ between bedside (mean r = 0.60) and laboratory-based (mean r = 0.72) QST. Bedside QST variables and corresponding laboratory-based QST variables were highly correlated, suggesting adequate criterion validity for the bedside tests.

CONCLUSIONS

Results from the present study may have important implications for the sensory phenotyping and subsequent management of patients with chronic NP. Implementation of a protocol that uses inexpensive, portable, and convenient tools may allow for the application of QST in variety of clinical settings and advance NP research.

Hand grip strength as a surrogate marker for postoperative changes in spinopelvic alignment in patients with lumbar spinal stenosis

There are a few studies on the postoperative changes in sagittal alignment and corresponding factors, including hand grip strength (HGS) and muscle performance tests for lumbar spinal stenosis (LSS). Thus, we aimed to determine whether HGS can be a surrogate marker for global sagittal alignment changes after decompression with fusion surgery for LSS. This retrospective observational study included 91 patients who underwent spine fusion surgery for LSS. Radiological spinopelvic parameters, including sagittal vertical axis (SVA), lumbar lordosis (LL), pelvic tilt (PT), pelvic incidence (PI), global tilt (GT), and T1 pelvic angle (T1PA), were analyzed preoperatively and 1 year after posterior decompression and fusion surgery. To assess muscle performance, the 6-m walk (SMT), timed up and go (TUGT), and sit-to-stand (STS) tests were conducted. The relationship between HGS and postoperative SVA was examined through multiple linear regression analysis. Additionally, the relationship between HGS and preoperative/postoperative radiologic spinopelvic parameters and muscle performance test results was analyzed through Pearson's correlation. HGS was significantly correlated with age, preoperative and postoperative SVA, and the muscle performance tests. Furthermore, HGS was a factor that can significantly influence postoperative SVA changes in multiple linear regression analyses. Therefore, HGS may be a good predictor of postoperative SVA change.

Feasibility and Outcomes of Tubular Decompression in Extreme Stenosis

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To report the feasibility, nuances, technical tips as well as outcomes of managing single-level grade D (extreme stenosis) and to compare the outcomes with nonextreme stenosis using the tubular retractor system.

SUMMARY OF BACKGROUND DATA

Minimally invasive decompression in extreme stenosis is a challenge due to technical difficulty, feasibility of adequate decompression, and a steep learning curve.

METHODS

Consecutive patients from January 2007 to January 2017 presenting with neurogenic claudication secondary to single-level spinal stenosis operated using tubular retractors were included in the study. The patients were divided into two groups; extreme-stenosis and nonextreme stenosis. The outcomes of surgery were evaluated and compared using visual analogue score (VAS) for leg and back pain, Oswestry disability index (ODI), and MacNab's criteria.

RESULTS

A total of 325 patients (out of 446 patients after excluding the multilevel cases) fulfilled the inclusion criteria. One hundred forty patients were cases of extreme stenosis and 185 were nonextreme stenosis. The mean VAS for back and leg pain for extreme stenosis improved from 3.23 ± 1.30 to 2.15 ± 0.91 and 7.33 ± 0.78 to 1.66 ± 1.03 respectively as compared with nonextreme stenosis where the mean VAS for back and leg pain improved from 3.01 ± 1.15 to 1.86 ± 1.10 and 6.57 ± 1.00 to 1.54 ± 1.12 respectively. The mean ODI changed from 66.47 ± 7.53 to 19.95 ± 2.90 in extreme stenosis as compared with nonextreme stenosis where mean ODI changed from 59.05 ± 5.08 to 19.88 ± 2.67. As per MacNab's criteria 102 (of 120 patients) and 139 (of 157 patients) reported excellent and good outcomes in extreme and nonextreme stenosis respectively.

CONCLUSION

Tubular decompression is feasible in patients with extreme-stenosis with no difference in the outcomes as well as complication rates when compared with a cohort of nonextreme stenosis.

LEVEL OF EVIDENCE

3.

Clinical validity of two different grading systems for lumbar central canal stenosis: Schizas and Lee classification systems

OBJECTIVE

To assess the learnability of two magnetic resonance imaging (MRI) grading systems for lumbar central canal stenosis based on inter-observer agreement and test-retest reliability of doctors with no prior knowledge of the two systems.

MATERIALS AND METHODS

Two clinical fellows, one novice radiology resident, one neurosurgeon, and one orthopedic surgeon, who were unaware of the two qualitative MRI grading systems prior to this study, acquainted themselves with the teaching files. All five observers independently assessed the LCCS grade of 70 patients using T2-weighted axial magnetic resonance images at the L2-3, L3-4, L3-4, and L5-S1 disc levels. Analysis was performed twice at an interval of two months.

RESULTS

The inter-observer agreement among all five readers was excellent and test-retest reliability was moderate to excellent for both the Schizas and Lee systems. Positive percentage agreements were found to be over 0.8 in almost all observers with relatively narrow 95% confidence limits.

CONCLUSION

Both Schizas and Lee MRI grading systems for LCCS are reliable grading systems, and can be used as a learnable method for both clinicians and radiologists.

Comparative Study Between Uniportal Full-Endoscopic Interlaminar and Tubular Approach in the Treatment of Lumbar Spinal Stenosis: A Pilot Study

STUDY DESIGN

Multicenter, prospective, randomized, and double-blinded study.

OBJECTIVES

To compare tubular and endoscopic interlaminar approach.

METHODS

Patients with lumbar spinal stenosis and neurogenic claudication of were randomized to tubular or endoscopic technique. Enrollment period was 12 months. Clinical follow up at 1, 3, 6 months after surgery with visual analogue scale (VAS), Oswestry Disability Index (ODI), and Japanese Orthopedic Association (JOA) score. Radiologic evaluation with magnetic resonance pre- and postsurgery.

RESULTS

Twenty patients were enrolled: 10 in tubular approach (12 levels) and 10 in endoscopic approach (11 levels). The percentage of enlargement of the spinal canal was higher in endoscopic approach (202%) compared with tubular approach (189%) but was not statistically significant (P = .777). The enlargement of the dural sac was higher in endoscopic group (209%) compared with tubular group (203%) but no difference was found between the 2 groups (P = .628). A modest significant correlation was found between the percentage of spinal canal decompression and enlargement of the dural sac (r = 0.5, P = .023). Both groups reported a significant clinical improvement postsurgery. However, no significant association was found between the percentage of enlargement of the spinal canal or the dural sac and clinical improvement as determined by scales scores. Endoscopic group had lower intrasurgical bleeding (P < .001) and lower disability at 6 months of follow-up than tubular group (p=0.037).

CONCLUSIONS

In the treatment of lumbar spinal stenosis, endoscopic technique allows similar decompression of the spinal canal and the dural sac, lower intrasurgical bleeding, similar symptoms improvement, and lower disability at 6 months of follow-up, as compared with the tubular technique.

Do lumbar magnetic resonance imaging changes predict neuropathic pain in patients with chronic non-specific low back pain?

The aim of this observational, cross-sectional study was to analyse lumbar magnetic resonance imaging (MRI) findings in patients with non-specific chronic low back pain (CLBP), and to evaluate any correlation with pain intensity and their capacity to predict neuropathic pain (NP) in these patients.Fifty-two patients with non-specific CLBP, between 21 and 62 years of age, 50% men, were investigated. Lumbar MRI was employed to assess disc degeneration, endplate changes, Modic changes, disc displacement, facet degeneration, foraminal stenosis and central lumbar spinal stenosis. The characteristics of pain were evaluated and patients were divided into 2 subgroups: with NP (24 patients) and without NP (28 patients), based on the results of a DN4-interview. Correlations between particular MRI changes and their relations to the intensity of pain were evaluated. Logistic regression was used to disclose predictors of NP.Lumbar spine degenerative features were frequent in patients with non-specific CLBP, with L4/5 the most affected level. A significant correlation emerged between the severity of degenerative changes in particular lumbar spine structures (correlation coefficient ranging between 0.325 and 0.573), while no correlation was found between severity of degenerative changes and pain. Multivariate logistic regression revealed only 2 independent predictors of NP - female sex (odds ratio [OR] = 11.9) and a mean pain intensity of ≥4.5 in the previous 4 weeks (OR = 13.1).Degenerative changes in the lumbar spine are frequent MRI findings, but do not correlate with the intensity of pain and do not predict NP. However, female sex and pain intensity do predict NP.

An observational study on trajectories and outcomes of chronic low back pain patients referred from a spine surgery division for chiropractic treatment

Background

A close collaboration between surgeons and non-surgical spine experts is crucial for optimal care of low back pain (LBP) patients. The affiliation of a chiropractic teaching clinic to a university hospital with a large spine division in Zurich, Switzerland, enables such collaboration. The aim of this study was to describe the trajectories and outcomes of patients with chronic LBP referred from the spine surgery division to the chiropractic teaching clinic.

Methods

The patients filled in an 11-point numeric rating scale (NRS) for pain intensity and the Bournemouth Questionnaire (BQ) (bio-psycho-social measure) at baseline and after 1 week, 1, 3, 6 and 12 months. Additionally, the Patient’s Global Impression of Change (PGIC) scale was recorded at all time points apart from baseline. The courses of NRS and BQ were analyzed using linear mixed model analysis and repeated measures ANOVA. The proportion of patients reporting clinically relevant overall improvement (PGIC) was calculated and the underlying factors were determined using logistic regression analyses.

Results

Between June 2014 and October 2016, 67 participants (31 male, mean age = 46.8 ± 17.6 years) were recruited, of whom 46 had suffered from LBP for > 1 year, the rest for > 3 months, but < 1 year. At baseline, mean NRS was 5.43 (SD 2.37) and mean BQ was 39.80 (SD 15.16) points. NRS significantly decreased [F(5, 106.77) = 3.15, p = 0.011] to 4.05 (SD 2.88) after 12 months. A significant reduction was not observed before 6 months after treatment start (p = 0.04). BQ significantly diminished [F(5, 106.47) = 6.55, p < 0.001] to 29.00 (SD 17.96) after 12 months and showed a significant reduction within the first month (p < 0.01). The proportion of patients reporting overall improvement significantly increased from 23% after 1 week to 47% after 1 month (p = 0.004), when it stabilized [56% after 3 and 6 months, 44% after 12 months]. Reduction in bio-psycho-social impairment (BQ) was of higher importance for overall improvement than pain reduction.

Conclusions

Chiropractic treatment is a valuable conservative treatment modality associated with clinically relevant improvement in approximately half of patients with chronic LBP. These findings provide an example of the importance of interdisciplinary collaboration in the treatment of chronic back pain patients.

Percutaneous endoscopic ventral facetectomy: An innovative substitute of open decompression surgery for lateral recess stenosis surgical treatment?

BACKGROUND

Percutaneous transforaminal endoscopic surgery (PTES) constitutes an innovative method principally recruited for the treatment of lumbar disc herniation. Indication spectrum of PTES is constantly widened in current years. Hence, PTES has been proposed to represent a satisfactory alternative for the treatment of lateral recess stenosis (LRS), being defined as percutaneous endoscopic ventral facetectomy (PEVF) in these cases. The aim of this original study is to determine, for the first time in the literature, the outcomes of PEVF, especially in otherwise healthy nonelderly patients with LRS, alongside with special focus in health-related quality of life (HRQoL) assessment.

MATERIALS AND METHODS

Eighty-five otherwise healthy individuals from 58 to 64 years were diagnosed with LRS, being subjected to successful PEVF. Patients were prospectively evaluated in 6 weeks, in 3, 6, and 12 months, and in 2 years postoperatively. Visual analog scales (VASs) were separately utilized for leg and low back pain evaluation (VAS-LP and VAS-BP, respectively), whereas Short Form-36 (SF-36) questionnaire was sequentially implemented for HRQoL assessment.

RESULTS

All indexes of SF-36 as well as VAS-LP featured maximal amelioration in 6 weeks postoperatively, with subsequent further enhancement until 3 months and successor stabilization until 2 years. In contrast, VAS-BP presented minimal quantitative amelioration in 6 weeks, featuring no additional alterations. Values of all indexes in all follow-up intervals were demonstrated to be statistically significant in comparison with preoperative values (P < 0.05). No remarkable differentiation was observed between distinct parameters of SF-36.

CONCLUSIONS

PEVF implementation in nonelderly patients with LRS was displayed to be safe and effective, providing alongside considerable improvement in HRQoL 2 years postoperatively.