Radiological Analysis of Cerebrospinal Fluid Dynamics at the Craniovertebral Junction Using Time-Spatial Labeling Inversion Pulse Magnetic Resonance Imaging in Patients with Cervical Spinal Canal Stenosis

OBJECTIVE

Spondylotic changes in the cervical spine cause degeneration, leading to cervical spinal canal stenosis. This stenotic change can affect cerebrospinal fluid (CSF) dynamics by compressing the dural sac and reducing space in the subarachnoid space. We examined CSF dynamics at the craniovertebral junction (CVJ) using time-spatial labeling inversion pulse magnetic resonance imaging (Time-SLIP MRI) in patients with cervical spinal canal stenosis.

METHODS

The maximum longitudinal movement of the CSF at the CVJ was measured as length of motion (LOM) in the Time-SLIP MRI of 56 patients. The sum of ventral and dorsal LOM was defined as the total LOM. Patients were classified into 3 groups depending on their spinal sagittal magnetic resonance imaging findings: control (n = 27, Kang classification grades 0 and 1), stenosis (n = 14, Kang classification grade 2), and severe stenosis (n = 15, Kang classification grade 3).

RESULTS

Time-SLIP MRI revealed pulsatile movement of the CSF at the CVJ. The mean total, ventral, and dorsal LOM was 14.2 ± 9, 8.1 ± 5.7, and 3.8 ± 2.9 mm, respectively. The ventral LOM was significantly larger than the dorsal LOM. The total LOM was significantly smaller in the severe stenosis group (6.1 ± 3.4 mm) than in the control (16.0 ± 8.4 mm) or stenosis (11 ± 5.4 mm) groups (P < 0.001, Kruskal-Wallis H-test). In 5 patients, postoperative total LOM was improved after adequate decompression surgery.

CONCLUSIONS

This study demonstrates that CSF dynamics at the CVJ are influenced by cervical spinal canal stenosis. Time-SLIP MRI is useful for evaluating CSF dynamics at the CVJ in patients with spinal canal stenosis.

Usefulness of lysophosphatidylcholine measurement in the cerebrospinal fluid for differential diagnosis of neuropathic pain: Possible introduction into clinical laboratory testing

BACKGROUND

The differential diagnosis of neuropathic pain, especially discrimination between neuropathic pain caused by spinal canal stenosis (SCS) and neuropathic pain associated with causes other than SCS, is sometimes difficult; however, it is important for surgical application.

METHODS

We established a reliable method for measuring lysophosphatidylcholine (LPC), a precursor of lysophosphatidic acids which are known as being pain initiators, using a liquid chromatography-tandem mass spectrometry method, and measured the LPC concentrations in the cerebrospinal fluid (CSF) in patients with SCS (SCS group; n = 76), patients with neuropathic pain caused by non-SCS diseases (Others group; n = 49), and control subjects without pain (control group; n = 92).

RESULTS

Both within-run and between-run CV(%) were almost < 10 %, suggesting an enough performance for clinical introduction. The CSF concentrations of LPC (16:0) and LPC (18:0) were higher in the SCS group than those in the Control or Others group; the concentrations of LPC (18:1), LPC (18:2), LPC (20:4), LPC (22:6) levels were higher in the SCS group than those in the control or others group, but they were also higher in the Others group than those in the control group. The areas under the curve in the ROC curve analyses of LPC (18:1) for discriminating between the SCS and control groups, others and control groups, and SCS and others groups were 0.994, 0.860, and 0.869, respectively.

CONCLUSIONS

LPC measurement in the CSF is useful for the differential diagnosis of neuropathic pain, especially for surgical decision-making, which is expected for clinical introduction.

Anterior cervical corpectomy and fusion with stand-alone cages in patients with multilevel degenerative cervical spine disease is safe

Background

In case of spinal cord compression behind the vertebral body, anterior cervical corpectomy and fusion (ACCF) proves to be a more feasible approach than cervical discectomy. The next step was the placement of an expandable titanium interbody in order to restore the vertebral height. The need for additional anterior plating with ACCF has been debatable and such technique has been evaluated by very few studies. The objective of the study is to evaluate radiographic and clinical outcomes in patients with multilevel degenerative cervical spine disease treated by stand-alone cages for anterior cervical corpectomy and fusion (ACCF).

Methods

Thirty-one patients (66.5 ± 9.75 years, range 53–85 years) were analyzed. Visual Analog Scale (VAS) and the 10-item Neck Disability Index (NDI) were assessed preoperatively and during follow-up on a regular basis after surgery and after one year at least. Assessment of radiographic fusion, subsidence, and lordosis measurement of Global cervical lordosis (GCL); fusion site lordosis (FSL); the anterior interbody space height (ant. DSH); the posterior interbody space height (post. DSH); the distance of the cage to the posterior wall of the vertebral body (CD) were done retrospectively. Mean clinical and radiographic follow-up was 20.0 ± 4.39 months.

Results

VAS-neck (p = 0.001) and VAS-arm (p < 0.001) improved from preoperatively to postoperatively. The NDI improved at the final follow-up (p < 0.001). Neither significant subsidence of the cages nor significant loss of lordotic correction were seen. All patients showed a radiographic union of the surgically addressed segments at the last follow up.

Conclusions

Application of a stand-alone expandable cage in the cervical spine after one or two-level ACCF without additional posterior fixation or anterior plating is a safe procedure that results in fusion. Neither significant subsidence of the cages nor significant loss of lordotic correction were seen.

Trial registration

Retrospectively registered. According to the Decision of the ethics committee, Jena on 25th of July 2018, that this study doesn’t need any registration. https://www.laek-thueringen.de/aerzte/ethikkommission/registrierung/.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04883-5.

Poor Fusion Rates Following Cervical Corpectomy Reconstructed With an Expandable Cage: Minimum 2-Year Radiographic and Clinical Outcomes

BACKGROUND

Expandable cages are often used to reconstruct cervical corpectomies but there are few long-term follow-up studies with large numbers.

OBJECTIVE

To analyze the clinical and radiographic results of cervical corpectomy reconstructed with expandable cages for degenerative stenosis.

METHODS

We performed a retrospective analysis of 78 patients with degenerative cervical stenosis treated with a corpectomy reconstructed with an expandable cage. We evaluated the clinical and radiographic outcomes, as well as complications of the procedure at a minimum 2-yr follow-up.

RESULTS

There was a decrease in the visual analog scale pain average from 75 mm to 8.5 mm (P = .02); a decrease in the Neck Disability Index average from 55% to 12% (P = .009); and improvement in the Japanese Orthopaedic Association average from 12 to 14 points (P = .01). There was a change in cervical lordosis (Cobb method) average from −9.3° to −15.1° (P = .002), without significant loss of lordosis (P = .63). The fusion rate, by criteria of the Cervical Spine Research Society (CSRS), was low: using dynamic X-rays – 50% (n = 39/78) and using computed tomography (CT) – 47.4% (n = 37/78). A total of 11 patients (14.1%) suffered complications.

CONCLUSION

To our knowledge, this is the largest series (78) with a minimum 2-yr follow-up in the literature and the first using the dynamic radiographic and CT criteria endorsed by the CSRS. Using these criteria, our fusion rates were much lower than all previous reports in the literature. Despite this, patient-reported outcomes were reasonable. There was a relatively low incidence of perioperative complications, most of which were likely not implant-specific and there was only 1 case of implant failure.

Cerebrospinal fluid leak presented with the C1-C2 sign caused by spinal canal stenosis: a case report

BACKGROUND

Intracranial hypotension is a disorder characterized by low cerebrospinal fluid (CSF) pressure typically caused by loss of CSF. Although some mechanisms account for the CSF leakage have been elucidated, spinal canal stenosis has never been reported as a pathological cause of intracranial hypotension. C1-C2 sign is a characteristic imaging feature, which indicates CSF collection between the spinous processes of C1 and C2, occasionally observed on magnetic resonance imaging (MRI) in patients with intracranial hypotension.

CASE PRESENTATION

A 58-year-old man was presented to our institute with complaints of posterior cervical pain persisting for 3 months, along with numbness and muscle weakness of extremities. A fat suppression T2-weighted image of MRI illustrated fluid collection in the retrospinal region at C1-C2 level, and an 111In-DTPA cisternoscintigram clearly revealed the presence of CSF leakage into the same region. The MRI also showed stenosis in spinal canal at C3/4 level, and a computed tomography (CT) myelogram suggested a blockage at the same level. We gave a diagnosis as intracranial hypotension due to the CSF leakage, which might be caused by the spinal canal stenosis at C3/4 level. Despite 72 h of conservative therapy, a brain CT showed the development of bilateral subdural hematomas. We, therefore, performed burr-hole drainage of the subdural hematoma, blood-patch therapy at C1/2 level, and laminoplasty at C3-4 at the same time. Improvement of symptoms and imaging features which suggested the CSF leak and subdural hematoma were obtained post-operatively.

CONCLUSION

The present case suggested the mechanism where the CSF leakage was revealed as fluid collection in the retrospinal region at C1-C2 level. Increased intradural pressure due to the spinal canal stenosis resulted in dural tear. CSF leaked into the epidural space and subsequently to the retrospinal region at C1-C2 level, due to the presence of spinal canal stenosis caudally as well as the vulnerability of the tissue structure in the retrospinal region at C1-C2 level. Thus, our theory supports the mechanisms of previously reported CSF dynamics associated to C1-C2 sign, and also, we suggest spinal canal stenosis as a novel etiology of intracranial hypotension.

Filum Terminale Arteriovenous Fistula in Association with Degenerative Lumbosacral Spinal Canal Stenosis: Report of 3 Cases and Review of the Literature

BACKGROUND

Filum terminale arteriovenous fistulas (FTAVFs) are rare, and the pathogenesis of these fistulas remains unclear. They may be either congenital or acquired in origin. The authors report 3 cases of FTAVFs in association with severe spinal canal stenosis. The authors also review literature of FTAVFs associated with spinal canal stenosis.

CASE DESCRIPTION

All 3 cases harboring FTAVFs manifested with progressive myelopathy and bowel/bladder dysfunction following long history of back pain, sciatica, and/or intermittent claudication. The fistulas were located around or at the level of spinal canal stenosis and supplied by the anterior spinal and/or lateral sacral arteries with cranial drainage from the dilated vein of the filum terminale to the perimedullary veins. The first and third cases were treated concomitantly by performing instrumented fusion with decompressive laminectomy along with occlusion of the fistula with good results. The second case was unsuccessfully treated by endovascular treatment through the lateral sacral artery and denied further surgical treatment.

CONCLUSIONS

Our 3 case reports may provide additional evidence supporting an acquired etiology of FTAVFs, probably secondary to the severe central canal stenosis. From our review, the level of the fistulas in most patients is correlated with the level of spinal canal stenosis. The authors preferred the concomitant surgical treatment by performing decompressive laminectomy and obliteration of the fistula in the same surgical session.

Spinal Sparganosis Coexisting with Acquired Arteriovenous Fistula of the Filum Terminale

BACKGROUND

Spinal sparganosis associated with filum terminale arteriovenous fistula (FTAVF) has not been reported in the literature. In previous studies, these 2 rare diseases were usually reported separately. We report the first case of spinal sparganosis with concomitant FTAVF.

CASE DESCRIPTION

Spinal sparganosis associated with FTAVF manifested in a middle-aged man with progressive back pain and paraparesis. Magnetic resonance imaging of the lumbosacral spine revealed large intradural mass-like lesions involving the conus medullaris and entire cauda equina. Additionally, there was degenerative spinal stenosis at the level of L2-3 to L5-S1. Magnetic resonance imaging of the thoracic spine disclosed abnormal hypersignal intensity extending from the level of the conus medullaris to T7 with tortuous intradural flow voids along the ventral more than dorsal surfaces of the spinal cord. Magnetic resonance angiography and spinal angiography confirmed FTAVF at the level of L3-4. The patient underwent surgical removal of the granulation tissues with lysis adhesions and obliteration of the FTAVF simultaneously in the same surgical session. Histologic findings were consistent with sparganosis.

CONCLUSIONS

The formation of FTAVF in the present case may have resulted from severe spinal canal stenosis caused by lumbar spondylosis and spinal sparganosis, inducing chronic inflammation and severe adhesion of spinal nerve roots. This evidence indicates that FTAVF may have been acquired.

Assessment of spinal cord motion as a new diagnostic MRI-parameter in cervical spinal canal stenosis: study protocol on a prospective longitudinal trial

Background

Increased spinal cord motion has been proven to be a relevant finding within spinal canal stenosis disclosed by phase-contrast MRI (PC-MRI). Adapted PC-MRI is a suitable and reliable method within the well deliberated setting. As the decision between conservative and operative treatment can be challenging in some cases, further diagnostic marker would facilitate the diagnostic process. We hypothesize that increased spinal cord motion will correlate to clinical course and functional impairment and will contribute as a new diagnostic marker.

Methods

A monocentric, prospective longitudinal observational trial on cervical spinal canal stenosis will be conducted at the University Medical Center Freiburg. Patients (n = 130) with relevant cervical spinal canal stenosis, being defined by at least contact to the spinal cord, will be included. Also, we will examine a control group of healthy volunteers (n = 20) as proof-of-principle. We will observe two openly assigned branches of participants undergoing conservative and surgical decompressive treatment (based on current German Guidelines) over a time course of 12 month, including a total of 4 visits. We will conduct a broad assessment of clinical parameters, standard scores and gradings, electrophysiological measurements, standard MRI, and adapted functional PC-MRI of spinal cord motion. Primary endpoint is the evaluation of an expected negative correlation of absolute spinal cord displacement to clinical impairment. Secondary endpoints are the evaluation of positive correlation of increased absolute spinal cord displacement to prolonged evoked potentials, prediction of clinical course by absolute spinal cord displacement, and demonstration of normalized spinal cord motion after decompressive surgery.

Discussion

With the use of adapted, non-invasive PC-MRI as a quantitative method for assessment of spinal cord motion, further objective diagnostic information can be gained, that might improve the therapeutic decision-making process. This study will offer the needed data in order to establish PC-MRI on spinal cord motion within the diagnostic work-up of patients suffering from spinal canal stenosis.

Trial registration

German Clinical Trials Register, ID: DRKS00012962, Register date 2018/01/17

[The importance of interspinous spacers in the treatment of lumbar spinal stenosis]

INTRODUCTION

In the treatment of lumbar spinal stenosis, interspinous spacers can be used in a tissue and time sparing technique. Relief of low back pain might be achieved by stress reduction of facet joints and limitation of segmental mobility.

AIM

Presentation of dynamic stabilization by means of an interspinous spacer with and without decompression and to compare it with the outcome of decompression and fusion.

MATERIAL AND METHODS

As part of a PubMed search, randomized controlled trials (RCTs) and non-RCTs from high-quality controlled clinical trials were selected and contrasted with our own experience.

RESULTS

The current literature was evaluated, which assesses interspinous spacers with and without decompression in comparison with the "gold standard", the microsurgical interlaminar decompression.

CONCLUSION

Published data indicate that the use of interspinous spacers with or without decompression for the treatment of lumbar spinal stenosis is not less effective than stand-alone decompression. The reoperation rate can only be proven for implants without decompression on the basis of Level I studies. However, as a link between decompression alone and fusion, it cannot yet provide a scientifically clear solution.

[Lumbar spinal canal stenosis : A historical perspective]

To know the history of a disease and its treatment is always instructive and helps us to understand the contexts better. It also shows what unbelievable preliminary work was necessary for us be able to treat patients today in the way we are used to. This article attempts to shed light on spinal canal stenosis from a historical perspective and to identify the pioneers who contributed to the understanding of the epidemiology, anatomy, pathogenesis, classification and diagnostic work-up of spinal canal stenosis. In addition, the efforts of scientists and clinicians who have participated in developing the treatment of lumbar spinal canal stenosis in the last seven decades should be recognized.

[Lumbar synovial cysts: literature review and original long-term results after microsurgical resection]

BACKGROUND

Intraspinal lumbar vertebral joint cysts are an unusual cause of nerve root compression symptoms and do not differ clinically from the symptoms of a herniated disc.

PATHOGENESIS

The cysts originate from the small vertebral joints and, depending on their size, compress the nerval structures. The affected vertebral joints typically show activated arthritic circumstances, which are associated with degenerative spondylolisthesis in about 50% of cases. In the majority of cases, MRT and CT can be used for diagnostic purposes. The exact etiology has not been fully clarified; various factors such as activated arthritis of the vertebral joints appear to be the major cause.

TREATMENT

Treatment options include conservative, semi-invasive and surgical therapy. Conservative and semi-invasive treatment methods lead to temporary improvement. The result of surgical treatment, however, is excellent in a complete resection of synovial cysts. In In rare cases, an initial fusion is necessary in rare cases.

Carpal tunnel syndrome and spinal canal stenosis: harbingers of transthyretin amyloid cardiomyopathy?

BACKGROUND

Carpal tunnel syndrome (CTS) and spinal canal stenosis can be frequently observed in the medical history of patients with transthyretin amyloidosis (ATTR), both in the hereditary (mt-ATTR) and wild-type (wt-ATTR) form. The aim of this retrospective single-center analysis was to determine the prevalence of these findings, delay to diagnosis of systemic amyloidosis and the prognostic value in a large cohort of patients with wt-ATTR and mt-ATTR amyloidosis.

METHODS

Medical records of 253 patients diagnosed with wt-ATTR, 136 patients with mt-ATTR and 77 asymptomatic gene carriers were screened for history of CTS and spinal canal stenosis and laboratory analysis, electrocardiography and echocardiographic results, respectively. Clinical follow-up was performed by phone assessment.

RESULTS

History of CTS was present in 77 patients (56%) with mt-ATTR, in 152 patients (60%) with wt-ATTR and even in 10 of the asymptomatic gene carriers (13%). Latency between carpal tunnel surgery and first diagnosis of systemic amyloidosis was significantly longer in wt-ATTR compared to mt-ATTR (117 ± 179 months vs. 66 ± 73 months; p = 0.02). In total, 36 patients (14%) with wt-ATTR and 7 patients (5%) with mt-ATTR had a history of clinically significant spinal canal stenosis. In the subgroup of mt-ATTR, patients with CTS had thicker IVS (19 ± 5 mm vs. 16 ± 5 mm, p < 0.05), higher LV mass index (225 ± 78 g vs. 193 ± 98 g, p < 0.05), lower Karnofsky index (78 ± 15% vs. 83 ± 17%, p < 0.05), and lower mitral annular plane systolic excursion (MAPSE; 9 ± 4 mm vs. 11 ± 5 mm, p < 0.05) compared to patients without CTS, whereas in wt-ATTR no significant differences could be observed. No significant difference in survival was observed between patients with and without CTS (wt-ATTR: 67 vs. 63 months, p = 0.45; mt-ATTR: 74 vs. 63 months, p = 0.60). A combination of CTS and spinal stenosis was present in 32 wt-ATTR patients (12%) and 3 mt-ATTR patients (2.2%).

CONCLUSIONS

The prevalence of CTS is high and the latency between CTS surgery and diagnosis of amyloidosis is long among patients with wt-ATTR and mt-ATTR. CTS might be predictive for future occurrence of systemic (predominantly cardiac) ATTR amyloidosis.

The impact of stenosis and translation on spinal cord injuries in traumatic cervical facet dislocations

BACKGROUND CONTEXT

Although facet dislocations account for only 6% of cervical trauma, the consequences are often devastating. Cervical facet dislocations are associated with a disproportionate amount of spinal cord injuries; however, neurologic examination of patients is often difficult, as patients commonly present with reduced levels of consciousness. There are limited studies that have investigated the impact of spinal canal diameter and translation on neurologic injury following facet dislocations.

PURPOSE

Review a consecutive series of patients with facet dislocations to assess the impact of sagittal diameter and translation on Spinal Cord Injury (SCI).

STUDY DESIGN

Retrospective review at a level I trauma center identified 97 patients with facet dislocations.

METHODS

Between 2004 and 2014, a retrospective review at a level I trauma center identified patients with traumatic facet dislocation. Demographic data, neurologic exams, and radiographic findings were reviewed. We assessed sagittal diameter at the injury level, as well as above and below, and translation. This study has no funding source and its authors have no potential conflicts of interest-associated biases.

RESULTS

Ninety-seven patients presented with facet dislocations. Fifty-nine (61%) presented with a SCI. Those with ASIA A averaged 8.0 mm of injury level canal diameter, and ASIA E averaged 12.6 mm (p < .001). Additionally, those with ASIA A averaged 8.0 mm of translation, and ASIA E averaged 4.2 mm (p < 0.001). Two groups were created based on their general motor function. Those with ASIA A-C averaged 8.4 mm of injury level canal diameter, and ASIA D-E averaged 12.3 mm (p < .001). Those with ASIA A-C averaged 7.8 mm of translation, and ASIA D-E averaged 4.4 mm (p < .001). Receiver operating characteristic (ROC) curves demonstrated that translation was a good predictor of ASIA A-C and canal diameter was an almost perfect predictor of ASIA D-E.

CONCLUSIONS

Our data indicate that patients with greater translation and/or a smaller canal diameter at the injury level have a higher rate of SCI. Adjacent canal diameter did not correlate with neurologic injury.

Urinary incontinence due to lumbar spinal stenosis causing disability and lowering quality of life

OBJECTIVES

Lumbar spinal stenosis may lead to urinary inconsistence and can have a negative impact on the quality of life. The aim of the study was to assess the incidence of urinary incontinence and quality of life in female patients with spinal canal stenosis comparing to control group.

METHODS

The study population consisted of 50 women diagnosed with severe lumbar spinal canal stenosis. Their mean age was 55.32 ± 12.97 years. The clinical control group consisted of 30 women who did not suffer from any spine disorders. Their mean age was 54.87 ± 12.01 years. There was no difference between both groups regarding age, weight, BMI and number of parity. The women diagnosed with clinical and radiographic symptoms of spinal canal stenosis filled out an anonymous questionnaire, ODI, ICIQ-UI-SF, and ICIQ-LUTSqol questionnaires.

RESULTS

We found urinary incontinence in 56% of women with lumbar spinal canal stenosis and in 43% of clinical control group. We also found a statistically significant correlation between duration of lumbar stenotic symptoms, the SLR sign, number of deliveries and the intensity of urinary incontinence.

CONCLUSIONS

Urinary incontinence in women with lumbar spinal canal stenosis is significantly different from the control group. Leakage of urine happened more frequently, the amount of urine leaked was greater, and the general impact on everyday life is harsher, as compared to the clinical control group.

Correlation of listhesis on upright radiographs and central lumbar spinal canal stenosis on supine MRI: is it possible to predict lumbar spinal canal stenosis?

OBJECTIVE

To investigate whether upright radiographs can predict lumbar spinal canal stenosis using supine lumbar magnetic resonance imaging (MRI) and to investigate the detection performance for spondylolisthesis on upright radiographs compared with supine MRI in patients with suspected lumbar spinal canal stenosis (LSS).

MATERIALS AND METHODS

In this retrospective study, conventional radiographs and MR images of 143 consecutive patients with suspected LSS (75 female, mean age 72 years) were evaluated. The presence and extent of listhesis (median ± interquartile range) were assessed on upright radiographs and supine MRI of L4/5. In addition, the grade of central spinal stenosis of the same level was evaluated on MRI according to the classification of Schizas and correlated with the severity/grading of anterolisthesis on radiographs.

RESULTS

Anterolisthesis was detected in significantly more patients on radiographs (n = 54; 38%) compared with MRI (n = 28; 20%), p < 0.001. Pairwise comparison demonstrated a significantly larger extent of anterolisthesis on radiographs (9 ± 5 mm) compared with MRI (5 ± 3 mm), p < 0.001. A positive correlation was found regarding the extent of anterolisthesis measured on radiographs and the grade of stenosis on MRI (r = 0.563, p < 0.001). Applying a cutoff value of ≥5 mm anterolisthesis on radiographs results in a specificity of 90% and a positive predictive value of 78% for the detection of patients with LSS, as defined by the Schizas classification.

CONCLUSION

Upright radiographs demonstrated more and larger extents of anterolisthesis compared with supine MRI. In addition, in patients with suspected LSS, the extent of anterolisthesis on radiographs (particularly ≥5 mm) is indicative of LSS and warrants lumbar spine MRI.

An increase in the degree of olisthesis during axial loading reduces the dural sac size and worsens clinical symptoms in patients with degenerative spondylolisthesis

BACKGROUND CONTEXT

Previous studies have shown that axial loading during magnetic resonance imaging (MRI) significantly reduces the size of the dural sac compared with conventional MRI in patients with degenerative lumbar disease. In our previous study, axial-loaded MRI showed a significantly larger degree of olisthesis than conventional MRI in patients with degenerative spondylolisthesis (DS). Furthermore, the degree of olisthesis on axial-loaded MRI correlated more strongly with that observed on X-ray in the upright position. However, no study has investigated whether or not the increase in the degree of olisthesis during axial loading correlates with the reduction in the dural sac size and affects the severity of clinical symptoms in patients with DS.

PURPOSE

The objective of this study was to determine whether or not the increase in the degree of olisthesis correlates with the reduction of the dural sac cross-sectional area (DCSA) detected on axial-loaded MRI and worsens the severity of clinical symptoms in patients with DS.

STUDY DESIGN/SETTING

This is an imaging cohort study.

PATIENT SAMPLE

A total of 41 consecutive patients with DS were prospectively evaluated in this study.

OUTCOME MEASURES

The outcome measures include the degree of olisthesis, the DCSA, the Pearson correlation coefficient, and the severity of clinical symptoms.

MATERIALS AND METHODS

The differences in the degree of olisthesis and the DCSA between conventional and axial-loaded MRIs were determined. The Pearson correlation coefficient of the increase in the degree of olisthesis with the reduction in the DCSA during axial loading was calculated. The reduction in the DCSA and the severity of clinical symptoms in patients exhibiting a ≥2-mm increase in the degree of olisthesis were compared with those in patients exhibiting a <2-mm increase.

RESULTS

The increase in the degree of olisthesis was significantly correlated with the reduction in the DCSA during axial loading (Pearson correlation coefficient=0.63, p<.001). The reduction in the DCSA during axial loading in patients with a ≥2-mm increase in the degree of olisthesis (26±3 mm²) was significantly greater than in those with a <2-mm increase (13±2 mm²) (p<.01). Clinical symptoms such as walking distance and activity of daily living evaluated using the Japanese Orthopaedic Association score were significantly worse in patients with a ≥2-mm increase in the degree of olisthesis (117±19 m and 6.7±0.5 points, respectively) than in those with a <2-mm increase (236±36 m and 8.4±0.4 points, respectively) (p<.05).

CONCLUSIONS

The present study demonstrated that the increase in the degree of olisthesis was significantly correlated with the reduction in the dural sac size detected on axial-loaded MRI and worsened the severity of clinical symptoms in patients with DS. These results suggest that axial-loaded MRI may be a useful imaging study for detecting dynamic changes in the degree of olisthesis during axial loading to the lumbar spine related to the narrowing of the spinal canal and the severity of clinical symptoms in the assessment of patients with DS.

[Operative treatment of degenerative diseases of the lumbar spine]

BACKGROUND

Degenerative diseases of the lumbar spine and associated lower back pain represent a major epidemiological and health-related economic challenge. A distinction is made between specific and unspecific lower back pain. In specific lower back pain lumbar disc herniation and spinal canal stenosis with or without associated segment instability are among the most frequent pathologies. Diverse conservative and operative strategies for treatment of these diseases are available.

OBJECTIVES

The aim of this article is to present an overview of current data and an evidence-based assessment of the possible forms of treatment.

MATERIAL AND METHODS

An extensive literature search was carried out via Medline plus an additional evaluation of the authors' personal experiences.

RESULTS

Conservative and surgical treatment represent efficient treatment options for degenerative diseases of the lumbar spine. Surgical treatment of lumbar disc herniation shows slight advantages compared to conservative treatment consisting of faster recovery of neurological deficits and a faster restitution of pain control. Surgical decompression is superior to conservative measures for the treatment of spinal canal stenosis and degenerative spondylolisthesis. In this scenario conservative treatment represents an important supporting measure for surgical treatment in order to improve the mobility of patients and the outcome of surgical treatment.

CONCLUSION

The treatment of specific lower back pain due to degenerative lumbar pathologies represents an interdisciplinary challenge, requiring both conservative and surgical treatment strategies in a synergistic treatment concept in order to achieve the best results for patients.

Shape of the Spinal Canal Is Not Associated with Success Rates of Microsurgical Unilateral Laminotomy and Bilateral Decompression for Lumbar Spinal Canal Stenosis

BACKGROUND

Anatomic shape of the spinal canal (oval, round, trefoil) has been reported to predict outcome of bilateral decompression performed in an undercutting technique via unilateral laminotomy in monosegmental lumbar spinal stenosis, with poorest results observed in a trefoil spinal canal, leading to the proposal of using bilateral instead of unilateral laminotomy. The aim of this study was to assess whether this anatomic classification into oval, round, and trefoil shapes is relevant to surgical treatment of lumbar spinal stenosis.

METHODS

Retrospective chart review of patients undergoing lumbar decompression surgery was performed. Spinal canal configuration was assessed on preoperative computed tomography based on maximal transverse and anteroposterior diameter, and shapes were classified into oval, round, and trefoil. Associations between spinal canal shape and outcome improvement (aggregate of walking distance and leg pain) were tested.

RESULTS

Decompression of 236 lumbar levels was performed in 159 patients (mean age, 73 ± 8 years; mean body mass index, 29 ± 6). Average number of operated segments was 1.3 ± 0.6. Oval configurations were detected in 155 (65%) levels, round configurations were detected in 11 (5%) levels, and trefoil configurations were detected in 70 (30%) levels. Postoperative improvement was recorded in 91.7% of patients. Spinal canal shape had no influence on surgical outcome (oval, area under the curve 0.529, P = 0.672; trefoil, area under the curve 0.500, P = 0.997; round, area under the curve 0.471, P = 0.670).

CONCLUSIONS

Spinal canal configuration varies in frequency with lumbar segment. Our results do not support the idea that this anatomic classification, particularly the nomenclature of oval, round, and trefoil, should influence surgical decision making.

ABCs of the degenerative spine

Degenerative changes in the spine have high medical and socioeconomic significance. Imaging of the degenerative spine is a frequent challenge in radiology. The pathogenesis of this degenerative process represents a biomechanically related continuum of alterations, which can be identified with different imaging modalities. The aim of this article is to review radiological findings involving the intervertebral discs, end plates, bone marrow changes, facet joints and the spinal canal in relation to the pathogenesis of degenerative changes in the spine. Findings are described in association with the clinical symptoms they may cause, with a brief review of the possible treatment options. The article provides an illustrated review on the topic for radiology residents.

TEACHING POINTS

• The adjacent vertebrae, intervertebral disc, ligaments and facet joints constitute a spinal unit. • Degenerative change is a response to insults, such as mechanical or metabolic injury. • Spine degeneration is a biomechanically related continuum of alterations evolving over time.

Three-dimensional visualization of internal vertebral venous plexuses relative to dural sac and spinal nerve root of spinal canal stenosis using MRI

PURPOSE

The aim of this study was to introduce a new method of producing three-dimensional (3D) images of vertebral venous plexuses (VVPs) by 3D-MRI with and without contrast media, to identify pathoanatomical features that might accelerate or modify spinal canal stenosis.

METHODS

We used a 1.5-T MRI unit with two different 3D sequences with and without contrast media. Multi planar reconstruction (MPR) images of VVPs could be obtained by volume image subtraction methods with a workstation for dural sac from whole 3D volume MPR without contrast media, using images before and after gadoteridol injection. Three patients with degenerative lumbar spine disease and one with cervical ossification of the posterior longitudinal ligament (OPLL) were studied with and without contrast media. As three patients underwent operations, we investigated intraoperative microscopic findings, and compared VVP images.

RESULTS

Abundant components of internal VVPs were identified on MRI in correlation with neural tissues such as dura and nerve roots.

CONCLUSIONS

Using 3D MRI without and with gadoteridol, we can evaluate morphological changes in VVP under degenerative spinal conditions. The MR anatomy of VVPs of the spine is important, as it has been implicated in many pathophysiological mechanisms and may also cause pitfalls in MRI.

Rib head dislocation causing spinal canal stenosis in a child with neurofibromatosis, type 1

A 10-year-old female with neurofibromatosis type 1 and severe dystrophic scoliosis presented with a two-month history of difficulty ambulating due to low back pain. The patient did not have any neurological symptoms. MRI of the thoracolumbar spine demonstrated subluxation of the right posterior tenth and eleventh ribs through their respective neural foramina, with mild mass effect on the thecal sac without abnormal cord signal or cord compression. Groups of neurofibromas were present along the right ribs and paravertebral soft tissues around these levels. CT evaluation was completed for greater osseous definition. Cases of rib head dislocation into the central canal in the setting of dystrophic scoliosis were documented in only a limited sample of case reports. The angulated short-segment curvature in dystrophic scoliosis causes vertebral body rotation, foraminal enlargement, spindling of transverse processes, and penciling of the apical ribs. These changes can alter the articulation of the rib along the transverse process. The enlarged foramina can also create a larger space into which a rib may displace. As a result, in most reported cases, the subluxed ribs were on the convex apex of the curve in the mid-to-lower thoracic region. The risk of cord injury from rib head dislocation makes the complete depiction of the anatomy essential for proper surgical management.

Bilateral TKA for Charcot arthropathy associated with multiple levels of spinal canal stenoses: A case report and review of literature

We report a case of an 84-year-old male with multiple levels of canal stenoses who are diagnosed as Charcot arthropathy of bilateral knees. Although he did not feel any pain, recurrence of joint fluid collection and severe instability prevented him from standing and walking. Deficit in superficial sensation and bathyesthesia below the level of Th10, and tendon reflexes of extremities were seen. Romberg test was positive. Laboratory data showed no abnormal findings. We performed bilateral TKA based on the diagnosis of Charcot arthropathy. At 3-year follow-up, there is no complaint about joint instability and collection of joint fluid.

Analysis of the Relationship between Hypertrophy of the Ligamentum Flavum and Lumbar Segmental Motion with Aging Process

Study Design

Retrospective cross-sectional study.

Purpose

To investigate the relationship between ligamentum flavum (LF) hypertrophy and lumbar segmental motion.

Overview of Literature

The pathogenesis of LF thickening is unclear and whether the thickening results from tissue hypertrophy or buckling remains controversial.

Methods

296 consecutive patients underwent assessment of the lumbar spine by radiographic and magnetic resonance imaging (MRI). Of these patients, 39 with normal L4–L5 disc height were selected to exclude LF buckling as one component of LF hypertrophy. The study group included 27 men and 12 women, with an average age of 61.2 years (range, 23–81 years). Disc degeneration and LF thickness were quantified on MRI. Lumbar segmental spine instability and presence of a vacuum phenomenon were identified on radiographic images.

Results

The distribution of disc degeneration and LF thickness included grade II degeneration in 4 patients, with a mean LF thickness of 2.43±0.20 mm; grade III in 10 patients, 3.01±0.41 mm; and grade IV in 25 patients, 4.16±1.12 mm. LF thickness significantly increased with grade of disc degeneration and was significantly correlated with age (r=0.55, p<0.01). Logistic regression analysis identified predictive effects of segmental angulation (odds ratio [OR]=1.55, p=0.014) and age (OR=1.16, p=0.008).

Conclusions

Age-related increases in disc degeneration, combined with continuous lumbar segmental flexion-extension motion, leads to the development of LF hypertrophy.

Acute traumatic cord injury associated with ossified ligamentum flavum

Ossification of the ligamentum flavum (OLF) is an uncommon condition, which usually occurs amongst people of Asian descent, and most commonly in the thoracic spine region. Whilst often asymptomatic, OLF can cause spinal canal stenosis, with patients presenting with back pain, posterior cord syndrome or myelopathy. We present a rare case of acute spinal cord injury associated with OLF after a kite surfing accident, with the resulting paraplegia partially improved after decompression was performed. The prevalence, presentation and management of OLF are also discussed.

The degenerative cervical spine

Imaging techniques provide excellent anatomical images of the cervical spine. The choice to use one technique or another will depend on the clinical scenario and on the treatment options. Plain-film X-rays continue to be fundamental, because they make it possible to evaluate the alignment and bone changes; they are also useful for follow-up after treatment. The better contrast resolution provided by magnetic resonance imaging makes it possible to evaluate the soft tissues, including the intervertebral discs, ligaments, bone marrow, and spinal cord. The role of computed tomography in the study of degenerative disease has changed in recent years owing to its great spatial resolution and its capacity to depict osseous components. In this article, we will review the anatomy and biomechanical characteristics of the cervical spine, and then we provide a more detailed discussion of the degenerative diseases that can affect the cervical spine and their clinical management.

Degenerative disease of the lumbar spine

In the last 25 years, scientific research has brought about drastic changes in the concept of low back pain and its management. Most imaging findings, including degenerative changes, reflect anatomic peculiarities or the normal aging process and turn out to be clinically irrelevant; imaging tests have proven useful only when systemic disease is suspected or when surgery is indicated for persistent spinal cord or nerve root compression. The radiologic report should indicate the key points of nerve compression, bypassing inconsequential findings. Many treatments have proven inefficacious, and some have proven counterproductive, but they continue to be prescribed because patients want them and there are financial incentives for doing them. Following the guidelines that have proven effective for clinical management improves clinical outcomes, reduces iatrogenic complications, and decreases unjustified and wasteful healthcare expenditures.

Bilateral spinal canal decompression via hemilaminectomy in cervical spondylotic myelopathy

BACKGROUND

In cervical spondylotic myelopathy (CSM), laminoplasty (LP) or laminectomy plus fusion (LF) are accepted operative options and alternatives to anterior approaches. Both LP and LF have distinctive disadvantages, which might be avoided by unilateral hemilaminectomy and bilateral decompression of the spinal cord.

METHODS

Description of the surgical technique, indications, and limitations. The potential advantages in comparison to LP and LF are discussed.

CONCLUSIONS

Unilateral hemilaminectomy allows bilateral decompression of the whole dorsal circumference of spinal cord from nerve root to nerve root. The potential major advantages are a reduction of invasiveness by only unilateral muscle detachment, avoidance of implants, and shorter operation times.

Changes in lumbar spondylolisthesis on axial-loaded MRI: do they reproduce the positional changes in the degree of olisthesis observed on X-ray images in the standing position?

BACKGROUND CONTEXT

Axial-loaded magnetic resonance imaging (MRI) can partially simulate the lumbar spine in patients in a standing position and potentially provides additional imaging findings that cannot be obtained with conventional MRI in the clinical assessment of patients with degenerative lumbar disease. Previous studies have shown that axial-loaded MRI demonstrates a significant reduction in the size of the dural sac compared with conventional MRI. However, there has been no study to compare the degree of olisthesis among conventional MRI, axial-loaded MRI, and upright X-ray imaging in patients with degenerative spondylolisthesis (DS).

PURPOSE

The purpose of the study is to determine whether axial-loaded MRI can demonstrate similar positional changes in lumbar olisthesis as those detected on upright lateral X-ray in patients with DS.

STUDY DESIGN

This is an imaging cohort study.

PATIENT SAMPLE

A total of 43 consecutive patients with DS exhibiting olisthesis of 3 mm or more on X-ray images in the standing position were prospectively evaluated in this study.

OUTCOME MEASURES

The degree of olisthesis, intraclass correlation coefficient (ICC), and percentage of patients exhibiting olisthesis of 3 mm or more on MRI.

METHODS

The degree of olisthesis was measured on conventional MRI, axial-loaded MRI, and lateral X-ray imaging performed in the upright position. The degree of olisthesis was compared among the three imaging techniques. The ICC values for the measurements of olisthesis between X-ray studies and conventional and axial-loaded MRI were calculated and compared. The percentage of patients exhibiting olisthesis of 3 mm or more was compared between conventional MRI and axial-loaded MRI.

RESULTS

The degree of olisthesis on axial-loaded MRI (5.9±2.5 mm) was significantly greater than that observed on conventional MRI (4.4±2.4 mm) (p<.05) although the degrees on conventional and axial-loaded MRI were significantly smaller than that on upright X-ray images (7.1±2.8 mm) (p<.05). The ICC between axial-loaded MRI and X-ray imaging (0.75, 95% confidence interval: 0.58-0.85) was considerably greater than that observed between conventional MRI and X-ray imaging (0.40, 95% confidence interval: 0.11-0.62). The percentage of patients exhibiting olisthesis of 3 mm or more was significantly higher on axial-loaded MRI (91%) than on conventional MRI (63%) (p<.01).

CONCLUSIONS

Axial-loaded MRI demonstrates a significantly larger degree of olisthesis than conventional MRI. In addition, the degree of olisthesis on axial-loaded MRI was found to be more strongly correlated with that observed on X-ray studies in the upright position. Furthermore, the use of axial-loaded MRI significantly reduced the misdiagnosis of olisthesis of 3 mm or more that was detected on X-ray imaging. These results suggest that axial-loaded MRI may be superior to identify the olisthesis of the lumbar spine and show the degrees of olisthesis correlated to those detected on upright X-ray imaging. Further studies should be needed to clarify the actual value of these findings on axial-loaded MRI and provide the evidence to support its clinical significance in the assessment of patients with DS.

Thickness of the ligamentum flavum: correlation with age and its asymmetry-an magnetic resonance imaging study

Study Design

A retrospective radiological study of the ligamentum flavum (LF).

Purpose

This study is an attempt to measure and compare the thickening of the LF on both the sides with the use of magnetic resonance imaging, to investigate if there is a predominant tendency to thicken a specific side and also to determine if a correlation between the thickening of the LF and increasing age exists.

Overview of Literature

Even though many studies measured the thickness of the LF, very few have compared it on each side, or determined its correlation with age.

Methods

The thickness of LF was measured at the L3-4, L4-5, L5-S1 levels on both sides using the magnetic resonance images of 200 patients (n=1,200). The sample population was divided into three groups: 21-40 years, 41-60 years, and 61-80 years. The data was analyzed statistically, comparing the thickness of LF on both sides and in various age-groups.

Results

The thickness of the LF was found to increase with age; however, there were several younger instances with thicknesses >4 mm. The mean thickness of the right LF at different spinal levels was measured (L3-L4=3.38±0.94 mm, L4-L5=3.70±1.16 mm, and L5-S1=3.65±1.16 mm) while the mean thickness of the left LF was higher (L3-L4=3.52±0.99 mm, L4-L5=3.84±1.12 mm, and L5-S1=3.78±1.24 mm).

Conclusions

The LF thickness does not appear to have any side dominance; however, it tends to thicken with increasing age.

The prevalence of cervical myelopathy among subjects with narrow cervical spinal canal in a population-based magnetic resonance imaging study: the Wakayama Spine Study

BACKGROUND CONTEXT

A narrow cervical spinal canal (CSC) is a well-known risk factor for cervical myelopathy (CM). However, no epidemiologic data of the CSC based on a population-based cohort are available.

PURPOSE

The purpose of the study was to investigate the age-related differences in CSC diameters on plain radiographs and to examine the associated magnetic resonance imaging (MRI) abnormalities including cervical cord compression and increased signal intensity (ISI) as well as the clinical CM with the narrow CSC.

STUDY DESIGN/SETTING

This was a cross-sectional study.

PARTICIPANT SAMPLE

Data were obtained from the baseline survey of the Wakayama Spine Study that was performed from 2008 to 2010 in a western part of Japan. Finally, a total of 959 subjects (319 men and 640 women; mean age, 66.4 years) were included.

OUTCOME MEASURES

The outcome measures included in the study were the CSC diameter at C5 level on plain radiographs, cervical cord compression and ISI on sagittal T2-weighted MRI, and physical signs related to CM (eg, the Hoffmann reflex, hyperreflexia of the patellar tendon, the Babinski reflex, sensory and motor function, and bowel/bladder symptoms).

METHODS

The age-related differences of CSC diameters in men and women were investigated by descriptive statistics. The prevalence of MRI abnormalities and clinical CM was compared among the groups divided by the CSC diameter (less than 13, 13-15, and 15 mm or more). In addition, a logistic regression analysis was performed to determine the association of the CSC diameter with cervical cord compression/clinical CM after overall adjustment for age, sex, and body mass index.

RESULTS

The CSC diameter was narrower with increasing age in both men and women. The prevalence of cervical cord compression, ISI, and the clinical CM was significantly higher in the narrower CSC group. The prevalence of cervical cord compression, ISI, and CM among subjects with CSC diameter less than 13 mm was 38.0%, 5.4%, and 10.1%, respectively. In the logistic model, the CSC diameter was a significant predictive factor for the clinical CM (p<.0001).

CONCLUSIONS

This study firstly confirmed the age-related differences in CSC diameters and the significant association of the narrow CSC diameter with CM in a population-based cohort.

Lumbar vertebral hemangioma mimicking lateral spinal canal stenosis: case report and review of literature

Context Hemangiomas are the commonest benign tumors of the spine. Most occur in the thoracolumbar spine and the majority are asymptomatic. Rarely, hemangiomas cause symptoms through epidural expansion of the involved vertebra, resulting in spinal canal stenosis, spontaneous epidural hemorrhage, and pathological burst fracture. Findings We report a rare case of a 73-year-old woman, who had been treated for two months for degenerative neurogenic claudication. On admission, magnetic resonance imaging and computed tomographic scans revealed a hemangioma of the third lumbar vertebra protruding to the epidural space producing lateral spinal stenosis and ipsilateral nerve root compression. The patient underwent successful right hemilaminectomy for decompression of the nerve root, balloon kyphoplasty with poly-methyl methacrylate (PMMA) and pedicle screw segmental stabilization. Postoperative course was uneventful. Conclusion In the elderly, this rare presentation of spinal stenosis due to hemangiomas may be encountered. Decompression and vertebral augmentation by means balloon kyphoplasty with PMMA plus segmental pedicle screw fixation is recommended.