Assessment of lumbar spinal canal stenosis by magnetic resonance phlebography

 There is evidence to suggest that cauda equina intermittent claudication is caused by local circulatory disturbances in the cauda equina as well as compression of the cauda equina. We evaluated the role of magnetic resonance phlebography (MRP) in identifying circulatory disturbances of the vertebral venous system in patients with lumbar spinal canal stenosis. Extensive filling defects of the anterior internal vertebral venous plexus were evident in patients with lumbar spinal canal stenosis (n = 53), whereas only milder abnormalities were noted in patients with other lumbar diseases (n = 16) and none in normal subjects (n = 13). The extent of the defect on MRP correlated with the time at which intermittent claudication appeared. In patients with lumbar spinal canal stenosis, extensive defects of the internal vertebral venous plexus on MRP were noted in the neutral spine position, but the defect diminished with anterior flexion of the spine. This phenomenon correlated closely with the time at which intermittent claudication appeared. Our results highlight the importance of MRP for assessing the underlying mechanism of cauda equina intermittent claudication in patients with lumbar spinal canal stenosis and suggest that congestive venous ischemia is involved in the development of intermittent claudication in these patients. Received: January 16, 2002 / Accepted: August 5, 2002 Offprint requests to: M. Manaka     

腰椎狭窄软性椎管的应力改变分析

目的 探讨腰椎软性椎管改变与椎管狭窄的关系。方法 在本研究52例中分为椎管狭窄组和对照组，2003年1月至2007年12月，推管狭窄组从因腰椎管狭窄病行后路椎板减压术的患者中取黄韧带标本对照组黄韧带标本共为10例，取自青年腰椎骨折行后路椎板减压术患者，后纵韧带标本共4例取自腰椎爆裂骨折前路椎体减压术患者。分别观察两组标本切片镜下的表现并加以分析。结果 在腰椎管狭窄病组，黄韧带及后纵韧带镜下表现为纤维肥大，基质内可见脂肪及小囊肿；对照组则表现为纤维细胞排列规则、无纤维化表现。结论 腰椎管软性椎管的应力改变及退行性变，是导致腰椎管狭窄的一个因素。     

Elevated concentration of hyaluronan in the cerebrospinal fluid is a secondary marker of spinal disorders: hyaluronan in the cerebrospinal fluid in patients with spinal disorders

BACKGROUND: Hyaluronan (HA) was measured in cerebrospinal fluid (CSF) to ascertain the clinical significance of this substance in patients with spinal disorders, a topic that, to the best of our knowledge, has not previously been studied. METHODS: We examined correlations of CSF HA concentration with age, sex, height, body weight, and spinal disorders. By using a sandwich-binding protein assay, HA was measured in CSF samples obtained from 500 patients aged 12 to 104 years who underwent lumbar spinal anesthesia for surgery, myelography, or CSF examination. These patients were classified into 3 groups: (1) a control group (306 patients with injury or benign tumor of the lower limbs); (2) a cervical disorders group (84 patients with cervical disc herniation, cervical spondylotic myelopathy, or ossification of the posterior longitudinal ligament); and (3) a lumbar disorders group (110 patients with lumbar disc herniation, lumbar spinal canal stenosis tethered cord syndrome, lumbar fracture, or spondylolytic spondylolisthesis). RESULTS: CSF HA concentration was found to be positively correlated with age, and was significantly higher in patients with cervical spondylotic myelopathy, ossification of the posterior longitudinal ligament, or lumbar spinal canal stenosis tumor than in the control group. CONCLUSIONS: CSF HA concentration might be a secondary marker for inflammation in patients with spinal disease.     

A novel MRI classification system for congenital functional lumbar spinal stenosis predicts the risk for tandem cervical spinal stenosis

Purpose

The purpose of this study was to develop a simple and clinically useful morphological classification system for congenital lumbar spinal stenosis using sagittal MRI, allowing clinicians to recognize patterns of lumbar congenital stenosis quickly and be able to screen these patients for tandem cervical stenosis.

Methods

Forty-four subjects with an MRI of both the cervical and lumbar spine were included. On the lumbar spine MRI, the sagittal canal morphology was classified as one of three types: Type I normal, Type II partially narrow, Type III globally narrow. For the cervical spine, the Torg-Pavlov ratio on X-ray and the cervical spinal canal width on MRI were measured. Kruskal–Wallis analysis was done to determine if there was a relationship between the sagittal morphology of the lumbar spinal canal and the presence of cervical spinal stenosis.

Results

Subjects with a type III globally narrow lumbar spinal canal had a significantly lower cervical Torg-Pavlov ratio and smaller cervical spinal canal width than those with a type I normal lumbar spinal canal.

Conclusion

A type III lumbar spinal canal is a globally narrow canal characterized by a lack of spinal fluid around the conus. This was defined as “functional lumbar spinal stenosis” and is associated with an increased incidence of tandem cervical spinal stenosis.

     

Analysis of cartilage-derived retinoic acid-sensitive protein in cerebrospinal fluid From patients With spinal diseases

STUDY DESIGN: The expression of cartilage-derived retinoic acid-sensitive protein (CD-RAP) was measured in cerebrospinal fluid from patients with spinal diseases. OBJECTIVES: To quantify the levels of CD-RAP in human cerebrospinal fluid and to clarify its character. SUMMARY OF BACKGROUND DATA: Cartilage-derived retinoic acid-sensitive protein is a newly discovered, secreted molecule that is expressed during the chondrogenesis phase of endochondral bone formation and in articular cartilage. In recent studies CD-RAP has been detected in the serum of patients with melanoma and breast cancer, and it has been used to monitor tumor activity. However, the function of CD-RAP is unknown, and the expression of CD-RAP in human cerebrospinal fluid has never been reported. METHODS: The concentration of CD-RAP in human cerebrospinal fluid was measured by enzyme-linked immunosorbent assay with antihuman CD-RAP antibodies. Cerebrospinal fluid samples were collected from two groups of patients. Group 1, the control group, consisted of 40 patients: 22 with trauma and 18 with gynecologic diseases. Group 2 consisted of 172 patients with spinal diseases: 5 with meningioma, 5 with neurinoma, 5 with arachnoid cyst, 30 with cervical spondylotic myelopathy, 35 with lumbar disc herniation, 56 with lumbar canal stenosis, and 36 with scoliosis. RESULTS: The concentration of CD-RAP in the control group was 16.5 +/- 8.3 ng/mL. The concentrations of CD-RAP in Group 2 were: 35.3 +/- 14.7 ng/mL in meningioma, 23.5 +/- 7.41 ng/mL in neurinoma, 26.0 +/- 22.2 ng/mL in arachnoid cyst, 41.7 +/- 22.3 ng/mL in cervical myelopathy, 27.8 +/- 14.7 ng/mL in lumbar disc herniation, 36.5 +/- 18.4 ng/mL in lumbar canal stenosis, and 13.4 +/- 7.48 ng/mL in scoliosis. The concentrations of CD-RAP in cervical myelopathy, lumbar canal stenosis, and lumbar disc herniation were significantly higher than in the control group (P < 0.001). CONCLUSIONS: The CD-RAP concentration was low in the control group, whereas it was significantly higher in spinal diseases that cause spinal stenosis. CD-RAP is expressed in cerebrospinal fluid as a result of damage to or stressing of neural structures and could be a marker for spinal diseases.     

胸腰椎爆裂骨折损伤部位和椎管内占位程度与神经损伤的关系

目的探讨胸腰椎爆裂骨折骨折部位及椎管内骨块占位程度与神经损伤的关系。方法对213例胸腰椎爆裂骨折根据骨折部位及CT测出的椎管内骨折骨块占位程度与神经损伤进行分析评定。结果神经损伤组椎管骨折骨块占位程度明显高于无神经损伤组;在有神经损伤情况下,骨折部位椎管内骨块占位程度腰段大于胸腰段;神经损伤程度与椎管内骨块占位程度无显著相关。结论胸腰椎爆裂骨折椎管内骨块占位压迫是神经损伤的重要因素;神经损伤与骨折部位和椎管内骨块占位程度联合相关。     

The narrowing of the lumbar spinal canal during loaded MRI: the effects of the disc and ligamentum flavum

Load and activity changes of the spine typically cause symptoms of nerve root compression in subjects with spinal stenosis. Protrusion of the intervertebral disc has been regarded as the main cause of the compression. The objective was to determine the changes in the size of the lumbar spinal canal and especially those caused by the ligamentum flavum and the disc during loaded MRI. For this purpose an interventional clinical study on consecutive patients was made. The lumbar spines in 24 supine patients were examined with MRI: first without any external load and then with an axial load corresponding to half the body weight. The effect of the load was determined through the cross-sectional areas of the spinal canal and the ligamentum flavum, the thickness of ligamentum flavum, the posterior bulge of the disc and the intervertebral angle. External load decreased the size of the spinal canal. Bulging of the ligamentum flavum contributed to between 50 and 85% of the spinal canal narrowing. It was concluded that the ligamentum flavum, not the disc had a dominating role for the load induced narrowing of the lumbar spinal canal, a finding that can improve the understanding of the patho-physiology in spinal stenosis.     

临床论腰椎管狭窄症狭窄因素分类及临床应用

目的:探讨腰椎管狭窄症CT影像学分类方法,为手术减压部位及术式选择提供依据。方法:把腰椎管管壁致狭窄病变的组织分为关节突(A)、椎体与椎弓骨性组织(B)、钙化结缔组织(C)、椎间盘(D)、硬膜外瘢痕(E)和黄韧带(F)六个类别,把椎管分为前壁(1)、侧壁(2)、后壁(3)三个区。通过对43例共70个节段腰椎管狭窄症的CT影像学病因诊断,用字母-数字化代码对椎管管壁狭窄因素进行分类,根据不同狭窄因素行个体化治疗。结果:共统计出12类椎管管壁狭窄因素。43例中40例得到定期随访,随访1~5年,优良率90.0%。结论:腰椎管狭窄症管壁狭窄因素分类方法可表达椎管狭窄的性质、部位,有助于术前减压目标的确定、术式选择和电脑信息化处理。     

CT analysis of developmental spinal canal stenosis

The cervical and the lumbar vertebrae were analyzed by computed tomography in two groups. One group consisted of the patients with developmental stenosis of the cervical spine (the smallest AP diameter of the cervical spinal canal in the lateral view of X-ray was less than 12 mm) and the other was the control group (the smallest diameter was more than 14 mm). The canal to body ratio of the cross-sectional area (CBR), the modified Jones' "canal to body ratio" (JNS) and the flat index of the vertebral canal (FI) were measured at C4,C5, C6, L4 and L5. The shape of the vertebral canal of L4 and L5 was classified according to Baddeley. In the stenosis group, CBR and JNS were smaller at every measured level and FI was smaller at C4, C5 and C6 compared with the control group, Trefoil canals were found more frequently in the stenosis group. There was a clear relationship between the developmental stenosis of the cervical and the lumbar spinal canal. On treating patients with cervical spondylotic myelopathy, one should consider the possibility of pan-spinal canal stenosis.     

MRI study of the lumbar spine in achondroplasia. A morphometric analysis for the evaluation of stenosis of the canal

We carried out an MRI study of the lumbar spine in 15 patients with achondroplasia to evaluate the degree of stenosis of the canal. They were divided into asymptomatic and symptomatic groups. We measured the sagittal canal diameter, the sagittal cord diameter, the interpedicular distance at the mid-pedicle level and the cross-sectional area of the canal and spinal cord at mid-body and mid-disc levels. The MRI findings showed that in achondroplasia there was a significant difference between the groups in the cross-sectional area of the body canal at the upper lumbar levels. Patients with a narrower canal are more likely to develop symptoms of spinal stenosis than others.     

Simultaneous cervical and lumbar surgery for combined symptomatic cervical and lumbar spinal stenoses

Spinal stenosis may rarely involve both cervical and lumbar spines. An alternative surgical strategy used for the treatment of combined cervical and lumbar spinal stenosis is presented. Two cases with symptomatic combined stenosis of the cervical and lumbar spinal canal are described. Simultaneous surgery was performed in both cases. The combined stenosis of the cervical and lumbar spinal canal dictates careful neurologic and neuroradiologic examinations. Simultaneous surgery is an alternative approach for patients with symptomatic multilevel spinal stenoses, whose general conditions necessitate a one-session and short-lasting surgery.     

马尾冗余症在腰椎管狭窄症患者中的临床意义及相关危险因素分析

目的:探究马尾冗余症(redundant nerve roots,RNRs)在腰椎管狭窄患者中的诊疗意义,并筛选与RNRs相关的危险因素。方法:回顾性分析2015年4月1日至2020年11月30日196例于皖南医学院弋矶山医院脊柱外科就诊的腰椎管狭窄症患者临床资料。根据是否出现RNRs将所有患者分为RNRs阳性组和RNRs阴性组。比较两组患者一般临床资料、影像学参数、视觉模拟评分(visual analogue scale,VAS)、Oswestry功能障碍指数(Oswestry disability index,ODI)等指标差异性,利用二元Logistic回归分析筛选与RNRs高度相关的危险因素。结果:RNRs阳性组59例,RNRs阴性组137例。196例腰椎管狭窄症患者RNRs发生率为30.10%(59/196)。两组患者VAS、ODI组间差异有统计学意义(P<0.05),RNRs阳性组患者临床症状较RNRs阴性组重。年龄、狭窄节段数、腰椎硬膜囊面积平均值、最狭窄节段及最狭窄节段硬膜囊面积差异有统计学意义(P<0.05)。二元Logistic回归分析显示狭窄节段数、椎...     

An evaluation of cervical spinal canal stenosis--a correlation with cerebrospinal fluid pressure using a semiconductor and its coefficients

This study was conducted to determine whether the cerebrospinal fluid pressure (CSFP) obtained by the lumbar puncture technique is capable of evaluating the pathological state of the cervical spinal canal stenosis (CSCS). A method was developed in which the CSFP was measured with a small piezoelectric semiconductor in combination with the lumbar puncture technique. The data thus obtained were quantitatively analysed using a personal computer. Using this method, we studied patients with cervical myelopathy due to vertebral canal stenosis. The CSFP wave form obtained by compression of the cervical region was converted into a regression curve using the computer. In order to estimate the vertebral canal stenosis ratio (spinal cord/dural tube) of patients with CSCS by CSFP, multiple regression analysis was performed to obtain a multiple regression with respective parameters as expository variables. Descending curve coefficients (CND, CFD and CED) were found to be useful as parameters estimating the state of CSCS by means of CSFP analysis. On the basis of these parameters, CND, the coefficient of a descending curve obtained at the neutral cervical position, and CED, the coefficient of a descending curve obtained at the extended position, patients with CSCS were able to distinguish from normal subjects. The multiple regression equation (Y = 73.2-3890 CNA-4740 CND + 3620 CFD-10470 CEA-802 CED-0.119 NPP) was statistically significant at P = 0.01, therefore, useful in estimating the vertebral canal stenosis ratio. On the contrary, the values calculated from the multiple regression equation were not well correlated with either the JOA (Japanese Orthopedic Association) scores evaluated in accordance with the JOA Criteria or with the spinal compression ratio (anterior-to-posterior diameter/right-to-left diameter).     

Lumbar canal stenosis with overactive bladder presenting urinary incontinence developed by walking: a case report

A 74-year-old male complained of lower back pain, paresthesia of the bilateral feet and urinary incontinence. Urinary incontinence manifested at rest and worsened with walking. He had a history of surgery for prostatic cancer. Lumbar magnetic resonance imaging (MRI) demonstrated lumbar canal stenosis at the L4/5 level. The investigations including a cystometrogram manifested an overactive bladder caused by lumbar canal stenosis. His clinical symptoms were unresponsive to conservative treatment and posterior decompression at the L4/5 level was performed surgically to treat lumbar canal stenosis. Postoperatively, his symptoms were relieved. Overactive bladder presenting urinary incontinence that deteriorates with walking due to lumbar canal stenosis is suspected of being caused by circulatory disturbance of the cauda equine or conus medullaris. Emergency treatment including surgery is required for urinary retention in patients with lumbar canal stenosis; however, some degree of urinary disturbance may persist even after prompt and adequate surgery. Overactive bladder such as the present case should be considered as a possible symptom of lumbar canal stenosis, and surgical treatment for lumbar canal stenosis may be considered in the 'overactive bladder' stage before urinary retention begins, if the patient does not respond to conservative treatment.     

Usefulness and limitations of neuroradiological examinations in lumbar canal stenosis

Since 1983, we have performed 434 spinal surgery operations. Among them are included 51 cases of lumbar canal stenosis. For these 51 cases, we performed several neuroradiological examinations, such as lumbar plain X-ray, myelography, metrizamide-CT scan (Met-CT) and magnetic resonance imaging (MRI). We discussed and examined the usefulness and limitations of such neuroradiological methods for diagnosis of lumbar canal stenosis. On myelography, these 51 patients were divided into three types; a complete block type with 29 patients, soy-beans type with 7 patients and strangulation type with 15 patients. Myelography could show the level of stenosis, but could give little information about the compressing factors, particularly in complete-block type. Met CT was performed in 37 cases. In both strangulation type and soy-beans type which had been shown through myelography, Met-CT could clearly demonstrate the subarachnoid space, and several structures around the lumbar spinal canal could be clearly identified. In cases which myelography revealed as complete-block type, we identified two subtypes. In the first type subarachnoid space was clearly demonstrated by Met-CT. The second type was comprised of those cases where Met-CT scan could not demonstrate subarachnoid space at all. In the former group, useful information about lumbar canal stenosis could be obtained, but, in the latter, information was scarce. MRI was performed on 21 patients. MRI clearly showed the anatomical relationship of disc, subarachnoid space, yellow ligament and hypertrophied bony structure.(ABSTRACT TRUNCATED AT 250 WORDS)     

腰椎管潜行扩大桥式椎管成形术

传统的全椎板切除减压术治疗腰椎管狭窄症，不仅影响脊柱的稳定性，还可能并发腰椎管继发狭窄．作者采用腰椎管潜行扩大桥式椎管成形术治疗１５例，优良率为９３．４％。本术式特点：１．充分扩大椎管，包括神经根管。２．不破坏脊柱稳定性。３．保持原腰椎活动范围、４．不再形成新的压迫．     

改良显微减压术治疗腰椎管狭窄症

目的总结改良显微减压术治疗腰椎管狭窄症的临床应用结果。方法 2004年1月至2008年12月对100例腰椎管狭窄症患者采用改良显微减压术治疗,其中男68例,女32例;年龄41～78岁,平均52岁。结果本组术后无神经损伤并发症,无伤口感染。手术时间50～90min,平均70min;术中出血量90～200mL,平均150mL。术后随访18～48个月,平均26个月。术后恢复率按Macnab评定标准进行疗效评定,优68例,良25例,差7例,优良率为93%。结论对腰椎管狭窄症的手术治疗重点应放在压迫引起症状的部位,而对无症状的部位不做预防性减压操作。改良显微减压术老年人更容易耐受,减轻了对腰椎后部结构的损伤,更容易进入椎管,有利于进行神经根减压。     

Disturbed vasomotion in chronic venous insufficiency

BACKGROUND: Vasomotion is the slow rhythmic contraction of the smooth muscles of arterioles, metarterioles, and precapillary sphincters. It improves rheologic function of capillary blood flow and guarantees cellular nutrition and oxygen supply. Oxygen supply to the skin by blood can be quantified by measuring oxyhemoglobin concentration and hemoglobin oxygen saturation.Material and methods We examined the consequences of disturbed vasomotion in 51 patients with chronic venous insufficiency (CVI) and 36 healthy control subjects. With the subjects supine as well as during orthostasis, intracutaneous changes in concentration of total hemoglobin and oxyhemoglobin and in oxygen saturation of hemoglobin were measured over 120 seconds with reflection spectrophotometry. Periodic variations in measured parameters were analyzed with modified digital Fourier transformation. RESULTS: In the supine position both groups demonstrated the same vasomotion frequency. During orthostasis, vasomotion frequency in patients with CVI decreased significantly, from 7.4 +/- 2.2 cpm to 5.4 +/- 2.5 cpm, whereas vasomotion frequency in control subjects increased significantly, from 4.5 +/- 1.6 cpm to 8.8 +/- 2.5 cpm. Correspondingly, hemoglobin saturation and oxyhemoglobin concentration in patients with CVI patients exhibited a significantly stronger decrease compared with that in control subjects. CONCLUSION: The failing increase in vasomotion frequency during standing leads to longer dilation of the distal vessels per time unit, with increase in hematocrit. This might favor formation of microthrombi in the capillaries and further perimalleolar tissue damage in CVI.     

单纯减压与减压后融合治疗单纯退变性腰椎管狭窄症疗效对比研究

【摘要】 目的 比较单纯椎管减压术和减压后器械内固定融合治疗无腰椎滑脱和失稳的退变性腰椎管狭窄症的临床疗效。方法 自2006年3月~2011年5月期间,在我院接受手术治疗的单纯退变性腰椎管狭窄症患者共63例,其中接受单纯选择性椎管减压术治疗的患者28例,接受椎管减压加器械内固定融合手术患者35例。手术前后分别使用腰椎JOA (Japanese Orthopedic Association) 评分、ODI(Oswestry Disability Index)评分和SF?鄄36(Short Form?鄄36)评分,评估两种术式的临床疗效。结果 两组患者术后1年均取得较好疗效。其中椎管减压加融合组患者术后ODI评分改善31.2分(P<0.001),由重度功能障碍改善至轻度功能障碍;单纯选择性椎管减压组术后ODI评分改善14.9分(P=0.004),由重度功能障碍改善至中度功能障碍;减压加融合组预后较单纯减压组显著改善(P<0.01),术后SF?鄄36评分得到相似结果。结论 手术治疗能极大地改善腰椎管狭窄患者的临床症状,椎管减压加融合术较单纯椎管减压术能更大程度改善该类患者的临床症状。     

Ultrasound in Sciatica

Investigation of the sagittal diameter of the spinal canal by ultrasound has shown a relative stenosis in patients with sciatica. In this study 12 patients who had recovered uneventfully after being operated on for herniated lumbar discs were found to have a broader spinal canal than 10 patients treated in the same way but still suffering from pain. Moreover, more difficulty was experienced investigating this latter group with the described “B-scan” technique. It is suggested that a preoperative ultrasound investigation would be able to indicate a narrow spinal canal and thereby reduce the number of disc operation failures.