Diagnosis of lumbar spinal stenosis: an updated systematic review of the accuracy of diagnostic tests

Deep learning-based detection of lumbar spinal canal stenosis using convolutional neural networks

BACKGROUND CONTEXT

Lumbar spinal canal stenosis (LSCS) is the most common spinal degenerative disorder in elderly people and usually first seen by primary care physicians or orthopedic surgeons who are not spine surgery specialists. Magnetic resonance imaging (MRI) is useful in the diagnosis of LSCS, but the equipment is often not available or difficult to read. LSCS patients with progressive neurologic deficits have difficulty with recovery if surgical treatment is delayed. So, early diagnosis and determination of appropriate surgical indications are crucial in the treatment of LSCS. Convolutional neural networks (CNNs), a type of deep learning, offers significant advantages for image recognition and classification, and work well with radiographs, which can be easily taken at any facility.

PURPOSE

Our purpose was to develop an algorithm to diagnose the presence or absence of LSCS requiring surgery from plain radiographs using CNNs.

STUDY DESIGN

Retrospective analysis of consecutive, nonrandomized series of patients at a single institution.

PATIENT SAMPLE

Data of 150 patients who underwent surgery for LSCS, including degenerative spondylolisthesis, at a single institution from January 2022 to August 2022, were collected. Additionally, 25 patients who underwent surgery at 2 other hospitals were included for extra external validation.

OUTCOME MEASURES

In annotation 1, the area under the curve (AUC) computed from the receiver operating characteristic (ROC) curve, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, positive likelihood ratio (PLR), and negative likelihood ratio (NLR) were calculated. In annotation 2, correlation coefficients were used.

METHODS

Four intervertebral levels from L1/2 to L4/5 were extracted as region of interest from lateral plain lumbar spine radiographs totaling 600 images were obtained. Based on the date of surgery, 500 images derived from the first 125 cases were used for internal validation, and 100 images from the subsequent 25 cases used for external validation. Additionally, 100 images from other hospitals were used for extra external validation. In annotation 1, binary classification of operative and nonoperative levels was used, and in annotation 2, the spinal canal area measured on axial MRI was labeled as the output layer. For internal validation, the 500 images were divided into each 5 dataset on per-patient basis and 5-fold cross-validation was performed. Five trained models were registered in the external validation prediction performance. Grad-CAM was used to visualize area with the high features extracted by CNNs.

RESULTS

In internal validation, the AUC and accuracy for annotation 1 ranged between 0.85-0.89 and 79-83%, respectively, and the correlation coefficients for annotation 2 ranged between 0.53 and 0.64 (all p<.01). In external validation, the AUC and accuracy for annotation 1 were 0.90 and 82%, respectively, and the correlation coefficient for annotation 2 was 0.69, using 5 trained CNN models. In the extra external validation, the AUC and accuracy for annotation 1 were 0.89 and 84%, respectively, and the correlation coefficient for annotation 2 was 0.56. Grad-CAM showed high feature density in the intervertebral joints and posterior intervertebral discs.

CONCLUSIONS

This technology automatically detects LSCS from plain lumbar spine radiographs, making it possible for medical facilities without MRI or nonspecialists to diagnose LSCS, suggesting the possibility of eliminating delays in the diagnosis and treatment of LSCS that require early treatment.

Development of a Deep-Learning Model for Diagnosing Lumbar Spinal Stenosis Based on CT Images

STUDY DESIGN

Retrospective study.

OBJECTIVES

This study aimed to develop an initial deep-learning (DL) model based on computerized tomography (CT) scans for diagnosing lumbar spinal stenosis.

SUMMARY OF BACKGROUND DATA

Magnetic resonance imaging is commonly used for diagnosing lumbar spinal stenosis due to its high soft tissue resolution, but CT is more portable, cost-effective, and has wider regional coverage. Using DL models to improve the accuracy of CT diagnosis can effectively reduce missed diagnoses and misdiagnoses in clinical practice.

MATERIALS AND METHODS

Axial lumbar spine CT scans obtained between March 2022 and September 2023 were included. The data set was divided into a training set (62.3%), a validation set (22.9%), and a control set (14.8%). All data were labeled by two spine surgeons using the widely accepted grading system for lumbar spinal stenosis. The training and validation sets were used to annotate the regions of interest by the two spine surgeons. First, a region of interest detection model and a convolutional neural network classifier were trained using the training set. After training, the model was preliminarily evaluated using a validation set. Finally, the performance of the DL model was evaluated on the control set, and a comparison was made between the model and the classification performance of specialists with varying levels of experience.

RESULTS

The central stenosis grading accuracies of DL Model Version 1 and DL Model Version 2 were 88% and 83%, respectively. The lateral recess grading accuracies of DL Model Version 1 and DL Model Version 2 were 75% and 71%, respectively.

CONCLUSIONS

Our preliminarily developed DL system for assessing the degree of lumbar spinal stenosis in CT, including the central canal and lateral recess, has shown similar accuracy to experienced specialist physicians. This holds great value for further development and clinical application.

Similar improvements in patient-reported outcomes for non-specific low back pain patients with and without lumbar spinal stenosis symptoms following a structured education and exercise therapy program

BACKGROUND

People with nonspecific low back pain (NSLBP) can also experience overlapping symptoms of lumbar spinal stenosis (LSS), but the impact on treatment outcomes is unknown. This study investigated differences in treatment outcomes for disability, back pain intensity, and leg pain intensity following an education and exercise therapy program for NSLBP patients with and without comorbid LSS symptoms.

METHODS

This was a longitudinal analysis of 655 Danish participants in the GLA:D® Back program; an education and exercise therapy program for people with persistent NSLBP. Participants were classified as having comorbid LSS symptoms based on self-report. Linear mixed models were used to assess differences in change in disability (Oswestry Disability Index [0-100]) and back and leg pain intensity (Numeric Rating Scale [0-10]) at 3-, 6-, and 12-months between those with and without LSS symptoms.

RESULTS

28% of participants reported LSS symptoms. No certain differences in change in disability or back pain intensity improvement were observed at any time-point between those with and without LSS symptoms. Participants with LSS symptoms had slightly greater improvement in leg pain intensity at 6- (-0.7, 95% CI -1.2 to -0.2) and 12-months (-0.6, 95% CI -1.2 to -0.1).

CONCLUSION

Compared to those without LSS symptoms, patients with persistent NSLBP and LSS symptoms can expect similar improvements in disability and back pain intensity, and slightly greater improvements in leg pain intensity with treatment. Therefore, education and exercise therapy programs designed for NSLBP are likely helpful for those also experiencing LSS symptoms.

Comparison of magnetic resonance imaging findings among sciatica patients classified as centralizers or non-centralizers

OBJECTIVE

To compare if the degenerative findings from MRI differ between the sciatica patients classified as centralizers (CEN) and non-centralizers (Non-CEN) according to the McKenzie Method of mechanical diagnosis and therapy.

STUDY DESIGN

A cross-sectional study.

METHODS

Patients (N = 100) referred to a spine clinic of a single tertiary hospital for specialist consultation for sciatica. The McKenzie-based assessment was performed by the mechanical diagnosis and therapy-trained physiotherapists. Clinical data and prevalence of lumbar MRI findings were compared between the groups.

RESULTS

There was no significant difference in leg pain intensity between the groups. The Non-CEN had significantly more intense back pain, mean 56 (SD 30) and were more disabled 44 (SD 15) compared to the CEN mean 41 (SD 25) and mean 31 (11), measured with a visual analogue scale (0-100), and the Oswestry Disability Index (0-100), respectively. The CEN had more severe degenerative findings on MRI than the Non-CEN: vertebral end-plate changes were 63% and 43%; mean Pfirrmann's disc degeneration lumbar summary score was 12.8, and 10.6; and severity score of total damage was 12.0 and 10.1, respectively. There were differences neither in disc contour changes nor nerve root stenosis on MRI.

CONCLUSIONS

Sciatica patients classified as non-centralizers had significantly more severe back pain, and were significantly more disabled than centralizers, who instead had more severe degenerative findings on MRI. Thus, classification to non-centralizers by the McKenzie method seems not predict higher incidence of degenerative findings on MRI compared to centralizers.

Diagnosis Value of Patient Evaluation Components Applicable in Primary Care Settings for the Diagnosis of Low Back Pain: A Scoping Review of Systematic Reviews

Low back pain ranks as the leading cause of years lived with disability worldwide. Although best practice guidelines share a consistent diagnostic approach for the evaluation of patients with low back pain, confusion remains as to what extent patient history and physical examination findings can inform management strategies. The aim of this study was to summarize evidence investigating the diagnostic value of patient evaluation components applicable in primary care settings for the diagnosis of low back pain. To this end, peer-reviewed systematic reviews were searched in MEDLINE, CINAHL, PsycINFO and Cochrane databases from 1 January 2000 to 10 April 2023. Paired reviewers independently reviewed all citations and articles using a two-phase screening process and independently extracted the data. Of the 2077 articles identified, 27 met the inclusion criteria, focusing on the diagnosis of lumbar spinal stenosis, radicular syndrome, non- specific low back pain and specific low back pain. Most patient evaluation components lack diagnostic accuracy for the diagnosis of low back pain when considered in isolation. Further research is needed to develop evidence-based and standardized evaluation procedures, especially for primary care settings where evidence is still scarce.

An Investigation Into the Relationship Between the Sedimentation Sign and Lumbar Disc Herniation in Upright Magnetic Resonance Images

STUDY DESIGN

Retrospective Upright MRI Study.

OBJECTIVES

Determine the relationship between lumbar disc herniation and presence of the nerve root sedimentation sign on upright kinematic MRI patients.

METHODS

T2-weighted axial upright kMRI images of 100 patients with the presence of disc herniation in at least 1 lumbar disc between L1/L2 and L5/S1 were obtained. Sedimentation sign, spinal canal anterior-posterior (AP) diameter, disc height, disc herniation size, type of herniation, and zone of herniation were evaluated. A positive sedimentation sign was defined as having either the majority of nerve roots running ventrally or centrally in the canal or conglomeration of the nerve roots at the mid-disc level. Herniation types were defined as either no herniation, disc bulge, protrusion, extrusion, or sequestration. Zones of herniation were categorized as either central, lateral, or far lateral.

RESULTS

The kappa value of intra-observer reliability was .915. The kappa value of disc levels with a negative sedimentation sign were seen more frequently (n = 326, 65.2%) than those with a positive sedimentation sign (n = 174, 34.8%). The spinal canal AP diameter was significantly decreased at the L3/L4 and L4/L5 level in patients with a positive sedimentation sign. Discs with a positive sedimentation sign had a larger average size of disc herniation compared to those with a negative sign at all levels. A relationship between positivity of the sedimentation sign and disc herniation type was significant at L2/L3, L3/L4, and L4/L5.

CONCLUSIONS

Patients with a positive sedimentation sign were seen to have larger disc herniations and more severely degenerated discs.

Characteristics associated with comorbid lumbar spinal stenosis symptoms in people with knee or hip osteoarthritis: an analysis of 9,136 good life with osteoArthritis in Denmark (GLA:D®) participants

BACKGROUND

Previous studies have found that lumbar spinal stenosis (LSS) often co-occurs with knee or hip OA and can impact treatment response. However, it is unclear what participant characteristics may be helpful in identifying individuals with these co-occurring conditions. The aim of this cross-sectional study was to explore characteristics associated with comorbid symptoms of lumbar spinal stenosis (LSS) in people with knee or hip osteoarthritis (OA) enrolled in a primary care education and exercise program.

METHODS

Sociodemographic, clinical characteristics, health status measures, and a self-report questionnaire on the presence of LSS symptoms was collected at baseline from the Good Life with osteoArthritis in Denmark primary care program for knee and hip OA. Cross-sectional associations between characteristics and the presence of comorbid LSS symptoms were assessed separately in participants with primary complaint of knee and hip OA, using domain-specific logistic models and a logistic model including all characteristics.

RESULTS

A total of 6,541 participants with a primary complaint of knee OA and 2,595 participants with a primary complaint of hip OA were included, of which 40% and 50% reported comorbid LSS symptoms, respectively. LSS symptoms were associated with similar characteristics in knee and hip OA. Sick leave was the only sociodemographic variable consistently associated with LSS symptoms. For clinical characteristics, back pain, longer symptom duration and bilateral or comorbid knee or hip symptoms were also consistently associated. Health status measures were not consistently related to LSS symptoms.

CONCLUSION

Comorbid LSS symptoms in people with knee or hip OA undergoing a primary care treatment program of group-based education and exercise were common and associated with a similar set of characteristics. These characteristics may help to identify people with co-occurring LSS and knee or hip OA, which can be used to help guide clinical decision-making.

Diagnostic value of a new axial loading MRI device in patients with suspected lumbar spinal stenosis

OBJECTIVES

This study was carried out to investigate a new device for axial loading MRI (alMRI) in the diagnosis of lumbar spinal stenosis (LSS).

METHODS

A total of 87 patients with suspected LSS sequentially underwent conventional MRI and alMRI using a new device with pneumatic shoulder-hip compression mode. Four quantitative parameters of dural sac cross-sectional area (DSCA), sagittal vertebral canal diameter (SVCD), disc height (DH), and ligamentum flavum thickness (LFT) at L3-4, L4-5, and L5-S1 in both examinations were measured and compared. Eight qualitative indicators were compared as valuable diagnostic information. Image quality, examinee comfort, test-retest repeatability, and observer reliability were also assessed.

RESULTS

Using the new device, all 87 patients successfully completed alMRI with no statistically significant differences in image quality and examinee comfort from conventional MRI. Statistically significant changes were observed in DSCA, SVCD, DH, and LFT after loading (p < 0.01). SVCD, DH, LFT, and DSCA changes were all positively correlated (r = 0.80, 0.72, 0.37, p < 0.01). Eight qualitative indicators increased from 501 to 669 after axial loading, for a total increase of 168 (33.5%). Nineteen patients (21.8%, 19/87) developed absolute stenosis after axial loading and 10 of them (11.5%, 10/87) also had a significant reduction in DSCA (> 15 mm²). The test-retest repeatability and observer reliability were good to excellent.

CONCLUSION

The new device is stable for performing alMRI and can exacerbate the severity of spinal stenosis, providing more valuable information for diagnosing LSS and reducing missed diagnoses.

KEY POINTS

• The new axial loading MRI (alMRI) device could detect a higher frequency of patients with lumbar spinal stenosis (LSS). • The new device with pneumatic shoulder-hip compression mode was used to investigate its applicability in alMRI and diagnostic value for LSS. • The new device is stable for performing alMRI and can provide more valuable information for diagnosing LSS.

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of lumbar spinal stenosis, 2021 - Secondary publication

BACKGROUND

The Japanese Orthopaedic Association (JOA) guideline for the management of lumbar spinal stenosis (LSS) was first published in 2011. Since then, the medical care system for LSS has changed and many new articles regarding the epidemiology and diagnostics of LSS, conservative treatments such as new pharmacotherapy and physical therapy, and surgical treatments including minimally invasive surgery have been published. In addition, various issues need to be examined, such as verification of patient-reported outcome measures, and the economic effect of revised medical management of patients with lumbar spinal disorders. Accordingly, in 2019 the JOA clinical guidelines committee decided to update the guideline and consequently established a formulation committee. The purpose of this study was to describe the formulation we implemented for the revision of the guideline, incorporating the recent advances of evidence-based medicine.

METHODS

The JOA LSS guideline formulation committee revised the previous guideline based on the method for preparing clinical guidelines in Japan proposed by the Medical Information Network Distribution Service in 2017. Background and clinical questions were determined followed by a literature search related to each question. Appropriate articles based on keywords were selected from all the searched literature. Using prepared structured abstracts, systematic reviews and meta-analyses were performed. The strength of evidence and recommendations for each clinical question was decided by the committee members.

RESULTS

Eight background and 15 clinical questions were determined. Answers and explanations were described for the background questions. For each clinical question, the strength of evidence and the recommendation were both decided, and an explanation was provided.

CONCLUSIONS

The 2021 clinical practice guideline for the management of LSS was completed according to the latest evidence-based medicine. We expect that this guideline will be useful for all medical providers as an index in daily medical care, as well as for patients with LSS.

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

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

Associations between comorbid lumbar spinal stenosis symptoms and treatment outcomes in 6,813 patients with knee or hip osteoarthritis following a patient education and exercise therapy program

Objective

People with knee or hip osteoarthritis (OA) can experience comorbid lumbar spinal stenosis (LSS), but the impact on treatment outcomes is unknown. The aim of this study was to investigate associations between comorbid LSS symptoms and changes in pain, function, and quality of life following a patient education and exercise therapy program.

Design

This was a longitudinal analysis of 6813 participants in the Good Life with osteoArthritis in Denmark (GLA:D®) program; a structured patient education and exercise therapy program for knee and hip OA. Participants were classified as having comorbid LSS symptoms based on self-report symptom items. Linear mixed models were used to assess differences in change in pain, function, and quality of life outcomes (0 worst to 100 best) at 3- and 12-month follow-up.

Results

15% and 23% of knee and hip OA participants had comorbid LSS symptoms, respectively. Knee participants with comorbid LSS symptoms had smaller improvement in pain at 3-months (-1.7, 95% CI -3.3 to -0.1) and hip participants with comorbid LSS symptoms had greater improvement in function at 3- (2.5, 95% CI 0.5 to 5.0) and 12-months (3.8, 95% CI 0.9 to 6.6), when compared to those without LSS symptoms. These differences were not clinically significant and no differences in other outcomes were observed.

Conclusion

Knee or hip OA patients with comorbid LSS symptoms should expect similar improvements in knee- or hip-related pain, function, and quality of life outcomes when undergoing a patient education and exercise therapy program compared to those without LSS symptoms.

Cauda equina movement during the Valsalva maneuver in two patients with Lumbar spinal canal stenosis

Lumbar spinal canal stenosis (LSS) is a common spinal disorder among older people. Some LSS patients say that their pain worsens when they lift heavy objects. The Valsalva maneuver is the optimal breathing pattern for producing maximal force. Herein, we present two cases of LSS where the movement of the cauda equina was observed during the Valsalva maneuver.

Outcome Domain and Measurement Instrument Reporting in Randomized Controlled Trials of Interventions for Lumbar Spinal Stenosis: A Systematic Review

OBJECTIVE

To describe outcome measurement instruments and outcome domains in randomized controlled trials of any interventions for lumbar spinal stenosis (LSS).

DESIGN

Systematic review.

LITERATURE SEARCH

The Cochrane Central Register of Controlled Trials (CENTRAL) and PubMed were searched from inception to May 2020.

STUDY SELECTION CRITERIA

Trials were eligible if patients were diagnosed with LSS, with or without neurogenic claudication. Trials were eligible if they used at least 1 outcome measurement instrument.

DATA SYNTHESIS

Measurement instruments used in trials were extracted and then classified into outcome domains. We described the frequency of measurement instruments and outcome domains.

RESULTS

After study screening, 29 trials were included. In total, 54 different individual outcome measurement instruments were used. The Visual Analogue Scale (59%; n = 17) and the Oswestry Disability Index (52%; n = 15) were the most frequently used outcome measurement instruments in trials; function (90%; n = 26) and pain (62%; n = 18) were the most common outcome domains.

CONCLUSION

In total, 54 different measurement instruments were used in trials of interventions for LSS. This diverse range of observations contributes to outcome instrument heterogeneity between trials and impedes the analysis of data due to lack of comparability. The most common outcome domains assessed were pain and function, which will help inform a core outcome measure set for symptomatic LSS. J Orthop Sports Phys Ther 2022;52(7):446-456. Epub: 18 May 2022. doi:10.2519/jospt.2022.10879.

Electrophysiological Characteristics of Cervical Spinal Stenosis

Objective

To investigate electrophysiological characteristics of patients with cervical spinal stenosis (CSS) due to cervical disc herniation.

Methods

A total of 51 patients with CSS diagnosed in our hospital from January 2018 to March 2020 were selected. According to magnetic resonance imaging (MRI), the degree of spinal cord compression was divided into 1-3 grades, namely, group A (MRI grade 1), group B (MRI grade 2), and group C (MRI grade 3), with 17 cases in each group. Subsequently, we analyzed the correlation of the degree of spinal cord compression with the general information, clinical data, and electromyography (EMG) of patients.

Results

Compared with group A and group B, group C had the longest disease course [(48.06 ± 17.71) months], the lowest JOA score (4.59 ± 2.15), and the highest number of positive results of EMG (EMG: A/B/C, 25/51/77); there were significant differences among the 3 groups. And group C had the higher number of positive cases of both upper and lower limbs in SEP test compared with the other two groups (SEP: A/B/C: 12/18/29: χ 2 = 7.559, P = 0.023). According to correlation analysis, MRI grading had no association with gender, age, and spinal canal diameter/volume but was positively correlated with disease course and negatively correlated with JOA score.

Conclusion

This study primarily verifies that higher MRI grade of CSS is associated with longer disease duration and lower JOA score and EMG. The obtained results secondarily demonstrate the correlation between abnormal neurological status and the MRI grade.

The clinical effectiveness of a physiotherapy delivered physical and psychological group intervention for older adults with neurogenic claudication: the BOOST randomised controlled trial

Background

Neurogenic claudication (NC) is a debilitating spinal condition affecting older adults’ mobility and quality of life.

Methods

A randomized controlled trial of 438 participants evaluated the effectiveness of a physical and psychological group intervention (BOOST program) compared to physiotherapy assessment and tailored advice (best practice advice [BPA]) for older adults with NC. Participants were identified from spinal clinics (community and secondary care) and general practice records and randomized 2:1 to the BOOST program or BPA. The primary outcome was the Oswestry Disability Index (ODI) at 12 months. Data were also collected at 6 months. Other outcomes included ODI walking item, 6-minute walk test (6MWT), and falls. The primary analysis was intention-to-treat.

Results

The average age of participants was 74.9 years (standard deviation [SD] 6.0) and 57% (246/435) were female. There was no significant difference in ODI scores between treatment groups at 12 months (adjusted mean difference [MD]: −1.4 [95% confidence intervals (CI) −4.03, 1.17]), but, at 6 months, ODI scores favored the BOOST program (adjusted MD: −3.7 [95% CI −6.27, −1.06]). At 12 months, the BOOST program resulted in greater improvements in walking capacity (6MWT MD: 21.7m [95% CI 5.96, 37.38]) and ODI walking item (MD: −0.2 [95% CI −0.45, −0.01]) and reduced falls risk (odds ratio: 0.6 [95% CI 0.40, 0.98]) compared to BPA. No serious adverse events were related to either treatment.

Conclusions

The BOOST program substantially improved mobility for older adults with NC. Future iterations of the program will consider ways to improve long-term pain-related disability.

Clinical Trials Registration Number: ISRCTN12698674

Prevalence of multimorbid degenerative lumbar spinal stenosis with knee or hip osteoarthritis: a systematic review and meta-analysis

Background

Musculoskeletal multimorbidity is common and coexisting lumbar spinal stenosis (LSS) with knee or hip osteoarthritis (OA) has been reported. The aim of this review was to report the prevalence of multimorbid degenerative LSS with knee or hip OA based on clinical and/or imaging case definitions.

Methods

Literature searches were performed in MEDLINE, EMBASE, CENTRAL, and CINAHL up to May 2021. Studies involving adults with cross-sectional data to estimate the prevalence of co-occurring LSS with knee or hip OA were included. Study selection, data extraction, and risk of bias assessment were performed independently by two reviewers. Results were stratified according to index and comorbid condition, and by case definitions (imaging, clinical, and combined).

Results

Ten studies from five countries out of 3891 citations met the inclusion criteria. Sample sizes ranged from 44 to 2,857,999 (median 230) and the mean age in the included studies range from 61 to 73 years (median 66 years). All studies were from secondary care or mixed settings. Nine studies used a combined definition of LSS and one used a clinical definition. Imaging, clinical, and combined case definitions of knee and hip OA were used. The prevalence of multimorbid LSS and knee or hip OA ranged from 0 to 54%, depending on the specified index condition and case definitions used. Six studies each provided prevalence data for index LSS and comorbid knee OA (prevalence range: 5 to 41%) and comorbid hip OA (prevalence range: 2 to 35%). Two studies provided prevalence data for index knee OA and comorbid LSS (prevalence range 17 to 54%). No studies reporting prevalence data for index hip OA and comorbid LSS were found. Few studies used comparable case definitions and all but one study were rated as high risk of bias.

Conclusions

There is evidence that multimorbid LSS with knee or hip OA occurs in people (0 to 54%), although results are based on studies with high risk of bias and surgical populations. Variability in LSS and OA case definitions limit the comparability of studies and prevalence estimates should therefore be interpreted with caution.

Review registration

PROSPERO (CRD42020177759).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05104-3.

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.

Symptoms of lumbar spinal stenosis in people with knee or hip osteoarthritis or low back pain: a cross-sectional study of 10,234 participants in primary care

OBJECTIVE

The aims of this study were to evaluate: the proportion of people reporting symptoms associated with lumbar spinal stenosis (LSS) in primary care programs for knee or hip osteoarthritis (OA) or persistent low back pain (LBP) and; the prevalence of self-reported clinical LSS in these three cohorts, according to two sets of adapted criteria.

METHOD

A cross-sectional analysis of baseline data from the Good Life with osteoArthritis in Denmark primary care programs. Self-report LSS symptom questions were administered to participants with knee OA, hip OA, and persistent LBP. The prevalence of eleven LSS symptoms and clinical LSS were calculated for each cohort.

RESULTS

A total of 10,234 participants were included in the analysis. A similar proportion of participants in each cohort were female (69%), with a 6- and 7-year older mean age in the knee and hip cohorts compared to the back cohort. A greater proportion of participants with LBP reported LSS symptoms (range 11-71%) than in the hip (11-50%) and knee (8-40%) cohorts. This pattern was observed for all but one symptom. The same pattern was observed for the prevalence of clinical LSS with less than 10% of people in each cohort satisfying the clinical criteria.

CONCLUSION

Self-reported LSS symptoms are commonly reported by people treated in primary care for knee or hip OA, although not as frequently as reported by those with LBP. Despite symptoms of LSS being common, only a small proportion of people were classified as having self-reported clinical LSS.

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

OBJECTIVE

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

DESIGN

Cross-sectional qualitative study.

METHODS

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

RESULTS

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

CONCLUSION

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

Association of Lumbar Spinal Stenosis with Severe Disability and Mortality Among Community-Dwelling Older Adults: The Locomotive Syndrome and Health Outcomes in the Aizu Cohort Study

STUDY DESIGN

This prospective cohort study analyzed data from the Locomotive Syndrome and Health Outcomes in the Aizu Cohort Study.

OBJECTIVE

To investigate the association between lumbar spinal stenosis (LSS) and severe disability and mortality among community-dwelling older adults.

SUMMARY OF BACKGROUND DATA

Only a few studies have investigated LSS longitudinally, and the study participants were limited to selected patients diagnosed with LSS during a hospital visit. Additionally, the prognosis of LSS remains unclear.

METHODS

We enrolled independent community-dwelling older adults aged 65 years or older at the time of a baseline health checkup in 2008. LSS was diagnosed using a validated diagnostic support tool for LSS. The primary endpoint was a composite of severe disability (long-term care insurance certification grade 4 or 5) and mortality. We used 1 minus Kaplan-Meier failure estimates and the log-rank test to compare the interval between baseline and the predetermined endpoint as well as a Cox proportional hazards model to estimate hazard ratios (HRs) for the LSS group with adjustment for possible confounders. Multiple imputation by chained equations was performed for sensitivity analysis.

RESULTS

Of 2058 subjects enrolled, 1560 did not have missing covariates; 269 (17%) were diagnosed with LSS. After a median follow-up of 5.8 years, the rates of severe disability and mortality were 0.022 per year in subjects with LSS and 0.012 per year in those without (P = 0.006). The adjusted HR for the composite endpoint in the LSS group was 1.55 (95% confidence interval [CI], 1.01-2.38). A similar association was observed after multiple imputation of missing covariates (adjusted HR, 1.51 [95% CI, 1.06-2.16]).

CONCLUSION

LSS was associated with severe disability and mortality in community-dwelling older adults. Detection of adults with LSS in the community may contribute to local health promotion.Level of Evidence: 2.

Comparison of walking variations during treadmill walking test between neurogenic and vascular claudication: a crossover study

Background

Lumbar spinal stenosis (LSS) and peripheral arterial disease (PAD) are two distinct conditions characterized by similar symptoms including leg pain and walking limitations due to claudication. Differentiation between both origins can be difficult and characteristics such as symptom manifestations, time to relief in rest position and pain localization should be considered when determining diagnosis and the treatment plan. The objectives of this study were to compare changes in walking time to symptom change during treadmill tests and self-reported outcomes measures related to claudication, kinesophobia and global health between individuals with LSS, PAD and non-specific low back pain (nLBP).

Method

Fifty-five patients (23 with LSS, 14 with PAD and 18 with nLBP) were recruited from May 2018 to March 2020 to complete a treadmill walking test involving two 5-min walking tasks (Upright and Forward Leaning Trunk (FLT) Walking tasks). The speed was set at 1.9 km/h (1.2 mph), and each task was followed by a 5-min rest period. Walking time to symptom change and Total walking time were recorded during each walking task. Patients were asked to complete four questionnaires related to the impact of claudication, walking impairment, kinesiophobia and global health. One-way ANOVAs were performed to compare walking time difference from the Upright to the FLT walking tasks and to compare questionnaires results between groups.

Results

One-way ANOVAs showed a significant difference between groups regarding difference in Walking time to symptom change between both tasks (F = 4.12, p = 0.022). The LSS group improved its Walking time to symptom change from the Upright to the FLT walking tasks more than the PAD (p = 0.34) and the nLBP group (p = 0.12). The nLBP group was less impacted by claudication and less impaired during walking compared to the LSS and PAD groups (ps < 0.001). The nLBP group also had less kinesiophobia than the LSS one (p < 0.001), but was similar to the PAD group. The global health rating was not statistically different between groups (p = 0.118).

Conclusion

The test was able to distinguish neurogenic from vascular or nLBP related claudication. However, further studies are needed to validate this new treadmill walking test.

Trial registration

clinicaltrials.gov (NCT04058171), Registered August 15, 2019 –Registered during recruitment

Effect of lumbar spinal stenosis on bone mineral density in osteoporosis patients treated with ibandronate

Background

Lumbar spinal stenosis (LSS) can cause various neurological symptoms and reduce the daily activity of patients. Many studies have shown that free physical activities and exercise can improve bone mineral density (BMD) in patients with osteoporosis. However, the effect of LSS on BMD has not been reported. The purpose of this study was to investigate the effects of LSS on BMD in patients treated with ibandronate for newly diagnosed osteoporosis.

Methods

Group 1 included 83 patients treated for osteoporosis alone, and group 2 included 76 patients treated for both osteoporosis and symptomatic LSS. We confirmed four BMD values presented as T-score at initial, and 1-, 2-, and 3-year follow-ups. Mean BMD and annual changes of BMD for three years were compared between the two groups. Correlations between initial BMD and total change of BMD, and related factors for continuous BMD improvement for three years were also evaluated.

Results

Mean annual BMDs were significantly higher in group 1 compared than in group 2 (-3.39 vs. -3.58 at 1-year; -3.27 vs. -3.49 at 2-year; -3.13 vs. -3.45 at 3-year; all p < 0.05). Annual change of BMD at 1-year follow-up (0.32 vs. 0.21, p = 0.036) and total change of BMD for three years (0.57 vs. 0.35, p = 0.002) were significantly higher in group 1. Group 1 had a strong negative correlation (r = -0.511, P = 0.000) between initial BMD and total change of BMD, whereas group 2 showed a weak negative correlation (r = -0.247, p = 0.032). In multivariate analysis, symptomatic LSS was the only independent risk factor for continuous BMD improvement (Odds ratio = 0.316, p = 0.001).

Conclusions

Symptomatic LSS may interfere with BMD improvement in the treatment of osteoporosis with ibandronate. Active treatment for LSS with more potent treatment for osteoporosis should be taken to increase BMD for patients with osteoporosis and LSS.

Low Back Pain in Adolescent and Geriatric Populations

Spinal pain is the most common form of musculoskeletal pain. Chronic low back pain may contain nociceptive, neuropathic, and central components. Children are at risk of developing spinal pain. An increasing proportion of children develop low back pain as they become adolescents. In most adolescents, no specific diagnosis is identified. Psychological factors play a role in adolescents with back pain. Lumbar spinal stenosis causes neurogenic claudication in older patients. Magnetic resonance imaging is the best radiographic technique to detect nerve compression. Surgical decompression with or without fusion may offer greater short-term benefit but may not be significantly better than medical therapy.

A critical appraisal of clinical practice guidelines for the treatment of lumbar spinal stenosis

OBJECTIVE

The aim of the review was to appraise clinical practice guidelines and their recommendations for the treatment of lumbar spinal stenosis.

METHODS

PubMed, Medline, CINAHL, Embase, and Cochrane Central Register of Controlled Trials were searched up until 25/01/2020 for clinical practice guidelines on the management of lumbar spinal stenosis with a systematic process to generate recommendations and were publicly available.

RESULTS

Ten guidelines were included, with a total of 76 recommendations for the treatment of lumbar spinal stenosis. Only 4 of the 10 guidelines were of satisfactory methodological quality according to the AGREE II instrument. Around three-quarters of recommendations (72.4%) were presented with poor evidence, with the remaining 21 presenting (27.6%) fair evidence. No recommendation presented good evidence. Recommendations were made on four types of interventions: surgery, injections, medications, and other nonsurgical treatments, with supporting evidence similar for all four treatment types. Positive recommendations were more common for injections (12/13=92.3%) and surgery (10/15=66%) than for nonsurgical treatments (6/21=28.6%) or medications (1/27=3.75%).

CONCLUSIONS

Ten guidelines on the management of lumbar spinal stenosis were identified in the systematic review, but only four were of adequate methodological quality. While the evidence underpinning the various types of interventions was similar, guidelines tended to endorse surgery and injections but not nonsurgical interventions and medicines. These results support the need for greater rigor and inclusion of steps to minimize bias in the production of guidelines.

Reliability and Validity of the Thai Version of the Swiss Spinal Stenosis Questionnaire

The original Swiss Spinal Stenosis (SSS) questionnaire was translated into the Thai version and culturally adapt for use in Thailand. The Thai version—SSS is valid and reliable to use in both clinical and research to address the functional, symptom severity, and satisfaction in Thai lumbar spinal stenosis patients.

Study Design..

Cross-sectional study.

Objective..

To evaluate the reliability and validity of the Thai version of the Swiss Spinal Stenosis (SSS) questionnaire.

Summary of Background Data..

The SSS questionnaire was developed to assess symptom severity, physical functional status, and patient satisfaction in spinal stenosis patients that was previously reported to have good reliability and validity. There is currently no Thai version of the SSS questionnaire.

Methods..

The SSS questionnaire was translated into Thai language to create the Thai version of the Swiss Spinal Stenosis (Thai-SSS) questionnaire. Translation was performed according to international standards using a forward-backward translation protocol. Translation was performed by two expert translators and one physician, and the final version was approved by an expert committee. Thai patients with degenerative lumbar spinal stenosis were enrolled and evaluated using the Thai-SSS questionnaire, the Thai version of the Short Form-36 (SF-36), and a visual analogue scale (VAS) before and after treatment. Reliability and validity of the Thai-SSS were assessed via comparison with the SF-36 and the VAS.

Results..

One hundred seven patients were included. Eighty patients underwent decompression and fusion surgery, and the others underwent decompression alone. Cronbach's alpha of all domains of the Thai-SSS showed excellent internal consistency (0.869–0.921). The intraclass correlation coefficient for test–retest reliability was 0.77 (95% CI: 0.65–0.85). Regarding concurrent validity, the physical function scale of the Thai-SSS was strongly correlated with the physical functioning domain of the SF-36 (r = 0.70). The symptom severity domain of the Thai-SSS was strongly correlated with the bodily pain domain of the SF-36 and the VAS (r = 0.76 and 0.78, respectively).

Conclusion..

The Thai-SSS was found to be a valid and reliable tool for evaluating symptom severity, physical function, and patient satisfaction after treatment in Thai patients with spinal stenosis.

Level of Evidence: 4

The Prevalence of Back and Leg Pain and the Cross-sectional Association With Adverse Health Outcomes in Community Dwelling Older Adults in England

STUDY DESIGN

Cross-sectional analysis of the Oxford Pain, Activity and Lifestyle (OPAL) Cohort Study.

OBJECTIVE

The aim of this study was to assess the prevalence of back pain (BP) and leg pain and determine their relationship with adverse health states among older adults in England.

SUMMARY OF BACKGROUND DATA

Epidemiological data describing the prevalence of BP and leg pain in older adults in England is lacking.

METHODS

A total of 5304 community-dwelling adults (aged 65-100 years) enrolled in the OPAL cohort study who provided data on BP and leg pain were included. Participants were classified into four groups based on reports of back and leg pain: no BP, BP only, BP and leg pain which was likely to be neurogenic claudication (NC), and BP and leg pain which was not NC. Adverse health states were frailty, falls, mobility decline, low walking confidence, poor sleep quality, and urinary incontinence. We collected demographic and socioeconomic information, health-related quality of life, and existing health conditions, and estimated the association between BP presentations and adverse health states using regression analysis.

RESULTS

Thirty-four percent of participants (1786/5304) reported BP only, 11.2% (n = 594/5304) reported BP and NC and 8.3% (n = 441/5304) reported BP and non-NC leg pain. Participants with BP had worse quality of life compared to those without BP. All BP presentations were significantly associated with adverse health states. Those with NC were most affected. In particular, there was greater relative risk (RR) of low walking confidence (RR 3.11, 95% confidence interval [CI] 2.56-3.78), frailty (RR 1.88, 95% CI 1.67-2.11), and mobility decline (RR 1.74, 95% CI 1.54-1.97) compared to no BP.

CONCLUSION

Back and leg pain is a common problem for older adults and associated with reduced quality of life and adverse health states. Findings suggest a need to develop more effective treatment for older adults with BP especially for those with neurogenic claudication.

LEVEL OF EVIDENCE

2.

Lumbar Spinal Stenosis: Pathophysiology and Treatment Principle: A Narrative Review

Patients with lumbar spinal stenosis may exhibit symptoms such as back pain, radiating pain, and neurogenic claudication. Although long-term outcome of treatments manifests similar results for both nonsurgical and surgical treatments, positive effects such as short-term improvement in symptoms and decreased fall risk may be expected with surgery. Surgical treatment is basically decompression, and a combination of treatments can be added depending on the degree of decompression and the accompanying instability. Recently, minimally invasive surgery has been found to result in excellent outcomes in the treatment of lumbar spinal stenosis. Therefore, better treatment effects can be anticipated with an approach aimed at understanding the overall pathophysiology and treatment methods of lumbar spinal stenosis.

Association Between Latency of Dermatomal Sensory-Evoked Potentials and Quantitative Radiologic Findings of Narrowing in Lumbar Spinal Stenosis

OBJECTIVE

To identify the difference of quantitative radiologic stenosis between a normal latency group and an abnormal latency group, and to investigate the association of dermatomal somatosensory-evoked potential (DSEP) with magnetic resonance imaging (MRI) findings of narrowing in patients with lumbar spinal stenosis (LSS).

METHODS

We retrospectively reviewed the clinical records and P40 latencies of L5 DSEP of 40 patients with unilateral symptoms of LSS at the L4-5 disc level. Quantitative assessments of stenosis in lumbar spine MRI were performed with measurements of the anteroposterior diameter (APD), cross-sectional area (CSA) of the dural sac, ligamentous interfacet distance (LID), CSA of the neural foramen (CSA-NF), and subarticular zone width. Analyses were conducted through comparisons of radiologic severity between the normal and abnormal latency groups and correlation between radiologic severity of stenosis and latency of DSEP in absolute (APD <10 mm) and relative (APD <13 mm) stenosis.

RESULTS

The radiologic severities of lumbar stenosis were not significantly different between the normal and abnormal latency groups. In absolute and relative stenosis, latency showed a significant negative correlation with APD (r=-0.539, r=-0.426) and LID (r=-0.459, r=-0.494). In patients with relative stenosis, a weak significant positive correlation was found between latency and CSA-NF (r=0.371, p=0.048). LID was the only significant factor for latency (β=-0.930, p=0.011).

CONCLUSION

The normal and abnormal DSEP groups showed no significant differences inradiologic severity. The latency of DSEP had a negative correlation with the severity of central stenosis, and LID was an influencing factor.

Cohort profile: Oxford Pain, Activity and Lifestyle (OPAL) Study, a prospective cohort study of older adults in England

PURPOSE

The 'Oxford Pain, Activity and Lifestyle' (OPAL) Cohort is a longitudinal, prospective cohort study of adults, aged 65 years and older, living in the community which is investigating the determinants of health in later life. Our focus was on musculoskeletal pain and mobility, but the cohort is designed with flexibility to include new elements over time. This paper describes the study design, data collection and baseline characteristics of participants. We also compared the OPAL baseline characteristics with nationally representative data sources.

PARTICIPANTS

We randomly selected eligible participants from two stratified age bands (65-74 and 75 and over years). In total, 5409 individuals (42.1% of eligible participants) from 35 general practices in England agreed to participate between 2016 and 2018. The majority of participants (n=5367) also consented for research team to access their UK National Health Service (NHS) Digital and primary healthcare records.

FINDINGS TO DATE

Mean participant age was 74.9 years (range 65-100); 51.5% (n=2784/5409) were women. 94.9% of participants were white, and 28.8% lived alone. Over 83.0% reported pain in at least one body area in the previous 6 weeks. Musculoskeletal symptoms were more prevalent in women (86.4%). One-third of participants reported having one or more falls in the last year. Most participants were confident in their ability to walk outside. The characteristics of OPAL Cohort participants were broadly similar to the general population of the same age.

FUTURE PLANS

Postal follow-up of the cohort is being undertaken at annual intervals, with data collection ongoing. Linkage to NHS hospital admission data is planned. This English prospective cohort offers a large and rich resource for research on the longitudinal associations between demographic, clinical, and social factors and health trajectories and outcomes in community-dwelling older people.

Better Outcomes for Older people with Spinal Trouble (BOOST) trial: statistical analysis plan for a randomised controlled trial of a combined physical and psychological intervention for older adults with neurogenic claudication

BACKGROUND

Neurogenic claudication is a common spinal condition affecting older adults that has a major effect on mobility and implicitly independence. The effectiveness of conservative interventions in this population is not known. We describe the statistical analysis plan for the Better Outcomes for Older people with Spinal trouble (BOOST) randomised controlled trial.

METHODS/DESIGN

BOOST is a pragmatic, multicentre, parallel, two-arm, randomised controlled trial. Participants are community-dwelling adults, 65 years or older, with neurogenic claudication, registered prospectively, and randomised 2:1 (intervention to control) to the combined physical and psychological BOOST group physiotherapy programme or best practice advice. The primary outcome is the Oswestry Disability Index at 12 months. Secondary outcomes include the Short Physical Performance Battery, Swiss Spinal Stenosis Scale, 6 Minute Walk Test, Fear Avoidance Beliefs Questionnaire, and Tilburg Frailty Indicator. Outcomes are measured at 6 and 12 months by researchers blinded to treatment allocation. The primary statistical analysis is by intention to treat. Further study design details are published in the BOOST protocol.

DISCUSSION

The planned statistical analyses for the BOOST trial aim to reduce the risk of outcome reporting bias from prior data knowledge. Any changes or deviations from this statistical analysis plan will be described and justified in the final study report.

TRIAL REGISTRATION

This study has been registered in the International Standard Randomised Controlled Trial Number registry, reference number ISRCTN12698674 . Registered on 10 November 2015.

Gait features for discriminating between mobility-limiting musculoskeletal disorders: Lumbar spinal stenosis and knee osteoarthritis

BACKGROUND

Functional ambulation limitations are features of lumbar spinal stenosis (LSS) and knee osteoarthritis (OA). With numerous validated walking assessment protocols and a vast number of spatiotemporal gait parameters available from sensor-based assessment, there is a critical need for selection of appropriate test protocols and variables for research and clinical applications.

RESEARCH QUESTION

In patients with knee OA and LSS, what are the best sensor-derived gait parameters and the most suitable clinical walking test to discriminate between these patient populations and controls?

METHODS

We collected foot-mounted inertial measurement unit (IMU) data during three walking tests (fast-paced walk test-FPWT, 6-min walk test- 6MWT, self-paced walk test - SPWT) for subjects with LSS, knee OA and matched controls (N = 10 for each group). Spatiotemporal gait characteristics were extracted and pairwise compared (Omega partial squared - ω_p²) between patients and controls.

RESULTS

We found that normal paced walking tests (6MWT, SPWT) are better suited for distinguishing gait characteristics between patients and controls. Among the sensor-based gait parameters, stance and double support phase timing were identified as the best gait characteristics for the OA population discrimination, whereas foot flat ratio, gait speed, stride length and cadence were identified as the best gait characteristics for the LSS population discrimination.

SIGNIFICANCE

These findings provide guidance on the selection of sensor-derived gait parameters and clinical walking tests to detect alterations in mobility for people with LSS and knee OA.

Diagnostic tests in the clinical diagnosis of lumbar spinal stenosis: Consensus and Results of an International Delphi Study

PURPOSE

Reach a consensus on which diagnostic tests are most important in confirming the clinical diagnosis of lumbar spinal stenosis (LSS).

METHODS

Phase 1: 22 members of the International Taskforce on the Diagnosis and Management of LSS confirmed 35 diagnostic items. An on-line survey was developed that allows experts to express the logical order in which they consider the diagnostic tests, and the level of certainty ascertained from each test. Phase 2, Round 1: Survey distributed to members of the International Society for the Study of the Lumbar Spine. Round 2: Meeting of 15 members of Taskforce defined final list of 10 items. Round 3: Survey was distributed internationally, followed by Taskforce consensus.

RESULTS

Totally, 432 clinicians from 28 different countries participated. Certainty of the diagnosis was 60% after selecting the first test and significant change in certainty ceasing after eight items at 90.8% certainty (p < 0.05). The most frequently selected tests included MRI/CT scan, neurological examination and walking test with gait observation. The diagnostic test selected most frequently as the first test was neurological examination.

CONCLUSIONS

This is the first study to reach an international consensus on which diagnostic tests should be used in the clinical diagnosis of LSS. The final recommendation includes three core diagnostic items: neurological examination, MRI/CT and walking test with gait observation. The Taskforce also recommends 3 'rule out' tests: foot pulses/ABI, hip examination and test for cervical myelopathy. If applied, this core set of diagnostic tests can standardize outcomes and improve clinical care of LSS globally.

Outcome of modified interlaminar decompression: A conservative decompressive surgery for lumbar spine stenosis

Objective:

To evaluate the outcomes of modified interlaminar decompression in patients with degenerative lumbar spinal stenosis (LSS).

Methods:

This descriptive observational study was conducted at the Department of Neurosurgery, Lady Reading Hospital Peshawar from July 2014 to June 2018. All patients with degenerative LSS who underwent modified interlaminar decompression during the study period were included in the study. The patients were followed up to one year after surgery. The data was entered into a structured questionnaire designed according to the study which was then analyzed using SPSS version 21.

Results:

A total of 182 LSS cases were included in the study and 236 levels were operated during the study period. According to the records increased prevalence of LSS was found among males i.e. 58.8%. The common level with degenerative stenosis involved was L4-5. Good to excellent outcomes were observed in 93.9% patients in the 1^st follow-up visit. The most common complication of surgery was dural tear followed by wound infection.

Conclusion:

Modified interlaminar decompression is a conservative surgical technique, proved to be a potential approach with acceptable complications, satisfactory outcomes and it is easy to learn.

An Algorithmic Approach to Treating Lumbar Spinal Stenosis: An Evidenced-Based Approach

OBJECTIVE

Lumbar spinal stenosis (LSS) can lead to compression of the neural and vascular elements and is becoming more common due to degenerative changes that occur because of aging processes. Symptoms may manifest as pain and discomfort that radiates to the lower leg, thigh, and/or buttocks. The traditional treatment algorithm for LSS consists of conservative management (physical therapy, medication, education, exercise), often followed by epidural steroid injections (ESIs), and when nonsurgical treatment has failed, open decompression surgery with or without fusion is considered. In this review, the variables that should be considered during the management of patients with LSS are discussed, and the role of each treatment option to provide optimal care is evaluated.

RESULTS

This review leads to the creation of an evidence-based practical algorithm to aid clinicians in the management of patients with LSS. Special emphasis is directed at minimally invasive surgery, which should be taken into consideration when conservative management and ESI have failed.

Cost-effectiveness and Safety of Interspinous Process Decompression (Superion)

Objective

There are several treatment options for patients suffering from lumbar spinal stenosis, including surgical and conservative care. Interspinous spacer decompression using the Superion device offers a less invasive procedure for patients who fail conservative treatment before traditional decompression surgery. This review assesses the current cost-effectiveness, safety, and performance of lumbar spinal stenosis treatment modalities compared with the Superion interspinous spacer procedure.

Methods

EMBASE and PubMed were searched to find studies reporting on the cost-effectiveness, safety, and performance of conservative treatment, including medicinal treatments, epidural injections, physical therapy, and alternative methods, as well as surgical treatment, including laminectomy, laminectomy with fusion, and interspinous spacer decompression. Results were supplemented with manual searches.

Results

Despite substantial costs, persistent conservative treatment (>12 weeks) of lumbar spinal stenosis showed only minimal improvement in pain and functionality. When conservative treatment fails, surgery is more effective than continuing conservative treatment. Lumbar laminectomy with fusion has considerably greater cost than laminectomy alone, as the length of hospital stay increases, the costs for implants are substantial, and complications increase. Although laminectomy and the Superion have comparable outcomes, the Superion implant is positioned percutaneously. This approach may minimize the direct and indirect costs of outpatient rehabilitation and absenteeism, respectively.

Conclusions

Superion interspinous lumbar decompression is a minimally invasive procedure for patients with lumbar spinal stenosis who have failed conservative treatment. Compared with extending conservative treatment or traditional spinal surgery, interspinous lumbar decompression reduces the direct and indirect costs associated with lumbar spinal stenosis.

Psychological factors outmatched morphological markers in predicting limitations in activities of daily living and participation in patients with lumbar stenosis

BACKGROUND

Recent demographic changes have led to a large population of older adults, many of whom experience degenerative disc diseases. Degenerative lumbar spinal stenosis (DLSS) is associated with considerable discomfort and limitations in activities of daily living (ADL). Symptomatic DLSS is one of the most frequent indications for spinal surgery. The aim of this study was to identify sociodemographic variables, morphological markers, depression as well as fear of movement that predict ADL performance and participation in social life in patients with DLSS.

METHODS

Sixty-seven patients with DLSS (mean age 62.5 years [11.7], 50.7% females) participated in the study. Predictor variables were age, gender, duration of disease, three morphological markers (severity of the lumbar stenosis, the number of affected segments and presence of spondylolisthesis) as well as self-reported depression and fear of movement. Dependent variables were pain interference with the performance of ADLs, ADLs and participation in social life. Correlations between predictor and dependent variables were calculated before stepwise, linear regression analyses. Only significant correlations were included in the linear regression analyses.

RESULTS

Variance explained by the predictor variables ranged between 12% (R2 = .12; pain interference-physical) and 40% (R2 = .40; ADL requiring lower extremity functioning; participation). Depression and fear of movement were the most powerful predictors for all dependent variables. Among the morphological markers only stenosis severity contributed to the prediction of ADLs requiring lower extremity functioning.

CONCLUSION

Depression and fear of movement were more important predictors of the execution of ADLs and participation in social life compared to morphological markers. Elevated depressive symptoms and fear of movement might indicate limited adaptation and coping regarding the disease and its consequences. Early monitoring of these predictors should therefore be conducted in every spine centre. Future studies should investigate whether psychological screening or a preoperative psychological consultation helps to avoid operations and enables better patient outcomes.

Provocative Walking Test of Strength for Diagnosis, Management, and Outcome Assessment of Symptomatic Lumbar Spinal Stenosis

Background. Clinical care and randomized trials of rehabilitation or surgery for symptomatic lumbar spinal stenosis with neurogenic claudication (LSS) are complicated by the lack of standard criteria for diagnosis and outcome measurement. Objective. To evaluate whether manual muscle testing (MMT) can detect transient lower-extremity weakness provoked by walking in patients with likely LSS. Methods. A total of 19 patients with symptoms and MRI findings suggestive of LSS were tested for a decline in lower-extremity strength, using the British Medical Council scale of MMT, by comparing strength at rest to a change in strength within 60 s of completing a 400-foot walk. They were retested after reclining supine for another 2 minutes. This examination was repeated following decompressive lumbar surgery. Results. All patients developed bilateral weakness in the distribution of their LSS, but always including the hip extensors and knee flexors, when tested immediately after the provocative walking test. Most patients were not aware of weakness or change in gait during the walking task. They recovered to baseline strength after resting supine. The patients did not improve with physical therapy. When examined within 8 weeks after decompressive laminectomy, no one developed weakness during the 400-foot walk, and daily lower-extremity pain had resolved. Conclusions. A careful repetitive motor examination can detect transient paraparesis in patients with definite LSS. This finding supports the diagnosis and the functional severity of LSS while providing an objective outcome measurement for physical therapy and surgical interventions that goes beyond symptoms of pain.

Diagnosis and management of lumbar spinal stenosis in primary care in France: a survey of general practitioners

Background

Lumbar spinal stenosis (LSS) is a common spinal condition and the most frequent indication for spinal surgery in elderly people. General practitioners (GPs) are on the 1^st line for its diagnosis and treatment. We aimed to assess how GPs diagnose and treat people with LSS in France.

Methods

We conducted a cross-sectional survey in a primary care setting. French GPs were selected by a random draw from the French Medical Board. The questionnaire was designed by 3 physicians specialized in physical and rehabilitation medicine and a resident in general practice. A provisional questionnaire was tested in a pilot survey of 11 French GPs. Participants’ feedbacks served to build the final questionnaire. This latter was submitted by e-mail or mail to 330 GPs. GPs were surveyed about the 3 main domains relevant to the management of people with LSS in primary care: 1/ diagnosis, 2/ pharmacological treatments and 3/ non-pharmacological treatments, using self-administered open- and closed-ended questions and visual analog scales.

Results

Overall, 90/330 (27.3%) GPs completed the survey. 51/89 (57.3%) GPs were confident with managing people with LSS. Low back pain 51/87 (58.6%), neurogenic claudication 38/87 (43.7%) and paresthesia in the lower limbs 31/87 (35.6%) were the 3 most frequently cited clinical signs leading to the diagnosis of LSS. Improvement with lumbar flexion was mentioned by 9/87 (10.3%) GPs. 85/86 (98.8%) would consider prescribing lumbar imaging, 60/84 (71.4%) corticoid spinal injections and 42/79 (53.2%) would never prescribe lumbar flexion-based endurance training. All GPs would refer people with LSS to another specialist.

Conclusions

French GPs lack confidence with diagnosing LSS and prescribing pharmacological and non-pharmacological treatments for people with LSS.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2782-y) contains supplementary material, which is available to authorized users.

[Research progress on nerve root sedimentation sign of lumbar spinal stenosis]

OBJECTIVE

To summarize the research progress on the nerve root sedimentation sign of lumbar spinal stenosis.

METHODS

The recent domestic and foreign literature in recent years was reviewed. The definition, classification, and mechanism of nerve root sedimentation sign and the relation of nerve root sedimentation sign to diagnosis and treatment of lumbar spinal stenosis were summarized.

RESULTS

Nerve root sedimentation sign is a phenomena which is found in MRI images of lumbar spine. Its mechanism is mainly increased intraoperative epidural pressure. There are two types of classification and the classification in which nerve root sedimentation sign is classified into "positive" and "negative" is widely applied. It has high sensitivity and specificity in differential diagnosis patients with severe lumbar spinal stenosis and patients with nonspecific low back pain. As for treatment, the nerve root sedimentation sign is related to the surgical disc levels. However, it's not sure if the nerve root sedimentation sign is related to surgical outcome. In addition, a positive sedimentation sign turns negative after sufficient surgical decompression and a new positive sedimentation sign after sufficient decompression surgery could be used as an indicator of new stenosis in previously operated patients.

CONCLUSION

For lumbar spinal stenosis, the nerve root sedimentation sign can be applied as an auxiliary diagnostic indicator, as a guidance for deciding the operated disc levels, and as a postoperative indicator for evaluating the effectiveness.

Practice Variation Among Surgeons Treating Lumbar Spinal Stenosis in a Single Institution

STUDY DESIGN

A retrospective study.

OBJECTIVE

The aim of this study was to examine practice variation in the treatment of lumbar spinal stenosis and identify targets for reducing variation.

SUMMARY OF BACKGROUND DATA

Lumbar spinal stenosis is a degenerative condition susceptible to practice variation. Reducing variation aims to improve quality, increase safety, and lower costs. Establishing differences in surgeons' practices from a single institution can help identify personalized variation.

METHODS

We identified adult patients first diagnosed with lumbar spinal stenosis between 2003 and 2015 in three hospitals of the same institution with ICD-9 codes.We extracted number of office visits, imaging procedures, injections, electromyographies (EMGs), and surgery within the first year after diagnosis; physical therapy within the first 3 months after diagnosis. Multivariable logistic regression was used to identify factors associated with surgery. The coefficient of variation (CV) was calculated to compare the variation in practice.

RESULTS

The 10,858 patients we included had an average of 2.5 visits (±1.9), 1.5 imaging procedures (±2.0), 0.03 EMGs (±0.22), and 0.16 injections (±0.53); 36% had at least one surgical procedure and 32% had physical therapy as part of their care. The CV was smallest for number of visits (19%) and largest for EMG (140%).Male sex [odds ratio (OR): 1.23, P < 0.001], seeing an additional surgeon (OR: 2.82, P < 0.001), and having an additional spine diagnosis (OR: 3.71, P < 0.001) were independently associated with surgery. Visiting an orthopedic clinic (OR: 0.46, P < 0.001) was independently associated with less surgical interventions than visiting a neurosurgical clinic.

CONCLUSION

There is widespread variation in the entire spectrum of diagnosis and therapy for lumbar spinal stenosis among surgeons in the same institution. Male gender, seeing an additional surgeon, having an additional spine diagnosis, and visiting a neurosurgery clinic were independently associated with increased surgical intervention. The main target we identified for decreasing variability was the use of diagnostic EMG.

LEVEL OF EVIDENCE

3.

The Rates of LSS Surgery in Norwegian Public Hospitals: A Threefold Increase From 1999 to 2013

STUDY DESIGN

Retrospective administrative database study.

OBJECTIVE

To assess temporal and regional trends, and length of hospital stay, in lumbar spinal stenosis (LSS) surgery in Norwegian public hospitals from 1999 to 2013.

SUMMARY OF BACKGROUND DATA

Studies from several countries have reported increasing rates of LSS surgery over the last decades. No such data have been presented from Norway.

METHODS

A database consisting of discharges from all Norwegian public hospitals was established. Inclusion criteria were discharges including a surgical procedure of lumbar spinal decompression and/or fusion in combination with an International Statistical Classification of Diseases and Related Health Problems, 10th Revision diagnosis of Spinal Stenosis (M48.0) or Other Spondylosis with Radiculopathy (M47.2), and a patient age of 18 years or older. Discharges with diagnoses indicating deformity, that is, spondylolisthesis or scoliosis were not included.

RESULTS

During the 15-year period, 19,543 discharges were identified. The annual rate of decompressions increased from 10.7 to 36.2 and fusions increased from 2.5 to 4.4 per 100,000 people of the general Norwegian population. The proportion of fusion surgery decreased from 19.3% to 10.9%. Among individuals older than 65 years, the annual rate of surgery per 10,000, including both decompressions and fusions, more than quadrupled from 40.2 to 170.3. The regional variation was modest, differing with a factor of 1.4 between the region with the highest and the lowest surgical rates. The mean length of hospital stay decreased from 11.0 (standard deviation 8.0) days in 1999 to 5.0 (4.6) days in 2013, but patients who received fusion surgery stayed on average 3.6 days longer than those who received decompression only.

CONCLUSION

The rate of LSS surgery more than tripled in Norway from 1999 to 2013. The mean length of hospital stay was reduced from 11 to 5 days.

LEVEL OF EVIDENCE

N/A.

SUcceSS, SUrgery for Spinal Stenosis: protocol of a randomised, placebo-controlled trial

INTRODUCTION

Central lumbar spinal stenosis (LSS) is a common cause of pain, reduced function and quality of life in older adults. Current management of LSS includes surgery to decompress the spinal canal and alleviate symptoms. However, evidence supporting surgical decompression derives from unblinded randomised trials with high cross-over rates or cohort studies showing modest benefits. This protocol describes the design of the SUrgery for Spinal Stenosis (SUcceSS) trial -the first randomised placebo-controlled trial of decompressive surgery for symptomatic LSS.

METHODS AND ANALYSIS

SUcceSS will be a prospectively registered, randomised placebo-controlled trial of decompressive spinal surgery. 160 eligible participants (80 participants/group) with symptomatic LSS will be randomised to either surgical spinal decompression or placebo surgical intervention. The placebo surgical intervention is identical to surgical decompression in all other ways with the exception of the removal of any bone or ligament. All participants and assessors will be blinded to treatment allocation. Outcomes will be assessed at baseline and at 3, 6, 12 and 24 months. The coprimary outcomes will be function measured with the Oswestry Disability Index and the proportion of participants who have meaningfully improved their walking capacity at 3 months postrandomisation. Secondary outcomes include back pain intensity, lower limb pain intensity, disability, quality of life, anxiety and depression, neurogenic claudication score, perceived recovery, treatment satisfaction, adverse events, reoperation rate and rehospitalisation rate. Those who decline to be randomised will be invited to participate in a parallel observational cohort. Data analysis will be blinded and by intention to treat. A trial-based cost-effectiveness analysis will determine the potential incremental cost per quality-adjusted life year gained.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the NSW Health (reference:17/247/POWH/601) and the Monash University (reference: 12371) Human Research Ethics Committees. Dissemination of results will be via journal articles and presentations at national and international conferences.

TRIAL REGISTRATION NUMBER

ACTRN12617000884303; Pre-results.