Abstract
BACKGROUND:
Lumbar nerve roots normally sediment, due to gravity, to the dorsal part of the dural sac, which is known as negative sedimentation sign. If there is a magnetic resonance finding of nerve roots in the ventral part of the dural sac the sedimentation sign is positive.
OBJECTIVE:
To evaluate the presence of the MRI finding of positive sedimentation sign in patients clinically suspected to have lumbar spinal stenosis and if this sign can be a valid tool to differentiate symptomatic spinal canal stenosis from other causes of non-specific back pain.
METHODS:
A planned cohort design prospective study had conducted over a year through July 2019 at the department of neurosurgery at Medical City / Baghdad / Iraq. The study incorporates 200 patients. Those with symptomatic lumbar spine canal stenosis (n=100) show claudication with or without low back pain, leg pain, a dural sac cross-sectional area < 80 mm2, and a walking interval < 200 meters. The nonspecific low back pain group (n=100) had no leg pain, no claudication, a cross-sectional area of the dural sac >120 mm2, and a walking interval >1000 meters. The frequency of a positive sedimentation sign compared between both groups to evaluate if this sign can be a valid tool to differentiate spinal canal stenosis from other causes of back pain, intra-rater and inter-rater assessment dependability in a stochastic subsample executed.
RESULTS:
A positive sedimentation sign recognized in 96 patients in the symptomatic lumbar spine canal stenosis group (96%; 95% Confidence Interval CI, 90%–98%), no positive sedimentation sign recognized in the nonspecific low back pain group (0%; 95% Confidence Interval CI, 0%–5%). Credibility was Kappa (ĸ) =1.0 (intra-rater) and Kappa (ĸ) =0.90 (inter-rater), in sequence.
CONCLUSION:
A positive sedimentation sign is dependably seen in lumbar spine canal stenosis cases, recommending its value in clinical application.
Keywords
10. Sekiguchi, M., Yonemoto, K., Kakuma, T. et al. Relationship between lumbar spinal stenosis and psychosocial factors: a multicenter cross-sectional study (DISTO project). Eur Spine J. 2015;24, 2288–2294. https://doi.org/10.1007/s00586-015-4002-2.
11. Verde Emílio Crisóstomo Lima, Risso Neto Marcelo Italo, Mistro Neto Sylvio, Veiga Ivan Guidolin, Zuiani Guilherme Rebechi, Pasqualini Wagner et al . Correlation between lumbar spinal stenosis based on morphology of the dural sac and the quality of life. Coluna/Columna [Internet].2019 Mar[cited 2020; 18:28-Availablefrom:http://www.scielo.br/scielo.php?script=sci_arttext&pid=S180818512019000100028&lng=en. https://doi.org/10.1590/s1808-185120191801178961.
12. Kuittinen, P., Sipola, P., Aalto, T.J. et al. Correlation of lateral stenosis in MRI with symptoms, walking capacity and EMG findings in patients with surgically confirmed lateral lumbar spinal canal stenosis. BMC Musculoskelet Disord. 2014;15, 247. https://doi.org/10.1186/1471-2474-15-247.
13. Shun-Wu Fan, et al. Reliability and variability in the interpretation of lumbar high intensity zone. Acta Orthop Traumatol Turc 2015;49:606–13 doi: 10.3944/AOTT.2015.14.0267.
14. Wu AM, Zou F, Cao Y, et al. Lumbar spinal stenosis: an update on the epidemiology, diagnosis and treatment. AME Med J 2017;2:63.
15. Vijay G Goni, Aravind Hampannavar,1 Nirmal Raj Gopinathan, et al. Comparison of the Oswestry Disability Index and Magnetic Resonance Imaging Findings in Lumbar Canal Stenosis: An Observational Study. Asian Spine J. 2014;8:44-50. Published online February 6, 2014.DOI: https://doi.org/10.4184/asj.2014.8.1.44.
16. Richard Herzog, et al. Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period. 2017;17: 554-61.
17. Hofmann, U.K., Keller, R.L., Walter, C. et al. Predictability of the effects of facet joint infiltration in the degenerate lumbar spine when assessing MRI scans. J Orthop Surg Res. 2017; 12:180. https://doi.org/10.1186/s13018-017-0685-x.
18. Hansen, B.B., Hansen, P., Christensen, A.F. et al. Reliability of standing weight-bearing (0.25T) MR imaging findings and positional changes in the lumbar spine. Skeletal Radiol. 2018; 47, 25–35. https://doi.org/10.1007/s00256-017-2746-y.
19. Borotikar B, Lempereur M, Lelievre M, et al. Dynamic MRI to quantify musculoskeletal motion: A systematic review of concurrent validity and reliability, and perspectives for evaluation of musculoskeletal disorders. PLoS ONE. 2017; 12(12): e0189587. https://doi.org/10.1371/journal.pone.0189587.
20. Simonovich, A., Nagar Osherov, A., Linov, L. et al. The influence of knee bolster on lumbar spinal stenosis parameters on MR images. Skeletal Radiol. 2020; 49, 299–305. https://doi.org/10.1007/s00256-019-03287-w
21. Nguyen HS, Doan N, Shabani S, Baisden J, Wolfla C, Paskoff G, et al. Upright magnetic resonance imaging of the lumbar spine: Back pain and radiculopathy. J Craniovert Jun Spine 2016;7:31-7.
22. Lim YS, Mun JU, Seo MS, et al. Dural sac area is a more sensitive parameter for evaluating lumbar spinal stenosis than spinal canal area: A retrospective study. Medicine (Baltimore). 2017;96(49):e9087. doi:10.1097/MD.0000000000009087.
23. Choi YK. Lumbar foraminal neuropathy: an update on non-surgical management. Korean J Pain. 2019;32:147-159. https://doi.org/10.3344/kjp.2019.32.3.147.
24. Ramos, R.M., da Costa, R.C., Oliveira, A.L. et al. Morphological changes of the caudal cervical intervertebral foramina due to flexion-extension and compression-traction movements in the canine cervical vertebral column. BMC Vet Res. 2015;11, 184. https://doi.org/10.1186/s12917-015-0508-4.
25. Michelini G, Corridore A, Torlone S, et al. Dynamic MRI in the evaluation of the spine: state of the art. Acta Bio-medica : Atenei Parmensis. 2018 Jan;89(1-S):89-101. DOI: 10.23750/abm.v89i1-s.7012.
26. Espeland A, Dalen N. Disc and nerve root findings on lumbar MRI with straightened vs flexed hips and knees—pilot study. Br J Radiol 2019; 92: 20180851.
27. Savarese Leonor Garbin, Ferreira-Neto Geraldo Dias, Herrero Carlos Fernando Pereira da Silva, et al. Cauda equina redundant nerve roots are associated to the degree of spinal stenosis and to spondylolisthesis. Arq. Neuro-Psiquiatr. [Internet]. 2014 Oct [cited 2020 Sep 23] ; 72: 782-787. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0004282X2014001000782&lng=en. https://doi.org/10.1590/0004-282X20140135.
28. Seok-Won Chung, et al. Postoperative Expansion of Dural Sac Cross-Sectional Area after Unilateral Laminotomy for Bilateral Decompression: Correlation with Clinical Symptoms. Neurospine. 2014;11:227-231. Published online December 31,2014. DOI: https://doi.org/10.14245/kjs.2014.11.4.227.
29. Fishchenko IV, Kravchuk LD, Perepechay OA. Lumbar spinal stenosis: symptoms, diagnosis and treatment (meta-analysis of literature data). PMJUA [Internet]. 2018Mar.7 [cited 2020Sep.24];3(1):18-32. Available from: https://painmedicine.org.ua/index.php/pnmdcn/article/view/83.
30. Goren A, Yildiz N, Topuz O, Findikoglu G, Ardic F. Efficacy of exercise and ultrasound in patients with lumbar spinal stenosis: a prospective randomized controlled trial. Clinical Rehabilitation. 2010;24(7):623-631. doi:10.1177/0269215510367539.
31. Prasad B. C. M., Ramesh Chandra V V, Devi B Vijayalakshmi, et al. Clinical, radiological, and functional evaluation of surgical treatment in degenerative lumbar canal stenosis. 2016; 64(4): 677-683.
32. Liu K, Liu P, et al. Steroid for epidural injection in spinal stenosis: a systematic review and meta-analysis. Drug Des Devel Ther. 2015;9:707-716. https://doi.org/10.2147/DDDT.S78070.
33. Jiangang Shi, Lanshun Jia, Wen Yuan, et al. Clinical classification of cauda equina syndrome for proper treatment, Acta Orthopaedica. 2010;81:3, 391-395, DOI: 10.3109/17453674.2010.483985.
34. Shi, Y., Zou, Y., Feng, Y. et al. A quantitative and clinical evaluation of nerve roots in lumbosacral radiculopathy using diffusion tensor imaging. Jpn J Radiol 2020;38: 222–30. https://doi.org/10.1007/s11604-019-00913-4.
35. Rowe PC, Fontaine KR, Lauver M, Jasion SE, Marden CL, Moni M, et al. Neuromuscular Strain Increases Symptom Intensity in Chronic Fatigue Syndrome. PLoS ONE. 2016;11:e0159386. https://doi.org/10.1371/journal.pone.0159386.
36. Nishida N, Kanchiku T, Ohgi J, Ichihara K, Chen X, Taguchi T. Mechanical properties of nerve roots and rami radiculares isolated from fresh pig spinal cords. Neural Regen Res [serial online] 2015 [cited 2020Sep23];10:1869-73.Available from: http://www.nrronline.org/text.asp?2015/10/11/1869/170319.
37. Garfin SR, Rydevik B, Lind B, et al. Dimensional changes of the neuroforamina in subaxial cervical spine during in vivo dynamic flexion-extension. 2016; 16 :540-46.
38. Hermansen, E., Austevoll, I.M., Hellum, C. et al. Comparable increases in dural sac area after three different posterior decompression techniques for lumbar spinal stenosis: radiological results from a randomized controlled trial in the NORDSTEN study. Eur Spine J. 2020; 29, 2254–61. https://doi.org/10.1007/s00586-020-06499-0.
39. Takahashi, N., Shirado, O., Kobayashi, K. et al. Classifying patients with lumbar spinal stenosis using painDETECT: a cross-sectional study. BMC Fam Pract. 2016;17, 90. https://doi.org/10.1186/s12875-016-0486-z.
40. Shigeru Kobayashi, et al. Blood Flow Analysis of Compressed Nerve Root after Intravenous Injection of Lipo-Prostaglandin E1. J Orthop Res. 2009;27:1252–1257.
41. Sahoo MM, Mahapatra SK, Kaur S, Sarangi J, Mohapatra M. Significance of Vertebral Endplate Failure in Symptomatic Lumbar Disc Herniation. Global Spine Journal. 2017;7:230-38. doi:10.1177/2192568217694142.
42. Freyr Gauti Sigmundsson. Determinants of outcome in lumbar spinal stenosis surgery, Acta Orthopaedica. 2014; 85:sup357, 1-45, DOI: 10.3109/17453674.2014.976807
43. Yang SM, Park HK, Cho SJ, Chang JC. Redundant nerve roots of cauda equina mimicking intradural disc herniation: a case report. Korean J Spine. 2013;10(1):41-43. doi:10.14245/kjs.2013.10.1.41.
44. Kawasaki Y, Seichi A, Zhang L, Tani S, Kimura A. Dynamic Changes of Cauda Equina Motion Before and After Decompressive Laminectomy for Lumbar Spinal Stenosis With Redundant Nerve Roots: Cauda Equina Activation Sign. Global Spine J. 2019;9:619-23. doi:10.1177/2192568218821344.
45. Shigeru Kobayashi. Pathophysiology, diagnosis and treatment of intermittent claudication in patients with lumbar canal stenosis. World J Orthop. Apr 18, 2014; 5(2): 134-145.
46. Sang Mi Yang, et al. Redundant Nerve Roots of Cauda Equina Mimicking Intradural Disc Herniation: A Case Report. Korean Journal of Spine 2013; 10:41-43.
47. Papavero, L., Marques, C.J., Lohmann, J. et al. Patient demographics and MRI-based measurements predict redundant nerve roots in lumbar spinal stenosis: a retrospective database cohort comparison. BMC Musculoskelet Disord. 2018;19, 452. https://doi.org/10.1186/s12891-018-2364-4.
48. Atsushi Ono M.D., Ph.D., Futoshi Suetsuna M.D., Ph.D., Tomoyuki Irie M.D., et al. Clinical significance of the redundant nerve roots of the cauda equina documented on magnetic resonance imaging.JNS. 2007;7:27-32.
49. Poureisa M, Daghighi MH, Eftekhari P, et al. Redundant nerve roots of the cauda equina in lumbar spinal canal stenosis, an MR study on 500 cases. .Eur Spine J. 2015;24:2315-20. doi: 10.1007/s00586-015-4059-y. Epub 2015 Jun 14.
50. Lee JH, Sim KC, Kwon HJ, et al. Effectiveness of lumbar epidural injection in patients with chronic spinal stenosis accompanying redundant nerve roots. Medicine (Baltimore). 2019;98(9):e14490. doi:10.1097/MD.0000000000014490.
51. SWV Chan, R Lee, MT Chau. Redundant Nerve Roots of the Cauda Equina. Hong Kong J Radiol. 2011;14:113-7.
52. Marques C.J., Hillebrand H., Papavero L. The clinical significance of redundant nerve roots of the cauda equina in lumbar spinal stenosis patients: A systematic literature review and meta-analysis Clinical Neurology and Neurosurgery. 2018;174.
53. Papavero, Ebert, S. & Marques, C.J. The prevalence of redundant nerve roots in patients with lumbar spinal stenosis is body position dependent: a retrospective observational study with repeated measures design in an upright MRI scanner. Neuroradiology. 2020; 62, 979–85. https://doi.org/10.1007/s00234-020-02423-x
54. Chen, J, Wang, J, Wang, B, Xu, H, Lin, S, Zhang, H. Post-surgical functional recovery, lumbar lordosis, and range of motion associated with MR-detectable redundant nerve roots in lumbar spinal stenosis. Clin Neurol Neurosurg. 2016;140:79–84.
55. Piechota M, Król R, Elias DA, Wawrzynek W, Lekstan A. The nerve root sedimentation sign in diagnosis of lumbar spinal stenosis. Acta Radiologica. 2019;60:634-42. doi:10.1177/0284185118795322
56. Kim HJ, Lee KY, Kim WC, Oh YS. Clinical Value of Nerve Root Sedimentation Sign in Lumbar Spinal Stenosis. J Korean Soc Spine Surg. 2011;18:117-22. https://doi.org/10.4184/jkss.2011.18.3.117.
57. Niskanen RO. The Oswestry Low Back Pain Disability Questionnaire a Two-Year Follow-Up of Spine Surgery Patients. Scandinavian Journal of Surgery. 2002;91:208-211. doi:10.1177/145749690209100214
58. Grunau G, Linn S. Detection and Diagnostic Overall Accuracy Measures of Medical Tests. Rambam Maimonides Med J 2018;9 :e0027. doi:10.5041/RMMJ.10351
59. Yong Ahn M.D. , Sang-Ho Lee M.D., Ph.D. , Woo-Min Park M.D. , Posterolateral percutaneous endoscopic lumbar foraminotomy for L5—S1 foraminal or lateral exit zone stenosis 2003;99:320 –23.
60. Wu AM, Zhang K, Li XL, Cheng XF, Zhou TJ, Du L, Chen C, Tian HJ, Sun XJ, Zhao CQ, Li YM, Zhao J. The compression of L5 nerve root, single or double sites?—radiographic graded signs, intra-operative detect technique and clinical outcomes. Quant Imaging Med Surg 2018;8:383-90. doi: 10.21037/qims.2018.05.08
61. Lang G, Vicari M, Siller A, et al. Preoperative Assessment of Neural Elements in Lumbar Spinal Stenosis by Upright Magnetic Resonance Imaging: An Implication for Routine Practice? Cureus. 2018;10:e2440. DOI: 10.7759/cureus.2440.
)
