Stress MRI for the assessment of lumbar canal stenosis in degenerative disc disease: comparison with routine MRI

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1 Stress MRI for the assessment of lumbar canal stenosis in degenerative disc disease: comparison with routine MRI Poster No.: B-0302 Congress: ECR 2015 Type: Scientific Paper Authors: S. Goel; Delhi/IN Keywords: Musculoskeletal spine, Neuroradiology spine, MR, Computer Applications-Detection, diagnosis, Pathology DOI: /ecr2015/B-0302 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 28

2 Purpose Routinely MRI is performed in psoas relaxed position which may not represent the state of spinal canal during walking or standing, when patient usually experiences symptoms so carries considerable risk of underestimating the degree of spinal canal stenosis. To overcome these problems, a device called axial compression device was invented which when applied during MR imaging could simulate the erect postion. The application of device during MR imaging is called as STRESS MRI. AIMS AND OBJECTIVES : To examine the changes in the dural sac area at the levels of degenerated lumbar intervertebral discs on MRI performed without and with axial loading. To study the effect of STRESS MRI on the management of the patients with degenerative disc disease. Images for this section: Page 2 of 28

3 Fig. 1: Patient undergoing MRI in Psoas relaxed position Fig. 2: Patient wearing axial loading device Page 3 of 28

4 Methods and materials Patients: During the period of more than one year, 48 patients were examined with chronic low backache and clinical suspicion of spinal canal stenosis. None of these patients had neurologic deficiets or any history of spinal surgery. Device: Axial loading was applied with a commercially available device (Dyna Well L-spine; Dyna Well Int. A B, Billdal, Sweeden), approved by Food and Drug Administration, to simulate the lumbar spine in upright, axial loaded position. This device consists of a nonmagnetic compression part and a harness worn by the patient. The harness (Figure 3) is attached to the compression part (Figure 4)using nylon straps, which are tightened to load the lumbar spine axially. During the procedure, the harness is tightened across the lower part of the chest to avoid pressure on the shoulders. It is crucial to control the straps passing the dorsal part of the femoral trochanters to maintain the lumbar lordosis. In this study, the load chosen was approximately 50% of the subject's body weight. This choice of load was based recommendations from previous studies. By tightening or loosening adjustment knobs on the compression part, the load was regulated and equally distributed on both legs. The device was compatible with MR scanners, enabling examination of the patients in a supine position with straightened legs, simulating the axial load on the lumbar spine in an upright position (i.e., when symptoms of sciatica and spinal stenosis most frequently appear). During the examination, the patients were asked regularly about pain in the spine or in the legs, especially during compression. If necessary, the pressure could be released immediately by knee flexion. To avoid loading in patients with a vertebral fracture, severe osteoporosis or tumors, all the patients were examined regularly in the conventional extended leg position before applying axial load. MR Protocol: MR imaging was performed with 3T wide bore system (Magnetom Verio; Siemens, Munchen, Germany) using surface coil. Page 4 of 28

5 After acquiring localizers, whole spine screening was done by using T2 sagittal. After which T2 and T1 axial images were obtained through the lumbar discs. Atleast 3 sections were obtained from each disc. Sagittal myelogram was obtained in the end. After applying axial load, T2 sagittal, T2 axial and myelogram were obtained in the similar manner. Performance of measurements: The degenerated intervertebral discs were identified on the midsagittal T2 W images as loss of signal intensity of the nucleus pulposus, herniation etc. The DCSA was measured at these levels on the section where the DCSA seemed to be smallest. The DCSA was determined on axial T2 W images using the standard measurement tools provided in the software of Siemen's Syngo MRC or on the Osirix workstation. The DCSA was measured at three separate time intervals and the mean value was used to reduce measurement errors. Similarly the DCSA was calculated on the Stress (axial loaded) T2 W axial images. Changes in the DCSA between the conventional and axial loading positions were calculated and compared. Images for this section: Page 5 of 28

6 Fig. 3: Axial loading device component: Harness jacket with straps Page 6 of 28

7 Fig. 4: Axial loading device component: Compression part Page 7 of 28

8 Fig. 5: Patient undergoing MRI with axial loading device Page 8 of 28

9 Results In total of 48 symptomatic patients studied, 120 degenerative discs were identified. The Dural Cross-sectional area (DCSA) at these intervertebral disc levels was measured in the routine and axial loading positions. Radiologically, the dural sac in the lumbar spine is considered narrow if the DCSA is less than 100 sq. mm. Between sq. mm, the stenosis is relative while <75 sq. mm is cosidered as absolute spinal stenosis. During routine examination in extension the DCSA was smaller than 100 sq. mm in 42 individuals at 66 levels (55%). This increased to 88 levels (73.3%) in 46 patients. Stress MRI also disclosed the severity of spinal stenosis as many patients with DCSA of less than 100 sq. mm showed further increase in stenosis. The mean decrease in dural cross sectional area after applying axial load was 23 sq. mm (range, 5-43 sq. mm) at L3-L4 and 19 sq. mm (range, 5-46sq. mm) at L4-L5. There were six patients in which increase in listhesis was noted after applying axial load. There were two patients in whom the Grade of spondylolisthesis changed from I to II. In rest of the patients occult listhesis was disclosed on axial loading. In all the six cases increase in listhesis was seen at the L4-L5 level. Images for this section: Page 9 of 28

10 Page 10 of 28

11 Fig. 6: Sagittal T2WI of lumbar spine in routine position showing posterior disc herniation indenting the thecal sac. Page 11 of 28

12 Page 12 of 28

13 Fig. 7: Sagittal T2WI in the same patient and at same level as in figure 5 after applying axial load showing increase in heniation of the degenerative disc at L4-L5 level. Fig. 8: T2 axial image at L4-L5 intervertebral disc level in a patient without axial loading. The dural cross sectional area measures 120 sq. mm Page 13 of 28

14 Fig. 9: T2 axial image in the same patient of figure 8 and at the same level reveals decrease in the dural cross sectional area to 90 sq. mm after applying axial load. Page 14 of 28

15 Fig. 10: T2 axial image at L4-L5 level in another patient shows dural cross sectional area of 94 sq. mm before applying axial load. Page 15 of 28

16 Fig. 11: T2 axial image in the same patient as in figure 10 and at the same level shows further increase in canal stenosis after applying axial load and the spinal canal now measures 52 sq. mm. Page 16 of 28

17 Page 17 of 28

18 Fig. 12: T2 sagittal image of the lumbar spine in a patient showing marked degerative changes with presence of mild anterolisthesis of L4 over L5 vertebral body before applying axial load. Page 18 of 28

19 Page 19 of 28

20 Fig. 13: T2 sagittal image in the same patient as in figure 12 shows increase in anterolisthesis at L4-L5 level after applying axial load. Page 20 of 28

21 Page 21 of 28

22 Fig. 14: T2 sagittal myelogram in a patient shows minimal posterior disc bulges at multiple levels indenting the anterior thecal sacs. Page 22 of 28

23 Page 23 of 28

24 Fig. 15: T2 sagittal MR myelogram in the same patient as in figure 14 shows obliteration of the thecal sac at L4-L5 level after applying axial load. Fig. 17: Number of discs with dural cross sectional area after applying axial load. Page 24 of 28

25 Fig. 16: Number of discs with dural cross sectional area before applying axial load. Page 25 of 28

26 Conclusion In the current study the percentage of patients benefitted from axial loading in which the decrease in DCSA was significant and in addition it disclosed spinal canal stenosis at one or more levels The other valuable information disclosed after applying axial load were increase in spondylolisthesis, increase in herniation of the discs, ligamentum flavum thickening and compresssion on the neural foramen. It was concluded that the stress MRI is a novel method for the evaluation of degenerative disc disease and is useful to assess the severity of spinal canal stenosis. It simulates the most symptomatic posture during the mri study. However, it is difficult to say whether that whether imaging with axial loading helps clinician in making treatment decisions or not, since most of the surgical decisions were taken on the basis of patient's symptoms and the response to the medical management. Experience with axially loaded MRI examination of the lumbar spine indicates that the risk of failing to detect an essential spinal canal stenosis is considerable if MR imaging is performed only in the traditional supine extension position. However, it is necessary to select the patients for the procedure after serious evaluation of their history of problems and the objective clinical and radiologic signs. According to the current results, the axially loaded examination should always be performed after the conventional examination in those with a dural sac cross-sectional area smaller than 120 sq. mm at or above L4-L5 especially at degenerated disc levels. However, no measurable guidelines have been established for L5-S1, partly because of the dural sac's tapered configuration at that level. Every MRI examination of a patient with a suspected encroachment into the lumbar spinal canal should start with a conventional investigation to avoid loading of an osteoporotic or fractured spine or a spine with a skeletal malignancy representing contraindications for loading. Personal information Dr Sudhir Goel DNB, Mahajan Imaging and B L Kapoor hospital, Delhi. Formerly at Max Healthcare, Delhi and Breach Candy Hospital, Mumbai, India: Page 26 of 28

27 References 1. Bolender NF, Schonstrom NS, Spengler DM. Role of computed tomography and myelography in the diagnosis of central spinal stenosis. J Bone Joint Surgery [Am] 1985;67: Hans-Ekkehart Vitzthum, M.D., Ph.D., Alexander König, And Volker Seifert, M.D., Ph.D. ; Dynamic examination of the lumbar spine by using vertical, open magnetic resonance imaging ; J Neurosurg (Spine 1) 1993:58-64, Dominik Weishaupt MD, Marius R. Schmid MD ; Positional MR Imaging of the Lumbar Spine: Does It Demonstrate Nerve Root Compromise Not Visible at Conventional MR Imaging? ; Radiology 2000; 215: A. Saifuddin, S.Blease, E. Macsweeney ; Axial Loaded MRI of the Lumbar Spine ; Clinical Radiology (2003) 58: Willen J, Danielson B, Gaulitz A, et al ; Dynamic effects on the lumbar spinal canal: axially loaded CT myelography and MRI in patients with sciatica and/or neurogenic claudication ; Spine 1997 Volume 22, pp Jan Willen, MD, PhD and Barbro Danielson, MD, PhD ; The Diagnostic Effect From Axial Loading of the Lumbar Spine During Computed Tomography and Magnetic Resonance Imaging in Patients With Degenerative Disorders ; Spine 2001 Volume 26, Number 23, pp Barbro Danielson MD, PhD and Jan Willen MD, PhD ; Axially Loaded Magnetic Resonance Image of the Lumbar Spine in Asymptomatic Individuals ; Spine 2001 Volume 26, Number 23, pp Jan Willen MD, PhD and Barbro Danielson MD, PhD ; The Diagnostic Effect From Axial Loading of the Lumbar Spine During Computed Tomography and Magnetic Resonance Imaging in Patients With Degenerative Disorders ; Spine 2001 Volume 26, Number 23, pp Akio Hiwatashi, Barbro Danielson et al ; Axial Loading during MR Imaging Can Influence Treatment Decision for Symptomatic Spinal Stenosis ; AJNR Am J Neuroradiol 25: , February S. Muehlhaus, W. Meier and F. Hartmann ; Biomechanical properties of human intervertebral discs subjected to axial dynamic compression - influence of age and degeneration ; Journal of biomechanics Volume 19 No. 10, pp , Page 27 of 28

28 11. Bruce H. Nowicki, BS Shiwei Yu, MD et al; Effect of Axial Loading on Neural Foramina and Nerve Roots in the limbar spine ; Radiology 1990; 176: Schimid et al; Changes in Cross-Sectional Measurements of the Spinal Canal and Intervertebral Foramina as a Function of Body Position ; AJR 1999:172: Jaykumar et al; Dynamic Degenerative Lumbar Spondylolisthesis- Diagnosis With Axial Loaded MRI ; SPINE 2006 Volume 31, Number 10, pp E298 -E Rasmus Madsen et al; The Effect of Body Position and Axial Load on Spinal Canal Morphology; SPINE 2008 Volume 33, Number 1, pp Tae-Joon AHN et al; Effect of intervertebral disc degeneration on spinal stenosis during MRI with axial loading; Neuro Med Chir (Tokyo) 49, , Tommy Hansson et al; The narrowing of the lumbar spinal canal during loaded MRI- the effects of the disc and ligamentum #avum; European Spine Journal (2009) 18: B. Coulier, B. Devyver, J. P. Ghosez; Severe Underestimation of Lumbar Spinal Stenosis by Supine Imaging; doi: /crad , available online at 18. Danielson BI, Wille n J, Gaulitz A, et al. Axial loading of the spine during CT and MR in patients with suspected lumbar spinal stenosis. Acta Radiol 1998; 39: Page 28 of 28

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