Wajokai Eniwa Hospital. Kentaro Yamada, Yuichiro Abe, Shigenobu Satoh

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1 Stenotic Ratio is the most useful parameter to identify patients with lumbar foraminal stenosis needing surgery or not -MRI study using 3D T1 SPACE sequence- Wajokai Eniwa Hospital Kentaro Yamada, Yuichiro Abe, Shigenobu Satoh

2 Introduction A case of difficult diagnosis for lumbar foraminal stenosis (LFS) Double crush of lumbar nerve root In case of comorbid LFS and superior adjacent lumbar canal stenosis, it is difficult to diagnose which level is responsible for the patient s symptom, especially at the time of surgical decision. *73 years old female, with left L5 radiculopathy T2 sagittal T2 axial 3D-MRI L4-5 L5 S1 L5 nerve root L4-5 Lumbar canal stenosis L5-S Lumbar foraminal stenosis

3 The reported diagnosis techniques for LFS using MRI Several imaging techniques have been reported. Perineural fat obliteration on the parasagittal plane (Wildermuth S. Radiology. 1998) Disrupted nerve root on the Diffusion Tensor Image (Eguchi Y. AJNR Am J Neuroradiol. 2011) Transversed pass of the nerve root on the 3D-MRI (Yamada H. J Orthop Sci. 2014) However, Most studies compared Requiring surgery V.S. Asymptomatic The differences between patients requiring surgery and those with successful conservative treatment have not been discussed.

4 Objective We established new diagnostic technique, focusing on Stenotic Ratio on the oblique images of 3D-MRI. The purpose of this retrospective study was to compare among the patients requiring surgery, those with nonsurgical treatment, and asymptomatic patients for LFS at L5-S using 3D MRI.

5 Methods Stenotic ratio (SR) : New diagnostic technique for LFS MRI machine: Skyra 3.0-T, Siemens, Munich, Germany sequence: T1 Sampling Perfection with Application optimized Contrasts using different flip angle Evolution (SPACE) sequence (Coronal Base) condition: FOV 300mm, Slice thickness 0.7mm TR/TE 500/34, Imaging time 5m25s L5 L5 Reconstruction of 3D-MRI: The oblique images were reconstructed along L5-S foramen using workstation software. The definition of LFS A slice of perineural fat obliteration either on cranial-caudal or front-back direction at the vertical plane to the oblique images Stenosis(+) Calculation of Stenotic ratio (SR) At the Oblique image SR= Length of Stenosis (+) Foraminal length 100 (%)

6 Patients enrollment Patients who have taken the 3D MRI to diagnose radicular leg pain between May 2014 and Jun Requiring surgery (Group 1) 124 pts For radiculopathy of L5 nerve root at L5-S lumbar foramen Conservative treatment (Group 2) 1. Under 40 years old 2. Trauma, Prior lumbar surgery 3. Suspicion of double crush* Asymptomatic (Group 3) 15 foramina 10 foramina 65 foramina * Exclusion for suspicion of double crush was determined by Schizas classification, which is used for evaluation of lumbar canal stenosis. Patients with more than Grade C have reportedly required surgery (Schizaz C. Spine 2010). In this study, following patients in Group 1 and 2 were excluded due to suspicion of double crush. Requiring surgery (Group 1) : L4/5 Schizas C, Exclusion; 45 pts, 90 foramina Conservative treatment (Group 2) : L4/5 Schizas B

7 Analysis Past reported parameters, the minimum diameter of the nerve root (d) and the maximum transverse angle of the nerve root (α), were also investigated on the vertical plane and the oblique plane, respectively. SR, d, and α were compared among Group1, 2 and 3 using post-hoc test after Kruskal-Wallis and Bonferroni corrected Mann-Whitney tests. A p value of 0.05 was considered statistically significant. Randomly chosen 10 foramina were measured twice by an author and an additional observer to evaluate interclass correlation coefficient (ICC) for intraand inter-observer reliabilities.

8 Results Stenotic Ratio (SR) (%) 75 P=0.003 P<0.001 P< Group 1 Group 2 Group 3 The reliability of CT measurements ICC for the intra-observer errors: ICC for the inter-observer errors: 0.953

9 Minimum diameter of the nerve root (d) Maximum transverse angle of the nerve root (α) P<0.001 P=0.002 (mm) 6 P=0.15 P=0.04 ( ) 40 P=0.999 P= Group 1 Group 2 Group 3 0 Group 1 Group 2 Group 3 The reliability of CT measurements ICC for the intra-observer errors: ICC for the inter-observer errors: ICC for the intra-observer errors: ICC for the inter-observer errors: 0.489

10 Discussion The advantage of SR SR were evaluated by combination of the oblique image and vertical images This study indicate that SR showed greatest difference between patients requiring surgery or not for LFS, among evaluated parameters. > SR might be useful to determine the treatment of LFS, even in case with far-lateral LFS.

11 Conclusions This study indicated that SR (the ratio of stenotic length to the foraminal length) was a most useful parameter to identify patients with LFS requiring surgery or not. The oblique imaging by 3D T1 SPACE was suitable to evaluate LFS including far-lateral stenosis.

12 Conflict of Interest All authors have declared no funding or conflict of interest in this study.

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