Conven6onal supine MRI with a lumbar pillow - an alterna6ve to weight-bearing MRI for diagnosing func6onal spinal stenosis? A cross-sec6onal study

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1 Bispebjerg og 1 The Parker Ins6tute, Department of Rheumatology, Copenhagen University 2 Department of Radiology, Copenhagen University Conven6onal supine MRI with a lumbar pillow - an alterna6ve to weight-bearing MRI for diagnosing func6onal spinal stenosis? A cross-sec6onal study Bjarke B Hansen 1 Philip Hansen 2 Jacob Grindsted 2 Zoreh Ras; 2 Henning Bliddal 1 Robert GC Riis 1 Mikael Boesen 1,

2 Background - degenera6ve spinal stenosis Typically occurs in people over 50 years of age 1 Degenera;ve disc bulging, hypertrophic ligamenta flava and facet joints 2 21% above 60 years have spinal stenosis by radiological criteria 3 (Lee et al, Skel Rad 2011) 1Arbit E Lumbar stenosis: a clinical review Clin Orthop Relat Res 2001;384: Lee G, Skel Rad 2011, 40(8): Kalff R, Dtsch Arztebl Int 2013; 110(37):

3 Background - degenera6ve spinal stenosis Typical psoas relaxed MRI scanning posi6on

4 Background - degenera6ve spinal stenosis Posi6onal MRI

5 Background posi6onal dural sac changes Spinal Cross Sec;onal Area (SCSA)/ Dural Sac Cross Sec;onal Diameter (DSCD) decreases 1,2 Ligamentum flavum buckling 2 Increased disc bulging 2 Schmid MR et al 1Wildermuth S, et al Lumbar spine: quan6ta6ve and qualita6ve assessment of posi6onal (upright flexion and extension) MR imaging and myelography Radiology 1998;207: Schmid MR et al Changes in cross-sec6onal measurements of the spinal canal and intervertebral foramina as a func6on of body posi6on: in vivo studies on an openconfigura6on MR system

6 Background posi6onal dural sac changes Hypothesis: Supine posi;on with extended legs and a lumbar pillow comparable to the upright standing posi;on, and that both posi;ons could improve the MRI diagnosis of LSS 1Wildermuth S, et al Lumbar spine: quan6ta6ve and qualita6ve assessment of posi6onal (upright flexion and extension) MR imaging and myelography Radiology 1998;207: Schmid MR et al Changes in cross-sec6onal measurements of the spinal canal and intervertebral foramina as a func6on of body posi6on: in vivo studies on an openconfigura6on MR system

7 Materials and Methods Screening of 350 high-field lumbar spine MRI scans Single level moderate spinal stenosis (DCSD 7-10mm) Inclusion of 27 pa;ents (86 inquiries) 025T open configura;on scanner Sagi`al TSE-T2 Axial 3D gradient echo-t2 (HYCE)

8 Semi-quan6ta6ve outcomes Evalua;on by two senior MSK radiologists in consensus I Disc degenera;on am Pfirrmann (1 to 5) II Hypertrophic ligamenta flava (+/-) III Spinal stenosis grade 0-3 (Lee et al, 2011)

9 Quan6ta6ve outcomes Performed by young orthopedic MD Measurement x 2 (hiatus 4 w) The smallest DCSD defined as the stenosis level The largest DCSD level as the control level Parameters: Lordosis angle (LA) Spinal Cross-Sec;onal Dia Dural Cross-Sec;onal Dia Dural Cross-Sec;onal Area

10 Results semiquan6ta6ve outcomes TABLE 1 Patient characteristics N 27 Age in years, mean (SD) 606 (±94) Females no (%) 10 (37%) Worsening pain when walking, no (%) 15 (55%) Walking distance in meters, mean (SD) 360 (±334) Stenosis level The Pfirrmann grading, mean (SD) 36 (06) Hypertrophic ligamenta flava, no (%) 27 (100%) Control level The Pfirrmann grading, mean (SD) 34 (06) Hypertrophic ligamenta flava, no (%) 10 (37%)

11 Results semiquan6ta6ve outcomes

12 Results quan6ta6ve outcomes One-way ANOVA for repeated measurements indicated at least one significant difference among the means between posi;ons (P <0001)

13 Results quan6ta6ve outcomes Stenosis level LA Mean Difference (95% Confidence Interval) Psoas-relaxed to Standing Psoas-relaxed to Lumbar pillow Standing to Lumbar pillow 32 o 128 o 96 o (12 o to 52 o ) (103 o to 153 o ) (63 o to 129 o ) SCSD (mm) -14 (-21 to -06) -11 (-16 to -06) NS DCSD (mm) -08 (-13 to -03) -07 (-12 to -03) NS DCSA (mm 2 ) -129 (-181 to -81) -91 (-142 to -40) NS

14 Pain (VAS) during the scan Start mean (SD) End mean (SD) 28 (±22) 40 (±27) P=048 P= (±22) 36 (±28) 40 (±25) 544 (±29) A P<0001 P=0003

15 Conclusion: Pa;ents suspected of LSS (inconclusive conven;onal MRI) can be considered for standing MRI, which seems most sensi;ve Addi;on of a lumbar pillow in conven;onal MRI is a useful but more painful alterna;ve

16 Bispebjerg og 1 The Parker Ins6tute, Department of Rheumatology, Copenhagen University 2 Department of Radiology, Copenhagen University Thank you for the alen6on!

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