eMedicine Specialties > Radiology > Brain/Spine

Spinal Stenosis

Lennard A Nadalo, MD, Clinical Professor, Department of Radiology, University of Texas Southwestern Medical School; Consulting Staff, Envision Imaging of Allen and Radiological Consultants Association
James A Moody, MD, Chief, Neurosurgery Section, Department of Surgery, Methodist Medical Center

Updated: Feb 17, 2010

Introduction

Background

Acute and chronic neck and lower back pain represents a major health care problem in the United States. An estimated 75% of all people will experience back pain at some time in their lives. Most patients who present with an acute episode of back pain recover without surgery, while 3-5% of patients presenting with back pain have a herniated disc, and 1-2% have compression of a nerve root. Older patients present with more chronic or recurrent symptoms of degenerative spinal disease. Progressive narrowing of the spinal canal may occur alone or in combination with acute disc herniations. Congenital and acquired spinal stenoses place the patient at a greater risk for acute neurologic injury.

Spinal stenosis images are provided below:

Oblique view of the cervical spine demonstrates 2 levels of foraminal stenosis (white arrows) resulting from facet hypertrophy (yellow arrow) and uncovertebral joint hypertrophy.

Axial cervical CT myelogram demonstrates marked hypertrophy of the right facet joints (black arrows), which results in tight restriction of the neuroforaminal recess and lateral neuroforamen.

Short recovery time T1-weighted spin-echo sagittal MRI scan demonstrates marked spinal stenosis of the C1/C2 vertebral level cervical canal resulting from formation of the panus (black arrow) surrounding the dens in a patient with rheumatoid arthritis. Long recovery time T2*-weighted fast spin-echo sagittal MRI scans better define the effect of the panus (yellow arrow) on the anterior cerebrospinal fluid space. Note the anterior displacement of the upper cervical cord and the lower brainstem.

Posterior view from a radionuclide bone scan. A focally increased uptake of nuclide (black arrow) is demonstrated within the mid-to-upper thoracic spine in a patient with Paget disease.

For excellent patient education resources, visit eMedicine's Bone Health Center and Back, Ribs, Neck, and Head Center. Also, see eMedicine's patient education article Back Pain.

Recent studies

Voulgaris et al performed a prospective study of 23 patients who underwent decompressive laminectomy for lumbar spinal stenosis to evaluate the efficacy of transcranial motor evoked potentials (TcMEP) and continuous electromyography (EMG) to prevent irreversible pyramidal tract damage during decompressive laminectomy. In 17 patients, there was an increase in TcMEP amplitudes of more than 50%, and the amplitudes only slightly increased or remained unchanged in 6 patients. The 17 patients with increased TcMEP amplitudes had the greatest improvement 3 and 12 months postoperatively, according to neurologic examination and visual analog scale pain ratings. The authors concluded that intraoperative monitoring may allow rapid identification of potential damage of the neural structures.^{[1 ]}

Chou et al reviewed randomized, controlled studies of surgery for symptomatic spinal stenosis, nonradicular back pain with common degenerative changes, and radiculopathy with herniated lumbar disc. They found that surgery for symptomatic spinal stenosis and for radiculopathy with herniated lumbar disc is associated with short-term benefits (1-2 years) when compared with nonsurgical therapy, but benefits decreased over time. For nonradicular back pain with common degenerative changes, fusion was found to be no more effective than intensive rehabilitation, but fusion was associated with small to moderate benefits when compared to standard (nonintensive) nonsurgical therapy.^{[2 ]}

Weinstein et al studied patients who had degenerative spondylolisthesis associated with spinal stenosis to compare surgical versus nonsurgical treatment results. Treatment consisted of standard decompressive laminectomy (with or without fusion) or usual nonoperative care. They found that patients in whom degenerative spondylolisthesis and associated spinal stenosis were treated surgically maintained substantially greater pain relief and improvement in function for 4 years versus patients who received nonoperative therapy.^{[3 ]}

Pathophysiology

Spinal stenosis results from progressive narrowing of the central spinal canal and the lateral resesses. The essential content of the spinal canal includes the spinal cord, the cerebrospinal fluid (CSF) of the thecal sac, and the dural membranes that enclose the thecal sac. In the absence of prior surgery, tumor, or infection, the spinal canal may become narrowed by bulging or protrusion of the intervertebral disc annulus, herniation of the nucleus pulposus posteriorly, thickening of the posterior longitudinal ligament, hypertrophy of the facet joints, hypertrophy of the ligamentum flavum, epidural fat deposition, spondylosis of the intervertebral disc margins, uncovertebral joint hypertrophy in the neck, or a combination of 2 or more of the above factors.^{[4 ]}

The central canal and the neurorecess may be compromised by tumor infiltration, such as metastatic disease of the spine, or by infectious spondylitis. An abscess may directly compress the spinal cord if it is contained in the epidural space, while discitis and vertebral osteomyelitis may compress the canal following vertebral collapse. Paget disease results in spinal stenosis as a result of enlargement of the vertebral body, while idiopathic ossification of the posterior longitudinal ligament directly narrows the central spinal canal most often in the cervical or thoracic regions.

Patients with spinal stenosis become symptomatic when pain, motor weakness, paresthesia, or another neurologic compromise causes distress. Spinal stenosis of the thoracic spine is more likely to directly affect the spinal cord because of the relatively narrow thoracic spinal canal. Compression of the thoracic spinal cord can result in myelopathy. Central compression of the cervical spinal cord also results in myelopathy, while paramedial and lateral disease causes radiculopathy and involvement of specific nerve root distributions.

Spinal stenosis of the cervical and thoracic regions may contribute to neurologic injury, such as development of a central spinal cord syndrome following spinal trauma. Spinal stenosis of the lumbar spine is associated most commonly with midline back pain and radiculopathy. In cases of severe lumbar stenosis, innervation of the urinary bladder and the rectum may be affected, but lumbar stenosis most often results in back pain with lower extremity weakness and numbness along the distribution of nerve roots of the lumbar plexus.

Frequency

United States

As many as 35% of persons who are asymptomatic and aged 20-39 years demonstrate disc bulging. Computed tomography (CT) and magnetic resonance imaging (MRI) studies in patients who are asymptomatic and younger than 40 years demonstrate a 4-28% occurrence of spinal stenosis. Most persons older than 60 years have spinal stenosis to some degree. Since most patients with mild spinal stenosis are asymptomatic, the absolute frequency can only be estimated.^{[5 ]}

International

Occurrence of spinal stenosis is similar to that in the United States. Nations with large numbers of older citizens tend to have a higher occurrence of spinal stenosis.

Mortality/Morbidity

Spinal stenosis can result in significant morbidity. The primary symptoms are pain, numbness, and motor weakness. Severe disability and death may result from the association of cervical stenosis with even minor trauma resulting in the central cord syndrome. Both upper (cervical) and lower (lumbar) spinal stenosis may result in motor weakness and chronic pain. Severe lumbar stenosis is associated with cauda equina syndrome.

• Central spinal stenosis of the cervical or thoracic regions may result in neurosensory changes at the level of the spinal stenosis or may further compress the spinal cord, resulting in myelopathy. In the patient with spinal canal stenosis, flexion or marked hyperextension may result in further compromise of the spinal canal in the absence of a fracture. Anterior compression of the cord may result in a central spinal cord syndrome. Dorsal compression of the spinal cord may result in a partial dorsal column syndrome. The effects of central spinal canal stenosis may result in lower extremity weakness and gait disturbance.
• Lateral spinal stenosis generally results in symptoms that are directly related to compression of the nerve roots at the level of the stenosis. Both pain and muscular weakness may result from hypertrophy of the facet joints, spondylosis deformity, bulging of the disc annulus, or herniation of the nucleus pulposus. Although large central disc herniations occur, most extruded disc fragments migrate laterally, and some disc fragments move to a position that is superior or inferior to the interspace.
• Metastatic and infectious processes that affect the spine may present with both regional pain and signs of central spinal canal narrowing. The regional pain may result from pathologic fractures or nerve root compression by the tumor or abscess. Long tract findings may result from bone fragments, a hemorrhage, an abscess, or a tumor compressing the spinal cord.

Race

Cervical stenosis resulting from ossification of the posterior longitudinal ligament is more common among Asians.

Sex

Lumbar spinal stenosis occurs more commonly in males. This may be a combination of a congenitally narrow canal and occupational risk.

Age

Spinal stenosis can be seen in both children and adults. Primary (congenital) lumbar spinal stenosis is associated with achondroplastic dwarfism. The incidence of acquired spinal stenosis increases with age.

Anatomy

The anteroposterior (AP) diameter of the normal adult male cervical canal has a mean value of 17-18 mm at vertebral levels C3-5. The lower cervical canal measures 12-14 mm. Cervical stenosis is associated with an AP diameter of less than 10 mm, while diameters of 10-13 mm are relatively stenotic in the upper cervical region.

In the central cervical spinal region, hypertrophy of the ligamentum flavum, bony spondylitic hypertrophy, and bulging of the disc annulus contribute to development of central spinal stenosis. In each case, the relative significance of each structure contributing to the stenotic pattern is variable.

Movement of the cervical spine exacerbates congenital or acquired spinal stenosis. In hyperextension, the cervical cord increases in diameter. Within the canal, the anterior roots are pinched between the annulus margins and spondylitic bony bars. In the posterior canal, hypertrophic facet joints and thickened infolded ligamentum flavum compress the dorsal nerve roots. In hyperflexion, neural structures are tethered anteriorly against the bulging disc annulus and spondylitic bars. In the event of a vertebral collapse, the cervical spine loses its shape, which may result in anterior cord compression.

Lateral cervical stenosis results from encroachment on the lateral recess and the neuroforamina of the cervical region, primarily as a result of hypertrophy of the uncovertebral joints, lateral disc annulus bulging, and facet hypertrophy. The thoracic spinal canal varies from 12 to 14 mm in diameter in the adult. Primary central thoracic spinal stenosis is rare. Occasionally, hypertrophy or ossification of the posterior longitudinal ligament results in central canal stenosis.

Lateral thoracic stenosis may result from hypertrophy of facet joints with occasional synovial cyst encroachment. The diameter of the normal lumbar spinal canal varies from 15 to 27 mm. Lumbar stenosis results from a spinal canal diameter of less than 12 mm in some patients; a diameter of 10 mm is definitely stenotic.

Presentation

The primary clinical manifestation of spinal stenosis is chronic pain. In patients with severe stenosis, weakness and regional anesthesia may result. Among the most serious complications of severe spinal stenosis is central cord syndrome. Central cord syndrome is the most common incomplete cord lesion. The presentation commonly is associated with an extension injury in a patient with an osteoarthritic spine. In hyperextension injury, the cord is injured within the central gray matter, which results in proportionally greater loss of motor function of upper extremities than loss of motor function of lower extremities, with variable sensory sparing. Cauda equina syndrome presents with urinary retention, saddle anesthesia, loss of rectal tone, and loss of bulbocavernosus reflex with sacral sparing.^{[6 ]}

Preferred Examination

Older patients in whom spinal stenosis is suspected should be examined using conventional spinal radiology, including AP, lateral, oblique, and lower lumbar–centered views. Lateral views are most sensitive for central spinal stenosis, while oblique views of the cervical and lumbar areas better demonstrate lateral stenosis syndromes. Younger patients and all patients in whom conventional radiology findings are negative should be evaluated using either spinal CT scanning with reformatted images, spinal MRI, or single-photon emission computed tomography (SPECT) bone scintigraphy.

Spinal MRI is the most universally suitable technique for the diagnosis of spinal stenosis. The examination should be performed using thin sections (3 mm) and high resolution (256 X 192 matrix). Spinal MRI should include imaging sets obtained in the axial and sagittal planes using T1-weighted, proton-density, and T2-weighted techniques. The bony and osteophytic components of the spinal stenosis pattern are seen best using a T2-weighted gradient-echo technique.

CT of the cervical, thoracic, and/or lumbar spine may be useful in certain patients, often during the performance of CT myelography. Indications for CT myelography include contraindications for MRI, implanted metal devices in patients, and postoperative patients with suggested complications. CT of the spine should be followed by multiplanar reformatted images and 3-dimensional imaging techniques in selected patients.

Nuclear medicine's SPECT bone scintigraphy is valuable primarily in differentiating spondylosis with stenosis from medical disease, infections, and tumors.

Limitations of Techniques

Radiography of the spine is insensitive for detection of spinal stenosis based on changes in soft tissues of the spine. Superimposed structures limit the accuracy of measurements of the spinal canal.

CT of the spine is not sensitive to lateral views and many central soft-tissue abnormalities. Use of intravenous contrast agents improves the soft-tissue resolution of CT to some degree.

MRI provides excellent soft-tissue differentiation but somewhat limited spatial resolution. MRI contrast agents further improve soft-tissue visualization but have no effect on spatial resolution.

SPECT bone scintigraphy is sensitive to diseases that actively affect bone pathophysiology, but spatial resolution is limited.

Differential Diagnoses

Achondroplasia
Osteogenesis Imperfecta
Osteoporosis, Involutional
Rheumatoid Arthritis, Spine
Spondylodiskitis

Other Problems to Be Considered

Metastatic breast cancer
Prostate cancer
Paget disease

Radiography

Radiographic images of spinal stenosis are provided below:

Lateral cervical spine radiographs may demonstrate significant degenerative changes with both interspace narrowing (yellow arrow) and osteophytic spinal canal narrowing (black arrow) in otherwise asymptomatic patients. This lateral radiographic film was taken for the evaluation of trauma. The patient had no chronic neurologic complaints.

To better evaluate the lower cervical spine, a lateral view of the cervical spine with the patient's right arm above the head (swimmer's view) may be helpful. In this case of trauma, the lower cervical spine (vertebral level C6/C7) was seen in the lateral project only on the swimmer's view (white arrow). Note the cervical spondylosis, which was an incidental finding.

Oblique view of the cervical spine demonstrates 2 levels of foraminal stenosis (white arrows) resulting from facet hypertrophy (yellow arrow) and uncovertebral joint hypertrophy.

Anteroposterior cervical myelogram demonstrates compression of a right-sided nerve root. Unfortunately, compression of a nerve root sleeve is a nonspecific finding that can be the result of a disc herniation of cervical spondylosis.

Anterior view of a lumbar myelogram demonstrates stenosis related to Paget disease. Myelography is limited because of the superimposition of multiple spinal structures that contribute to the overall pattern of stenosis.

Lateral view of a lumbar myelogram performed in a patient who has been fused across the L4-L5 and the L5-S1 vertebral interspaces using transpedicular screws. Treatment of lumbar spinal stenosis may include decompression laminectomies, followed by the placement of transpedicular screws (yellow arrows) with a posterior stabilization bar.

Sagittal view of a 3-dimensional volume image of the lumbar spine in a patient with a posterior fusion using transpedicular screws in L4 and L5. Note that an interposition graft has been placed between L4 and L5 to maintain satisfactory intervertebral distance.

Findings

The lateral view of the spine is the most useful. Spondylosis appears as curvilinear bony outgrowths from the lateral and posterior margins of the vertebral body endplates. The general outline of each vertebral body should be reviewed to exclude possible compression injuries or pathologic compression fractures. Hypertrophic facet joints are best seen on oblique views in which narrowing of the neuroforaminal spaces in the cervical spine and lumbar spine regions are commonly visualized. In the cervical spine, uncovertebral hypertrophy is best visualized on oblique and lateral views. The AP view is useful for the assessment of alignment and uniformity of the interspinous process distances. The soft tissues surrounding the lumbar spine can be evaluated on the standard AP radiograph. Disruption of the psoas muscle stripe may indicate a paravertebral abscess or tumor.^{[7 ]}

Degree of Confidence

Standard radiographs remain the recommended initial imaging study of choice. In patients with severe stenosis, cervical spine radiographs are useful; however, radiographic studies are insensitive to soft-tissue hypertrophy and other nonosseous causes of spinal stenosis. In the older patient, standard radiographs help exclude more serious conditions, such as pathologic compression fracture. Anterior osteophytes, even when they become very large, may not be related to spinal symptoms.

False Positives/Negatives

While few false-positive findings exist, occasionally, even marked anterior spondylosis is not associated with significant central spinal canal narrowing. Diseases associated with bone softening may be related to significant spinal canal narrowing without obvious radiographic findings.

Computed Tomography

CT images of spinal stenosis are provided below:

This midline sagittal multireformatted CT scan of the cervical spine (left image) demonstrates a very large anterior osteophyte (yellow arrow) that is causing dysphasia. The spinal canal is normal in diameter (black double arrows). The shaded surface volume image of the same patient (right image) demonstrates the uniformly dense nature of the hypertrophic bone in this patient (white arrow).

Sagittal volume reconstruction of a CT scan of cervical spinal stenosis. The reconstructed image has been cut along the midline sagittal plane to demonstrate the spinal canal. Note the large central osteophyte (black arrow) at the C3/C4 vertebral level, which narrows the anteroposterior diameter of the cervical spine.

Axial CT myelogram. Note the excellent visualization of the cervical spinal cord (C.S.C), as well as the ventral and dorsal nerve roots.

Axial cervical CT myelogram demonstrates marked hypertrophy of the right facet joints (black arrows), which results in tight restriction of the neuroforaminal recess and lateral neuroforamen.

This axial CT image from a CT myelogram of the cervical spine demonstrates left-sided spondylosis (black arrow) resulting in lateral recess stenosis (double yellow arrow) and lateral neuroforaminal stenosis (white arrow). In this case the hypertrophy is primarily an osteophytic overgrowth of the uncovertebral joint on the left. This is an example of lateral cervical spinal stenosis resulting in primarily upper extremity nerve root symptoms.

Axial CT image from a CT myelogram demonstrates central cervical canal stenosis. Note the spondylosis with hypertrophic bone spurs (black arrows) and the central disc protrusion (yellow arrow), which result in severe cervical spinal cord compression (C.S.C., blue arrow).

Sagittal 3-dimensional reconstruction CT scan of the thoracic spine in chronic thoracic disc herniation.

Sagittal reformatted CT scan demonstrates central canal mass (arrow), which was determined to be a meningioma.

Sagittal midline-cut view of a 3-dimensional reconstruction of CT images in tuberculosis spondylitis. Note the cavity within the central portion of the thoracic vertebral body (black arrow). The posterior margin of the vertebral endplate has begun to displace into the spinal canal (blue arrow), resulting in spinal canal stenosis.

Axial CT image from a patient who presented with left-sided paraspinal back pain. A left psoas muscle abscess is indicated by the white arrow. Tuberculosis bacteria were cultured from a needle aspiration.

Thoracic spinal hemangioma associated with a pathologic fracture in a young pregnant woman.

Axial 3-dimensional image from CT myelography in a patient with severe spinal stenosis. The stenotic pattern (yellow arrow) results from hypertrophic facet joints (black arrow), bulging of disc annulus (white arrow), and thickened ligamentum flavum posteriorly.

Axial CT image through the pedicles of L4 demonstrates the desired position of transpedicular screws (black arrow). The screws are connected posteriorly by a bar (blue arrow) to provide posterior spinal fixation.

Findings

On CT scans, spinal stenosis is well defined as the diminished diameter(s) and cross-sectional area of the spinal canal. CT of the cervical spine can be improved using intravenous contrast agents to enhance the epidural veins, thus better defining the margins of the epidural space. Enhancement of epidural fibrosis is greatest soon after surgery. Paraspinal masses may present with associated calcifications or may appear as cystic or fluid collections in the case of abscess. In all cases the relationship of the mass to the central spinal canal, the lateral spinal canal recess, and the neuroforamen should be determined. All images should be reviewed with both a standard soft-tissue window and a narrow window to evaluate bone disease and calcifications.

Degree of Confidence

Osseous and calcified features are well outlined on CT scans. Findings in epidural soft-tissue diseases rely on the displacement of epidural fat or contrast enhancement, which may vary. In general, the use of intravenous contrast agents improves the visualization of soft tissue diseases, masses, and abscesses.

False Positives/Negatives

False-positive findings related to epidural scar result from a failure of fibrotic tissue to enhance years after surgery. False-negative CT examinations occur because of far lateral lesions, which become averaged together with the surrounding bone of the neuroforaminal space. The evaluation for an abscess is difficult immediately following surgery. The residual blood and gas in the tissues may appear similar to an infectious process. Delayed follow-up examinations are recommended.

Magnetic Resonance Imaging

Magnetic resonance images of spinal stenosis are provided below:

Short recovery time T1-weighted spin-echo sagittal MRI scan demonstrates marked spinal stenosis of the C1/C2 vertebral level cervical canal resulting from formation of the panus (black arrow) surrounding the dens in a patient with rheumatoid arthritis. Long recovery time T2*-weighted fast spin-echo sagittal MRI scans better define the effect of the panus (yellow arrow) on the anterior cerebrospinal fluid space. Note the anterior displacement of the upper cervical cord and the lower brainstem.

This sagittal T2-weighted cervical spine MRI scan demonstrates a high-grade spinal stenosis of the vertebral level C3/C4 interspace resulting from spondylosis (arrow). Sagittal T2-weighted images provide excellent visualization of the CSF, which has a bright signal, compared to the narrowed canal and compressed cervical cord.

Sagittal MRI scan of a meningioma of the lower thoracic spine obtained without contrast enhancement. The anterior spinal canal is occupied by a mass that displaces and compresses the conus medullaris at the T12 level. The mass (white arrow) is of intermediate increased signal brightness, compared to the normal spinal cord.

Long recovery time T2*-weighted fat-suppressed sagittal MRI of the thoracic spine demonstrates central canal spinal stenosis (white arrows). Note the decreased signal from the abnormal interspace in this patient with tuberculosis spondylitis.

Sagittal T1-weighted MRI scan of the spine in discitis. Note the posterior bulging of the vertebral body endplate and disc annulus into the spinal canal (black arrow). The endplates of the disc interspace enhance following an injection of gadolinium diethylenetriamine pentaacetic acid (white arrows), while the central abscess within the disc space remains dark (yellow arrow).

Sagittal noncontrast T1-weighted MRI scan of the thoracic spine in a renal transplant recipient. Note the extra-axial posterior mass within the thoracic spinal canal (arrow). The thoracic spinal cord is displaced forward by an extramedullary lipid-rich (fat) mass.

Axial T1-weighted MRI scan of the lower thoracic spine and chest. Biopsy was performed on a large left paraspinal mass. The mass in the spinal canal and in the paraspinal area is extramedullary hematopoietic tissue.

Findings

On MRI, findings of spinal stenosis have a variable presentation depending on the specific disease causing the stenosis as well as associated edema of the related vertebral bodies.^{[8,9 ]}

• Osteophytes and calcified bulging disc structures are dark on T2-weighted fast spin-echo and T1-weighted spin-echo imaging.
• Osteophytic tissues are dark on T2-weighted gradient-echo images.
• Epidural soft tissues and related disease processes typically are isointense on T1-weighted noncontrast images, compared to muscle, synovial tissues, and most spinal ligaments.
• Vertebral endplates present a variable degree of increased or even decreased brightness on T2-weighted images, depending on the degree of inflammation and the chronic nature of the degenerative changes.
• Following intravenous administration of gadolinium diethylenetriamine pentaacetic acid (DTPA), fibrosis or surgical inflammatory changes, extra-axial tumors, and stress reactions within vertebral body endplates present an increased signal pattern on T1-weighted images.
  • Gadolinium-based contrast agents (gadopentetate dimeglumine [Magnevist], gadobenate dimeglumine [MultiHance], gadodiamide [Omniscan], gadoversetamide [OptiMARK], gadoteridol [ProHance]) have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). For more information, see the eMedicine topic Nephrogenic Fibrosing Dermopathy. The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans.
  • NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness. For more information, see the FDA Public Health Advisory or Medscape.
• Postcontrast T1-weighted images are most useful if a fat-suppression technique is used.

The assessment of cervical spine stenosis is improved by careful evaluation of CSF flow in the region of the stenosis. Spatial modulation of magnetization allows the degree of stenosis to be correlated with restriction to the CSF flow. In high-grade stenosis both the diastolic and the systolic CSF flow velocities are reduced. The degree of symptoms has been correlated to the compromised cervical cord and the related effects upon CSF flow.

Degree of Confidence

Spinal stenosis is best diagnosed using MRI. Measurements taken from sagittal images are particularly useful and, in most patients, can be accepted as accurate. Although measurement of the cervical canal are important, interpretation of the diagnosis of spinal canal stenosis must be made carefully. The clinical significance of spinal canal stenosis in children is probably less important than the increased mobility of the child's neck compared to that of the adult. Due to susceptibility artifacts related to osseous and calcified structures, gradient-echo images tend to result in slight overestimations of the degree of stenosis in the lateral recesses and neuroforaminal spaces.

False Positives/Negatives

On MRI, a false-positive finding of the spine rarely occurs except in patients with central spinal canal stenosis. Gradient-echo images may lead to overestimation of the degree of lateral recess and neuroforaminal space stenosis. CSF-pulsation artifacts seen on sagittal T2-weighted fast spin-echo images may give rise to a false impression of dorsal stenosis. False-negative MRI results are generally related to movement artifacts and the presence of metal in the region of interest.

Nuclear Imaging

Findings

Spinal stenosis may be reflected on SPECT nuclear medicine images as areas of increased activity related to the vertebral body endplates, facet joints, and uncovertebral joints. Medical diseases related to the bones of the vertebral bodies, such as Paget disease, present with markedly increased nuclide uptake. Metastatic disease, which may cause spinal canal stenosis, is usually associated with increased uptake of the nuclide agent in the areas of abnormal bone.

Degree of Confidence

Most causes of spinal stenosis have nonspecific findings on nuclear medicine studies. Paget disease, osteomyelitis, and spinal metastasis have strongly positive focal findings.

False Positives/Negatives

Many cases of spinal stenosis are not identified using SPECT nuclear medicine as a primary diagnostic method. Nuclear medicine scans may demonstrate positive findings in the absence of spinal stenosis. SPECT spinal imaging should be reserved for patients in whom osteomyelitis, Paget disease, or other specific disease conditions exist. Some diseases in which only bone destruction occurs may not have increased uptake in the areas of metastatic disease.

Angiography

Findings

Angiography is rarely indicated except in patients with arteriovenous malformations, dural fistulas, and vascular spinal tumors. In these patients, the degree of spinal canal narrowing can only be inferred on the basis of venous or arterial displacement or neovascularity.

Degree of Confidence

Spinal angiography can indicate spinal canal narrowing only indirectly, based on epidural enhancement and vascular (venous) dilatation.

False Positives/Negatives

Spinal angiography should be reserved for specific indications related to arteriovascular malformations, arteriovascular fistulae, and highly vascular tumors. Epidural venography was performed prior to the availability of MRI. As a result of the variability of the epidural venous plexus, use of epidural vein displacement as an indication of a lateral disc herniation is subject to both false-positive and false-negative diagnoses.

Intervention

Unlike acute lumbar disc herniation, spinal stenosis is not typically treated using interventional radiologic techniques. Pain management, including facet injections, may provide temporary relief in patients; however, biopsy of metastatic spinal disease is performed easily using CT guidance. Spinal stenosis associated with compression fractures has been successfully treated using percutaneous vertebroplasty.^{[10,11,12 ]}

Multimedia

Media file 1: Sagittal measurements taken of the anteroposterior diameter of the cervical spinal canal are highly variable in otherwise healthy persons. An adult male without spinal stenosis has a diameter of 16-17 mm in the upper and middle cervical levels. Magnetic resonance imaging (MRI) scans and reformatted computed tomography (CT) images are equally as effective in obtaining these measurements, while radiography is not accurate.

Media file 2: Lateral cervical spine radiographs may demonstrate significant degenerative changes with both interspace narrowing (yellow arrow) and osteophytic spinal canal narrowing (black arrow) in otherwise asymptomatic patients. This lateral radiographic film was taken for the evaluation of trauma. The patient had no chronic neurologic complaints.

Media file 3: To better evaluate the lower cervical spine, a lateral view of the cervical spine with the patient's right arm above the head (swimmer's view) may be helpful. In this case of trauma, the lower cervical spine (vertebral level C6/C7) was seen in the lateral project only on the swimmer's view (white arrow). Note the cervical spondylosis, which was an incidental finding.

Media file 4: Oblique view of the cervical spine demonstrates 2 levels of foraminal stenosis (white arrows) resulting from facet hypertrophy (yellow arrow) and uncovertebral joint hypertrophy.

Media file 5: This midline sagittal multireformatted CT scan of the cervical spine (left image) demonstrates a very large anterior osteophyte (yellow arrow) that is causing dysphasia. The spinal canal is normal in diameter (black double arrows). The shaded surface volume image of the same patient (right image) demonstrates the uniformly dense nature of the hypertrophic bone in this patient (white arrow).

Media file 6: Sagittal volume reconstruction of a CT scan of cervical spinal stenosis. The reconstructed image has been cut along the midline sagittal plane to demonstrate the spinal canal. Note the large central osteophyte (black arrow) at the C3/C4 vertebral level, which narrows the anteroposterior diameter of the cervical spine.

Media file 7: Oblique 3-dimensional shaded surface display CT reconstruction of right foraminal stenosis resulting from unilateral facet hypertrophy (black arrow). The volume of the reconstruction has been cut obliquely across the neuroforaminal canal.

Media file 8: Anteroposterior cervical myelogram demonstrates compression of a right-sided nerve root. Unfortunately, compression of a nerve root sleeve is a nonspecific finding that can be the result of a disc herniation of cervical spondylosis.

Media file 9: Lateral swimmer's radiographic view demonstrates compression of the anterior contrast-filled cervical thecal sac. The defect helps localize the stenosis; however, the pattern does not reflect lateral disc herniation or spondylosis directly.

Media file 10: Axial CT myelogram. Note the excellent visualization of the cervical spinal cord (C.S.C), as well as the ventral and dorsal nerve roots.

Media file 11: Axial cervical CT myelogram demonstrates marked hypertrophy of the right facet joints (black arrows), which results in tight restriction of the neuroforaminal recess and lateral neuroforamen.

Media file 12: This axial CT image from a CT myelogram of the cervical spine demonstrates left-sided spondylosis (black arrow) resulting in lateral recess stenosis (double yellow arrow) and lateral neuroforaminal stenosis (white arrow). In this case the hypertrophy is primarily an osteophytic overgrowth of the uncovertebral joint on the left. This is an example of lateral cervical spinal stenosis resulting in primarily upper extremity nerve root symptoms.

Media file 13: Axial CT image from a CT myelogram demonstrates central cervical canal stenosis. Note the spondylosis with hypertrophic bone spurs (black arrows) and the central disc protrusion (yellow arrow), which result in severe cervical spinal cord compression (C.S.C., blue arrow).

Media file 14: Short recovery time T1-weighted spin-echo sagittal MRI scan demonstrates marked spinal stenosis of the C1/C2 vertebral level cervical canal resulting from formation of the panus (black arrow) surrounding the dens in a patient with rheumatoid arthritis. Long recovery time T2*-weighted fast spin-echo sagittal MRI scans better define the effect of the panus (yellow arrow) on the anterior cerebrospinal fluid space. Note the anterior displacement of the upper cervical cord and the lower brainstem.

Media file 15: Axial T2-weighted gradient echo MRI scan. Note the high-grade spinal stenosis resulting in severe upper cervical cord compression (arrows). This patient presented with a central spinal cord syndrome that improved following surgical decompression.

Media file 16: This sagittal T2-weighted cervical spine MRI scan demonstrates a high-grade spinal stenosis of the vertebral level C3/C4 interspace resulting from spondylosis (arrow). Sagittal T2-weighted images provide excellent visualization of the CSF, which has a bright signal, compared to the narrowed canal and compressed cervical cord.

Media file 17: Sagittal T2-weighted MRI image demonstrates severe stenosis. Spinal stenosis is demonstrated at several levels (white and yellow arrows) resulting from a combination of disc annulus bulging (white arrow) and epidural soft-tissue thickening (yellow arrow).

Media file 18: Superior-to-inferior view of 3-dimensional volume reconstruction of central canal spinal stenosis resulting from chronic disc herniation. The patient presented with lower extremity weakness and loss of bladder control.

Media file 19: Sagittal 3-dimensional reconstruction CT scan of the thoracic spine in chronic thoracic disc herniation.

Media file 20: Sagittal reformatted CT scan demonstrates central canal mass (arrow), which was determined to be a meningioma.

Media file 21: Sagittal MRI scan of a meningioma of the lower thoracic spine obtained without contrast enhancement. The anterior spinal canal is occupied by a mass that displaces and compresses the conus medullaris at the T12 level. The mass (white arrow) is of intermediate increased signal brightness, compared to the normal spinal cord.

Media file 22: Sagittal T2 weighted fast spin-echo (FSE) MRI scan of a meningioma of the lower thoracic spine obtained without contrast enhancement. The effect of the mass is better seen because of the contrast between the mass and the cerebrospinal fluid (CSF). The anterior spinal canal is occupied by a mass that displaces and compresses the conus medullaris (C) at the T12 level. The mass (white arrow) is of intermediate increased signal brightness, compared to the normal spinal cord.

Media file 23: Sagittal T1-weighted spin-echo (SE) MRI scan of a meningioma of the lower thoracic spine obtained following IV gadolinium contrast enhancement. The mass is better seen because of the contrast enhancement within the meningioma (M). The anterior spinal canal is occupied by a mass that displaces and compresses (white arrows) the conus medullaris (C) at the T12 level. The mass (white arrow) is of intermediate increased signal brightness, compared to the normal spinal cord.

Media file 24: Normal findings in the thoracic spine as demonstrated by CT myelography. Note the detail of the spinal cord and the ventral and dorsal nerves surrounded by contrast.

Media file 25: Long recovery time T2*-weighted fat-suppressed sagittal MRI of the thoracic spine demonstrates central canal spinal stenosis (white arrows). Note the decreased signal from the abnormal interspace in this patient with tuberculosis spondylitis.

Media file 26: Sagittal midline-cut view of a 3-dimensional reconstruction of CT images in tuberculosis spondylitis. Note the cavity within the central portion of the thoracic vertebral body (black arrow). The posterior margin of the vertebral endplate has begun to displace into the spinal canal (blue arrow), resulting in spinal canal stenosis.

Media file 27: Coronal-cut view of 3-dimensional reconstruction CT scan of the thoracic spine in tuberculosis spondylitis. Note the central spinal cavity (black arrow). The vertebral endplate has compressed downward (double blue arrows). The advantage of 3-dimensional reconstructions is the ability to better evaluate preoperatively the type of surgery needed to stabilize spinal compression fractures.

Media file 28: Axial CT image from a patient who presented with left-sided paraspinal back pain. A left psoas muscle abscess is indicated by the white arrow. Tuberculosis bacteria were cultured from a needle aspiration.

Media file 29: Paraspinal abscess aspiration biopsy. The stains were positive for mycobacteria (black arrows; acid-fast stain, magnification X100).

Media file 30: Sagittal T1-weighted MRI scan of the spine in discitis. Note the posterior bulging of the vertebral body endplate and disc annulus into the spinal canal (black arrow). The endplates of the disc interspace enhance following an injection of gadolinium diethylenetriamine pentaacetic acid (white arrows), while the central abscess within the disc space remains dark (yellow arrow).

Media file 31: With the patient in a prone position and using CT localization, a bone biopsy and aspiration were performed from the area of greatest destruction within the vertebral endplate (arrow).

Media file 32: Aspergillosis organisms were recovered from a lumbar disc space abscess. The patient had received a renal transplant 12 months prior to the infection (hematoxylin and eosin, magnification X40).

Media file 33: Long recovery time T2*-weighted fat-suppressed sagittal MRI scan of the thoracic spine demonstrates subtle enlargement of a thoracic vertebral body (double white arrows) and a slightly increased degree of signal brightness within the vertebral body (yellow arrow).

Media file 34: Posterior view from a radionuclide bone scan. A focally increased uptake of nuclide (black arrow) is demonstrated within the mid-to-upper thoracic spine in a patient with Paget disease.

Media file 35: Paget disease of the thoracic spine. Thoracic spinal CT scan demonstrates enlarged vertebral body endplates (black arrows). The axial image on the left demonstrates the characteristic thickening of the bony matrix of the vertebral body.

Media file 36: Thoracic spinal hemangioma associated with a pathologic fracture in a young pregnant woman.

Media file 37: Axial lumbar CT scan demonstrates marked right-sided spinal canal stenosis (black arrow) resulting from advanced right-sided facet hypertrophy. Note the vacuum disc sign within the intervertebral disc (double yellow arrow). The vacuum disc sign is further indication of degenerative changes and spinal instability.

Media file 38: Lumbar CT myelogram demonstrates a normal central canal diameter.

Media file 39: Anterior view of a lumbar myelogram demonstrates stenosis related to Paget disease. Myelography is limited because of the superimposition of multiple spinal structures that contribute to the overall pattern of stenosis.

Media file 40: Axial 3-dimensional image from CT myelography in a patient with severe spinal stenosis. The stenotic pattern (yellow arrow) results from hypertrophic facet joints (black arrow), bulging of disc annulus (white arrow), and thickened ligamentum flavum posteriorly.

Media file 41: Pantopaque tracer in the epidural spaces. Pantopaque can remain in the epidural and facial spaces for years following a myelogram. Chronic inflammatory arachnoiditis has been associated with a combination of trauma (bleeding) with administration of Pantopaque.

Media file 42: Sagittal noncontrast T1-weighted MRI scan of the thoracic spine in a renal transplant recipient. Note the extra-axial posterior mass within the thoracic spinal canal (arrow). The thoracic spinal cord is displaced forward by an extramedullary lipid-rich (fat) mass.

Media file 43: Axial T1-weighted MRI scan of the lower thoracic spine and chest. Biopsy was performed on a large left paraspinal mass. The mass in the spinal canal and in the paraspinal area is extramedullary hematopoietic tissue.

Media file 44: Localization of thoracic lesion prior to surgical correction. A needle/wire localization technique is used to ensure the correct surgical level. Such preoperative localizations save time in the operating suite while reducing the need for intraoperative radiology.

Media file 45: Sagittal 3-dimensional CT reconstruction of the lumbar spine in a patient with multiple myeloma. The central portions of the vertebral bodies (yellow arrows) have been replaced by the nonossified tumor.

Media file 46: Biopsy (yellow arrow) of a multiple myeloma mass (black arrow) that has replaced the lumbar spinal canal (blue arrow) completely.

Media file 47: Multiple myeloma. Photomicrograph of an aspiration biopsy specimen.

Media file 48: Lateral view of a lumbar myelogram performed in a patient who has been fused across the L4-L5 and the L5-S1 vertebral interspaces using transpedicular screws. Treatment of lumbar spinal stenosis may include decompression laminectomies, followed by the placement of transpedicular screws (yellow arrows) with a posterior stabilization bar.

Media file 49: Sagittal view of a 3-dimensional volume image of the lumbar spine in a patient with a posterior fusion using transpedicular screws in L4 and L5. Note that an interposition graft has been placed between L4 and L5 to maintain satisfactory intervertebral distance.

Media file 50: Three-dimensional surface CT image of the lumbar spine following transpedicular screw placement across the L4-L5 interspace. Note how the tips of the screws project beyond the anterior margins of the L5 vertebral body.

Media file 51: Axial CT image through the pedicles of L4 demonstrates the desired position of transpedicular screws (black arrow). The screws are connected posteriorly by a bar (blue arrow) to provide posterior spinal fixation.

Media file 52: Axial CT image taken through L5 in a patient in whom transpedicular screws have been placed. Note that the screws (black arrows) are too far lateral and anterior. The iliac veins lie just anterior to tips of the screws (white arrows). Both the angle of screw placement and the length of the screws must be tailored to the individual patient.

Media file 53: Spinal stenosis. Sagittal multiplanar reconstruction (MPR) image from a CT scan of the lumbar spine following posterior decompression and fusion of the L4-L5 interspace. The interposition graft (white arrow) is posterior to the desired position. The patient remained asymptomatic. Follow-up imaging should focus upon the stability of the posterior fusion, the position of the pedicle screws, and the position of the interposition graft.

Media file 54: Sagittal reformatted image from a CT of the cervical spine following anterior spinal decompression and fusion. Surgical treatment of spinal canal stenosis often involves anterior vertebrectomy and bone graft interposition. The goal in such cases is to restore cervical spinal alignment (white line) while securing anterior stability. In this patient, the bone graft (double black arrows) has migrated forward (double yellow arrows).

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Keywords

spinal stenosis, spondylosis, back pain

Contributor Information and Disclosures

Author

Lennard A Nadalo, MD, Clinical Professor, Department of Radiology, University of Texas Southwestern Medical School; Consulting Staff, Envision Imaging of Allen and Radiological Consultants Association
Lennard A Nadalo, MD is a member of the following medical societies: American College of Radiology, American Society of Neuroradiology, American Society of Pediatric Neuroradiology, Radiological Society of North America, and Texas Radiological Society
Disclosure: Nothing to disclose.

Coauthor(s)

James A Moody, MD, Chief, Neurosurgery Section, Department of Surgery, Methodist Medical Center
James A Moody, MD is a member of the following medical societies: American Association of Neurological Surgeons, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Lucien M Levy, MD, PhD, Director of Neuroradiology, Professor of Radiology, Department of Radiology, George Washington University Medical Center
Lucien M Levy, MD, PhD is a member of the following medical societies: American Cancer Society, American College of Radiology, American Heart Association, American Medical Association, American Roentgen Ray Society, American Society of Neuroradiology, and Radiological Society of North America
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

C Douglas Phillips, MD, Director of Head and Neck Imaging, Division of Neuroradiology, Weill Medical College of Cornell University/New York Presbyterian Hospital
C Douglas Phillips, MD is a member of the following medical societies: American College of Radiology, American Medical Association, American Society of Head and Neck Radiology, American Society of Neuroradiology, Association of University Radiologists, and Radiological Society of North America
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Resolution Imaging Medical Corporation
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

James G Smirniotopoulos, MD, Professor of Radiology, Neurology, and Biomedical Informatics, Chairman, Department of Radiology and Radiological Sciences, Uniformed Services University of the Health Sciences
James G Smirniotopoulos, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, American Society of Head and Neck Radiology, American Society of Neuroradiology, American Society of Pediatric Neuroradiology, Association of University Radiologists, and Radiological Society of North America
Disclosure: Nothing to disclose.

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