Spinal Stenosis Workup

Updated: Mar 05, 2018
  • Author: John K Hsiang, MD, PhD; Chief Editor: Stephen Kishner, MD, MHA  more...
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Workup

Approach Considerations

Neuronal studies include the following:

  • Needle electromyography - Can help to diagnose lumbosacral radiculopathy with axonal loss

  • Nerve conduction studies - Can help to differentiate lumbar spinal stenosis (LSS) from other confounding neuropathic conditions (eg, lumbosacral plexopathy, generalized peripheral neuropathy, tarsal tunnel syndrome, other mononeuropathies)

  • Somatosensory evoked potentials - Are useful in the diagnosis of central nervous system (CNS) pathology and are also used intraoperatively during decompressive surgery to assist the physician in dynamically identifying any iatrogenic changes to the sensory pathways

The goal of spinal imaging is to localize the site and level of disease. It also is used to help differentiate conditions for which patients require surgery and conditions for which patients can recover with conservative treatment. Imaging studies used in LSS include standard radiography, magnetic resonance imaging (MRI), computed tomography (CT) scanning, nuclear imaging, and angiography (rarely). In a prospective study, Burgstaller et al found no correlation between MRI findings and severity of pain in spinal stenosis. [36]

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Imaging Studies

Standard radiographs have been the recommended initial imaging study of choice, with MRI as the imaging modality of choice for lumbar spinal stenosis. CT scanning provides excellent central canal, lateral recess, and neuroforaminal visualization. With regard to nuclear imaging, medical diseases related to the bones of the vertebral bodies present with markedly increased nuclide uptake. Angiography is rarely indicated except in patients with arteriovenous malformations, dural fistulas, and vascular spinal tumors.

In 2007, however, the American College of Physicians (ACP) and the American Pain Society issued new guidelines for the diagnosis and treatment of low back pain that strongly opposed the early use of radiographic imaging, as randomized trials showed no benefit, and recommended that other diagnostic imaging be avoided unless serious conditions such as cancer are suspected. [37]

These guidelines were reinforced by the ACP's 2011 guidelines for the diagnostic imaging of low back pain, which emphasized even more strongly that routine diagnostic imaging of patients with low back pain does not improve the patient's condition and may, in fact, cause harm. Early imaging is recommended only for patients who also have serious risk factors for cancer, spinal infection, cauda equina syndrome, or neurologic disorders. Follow-up imaging is recommended only for patients who have undergone treatment and have minor risk factors for cancer, inflammatory back disease, vertebral compression fracture, radiculopathy, or symptomatic spinal stenosis. [38]

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