Morphological grade II corresponded to maximum number of cases, amounting

to 46%, followed by 36 % of Grade III. Grade I corresponded to 14% of cases and

Grade IV corresponded to 4% of cases. More number of morphological grade III

patients are associated with mild grade of clinical symptomatology as per the clinical

protocol.This explains that pathological process may exceed the underlying clinical

symptomatology in most of the subjects. Though the patients present with mild clinical

symptoms, the presence of pre-existing age related degenerative changes in the spine

may aggravate the morphological grade of the study populationas was observed by

Yuan et al[38] and Haig et al[6] in their study.

Significant association was obtained in the present study between the

morphological grade and the thecal sac measurements with a strong positive rank

correlation, which was in accordance with study done by Sigmundsson et al [21] and

Park HJ et al.[33]

Grade I morphological grade was seen in 14% of patients who had the thecal sac

axial antero-posterior diameters ranging from 7.4 to 9.4 mm and mean antero-posterior

thecal sac diameter of 8.3 mm.Grade II morphological grade was seen in 46% of

patients who had the thecal sac axial antero-posterior diameters ranging from 2.8 to 8.4

mm and mean antero-posterior thecal sac diameter of 6.2 mm.Grade III morphological

grade was seen in 36% of patients who had the thecal sac axial antero-posterior

diameters ranging from 3.2 to 5.9 mm and mean antero-posterior thecal sac diameter of

4.5 mm.Grade IV morphological grade was seen in 4% of patients who had the thecal

sac axial antero-posterior diameters ranging from 0-2.2 mm and mean antero-posterior
thecal sac diameter of 1.1 mm. The severe morphological grade is seen to be

associated with least thecal sac axial antero-posterior diameters of the spinal canal.

The thecal sac morphological grade helps in the assessment of the

measurements of the canal diameters on an approximate basis as per the present

study. The measurement of quantitative parameters is time-consuming, and is operator

dependent, whereas the thecal sac visual assessment or morphological grade can be

applied for evaluation of severity of central canal stenosis, thereby avoiding the

quantitative parameters. Similar results were obtained by Yuan et al.[38]

Developmental bony canal stenosis was considered when the anteroposterior

midsagittal canal diameters at the level of mid vertebra was less than or equal to 10 mm

in the present study which is based upon the mean value obtained from the bony canal

measurements of the study population.

As the most common affected disc level is L4-L5 in the present study, the bony

canal measurements are obtained at L4 vertebral level in majority of the cases.19% of

the patients had severe form of developmental canal stenosis in the present study

which also contributed to the symptomatic central canal stenosis. Developmental canal

stenosis is reported more in the early adult population in the present study (36-45

years). Though DSS occurs in young individuals, it may not be symptomatic. The

selection of only the patients with lumbar canal stenosis may have reported the

incidence of developmental canal stenosis in adult population in the present study.

However the purpose of the present study is to determine developmental stenosis as a

contributory factor for lumbar central canal stenosis.

 Co- existing bony canal stenosis further contributes to central canal stenosis,

which was evident in this study. This result is in close approximation to the study done

by Chatha et al[44]andEisenstein et al[49].

The bony canal measurements are taken at the vertebral level in the present

study on sagittal images , so as to avoid the effect of discogenic degenerative disease

and adjacent soft tissues at intervertebral disc level.

Prior to the emergence of MRI, the bony canal was assessed with the

measurements obtained on sagittal view of lumbar spine radiographs. Radiographic

determination has a disadvantage of inclusion of soft tissue within the field of

measurement. MRI is diagnostic for assessment of bony canal stenosis, where high soft

tissue resolution can accurately diagnose the actual bony canal diameterwhich was also

observed by Chatha et al[44].

The contributory factors to canal stenosis include disc degeneration, ligamentum

flavum hypertrophy and facet joint arthropathy.[5]

In the present study, disc degeneration was seen causing central canal stenosis in all

the study subjects(100%).LFH was seen in 32% of cases contributing to canal stenosis,

whereas FJA was seen in 12% of patients .

Spondylolisthesis was seen in 9% of patients and epidural lipomatosis

contributing to canal stenosis was seen in 2 patients.

Ligamentum flavum thickening is considered significant if morphologically it is

seen causing compression of the postero-lateral aspects of the thecal sac and it

measures more than 5 mm in the lumbar spine on axial sections at disc level.
 Facet joint arthropathy is defined by thickening of the joint synovium and loss of

joint fluid in acute cases. Chronic FJA is characterized by hypertrophic osteoarthropathy

with erosions in the articular surfaces of the facet joints.

Spondylolisthesis denotes the slippage of one vertebra relative to the one below.

Spondylolisthesis can occur anywhere but is most frequent, particularly when due to

spondylolysis, at L5/S1 and to a lesser degree L4/L5. Spondylolisthesis was seen in 9

patients out of which 5 were females and 4 were male patients, the result was similar to

the study done by Newman PH et al.[51] .Lower lumbar levels are commonly involved in

the present study with spondylolisthesis, most common L4 over L5.

In the present study, single level stenosis is seen in majority of patients (63%)

where as two level stenosis seen in 18% of population and multilevel stenosis in 19%

population.

In the present study, single and even multilevel stenosis was reported to be

common in females compared to male population.

Majority of single level stenosis patients presented with mild symptomatology.No

significant variation is observed between two and multiple level stenosis patients with

regard to clinical grade, but multilevel stenosis subjects have relatively low or equal

degree of clinical symptoms with that two level stenosis patients. The presence of mild

symptoms of low back pain or claudication in multilevel stenosis when compared to two

level stenosis may be attributed to co-existing radiculopathy as a significant factor in the

causation of pain. Similar result was obtained by a study done by Sigmundson et al [21]
 Degenerative disc disease is also associated with posterior annular fissure in

30% of patients in the present study. Posterior annular fissure has an implication in the

causation of claudication pain as described by Kalichman et al [21]. Posterior annular

fissure was more commonly reported in 56-65 year age group(17%) , followed by 36-55

year age group, indicating the degenerative nature of the disease process.

Ligamentum flavum hypertrophy is reported more commonly in 56-65 year age

group patients, whereas distribution of facet joint arthropathy is also common in the age

group of 46-65 years. Spondylolisthesis is also seen in patients with age group of 56-65

years. The presence of LFH, FJA and spondylolisthesis in elderly age group is also in

keeping with degenerative etiology of lumbar spinals stenosis. Similar results were

obtained in the study done by Brinjiki et .