MRI Findings in Pre-Operative Degenerative Lumbar Stenosis Patients

Dahlan, Rully Hanafi; Yudhoyono, Farid; Ompusunggu, Sevline Estethia; Pamolango, Robert Tengar; Lazuardy,
Muhammad Azhary; Samuel Willyarto

Spine, pain, and peripheral nerve division, Neurosurgery Department, of Padjajaran University / Hasan Sadikin
Hospital

Corresponding author: Rully Hanafi Dahlan, Department of Neurosurgery, Hasan Sadikin General
Hospital/ Padjadjaran University, Bandung, Indonesia. Phone: +62822022044.
Email: rullyspinebandung@gmail.com

I. Introduction
Magnetic resonance imaging (MRI) is a very helpful tool in the evaluation of patients
with spinal symptoms since it allows an accurate morphologic evaluation of the lumbar
spine. In fact, it is considered the best imaging instrument to evaluate spinal stenosis. MRI
also can show degenerative changes of the lumbar spine, like disc degeneration, end plate
changes, facet joint osteoarthritis, and ligamentum flavum thickening1,2.

Operative treatment is indicated for patients with severe pain and constant neurologic
symptoms, and in patients where conservative treatment has failed 3. Surgery for spinal
stenosis consists of either decompression alone, or decompression with spinal fusion.
Decompression by laminectomy is the treatment of choice for central or lateral recess
stenosis. On the other hand, fusion is required if foraminal stenosis is present, in multilevel
laminectomy, or instability of lumbar spine4.

In this study, we attempted to collect the factors visible on conventional supine MR

images that found in lumbar stenosis patient who underwent operative treatment in
Neurosurgery Department, Hasan Sadikin Hospital in a periode 2015-2018.

II. Material and Methods

Subjects
We recruited 20 patient ( 7 women and 13 men) 44 to 70 years old (mean: 55,75 years),
who underwent posterior lumbar surgery after being symptomatic after conservative therapy.
All patient underwent Supine Lumbosacral MRI (1,5T, Siemens) preoperatively. Exclusion
criteria were patient with lumbar spinal tumor, infectious diseases, or prior surgical
treatment.

Image Evaluation
All grading data were independently evaluated by an experienced Neurospine surgeon
(10 years of specialization in spine surgery) who was blind for patients symptoms, and
grading was performed. 
 Lumbar stenosis
Lumbar stenosis can be categorized as central stenosis, lateral recess stenosis, and
foraminal stenosis5. Despite this, the correlation between MRI characteristics and
clinical symptomps remains elusive as a considerable number of asymptomatic
subjects have MRI-Verified spinal stenosis1. Due to great variation is observed
though in surfaces recorded between symptomatic and asymptomatic individuals, in
some study prefer to use qualitative MRI grading for lumbar stenosis6,7,8.

o Central stenosis (LCCS) are defined as the obliteration of the CSF space in
front of the cauda equina in the dural sac on T2-weighted axial images. We
used Lee et all grading system, LCCS was divided into four grades according
to degree of separation of the cauda equina on T2-weighted axial images:
grade 0: defined as no LCCS as the anterior CSF space was not obliterated;
grade 1: defined as mild LCCS, in which the anterior CSF space was mildly
obliterated, but all cauda equina could be clearly separated from each other;
grade 2: defined as moderate LCCS, in which the anterior CSF space was
moderately obliterated and some of the cauda equina were aggregated,
making it impossible to visually separate them; and grade 3: defined as severe
LCCS, in which the anterior CSF space was obliterated so severely as to
show marked compression of the dural sac, and none of the cauda equina
could be visually separated from each other, appearing instead as one bundle6
Fig. 1 Lumbar central canal stenosis (LCCS) is defined when anterior CSF space is obliterated and is
divided into four grades: grade 0, no LCCS (a, b); grade 1, mild stenosis with clear separation of each
cauda equine (c, d); grade 2, moderate stenosis with some cauda equina aggregation (e, f); grade 3,
severe stenosis with the entire cauda equina as a bundle (g, h). Diagrams on left and T2-weighted
axial images on right side of each LCCS grade are illustrated6.

o Lateral recess stenosis (LRS) affects the lateral region of the lumbar spinal
canal that is bordered laterally by the pedicle, posteriorly by the superior
articular facet, and anteriorly by the vertebral body, endplate margin, and disc
margin7

We used Bartynski et all grading system. Grade 0 as a normal LR in

which the nerve root is bathed in cerebrospinal fluid. There is no contact to
the adjacent structures. Grade 1 represents a narrowing of the LR without root
deviation. Grade 2 additionally reveals a root deviation. Grade 3 describes a
compression of the nerve root. If there was a different between the right side
and the left side, the worst grading was recorded
 Figure 2. Axial T2-weighted magnetic resonance images illustrate the grading system of lateral
recess stenosis. A: Grade 0 bilaterally; B: Grade 1 bilaterally; C: Grade 2 bilaterally; D: Grade 3 on
the left, Grade 1 on the right.

o Foraminal stenosis is defined as the narrowing of the bony exit of the nerve
root caused by a decrease in the height of an intervertebral disk, osteoarthritic
changes in the facet joints, cephalad subluxation of the superior articular
process of the inferior vertebra, and buckling of the ligamentum flavum or
protrusion of the annulus fibrosus8. We use Lee et all foraminal stenosis
grading system, where . Grade 0 (normal). Grade 1 (mild degree of foraminal
stenosis). perineural fat obliteration surrounding nerve root in transverse
direction or vertical direction. No evidence of morphologic change in nerve
root is seen. Grade 2 (moderate degree of foraminal stenosis). perineural fat
obliteration surrounding nerve root in four directions (vertical and transverse)
(arrows) without morphologic change. There is narrowing of foraminal width
and height due to disk space narrowing, thickened ligamentum flavum, facet
arthropathy, and diskoosteophytic protrusion in foraminal zone. Grade 3
(severe degree of foraminal stenosis). nerve root collapse or morphologic
change due to severe disk space narrowing, severe thickened ligamentum
flavum, facet arthropathy and diskoosteophytic protrusion in foraminal zone8.
 If there was a different between the right side and the left side, the worst
grading was recorded.

Figure 3. Schematic illustrations of 4-point-scale for grading foraminal stenosis in sagittal MRI of
lumbar spine. NR = nerve root, V = vertebral body, D = intervertebral disk, LF = ligamentum flavum,
FJ = facet joint. A, Grade 0 (normal). B, Grade 1 (mild degree of foraminal stenosis in transverse
direction). C, Grade 1 (mild degree of foraminal stenosis in vertical direction). D, Grade 2 (moderate
degree of foraminal stenosis). E, Grade 3 (severe degree of foraminal stenosis) 8.

 Facet joint osteoarthritis

The severity of facet joint degeneration was evaluated from axial T2-weighted
images based on Grogan’s classification and included the three grades of facet-joint
cartilage, subchondral sclerosis, and osteophyte formation9.

The cartilage within the facet joint was classified into four grades: Grade 1,
characterized by uniformly thick cartilage covering both articular surfaces
completely; Grade 2, characterized by cartilage covering the entire surface with
eroded or irregular regions; Grade 3, characterized by cartilage incompletely
covering the articular surface with the underlying bone exposed to the joint space;
and Grade 4, characterized by the complete absence of cartilage9.

The degree of subchondral sclerosis was classified into four grades: Grade 1 was
defined as a uniform thin band of cortical bone; Grade 2 represented a thin band of
cortical bone that extended into the space from the articular surface; Grade 3 was
defined as dense bone that extended into the joint space but covered less than half the
facet; and Grade 4 represented the presence of dense cortical bone that covered
greater than half the facet joint9.

The size of osteophytes at the facet joints also was classified into four grades:
Grade 1 indicated no osteophyte; Grade 2 indicated a mild or possible osteophyte;
Grade 3 indicated a moderate osteophyte; and Grade 4 indicated a large osteophyte.
The three grades of Grogan’s classification were summed up into a facet
degeneration index (FDI). The side of the more degenerated facet joint with a higher
FDI was selected for analysis, and the severity of facet-joint degeneration was given
a “facet joint degeneration grading” according to the value of the higher measured
FDI9. If there was a different between the right side and the left side, the worst
grading was recorded.

Figure 4. Facet-joint degeneration was graded using axial T2-weighted magnetic resonance images
based on Grogan’s classification, including grades of cartilage, subchondral sclerosis, and
osteophytes. The three grades of Grogan’s classification were summed up into a facet degeneration
index (FDI). In this image, cartilage degenerations were Grade 2 for the right side and Grade 3 for the
left side (short arrows), subchondral scleroses were Grade 2 for the right side and Grade 3 for the left
side (long arrows), and osteophytes were Grade 3 for the right side and Grade 3 for the left side
(broken arrows). The FDI was 7 for the right facet joint and 9 for the left; thus, the higher FDI value
of 9 was recorded for analysis of the facetjoint degeneration of L4e5. FDI, facet degeneration index.
 Modic changes
We used Modic classification to defined bone marrow changes that detected on
MR Imaging. Modic type 1 is represented with decreased signal intensity on T1-
weighted MRI and increased signal intensity on T2-weighted MRI. Modic type 2 has
increased signal intensity on T1-weighted MRI and isointense or slightly increased
signal intensity on T2-weighted MRI, while Modic type 3 has a decreased signal
intensity on both T1 and T2-weighted MRI. MCs are detected not only during disc
degeneration but also in an early infection process and some immunological
diseases10.

Figure 5. Modic Changes

 Disc Degeneration
We use Pfirmann classification to describe the degenerative disc11

Figure 6. T2-weighted sagittal images used to evaluate disc degeneration. a Disc degeneration as described
by Pfirrmann: mainly inhomogeneous black discs with no distinction between nucleus and annulus;
collapsed disc spaces at L1–L2 and L4–L5. b Lumbar discs that obtained high reliability for low grade
Pfirrmann grades across our evaluators, showing homogeneous structure, with bright hyperintense signal
intensity and normal height11

 Herniated Disc
We use the recommendation of the Working Group (now called the Section) on
Degenerative Spinal Diseases of the German Society for Orthopedic Surgery. A disk
protrusion is a bulging of a disk whose anulus fibrosus is more or less well
preserved. A disk prolapse is a disk herniation with perforation of the anulus
fibrosus. Grade 1 disk tissue is displaced within the disk, the fibrous ring around it is
largely intact. Grade II disk tissue is displaced within the disk up to the outer layer of
the anulus. Grade III disk tissue displaced has completely perforated the anulus
fibrosus and is only covered by a thin membrane (the ventral epidural membrane).
Grade IV, disk tissue is found partly inside and partly outside the disk. This situation
generally obtains only at the discal level, when the ventral epidural membrane is also
perforated at this level. Grade V, The prolapse is found as a free fragment in the
spinal canal or the intervertebral foramen12.
 Figure 7. Grading of herniated disc12

Standing lateral flexion–extension radiographs have been used as the gold standard for
the diagnosis of lumbar instability13,14. However, supine magnetic resonance imaging (MRI) is
almost routinely used to assess for the diagnosis of lumbar disease in elderly patients recently 15.
In this study, we still used supine MRI to evaluate lumbar segmental instability and deformity
curve for practically reason

 Lumbar segmental instability

Lumbar segmental instability is an abnormal motion to physiologic loads,

characterized by greater than normal range of motion16-19. We use a translation
greater than 5 mm in sagittal or coronal direction in supine MRI to describe lumbar
segmental instability.
 Figure 8. Anteroisthesis L4-L5 >5 mm show segmental instability

 Adult Degenerative Scoliosis

Represents a structural curve developed after skeletal maturity without previous
scoliosis history20,21. those measuring >10° were termed scoliotic and the rest were
labeled nonscoliotic22. Lumbar lordosis was measured from the superior endplate of
L1 to the superior endplate of S1. The normal range of LLA in the current study was
30∘ to 67∘23. We used LLA < 30 in supine MRI to describe lumbar hipolordotic and
> 30 to normal lordotic curve.

Figure 9. Left: Measurement technique for lumbar lordotic. Right: measurement technique for lumbar scoliosis
III. Result
A total 20 patient who a candidate for lumbar decompression surgery were
evaluated. 13 Men (65%) and 7 Female (35%), and mean age was 57,75 years. (Table
1)

Number

Degenerative lumbar stenosis 20

Mean Age (Years) 57,75

Sex (Male/Female) 13/7

Table 1. Demographic Characteristics

From clinical findings, Mild axial pain were dominant, with 12 patient ( 60%),
followed 8 patient with moderate axial pain (40%). Moderate radicular pain in 18
patient (90%), and 2 severe radicular pain (10%). Severe neurogenic claudication
intermitten (<50 M walking distance) was found in 12 patients (60%), followed by
moderate neurogenic claudication intermitten in 6 patients (30%). Paresthesia or “pin
and needle sensastion” was found in 17 patients (85%) and numbness in 15 patients
(75%). 3 patiens (15%) have a slight motoric deficit (grade 4). (Table 2)

Clinical Findings Number

Axial Pain
Mild (VAS 0-2) 12
Moderate (VAS 3-7) 8
Severe (VAS 8-10) 0
Radicular Pain
Mild (VAS 0-2) 0
Moderate (VAS 3-7) 18
Severe (VAS 8-10) 2
Neurogenic Claudicatio Intermitten
>100 M 2
50-100 M 6
<50 M 12
Sensoric Deficit
Paresthesia 17
Numbness 15
Anesthesia 0
Motoric Deficit
Grade 0 0
Grade 1 0
Grade 2 0
Grade 3 0
Grade 4 3
Grade 5 17
Table 2. Clinical Findings Characteristics
MRI Findings (table 3 and 4)

We found all of the patient have degenerative disc diseases. For instance, we
recorded patient with moderate and severe stenotic on MRI. Only 4 patient (20%) with 1
level moderate to severe lumbar stenosis (3 patient at L4-L5 and 1 patient at L3-L4), 8
patient (40%) with 2 level moderate – severe lumbar stenosis (4 patient at L3-L4-L5, and
4 patient at L4-L5-S1) and 8 patient (40%) with 3 level moderate – severe lumbar
stenosis (6 patient at L3-S1 and 2 patient at L2-L5). There was no patient with >3 level
moderate-severe lumbar stenosis.(table 3)

Number

1 level moderate-severe stenosis 4

2 level moderate-severe stenosis 8
3 level moderate-severe stenosis 8
Table 3 Stenosis level involved Characteristics

The most common site for severe central stenosis (grade 3) was at L4-L5 level.
there were 16 patient (80%), followed by L5-S1 level with 6 patient (30%), and L3-L4
level with 5 patient 25%. For moderate stenosis (grade 2) the most common site was at
L3-L4 level with 8 patient (40%).
The most common site for severe lateral recess stenosis (grade 3) was at L4-L5
level with 11 patient (55%), followed by L3-L4 level with 6 patient (30%) and L5-S1
level with 5 patient (25%). For moderate stenosis (grade 2) the most common site was at
L4-L5 level with 3 patient (15%).
The most common site for severe foraminal stenosis (grade 3) was at L4-L5 level
with 6 patient (30%), followed by L5-S1 with 5 patient (25%) and for moderate stenosis
still at L4-L5 level with 5 patient (25%).
The most common site for prolapse disc (grade 4 and 5 herniated disc) was at L4-
L5 level with 15 patient (75%) grade 4 herniated disc, followed by L5-S1 level with 6
patient, 5 (25%) grade 4 and 1 (5%) grade 5, and L3-L4 level with 4 patient (20%) grade
4.
 The most common site for severe facet joint degeneration was at L4-L5 level with
14 patient (70%) followed by L5-S1 level with 6 patient (30%) and L3-L4 level with 4
patient (20%).
L4-L5 level was the most common site for modic changes (9 end plate level or
9%) with modic type 1 found at 3 end plate and type 3 at 6 end plate . there were no end
plate changes in 17 patient
The most common site for severe disc degeneration (pfirman grade 5) was at L4-
L5 level with 9 patient (45%) followed by L5-S1 level with 5 patient (25%) and L3-L4
level with 4 patient (20%).
3 patient show a segmental instability on supine MRI, 2 patient at L4-L5 level
show anterior listhesis, and 1 patient at L3-L4 show a lateral listhesis.

MRI Findings L1-L2 L2-L3 L3-L4 L4-L5 L5-S1

Canal stenosis
Grade 0 6 7 1 0 0
Grade 1 14 12 6 2 11
Grade 2 0 3 8 2 3
Grade 3 0 0 5 16 6
Lateral Recess Stenosis
Grade 0 17 18 10 2 7
Grade 1 3 1 4 4 7
Grade 2 0 0 0 3 1
Grade 3 0 1 6 11 5
Foraminal Stenosis
Grade 0 17 17 5 2 6
Grade 1 1 1 12 7 8
Grade 2 0 0 3 5 1
Grade 3 2 3 0 6 5
Facet Joint Degeneration
Grade 0 1 0 0 0 0
Grade 1 4 2 0 0 2
Grade 2 14 10 6 1 3
Grade 3 1 6 10 5 9
Grade 4 4 2 4 14 6
Modic Changes
Normal 17 15 17 11 15
Type 1 1 3 2 3 1
Type 2 1 0 0 0 0
Type 3 1 2 1 6 4
Pfirman Grading
Grade 0 6 4 4 0 4
Grade 1 3 2 1 0 3
Grade 2 4 2 2 2 1
Grade 3 5 6 7 7 7
Grade 4 1 3 2 2 2
 Grade 5 1 3 4 9 5
MRI Findings L1-L2 L2-L3 L3-L4 L4-L5 L5-S1
Herniated Disc
Grade 0 10 8 5 1 2
Grade 1 6 6 2 0 0
Grade 2 2 3 6 2 5
Grade 3 2 3 3 2 7
Grade 4 0 0 4 15 5
Grade 5 0 0 0 0 1
Segmental Instability
Anterolisthesis 0 0 0 2 0
Retrolisthesis 0 0 0 0 0
Lateral listhesis 0 0 1 0 0
Table 3 MRI Findings Characteristics

At the supine MRI, 8 patient (35%) have kyposcoliotic deformity and 3 (15%)
patient with hipolordotic deformity. All the patient who have kyphoscoliotic curve
deformity curve were found have 3 or more moderate to severe herniated disc and or
facet joint degeneration.

Number

Kyposcoliotic 8

Hipolordotic 3

Table 4. Deformity Characteristics

IV. Discussion

For patient who a candidate for lumbar decompression surgery the typical clinical
findings show mild axial pain accompanied with moderate to severe radicular pain ,
moderate to severe neurogenic claudication intermitten and almost all patient have
sensoric deficit, and a few patient have slight motoric deficit. They show severe
simptomps due to in our institute, we try conservative treatment first, and surgery was
considered after failure conservative therapy or progressive neurological deficit.

The most common involved level that show moderate to severe lumbar stenosis,
facet joint degeneration, disc degeneration, lumbar segmental instability and
herniated disc was L4-L5 level followed by L5-S1 and L3-L4 level. They are the
most lower lumbar segment, that have weight bearing function, and transmit the
weight to pelvic and limb. The pathology was multiple due to degenerative process of
the motion segment of lumbar spine. Disc degeneration leads to increased rotational
instability of the Z joints, resulting in further degeneration of these structures. This
process of degenerative changes of the IVDs leading to degeneration of the Z joints
also has been supported with computer models of spine function 24. The iliolumbar
ligament probably function to stabilize the L5-S1 junction, helping to maintain the
proper relationship of L5 on S125 and also to prevent disc degeneration at this level26.
The greater degeneration at the L4-5 level is presumably the result of increased loads
being transmitted there, secondary to decreased motion at the L5-S1 motion
segment26.

Our data show all of 8 patient with degenerative kyposcoliotic deformity have 3
level moderate to severe lumbar stenosis accompanied with multiple level severe
facet joint osteoarthritis. Although the gold standad to measured adult degenerative
scoliosis (ADS) was standing X ray, we still record data that show in supine MRI.
This characteristic study show 8 or 40% patient who show severe simptomps of
lumbar stenosis also have ADS and this number probably increase if we performed
standing and dynamic imaging. ADS is thought to initiate from degeneration first of
 the intervertebral discs followed by the posterior column 27. In a healthy spine, the
facet joints provide stability in flexion and extension and protect the disc from
excessive torsion. When discs begin to degenerate, resulting in loss of height and
segmental instability, increased loads are placed on the facets. It is generally accepted
that degenerative changes lead to asymmetric loads on the disc and facet joints
leading to progressive deformity with the potential for foraminal or central canal
stenosis due to osteophytes and ligamentum buckling. Axial rotation can then ensue
putting stretch on surrounding ligaments and instability and lateral listhesis can ensue.
In terms of supporting structures, extensor muscles of the spine decrease in density
and increase in fatty infiltration with increasing age, a process that begins in the lower
segments and extends proximally with increasing age28.

Conclusion
Multiple lumbar spinal pathology always seen when we measure a MRI of a symptomatic
degenerative lumbar stenosis patient, and the most common level involved was three most lower
segment of the lumbar spine (L3-L4, L4-L5, and L5-S1). Indication of surgery must choose
wisely based on patient symptomps accompanied a neural compression on MRI.

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