Neuroradiolog y / Head and Neck Imaging • Original Research

Lee et al.
MRI Grading of Lumbar Foraminal Stenosis

Neuroradiology/Head and Neck Imaging

Original Research
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A Practical MRI Grading System for

Lumbar Foraminal Stenosis
Seunghun Lee1 OBJECTIVE. This study aimed to evaluate the reproducibility of a new grading system
Joon Woo Lee1 for lumbar foraminal stenosis.
Jin Sup Yeom2 MATERIALS AND METHODS. Four grades were developed for lumbar foraminal
Ki-Jeong Kim 3 stenosis on the basis of sagittal MRI. Grade 0 refers to the absence of foraminal stenosis;
Hyun-Jib Kim 3 grade 1 refers to mild foraminal stenosis showing perineural fat obliteration in the two oppos-
ing directions, vertical or transverse; grade 2 refers to moderate foraminal stenosis showing
Soo Kyo Chung 4
perineural fat obliteration in the four directions without morphologic change, both vertical
Heung Sik Kang1 and transverse directions; and grade 3 refers to severe foraminal stenosis showing nerve root
Lee S, Lee JW, Yeom JS, et al. collapse or morphologic change. A total of 576 foramina in 96 patients were analyzed (from
L3–L4 to L5–S1). Two experienced radiologists independently assessed the sagittal MR im-
ages. Interobserver agreement between the two radiologists and intraobserver agreement by
one reader were analyzed using kappa statistics.
RESULTS. According to reader 1, grade 1 foraminal stenosis was found in 33 foramina,
grade 2 in six, and grade 3 in seven. According to reader 2, grade 1 foraminal stenosis was
found in 32 foramina, grade 2 in six, and grade 3 in eight. Interobserver agreement in the
grading of foraminal stenosis between the two readers was found to be nearly perfect (κ value:
right L3–L4, 1.0; left L3–L4, 0.905; right L4–L5, 0.929; left L4–L5, 0.942; right L5–S1,
0.919; and left L5–S1, 0.909). In intraobserver agreement by reader 1, grade 1 foraminal
stenosis was found in 34 foramina, grade 2 in eight, and grade 3 in seven. Intraobserver agree-
ment in the grading of foraminal stenosis was also found to be nearly perfect (κ value: right
L3–L4, 0.883; left L3–L4, 1.00; right L4–L5, 0.957; left L4–L5, 0.885; right L5–S1, 0.800;
and left L5–S1, 0.905).
Keywords: foraminal stenosis, lumbar vertebrae, neural CONCLUSION. The new grading system for foraminal stenosis of the lumbar spine
foramen, sagittal MRI
showed nearly perfect interobserver and intraobserver agreement and would be helpful for
DOI:10.2214/AJR.09.2772 clinical study and routine practice.

Received March 20, 2009; accepted after revision

September 11, 2009.
1
Department of Radiology, Seoul National University
Bundang Hospital, 300 Gumi-dong, Bundang-gu,
Seongnam-si, Gyeongi-do 463-707, Korea. Address
correspondence to J. W. Lee (joonwoo2@gmail.com).
2
Department of Orthopaedic Surgery, Seoul National
University Bundang Hospital, Gyeongi-do, Korea.
3
Department of Neurosurgery, Seoul National University
Bundang Hospital, Gyeongi-do, Korea.
4
Department of Radiology, Kangnam St. Mary’s Hospital,
Catholic University, Seoul, Korea.
AJR 2010; 194:1095–1098
0361–803X/10/1944–1095
© American Roentgen Ray Society
L
umbar foraminal stenosis is de-
fined 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 verte-
bra, and buckling of the ligamentum flavum
or protrusion of the annulus fibrosus [1].
MRI is widely used in the evaluation of
lumbar foraminal stenosis; however, there is
no widely used diagnostic criterion or grad-
ing system for lumbar foraminal stenosis on
MRI. For clinical studies with the objective
of comparing different therapeutic methods
for lumbar foraminal stenosis, an adequate
grading system that has good reproducibil-
ity is necessary. In addition, in daily routine
practice, a grading system for lumbar foram-
inal stenosis is necessary for writing radio-
logic reports.
There have been few reports on the grading
or classification of lumbar foraminal stenosis
on MRI [2, 3]. The grading system suggested
by Wildermuth et al. [2] focused on only the
degree of epidural fat obliteration. The classi-
fication of lumbar foraminal stenosis proposed
by Kunogi and Hasue [4] included the antero-
posterior, cephalocaudal, and circumferential
types without stenosis grade. The grading sys-
tem of Wildermuth et al. and the classification
proposed by Kunogi and Hasue do not con-
sider direct nerve root compression or defor-
mity, which may be important. In our depart-
ment, we have created a new grading system;
it is a modification of the previous systems

AJR:194, April 2010 1095

 Lee et al.

that takes into consideration the type of steno-
sis, amount of fat obliteration, and presence of
nerve root compression.
The purpose of this study was to evaluate
the reproducibility of this new grading sys-
tem for lumbar foraminal stenosis and to dis-
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Hasue [4], as illustrated in Figure 1. Grade 0 refers
to the absence of foraminal stenosis; grade 1 refers
to mild foraminal stenosis showing perineural fat
obliteration surrounding the nerve root in the two
opposing directions (vertical or transverse). It in-
volves contact with the superior and inferior por-
spin-echo (FSE) sagittal and axial images were ob-
tained (TR/TE, 500/15 for T1-weighted images and
3,600/120 for T2-weighted images; slice thickness,
4 mm; slice gap, 0.4 mm; field of view, 32 cm for
sagittal images and 16 cm for axial images; matrix,
512 × 512; flip angle, 90°; and excitations, 3).

cuss its clinical relevance.
Materials and Methods
Establishment of MRI Grading System for
Lumbar Foraminal Stenosis
After several meetings with two radiologists,
two orthopedic surgeons, and three neurosurgeons,
we determined the criteria for lumbar foraminal
stenosis on sagittal MRI. Sagittal T1-weighted im-
aging was the main sequence evaluated with T2-
weighted imaging also used as an additional tool
to exclude false-positive findings resulting from
the misinterpretation of perineural cysts or nerve
root swelling. This grading system was established
without changing the classic MRI protocol in the
lumbar spine. Four grades were developed using
a modification of the classification by Kunogi and
tions of the nerve root or anterior and posterior por-
tions of the nerve root. No evidence of morphologic
change in the nerve root is shown. Grade 2 refers
to moderate foraminal stenosis showing perineu-
ral fat obliteration surrounding the nerve root in the
four directions without morphologic change in both
vertical and transverse directions. Grade 3 refers to
severe foraminal stenosis showing nerve root col-
lapse or morphologic change.
MRI
All patients underwent imaging using a 1.5-T im-
ager (Gyroscan Intera Achieva, Philips Healthcare)
with a Synergy Spine Coil (Philips Healthcare). The
patients were placed in the supine position with a
cushion under both knees. T1-weighted spin-echo
sagittal and axial images and T2-weighted fast
Case Selection
Our study was approved by the institutional re-
view board. Informed consent was not required
for this MRI analysis. All 440 consecutive pa-
tients were selected from a database of MR ex-
aminations of the lumbar spine performed at our
institution in June 2007.
The exclusion criteria were patients under 60
years old; evidence of infection, tumor, or frac-
ture on MRI; previous lumbar operation; and ev-
idence of foraminal disk extrusion with superior
migration. Thus, 344 patients were excluded and
96 patients were included in this study. The av-
erage patient age was 69.35 years (range, 60–86
years) and there were 35 men (36.5%) and 61
women (63.5%).

A B C

D E
Fig. 1—Schematic illustrations of 4-point-scale for grading foraminal stenosis in sagittal MRI of lumbar spine.
A, Grade 0 (normal). Schematic diagram of sagittal cross section through foramen shows relationships between foramen and surrounding structures. NR = nerve root,
V = vertebral body, D = intervertebral disk, LF = ligamentum flavum, FJ = facet joint.
B, Grade 1 (mild degree of foraminal stenosis). Schematic diagram shows perineural fat obliteration surrounding nerve root in transverse direction (arrows). There is
narrowing of superior foraminal width due to disk space narrowing and thickened ligamentum flavum. No evidence of morphologic change in nerve root is seen.
C, Grade 1 (mild degree of foraminal stenosis). Schematic diagram shows perineural fat obliteration surrounding nerve root in vertical direction (arrows). There is
narrowing of foraminal height due to disk space narrowing and diskoosteophytic protrusion in foraminal zone. No evidence of morphologic change in nerve root is seen.
D, Grade 2 (moderate degree of foraminal stenosis). Schematic diagram shows 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. No evidence of morphologic change in nerve root is seen.
E, Grade 3 (severe degree of foraminal stenosis). Schematic diagram shows nerve root collapse or morphologic change (arrows) due to severe disk space narrowing,
severe thickened ligamentum flavum, facet arthropathy and diskoosteophytic protrusion in foraminal zone.

1096 AJR:194, April 2010

 MRI Grading of Lumbar Foraminal Stenosis
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Fig. 2—Case of grade 0 foraminal stenosis. T1-
weighted sagittal image of 62-year-old woman with
lower back pain shows normal nerve root without
compression.
Fig. 3—Case of grade 1 foraminal stenosis in
transverse direction. T1-weighted sagittal image of
69-year-old woman with right lower extremity pain
shows that narrowing of transverse width of neural
foramen and thick ligamentum flavum decrease
anteroposterior width of right L4–L5 neural foramen.
Perineural fat obliteration surrounding nerve root in
transverse direction (arrows) is noted.
Fig. 4—Case of grade 1 foraminal stenosis in vertical
direction. T1-weighted sagittal image of 63-year-old
man with left lower extremity weakness shows that
narrowing of intervertebral disk space decreases
height of left L4–L5 neural foramen. Vertical abutting
of nerve root (arrows) is noted.

MRI Imaging Analysis Results patients; reader 2 detected foraminal steno-

Two experienced spine radiologists (readers 1 MR images of varying degrees of fo- sis in 30 patients; Also, reader 1 again de-
and 2), who had 7 and 10 years of experience, re- raminal stenosis are shown in Figures 2–6. tected foraminal stenosis in 31 patients after
spectively, at the time of MR analysis, were blind- Reader 1 detected 29 patients with foram- more than 12 months. According to reader 1,
ed to the clinical information and radiologic re- inal stenosis on the MR examinations of 96 grade 1 foraminal stenosis was found in 33
ports. To assess reproducibility, they evaluated
the sagittal MR images of the selected cases inde-
pendently, and reader 1 evaluated the sagittal MR
images of the selected cases after more than 12
months. The examinations were reviewed in a ran-
dom order to avoid bias.
A total of 960 foramina and corresponding nerve
roots in 96 patients were qualitatively analyzed (six
foramina/person) from L1–L2 to L5–S1. A total of
384 foramina of the L1–L2 and L2–L3 levels were
excluded because of the rarity of foraminal steno-
sis on these levels. A total of 576 foramina were
assessed for possible foraminal stenosis through a
combination of both T1- and T2-weighted sagittal
images. Each radiologist assessed the presence and
grade of foraminal stenosis according to the new
grading system previously described.

Statistical Analysis
Interobserver agreement between the two radiol-
ogists and intraobserver agreement (reader 1) were
analyzed by using kappa statistics. A kappa value of
less than 0.20 indicated slight; 0.21–0.40, fair; 0.41–
0.60, moderate; 0.61–0.80, substantial; and 0.81 or
greater, nearly perfect agreement [5]. The Statistical
Package for the Social Sciences for Windows (ver-
sion 13.0, SPSS) was used for statistical analyses.
Fig. 5—Case of grade 2 foraminal stenosis. T1-
weighted sagittal image of 65-year-old woman
with right lower extremity pain shows narrowing
of intervertebral disk space, thickened ligamentum
flavum, and focal disk protrusion in foraminal zone
cause perineural fat obliteration surrounding nerve
root of left L5–S1 in both vertical and transverse
directions (arrows).
Fig. 6—Case of grade 3 foraminal stenosis. T1-
weighted sagittal image of 82-year-old woman with
right lower extremity pain shows collapse of right
L4–L5 nerve root (arrows). This finding is compatible
with grade 3 foraminal stenosis.

AJR:194, April 2010 1097


foramina, grade 2 in six, and grade 3 in sev-
en. According to reader 2, grade 1 foraminal
stenosis was found in 32 foramina, grade 2
in six, and grade 3 in eight. After more than
12 months, reader 1 found grade 1 foraminal
stenosis in 34 foramina; grade 2 in eight; and
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grade 3 in seven.
Interobserver agreement in the grading
of foraminal stenosis between the two read-
ers on sagittal MRI was found to be nearly
perfect (κ value: right L3–L4, 1.0; left L3–
L4, 0.905; right L4–L5, 0.929; left L4–L5,
0.942; right L5–S1, 0.919; and left L5–S1,
0.909). Intraobserver agreement by reader 1
also was found to be nearly perfect (κ value:
right L3–L4, 0.883; left L3–L4, 1.00; right
L4–L5, 0.957; left L4–L5, 0.885; right L5–
S1, 0.800; and left L5–S1, 0.905).
Regarding the frequency of foraminal
stenosis, there were four instances (4.16%)
at the level of right L3–L4, six (6.25%) at
left L3–L4, eight (8.33%) at right L4–L5,
10 (10.42%) at left L4–L5, seven (7.29%) at
right L5–S1, and 11 (11.46%) at left L5–S1 for
reader 1. For reader 2, there were four instanc-
es (4.16%) at the level of right L3–L4, five
(5.21%) at left L3–L4, eight (8.33%) at right
L4–L5, 10 (10.42%) at left L4–L5, six (6.25%)
at right L5–S1, and 13 (13.54%) at left L5–
S1. For reader 1 (after more than 12 months),
there were five instances (5.21%) at the lev-
el of right L3–L4, six (6.25%) at left L3–L4,
eight (8.33%) at right L4–L5, nine (9.38%) at
left L4–L5, nine (9.38%) at right L5–S1, and
12 (12.50%) at left L5–S1. A higher incidence
of foraminal stenosis was found in the left side
and lower lumbar segments.
Discussion
In this study, the new grading system for
lumbar foraminal stenosis showed high in-
terobserver and intraobserver agreements.
The existing qualitative grading system by
Wildermuth et al. [2] is described as follows:
grade 0 indicates normal foramina (normal
dorsolateral border of the intervertebral disk
and normal form at the foraminal epidural
fat [oval or inverted pear shape]); grade 1,
slight foraminal stenosis and deformity of
the epidural fat, with the remaining fat still
completely surrounding the exiting nerve
root; grade 2, marked foraminal stenosis
with epidural fat only partially surrounding
the nerve root; and grade 3, advanced steno-
sis with obliteration of the epidural fat. How-
1098
Lee et al.
ever, this scoring system lacks characteris-
tics of the morphologic nerve root change.
Hasegawa et al. [1], in a cadaveric study,
showed that significant nerve root compres-
sion is commonly associated with a foraminal
height of 15 mm or less and a posterior disk
height of 4 mm or less. They concluded that
these critical dimensions might be indicators
of lumbar foraminal stenosis. As the superi-
or facet continues to subluxate, the alteration
of biomechanical forces contributes to the de-
velopment of a hypertrophic ligamentum fla-
vum and bony spurs, which may diminish the
volume of the foramen to a greater extent.
This combination of disk space narrowing
and overgrowth of structures anterior to the
facet joint capsule may lead to anteroposteri-
or stenosis (transverse stenosis). The exiting
nerve root is compressed between the supe-
rior articular facet and the posterior vertebral
body in a transverse direction.
An additional cause of foraminal stenosis is
craniocaudal compression (vertical stenosis).
Posterolateral osteophytes from the vertebral
endplates protrude into the foramen along with
a laterally bulging annulus fibrosis or herni-
ated disk, compressing the nerve root against
the superior pedicle. In this case, the posterior
aspect of the foramen may remain patent to
palpation, possessing adequate amounts of fat
despite significant compromise of the avail-
able space for the nerve root [6]. A combina-
tion of these two types of static changes in fo-
raminal volume may develop and cause severe
circumferential stenosis [1]. However, critical
dimensions for foraminal stenosis differ ac-
cording to race, sex, and age.
Compared with the previous grading sys-
tems that focused on perineural fat obliteration
only or quantitative assessment of the foram-
inal dimension, our grading system for lum-
bar foraminal stenosis includes both perineu-
ral fat obliteration and nerve root morphology
on the basis of sagittal MR images. This sys-
tem is more practicable for grading foraminal
stenosis considering the frequency of radicul-
opathy caused by nerve root irritation.
A higher incidence of foraminal steno-
sis is found in the left side and lower lum-
bar segments. According to previous reviews
[1, 7], the most common roots involved were
the fifth lumbar root, followed by the fourth,
third, and second.
The higher incidence of disk degenera-
tion and spondylosis at the L4–L5 and L5–
S1 levels leading to subluxation and foram-
inal narrowing contributes to the increased
susceptibility of the L4 and L5 nerve roots
to static and dynamic compression. The low-
er lumbar nerve roots are also characterized
by a more oblique course throughout the lat-
eral canal, increasing their susceptibility to
the effects of pedicular kinking and foram-
inal stenosis [6].
There are several limitations to our study.
One limitation was that our grading system
is based on sagittal MR morphology without
symptomatic correlation. Symptomatic fo-
raminal stenosis may be caused by dynam-
ic changes, such as lumbar extension, which
cannot be detected in the closed MR system.
Therefore, future studies will be necessary
that include correlation of the dynamic posi-
tional effects on the foraminal stenosis with
clinical symptoms in open or closed MR sys-
tems. A second limitation was that direct
comparison with previous grading systems
was not conducted in this study.
In conclusion, preliminary results suggest
that our new grading system for foraminal
stenosis is reproducible and may be helpful
in the diagnosis and grading of lumbar fo-
raminal stenosis. Further studies will be re-
quired to determine its clinical utility.
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