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Finkenstaedt2018 PDF
Finkenstaedt2018 PDF
https://doi.org/10.1007/s00256-018-2935-3
SCIENTIFIC ARTICLE
Received: 23 November 2017 / Revised: 20 March 2018 / Accepted: 22 March 2018 / Published online: 13 April 2018
# ISS 2018
Abstract
Objective To investigate whether upright radiographs can predict lumbar spinal canal stenosis using supine lumbar magnetic
resonance imaging (MRI) and to investigate the detection performance for spondylolisthesis on upright radiographs compared
with supine MRI in patients with suspected lumbar spinal canal stenosis (LSS).
Materials and Methods In this retrospective study, conventional radiographs and MR images of 143 consecutive patients with
suspected LSS (75 female, mean age 72 years) were evaluated. The presence and extent of listhesis (median ± interquartile range)
were assessed on upright radiographs and supine MRI of L4/5. In addition, the grade of central spinal stenosis of the same level
was evaluated on MRI according to the classification of Schizas and correlated with the severity/grading of anterolisthesis on
radiographs.
Results Anterolisthesis was detected in significantly more patients on radiographs (n = 54; 38%) compared with MRI (n = 28;
20%), p < 0.001. Pairwise comparison demonstrated a significantly larger extent of anterolisthesis on radiographs (9 ± 5 mm)
compared with MRI (5 ± 3 mm), p < 0.001. A positive correlation was found regarding the extent of anterolisthesis measured on
radiographs and the grade of stenosis on MRI (r = 0.563, p < 0.001). Applying a cutoff value of ≥5 mm anterolisthesis on
radiographs results in a specificity of 90% and a positive predictive value of 78% for the detection of patients with LSS, as
defined by the Schizas classification.
Conclusion Upright radiographs demonstrated more and larger extents of anterolisthesis compared with supine MRI. In addition,
in patients with suspected LSS, the extent of anterolisthesis on radiographs (particularly ≥5 mm) is indicative of LSS and warrants
lumbar spine MRI.
Keywords Magnetic resonance imaging . Radiography . Spine . Lumbar spine . Spinal canal stenosis . Degenerative spinal
changes . Lower back pain . Claudication . Listhesis . Anterolisthesis . Spondylolisthesis
* Sebastian Winklhofer 5
Department of Neurosurgery, Spine Center, Schulthess Clinic,
sebastian.winklhofer@usz.ch Zurich, Switzerland
6
1
Horten Center for Patient Oriented Research and Knowledge
Institute of Diagnostic and Interventional Radiology, University Transfer, University of Zurich, Zurich, Switzerland
Hospital Zurich, University of Zurich, Zurich, Switzerland 7
2
Department of Radiology, Kantonsspital Muensterlingen,
Department of Radiology, University of California, San Diego, Münsterlingen, Switzerland
School of Medicine, La Jolla, CA 92093, USA 8
3
Department of Neuroradiology, University Hospital Zurich,
Institute of Diagnostic and Interventional Radiology, Ospedale University of Zurich, Frauenklinikstrasse 10,
Regionale di Lugano, Lugano, Switzerland 8091 Zurich, Switzerland
4
Phoenix Diagnostic Clinic, Bucharest, Romania
1270 Skeletal Radiol (2018) 47:1269–1275
Introduction
written and oral information about the study and gave their Radiographs
written informed consent to participation.
The lumbar spine was examined using standard digital X-ray
equipment in lateral and anteroposterior projection in an up-
Study population right position.
Fig. 2 Example of a 58-year-old male patient with lower back pain and Schizas et al. [14] as assessed on c the axial T2w MR image. In c, no
abnormal sensations in both lower extremities and buttocks, suggestive of rootlets or cerebrospinal fluid signal are distinguishable within the dural
lumbar spinal stenosis. The anterolisthesis visible at L4/5 on a the upright sac at level L4/5, but there is still epidural fat present, which is equivalent
radiograph is markedly greater (arrow) compared with b the supine ac- to a severe grade C stenosis. Blue dashed line in b indicates the axial level
quired sagittal T2w MR image. The extent of anterolisthesis measured on shown in c
the radiograph (a) correlates with the grade of stenosis according to
Presence or absence of anterolisthesis was compared among degree of anterolisthesis in millimeters (ICC = 0.945 [95%
radiographs and MRI using the Chi-squared test. Student’s CI, 0.907–0.968] and ICC = 0.918 [95% CI, 0.831–0.961]
paired t test was used for comparing anterolisthesis measure- respectively, each p < 0.001).
ments (in millimeters) from radiographs with measurements Similarly, the inter-reader analysis demonstrated a high
on MRI with corresponding mean differences. The Wilcoxon agreement regarding the degree of anterolisthesis on radio-
signed-rank test was used to assess differences among the graphs and MRI in millimeters (ICC = 0.907 [95% CI,
listhesis grading (Meyerding classification) among radio- 0.845–0.945] and ICC = 0.9 [95% CI, 0.795–0.952] respec-
graphs and MRI. Spearman’s rho correlation test was used to tively, each p < 0.001).
assess for correlations between the extent of anterolisthesis on
radiographs and MRI and the grade of central spinal canal
stenosis according to the Schizas classification. Sensitivity Listhesis and spinal canal stenosis
and specificity in addition to positive predictive value (PPV)
and negative predictive value (NPV), with their corresponding Anterolisthesis was detected in 54 patients on radiographs
95% CI for the determination of the grade of spinal canal (38%) and in 28 patients on MRI (20%, p < 0.001, Fig. 3).
stenosis by the grade of anterolisthesis on radiographs, were This results in 18% more detected patients with anterolisthesis
calculated using Chi-squared tests. A p value of <0.05 was ≥3 mm by means of standing radiographs compared with MRI.
used to denote statistical significance. With the exception of one case, all cases of anterolisthesis that
were detected by MRI were also visible on the corresponding
radiographs. Retrospectively, in this single case, an
anterolisthesis of 3 mm was measured on the MR scan, whereas
Results only a small step of 2 mm was visible on the radiograph.
Therefore, in a total of 55 patients, an anterolisthesis was de-
The Shapiro–Wilk test demonstrated non-normally distributed
tected on radiographs and/or MRI. In cases with detected
data for listhesis measurement on radiographs and MRI
listhesis on both imaging modalities (n = 27), the extent of
(p < 0.05, each).
listhesis was significantly (p < 0.001) larger on upright radio-
graphs (9 ± 5 mm, 95% CI, 7–10) compared with supine MRI
Intra-and inter-reader analysis (5 ± 3 mm, 95% CI, 4–7), mean difference 2.9 ± 1.9 mm
(Fig. 4). The Meyerding listhesis classification demonstrated
Measurements of the anterolisthesis on radiographs and MRI a statistically significantly higher grade of listhesis on radio-
demonstrated a high intra-reader agreement regarding the graphs (median Meyerding: grade 1 = 76%, grade 2 = 25%,
Skeletal Radiol (2018) 47:1269–1275 1273
Discussion
grade 3 = 0%) compared with MRI (median Meyerding: grade
1 = 96%, grade 2 = 4%, grade 3 = 0%; p < 0.001). Our study showed that in 18% of patients, anterolisthesis of the
According to the LSOS database [16], the following lumbar segment L4/5 would have been missed if only supine
Schizas grades have been assigned to the 55 patients of our MRI and no upright radiographs were taken into account.
study who showed an anterolisthesis on radiographs and/or Furthermore, the extent of anterolisthesis was significantly
MRI: Schizas grade A: n = 14 (25.5%); grade B: n = 7 underestimated on MRI alone. Both conclusions are likely
(13%), grade C: n = 20 (36%); grade D: n = 14 (25.5%). A due to the weight-bearing conditions prevailing during upright
positive correlation was found regarding the extent of listhesis radiograph acquisition [22, 23]. In the standing position, the
spine is loaded, the intervertebral space decreases in cases with
preexisting osteochondrosis, which leads not only to a decrease
in the craniocaudal neuroforamina diameter [24], but also to an
increase in the pressure on the facet joints, which in turn leads
to anterior slipping of the superior vertebra in the further stages
of spondylarthrosis [25–28]. These secondary findings of our
study concur with those of other studies that showed that up-
right imaging modalities detect more anterolisthesis than su-
pine imaging [24, 29]. In particular, the study by Segebarth
et al. showed that 28% of patients with degenerative LSS
would be missed on supine MRI alone [30]. The clinical benefit
from the detection of anterolisthesis in addition to its severity
using upright lumbar radiographs is that the treating physician
can estimate to what extent the MRI findings worsen under
load-bearing conditions, and that within the scope of surgery
planning, a considerable anterolisthesis may require additional
dorsal instrumentation [31].
Degenerative spondylolisthesis is a well-known cause of
Fig. 4 Larger extents of anterolisthesis were found on radiographs (9 ±
LSS and its extent on upright radiographs may point to the
5 mm; hatched boxplot) compared with MRI (mean 5 ± 3 mm; plain grade of stenosis, the primary hypothesis examined in this
boxplot), p < 0.001 current study. To the best of our knowledge, there has been
1274 Skeletal Radiol (2018) 47:1269–1275
no previous work that assessed the relationship between In conclusion, upright radiographs demonstrated more and
spondylolisthesis on upright radiographs and central spinal larger extents of anterolisthesis compared with supine. In ad-
canal stenosis, as defined by Schizas et al., a MRI classifica- dition, in patients with suspected LSS, the extent of
tion system that considers impingement of neural tissue to anterolisthesis on radiographs (particularly ≥5 mm) is indica-
yield a better morphoclinical correlation. In our study, we tive of lumbar spinal canal stenosis and warrants lumbar spine
found a positive correlation regarding the grade of listhesis MRI.
measured on radiographs and the grade of stenosis on MRI
(r = 0.563). Applying a cutoff value for anterolisthesis ≥5 mm Compliance with ethical standards
on radiographs results in a specificity of 90% (= high certainty
that in the case of anterolisthesis ≥5 mm on radiographs, a Conflicts of interest This study was supported by the Helmut Horten
Foundation, Baugarten Foundation, Pfizer-Foundation for geriatrics and
Schizas’ grade C/D stenosis is present) and a PPV of 78%
research into geriatrics, Symphasis Charitable Foundation and OPO-
for the detection of patients with Schizas’ grade C/D stenosis. Foundation. We disclose any financial support or author involvement
We have set the cutoff value to 5 mm for anterolisthesis be- with organization(s) with a financial interest in the subject matter.
cause = that is above the currently accepted threshold of 4 mm
for diagnosing lumbar segmental instability [32] and to in- IRB statement This study was approved by the local ethical committee
of the University of Zurich, Switzerland. All procedures performed in this
crease the test specificity. The low NPV and sensitivity sug-
study involving human participants were in accordance with the ethical
gest that the threshold of ≥5 mm anterolisthesis on radio- standards of the institutional and/or national research committee and with
graphs is not suitable for ruling out high-grade spinal canal the 1964 Declaration of Helsinki and its later amendments or comparable
stenosis. ethical standards.
The clinical benefit resulting from our primary study goal is
Informed consent All patients received written and oral information
as follows. In reality, most patients with back pain are treated
about the study and gave their written informed consent for participation.
beyond the setting of University Hospitals and highly special- The project was registered at http://www.research-projects.uzh.ch/
ized spine centers. Most frequently, upright radiographs only p16804.htm.
are performed in patients seeking help for lumbar back pain as
MRI is not affordable in many cases. Our study provides evi-
dence that an anterolisthesis of ≥5 mm on upright radiographs
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