CHAPTER
71
538  IMAGING PAINFUL SPINE DISORDERS
SPINAL STENOSIS—CERVICAL
Douglas S. Fenton, M.D.
CLINICAL PRESENTATION
The patient is a 60-year-old woman complaining of headache,
imbalance, lightheadedness, and left-leg numbness. She also com-
plains of increasing numbness in her hands with some hand disco-
ordination. She has had significant neck and bilateral shoulder
pain, possibly somewhat worse on the left side. On examination,
she demonstrates −1 paresis of the biceps, triceps, wrist extensors,
wrist flexors, and interossei musculature. Her grasp is diminished,
particularly on the right.
IMAGING PRESENTATION
Sagittal T2-weighted and axial fat-saturated, T2-weighted mag-
netic resonance (MR) images were obtained and demonstrate a
long segment region of decreased signal intensity along the poste-
rior aspect of the vertebral bodies from C3-C5, which is greatest
at the C3-4 level. The findings represent a disc herniation at C3-4
in a patient with ossification of the posterior longitudinal ligament.
There is severe spinal stenosis at C3-4 and a long segment region
of abnormal increased T2 signal intensity in the cervical spinal
cord from mid C3 to the C5-6 level compatible with spinal cord
ischemia and/or myelomalacia (Fig. 71-1).
DISCUSSION
Cervical spinal stenosis can be defined as any narrowing of the
spinal canal that causes compression of the contents of the spinal
canal because of a mismatch between the available space in the
spinal canal and its contents. If the stenosis becomes severe enough,
myelopathic symptoms can arise. Cervical myelopathy is the most
serious condition that can arise from cervical spinal stenosis. The
signs and symptoms of this condition depend on which part of the
cervical cord is compressed.
Cervical spinal stenosis can be divided into congenital, devel-
opmental, and acquired causes. Congenital cervical stenosis often
affects the craniovertebral junction. Patients with malformation of
the dens or achondroplasia or who have Down syndrome or
Klippel-Feil syndrome can present with cervical spinal stenosis.1-4
Developmental stenosis is usually caused by short pedicles. As a
person ages, degenerative changes ensue. Normally, a person
would not be symptomatic from degenerative changes until they
were moderate or severe. However, with short pedicles, one tends
to see symptoms with much milder degenerative changes because
the available spinal canal space is already diminished in anterior-
posterior diameter and area. Therefore, patients with developmen-
tal stenosis tend to have symptoms at a younger age. Acquired
stenosis is much more common than congenital or developmental
stenosis. Degenerative stenosis is the most common type of
acquired stenosis. Other causes of acquired cervical spine stenosis
include ossification of the posterior longitudinal ligament,
ossification/thickening of the ligamentum flavum, rheumatoid
arthritis with pannus formation, ankylosing spondylitis, Paget’s
disease with basilar impression, and metastatic disease.5,6
Disc degeneration and the degenerative cascade that follows is
the most common cause of acquired cervical spinal stenosis. Gen-
erally, the midcervical region is most affected. In healthy individu-
als, the cervical intervertebral disc is similar to the lumbar
intervertebral disc, consisting of an annulus fibrosis and nucleus
pulposus. In the first and second decades of life, lateral tears occur
in the annulus fibrosis.7 These tears, over time, enlarge and extend
toward the medial aspect of the disc. As we age, the degenerating
disc cannot bear or transfer load because of annular fissuring, dis-
appearance of the nucleus pulposus, and dehydration of the disc.8
There is increased load upon the uncovertebral joints, which
become flattened to accept the additional load. This then puts
greater stress on the vertebral endplates. Osteophytes develop
because of periosteal irritation at the vertebral margins in order to
increase the weight-bearing surface of the endplates, stabilizing the
adjacent vertebra.9 The osteophytes can become quite large, bring-
ing the degenerated disc material along with them. The interverte-
bral disc may calcify to further stabilize the vertebral motion
segment.8 The ligamentum flavum may hypertrophy and buckle
into the spinal canal. The combination of the osteophyte/disc
complex and thickened ligamentum flavum causes narrowing of
the central spinal canal. The combination of the flattened, degener-
ated uncovertebral joints and facet joint hypertrophy can cause
neural foraminal narrowing. Vertebral subluxations, secondary to
facet degeneration and ligamentous laxity, can further contribute
to spinal stenosis and foraminal narrowing.
Ossification of the posterior longitudinal ligament (OPLL) is a
condition in which there is pathologic ossification of this ligament
in the cervical and/or thoracic spine. When this ossification occu-
pies enough of the spinal canal, it will result in cervical spinal ste-
nosis, which can lead to myelopathy and/or radiculopathy
secondary to chronic pressure on the spinal cord and nerve roots.10
The posterior longitudinal ligament (PLL) is a band of collagen
and elastin fibers that extends along a line along the posterior

A B
Figure 71-1 ▶ Cervical Spinal Stenosis Due to Large Disc Herniation. Sagittal T2 image A. Large cervical disc herniation (large arrow) at C3-4 in a patient that also
has ossification of the posterior longitudinal ligament. Abnormal increased T2 signal in the cervical cord (small arrows) consistent with cord ischemia and/or myelomalacia due to
chronic compressive changes. Axial T2 image B demonstrates a moderate disc herniation (D) with severe central spinal canal stenosis and the same T2 signal abnormality (arrow).
margins of the vertebral bodies from the atlas to the sacrum. The
PLL is narrower and weaker than the anterior longitudinal liga-
ment (ALL), which extends along the anterior margins of the ver-
tebral bodies, also from the atlas to the sacrum. The fibers of both
of these ligaments are firmly attached to the annulus of the inter-
vertebral discs and the corner of the vertebral bodies.11 The liga-
ment is widest at the disc spaces and narrowest at the mid-vertebral
levels. The ligament is also thicker centrally and progressively thins
out laterally. OPLL usually occurs in patients over 40 years of age
and is very rare until the third decade. OPLL has been well studied
in East Asian countries with an incidence of 2% to 4%.12 The pre­
valence of OPLL in other countries has not been well studied.
OPLL has been estimated to have a prevalence of 0.12% in a radiol-
ogy review.13 One quarter of North Americans and Japanese
patients with cervical myelopathy exhibit OPLL.14 Most often,
OPLL is found in the upper cervical spine (70%, C2-C4) and less
often in the upper thoracic spine (15%, T1-T4). Cervical OPLL
occurs twice as often in males as in females.15
Ossification of the ligamentum flavum (OLF) is more common
in the lumbar and thoracic regions; however, it may occur at the
atlantoaxial region as well.16,17 OLF is common in the Japanese
population, affecting up to 20% of Japanese patients greater than
65 years of age, with rare reports in Caucasians and people of
African descent.18-20 Neck pain and arm weakness are the most
common symptoms; however, with greater spinal stenosis, bowel
and bladder dysfunction can occur.
Cervical stenosis can be a dynamic process. Typical computed
tomography (CT) and magnetic resonance imaging (MRI) dem-
onstrate static abnormalities that can cause cervical stenosis.
However, the size and shape of the available space in the central
spinal canal can change with motion, particularly flexion and
extension. Chen and colleagues21 measured these changes in
CHAPTER 71: Spinal Stenosis—Cervical  539
human cadavers and discovered that from flexion to extension,
disc bulging decreased the spinal canal diameter by 10.8% and
ligamentum flavum bulging decreased the spinal canal diameter
by 24.3%. Similar changes were seen with axial loading on the
cervical spine.
Upper cervical spinal stenosis, often due to congenital abnor-
malities, may cause neck pain and restricted movement. With
greater stenosis, these patients can suffer from respiratory paralysis
or even sudden death. Developmental stenosis secondary to short
pedicles can have myelopathic symptoms and/or radicular pain.
Acquired degenerative cervical spinal stenosis may have myelo-
pathic symptoms such as weakness in the arms and hands; a stag-
gering, wide gait; and interosseous atrophy.22 With foraminal and
lateral recess narrowing, shoulder and arm pain can appear.
IMAGING FEATURES
The role of imaging is not only to define whether spinal stenosis is
present but also to determine what the cause is and what the
relative contribution of bony versus soft tissue spinal stenosis is.
Plain radiographs are often not useful. Although radiographs can
demonstrate changes of disc space narrowing and osteophytes,
the relative contribution of these abnormalities to spinal stenosis
is not evident. Myelography has been used in the past but has
been supplanted by less invasive cross-sectional imaging.
Myelography indirectly demonstrates spinal stenosis as a narrow-
ing of the contrast-filled thecal sac (Fig. 71-2). One then needs to
deduce whether the narrowing is caused by soft tissue and/or a
bony substance. Myelography is very insensitive to abnormalities
outside of the central canal and does not allow for visualization of
abnormalities lateral to the midneural foramen. A combination of
540  IMAGING PAINFUL SPINE DISORDERS
Figure 71-2 ▶ Cervical Spinal Stenosis, Myelography. Lateral view from
cervical myelography demonstrates a negative filling defect on the ventral surface of
the thecal sac (between arrows). The cause of the negative defect is unknown from
myelography alone.
A B
Figure 71-3 ▶ Cervical Spinal Stenosis, Post-Myelogram CT. Same patient as in Figure 71-2. Axial image A and reformatted sagittal image B post-myelography. The
negative defect on myelography represents a left paramidline disc herniation (arrow). The disc herniation has the same density as the parent disc (D).
myelography followed by CT can improve visualization of both the
bony detail and nerve root compression (Fig. 71-3), but because
myelography is invasive and requires an intrathecal injection of
contrast material, MRI and plain CT are the imaging modalities of
choice for spinal stenosis.
Both CT and MRI can demonstrate the presence of spinal ste-
nosis. CT has a clear advantage in the evaluation of the bony con-
tribution to spinal stenosis (osteophytes, facet degeneration) (Fig.
71-4), whereas MRI has the advantage of soft tissue contributions
to spinal stenosis (disc bulge/herniation, ligamentous hypertro-
phy, synovial cysts). Whether by CT or MR imaging, the imaging
characteristics of spinal stenosis show a change in shape of the
spinal canal from its rounded or oval shape to a more irregular or
flattened appearance (Fig. 71-5). There may be displacement or
obliteration of the epidural fat adjacent to the thecal sac or in the
neural foramen (Fig. 71-6). With MRI, there may be loss of cere-
brospinal fluid (CSF) around the nerve roots on T2-weighted
sequences.23 If stenosis is severe enough, there may be increased
T2 signal intensity within the cervical cord compatible with cord
ischemia, which could lead to cord infarction (Fig. 71-7).
Foraminal narrowing can be evaluated on the sagittal MR images
(which tends to overestimate foraminal narrowing) or from refor-
matted sagittal images from the CT axial data.
Most evaluation of spinal stenosis is subjective rather than
objective and relies upon the experience of the interpreter. Various
studies have shown moderate to poor interobserver results in
agreement as to the presence or absence of stenosis, the degree of
stenosis, and the cause of the stenosis.24,25 Furthermore, spinal ste-
nosis is a dynamic process, and imaging is a static process. If a
patient is never symptomatic lying supine, then imaging studies
performed in a supine position may not reveal the abnormality or
may minimize the abnormality. Therefore, if one has high clinical
suspicion of spinal stenosis that is not explained by cross-sectional

Figure 71-4 ▶ Uncovertebral Joint Spur. Axial CT of the cervical spine.
Prominent left uncovertebral joint spur (U) causes moderate narrowing of the neural
foramen (bounded by arrows).
Figure 71-6 ▶ Subtle Cervical Disc Herniation. Postmyelogram axial CT. Loss
of normal ventrolateral epidural fat (large arrow) with flattening of the right ventro-
lateral thecal sac (small arrows) caused by a subtle disc herniation. Note the normal
ventrolateral epidural fat density on the left (arrowhead).
imaging, it may be prudent to perform a diagnostic study with axial
loading (myelography, upright MRI or CT) and/or dynamic
maneuvers of flexion/extension and lateral bending (myelogra-
phy). Lastly, the importance of scanning angle cannot be empha-
sized enough. An accurate measurement of spinal stenosis must
include an evaluation of the disc level parallel to the disc. If scan-
ning is not parallel to the affected disc levels, one could easily
underestimate or overestimate stenosis. With new imaging soft-
ware, reformatted corrections of the angles can be made to give a
more accurate evaluation of spinal stenosis.
CHAPTER 71: Spinal Stenosis—Cervical  541
Figure 71-5 ▶ Large Right Posterolateral Osteophyte. Axial gradient recall
image. Distorted shape of the thecal sac (T) secondary to a large right posterolateral
osteophyte/disc complex (arrows).
Studies have defined some average cervical spinal measure-
ments. The mean anteroposterior (AP) diameter of the cervical
spinal canal is approximately 17 to 18 mm between C3-C7.26
There have been several methods of measuring devised to evaluate
for cervical spinal stenosis. Plain lateral radiographs were used to
measure the distance from the middle of the posterior surface of
a vertebral body to the spinolaminar line (Fig. 71-8). This mea-
surement is known as the developmental segmental sagittal diameter
and is not altered by degenerative changes because those occur
at the disc level. The segmental sagittal diameter is a measure of
congenital narrowing and can be used to identify whether a person
is congenitally at risk for neurologic injuries and has been used
in athletes. Patients with a segmental sagittal diameter of less than
13 mm are at a high risk for developing signs and symptoms of
cervical myelopathy.27 A canal AP diameter of less than 10 mm is
considered absolutely stenotic. However, this measurement relies
on the distance at which the image was obtained because there
can be wide variations in the measurement as a result of
magnification.28
The spinal canal-to-vertebral body ratio,29 Torg ratio, was made
to adjust for magnification error. The Torg ratio is made by dividing
the sagittal diameter of the spinal canal (the developmental seg-
mental sagittal diameter) by the sagittal diameter of the vertebral
body at the same level (Fig. 71-9). These measurements are also
performed at the mid vertebral body level and have been used to
measure the risk of neurologic injury due to congenital cervical
narrowing. A ratio of 1.0 is considered normal and a ratio of 0.82
or less was said to represent stenosis in 92% of cases with a 6%
false-positive rate.29 However, this ratio does not account for
persons that may have larger vertebral bodies rendering a low Torg
ratio in the face of no significant spinal stenosis.
The compression ratio is correlated with prognosis for recovery
after decompression.30 The compression ratio is obtained by divid-
ing the smallest AP measurement of the spinal cord by the trans-
verse measurement of the spinal cord at the same level (Fig.
71-10). A ratio of less than 0.4 has a poor prognosis for recovery.
 A B
Figure 71-7 ▶ Spinal Cord Myelomalacia. Sagittal T2 image A and axial T2 image B after C3-C7 laminectomies for severe spinal stenosis. There is no evidence of residual
central spinal canal stenosis; however, there is abnormal increased T2 signal intensity in both halves of the cervical cord, sometimes called snake eyes or owl eyes (arrows),
compatible with spinal cord myelomalacia in the central gray matter.

Figure 71-8 ▶ Developmental Segmental Sagittal Diameter. Straight line measurements taken from a cervical lateral radiograph. Distance from the posterior surface
of the mid vertebral body to the mid portion of the spinolamellar line at the same level. Patients with a segmental sagittal diameter of less than 13 mm are at a high risk for
developing signs and symptoms of cervical myelopathy. This measurement can be falsely positive or negative based on differences in magnification when the image is obtained.

542
 CHAPTER 71: Spinal Stenosis—Cervical  543
 

Figure 71-9 ▶ Torg Ratio. Also called the spinal canal-to-vertebral body ratio, the Torg ratio was made to adjust for magnification error. The Torg ratio is determined by
dividing the sagittal diameter of the spinal canal (the developmental segmental sagittal diameter) by the sagittal diameter of the vertebral body at the same level. A ratio of
1.0 is considered normal and a ratio of 0.82 or less was said to represent stenosis in 92% of cases with a 6% false-positive rate. However, this ratio does not account for
persons who may have larger vertebral bodies that would render a low Torg ratio in the face of no significant spinal stenosis.

Figure 71-10 ▶ Compression Ratio. The compression ratio is obtained by dividing the smallest anteroposterior (AP) measurement of the spinal cord by the transverse
measurement of the spinal cord at the same level. The compression ratio is correlated with prognosis for recovery after decompression. A ratio of less than 0.4 has a poor
prognosis for recovery.

To date, there are no studies that give standardized measurements
at the level of the disc in patients with cervical spondylosis.
DIFFERENTIAL DIAGNOSIS
1. Epidural abscess/phlegmon: Typically there is enhance-
ment of an epidural phlegmon and peripheral enhancement of
an epidural abscess (Fig. 71-11). Laboratory evaluation
including white blood cell count, sedimentation rate, and
C-reactive protein is often abnormal.
2. Epidural hemorrhage: Classically, epidural hemorrhage
manifests with abrupt symptoms as opposed to the gradual
and progressive symptomatology of spinal stenosis. It is often
posterior to the cervical spinal cord and demonstrates variable
signal intensity. Blood sensitive MRI sequences can assist in
the diagnosis (Fig. 71-12).
3. Metastatic disease: Many times, patients with metastatic
disease have a known primary tumor. Metastatic disease that
544  IMAGING PAINFUL SPINE DISORDERS

A B
Figure 71-11 ▶ Cervical Discitis with Abscess Formation. Abnormal mixed signal intensity in the ventral epidural space spanning the C5 and C6 vertebral
segments (arrow) as well as abnormal signal intensity within these vertebral bodies on sagittal T2 image A. Post-contrast T1 image B shows a nonenhancing abscess cavity
(short arrow) with surrounding enhancing phlegmon (long arrow).
 CHAPTER 71: Spinal Stenosis—Cervical  545
 

A B
Figure 71-12 ▶ Spontaneous Cervical Epidural Hematoma. Dorsal intermediate T1 intensity epidural mass extending from the skull base to the C4-5 level (arrows)
causing mass effect with ventral displacement of the cervical spinal cord. Blood-sensitive axial gradient image B confirms the mass as hemorrhage (arrow).
546  IMAGING PAINFUL SPINE DISORDERS
A B
Figure 71-13 ▶ Metastatic Disease with Pathologic Fracture. Sagittal T2 image A, sagittal Tl image B and sagittal post-contrast T1 image C. Complete replacement
of a partially collapsed C5 vertebral body with retropulsion of pathologic bone into the spinal canal causing stenosis. Increased T2 signal intensity within the cervical cord
(arrow, image A) from the C4-5 to CS-6 level compatible with cord ischemia.
causes spinal stenosis has typical imaging findings of a soft
tissue mass involving bone that enhances (Fig. 71-13).
TREATMENT
1. Nonoperative management of pain: Typically managed
with acetaminophen, nonsteroidal anti-inflammatory drugs
(NSAIDs), and/or muscle relaxants. If these medications do
not control the pain, then a mild oral narcotic can be pre-
scribed. The patient’s neck may need to be immobilized in a
firm cervical orthosis. Physical therapy with isometric muscle
strengthening and symptomatic measures such as heat, ice,
and massage can be performed.31 Injection therapy with corti-
costeroids can be used for pain flare-ups if it is felt to be
inflammatory-mediated. An interlaminar injection can be per-
formed if the pain is mainly in the neck. If there is lateralization
of the pain to a single side or evidence of radicular pain, a
transforaminal epidural injection can be performed. These
injections can be quite beneficial not only in pain relief but
also in allowing the patient to participate more in exercise
therapy.
2. Surgery: Surgical treatment of symptomatic spinal stenosis
(central canal, foraminal, or lateral recess) is performed to
reestablish sufficient space for the thecal sac and its contents,
as well as the traversing and exiting nerve roots. Surgical treat-
ment depends on the site of compression and levels of abnor-
mality. Decompression may be achieved with an anterior,
posterior, or combined approach.
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