European Spine Journal

https://doi.org/10.1007/s00586-020-06656-5

ORIGINAL ARTICLE

The Haleem–Botchu classification: a novel CT‑based classification

for lumbar foraminal stenosis
S. Haleem1 · M. Malik2 · V. Guduri1 · C. Azzopardi1 · S. James1 · R. Botchu1

Received: 21 September 2020 / Revised: 21 October 2020 / Accepted: 1 November 2020

© Springer-Verlag GmbH Germany, part of Springer Nature 2020

Abstract
Purpose No clinical CT-based classification system is currently in use for lumbar foraminal stenosis. MRI scanners are not
easily available, are expensive and may be contraindicated in an increasing number of patients. This study aimed to propose
and evaluate the reproducibility of a novel CT-based classification for lumbar foraminal stenosis.
Materials and methods The grading was developed as four grades: normal foramen—Grade 0, anteroposterior (AP)/supero-
inferior (SI) (single plane) fat compression—Grade 1, both AP/SI compression (two planes) without distortion of nerve
root—Grade 2 and Grade 2 with distortion of nerve root—Grade 3.
A total of 800 lumbar foramen of a cohort of 100 random patients over the age of 60 who had undergone both CT and MRI
scans were reviewed by two radiologists independently to assess agreement of the novel CT classification against the MRI-
based grading system of Lee et al. Interobserver(n = 400) and intraobserver agreement(n = 160) was also evaluated. Agree-
ment analysis was performed using the weighted kappa statistic.
Results A total of 100 patients (M:F = 45:55) with a mean age of 68.5 years (range 60–83 years were included in the study.
The duration between CT and MRI scans was 98 days (range 0–540, SD—108). There was good correlation between CT
and MRI with kappa scores (k = 0.81) and intraobserver kappa of 0.89 and 0.98 for the two readers.
Conclusion The novel CT-based classification correlates well with the MRI grading system and can safely and accurately
replace it where required.

Keywords Lumbar foraminal stenosis · Novel classification system · Computed tomography · Magnetic resonance
imaging · Interobserver agreement · Intraobserver agreement

Introduction using either a partially quantitative system looking at fat

Lumbar foraminal stenosis (LFS) is an important cause for
radiculopathy of the lower limb (8–11%) with the foraminal
zone lying beneath the lamina and facet joints [1–4] (Fig. 1
Diagrammatic representation of classification showing anat-
omy of spinal unit and lumbar foramen). First described in
1927, it is recognised as the leading cause of failed back sur-
gery (up to 60%) mostly because it is not recognised [5–8].
Various attempts have been made to classify LFS radiologi-
cally mostly based on magnetic resonance imaging (MRI)
* S. Haleem
shahnawaz.haleem@gmail.com
1
Royal Orthopaedic Hospital, The Woodlands, Bristol Road
South, Birmingham B31 2AP, UK
2
Division of Medical Education, University of Brighton,
Brighton, UK
obliteration or a combination of various parameters (types
of stenosis, amount of fat obliteration and nerve root com-
pression) correlated with clinical findings [9–11]. To the
authors’ knowledge, no computed tomography (CT)-based
classification system is currently in clinical use.
While MRI is now available in many urban centres,
it is still relatively scarce in rural areas and generally
worldwide [12–17]. Data from the World Health Organi-
sation (WHO) and Global Health Observatory (GHO)
show that MRI scanners are globally available but at only
0.00000–0.07000 units per million population in most areas
while the minimum requirement to fully satisfy a popula-
tions needs are 12–15 units per million population [18–20].
It was felt therefore that there was a clinical need to develop
a CT-based classification system to overcome these hurdles,
providing a common language linked to an easily available
resource and thus improve patient care. Furthermore, the

13
Vol.:(0123456789)
 European Spine Journal

Fig. 2  CT and MRI (a and b) examples of Grade 0—L3 and L4

foramina, Grade 3—L5 foramen

Fig. 1  Diagrammatic representation of classification showing anat-

omy of spinal unit and lumbar foramen

classification system is of value when MRI is contraindi-

cated in patients with ferromagnetic foreign bodies such
as certain types of stents, pacemakers, implantable cardi-
overter-defibrillators(ICDs), nerve stimulators, intrauterine
contraceptive devices (IUCDs), cochlear implants, contact
lens and insulin pumps [21, 22].

Materials and methods

After discussions between senior authors, a novel CT-based

classification system was established after consensus was Fig. 3  CT and MRI (a and b) examples of Grade 1—L5 foramen
reached on clarity and appropriateness of a simplified clas-
sification. The grading was developed as four grades on
CT sagittal images as follows: normal foramen—Grade 0,
anteroposterior (AP)/superoinferior (SI) fat compression—
Grade 1, both AP/SI compression with no distortion of nerve
root—Grade 2, Grade 2 with additional distortion of nerve
root—Grade 3 (Fig. 2 CT and MRI (a & b) examples of
Grade 0—L3 and L4 foramina, Grade 3—L5 foramen, Fig. 3
CT and MRI (a & b) examples of Grade 1—L5 foramen
and Fig. 4 CT and MRI (a and b) examples of Grade 2—
L4 foramen). CT was performed on a 64 slice Somatom
AS, (Siemens, Germany) and MRI was on a 3 T Magnetom
Skyra (Seimens, Germany) MR and CT was analysed by two
experienced musculoskeletal radiologists. The foramen was
analysed on bone and soft tissue windows. The foramen on
MRI were assessed using the T1 and T2 weighted sagittal
sequences.
This novel CT classification was then assessed against the
MRI grading system proposed by Lee et al. and validated by Fig. 4  CT and MRI (a and b) examples of Grade 2—L4 foramen

13
European Spine Journal

Park et al. [10, 11]. A total of 800 foramen of the lumbar Table 2  Interobserver agreement for CT classification between
spine (Right and Left L2 to L5) of a cohort of a 100 random Reader 1 and Reader 2
patients referred for back and leg pain were independently Level of foramen Interobserver (k)
assessed by two fellowship trained radiologists to assess n = 400
correlation. This cohort of patients was above the age of
Right L2 0.79
60 years, and they had undergone both CT and MRI scans.
Right L3 0.63
Both readers analysed the CT and MRI scans and repeated
Right L4 0.43
the same after an interval of one week.
Right L5 0.66
Local research committee approval was obtained
Left L2 1.00
in the form of service evaluation (Project reference
Left L3 0.54
number—20–037).
Left L4 0.45
Left L5 0.59
Statistical analysis
All levels 0.58

Weighted kappa (k) statistic applying linear weighting was
used to assess agreement. Agreement was analysed between
the CT and MRI scores for each Reader separately and
across both Readers combined. Interobserver agreement for
each Reader of their first and second readings of the CT
studies (50 patients = 400 foramen) and intraobserver agree-
ment between the two readers for both CT and MRI were
also analysed (20 patients = 160 foramen). A kappa value
of ≤ 0 indicated no agreement, 0.01–0.20 indicated slight
agreement; 0.21–0.40, fair agreement; 0.41–0.60, moderate
agreement; 0.61–0.80, substantial agreement; and 0.81 or
greater, nearly perfect agreement [23, 24]. Social Sciences
for Windows (version 24, SPSS) was used for statistical
analyses [25].
Results—100 patients (M:F = 45:55) with a mean age of
68.5 years (range 60–83 years) were included in the study.
The duration between CT and MRI scans was 98 days (range
0–540, SD—108).
Kappa scores for both readers combined (k = 0.81)
revealed a near-perfect agreement (Table 1). Kappa scores
for interobserver analysis revealed moderate agreement
(k = 0.58) (Table 2) and intraobserver analysis revealed
k weighted kappa value; n total number of foramina analysed
near-perfect agreement for both Reader 1 (k = 0.89) and
Reader 2 (k = 0.98) (Table 3).
Discussion
The lumbar foramen described as an oval, round or inverted
teardrop-shaped “window” is also known as the “hid-
den zone” [26, 27]. The intervertebral disc anteriorly, the
facet joint and articular process posteriorly, superior pedi-
cle (roof) and inferior pedicle (floor) form the borders of
the foramen [28]. Stenosis can occur in all of these direc-
tions causing neural compression. The concept of LFS was
known previously as lateral spinal stenosis [29]. Realising
the importance of not addressing LFS adequately subsequent
authors have attempted to quantify it numerically by using
MRI-based studies with Lee et al. proposing an MRI LFS
grading system [10, 30–32].

Table 1  Agreement between CT vs MRI classifications for Reader 1, Table 3  Intraobserver agreement for CT classifications at two differ-
Reader 2 and Combined ent time points for Reader 1 and Reader 2
Level of foramen Reader 1 (k) Reader 2 (k) Combined* (k) Level of foramen Reader 1 (k) Reader 2 (k)
n = 800 n = 400 n = 1200 n = 160 n = 160

Right L2 0.92 0.79 0.88 Right L2 0.84 1.00

Right L3 0.77 0.77 0.78 Right L3 0.78 1.00
Right L4 0.77 0.78 0.78 Right L4 0.72 1.00
Right L5 0.80 0.85 0.82 Right L5 0.96 1.00
Left L2 0.66 1.00 0.72 Left L2 1.00 0.66
Left L3 0.81 0.84 0.82 Left L3 0.77 0.82
Left L4 0.69 0.90 0.77 Left L4 0.96 1.00
Left L5 0.79 0.85 0.81 Left L5 0.85 1.00
All levels 0.80 0.85 0.81 All levels 0.89 0.98

k weighted kappa value; n total number of foramina analysed k weighted kappa value; n total number of foramina analysed

13

Our CT-based classification showed near-perfect agree-
ment when compared to the MRI grading system [23, 24].
This implies that it can provide a reliable replacement for
reporting LFS. This aspect is important for a number of
reasons.
There are currently only approximately 50,000 MRI scan-
ners in use worldwide with 5000 sold every year with most
scanners being situated in urban centres of developed coun-
tries [20]. MRI scanners are limited by cost, lack of expertise
and infrastructure in most developing nations. As an exam-
ple, the whole of Western Africa has only 84 MRI scanners
serving a population of 372 million, whereas Nigeria by
itself has 183 CT scanners [33, 34]. A CT-based grading
would simplify reporting and allow a common language to
be utilised which would benefit patient care in these areas
of need.
Other drawbacks of MRI are the amount of time taken
per examination which would preclude it’s use in the trauma
situation whereas the presence of CT-based classification for
LFS would obviate the need for further imaging to diagnose
any spinal cause for leg pain. 4% to 30% of patients report
anxiety related reactions with 3% to 15% of scans unable to
be completed for the same reason [35–39]. The prevalence
of claustrophobia amongst the population is increasingly
necessitating the need for open MRI scanners [35, 38, 39].
Another important reason is the increasing utilisation of car-
diac and neural stimulation implants that prevent the use of
MRI scan in those patients [21, 22].
While our study showed near perfect intraobserver agree-
ment it revealed a moderate agreement in interobserver anal-
ysis [23, 24]. This could be due to user preference for the
choice of window settings or slice thickness which could
lead to a possible distortion in assessing foraminal diameters
and can be easily overcome by using standardised depart-
mental protocols [40].
The limitations of our study are the use of the static CT
scan as dynamic changes are known to occur in extension
[41]. The well documented radiation hazards of CT scans
(increased incidence of cataracts, glaucoma, leukaemia
and brain tumours, etc.) as compared to MRI may limit its
repeatability in a patient presenting with persistent/recurrent
symptoms [42–48].
Conclusion
Our study assessed bony stenosis, fat compression and nerve
root distortion in grading LFS. There is perfect agreement
between the novel CT-based classification and the MRI
grading system, indicating that it can safely and accurately
replace the MRI grading system where required.
13
European Spine Journal
Author contributions SH contributed to original concept, discussed
framework, analysed data, wrote and critically reviewed article for
final acceptance. MM discussed framework, analysed data, critically
reviewed article for final acceptance. VG discussed framework and
critically reviewed article for final acceptance. CA analysed scans and
data and critically reviewed article for final acceptance. SJ analysed
scans and data, critically reviewed article for final acceptance. RB dis-
cussed framework, analysed data, wrote and critically reviewed article
for final acceptance.
Funding No funding was received in relation to this article.
Compliance with ethical standards
Conflict of interest The authors declare no conflict of interest in rela-
tion to this article.
References
1. Orita S, Inage K, Eguchi Y et al (2016) Lumbar foraminal steno-
sis, the hidden stenosis including at L5/S1. Eur J OrthopSurgTrau-
matol 26:685–693. https​://doi.org/10.1007/s0059​0-016-1806-7
2. Porter RW, Hibbert CEC (1984) The natural history of root entrap-
ment syndrome. Spine 9:418–421 ((Phila Pa 1976))
3. Kunogi JHM (1991) Diagnosis and operative treatment of intra-
foraminal and extraforaminal nerve root compression. Spine
16:1312–1320 ((Phila Pa 1976))
4. Jenis LG, An HS (2000) Spine update: lumbar foraminal stenosis.
Spine 25:389–394 ((Phila Pa 1976))
5. Putti V (1927) New conceptions in the pathogenesis of sci-
atic pain. Lancet 210:53–60. https​: //doi.org/10.1016/S0140​
-6736(01)30667​-0
6. Mitchell C (1934) Lumbosacral facetectomy for relief of sciatic
pain. J Bone JtSurg Br 36-B:230–237
7. Burton CV, Kirkaldy-Willis WH, Yong-Hing KHK (1981) Causes
of failure of surgery on the lumbar spine. ClinOrthopRelat Res
157:183–187
8. Jenis LG, An HSGR (2001) Foraminal stenosis of the lumbar
spine: a review of 65 surgical cases. Am J Orthop (Belle Mead
NJ) 30:205–211
9. Wildermuth S, Zanetti M, Duewell S, Schmid MR, Romanow-
ski B, Benini A, Böni T, Hodler J (1998) Lumbar spine: quan-
titive and qualitative assessment of positional (upright flex-
ion and extension) MR imaging and myelography. Radiology
207:391–398
10. Lee S, Lee JW, Yeom JS, Kim K-J, Kim H-J, SooKyo Chung
HSK (2010) A practical MRI grading system for lumbar foraminal
stenosis. AJR Am J Roentgenol 194:1095–1098
11. Park HJ, Kim SS, Lee SY, Park NH, Rho MH, Hong HP, Kwag
HJ, Kook SH, Choi SH (2012) Clinical correlation of a new MR
imaging method for assessing lumbar foraminal stenosis. Am J
Neuroradiol 33:818–822
12. No authors listed (2017) Geographical distribution of MRI—Fig-
ure 5: distribution of MRI units across Canada in 2017. In: Can.
Med. Imaging Invent. 2017. https:​ //www.cadth.​ ca/canadi​ an-medic​
al-imagi​ng-inven​tory-2017. Accessed 20 Oct 2020
13. Matsumoto KS, Kashima S, Awai K (2015) Geographic distribu-
tion of CT, MRI and PET devices in Japan: a longitudinal analysis
based on national census data. PLoS ONE 10:e0126036. https​://
doi.org/10.1371/journ​al.pone.01260​36
14. Khaliq AA, Deyo D, Duszak R Jr (2015) The impact of hospital
characteristics on the availability of radiology services at critical
European Spine Journal
access hospitals. J Am CollRadiol 12:1351–1356. https​://doi.
org/10.1016/j.jacr.2015.09.008
15. Ginde AA, Foianini A, Renner DM et al (2008) Availability and
quality of computed tomography and magnetic resonance imag-
ing equipment in U.S. emergency departments. AcadEmerg Med
15:780–783. https​://doi.org/10.1111/j.1553-2712.2008.00192​.x
16. No Authors Listed (2011) Pakistan country report. In:
RAD-AID-Pakistan-health-care-radiology-report
17. Moser JW (2008) 2007 Survey of radiologists: practice charac-
teristics, ownership, and affiliation with imaging centers. J Am
CollRadiol 5:965–971. https​://doi.org/10.1016/j.jacr.2008.03.011
18. No authors listed (2014) Medical equipment: magnetic resonance
imaging (MRI) units per million population. In: World Heal.
Organ. https​://www.who.int/diagn​ostic​_imagi​ng/colla​borat​ion/
mripe​rmill​_14.jpg?ua=1. Accessed 20 Oct 2020
19. No authors listed (2016) Global health observatory data reposi-
tory—Medical equipment—Data by country. In: World Heal.
Organ. https​://apps.who.int/gho/data/node.main.510. Accessed
20 Oct 2020
20. Rinck PA (2020) 21–02 How many MRI machines are there?—
MR imaging: facts and figures. In: Rinck PA (ed) Magnetic reso-
nance in medicine a critical introduction, 12th edn. BoD, Ger-
many, p 432
21. Dill T (2008) Contraindications to magnetic resonance imaging.
Heart 94:943–948. https​://doi.org/10.1136/hrt.2007.12503​9
22. Shellock FG, Crues JV (2004) MR procedures: biologic effects,
safety, and patient care. Radiology 232:635–652
23. Cohen J (1968) Weighted kappa: nominal scale agreement pro-
vision for scaled disagreement or partial credit. Psychol Bull
70:213–220. https​://doi.org/10.1037/h0026​256
24. McHugh ML (2012) Lessons in biostatistics Interrater reliability:
the kappa statistic. BiochemMedica 22:276–282
25. SPSS version 24, SPSS Inc, Chicago, Illinois U SPSS version 24
26. Stephens M, Evans J, O’Brien J (1991) Lumbar intervertebral
foramens: an in vitro study of their shape in relation to interver-
tebral disc pathology. Spine 16:525–529 ((Phila Pa 1976))
27. Macnab I (1971) Negative disc exploration: an analysis of the
causes of nerve-root involvement in sixty-eight patients. J Bone
JtSurg Am 53:891–903
28. Mandell JC, Czuczman GJ, Gaviola GC et al (2017) The lumbar
neural foramen and transforaminal epidural steroid injections: an
anatomic review with key safety considerations in planning the
percutaneous approach. Am J Roentgenol 209:W26–W35. https​
://doi.org/10.2214/AJR.16.17471​
29. Arnoldi CC, Brodsky AE, Cauchoix J et al (1976) Lumbar spi-
nal stenosis and nerve root entrapment syndromes. Definition
and classification. ClinOrthopRelat Res 115:4–5. https​://doi.
org/10.1097/00003​086-19760​3000-00002​
30. Hasegawa T, An HS, Haughton VM (1993) Imaging anatomy
of the lateral lumbar spinal canal. Semin Ultrasound, CT, MRI
14:404–413. https​://doi.org/10.1016/S0887​-2171(05)80034​-4
31. Aota Y, Niwa T, Yoshikawa K et al (2007) Magnetic resonance
imaging and magnetic resonance myelography in the presurgical
diagnosis of lumbar foraminal stenosis. Spine 32:896–903. https:​ //
doi.org/10.1097/01.brs.00002​59809​.75760​.d5 ((Phila Pa 1976))
32. Eguchi Y, Ohtori S, Suzuki M et al (2016) Diagnosis of lumbar
foraminal stenosis using diffusion tensor imaging. Asian Spine J
10:164–169. https​://doi.org/10.4184/asj.2016.10.1.164
33. Ogbole GI, Adeyomoye AO, Badu-Peprah A et al (2018) Survey
of magnetic resonance imaging availability in West Africa. Pan
Afr Med J 30:240
34. Adejoh T, Onwujekwe EC, Abba M et al (2018) Computed tomog-
raphy scanner census and adult head dose in Nigeria. Egypt J
RadiolNucl Med 49:66–70. https ​ : //doi.org/10.1016/j.ejrnm​
.2017.09.001
35. Hricak H, Amparo EG (1984) Body MRI: alleviation of claus-
trophobia by prone positioning. Radiology 152:819. https​://doi.
org/10.1148/radio​logy.152.3.64632​67
36. Quirk ME, Letendre AJ, Ciottone RA, Lingley JF (1989) Anxiety
in patients undergoing MR imaging. Med Dosim 14:294. https​://
doi.org/10.1016/0958-3947(89)90021​-6
37. Meléndez JC, Mccrank E (1993) Anxiety-related reactions
associated with magnetic resonance imaging examinations.
JAMA J Am Med Assoc 270:745–747. https​://doi.org/10.1001/
jama.1993.03510​06009​1039
38. Katznelson R, Djaiani GN, Minkovich L et al (2008) Prevalence
of claustrophobia and magnetic resonance imaging after coronary
artery bypass graft surgery. Neuropsychiatr Dis Treat 4:487–493.
https​://doi.org/10.2147/ndt.s2699​
39. Koh SAS, Lee W, Rahmat R et al (2017) Interethnic variation in
the prevalence of claustrophobia during MRI at Singapore general
hospital: does a wider bore MR scanner help? ProcSingapHealthc
26:1–5. https​://doi.org/10.1177/20101​05817​69581​9
40. Beers GJ, Carter AP, Leiter BE et al (1985) Interobserver discrep-
ancies in distance measurements from lumbar spine CT scans. Am
J Roentgenol 144:395–398. https​://doi.org/10.2214/ajr.144.2.395
41. Mayoux-Benhamou MA, Revel M, Aaron C et al (1989) A mor-
phometric study of the lumbar foramen—Influence of flexion-
extension movements and of isolated disc collapse. SurgRadiolA-
nat 11:97–102. https​://doi.org/10.1007/BF020​96463​
42. No authors listed (2019) Radiation dose in X-ray and CT exams.
In: RadiologyInfo.org. https​://www.radio​logyi​nfo.org/en/info.
cfm?pg=safet​y-xray. Accessed 20 Oct 2020
43. de Gonzalez AB, Mahesh M, Kim K-P et al (2009) Projected
cancer risks from computed tomographic scans performed in the
United States in 2007. Arch Intern Med 169:2071–2077. https​://
doi.org/10.1016/j.physb​eh.2017.03.040
44. Smith-Bindman R, Lipson J, Marcus R et al (2009) Radiation dose
associated with common computed tomography examinations and
the associated lifetime attributable risk of cancer. Arch Intern Med
169:2078–2086. https:​ //doi.org/10.1001/archin​ ternm​ ed.2009.427.
Radia​tion
45. Pearce MS, Salotti JA, Little MP et al (2012) Radiation exposure
from CT scans in childhood and subsequent risk of leukaemia and
brain tumours: a retrospective cohort study. Lancet 380:499–505.
https​://doi.org/10.1016/S0140​-6736(12)60815​-0
46. Lin EC (2010) Radiation risk from medical imaging. Mayo Clin-
Proc 85:1142–1146. https​://doi.org/10.4065/mcp.2010.0260
47. Sagerman RH (1993) Radiation-induced cataracts: simple but dif-
ficultto quantify. Int J RadiatOncolBiolPhys 26:713–714
48. Takeda A, Shigematsu N, Suzuki S et al (1999) Late retinal com-
plications of radiation therapy for nasal and paranasal malignan-
cies: relationship between irradiated-dose area and severity. Int J
RadiatOncolBiolPhys 44:599–605
Publisher’s Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
13