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Lumbar foraminal stenosis, the hidden stenosis including at L5/S1

  • Sumihisa Orita
  • Kazuhide Inage
  • Yawara Eguchi
  • Go Kubota
  • Yasuchika Aoki
  • Junichi Nakamura
  • Yusuke Matsuura
  • Takeo Furuya
  • Masao Koda
  • Seiji Ohtori
Expert's Opinion • SPINE - LUMBAR

Abstract

In patients with lower back and leg pain, lumbar foraminal stenosis (LFS) is one of the most important pathologies, especially for predominant radicular symptoms. LFS pathology can develop as a result of progressing spinal degeneration and is characterized by exacerbation with foraminal narrowing caused by lumbar extension (Kemp’s sign). However, there is a lack of critical clinical findings for LFS pathology. Therefore, patients with robust and persistent leg pain, which is exacerbated by lumbar extension, should be suspected of LFS. Radiological diagnosis is performed using multiple radiological modalities, such as magnetic resonance imaging, including plain examination and novel protocols such as diffusion tensor imaging, as well as dynamic X-ray, and computed tomography. Electrophysiological testing can also aid diagnosis. Treatment options include both conservative and surgical approaches. Conservative treatment includes medication, rehabilitation, and spinal nerve block. Surgery should be considered when the pathology is refractory to conservative treatment and requires direct decompression of the exiting nerve root, including the dorsal root ganglia. In cases with decreased intervertebral height and/or instability, fusion surgery should also be considered. Recent advancements in minimally invasive lumbar lateral interbody fusion procedures enable effective and less invasive foraminal enlargement compared with traditional fusion surgeries such as transforaminal lumbar interbody fusion. The lumbosacral junction can cause L5 radiculopathy with greater incidence than other lumbar levels as a result of anatomical and epidemiological factors, which should be better addressed when treating clinical lower back pain.

Keywords

Foramen Lumbar spine Radiculopathy Fusion Diffusion tensor imaging (DTI) Oblique lateral interbody fusion (OLIF) 

Notes

Compliance with ethical standards

Conflict of interest

All of the authors do not have any conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

References

  1. 1.
    Jenis LG, An HS (2000) Spine update. Lumbar foraminal stenosis. Spine (Phila Pa 1976) 25(3):389–394CrossRefGoogle Scholar
  2. 2.
    Lee CK, Rauschning W, Glenn W (1988) Lateral lumbar spinal canal stenosis: classification, pathologic anatomy and surgical decompression. Spine (Phila Pa 1976) 13(3):313–320CrossRefGoogle Scholar
  3. 3.
    Macnab I (1971) Negative disc exploration. An analysis of the causes of nerve-root involvement in sixty-eight patients. J Bone Joint Surg Am 53(5):891–903PubMedGoogle Scholar
  4. 4.
    Putti V (1927) New conceptions in the pathogenesis of sciatic pain. Lancet 2:53–60CrossRefGoogle Scholar
  5. 5.
    Mitchell C (1934) Lumbosacral facetectomy for relief of sciatic pain. J Bone Joint Surg Br 36-B:230–237Google Scholar
  6. 6.
    Verbiest H (1954) A radicular syndrome from developmental narrowing of the lumbar vertebral canal. J Bone Joint Surg Br 36-B(2):230–237PubMedGoogle Scholar
  7. 7.
    Arnoldi CC, Brodsky AE, Cauchoix J, Crock HV, Dommisse GF, Edgar MA, Gargano FP, Jacobson RE, Kirkaldy-Willis WH, Kurihara A, Langenskiold A, Macnab I, McIvor GW, Newman PH, Paine KW, Russin LA, Sheldon J, Tile M, Urist MR, Wilson WE, Wiltse LL (1976) Lumbar spinal stenosis and nerve root entrapment syndromes. Definition and classification. Clin Orthop Relat Res 115:4–5PubMedGoogle Scholar
  8. 8.
    Porter RW, Hibbert C, Evans C (1984) The natural history of root entrapment syndrome. Spine (Phila Pa 1976) 9(4):418–421CrossRefGoogle Scholar
  9. 9.
    Kunogi J, Hasue M (1991) Diagnosis and operative treatment of intraforaminal and extraforaminal nerve root compression. Spine (Phila Pa 1976) 16(11):1312–1320CrossRefGoogle Scholar
  10. 10.
    Hasegawa T, An HS, Haughton VM, Nowicki BH (1995) Lumbar foraminal stenosis: critical heights of the intervertebral discs and foramina. A cryomicrotome study in cadavera. J Bone Joint Surg Am 77(1):32–38PubMedGoogle Scholar
  11. 11.
    Burton CV, Kirkaldy-Willis WH, Yong-Hing K, Heithoff KB (1981) Causes of failure of surgery on the lumbar spine. Clin Orthop Relat Res 157:191–199PubMedGoogle Scholar
  12. 12.
    Stephens MM, Evans JH, O’Brien JP (1991) Lumbar intervertebral foramens. An in vitro study of their shape in relation to intervertebral disc pathology. Spine (Phila Pa 1976) 16(5):525–529CrossRefGoogle Scholar
  13. 13.
    Hasegawa T, An HS, Haughton VM (1993) Imaging anatomy of the lateral lumbar spinal canal. Semin Ultrasound CT MR 14(6):404–413CrossRefPubMedGoogle Scholar
  14. 14.
    Nowicki BH, Haughton VM (1992) Neural foraminal ligaments of the lumbar spine: appearance at CT and MR imaging. Radiology 183(1):257–264. doi: 10.1148/radiology.183.1.1549683 CrossRefPubMedGoogle Scholar
  15. 15.
    Hasue M, Kunogi J, Konno S, Kikuchi S (1989) Classification by position of dorsal root ganglia in the lumbosacral region. Spine (Phila Pa 1976) 14(11):1261–1264CrossRefGoogle Scholar
  16. 16.
    Kikuchi S, Sato K, Konno S, Hasue M (1994) Anatomic and radiographic study of dorsal root ganglia. Spine (Phila Pa 1976) 19(1):6–11CrossRefGoogle Scholar
  17. 17.
    Sato K, Kikuchi S (1993) An anatomic study of foraminal nerve root lesions in the lumbar spine. Spine (Phila Pa 1976) 18(15):2246–2251CrossRefGoogle Scholar
  18. 18.
    Inufusa A, An HS, Lim TH, Hasegawa T, Haughton VM, Nowicki BH (1996) Anatomic changes of the spinal canal and intervertebral foramen associated with flexion–extension movement. Spine (Phila Pa 1976) 21(21):2412–2420CrossRefGoogle Scholar
  19. 19.
    Weinstein J (1986) Report of the 1985 ISSLS Traveling Fellowship. Mechanisms of spinal pain. The dorsal root ganglion and its role as a mediator of low-back pain. Spine (Phila Pa 1976) 11(10):999–1001CrossRefGoogle Scholar
  20. 20.
    Wiltse LL, Guyer RD, Spencer CW, Glenn WV, Porter IS (1984) Alar transverse process impingement of the L5 spinal nerve: the far-out syndrome. Spine (Phila Pa 1976) 9(1):31–41CrossRefGoogle Scholar
  21. 21.
    Yamada K, Aota Y, Higashi T, Ishida K, Nimura T, Konno T, Saito T (2014) Lumbar foraminal stenosis causes leg pain at rest. Eur Spine J 23(3):504–507. doi: 10.1007/s00586-013-3055-3 CrossRefPubMedGoogle Scholar
  22. 22.
    Orita S, Yamashita T, Ohtori S, Yonenobu K, Kawakami M, Taguchi T, Kikuchi SI, Ushida T, Konno SI, Nakamura M, Fujino K, Matsuda S, Yone K, Takahashi K (2016) Prevalence and location of neuropathic pain in lumbar spinal disorders: analysis of 1,804 consecutive patients with primary lower back pain. Spine (Phila Pa 1976). doi: 10.1097/BRS.0000000000001553 Google Scholar
  23. 23.
    Aota Y, Niwa T, Yoshikawa K, Fujiwara A, Asada T, Saito T (2007) Magnetic resonance imaging and magnetic resonance myelography in the presurgical diagnosis of lumbar foraminal stenosis. Spine (Phila Pa 1976) 32(8):896–903. doi: 10.1097/01.brs.0000259809.75760.d5 CrossRefGoogle Scholar
  24. 24.
    Eguchi Y, Ohtori S, Orita S, Kamoda H, Arai G, Ishikawa T, Miyagi M, Inoue G, Suzuki M, Masuda Y, Andou H, Takaso M, Aoki Y, Toyone T, Watanabe A, Takahashi K (2011) Quantitative evaluation and visualization of lumbar foraminal nerve root entrapment by using diffusion tensor imaging: preliminary results. AJNR Am J Neuroradiol 32(10):1824–1829. doi: 10.3174/ajnr.A2681 CrossRefPubMedGoogle Scholar
  25. 25.
    Eguchi Y, Ohtori S, Suzuki M, Oikawa Y, Yamanaka H, Tamai H, Kobayashi T, Orita S, Yamauchi K, Suzuki M, Aoki Y, Watanabe A, Kanamoto H, Takahashi K (2016) Diagnosis of lumbar foraminal stenosis using diffusion tensor imaging. Asian Spine J 10(1):164–169. doi: 10.4184/asj.2016.10.1.164 CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Eguchi Y, Ohtori S, Yamashita M, Yamauchi K, Suzuki M, Orita S, Kamoda H, Arai G, Ishikawa T, Miyagi M, Ochiai N, Kishida S, Masuda Y, Ochi S, Kikawa T, Takaso M, Aoki Y, Toyone T, Suzuki T, Takahashi K (2010) Clinical applications of diffusion magnetic resonance imaging of the lumbar foraminal nerve root entrapment. Eur Spine J 19(11):1874–1882. doi: 10.1007/s00586-010-1520-9 CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Yamashita T, Kwee TC, Takahara T (2009) Whole-body magnetic resonance neurography. N Engl J Med 361(5):538–539. doi: 10.1056/NEJMc0902318 CrossRefPubMedGoogle Scholar
  28. 28.
    Herron LD (1989) Selective nerve root block in patient selection for lumbar surgery: surgical results. J Spinal Disord 2(2):75–79CrossRefPubMedGoogle Scholar
  29. 29.
    Iwasaki H, Yoshida M, Yamada H, Hashizume H, Minamide A, Nakagawa Y, Kawai M, Tsutsui S (2014) A new electrophysiological method for the diagnosis of extraforaminal stenosis at L5-S1. Asian Spine J 8(2):145–149. doi: 10.4184/asj.2014.8.2.145 CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Kanamoto H, Eguchi Y, Suzuki M, Oikawa Y, Yamanaka H, Tamai H, Kobayashi T, Orita S, Yamauchi K, Suzuki M, Aoki Y, Watanabe A, Takahashi K, Ohtori S (2016) The diagnosis of double-crush lesion in the L5 lumbar nerve using diffusion tensor imaging. Spine J 16(3):315–321. doi: 10.1016/j.spinee.2015.11.003 CrossRefPubMedGoogle Scholar
  31. 31.
    Schlegel JD, Champine J, Taylor MS, Watson JT, Champine M, Schleusener RL, Savory KM (1994) The role of distraction in improving the space available in the lumbar stenotic canal and foramen. Spine (Phila Pa 1976) 19(18):2041–2047CrossRefGoogle Scholar
  32. 32.
    Abe K, Orita S, Mannoji C, Motegi H, Aramomi M, Ishikawa T, Kotani T, Akazawa T, Morinaga T, Fujiyoshi T, Hasue F, Yamagata M, Hashimoto M, Yamauchi T, Eguchi Y, Suzuki M, Hanaoka E, Inage K, Sato J, Fujimoto K, Shiga Y, Kanamoto H, Yamauchi K, Nakamura J, Suzuki T, Hynes RA, Aoki Y, Takahashi K, Ohtori S (2016) Perioperative complications in 155 patients who underwent oblique lateral interbody fusion surgery: perspectives and indications from a retrospective, multicenter survey. Spine (Phila Pa 1976). doi: 10.1097/BRS.0000000000001650 Google Scholar
  33. 33.
    Orita S, Inage K, Kubota G, Sainoh T, Sato J, Fujimoto K, Shiga Y, Nakamura J, Matsuura Y, Eguchi Y, Aoki Y, Toyone T, Yamauchi K, Sakuma Y, Oikawa Y, Suzuki T, Takahashi K, Hynes RA, Ohtori S (2016) One-year prospective evaluation of the technique of percutaneous cortical bone trajectory spondylodesis in comparison with percutaneous pedicle screw fixation: a preliminary report with technical note. J Neurol Surg A Cent Eur Neurosurg. doi: 10.1055/s-0035-1566118 PubMedGoogle Scholar
  34. 34.
    Sato J, Ohtori S, Orita S, Yamauchi K, Eguchi Y, Ochiai N, Kuniyoshi K, Aoki Y, Nakamura J, Miyagi M, Suzuki M, Kubota G, Inage K, Sainoh T, Fujimoto K, Shiga Y, Abe K, Kanamoto H, Inoue G, Takahashi K (2015) Radiographic evaluation of indirect decompression of mini-open anterior retroperitoneal lumbar interbody fusion: oblique lateral interbody fusion for degenerated lumbar spondylolisthesis. Eur Spine J. doi: 10.1007/s00586-015-4170-0 Google Scholar
  35. 35.
    Jang JS, An SH, Lee SH (2006) Transforaminal percutaneous endoscopic discectomy in the treatment of foraminal and extraforaminal lumbar disc herniations. J Spinal Disord Tech 19(5):338–343. doi: 10.1097/01.bsd.0000204500.14719.2e CrossRefPubMedGoogle Scholar
  36. 36.
    Hasegawa T, Mikawa Y, Watanabe R, An HS (1996) Morphometric analysis of the lumbosacral nerve roots and dorsal root ganglia by magnetic resonance imaging. Spine (Phila Pa 1976) 21(9):1005–1009CrossRefGoogle Scholar
  37. 37.
    Epstein NE (2002) Foraminal and far lateral lumbar disc herniations: surgical alternatives and outcome measures. Spinal Cord 40(10):491–500. doi: 10.1038/sj.sc.3101319 CrossRefPubMedGoogle Scholar
  38. 38.
    Yamada K, Aota Y, Higashi T, Ishida K, Niimura T, Konno T, Saito T (2015) Roentgenographic and computed tomographic findings in symptomatic lumbar foraminal stenosis. Eur Spine J 24(2):333–338. doi: 10.1007/s00586-014-3683-2 CrossRefPubMedGoogle Scholar
  39. 39.
    Kanno K, Ohtori S, Orita S, Yamauchi K, Eguchi Y, Aoki Y, Nakamura J, Miyagi M, Suzuki M, Kubota G, Inage K, Sainoh T, Sato J, Shiga Y, Abe K, Fujimoto K, Kanamoto H, Toyone T, Inoue G, Hanaoka E, Takahashi K (2014) Miniopen oblique lateral L5-s1 interbody fusion: a report of 2 cases. Case Rep Orthop. doi: 10.1155/2014/603531 PubMedPubMedCentralGoogle Scholar
  40. 40.
    Wakita H, Shiga Y, Ohtori S, Kubota G, Inage K, Sainoh T, Sato J, Fujimoto K, Yamauchi K, Nakamura J, Takahashi K, Toyone T, Aoki Y, Inoue G, Miyagi M, Orita S (2015) Less invasive corrective surgery using oblique lateral interbody fusion (OLIF) including L5-S1 fusion for severe lumbar kyphoscoliosis due to L4 compression fracture in a patient with Parkinson’s disease: a case report. BMC Res Notes 8:126. doi: 10.1186/s13104-015-1087-y CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Orita S, Ohtori S, Eguchi Y, Kamoda H, Arai G, Ishikawa T, Miyagi M, Inoue G, Ochiai N, Kishida S, Takaso M, Aoki Y, Takahashi K (2010) Radiographic evaluation of monocortical versus tricortical purchase approaches in lumbosacral fixation with sacral pedicle screws: a prospective study of ninety consecutive patients. Spine (Phila Pa 1976) 35(22):E1230–E1237. doi: 10.1097/BRS.0b013e3181e5092c CrossRefGoogle Scholar
  42. 42.
    Fokter SK (2011) Update review and clinical presentation on chronic low back pain treated by AxiaLIF. Eur J Orthop Surg Traumatol 21(1):39–42. doi: 10.1007/s00590-010-0656-y CrossRefGoogle Scholar

Copyright information

© Springer-Verlag France 2016

Authors and Affiliations

  1. 1.Department of Orthopaedic Surgery, Graduate School of MedicineChiba UniversityChibaJapan
  2. 2.Department of Orthopaedic Surgery, National Hospital OrganizationShimoshizu HospitalYotsukaidoJapan
  3. 3.Department of Orthopaedic SurgeryEastern Chiba Medical CenterToganeJapan

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