Table Of ContentA.Wackenheim E. Babin
The Narrow
Lumbar Canal
Radiologic Signs and Surgery
With a Foreword by L.Jeanmart
With 139 Figures in 292 Separate Illustrations
Springer-Verlag Berlin Heidelberg New York 1980
The cover picture shows a narrowed spinal canal which is shown in more detail in Figure 30 on p. 45
TSBN-13: 978-3-642-67349-8 e-ISBN-13: 978-3-642-67347-4
DOT: 10.1007/978-3-642-67347-4
library of Congress Cataloging in Publication Data. Wackenheim, Auguste. The narrow lumbar canal. Biblio
graphy: p. Includes index. 1. Spinal canal - Stenosis - Diagnosis. 2. Vertebrae, Lumbar - Abnormalities -
Radiography. 3. Vertebrae, Lumbar - Surgery. I. Babin, Elisabeth, 1938- joint author. II. Title.
RD771.S74W32 617'.482 79-13720
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Softcover reprint of the harcover I st edition 1980
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Foreword
It is amazing to discover how little importance has been attached to narrow
lumbar canal syndromes up to now. Though H. VERBIEST gave a very accurate
description in 1949, the neurologist's and neurosurgeon's preoccupations were
mainly focused on discal pathology, disregarding the problem of an exclusively
bony origin in canalar stenosis.
A. WACKENHEIM and E. BABIN have the merit of becoming aware of the impor
tance and originality of this problem; they organized in the beautiful surround
ings of the Bischenberg near Strasbourg, a postgraduate course, in which the
most eminent European specialists in this field participated.
I am very honored to have been asked to write the introduction to this mono
graphy, which contains all the studies reported and commented on during this
meeting.
Before considering the problem from the various radiologic points of view, it is
in my opinion indispensable to define the term "stenosis." We could not do so
more accurately than by assuming the definition proposed by A. WACKENHEIM
and E. BABIN and unanimously confirmed by all those who attented the session.
"The term stenosis must be understood in the strict sense of the word, that is to
say in the sense of narrowness, without any implication of nature, origin, or
evolutivity." The main merit of the promoters of the meeting devoted to the
diagnosis of "idiopathic canalar stenosis" is to have gathered a group of neurora
diologists who made a review of the various investigation methods utilized for
this diagnosis. Thanks to well-standardized techniques, plain radiographs com
bined with tomographs of the lumbosacral segment provide a detailed and pre
cise image of the morphology of the bony parts of the posterior arch.
The exploration techniques by opacification of the subarachnoidal spaces with
oily contrast media utilized in anglosaxon countries have been replaced by radi
oculosaccography with watersoluble contrast media (E. BABIN and A. CAPES IUS )
which, thanks to the fluidity of the contrast agent and its better dilution in the
cerebrospinal fluid, seems to provide better results. 1. RouLLEAu (Toulouse)
discussed the very difficult problem of the diagnosis made on plain films. M. ME
GRET (Geneva) performs tomography with complex movements of the tube in gas
myelography, which permits a better visualization of the lumbar and dorsolum
bar spine.
Lumbar phlebography practiced by specialists, such as 1. THERON (Caen), pro
vides significant data about extradural root compression. L. PICARD and 1. Ro
LAND also contributed to the very high scientific level of this course. Tomodensi
tometry, the most recent complementary radiologic technique, provides for the
first time, an image of the morphology of the spinal canal in axial section. This
latter technique allowed D. BALERIAUX-W AHA to report extremely precise meas
urements of the different canalar diameters. This method contributes signifi-
v
cantly to the elaboration of the diagnosis of lumbar canal narrowing. I would also
like to mention the original contribution concerning the cheirolumbar dysostosis.
Because of his extensive experience in this field, Professor H. VERBIEST was a
precious guide throughout the session, not to mention his closing lecture, which
was particularly appreciated.
We would also like to thank Professor Wackenheim and Doctor Babin for
having placed this meeting under the auspices of the C. E. P. U. R. and for devot
ing this postgraduate course in neuroradiology to this somewhat misknown
subject.
Brussels, September 1979 L.JEANMART
VI
Contents
1. Radiology of the Narrow Lumbar Canal
E. Babin (Strasbourg)
1.1 History 1
1.2 Tenninology.. 1
1.3 Anatomy 1
1.3.1 Spinal Canal 1
1.3.2 Radicular Canal 2
1.3.3 Intervertebral Foramen 2
1.4 Clinical Data ......... 2
1.4.1 Neurogenic Intermittent Claudication 2
1.4.2 Further Aspects of the Clinical Data 2
1.5 Radiologic Techniques and Their Indications 3
1.5.1 Plain Films and Tomographs of the Lumbosacral Spine 3
1.5.2 Opacification Techniques of the Subarachnoidal Space 4
1.5.3 Further Radiologic Techniques . . . . 4
1.6 Radiologic Signs of Lumbar Canal Narrowness 4
1.6.1 Anomalies of the Bones 4
1.6.1.1 Lateral Projection 4
1.6.1.2 Frontal Projection 4
1.6.1.3 Oblique Projections 5
1.6.2 Morphological Classification of the Bony Anomalies 5
1.6.2.1 Diffuse Anteroposteriorly Predominant Canalar Stenosis 5
1.6.2.2 Concentric Stenosis of the Canal Related to a Hypertrophy
and a Disorientation of the Structures of the Posterior Arch
on a Few or Several Segments . . . . . . . . . . . . . . 5
1.6.2.3 Stenosis of the Lateral Parts of the Canal Related to a
Defonnation of Its Lumen by Abnonnal (Arthrosic or
Dysplastic) Facetal Joints 5
1.6.3 Radiculosaccographic Signs 5
1.6.4 Phlebographic Signs 6
1.7 Nosology ............. 6
1.7.1 Developmental Spinal Stenosis 6
1.7.2 Acquired Spinal Stenoses 6
1.7.3 Congenital Stenoses 6
Figures 1-7 ........... 7
VII
2. Plain X-Ray Diagnosis of Developmental Narrow Lumbar Canal
J. Roulleau and J. Guillaume (Toulouse)
2.1 Technique.............................. 11
2.2 Findings: To Measure or Not to Measure? That is Not the Question 12
2.3 Requirements for Reliable Measurements and Pitfalls 12
2.4 Radiologic Features of the Narrow Lumbar Canal Without
Contrast Medium .................. 13
2.4.1 Anteroposterior Plain Films or Tomograms 13
2.5 Findings on Lateral Projection ........... 15
2.6 Various Types of Developmental Stenosis . . . . . . 16
2.7 Correlation Between Surgical and Radiologic Reports 16
2.8 Narrow Lumbar Canal and Associated Diseases 17
Figures 8-14 ..................... 18
3. Interapophysolaminar Spaces (IALS) of the Lumbar Spine and
Their Utility in the Diagnosis of Narrow Lumbar Canal
M. Vouge (Strasbourg)
3.1 Introduction.. 23
3.2 Material and Methods 23
3.3 Results ....... 23
3.3.1 Morphological Data 23
3.3.2 Measurements 25
3.4 Conclusion 25
Figures 15-18 . . . . . 24
4. Myelographic Signs of Narrow Lumbar Canal
P. Capesius (Luxembourg)
4.1 Technical Particularities . . . . . . . . . . . . . . . . . . . . .. 27
4.2 Limits of the LM as an Investigation of the Narrow Lumbar Canals 27
4.3 LM Anomalies . . . . . . . . . . . . . . . . . . . . . . . 28
4.3.1 Elementary Semeiology of Spinal Stenoses in LM 28
4.3.1.1 Anomalies of the Dural Sac and of Its Contents . . 28
4.3.1.2 Anomalies of the Epidural Space and Its Contents
(Radicular Sheaths and Extrasaccular Parts of the Roots) 29
4.3.2 Groups of Elementary Signs in Some Types of Stenoses 29
Figures 19-28 . . . . . . . . . . . . . . . . . . . . . . . . . .. 30
5. Gas Myelography in Verbiest's Developmental Spinal Canal Stenosis
M. Megret and C. Marsault (Geneva - Paris)
5.1 Symptomatology ..... . 39
5.2 Radiologic Examination . . . 39
5.2.1 Conventional X-Rays 40
5.2.1.1 Frontal Projection 40
5.2.1.2 Lateral Projection 40
5.2.2 Gas Myelography . 40
VIII
5.2.2.1 Technique ........... 40
5.2.2.2 Radiologic Findings . . . . . . . 41
5.2.2.3 Drawbacks of Gas Myelography 41
5.3 Clinical Forms of Idiopathic Developmental Spinal Stenosis 41
5.3.1 Anatomic Forms of Idiopathic Developmental Spinal
Stenosis . . . . . . . . . . . . . . . . . . 41
5.3 .1.1 Stenosis of the Entire Lumbar Canal ......... 42
5.3.1.2 Stenosis Involving One or Two Vertebrae ...... 42
5.3.2 Lumbar Canal Stenosis Associated with Narrowing of Other
Spinal Segments ...................... 42
5.3.2.1 Lumbar Spinal Stenosis Associated with Narrowing of the
Cervical Canal ....................... 42
5.3.2.2 Stenosis ofthe Entire Spinal Canal . . . . . . . . . . . .. 42
5.3.3 Familial Forms of Idiopathic Developmental Spinal Stenosis 42
Figures 29-42 . . . . . . . . . . . . . . . . . . . . . . . . . . .. 43
6. Phlebographic Signs of the Narrow Lumbar Canal
H. Ammerich and F. Quintana (Strasbourg - Santander)
6.1 Physiopathology ofthe Venous Compression .... 59
6.2 Phlebographic Signs of Narrow Lumbar Canal 59
6.2.1 Narrowing of the Lumbar Canal in Its Entire Length 59
6.2.2 Segmental Stenoses of the Lumbar Canal 60
Figures 43-47 . . . . . . . . . . . . . . . . . . . . . . . . 61
7. Narrow Lumbar Canal by Postoperative Epidural Lesions
J. Roland, L. Picard, P. Blanchot, J. C. Guyonnaud, G. L'Esperance,
A. De Ker Saint Gilly (Nancy)
7.1 Radiculosaccographic Semeiology of Epidural Scarring 65
7.2 Phlebographic Semeiology of Epidural Scarring 65
7.3 Surgical Findings 66
7.4 Clinical Aspects 66
7.5 Physiopathology 66
7.6 Conclusion 67
Figures 48-60 . 68
8. Spinal Phlebography in the Stenosis of the Lumbar Canal 75
J. Theron (Caen)
Figures 61-72 . . . . . . . . . . . . . . . . . . . . . . 77
9. Computerized Tomography in Lumbar Spinal Stenosis
D. Baleriaux-Waha, M. Soeur, T. Stadnik, M. Dupont, L. Jeanmart
(Brussels)
9.1 Material and Methods 83
9.2 Results ....... 83
IX
9.2.1 Nonnal Lumbar Spinal Canal 83
9.2.2 Lumbar Spinal Stenosis 84
9.3 Conclusion 84
Figures 73-84 . . . . . . . . . 85
10. Lumbar Spinal Stenosis
J. Cauchoix, V. Chassaing, M. Benoist, J. L. Briard (Paris)
10.1 Etiology ............ . 91
10.1.1 Developmental Stenosis 91
10.1.2 Degenerative Stenosis 92
10.1.2.1 Without Slip ... . 92
10.1.2.2 With a Slip ..... . 92
10.1.3 Iatrogenic Stenosis 93
10.1.4 Other Etiologies of Lumbar Stenosis 93
10.2 Symptomatology 93
10.3 Treatment . . 93
Figures 85-98 . . 95
11. Narrow Radicular Canal
F. Buchheit, D. Maitrot, L. Middleton, S. Gusmao (Strasbourg)
11.1 Nosologic Importance of the Narrow Radicular Canal with Regard
to the Narrow Lumbar Canal .. 105
11.2 Anatomy ofthe Radicular Canal ........ 105
11.3 Etiologies .................... 106
11.4 Symptomatology of the Narrow Radicular Canal 106
11.5 Radiologic Findings 106
11.6 Surgical Procedures 107
11. 7 Conclusion 107
Figures 99-108 .. 108
12. Stenosis of the Bony Lumbar Vertebral Canal
H. Verbiest (Utrecht)
12.1 Introduction . . . . . . . . . . . . . . . 115
12.2 Historical Review: Evolution of the Idea 115
12.3 Nomenclature . . . . . . . . . . . . . . 117
12.3.1 Quantitative Aspects in the Definition of Stenosis 118
12.4 Oassification of the Types of Stenoses of the Lumbar
Vertebral Canal . . . . . . . . . . . . . . . . . . . . . . 118
12.4.1 Nomenclature Based on Simple Deduction from
Observation . . . . . . . . . . . . . . . . . . . . 119
12.4.1.1 Pathomorphology of Idiopathic Developmental Stenosis of
the Bony Lumbar Vertebral Canal 120
Figures 109-124 ....... 122
12.4.1.2 Additional Compressive Agents . . 130
x
12.4.2 Nomenclature Based on Observation and Conjectures . 131
12.4.3 Inaccurate Nomenclature ................ 132
12.4.3.1 Preoperative Visualization of th~ Pathomorphology of
Stenosis of the Bony Vertebral Canal . . . . . . . . . . . 134
12.5 Semiological Aspects ............ . 140
12.5.1 Permanent Signs of Radiculopathy . 140
12.5.2 Vertebrogenous Symptoms ..... 140
12.5.3 Neurogenic Intermittent Claudication 141
Figures 125-127 142
12.5.4 Diagnosis ..... . 144
12.6 Surgical Treatment and Results 145
12.6.1 Absolute Stenosis . 145
12.6.2 Vertebral Instability . 145
12.6.3 Arachnitis...... 145
12.6.4 Relative Stenosis 145
12.6.5 Postoperative Results 145
13. Cheirolumbar Dysostosis: Developmental Brachycheiry and
Narrowness o/the Lumbar Canal . . . . . . . . . . . . . . . . . . . . 147
A. Wackenheim (Strasbourg)
Figures 128-139 . . ...................... 148
References . . 157
Author Index 167
Subject Index . 169
XI
