Skip to main content
Advertisement

Main menu

  • Home
  • Content
    • Current Issue
    • Publication Preview--Ahead of Print
    • Past Issue Archive
    • Case of the Week Archive
    • Classic Case Archive
    • Case of the Month Archive
  • For Authors
  • About Us
    • About AJNR
    • Editors
    • American Society of Neuroradiology
  • Submit a Manuscript
  • Podcasts
    • Subscribe on iTunes
    • Subscribe on Stitcher
  • More
    • Subscribers
    • Permissions
    • Advertisers
    • Alerts
    • Feedback
  • Other Publications
    • ajnr

User menu

  • Subscribe
  • Alerts
  • Log in

Search

  • Advanced search
American Journal of Neuroradiology
American Journal of Neuroradiology

American Journal of Neuroradiology

  • Subscribe
  • Alerts
  • Log in

Advanced Search

  • Home
  • Content
    • Current Issue
    • Publication Preview--Ahead of Print
    • Past Issue Archive
    • Case of the Week Archive
    • Classic Case Archive
    • Case of the Month Archive
  • For Authors
  • About Us
    • About AJNR
    • Editors
    • American Society of Neuroradiology
  • Submit a Manuscript
  • Podcasts
    • Subscribe on iTunes
    • Subscribe on Stitcher
  • More
    • Subscribers
    • Permissions
    • Advertisers
    • Alerts
    • Feedback
  • Follow AJNR on Twitter
  • Visit AJNR on Facebook
  • Follow AJNR on Instagram
  • Join AJNR on LinkedIn
  • RSS Feeds
EditorialEDITORIAL

My Legs Only Hurt When I Stand Up!

Christopher G. Ullrich
American Journal of Neuroradiology February 2004, 25 (2) 165;
Christopher G. Ullrich
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Info & Metrics
  • References
  • PDF
Loading

In this issue of the AJNR, Hiwatashi et al provide an important reminder of several fundamental medical concepts that have sometimes been forgotten by many radiologists. This study looks at a group of 200 symptomatic spinal stenosis patients examined with MR imaging by using routine supine imaging techniques. By using a device that applied an axial load equivalent to 50% of patient body weight, additional supine axial loaded images were obtained. Upright MR imaging techniques take a similar approach and offer the additional possibility of dynamic imaging. A subset of 20 patients whose images showed substantial change after axial loading was then analyzed by three neurosurgeons with regard to treatment recommendations. On the basis of axial loaded images, changes in surgical therapy would have been made for as many as 10 of these patients. No attempt was made to determine actual improvements in outcomes for these patients.

Most of our statistics for effective imaging tests have tended to look at single variables, such as herniated disk versus no disk herniation, whereas lumbar spinal stenosis is a multivariable disease that can challenge correct interpretation of images. The lumbar spine is a dynamic structure that permits flexibility within well-defined physiologic limits, and, under normal circumstances, no neural compression occurs. As spinal integrity deteriorates, abnormal motion or structural shifting occurs, which may only be evident in a certain position or mechanical loading situation. These more subtle abnormalities can cause patient symptoms. Failure to recognize these more dynamic structural abnormalities can lead to suboptimal surgical therapy in some patients. It is interesting that about 5% of the patients in this study had such a change in recommended surgical therapy. Although this number is not large, this distinction could be very important for that patient group.

Physicians understand that appropriate patient treatment is determined by a combination of patient history, physical examination, and diagnostic testing. As radiologists, we naturally focus on diagnostic testing, and we have great confidence in the quality of our work. Many of us consider routine MR as the only diagnostic test that is needed for evaluating the lumbar spine. As Hiwatashi et al show, for many but not all patients, this assumption is correct. Well-trained spinal surgeons are aware of the dynamic element of lumbar spinal disease, and many of their procedures are predicated on stabilizing symptomatic “instability.” For them, diagnostic imaging is often done to confirm their clinical findings before surgery. If the imaging does not confirm their clinical opinion, additional testing may be needed. Some spine surgeons continue to use lumbar myelography as a problem-solving examination, particularly when they are concerned about dynamic changes in the spine or there is a significant discordance between the history, physical examination, and the routine MR imaging findings. Anyone who performs myelography has seen important structural findings in some patients that were “missed” on routine MR or CT images. Unfortunately many radiologists do not fully appreciate this point and treat myelography as a relatively unimportant and perhaps obsolete examination. The data in the article suggest that a further reduction in the need for myelography is possible with improved MR imaging strategies.

Because many spine surgeons perform imaging as a confirmatory test before surgery that they believe is indicated on the basis of history and physical examination, it can be rationally argued that for a small group of spinal stenosis patients it is more effective to perform CT myelography. This remains the best dynamic evaluation presently available at most medical centers, and the CT assessment of the lumbar spine is actually very effective, especially with multidetector CT and two-dimensional multiplanar reconstructions. If this is done as a presurgical study, additional imaging is almost never needed. In the previously instrumented patient, CT myelography is often the best study available. The same cannot be said for MR imaging.

With these concepts in mind, and with Hiwatashi’s information, it can be suggested that current routine lumbar MR imaging techniques are less than fully adequate for a small group of patients. With further refinements and validation of MR axial loaded and dynamic lumbar studies, the need for lumbar myelography will be further diminished. In the meantime, lumbar myelography is still valuable in deciding on clinical management and surgical approaches for spinal stenosis.

  • Copyright © American Society of Neuroradiology
PreviousNext
Back to top

In this issue

American Journal of Neuroradiology: 25 (2)
American Journal of Neuroradiology
Vol. 25, Issue 2
1 Feb 2004
  • Table of Contents
  • Index by author
Advertisement
Print
Download PDF
Email Article

Thank you for your interest in spreading the word on American Journal of Neuroradiology.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
My Legs Only Hurt When I Stand Up!
(Your Name) has sent you a message from American Journal of Neuroradiology
(Your Name) thought you would like to see the American Journal of Neuroradiology web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
My Legs Only Hurt When I Stand Up!
Christopher G. Ullrich
American Journal of Neuroradiology Feb 2004, 25 (2) 165;

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
My Legs Only Hurt When I Stand Up!
Christopher G. Ullrich
American Journal of Neuroradiology Feb 2004, 25 (2) 165;
del.icio.us logo Digg logo Reddit logo Twitter logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
  • Info & Metrics
  • References
  • PDF

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • No citing articles found.
  • Crossref
  • Google Scholar

This article has not yet been cited by articles in journals that are participating in Crossref Cited-by Linking.

More in this TOC Section

  • The Z-Shift: A Need for Quality Management System Level Testing and Standardization in Neuroimaging Pipelines
  • Digital Didactics: Introducing the New ASNR Neuroradiology Fellowship Curriculum
  • Insights into the AJNR Review Process
Show more Editorial

Similar Articles

Advertisement

News and Updates

  • Lucien Levy Best Research Article Award
  • Thanks to our 2021 Distinguished Reviewers
  • Press Releases

Resources

  • Evidence-Based Medicine Level Guide
  • How to Participate in a Tweet Chat
  • AJNR Podcast Archive
  • Ideas for Publicizing Your Research
  • Librarian Resources
  • Terms and Conditions

Opportunities

  • Share Your Art in Perspectives
  • Get Peer Review Credit from Publons
  • Moderate a Tweet Chat

American Society of Neuroradiology

  • Neurographics
  • ASNR Annual Meeting
  • Fellowship Portal
  • Position Statements

© 2022 by the American Society of Neuroradiology | Print ISSN: 0195-6108 Online ISSN: 1936-959X

Powered by HighWire