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Spinal stenosis subsequent to juvenile lumbar osteochondrosis


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This paper describes eight patients with spinal stenosis associated with marked osteochondrous changes in the vertebral bodies due to juvenile lumbar osteochondrosis (Scheuermann's disease). In no case was the midsagittal or interpedicular diameter of the spinal canal indicative of bony stenosis. On the other hand, in the myelograms the sagittal diameter of the dural sac was in all cases significantly narrowed, a diagnostic sign of central spinal stenosis. Therefore, myelography should always be contemplated when osteochondrous changes are present and spinal stenosis is suspected clinically regardless of whether the spinal canal diameters are normal in plain films.
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Skeletal Radiol (1990) 19:203-205
Spinal stenosis subsequent to juvenile lumbar osteochondrosis
Kaj Tallroth, M.D., F.I.C.A. 1,, and Dietrich Schlenzka, M.D. 2
1 Department of Radiology and 2 Department of Orthopaedic Surgery, Orthopaedic Hospital of the Invalid Foundation,
Helsinki, Finland
This paper describes eight patients with spinal
stenosis associated with marked osteochondrous
changes in the vertebral bodies due to juvenile lumbar
osteochondrosis (Scheuermann's disease). In no case was
the midsagittal or interpedicular diameter of the spinal
canal indicative of bony stcnosis. On the other hand,
in the myelograms the sagittal diameter of the dural
sac was in all cases significantly narrowed, a diagnostic
sign of central spinal stenosis. Therefore, myelography
should always be contemplated when osteochondrous
changes are present and spinal stenosis is suspected clini-
cally regardless of whether the spinal canal diameters
are normal in plain films.
Key words: Lumbar osteochondrosis - Radiology -
Myelography - Spinal stenosis
Narrowing of the lumbar spinal canal can be classified
by the constituents of the wall (bone or soft tissue), the
localization of the stenosis (central or lateral), or the
etiology. The most common etiologic type is acquired
spinal stenosis which includes such conditions as trauma,
severe kyphosis or scoliosis, spondylolisthesis, Paget's
disease, tabetic osteoarthropathy and acromegaly as well
as degenerative spondylosis and osteoarthritis with os-
teophytes and hyperostosis [2, 10, 11, 15, 19]. As far
as we have learned from literature surveys, juvenile lum-
bar osteochondrosis has not been documented as a cause
of or predisposing factor in developmental spinal steno-
sis. In this paper we present eight patients with a nar-
rowed spinal canal subsequent to juvenile lumbar osteo-
chondrosis. Further, we discuss the difficulties associated
with plain film diagnosis and the valuable role of mye-
* Current address.
Department of Radiology, University of Michi-
gan Hospitals, Ann Arbor, MI 48109-0030, USA
Address reprint requests to :
Dr. D. Schlenzka, Orthopaedic Hospi-
tal of the Invalid Foundation, Tenholantie 10, SF-00280 Helsinki,
Material and methods
From April 1985 to April 1989 we performed lumbar myelography
on eight patients (all male, mean age 43.4 years, range 2%51 years)
in whom the diagnosis was registered as spinal stenosis due to
vertebral changes typical of juvenile lumbar osteochondrosis. The
indications for myelography were sciatic syndrome in two patients
and chronic lumbar pain in six. Spinal stenosis was suspected in
five patients as a result of clinical examination and a history of
bilateral, intermittent pain and claudication without signs of arteri-
al insufficiency. After retrospective review of the plain radiographs
and myelograms, the findings were classified and recorded.
We assessed the number of vertebrae affected by osteochon-
drosis and showing elongated and wedge*shaped bodies and end-
plate depressions (Schmorl's nodes) as well as signs of central spinal
stenosis. This assessment included measurement of the midsagittal
diameter using the method originally described by Eisenstein [7,
8]. According to his experimental work, the posterior limit of the
spinal canal from the first to the fourth lumbar vertebrae is located
at the level of the cephalad half of the vertebral body on a line
joining the apices of the superior and inferior articular facets. For
the fifth lumbar vertebra, the posterior limit of the spinal canal
is located just anterior to a well-demarcated radiolucent area in
the spinous process. The interpedicular diameter is measured as
the distance between the oval pedicles in the frontal radiograph.
In this study, we noted common features of spinal stenosis: high,
narrowed intervertebral windows; sagittally oriented, long interver-
tebral joints; and thickened, enlarged laminae. The diameters were
measured in millimeters and adjusted by a geometrical magnifica-
tion factor of 0.82. A midsagittal diameter __< 11 mm or an interpe-
dicular diameter __< 18 mm was regarded as indicative of spinal sten-
osis [8, 9].
The myelograms were all performed with a nonionic, water-
soluble contrast medium (metrizamide or iohexol). The radio-
graphic criterion for central spinal stenosis was a sagittal diameter
of the dura less than 10.5 mm in an extended position [17]. Further-
more, the coexistence of bilateral indentation of the dura and intra-
dural redundant nerve roots (serpentine filling defects) was docu-
mented [13, 16].
All eight patients had five lumbar vertebrae. Typical fea-
tures of osteochondrosis could be noted in five vertebrae
in one patient, in four vertebrae in four patients, and
9 1990 International Skeletal Society
204 Kaj Tallroth and D. Schlenzka: Lumbar osteochondrosis and spinal stenosis
1. A The lumbar vertebrae are sagittally elongated and show
end-plate depressions typical of lumbar osteochondrosis. The small
osteophytes and narrowed discs indicate a general spondylosis in
this 49-year-old man. B A metrizamide myelogram shows compres-
sion of the subarachnoid space at several disc spaces
Fig. 2. A All vertebral bodies are deformed by juvenile osteochon-
drosis in this 41-year-old man. The bodies have large end-plate
depressions, LI-2 bodies are wedge-shaped, and L1-4 are elongat-
ed, The retrolisthesis of L2-4 is due to osteoarthrosis and incon-
gruence of the intervertebral joints, B The retrolisthesis and spinal
stenosis are elegantly portrayed on the Iohexol myelogram
in three vertebrae in three patients (Fig. 1). The smallest
midsagittal diameter of the central spinal canal assessed
from the lateral plain film ranged from 12 to 19 ram,
The interpedicular distance in the frontal plain film
ranged from 19 to 26 ram. In two of the eight patients
Fig. 3. Frontal myelogram demonstrating multiple bilateral inden-
tations in a 36-year-old patient with severe symptoms of spinal
Fig. 4, This frontal myelogram shows tortuous defects in the con-
trast column. These are redundant nerve roots and are localized
above the stenotic disc interspaces
the frontal radiograph showed at least two of the signs
often related to stenosis, namely, narrow intervertebral
windows, sagittally-oriented intervertebral joints, or en-
larged laminae. In four patients the posterior elements
of the vertebrae did not show any signs of central or
lateral spinal stenosis. Degenerative osteoarthritis and
incongruence in the intervertebral joints occurred in
three patients at the three most caudad levels (Fig. 2).
Myelography demonstrated an obvious central spi-
nal stenosis in all patients. The smallest sagittal diameter
of the dura ranged from 5 to 9 ram. In two patients
the stenosis involved four vertebral levels; in four, three
levels; and in two, two levels. In all cases the narrowest
space was at an intervertebral disc level. Four patients'
frontal myelograms demonstrated hourglass constric-
tions of the contrast medium column at several disc lev-
els (Fig. 3). One of these three had, in addition, redun-
dant nerve roots, a manifestation of spinal stenosis
(Fig. 4).
In 1957 Edgren and Vainio [6] described a series of pa-
tients with atypical Scheuermann's disease with osteo-
chondrotic changes in the thoracolumbar and lumbar
regions. They named this clinico-radiographic entity
"osteochondrosis juvenilis lumbalis". This thoracolum-
bar and lumbar type of juvenile osteochondrosis is typi-
fied by the almost constant presence of severe pain dur-
ing adolescence, which distinguishes it from the classic
Scheuermann's disease of the thoracic region in which
Kaj Tallroth and D. Schlenzka: Lumbar osteochondrosis and spinal stenosis 205
pain is rare and mild [1, 4]. Excessive mechanical load
applied to the growing spine was identified as an impor-
tant etiological factor causing such changes of the verte-
brae [3, 12]. Green et al. [12] considered these changes
abnormalities of a nonprogressive nature. Stoddard and
Osborne [18], however, reported a significantly higher
incidence of spondylotic changes and backache in pa-
tients who had previous lumbar osteochondrosis than
in those who did not.
There are reports in the literature on the extremely
rare condition of compression of the myelon in the thor-
acic region in classic Scheuermann's disease, either due
to angular deformity alone or associated with thoracic
herniated disc [5, 14]. However, as far as we know, lum-
bar spinal stenosis has not been cited as a late complica-
tion of lumbar osteochondrosis.
All patients included in this series demonstrated sig-
nificant narrowing of the sagittal diameter of the dural
sac at myelography, whereas the measurements on plain
radiographs were not indicative of bony stenosis. This
discrepancy illustrates the importance of using an addi-
tional imaging modality for the definitive diagnosis. We
chose myelography instead of computed tomography be-
cause of the tendency of spinal stenosis to involve multi-
ple levels of the lumbar spine. In many centers, magnetic
resonance imaging has already supplanted both myelog-
raphy and computed tomography in the evaluation of
certain conditions of the spine.
In all of our patients maximum narrowing occurred
at the level of the intervertebral disc and was secondary
to the combined effects of posterior disc protusion and
posterior prominence of the vertebral end-plates. We
considered the end-plate deformity a sequel of juvenile
lumbar osteochondrosis. Because the mean age of the
patients was 43.4 years, it is probable that the original
abnormality was accentuated by degenerative osteo-
phyte formation. Because of the prominence of the end-
plates, the posterior surfaces of the vertebral bodies were
concave. Thus, it is quite logical that the mid-sagittal
diameter measured between the end-plates was within
normal limits in all cases.
Our observation supports the opinion that there are
marked differences between the thoracic and the lumbar
types of juvenile osteochondrosis. Lumbar spinal steno-
sis should be considered in young adults with signs of
osteochondrosis of the lumbar spine.
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... In some cases, especially when the pathology is present at the lumbar level, spine osteochondrosis is asymptomatic, and the related LBP can appear only in adulthood [6][7][8][9]. ...
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Scheuermann’s disease is a thoracic or thoracolumbar hyperkyphosis due to wedged vertebrae developing during adolescence. Ancient presentations of hyperkyphosis usually depict extreme gibbus formations as seen due to infection (tuberculosis) or congenital vertebral anomalies. Michelangelo—s ceiling fresco in the Sistine Chapel at the Vatican shows an ignudo with a kyphosis resembling a thoracolumbar juvenile kyphosis (Fig. 1). It was painted in 1511 and is possibly the earliest pictorial representation of the disease [30]. Following Schanz, Haglund named the deformity “Lehrlingskyphose” (apprentice’s kyphosis) as it was detected mainly in youngsters involved in heavy labor [27, 61]. He saw the cause as muscular insufficiency and mechanical overloading during growth. Credit is due to Holger Werfel Scheuermann from Denmark for first describing it in 1920 as being different from mobile postural kyphosis [62, 63, 64]. He recognized from radiographs that the wedge vertebrae formation in the thoracic spine was the underlying reason for the deformity. Scheuermann was the first to describe its typical radiographic features and named it “osteochondritis deformans juvenilis dorsi”. The true incidence of juvenile kyphosis is not known. It ranges from 1% to 8%, being more common in boys than in girls (ratio 2/1 to 7/1). Open image in new window
Modern sports activities are associated with a high incidence of spine pain. Low back pain (LBP) occurs in up to 50% of elite athletes (Curr Sports Med Rep 3(1):41–46, 2004). The majority are under 40 years of age. Most acute spinal injuries are soft tissue related, attributed to muscle and ligament strains, which can be successfully managed with non-invasive therapies. LBP may not be spine related but secondary to injury at other sites resulting in a breakdown of the bio-mechanical linkage of the spine, pelvis and lower limb. Changes in training regime, running surfaces and even footwear can all be responsible for LBP. It is therefore vital that athletes have a full clinical assessment prior to imaging of the spine. MRI is the primary imaging modality for diagnosis of most spinal pathology. Fat-suppressed T2W or STIR images are the most sensitive techniques for identifying bone marrow oedema, and should be included in MR protocols for investigation of back pain (Table 10.1). Radiological interpretation should always be informed by clinical findings. Asymptomatic abnormalities such as pars injuries and facet disease in the lower lumbar spine are common in elite athletes (Br J Sports Med 41(11):836–841, 2007). Radiography, CT and SPECT imaging have a limited and specific role in a minority of cases, where MR imaging is normal or required for further evaluation of a bony lesion. Spinal interventional procedures maybe required as part of the diagnostic or therapeutic management following clinical review. These are often safer and more effectively performed under image guidance. KeywordsSpine-Sports injury-Stress fracture-Spondylolysis-Facet joint-Ring apophysis-Sacro-iliac joint-Biomechanics
Our aim was to find out which factors favor the occurrence of pain in adult patients with Scheuermann's disease--a juvenile manifestation of osteochondrosis of the spine, to study the clinical and radiological signs, the role of rehabilitation and the means to avoid the recurrence of pain. Descriptive and retrospective study about 45 adults treated by rehabilitation. A data sheet listed the patient's occupation, current practice of sport, antecedents (violent sport, traumatism, pain), presence of a family form, motive of consultation, clinical and paraclinical examinations and immediate and long-term results of rehabilitation. Average age 35 years (18 to 65), male predominance (1.8:1), occupational risk factors: 16%; only 24% practiced sports currently. Antecedents: sports 49%, spinal column traumatism 13%, dorsal and lumbar pain during adolescence 16%. Consultation motive: abnormal posture 4% and pain 96%. According to the examination: abnormal spinal column in 80% of cases. According to radiography, our patients were divided into 49% who were carriers of growth vertebral dystrophy and 51% who were carriers of the real Scheuermann's disease. The immediate results of rehabilitation were satisfactory, 75% of the results were very good and good. Between six months and four years, 70% of the results were very satisfactory. Exercises were observed in only 11% of the cases, and stopped after two months on average. Scheuermann's disease in adults is a different entity from that of the teenager for the major manifestation is pain and not aesthetic quality. The patient's occupation is rather sedentary; sport is beneficial. The functional rehabilitation is the basic treatment and recourse to surgery or dorso-lumbar braces is rare.
Clinical findings of spinal stenosis were compared to graded radiologic findings of dural sac narrowing. To examine the changes of the dural sac area of the lumbar spine on computerized tomography (CT) performed without and with axial loading, and study the correlations between the radiologic findings and clinical symptoms suggestive of spinal stenosis. Although several studies have been performed regarding the advantage of an external compression device in lumbar CT, to our knowledge, none of these studies have correlated radiologic findings with clinical symptoms. The cross-sectional areas of the dural sac at the 3 lowest lumbar intravenous spaces, measured by CT both without and with external compression, were correlated to the clinical symptoms suggestive of spinal stenosis in 117 patients and 351 intervertebral levels. No statistically significant correlation between the severity of the clinical symptoms of spinal stenosis and dural cross-sectional areas was found. Neither did the use of an external compression device improve the correlation. Although an external compression simulates the dynamic condition in the back during standing position, it does not eliminate the need to compare the radiologic findings with the clinical symptoms of patients examined because of a suspected narrowing of the spinal canal.
A broader knowledge of the pathology of lumbar spinal stenosis was somewhat delayed because of the prominent attention given to disc herniations since Mixter and Barr demonstrated their frequency and importance in 1934.
1. Nine patients with radiological evidence of narrowing of the lumbar spinal canal, proved at operation, are reviewed. 2. They presented with either a claudicant or a sciatic clinical picture. 3. A classification into primary or secondary spinal stenosis is described. The primary type may be due to a reduction in either the sagittal, coronal or both diameters of the spinal canal. 4. Secondary narrowing of the canal may be superimposed upon a primary anatomical abnormality or may cause narrowing in a previously normal canal. 5. The symptoms are thought to be caused by a further reduction in the size of an already narrow canal, producing traction on the nerve tissue, which is then unable to move freely.
Forty-three cases of neurologic complications of untreated spinal deformities are reviewed. Kyphosis, averaging 95[degrees], was present in all but one patient. The most common deformity was a congenital kyphosis, present in 17 patients. The complication was more common in males, in the presence of thoracic deformities, and in the second decade. Treatment consisted of anterior spinal cord decompression in 25 patients, laminectomy in ten, Capener decompression in six, correction and fusion in five, and Hyndman-Schneider decompression in three. Laminectomy gave the worst results; six of ten patients who received this treatment showed deterioration. Anterior cord decompression gave the best results, with 16 of 25 showing improvement. A treatment plan for this complication is proposed. A plea for prevention is made, as it is far preferable to avoid this dreaded complication by early fusion of kyphotic problems.
The fallacies of the term stenosis are discussed. Propositions for a more precise definition of the stenotic conditions are given, based on the distinction between transport stenosis and compressive stenosis and their different properties. Uncertainties in the present nomenclature of the various forms of stenosis of the lumbar vertebral canal are discussed. Measuring the diameters of the lumbar vertebral canal, not only in roentgenograms but also during surgery, is an important aid to more precision in nomenclature. (C) Lippincott-Raven Publishers.
Lumbar spinal stenosis (LSS) is most commonly due to degenerative changes in older individuals. LSS is being more commonly diagnosed and may relate to better access to advanced imaging and to an ageing population. This review focusses on radicular symptoms related to degenerative central and lateral stenosis and updates knowledge of LSS pathophysiology, diagnosis and management. Since patients with anatomic LSS can range from asymptomatic to severely disabled, the clinical diagnosis focusses on symptoms and examination findings associated with LSS. Imaging findings are helpful for patients with persistent, bothersome symptoms in whom invasive treatments are being considered. There is limited information from high-quality studies about the relative merits and demerits of commonly used treatments. Interpreting and comparing results of available research are limited by a lack of consensus about the definition of LSS. Nevertheless, evidence supports decompressive laminectomy for patients with persistent and bothersome symptoms. Recommendations favour a shared decision-making approach due to important trade-offs between alternative therapies and differences among patients in their preferences and values.
Spinal osteochondrosis, previously known as Scheuermann's disease and spinal osteochondritis, is common and is probably becoming increasingly prevalent. Its incidence in patients whose primary complaint was of backache was shown to be twice as great as that in the general population. There was also a significantly higher incidence of lower lumbar spondylosis in patients with previous osteochondrosis compared with those without. Osteochondrosis is thereby shown to be an important aetiological factor in spondylosis.