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Skeletal Radiol (1990) 19:203-205
Skeletal
Radiology
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
Abstract.
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-
lography.
* 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,
Finland
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].
Results
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
Fig.
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
stenosis
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).
Discussion
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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