The Narrow Lumbar Canal : Radiologic Signs and Surgery

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.

1. Radiology of the Narrow Lumbar Canal.- 1.1 History.- 1.2 Terminology.- 1.3 Anatomy.- 1.3.1 Spinal Canal.- 1.3.2 Radicular Canal.- 1.3.3 Intervertebral Foramen.- 1.4 Clinical Data.- 1.4.1 Neurogenic Intermittent Claudication.- 1.4.2 Further Aspects of the Clinical Data.- 1.5 Radiologic Techniques and Their Indications.- 1.5.1 Plain Films and Tomographs of the Lumbosacral Spine.- 1.5.2 Opacification Techniques of the Subarachnoidal Space.- 1.5.3 Further Radiologic Techniques.- 1.6 Radiologic Signs of Lumbar Canal Narrowness.- 1.6.1 Anomalies of the Bones.- 1.6.1.1 Lateral Projection.- 1.6.1.2 Frontal Projection.- 1.6.1.3 Oblique Projections.- 1.6.2 Morphological Classification of the Bony Anomalies.- 1.6.2.1 Diffuse Anteroposteriorly Predominant Canalar Stenosis.- 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.- 1.6.2.3 Stenosis of the Lateral Parts of the Canal Related to a Deformation of Its Lumen by Abnormal (Arthrosic or Dysplastic) Facetal Joints.- 1.6.3 Radiculosaccographic Signs.- 1.6.4 Phlebography Signs.- 1.7 Nosology.- 1.7.1 Developmental Spinal Stenosis.- 1.7.2 Acquired Spinal Stenoses.- 1.7.3 Congenital Stenoses.- Figures 1–7.- 2. Plain X-Ray Diagnosis of Developmental Narrow Lumbar Canal.- 2.1 Technique.- 2.2 Findings: To Measure or Not to Measure? That is Not the Question.- 2.3 Requirements for Reliable Measurements and Pitfalls.- 2.4 Radiologic Features of the Narrow Lumbar Canal Without Contrast Medium.- 2.4.1 Anteroposterior Plain Films or Tomograms.- 2.5 Findings on Lateral Projection.- 2.6 Various Types of Developmental Stenosis.- 2.7 Correlation Between Surgical and Radiologic Reports.- 2.8 Narrow Lumbar Canal and Associated Diseases.- Figures 8–14.- 3. Interapophysolaminar Spaces (IALS) of the Lumbar Spine and Their Utility in the Diagnosis of Narrow Lumbar Canal.- 3.1 Introduction.- 3.2 Material and Methods.- 3.3 Results.- 3.3.1 Morphological Data.- 3.3.2 Measurements.- 3.4 Conclusion.- Figures 15–18.- 4. Myelographic Signs of Narrow Lumbar Canal.- 4.1 Technical Particularities.- 4.2 Limits of the LM as an Investigation of the Narrow Lumbar Canals.- 4.3 LM Anomalies.- 4.3.1 Elementary Semeiology of Spinal Stenoses in LM.- 4.3.1.1 Anomalies of the Dural Sac and of Its Contents.- 4.3.1.2 Anomalies of the Epidural Space and Its Contents (Radicular Sheaths and Extrasaccular Parts of the Roots).- 4.3.2 Groups of Elementary Signs in Some Types of Stenoses.- Figures 19–28.- 5. Gas Myelography in Verbiest’s Developmental Spinal Canal Stenosis.- 5.1 Symptomatology.- 5.2 Radiologic Examination.- 5.2.1 Conventional X-Rays.- 5.2.1.1 Frontal Projection.- 5.2.1.2 Lateral Projection.- 5.2.2 Gas Myelography.- 5.2.2.1 Technique.- 5.2.2.2 Radiologic Findings.- 5.2.2.3 Drawbacks of Gas Myelography.- 5.3 Clinical Forms of Idiopathic Developmental Spinal Stenosis.- 5.3.1 Anatomic Forms of Idiopathic Developmental Spinal Stenosis.- 5.3.1.1 Stenosis of the Entire Lumbar Canal.- 5.3.1.2 Stenosis Involving One or Two Vertebrae.- 5.3.2 Lumbar Canal Stenosis Associated with Narrowing of Other Spinal Segments.- 5.3.2.1 Lumbar Spinal Stenosis Associated with Narrowing of the Cervical Canal.- 5.3.2.2 Stenosis of the Entire Spinal Canal.- 5.3.3 Familial Forms of Idiopathic Developmental Spinal Stenosis.- Figures 29–42.- 6. Phlebographic Signs of the Narrow Lumbar CanaL.- 6.1 Physiopathology of the Venous Compression.- 6.2 Phlebographic Signs of Narrow Lumbar Canal.- 6.2.1 Narrowing of the Lumbar Canal in Its Entire Length.- 6.2.2 Segmental Stenoses of the Lumbar Canal.- Figures 43–47.- 7. Narrow Lumbar Canal by Postoperative Epidural Lesions.- 7.1 Radiculosaccographic Semeiology of Epidural Scarring.- 7.2 Phlebographic Semeiology of Epidural Scarring.- 7.3 Surgical Findings.- 7.4 Clinical Aspects.- 7.5 Physiopathology.- 7.6 Conclusion.- Figures 48–60.- 8. Spinal Phlebography in the Stenosis of the Lumbar Canal.- Figures 61–72.- 9. Computerized Tomography in Lumbar Spinal Stenosis.- 9.1 Material and Methods.- 9.2 Results.- 9.2.1 Normal Lumbar Spinal Canal.- 9.2.2 Lumbar Spinal Stenosis.- 9.3 Conclusion.- Figures 73–84.- 10. Lumbar Spinal Stenosis.- 10.1 Etiology.- 10.1.1 Developmental Stenosis.- 10.1.2 Degenerative Stenosis.- 10.1.2.1 Without Slip.- 10.1.2.2 With a Slip.- 10.1.3 Iatrogenic Stenosis.- 10.1.4 Other Etiologies of Lumbar Stenosis.- 10.2 Symptomatology.- 10.3 Treatment.- Figures 85–98.- 11. Narrow Radicular Canal.- 11.1 Nosologic Importance of the Narrow Radicular Canal with Regard to the Narrow Lumbar Canal.- 11.2 Anatomy of the Radicular Canal.- 11.3 Etiologies.- 11.4 Symptomatology of the Narrow Radicular Canal.- 11.5 Radiologic Findings.- 11.6 Surgical Procedures.- 11.7 Conclusion.- Figures 99–108.- 12. Stenosis of the Bony Lumbar Vertebral Canal.- 12.1 Introduction.- 12.2 Historical Review: Evolution of the Idea.- 12.3 Nomenclature.- 12.3.1 Quantitative Aspects in the Definition of Stenosis.- 12.4 Classification of the Types of Stenoses of the Lumbar Vertebral Canal.- 12.4.1 Nomenclature Based on Simple Deduction from Observation.- 12.4.1.1 Pathomorphology of Idiopathic Developmental Stenosis of the Bony Lumbar Vertebral Canal.- Figures 109–124.- 12.4.1.2 Additional Compressive Agents.- 12.4.2 Nomenclature Based on Observation and Conjectures.- 12.4.3 Inaccurate Nomenclature.- 12.4.3.1 Preoperative Visualization of the Pathomorphology of Stenosis of the Bony Vertebral Canal.- 12.5 Semiological Aspects.- 12.5.1 Permanent Signs of Radiculopathy.- 12.5.2 Vertebrogenous Symptoms.- 12.5.3 Neurogenic Intermittent Claudication.- Figures 125–127.- 12.5.4 Diagnosis.- 12.6 Surgical Treatment and Results.- 12.6.1 Absolute Stenosis.- 12.6.2 Vertebral Instability.- 12.6.3 Arachnitis.- 12.6.4 Relative Stenosis.- 12.6.5 Postoperative Results.- 13. Cheirolumbar Dysostosis: Developmental Brachycheiry and Narrowness of the Lumbar Canal.- Figures 128–139.- References.- Author Index.