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(1)

But My Back Hurts Only

When I

’

m Standing !

Axial Loading for Spinal Canal Stenosis

Matthew Cham, MD; Akio Hiwatashi, MD; Per-Lennart Westesson, MD, PhD, DDS

(2)

Spinal Canal Stenosis

!

Progressive narrowing

of the central canal,

lateral recesses, and

neural foramina most

commonly due to

degenerative disease

!

In the United States,

majority of individuals

over 60 years old are

affected

(3)

Symptoms of Lumbar Stenosis

!

Most commonly presents

as midline back pain

aggravated by standing

or walking

!

Improved by leaning

(4)

!

To review the role of axial-loading in MRI

for the diagnosis of spinal canal stenosis

!

To learn how axial-loading in MRI can be

performed during conventional supine MRI

(5)

Effect of Positioning

!

Myelography may

demonstrate

worsening of

spinal stenosis

during extension

(6)

!

Some individuals are

symptomatic only in the

upright position

!

May be secondary to axial

load exerted by bodyweight

on the spine, making spinal

stenosis worse in the

standing position

Axial Loading

(7)

Effects of Axial Loading

!

MRI is typically

performed in the

supine position with

no axial load

!

Surgically treatable

spinal stenosis may

become hidden during

supine MRI

(8)

Axial Loading Device

!

Device used to generate

axial loading

!

Simulates the upright

standing position during

conventional supine MRI

!

Consists of a harness

(9)

Harness

!

Harness comes

in several sizes

to fit various

body types

!

Two nylon

straps fasten

the harness to

the foot platform

(10)

Foot Platform

!

Foot platform applies an

adjustable tension to

the harness

(11)

Patient Interview

!

Identify patients

who might benefit

from axial-loading

during MRI

(12)

Evaluation of Symptoms

My back hurts only

when I’m standing!

!

Patient may

complain of pain that

occurs only when

standing

!

Pain may be

relieved by lying

down

(13)

Evaluation of Prior MRI

My back doesn’t

hurt lying down.

I have no pain at

all !

!

Prior MRI might show

no significant spinal

stenosis due to lack

of axial load

!

Patient may have

been asymptomatic

during prior MRI due

(14)

Using the Axial Loading Device

!

Harness is worn

like a vest

(15)

!

The foot platform

is placed at

patient’s feet

!

One size fits all

(16)

!

Harness is

fastened to

the foot

platform with

two nylon

straps

(17)

!

Tension is applied to the

harness by adjusting two

large blue knobs

!

As the two knobs are

(18)

!

Axial load (in pounds) is

indicated by two display gauges.

!

Recommended total axial load is

50% of patient’s bodyweight

(19)

MRI with Axial Loading

My back hurts!

It feels as if I

am standing!

!

Patients usually become

symptomatic due to the

axial load

!

Patient should be given

(20)

MRI with Axial Loading

No Axial Load

With Axial Load

(21)

Female 41y

No Axial Load

!

Neurogenic claudication

at L4-L5

!

Increasing central

(22)

Male 63y

No Axial Load

!

Neurogenic claudication

at L4-L5

!

Increasing disc

herniation and central

stenosis with axial load

(23)

Female 58y

No Axial Load

!

Neurogenic Claudication

at L4-L5

!

Increasing synovial cyst

(24)

Female 52y

No Axial Load

!

Neurogenic Claudication

at L4-L5

!

Increasing central

(25)

!

The incremental increase in

diagnosis of operative spinal

canal stenosis with the use

of an axial-loading device is

currently under investigation.

!

There is some evidence that

management could change

for some patients.

(Hiwatashi, et

al. AJNR 2004; 25:170-174)

(26)

!

FDA-approved for both CT and MRI

!

If patient cannot tolerate their back

pain, hip or knee flexion instantly

relieves the axial load

!

Large display gauge allows MRI

technologist to see absence of axial

load in those situations

Is it safe?

Axial load is

relieved by

knee flexion

(27)

What are other options?

(28)

!

Axial-loading during MRI can unmask operative

cases of spinal canal stenosis that may

otherwise appear inconsequential

!

Axial-loading can be performed during

conventional supine MRI

!

The incremental diagnostic yield of axial loading

for spinal canal stenosis is currently under

investigation

(29)

!

Danielson BI, Willen J, Gaulitz A, et al. Axial loading of the spine during CT

and MR in patients with suspected lumbar spinal stenosis. Acta Radiol.

1998; 39(6):604-11.

!

Hiwatashi A, Danielson B, Moritani T. Axial loading during MRI imaging can

influence treatment decision for symptomatic spinal stenosis. AJNR 2004;

25:170-174.

!

Jinkins JR, Dworkin J. Upright, weight-bearing, dynamic-kinetic MRI of the

spine. Acta Clin Croat 2002; 41(Suppl):31-35.

!

Kimura S, Steinbach GC, Watenpaugh DE. Lumbar spine disc height and

curvature responses to an axial load. Spine 2001; 26:2596-2600.

!

Willen J, Danielson B. The diagnostic effect from axial loading of the lumbar

spine during computed tomography and magnetic resonance imaging in

patients with degenerative disorders. Spine 2001; 26(23):2607-14.

References

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