Axial (A) and sagittal (B) T2-weighted MRI of the lumbar spine showing a facet joint synovial cyst (arrow) bulging into the spinal canal. Note that the facet signal is similar to that of the CSF and it does not enhance with gadolinium.
cord edema, demyelination, or gliosis (Figure 4-8). In the acute and subacute phases enhancement may appear following contrast administration (Figure 4-9). On T2 axial cuts the increased signal may be diffuse and difficult to discern without the respective sagittal images. At times, the increased signal appears in two symmetrical discrete spots akin to "cobra eyes" (Figures 4-10A and 4-10B). Longstanding compression can result in severe cord atrophy, which may be a bad prognostic sign. In late stages the atrophic cord appears homogenous with no difference between white and gray matter.
Progressive degenerative changes in the lumbar region result in canal shape change. Normally, the lumbar canal is oval in shape. Degenerative changes lead to narrowing of the canal in the sagittal diameter, coronal diameter, or both. Eventually it may become trefoil-shaped with apparent, severe thecal sac compression (Figures 4-11 and 4-12). Some patients develop severe stenosis at one level, usually at the L4-L5 level, and some at multiple levels.
The management of spinal stenosis includes conservative and surgical measures. Patients with mild to moderate cervical stenosis are instructed to avoid cervical hyperextension as it decreases the antero-posterior diameter of the canal. Rather than drinking directly from a bottle, the patient is urged to drink with a straw. The patient is told to avoid overhead activities and to adjust his work environment (such as seat height or monitor height) so that hyperextension is avoided. Chin-tuck and isometric neck exercises are emphasized. Analgesic and anti-inflammatory medications may provide some relief. Protracted use of cervical collars is not recommended.
Lumbar stenosis patients are taught to perform pelvic tilt, William flexion, and lumbar stabilization exercises. They are instructed to avoid hyperextension (arching) of the back and to incorporate flattening of the lumbar lordosis by pelvic tilt exercises in their daily routine. Analgesic and anti-inflammatory medications are prescribed. These may provide temporary relief. Epidural steroid injections usually provide only part-time relief but should be tried prior to surgery.
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