Clinical Cases

Functional severe spinal canal stenosis due to unstable anterolisthesis and position-dependent intraspinal synovial cysts.

This case refers to a 62 year-old male patient presenting recurrent lumbar syndrome for 2 years and treated with conservative pain therapy. Symptoms include persistent low back pain and pseudoradical lumbar ischialgia, clearly radiating as far as the feet on the right side. In addition, his walking ability is limited to 100 m.

Marked additional weight-bearing and posture-dependent symptoms especially on standing and walking as well as functional improvement in symptoms when load is lifted in seated and anteflexion positions.

No clear indication from external MRI previously taken in the supine position. The consultation comprised Upright MRI to examine the lumbar spine under natural weight-bearing conditions and in functional positions in a patient presenting treatment-refractory lumbar syndrome.

Lumbar Spine
The Upright MRI scan was performed with the patient upright and in a natural weight-bearing position. Sagittal T2-weighted images in seated anteflexion (Fig. A), upright seated (Fig. B) and standing (Fig. C) positions. Fig. D) shows axial T2-weighted images in the standing position at L4 / L5.

In segment L5/S1, there is evidence of a mediodorsal disc prolapse, predominantly to the left side, with moderate to severe narrowing of the spinal canal and bilateral hypertrophic facet joint osteoarthritis.

In the seated anteflexion position (Fig. A) there is evidence in segment L4/L5 of anterolisthesis extending over 5 mm from L4 to L5, regressing to 3 mm on standing retroflexion (Fig. C).

In this segment, there is also evidence of extensively hypertrophic Ligamenta flava and severe facet joint osteoarthritis with functional, intraspinal facet joint cysts to the right, increasing to 7 mm in diameter in the standing position (Figs. C + D).

In segment L3/L4, unstable retrolisthesis of 2 mm is apparent in the standing position (Fig. C) accompanied by hypermobility of the disc, regressing in anteflexion (Fig. A), and associated with active facet joint osteoarthritis, predominantly to the right, with marked hypertrophy of the Ligamenta flava and broad-based disc protrusion with slight narrowing of the neural foramina and spinal canal.

Severe functional spinal canal stenosis to the right is of crucial significance in terms of the patient’s weight-bearing-dependent symptoms.

This is triggered by unstable antelisthesis from L4 to L5 with severe, bilateral facet joint osteoarthritis and functionally increasing intraspinal facet joint cysts to the right.

In this case, Upright MRI again highlighted the cause of the patient’s weight-bearing-dependent symptoms as a result of the individually adapted examination performed in various weight-bearing positions.

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