Clinical Cases

Spinal narrowing caused by unstable anterolisthesis and intraspinal synovial cysts.

The 77 year-old patient presented here complained of weight-bearing-dependent lumboischialgia persisting for more than one year.

Nine months before the Upright MRI, a synovial cyst, believed to be causing the symptoms, was removed from the small left vertebral joint L4/5. The back pain and pain in the right leg have improved. The pains in the left leg, in L5 – dermatoma – improved for only three months.

Given the persistent symptoms, a Coflex implant was introduced between L4 and L5, one month before the Upright MRI, in order to stabilise the affected segment. Post-surgical pain was identical to that experienced prior to surgery.

An examination conducted in the supine position highlighted degenerative changes overall, as it did prior to surgery, but without severe spinal or neural foraminal narrowing. A kinetic positional Upright MRI scan was then performed to rule out functional instability.

Standard supine MRI scan

Lumbar Spine
A-B: Sagittal T2-weighted standard supine image

The conventional supine MRI scan confirmed that severe neural foraminal or spinal narrowing could be ruled out with status post Coflex implantation in L4/5.

Upright MRI functional examination in a natural weight-bearing standing position

Lumbar Spine
C-D: Sagittal T2-weighted functional image in standing position
Lumbar Spine
E-F: Axial T2-weighted functional image in standing position

Natural weight-bearing revealed severe spinal narrowing in L4/5. This is due to degenerative anterolisthesis measuring 7 mm, from L4 to L5, with severe, bilateral, hypertrophic spondylarthrosis.

The ventral shift does not change position with loading. Spinal narrowing is accentuated by bilateral synovial cysts, curving in an intraspinal direction, on the small vertebral joints L4/5, on both sides. The cysts have a diameter of 11 mm to the left and 6 mm to the right. Accentuation of spinal narrowing is apparent in both the reclining and standing positions.

The examination shows severe, spinal narrowing exacerbated in the reclining and standing positions with unstable, degenerative anterolisthesis from L4 to L5 and severe, hypertrophic spondylarthrosis following intraspinal synovial cysts, predominantly to the left.

This particular case clearly accentuates the dynamic components and various factors that can lead to spinal narrowing. These components cannot be highlighted with a conventional supine MRI scan alone.

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