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Correlation between clinical scoring systems and quantitative MRI parameters in degenerative lumbar spinal stenosis

Published:October 19, 2022DOI:https://doi.org/10.1016/j.jcot.2022.102050

      Abstract

      Background

      Many quantitative MRI parameters and clinical scores have been used patients with lumbar spinal stenosis (LSS). However, the correlation between clinical scores and MRI parameters is not very clear. The objective of the study was to find out the correlation between commonly used clinical scoring systems and quantitative MRI parameters.

      Methods

      Eighty two patients (more than 40 years) with clinical and radiological characteristics of degenerative LSS completed 10 clinical questionnaires which included Oswestry disability index (ODI), Swiss spinal stenosis (SSS) questionnaire, Quebec pain disability scale (QPD), Visual analogue scale (VAS), modified Japanese orthopaedic association scale (mJOA), Pain disability index (PDI), Short form health survey (SF-36), Self-paced walking test (SPWT), Euro quality of life-5D (EQ-5D) and Neurogenic claudication outcome score (NCOS). Lumbosacral MRIs were performed and 8 quantitative parameters namely transverse & AP diameter of dural sac (TDD, APDD), anteroposterior diameter of spinal canal (APDS), ligamentous interfacet distance (LID), mid-sagittal diameter of thecal sac (MSDT), cross-sectional area dural sac (CSAD), lateral recess depth and angle (LRD, LRA) were measured at the maximum stenotic level at the level of the disc. The clinical and radiological parameters were then statistically analysed.

      Results

      There were 51 females and 31 males in the study with a mean age of 53.0253.02 ± 9.18 years. NCOS score had a moderate correlation with CSAD, LID and TDS (p<0.05,0.7>r ≥ 0.3). MSDT showed a moderate negative correlation with SSS, VAS, ODI and QPD (p<0.05,0.7>r ≥ 0.3). LRD had a moderate negative correlation with ODI and VAS score (p<0.05,0.7>r ≥ 0.3). LRA had a moderate correlation with the EQ-5D and ODI (p<0.05,0.7>r ≥ 0.3). The CSAD had a moderate negative correlation with PDI (r = −0.383, p = 0.000). For all other comparisons, there was poor or no correlation. MRI parameters showed poor or no correlation with most of components of SF-36 score.

      Conclusions

      A poor correlation or no correlation was noted for most of the MRI parameters when compared to commonly used clinical scores. Hence, poor MRI's don't necessarily mean poor clinical scores in LSS. The role of MRI parameters should be supplementary and overreliance on them in LSS management should be avoided.

      Keywords

      1. Introduction

      Lumbar Spinal Stenosis is one of the most common indications spinal surgery is worldwide.
      • Deyo R.A.
      • Gray D.T.
      • Kreuter W.
      • Mirza S.
      • Martin B.I.
      United States trends in lumbar fusion surgery for degenerative conditions.
      It is not only associated with high morbidity for the patients but also has enormous economic implications on health care
      • Deyo R.A.
      • Mirza S.K.
      • Martin B.I.
      • Kreuter W.
      • Goodman D.C.
      • Jarvik J.G.
      Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults.
      Back pain, leg pain, neurogenic claudication and sometimes neurological deficit are the major symptoms affecting patients of LSS. A plethora of clinical scores has been used in LSS to quantify the severity and guide management.
      • Ravindra V.M.
      • Senglaub S.S.
      • Rattani A.
      • et al.
      Degenerative lumbar spine disease: estimating global incidence and worldwide volume.
      Some scales like EQ-5D
      • Shiroiwa T.
      • Ikeda S.
      • Noto S.
      • et al.
      Comparison of value set based on DCE and/or TTO data: scoring for EQ-5D-5L health states in Japan.
      and VAS
      • Fritz J.M.
      • Irrgang J.J.
      A comparison of a modified Oswestry low back pain disability questionnaire and the Quebec back pain disability scale.
      mainly take into account the pain while other scales like ODI,
      • Sirvanci M.
      • Bhatia M.
      • Ganiyusufoglu K.A.
      • et al.
      Degenerative lumbar spinal stenosis: correlation with Oswestry Disability Index and MR imaging.
      QPD
      • Kopec J.A.
      • Esdaile J.M.
      • Abrahamowicz M.
      • et al.
      The Quebec back pain disability scale. Measurement properties.
      and PDI
      • Chibnall J.T.
      • Tait R.C.
      The Pain Disability Index: factor structure and normative data.
      concentrate on the disability associated with the disease. SPWT
      • Rainville J.
      • Childs L.A.
      • Peña E.B.
      • et al.
      Quantification of walking ability in subjects with neurogenic claudication from lumbar spinal stenosis--a comparative study.
      is the most widely used objective parameter for claudication distance while mJOA
      • Fukui M.
      • Chiba K.
      • Kawakami M.
      • et al.
      Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ): part 4. Establishment of equations for severity scores. Subcommittee on low back pain and cervical myelopathy, evaluation of the clinical outcome committee of the Japanese Orthopaedic Association.
      takes into account the neurological component. Among the commonly used scales, ODI and VAS are the most widely used scales but recently, LSS specific scales like SSS
      • Comer C.M.
      • Conaghan P.G.
      • Tennant A.
      Internal construct validity of the Swiss Spinal Stenosis questionnaire: rasch analysis of a disease-specific outcome measure for lumbar spinal stenosis.
      and NCOS
      • Azimi P.
      • Mohammadi H.R.
      • Montazeri A.
      An outcome measure of functionality in patients with lumber spinal stenosis: a validation study of the Iranian version of Neurogenic Claudication Outcome Score (NCOS).
      also come into the limelight. These scales are often used to quantify the severity of symptoms associated with LSS and gauge the improvement post intervention.
      • Abou-Al-Shaar H.
      • Adogwa O.
      • Mehta A.I.
      Lumbar spinal stenosis: objective measurement scales and Ambulatory status.
      As LSS is primarily a clinico-radiological diagnosis, MRI is an integral part of diagnosis and also plays a key role in surgical decision making.
      • Chatha D.S.
      • Schweitzer M.E.
      MRI criteria of developmental lumbar spinal stenosis revisited.
      Several parameters like the cross sectional area of dural sac (CSAD),
      • Hamanishi C.
      • Matukura N.
      • Fujita M.
      • Tomihara M.
      • Tanaka S.
      Cross-sectional area of the stenotic lumbar dural tube measured from the transverse views of magnetic resonance imaging.
      anteroposterior diameter of dural sac (APDD),
      • Amadou A.
      • Sonhaye L.
      • James Y.
      • et al.
      Normative dimensions of lumbar canal and dural sac by computer tomography in Togo.
      ,
      • Steurer J.
      • Roner S.
      • Gnannt R.
      • Hodler J.
      Quantitative radiologic criteria for the diagnosis of lumbar spinal stenosis: a systematic literature review.
      transverse diameter (dural sac) (TDD),
      • Hughes A.
      • Makirov S.K.
      • Osadchiy V.
      Measuring spinal canal size in lumbar spinal stenosis: description of method and preliminary results.
      anteroposterior diameter (spinal canal) (APDS),
      • Korse N.S.
      • Kruit M.C.
      • Peul W.C.
      • Vleggeert-Lankamp C.L.A.
      Lumbar spinal canal MRI diameter is smaller in herniated disc cauda equina syndrome patients.
      mid sagittal diameter of thecal sac (MSDT)
      • Hughes A.
      • Makirov S.K.
      • Osadchiy V.
      Measuring spinal canal size in lumbar spinal stenosis: description of method and preliminary results.
      and ligamentous interfacet distance (LID)
      • Steurer J.
      • Roner S.
      • Gnannt R.
      • Hodler J.
      Quantitative radiologic criteria for the diagnosis of lumbar spinal stenosis: a systematic literature review.
      have been described to measure the extent of central lumbar stenosis.
      • Chatha D.S.
      • Schweitzer M.E.
      MRI criteria of developmental lumbar spinal stenosis revisited.
      ,
      • Steurer J.
      • Roner S.
      • Gnannt R.
      • Hodler J.
      Quantitative radiologic criteria for the diagnosis of lumbar spinal stenosis: a systematic literature review.
      ,
      • Azimi P.
      • Mohammadi H.R.
      • Benzel E.C.
      • Shahzadi S.
      • Azhari S.
      Lumbar spinal canal stenosis classification criteria: a new tool.
      Over the last decade or so, the lateral recess has also been recognized as a potential site of stenosis resulting in a description of lateral recess angle
      • Hughes A.
      • Makirov S.K.
      • Osadchiy V.
      Measuring spinal canal size in lumbar spinal stenosis: description of method and preliminary results.
      ,
      • Birjandian Z.
      • Emerson S.
      • Telfeian A.E.
      • Hofstetter C.P.
      Interlaminar endoscopic lateral recess decompression-surgical technique and early clinical results.
      and lateral recess depth
      • Birjandian Z.
      • Emerson S.
      • Telfeian A.E.
      • Hofstetter C.P.
      Interlaminar endoscopic lateral recess decompression-surgical technique and early clinical results.
      ,
      • Wu A.-M.
      • Zou F.
      • Cao Y.
      • et al.
      Lumbar spinal stenosis: an update on the epidemiology, diagnosis and treatment.
      to measure the extent of lateral recess stenosis. There are few studies available that have compared some clinical scores like ODI, VAS, SF-36 and claudication distance with only a few MRI parameters like APDD, CSAD
      • Sirvanci M.
      • Bhatia M.
      • Ganiyusufoglu K.A.
      • et al.
      Degenerative lumbar spinal stenosis: correlation with Oswestry Disability Index and MR imaging.
      ,
      • Andrasinova T.
      • Adamova B.
      • Buskova J.
      • Kerkovsky M.
      • Jarkovsky J.
      • Bednarik J.
      Is there a correlation between degree of radiologic lumbar spinal stenosis and its clinical manifestation?.
      • Hong J.H.
      • Lee M.Y.
      • Jung S.W.
      • Lee S.Y.
      Does spinal stenosis correlate with MRI findings and pain, psychologic factor and quality of life?.
      • Kuittinen P.
      • Sipola P.
      • Saari T.
      • et al.
      Visually assessed severity of lumbar spinal canal stenosis is paradoxically associated with leg pain and objective walking ability.
      and have found no correlation between them. However, many of the commonly used clinical scores (SSS, NCOS, QPD, PDI, mJOA, etc.) and MRI parameters (TDD, APDS, MSDT, LID, LRA, LRD) have not been compared and correlated with each other and other parameters. The importance of such comparisons lies in the fact that they help the clinicians and researchers to gauge and predict if patients with poor MRI parameters also have poor clinical scores and vice versa or not. Hence we designed this comprehensive study to look out for correlations between ten commonly used clinical scores and eight quantitative MRI parameters in LSS patients.

      2. Materials and Methods

      A total of 82 patients aged more than 40 years attending the outpatient department of our hospital with clinico-radiological features suggestive of degenerative LSS over around 1.5 years were recruited for this prospective observational study. The patients were asked about the presence of low back pain, the appearance of pain in buttocks and legs on walking, the appearance of motor and sensory symptoms on walking and relief of pain symptoms on bending forward, riding a bicycle or bending over a shopping cart. These findings were supplemented with the finding of MRI showing atleast one stenotic level.
      • Tomkins-Lane C.
      • Melloh M.
      • Lurie J.
      • et al.
      ISSLS prize winner: consensus on the clinical diagnosis of lumbar spinal stenosis: results of an international delphi study.
      The study was conducted in a public tertiary health care facility and the patients were recruited from those attending a busy orthopaedic out-patient department at our hospital with clinical features and radiological findings suggestive of LSS. The study was registered in the university database (2018/469) and the clearance for the study was obtained from the institutional ethics committee (IEC/2018/14) and all patients provided consent.
      The present study was aimed to find how the various clinical scores and quantitative MRI parameters correlate with each other. Our hypothesis was the commonly used clinical scores and MRI parameters would show poor or no correlation among each other.
      The inclusion criteria were patients aged 40 years or more with the neurogenic claudication. It may or may not be associated with radiating pain on sitting or lying down. Neurogenic claudication was defined as fatigue pain and/or parasthesias one or both lower limbs which was caused by standing or walking and was relieved when the patient was sitting lying down and bending forward. MRI features with atleast one level of an osteoligamentous spinal canal narrowing and findings like ligamentum flavum thickening, degenerative disc prolapse and facetal hypertrophy were considered. The exclusion criteria included primary canal stenosis including achondroplasia, traumatic, dysplastic and isthmic causes of canal stenosis; congenital spine anomalies, prior lumbar spine surgery, polyneuropathy, myopathy, osteoporosis or kyphotic deformity/vertebral collapse in the lumbar region. All patients also underwent measurement of pulses and ankle brachial index in the lower extremity. Any patients with abnormalities in these parameters were excluded from the study. Patients with peripheral vascular disease, advanced hip, knee or ankle arthritis or any other reason that may lead to neurological and walking ability impairment were also excluded. Patients with the presence of significant leg pain on rest
      • Yamada K.
      • Aota Y.
      • Higashi T.
      • et al.
      Lumbar foraminal stenosis causes leg pain at rest.
      without much increase in pain on walking were also excluded.
      All patients completed 10 clinical questionnaires which included ODI,
      • Fairbank J.C.
      • Pynsent P.B.
      The Oswestry disability index.
      ,
      • Tonosu J.
      • Takeshita K.
      • Hara N.
      • et al.
      The normative score and the cut-off value of the Oswestry Disability Index (ODI).
      SSS questionnaire,
      • Comer C.M.
      • Conaghan P.G.
      • Tennant A.
      Internal construct validity of the Swiss Spinal Stenosis questionnaire: rasch analysis of a disease-specific outcome measure for lumbar spinal stenosis.
      ,
      • Tomkins C.C.
      • Battié M.C.
      • Hu R.
      Construct validity of the physical function scale of the Swiss Spinal Stenosis Questionnaire for the measurement of walking capacity.
      ,
      • Pratt R.K.
      • Fairbank J.C.
      • Virr A.
      The reliability of the shuttle walking test, the Swiss spinal stenosis questionnaire, the oxford spinal stenosis score, and the Oswestry disability index in the assessment of patients with lumbar spinal stenosis.
      QPD,
      • Fritz J.M.
      • Irrgang J.J.
      A comparison of a modified Oswestry low back pain disability questionnaire and the Quebec back pain disability scale.
      ,
      • Kopec J.A.
      • Esdaile J.M.
      • Abrahamowicz M.
      • et al.
      The Quebec back pain disability scale. Measurement properties.
      VAS,
      • Reips U.D.
      • Funke F.
      Interval-level measurement with visual analogue scales in Internet-based research: VAS Generator.
      ,
      • Klimek L.
      • Bergmann K.-C.
      • Biedermann T.
      • et al.
      Visual analogue scales (VAS): measuring instruments for the documentation of symptoms and therapy monitoring in cases of allergic rhinitis in everyday health care: position paper of the German society of Allergology (AeDA) and the German society of Allergy and clinical immunology (DGAKI), ENT section, in collaboration with the working group on clinical immunology, Allergology and environmental medicine of the German society of otorhinolaryngology, head and neck surgery (DGHNOKHC).
      mJOA,
      • Fukui M.
      • Chiba K.
      • Kawakami M.
      • et al.
      Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ): part 4. Establishment of equations for severity scores. Subcommittee on low back pain and cervical myelopathy, evaluation of the clinical outcome committee of the Japanese Orthopaedic Association.
      ,
      • Yonenobu K.
      • Abumi K.
      • Nagata K.
      • Taketomi E.
      • Ueyama K.
      Interobserver and intraobserver reliability of the Japanese orthopaedic association scoring system for evaluation of cervical compression myelopathy.
      ,
      • Benzel E.C.
      • Lancon J.
      • Kesterson L.
      • Hadden T.
      Cervical laminectomy and dentate ligament section for cervical spondylotic myelopathy.
      PDI,
      • Chibnall J.T.
      • Tait R.C.
      The Pain Disability Index: factor structure and normative data.
      ,
      • Tait R.C.
      • Pollard C.A.
      • Margolis R.B.
      • Duckro P.N.
      • Krause S.J.
      The Pain Disability Index: psychometric and validity data.
      SF-36,
      • Wu A.W.
      • Hays R.D.
      • Kelly S.
      • Malitz F.
      • Bozzette S.A.
      Applications of the Medical Outcomes Study health-related quality of life measures in HIV/AIDS.
      • Brazier J.
      • Roberts J.
      • Deverill M.
      The estimation of a preference-based measure of health from the SF-36.
      • Ware Jr., J.E.
      • Sherbourne C.D.
      The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection.
      • Franks P.
      • Lubetkin E.I.
      • Gold M.R.
      • Tancredi D.J.
      • Jia H.
      Mapping the SF-12 to the EuroQol EQ-5D index in a national US sample.
      SPWT,
      • Rainville J.
      • Childs L.A.
      • Peña E.B.
      • et al.
      Quantification of walking ability in subjects with neurogenic claudication from lumbar spinal stenosis--a comparative study.
      • Lee S.I.
      • Park E.
      • Huang A.
      • et al.
      Objectively quantifying walking ability in degenerative spinal disorder patients using sensor equipped smart shoes.
      EQ-5D,
      • Shiroiwa T.
      • Ikeda S.
      • Noto S.
      • et al.
      Comparison of value set based on DCE and/or TTO data: scoring for EQ-5D-5L health states in Japan.
      EuroQol--a new facility for the measurement of health-related quality of life.
      • Janssen M.F.
      • Birnie E.
      • Haagsma J.A.
      • Bonsel G.J.
      Comparing the standard EQ-5D three-level system with a five-level version.
      NCOS.
      • Azimi P.
      • Mohammadi H.R.
      • Montazeri A.
      An outcome measure of functionality in patients with lumber spinal stenosis: a validation study of the Iranian version of Neurogenic Claudication Outcome Score (NCOS).
      The SSS questionnaire has 3 sections with 18 questions including a section with post management questions. Post management questions were excluded from the present study. Hence, only 2 sections (12 questions) were administered giving a total score of 53 (instead of 77). For the self-paced walking test, the patients were asked to walk in a 50-m hallway at a self-selected pace with the option to stop and sit when symptoms of neurogenic claudication appeared. The distance at which symptoms of neurogenic claudication appeared was recorded in meters. For MRI parameters, MRI files were uploaded in the RadiAnt DICOM Viewer 2020.0 beta (free). The maximum stenosis level was identified and the following parameters were measured by the method as described below at the level of the disc using the same software. The various MRI parameters that were measured along with their description are represented in Table 1. Illustrative MRI images depicting how the measurements were made are represented in Fig. 1, Fig. 2, Fig. 3, Fig. 4. All the radiographic measurements were performed by two orthopaedic surgeons with over 5 years’ experience in spine surgery and were well versed and proficient with the use of the above radiological software (SG, TB) and an average of the 2 measurements was used.
      Table 1Summary of the MRI parameters used in the study and their description.
      MRI parameterDescription
      Transverse diameter of dural sac (TDD)Distance between lateral borders of dural sac on the level of lateral canals [18].
      Antero-posterior diameter of dural sac (APDD)The AP diameter at disc level was measured by drawing a line between the anterior and posterior border of the dural sac [16, 17].
      Anteroposterior diameter of spinal canal (APDS)It was measured at the disc level by drawing a line between the posterior border of discus and the ligamentum flavum at midline [19].
      Ligamentous interfacet distance (LID)It was measured as the distance between the inner surfaces of flaval ligaments on a line connecting the joint space of facet joints [17].
      Mid sagittal diameter of thecal sac (MSDT)It was measured on a mid-sagittal cut at the level of disc as a distance between most anterior and posterior point of the thecal sac [18].
      Cross sectional area of dural sac (CSAD)The area of the dural sac was measured using ellipse tool provided in the software [15].
      Lateral recess depth (LRD)It was measured as the distance between the most anterior point of superior articular facet and the posterior border of spinal canal at the level of superior margin of the corresponding pedicle [21, 22].
      Lateral recess angle (LRA)It was measured as the angle between the lines parallel to the floor and the roof of the lateral recess [18, 21].
      Fig. 1
      Fig. 1Figure representing the points taken for measurements of linear sizes of dural sac on axial section of MRI at the level of disc: 1. Anteroposterior diameter of dural sac (APDD), 2. Transverse diameter of dural sac (TDD).
      Fig. 2
      Fig. 2Figure representing the points taken for measurements of linear sizes of spinal canal on axial section of MRI at the level of disc: 1. Anteroposterior diameter of spinal canal (APDS), 2. Ligamentous interfacet distance (LID), 3. Lateral recess depth (LRD), 4. Lateral recess angle (LRA).
      Fig. 3
      Fig. 3Figure representing the points taken for measurement of mid sagittal diameter of thecal sac (MSDT) at the level of intervertebral disc on mid saggital section of MRI.
      Fig. 4
      Fig. 4Figure representing the use of ellipse tool for measuring cross sectional area of dural sac (CSA) on the axial section of MRI at the level of disc.

      3. Statistical analysis

      The data was entered in an excel sheet and SPSS-PC-19 was used for statistical analysis. Percentages were used to express qualitative data and mean and standard deviation were used to quantify quantitative data. Correlation between two quantitative variables was studies with spearman correlation coefficient(r). P-value < 0.05 was considered statistically significant. The value of r ≥ 0.7 was considered a strong correlation, 0.7> r ≥ 0.3 was considered a moderate correlation and r < 0.3 was considered a weak correlation.
      • Dancey C.
      • Reidy J.
      Statistics without Maths for Psychology.
      The intraclass correlation coefficient (ICC) was used to measure reliability across radiographic measurements. ICC>0.9 was considered excellent, 0.9 > ICC>0.75 was considered good.
      • Koo T.K.
      • Li M.Y.
      A guideline of selecting and reporting intraclass correlation coefficients for reliability research.

      4. Results

      In this study, 82 consecutive patients were selected aged more than 40 years out of which 33 patients (40.2%) were aged less than 50 years, 22 (26.8%) were between 50 and 59 years and 27 (32.9%) of more than 60 years. The mean age was 53.02 ± 9.18 years. Among selected patients, 51 (62.2%) were females and the rest 31 (37.8%) were males. In our study, 21 patients (25.6%) had single level involvement, two levels were involved in 39 patients (47.56%), 3 or more levels involved in 22 patients (26.8%). For multi-level LSS, the maximum stenotic level was used to measure the MRI parameters. The most commonly involved maximum stenotic level was L4-L5 in 38 patients (46.3%), followed by L5-S1 in 33 patients (40.02%) and L3-L4 in 11 patients (13.4%). Isolated central canal stenosis was seen in 9 patients (11.0%) while the rest 73 patients (89%) had both central and lateral recess stenosis. The mean, median, standard deviation and range for all MRI parameters and clinical scores are represented in Table 2. The intraclass correlation coefficient (ICC) was good to excellent (range 0.8–0.96) for all radiographic measurements.
      Table 2Table representing the mean, standard deviation and range for MRI parameters and various clinical scores measures in LSS patients.
      MRI Parameters
      ParameterMean ± SDRange
      Transverse diameter of dural sac (mm10.5 ± 3.74.11–18.5
      AP diameter of spinal canal (mm)10.9 ± 3.34.78–18.7
      Ligamentous interfacet distance (mm)6.9 ± 2.63.12–14
      AP diameter of dural sac (mm)6.5 ± 2.13.33–11.6
      Mid sagittal diameter of thecal sac (mm)6.2 ± 2.42.19–16.9
      CSA of dural sac (mm)54.5 ± 29.525.87–129.5
      Lateral recess depth (mm)2.7 ± 1.01.09–5.33
      Lateral recess angle (°)9.9 ± 4.53.7–23.1
      Clinical Scores
      ScoreMean ± SDRange
      ODI score (/50)33.6 ± 6.512–44
      SSS questionnaire (/53)33 ± 6.523–50
      Quebec pain disability scale (/100)69.1 ± 8.444–85
      VAS scale (/10)7.2 ± 1.05–9
      mJOA scale (/18)11.6 ± 1.98–16
      Pain Disability index (/100)69.7 ± 8.844–86
      Self-Paced walking test (metres)231.7 ± 148.850–700
      Euro quality of life- 5D (/100)32.1 ± 20.3−13.9–70.7
      NCOS (/100)34.1 ± 8.918–54
      SF-36Physical functioning (/100)41.5 ± 17.910–95
      Role limitations due to physical health (/100)23.7 ± 21.90–75
      Role limitations due to emotional problems (/100)30.2 ± 25.70–100
      Energy/fatigue (/100)39.6 ± 17.30–75
      Emotional well-being (/100)39.9 ± 19.40–80
      Social functioning (/100)39.6 ± 15.212.5–75
      Pain(/100)34.7 ± 15.30–77.5
      General health (/100)45.9 ± 17.010–80
      Health change (/100)24.4 ± 16.40–70
      (AP- Anteroposterior, CSA-Cross sectional area, MRI Magnetic Resonance Imaging, mJOA-modified Japanese Orthopaedic Association, NCOS-Neurogenic Outcome Claudication Score, ODI-Oswestry Disability Index, SD- Standard Deviation, SF - 36-Short Form Health Survey, SSS-Swiss Spinal Stenosis,VAS- Visual Analogue scale).
      Various clinical scores were compared with MRI parameters. The correlation coefficient and p-value of each comparison were recorded and are represented in Table 3. The neurological claudication outcome score had a moderate positive correlation with TDD (r = 0.606, p = 0.00), CSAD (r = 0.580, p = 0.00) and LID (r = 0.519, p = 0.00). MSDT had a moderate negative correlation with SSS questionnaire (r = −0.426, p = 0.00), VAS scale (r = −0.407, p = 0.00), ODI scale (r = −0.389, p = 0.00), and QPD scale (r = −0.306, p = 0.005). LRD had a significant moderate negative correlation with ODI scale (r = −0.447, p = 0.00) and VAS score (r = −0.315, p = 0.00). LRA had a moderate correlation with the EQ-5D (r = 0.536, p = 0.00) and ODI scale (r = −0.377, p = 0.00). CSAD had a moderate negative correlation with PDI (r = −0.383, p = 0.000). For all other comparison there poor or no correlation between clinical scores and MRI parameters (Table 3).
      Table 3Table representing the correlation coefficients (r) and p – value for comparison among various MRI parameters and clinical scoring systems.
      Table thumbnail fx1
      Various components of SF-36 were correlated with MRI parameters and are represented in Table 4. APDS had a significant moderate correlation with role limitations due to emotional problems (r = 0.326, p = 0.003), APDD (r = 0.305, p = 0.005) and LRA (r = −0.345, p = 0.001). Mental health had moderate correlation with LID (r = −0.308, p = 0.005) and general health with LRA (r = 0.315, p = 0.004). The other comparisons among SF-36 components and MRI parameters yielded no or poor correlation. Bodily pain, social functioning, role limitations due to physical health and physical functioning demonstrated no significant strong or moderate correlation with any of the parameters (Table 4).
      Table 4Table representing the correlation coefficients (r) and p – value for comparison among various MRI parameters and components of SF-36 scale.
      Table thumbnail fx2

      5. Discussion

      Back pain, leg pain, neurogenic claudication and in some cases neurological deficit constitute the spectrum of symptoms of LSS.
      • Munakomi S.
      • Foris L.A.
      • Varacallo M.
      Spinal stenosis and neurogenic claudication.
      Several clinical scores have been used in lumbar spinal stenosis to quantify the pain, disability and morbidity associated with it.
      • Abou-Al-Shaar H.
      • Adogwa O.
      • Mehta A.I.
      Lumbar spinal stenosis: objective measurement scales and Ambulatory status.
      Similarly, a number of MRI parameters have been used for defining and quantifying LSS but no consensus on the best parameters exists.
      • Mamisch N.
      • Brumann M.
      • Hodler J.
      • Held U.
      • Brunner F.
      • Steurer J.
      Radiologic criteria for the diagnosis of spinal stenosis: results of a Delphi survey.
      As LSS is a clinico-radiological diagnosis, both MRI parameters and clinical scores often form a part of decision making, but how these two correlate with each other is still a bone of contention.
      • Sirvanci M.
      • Bhatia M.
      • Ganiyusufoglu K.A.
      • et al.
      Degenerative lumbar spinal stenosis: correlation with Oswestry Disability Index and MR imaging.
      ,
      • Andrasinova T.
      • Adamova B.
      • Buskova J.
      • Kerkovsky M.
      • Jarkovsky J.
      • Bednarik J.
      Is there a correlation between degree of radiologic lumbar spinal stenosis and its clinical manifestation?.
      • Hong J.H.
      • Lee M.Y.
      • Jung S.W.
      • Lee S.Y.
      Does spinal stenosis correlate with MRI findings and pain, psychologic factor and quality of life?.
      • Kuittinen P.
      • Sipola P.
      • Saari T.
      • et al.
      Visually assessed severity of lumbar spinal canal stenosis is paradoxically associated with leg pain and objective walking ability.
      Many of the commonly used clinical scores and MRI parameters have never been correlated with each other. Hence, the present study was designed to provide a comprehensive correlation analysis among ten commonly used clinical scores and eight quantitative MRI parameters.
      Most of the studies presently available have correlated VAS and ODI score with CSAD and APDD and no significant correlation between these parameters has been found.
      • Sirvanci M.
      • Bhatia M.
      • Ganiyusufoglu K.A.
      • et al.
      Degenerative lumbar spinal stenosis: correlation with Oswestry Disability Index and MR imaging.
      ,
      • Andrasinova T.
      • Adamova B.
      • Buskova J.
      • Kerkovsky M.
      • Jarkovsky J.
      • Bednarik J.
      Is there a correlation between degree of radiologic lumbar spinal stenosis and its clinical manifestation?.
      • Hong J.H.
      • Lee M.Y.
      • Jung S.W.
      • Lee S.Y.
      Does spinal stenosis correlate with MRI findings and pain, psychologic factor and quality of life?.
      • Kuittinen P.
      • Sipola P.
      • Saari T.
      • et al.
      Visually assessed severity of lumbar spinal canal stenosis is paradoxically associated with leg pain and objective walking ability.
      Burg staller et al.
      • Burgstaller J.M.
      • Schüffler P.J.
      • Buhmann J.M.
      • et al.
      Is there an association between pain and magnetic resonance imaging parameters in patients with lumbar spinal stenosis?.
      also found similar findings in a literature review where did not find a significant correlation between pain scores and several MRI parameters that were evaluated. A few other scores like the SPWT and SF-36 have also met a similar fate where no correlation was seen on comparison with CSAD and APDD.
      • Andrasinova T.
      • Adamova B.
      • Buskova J.
      • Kerkovsky M.
      • Jarkovsky J.
      • Bednarik J.
      Is there a correlation between degree of radiologic lumbar spinal stenosis and its clinical manifestation?.
      • Hong J.H.
      • Lee M.Y.
      • Jung S.W.
      • Lee S.Y.
      Does spinal stenosis correlate with MRI findings and pain, psychologic factor and quality of life?.
      • Kuittinen P.
      • Sipola P.
      • Saari T.
      • et al.
      Visually assessed severity of lumbar spinal canal stenosis is paradoxically associated with leg pain and objective walking ability.
      ,
      • Zeifang F.
      • Schiltenwolf M.
      • Abel R.
      • Moradi B.
      Gait analysis does not correlate with clinical and MR imaging parameters in patients with symptomatic lumbar spinal stenosis.
      A summary of available studies from literature comparing various clinical scores and MRI parameters have been presented in Table 5. Besides these popular MRI parameters (CSAD, APDD), various other MRI parameters (TDD, APDS, LID, MSDT, LRD and LRA) have gained popularity over the last decade
      • Sirvanci M.
      • Bhatia M.
      • Ganiyusufoglu K.A.
      • et al.
      Degenerative lumbar spinal stenosis: correlation with Oswestry Disability Index and MR imaging.
      ,
      • Andrasinova T.
      • Adamova B.
      • Buskova J.
      • Kerkovsky M.
      • Jarkovsky J.
      • Bednarik J.
      Is there a correlation between degree of radiologic lumbar spinal stenosis and its clinical manifestation?.
      • Hong J.H.
      • Lee M.Y.
      • Jung S.W.
      • Lee S.Y.
      Does spinal stenosis correlate with MRI findings and pain, psychologic factor and quality of life?.
      • Kuittinen P.
      • Sipola P.
      • Saari T.
      • et al.
      Visually assessed severity of lumbar spinal canal stenosis is paradoxically associated with leg pain and objective walking ability.
      and comparison and correlation between these quantitative MRI parameters and commonly used clinical scores is lacking.
      Table 5Summary of studies correlating MRI parameters with clinical scores.
      S. No.Author and yearNumber of patientsType of MRIMRI parameters usedClinical scoresResults
      1Sirvanci 200863SupineCSADODINo correlation
      2Zeifang et al., 200863SupineCSADSPWTNo correlation
      3Kuittinen et al., 201480SupineCSADVASNo straightforward association between the stenosis of dural sac and patient symptoms or functional capacity.
      ODI
      4Hong et al., 2015117SupineCSADVASNo correlation
      ODI
      SF-36
      5Andrasinova et al., 201884SupineAPDDVASNo correlation
      CSADODI
      SPWT
      6Kanno et al., 201288SupineCSADVASSupine MRI did not correlate.
      Axial loading MRI (standing MRI)Walking distanceStanding MRI values had moderate correlation with clinical scores.
      JOA score
      7Zhou et al., 2020110Supine and Standing MRICSADODIDural sac size on MRI was reduced significantly from supine to standing position. Standing MRI and the changes of DCSA significantly correlated with all clinical parameters
      APDDVAS
      SPWT
      Most of the clinical scores in our study had sparring significant correlation with MRI parameters. In this study, we performed over 160 correlations and approximately only 12% of the comparison yielded a significant moderate correlation. This again reinstates the fact that radiological parameters correlate poorly to clinical scores.
      • Sirvanci M.
      • Bhatia M.
      • Ganiyusufoglu K.A.
      • et al.
      Degenerative lumbar spinal stenosis: correlation with Oswestry Disability Index and MR imaging.
      ,
      • Kuittinen P.
      • Sipola P.
      • Saari T.
      • et al.
      Visually assessed severity of lumbar spinal canal stenosis is paradoxically associated with leg pain and objective walking ability.
      ,
      • Zeifang F.
      • Schiltenwolf M.
      • Abel R.
      • Moradi B.
      Gait analysis does not correlate with clinical and MR imaging parameters in patients with symptomatic lumbar spinal stenosis.
      It is not uncommon for patients in developing countries to be advised surgical management based on MRI imaging and patients seeking treatment based on their MRI pictures showing canal stenosis. Studies have shown that factual reporting of MRI images can result in patients having decreased improvement in pain, poor functional status and a negative perception for their spinal conditions. On the other hand, clinical reporting which takes into account both the clinical picture and imaging leads to decrease in assessment of severity of disease and cause the health care practitioners to move to less degree of interventions and surgery.
      • Rajasekaran S.
      • Dilip Chand Raja S.
      • Pushpa B.T.
      • Ananda K.B.
      • Ajoy Prasad S.
      • Rishi M.K.
      The catastrophization effects of an MRI report on the patient and surgeon and the benefits of 'clinical reporting': results from an RCT and blinded trials.
      Studies relating to lumbar disc herniation have also shown that percentage of canal occupied and the size of disc herniation were not predictive of need for surgery in these cases or conservative management failure.
      • Gupta A.
      • Upadhyaya S.
      • Yeung C.M.
      • et al.
      Does size matter? An analysis of the effect of lumbar disc herniation size on the success of nonoperative treatment.
      A number of factors may be responsible for these findings. These include hypertrophy of facets and endplates leading to stabilization of spine,
      • Kuittinen P.
      • Sipola P.
      • Saari T.
      • et al.
      Visually assessed severity of lumbar spinal canal stenosis is paradoxically associated with leg pain and objective walking ability.
      the inability of the supine MRI's to recreate axial loading
      • Kanno H.
      • Ozawa H.
      • Koizumi Y.
      • et al.
      ,
      • Zhou Z.
      • Jin Z.
      • Zhang P.
      • et al.
      Correlation between dural sac size in dynamic magnetic resonance imaging and clinical symptoms in patients with lumbar spinal stenosis.
      and dynamic compression of standing position and variability of the sensitivity of pain among patients.
      • Kim H.J.
      • Suh B.G.
      • Lee D.B.
      • et al.
      The influence of pain sensitivity on the symptom severity in patients with lumbar spinal stenosis.
      Studies have suggested that even in the asymptomatic population over 55 years, one third of patients can have moderate to severe stenosis on MRI at atleast one level.
      • Tong H.
      • Carson J.
      • Haig A.
      • et al.
      Magnetic resonance imaging of the lumbar spine in asymptomatic older adults.
      Moreover, psychological factors may also play a role and lead to higher disability scores in some patients.
      • Carragee E.J.
      • Alamin T.F.
      • Miller J.L.
      • Carragee J.M.
      Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain.
      This discussion again reiterates the fact that LSS is a clinicoradiological diagnosis but an unpredictable and complex relationship exists between most MRI parameters and clinical scores. Radiological findings alone may not justify the treatment of spinal stenosis and management decisions should be based on the degree of clinical impairment with MRI findings supplementing the same.
      • Haig A.J.
      • Geisser M.E.
      • Tong H.C.
      • et al.
      Electromyographic and magnetic resonance imaging to predict lumbar stenosis, low-back pain, and no back symptoms.
      We acknowledge that our study is fraught with some limitations: 1) We utilized supine MRI in our study. Some studies have shown that standing MRI may better recreate spinal stenosis conditions due to axial loading of the spine and result in good correlation between clinical scores and MRI parameters.
      • Kanno H.
      • Ozawa H.
      • Koizumi Y.
      • et al.
      ,
      • Zhou Z.
      • Jin Z.
      • Zhang P.
      • et al.
      Correlation between dural sac size in dynamic magnetic resonance imaging and clinical symptoms in patients with lumbar spinal stenosis.
      However, the use of standing MRIs remains largely restricted to research and such a facility is not available widely and at our center. At present, supine MRI remains the most widely used and practical approach for diagnosis of LSS in most parts of the world and this is unlikely to change in the near future. 2) As degenerative LSS is majorly a disorder of the elderly and hence comorbidities, polypharmacy and other degenerative disorders of the lower limbs may act as confounding factors. It may have had an impact on their pain tolerance and walking distance. 3) Single-center study and heterogeneous group of patients are some other limitations.

      6. Conclusion

      A poor correlation or no correlation was noted for most of the MRI parameters when compared to clinical scores utilized in common practice. Hence, poor MRI's don't necessarily mean poor clinical scores in LSS. The role of MRI parameters should be supplementary and overreliance on them in LSS management should be avoided.

      Funding statement

      There is no funding source for this publication/study.

      Ethics approval

      Approval was obtained from the ethics committee of Maulana azad medical college, New Delhi. The procedures used in this study adhere to the tenets of the Declaration of Helsinki.

      Consent to participate

      Informed consent was obtained from all individual participants included in the study.

      Consent to publish

      Patients signed informed consent regarding publishing their data and photographs.

      Code availability

      Not applicable.

      Declaration of competing interest

      Dr Siddharth Gupta, Dr Tungish Bansal, Dr Abhishek Kashyap, and Dr Sumit Sural declare that they have no conflict of interest.

      Acknowledgments

      None.

      References

        • Deyo R.A.
        • Gray D.T.
        • Kreuter W.
        • Mirza S.
        • Martin B.I.
        United States trends in lumbar fusion surgery for degenerative conditions.
        Spine. 2005; 30 (discussion 1446-1447): 1441-1445
        • Deyo R.A.
        • Mirza S.K.
        • Martin B.I.
        • Kreuter W.
        • Goodman D.C.
        • Jarvik J.G.
        Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults.
        JAMA. 2010; 303: 1259-1265
        • Ravindra V.M.
        • Senglaub S.S.
        • Rattani A.
        • et al.
        Degenerative lumbar spine disease: estimating global incidence and worldwide volume.
        Global Spine J. 2018; 8: 784-794
        • Shiroiwa T.
        • Ikeda S.
        • Noto S.
        • et al.
        Comparison of value set based on DCE and/or TTO data: scoring for EQ-5D-5L health states in Japan.
        Value Health : the journal of the International Society for Pharmacoeconomics and Outcomes Research. 2016; 19: 648-654
        • Fritz J.M.
        • Irrgang J.J.
        A comparison of a modified Oswestry low back pain disability questionnaire and the Quebec back pain disability scale.
        Phys Ther. 2001; 81: 776-788
        • Sirvanci M.
        • Bhatia M.
        • Ganiyusufoglu K.A.
        • et al.
        Degenerative lumbar spinal stenosis: correlation with Oswestry Disability Index and MR imaging.
        Eur Spine J. 2008; 17: 679-685
        • Kopec J.A.
        • Esdaile J.M.
        • Abrahamowicz M.
        • et al.
        The Quebec back pain disability scale. Measurement properties.
        Spine. 1995; 20: 341-352
        • Chibnall J.T.
        • Tait R.C.
        The Pain Disability Index: factor structure and normative data.
        Arch Phys Med Rehabil. 1994; 75: 1082-1086
        • Rainville J.
        • Childs L.A.
        • Peña E.B.
        • et al.
        Quantification of walking ability in subjects with neurogenic claudication from lumbar spinal stenosis--a comparative study.
        Spine J. 2012; 12: 101-109
        • Fukui M.
        • Chiba K.
        • Kawakami M.
        • et al.
        Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ): part 4. Establishment of equations for severity scores. Subcommittee on low back pain and cervical myelopathy, evaluation of the clinical outcome committee of the Japanese Orthopaedic Association.
        J Orthop Sci. 2008; 13: 25-31
        • Comer C.M.
        • Conaghan P.G.
        • Tennant A.
        Internal construct validity of the Swiss Spinal Stenosis questionnaire: rasch analysis of a disease-specific outcome measure for lumbar spinal stenosis.
        Spine. 2011; 36: 1969-1976
        • Azimi P.
        • Mohammadi H.R.
        • Montazeri A.
        An outcome measure of functionality in patients with lumber spinal stenosis: a validation study of the Iranian version of Neurogenic Claudication Outcome Score (NCOS).
        BMC Neurol. 2012; 12: 101
        • Abou-Al-Shaar H.
        • Adogwa O.
        • Mehta A.I.
        Lumbar spinal stenosis: objective measurement scales and Ambulatory status.
        Asian spine journal. 2018; 12: 765-774
        • Chatha D.S.
        • Schweitzer M.E.
        MRI criteria of developmental lumbar spinal stenosis revisited.
        Bull NYU Hosp Jt Dis. 2011; 69: 303-307
        • Hamanishi C.
        • Matukura N.
        • Fujita M.
        • Tomihara M.
        • Tanaka S.
        Cross-sectional area of the stenotic lumbar dural tube measured from the transverse views of magnetic resonance imaging.
        J Spinal Disord. 1994; 7: 388-393
        • Amadou A.
        • Sonhaye L.
        • James Y.
        • et al.
        Normative dimensions of lumbar canal and dural sac by computer tomography in Togo.
        Med Imag Radiol. 2017; 5: 3
        • Steurer J.
        • Roner S.
        • Gnannt R.
        • Hodler J.
        Quantitative radiologic criteria for the diagnosis of lumbar spinal stenosis: a systematic literature review.
        BMC Muscoskel Disord. 2011; 12: 175
        • Hughes A.
        • Makirov S.K.
        • Osadchiy V.
        Measuring spinal canal size in lumbar spinal stenosis: description of method and preliminary results.
        Internet J Spine Surg. 2015; 9: 3
        • Korse N.S.
        • Kruit M.C.
        • Peul W.C.
        • Vleggeert-Lankamp C.L.A.
        Lumbar spinal canal MRI diameter is smaller in herniated disc cauda equina syndrome patients.
        PLoS One. 2017; 12e0186148
        • Azimi P.
        • Mohammadi H.R.
        • Benzel E.C.
        • Shahzadi S.
        • Azhari S.
        Lumbar spinal canal stenosis classification criteria: a new tool.
        Asian spine journal. 2015; 9: 399-406
        • Birjandian Z.
        • Emerson S.
        • Telfeian A.E.
        • Hofstetter C.P.
        Interlaminar endoscopic lateral recess decompression-surgical technique and early clinical results.
        Journal of spine surgery (Hong Kong). 2017; 3: 123-132
        • Wu A.-M.
        • Zou F.
        • Cao Y.
        • et al.
        Lumbar spinal stenosis: an update on the epidemiology, diagnosis and treatment.
        AME Medical Journal. 2017; 2 (63-63)
        • Andrasinova T.
        • Adamova B.
        • Buskova J.
        • Kerkovsky M.
        • Jarkovsky J.
        • Bednarik J.
        Is there a correlation between degree of radiologic lumbar spinal stenosis and its clinical manifestation?.
        Clin Spine Surg. 2018; 31: E403-e408
        • Hong J.H.
        • Lee M.Y.
        • Jung S.W.
        • Lee S.Y.
        Does spinal stenosis correlate with MRI findings and pain, psychologic factor and quality of life?.
        Korean journal of anesthesiology. 2015; 68: 481-487
        • Kuittinen P.
        • Sipola P.
        • Saari T.
        • et al.
        Visually assessed severity of lumbar spinal canal stenosis is paradoxically associated with leg pain and objective walking ability.
        BMC Muscoskel Disord. 2014; 15 (348-348)
        • Tomkins-Lane C.
        • Melloh M.
        • Lurie J.
        • et al.
        ISSLS prize winner: consensus on the clinical diagnosis of lumbar spinal stenosis: results of an international delphi study.
        Spine. 2016; 41: 1239-1246
        • Yamada K.
        • Aota Y.
        • Higashi T.
        • et al.
        Lumbar foraminal stenosis causes leg pain at rest.
        Eur Spine J. 2014; 23: 504-507
        • Fairbank J.C.
        • Pynsent P.B.
        The Oswestry disability index.
        Spine. 2000; 25 (discussion 2952): 2940-2952
        • Tonosu J.
        • Takeshita K.
        • Hara N.
        • et al.
        The normative score and the cut-off value of the Oswestry Disability Index (ODI).
        Eur Spine J. 2012; 21: 1596-1602
        • Tomkins C.C.
        • Battié M.C.
        • Hu R.
        Construct validity of the physical function scale of the Swiss Spinal Stenosis Questionnaire for the measurement of walking capacity.
        Spine. 2007; 32: 1896-1901
        • Pratt R.K.
        • Fairbank J.C.
        • Virr A.
        The reliability of the shuttle walking test, the Swiss spinal stenosis questionnaire, the oxford spinal stenosis score, and the Oswestry disability index in the assessment of patients with lumbar spinal stenosis.
        Spine. 2002; 27: 84-91
        • Reips U.D.
        • Funke F.
        Interval-level measurement with visual analogue scales in Internet-based research: VAS Generator.
        Behav Res Methods. 2008; 40: 699-704
        • Klimek L.
        • Bergmann K.-C.
        • Biedermann T.
        • et al.
        Visual analogue scales (VAS): measuring instruments for the documentation of symptoms and therapy monitoring in cases of allergic rhinitis in everyday health care: position paper of the German society of Allergology (AeDA) and the German society of Allergy and clinical immunology (DGAKI), ENT section, in collaboration with the working group on clinical immunology, Allergology and environmental medicine of the German society of otorhinolaryngology, head and neck surgery (DGHNOKHC).
        Allergo J Int. 2017; 26: 16-24
        • Yonenobu K.
        • Abumi K.
        • Nagata K.
        • Taketomi E.
        • Ueyama K.
        Interobserver and intraobserver reliability of the Japanese orthopaedic association scoring system for evaluation of cervical compression myelopathy.
        Spine. 2001; 26 (discussion 1895): 1890-1894
        • Benzel E.C.
        • Lancon J.
        • Kesterson L.
        • Hadden T.
        Cervical laminectomy and dentate ligament section for cervical spondylotic myelopathy.
        J Spinal Disord. 1991; 4: 286-295
        • Tait R.C.
        • Pollard C.A.
        • Margolis R.B.
        • Duckro P.N.
        • Krause S.J.
        The Pain Disability Index: psychometric and validity data.
        Arch Phys Med Rehabil. 1987; 68: 438-441
        • Wu A.W.
        • Hays R.D.
        • Kelly S.
        • Malitz F.
        • Bozzette S.A.
        Applications of the Medical Outcomes Study health-related quality of life measures in HIV/AIDS.
        Qual Life Res. 1997; 6: 531-554
        • Brazier J.
        • Roberts J.
        • Deverill M.
        The estimation of a preference-based measure of health from the SF-36.
        J Health Econ. 2002; 21: 271-292
        • Ware Jr., J.E.
        • Sherbourne C.D.
        The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection.
        Med Care. 1992; 30: 473-483
        • Franks P.
        • Lubetkin E.I.
        • Gold M.R.
        • Tancredi D.J.
        • Jia H.
        Mapping the SF-12 to the EuroQol EQ-5D index in a national US sample.
        Med Decis Making. 2004; 24: 247-254
        • Lee S.I.
        • Park E.
        • Huang A.
        • et al.
        Objectively quantifying walking ability in degenerative spinal disorder patients using sensor equipped smart shoes.
        Med Eng Phys. 2016; 38: 442-449
      1. EuroQol--a new facility for the measurement of health-related quality of life.
        Health Pol. 1990; 16: 199-208
        • Janssen M.F.
        • Birnie E.
        • Haagsma J.A.
        • Bonsel G.J.
        Comparing the standard EQ-5D three-level system with a five-level version.
        Value Health : the journal of the International Society for Pharmacoeconomics and Outcomes Research. 2008; 11: 275-284
        • Dancey C.
        • Reidy J.
        Statistics without Maths for Psychology.
        2011
        • Koo T.K.
        • Li M.Y.
        A guideline of selecting and reporting intraclass correlation coefficients for reliability research.
        Journal of chiropractic medicine. 2016; 15: 155-163
        • Munakomi S.
        • Foris L.A.
        • Varacallo M.
        Spinal stenosis and neurogenic claudication.
        in: StatPearls [Internet]. StatPearls Publishing, 2020
        • Mamisch N.
        • Brumann M.
        • Hodler J.
        • Held U.
        • Brunner F.
        • Steurer J.
        Radiologic criteria for the diagnosis of spinal stenosis: results of a Delphi survey.
        Radiology. 2012; 264: 174-179
        • Burgstaller J.M.
        • Schüffler P.J.
        • Buhmann J.M.
        • et al.
        Is there an association between pain and magnetic resonance imaging parameters in patients with lumbar spinal stenosis?.
        Spine. 2016; 41: E1053-e1062
        • Zeifang F.
        • Schiltenwolf M.
        • Abel R.
        • Moradi B.
        Gait analysis does not correlate with clinical and MR imaging parameters in patients with symptomatic lumbar spinal stenosis.
        BMC Muscoskel Disord. 2008; 9: 89
        • Rajasekaran S.
        • Dilip Chand Raja S.
        • Pushpa B.T.
        • Ananda K.B.
        • Ajoy Prasad S.
        • Rishi M.K.
        The catastrophization effects of an MRI report on the patient and surgeon and the benefits of 'clinical reporting': results from an RCT and blinded trials.
        Eur Spine J. 2021; 30: 2069-2081
        • Gupta A.
        • Upadhyaya S.
        • Yeung C.M.
        • et al.
        Does size matter? An analysis of the effect of lumbar disc herniation size on the success of nonoperative treatment.
        Global Spine J. 2020; 10: 881-887
        • Kanno H.
        • Ozawa H.
        • Koizumi Y.
        • et al.
        (3)Dynamic Change of Dural Sac Cross-Sectional Area in Axial Loaded Magnetic Resonance Imaging Correlates with the Severity of Clinical Symptoms in Patients with Lumbar Spinal Canal Stenosis. vol. 37. 2012: 207-213
        • Zhou Z.
        • Jin Z.
        • Zhang P.
        • et al.
        Correlation between dural sac size in dynamic magnetic resonance imaging and clinical symptoms in patients with lumbar spinal stenosis.
        World Neurosurg. 2020; 134: e866-e873
        • Kim H.J.
        • Suh B.G.
        • Lee D.B.
        • et al.
        The influence of pain sensitivity on the symptom severity in patients with lumbar spinal stenosis.
        Pain Physician. 2013; 16: 135-144
        • Tong H.
        • Carson J.
        • Haig A.
        • et al.
        Magnetic resonance imaging of the lumbar spine in asymptomatic older adults.
        J Back Musculoskelet Rehabil. 2006; 19: 67-72
        • Carragee E.J.
        • Alamin T.F.
        • Miller J.L.
        • Carragee J.M.
        Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain.
        Spine J. 2005; 5: 24-35
        • Haig A.J.
        • Geisser M.E.
        • Tong H.C.
        • et al.
        Electromyographic and magnetic resonance imaging to predict lumbar stenosis, low-back pain, and no back symptoms.
        J Bone Jt Surg Am Vol. 2007; 89: 358-366