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Dynamic foraminal stenosis
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The 33 year old patient had been suffering from low-back pain for 12 years. The pain increases during standing (particularly in extension) and radiates into both legs. A definitive radicular assignment was not possible. The pain gradually became disabling, the patient unable to work and requiring crutches for daily walks. He was seen as outpatient, then investigated as inpatient using all techniques of modern medicine, but the cause of his pain could not be found. Shortly before an intended transfer to a psychosomatic clinic, his attending physician suggested an Upright MRI.
Recumbent MRI had shown moderate disc degeneration L4/5/S1 (image 1), relatively narrow neural foramina L4-S1 (image 2) and a spina bifida occulta S1-S2 (image 3) was diagnosed by plain X-ray. A subsequent Upright MRI in extension showed a pronounced lordosis between L4 and S1 and massive narrowing of the respective neural foramina. The images are slightly blurred due to pain-related movements (images 4-6), but undoubtedly show complete disappearance of the intraforaminal adipose tissue and no demarcation of the outgoing nerve roots. These findings explained the cause and the course of the disease: after gradual disc degeneration L4-S1, the hyperlordosis (which was in turn potentiated by the spina bifida S1-S2) caused further dynamic stenosis of the congenitally narrow neural foramina with root compression – This was only visible in standing position. This case demonstrates the importance and so the necessity to perform an examination in a symptomatic position.
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Group studies