Neuroradiolog y / Head and Neck Imaging • Original Research

Lee et al.
MRI Grading of Lumbar Foraminal Stenosis

Neuroradiology/Head and Neck Imaging

Original Research
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A Practical MRI Grading System for

Lumbar Foraminal Stenosis
Seunghun Lee1 OBJECTIVE. This study aimed to evaluate the reproducibility of a new grading system
Joon Woo Lee1 for lumbar foraminal stenosis.
Jin Sup Yeom2 MATERIALS AND METHODS. Four grades were developed for lumbar foraminal
Ki-Jeong Kim 3 stenosis on the basis of sagittal MRI. Grade 0 refers to the absence of foraminal stenosis;
Hyun-Jib Kim 3 grade 1 refers to mild foraminal stenosis showing perineural fat obliteration in the two oppos-
ing directions, vertical or transverse; grade 2 refers to moderate foraminal stenosis showing
Soo Kyo Chung 4
perineural fat obliteration in the four directions without morphologic change, both vertical
Heung Sik Kang1 and transverse directions; and grade 3 refers to severe foraminal stenosis showing nerve root
Lee S, Lee JW, Yeom JS, et al. collapse or morphologic change. A total of 576 foramina in 96 patients were analyzed (from
L3–L4 to L5–S1). Two experienced radiologists independently assessed the sagittal MR im-
ages. Interobserver agreement between the two radiologists and intraobserver agreement by
one reader were analyzed using kappa statistics.
RESULTS. According to reader 1, grade 1 foraminal stenosis was found in 33 foramina,
grade 2 in six, and grade 3 in seven. According to reader 2, grade 1 foraminal stenosis was
found in 32 foramina, grade 2 in six, and grade 3 in eight. Interobserver agreement in the
grading of foraminal stenosis between the two readers was found to be nearly perfect (κ value:
right L3–L4, 1.0; left L3–L4, 0.905; right L4–L5, 0.929; left L4–L5, 0.942; right L5–S1,
0.919; and left L5–S1, 0.909). In intraobserver agreement by reader 1, grade 1 foraminal
stenosis was found in 34 foramina, grade 2 in eight, and grade 3 in seven. Intraobserver agree-
ment in the grading of foraminal stenosis was also found to be nearly perfect (κ value: right
L3–L4, 0.883; left L3–L4, 1.00; right L4–L5, 0.957; left L4–L5, 0.885; right L5–S1, 0.800;
and left L5–S1, 0.905).
Keywords: foraminal stenosis, lumbar vertebrae, neural CONCLUSION. The new grading system for foraminal stenosis of the lumbar spine
foramen, sagittal MRI
showed nearly perfect interobserver and intraobserver agreement and would be helpful for
DOI:10.2214/AJR.09.2772 clinical study and routine practice.

Received March 20, 2009; accepted after revision

L
umbar foraminal stenosis is de- practice, a grading system for lumbar foram-
September 11, 2009.
fined as the narrowing of the inal stenosis is necessary for writing radio-
1
Department of Radiology, Seoul National University bony exit of the nerve root caused logic reports.
Bundang Hospital, 300 Gumi-dong, Bundang-gu, by a decrease in the height of an There have been few reports on the grading
Seongnam-si, Gyeongi-do 463-707, Korea. Address intervertebral disk, osteoarthritic changes in or classification of lumbar foraminal stenosis
correspondence to J. W. Lee ([email protected]).
the facet joints, cephalad subluxation of the on MRI [2, 3]. The grading system suggested
2
Department of Orthopaedic Surgery, Seoul National superior articular process of the inferior verte- by Wildermuth et al. [2] focused on only the
University Bundang Hospital, Gyeongi-do, Korea. bra, and buckling of the ligamentum flavum degree of epidural fat obliteration. The classi-
or protrusion of the annulus fibrosus [1]. fication of lumbar foraminal stenosis proposed
3
Department of Neurosurgery, Seoul National University MRI is widely used in the evaluation of by Kunogi and Hasue [4] included the antero-
Bundang Hospital, Gyeongi-do, Korea.
lumbar foraminal stenosis; however, there is posterior, cephalocaudal, and circumferential
4
Department of Radiology, Kangnam St. Mary’s Hospital, no widely used diagnostic criterion or grad- types without stenosis grade. The grading sys-
Catholic University, Seoul, Korea. ing system for lumbar foraminal stenosis on tem of Wildermuth et al. and the classification
MRI. For clinical studies with the objective proposed by Kunogi and Hasue do not con-
AJR 2010; 194:1095–1098 of comparing different therapeutic methods sider direct nerve root compression or defor-
0361–803X/10/1944–1095
for lumbar foraminal stenosis, an adequate mity, which may be important. In our depart-
grading system that has good reproducibil- ment, we have created a new grading system;
© American Roentgen Ray Society ity is necessary. In addition, in daily routine it is a modification of the previous systems

AJR:194, April 2010 1095

 Lee et al.

that takes into consideration the type of steno- Hasue [4], as illustrated in Figure 1. Grade 0 refers spin-echo (FSE) sagittal and axial images were ob-
sis, amount of fat obliteration, and presence of to the absence of foraminal stenosis; grade 1 refers tained (TR/TE, 500/15 for T1-weighted images and
nerve root compression. to mild foraminal stenosis showing perineural fat 3,600/120 for T2-weighted images; slice thickness,
The purpose of this study was to evaluate obliteration surrounding the nerve root in the two 4 mm; slice gap, 0.4 mm; field of view, 32 cm for
the reproducibility of this new grading sys- opposing directions (vertical or transverse). It in- sagittal images and 16 cm for axial images; matrix,
tem for lumbar foraminal stenosis and to dis- volves contact with the superior and inferior por- 512 × 512; flip angle, 90°; and excitations, 3).
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cuss its clinical relevance. tions of the nerve root or anterior and posterior por-
tions of the nerve root. No evidence of morphologic Case Selection
Materials and Methods change in the nerve root is shown. Grade 2 refers Our study was approved by the institutional re-
Establishment of MRI Grading System for to moderate foraminal stenosis showing perineu- view board. Informed consent was not required
Lumbar Foraminal Stenosis ral fat obliteration surrounding the nerve root in the for this MRI analysis. All 440 consecutive pa-
After several meetings with two radiologists, four directions without morphologic change in both tients were selected from a database of MR ex-
two orthopedic surgeons, and three neurosurgeons, vertical and transverse directions. Grade 3 refers to aminations of the lumbar spine performed at our
we determined the criteria for lumbar foraminal severe foraminal stenosis showing nerve root col- institution in June 2007.
stenosis on sagittal MRI. Sagittal T1-weighted im- lapse or morphologic change. The exclusion criteria were patients under 60
aging was the main sequence evaluated with T2- years old; evidence of infection, tumor, or frac-
weighted imaging also used as an additional tool MRI ture on MRI; previous lumbar operation; and ev-
to exclude false-positive findings resulting from All patients underwent imaging using a 1.5-T im- idence of foraminal disk extrusion with superior
the misinterpretation of perineural cysts or nerve ager (Gyroscan Intera Achieva, Philips Healthcare) migration. Thus, 344 patients were excluded and
root swelling. This grading system was established with a Synergy Spine Coil (Philips Healthcare). The 96 patients were included in this study. The av-
without changing the classic MRI protocol in the patients were placed in the supine position with a erage patient age was 69.35 years (range, 60–86
lumbar spine. Four grades were developed using cushion under both knees. T1-weighted spin-echo years) and there were 35 men (36.5%) and 61
a modification of the classification by Kunogi and sagittal and axial images and T2-weighted fast women (63.5%).

A B C

D E
Fig. 1—Schematic illustrations of 4-point-scale for grading foraminal stenosis in sagittal MRI of lumbar spine.
A, Grade 0 (normal). Schematic diagram of sagittal cross section through foramen shows relationships between foramen and surrounding structures. NR = nerve root,
V = vertebral body, D = intervertebral disk, LF = ligamentum flavum, FJ = facet joint.
B, Grade 1 (mild degree of foraminal stenosis). Schematic diagram shows perineural fat obliteration surrounding nerve root in transverse direction (arrows). There is
narrowing of superior foraminal width due to disk space narrowing and thickened ligamentum flavum. No evidence of morphologic change in nerve root is seen.
C, Grade 1 (mild degree of foraminal stenosis). Schematic diagram shows perineural fat obliteration surrounding nerve root in vertical direction (arrows). There is
narrowing of foraminal height due to disk space narrowing and diskoosteophytic protrusion in foraminal zone. No evidence of morphologic change in nerve root is seen.
D, Grade 2 (moderate degree of foraminal stenosis). Schematic diagram shows perineural fat obliteration surrounding nerve root in four directions (vertical and
transverse) (arrows) without morphologic change. There is narrowing of foraminal width and height due to disk space narrowing, thickened ligamentum flavum, facet
arthropathy, and diskoosteophytic protrusion in foraminal zone. No evidence of morphologic change in nerve root is seen.
E, Grade 3 (severe degree of foraminal stenosis). Schematic diagram shows nerve root collapse or morphologic change (arrows) due to severe disk space narrowing,
severe thickened ligamentum flavum, facet arthropathy and diskoosteophytic protrusion in foraminal zone.

1096 AJR:194, April 2010

 MRI Grading of Lumbar Foraminal Stenosis
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Fig. 2—Case of grade 0 foraminal stenosis. T1- Fig. 3—Case of grade 1 foraminal stenosis in Fig. 4—Case of grade 1 foraminal stenosis in vertical
weighted sagittal image of 62-year-old woman with transverse direction. T1-weighted sagittal image of direction. T1-weighted sagittal image of 63-year-old
lower back pain shows normal nerve root without 69-year-old woman with right lower extremity pain man with left lower extremity weakness shows that
compression. shows that narrowing of transverse width of neural narrowing of intervertebral disk space decreases
foramen and thick ligamentum flavum decrease height of left L4–L5 neural foramen. Vertical abutting
anteroposterior width of right L4–L5 neural foramen. of nerve root (arrows) is noted.
Perineural fat obliteration surrounding nerve root in
transverse direction (arrows) is noted.

MRI Imaging Analysis Results patients; reader 2 detected foraminal steno-

Two experienced spine radiologists (readers 1 MR images of varying degrees of fo- sis in 30 patients; Also, reader 1 again de-
and 2), who had 7 and 10 years of experience, re- raminal stenosis are shown in Figures 2–6. tected foraminal stenosis in 31 patients after
spectively, at the time of MR analysis, were blind- Reader 1 detected 29 patients with foram- more than 12 months. According to reader 1,
ed to the clinical information and radiologic re- inal stenosis on the MR examinations of 96 grade 1 foraminal stenosis was found in 33
ports. To assess reproducibility, they evaluated
the sagittal MR images of the selected cases inde-
pendently, and reader 1 evaluated the sagittal MR
images of the selected cases after more than 12
months. The examinations were reviewed in a ran-
dom order to avoid bias.
A total of 960 foramina and corresponding nerve
roots in 96 patients were qualitatively analyzed (six
foramina/person) from L1–L2 to L5–S1. A total of
384 foramina of the L1–L2 and L2–L3 levels were
excluded because of the rarity of foraminal steno-
sis on these levels. A total of 576 foramina were
assessed for possible foraminal stenosis through a
combination of both T1- and T2-weighted sagittal
images. Each radiologist assessed the presence and
grade of foraminal stenosis according to the new
grading system previously described.

Statistical Analysis
Interobserver agreement between the two radiol-
ogists and intraobserver agreement (reader 1) were
Fig. 5—Case of grade 2 foraminal stenosis. T1- Fig. 6—Case of grade 3 foraminal stenosis. T1-
analyzed by using kappa statistics. A kappa value of
weighted sagittal image of 65-year-old woman weighted sagittal image of 82-year-old woman with
less than 0.20 indicated slight; 0.21–0.40, fair; 0.41– with right lower extremity pain shows narrowing right lower extremity pain shows collapse of right
0.60, moderate; 0.61–0.80, substantial; and 0.81 or of intervertebral disk space, thickened ligamentum L4–L5 nerve root (arrows). This finding is compatible
greater, nearly perfect agreement [5]. The Statistical flavum, and focal disk protrusion in foraminal zone with grade 3 foraminal stenosis.
cause perineural fat obliteration surrounding nerve
Package for the Social Sciences for Windows (ver- root of left L5–S1 in both vertical and transverse
sion 13.0, SPSS) was used for statistical analyses. directions (arrows).

AJR:194, April 2010 1097

 Lee et al.

foramina, grade 2 in six, and grade 3 in sev- ever, this scoring system lacks characteris- S1 levels leading to subluxation and foram-
en. According to reader 2, grade 1 foraminal tics of the morphologic nerve root change. inal narrowing contributes to the increased
stenosis was found in 32 foramina, grade 2 Hasegawa et al. [1], in a cadaveric study, susceptibility of the L4 and L5 nerve roots
in six, and grade 3 in eight. After more than showed that significant nerve root compres- to static and dynamic compression. The low-
12 months, reader 1 found grade 1 foraminal sion is commonly associated with a foraminal er lumbar nerve roots are also characterized
stenosis in 34 foramina; grade 2 in eight; and height of 15 mm or less and a posterior disk by a more oblique course throughout the lat-
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grade 3 in seven. height of 4 mm or less. They concluded that eral canal, increasing their susceptibility to
Interobserver agreement in the grading these critical dimensions might be indicators the effects of pedicular kinking and foram-
of foraminal stenosis between the two read- of lumbar foraminal stenosis. As the superi- inal stenosis [6].
ers on sagittal MRI was found to be nearly or facet continues to subluxate, the alteration There are several limitations to our study.
perfect (κ value: right L3–L4, 1.0; left L3– of biomechanical forces contributes to the de- One limitation was that our grading system
L4, 0.905; right L4–L5, 0.929; left L4–L5, velopment of a hypertrophic ligamentum fla- is based on sagittal MR morphology without
0.942; right L5–S1, 0.919; and left L5–S1, vum and bony spurs, which may diminish the symptomatic correlation. Symptomatic fo-
0.909). Intraobserver agreement by reader 1 volume of the foramen to a greater extent. raminal stenosis may be caused by dynam-
also was found to be nearly perfect (κ value: This combination of disk space narrowing ic changes, such as lumbar extension, which
right L3–L4, 0.883; left L3–L4, 1.00; right and overgrowth of structures anterior to the cannot be detected in the closed MR system.
L4–L5, 0.957; left L4–L5, 0.885; right L5– facet joint capsule may lead to anteroposteri- Therefore, future studies will be necessary
S1, 0.800; and left L5–S1, 0.905). or stenosis (transverse stenosis). The exiting that include correlation of the dynamic posi-
Regarding the frequency of foraminal nerve root is compressed between the supe- tional effects on the foraminal stenosis with
stenosis, there were four instances (4.16%) rior articular facet and the posterior vertebral clinical symptoms in open or closed MR sys-
at the level of right L3–L4, six (6.25%) at body in a transverse direction. tems. A second limitation was that direct
left L3–L4, eight (8.33%) at right L4–L5, An additional cause of foraminal stenosis is comparison with previous grading systems
10 (10.42%) at left L4–L5, seven (7.29%) at craniocaudal compression (vertical stenosis). was not conducted in this study.
right L5–S1, and 11 (11.46%) at left L5–S1 for Posterolateral osteophytes from the vertebral In conclusion, preliminary results suggest
reader 1. For reader 2, there were four instanc- endplates protrude into the foramen along with that our new grading system for foraminal
es (4.16%) at the level of right L3–L4, five a laterally bulging annulus fibrosis or herni- stenosis is reproducible and may be helpful
(5.21%) at left L3–L4, eight (8.33%) at right ated disk, compressing the nerve root against in the diagnosis and grading of lumbar fo-
L4–L5, 10 (10.42%) at left L4–L5, six (6.25%) the superior pedicle. In this case, the posterior raminal stenosis. Further studies will be re-
at right L5–S1, and 13 (13.54%) at left L5– aspect of the foramen may remain patent to quired to determine its clinical utility.
S1. For reader 1 (after more than 12 months), palpation, possessing adequate amounts of fat
there were five instances (5.21%) at the lev- despite significant compromise of the avail- References
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