Elsevier

The Spine Journal

Volume 9, Issue 7, July 2009, Pages 545-550
The Spine Journal

Clinical Study
Spinal stenosis prevalence and association with symptoms: the Framingham Study

https://doi.org/10.1016/j.spinee.2009.03.005Get rights and content

Abstract

Background context

The prevalence of lumbar spinal stenosis (LSS) in the general population and association with low back pain (LBP) remain unclear.

Purpose

To evaluate the prevalence of congenital and acquired LSS observed on computed tomography in a community-based sample; and to evaluate the association between LSS and LBP.

Study design/setting

Cross-sectional observational study. This study was an ancillary project to the Framingham Heart Study.

Patient sample

A total of 3,529 participants underwent multidetector computed tomography; 191 were enrolled in this study.

Outcome measures

Self-report measures: LBP in the preceding 12 months was evaluated using a self-report questionnaire. Physiologic measures: LSS (congenital and acquired) was characterized using two cut-points: 12 mm for relative LSS and 10 mm for absolute LSS.

Methods

Using multiple logistic regression, we examined the association between LSS and LBP, adjusting for sex, age, and body mass index.

Results

In the congenital group, relative LSS was found in 4.7% and absolute LSS in 2.6% of patients. Acquired LSS was found in 22.5% and in 7.3%, respectively. Acquired LSS showed increasing prevalence with age less than 40 years, the prevalence of relative and absolute LSS was 20.0% and 4.0%, respectively, and in those 60 to 69 years the prevalence was 47.2% and 19.4%, respectively. The presence of absolute LSS was associated with LBP with an odds ratio of 3.16 (95% confidence interval [CI]: 1.05–9.53).

Conclusions

The prevalence of congenital and acquired LSS in a community-based sample was characterized. The prevalence of acquired stenosis increased with age. LSS is associated with a threefold higher risk of experiencing LBP.

Introduction

Despite the fact that lumbar spinal stenosis (LSS) is one of the most commonly diagnosed and treated pathologic conditions affecting the spine, very little is known about the epidemiology of stenosis in the general population. The prevalence of acquired, so-called “degenerative” lumbar stenosis has been suggested as ranging from 1.7% to 13.1% [1], [2], [3]. However, previously reported studies have used asymptomatic populations or selected clinical populations undergoing imaging studies for other reasons. Furthermore, the methods of LSS evaluation were often not described or inappropriate. There have been no prevalence rates reported in unselected populations. Given the increasing use of diagnostic imaging, the unclear association of spinal stenosis radiographic findings with symptoms, and the fact that spinal stenosis is one of the most common indications for spinal surgery, a clear understanding of the prevalence of spinal stenosis in the community and its association with symptoms is greatly needed.

One major difficulty in performing any epidemiologic analysis is the absence of universally accepted diagnostic criteria for spinal stenosis [4]. Magnetic resonance imaging (MRI) and computed tomography (CT) are the most frequently used diagnostic modalities in clinical practice, but strict measurements defining the presence of clinically significant canal, subarticular, or foraminal narrowing do not exist. The concept that overall rates of spinal stenosis reflect the relative contribution of two distinct types of stenosis, congenital (or developmental) and acquired (or degenerative), is however generally acknowledged [5].

Recognizing these limitations, the aims of the present study were 1) to evaluate the prevalence of congenital and acquired radiographic spinal stenosis in an unselected community-based population and 2) to evaluate the association between spinal stenosis observed on CT and the risk of experiencing low back pain (LBP).

Section snippets

Study design

The design used is a cross-sectional study.

Sample

This study was an ancillary project to the Framingham Heart Study. The Framingham Heart Study began in 1948 as a longitudinal population-based cohort study of the causes of heart disease. Initially, 5,209 men and women between the ages of 30 and 60 years living in Framingham, MA were enrolled. Biennial examinations were conducted by trained research staff at the study clinic located in Framingham. In 1971, 5,124 offspring (and their spouses) of the

Results

The study sample included 191 study participants, 104 (55.6%) males and 87 (44.4%) females. The mean age was 52.6±10.8 (age range: 32–79 years) and the mean BMI was 27.8±5.0. This subsample was representative of the whole group of individuals who underwent multidetector CT scanning (N=3,590). The percent of males in whole sample was 51.8%, mean age 52.7±11.8, and mean BMI 27.8±5.3. The comparison tests showed that there was no difference between the whole sample and the subsample studied here

Discussion

Although LSS is one of the most commonly diagnosed spinal disorders, is the major reason for surgery in older adults [18], and is considered a major cause of pain and disability, little is known regarding the epidemiology of this condition. This is the first cross-sectional study to describe the prevalence of radiographic LSS in a community-based population. There are few previously published reports that include any estimate of the population prevalence of LSS. De Villiers and Booysen [1] in a

Conclusions

The prevalence of congenital LSS in the US community-based sample is 4.71% and 2.62% for relative and absolute stenosis, respectively. The prevalence of relative and absolute acquired stenosis increases with age to 47.2% and 19.4%, respectively, in the 60- to 69-year-old age group. The very high prevalence of stenosis in the general population aged older than 60 years warns against attributing pain and neurological symptoms in this patient population to LSS based solely on the appearance of

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    FDA device/drug status: not applicable.

    Author disclosures: LK (supported by an Arthritis Foundation Postdoctoral Grant); DJH (supported by a research grant from DonJoy, Wyeth, MERCK, Pfizer, Stryke, and Lilly); DHK (consulting fees from Medtronic, DePuy, Stryker, Zimmer, Syntle; research support for staff and materials from New England Baptist Hospital); and AG (stock ownership in Synarc Inc; office in a company, president, BICL, LLC).

    This work was supported by the National Heart, Lung, and Blood Institute's Framingham Heart Study contract (No. N01-HC-25195) for the recruitment, enrollment, and examination of the Offspring and Third Generation cohort and the imaging by computed tomography scan.

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