Dynamic electrophysiological examination in patients with lumbar spinal stenosis: is it useful in clinical practice?

Abstract

Neurogenic claudication (NC) is typical of lumbar spinal stenosis (LSS). One suspected pathophysiological mechanism underlying NC is intermittent hypoxia of cauda equina fibres resulting from venous pooling, which may lead to ischaemic nerve conduction failure and to transient clinical and electrophysiological changes after exercise. The aim of this study was to evaluate the appearance of significant transient electrophysiological abnormalities after walking exercise in patients with LSS and to establish the contribution of dynamic electrophysiological examination in the differential diagnostics of patients with LSS. The study participants were 36 consecutive patients with LSS demonstrated by computed tomography (CT). The control groups included, respectively, 28 patients with diabetes mellitus and clinically manifested polyneuropathy, and 32 healthy volunteers. The LSS patients were divided into four subgroups based on the clinical severity of the disease (with respect to the presence or absence of NC in the history and pareses on neurological examination). Soleus H-reflex, tibial F-wave and motor evoked potentials (MEPs) to abductor hallucis muscle were examined in all groups, before and after quantified walking on a treadmill. The electrophysiological parameters measured after an exercise treadmill test (ETT) in LSS patients and in both control groups were compared with the same parameters obtained before ETT. The study shows that the electrophysiological parameters reveal minimal but statistically significant changes after walk loading in patients with LSS (a prolongation of the minimal latency of the tibial F-wave and of the latency of the soleus H-reflex). The changes in these parameters were demonstrated not only in patients with NC but also in patients without NC. More pronounced changes were found in LSS patients exhibiting chronic lower extremity pareses.

Conclusions: From among a large battery of electrophysiological tests, only the minimal latency of the tibial F-wave and the latency of the soleus H-reflex exhibit changes after walk loading in patients with LSS. These are minimal but statistically significant. Dynamic electrophysiological examination can illustrate the pathophysiology of NC in LSS, but from a practical point of view its contribution to the differential diagnostics of LSS or diabetic polyneuropathy is limited by an absence of established cut-off values.

Fig. 1

Pairwise comparison of changes in electrophysiological parameters influenced by exercise treadmill test in healthy volunteers, patients with diabetic polyneuropathy and two subgroups of lumbar spinal stenosis (LSS) patients. (HV healthy volunteers, DM patients with diabetic polyneuropathy, LS1–2 LSS patients without pareses, LS3–4 LSS patients with pareses). Data are expressed as arithmetical mean supplied with 95% confidence limit. P-level: significance level of pairwise t- test. A: differences are not statistically significant. B: differences are statistically significant in specified parameter (p<0.05)

Fig. 2

Frequency histogram of differences between post- and pre-exercise values of latency of the tibial F-wave and latency of the soleus H-reflex. (LSS patients: patients with lumbar spinal stenosis, L₃₊₄ patients with lumbar spinal stenosis with pareses)

Fig. 3

Pairwise comparison of changes in electrophysiological parameters influenced by exercise treadmill test in healthy volunteers, patients with diabetic polyneuropathy and two subgroups of lumbar spinal stenosis (LSS) patients. (HV healthy volunteers, DM patients with diabetic polyneuropathy, LS1–3 LSS patients without NC, LS2–4 LSS patients with NC). Data are expressed as arithmetical mean supplied with 95% confidence limit. P-level: significance level of pairwise t-test. A: differences are not statistically significant. B: differences are statistically significant in specified parameter (p<0.05)