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stenosis but without neurologic symptoms, surgery can be deferred with close
monitoring [
26
,
27
].
Acute nerve symptoms may be the
first presentation in some patients, and is a
medical emergency. Immediate MRI is indicated for diagnosis and assessment of
severity. Neurosurgery or orthopedic evaluation for potential surgical intervention
is essential. Treatment with high dose intravenous corticosteroids to decrease acute
in
fl
ammatory changes in the spinal cord may improve outcomes [
28
].
2.3.4 Imaging
The diagnosis of spinal stenosis is based on imaging and a compatible clinical
presentation. Plain radiographs have limited utility for this condition. It is used in
cases of neck pain or back pain without neurologic symptoms to exclude other
conditions. In patients with nerve symptoms, MRI is the study of choice, while CT
with myelography is used in patients with contraindications to MRI. Direct com-
pression of the spinal cord can be visualized on MRI, and it may or may not be
associated with a signal change in the spinal cord. Findings may be present in one
or multiple vertebral levels.
Measurement of the anteroposterior diameter of the spinal canal or the intra-
spinal canal area has been suggested as radiologic diagnostic criteria of spinal
stenosis [
24
], and for assessment of myelopathy [
29
,
30
], however it has not been
routinely used in clinical practice. More importantly, radiologic spinal stenosis is an
incidental
finding in 6
7 % of asymptomatic individuals, and its prevalence
-
increases to 20
30 % in people older than 60 years [
24
].
Abnormal MRI signal in the spinal cord can be a useful marker of myelopathy
(Fig.
6
). Hyperintense signal on T2-weighted imaging, hypointense signal on
T1-weighted imaging, and hyperintense signal on diffusion-weighted imaging
(DWI) have been evaluated for their correlation with clinical
-
findings, and DWI has
a better correlation [
31
,
32
].
2.4 Diffuse Idiopathic Skeletal Hyperostosis
2.4.1 De
nition and Occurrence
Diffuse idiopathic skeletal hyperostosis (DISH) is a non-in
fl
ammatory condition
characterized by calci
cation of ligaments, with a predilection for
the spine. It most commonly affects the anterior longitudinal spinal
cation and ossi
ligament,
particularly in the thoracic spine. Large
fl
flowing osteophytes with an appearance of
'
'
candle wax dripping down the spine
is the typical
finding in this condition.
Thickening, calci
cation may also involve peripheral ligaments,
especially at sites of the tendon insertions. Unlike spondylosis, in which the primary
pathologic target is cartilage, the discovertebral joints and the facet joints are
cation, and ossi
