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Due to the nearly universal prevalence of degenerative spinal changes in the population, lumbar spinal radiographs will almost always be "positive" for bone spurs, decreased disc height and facet hypertrophy in older patients. Radiographs, particularly with flexion and extension views, can be helpful in excluding other etiologies or contributing features such as gross spinal instability or spondylolithesis. MRI (without gadolinium) currently represents the "gold standard" in the evaluation of central stenosis. This modality allows the visualization of the disc, neural elements, ligaments and thecal sac in a non-invasive manner. CT scanning does give a more accurate and detailed picture of the bony anatomy, but is less accurate in estimating the degree of compromise of the soft tissue elements, and is not usually adequate as a stand-alone imaging modality. Myelography is no longer routinely necessary, although it can be useful in selected cases, such as where MRI is contraindicated. Electrophysiologic testing is rarely contributory, unless a contributory diagnosis such as peripheral neuropathy is being considered.
MRI also remains the mainstay of screening in the evaluation of lateral recess or foramenal stenosis, although it can over- or under-estimate the degree of narrowing due to the signal characteristics of bone in standard MRI imaging sequences. In some cases, myelography with postmyelo-graphic CT scanning may give a more accurate picture of the relationship between the bony and neural elements in this clinical setting. MRI with gadolinium may be helpful in evaluating cases of residual or recurrent stenosis after previous lumbar surgery, because of the ability to differentiate between epidural scar and other tissue types. Electrophysiologic testing can be confirmatory if adequate time has passes from the onset of symptoms, or can help to exclude neuropathies in unclear cases. Selective injection of an individual nerve root with local anesthetic under fluoroscopic control can be performed as a diagnostic test, and can be useful in cases of widespread degeneration when multiple levels reveal stenotic changes. In these cases, significant, temporary relief of the patient's characteristic symptoms following injection of the nerve at the suspected spinal level provides confirmation of the clinical impression, while lack of relief indicates a need for further diagnostic testing prior to undertaking surgical intervention.