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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
MRI Study of Lumbar Canal Stenosis by Morphological Grading and Thecal Sac Measurement: A Cross-sectional Study
Correspondence Address :
Kesinakurthi Satish Kumar,
Resident, Department of Radiodiagnosis, Dr. Pinnamaneni Siddartha Institute of
Medical Sciences and Research Foundation, Gannavaram, Andhra Pradesh, India.
E-mail: satishkmr665@gmail.com
Introduction: Lumbar Spinal Stenosis (LSS) is a condition in which the spinal canal narrows to the point at which it can exert pressure on the nerves that travel through the spine. Aetiology is categorised into congenital, developmental and acquired (degenerative) causes. Magnetic Resonance Imaging (MRI) is an investigation of choice in the evaluation of patients with symptoms related to lumbar central canal stenosis.
Aim: To assess the morphologically grade of thecal sac in lumbar central canal stenosis on MRI.
Materials and Methods: This cross-sectional observational study was conducted from November 2017 to October 2019 at Department of Radiology of Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Gannavaram, Andhra Pradesh, India. Study included 100 patients who were referred with symptoms of lumbar stenosis and outcome was to determine the correlation between the morphological grade and thecal sac axial anteroposterior diameter grade. Correlation was assessed by Fisher’s-exact test and Spearman’s rank correlation coefficient test. A p-value <0.0001 was considered highly significant.
Results: Morphological Grade II corresponded to maximum number of cases, amounting to 46% with mean anteroposterior thecal sac diameter of 6.21 mm, followed by 36% of Grade III with mean thecal sac diameter of 4.57 mm. Grade I corresponded to 14% of cases mean thecal sac diameter of 8.35 mm and Grade IV corresponded to 4% of cases with mean thecal sac diameter of 1.1 mm. A significant correlation was obtained (r=0.78) in this study between the morphological grade and thecal sac measurement.
Conclusion: Morphological grade of the thecal sac has significant correlation with the canal measurements and it helps in quick assessment of the severity of the lumbar canal stenosis.
Lumbar spine, Magnetic resonance imaging, Spinal canal stenosis, Thecal sac narrowing
Spinal canal narrowing can be seen in stenosis which causes pressure effects on the nerves that travel through the spine. The aetiology of Lumbar Spinal Stenosis (LSS) is categorised into congenital, developmental and acquired (degenerative) causes (1). Congenital LSS has a different epidemiology compared to acquired/degenerative LSS. It tends to affect patients at a younger age (30-50 years old). Developmental canal stenosis is a condition in which there is narrowed bony spinal canal; possibly defect in normal developmental process. In degenerative stenosis there is diminished space available for the neural and vascular elements in the lumbar spine secondary to degenerative changes in the spinal canal.
Symptoms of stenosis include pain in the groin, hips, and buttocks with numbness or weakness in the legs and lower back and in severe cases associated with bowel, bladder, and sexual dysfunction (2). Magnetic Resonance Imaging (MRI) is investigation of choice in the evaluation of patients with symptoms related to lumbar canal stenosis. Various qualitative (thecal sac morphological/visual grading system) and quantitative (thecal sac/spinal canal diameters) parameters have been described in the literature for diagnosis of lumbar canal stenosis using MRI (3). MRI had become modality of choice in patients suffering with lumbar canal stenosis related symptoms. Hence, the present study aimed to asses lumbar canal stenosis by morphological grading and thecal sac measurement.
This was a cross-sectional observational study conducted for a period of two years, from November 2017 to October 2019 on 100 patients who were referred with symptoms of lumbar stenosis on MRI 1.5 Tesla Philips Achieva in the Department of Radiology of Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Gannavaram, Andhra Pradesh, India. Study was conducted after obtaining approval from the Institutional Research and Ethics Committee (Approval no: PG-17-40). Informed consent from the respective patients had been taken related to the study.
Inclusion criteria: Patients with age more than 18 years and patients with symptoms related to spine were included in this study.
Exclusion criteria: Patient with spinal tumours, spinal fractures, spinal postoperative cases were excluded. Heart pacemakers and other metal implanted patients were also excluded from the study.
Patient was placed in supine position on MRI table. A 1.5 Tesla Philips Achieva MR scanner (16 channel) was used in the present study for obtaining scans. MRI of the lumbar spine was done. Essential sequences were:
(i) T1Weighted Axial and Sagittal images
(ii) T2W Fast Spin Echo/Turbo Spin Echo (FSE/TSE) axial and sagittal images for which MR parameters are as follows (Table/Fig 1):
MRI Image Interpretation and Analysis
Image stacks were transferred to advanced workstation and interpretation was done by a Radiologist with 20 years of experience. After acquiring the required scans, the dural sac morphology of the most significantly stenosed level was assessed and further graded based on the Cerebrospinal Fluid (CSF)/nerve rootlet ratio on T2W axial images. The morphological/visual grading of lumbar central canal on T2W axial MR image consists of four grades. Grading was done according to the Schizas C et al., grading system (Table/Fig 2), (Table/Fig 3), (Table/Fig 4), (Table/Fig 5), (Table/Fig 6) (4).
Grade I- Decreased anterior CSF space, CSF present between rootlets.
Grade II- Loss of anterior CSF space, still CSF presents between rootlets and they can be individualised.
Grade III- Complete obliteration of CSF and rootlets are clumped. Epidural fat can be normally delineated.
Grade IV- Complete obliteration of CSF and the epidural fat also cannot be delineated.
Statistical Analysis
All statistical analysis was done through Statistical Package for the Social Sciences (SPSS) Windows Version 24.0. Correlation was assessed by Fischer-exact test and Spearman’s rank correlation coefficient test. A p-value <0.0001 was considered highly significant.
During the period of 24 months, out of 100 patients 46% were males and 54% are females. Age of the patients ranged from 18 years to 78 years with mean age of 49.73±13.29. Maximum i.e., 29% of the cases were in the age group of 36-45 years, followed by 26% in the age group of 46-55 years (Table/Fig 7).
Grade I morphological grade was seen in 14% patients who had the thecal sac axial anteroposterior diameters ranging from 7.4 to 9.4 mm and mean anteroposterior thecal sac diameter of 8.35 mm (Table/Fig 8). Grade II morphological grade was seen in 46% of patients who had the thecal sac axial anteroposterior diameters ranging from 2.8 to 8.4 mm and mean anteroposterior thecal sac diameter of 6.2 mm.
Grade III morphological grade was seen in 36% patients who had the thecal sac axial anteroposterior diameters ranging from 3.2 to 5.9 mm and mean anteroposterior thecal sac diameter of 4.5 mm.
Grade IV morphological grade was seen in 4% patients who had the thecal sac axial anteroposterior diameters ranging from 0-2.2 mm and mean anteroposterior thecal sac diameter of 1.1 mm.
A significant correlation was obtained in this study between the morphological grade and thecal sac axial anteroposterior diameter grade with a significant p-value <0.0001 (Table/Fig 9). The correlation coefficient between morphological grading and thecal sac diameter was r=0.78 which indicates a strong correlation.
A 19% of the patients had severe form of developmental bony canal stenosis in the present study (Table/Fig 10).
In central canal stenosis, most commonly L4-L5 level was affected in 64% of population followed by L3-L4 level in 20% of cases; 7% at L5-S1, 7% at L2-L3 and 2% at L1-L2.
Among contributory factors to central canal stenosis, Disc Degeneration (DD) accounted for central canal stenosis in all the cases. Ligamentum flavum hypertrophy contributed to canal stenosis in 32% of patients. Facet joint arthropathy was seen in 12% of patients contributing to canal stenosis (Table/Fig 11).
Single level stenosis was seen in majority i.e., 63%, 18% of patients had two level stenosis and multilevel stenosis was seen in 19% of patients. Both single and multiple level stenosis is more commonly reported in females, 32 and 12, respectively. Posterior annular fissure was seen in 30 patients.
Term Lumbar Spinal Stenosis (LSS) refers to the anatomical narrowing of the spinal canal. The annual incidence of LSS is reported to be five cases per 100,000 individuals (5). Characteristic symptom is neurogenic claudication (6). Diagnosis of LSS relies primarily on imaging to provide objective evidence of neurovascular compromise. MRI is suggested as the most appropriate, non invasive test to diagnose LSS (7). Qualitative imaging findings in stenosis of the lumbar spine may be broadly classified into the specific causes spine include disc herniation, facet joint hypertrophic arthropathy, and ligamentum flavum hypertrophy. MRI is the preferred modality for the assessment of central canal stenosis, as it provides superior soft tissue resolution and nerve rootlets can be assessed with greater resolution (8). Morphological grade II corresponded to maximum number of cases, i.e., 46%, followed by 36% of grade III. Grade I corresponded to 14% of cases and grade IV corresponded to 4% of cases. In the study done by Lee S et al., grade 1 foraminal stenosis was found in 34 foramina, grade 2 in eight, and grade 3 in seven (9). More number of morphological grade III patients are associated with mild grade of clinical symptomatology as per the clinical protocol. This explains that pathological process may exceed the underlying clinical symptomatology in most of the subjects.
Though the patients present with mild clinical symptoms, the presence of pre-existing age related degenerative changes in the spine may aggravate the morphological grade of the study population as was observed by Yuan S et al., and Haig AJ et al., in their study (10),(11). Significant association was obtained in the present study between the morphological grade and the thecal sac measurements with a strong positive rank correlation, which was in accordance with study done by Sigmundsson FG et al., and Park HJ et al., (12),(13). Dynamic changes in the dural sac cross-sectional area on axial loaded MR imaging was evaluated to see whether there is difference between Degenerative Spondylolisthesis (DS) and Spinal Stenosis (SpS). The change in the DCSA induced by axial loading was significantly larger in the DS group (17±12 mm2) compared with the SpS group (8±8 mm2). Axial loaded MR imaging may therefore be a more useful tool to decrease the risk of underestimating the spinal canal narrowing in patients with DS than in those with SpS (14). Study done by Ozawa H et al., concluded axial loaded MR imaging demonstrated significantly smaller DCSA in the DS group (35±22 mm2) than in the SpS group (50±31 mm2), though conventional MR imaging did not showed any differences between the two groups (15).
Limitation(s)
Clinical significance of the proposed morphological grade was not explained in the present study. The quantitative assessment of the clinical parameters was not carried out in the present study.
The morphological grade of the thecal sac has significant correlation with the canal measurements as described in the present study. Traditional analysis of the lumbar central canal stenosis by canal diameters and cross-sectional areas are time-consuming and are operator dependent. Morphological grade of the thecal sac helps in quick assessment of the severity of the lumbar canal stenosis. Hence, morphological grading system helps the radiologist in rapid and reliable determination of lumbar central canal stenosis.
DOI: 10.7860/JCDR/2022/51784.15977
Date of Submission: Aug 06, 2021
Date of Peer Review: Oct 29, 2021
Date of Acceptance: Dec 09, 2021
Date of Publishing: Feb 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
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