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Published in: BMC Musculoskeletal Disorders 1/2011

Open Access 01-12-2011 | Research article

Quantitative radiologic criteria for the diagnosis of lumbar spinal stenosis: a systematic literature review

Authors: Johann Steurer, Simon Roner, Ralph Gnannt, Juerg Hodler

Published in: BMC Musculoskeletal Disorders | Issue 1/2011

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Abstract

Background

Beside symptoms and clinical signs radiological findings are crucial in the diagnosis of lumbar spinal stenosis (LSS). We investigate which quantitative radiological signs are described in the literature and which radilogical criteria are used to establish inclusion criteria in clincical studies evaluating different treatments in patients with lumbar spinal stenosis.

Methods

A literature search was performed in Medline, Embase and the Cochrane library to identify papers reporting on radiological criteria to describe LSS and systematic reviews investigating the effects of different treatment modalities.

Results

25 studies reporting on radiological signs of LSS and four systematic reviews related to the evaluation of different treatments were found. Ten different parameters were identified to quantify lumbar spinal stenosis. Most often reported measures for central stenosis were antero-posterior diameter (< 10 mm) and cross-sectional area (< 70 mm2) of spinal canal. For lateral stenosis height and depth of the lateral recess, and for foraminal stenosis the foraminal diameter were typically used. Only four of 63 primary studies included in the systematic reviews reported on quantitative measures for defining inclusion criteria of patients in prognostic studies.

Conclusions

There is a need for consensus on well-defined, unambiguous radiological criteria to define lumbar spinal stenosis in order to improve diagnostic accuracy and to formulate reliable inclusion criteria for clinical studies.
Appendix
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Literature
1.
go back to reference Deyo RA: Treatment of lumbar spinal stenosis: a balancing act. Spine J. 2010, 10 (7): 625-627. 10.1016/j.spinee.2010.05.006.CrossRefPubMed Deyo RA: Treatment of lumbar spinal stenosis: a balancing act. Spine J. 2010, 10 (7): 625-627. 10.1016/j.spinee.2010.05.006.CrossRefPubMed
2.
go back to reference North American Spine Society: Evidence Based Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis. 2007, In. Burr Ridge, IL.: North American Spine Society North American Spine Society: Evidence Based Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis. 2007, In. Burr Ridge, IL.: North American Spine Society
3.
go back to reference Kalichman L, Cole R, Kim D, Li L, Suri P, Guermazi A, Hunter D: Spinal stenosis prevalence and association with symptoms: the Framingham Study. Spine J. 2009, 9 (7): 545-550. 10.1016/j.spinee.2009.03.005.CrossRefPubMedPubMedCentral Kalichman L, Cole R, Kim D, Li L, Suri P, Guermazi A, Hunter D: Spinal stenosis prevalence and association with symptoms: the Framingham Study. Spine J. 2009, 9 (7): 545-550. 10.1016/j.spinee.2009.03.005.CrossRefPubMedPubMedCentral
4.
go back to reference Haig AJ, Geisser ME, Tong HC, Yamakawa KS, Quint DJ, Hoff JT, Chiodo A, Miner JA, Phalke VV: Electromyographic and magnetic resonance imaging to predict lumbar stenosis, low-back pain, and no back symptoms. J Bone Joint Surg Am. 2007, 89 (2): 358-366. 10.2106/JBJS.E.00704.CrossRefPubMed Haig AJ, Geisser ME, Tong HC, Yamakawa KS, Quint DJ, Hoff JT, Chiodo A, Miner JA, Phalke VV: Electromyographic and magnetic resonance imaging to predict lumbar stenosis, low-back pain, and no back symptoms. J Bone Joint Surg Am. 2007, 89 (2): 358-366. 10.2106/JBJS.E.00704.CrossRefPubMed
5.
go back to reference Boden S, Davis D, Dina T, Patronas N, Wiesel S: Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990, 72 (3): 403-408.PubMed Boden S, Davis D, Dina T, Patronas N, Wiesel S: Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990, 72 (3): 403-408.PubMed
6.
go back to reference Wiesel S, Tsourmas N, Feffer H, Citrin C, Patronas N: A study of computer-assisted tomography. I. The incidence of positive CAT scans in an asymptomatic group of patients. Spine (Phila Pa 1976). 1984, 9 (6): 549-551. 10.1097/00007632-198409000-00003.CrossRef Wiesel S, Tsourmas N, Feffer H, Citrin C, Patronas N: A study of computer-assisted tomography. I. The incidence of positive CAT scans in an asymptomatic group of patients. Spine (Phila Pa 1976). 1984, 9 (6): 549-551. 10.1097/00007632-198409000-00003.CrossRef
7.
go back to reference Miettinen OS, Flegel KM: Elementary concepts of medicine: III. Illness: somatic anomaly with. J Eval Clin Pract. 2003, 9 (3): 315-317. 10.1046/j.1365-2753.2003.00416.x.CrossRefPubMed Miettinen OS, Flegel KM: Elementary concepts of medicine: III. Illness: somatic anomaly with. J Eval Clin Pract. 2003, 9 (3): 315-317. 10.1046/j.1365-2753.2003.00416.x.CrossRefPubMed
8.
go back to reference Genevay S, Atlas SJ, Katz JN: Variation in eligibility criteria from studies of radiculopathy due to a herniated disc and of neurogenic claudication due to lumbar spinal stenosis: a structured literature review. Spine (Phila Pa 1976). 2010, 35 (7): 803-811.CrossRef Genevay S, Atlas SJ, Katz JN: Variation in eligibility criteria from studies of radiculopathy due to a herniated disc and of neurogenic claudication due to lumbar spinal stenosis: a structured literature review. Spine (Phila Pa 1976). 2010, 35 (7): 803-811.CrossRef
9.
go back to reference Aalto T, Malmivaara A, Kovacs F, Herno A, Alen M, Salmi L, Kröger H, Andrade J, Jiménez R, Tapaninaho A, Turunen V, Savolainen S, Airaksinen O: Preoperative predictors for postoperative clinical outcome in lumbar spinal stenosis: systematic review. Spine (Phila Pa 1976). 2006, 31 (18): E648-663. 10.1097/01.brs.0000231727.88477.da.CrossRef Aalto T, Malmivaara A, Kovacs F, Herno A, Alen M, Salmi L, Kröger H, Andrade J, Jiménez R, Tapaninaho A, Turunen V, Savolainen S, Airaksinen O: Preoperative predictors for postoperative clinical outcome in lumbar spinal stenosis: systematic review. Spine (Phila Pa 1976). 2006, 31 (18): E648-663. 10.1097/01.brs.0000231727.88477.da.CrossRef
10.
go back to reference Gibson JN, Waddell G: Surgery for degenerative lumbar spondylosis: updated Cochrane Review. Spine (Phila Pa 1976). 2005, 30 (20): 2312-2320. 10.1097/01.brs.0000182315.88558.9c.CrossRef Gibson JN, Waddell G: Surgery for degenerative lumbar spondylosis: updated Cochrane Review. Spine (Phila Pa 1976). 2005, 30 (20): 2312-2320. 10.1097/01.brs.0000182315.88558.9c.CrossRef
11.
go back to reference Coronado-Zarco R, Cruz-Medina E, Arellano-Hernandez A, Chavez-Arias D, Leon-Hernandez SR: Effectiveness of calcitonin in intermittent claudication treatment of patients with lumbar spinal stenosis: a systematic review. Spine (Phila Pa 1976). 2009, 34: (22):E818-822.CrossRef Coronado-Zarco R, Cruz-Medina E, Arellano-Hernandez A, Chavez-Arias D, Leon-Hernandez SR: Effectiveness of calcitonin in intermittent claudication treatment of patients with lumbar spinal stenosis: a systematic review. Spine (Phila Pa 1976). 2009, 34: (22):E818-822.CrossRef
12.
go back to reference Amundsen T, Weber H, Nordal H, Magnaes B, Abdelnoor M, Lilleâs F: Lumbar spinal stenosis: conservative or surgical management?: A prospective 10-year study. Spine (Phila Pa 1976). 2000, 25 (11): 1424-1435. 10.1097/00007632-200006010-00016.CrossRef Amundsen T, Weber H, Nordal H, Magnaes B, Abdelnoor M, Lilleâs F: Lumbar spinal stenosis: conservative or surgical management?: A prospective 10-year study. Spine (Phila Pa 1976). 2000, 25 (11): 1424-1435. 10.1097/00007632-200006010-00016.CrossRef
13.
go back to reference Herkowitz H, Kurz L: Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am. 1991, 73 (6): 802-808.PubMed Herkowitz H, Kurz L: Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am. 1991, 73 (6): 802-808.PubMed
14.
go back to reference Tafazal S, Ng L, Sell P: Randomised placebo-controlled trial on the effectiveness of nasal salmon calcitonin in the treatment of lumbar spinal stenosis. Eur Spine J. 2007, 16 (2): 207-212. 10.1007/s00586-006-0154-4.CrossRefPubMed Tafazal S, Ng L, Sell P: Randomised placebo-controlled trial on the effectiveness of nasal salmon calcitonin in the treatment of lumbar spinal stenosis. Eur Spine J. 2007, 16 (2): 207-212. 10.1007/s00586-006-0154-4.CrossRefPubMed
15.
go back to reference Herzog RJ, Kaiser JA, Saal JA, Saal JS: The importance of posterior epidural fat pad in lumbar central canal stenosis. Spine (Phila Pa 1976). 1991, 16 (6 Suppl): S227-233.CrossRef Herzog RJ, Kaiser JA, Saal JA, Saal JS: The importance of posterior epidural fat pad in lumbar central canal stenosis. Spine (Phila Pa 1976). 1991, 16 (6 Suppl): S227-233.CrossRef
16.
go back to reference Strojnik T: Measurement of the lateral recess angle as a possible alternative for evaluation of the lateral recess stenosis on a CT scan. Wien Klin Wochenschr. 2001, 113 (Suppl 3): 53-58.PubMed Strojnik T: Measurement of the lateral recess angle as a possible alternative for evaluation of the lateral recess stenosis on a CT scan. Wien Klin Wochenschr. 2001, 113 (Suppl 3): 53-58.PubMed
17.
go back to reference Beers GJ, Carter AP, Leiter BE, Tilak SP, Shah RR: Interobserver discrepancies in distance measurements from lumbar spine CT scans. AJR Am J Roentgenol. 1985, 144 (2): 395-398.CrossRefPubMed Beers GJ, Carter AP, Leiter BE, Tilak SP, Shah RR: Interobserver discrepancies in distance measurements from lumbar spine CT scans. AJR Am J Roentgenol. 1985, 144 (2): 395-398.CrossRefPubMed
18.
go back to reference Yukawa Y, Lenke L, Tenhula J, Bridwell K, Riew K, Blanke K: A comprehensive study of patients with surgically treated lumbar spinal stenosis with neurogenic claudication. J Bone Joint Surg Am. 2002, 84-A (11): 1954-1959.PubMed Yukawa Y, Lenke L, Tenhula J, Bridwell K, Riew K, Blanke K: A comprehensive study of patients with surgically treated lumbar spinal stenosis with neurogenic claudication. J Bone Joint Surg Am. 2002, 84-A (11): 1954-1959.PubMed
19.
go back to reference Eskola A, Pohjolainen T, Alaranta H, Soini J, Tallroth K, Slätis P: Calcitonin treatment in lumbar spinal stenosis: a randomized, placebo-controlled, double-blind, cross-over study with one-year follow-up. Calcif Tissue Int. 1992, 50 (5): 400-403. 10.1007/BF00296769.CrossRefPubMed Eskola A, Pohjolainen T, Alaranta H, Soini J, Tallroth K, Slätis P: Calcitonin treatment in lumbar spinal stenosis: a randomized, placebo-controlled, double-blind, cross-over study with one-year follow-up. Calcif Tissue Int. 1992, 50 (5): 400-403. 10.1007/BF00296769.CrossRefPubMed
20.
go back to reference Grob D, Humke T, Dvorak J: Degenerative lumbar spinal stenosis. Decompression with and without arthrodesis. J Bone Joint Surg Am. 1995, 77 (7): 1036-1041.PubMed Grob D, Humke T, Dvorak J: Degenerative lumbar spinal stenosis. Decompression with and without arthrodesis. J Bone Joint Surg Am. 1995, 77 (7): 1036-1041.PubMed
21.
go back to reference Malmivaara A, Slätis P, Heliövaara M, Sainio P, Kinnunen H, Kankare J, Dalin-Hirvonen N, Seitsalo S, Herno A, Kortekangas P, Niinimäki T, Rönty H, Tallroth K, Turunen V, Knekt P, Härkänen T, Hurri H, Finnish Lumbar Spinal Research Group: Surgical or nonoperative treatment for lumbar spinal stenosis? A randomized controlled trial. Spine (Phila Pa 1976). 2007, 32 (1): 1-8. 10.1097/01.brs.0000251014.81875.6d.CrossRef Malmivaara A, Slätis P, Heliövaara M, Sainio P, Kinnunen H, Kankare J, Dalin-Hirvonen N, Seitsalo S, Herno A, Kortekangas P, Niinimäki T, Rönty H, Tallroth K, Turunen V, Knekt P, Härkänen T, Hurri H, Finnish Lumbar Spinal Research Group: Surgical or nonoperative treatment for lumbar spinal stenosis? A randomized controlled trial. Spine (Phila Pa 1976). 2007, 32 (1): 1-8. 10.1097/01.brs.0000251014.81875.6d.CrossRef
22.
go back to reference Fukusaki M, Kobayashi I, Hara T, Sumikawa K: Symptoms of spinal stenosis do not improve after epidural steroid injection. Clin J Pain. 1998, 14 (2): 148-151. 10.1097/00002508-199806000-00010.CrossRefPubMed Fukusaki M, Kobayashi I, Hara T, Sumikawa K: Symptoms of spinal stenosis do not improve after epidural steroid injection. Clin J Pain. 1998, 14 (2): 148-151. 10.1097/00002508-199806000-00010.CrossRefPubMed
23.
go back to reference Koc Z, Ozcakir S, Sivrioglu K, Gurbet A, Kucukoglu S: Effectiveness of physical therapy and epidural steroid injections in lumbar spinal stenosis. Spine (Phila Pa 1976). 2009, 34 (10): 985-989. 10.1097/BRS.0b013e31819c0a6b.CrossRef Koc Z, Ozcakir S, Sivrioglu K, Gurbet A, Kucukoglu S: Effectiveness of physical therapy and epidural steroid injections in lumbar spinal stenosis. Spine (Phila Pa 1976). 2009, 34 (10): 985-989. 10.1097/BRS.0b013e31819c0a6b.CrossRef
24.
go back to reference Hamanishi C, Matukura N, Fujita M, Tomihara M, Tanaka S: Cross-sectional area of the stenotic lumbar dural tube measured from the transverse views of magnetic resonance imaging. J Spinal Disord. 1994, 7 (5): 388-393.CrossRefPubMed Hamanishi C, Matukura N, Fujita M, Tomihara M, Tanaka S: Cross-sectional area of the stenotic lumbar dural tube measured from the transverse views of magnetic resonance imaging. J Spinal Disord. 1994, 7 (5): 388-393.CrossRefPubMed
25.
go back to reference Mariconda M, Fava R, Gatto A, Longo C, Milano C: Unilateral laminectomy for bilateral decompression of lumbar spinal stenosis: a prospective comparative study with conservatively treated patients. J Spinal Disord Tech. 2002, 15 (1): 39-46. 10.1097/00024720-200202000-00006.CrossRefPubMed Mariconda M, Fava R, Gatto A, Longo C, Milano C: Unilateral laminectomy for bilateral decompression of lumbar spinal stenosis: a prospective comparative study with conservatively treated patients. J Spinal Disord Tech. 2002, 15 (1): 39-46. 10.1097/00024720-200202000-00006.CrossRefPubMed
26.
go back to reference Laurencin C, Lipson S, Senatus P, Botchwey E, Jones T, Koris M, Hunter J: The stenosis ratio: a new tool for the diagnosis of degenerative spinal stenosis. Int J Surg Investig. 1999, 1 (2): 127-131.PubMed Laurencin C, Lipson S, Senatus P, Botchwey E, Jones T, Koris M, Hunter J: The stenosis ratio: a new tool for the diagnosis of degenerative spinal stenosis. Int J Surg Investig. 1999, 1 (2): 127-131.PubMed
27.
go back to reference Ullrich C, Binet E, Sanecki M, Kieffer S: Quantitative assessment of the lumbar spinal canal by computed tomography. Radiology. 1980, 134 (1): 137-143.CrossRefPubMed Ullrich C, Binet E, Sanecki M, Kieffer S: Quantitative assessment of the lumbar spinal canal by computed tomography. Radiology. 1980, 134 (1): 137-143.CrossRefPubMed
28.
go back to reference Bolender N, Schönström N, Spengler D: Role of computed tomography and myelography in the diagnosis of central spinal stenosis. J Bone Joint Surg Am. 1985, 67 (2): 240-246.PubMed Bolender N, Schönström N, Spengler D: Role of computed tomography and myelography in the diagnosis of central spinal stenosis. J Bone Joint Surg Am. 1985, 67 (2): 240-246.PubMed
29.
go back to reference Lee B, Kazam E, Newman A: Computed tomography of the spine and spinal cord. Radiology. 1978, 128 (1): 95-102.CrossRefPubMed Lee B, Kazam E, Newman A: Computed tomography of the spine and spinal cord. Radiology. 1978, 128 (1): 95-102.CrossRefPubMed
30.
go back to reference Verbiest H: The significance and principles of computerized axial tomography in idiopathic developmental stenosis of the bony lumbar vertebral canal. Spine (Phila Pa 1976). 1979, 4 (4): 369-378. 10.1097/00007632-197907000-00005.CrossRef Verbiest H: The significance and principles of computerized axial tomography in idiopathic developmental stenosis of the bony lumbar vertebral canal. Spine (Phila Pa 1976). 1979, 4 (4): 369-378. 10.1097/00007632-197907000-00005.CrossRef
31.
go back to reference Jönsson B, Annertz M, Sjöberg C, Strömqvist B: A prospective and consecutive study of surgically treated lumbar spinal stenosis. Part I: Clinical features related to radiographic findings. Spine (Phila Pa 1976). 1997, 22 (24): 2932-2937. 10.1097/00007632-199712150-00016.CrossRef Jönsson B, Annertz M, Sjöberg C, Strömqvist B: A prospective and consecutive study of surgically treated lumbar spinal stenosis. Part I: Clinical features related to radiographic findings. Spine (Phila Pa 1976). 1997, 22 (24): 2932-2937. 10.1097/00007632-199712150-00016.CrossRef
32.
go back to reference Schonstrom N, Bolender N, Spengler D: The pathomorphology of spinal stenosis as seen on CT scans of the lumbar spine. Spine (Phila Pa 1976). 1985, 10 (9): 806-811. 10.1097/00007632-198511000-00005.CrossRef Schonstrom N, Bolender N, Spengler D: The pathomorphology of spinal stenosis as seen on CT scans of the lumbar spine. Spine (Phila Pa 1976). 1985, 10 (9): 806-811. 10.1097/00007632-198511000-00005.CrossRef
33.
go back to reference Schonstrom N, Willen J: Imaging lumbar spinal stenosis. Radiol Clin North Am. 2001, 39 (1): 31-53. 10.1016/S0033-8389(05)70262-1.CrossRefPubMed Schonstrom N, Willen J: Imaging lumbar spinal stenosis. Radiol Clin North Am. 2001, 39 (1): 31-53. 10.1016/S0033-8389(05)70262-1.CrossRefPubMed
34.
go back to reference Wilmink J, Korte J, Penning L: Dimensions of the spinal canal in individuals symptomatic and non-symptomatic for sciatica: a CT study. Neuroradiology. 1988, 30 (6): 547-550. 10.1007/BF00339699.CrossRefPubMed Wilmink J, Korte J, Penning L: Dimensions of the spinal canal in individuals symptomatic and non-symptomatic for sciatica: a CT study. Neuroradiology. 1988, 30 (6): 547-550. 10.1007/BF00339699.CrossRefPubMed
35.
go back to reference Airaksinen O, Herno A, Turunen V, Saari T, Suomlainen O: Surgical outcome of 438 patients treated surgically for lumbar spinal stenosis. Spine (Phila Pa 1976). 1997, 22 (19): 2278-2282. 10.1097/00007632-199710010-00016.CrossRef Airaksinen O, Herno A, Turunen V, Saari T, Suomlainen O: Surgical outcome of 438 patients treated surgically for lumbar spinal stenosis. Spine (Phila Pa 1976). 1997, 22 (19): 2278-2282. 10.1097/00007632-199710010-00016.CrossRef
36.
go back to reference Herno A, Airaksinen O, Saari T: Computed tomography after laminectomy for lumbar spinal stenosis. Patients' pain patterns, walking capacity, and subjective disability had no correlation with computed tomography findings. Spine (Phila Pa 1976). 1994, 19 (17): 1975-1978. 10.1097/00007632-199409000-00019.CrossRef Herno A, Airaksinen O, Saari T: Computed tomography after laminectomy for lumbar spinal stenosis. Patients' pain patterns, walking capacity, and subjective disability had no correlation with computed tomography findings. Spine (Phila Pa 1976). 1994, 19 (17): 1975-1978. 10.1097/00007632-199409000-00019.CrossRef
37.
go back to reference Sortland O, Magnaes B, Hauge T: Functional myelography with metrizamide in the diagnosis of lumbar spinal stenosis. Acta Radiol Suppl. 1977, 355: 42-54.PubMed Sortland O, Magnaes B, Hauge T: Functional myelography with metrizamide in the diagnosis of lumbar spinal stenosis. Acta Radiol Suppl. 1977, 355: 42-54.PubMed
38.
go back to reference Verbiest H: Chapter 16. Neurogenic intermittent claudication in cases with absolute and relative stenosis of the lumbar vertebral canal (ASLC and RSLC), in cases with narrow lumbar intervertebral foramina, and in cases with both entities. Clin Neurosurg. 1973, 20: 204-214.PubMed Verbiest H: Chapter 16. Neurogenic intermittent claudication in cases with absolute and relative stenosis of the lumbar vertebral canal (ASLC and RSLC), in cases with narrow lumbar intervertebral foramina, and in cases with both entities. Clin Neurosurg. 1973, 20: 204-214.PubMed
39.
go back to reference Ciric I, Mikhael MA, Tarkington JA, Vick NA: The lateral recess syndrome. A variant of spinal stenosis. J Neurosurg. 1980, 53 (4): 433-443. 10.3171/jns.1980.53.4.0433.CrossRefPubMed Ciric I, Mikhael MA, Tarkington JA, Vick NA: The lateral recess syndrome. A variant of spinal stenosis. J Neurosurg. 1980, 53 (4): 433-443. 10.3171/jns.1980.53.4.0433.CrossRefPubMed
40.
go back to reference Dincer F, Erzen C, Basgöze O, Özker R, Celiker R: Lateral recess syndrome and computed tomography. Turkish Neurosurgery. 1991, 2: 30-35. Dincer F, Erzen C, Basgöze O, Özker R, Celiker R: Lateral recess syndrome and computed tomography. Turkish Neurosurgery. 1991, 2: 30-35.
41.
go back to reference Mikhael M, Ciric I, Tarkington J, Vick N: Neuroradiological evaluation of lateral recess syndrome. Radiology. 1981, 140 (1): 97-107.CrossRefPubMed Mikhael M, Ciric I, Tarkington J, Vick N: Neuroradiological evaluation of lateral recess syndrome. Radiology. 1981, 140 (1): 97-107.CrossRefPubMed
Metadata
Title
Quantitative radiologic criteria for the diagnosis of lumbar spinal stenosis: a systematic literature review
Authors
Johann Steurer
Simon Roner
Ralph Gnannt
Juerg Hodler
Publication date
01-12-2011
Publisher
BioMed Central
Published in
BMC Musculoskeletal Disorders / Issue 1/2011
Electronic ISSN: 1471-2474
DOI
https://doi.org/10.1186/1471-2474-12-175

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