Evidence-based guidelines often use a circuitous logic in supporting imaging as the key diagnostic test for stenosis. For instance, the North American Spine Society (NASS) guidelines2 conclude that imaging is the key noninvasive test for diagnosis. The guidelines do not specify radiological criteria for stenosis and yet exclude from review any studies that do not use imaging as an inclusion criterion. Research on spinal stenosis almost always uses imaging to establish the diagnosis. However, the inclusion criterion is typically based on an opinion of a radiologist or surgeon who reviewed the images rather than some stated definition. The interrater reliability of the clinical impression is seldom established, masking clinical data is rare, and control populations are seldom included. Anatomical cutoffs relating to anterior-posterior spinal canal diameter or the-cal sac diameter have been proposed as diagnostic criteria for spinal stenosis; however, these measurements are not necessarily tied to clinical evidence or statistical norms.
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