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L. van den Hauwe
J.W. Van Goethem, J. Huyskens, S. Nicolai, E. De Smet, P.M. ParizelAntwerp University Hospital - University of Antwerp, Antwerp/B & AZ KLINA, Brasschaat/B
degenerative posterior elements
financial disclosures
medical advisor, icometrix, Leuven/B
overview• background• facet joints: facet joint syndrome
– diagnosis– can we do better?– Breughel and the tower of Babel: do we speak the same language?
• posterior elements– pedicles and pars interarticularis– spinous processes and interspinous ligaments
• take home messages
background -low back pain• low back pain (LBP)
– most common pain symptom in adults– 2nd most common reason for primary care physician visits– lifetime prevalence 11%-84%– most cases: spontaneous regression, self-limiting– pain related to facet joints:15%-40%
• chronic low back pain: > 3 months: 23%– recurrent disease
• financial burden: personal, social security, …– total costs per capita €116 ... €399/year
Tessitore E et al. Eur J Radol 2015;84:765-770
• c
• f
background – low back pain• low back pain (LBP)
– most common pain symptom in adults– 2nd most common reason for primary care physician visits– lifetime prevalence 11%-84%– most cases: spontaneous regression, self-limiting– pain related to facet joints:15%-40%
• chronic low back pain: > 3 months: 23%– recurrent disease
• financial burden: personal, social security, …– total costs per capita €116 ... €399/year
Tessitore E et al. Eur J Radol 2015;84:765-770
background – low back pain• discogenic pain• facet joint syndrome
• other causes: “red flags”– infection, metastasis, vertebral fracture, …
Tessitore AC et al. Spine 1994;19:801-806
• tend to occur separately• only 3% had concordant pain on discography and pain relief after facet
joint injectionSchwarzer E et al. Eur J Radol 2015;84:765-770
non-specific LBP
pain generators– anterior spinal column: intervertebral disc
– posterior elements• facet joints & ligamentum flavum• pedicles & pars interarticularis• spinous processes & interspinous ligaments• sacroiliac joints• transitional lumbosacral segments
Kotsenas AL. Radiol Clin N Am 2012; 50:705-730
discogenic pain
facet joint syndrome
pain generators– anterior spinal column: intervertebral disc
– posterior elements• facet joints & ligamentum flavum• pedicles & pars interarticularis• spinous processes & interspinous ligaments• sacroiliac joints• transitional lumbosacral segments
Kotsenas AL. Radiol Clin N Am 2012; 50:705-730
discogenic pain
facet joint syndrome
all may be sources of axial back pain and radicular symptoms
background• segmental anatomy• the intervertebral disc and the 2 facet joints
function as a three joint complex– degenerative changes of the intervertebral disc will
affect the normal anatomy and function of the posterior elements
chronic overload (scoliosis, trauma, …)
degenerative disc disease: disc space narrowing
segmental instability – increased loading of facet joints
biomechanical pathofysiology
chronic overload (scoliosis, trauma, …)
degenerative disc disease: disc space narrowing
segmental instability – increased loading of facet joints
Osteoarthritic changes – subluxation – spondylolisthesis
biomechanical pathofysiology
chronic overload (scoliosis, trauma, …)
degenerative disc disease: disc space narrowing
segmental instability – increased loading of facet joints
biomechanical pathofysiology
chronic overload (scoliosis, trauma, …)
degenerative disc disease: disc space narrowing
segmental instability – increased loading of facet joints
osteoarthritic changes – subluxation – spondylolisthesis
biomechanical pathofysiology
chronic overload (scoliosis, trauma, …)
degenerative disc disease: disc space narrowing
segmental instability – increased loading of facet joints
osteoarthritic changes – subluxation – spondylolisthesis
biomechanical pathofysiology
segmental instabillitiiiiity –––––– ii
patient with low back pain
adequate treatment is only possible if a correct diagnosis is made
what’s the problem…?• unawerenesss of radiologists and referring clinicians:
“what’s wrong with the disc?”/CT
• when Mixter and Barr in 1934 first emphasized that hernation of disc material caused low back pain and sciatia,almost all discussion, research and therapy shifted to the herniated nucleus pulposus
• ever since, the role of the facet joints in evaluating patients with LBP and sciatica has been underestimated
“tunnel vision”“the enemy of strategic thinking”
what’s the problem…?• unawerenesss of radiologists and referring clinicians:
“what’s wrong with the disc?”
• low specificity of morphologic changes; frequent finding in the general - often asymptomatic – population– plain film radiography, CT, MRI, …
• bulging: 52%; protrusion: 27%; extrusion: 1%• multilevel disease: 38%• Schmorl's nodes : 19% • annular tears: 14 %• facet arthropathy: 8%
asymptomatic populations
Brinjikji W et al. AJNR Am J Neuroradiol 2015;36:811-816
asymptomatic populations
Brinjikji W et al. AJNR Am J Neuroradiol 2015;36:811-816
•
Eubanks JD et al. Spine 2007;32(19):2058-2062
facet joint osteoarthritis• both disc degeneration and facet joint osteoarthritis increase
with age• degeneration of the lumbar spine occurs from age 30 and is
almost invariably present after 60 years
• factors contributing to facet joint degeneration include weight, scoliosis and lordosis
Eubanks JD et al. Spine 2007;32(19):2058-2062
what’s the problem…?• unawerenesss of radiologists and referring clinicians:
“what’s wrong with the disc?”
• low specificity of morphologic changes; frequent finding in the general - often asymptomatic – population– plain film radiography, CT, MRI, …
• posterior element causes of LBP (and neck pain) may remain underrecognized as conventional MR imaging techniques fail to demonstrate
• bone marrow edema, soft- tissue inflammation, hypervascularity
facet joint syndrome
diagnosis• clinical history• clinical examination• imaging
– CR– CT– Conv MR imaging
facet joint disease: clinical symptoms
• aspecific• can mimic symptoms of many back pain conditions• acute pain, especially during movement• usually worse when bending backwards or
straightening up• loss of range of motion• (sciatica)
diagnosis - imaging• plain film
• CT
• conventional MR imaging
diagnosis - imaging• plain film
• CT
• conventional MR imaging
facet joint surfaces• are smooth and slightly curved
– superior facets: concave– inferior facets: convex
• are lined by hyaline cartilage
• are oriented in an oblique plane halfway between the sagittal and coronal planes ( 45 )
R L
facet joint anatomy
I IS S
L5
L4
facet joint tropism• asymmetry between
the left and right facet joint angles, with one joint having a more sagittal orientation
• conflicting results on the association with:– facet joint osteoarthritis– disc herniation– degenerative
d l li th i
R L
association between facet jointangulation and osteoarthritis
facet joint osteoarthritis• degenerative changes are similar to those observed
in peripheral joints– osteophyte formation– hypertrophy of the articular processes– osteosclerosis– thinning of the articular cartilage– erosions and subchondral cyst formation– vacuum joint phenomenon– joint effusion– hypertrophy and/or calcification of the joint capsule and
ligamentum flavum
facet hypertophy
kapsel
subchondral bone changes
facet joint subluxation
vacuum joint phenomenon
joint space changes
L5-S1
L4-L5
conventional MR imaging• sagittal T1-wi• sagittal T2-wi• sagittal T2-wi with FS (STIR)• axial T1-wi• axial T2-wi
conventional MR imaging• sagittal T1-wi• sagittal T2-wi• sagittal T2-wi with FS (STIR)• axial T1-wi• axial T2-wi
• 12 grading systems for lumbar facet joint degeneration– macroscopic anatomy– histology– plain radiography– conventional tomography– CT– MRI
Facet joint osteoarthritis
grading facet joint osteoarthritis
Grade 1 and 2 Grade 3
L4-L5L5-S1
facet mediated radicular pain• due to mass effect and/or central/lateral recess stenosis
– hypertrophic degeneration– osteophytes– ligamentum flavum redundancy– synovial cysts
diagnosis – diagnostic blocks• selective blocks: gold standard?• considered to be a valuable tool for confirming
facetogenic pain• a block of the ramus medialis of the ramus
dorsalis is preferred over intra-articular injections
facet joint innervation• facet joints are innervated by the medial branches
of the posterior (dorsal) lumbar ramus of the spinal nerves
facet joint innervation
• complex pattern
• each medial branch: 2 (3) branches– facet joint of that level– facet joint of the level below
• L4-L5 facet joints are innervated by the L3 and L4 medial branches
associated changessoft tissue changes• degenerative cysts arising from the facet joints, aka
juxtafacet cysts• hypertrophy and/or calcification of the ligamentum flavum• ligamentum flavum cysts
degenerative changes of the neural arch• neoarthrosis of the pedicles and laminae• Baastrup's disease
synovial cyst
synovial cyst
synovial cyst
synovial cyst• Ouaissa Mohammed
• a tough fibrous capsule is present on theposterolateral aspect of the facet joint.
• on the ventral aspect of the joint, there is nofibrous capsule
• the ligamentum flavum and synovialmembrane are the only barriers between thefacet joint space and the spinal canal
facet joint anatomy
ligamentum flavum• redundancy• severe spinal stenosis
spinal stenosis
can we do better ???
can we do better ???
YES, WE CAN !!!
Can we do better?• FS MR imaging• SPECT/CT• PET/CT
fat-suppressed imaging • bone marrow edema• soft-tissue inflammation is much more conspicuous on fat-
suppressed T2-weighted images• the hypervascularity associated with soft tissue inflammation can
best be seen on fat-suppressed CE T1-weighted images• fat-suppressed T2-weighted and CE T1-weighted sequences
therefore enable the clear visualization of:– facet joint effusions– subchondral bone marrow edema– paraspinal soft-tissue inflammation
• which may be overlooked with conventional non–fat- suppressed MR imaging techniques
fat-suppressed MR imaging techniques• fat-saturation
– fast spin-echo (FSE) T2- weighted– contrast-enhanced (CE) T1- weighted
• short tau inversion recovery (STIR)• water-excitation
– FSE T2-weighted– CE T1- weighted
• Dixon water-fat separation– IDEAL (GE)– mDIXON (Philips)– Dixon (Siemens)
16-year-old boy
T1 T2 T1 SPIR + Gd T2 SPAIR
16-year-old man with LBP for years
16-year-old boy
T1 T2 T1 SPIR + Gd T2 SPAIR
T1 T2 T1 SPIR + Gd T2 SPAIR
T1 SPIR + Gd T2 SPAIR
T1 SPIR + Gd
T1 SPIR + Gd T2 SPAIR
T1 SPIR + Gd T2 SPAIR
facet joint synovitis
D’Aprile• non-radicular low back pain
– facet joint pathology• osteoarthritis• joint effusion• synovitis• synovial cysts
– spondylolysis– spinal/perispinal ligamentous degenerative-inflammatory
changes– perispinal muscular changes
facet joint synovitis/sterile osteoarthritis
facet joint effusion
Czervionke• 41% in 200 consecutive lumbar MR-studies• side of the facet synovits correlated with the side
of the patient’s clinical symptoms• classification
SPECT/CT
patients with non specific chronic low back pain
• plain film radiography• CT• MRI• SPECT• hybrid imaging SPECT-CT
identification of the pain generator
lack of correlation between imaging findings and clinic
Modic type 1, active Schmorl nodules
patients with non specific chronic low back pain
• plain film radiography• CT• MRI• SPECT• hybrid imaging SPECT-CT
identification of the pain generator
lack of correlation between imaging findings and clinic
Modic type 1, active Schmorl nodules
facet joint synovitis• CT: -• SPECT/CT: • cMRI: -• fsMRI: +
take home messages• LBP is more than degenerative disc degeneration• look at the facet joints and other posterior elements• use appropriate imaging
– CT– MR: fat-supressed techniques
– SPECT/CT• more and larger studies are needed to correlate
imaging findings with diagnostic nerve blocks
• to be added to standard imaging protocol?• FS Gd-enhanced T1-weighted imaging