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

lucvdhauwe@mac.com

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

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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