Does lumbar spinal degeneration begin with the anterior structures? A study of the observed epidemiology in a community-based population

Enhancing Clinical Insights: New Radiographic Grading for Lumbar Facet Joint Degeneration, A Reliability Study

Background

Lumbar facet joint diseases can often lead to reduced work efficiency and increased medical costs. As a primary imaging tool in orthopedics, X-rays offer numerous advantages. However, there is no consensus on the classification of lumbar facet joints based on X-ray imaging.

Methods

This study was conducted for 356 patients between November 2017 and September 2023. A senior radiologist and a senior orthopedic surgeon discussed and established a grading system for lumbar facet joints based on both X-ray and MRI findings. Two double-blind attending spinal surgeons were asked to evaluate and grade the included cases. The intra-rater reliability and inter-rater reliability were evaluated by assessing the weighted kappa (κw) coefficient.

Results

The level of inter-rater reliability of MRI for complete agreement was good for Doctor A (κw = 0.792) and Doctor B (κw = 0.869). The inter-rater reliability coefficient for grading lumbar facet joint degeneration based on the radiograph was as follows: for Doctor A (κw = 0.702, session 1; κw = 0.847, session 2) and Doctor B (κw = 0.714, session 1; κw = 0.828, session 2). Moreover, the level of intra-rater reliability based on X-ray for complete agreement was excellent for Doctor A (κw = 0.843) and Doctor B (κw = 0.836).

Conclusion

We propose a new grading system for lumbar facet joint degeneration based on X-rays, which serves as a supplement to the Weishaupt and Pathria classifications. This grading system aims to provide clinicians with a more comprehensive understanding of lumbar facet joint degeneration, allowing for the use of a broader range of diagnostic tools to evaluate facet joint degeneration from multiple perspectives. We believe that this grading system can be valuable in assessing potential anatomical changes related to the facet joint, thereby informing modifications to surgical techniques and procedural steps.

Senolytics cocktail dasatinib and quercetin alleviate chondrocyte senescence and facet joint osteoarthritis in mice

BACKGROUND CONTEXT

Low back pain (LBP) is a pervasive issue, causing substantial economic burden and physical distress worldwide. Facet joint osteoarthritis (FJ OA) is believed to be a significant contributor to this problem. However, the precise role of chondrocyte senescence in FJ OA remains unclear, as does whether the clearance of chondrocyte senescence can alleviate the progression of FJ OA.

PURPOSE

The goal of this study was to understand the potential of Dasatinib (D) and Quercetin (Q) as a treatment to clear chondrocyte senescence during the progression of FJ OA.

STUDY DESIGN

We used a preclinical bipedal standing mice model with the administration of Dasatinib (D) (5 mg/kg) and Quercetin (Q) (50 mg/kg) after 10 weeks of bipedal standing.

MATERIALS AND METHODS

Human degenerative lumbar facet joint (LFJ) samples were obtained to investigate the relationship between chondrocyte cellular senescence and LFJ osteoarthritis (OA). Subsequently, we established an in vitro model of excessive mechanical stress on chondrocytes and an in vivo bipedal standing mice model to induce LFJ OA. IHC (immunohistochemistry) staining in vivo and SA-β-gal staining, qRT-PCR and Western blot analysis were applied to test the senolytic effect of the combination of Dasatinib (D) and Quercetin (Q). IHC staining and X-ray microscope were also performed to examine the contribution of D+Q to the anabolism in cartilage and subchondral bone recoupling. Immunofluorescence and Western blot analysis in vitro and IHC staining in vivo were conducted to assess the impact of D+Q on the regulation of the NF-κB pathway activation during chondrocyte senescence.

RESULTS

We observed that facet joint cartilage degeneration is associated with chondrocyte cellular senescence in both human and mouse degenerative samples. Following treatment with D+Q in vitro, cellular senescence was significantly reduced. Upon oral gavage administration of D+Q in the bipedal standing mice model, decreased cellular senescence and reversed chondrocyte anabolism were observed. Furthermore, administration of D+Q maintained subchondral bone remodeling homeostasis and potentially reversed the activation of the NF-κB pathway in chondrocytes of the lumbar facet joint.

CONCLUSIONS

In summary, our investigation unveiled a significant correlation between chondrocyte senescence and LFJOA. Treatment with the senolytic combination of D+Q in FJ OA yielded a notable reduction in chondrocyte senescence, along with a decrease in the release of SASP factors. Additionally, it facilitated the promotion of cartilage anabolism, maintenance of subchondral bone coupling, and amelioration of NF-κB pathway activation.

CLINICAL SIGNIFICANCE

Our outcomes revealed that D+Q, the renowned combination used for senolytic treatment, alleviate the progression of LFJ OA. The utilization of D+Q as a senolytic demonstrates a novel and promising alternative for LFJ OA treatment.

Association of vertebral fractures with worsening degenerative changes of the spine: a longitudinal study

Vertebral compression fractures (VFs) and spinal degeneration are both common causes of back pain, particularly in older adults. Previous cross-sectional studies have shown a potential association between these entities, but there is limited evidence on the role of VFs in spinal degeneration. In this longitudinal study, we evaluated the association between prevalent VFs and the subsequent progression of facet joint osteoarthritis (FJOA) and intervertebral disc height narrowing (DHN), using data from the Framingham Heart Study Offspring and Third Generation Multi-Detector Computed Tomography study. Summary indices representing the total burden of each spinal parameter (VFs, DHN, and FJOA) were calculated for each individual. We hypothesized that prevalent VFs are associated with worsening spinal degeneration. Three hundred and seventy (31%) of 1197 participants had a baseline (prevalent) VF. The change in summary index of DHN over the follow-up period was significantly higher in those with vs without prevalent VF (difference in change in DHN 0.38, 95% CI 0.18 to 0.59, p<.001), but the change in summary index of FJOA was similar between those with and without prevalent VF. However, once adjusted for age, sex, cohort, smoking status, BMI, and baseline DHN, the change in summary index of DHN did not differ by prevalent VF status. There was a modestly higher change in the FJOA summary index in those with prevalent VFs compared to those without in the fully adjusted model (difference in change in FJOA 0.62, 95% CI -0.01 to 1.24, p = .054), driven primarily by those with severe (grade 3) VF (difference in change in FJOA 4.48, 95% CI 1.99-6.97). Moreover, there was greater change in the summary index of FJOA with increasing severity of prevalent VF (linear trend p = .005). Beyond the established morbidity and mortality associated with VFs, our study suggests that VFs may also lead to worsening spine osteoarthritis.

The association of limited or painful spinal range of motion with lumbar disc degeneration: the back complaints in older adults (BACE) study

BACKGROUND

We currently lack clear definitions for structural and symptomatic spinal osteoarthritis (OA). To define spinal OA and create diagnostic criteria for this condition, it is necessary to determine the relationship between clinical signs and symptoms of back pain and radiographic features of OA. Notably, recent studies suggest a defining sign of spinal OA could be a limited or painful spinal range of motion (ROM). Therefore, our objective was to assess the association between restricted or painful active spinal ROM, and multilevel structural features of lumbar disc degeneration (LDD) (i.e., disc space narrowing, osteophytes) on radiographs.

METHODS

We used the baseline data from the'Back Complaints in Older Adults' (BACE) study. The association between a limited or painful active spinal ROM, and multilevel disc space narrowing or osteophytes was assessed using multivariable logistic regression adjusted for age, mean pain intensity in the previous week, sex, BMI, and the Fear Avoidance Belief Questionnaire score. Primary analyses were performed on imputed datasets.

RESULTS

We included 675 patients with a mean age of 66.52 years (SD 7.69). Limited latero-flexion (fingertip that at best reached halfway up the upper leg) was associated with increased odds of having multilevel osteophytes (OR 1.85; 95% CI: 1.13 to 3.01). However, a limited or painful ROM in other directions (i.e., rotation, ante-flexion) was not associated with multilevel osteophytes, and a limited or painful active ROM in any direction was found to have no association with multilevel disc space narrowing.

CONCLUSIONS

Our study indicates that a restricted ROM in latero-flexion could potentially be a defining sign in future definitions of symptomatic spinal OA. However, since our results partially differ from previous studies, further research is needed to explore the association between active ROM and LDD.

CellKine clinical trial: first report from a phase 1 trial of allogeneic bone marrow-derived mesenchymal stem cells in subjects with painful lumbar facet joint arthropathy

Background

Lumbar facet joint arthropathy (LFJA) is a major cause of low back pain (LBP), with current treatments offering limited long-term benefits. Bone marrow-derived mesenchymal stem cells (BM-MSCs) show promise due to their immunomodulatory and trophic effects, potentially addressing underlying degenerative processes in LFJA.

Objectives

This initial report describes the outcomes of the first treated patient in an ongoing mutidisciplinary phase 1 clinical trial evaluating the safety and feasibility of intra-articular allogeneic BM-MSCs for painful LFJA.

Methods

Following enrollment in our IRB-approved protocol, symptomatic LFJA was confirmed through double blocks on L4 and L5 medial branches. Two 1-mL syringes, each containing 10 million BM-MSCs, were prepared in the cGMP facility and administered bilaterally to the patient's L4-L5 lumbar facet joints. The patient underwent standardized follow-ups, including clinical examinations and functional and imaging assessments for 2 years, utilizing patient-reported outcomes measurement information system-computer adaptive tests (PROMIS CATs), visual analogue scale, Oswestry disability index, work functional status and opioid pain medication use, and MR imaging Fenton-Czervionke score.

Results

The patient tolerated the procedure well, with no drug-related adverse events during the study period. Pain, spine function, and work functional status improved at multiple follow-ups. This patient also reported improvements in mental and social health, along with a notable improvement in the grade of facet synovitis observed at the one-year follow-up MRI evaluation.

Conclusions

This case report suggests the safety and feasibility of administering intra-articular allogeneic BM-MSCs, offering therapeutic benefits for pain management and functional activities.

Exploration of the correlation between facet joints cross-sectional area asymmetry and cervical disc herniation

PURPOSE

To evaluate the association between facet joints cross-sectional area asymmetry (FCAA) and cervical intervertebral disc herniation (CDH).

METHODS

Overall, we retrospectively recruited 390 consecutive patients with CDH who underwent surgical treatment at our institution and 50 normal participants. Clinical variables and radiological findings related to CDH were collected.

RESULTS

Patients with CDH were more likely to have a higher absolute value of the facet asymmetry factor (FAF) (p  < .001), in which the FAF value of the left group was significantly higher than the other groups (p  < .001) and the right group was lower than the central group (p  < .001). 9.62% (C3/4), 12.19% (C4/5), 8.70% (C5/6), and 8.14% (C6/7) were determined as cutoff values for each variable that maximized sensitivity and specificity. Furthermore, multivariate analysis showed that cross-sectional area asymmetry of the facet joint (FCAA) was an independent risk factor for the occurrence of CDH. Also, the Chi-square test showed a significant difference in the distribution of the degeneration classification of the disc between the facet-degenerated group and the nondegenerated group at C5/6 (p = 0.026) and C6/7 (p = 0.005) in the facet asymmetry (FA) group.

CONCLUSIONS

FCAA is evaluated as an independent risk factor for CDH and associated with the orientation of disc herniation. And facet joint orientation may also play a role in cervical spine degeneration rather than facet joint tropism.

Evolution of lumbar degenerative spondylolisthesis with key radiographic features

Spondylolisthesis is a common finding in middle-aged and older adults with back pain. The pathophysiology of degenerative spondylolisthesis is a subject of controversy regarding not only its etiology but also the mechanisms of its progression. It is theorized that degeneration of the facets and discs can lead to segmental instability, leading to displacement over time. Kirkaldy-Willis divided degenerative spondylolisthesis into three phases: dysfunction, instability, and finally, restabilization. There is a paucity of literature on the unification of the radiological hallmarks seen in spondylolisthesis within these phases. The radiographic features include (1) facet morphology/arthropathy, (2) facet effusion, (3) facet vacuum, (4) synovial cyst, (5) interspinous ligament bursitis, and (6) vacuum disc as markers of dysfunction, instability, and/or restabilization. We discuss these features, which can be seen on X-ray, CT, and MRI, with the intention of establishing a timeline upon which they present clinically. Spondylolisthesis is initiated as either degeneration of the intervertebral disc or facet joints. Early degeneration can be seen as facet vacuum without considerable arthropathy. As the vertebral segment becomes increasingly dynamic, fluid accumulates within the facet joint space. Further degeneration will lead to the advancement of facet arthropathy, degenerative disc disease, and posterior ligamentous complex pathology. Facet effusion can eventually be replaced with a vacuum in severe facet osteoarthritis. Intervertebral disc vacuum continues to accumulate with further cleft formation and degeneration. Ultimately, autofusion of the vertebra at the facets and endplates can be observed. With this review, we hope to increase awareness of these radiographical markers and their timeline, thus placing them within the framework of the currently accepted model of degenerative spondylolisthesis, to help guide future research and to help refine management guidelines.

Correlating SPECT-CT activity in lumbar facet joints with response to lumbar medial branch and L5 dorsal ramus blocks

Introduction

Lumbar facet arthritis is a significant source of back pain and impaired function that is amenable to treatment with medial branch radiofrequency neurotomy (RFN). Identifying appropriate patients for this treatment requires integration of information from the history, physical exam, and diagnostic imaging, but the current diagnostic standard for facet-mediated pain is positive comparative medial branch blocks (MBBs). Lumbar SPECT-CT has recently been evaluated as a potential predictor of positive MBBs with mixed results. The purpose of this retrospective analysis was to determine if the level of concordance between SPECT-CT uptake and facet joints targeted with MBB was associated with a positive block.

Methods

A retrospective review was performed to identify all patients undergoing lumbar MBB within 12 months after having a lumbar SPECT-CT. Each procedure was classified into one of four categories based on the level of concordance between facet joints demonstrating increased 99mTc uptake on SPECT-CT and those being blocked: 1) Complete Concordance (all joints demonstrating increased uptake were blocked and no additional joints blocked); 2) Partial Concordance (all joints demonstrating increased uptake were blocked, with at least one joint not demonstrating increased uptake blocked); 3) Partial Discordance (at least one but not all joints demonstrating increased uptake were blocked); 4) Complete Discordance (all blocks performed at joints not demonstrating increased uptake). Statistical analysis was performed to determine if the level of concordance between increased uptake on SPECT-CT and joints undergoing MBB was associated with a positive block using cutoffs of 50 % and 80 % pain relief.

Results

A total of 180 procedures were analyzed (23 % Complete Concordance, 22 % Partial Concordance, 31 % Partial Discordance, 24 % Complete Discordance) and all groups demonstrated improvement in pain Numeric Rating Scale (NRS) scores. There was no significant association between level of concordance and having a positive block using thresholds of 50 % pain relief, χ 2(3, N = 180) = 4.880, p = .181; or 80 % pain relief, χ 2(3, N = 180) = 1.272, p = .736.

Conclusion

SPECT-CT findings do not accurately predict positive lumbar MBB but may provide valuable information that can be considered with other factors when deciding which joints to treat.

Systematic review of computed tomography parameters used for the assessment of subchondral bone in osteoarthritis

OBJECTIVE

To systematically review the published parameters for the assessment of subchondral bone in human osteoarthritis (OA) using computed tomography (CT) and gain an overview of current practices and standards.

DESIGN

A literature search of Medline, Embase and Cochrane Library databases was performed with search strategies tailored to each database (search from 2010 to January 2023). The search results were screened independently by two reviewers against pre-determined inclusion and exclusion criteria. Studies were deemed eligible if conducted in vivo/ex vivo in human adults (>18 years) using any type of CT to assess subchondral bone in OA. Extracted data from eligible studies were compiled in a qualitative summary and formal narrative synthesis.

RESULTS

This analysis included 202 studies. Four groups of CT modalities were identified to have been used for subchondral bone assessment in OA across nine anatomical locations. Subchondral bone parameters measuring similar features of OA were combined in six categories: (i) microstructure, (ii) bone adaptation, (iii) gross morphology (iv) mineralisation, (v) joint space, and (vi) mechanical properties.

CONCLUSIONS

Clinically meaningful parameter categories were identified as well as categories with the potential to become relevant in the clinical field. Furthermore, we stress the importance of quantification of parameters to improve their sensitivity and reliability for the evaluation of OA disease progression and the need for standardised measurement methods to improve their clinical value.

Effects of lumbar-pelvic training combined with electroacupuncture on chronic nonspecific low back pain

This observational study was conducted to investigate the effect of lumbar-pelvic training (LP) combined with electroacupuncture (EA) in the treatment of chronic nonspecific low back pain. One hundred and twenty patients diagnosed with chronic nonspecific low back pain were evenly randomized to receive the following 4 treatments for 2 weeks: LP combined with EA (Group A), EA (Group B), LP (Group C) or no intervention (Group D). The LP was a self-developed training program containing 5 movements and was conducted three times a week to build up the strength of abdomen muscle groups. Four acupoints along the foot-taiyang bladder meridian and the governor vessel were chosen for EA five times a week based on the theory of Traditional Chinese Medicine. The Visual Analog Scale and Oswestry Disability Index were measured before and after treatment to assess the reduction of pain intensity and functional disability, respectively. Following the treatments, Visual Analog Scale and Oswestry Disability Index scores in all 3 intervention groups were significantly lower than those in the Group D without intervention (P < .01). Among the intervention groups, Group A's scores were lower than those of Group B or Group C (P < .01). The overall efficacy of Group A was 93.33%, which was higher than that of Group B (76.67%) and Group C (70.00%) (P < .01). In conclusion, this study suggest that our self-developed lumbar-pelvic training combined with electroacupuncture is effective for chronic nonspecific low back pain in terms of pain and disability reduction.

The Lumbar Facet Capsular Ligament Becomes More Anisotropic and the Fibers Become Stiffer With Intervertebral Disc and Facet Joint Degeneration

Degeneration of the lumbar spine, and especially how that degeneration may lead to pain, remains poorly understood. In particular, the mechanics of the facet capsular ligament may contribute to low back pain, but the mechanical changes that occur in this ligament with spinal degeneration are unknown. Additionally, the highly nonlinear, heterogeneous, and anisotropic nature of the facet capsular ligament makes understanding mechanical changes more difficult. Clinically, magnetic resonance imaging (MRI)-based signs of degeneration in the facet joint and the intervertebral disc (IVD) correlate. Therefore, this study examined how the nonlinear, heterogeneous mechanics of the facet capsular ligament change with degeneration of the lumbar spine as characterized using MRI. Cadaveric human spines were imaged via MRI, and the L2-L5 facet joints and IVDs were scored using the Fujiwara and Pfirrmann grading systems. Then, the facet capsular ligament was isolated and biaxially loaded. The nonlinear mechanical properties of the ligament were obtained using a nonlinear generalized anisotropic inverse mechanics analysis (nGAIM). Then a Holzapfel-Gasser-Ogden (HGO) model was fit to the stress-strain data obtained from nGAIM. The facet capsular ligament is stiffer and more anisotropic at larger Pfirrmann grades and higher Fujiwara scores than at lower grades and scores. Analysis of ligament heterogeneity showed all tissues are highly heterogeneous, but no distinct spatial patterns of heterogeneity were found. These results show that degeneration of the lumbar spine including the facet capsular ligament appears to be occurring as a whole joint phenomenon and advance our understanding of lumbar spine degeneration.

Facet joint degeneration-An initial procedure of the cervical spine degeneration

Objective

This study aims to emphasize the initiating role of facet joint (FJ) degeneration in the process of cervical spine degeneration induced by tangential load, and we further validate it in a novel cervical spine degeneration animal model.

Methods

The characteristics of cervical degeneration in patients of different ages were summarized through case collection. In the rat models, Hematoxylin-Eosin, Safranin O staining, and micro-computed tomography were used to show the histopathological changes and bone fiber structure of FJ and the height of intervertebral disc (IVD) space. The ingrowth of nociceptive sensory nerve fibers was observed by immunofluorescence staining.

Results

FJ degeneration without IVDs degeneration was more common in people with cervical spondylosis in young patients. The obvious degeneration phenotypes of the FJs preceded the IVDs at the same cervical segment in our animal model. The SP+ and CGRP+ sensory nerve fibers were observed in the articular subchondral bone of degenerated FJs and porous endplates of degenerated IVDs.

Conclusion

The FJ degeneration may act as the major contributor to cervical spine degeneration in young people. The dysfunction of functional unit of spine, not a certain part of IVD tissue, results in the occurrence of cervical degeneration and neck pain.

Intervertebral disc degeneration and osteoarthritis: a common molecular disease spectrum

Intervertebral disc degeneration (IDD) and osteoarthritis (OA) affecting the facet joint of the spine are biomechanically interdependent, typically occur in tandem, and have considerable epidemiological and pathophysiological overlap. Historically, the distinctions between these degenerative diseases have been emphasized. Therefore, research in the two fields often occurs independently without adequate consideration of the co-dependence of the two sites, which reside within the same functional spinal unit. Emerging evidence from animal models of spine degeneration highlight the interdependence of IDD and facet joint OA, warranting a review of the parallels between these two degenerative phenomena for the benefit of both clinicians and research scientists. This Review discusses the pathophysiological aspects of IDD and OA, with an emphasis on tissue, cellular and molecular pathways of degeneration. Although the intervertebral disc and synovial facet joint are biologically distinct structures that are amenable to reductive scientific consideration, substantial overlap exists between the molecular pathways and processes of degeneration (including cartilage destruction, extracellular matrix degeneration and osteophyte formation) that occur at these sites. Thus, researchers, clinicians, advocates and policy-makers should consider viewing the burden and management of spinal degeneration holistically as part of the OA disease continuum.

Level dependent alterations in human facet cartilage mechanics and bone morphometry with spine degeneration

The zygapophyseal joints of the spine, also known as the facet joints, are paired diarthrodial joints posterior to the intervertebral disc and neural elements. The pathophysiology of facet osteoarthritis (OA), as well as crosstalk between the disc and facets, remains largely understudied compared to disc degeneration. The purpose of this study was to characterize alterations to human facet cartilage and subchondral bone across a spectrum of degeneration and to investigate correlations between disc and facet degeneration. Human lumbar facet articular surfaces from six independent donors were subject to creep indentation mechanical testing to quantify cartilage mechanical properties, followed by microcomputed tomography (µCT) analyses for subchondral bone morphometry. The degenerative state of each articular surface was assessed via macroscopic scoring and via Osteoarthritis Research Society International histopathology scoring. Our data suggest reduced facet cartilage compressive and tensile moduli and increased permeability with increasing degenerative grade, particularly at the lower levels of the spine. µCT analyses revealed spinal level-dependent alterations to the subchondral bone, with an increase in trabecular bone at the L4-L5 level, but a decrease at the upper levels of the lumbar spine with increasing degenerative grade. Cortical bone volume fraction was generally decreased with increasing degenerative grade across spinal levels. Correlation analysis revealed several associations between quantitative measures of disc degeneration and facet OA. This study showed that alterations in the mechanical properties of facet cartilage and in the structural properties of facet subchondral bone correlated with aspects of disc degeneration and were highly dependent on spinal level.

Sex Difference in OA: Should We Blame Estrogen?

Osteoarthritis (OA) is a leading cause of chronic pain and disability, not only in the United States but also worldwide. The burden of OA is higher in women than in men. Estrogen as a possible explanation for observed sex differences in OA has not been definitively established. The purpose of this review was to summarize the results from studies of estrogen, estrogen depletion and treatment, and their impact on knee, hip, hand, and spine OA. We conducted a targeted review of the literature using PubMed. Although several studies show that hormone replacement therapy has the potential to be protective of OA for some joints, there are studies that showed no protective effect or even adverse effect. Taken together, the evidence for the protective effect of estrogen therapy depends on OA joint, OA outcome, and study design. Although this area has been studied for decades, more exclusively since the 1990s, there is a lack of high-quality experimental research in this topic. The lack of definitive conclusion on whether estrogen can play a role in the development in OA of either the knee, hip, spine, or hand is often in part due to the noncomparability of studies existing within the literature. Differences in diagnostic criteria, imaging modalities, populations studied, study designs, and outcome measures, as well as random error, have all contributed to inconclusive evidence. Future research on the role of estrogen in OA is needed, particularly as global demographic shifts in increasing overweight/obesity prevalence and ageing populations may contribute to widening OA-related health inequalities.

Facet Joint Syndrome: Pathophysiology, Diagnosis, and Treatment

Facet joint osteoarthritis (OA) is the most frequent form of facet joint syndrome. Medical history, referred pain patterns, physical examination, and diagnostic imaging studies (standard radiographs, magnetic resonance imaging, computed tomography and single-photon emission computed tomography) may suggest but not confirm lumbar facet joint (LFJ) syndrome as a source of low back pain (LBP). However, the diagnosis and treatment of facet joint syndrome is still controversial and needs further study. It is widely acknowledged that block with local anesthetic is perhaps the most effective method to establish a diagnosis of pain from LFJ. Particularly, there are different rates of success among different populations selected for diagnostic block with various positive criteria. Currently, in addition to conservative treatments for pain such as painkillers, functional exercises, and massage, there are many other methods, including block, denervation of the nerves that innervate the joints by radiofrequency, freezing or endoscopy, and injections. Due to the limited duration of pain relief from neurolysis of medial branch, many scholars have recently turned their targets to dorsal roots and LFJ capsules. Therefore, we reviewed the latest research progress of facet joint syndrome from diagnosis to treatment.

Chronology of disc degeneration and facet joint arthritis in lumbar spine is variable - A CT based cross-sectional study

BACKGROUND

The notion that disc degeneration (DD) always precedes facet joint arthritis (FJA) has held sway for many decades. However, it is not always the case. We hypothesized that DD is not always the first offender studied the prevalence of isolated DD and isolated FJA in the lumbar spine.

METHODS

Inter-vertebral discs and bilateral facet joints of lumbar spines of 135 participants were graded. The participants were divided into one of the four categories. 'No degeneration,' 'Isolated disc degeneration without facet joint arthritis,' 'Combined disc degeneration and facet joint arthritis,' and 'Isolated facet joint arthritis without disc degeneration.' Multivariate logistic regression analysis was done to evaluate the predictive factors for spinal degeneration using FJA as a dependent variable while age, sex, BMI, smoking history, and DD as predictor variables.

RESULTS

The majority of participants had isolated FJA 64 (47.4%). Combined DD and FJA were noted in 32 (23.7%), isolated DD in 8 (5.9%), while 31(23%) had no degeneration. Only age was found to be significantly contributing to the prediction model in multivariate analysis.

CONCLUSION

Our study shows that spinal degeneration may begin either in the disc or in the facet joints depending upon the aetiological factors. It is a vicious circle that may be entered at any point, FJA or DD.

Lumbar facet joint osteoarthritis as the underlying reason for persistent low back pain after minimally invasive discectomy

INTRODUCTION

A post-hoc subgroup analysis of prospective collected data in a randomized controlled trial (RCT) of minimally invasive discectomy was conducted, to find out the possible underlying reasons for patients with persistent low back pain (LBP) following surgery.

MATERIALS AND METHODS

Patients who were diagnosed with lumbar disc herniation (LDH) and underwent either percutaneous transforaminal endoscopic discectomy or microendoscopic discectomy in our RCT were analyzed. Patients with persistent LBP in 2-year follow-up were compared with the non-LBP patients to determine the underlying reasons. Then, the demographic characteristics, clinical outcomes and radiological parameters of patients with preoperative lumbar facet joint osteoarthritis (LFJOA) were assessed and compared with the non-LFJOA subgroup.

RESULTS

18 patients (8.1%) were reported to have persistent LBP in 2-year follow-up. Significantly higher proportion of preoperative LFJOA were found in the persistent LBP subgroup and was considered to be a risk factor using multivariate analysis. The prevalence of LFJOA is strongly associated with older age, female, high BMI and heavy labor in the LDH population. All of the clinical outcomes including ODI, SF36-PF, SF36-BP, EQ-5D, VAS-back and VAS-leg were worse in LFJOA subgroup in 2-year follow-up. LFJOA subgroup was associated with more adjacent segment degeneration and more lateral recess stenosis.

CONCLUSIONS

LFJOA is a possible underlying reason for patients with persistent LBP after minimally invasive discectomy. Surgeons should carefully review the preoperative radiological images to find out whether there is LFJOA in the LDH segment, and kindly diminish the expectation of back pain relief for those patients.

TRIAL REGISTRATION

This trial was registered at ClinicalTrials.gov at November 14, 2013, registration number NCT01997086. ( https://clinicaltrials.gov/ct2/show/NCT01997086 ).

Biochemical and biomechanical characterization of the cervical, thoracic, and lumbar facet joint cartilage in the Yucatan minipig

Facet joint arthrosis causes pain in approximately 7 % of the U.S. population, but current treatments are palliative. The objective of this study was to elucidate structure-function relationships and aid in the development of future treatments for the facet joint. This study characterized the articular surfaces of cervical, thoracic, and lumbar facet cartilage from skeletally mature (18-24 mo) Yucatan minipigs. The minipig was selected as the animal model because it is recognized by the U.S. Food and Drug Administration (FDA) and the American Society for Testing and Materials (ASTM) as a translationally relevant model for spine-related indications. It was found that the thoracic facets had a ∼2 times higher aspect ratio than lumbar and cervical facets. Lumbar facets had 6.9-9.6 times higher % depth than the cervical and thoracic facets. Aggregate modulus values ranged from 135 to 262 kPa, much lower than reported aggregate modulus in the human knee (reported to be 530-701 kPa). The tensile Young's modulus values ranged from 6.7 to 20.3 MPa, with the lumbar superior facet being 304 % and 286 % higher than the cervical inferior and thoracic superior facets, respectively. Moreover, 3D reconstructions of entire vertebral segments were generated. The results of this study imply that structure-function relationships in the facet cartilage are different from other joint cartilages because biochemical properties are analogous to other articular cartilage sources whereas mechanical properties are not. By providing functional properties and a 3D database of minipig facet geometries, this work may supply design criteria for future facet tissue engineering efforts.

The value of magnetic resonance imaging and computed tomography in the study of spinal disorders

Computed tomography (CT) and magnetic resonance imaging (MRI) have replaced conventional radiography in the study of many spinal conditions, it is essential to know when these techniques are indicated instead of or as complementary tests to radiography, which findings can be expected in different clinical settings, and their significance in the diagnosis of different spinal conditions. Proper use of CT and MRI in spinal disorders may facilitate diagnosis and management of spinal conditions. An adequate clinical approach, a good understanding of the pathological manifestations demonstrated by these imaging techniques and a comprehensive report based on a universally accepted nomenclature represent the indispensable tools to improve the diagnostic approach and the decision-making process in patients with spinal pain. Several guidelines are available to assist clinicians in ordering appropriate imaging techniques to achieve an accurate diagnosis and to ensure appropriate medical care that meets the efficacy and safety needs of patients. This article reviews the clinical indications of CT and MRI in different pathologic conditions affecting the spine, including congenital, traumatic, degenerative, inflammatory, infectious and tumor disorders, as well as their main imaging features. It is intended to be a pictorial guide to clinicians involved in the diagnosis and treatment of spinal disorders.

Prevalence of symptomatic axial osteoarthritis phenotypes in Spain and associated socio-demographic, anthropometric, and lifestyle variables

OBJECTIVE

Axial osteoarthritis (OA) is a common cause of back and neck pain, however, few studies have examined its prevalence. The aim was to estimate the prevalence and the characteristics of symptomatic axial OA in Spain.

METHODS

EPISER2016 is a cross-sectional multicenter population-based study of people aged 40 years or older. Subjects were randomly selected using multistage stratified cluster sampling. Participants were contacted by telephone to complete rheumatic disease screening questionnaires. Two phenotypes were analyzed, patients with Non-exclusive axial OA (NEA-OA) and Exclusive axial OA (EA-OA). To calculate the prevalence and its 95% confidence interval (CI), the sample design was considered and weighting was calculated according to age, sex and geographic origin.

RESULTS

Prevalence of NEA-OA by clinical or clinical-radiographic criteria was 19.17% (95% CI: 17.82-20.59). The frequency of NEA-OA increased with age (being 3.6 times more likely in patients aged 80 s or more than in those between 40 and 49 years) and body mass index. It was significantly more frequent in women, as well as in the center of Spain. It was less frequent in those with a higher level of education. Lumbar OA was more frequent than cervical OA. This difference grew with increasing age and was not associated with gender. It was also greater in overweight and obese subjects.

CONCLUSIONS

This is the first study on the prevalence of axial OA phenotypes in Europe describing the associated socio-demographic, anthropometric, and lifestyle variables.

Distribution Patterns of Degeneration of the Lumbar Spine in a Cohort of 200 Patients with an Indication for Lumbar MRI

Lower back pain is one of the most common causes of a reduced quality of life. Magnetic resonance imaging (MRI) is the best suited imaging technique to detect causes of that pain. We retrospectively evaluated the MRIs of the lumbar spine for 200 patients in order to describe the distribution of signs of degeneration with regard to age, sex, and position of the disc affected. The number of spinal segments affected by degeneration increased with age, as did the number of signs of degeneration per segment. In patients aged between 21 and 30, 38.8% of discs were affected, while for patients aged between 51 and 60, 91.6% of discs were affected. There was no statistically significant gender difference. The lower two segments were most commonly affected by degeneration. The most common were structural changes to the discs, which affected 88.4% of patients over 50. Spondylosis was the most common bone-related change, found in 60.4% of patients over the age of 50. A reduction in disc height increases the likelihood of structural changes to the disc and bone-related changes. When investigating risk factors for developing disc-related diseases, the complex disc degeneration patterns described here should be taken into account.

CT guided minimal invasive oxygen ozone therapy in patients with degenerative changes of lumbosacral spine

Degenerative spine conditions involve the gradual loss of normal structure and function of spine over time. They are usually caused by aging, but may also be the result of tumors, infections or arthritis. Pressure on the spinal cord and nerve roots caused by degeneration can be caused by herniated discs. Degenerative disc disease is one of the most common causes of low back and neck pain, and also one of the most misunderstood ones. Low back pain (LBP) is a common disorder affecting an increasing number of people worldwide, whose diagnosis is focused on the identification of triggering causes. First line therapy usually starts from conservative approaches, whereas second line treatments include a spectrum of minimally invasive techniques, before resorting to more invasive surgical approaches. Among minimally invasive techniques, percutaneous oxygen-ozone injections represent one of the most common and cost-effective procedures. Oxygen-ozone therapy is a minimally invasive treatment for lumbar disc herniation that uses the biochemical properties of the gas mixture of oxygen and ozone. Intradiscal, periradicular or intraarticular ozone therapy is used in patients that do not respond to standard conservative therapies for low back pain due to degenerative disc-induced lumbar disc herniation (LDH) or other degenerative process of nearby structures such as zygapophyseal articulations. All the interventional procedures for low back pain may be guided by ultrasound, computerized tomography or fluoroscopy.

In vivo relationships between lumbar facet joint and intervertebral disc composition and diurnal deformation

BACKGROUND

Spinal motion is facilitated by a "three joint complex", two facet joints and one intervertebral disc at each spinal level. Both the intervertebral discs and facet joints are subject to natural age-related degeneration, and while these processes may be linked it is not clear how. As instability in the disc could underlie facet arthritis, we evaluated the hypothesis that the discs and facet joints are mechanically coupled.

METHODS

We recruited young, asymptomatic volunteers (n = 10; age: mean 25, range 21-30 years; BMI: mean 23.1, range 19.1-29.0 kg/m²) and applied magnetic resonance imaging (MRI) and three-dimensional (3D) modeling to measure facet and disc composition (MRI T1rho relaxation time) and facet and disc function (diurnal changes in facet space width, disc height) in the lumbar spine.

FINDINGS

We found that facet space width was positively associated with facet T1rho relaxation time (fluid content) and negatively associated with disc T1rho, and that facets adjacent to degenerated discs were significantly thicker and had significantly higher T1rho. Furthermore, the diurnal change in wedge angle was positively associated the diurnal change in facet space width, while disc degeneration, the diurnal change in disc height, and facet T1rho were not.

INTERPRETATION

These data demonstrate an interdependence between disc and facet health, but not between disc and facet mechanical function. Furthermore, the weak relationship between facet cartilage composition and in vivo function suggests that other factors, like spinal curvature, determine in vivo spine mechanics. Future work in symptomatic or aged populations are warranted to confirm these findings.

TELD with limited foraminoplasty has potential biomechanical advantages over TELD with large annuloplasty: an in-silico study

Background

Facetectomy, an important procedure in the in–out and out–in techniques of transforaminal endoscopic lumbar discectomy (TELD), is related to the deterioration of the postoperative biomechanical environment and poor prognosis. Facetectomy may be avoided in TELD with large annuloplasty, but iatrogenic injury of the annulus and a high grade of nucleotomy have been reported as risk factors influencing poor prognosis. These risk factors may be alleviated in TELD with limited foraminoplasty, and the grade of facetectomy in this surgery can be reduced by using an endoscopic dynamic drill.

Methods

An intact lumbo-sacral finite element (FE) model and the corresponding model with adjacent segment degeneration were constructed and validated to evaluate the risk of biomechanical deterioration and related postoperative complications of TELD with large annuloplasty and TELD with limited foraminoplasty. Changes in various biomechanical indicators were then computed to evaluate the risk of postoperative complications in the surgical segment.

Results

Compared with the intact FE models, the model of TELD with limited foraminoplasty demonstrated slight biomechanical deterioration, whereas the model of TELD with large annuloplasty revealed obvious biomechanical deterioration. Degenerative changes in adjacent segments magnified, rather than altered, the overall trends of biomechanical change.

Conclusions

TELD with limited foraminoplasty presents potential biomechanical advantages over TELD with large annuloplasty. Iatrogenic injury of the annulus and a high grade of nucleotomy are risk factors for postoperative biomechanical deterioration and complications of the surgical segment.

Spinal Care in the Aging Athlete

Aging athletes face unique, increased adversities related to increased mobility and age-related spine issues, such as spinal stenosis, osteoporosis complicated by fragility fractures, and degenerative disk disease. This article covers various spine pathologies that aging athletes experience and ideal treatment of this population to allow safe return to activity.

Preoperative facet joint arthropathy does not impact long-term clinical outcomes after lumbar-stability-preserving decompression and dynesys fixation

To evaluate the impact of the preoperative severity of facet joint arthropathy on long-term functional outcomes and spinopelvic parameters in patients undergoing lumbar-stability-preserving decompression and Dynesys fixation. In this retrospective study, 88 patients undergoing combined surgery at our hospital from 2008 to 2015 were included. The patients were divided into two groups, the less and more than mean degeneration groups, based on preoperative facet joint arthropathy of the index level(s). The clinical outcomes were the Visual Analogue Scale (VAS) score, the Oswestry Disability Index (ODI) score and spinopelvic parameters. The mean follow-up durations for the less and more than mean degeneration groups were 84.83 ± 27.58 and 92.83 ± 20.45 months, respectively. The combined surgery significantly improved VAS and ODI scores, and increased sacral slope (SS) regardless of preoperative arthropathy severity. In addition, facet joint arthropathy at adjacent levels continued to worsen after surgery in both arthropathy severity groups. Preoperative facet joint arthropathy did not influence most long-term clinical outcomes in patients undergoing lumbar-stability-preserving decompression and Dynesys fixation. This combined surgery may be suitable for patients with facet joint arthropathy regardless of disease severity.

The Diagnostic Value of an X-ray-based Scoring System for Degeneration of the Cervical Spine: A Reproducibility and Validation Study

Background

In interventional pain medicine, cervical facet joint (CFJ) pain is commonly treated with CFJ denervation techniques, almost automatically assuming degeneration of the CFJs as an important cause of CFJ pain. A standard cervical X‐ray is still commonly used in the clinical evaluation of patients suspected for CFJ degeneration. Although degenerative features can be visualized by different radiological imaging techniques, the relation between radiological degenerative features of the cervical spine and pain remains controversial. Paramount in order to estimate the clinical usefulness of a radiological imaging is to establish the reproducibility of the radiological scoring system. A reproducible and clinically feasible diagnostic scoring system was developed to estimate cervical degeneration on standard cervical X‐rays.

Materials and Methods

A reproducibility study for the interpretation of degenerative abnormalities on standard cervical X‐rays was performed, using a dichotomous outcome (degenerative abnormalities present Yes/No). The estimation of intervertebral disc height loss on standard cervical X‐rays was validated with computed tomography (CT) scan measurements.

Results

Five radiological degenerative features on standard cervical X‐rays (disc height loss, anterior vertebral osteophytes, posterior vertebral osteophytes, vertebral end plate sclerosis, and uncovertebral osteoarthritis) showed a substantial to excellent reproducibility (kappa value ≥ 0.60). The qualitative definition of disc height loss used in the reproducibility study showed a substantial agreement with the actual measurements of disc height loss on CT scan (kappa value = 0.69).

Conclusion

Subjective judgment of a cervical standard X‐ray is a reproducible method to demonstrate degenerative abnormalities of the cervical spine.

The Effectiveness of Radiofrequency Ablation of Medial Branch Nerves for Chronic Lumbar Facet Joint Syndrome in Patients Selected by Guideline-Concordant Dual Comparative Medial Branch Blocks

OBJECTIVES

Although the effectiveness of lumbar medial branch radiofrequency ablation (RFA) for the treatment of zygapophyseal joint (z-joint)-mediated low back pain has been characterized, few studies have described outcomes in patients selected using a guideline-concordant paradigm of ≥80% pain relief with dual comparative medial branch blocks (MBBs). We investigated long-term treatment outcomes of patients selected according to this paradigm.

DESIGN

Cross-sectional cohort study.

METHODS

The medical records of 111 consecutive patients were reviewed; 85 met inclusion criteria. A standardized telephone survey was used to capture current numerical rating scale (NRS) and Patient Global Impression of Change (PGIC) scores. The primary outcome was the proportion of patients reporting ≥50% reduction of index pain. Binary logistic regression analysis was performed to explore associations between the primary outcome and covariates, including age, duration of pain, presence of scoliosis, degenerative spondylolisthesis, and >75% disc height loss.

RESULTS

At six to 12, 12-24, and >24 months, 63.2% (95% confidence interval [CI] = 41-85%), 65.6% (95% CI = 49-82%), and 44.1% (95% CI = 27-61%) of patients reported a ≥50% pain reduction (P = 0.170), respectively. At a minimum of six months, 70.6% of patients reported a pain reduction of two or more points (minimally clinically important change), and 54.1% reported a PGIC score consistent with "much improved" or better. Older age and a smaller Cobb angle were associated with a ≥50% pain reduction (P < 0.05).

CONCLUSION

Lumbar medial branch RFA is an effective, durable treatment for a significant proportion of patients with recalcitrant lumbar z-joint pain when candidacy is determined by the guideline-concordant paradigm of ≥80% pain relief with dual comparative MBBs.

Intervertebral disc degeneration and regeneration: a motion segment perspective

Back and neck pain have become primary reasons for disability and healthcare spending globally. While the causes of back pain are multifactorial, intervertebral disc degeneration is frequently cited as a primary source of pain. The annulus fibrosus (AF) and nucleus pulposus (NP) subcomponents of the disc are common targets for regenerative therapeutics. However, disc degeneration is also associated with degenerative changes to adjacent spinal tissues, and successful regenerative therapies will likely need to consider and address the pathology of adjacent spinal structures beyond solely the disc subcomponents. This review summarises the current state of knowledge in the field regarding associations between back pain, disc degeneration, and degeneration of the cartilaginous and bony endplates, the AF-vertebral body interface, the facet joints and spinal muscles, in addition to a discussion of regenerative strategies for treating pain and degeneration from a whole motion segment perspective.

Facet Joint Replacement: Intermediate- and Long-Term Outcome in a Large Case Series

BACKGROUND

 The long-term outcome of facet joint replacement (FJR) still is to be proven.

METHODS

 We present a prospective case series of 26 (male-to-female ratio of 1:1; mean age: 61 years) patients undergoing FJR with a follow-up of at least 1 year (range: 12-112; mean: 67 months). Visual analog scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), and the 12-Item Short Form Health Survey (SF-12) were applied pre- and postoperatively (after 3, 6, and 12 months) as well as at the last follow-up (N = 24). Using X-rays of the lumbar spine (N = 20), the range of motion (ROM) and disk height in the indicator and adjacent levels were assessed.

RESULTS

 FJR was performed at L3/L4 (N = 7), L4/L5 (N = 17), and L5/S1 (N = 2). Mean VAS (mm) for back pain decreased from 71 to 18, mean VAS for right leg pain from 61 to 7, and from 51 to 3 for the left leg. Mean ODI dropped from 51 to 22% (for all p < 0.01). Eighty seven percent of patients were satisfied and pretreatment activities were completely regained in 78.3% of patients. Disk height at the indicator and adjacent levels and ROM at the indicator segment and the entire lumbar spine were preserved. No loosening of implants was observed. Explantation of FJR and subsequent fusion had to be performed in four cases (15.4%).

CONCLUSIONS

 In selected cases, long-term results of FJR show good outcome concerning pain, quality of life, preservation of lumbar spine motion, and protection of adjacent level.

Effect of facet-joint degeneration on the in vivo motion of the lower lumbar spine

Objective

This research studied the in vivo motion characteristics of the L3–S1 lumbar spine with facet-joint degeneration during functional activities.

Methods

Thirteen male and 21 female patients with facet-joint degeneration at the L3–S1 spinal region were included in the study. The L3–S1 lumbar segments of all the patients were divided into 3 groups according to the degree of facet-joints degeneration (mild, moderate, or severe). The ranges of motion (ROM) of the vertebrae were analyzed using a combination of computed tomography and dual fluoroscopic imaging techniques. During functional postures, the ROMs were compared between the 3 groups at each spinal level (L3–L4, L4–L5, and L5–S1).

Results

At L3–L4 level, the primary rotations between the mild and moderate groups during left-right twisting activity were significantly different. At L4–L5 level, the primary rotation of the moderate group was significantly higher than the other groups during flexion-extension. During left-right bending activities, a significant difference was observed only between the moderate and severe groups. At L5–S1 level, the rotation of the moderate group was significantly higher than the mild group during left-right bending activity.

Conclusions

Degeneration of the facet joint alters the ROMs of the lumbar spine. As the degree of facet-joint degeneration increased, the ROMs of the lumbar vertebra that had initially increased declined. However, when there was severe facet-joint degeneration, the ROMs of the lumbar spine declined to levels comparative to the moderate group. The relationship between the stability of the lumbar vertebra and the degree of facet-joint degeneration requires further study.

Relationship Between Endplate Defects, Modic Change, Facet Joint Degeneration, and Disc Degeneration of Cervical Spine

Objective

The “disc degeneration precedes facet joint osteoarthritis” hypothesis and multidimensional analysis were actively discussed in lumbar spine. However, in cervical spine degeneration, the multifactorial analyzes of disc degeneration (DD), Modic changes (Mcs), facet degeneration, and endplate degeneration (ED) is still limited. In this cross-sectional study, we aimed to analyze the prevalence and interrelationship of cervical DD parameters.

Methods

We retrospectively recruited 62 patients aged between 60 and 70 years. The disc height, segmental angle, ossified posterior longitudinal ligament (OPLL), ED, facet joint degeneration (FD), uncovertebral joint degeneration (UD), DD, spinal stenosis (SS), Mc, and cord signal change (CS) were evaluated using a previously well-known grading system.

Results

The prevalence of cervical degenerative parameters were DD (grade 1, 1.2%; grade 2, 13.3%; grade 3, 54.8%; grade 4, 19.0%; grade 5, 11.7%), OPLL (26.2%), SS (grade 0, 7.7%; grade 1, 42.3%; grade 2, 26.2%; grade 3, 23.8%), UD (39.1%), ED (normal, 69.0%; focal defect, 9.7%; corner defect, 11.7%; erosion, 6.9%; sclerosis, 2.8%), and FD (normal, 48.8%; narrowing, 27.0%; hypertrophied, 24.2%). The interrelationship of degenerative parameters showed close relation between UD, SS, DD, OPLL, Mc. ED, and CS has partial relation with degenerative finding. FD only has relation with UD, and Mc.

Conclusion

Our results may indicate that FD is a degeneration that occurs independently, rather than as a result of other degenerative factors.

Evaluation of facet joints and segmental motion in patients with different grades of L5/S1 intervertebral disc degeneration: a kinematic MRI study

PURPOSE

This study aimed to evaluate facet joint parameters and osteoarthritis grades, and segmental angular and translational motions among different grades of L5/S1 intervertebral disc (IVD) degeneration.

METHODS

This retrospective study analysed kinematic magnetic resonance imaging (kMRI) images of the lumbar spine of 214 patients with low back pain. Degenerations of the L5/S1 IVDs and facet joints osteoarthritis were assessed using the Pfirrmann and Pathria grading scales, respectively. Facet joint parameters included facet joint angle and facet joint space width. Angular and translation segmental motions were measured using MRI Analyzer software.

RESULTS

The mean age of the studied patients was 44.1 ± 13.9 years. Patients with L5/S1 disc degeneration were associated with higher odds of facet joint osteoarthritis (odds ratio = 2.28, 95% confidence interval = 1.23-4.23, P = 0.008). There was a positive correlation between L5/S1 disc degeneration grade and the facet joint grade (r = 0.365, P > 0.001). Grade IV facet joint osteoarthritis did not appear in grades I or II disc degeneration (P > 0.001). The average facet joint width decreased significantly with increasing Pfirrmann grading (P = 0.017). The difference in facet joint angle between groups was not statistically significant (P = 0.532). The differences in the angular and translational motions were not statistically significant (P = 0.530, and 0.510, respectively).

CONCLUSION

A positive correlation exists between L5/S1 disc degeneration and facet joint osteoarthritis grades. The facet joint space width decreases significantly with increasing grade of disc degeneration.

Percutaneous cement augmentation in the treatment of osteoporotic vertebral fractures (OVFs) in the elderly: a systematic review

Purpose

A systematic review, to study treatment effects for osteoporotic vertebral fractures (OVFs) in the elderly including all available evidence from controlled trials on percutaneous cement augmentation.

Methods

Primary studies, published up to December, 2019, were searched in PubMed and the Cochrane Library. Selected were all prospective controlled studies including patients > 65 years of age and reporting on at least one main outcome. Main outcomes were pain, disability and quality of life (QOL) 1 day post-intervention and at 6 months postoperatively. Excluded were meta-analyses or reviews, retrospective or non-controlled studies, case studies, patients’ groups with neoplastic and/or traumatic fractures and/or neurologically compromised patients.

Results

Eighteen studies comprising 2165 patients (n = 1117 percutaneous cement augmentation, n = 800 conservative treatment (CT), n = 248 placebo) with a mean follow-up of up to 12 months were included. Pooled results showed significant pain relief in favor of percutaneous cement augmentation compared to CT, direct postoperative and at 6 months follow-up. At 6 months, a significant difference was observed for functional disability scores in favor of percutaneous cement augmentation. When comparing percutaneous cement augmentation to placebo, no significant differences were observed.

Conclusion

This review incorporates all current available evidence (RCTs and non-RCTs) on the efficacy of percutaneous cement augmentation in the treatment of OVFs in the elderly. Despite methodological heterogeneity of the included studies, this review shows overall significant sustained pain relief and superior functional effect in the short- and long term for percutaneous cement augmentation compared to conservative treatment.

Graphic abstract

These slides can be retrieved under Electronic Supplementary Material.

Association between lumbar disc herniation and facet joint osteoarthritis

Background

This study was performed to investigate the association between lumbar disc herniation (LDH) and facet joint osteoarthritis (FJOA) using magnetic resonance imaging (MRI).

Methods

Between March 2012 and September 2018, a total of 441 segments from 394 patients with LDH were included in the study. LDH was classified according to the Michigan State University (MSU) classification, in which the degree of LDH is divided into 3 levels (expressed as 1, 2, and 3) and the location of LDH is divided into 4 zones (described as A, AB, B, and C). Bilateral FJOA was graded from 0 to 3 using the criteria introduced by Weishaupt et al., and bilateral facet orientations were measured on axial MRI slices. A mixed-effects ordinal logistic regression model was utilized to determine the potential factors that may be associated with FJOA, including sex, age, body mass index (BMI), segment, facet orientation and tropism, and the degree and location of LDH.

Results

In general, the prevalence of FJOA (grade ≥ 2) was 66.2% in LDH segments. For both the left and right sides, the degree of LDH was associated with the severity of FJOA (p < 0.01). Age and BMI were also associated with the severity of left and right FJOA (p = 0.002 and p < 0.001 for age, p < 0.001 and p = 0.003 for BMI, respectively), while segment, facet orientation, and facet tropism were not (p > 0.05 for all). Notably, MSU-B LDH was associated with greater odds of having more severe FJOA on the herniation side (left: p < 0.001, odds ratio (OR) = 2.714, 95% confidence interval (CI) = 1.583~4.650; right: p = 0.003, OR = 2.615, 95% CI = 1.405~4.870). However, other locations of LDH were not associated with the severity of FJOA (p > 0.05 for all).

Conclusions

Both the degree of LDH and MSU-B LDH are associated with the severity of FJOA. The association between LDH and FJOA highlights the complexity of the etiology of FJOA.

Selective local anesthesia versus corticosteroid infiltration on low back pain: a randomized clinical trial

ANTECEDENTS AND OBJECTIVE

Local infiltrations are second line therapy in the treatment of chronic low back pain, although their use is controversial in the literature. Our objective was to compare the effectiveness of 2 types of infiltration at the paravertebral lumbar level in two groups of patients diagnosed with low back pain: corticosteroids, and selective local anaesthetic administered using segmental neural therapy (SNT).

MATERIAL AND METHODS

Double-blind clinical trial in 55 patients diagnosed with low back pain in the neurosurgery department of the Hospital Central de la Defensa Gómez Ulla. Patients were randomised to 2 treatment groups to receive either paravertebral injections of corticosteroids or SNT. Outcomes were measured using a visual analogue scale, the Oswestry Disability Index, the Short Form-36, and patient satisfaction at the start of treatment (baseline) and at 3 and 12 months post intervention.

RESULTS

The combined treatment group showed a statistically significant improvement in Oswestry Disability Index at 3 months. The SNT group showed a statistically significant improvement in baseline visual analogue scale vs. visual analogue scale at 3 (1.398cm, p=0.001) and 12 months (0.791cm, p=0.007). No differences were observed in the remaining variables measured. The percentage of patients that would repeat the treatment was 81% and 83%, respectively.

CONCLUSIONS

Significant pain relief was achieved with SNT, and disability improved with the combined treatment. Although clinical improvement was limited, patients were satisfied. Local infiltrations should be considered as an alternative treatment for chronic low back pain.

CLINICAL TRIAL REGISTRATION

This clinical trial was registered at the European Union Clinical Trials Register with EUDRA-CT number 2015-001146-29.

Evaluation of MRI and CT parameters to analyze the correlation between disc and facet joint degeneration in the lumbar three-joint complex

Lumbar 3-joint complex degeneration is a multifactorial, pathological process. Previous studies included insufficient quantitative analyses to prove the relationship between disc degeneration and facet joint osteoarthritis (OA). We assessed the correlation between intervertebral disc and lumbar facet joint degeneration using computed tomography (CT) and magnetic resonance imaging (MRI) parameters.A total of 152 participants who underwent conventional MRI and CT in the clinostat position were included in this study. The presence of lumbar disc degeneration was identified using the Pfirrmann grading system, and the presence of lumbar facet joint degeneration was identified using the Weishaupt grading system. Facet tropism was defined as a divergence more than 7° between the facet joint angles of both sides at the same segment. The intervertebral disc heights were also measured.Most facet joint OA probably appeared at the segment with intervertebral disc degeneration of more than grade III. Facet joint OA was significantly exacerbated with the progression of disc degeneration grade. The intervertebral height significantly decreased with the progression of facet joint degeneration grades, except for grades 0 and 1.Our current study found that each individual joint degeneration influences the other 2 in the lumbar 3-joint complex. Facet tropism was significantly associated with lumbar disc degeneration. Narrowing of the intervertebral disc height probably aggravates the facet joint degeneration further at the same level.

Protective Effect of Alendronate on Lumbar Facet Degeneration in Ovariectomized Rats

Background

Facet joint degeneration (FJD) is a potential source of lower back pain, and estrogen deficiency can accelerate FJD. The present study aimed to investigate the effects of alendronate (ALN) on FJD induced by ovariectomy (OVX) in rats.

Material/Methods

Thirty female Sprague-Dawley rats underwent either bilateral OVX (n=20) or sham surgery (n=10). The OVX rats subsequently received either subcutaneous ALN (70 μg/kg/week) or vehicle for 12 weeks. Subchondral bone mass and microarchitecture were evaluated by micro-computed tomography. Cartilage degradation was evaluated by toluidine blue staining and histological scoring.

Results

Compared with the Sham group, the OVX group had significantly decreased bone mineral density, bone volume/trabecular volume, and trabecular thickness, significantly increased trabecular separation in subchondral bone, and significantly higher histological score for cartilage degeneration, particularly loss of cartilage thickness. ALN treatment significantly reversed the changes in subchondral bone, preserved cartilage thickness, and reduced the histological score. Immunohistochemical analyses showed significantly decreased expression of ADAMTS-4, MMP-13, and caspase-3 in the OVX+ALN group compared with the OVX group.

Conclusions

Treatment with ALN suppressed bone loss, subchondral bone architecture deterioration, and cartilage degeneration in OVX rats, which can be explained by roles of ALN in preservation of subchondral bone mass and microarchitecture, and counteraction of catabolism and chondrocyte apoptosis in cartilage.

Trends in lumbar radiofrequency ablation utilization from 2007 to 2016

BACKGROUND CONTEXT

Lumbar radiofrequency ablation (RFA) is an intervention used to treat facet-mediated chronic low back pain. In some studies with methods consistent with clinical practice guidelines, RFA results in improvements in pain and functional limitations. However, in other studies, RFA demonstrates limited benefit. Despite unanswered questions regarding efficacy of RFA, its use is widespread.

PURPOSE

To describe trends in the utilization and cost of lumbar RFA and lumbar facet injections.

STUDY DESIGN/SETTING

Retrospective cohort study.

PATIENT SAMPLE

The sample was derived from the IBM/Watson MarketScan Commercial Claims and Encounters Databases from 2007 to 2016.

OUTCOME MEASURES

Longitudinal trends in the distribution and quantity of lumbar facet injections before lumbar RFA, corticosteroid administration during lumbar facet injections, progression to lumbar RFA after lumbar facet injections, lumbar RFA utilization, and costs of these interventions.

METHODS

Two primary cohorts were identified from patients who received lumbar RFA or lumbar facet injection procedures. Utilization rates per 100,000 enrollees were determined for both cohorts. The mean, median, and interquartile ranges of the number of facets targeted and costs per procedure were calculated by year and laterality, as well as overall. Costs in 2018 dollars were estimated by summing gross payment totals from patients and insurance plans. This study was supported by funds from the NIH, and has no conflict of interest associated biases.

RESULTS

From 2007 to 2016, lumbar RFA sessions performed per 100,000 enrollees per year increased from 49 to 113, a 130.6% overall increase (9.7% annually). Lumbar facet injection use increased from 201 to 251 sessions per 100,000 enrollees, a 24.9% overall increase (2.5% annually). In the year after a lumbar facet injection, 26.7% of patients received lumbar RFA; 28.6% received another injection but not RFA; and 44.7% received neither. The number of patients receiving two lumbar facet injection procedures prior to lumbar RFA grew from 51.1% in 2010 to 58.8% in 2016. For lumbar RFA, the cost per 100,000 enrollees went from $94,570 in 2007 to $266,680 in 2016, a 12.2% annual increase. For lumbar facet injections, the cost per 100,000 enrollees went from $257,280 in 2007 to $396,580 in 2016, a 4.9% annual increase.

CONCLUSIONS

This analysis showed consistent growth in both the frequency and procedure cost of lumbar RFA and facet injections among a large, national, commercially insured population from 2007 to 2016.

Percutaneous transforaminal endoscopic discectomy in the treatment of senior patients with lumbar degenerative disc disease

The aim of the current study was to analyze the efficacy of percutaneous transforaminal endoscopic discectomy (PTED) in the treatment of lumbar degenerative disc disease for senior patients. The clinical and follow-up data of senior patients were retrospectively reviewed. Patients were divided into a PTED group and an open surgery group. Parameters were analyzed, including surgery time, intraoperative fluoroscopy time, intraoperative blood loss, postoperative complications, visual analog scale (VAS) and Japan Orthopedic Association (JOA) scores. Compared with the open surgery group, the surgery time and intraoperative blood loss were decreased, while the intraoperative fluoroscopy time was increased, in the PTED group (P<0.001). Significant improvements in VAS and JOA scores were identified within both groups from preoperative to 12 months following surgery (P<0.001). VAS and JOA scores were significantly improved in the PTEN group compared with the open surgery group at 1 week after surgery (P<0.001), but there was no significant difference between groups prior to and at 12 months following surgery. The incidence of venous thrombosis of the lower extremities in the PTED group was decreased compared with the open surgery group (P<0.05). In the open surgery group, patients suffered from multiple postoperative complications, including constipation, urinary system infection, wound infection, gastrointestinal hemorrhagic stress ulcer, pneumonia, pulmonary embolism, mortality following myocardial infarction, mortality following cerebral infarction, and hemiplegia following cerebral hemorrhage. By contrast, patients in the PTED group did not experience any of these complications. In conclusion, PTED resulted in reduced trauma and a lower incidence of severe complications compared with open surgery, which suggests that PTED is a safe and effective minimally invasive surgery for senior patients with lumbar degenerative disc disease.

A longitudinal study of disc height narrowing and facet joint osteoarthritis at the thoracic and lumbar spine, evaluated by computed tomography: the Framingham Study

BACKGROUND CONTEXT

Prevalence and progression of disc height narrowing (DHN) and facet joint osteoarthritis (FJOA) in the thoracic and lumbar regions in non-clinical populations are not well established.

PURPOSE

The present study aimed to use computed tomography (CT) images to determine the prevalence and progression of DHN and FJOA according to age, sex, and spinal region.

STUDY DESIGN

This is a 6-year longitudinal study.

SAMPLE

A total of 1,195 members of the Framingham Study (mean baseline age 61±9 years) were included in the study.

OUTCOME MEASURES

We compared the prevalence and progression (new or worsening) of moderate-to-severe DHN and FJOA by age, sex, and spinal region.

METHODS

A musculoskeletal radiologist evaluated DHN and FJOA from T4/T5 to L4/L5 on baseline and follow-up CT images using a semi-quantitative scale: 0=normal, 1=mild, 2=moderate, and 3=severe.

RESULTS

One-third or more of women and men ages 40-59 years at baseline had imaged-based evidence of prevalent DHN, more than half had prevalent FJOA, and DHN and FJOA prevalence increased approximately two- to fourfold in those age 60-69 and 70-89 years at baseline, respectively (p<.01). Progression of DHN and FJOA occurred more frequently at the lumbar than at the thoracic spine and more in women than in men (DHN: odds ratio [OR]=1.42, 95% confidence interval [CI]=1.07, 1.88; FJOA: OR=1.70, CI=1.33, 2.17).

CONCLUSIONS

Prevalence and progression of moderate-to-severe DHN and FJOA are common in non-clinical populations of older adults. The high frequency of spinal degeneration observed on CTs in this community-based study may contribute to challenges in interpreting the clinical significance of imaging evidence of DHN and FJOA. Future studies investigating the association of CT-based spinal degenerative features with pain and functional impairments in population-based samples are needed to help determine the clinical significance of imaged-based findings of DHN and FJOA.

The Effect of Pain Relief on Daily Physical Activity: In-Home Objective Physical Activity Assessment in Chronic Low Back Pain Patients after Paravertebral Spinal Block

This study evaluates the effect of paravertebral spinal injection (PSI), utilizing both subjective and objective assessments in chronic low back pain (LBP) associated with facet joint arthrosis over a one-month duration. Subjective questionnaires included the visual analogue scale (VAS) for pain, the Oswestry Disability Index, the Health Survey SF-12, and the short Falls Efficacy Scale International (FES-I). Objective assessments included in-clinic gait and Timed Up and Go (TUG) tests using wearable sensors, as well as 48 h daily physical activity (DPA) monitored using a chest-worn triaxial accelerometer. Subjective and objective measures were performed prior to treatment, immediately after the treatment, and one month after the treatment. Eight LBP patients were recruited for this study (mean age = 54 ± 13 years, body mass index = 31.41 ± 6.52 kg/m², 50% males). Results show significant decrease in pain (~55%, p < 0.05) and disability (Oswestry scores, ~21%, p < 0.05). In-clinic gait and TUG were also significantly improved (~16% and ~18% faster walking and shorter TUG, p < 0.05); however, DPA, including the percentage of physical activities (walking and standing) and the number of steps, showed no significant change after PSI (p > 0.25; effect size ≤ 0.44). We hypothesize that DPA may continue to be truncated to an extent by conditioned fear-avoidance, a psychological state that may prevent increase in daily physical activity to avoid pain.

Facet joint syndrome: from diagnosis to interventional management

Abstract

Low back pain (LBP) is the most common pain syndrome, and is an enormous burden and cost generator for society. Lumbar facet joints (FJ) constitute a common source of pain, accounting for 15–45% of LBP. Facet joint degenerative osteoarthritis is the most frequent form of facet joint pain. History and physical examination may suggest but not confirm facet joint syndrome. Although imaging (radiographs, MRI, CT, SPECT) for back pain syndrome is very commonly performed, there are no effective correlations between clinical symptoms and degenerative spinal changes. Diagnostic positive facet joint block can indicate facet joints as the source of chronic spinal pain. These patients may benefit from specific interventions to eliminate facet joint pain such as neurolysis, by radiofrequency or cryoablation. The purpose of this review is to describe the anatomy, epidemiology, clinical presentation, and radiologic findings of facet joint syndrome. Specific interventional facet joint management will also be described in detail.

Teaching points

• Lumbar facet joints constitute a common source of pain accounting of 15–45%.

• Facet arthrosis is the most frequent form of facet pathology.

• There are no effective correlations between clinical symptoms, physical examination and degenerative spinal changes.

• Diagnostic positive facet joint block can indicate facet joints as the source of pain.

• After selection processing, patients may benefit from facet joint neurolysis, notably by radiofrequency or cryoablation.

Wnt/β-catenin Signaling in Osteoarthritis and in Other Forms of Arthritis

PURPOSE OF REVIEW

Arthritis defines a large group of diseases primarily affecting the joint. It is the leading cause of pain and disability in adults. Osteoarthritis (OA) affecting the knee or hip is the most common form among over 100 types of arthritis. Other types of arthritis include erosive hand OA, temporomandibular joint (TMJ) OA, facet joint OA, diffuse idiopathic skeletal hyperostosis (DISH), and spondyloarthritis (SpA). However, the specific molecular signals involved in the development and progression of OA and related forms of arthritis remain largely unknown. The canonical wingless/integrated (Wnt)/β-catenin signaling pathway could play a unique role in the pathogenesis of arthritis. In this review article, we will focus on the molecular mechanisms of Wnt/β-catenin signaling in the pathogenesis of OA and other types of arthritis.

RECENT FINDINGS

Emerging evidence demonstrates that Wnts and Wnt-related molecules are involved in arthritis development and progression in human genetic studies and in vitro studies. Also, mouse models have been generated to determine the role of Wnt/β-catenin signaling in the pathogenesis of arthritis. Wnt/β-catenin signaling represents a unique signaling pathway regulating arthritis development and progression, and the molecules in this particular pathway may serve as targets for the therapeutic intervention of arthritis. Mediators and downstream effectors of Wnt/β-catenin signaling are increased in OA as well other forms of arthritis, including DISH and SpA. Through extensive investigations, including pre-clinical studies in transgenic mice and translational and human studies, the Wnt/β-catenin signaling pathway has been proven to play roles in bone and joint pathology by directly affecting bone, cartilage, and synovial tissue; further, these pathologies can be reduced through targeting this pathway. Continued investigation into the distinct molecular signaling of the Wnt/β-catenin pathway will provide additional insights toward the therapeutic intervention in arthritis.

Facet Joints of the Spine: Structure–Function Relationships, Problems and Treatments, and the Potential for Regeneration

The zygapophysial joint, a diarthrodial joint commonly referred to as the facet joint, plays a pivotal role in back pain, a condition that has been a leading cause of global disability since 1990. Along with the intervertebral disc, the facet joint supports spinal motion and aids in spinal stability. Highly susceptible to early development of osteoarthritis, the facet is responsible for a significant amount of pain in the low-back, mid-back, and neck regions. Current noninvasive treatments cannot offer long-term pain relief, while invasive treatments can relieve pain but fail to preserve joint functionality. This review presents an overview of the facet in terms of its anatomy, functional properties, problems, and current management strategies. Furthermore, this review introduces the potential for regeneration of the facet and particular engineering strategies that could be employed as a long-term treatment.

A Study of Lumbar Disc Herniation and Facet Joint Asymmetry

Purpose:

To investigate the association of facet joint asymmetry with lumbar disc herniation at the lower lumbar spine.

Methods:

A total of 90 patients (ages 18–40 years) with single-level disc herniation (L3–L4, L4–L5, or L5–S1) were included in the study. Facet asymmetry was defined as a difference of 10° in facet joint angles between right and left sides. Normal discs in the same segment of other individuals were used as a control. Patients had facet asymmetry measured for L3 to S1 through 3.0T magnetic resonance imaging, and information was collected, including age, sex, degenerative degree of lumbar facet joints, and the presence or absence of lumbar disc herniation and type.

Results:

At the L3 to L4 level, 2 cases had facet asymmetry in 8 patients with lumbar disc herniation, compared with 17 cases of facet asymmetry in 82 patients without disc herniation (P = 0.7776, r = 0.030). At the L4 to L5 level, there were 21 cases of facet asymmetry in 45 patients with lumbar disc herniation, compared with 5 cases of asymmetry in 45 patients without disc herniation (P = 0.00019, r = 0.392). At the L5 to S1 level, there were 25 cases of facet asymmetry in 37 patients with lumbar disc herniation, compared with 11 cases of facet asymmetry in 53 patients without disc herniation (P = 0.0000, r = 0.492). There were 23 cases of facet asymmetry in 28 disc herniations of side type compared with 2 cases of facet asymmetry in 9 herniations of center type (P = 0.0008, r = 0.364). There was no significant difference in the relationship between age, facet joint degeneration, and lumbar facet joint asymmetry (P &gt; 0.05).

Conclusion:

Facet asymmetry is significantly associated with lumbar disc herniation at the L4 to L5 and the L5 to S1 levels, whereas there is an obvious association with the side type of lumbar disc herniation at the L5 to S1 level.