Degenerative posterior elements ECNR2020
10/11/2020
degenerative posterior elements
L. van den Hauwe
J.W. Van Goethem, P.M. Parizel T. Van Thielen, S. Dekeyzer, S. Vanden Bossche, S. Nicolai, E. De Smet, D. Cools
Antwerp University Hospital - University of Antwerp, Antwerp/BE AZ KLINA, Brasschaat/BE
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no financial disclosures
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overview
? background ? facet joints: `facet 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
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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
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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 medical costs per capita 1,842/person
Tessitore E et al. Eur J Radol 2015;84:765-770
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background ? low back pain
? discogenic pain ? facet syndrome
non-specific LBP
? tend to occur separately ? only 3% had concordant pain on discography and pain relief after facet
joint injection
Schwarzer E et al. Eur J Radol 2015;84:765-770
? other causes: "red flags"
? infection, metastasis, vertebral fracture, ...
Tessitore AC et al. Spine 1994;19:801-806
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pain generators
? anterior spinal column: intervertebral disc
discogenic pain
? posterior elements
? facet joints & ligamentum flavum
? pedicles & pars interarticularis: spondylolysis
? spinous processes & interspinous ligaments
? sacroiliac joints
? transitional lumbosacral segments Kotsenas AL. Radiol Clin N Am 2012; 50:705-730
facet syndrome
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pain generators
? anterior spinal column: intervertebral disc
all may be sources of axial back pain and radicular symptoms
? 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
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background - anatomy
? 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
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biomechanical pathofysiology
chronic overload (scoliosis, trauma, ...)
degenerative disc disease: disc space narrowing
segmental instability ? increased loading of facet joints
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biomechanical pathofysiology
chronic overload (& scoliosis, trauma, ...)
degenerative disc disease: disc space narrowing
segmental instability ? increased loading of facet joints
Osteoarthritic changes ? subluxation ? spondylolisthesis
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biomechanical pathofysiology
chronic overload (& scoliosis, trauma, ...) degenerative disc disease: disc space narrowing segmental instability ? increased loading of facet joints
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biomechanical pathofysiology
chronic overload (& scoliosis, trauma, ...)
degenerative disc disease: disc space narrowing
segmental instability ? increased loading of facet joints
osteoarthritic changes ? subluxation ? spondylolisthesis
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biomechanical pathofysiology
chronic overload (& scoliosis, trauma, ...)
degenerative disc disease: disc space narrowing
segmental instability ? increased loading of facet joints
osteoarthritic changes ? subluxation ? spondylolisthesis
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patient with low back pain
adequate treatment is only possible if a correct diagnosis is made
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what's the problem...?
? unawerenesss of radiologists and referring clinicians: "what's wrong with the disc?"
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? 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
for a long time ? ever since, the role of the facet joints in evaluating
patients with LBP and sciatica has been underestimated
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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%
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asymptomatic populations
Brinjikji W et al. AJNR Am J Neuroradiol 2015;36:811-816
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