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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