THE
LUMBAR
CLINICAL
FACET
PRESENTATION
AND
S. M.
From
We describe normal
plain
surfaces
large
Local
of the histological
The most
aged
The
clinical Facet
spinal
change
the patients and normal
and
histological may
the
these
arthrosis
aggravated
low-back
with
symptoms
disabling radiographs. there
In
in any
relieved Rising
range
posture,
by pain
and
implies
in many low
are
Requests
for
of
the
at
least
two
and
in osteoarthritis
or loss of cartilage
in all specimens. arthrosis syndrome
of intractable
may
or
have
called
need
to be up and
in
of pain; and the aimed to in the
joints
back
be
of
with
exposure
of
We suggest that there and chondromalacia
pain
Oswestry,
Johannesburg, for reprints
No.
South should
pain
is
in young
and middle-
with known presentation
Editorial 1 $2.00
1, JANUARY
Society
spinal
as
provide
physical activity pain is commonly flexion. Backward bending
little
is usually
or no pain.
Jones
& Agnes
We
Hunt
England.
School,
York
Africa. S. M. and
Joint
Eisenstein. Surgery
bending
Road,
altering
pain. is recognisably
similar
inflammatory
arthritis
In this
forgotten
who
of their posture
in
to that in
seen other
minor
by pain
the
result
injuries.
some of
for this syndrome a similar pattern
helpful in both investigation,
be
found
syndrome confusion.
segment time.
in
may fail in more Both
pain
pain
two
patient.
patterns
in the lower
patterns treatment of both
The and
fact
than
may than
spondylolysis, and signs
conservative but elements
one
of long-
pattern
instability
is symptomatic of symptoms
must be recognised It reflects the
or
the
have failed in practical 1985). One clinical
the ununited fracture. The differentiation of these
tant and operative
fits
or strain
clinical
of lumbar
more objective definitions which clinical application (Nachemson model which
description
sprain
unrecognised
This
definition
the
by rest the day.
and characterised
This
had
the
by contrast,
pain is relieved throughout
movements.
have
tissues,
a better
syndrome,
whose increases
is restricted
or jerking
soft
referred 1987
instability.
patients
may
Fellow Medical
of Bone
or
because
or constantly
disease of the spinal synovial joints, may be much as described above.
by swaying
continuous gentle is difficult because of
Robert
to Mr
the “uppers”
about
synovial joints, including the hip, knee and those of the hand. Ankylosing spondylitis in its early stages provides one clinical model for this syndrome ; in a young adult
those
recumbency,
Salop SY1O 7AG,
be sent
patients
degenerative
Forward
with
FRCS, Director Disorders, The
these
to reduce their This type of pain
Lumbar
including
character,
PhD, Spinal
Hospital,
1987 British 0301-620X/87/lOl
69-B,
facet
order
back pain We suggest
syndrome
; forward
BSc (Hons), Research of the Witwatersrand
©
VOL.
patellae
patients are “downers”, and recumbency and
this
by repeated in the morning
is restricted
Eisenstein,
Parktown,
are associated with normal or nearin 12 patients; the excised facet joint
necrosis
absent
cause
from
CR. Parry, University
symptoms
in chondromalacia
between
SYNDROMES
syndrome.
by rest
of normal
Department Orthopaedic
Witwatersrand
cartilage
important
pain”
changes
pain and stiffness, which ease increases. When rest is unavoidable, reduced by a position of lumbar
SM.
R. PARRY
was remarkably
similarities
of the lumbar facet arthrosis syndrome.
PAIN
bending
seen
full-thickness
be a relatively
pathological
patients,
cartilage to the facet
and is movement.
relieved
changes
syndromes, each with a recognisable pattern these are the “facet arthrosis syndrome” “instability syndrome”. Our investigation provide evidence that pathological changes
Facet
disabling
formation
arthrosis
who present or near-normal
among
articular related
in which fusion
was focal
but osteophyte
“non-specific
to establish
that,
of the
CHANGES
adults.
designation
failure
frequent
bone,
both
University
syndrome
some
C.
SURFACE
joints.
subchondral patellae.
facet
SYNDROME
ARTICULAR
EISENSTEIN,
the
radiographs.
showed
other
are
a lumbar
ARTHROSIS
not that
limbs,
be
is imporand prepatterns
“combination” allowed to cause an intervertebral
one of its parts
may
in result
associated
but this can
at the same with
readily
some
be 3
4
SM.
distinguished nerve
from
root
We
the major
disabling
pain
EISENSTEIN.
produced
by
compression.
have
arthrosis pathological
investigated
syndrome changes.
in
12 patients an
with
attempt
to
the
relate
facet this
AND
Nine
All had
were
had
before
failed
had
referral,
symptoms
and
to respond
1 1 women
and
spinal
operations
: one
man
for
with
the
decrease
in the joint
facet joints. Mild reduction was seen at one or more patient
had
a lumbar
Osteophytosis associated
space
lumbar
of the lumbosacral
facet
joints,
“spondylosis”,
not
Facetjoints.
There
way as those of the patients. It whether or not these subjects
was
articular cartilage The most frequent
some
in the finding
evidence
ofearly
damage
but we also saw ulceration, (Figs 1 to 4). We suspect
cartilage necrotic
is the
“ulcer” cartilage.
increased
to
facet joints of all I 2 patients. was a focus of full-thickness
cartilage necrosis, and eburnation
result
clusters,
fibrillation that the
of sloughing
of a plug
of
foci of fibrocartilage
(Fig.
metachromasia
provided
perichondrocyte
5)
evidence of repair. The only noteworthy change in the subchondral bone was early subchondral cyst formation (Fig. 2). No specific part of the facet surface appeared to
a
be particularly osteophyte
commonly
was
Death had occurred at and the specimens were
RESULTS
and
spine
scoliosis.
lumbar
been studied
material without too much low lumbar facet joints were cadavers whose kidneys were
for transplantation. from 17 to 48 years
Chondrocyte
and
of intervertebral disc height levels in six patients, and one
of the lumbar
with
necessarily not be
control
the fresh
12
ages
an L5 laminectomy of
had could
for
three
were helpful only in excluding other causes of backache. In four patients they were normal, in three there was detectable
some
to conservative
one
one a lumbosacral discectomy. Investigations. Plain radiographs
capsules and
examined in the same could not be established had suffered backache.
ranging from 24 to 60 years. The average age was 40; only one patient was under 30 and one over 50. Pain and tenderness were localised to the general area of the lumbosacral junction in all cases. Two patients had had previous
To provide
being taken ages ranging
treatment given for an average of four months after referral. Four patients had some lower limb pain but of a lesser degree than their low back pain.
There
facet joint or destroyed
histologically.
METHODS
of the patients
of 1 5 months
to 20 years.
blue. The damaged
to
Of a very large number of patients seen for low back pain, 12 patients with characteristic facet arthrosis syndrome and significant disability were fully investigated.
PARRY
postmortem change excised from four
PATIENTS
an average
CR.
involved formation
The
and, in any
common
feature
exposure of subchondral else potentially present cartilage
there
was
no
of
all
specimens
was
the
bone, sometimes in an ulcer, in an area of full-thickness
or
necrosis.
The
seen.
strikingly, specimen.
control
specimens
were
completely
normal
in
Computerised tomography failed to show any additional pathological change in the facet joints and showed no other segmental sources of pain. More specific localisation of the cause of symptoms was
three subjects aged 17, 17 and 26 years, but old man killed in a motor vehicle accident surface fibrillation of the articular cartilage
in a 48-yearthere was and minor
peripheral
facet
achieved
palpation
without
by radio-
Clinical
by facet
for points graphs
arthrography
of maximum
with
skin
or by diligent
tenderness
markers.
followed
Arthrography
was
considered
provided
Several and
by
subsequent
of the patients
discography
infiltration
had negative
in the
search
with
lumbar
for
other
causes
12 patients had posterolateral and fusion operations. Both L4-5 and L5-Sl in seven patients, L5-Sl alone in four
while
fusion
from
instrumentation with progressive
L2
to
the
pain at the lumbosacral junction. During the operations the facet joints
and
preserved
stained
cut
for
perpendicular with
either
histological
to the haematoxylin
sacrum
with
was required for a 32-yearscoliosis and intractable
facet
examination.
plane and
relief
were
excised Sections
of the joint eosin
in an
but
joints,
necrosis.
required revision of his all patients achieved
average
of
3.5
months
after
we found
have
DISCUSSION
of their
All
Harrington old woman
pain
lumbar
cartilage
lignocaine.
Many
patients,
were
gratifying
all
focal
operation.
myelography
pain.
Operation. intertransverse were fused
in
of any
results. One patient for pseudarthrosis,
fusion
to be positive only when the injection reproduced some or all of the usual symptoms, and when some relief was
osteophytosis evidence
and
or toluidine
been
of the histological described
changes
in classic
and
which
standard
texts
as those
of
osteoarthritis or arthritis Leubner 1936 ; Oppenheimer
deformans (Ayers 1935; 1938 ; Badgley 194 1 ; Putti
and
1964;
Logr#{244}scino 1952;
Lewin
Schmorl
and
Jungh-
anns 1971 ; Vernon-Roberts 1980). All these studies are anatomical descriptions only and therefore cannot relate the abnormalities to the causes of low back pain. Ayers (1935) describes what is probably of a lumbar facet joint excised histology degeneration.
suggests
THE
the first examination at operation, but
inflammation
JOURNAL
OF BONE
rather
AND
JOINT
the than
SURGERY
THE
LUMBAR
FACET
ARTHROSIS
5
SYNDROME
I.. Fig.
I.
4
Histological sections of facet joints excised from patients with facet arthrosis syndrome. Figure 1 - Full-thickness cartilage necrosis, between the short arrows. This shows lighter staining and no viable chondrocytes. There is some separation at the cartilage-bone junction (long arrow) and the space is filled with exudate (toluidine blue, x 7). Figure 2 - An articular cartilage ulcer which exposes bone. This is presumed to represent a stage beyond the “necrosis-in-situ” in Figure 1. An early cyst in subchondral bone is arrowed (toluidine blue, x 3). Figure 3 - A fibrillation cleft with adjacent cartilage necrosis down to bone. Chondrocyte clusters are arrowed (toluidine blue x 1 2). Figure 4 To show grooved eburnation exposing subchondral bone. A fibrocartilaginous plug (between arrows) fills a cyst (toluidine blue x 3). Figure 5 - Full-thickness fibrocartilage (between arrows) at the edge of an ulcer which exposes subchondral bone (toluidine blue, x 12).
Fig. 5
These
tosis
studies
or bony
pathology
do,
however,
spurring
of osteoarthritis.
appear
to
have
been
all emphasise
as an important A finding described
osteophy-
feature which
previously
of the does
not
is the
full-
thickness “necrosis-in-situ” shown in Figure 1 but this is not associated with osteophytes and resembles the “intermediate stage destruction” which Meachim (1980) ,
reported “basal ford
in his study degeneration”
and The
Woods atrophic
of excised described
of our relatively which is currently
VOL.
No.
I, JANUARY
1987
heads,
by Goodfellow,
(1976) in chondromalacia features we found
cartilage question 69-B,
femoral
young exercising
in
and
the
Hungerpatellae. the articular
patients raises the the minds of those
engaged fellow
Ct
in the study of chondromalacia al. 1976; Insall 1982; Bentley
Bentley
1985):
course
of
bridge
1961)
There
are
whether
“classic”
this
is merely
spondylotic
or a peculiarly
similarities
patellae (Goodand Dowd 1984;
chondrocyte
fellow
et al. 1976)
both with
clusters but also
in the
osteoarthritis symptomatic
between
the
syndrome and chondromalacia patellae. ties are found not only in the histological thickness cartilage necrosis, separation
bone,
a stage
and
facet
of it.
arthrosis
These similarichanges of fullof cartilage from
metachromasia
in the clinical
conditions relatively young severe disability from pain,
(Outervariant
(Good-
presentation;
patients associated
in
may present with local
6
SM.
tenderness As
in
between
and normal chondromalacia
the
plain
histology
the
to the physical have only
changes
proposed to confer
patients arthritis”
which
the term a degree
who do not and are
the
relationship
symptoms
arthrosis is not clear. Clinicians may the degree of pain in both conditions
in
facet
feel intuitively is disproportionate
that
can be demonstrated.
“chondromalacia of respectability
qualify sometimes
for
CR.
PARRY
that
radiographs. patellae,
and
EISENSTEIN,
We
facetae”, if upon those
a diagnosis unjustly
increased
sensitive cartilage, (1976),
minor
psychologically suspect. Fifty years ago Hugo Leubner (1936) appealed to colleagues to consider a diagnosis of “early arthritis deformans” in patients presenting with low back pain but normal radiographs. We suggest that this appeal is now supported by a link between symptoms
possible relatively subchondral
causes
described conjectured variations
for
the
articular
changes
we
have
for
opposite
predisposition. It is possible that asymmetric angulation of left and right facet joints could produce stresses sufficient to cause early articular cartilage injury, but
the
presence
and
osteophytosis.
situation
syndromes”
of
are
advanced
also
conjectural.
of pressure
have
been
joint
Explanations
loss of cartilage of joint pressure less pain than
ing from high concentrations small areas of cartilage loss.
“Facet
to pain-
changes confined to articular by the fact, well known to that many patients present with
that widespread even diffusion bone, producing
It is
allows a into the that result-
acting
described
through
previously,
but with different features on each occasion. Ghormley (1933) pioneered the association of low back pain with radiographic evidence of advanced degenerative changes
in
between
the
facet
arthritis
with some symptomatic
are obscure, but no less so than those for chondromalacia patellae, which include of normal biomechanics, trauma and genetic
in
sclerosis
this
is transmitted
bone through foci of necrotic for the patella by Goodfellow et al. Any attempt to explain major pain
symptoms
destruction,
The
pressure
by relatively minor cartilage is confronted clinicians in this field,
of “spinal classified as
and pathology. We also suspect that a similar syndrome may present in the thoracic spine, that it can be distinguished from myofascial pain and that it may similarly require spinal arthrodesis if other treatment fails.
joint
subchondral as described is plausible.
joints.
He
and instability,
diffidence, relief.
that Mooney
did
not
distinguish
but ventured
to suggest,
arthrodesis Robertson
produced (1976) also
spinal and
failed to make this distinction but contribution by describing joint injection cation of symptomatic facet joints and
made a major for the identififor treatment of
pain.
asymmetry was not a prominent feature in our patients and yet is so common (Badgley 1941) that it may be considered to be a variation of normal anatomy. Putti (1927) originally described these anomalies of facet
Our patients to local infiltration
most closely described
resemble the “responders” by Fairbank (1981) except
that
experienced
more
angulation
relief
and
as a possible
sciatic
pain
rather
of an intervertebral increased pressure
it (Dunlop, 1984)
but
normal
than
of nerve low back
disc can be on the facetjoint
Adams in most
height
cause
and
Hutton
of our
or only
root pain.
Loss
expected surfaces
1984;
patients
the
slightly
disc
reduced.
obvious
argument
against
spaces
We
King were
found
of
little
facet joints, described
an attempt
minor changes in articular surfaces symptoms is that these changes are
of height
and
patients
compression with
(lumbar
joint
surfaces
to relate
to major pain probably almost
For
a
patient
conservative fusion, levels
diagnosis is crucial.
more than degeneration
arthrographic
donors
available
low
pain,
accurate fall back
that the
history on the
of spinal findings
subjects under vast majority
arthritic
The changes
and
no
pain is available. We have to of Putti and Logr#{244}scino (1952)
30 years of age had normaljoints of those under 40 had only
and mild
changes.
mechanism may
produce
whereby pain
is not
these known.
of
secondary
confirmation
and spine
in
by
pain
is facing
refractory
operation
to
for spinal level offers
or no
described
by Dory
(1981)
but
provide
useful
importance of a positive
pain
may
response.
CONCLUSIONS back
joints, surfaces affected
links
between
localisation
histological and clinical
of the
surface
The
a matter
a clinical source
abnormalities reliefobtained
syndrome of pain
in the through
of
in facet
excised fusion
joint of the
segments.
The causes for the facet unknown and the association
pathological concept
who
abnormalities
described
adults
(lumbar
while invasive and painful, remains the best preoperative investigation by virtue of the provocation of pain in the affected joints (Park and McCall, personal communication 1976; Fairbank et al. 1981). The
We have
young
joints
plain radiographs, unless there is advanced (Carrera et al. 1980). Facet arthrography,
are
are
their
of the responsible segmental Computerised tomography
in middle-aged adults yet few have disabling pain. The purpose ofour limited study of cadaver was to attempt to discover if the described changes were indeed universal. The results so unsatisfactory; most of the few renal transplant
study
with
in extension),
separated
disabled
measures
universal lumbar material articular far are
for
pain
spine
flexion).
to produce posterior to
Yang
change in the subchondral bone of the certainly nothing like the patellar osteoporosis by Darracott and Vernon-Roberts (1971).
The
compression
our
under
changes
and
pain
joint abnormalities between these
has not been
proved
remain articular ; it remains
of conjecture. THE
JOURNAL
OF BONE
AND
JOINT
SURGERY
THE
At as
to
this
stage,
whether
the
it is facet
impossible
to
syndrome
(“chondromalacia facetae”) arthrosis, or merely a stage
LUMBAR
we
is a distinct (possibly
be
FACET
ARTHROSIS
Fairbank JC, Park WM, McCall 1W, O’Brien JP. Apophyseal injection of local anaesthetic as a diagnostic aid in primary low-back pain syndromes. Spine 1981 ;6:598-605.
dogmatic
have
described
non-osteophytic reversible) in the
progression of age-related hypertrophic osteoarthritis. It is important that the condition should be recognised so that patients who are disabled by the syndrome may receive appropriate treatment rather than be considered neurotic.
Ghormley RK. Low back with presentation 1933;lOl :1773-7.
Goodfeilow J, mechanics
excellent and
translation
to Ms
by J. Hart
Dolores
Rokos
of the paper
for
the
by Putti
Lewin
and Logr#{244}scino,
illustrations.
concepts :147-52.
T. study.
Meachim
Osteoarthritis Ada Orthop C. Ways
rosis.
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