CLINICAL
LUMBAR
PRESENTATION
FACET
AND
ARTHROSIS
ARTICULAR
SYNDROME
SURFACE CHANGES
S. M.
EISENSTEIN,
C.
R. PARRY
From
the
University
of the
Witwatersrand
facet Local
syndrome spinal
disabling
seen
symptoms
radiographs.
relieved
symptoms
are associated with normal or nearin 12 patients; the excised facet joint
patellae and in osteoarthritis with exposure of of
The most
or loss of cartilage
subchondral
are aged both adults. patellae.
bone,
clinical Facet
but osteophyte
and
formation
similarities be a relatively
was remarkably
between important
absent
arthrosis
of intractable
The
failure
designation
to establish
non-specific
the pathological with who present or near-normal these
low-back
changes disabling radiographs. there are
pain
low at
implies
of
have
need
called
these
patients
about
the uppers
or constantly
because
altering
of their
posture in
in many
to be up and
back pain We suggest least two of pain; and the aimed to in the may be
order
in
pain. is recognisably
inflammatory
similar
arthritis
to that
in
seen
other
patients,
syndromes, each with a recognisable pattern these are the facet arthrosis syndrome instability syndrome. Our investigation provide evidence that pathological changes articular related cartilage to the facet of the lumbar facet arthrosis syndrome. joints
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 with known presentation disease of the spinal synovial joints, may be much as described above. the
Lumbar
instability.
In this
syndrome,
by contrast,
the
PAIN
Facet aggravated and is movement. arthrosis by rest relieved Rising syndrome. in any
SYNDROMES
In posture, this or syndrome pain recumbency, is
Forward
by swaying
bending patients
soft
by pain some
of
and characterised
description
or jerking tissues,
This
including
those
spinal
had
result
sprain
or strain
or
of
long-
continuous gentle is difficult because of as physical activity pain is commonly flexion. Backward bending little is usually We or no pain.
unrecognised
forgotten
provide
minor
a better
injuries.
definition
This
of lumbar
clinical
pattern
than
may
the
pain and stiffness, which ease increases. When rest is unavoidable, reduced by a position of lumbar bending of normal is restricted range and by pain character, ; forward with
instability
more objective definitions which clinical application (Nachemson model which for this syndrome a similar pattern
have failed in practical 1985). One clinical spondylolysis, and signs in result
is symptomatic of symptoms
from
SM. Eisenstein, for PhD, Spinal FRCS, Director Disorders, The
two
patterns
treatment of both
is imporand prepatterns
Department Orthopaedic
CR. Parry, University
Robert
Jones
& Agnes
Hunt
Hospital,
Oswestry,
England.
York Road,
The
Parktown,
Requests
Johannesburg,
for reprints should
South
Africa.
to Mr S. M. and Joint Eisenstein. Surgery
be sent Society
segment
time.
than
at the same
with some
Editorial 1 $2.00
of Bone
referred
1987
pain
in the lower
limbs,
readily
be
3
VOL.
69-B,
No.
1, JANUARY
SM.
EISENSTEIN.
CR.
PARRY
distinguished
nerve root
from
compression.
the major
disabling 12 patients
pain
produced the
this
by facet
to
capsules and
had could
necessarily not be
been studied
We
arthrosis pathological
have
investigated
in an
with
to relate
syndrome changes.
attempt
To provide
some
control
the fresh
material without too much low lumbar facet joints were cadavers whose kidneys were
Death had occurred at and the specimens were
PATIENTS
AND
METHODS
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. an average Nine of the patients before had referral, had symptoms three for for 12 of 1 5 months and
to 20 years.
All had
failed
to respond
to conservative
Facetjoints. There was articular cartilage The most frequent cartilage necrosis, and eburnation cartilage necrotic and ulcer cartilage.
RESULTS
some evidence ofearly damage to
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.
in the finding
facet joints of all I 2 patients. was a focus of full-thickness fibrillation that the of a plug of
There
were
1 1 women
and
one
man
with
ages
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 spinal operations : one an L5 laminectomy of the lumbar and spine one a lumbosacral discectomy. Investigations. Plain radiographs
but we also saw ulceration, (Figs 1 to 4). We suspect is the result of sloughing
Chondrocyte
increased
clusters,
perichondrocyte
foci of fibrocartilage
metachromasia
(Fig.
provided
5)
were helpful only in excluding other causes of backache. In four patients they were normal, in three there was
detectable decrease in the joint space of the lumbosacral facet joints. Mild reduction was seen at one or more patient associated had a lumbar with lumbar of intervertebral disc height levels in six patients, and one
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
be particularly
osteophyte
involved
formation
and,
in any
strikingly,
specimen.
there
was was
no the
or
The
common
feature
of
all
specimens
scoliosis.
Osteophytosis
of the lumbar
spondylosis,
facet
joints,
was
commonly
not seen.
The
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 achieved by facet with skin arthrography markers. or by diligent palpation
three subjects aged 17, 17 and 26 years, but old man killed in a motor vehicle accident surface fibrillation of the articular cartilage
peripheral
without
osteophytosis
evidence of any results. One patient for pseudarthrosis, pain relief in an
in
focal
all
lumbar
facet
necrosis.
joints,
cartilage but
for points
graphs
of maximum
tenderness
Arthrography
followed
was
by radioconsidered
Clinical
fusion gratifying
to be positive only when the injection reproduced some or all of the usual symptoms, and when some relief was
provided by subsequent in the infiltration with lignocaine.
average
3.5
months
after
operation.
Several
and pain.
of the patients
had negative
search for
lumbar
other
myelography
causes of their
discography
changes
and
which
we found
texts as those
have
of
All
12 patients had posterolateral and fusion operations. Both L4-5 and L5-Sl in seven patients, L5-Sl alone in four
fusion from L2 to the sacrum with was required for a 32-yearscoliosis and intractable
been
standard
deformans (Ayers 1935; 1938 ; Badgley 194 1 ; Putti 1964; Schmorl and Jungh-
while
facet
and
pain at the lumbosacral junction. During the operations the facet joints
preserved for either histological examination.
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 inflammation the first examination at operation, but rather the than
were
excised
Sections
were
stained
cut
perpendicular
with
to the
haematoxylin
plane
and
of the joint
eosin
and
or toluidine
THE
JOURNAL
OF BONE
AND
JOINT
SURGERY
THE
LUMBAR
FACET
ARTHROSIS
SYNDROME
I..
I.
Fig.
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
studies
do,
however,
all emphasise
osteophy-
tosis
appear
or bony
to have
spurring
been
as an important
A finding described previously
feature
which is the
,
of the
does not full-
engaged fellow
Ct
pathology
of osteoarthritis.
Bentley
course bridge of
1985):
1961)
whether
or a peculiarly
this
is merely
symptomatic
a stage
variant
in the
(Outerof it.
classic
spondylotic
osteoarthritis
thickness necrosis-in-situ shown in Figure 1 but this is not associated with osteophytes and resembles the intermediate stage destruction which Meachim (1980)
There
are
similarities
between
the
facet
arthrosis
reported
basal ford and The
in his study
degeneration Woods atrophic
of excised
described
femoral
heads,
and
Hunger-
the
by Goodfellow, in
syndrome and chondromalacia patellae. ties are found not only in the histological thickness cartilage necrosis, separation
bone,
fellow
chondrocyte
et al. 1976)
clusters
but also
and
metachromasia
presentation;
(Goodin
in the clinical
cartilage question
VOL. 69-B,
both with
patients associated
6
tenderness As in and normal chondromalacia plain radiographs. patellae, the
SM.
EISENSTEIN,
CR.
PARRY
that
relationship
increased
joint
pressure
is transmitted
to pain-
between
the
histology
and
the
symptoms
in
facet
that
arthrosis is not clear. Clinicians may the degree of pain in both conditions
bone through foci of necrotic for the patella by Goodfellow et al. Any attempt to explain major pain changes confined to articular by the fact, well known to that many patients present with
to the physical
have only patients arthritis proposed to confer
changes
the term a degree
which
can be demonstrated.
We
minor
destruction,
symptoms
sclerosis
in
the
and
presence
osteophytosis.
of also
advanced
Explanations
joint It is
qualify sometimes
for
this
opposite
situation
are
conjectural.
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 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. The described conjectured variations causes for the articular changes we have are obscure, but no less so than those for chondromalacia patellae, which include of normal biomechanics, trauma and genetic
Facet
syndromes
have
been
described
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 the facet joints. that Mooney He spinal and did not distinguish
between
with some symptomatic
arthritis
and instability,
but ventured
arthrodesis Robertson
to suggest,
produced (1976) also
diffidence, relief.
predisposition. It is possible that asymmetric angulation of left and right facet joints could produce stresses sufficient to cause early articular cartilage injury, but 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 angulation and sciatic as a possible pain rather cause than of nerve low back root pain. expected surfaces compression Loss of height to produce posterior to
failed to make this distinction but contribution by describing joint injection cation of symptomatic facet joints and pain.
under
relief flexion).
compression
with joint
(lumbar
surfaces
spine
separated
in extension),
spine
and
in
For
conservative fusion, levels
patient
measures
disabled
who
by
is facing
pain
operation
refractory
for spinal level offers
to
or no
it (Dunlop,
1984) but
Adams
in most
and
of our
Hutton
patients
1984;
the disc
Yang
spaces
and found
King
were of
diagnosis is crucial.
normal
height
or only
slightly
reduced.
We
little
change in the subchondral bone of the certainly nothing like the patellar osteoporosis by Darracott and Vernon-Roberts (1971).
plain radiographs, unless there is advanced (Carrera et al. 1980). Facet arthrography,
The
obvious
argument
against
an attempt
to relate
minor changes in articular surfaces symptoms is that these changes are universal lumbar material articular far are
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
arthrographic
are of secondary confirmation
abnormalities
importance of a positive
described
but pain may response.
by Dory
provide
(1981)
useful
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
CONCLUSIONS
We have
low back joints, surfaces affected
described
pain, histological and clinical segments.
links
between
of the
a clinical
source in the through
syndrome
of pain excised fusion
of
joint of the
donors
accurate fall back
available
history on the
for
study
are
young
adults
and
no
localisation
in facet
of spinal findings
abnormalities reliefobtained
that the
and mild
arthritic
remain articular
; it remains
The
changes
mechanism
may produce
these
known.
pathological
The concept
a matter
of conjecture.
THE JOURNAL OF BONE AND JOINT SURGERY
THE
LUMBAR
FACET
ARTHROSIS
SYNDROME
At
as to
this
stage,
the
it is
facet
impossible
syndrome is a distinct (possibly we
to
be
dogmatic
described
whether
have
Fairbank JC, Park WM, McCall 1W, OBrien JP. Apophyseal injection of local anaesthetic as a diagnostic aid in primary low-back pain syndromes. Spine 1981 ;6:598-605. Ghormley RK. Low back with presentation 1933;lOl :1773-7. pain, of with an special reference to articular operative procedure. facet, JAMA
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.
The authors radiological preparations, are grateful to Dr F. Spiro and Dr I. Van Niekerk for the investigations, to Mrs Coleen Waither for the histology to Dr Jeremy Fairbank for making available the
Goodfeilow J, mechanics
Insall
Patello-femoral patellae.
J Bone kleinen Joint
joint
J Bone Surg [Am]
J. Current 1982;64-A
Leubner
z
Lewin
H. Die Arthritis deformans Orthop I936;65 :42-52. Osteoarthritis Ada Orthop C. Ways Tunbridge
excellent
and to Ms
translation
Dolores
by J. Hart
Rokos for
of the paper
the illustrations.
by Putti
and Logr#{244}scino,
T. study.
Meachim rosis.
ofcartilage
osteoarthrosis.
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VOL.
69-B,
No.
1, JANUARY
1987