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Archives of Orthopaedic

and Traumatic Surgery

Arch Orthop Trauma Surg (1984) 103:201-211

Springer-Verlag 1984

On the Pathogenesis of Spondylosis Deformans and Arthrosis Uncovertebralis:


Comparative Form-Analytical Radiological and Statistical Studies
on Lumbar and Cervical Vertebral Bodies
H.-J Pesch, W Bischoff', Th Becker l, and H Seibold 2
1

Pathologisches Institut (Director: Prof Dr V Becker), Krankenhausstra Be 8-10, and

2 Institut fir Medizinische Statistik und Dokumentation (Director: Prof Dr L Horbach) der Universitit Erlangen-Niirnberg,

Waldstra Be 6, D-8520 Erlangen, Federal Republic of Germany

Summary To investigate the etiopathogenesis of the


common clinical symptoms of the lower lumbar spine
(LS) and cervical spine (CS) (lower back pain and
local cervical spine syndrome), the dimensions of the
third to fifth lumbar vertebral bodies (LVB) and the
fifth to seventh cervical vertebral bodies (CVB) were
studied quantitatively and morphometrically in frontal and sagittal planes, as a function of sex and age, in
105 human cadavers of both sexes aged between 16
and 91 years The evaluation was done in X-ray pictures of 100-ptm-thick polished bone sections with
the aid of the Macro Facility of the Leitz Texture
Analysis System In each case, the maximum and
minimum heights and widths and depths and the
computed differences in heights, widths, and depths
were determined The results were evaluated statistically and compared within and between the two
regions of the spine, using regression-correlation
analyses The heights, widths, and depths of the VB
are all greater in men than in women; their behavior
during ageing is, however, identical for both sexes.
The heights of all the VB examined remain constant
throughout life after termination of growth The
maximun widths and the width differences reveal an
increase in both LVB and CVB in old age All depth
parameters reveal constancy in the case of the LVB
but an increase in the case of the CVB in old age The
correlation coefficients of the maximum width of the
VB within the spinal regions are very high in the
LVB, but lower in the CVB Between the two
regions, in contrast, they are very low This behavior
suggests a superordinate action principle within each
of the spinal regions which is based on characteristic
Offprint requests to: Prof H -J Pesch, Pathologisches Institut
der Universitat Erlangen-Nurnberg, Krankenhausstra Be 8-10,
D-8520 Erlangen, Federal Republic of Germany

anatomical construction and functional stressing The


static stressing of the LVB leads, laterallyto disc protrusions As a result of this, traction forces acting on
the weak lateral elements of the anterior longitudinal
ligament, stimulate the accretion of spondylotic
osteophytes at the point of insertion of the ligament
on the vertebral body Anteriorly, in contrast, the
particular strong anterior longitudinal ligament prevents such a remodelling process Posteriorly, the
longitudinal ligament is attached to the intervertebral
discs, and can thus not stimulate the vertebral body
to produce osteophytes The dynamic stressing of the
CVB leads laterally to friction between the VB in the
region of the uncovertebral joints and to the formation of arthroticosteophytes Anteriorly, owing to the
weak configuration of the anterior longitudinal ligament in this aspect, disc protrusion occur and, subsequently, spondylotic osteophytes accrete Posteriorly, the (posterior) longitudinal ligament is also
attached to the intervertebral discs, and can thus provide no ossification stimulus Lateral arthrotic and
anteriorspondylotic osteophytes at the CVB are thus
the result of etiopathogenetically different processes,
and can occur independently of each other The also
differing etiopathogenesis of lateral osteophytes in
the case of the LVB and CVB, presenting as spondylosis or arthrosis, also finds statistical expression in a
very small correlation of the maximum widths of the
VB in both regions of the spine Spondylotic osteophytes occurring laterally at the LVB and anteriorly
at the CVB do not of themselves cause clinical symptoms These are rather a sequela of motion segment
instability, where overloading of the supporting
structures can give rise to a local chronic spinal syndrome Arthrotic osteophytes occurring laterally on
the CVB, in contrast, can, as a result of the pressure

202

H.-J Pesch et al : Pathogenesis of Spondylosis Deformans and Arthrosis Uncovertebralis

they exert on nerves and blood vessels, themselves


give rise to clinical symptoms with radiating pain and
neurovegetative phenomena, known as chronic cervical syndrome, in distant organs Contrasting with
these chronic, bone-associated spinal syndromes of
old age, are the acute soft-tissue-associated spinal
syndromes with radicular symptomatology, seen in
younger patients These arise through intervertebral
disc prolapse with root entrapment, by reason of the
particular anatomical and functional situation, predominantly in the lower LS In addition to the new
formation of bone seen in spondylosis and arthrosis,
within the framework of osteoporosis with ageing, a
breakdown of cancellous structure, which is said to
be due to osteoblast insufficiency, occurs simultaneously This apparent contradiction of simultaneous
new formation and breakdown of bone resolves itself, however, when one considers the reactive plasticity of bone tissue This implies that both processes
are the result of the self-regulating adaptation of connective and supporting tissue to mechanical stresses.
Zusammenfassung Zur Atiopathogenese des gehauften, jedoch unterschiedlich hiufigen Auftretens
klinischer Beschwerden im Bereich der unteren LWS
und HWS in Form akuter bzw chronischer WS-Syndrome wurden bei 105 Verstorbenen beiderlei Geschlechts im Alter von 16 bis 91 Jahren nach Ausschlu13 klinisch manifester Knochenerkrankungen
die Abmessungen des 3 -5 Lendenwirbelk 6 rpers
(LWK) und des 5 -7 Halswirbelk 6 rpers (HWK) in
frontaler bzw sagittaler Ebene in Abhaingigkeit von
Geschlecht und Lebensalter quantitativ-morphometrisch untersucht Die Auswertung erfolgte an
Rontgenbildern 100 ~t dicker Knochengro 13flichenschliffe mit Hilfe der Makroeinrichtung des LeitzTextur-Analyse-Systems Dabei wurden die jeweils
gr 6f3te und kleinste Hohe und Breite bzw Tiefe
sowie die daraus berechneten Differenzen der
Hohen, Breiten bzw Tiefen ermittelt Die Ergebnisse wurden statistisch ausgewertet und durch
Regressions-Korrelations-Analysen innerhalb und
zwischen den beiden Regionen der LWS und HWS
untersucht Hohe, Breite und Tiefe der WK sind bei
den Mannern durchwegs gr 6Ber als bei den Frauen;
ihr Verhalten im Alter ist jedoch bei beiden Geschlechtern gleich Die Hohen aller untersuchten
WK sind nach Abschlu1 des Wachstums lebenslang
konstant Die maximale Breite und die Differenz der
Breiten weisen bei den Lenden und Halswirbelk6rpern eine Zunahme im Alter auf Samtliche Parameter der Tiefe zeigen beim Lendenwirbelk6rper
eine Konstanz, beim Halswirbelk6rper dagegen eine
Zunahme im Alter Die Korrelationskoeffizienten
der maximalen Breite der WK sind innerhalb der

WS-Regionen in der LWS sehr hoch, in der HWS


niedriger, zwischen beiden WS-Regionen dagegen
sehr niedrig Dieses Verhalten spricht fiir ein jeweils
iibergeordnetes Wirkungsprinzip innerhalb der WSRegionen, das auf gleicher anatomischer Konstruktion und funktioneller Beanspruchung beruht Die
statistische Beanspruchung der LWS fihrt lateral zu
Bandscheibenprotrusionen Diese rufen fiber Zerrung des dort schwicheren vorderen Lingsbandes an
dessen Insertionsstelle am Wirbelkorper den Anbau
spondylotischer Knochenzacken hervor Ventral
dagegen verhindert das besonders straffe vordere
Ungsband diesen Umbau Dorsal inseriert das
L
Lingsband an den Bandscheiben und kann so keinen
Reiz zur Ossifikation auf den WK ausiiben Die
dynamische Beanspruchung der HWS fhrt lateral
zum Aufeinanderreiben der WK im Bereich der Uncovertebralgelenke und zum Anbau arthrotischer
Knochenzacken Ventral kommt es wegen des hier
nur schwach ausgebildeten vorderen Langsbandes zu
Bandscheibenprotrusionen und daraufhin ebenfalls
zum Anbau spondylotischer Randzacken Dorsal
inseriert auch hier das Langsband an den Bandscheiben und kann somit keinen Reiz zur Ossifikation auf
den WK ausfiben Laterale und ventrale spondylotische Knochenzacken am HWK sind somit Ergebnis
atiopathogenetisch verschiedener Prozesse und k6nnen unabhaingig voneinander auftreten Die ebenfalls
unterschiedliche Atiopathogenese lateraler Knochenzacken an LWK und HWK als Spondylose bzw.
Arthrose findet auch statistisch ihren Ausdruck in
einer sehr geringen Korrelation der maximalen Breiten der WK in beiden WS-Regionen Spondylotische
Randzacken lateral am LWK und ventral am HWK
rufen selbst keine klinischen Beschwerden hervor.
Diese sind vielmehr Folge der Insuffizienz im Bewegungssegment, wobei durch die Oberbeanspruchung der Haltestrukturen lokalisierte chronische
WS-Syndrome auftreten k 6nnen Arthrotische Randzacken lateral am HWK k 6nnen dagegen selbst durch
Nerven und GefaBlkompression klinische Beschwerden mit ausstrahlenden Schmerzen und neurovegetativen Erscheinungen als chronische HWS-Syndrome in entfernt liegenden Organen hervorrufen.
Im Gegensatz zu diesen chronischen, knochenassoziierten, WS-Syndromen des hheren Alters stehen
die akuten, weichteilassoziierten WS-Syndrome mit
radikulirer Symptomatik des jfingeren Alters Sie
entstehen durch Bandscheibenprolapse mit Wurzeleinklemmung aufgrund der besonderen anatomischen und funktionellen Situation vorwiegend in der
unteren LWS Neben dem durch Spondylose und
Arthrose bedingten Knochenanbau kommt es gleichzeitig im Rahmen der physiologischen Altersosteoporose zum Abbau spongi 6 ser Strukturen, der auf

H.-J Pesch et al : Pathogenesis of Spondylosis Deformans and Arthrosis Uncovertebralis

203

der sogenannten Osteoblasteninsuffizienz beruhen


soll Dieser scheinbare Widerspruch des gleichzeitigen An und Abbaus von Knochen 16st sich jedoch
unter Beriicksichtigung der reaktiven Plastizitit des
Knochengewebes Danach sind beide Vorgiinge
Ergebnis der selbstgesteuerten Anpassung von
Binde und Stiitzgewebe an mechanische Beanspruchungen.
Intervertebral-disc-related symptoms affecting the
lumbar spine (LS) and the cervical spine (CS) more
and more frequently induce patients of varying ages
to seek the aid of an orthopedic specialist X-ray
films obtained from such patients often reveal a narrowing of the disc space, sclerosis of the end plates
and/or lipping at the edges of the vertebral bodies
(VB) (marginal osteophytes) In the LS such changes
are always referred to as spondylosis deformans, in
the CS sometimes as arthrosis uncovertebralis.
The clinical and radiological experience of such
conditions already indicate that these two entities
must represent two pathogenetically different bone
lesions.
Thus, for example, LS symptoms occur earlier
and more frequently, and are more uniform in
nature, while CS symptoms have a later onset, are
less frequent, and are more multifarious (Kramer
1978) Laterally in the lumbar vertebral body (LVB),
and anteriorly in the cervical vertebral body (CVB),
submarginal osteophytes are found, while laterally in
the CVB, osteophytes are uncovertebral in location
(Idelberger 1975).
Today, it is possible to subject a large number of
human cadaver VB to structural and form analyses.
The aim of such investigations is to draw conclusions
as to the origin of the radiological changes seen in the
VB, and thus of the symptomatology they cause.
For this purpose, the three lowest LVB and the
three lowest CVB were analysed morphometrically
as a function of sex and age, and the results evaluated
statistically.
Table 1 Age and sex distribution of the 105 cases investigated
Age lyearsl

Sex (n)

&

16-40
41-50
51-60
61-70
71-80
81-91

13
10
12
11
7
6

7
9
5
8
12
5

20
19
17
19
19
11

YZ

59

46

105

Fig la, b Schematic representation of the investigated frontal


and sagittal vertebral body sections (magnification x 0 51) of
the a LVB, b CVB

Fig 2 a,b Monitor picture of X-ray views of 100-lgm-thick


polished bone sections taken from the fifth CVB of a 49-yearold man (magnification approx x 1 93) with a smallest outer
and b largest inner rectangular "mask"

Material and Methods


In 105 autopsy cases of both sexes, aged between 16 and
91 years (Table 1) with no evidence of clinically manifest bone
disease, the dimensions of the third to fifth LVB, and of the
fifth to seventh CVB were studied From the middle of the
third and fifth LVB and of the fifth and seventh CVB, 3-5mm-thick slices were sawn out parallel to the frontal plane,
and out of the middle of the fourth LVB and the sixth CVB,
3-5-mm-thick slices were sawn out parallel to the sagittal plane
(Fig i1), and after fixation in Schaffer's solution, embedded in
methyl methacrylate From these blocks, 100-gm-thick polished bone sections' were prepared on Plexiglas slides 2, and highcontrast X-ray pictures obtained 3 (further methodological
details can be found in Pesch et al 1975, 1977 ; Henschke and
Pesch 1978) With the aid of the Leitz Texture Analysis
System 4 (Serra 1973), these polished sections were transmitted
1 Cutting machine Woco p 50, Conrad, Clausthal-Zellerfeld
and precision polishing machine, Miller, Nuremberg, FRG
2 Plexiglas slides, Rohm, Darmstadt, FRG
Cyanoacrylate adhesive, Delo, Munich, FRG
3 Fully enclosed table X-ray unit, Faxitron, Priizisionstechnik,
Cologne, now Hewlett and Packard, B6 blingen, FRG
4 TAS, Leitz, Wetzlar, FRG

H.-J Pesch et al : Pathogenesis of Spondylosis Deformans and Arthrosis Uncovertebralis

204

to a monitor screen via a black-and-white television camera for


a quantitative analysis of the form of the VB.
In the VB sectioned in the frontal plane, the maximum

were determined in the same way (Figs 6 and 7) Hereby, the


maximum width of CVB 5 and 7 was selected to be the distance
between the extreme tips of the uncinate processes, since the
lateral transition of the VB into the costal process did not permit an accurate delimitation (Fig 2 a, b).
From the maximum and minimum heights, widths and

(outside) height Hmax and width Wma, and the minimum


(inside) height Hmin and width Wjinwere determined with the

aid of the smallest rectangular "mask" that could be placed


outside the VB to include the cortical bone, and the largest
rectangular "mask" that could be placed inside the VB to
exclude the cortical bone Likewise, in the VB section in the
sagittal plane, the maximum (outside) height Hmax and depth

depths, the magnitudes AH = Hm


Hmin, AW = Wmax Wmi, and AD = Dma
Din were computed as a measure of

the deviation of the VB from the rectangular form To investigate possible sex or age-dependency, variance analyses were
carried out at a significance level of a = 5% Taking into

Dma,,, and the minimum (inside) height Hmin and depth Dmin,

Table 2 Mean values and standard deviations of the mean for maximum and minimum heights, and the differences in heights and
maximum and minimum widths, and the differences in widths of the (a) 3rd LVB, (b) 5th LVB, (d) 5th CVB, (e) 7th CVB, and
maximum and minimum depths, and the differences in depths of the (c) 4th LVB and (f) 6th CVB as a function of age
Age
(years)

No of
cases
(n)

Heights
Maximum
lmml S

Minimum
lmml S

Differences
lmml S

Widths or depths
Maximum
Minimum
lmml S
lmml S

Differences
lmml s

a) 16-40
41-50
51-60
61-70
71-80
81-91

20
19
17
19
19
11

29 85
28 46
30 08
29 21
28 89
28 82

0.31
0.39
0.42
0.41
0.52
0.45

23.71
22.68
23.11
22.40
21.72
21.96

6.14 0 30
5.78 0 22
6.98 0 50
6.81 0 44
7.17 0 40
6.86 0 61

51.21
50.36
53.55
54.54
55.13
53.88

1 23
0 87
1 44
1.28
1.56
1.29

38.25
36.88
39.20
37.75
37.53
37.70

1.13
0.79
1.07
0.86
0.88
0.94

12.95
13.49
14.35
16.79
17.59
16.19

0.41
0.44
0.85
0.73
1.13
1.19

b) 16-40
41-50
51-60
61-70
71-80
81-91

20
19
17
19
19
11

32 03
29 39
30 06
30 34
30 84
30 70

1.17
0.31
0.67
0.45
0.64
0.73

23.64 0.45
22.74 0.54
21.84 0.94
22.43 0.41
22.83 0.55
22.71 0.85

8.38
6.65
8.22
7.92
8.01
7.99

1.26
0.38
0.51
0.59
0.61
0.75

53.53
52.47
57.76
57.56
58.44
58.94

1.13
1.13
1.32
1.47
1.82
1.76

41.57
36.93
43.26
40.19
38.82
41.07

1.81
1.23
1.04
0.98
1.00
1.00

11.96
15.54
14.50
17.37
19.62
17.87

1.56
1.15
0.84
1.15
1.46
1.21

c) 16-40
41-50
51-60
61-70
71-80
81-91

20
19
17
19
19
11

30 95
29 62
31 23
30 16
30 41
30 23

0.42
0.36
0.32
0.39
0.39
0.31

23.17
22.29
24.07
21.70
21.70
22.63

0.41
0.40
1.19
0.45
0.60
0.37

7.78
7.33
7.15
8.46
8.71
7.60

0.40
0.39
1.17
0.31
0.43
0.26

37.18
36.16
38.08
37.41
37.66
37.62

0.90
0.72
1.11
0.75
1.00
0.93

29.94
28.06
30.95
28.86
28.86
29.62

0.79
0.72
0.93
0.59
0.69
0.95

7.24
8.10
7.14
8.55
8.80
7.99

0.40
0.50
0.57
0.40
0.62
0.40

d) 16-40
41-50
51-60
61-70
71-80
81-91

20
19
17
19
19
11

16
16
17
17
16
17

66
88
37
30
60
07

0.40
0.35
0.51
0.41
0.42
0.61

10.35
9.79
10.13
10.04
9.60
9.98

0.24
0.26
0.43
0.31
0.21
0.40

6.31
7.09
7.24
7.26
7.00
7.09

0.30
0.25
0.42
0.33
0.34
0.40

21.63
21.39
23.03
22.78
21.91
23.18

0.69
0.47
0.52
0.62
0.36
0.71

16.91
16.14
16.85
16.88
15.82
16.85

0.48
0.39
0.49
0.52
0.36
0.71

4.71 0.56
5.25 0.46
6.18 0.48
5.90 0.65
6.08 0.43
6.32 0.82

e) 16-40
41-50
51-60
61-70
71-80
81-91

20
19
17
19
19
11

18 67
17 92
18 86
18 26
17 51
18 17

0.42
0.50
0.45
0.39
0.52
0.56

11.01
10.09
10.52
10.38
9.88
10.24

0.35
0.35
0.28
0.28
0.29
0.36

7.66
7.82
7.93
7.88
7.62
7.92

0.43
0.36
0.37
0.29
0.42
0.52

25.29 0.54
24.07 0.53
25.97 0.65
24.74 0.53
25.68 0.78
28.28 1.16

21.74 0.80
20.56 0.75
20.94 0.81
19.98 0.73
21.18 0.88
23.61 1.08

3.55
3.50
4.92
4.75
4.49
4.67

0.48
0.44
0.52
0.57
0.52
0.76

f)

20
19
17
19
19
11

16 42
14 19
14 57
14 23
13 90
14 15

0.29
0.30
0.28
0.26
0.28
0.35

10.13 0.26
9.55 0.26
9.85 0.32
9.48 0.31
9.10 0.23
9.28 0.27

4.49
4.64
4.72
4.75
4.82
4.78

0.19
0.13
0.13
0.21
0.20
0.25

17.17
17.90
19.56
19.71
19.54
20.53

12.13
11.90
13.10
12.76
13.25
14.10

5.03
6.00
6.45
6.95
6.28
6.44

0.23
0.36
0.43
0.59
0.45
0.35

16-40
41-50
51-60
61-70
71-80
81-91

0 35
0 34
0 59
0 39
0 63
O78

0.26
0.30
0.54
0.67
0.60
0.78

0.31
0.36
0.33
0.29
0.38
0.55

205

H.-J Pesch et al : Pathogenesis of Spondylosis Deformans and Arthrosis Uncovertebralis


account adequate group size and biological ageing, six agegroups were formed, and the mean values and standard deviations of these values computed for all the parameters Finally,
with the aid of regression-correlation analyses, the relationship
of the measured parameters of the individual VB within and
between the two regions of LS and CS were investigated.
All computations were carried out with the aid of the statistic programme package SPSS (Beutel et al 1978) on the
Siemens 7,541 computer system at the Computer Center of the
Medical Department of the University Hospital, Erlangen.

Firstly, the mean values of the parameters were


determined, irrespective of age, for each sex separately.
The maximum and minimum heights of all VB,
the maximum and minimum widths of the frontally
sectioned LVB 3 and 5 and CVB 7, and the maximum and minimum depths of the sagittally sectioned
LVB 4 and CVB 6, differ between the sexes In contrast, the differences in heights, widths, and depths of
all VB, and the maximum and minimum widths of
CVB 5, show no dependency on sex.

The maximum and minimum heights of the VB


investigated are greater in men, both in the LS and in
the CS, than in women by an average of 1 2 mm,
while the maximum and minimum widths and depths
are greater in men than in women by 3 mm in the LS
and by 1 mm in the CS.
Finally, the mean values of the parameters as a
function of age were again determined separately for
each sex.
Corresponding parameters in the two sexes showed the same behavior with respect to the significance
of their age-related changes For this reason, for further evaluation, male and female data were pooled
and investigated in six age-groups (Table 1).
The maximum heights (Table 2, Figs 3 and 4) of
all the VB show no significant changes in old age In
the case of the LVB, the heights are, at 30 mm,
approximately identical, whereas at 17 0 mm for
CVB 5, 14 3 mm for CVB 6, and 18 2 mm for CVB 7
they differ among the CVB.
The minimum heights of all VB also show no age
dependency In the LVB they are equal at 22 6 mm,
while in the CVB they differ appreciably, being 10 0

Height 3 LVB

Height' 5.CVB

Results

lmml

lmml

Hmax

H _.

15-

'I

20

1010

Width

.
:
t

5-

5 LVB

ra-i-_

li

fe _

Width 7 CVB
lmml

50

i:i

25-

2015-

Depth
lmml

__

4 LVB
Dmx

160-40

4150

5 I-60

6I-70

7I- 80

81

__

Age

Fig 3 Mean values and standard deviations of the means for

Fig 4 Mean values and standard deviations of the means for

maximum and minimum heights (Hma, and Hmin), widths (Wmax

the maximum and minimum heights (Hmax and Hin), widths


(Wma, and Wmin), and depths (Dma and Dmin), and their differ-

and Wmin), and depths (Dma, and Dmi)

and their differences

(A) of the three investigated LVB as a function of age

ences (A) of the three investigated CVB as a function of age

H.-J Pesch et al : Pathogenesis of Spondylosis Deformans and Arthrosis Uncovertebralis

206

Table 3 Correlation coefficients of the maximum width (Wmax)


of the frontally sectioned LVB and CVB

CVB 7
LVB 3
LVB 5

CVB 5

CVB 7

LVB 3

0 40
0 33
0 30

0 21
0 25

0 74

Wmax 3.LVB
lmml

r= 074

60
55

50
45
//:

5 LVB
65 Wmax lmml

55

50

45

wma, 5.CV 1
lmml
25

60

r= O4

20

15
b

20

7 CVB
3 Wmax l m ml

25

Wmax 757.CVB
CVB
lmml

r= 0,2
'r,-021

30

l I
25

I/

20

45

/
50

LVB

3~~~LVB'

*
55

60 Wmax lmml

Fig 5 a-c Correlation diagrams for maximum width (Wmax) of


the a LVB 3 and 5 (r = 0 74), b CVB 5 and 7 (r = 0 40), c CVB
7 and LVB 3 (r = 0 21)

mm for CVB 5, 9 6 mm for CVB 6, and 10 4 mm for


CVB 7.
In both regions of the spine, the height differences
also reveal no dependency on age, and, at about
7.4 mm, are similar in the LVB, whereas they differ
among the CVB, being 7 0 mm for CVB 5, 4 7 mm
for CVB 6, and 7 8 mm for CVB 7.
The maximum width (Table 2, Figs 3 and 4) of
the four frontally sectioned VB increases differently
with age A significant increase of 5 % is found in
LVB 3 from 51 5 mm, of 10 % in LVB 5 from 53 5
mm, and of 12 % in CVB 7 from 23 3 mm Although
no significant changes were demonstrable in CVB 5,
the maximum width increased by 7 % from 21 6 mm.
The minimum widths of these four VB differ from
one another, and usually show no change with age.
The figures are 37 9 mm for LVB 3, 40 2 mm for
LVB 5, and 16 6 mm for CVB 5 An increase is also
seen in CVB 7 of 8 % from 21 7 mm, but this is not
significant.
The differences in the widths increase with age in
both regions of the spine This increase is significant
for LVB 3, namely 25 % from 13 0 mm, and for
LVB 5, which increases by 50 % from 12 0 mm, but
on account of marked variance of the measured
values, is not significant for CVB 5, which shows an
increase of 33 % from 4 7 mm, or in CVB 7, which
increases by 32 % from 3 5 mm.
The maximum and minimum depths, and also the
difference between the depths in the two sagittally
sectioned VB (Table 2, Figs 3 and 4) show a different
pattern of behavior with ageing No difference is
found for LVB 4 at 37 2 mm and 29 4 mm, for maximum and minimum depth respectively, or for their
difference.
In contrast, in CVB 6, there is a significant agerelated increase in maximum depth by 20 % from 17 2
mm, of 14 % in minimum depth from 12 2 mm, and of
28 % in the difference in depths from 5 0 mm.
Correlation coefficients and regression lines describe same-sense relationships between height,
width, and depth among the three LVB and the
three CVB It appears that the relationship of the
LVB to one another (Table 3, Fig 5a) is markedly
close than that of the CVB to one another (Table 3,
Fig 5 b) In contrast, there is hardly any relationship
between the VB of these two regions of the spine
(Table 3, Fig 5 c).
These differences between LVB and CVB are
seen to be particularly marked in form-analytical Xray images of the two regions of the spine in young
and advanced age (Figs 6 and 7) Owing to the agedependent increase in maximum width, and the difference in widths of the LVB (Fig 6), in this region,
marginal osteophytes associated with the upper and

H.-J Pesch et al : Pathogenesis of Spondylosis Deformans and Arthrosis Uncovertebralis

__

<

_-Wmax

11

Wmin

207

Dmax

Dmin
-4-

7
1

mr
Hmin
Hmax

_I

Hmin
Hmax

L -Dmin
I
-I

I I-Wmin

n
-~~"~
I LlUX

,Dmax 1
I Dmin
f1

Wmax-1

Hmax
Hmax

Hmir

714

Hmax
Hmir

Hmax

L|

i m in

rmin

Fig 6a-d Form-analytical X-ray pictures


of 100-gm-thick polished bone sections of
the frontally sectioned fifth LVB (left)
with maximum and minimum heights
(Hmax and Hmin) and widths (Wax and
Wmin) and of the sagittally sectioned
fourth LVB (right) showing maximum
and minimum heights (Hmax and Hmi,)
and depths (Dmax and Din) a and c of a
39-year-old man, b and d of a 76-year-old
man (magnification approx x 0 94)

Dmax
a

Fig 7 a-d Form-analytical X-ray pictures of 100-jim-thick


polished bone sections of the frontally sectioned seventh CVB
(left) showing maximum and minimum heights (H,ma and Hmin)
and widths (Wmx and Wmin) and of the sagittally sectioned sixth
CVB (right) showing maximum and minimum heights (Hm,,
and Hmin) and depths (Dm, and Dmin) a and c of a 49-year-old
woman, b and d of a 91-year-old man (magnification x 0 86)

lower plates are seen only laterally (Fig 6 a and b);


anteriorly, owing to the age-constant depth, they are
lacking (Fig 6 c and d) In contrast, in the case of the
CVB (Fig 7), as a result of the slight increase in
width and of the difference in widths in old age, only
slight "lipping" of the uncinate process or slight formation of marginal osteophytes are seen laterally
(Fig 7 a and b), while anteriorly, as a result of an
increase in the maximum and minimum depths and of
their difference, a beak-like remodeling of the vertebral body margin has occurred (Fig 7 c and d).
Discussion
The fact that the maximum and minimum heights of
all VB examined were greater by 1 2 mm in men than

-rnu

in women is explainable by the fact that men are, on


average, taller The resulting 3 cm greater length of
the bony vertebral column (VC) in men is associated
with a widening of the VB in the lower LS by about
3 mm, but only of about 1 mm in the lower CS A
technical equivalent of this situation would be a factory chimney which is broader at the base.
Although the VC is described anatomically as a
unit, there are considerable morphological and functional differences between the LS and the CS.
The LVB are largely constant in form With the
exception of the maximum width and the difference
between widths in old age, the other parameters,
such as maximum and minimum height and their difference, show no age-related changes This result is
in agreement with the VC index described by Barnett
and Nordin ( 1960), which also reveals no significant
dependence on age, and is also in accordance with
earlier investigations (Pesch et al 1980 b).
The equal-sense behavior of the form parameters
of LVB 3 and 5 points to a mechanism of action in
this region of the spine that remains constant throughout life.
On the basis of the anatomical construction of the
LS, the range of movement between the individual
LVB is restricted in all directions by the strong ligaments, the powerful supporting muscles, and the
sagittally oriented vertebral joints In particular, no
rotational movements are possible between the LVB
(Lippert 1966; Gregerson and Lucas 1967 ; Tittel
1974 ; Wood 1979) This means that the LVB are subjected mainly to static forces, the force being transmitted through the elastic intervertebral disc in the
form of pressure acting over the surface area of the
two end plates (Pesch et al 1980 b).

208

H.-J Pesch et al : Pathogenesis of Spondylosis Deformans and Arthrosis Uncovertebralis

The always greater maximum and minimum


widths of LVB 5 as compared with LVB 3 seen after
termination of growth can be traced back to the
increasing loading of the VC in the craniocaudal
direction (Braus 1921 ; Benninghoff 1954 ; Schmorl
and Junghanns 1968) As a result of the simultaneous
enlargement of the area of the upper end plate and
increase in the volume of the VB, an enlargement of
the cross-section of the bearing cancellous bone
occurs, so that no increase in the loading of the individual bony trabeculae takes place (Kummer 1962 ;
Pesch et al 1980b).
As a result of the lateral waist-like concavities of
the VB, differences in maximum and minimum
widths occur on termination of growth These concavities in the lateral aspects, are statically highly favorable forms that can also be found in technical constructions (e g , dams) Taking into account the
course of the transverse force (Schliter 1965) and of
the fracture behavior known from pressure experiments in material-testing laboratories (Sigwart 1974),
the form of the LVB may be compared to apposed
cones of pressure Accordingly, the material "removed" by the central concavities corresponds to that
part of the body which, subjected to critical compressive force, would be the first to rupture outward The
increase in the difference in widths that can be seen
with advancing age is due to a continuous increase in
maximum width, associated with a constant minimum width (Pesch et al 1980 b) This "submarginal"
(Idelberger 1975) accretion of bone in the form of
osteophytes or thickenings close to the upper and
lower end plates is pathognomonic for spondylosis
deformans It occurs against the background of
underlying insufficiency in the motion segment
(Schmorl and Junghanns 1968), the localization of
the osteophytes being determined by the anatomical
construction.
In the LS, the anterior longitudinal ligament is
particularly strong and thick in the anteromedial
aspect, while laterally it comprises weaker and thinner fibers (Johnson et al 1975 ; Worsdorfer and
Magerl 1980) Degenerative fissures in the annulus
fibrosus of the intervertebral disc lead to protrusion
of the disc at the "locus minoris resistentiae", while
the "explosive potential" of the gelatinous nucleus is
maintained The point of least resistance is located
laterally where the components of the anterior longitudinal ligament are relatively weak As a result,
instability of the motion segment occurs (Schmorl
and Junghanns 1968), and intermittent traction
forces act on the points of insertion of the lateral
fibers of the longitudinal ligament As a result of this,
owing to the increase in stretching stresses, ossification is initiated (Pauwels 1965) This bone formation

can lead to the production of spurs, marginal thickenings, and even bars that can develop to the extent of
producing bone ankylosis between neighboring VB.
Anteriorly, medially, the strong anterior longitudinal ligament prevents such a remodeling process.
Posteriorly, the (posterior) longitudinal ligament is
attached only to the intervertebral discs (Johnson et
al 1975), and thus cannot act on the VB to provide a
stimulus for ossification This is the reason why, in
agreement with earlier investigations (Nathan 1962),
consistency of form is found in the sagittal sectioned
LVB 4, even in advanced age.
The CVB have a characteristic appearance They
therefore differ among themselves, and also frontally
and sagittally, more markedly than do the LVB.
Owing to the median sectioning plane, the uncinate
processes are not involved, so that compared with the
frontal section, sagittal measurements reveal a much
lower maximum height.
As in the case of the LVB, greater maximum
and minimum widths and also heights are found in
CVB 7 than in CVB 5, being the expression of the
increasing loading of the VC in the craniocaudal
direction The same-sense behavior of the form parameters of these two VB in old age also points to a
uniform action mechanism in the lower CS throughout life Owing to the complicated anatomical construction of the CS, the transmission of forces between the individual CVB is not in the vertical direction, so characteristic of all LVB, but varies in the
three functionally different sections of the CS Thus,
in the lower CS (CVB 5-7), in addition to anterior
and posterior flexion and lateral bending, torsional
movements also occur In the upper CS (CVB 1 and
2) at the atlanto-occipital joint, in contrast, mainly
rotational and anterior or posterior movements
occur, while in the middle CS (CVB 3 and 4) mainly
posterior, to a lesser extent also anterior, flexion and
lateral bending occur.
Thus, the three lower CVB are stressed largely
dynamically The range of movement and the stressing of the intervertebral discs achieve their maxima
for anterior and posterior flexion (Bowden 1966 ;
White and Panjabi 1978 ; ten Have 1978 ; Isaacson
1979 ; W6rsdorfer and Magerl 1980).
Torsional movements are readily possible owing
to the upward inclination of the articular facets of the
apophyseal joints In flexion-extension movements,
the shovel-like uncinate processes are involved,
which, in about the 9th year of life, develop upwards
from elements of the VB, as a result of which, in conjunction with a simultaneous curvature in the sagittal
direction, they give the upper end plate a saddle-like
shape.

H.-J Pesch et al : Pathogenesis of Spondylosis Deformans and Arthrosis Uncovertebralis

During the "erection" of the uncinate processes,


horizontal fissures can develop in the intervertebral
discs, in the lateral uncovertebral region (Ecklin
1960; T 6ndury 1974); however, these must be considered physiological Through synovial lining and insprouting of lateral menisci, these gaps secondarily
develop an articular configuration (Ecklin 1960 ; T 6ndury 1974 ; Stahl and Huth 1980).
This anatomical structure of the CVB, which is
complicated as compared with LVB, in conjunction
with the functionally more multifarious dynamic
stressing, leads to more complex changes of form in
old age.
The increase in maximum width and the difference in widths observed in CVB 5 and 7 correspond
to a greater distance between the tips of the uncinate
processes in the aged, which is caused by a lateral
"bending" of the processes, or lateral accretion of
osteophytes These lateraluncovertebral osteophytes
are pathognomonic for arthrosis uncovertebralisand
in the CS are most frequently found in the three
lower CVB (Krogdahl and Torgersen 1940 ; Epp
1950; Exner 1954 ; Nathan 1962 ; Friedenberg and
Miller 1963 ; Sager 1969) Since it is here that the
range of movement is greatest, the most marked
signs of wear of the intervertebral discs also occur
here (Friedenberg et al 1959 ; Payne and Spillane
1957 ; W6 rsdorfer and Magerl 1980) These lead to a
narrowing of the intervertebral space, to contact of
the neighboring VB, with reactive sclerosis of the
upper end plate, and to lateral "bending" of the uncinate process (Giraudi 1931 ; Krogdahl and Torgersen 1940 ; Lyon 1945 ; Frykholm 1951 ; Exner 1954 ;
Friedenberg and Miller 1963 ; Hirsch et al 1967 ;
Schmorl and Junghanns 1968), with the result that in
the extreme case, the CS presents a pot or plate-like
appearance in the a p X-ray film (Ecklin 1960) As a
result of these pathological anatomical changes in the
region of the uncovertebral joints, arthrotic osteophytes are then accreted laterally.
In the sagittally sectioned CVB 6, the maximum
and minimum depths and their differences increase
with age At the anterioraspect, accretion of osteophytes occurs close to the end plates, to produce
beak-like projections which must be considered
morphological variants of spondylosis deformans.
Since in the CS the anterior longitudinal ligament
is weakly developed (Johnson et al 1975), anteromedially, disc protrusion, and thus the development
of osteophytes, can occur Posteriorly, as in the case
of the LS, the longitudinal ligament is attached only
to the intervertebral discs, and thus cannot induce
ossification in the VB Therefore, lateral arthrotic
and anteriorspondylotic osteophytes in the CVB can,
in consequence of etiopathogenetically different pro-

209

cesses, occur independently of one another (Giraudi


1931 ; Krogdahl and Torgersen 1940; Lyon 1945 ;
Frykholm 1951 ; Schmorl and Junghanns 1968).
The likewise differing etiopathogenesis of lateral
osteophytes at the LVB and CVB, in the form of
spondylosis deformans and arthrosis uncovertebralis
respectively, finds static expression, too, in the fact
that the maximum width of the VB in the two regions
of the spine correlate only slightly with each other.
The contrasting high correlation of the maximum
widths among the LVB suggests that lateral spondylosis frequently occurs simultaneously at several VB,
while the lower correlation of this parameter among
the CVB indicates that lateral arthrosis uncovertebralis occurs isolated in individual VB.
Spondylosis deformans is the formation in the VB
of end plate proximal osteophytes, due to an underlying degenerative disc injury with consecutive insufficiency in the motion segment It occurs very commonly with increasing age in all regions of the VC,
but predominantly in the LS The extent and localization of the bone changes are determined individually
by the anatomical situation presenting and by the
functional stressing In the case of the LS, predominantly static loading leads to lateral disc protrusions,
which, anteriorly, are prevented by the in this aspect
strong anterior longitudinal ligament In the CS, in
contrast, mainly dynamic stressing leads to anterior
protrusions, since here the longitudinal ligament is
much more weakly structured Any disc protrusion
and insufficiency of the motion segment lead to traction on the longitudinal ligament and thus induce
ossification in the form of spondylotic marginal
osteophytes.
Clinically, during these remodeling processes, the
spectrum of symptoms ranges from relative freedom,
to severe localized chronic manifestations The
chronic spinal syndromes are not caused by the osteophytes themselves, but rather by the insufficiency of
the motion segment and the associated overloading
of the ligamentous and muscular supporting structures of the spine (Idelberger 1975 ; Rizzi 1976 ; Kramer 1978 ; Wood 1979) With further progress of the
spondylosis to ankylosing bar formations and stiffening of the motion segment, these symptoms can
disappear spontaneously at the cost of limitation of
mobility.
Arthrosis uncovertebralisis the formation of lateral arthrotic osteophytes at the uncovertebral process,
which develop as a late sequela of disc degeneration
with narrowing of the intervertebral spaces and
which, on account of the high dynamic loading, occur
preferentially in the lower CS The condition occurs
with increasing age, and is restricted to the CS Here,
symptoms may be caused by the osteophytes them-

210

H.-J Pesch et al : Pathogenesis of Spondylosis Deformans and Arthrosis Uncovertebralis

selves Clinically, on account of the intimate anatomical relationship of the uncovertebral region to the
spinal nerves, blood vessels, and the cervical sympathetic trunk, these symptoms comprise radiated pain,
blood flow disturbances, and neurovegetative phenomena in distinct organs (Krogdahl and Torgersen
1940 ; Friedenberg et al 1959 ; Bowden 1966 ; Penning 1978; Stahl 1977 ; Kramer 1978 ; Wood 1979) In
consequence of the bone changes, the chronic CS
syndromes only occur in middle to old age, with a
peak in the 4th-6th decades (Krimer 1978).
In contrast to the bone-associated chronic symptoms caused by spondylosis or arthrosis, the acute
vertebral syndromes with radicular character and
relatively uniform symptomatology, are based on
soft-tissue changes that take the form of disc prolapse They occur, on average, 10 years earlier than
the chronic CS syndromes (Kramer 1978), and more
than 90 % are located in the two lowermost motion
segments, L4/L 5 and L 5/51 (Idelberger 1975) Here,
the high and constant stressing by compressive forces
in the region of transition between the lumbar lordosis and the fixed sacral kyphosis, in conjunction with
maximum loading through anteroposterior flexion,
may cause disc diseases at a young age.
Prolapse of the two lower intervertebral discs
most frequently lead to clinically manifested sciatiform symptoms Both in monoradicular and biradicular entrapment, owing to the anatomical situation,
these symptoms are relatively uniform, since, on the
one hand, the discs and intervertebral foramina are
located at the same level, while on the other, the diameter of the intervertebral foramen vis-a-vis that of
the nerve root becomes relatively smaller in the caudal direction On the basis of their anatomical construction and their high static and dynamic stressing
respectively, the lower LS and the lower CS are "predestined" to develop acute and chronic diseases.
In the thoracic spine, in contrast, clinically relevant acute or chronic symptoms are virtually never
seen, since on the one hand, owing to the position of
the intervertebral foramen on the level of the VB,
the intimate spatial relationship of disc and nerve
roots is lacking, while on the other, on the basis of
the functional-anatomical integration, extreme static
and dynamic stresses usually do not occur in the thorax.
The changes in external form of the VB due to
spondylosis and arthrosis are brought about by bone
accretion At the same time, however, changes in the
internal structure also occur, in the sense of physiological age-related osteoporosis This breakdown of
bone is commonly (Albright et al 1940 ; Bartelheimer and Schmitt-Rohde 1956 ; Frost 1963 ; Eger et al.
1967; Schenk et al 1969 ; Schenk and Merz 1969 ;
Delling 1973, 1974 ; Tanaka 1974 ; Jesserer 1975,

1978) ascribed to an age-related diminishment in


osteoblast activity-so-called osteoblast insufficiency.
The apparent contradiction between simultaneous
new formation and breakdown of bone resolves,
however, when one considers the reactive plasticity
of bone tissue (Pliess 1969), which adapts itself to the
age-related mechanical situation presenting Thus,
bone accretion, in the form of spondylotic or arthrotic osteophytes, must be considered a local reaction to
mechanical stimuli, which act on the bone tissue subsequent to chronic disc degeneration with instability
of the motion segment.
Bone breakdown in old age varies locally (Lauer
1980) Thus, the LVB loses more than 1/3, the CVB
only just loO of its original bony mass (Pesch et al.
1980b,1985) Owing to the age-related reduction in
the range of movements, and in physical activity,
there is but a weak "preservation stimulus" for the
cancellous bone in the LS, which is stressed largely
statically by axial compressive forces In contrast,
the dynamic loading of the CS, which remains largely
constant even in old age (Buytendijk 1956), which
subserves orientation in space, and which consists of
traction and torsional forces acting from various
directions, provides a powerful stimulus that secures
the preservation of the cancellous trabeculae For
this reason, a considerably smaller breakdown of
spongy bone occurs in the CVB than in the LVB in
old age.
The new formation and breakdown of bone thus
represent reactive-adaptive processes that are the
result of the self-regulating adaptation of connective
and supporting tissue to mechanical stressing (Pesch
et al 1980 a, von Glass and Pesch 1983).
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Received August 7, 1984