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Radiologic Imaging of Facet Joints Final PDF
Radiologic Imaging of Facet Joints Final PDF
2.
Introduction
Low
back
pain
has
a
high
prevalence
and
has
substantial
socioeconomic
implications.
Imaging
is
frequently
used
to
examine
patients
with
aspecific
back
pain
with
or
without
irradiating
pain.
The
correlation
between
anatomic
abnormalities
seen
on
imaging,
clinical
history
and
outcome
remains
controversial.
In
some
cases
the
source
of
back
pain
cannot
be
determined
with
certainty
on
imaging
studies.
The
diagnosis
and
treatment
of
back
pain
remains
problematic
due
to
the
large
number
and
diversity
of
potential
pain
generators
in
the
lumbar
spine.
Most
literature
focuses
on
the
intervertebral
discs,
however
it
is
increasingly
apparent
that
the
zygapophysial
joint
aka
“facet”
joints
also
play
a
major
role
in
low
back
pain.
Diagnosis
of
facet-‐mediated
spinal
pain
is
difficult.
History
and
physical
examination
may
suggest,
but
cannot
confirm,
the
facet
joint
as
the
source
of
pain
(Hancock
et
al.
2007).
Although
radiologists
are
commonly
asked
by
clinicians
to
determine
the
degree
of
facet
joint
osteoarthritis,
the
published
radiological
investigations
report
no
correlation
between
the
clinical
symptoms
of
low
back
pain
and
degenerative
spinal
changes
observed
on
radiologic
imaging
studies
(Schwarzer
et
al.
1995).
Specifically,
the
association
between
degenerative
changes
in
the
lumbar
facet
joints
and
symptomatic
low
back
pain
remains
unclear
and
is
a
subject
of
ongoing
debate.
Facet
joint
osteoarthritis
is
intimately
linked
to
the
distinct
but
functionally
related
condition
of
degenerative
disc
disease
(figure
1),
which
affect
structures
in
the
anterior
aspect
of
the
vertebral
column
(Gellhorn
et
al
2012).
3.
Facet
joint
disease
The
facet
joints
are
the
articulations
of
the
posterior
arch
of
the
vertebrae.
They
are
an
important
part
of
the
posterior
column
and
provide
structural
stability
to
the
vertebral
column.
These
joints
are
surrounded
with
a
fibrous
capsule
and
connect
the
superior
and
interior
articular
facets
of
the
vertebrae.
The
posterior
ligamentous
complex
(facet
joint
capsule,
ligamentum
flavum,
interspinous
ligament
and
suprapinous
ligament)
keeps
the
facet
joints
and
the
vertebrae
in
a
fixed
position
with
each
other.
Injury
of
this
complex
can
result
in
subluxation
or
dislocation
of
the
facet.
The
facet
joints
are
composed
of
two
articular
surfaces.
Unlike
the
intervertebral
disc,
they
are
true
synovial
joints.
The
joint
produces
synovial
fluid,
the
prime
lubricant
for
the
joint
and
the
nutritional
source
for
the
joint
surface
cartilage.
Like
in
all
synovial
lined
joints,
arthrosis
is
a
continuum
between
loss
of
joint
space
narrowing,
loss
of
synovial
fluid
and
cartilage
and
bony
overgrowth.
High
grade
cartilage
necrosis
arises
quite
rapidly
in
facets.
Facet
arthrosis
or
degenerative
facet
disease
is
the
most
frequent
form
of
facet
pathology.
It
is
mainly
a
disease
affecting
the
elderly
population,
present
in
virtually
everyone
after
the
each
of
60
and
in
varying
degrees
affecting
the
majority
of
adults,
suggesting
that
facet
arthrosis
has
a
major
role
in
neck
pain
and
back
pain
in
the
elderly
population.
Degenerative
facet
disease
in
many
cases
already
begins
before
the
age
of
20.
There
is
no
gender
preference.
It
is
probably
related
to
mechanical
loading,
minor
repetitive
trauma
and/or
a
form
of
predisposition.
Symptoms
and
signs
are
very
aspecific
and
can
be
variably
progressive.
Most
commonly
it
gives
rise
to
a
mechanical
type
of
neck
or
back
pain,
but
it
can
also
be
asyptomatic.
Studies
have
shown
that
facet
joints
are
clinically
important
spinal
pain
generators
and
patients
with
symptomatic
facet
joints
can
benefit
from
specific
interventions
.
The
symptoms
are
frequently
aggrevated
by
extension
and
alleviated
by
flexion,
with
pain
not
irradiating
below
the
knee.
There
is
a
poor
correlation
between
pain
and
the
extent
of
degeneration.
Mechanical
stress
is
exacerbated
in
facets
that
are
more
horizontal
in
a
sagittal
plane,
typically
at
the
L4-‐L5
level
(figure
2).
In
imaging
studies
more
and
more
the
emphasis
lies
on
the
visualization
of
inflammation
of
the
facet
joint
and
the
surrounding
soft
tissues.
It
is
believed
that
this
inflammation
is
the
cause
of
local,
i.e.
non-‐irradiating,
pain.
Not
all
changes
are
inflammatory,
especially
bony
overgrowth
is
a
protective
reaction
to
inflammation,
diminishing
inflammatory
response.
However
bony
overgrowth
can
be
an
important
cause
of
neuroforaminal
narrowing,
giving
rise
to
irradiating
pain.
Degenerative
spondylolisthesis
is
a
displacement
of
one
vertebra
relative
to
another
in
the
sagittal
plane.
In
many
cases
it
is
related
to
facet
joint
arthrosis
and
failure
of
the
motion
segment.
Listhesis
occurs
as
a
result
of
subluxation
of
the
facet
joint,
related
to
important
and
progressive
loss
of
cartilage
and
articular
remodeling
(figure
2).
A
more
sagittal
joint
orientation
might
lessen
the
amount
of
anterior
restraint
that
the
facet
joints
are
able
to
supply
to
the
vertebral
column
simply
because
there
is
less
of
a
bony
barrier
in
the
sagittal
plane.
This
lack
of
restraint
can
result
in
anterior
slippage
of
the
superior
vertebra
in
the
motion
segment.
Spondylolisthesis
therefore
most
often
occurs
at
L4–L5,
the
same
level
that
is
most
often
affected
by
arthrosis.
This
can
narrow
the
spinal
canal
and
the
neuroforamina
(Gellhorn
et
al.
2012).
Septic
facet
arthritis
or
pyogenic
facet
arthritis
is
a
completely
different
and
rare
entity.
It
can
give
rise
to
similar
imaging
findings
as
degenerative
disease,
usually
with
more
inflammation
and
a
more
aggressive
course.
The
isolated
form
should
always
arise
suspicion
of
tuberculosis
or
an
iatrogenic
cause
(figure
3).
In
some
cases
it
is
secondary
to
infection
of
the
discs
and/or
vertebrae
(spondylodiscitis).
4.
Radiography
Osteoarthritis
of
the
facet
joints
is
a
frequent
radiographic
finding,
particularly
among
the
elderly.
Standard
frontal
and
lateral
radiographs
are
of
limited
value.
Oblique
radiographs
are
the
best
projections
to
demonstrate
the
facet
joints
of
the
lower
lumbar
spine
because
of
their
oblique
position
and
curved
configuration.
Even
on
oblique
views,
however,
only
the
portion
of
each
joint
that
is
oriented
parallel
to
the
X-‐ray
beam
is
clearly
visible.
Degeneration
is
characterized
by
joint
space
narrowing,
sclerosis,
bone
hypertrophy
and
osteophytes.
Intraarticular
gas
(“vacuum
phenomenon”)
(figure
4)
may
be
present
and
spondylolisthesis
is
not
uncommon.
Conventional
radiography
is
insensitive
in
the
detection
of
mild
facet
joint
disease
and
becomes
slightly
more
sensitive
for
detecting
severe
disease.
Also,
with
this
technique
the
degree
of
involvement
tends
to
be
underestimated.
Therefore,
standard
radiographs
can
best
be
used
for
screening
for
facet
joint
osteoarthritis
and
grading
spondylolisthesis
according
to
the
Meyerding
classification
(table
1)
(Meyerding
HW.
1932).
It
is
particulary
useful
for
evaluating
motion
related
abnormalities
in
flexion
or
extension.
This
can
be
very
important
for
assessing
instability
in
case
of
spondylolisthesis.
As
mentioned
before,
the
clinical
relevance
of
detecting
osteoarthritis
of
the
facet
joints
remains
unclear
and
controversial
(Pathria
M,
Sartoris
DJ,
Resnick
D.
1987,
Weishaupt
D
et
al.
1999).
A
B
Figure
2:
CT-‐scan
of
the
lumbar
spine.
Sagittal
(A)
and
axial
(B)
reconstructions
show
degenerative
facet
joints
with
an
anterolisthesis
of
L4
due
to
degeneration
of
the
facet
joints.
We
see
hypertrophic
bone
osteofytes,
loss
of
the
articular
space
and
subchondral
geode.
A
B
Figure
3:
MRI
of
the
lumbar
spine.
Sagittal
T2-‐
(A),
STIR
(short
TI
inversion
recovery)
(B),
T1-‐(C)
and
CE
(contrast
enhanced)
T1-‐weighted
(D)
images.
Axial
T2-‐
(E),
T1-‐
and
CE
T1-‐
weighted
images.
58-‐year-‐old
woman
with
erysipelas
of
the
right
leg
with
back
pain.
Important
synovitis
of
the
right
facet
joint
L4-‐L5
with
inflammation
in
the
surrounding
soft-‐tissue,
especially
on
the
fluid
sensitive
sequence
(STIR),
with
enhancement
of
the
subchondral
bone
after
intravenous
gadolinium.
A
B
C
D
E
F
G
Figure
4:
Conventional
radiography
of
the
lumbar
spine.
Anteroposterior
(A),
lateral
(B),
left
(C)
and
right
(D)
oblique
images.
56-‐year-‐old
woman
with
back
pain.
Degenerative
discs
at
the
L3-‐L4,
L4-‐L5
and
L5-‐S1
level
with
associated
facet
arthrosis,
especially
at
the
L2-‐L3
level
on
the
right
side,
best
seen
on
the
right
oblique
(D).
A
B
C
D
Figure
5:
MRI
of
the
lumbar
spine.
Axial
T2-‐weighted
image
showing
an
intraspinal
cyst
of
the
left
L4-‐L5
facet
joint.
Compression
of
the
dural
sac
and
displacements
of
nerve
roots
of
the
cauda
equina.
Figure
6:
MRI
of
the
lumbar
spine.
58-‐year-‐old
man
with
radiculating
back
pain
and
claudicatio.
Sagittal
T2-‐weighted
(A),
T1-‐weighted
(B)
and
STIR
images.
Axial
T2-‐
weighted
(D),
T1-‐weighted
(E)
images.
Disc
degeneration
with
bulging
of
the
contours
and
hypertrophic
facet
arthrosis
with
spinal
stenosis
at
the
L4-‐L5
level
and
neuroforaminal
stenosis
at
the
L3-‐L4,
L4-‐L5
and
L5-‐S1
level
at
the
left
side.
Note
also
subchondral
bone
edema
in
the
left
facet
joint
L4-‐L5
with
intra-‐articular
fluid,
signs
of
arthrosynovitis.
A
B
C
D
E
Figure
7:
MRI
of
the
lumbar
spine.
61-‐year-‐old
man
with
radiculating
back
pain.
Sagittal
T2-‐
weighted
(right
A,
left
B),
T1-‐weighted
(right
C,
left
D)
and
STIR
(right
E,
left
F)
images.
Axial
T2-‐
(G)
and
T2-‐
weighted
(H)
images.
Degenerative
anterolisthesis
of
L5
with
hypertrophic
facet
arthrosis
at
the
L3-‐L4,
L4-‐L5
and
L5-‐S1
level
on
both
sides.
Note
the
radicular
compression
of
the
left
L5
root
(D)
due
to
foraminal
stenosis.
The
axial
images
clearly
show
fluid
in
the
degenerative
facet
joints
at
the
L4-‐L5
level
with
an
arthrosynovial
cyst
(ganglion)
at
the
left
side
(G).
A
B
C
D
E
F
G
H
Figure
8:
Single
photon
emission
tomography
(SPECT)
of
the
lumbar
spine.
56-‐year-‐old
man
with
radicular
back
pain.
Bone
scintigraphy
(A)
and
axial
SPECT-‐CT-‐fused
(B
and
C)
and
axial
CT
(D)
images
at
the
L2-‐L3
level
show
increased
Technetium
uptake
in
the
facet
joint
on
the
left
side.
The
other
foci
of
increased
uptake
where
due
to
disc
degeneration.
A
B
C
D
10.
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