spondylosis, facet joint arthropathy and pain cme/friday/c5 1630 borowczyk.pdfand why enquire about...

Spondylosis, Facet Joint Arthropathy and Pain

Jim Borowczyk Department of Orthopaedics and Musculoskeletal Medicine

Christchurch School of Medicine University of Otago

Do ‘Age Related’ Changes in the Spinal Column

Cause or Contribute to Chronic Pain?

And why enquire about this?

Major insurance agencies worldwide covering work and other accident related injury often use the presence of ‘spondylosis’ and ‘facet joint arthropathy’, as seen on imaging, to decline further cover for a particular incident

This often occurs without warning in a setting in which the patient felt an inherent security in the system or process that was expected to provide for his medical rehabilitation, and protection of income while injured

Question Is this a justifiable stance? Yes or No?

GPCME South 2010 - Spondylosis and Pain 4

Questions requiring answers . . .

What is the true prevalence of spinal spondylosis and altered zygapophysial (facet joint) morphology?

What is its relation to increasing age?

How much do these changes contribute to spinal pain syndromes?


Spondylosis - Definitions

GPCME South 2010 - Spondylosis and Pain

‘Spondylosis is a process whereby the morphology of the vertebral bodies change,

with the production of marginal osteophytes at the superior and inferior bodies’

‘One cardinal feature of spondylosis is said to

be the development of vertebral body osteophytes’ Bogduk, 1997 (1)

6

Spondylosis - Definition


‘Spondylosis is a term referring to degenerative osteoarthritis of the joints

between the centra of the spinal vertebrae and or neural foraminae. In this condition

the interfacetal joints are not involved’

(Wikipedia – the online encyclopaedia)

7

Age Changes in the Spinal

Column

The ‘Wear and Tear’ of Life

Intervertebral

Discs

10

The Ageing Disc

Reduced proteoglycan synthesis (65% by dry weight > 30% as early adulthood > age 60)

Reduction in proteoglycan size

Ratio of chondroitin/keratin drops

This decreases water binding capacity

Number of viable chondrocytes decreases with increasing evidence of necrosis


The End Result . . .

The end result is that with increasing age the discs become drier with an increase in collagen density and become more fibrous and less resilient


MRI

Imaging

Normal

Sagittal

T2


MRI Sagittal

T2

Loss of Disc

Signal and

Height

14

Anulus fibrosis

As the nucleus dries more load is borne by the anulus

The lamellae of the anulus become thickened and fibrillated

Cracks cavities and fissures may develop in the anulus

Intervertebral disc height and diameter tend to increase with age


Vertebral Body

Bone density decreases with age

There is a relative loss of horizontal trabeculae

This reduces the load bearing capacity of the vertical trabeculae and, greater load is borne by the cortical bone of the vertebra

Cortical bone is more prone to failing under deformation than trabecular bone so that the vertebral body is more liable to deformation

Osteophytes occur at the bony margins


GPCME South 2010 - Spondylosis and Pain Vertebral Body 19

X-Ray Imaging

20

Zygapophysial (‘z’ ‘facet’) joints

23

‘Z’ Joint Arthropathy

The subchondral bone gradually increase in thickness with age

Cartilage fibrillation occurs from repeated stresses of daily living with erosion and focal thinning of the cartilage

Osteophytes develop at the attachment sites of the joint capsule and the ligamentum flavum hypertrophies

There may be excess intra-articular fluid


MRI Imaging

Normal

Axial

25


MRI Imaging

Facet Joint Fluid

27

So What Are the Real

Causes of

Spinal Pain?

What Does Cause Spinal Pain?

Any tissue in the spinal column, with the exception of an intact nucleus pulposus may cause pain

These tissues include: Intervertebral discs – nucleus and anulus

Facet joints

Vertebral bodies

Muscle, ligament and tendon

Nerves and dorsal root ganglia


3 main sources are . . .

Discs up to 40% Schwarzer, 1995 (2)

Facet joints 15 – 40% Schwarzer, 1994 (3)

In a study of 438 patients with presumed facet joint pain: Cervical – 39%

Thoracic – 34%

Lumbar – 27% Manchukonda,2007 (4)

Lumbar facets 33 – 42% Manchikanti, 2008 (5)

And for low back, the SIJ (15%) Schwarzer 1995 (6)


Discogenic Pain

Spondylosis per se is not a cause

The pathogenesis of discogenic pain is internal disc disruption

This is a process that is first initiated by microfracture of the endplates


Vertebral end-plates

Each end-plate is a layer of cartilage 1 mm thick. In infancy the vertebral end-plate is part of the growth plate of the vertebral body

By age 20 the end-plate is gradually sealed of from the vertebral body

With age the end-plate becomes thinner with increasing cell death


Facet Joint Pain

When facet joints are injured (MVA) the non radiological pathology includes:

Joint capsule stretching and tearing

Gouging , tears, splits and partial loss of the articular cartilage

Damage to the surface layers of the underlying subchondral bone – infraction

Small undisplaced fractures of facet tips


39

Joint

Haemarthrosis

Cartilage Damage

40

41

Bone

Bruising

Fracture

Facet Joint

Tip

42

However . . .

Whilst these tissues are frequently the cause of spinal pain, there is no reason to suspect that there is any particular relationship to spondylosis and altered facet joint anatomy changes that occur with age

For example, in patients with whiplash, particularly in younger patients, imaging commonly shows no abnormality


Prevalence of Spondylosis


Prevalence of Spondylosis

By Age

20 -39 40 - 49 50 –59 60 – 69 70 + 80 +

24% 45% 74% 90% 70% * Kalichman, 200810

N = 188 patients

14% 45% 73% 75% 85% 90% Yoshimura, 2009 11

N = 3,040

34% * * * * * Boden, 1996 12


By Level

L2 - 3 L3 - 4 L4 - 5 L5 – S1

15% 30% 45% 40% Kalichman 2008 10


And, as we get older . . .

Two hundred twenty-three subjects who underwent MRI 10 years ago, underwent another MRI, neurologic examination, and questionnaire survey regarding symptoms related to cervical spine and life style. Progression of degeneration of cervical spine on MRI was frequently observed during 10-year period. No factor related to progression of degeneration of cervical spine was identified except for age.

(Okada, E., et al., Aging of the cervical spine in healthy volunteers: a 10-year longitudinal magnetic resonance imaging study. Spine, 2009. 34(7): p. 706-12. 27)


So Does Spondylosis

and Arthropathy cause

Spinal Pain?

The Medical Literature

For the Affirmative

Class IV evidence . . .

‘Low back pain is responsive to therapies that are effective for osteoarthritis in other locations. Osteoarthritis of the lumbar spine does cause low back pain’. Patients who do not have osteoarthritis of the facet joints on magnetic resonance scan do not have back pain’ (Borenstein 2004 13)

‘When mechanical factors are prominent, the condition is often referred to as “cervical spondylosis,” although the term is often applied to all non-specific neck pain. Mechanical and degenerative factors are more likely to be present in chronic neck pain.’ (Binder 2007 14)


For the Negative

For the Negative . . .

Studies have highlighted the fact that a simple relationship of structural abnormalities to low back pain is impossible because similar alterations can be found in symptomatic as well as in asymptomatic individuals (Boos, 1998 19)


Since the 1960’s . . .

The relationship between degenerative changes seen on imaging and back pain has been questioned . . .

Lawrence 1966 (15)

Biering-Sorensen, 1985 (16)

Frymoyer 1984 (17)


As for imaging . . .

With normal X-ray the documented reliability of reporting for facet joint disease is poor, with kappa scores ranging from 0.2 to 0.3 (Coste 1991)

Although some diagnoses related to low back pain were quite consistently evaluated, the substantial disagreement on many findings should alert clinicians and radiologists against overestimating the validity and usefulness of the examinations (Espeland 1998 28)


There is a weak correlation between back pain and spondylosis on plain films. The data have poor sensitivity, poor specificity, and only generate likelihood ratios (LR) of a little over 1 (Bogduk 2002 18)

Plain X-ray lacks validity, and with some exception, generates Likelihood Ratios seldom better than 1.5 (Bogduk 200218)


van Tulder, M.W., et al., Spinal radiographic findings and nonspecific low back pain. A systematic review of observational studies. Spine, 1997. 22(4): p. 427-34. 25

Degeneration, defined by the presence of disc space narrowing, osteophytes, and sclerosis, turned out to be associated with nonspecific low back pain with odds ratios ranging from 1.2 to 3.3.

There is no firm evidence for the presence or absence of a causal relationship between radiographic findings and nonspecific low back pain.


MRI . . .

Two decades following their description, the significance of Modic vertebral endplate and marrow changes remains a matter of debate. These changes are closely related to the normal degenerative process affecting the lumbar spine, and their prevalence increases with age. (Rahme, 2008 24)

MRI has been recognized as a modality of choice in the evaluation of the spine. Morphological abnormalities demonstrated by MR imaging do not always reflect low back pain (Fukuda, 2001 7)


And . . .

Low back pain is a common but poorly understood entity. Features of degeneration depend on which component of the motion segment is predominantly affected, and include disk space narrowing, vacuum phenomenon, disk desiccation, vertebral osteophyte formation, disk herniation, and facet arthrosis, but these features do not necessarily have any relationship to symptoms (Miller, 2004 20)


And . . .

Degenerative changes of the spinal column have long been and continue to be confused with the presence of spinal distress and pain (Anderrson 1998 22)

Degenerative disorders in the spine are normal, age-related phenomena and largely asymptomatic in most cases (Roh, 2005 21)


And this is telling . . .

Degenerative spinal pathology is often implicated as the primary reason for chronic low back pain in older adults. Despite evidence that spinal pathology may be ubiquitous in older adults regardless of pain status, radiography continues to be heavily used in the diagnostic process (Hicks 2004 23)

Radiographic severity of disc and facet disease was not associated with pain severity among those with

chronic low back pain (Hicks 2004 23)


Influence of occupation

An MRI study was performed in female subjects aged 45 to 62 years with persistent LBP and in age-matched controls. Subjects (n = 109) were selected from nursing and administrative professions

These findings give evidence that in subjects performing non-heavy work, patterns of lumbar disc degeneration are not associated with the job type and characteristic physical loadings (Schenk et al, Spine, 2006 26)


Imaging Reporting

Roland, M. and M. van Tulder, Should radiologists change the way they report plain radiography of the spine? Lancet, 1998. 352(9123): p. 229-30. (31)

‘Radiologists must take some responsibility for the way their reports are used and interpreted. At present reports of plain radiographs are relayed in a manner that is unintentionally damaging to patients because they promote beliefs and patterns of behaviour that contravene current guidelines on the management of back pain.

Radiologists should use epidemiological information to convey precise and useful information, to reduce potential harm, and to educate their users’


And should spondylosis be

reported at all?

The labeling of disease can be beneficial in terms of defining appropriate treatment such as in coronary artery disease. However, sometimes it may be detrimental such as when x-rays are used to diagnose lumbar spondylosis

(Bedson 2004 30)


Illustrative Case 1

Mrs G

Age 79


Mrs G’s History . . .

Mrs G tripped over a kerb, whilst running to catch a plane in the airport in the semi darkness

She fell heavily striking her head and breaking a rib

The rib healed, but six weeks later she still had significant left sub-occipital neck pain and headache VAS 70-90/100 with marked restriction of movement


68

CT Imaging

Loss of Disc

Space

C1-2 Facet

Arthropathy

CT

Imaging

Loss of

Disc

Space

Ankylosis

Spondyo-

listhesis


CT

Imaging

Facet

Arthropathy

70

73

Left

C1-2

Facet

Injection

Illustrative Case 2

Mr ‘C’

Age 39


Mr C’s History . . .

39 year old truck driver

Helping to lift 200kg sheet of metal

Slipped, twisted and developed ALBP

Previously fit and healthy, an active sportsman, 9 months later he cannot work or play sport

Was assessed by an orthopaedic specialist on behalf of ACC who organised an MRI scan


Summary

Bogduk 1997 (1)

Traditionally certain changes in the intervertebral discs and zygapophysial joints have been described as features of a disease

With respect to the intervertebral discs, the term used is ‘spondylosis’

With respect to the zygapophysial (or facet) joints the terms used are ‘osteoarthrosis’, or ‘degenerative joint disease’


Spondylosis and spinal osteoarthrosis are irregularly, if ever, in themselves associated with symptoms and disability

Osteoarthrosis or altered morphology of the z joints is not a disease, but an expression of the morphological changes resulting as a natural consequence of the stresses applied to the zygapophysial joints during life.


Conclusion

Patients with spondylosis and osteoarthrosis may present with pain, but there are a greater number of others of the same age with spondylosis who do not have pain, and many with pain who have no changes at all

The presence of these findings on imaging should be interpreted with great caution, and should never be relied upon to establish a tissue-specific diagnosis for spinal pain.


References

1. Bogduk, N., Age Changes in the Lumbar Spine, in Clinical Anatomy of the Lumbar Spine and Sacrum. 1997,

Churchill Livingstone: Edinburgh, London, New York, Philadelphia, Sydney, Toronto. p. 171-176.

2. Schwarzer, A.C., Aprill, C. N., Derby, R., Fortin, J., Kine, G., Bogduk, N., The prevalence and clinical features of internal disc disruption in patients with chronic low back pain. Spine., 1995. 20(17): p. 1878-83.

3. Schwarzer, A.C., et al., Pain from the lumbar zygapophysial joints: a test of two models. Journal of Spinal Disorders., 1994. 7(4): p. 331-6.

4. Manchukonda, R., et al., Facet joint pain in chronic spinal pain: an evaluation of prevalence and false-positive rate of diagnostic blocks. Journal of Spinal Disorders & Techniques, 2007. 20(7): p. 539-45.

5. Manchikanti, L., et al., Age-related prevalence of facet-joint involvement in chronic neck and low back pain. Pain Physician, 2008. 11(1): p. 67-75.

6. Schwarzer, A.C., C.N. Aprill, and N. Bogduk, The sacroiliac joint in chronic low back pain. Spine., 1995. 20(1): p. 31-7.

7. Fukuda, K. and G. Kawakami, Proper use of MR imaging for evaluation of low back pain (radiologist' view). Seminars in Musculoskeletal Radiology, 2001. 5(2): p. 133-6.

8. Kalichman, L. and D.J. Hunter, Lumbar facet joint osteoarthritis: a review. Seminars in Arthritis & Rheumatism, 2007. 37(2): p. 69-80.

9. Cavanaugh, J.M., et al., Pain generation in lumbar and cervical facet joints. Journal of Bone & Joint Surgery - American Volume, 2006. 88 Suppl 2: p. 63-7.

10. Kalichman, L., et al., Facet joint osteoarthritis and low back pain in the community-based population. Spine, 2008. 33(23): p. 2560-5.


11. Yoshimura, N., et al., Prevalence of knee osteoarthritis, lumbar spondylosis, and osteoporosis in Japanese men and women: the research on osteoarthritis/osteoporosis against disability study. Journal of Bone & Mineral Metabolism, 2009. 27(5): p. 620-8.

12. Boden, S.D., The use of radiographic imaging studies in the evaluation of patients who have degenerative disorders of the lumbar spine. Journal of Bone & Joint Surgery - American Volume, 1996. 78(1): p. 114-24.

13. Borenstein, D., Does osteoarthritis of the lumbar spine cause chronic low back pain? Current Pain & Headache Reports, 2004. 8(6): p. 512-7.

14. Binder, A.I., Cervical spondylosis and neck pain. BMJ, 2007. 334(7592): p. 527-31.

15. Lawrence, J., J. Bremner, and F. Bier, Osteoarthrosis: prevalence in the poulation and relationship between symptons and X-ray changes. Ann Rheum Dis, 1966. 25: p. 1-24.

16. Biering-Sorensen, F., The relation of spinal X-ray to low back pain and physical activity among 60-year old men and women. Spine, 1985. 10: p. 445-451.

17. Frymoyer, J., Spine radiographs in patients with low back pain. J Bone Joint Surg, 1984. 66A: p. 1048-1055.

18. Bogduk, N. and B. McGuirk, Imaging. Spondylosis, in Medical Management of Acute and Chronic Low Back Pain. An Evidence-Based Approach. 2002, Elsevier: Amsterdam. p. 50.

19. Boos, N. and J. Hodler, What help and what confusion can imaging provide? Baillieres Clinical Rheumatology, 1998. 12(1): p. 115-39.

20. Miller, T.T., Imaging of disk disease and degenerative spondylosis of the lumbar spine. Seminars in Ultrasound, CT & MR, 2004. 25(6): p. 506-22.


21. Roh, J.S., et al., Degenerative disorders of the lumbar and cervical spine. Orthopedic Clinics of North America, 2005. 36(3): p. 255-62.

22. Andersson, G.B., What are the age-related changes in the spine? Baillieres Clinical Rheumatology, 1998. 12(1): p. 161-73.

23. Hicks, G.E., N. Morone, and D.K. Weiner, Degenerative lumbar disc and facet disease in older adults: prevalence and clinical correlates. Spine, 2009. 34(12): p. 1301-6.

24. Rahme, R. and R. Moussa, The modic vertebral endplate and marrow changes: pathologic significance and relation to low back pain and segmental instability of the lumbar spine. Ajnr: American Journal of Neuroradiology, 2008. 29(5): p. 838-42.

25. van Tulder, M.W., et al., Spinal radiographic findings and nonspecific low back pain. A systematic review of observational studies. Spine, 1997. 22(4): p. 427-34.

26. Schenk, P., et al., Magnetic resonance imaging of the lumbar spine: findings in female subjects from administrative and nursing professions. Spine, 2006. 31(23): p. 2701-6.

27. Okada, E., et al., Aging of the cervical spine in healthy volunteers: a 10-year longitudinal magnetic resonance imaging study. Spine, 2009. 34(7): p. 706-12.

28. Espeland, A., et al., Observer variation in plain radiography of the lumbosacral spine. British Journal of Radiology, 1998. 71(844): p. 366-75.

29. Beattie, P.F. and S.P. Meyers, Magnetic resonance imaging in low back pain: general principles and clinical issues. Physical Therapy, 1998. 78(7): p. 738-53.

30. Bedson, J., R. McCarney, and P. Croft, Labelling chronic illness in primary care: a good or a bad thing? British Journal of General Practice, 2004. 54(509): p. 932-8.

31. Roland, M. and M. van Tulder, Should radiologists change the way they report plain radiography of the spine? Lancet, 1998. 352(9123): p. 229-30.


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