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? GPCME South 2010 - Spondylosis and Pain 5
Spondylosis - Definitions 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) GPCME South 2010 - Spondylosis and Pain 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) GPCME South 2010 - Spondylosis and Pain 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 GPCME South 2010 - Spondylosis and Pain 11
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 GPCME South 2010 - Spondylosis and Pain 12
MRI Imaging Normal Sagittal T2 GPCME South 2010 - Spondylosis and Pain 13
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 GPCME South 2010 - Spondylosis and Pain 15
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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 18
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 GPCME South 2010 - Spondylosis and Pain 24
MRI Imaging Normal Axial 25
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MRI Imaging Facet Joint Fluid GPCME South 2010 - Spondylosis and Pain 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 GPCME South 2010 - Spondylosis and Pain 30
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) GPCME South 2010 - Spondylosis and Pain 31
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 GPCME South 2010 - Spondylosis and Pain 32
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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 GPCME South 2010 - Spondylosis and Pain 34
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 GPCME South 2010 - Spondylosis and Pain 38
Joint Haemarthrosis 39
Cartilage Damage 40
Bone Bruising 41
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 GPCME South 2010 - Spondylosis and Pain 43
Prevalence of Spondylosis GPCME South 2010 - Spondylosis and Pain 45
Prevalence of Spondylosis By Age 20-39 40-49 50 59 60 69 70 + 80 + 24% 45% 74% 90% 70% * Kalichman, 2008 10 N = 188 patients 14% 45% 73% 75% 85% 90% Yoshimura, 2009 11 N = 3,040 34% * * * * * Boden, 1996 12 GPCME South 2010 - Spondylosis and Pain 46
By Level L2-3 L3-4 L4-5 L5 S1 15% 30% 45% 40% Kalichman 2008 10 GPCME South 2010 - Spondylosis and Pain 47
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 ) GPCME South 2010 - Spondylosis and Pain 48
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 ) GPCME South 2010 - Spondylosis and Pain 50
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 ) GPCME South 2010 - Spondylosis and Pain 52
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) GPCME South 2010 - Spondylosis and Pain 53
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 ) GPCME South 2010 - Spondylosis and Pain 54
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 2002 18 ) GPCME South 2010 - Spondylosis and Pain 55
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. GPCME South 2010 - Spondylosis and Pain 56
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 ) GPCME South 2010 - Spondylosis and Pain 57
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 ) GPCME South 2010 - Spondylosis and Pain 58
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 ) GPCME South 2010 - Spondylosis and Pain 59
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 ) GPCME South 2010 - Spondylosis and Pain 60
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 ) GPCME South 2010 - Spondylosis and Pain 61
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 GPCME South 2010 - Spondylosis and Pain 63
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 ) GPCME South 2010 - Spondylosis and Pain 64
Illustrative Case 1 Mrs G Age 79 GPCME South 2010 - Spondylosis and Pain 65
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 GPCME South 2010 - Spondylosis and Pain 66
CT Imaging Loss of Disc Space C1-2 Facet Arthropathy 68
CT Imaging Loss of Disc Space Ankylosis Spondyolisthesis GPCME South 2010 - Spondylosis and Pain 69
CT Imaging Facet Arthropathy 70
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Left C1-2 Facet Injection 73
Illustrative Case 2 Mr C Age 39 GPCME South 2010 - Spondylosis and Pain 74
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 GPCME South 2010 - Spondylosis and Pain 75
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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 GPCME South 2010 - Spondylosis and Pain 78
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. GPCME South 2010 - Spondylosis and Pain 79
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. GPCME South 2010 - Spondylosis and Pain 80
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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. GPCME South 2010 - Spondylosis and Pain 83
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. GPCME South 2010 - Spondylosis and Pain 84