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THE

CLINICAL

LUMBAR

PRESENTATION

FACET

AND

ARTHROSIS

ARTICULAR

SYNDROME

SURFACE CHANGES

S. M.

EISENSTEIN,

C.

R. PARRY

From

the

University

of the

Witwatersrand

We describe normal surfaces other plain showed large joints.

a lumbar some frequent

facet Local

syndrome spinal

in which fusion changes full-thickness

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

of the histological change histological may was focal

in chondromalacia cartilage the cause facet necrosis

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

in all specimens. arthrosis syndrome

back pain

We suggest that there and chondromalacia

in young and middle-

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

the patients and normal that, among

back pain We suggest least two of pain; and the aimed to in the may be

order

in

to reduce their This type of pain

degenerative or

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

patients are "downers", and recumbency and

whose increases movements.

pain is relieved throughout

by rest the day. fits

Forward

by swaying

bending patients

soft

is restricted who have

the

by pain some

of

and characterised

description

or jerking tissues,

This

including

those

spinal

had

result

sprain

or strain

or

of

long-

by repeated in the morning

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

the ununited fracture. The differentiation of these

helpful in both investigation, found in one

two

patterns

treatment of both

is imporand prepatterns

Department Orthopaedic

CR. Parry, University

Robert

Jones

& Agnes

Hunt

Hospital,

Oswestry,

Salop SY1O 7AG,

Fellow Medical School,

England.

York Road,

tant and operative may be syndrome confusion.

conservative but elements patient. and fact may be that not

BSc (Hons), Research of the Witwatersrand

The

"combination" allowed to cause an intervertebral

Parktown,

Requests

Johannesburg,

for reprints should

South

Africa.

to Mr S. M. and Joint Eisenstein. Surgery

must be recognised It reflects the

be sent Society

segment

time.

may fail in more

Both pain patterns

than

one of its parts

associated

at the same

with some

1987 British 0301-620X/87/lOl

©

Editorial 1 $2.00

of Bone

referred

1987

pain

in the lower

limbs,

but this can

readily

be

3

VOL.

69-B,

No.

1, JANUARY

4

SM.

EISENSTEIN.

CR.

PARRY

distinguished

nerve root

from

compression.

the major

disabling 12 patients

pain

produced the

this

by facet

to

blue. The damaged histologically.

facet joint or destroyed

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

postmortem change excised from four

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

being taken ages ranging

for transplantation. from 17 to 48 years

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

examined in the same could not be established had suffered backache.

way as those of the patients. It whether or not these subjects

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

a

be particularly

osteophyte

involved

formation

and,

in any

strikingly,

specimen.

there

was was

no the

or

The

common

feature

of

all

specimens

scoliosis.

exposure of subchondral else potentially present cartilage necrosis.

bone, sometimes in an ulcer, in an area of full-thickness

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

in a 48-yearthere was and minor

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

required revision of his all patients achieved of

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

DISCUSSION Many of the histological

described in classic

changes

and

which

we found

texts as those

have

of

Operation. intertransverse were fused

patients, Harrington old woman

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

osteoarthritis or arthritis Leubner 1936 ; Oppenheimer and Logr#{244}scino 1952; Lewin

deformans (Ayers 1935; 1938 ; Badgley 194 1 ; Putti 1964; Schmorl and Jungh-

while

instrumentation with progressive

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

5

I..

I.

Fig.

4

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

in the study of chondromalacia al. 1976; Insall 1982; Bentley

patellae (Goodand Dowd 1984;

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

These similarichanges of fullof cartilage from

(1976) in chondromalacia features we found young exercising

patellae. the articular

bone,

fellow

chondrocyte

et al. 1976)

clusters

but also

and

metachromasia

presentation;

(Goodin

in the clinical

cartilage question

VOL. 69-B,

of our relatively which is currently

No. I, JANUARY 1987

patients raises the the minds of those

both with

conditions relatively young severe disability from pain,

patients associated

may present with local

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

feel intuitively is disproportionate

sensitive cartilage, (1976),

subchondral as described is plausible.

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

"chondromalacia of respectability for a diagnosis unjustly

facetae", if upon those of "spinal classified as

by relatively minor cartilage is confronted clinicians in this field,

minor

destruction,

symptoms

sclerosis

in

the

and

presence

osteophytosis.

of also

advanced

Explanations

joint It is

who do not and are

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

possible relatively subchondral

that widespread even diffusion bone, producing

loss of cartilage of joint pressure less pain than of pressure acting

allows a into the that resultthrough

ing from high concentrations small areas of cartilage loss.

"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.

made a major for the identififor treatment of

Our patients to local infiltration

that our patients

most closely described

experienced

resemble the "responders" by Fairbank (1981) except

more pain with (lumbar their joints

under

relief flexion).

compression

with joint

(lumbar

surfaces

spine

separated

in extension),

spine

and

in

of an intervertebral increased pressure

disc can be on the facetjoint

For

conservative fusion, levels

a

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.

of the responsible segmental Computerised tomography

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).

facet joints, described

more than degeneration

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

to major pain probably almost

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

pain is available. We have to of Putti and Logr#{244}scino (1952)

abnormalities reliefobtained

that the

subjects under vast majority

changes.

30 years of age had normaljoints of those under 40 had only whereby

pain is not

and mild

arthritic

The causes for the facet unknown and the association

surface changes and pain

joint abnormalities between these

proved

remain articular

; it remains

The

changes

mechanism

may produce

these

known.

pathological

The concept

has not been

a matter

of conjecture.

THE JOURNAL OF BONE AND JOINT SURGERY

THE

LUMBAR

FACET

ARTHROSIS

SYNDROME

7

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, O'Brien 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

("chondromalacia facetae") arthrosis, or merely a stage

non-osteophytic reversible) in the

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

Hungerford DS, Woods C. and pathology. 2. Chondromalacia

concepts :147-52. review. Patellar pain. der

Patello-femoral patellae.

J Bone kleinen Joint

joint

J Bone Surg [Am]

Joint Surg [Br] 1976;58-B:29l-9.

J. Current 1982;64-A

Leubner

z

Lewin

H. Die Arthritis deformans Orthop I936;65 :42-52. Osteoarthritis Ada Orthop C. Ways Tunbridge

Wirbelgelenke. a morphological and experimental of osteoarthClin Orthop articulaJ Bone Joint

excellent

and to Ms

translation

Dolores

by J. Hart

Rokos for

of the paper

the illustrations.

by Putti

and Logr#{244}scino,

T. study.

in lumbar synovial Scand 1964;Suppl breakdown Pitman

joints: 73. in human

Meachim rosis.

ofcartilage

osteoarthrosis.

REFERENCES Ayres CE. Further case studies of lumbo-sacral pathology with

In : Nuki

Wells:

G, ed. The aetiopathogenesis

Medical, 1980:16-28.

Mooney

consideration

of involvement

of intervertebral

discs

and articular

pain and

V, Robertson 1976;l 15:149-56.

J.

The

facet

syndrome.

facets. N EngI J Med

1935;213:7l6-2I. in relation to low-back Surg 1941 ;23 :481-96.

Badgley CE. The articular facets sciatic radiation. J Bone Joint Bentley G, Dowd chondromalacia G. Current patellae. Clin

Oppenheimer A. Diseases of the apophyseal (intervertebral) tions. J Bone Joint Surg 1938;20:285-313. Outerbridge RE. The etiology ofchomdromalacia Surg [Br] 1961 ;43-B:752-7. Putti J Putti patellae.

concepts

of etiology Orthop l984;189

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patellae.

of

Bentley G. Articular cartilage changes in chondromalacia Bone Joint Surg [Br] l985;67-B:769-74.

V. Lady of sciatic

Jones pain.

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On new conceptions

I927;2:53-60.

in the pathogenesis

Carrera Darracott Dory Dunlop

GF,

Haughton

of the

VM,

lumbar Phys

Syvertsen

facetjoints. Med

A, Williams

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AL.

Computed

V, Logr#{226}scino Anatomia D. dell'artritismo vertebrale apofisario. In : Putti V, ed. Scritti medici.Vol II. Bologna : Edizioni Scienti-

tomography

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fiche

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Rizzoli,

1952:53.

5th by

J, Vernon-Roberts

Arthrography

Adams MA, facet joints.

B. The bony changes

1971 ;l 1 :175-9.

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Radiology and the

patellae". Rheumatol

Schmorl G, Junghanns German edition Besemann EF.

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MA.

RB, lumbar reference University

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WC.

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Fairbank

JC, The

anatomical sources to the intervertebral of Cambridge, 1981.

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Vernon-Roberts B. The pathology and interrelation of intervertebral disc lesions, osteoarthrosis of the apophyseal joints, lumbar spondylosis and low back pain. In : Jayson MIV, ed. The lumbar spine andback pain. 2nd ed. Tunbridge Wells etc : Pitman Medical, 1980:83-114. Yang

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a

VOL.

69-B,

No.

1, JANUARY

1987

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