THE
LUMBAR
CLINICAL
FACET
PRESENTATION
AND
S. M.
From
We describe
normal
plain
surfaces
large
Local
of the histological
The most
aged
The
clinical
Facet
spinal
change
the patients
and
normal
and
histological
may
the
these
arthrosis
aggravated
low-back
with
symptoms
disabling
radiographs.
there
In
in any
relieved
Rising
range
posture,
by pain
and
implies
in many
low
are
Requests
for
of
the
at
least
two
and
in osteoarthritis
or loss of cartilage
in all specimens.
arthrosis
syndrome
of intractable
may
or
have
called
need
to be up and
in
of pain;
and
the
aimed
to
in the
joints
back
be
of
with
exposure
of
We suggest that there
and chondromalacia
pain
Oswestry,
Johannesburg,
for reprints
No.
South
should
pain
is
in young
and middle-
with
known
presentation
Editorial
1 $2.00
1, JANUARY
Society
spinal
as
provide
physical
activity
pain is commonly
flexion.
Backward
bending
little
is usually
or no pain.
Jones
& Agnes
We
Hunt
England.
School,
York
Africa.
S. M.
and
Joint
Eisenstein.
Surgery
bending
Road,
altering
pain.
is recognisably
similar
inflammatory
arthritis
In this
forgotten
who
of their
posture
in
to that
in
seen
other
minor
by pain
the
result
injuries.
some
of
for this syndrome
a similar
pattern
helpful
in both
investigation,
be
found
syndrome
confusion.
segment
time.
in
may fail in more
Both
pain
pain
two
patient.
patterns
in the lower
patterns
treatment
of both
The
and
fact
than
may
than
spondylolysis,
and signs
conservative
but elements
one
of
long-
pattern
instability
is symptomatic
of symptoms
must be recognised
It reflects
the
or
the
have failed
in practical
1985).
One
clinical
the ununited
fracture.
The differentiation
of these
tant and
operative
fits
or strain
clinical
of lumbar
more objective
definitions
which
clinical
application
(Nachemson
model
which
description
sprain
unrecognised
This
definition
the
by rest
the day.
and characterised
This
had
the
by contrast,
pain
is relieved
throughout
movements.
have
tissues,
a better
syndrome,
whose
increases
is restricted
or jerking
soft
referred
1987
instability.
patients
may
Fellow
Medical
of Bone
or
because
or constantly
disease
of the spinal
synovial
joints,
may be much
as described
above.
by swaying
continuous
gentle
is difficult
because
of
Robert
to Mr
the “uppers”
about
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
those
recumbency,
Salop SY1O 7AG,
be sent
patients
degenerative
Forward
with
FRCS,
Director
Disorders,
The
these
to reduce
their
This type of pain
Lumbar
including
character,
PhD,
Spinal
Hospital,
1987 British
0301-620X/87/lOl
69-B,
facet
order
back
pain
We suggest
syndrome
; forward
BSc (Hons),
Research
of the
Witwatersrand
©
VOL.
patellae
patients
are “downers”,
and
recumbency
and
this
by repeated
in the morning
is restricted
Eisenstein,
Parktown,
are associated
with normal or nearin 12 patients;
the excised
facet joint
necrosis
absent
cause
from
CR.
Parry,
University
symptoms
in chondromalacia
between
SYNDROMES
syndrome.
by rest
of normal
Department
Orthopaedic
Witwatersrand
cartilage
important
pain”
changes
pain
and
stiffness,
which
ease
increases.
When
rest is unavoidable,
reduced
by a position
of lumbar
SM.
R. PARRY
was remarkably
similarities
of the lumbar
facet
arthrosis
syndrome.
PAIN
bending
seen
full-thickness
be a relatively
pathological
patients,
cartilage
to the facet
and
is
movement.
relieved
changes
syndromes,
each
with
a recognisable
pattern
these
are
the
“facet
arthrosis
syndrome”
“instability
syndrome”.
Our
investigation
provide
evidence
that
pathological
changes
Facet
disabling
formation
arthrosis
who present
or near-normal
among
articular
related
in which
fusion
was focal
but osteophyte
“non-specific
to establish
that,
of the
CHANGES
adults.
designation
failure
frequent
bone,
both
University
syndrome
some
C.
SURFACE
joints.
subchondral
patellae.
facet
SYNDROME
ARTICULAR
EISENSTEIN,
the
radiographs.
showed
other
are
a lumbar
ARTHROSIS
not
that
limbs,
be
is imporand prepatterns
“combination”
allowed
to cause
an intervertebral
one of its parts
may
in
result
associated
but this can
at the same
with
readily
some
be
3
4
SM.
distinguished
nerve
from
root
We
the major
disabling
pain
EISENSTEIN.
produced
by
compression.
have
arthrosis
pathological
investigated
syndrome
changes.
in
12 patients
an
with
attempt
to
the
relate
facet
this
AND
Nine
All had
were
had
before
failed
had
referral,
symptoms
and
to respond
1 1 women
and
spinal
operations
: one
man
for
with
the
decrease
in the joint
facet joints.
Mild reduction
was seen at one or more
patient
had
a lumbar
Osteophytosis
associated
space
lumbar
of the lumbosacral
facet
joints,
“spondylosis”,
not
Facetjoints.
There
way as those
of the patients.
It
whether
or not these
subjects
was
articular
cartilage
The most frequent
some
in the
finding
evidence
ofearly
damage
but we also saw ulceration,
(Figs
1 to 4). We
suspect
cartilage
necrotic
is the
“ulcer”
cartilage.
increased
to
facet joints
of all I 2 patients.
was a focus of full-thickness
cartilage
necrosis,
and
eburnation
result
clusters,
fibrillation
that
the
of sloughing
of a plug
of
foci of fibrocartilage
(Fig.
metachromasia
provided
perichondrocyte
5)
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
commonly
was
Death
had occurred
at
and the specimens
were
RESULTS
and
spine
scoliosis.
lumbar
been
studied
material
without
too much
low lumbar
facet
joints
were
cadavers
whose
kidneys
were
for transplantation.
from 17 to 48 years
Chondrocyte
and
of intervertebral
disc height
levels
in six patients,
and one
of the lumbar
with
necessarily
not
be
control
the
fresh
12
ages
an L5 laminectomy
of
had
could
for
three
were helpful only in excluding
other causes of backache.
In four patients
they were normal,
in three there was
detectable
some
to conservative
one
one a lumbosacral
discectomy.
Investigations.
Plain
radiographs
capsules
and
examined
in the same
could
not be established
had suffered
backache.
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
To provide
being
taken
ages ranging
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.
There
facet
joint
or destroyed
histologically.
METHODS
of the patients
of 1 5 months
to 20 years.
blue.
The
damaged
to
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.
PARRY
postmortem
change
excised
from
four
PATIENTS
an average
CR.
involved
formation
The
and,
in any
common
feature
exposure
of subchondral
else
potentially
present
cartilage
there
was
no
of
all
specimens
was
the
bone,
sometimes
in an ulcer,
in an area
of full-thickness
or
necrosis.
The
seen.
strikingly,
specimen.
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
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
facet
achieved
palpation
without
by radio-
Clinical
by facet
for points
graphs
arthrography
of maximum
with
skin
or by diligent
tenderness
markers.
followed
Arthrography
was
considered
provided
Several
and
by
subsequent
of the patients
discography
infiltration
had negative
in the
search
with
lumbar
for
other
causes
12 patients
had
posterolateral
and
fusion operations.
Both L4-5 and L5-Sl
in seven
patients,
L5-Sl
alone
in four
while
fusion
from
instrumentation
with
progressive
L2
to
the
pain at the lumbosacral
junction.
During
the operations
the facet joints
and
preserved
stained
cut
for
perpendicular
with
either
histological
to the
haematoxylin
sacrum
with
was required
for a 32-yearscoliosis
and
intractable
facet
examination.
plane
and
relief
were
excised
Sections
of the joint
eosin
in an
but
joints,
necrosis.
required
revision
of his
all patients
achieved
average
of
3.5
months
after
we found
have
DISCUSSION
of their
All
Harrington
old woman
pain
lumbar
cartilage
lignocaine.
Many
patients,
were
gratifying
all
focal
operation.
myelography
pain.
Operation.
intertransverse
were fused
in
of any
results.
One
patient
for pseudarthrosis,
fusion
to be positive
only when the injection
reproduced
some
or all of the usual symptoms,
and when some relief was
osteophytosis
evidence
and
or toluidine
been
of the histological
described
changes
in classic
and
which
standard
texts
as those
of
osteoarthritis
or
arthritis
Leubner
1936 ; Oppenheimer
deformans
(Ayers
1935;
1938 ; Badgley
194 1 ; Putti
and
1964;
Logr#{244}scino 1952;
Lewin
Schmorl
and
Jungh-
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
THE
the first examination
at operation,
but
inflammation
JOURNAL
OF BONE
rather
AND
JOINT
the
than
SURGERY
THE
LUMBAR
FACET
ARTHROSIS
5
SYNDROME
I..
Fig.
I.
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
tosis
studies
or bony
pathology
do,
however,
spurring
of osteoarthritis.
appear
to
have
been
all emphasise
as an important
A finding
described
osteophy-
feature
which
previously
of the
does
not
is the
full-
thickness
“necrosis-in-situ”
shown
in Figure
1 but this is
not
associated
with
osteophytes
and
resembles
the
“intermediate
stage destruction”
which
Meachim
(1980)
,
reported
“basal
ford
in his study
degeneration”
and
The
Woods
atrophic
of excised
described
of our
relatively
which
is currently
VOL.
No.
I, JANUARY
1987
heads,
by Goodfellow,
(1976)
in chondromalacia
features
we found
cartilage
question
69-B,
femoral
young
exercising
in
and
the
Hungerpatellae.
the articular
patients
raises
the
the minds
of those
engaged
fellow
Ct
in the study of chondromalacia
al. 1976; Insall
1982; Bentley
Bentley
1985):
course
of
bridge
1961)
There
are
whether
“classic”
this
is merely
spondylotic
or a peculiarly
similarities
patellae
(Goodand Dowd
1984;
chondrocyte
fellow
et al. 1976)
both
with
clusters
but also
in the
osteoarthritis
symptomatic
between
the
syndrome
and chondromalacia
patellae.
ties are found
not only in the histological
thickness
cartilage
necrosis,
separation
bone,
a stage
and
facet
of it.
arthrosis
These
similarichanges
of fullof cartilage
from
metachromasia
in the clinical
conditions
relatively
young
severe disability
from pain,
(Outervariant
(Good-
presentation;
patients
associated
in
may present
with local
6
SM.
tenderness
As
in
between
and normal
chondromalacia
the
plain
histology
the
to the physical
have
only
changes
proposed
to confer
patients
arthritis”
which
the term
a degree
who do not
and
are
the
relationship
symptoms
arthrosis
is not clear.
Clinicians
may
the degree
of pain in both conditions
in
facet
feel intuitively
is disproportionate
that
can be demonstrated.
“chondromalacia
of respectability
qualify
sometimes
for
CR.
PARRY
that
radiographs.
patellae,
and
EISENSTEIN,
We
facetae”,
if
upon
those
a diagnosis
unjustly
increased
sensitive
cartilage,
(1976),
minor
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
possible
relatively
subchondral
causes
described
conjectured
variations
for
the
articular
changes
we
have
for
opposite
predisposition.
It is possible
that asymmetric
angulation
of left and
right
facet
joints
could
produce
stresses
sufficient
to cause
early
articular
cartilage
injury,
but
the
presence
and
osteophytosis.
situation
syndromes”
of
are
advanced
also
conjectural.
of pressure
have
been
joint
Explanations
loss
of cartilage
of joint
pressure
less pain than
ing from high concentrations
small
areas
of cartilage
loss.
“Facet
to pain-
changes
confined
to articular
by the fact,
well
known
to
that many
patients
present
with
that
widespread
even
diffusion
bone,
producing
It is
allows
a
into
the
that result-
acting
described
through
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
between
the
facet
arthritis
with some
symptomatic
are
obscure,
but
no less
so than
those
for chondromalacia
patellae,
which
include
of normal
biomechanics,
trauma
and genetic
in
sclerosis
this
is transmitted
bone
through
foci
of necrotic
for the patella
by Goodfellow
et al.
Any attempt
to explain
major
pain
symptoms
destruction,
The
pressure
by relatively
minor
cartilage
is confronted
clinicians
in this field,
of “spinal
classified
as
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.
joint
subchondral
as described
is plausible.
joints.
He
and instability,
diffidence,
relief.
that
Mooney
did
not
distinguish
but ventured
to suggest,
arthrodesis
Robertson
produced
(1976)
also
spinal
and
failed
to make
this
distinction
but
contribution
by describing
joint injection
cation
of symptomatic
facet joints
and
made
a major
for the identififor treatment
of
pain.
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
Our patients
to local infiltration
most closely
described
resemble
the “responders”
by Fairbank
(1981) except
that
experienced
more
angulation
relief
and
as a possible
sciatic
pain
rather
of an intervertebral
increased
pressure
it (Dunlop,
1984)
but
normal
than
of nerve
low back
disc can be
on the facetjoint
Adams
in most
height
cause
and
Hutton
of our
or only
root
pain.
Loss
expected
surfaces
1984;
patients
the
slightly
disc
reduced.
obvious
argument
against
spaces
We
King
were
found
of
little
facet
joints,
described
an attempt
minor
changes
in articular
surfaces
symptoms
is that
these
changes
are
of height
and
patients
compression
with
(lumbar
joint
surfaces
to relate
to major
pain
probably
almost
For
a
patient
conservative
fusion,
levels
diagnosis
is crucial.
more than
degeneration
arthrographic
donors
available
low
pain,
accurate
fall back
that
the
history
on the
of spinal
findings
subjects
under
vast majority
arthritic
The
changes
and
no
pain is available.
We have to
of Putti and Logr#{244}scino (1952)
30 years of age had normaljoints
of those
under
40 had only
and
mild
changes.
mechanism
may
produce
whereby
pain
is not
these
known.
of
secondary
confirmation
and
spine
in
by
pain
is facing
refractory
operation
to
for spinal
level
offers
or
no
described
by Dory
(1981)
but
provide
useful
importance
of a positive
pain
may
response.
CONCLUSIONS
back
joints,
surfaces
affected
links
between
localisation
histological
and clinical
of the
surface
The
a matter
a clinical
source
abnormalities
reliefobtained
syndrome
of pain
in the
through
of
in facet
excised
fusion
joint
of the
segments.
The causes for the facet
unknown
and the association
pathological
concept
who
abnormalities
described
adults
(lumbar
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
We have
young
joints
plain radiographs,
unless there is advanced
(Carrera
et al. 1980). Facet arthrography,
are
are
their
of the responsible
segmental
Computerised
tomography
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
study
with
in extension),
separated
disabled
measures
universal
lumbar
material
articular
far are
for
pain
spine
flexion).
to produce
posterior
to
Yang
change
in the subchondral
bone
of the
certainly
nothing
like the patellar
osteoporosis
by Darracott
and Vernon-Roberts
(1971).
The
compression
our
under
changes
and
pain
joint abnormalities
between
these
has not been
proved
remain
articular
; it remains
of conjecture.
THE
JOURNAL
OF BONE
AND
JOINT
SURGERY
THE
At
as
to
this
stage,
whether
the
it is
facet
impossible
to
syndrome
(“chondromalacia
facetae”)
arthrosis,
or merely
a stage
LUMBAR
we
is a distinct
(possibly
be
FACET
ARTHROSIS
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.
dogmatic
have
described
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.
Ghormley
RK. Low back
with
presentation
1933;lOl :1773-7.
Goodfeilow
J,
mechanics
excellent
and
translation
to Ms
by J. Hart
Dolores
Rokos
of the paper
for
the
by Putti
Lewin
and Logr#{244}scino,
illustrations.
concepts
:147-52.
T.
study.
Meachim
Osteoarthritis
Ada
Orthop
C. Ways
rosis.
REFERENCES
CE.
Further
case
consideration
studies
of
of involvement
facets. N EngI J Med
G.
pathology
discs
concepts
Current
patellae.
of etiology
Orthop
l984;189
Clin
GF,
Haughton
tomography
of the
VM,
Syvertsen
lumbar
facetjoints.
J, Vernon-Roberts
Darracott
patellae”. Rheumatol
Dory
MA.
Arthrography
Med
of
the
of
ofcartilage
AL.
Putti
J
Computed
lumbar
facet
Radiology
1981 ;140:23-7.
Dunlop
RB,
lumbar
Fairbank
Adams
MA,
facet joints.
JC, The
69-B,
WC.
Joint
anatomical
sources
to
the
intervertebral
of Cambridge,
1981.
reference
University
VOL.
Hutton
J Bone
No.
1, JANUARY
1987
Disc
Surg
space
narrowing
[Br] l984;66-B:706-10.
of low back
apophyseal
pain
with
joints.
and
Wells:
Jones
pain.
Lecture.
Lancet
the
particular
Thesis,
facet,
JAMA
joint
J Bone
Joint
kleinen
joints:
a morphological
in human
facet
[Am]
73.
Medical,
The
Surg
Wirbelgelenke.
and
G, ed. The aetiopathogenesis
Pitman
J.
J Bone
experimental
of osteoarth-
1980:16-28.
syndrome.
Clin
On new conceptions
patellae.
Orthop
articula-
J Bone
Joint
in the pathogenesis
I927;2:53-60.
V, Logr#{226}scinoD. Anatomia
dell’artritismo
vertebrale
apofisario.
In : Putti
V, ed. Scritti
medici.Vol
II. Bologna : Edizioni
Scienti-
Instituto
Rizzoli,
Schmorl
G, Junghanns
German
edition
Besemann
EF.
in “chondromalacia
joints.
V. Lady
of sciatic
fiche
1980;134:l45-8.
1971 ;l 1 :175-9.
der
breakdown
In : Nuki
Tunbridge
pain.
Outerbridge
RE. The etiology
ofchomdromalacia
Surg [Br] 1961 ;43-B:752-7.
Putti
Radiology
Patello-femoral
patellae.
Oppenheimer
A. Diseases
of the apophyseal
(intervertebral)
tions. J Bone Joint Surg 1938;20:285-313.
and
patellae.
A, Williams
B. The bony changes
Phys
pain
and treatment
:209-28.
Bentley
G. Articular
cartilage
changes
in chondromalacia
Bone Joint Surg [Br] l985;67-B:769-74.
Carrera
with
Patellar
in lumbar
synovial
Scand
1964;Suppl
V,
Robertson
1976;l 15:149-56.
and articular
in relation
to low-back
Surg 1941 ;23 :481-96.
review.
Mooney
1935;213:7l6-2I.
Badgley
CE. The
articular
facets
sciatic
radiation.
J Bone Joint
Bentley
G, Dowd
chondromalacia
lumbo-sacral
of intervertebral
special
reference
to articular
operative
procedure.
H. Die
Arthritis
deformans
Orthop I936;65
:42-52.
osteoarthrosis.
Ayres
with
an
Hungerford
DS, Woods
C.
and pathology.
2. Chondromalacia
J. Current
1982;64-A
z
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
pain,
of
Joint Surg [Br] 1976;58-B:29l-9.
Insall
Leubner
The authors
radiological
preparations,
7
SYNDROME
1952:53.
H. The human
spine in health
and disease.
by Junghanns
H. Translated
and
edited
New
York etc : Grune
& Stratton,
1971.
5th
by
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
KH,
hypothesis
King
for
Al.
Mechanism
low-back
pain.
of facet
load
transmission
Spine
1984,9:557-65.
as
a