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?
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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?
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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)
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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)
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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
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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
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MRI
Imaging
Normal
Sagittal
T2
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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
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16
17
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
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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
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MRI
Imaging
Normal
Axial
25
26
MRI
Imaging
Facet
Joint
Fluid
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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
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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)
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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
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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
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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
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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
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Prevalence of Spondylosis
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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
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By Level
L2 - 3
L3 - 4
L4 - 5
L5 – S1
15%
30%
45%
40%
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Kalichman 2008 10
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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)
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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)
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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)
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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)
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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)
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 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)
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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.
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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)
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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)
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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)
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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)
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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)
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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’
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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)
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Illustrative Case 1
Mrs G
Age 79
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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
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CT
Imaging
Loss of Disc
Space
C1-2
Facet
Arthropathy
68
CT
Imaging
Loss of
Disc
Space
Ankylosis
Spondyolisthesis
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CT
Imaging
Facet
Arthropathy
70
71
72
Left
C1-2
Facet
Injection
73
Illustrative Case 2
Mr ‘C’
Age 39
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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




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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’
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 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.
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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.
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3.
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
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imaging study. Spine, 2009. 34(7): p. 706-12.
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