Atsushi Fujiwara, Kazuya Tamai, Minoru Yamato, Howard S.

An, Hiroyuki Yoshida, Koichi Saotome, Akira Kurihashi Eur Spine J (1999) 8 : 396401

Patrick William Gading Examiner : dr.Nyimas Diana Yulisa, SpRad(K)

 Disc degeneration & facet joint OA play an important

role in spinal degeneration . Previous studies incidence of these changes increases with age and disc degeneration usually proceeds facet joint OA MRI diagnostic test of choice in evaluating disc degeneration not evaluate facet joint OA as accurately as CT

Purpose
Evaluate the accuracy of MRI in assessing facet joint

OA. Determine the relationship between disc degeneration and facet joint OA. A grading system for facet joint OA relationship between disc degeneration & facet joint OA determined more accurately.

Assessment of facet joint OA on MRI

84 lumbar facet joints 14 candidates (7 male & 7

female) for lumbar spine surgery with degenerative disc disease Analyzed MRI (a 1.5-T unit, Shimadzu 150SMT) and CT (Xforce or TCT-900S, Toshiba). Average age 52.7 yrs (2275 yrs). Parallel to disc spaces at L3-4, L4-5, and L5-S1 levels, with 5-mm consecutive slice thickness. Degrees of OA Pathrias criteria for grading of facet joint OA on CT

Grade 1

Normal

Grade 2

Mild (joint space narrowing or mild osteophyte)

Grade 3

Moderate (sclerosis or moderate osteophyte)

Grade 4

Severe (marked osteophyte)

Relationship between disc degeneration and facet joint OA

183 consecutive patients with LBP and/or leg

symptoms both MRI (SHIMADZ SMT 150GUX, 1.5 T) & x-rays of the lumbar spine. Excluded Previous back surgery, congenital anomalies, or infectious, traumatic or tumorous disorders. Average age 46.8 18.2 yrs (13 to 81 yrs). 88 patients male and 95 female. L3-4, L4-5, and L5-S1 were examined.

 Disc degeneration Thompsons grading system (5

grades on T2-weighted midsagittal images) degenerative status of the nucleus, annulus, endplate and vertebral body. Facet joint OA four grades on axial spin echo T1weighted images To minimize bias disc degeneration and facet joint OA were scored independently.

 Mean age determined at each grade of disc

degeneration & facet joint OA Differences between the grades one-way ANOVA. Median grade of disc degeneration & facet joint OA was calculated at each intervertebral level. Correlation between disc degeneration and facet joint OA Kendalls tau-b test. Statistical significance P < 0.05.

Assessment of facet joint OA on MRI

82 facet joints were evaluated on both CT & MRI.
CT scans 30 joints (37%) were considered to be

grade 1, 19 (23%) grade 2, 25 (31%) grade 3, and 8 (9.8%) grade 4. MRI reader 1 36 joints (44%) as grade 1, 28 joints (34%) as grade 2, 12 joints (15%) as grade 3, and 6 joints (7%) as grade 4. MRI reader 2 29 joints (35%) as grade 1, 36 joints (44%) as grade 2, 11 joints (13%) as grade 3, and 6 joints (7%) as grade 4.

 52 facet joints regarded as having OA on CT: MRI Reader 1 OA in 46 joints MRI Reader 2 OA in 51 joints. 30 facet joints regarded as normal on CT: MRI Reader 1 normal in 28 joints MRI Reader 2 normal in 26 joints

Sensitivity for MRI 88% and 98% Specificity for MRI 90% and 87% Accuracy for MRI 93% and 94%

 Perfect interobserver agreement in MRI in 62 of 82

joints (76%), and agreement to within one grade in an additional 20 joints (24%). The calculated kappa value for perfect agreement was 0.636.

Disc degeneration and facet joint OA

183 intervertebral levels in L3-4, 181 in L4-5, and 173 in

L5-S1. No significant differences mean age between male and female patients (male: 48.0 years, female: 45.7 years). No significant sex difference grade of disc degeneration at each intervertebral level. No significant sex difference grade of facet joint OA at each intervertebral level.

 Table 2 relationship between disc degeneration and

facet joint OA No facet joint OA was found in the absence of disc degeneration. Most facet joint OA appeared at the intervertebral levels with grade IV or V disc degeneration. There was a significant correlation between severity of disc degeneration and facet joint OA (P < 0.001). The calculated correlation coefficient value was 0.584 at the L3-4 level, 0.460 at the L4-5 level, and 0.310 at the L5-S1 level.

 Median of disc degeneration grade at the L3-4

significantly lower than L4-5 and L5-S1 levels (P < 0.001) no significant difference in the grade of disc degeneration between L4-5 and L5-S1. Median grade of facet joint OA at L4-5 significantly higher than that at L3-4 (P < 0.05) no significant differences between L3-4 and L5-S1, and between L4-5 and L5-S1. Degree of disc degeneration varied among individuals under 40 years of age. Over the age 60, most of the discs were markedly degenerated.

 Mean age of each grade of disc degeneration L4-5: 23.1 years for grade I, 35.5 years for grade II, 41.8 years for grade III, 52.2 years for grade IV, 61.8 years for grade V. Mean age significantly increased with the progression of

disc degeneration grade, except for the difference between grades II and III

 Osteoarthritic changes facet joints were minimal

under 40 years of age after that age facets gradually degenerated. Mean age of each grade of facet joint OA 35.9 years for grade 1, 57.5 years for grade 2, 65.5 years for grade 3, and 68.8 years for grade 4. The mean age increased with the progression of facet joint OA but statistical significance only between grade 1 and all other grades (P < 0.001), and between grades 2 and 4 (P < 0.05).

Assessment of facet joint OA on MRI

Osteoarthritic changes pathologically defined as

cartilage loss, subchondral bone sclerosis, and osteophyte formation. Conventional radiography common screening method to evaluate these changes has significant limitations in detecting early facet joint OA CT depict the facet joint in the axial plane and has accurately demonstrated the osteoarthritic changes of the facet joint. MRI axial and sagittal images of the lumbar facet joints in degenerative spinal disease but capability of depicting facet joint OA has been less examined in the literature

 Weishaupt et al. accuracy of facet joint OA against CT

MRI accuracy in assessing facet joint OA was 95%, although they used T2-weighted spin echo images. The present study supported their results and demonstrated the 93% accuracy. Butler et al. presence of facet joint OA using CT; 21% of their patients, with a mean age of 41.8, showed OA. This study patients mean age was 46.8 years and the prevalence of facet joint OA was 38%, consistent with previous CT studies.

 MRI tends to underestimate the severity of OA as

compared with CT. MRI less sensitive in depicting the bony cortex margin & thinning of the cartilage can not be measured accurately with MRI partial volume effect & chemical-shift artifact. Accuracy and interobserver agreement of MRI for assessing OA of the lumbar facet joints are acceptable. Therefore, MRI can be a substitute for CT in assessing OA of the lumbar facet joints.

Disc degeneration and facet joint OA

Postmortem and radiographic studies close

relationship between disc degeneration & aging. Males > females disc degeneration and the L4-5 and L5-S1 levels > degenerated than the L3-4 level. Miller et al. study of a large sample of autopsies L3-4 and L4-5 discs > degenerated than the L5-S1 discs This study also showed that there is a relationship between disc degeneration and aging. The L4-5 and L5-S1 discs were more significantly degenerated than the L3-4 discs in our study.

 The prevalence of facet joint OA also increases with

age. Lewin facet joints showed only minor chondral changes before the age of 45. After 45 advanced chondral changes, subchondral sclerosis and osteophytes became common phenomena. The present study demonstrated a similar prevalence of facet joint OA.

 Previous studies intervertebral disc as initial site of

spinal degeneration, as facet joints degenerate as a result of disc degeneration. Vernon-Roberts & Pirie disc degeneration was the primary event leading to osteophyte formation and to facet joint changes. Also determined an inverse relationship between severity of OA and the preservation of the disc structure. Lewin apart from the L5-S1 motion segment, disc degeneration did not seem to be the sole or dominant factor predisposing to the onset and development of OA of the lumbar synovial joints.

 Butler et al. MRI and CT scans to determine disc

degeneration to determine the occurrence of facet joint OA, and concluded that discs degenerated before facets. Videman et al. 20% of degenerative spines, facet degeneration preceded disc degeneration. Our results facet joint OA was not found without disc degeneration & most facet joint OA was associated with the grade IV or V disc degeneration. This study supports the hypothesis that disc degeneration precedes facet joint OA. Also supports the concept that it may take many years to develop facet joint OA following the onset of disc degeneration.

 Limitations Routine MRI or CT, can not detect early

changes of facet joint OA, such as minor chondral changes and synovial inflammation. Clinically, it is important to know whether the facet joint is painful or not limits imaging studies based on the morphological changes of facet joint OA. Further studies are needed in assessing the morphology and pathogenesis of facet joint OA

 This paper showed that MRI is a reasonable tool for

assessment of facet joint OA. A grading system to assess the severity of the facet joint OA is presented, which can be helpful in research as well as clinically. The relationship between disc degeneration and facet joint OA is an expected finding, but this paper showed that disc degeneration is more closely associated with aging than with facet joint OA. It is clear that discs degenerate prior to facets become arthritic, and facet joint OA is usually associated with advanced disc degeneration.