Facet Degeneration Research Articles

Automated magnetic resonance imaging-based grading of the lumbar intervertebral disc and facet joints.

Degeneration of both intervertebral discs (IVDs) and facet joints in the lumbar spine has been associated with low back pain, but whether and how IVD/joint degeneration contributes to pain remains an open question. Joint degeneration can be identified by pairing T1 and T2 magnetic resonance imaging (MRI) with analysis techniques such as Pfirrmann grades (IVD degeneration) and Fujiwara scores (facet degeneration). However, these grades are subjective, prompting the need to develop an automated technique to enhance inter-rater reliability. This study introduces an automated convolutional neural network (CNN) technique trained on clinical MRI images of IVD and facet joints obtained from public-access Lumbar Spine MRI Dataset. The primary goal of the automated system is to classify health of lumbar discs and facet joints according to Pfirrmann and Fujiwara grading systems and to enhance inter-rater reliability associated with these grading systems. Performance of the CNN on both the Pfirrmann and Fujiwara scales was measured by comparing the percent agreement, Pearson's correlation and Fleiss kappa value for results from the classifier to the grades assigned by an expert grader. The CNN demonstrates comparable performance to human graders for both Pfirrmann and Fujiwara grading systems, but with larger errors in Fujiwara grading. The CNN improves the reliability of the Pfirrmann system, aligning with previous findings for IVD assessment. The study highlights the potential of using deep learning in classifying the IVD and facet joint health, and due to the high variability in the Fujiwara scoring system, highlights the need for improved imaging and scoring techniques to evaluate facet joint health. All codes required to use the automatic grading routines described herein are available in the Data Repository for University of Minnesota (DRUM).

Relationship between joint structure of the first tarsometatarsal joint and its degeneration

This study aimed to elucidate the relationship between joint structures of the first tarsometatarsal and articular facet degeneration. A total of 100 feet from 50 cadavers were examined. The articular facets of the first metatarsal and medial cuneiform were categorized into four types based on the superior and inferior facets' separation, and the formation of the inferior lateral facet on the lateral plantar prominence: Type I, a single facet with no separation or inferior lateral facet; Type II-a, two facets with separation but no inferior lateral facet; Type II-b, two facets, no separation, but with an inferior lateral facet; Type III, three facets with separation and an inferior lateral facet. When both bone types matched, they were defined as Type I, Type II-a, Type II-b, and Type III joints, respectively; unmatched types were classified as Unpair joints. The severity of articular cartilage degeneration on both bones was assessed using a 5-point scale. The degeneration grade was compared among joint types. Type III joints exhibited significantly milder articular cartilage degeneration in medial cuneiform compared to Type II-a, II-b, Unpair joints. The formation of inferior lateral facet and separation of the superior and inferior facets might be crucial for the joint's stability.

Risk factors of revision operation and early revision for adjacent segment degeneration after lumbar fusion surgery: a case-control study

Background contextAdjacent segment degeneration (ASD) following lumbar fusion operation is common and can occur at varying timepoints after index surgery. An early revision operation for ASD, however, signifies a short symptom-free period and might increase the risk of successive surgeries. PurposeWe aimed to elucidate the overall risk factors associated with revision surgeries for ASD with distinct attention to early revisions. Study design/SettingRetrospective, case-control study. Patient SampleThe study included 86 patients who underwent revision operations for ASD after lumbar fusion in the revision group and 166 patients who did not for at least 5 years after index surgery. Outcome measuresSagittal parameters, Pfirrmann grading, facet degeneration grading, and disc space height (DSH) of adjacent segments were assessed. MethodsRevision operations within 5 years postsurgery were defined as early revision. We compared the revision and no-revision groups as well as the early- and late-revision groups. ResultsThe revision group demonstrated a significantly greater preoperative C7–S1 sagittal vertical axis (SVA) (p=.001), postoperative C7–S1 SVA (p<.001), and postoperative pelvic incidence (PI)–lumbar lordosis (LL) (p<.001) than those in the no-revision group. Preoperative DSH of the proximal adjunct segment (p=.001), postoperative PI–LL (p=.014), and postoperative C7–S1 SVA (p=.037) exhibited significant association with ASD in logistic regression analysis. The early-revision group had a significantly higher patient age (p=.001) and a greater number of levels fused (p=.030) than those in the late-revision group. Multivariate Cox regression analysis demonstrated that old age (p=.045), a significant number of levels fused (p=.047), and a narrow preoperative DSH of the proximal adjacent level (p=.011) were risk factors for early revision. ConclusionsPostoperative sagittal imbalance, including significant PI–LL and C7–S1 SVA were risk factors for revision operation for ASD but not for early revision. These factors are likely to affect the long-term risk of revision operation due to ASD and thus are not considered risk factors for early revision. Narrow DSH of the proximal adjacent level increased the risks of both revision and early revision surgeries. Moreover, old age and a significant number of levels fused further increased the risk for early revision for ASD.

A Propensity Score-Matched Cohort Study Comparing 3 Different Spine Pedicle Screw Fixation Methods: Freehand, Fluoroscopy-Guided, and Robot-Assisted Techniques.

This study aimed to compare the accuracy of robotic spine surgery and conventional pedicle screw fixation in lumbar degenerative disease. We evaluated clinical and radiological outcomes to demonstrate the noninferiority of robotic surgery. This study employed propensity score matching and included 3 groups: robot-assisted mini-open posterior lumbar interbody fusion (PLIF) (robotic surgery, RS), c-arm guided minimally invasive surgery transforaminal lumbar interbody fusion (C-arm guidance, CG), and freehand open PLIF (free of guidance, FG) (54 patients each). The mean follow-up period was 2.2 years. The preoperative spine condition was considered. Accuracy was evaluated using the Gertzbein-Robbins scale (GRS score) and Babu classification (Babu score). Radiological outcomes included adjacent segmental disease (ASD) and mechanical failure. Clinical outcomes were assessed based on the visual analogue scale, Oswestry Disability Index, 36-item Short Form health survey, and clinical ASD rate. Accuracy was higher in the RS group (p < 0.01) than in other groups. The GRS score was lower in the CG group, whereas the Babu score was lower in the FG group compared with the RS group. No significant differences were observed in radiological and clinical outcomes among the 3 groups. Regression analysis identified preoperative facet degeneration, GRS and Babu scores as significant variables for radiological and clinical ASD. Mechanical failure was influenced by the GRS score and patients' age. This study showed the superior accuracy of robotic spine surgery compared with conventional techniques. When combined with minimally invasive surgery, robotic surgery is advantageous with reduced ligament and muscle damage associated with traditional open procedures.

Complex neuroimaging study of the proximal segment after rigid fixation and dynamic stabilization in patients with degenerative lumbar disease

Background. The development of the adjacent level syndrome and, as a consequence, adjacent segment degenerative disease are currently the most common complications of decompression and stabilization surgery with the development of segmental instability. The aim of the study. To conduct a comprehensive neuroimaging assessment of the proximal adjacent segment after rigid fixation and dynamic stabilization in degenerative lumbar disease. Materials and methods. We conducted a prospective multicenter study of the results of surgical treatment of 274 patients with degenerative-dystrophic diseases of the lumbar spine, who underwent monosegmental decompression and stabilization surgery using the TLIF (transforaminal lumbar interbody fusion) technique and open transpedicular rigid fixation, as well as open hemilaminectomy with stabilization of the operated segments with nitinol rods. The study included radiography, diffusion-weighted magnetic resonance imaging and computed tomography (dualenergy mode) of intervertebral discs and isolated facet degeneration of the upper adjacent level. Results and discussion. Combination of the initial proximal segment degeneration in the form of facet joints degeneration (density of cartilaginous plate – 163.5 ± 14.2 HU, density of external facet – 709.35 ± 13.6 HU, density of internal facet – 578.1 ± 12.1 HU), Pfirrmann III, IV grade degeneration of intervertebral disc and a measured diffusion coefficient of less than 1300 mm2/s cause high risks of developing adjacent segment degenerative disease, which regulates the use of monosegmental dynamic fixation with nitinol rods, or preventive rigid fixation of the adjacent segment. Conclusion. Using complex neuroimaging in the preoperative period makes it possible to predict the results of surgical treatment, take timely measures to prevent degenerative diseases of the adjacent segment, and to carry out dynamic monitoring of processes in the structures of the spinal motion segment.

Mechanical crosstalk between the intervertebral disc, facet joints, and vertebral endplate following acute disc injury in a rabbit model.

Vertebral endplate sclerosis and facet osteoarthritis have been documented in animals and humans. However, it is unclear how these adjacent pathologies engage in crosstalk with the intervertebral disc. This study sought to elucidate this crosstalk by assessing each compartment individually in response to acute disc injury. Eleven New Zealand White rabbits underwent annular disc puncture using a 16G or 21G needle. At 4 and 10 weeks, individual compartments of the motion segment were analyzed. Discs underwent T 1 relaxation mapping with MRI contrast agent gadodiamide as well T 2 mapping. Both discs and facets underwent mechanical testing via vertebra-disc-vertebra tension-compression creep testing and indentation testing, respectively. Endplate bone density was quantified via μCT. Discs and facets were sectioned and stained for histology scoring. Intervertebral discs became more degenerative with increasing needle diameter and time post-puncture. Bone density also increased in endplates adjacent to both 21G and 16G punctured discs leading to reduced gadodiamide transport at 10 weeks. The facet joints, however, did not follow this same trend. Facets adjacent to 16G punctured discs were less degenerative than facets adjacent to 21G punctured discs at 10 weeks. 16G facets were more degenerative at 4 weeks than at 10, suggesting the cartilage had recovered. The formation of severe disc osteophytes in 16G punctured discs between 4 and 10 weeks likely offloaded the facet cartilage, leading to the recovery observed. Overall, this study supports that degeneration spans the whole spinal motion segment following disc injury. Vertebral endplate thickening occurred in response to disc injury, which limited the diffusion of small molecules into the disc. This work also suggests that altered disc mechanics can induce facet degeneration, and that extreme bony remodeling adjacent to the disc may promote facet cartilage recovery through offloading of the articular cartilage.

Endplate and Facet Joint Changes in Cervical Spondylotic Myelopathy

Modic changes (MC) of the vertebral endplates and facet joint degeneration are common causes of neck pain. No previous study has shown the prevalence of and relationship between MC and facet joint changes in cervical spondylotic myelopathy (CSM). The objective of this article was to study the endplate and facet joint changes in CSM. Magnetic resonance imaging of the cervical spine in 103 patients with CSM was retrospectively evaluated. The scans were evaluated by 2 raters, who classified spinal segments according to the Modic classification and the degree of facet degeneration. In patients <50 years old, there were no MC in 61.5%. In patients with MC, Modic type II at C4-C5 was observed most frequently. MC were found in 71.4% of patients ≥50 years old. In patients with MC, Modic type II at C3-C4 was observed most frequently. Degenerative changes of the facet joints were found frequently in both patients <50 years old (77.5%) and patients ≥50 years (90.2%), and grade I degeneration was observed most frequently in both groups. There was a significant correlation between MC and facet joint changes. MC in the cervical spine are common magnetic resonance imaging findings in patients with CSM ≥50 years old. Degenerative facet joint changes are found in the majority of patients with CSM regardless of age. We found a significant correlation between MC and facet joint changes at the same level, indicating that both imaging findings are involved in a common pathophysiological pathway.

Relative risk factors of nerve root sedimentation sign (SedSign) in patients with severe central lumbar spinal stenosis (LSS)

The incidence of nerve root sedimentation sign (SedSign) was evaluated to explore potential pathogenesis in patients with severe lumbar spinal stenosis (LSS). In a total of 209 patients with severe LSS, 290 intervertebral levels were narrow, among which 248 showed a positive SedSign, giving a prevalence of 85.52%. Those levels with a positive SedSign were further analyzed relative to those with a negative SedSign. There was no significant difference between the two groups for the cross-sectional area (CSA) or the posteroanterior diameter (PAD). In contrast, there was a significant difference between the groups for the grade of degenerative facet joint (DFJ) (p < 0.05), the thickness of ligamentum flavum (TLF) (p < 0.01), and the cross-sectional area difference (CSAD) (p < 0.01). In addition, receiver operating characteristic (ROC) curves were used to identify associated factors. The area under the ROC curve for PAD was 0.608 (p < 0.05), for DFJ was 0.634 (p < 0.05), for TLF was 0.74 (p < 0.01), and for CSAD was 0.911 (p < 0.01). In summary, a positive SedSign has notable advantages in assisting with the diagnosis of severe LSS. Compression of the dural sac from the rear may be the main risk factors of a positive SedSign.

Identification of preoperative radiological risk factors for reoperation following percutaneous endoscopic lumbar decompression to treat degenerative lumbar spinal stenosis.

This study aimed to identify radiological risk factors associated with reoperation after percutaneous transforaminal endoscopic decompression (PTED) for degenerative lumbar spinal stenosis (DLSS). The preoperative clinical data of 527 consecutive patients with DLSS who underwent PTED were retrospectively reviewed. Overall, 44 patients who underwent reoperation were matched for age, sex, body mass index, and surgical segment to 132 control patients with excellent or good clinical outcomes. Radiological characteristics were compared between the groups using independent sample t-tests and Pearson's chi-square tests. A predictive model was established based on multivariate logistic regression analysis. The analyses revealed significant differences in the presence of lumbosacral transitional vertebra (LSTV, 43.2% vs. 17.4%, p = 0.001), the number of levels with senior-grade disc degeneration (2.57 vs. 1.96, p = 0.018) and facet degeneration (1.91 vs. 1.25 p = 0.002), and the skeletal muscle index (SMI, 849.7 mm2/m2 vs. 1008.7 mm2/m2, p < 0.001) between patients in the reoperation and control groups. The results of the logistic analysis demonstrated that LSTV (odds ratio [OR] = 2.734, 95% confidence interval [CI]:1.222-6.117, p < 0.014), number of levels with senior-grade facet degeneration (OR = 1.622, 95% CI:1.137-2.315, p = 0.008), and SMI (OR = 0.997, 95% CI:0.995-0.999, p = 0.001) were associated with reoperation after PTED. The application of the nomogram based on these three factors showed good discrimination (area under the receiver operating characteristic curve 0.754, 95% CI 0.670-0.837) and good calibration. LSTV, more levels with senior-grade facet degeneration, and severe paraspinal muscle atrophy are independent risk factors for reoperation after PTED. These factors can thus be used to predict reoperation risk and to help tailor treatment plans for patients with DLSS.

Back pain “not just herniated disc”: results of treatment with oxygen-ozone therapy in selected applications.

Low back pain and lumbosciatica are highly disabling pathologies, more and more widespread in every social category and manifest themselves at an&#x0D; increasingly precocious age. They can be supported by numerous different vertebral pathologies, often concomitant: diseases of the disc, of the facet joints, spondylolysis (with or without listesis), somatic and interapophyseal arthrosis, stenosis of the vertebral canal, radicular and synovial cysts, meningiomas, primary or metastatic neoplastic pathology etc.&#x0D; In order to choose the best therapy, in cases of low back pain and / or sciatica pain, a precise diagnosis made after a careful objective examination and supported by suitable instrumental examinations is therefore essential. In particular, in addition to standard radiograms of the spine, in these patients the Computed Tomography and / or Magnetic Resonance Imaging is essential.&#x0D; In recent years, several studies have demonstrated the utility of oxygen-ozone therapy in the treatment of herniated discs with the result of herniated discs reduced in size.&#x0D; In this study the authors evaluated the therapeutic results obtained in the treatment with oxygen-ozone therapy of 416 patients suffering from non-discogenic low back pain caused by pathology of the posterior vertebral compartment (facet synovitis, Baastrup syndrome, spondylolysis and spondylolisthesis, facet degeneration).

Lumbar Degenerative Disease and Muscle Morphology Before and After Lower Limb Loss in Four Military Patients.

Low back pain (LBP) is highly prevalent after lower limb amputation (LLA). Reports describing longitudinal changes in spine health before and after amputation are rare. This study describes lumbar spine pathology, muscle morphology, and the continuum of care for LBP before and after LLA. We queried electronic medical records of patients who sought care for LBP before and after unilateral LLA between January 2002 and April 2020 and who had documented lumbar imaging pre- and post-LLA. Patient demographics, muscle morphology, spinal pathology, premorbid and comorbid conditions, self-reported pain, and treatment interventions were assessed. Four patients with LBP and imaging before and after LLA were identified. Intervertebral disc degeneration progressed after amputation in three patients, whereas facet arthrosis progressed in both female patients. The fat content of lumbar musculature generally increased after amputation. Conservative management of LBP before and after amputation was standard, with progression to steroidal injections. Lumbar spine health may degrade after amputation. Here, lumbar muscle size did not change after LLA, yet the fat content increased in combination with increases in facet and intervertebral disc degeneration.

Surgical outcome of minimal invasive oblique lateral interbody fusion with percutaneous pedicle screw fixation in the treatment of adult degenerative scoliosis

Oblique lateral interbody fusion is performed for lumbar spinal restoration and stabilization, without extensive paraspinal muscle damage or massive bleeding. This study aimed to confirm the radiological and clinical outcomes of minimally invasive oblique lateral interbody fusion (OLIF) with percutaneous pedicle screw fixation (PPSF) as treatment for adult degenerative lumbar scoliosis. Medical records of 40 patients with degenerative lumbar spinal deformities who underwent selective OLIF and PPSF at our hospital between April 2018 and February 2021 were retrospectively reviewed. The study population comprised 7 male and 33 female patients aged 55-79 years. Standing radiography was performed, and the coronal cobb angle, distance between the C7 plumb line and central sacral vertical line, sagittal vertical axis, pelvic tilt, lumbar lordosis (LL), pelvic incidence (PI), and difference between PI and LL (PI-LL) were measured. Coronal scoliosis was defined as a lumbar coronal plane curve of > 15°. All patients achieved statistically significant improvements in coronal and sagittal alignment. The coronal cobb angle was corrected from 18.82° to 11.52°, and the central sacral vertical line was reduced from 18.30 mm to 15.47 mm. The sagittal vertical axis was significantly reduced from 45.95 mm to 32.72 mm. In contrast, the pelvic tilt and LL were minimally changed. For subgroup analyses, patients were divided into the convex and concave groups according to the direction of coronal curve correction. Vertebral body rotation was superior in the convex group than in the concave group. Furthermore, we checked for asymmetric facet degeneration at the upper instrumented vertebra (UIV) level at 1 year postoperatively. Of the 22 patients who underwent more than 3 level fusion surgery, 8 patients were confirmed the postoperative asymmetric facet degeneration in above UIV. Minor complications occurred in 16 patients, who recovered without any problems. Revision surgery was not performed in all cases. Minimally invasive OLIF with PPSF has a lower risk of complications and favorable surgical outcomes in patients with adult degenerative lumbar scoliosis. Access from the convex side is advantageous for the correction of the rotated vertebra. Extending the UIV level to the neutral vertebra can reduce the occurrence of postoperative asymmetric facet degeneration.

Lumbar spine MRI findings in asymptomatic elite male academy footballers: a case series

BackgroundUnderstanding common MRI findings may allow clinicians to appreciate the sport-specific effects on the lumbar spine, and to discern clinically significant pathology. Prevalence data regarding radiological abnormalities seen during the surveillance of asymptomatic elite footballers is, therefore, important to help understand injury mechanisms and to prevent associated injuries. The purpose of this study was to evaluate the magnetic resonance imaging (MRI) findings in the lumbar spines of asymptomatic elite male adolescent footballers.MethodsA prospective case-series study was carried out. MRI was performed using a 3T Siemens Prisma scanner including a 3D VIBE sequence in 18 asymptomatic male elite adolescent footballers recruited from a professional academy in England (mean age 17.8, range 16.9–18.6 years). The images were independently reported by two consultant musculoskeletal radiologists to achieve consensus opinion. Standardised classification criteria were used to assess and report abnormalities descriptively.ResultsFifteen players (15/18, 83%) showed ≥1 abnormalities, included facet degeneration, synovial cysts, disc degeneration, disc herniation, and pars injury. One player (1/18, 6%) had mild (Grade 1) facet joint arthropathy at L4/L5 and 3/18 (16.7%) showing evidence of bilateral facet joint effusions. Three synovial cysts were identified in 2/18 players (11%), 4/18 players (22%) presented asymptomatic pars injuries, with 4 showing a grade 2 subtotal stress fracture and 1 player a grade 4 chronic stress fracture seen on 3D VIBE sequencing. Disc degeneration at one or more levels was demonstrated in 7/18 players (38%). Disc herniation was present in 5/18 players (27%).ConclusionA range of unsuspected findings on MRI of the lumbar spine are common in elite adolescent footballers.

Dejeneratif Lomber Hastalıklarda Uygulanan Spinal Enstrümantasyon Sonrası Gelişen Komşu Segment Dejenerasyonu: İnsidans ve Risk Faktörleri

Posterior spinal enstrümantasyon, dejeneratif omurga patolojilerinin tedavisi için oldukça yaygın uygulanan cerrahi bir prosedürdür. Spinal enstrümantasyon sonrası komşu segment dejenerasyonu (KSD) gelişimi önemli bir problem olarak karşımıza çıkmaktadır. Bu çalışmanın amacı KSD gelişimi için risk faktörlerinin değerlendirilmesidir. Bu çalışmada posterior segmental enstrümantasyon uygulanan ve cerrahi işlemi üzerinden 4 yıldan fazla geçen 126 hasta retrospektif olarak incelenmiştir. Bu hastalar KSD ve n-KSD olarak iki gruba ayrılmıştır. İki grubun hasta karakteristikleri, preoperatif ve postoperatif radyolojik parametreleri ve cerrahi farklılıkları karşılaştırılarak KSD gelişimi için prediktif faktörler ortaya konulmaya çalışıldı. Çalışmaya dahil edilen hastaların on beşinde (%11.9) KSD geliştiği görüldü. Her iki grup arasında cinsiyet, diyabetes mellitus, sigara kullanımı ve osteoporoz açısından anlamlı farklılık yok idi (p&gt;0.05). Lojistik regresyon analizine göre preoperatif yüksek vücut kitle indeksi, preoperatif komşu segmentteki faset dejenerasyonu varlığı, postoperatif lomber lordozda azalma ve 4 seviyeden daha fazla posterior enstürman uygulanması KSD gelişimi için bağımsız risk faktörleridir. Spinal enstrümantasyon cerrahisi öncesi yukarıda bahsedilen risk faktörlerinin bilinmesi, cerrahi açıdan daha uygun sonuçlar alınabilmesi için önlem almaya imkan tanımaktadır. Hastaların ve işlemi uygulayacak cerrahların modifiye edilebilecek risk faktörleri açısından gerekli önlemleri almaları uzun dönem komplikasyonları azaltabileceğini düşünmekteyiz.

Comprehensive analysis of the results of surgical treatment of patients with degenerative diseases of the lumbar spine using rigid fixation systems

Introduction. According to the literature, the development of adjacent-level syndrome 10 years after posterior rigid stabilization is noted in 6.7–80 % of patients, of which 24 % require revision surgery.The aim: to conduct a comprehensive analysis of the results of surgical treatment of patients with degenerative diseases of the lumbar spine using rigid fixation systems.Materials and methods. A multicenter retrospective study of the results of surgical treatment of 268 patients with degenerative-dystrophic diseases of the lumbar spine, who underwent mono- or bisegmental decompression-stabilizing intervention with the implementation of the TLIF (Transforaminal Lumbar Interbody Fusion) technique and open transpedicular rigid fixation, was conducted. The study included radiography, MRI and CT (in 2-energy mode) of intervertebral discs and isolated facet degeneration of the upper adjacent level.Results and discussion. The combination of the initial degeneration of the adjacent spinal motion segment in the form of disc degeneration of grade III and higher according to Pfirrmann with threshold values of the density of the outer cartilaginous plate from 161.7 ± 18.8 to 164.8 ± 14.2 HU, the density of the outer facet – from 702.43 ± 12.3 to 713.65 ± 13.6 HU and the density of the inner facet – from 580.5 ± 11.6 to 582.1 ± 15.1 HU, as well as with signs of segmental instability of the adjacent segment can be considered as risk factors for the development of its degeneration. With the progression of degeneration of the upper intervertebral disc, revision interventions were performed within 12–60 months after surgery.Conclusion. Bisegmental stabilization with signs of initial degeneration in the intervertebral disc and facet joints in the upper segment has proven its clinical and instrumental effectiveness in the period of 36 months and reduces the risks of developing degenerative disease of the adjacent disc.

Impact of Adjacent Facet Joint Osteoarthritis on Adjacent Segment Degeneration after Short-Segment Lateral Lumbar Interbody Fusion for Indirect Decompression: Minimum 5-Year Follow-Up.

Purpose Lumbar fusion combined with lateral lumbar interbody fusion (LLIF) and percutaneous pedicle screws (PPS) is a widely used, minimally invasive surgical treatment, but studies on incidence and risk factors for subsequent adjacent segment degeneration (ASD) are limited. This study was aimed at investigating midterm incidence and reoperation rate of ASD after indirect decompression (IDD) with LLIF and PPS and at clarifying the impact of preexisting adjacent facet osteoarthritis on development of ASD after IDD. Methods Forty-one patients who underwent short-segment (1- or 2-level) lumbar fusion with LLIF and PPS with a minimum 5-year follow-up were analyzed. Cephalad adjacent facet osteoarthritis was classified as 1 (normal) to 4 (severe) by an established classification system on preoperative CT. ASD was diagnosed with plain radiographs taken preoperatively and up to 5 years postoperatively, and preoperative degree of facet osteoarthritis was compared between the ASD+ group and ASD- group (control). We also divided patients into two groups according to severity of facet degeneration, mild (grades 1-2) group and severe (grades 3-4) group, and investigated ASD-free survival of the groups by the Kaplan-Meier method. Results The incidence of ASD at 5 years postoperatively was 34.1%, and the reoperation rate for ASD was 4.9%. The degree of preexisting facet joint osteoarthritis was significantly different between the ASD+ and ASD- groups (grade 1/2/3/4: 0/29/64/7% and 29/62/29/10%, P = 0.008). Kaplan-Meier analysis showed the severe group to have significantly lower ASD-free survival than the mild group (P = 0.017) at 5 years postoperatively. Conclusion Comparative analysis of the ASD+ versus ASD- group showed preexisting facet joint osteoarthritis to be a risk factor for ASD progression after IDD. Additional longitudinal studies with long-term follow-up are needed to understand the causal relationship between facet joint degeneration and progression of adjacent segment deterioration following IDD.

29. Imaging outcome at 24-month follow-up in a prospective, multicenter study of two-level cervical arthroplasty with a PEEK on ceramic artificial disc

<h3>BACKGROUND CONTEXT</h3> The use of cervical total disc replacement (cTDR) continues to increase. The implants continually evolve with respect to design and materials. Imaging studies of these devices provides insight to their ability to provide and maintain range of motion (ROM), disc height, and depending on the implant materials, facet joint assessment. <h3>PURPOSE</h3> The purpose of this study was to evaluate the imaging outcome of a PEEK-on-ceramic artificial disc for the treatment of two-level cervical disc disease. <h3>STUDY DESIGN/SETTING</h3> Data for this study came from a prospective, multicenter, non-randomized, historically controlled FDA Investigational Device Exemption (IDE) trial evaluating the Simplify®Cervical Artificial Disc for use at two levels. <h3>PATIENT SAMPLE</h3> Two-level cTDR was performed in 182 patients treated for symptomatic cervical disc degeneration with radiculopathy/myelopathy. <h3>OUTCOME MEASURES</h3> The primary outcome measures were ROM, disc height, and heterotopic ossification (HO) of the treated levels. MRI was used to assess the facet joints. <h3>METHODS</h3> The cTDR is composed of PEEK endplates with a mobile ceramic core. Radiographic evaluations were performed preoperatively, at hospital discharge, and 6 weeks, and 3, 6, 12, and 24 months postoperatively. MRI was performed pre- and 24 months postoperatively. All images were evaluated by an independent core lab. HO was evaluated based on a 0 (normal) to 4 (bridging bone) scale. Facets joints were scored on a 4-point scale ranging from 0 (normal) to 3 (severe degeneration) based on the MRI performed pre- and 24 months postoperatively. <h3>RESULTS</h3> At the superior cTDR level, the mean ROM improved from 8.0° prior to surgery to 9.5° at 24-month follow-up. At the inferior level, the values were 6.6° and 8.9°, respectively. At both operated levels, mean disc height increased postoperatively and the increase was maintained through 24-month follow-up. At the superior index level, the preoperative mean height was 3.1 mm and at 24 months it was 4.3 mm. At the inferior index level, the preoperative height was 3.1 mm and was 4.0 at 24 months. HO rates at 24-month follow-up were, the superior index level, severe HO (Grade 3) occurred in 8 patients (5%). Bridging HO (Grade 4) was also seen in 8 patients (5%). At the inferior index level, severe and bridging HO was seen in 17 (10%) and 5 (3%) patients, respectively. There was a lack of facet degeneration progression assessed on MRI between pre- and 24-month follow-up. No patient had severe facet degeneration at either operated level at either time point. The percentage of patients with a grade of moderate facet degeneration did not change at either level 8% at the superior index level and 5% at the inferior index level. At both levels, there appeared to be patients changing from the "none" category to the "mild" category. At the superior level prior to surgery, the figures for "none" and "mild" were 62% and 30% respectively. At 24-month follow-up, the figures were 52% and 39%, respectively. A similar pattern was seen at the inferior index level. <h3>CONCLUSIONS</h3> This study adds to the expanding evidence that two-level cTDR increases and maintains ROM and disc height and through 24-month follow-up. The majority of cTDR patients did not experience bridging HO. This PEEK-on-ceramic cTDR produces minimal artifact, allowing for reliable MRI visualization. This was used to evaluate the facet joints and a lack of facet degeneration progression was found. <h3>FDA DEVICE/DRUG STATUS</h3> Simplify Cervical Artificial Disc 2-level (Approved for this indication).

PERCUTANEOUS CD FIXATION OF SPINE IN SPINAL FRACTURES/ INSTABILITY BY FREE HAND TECHNIQUE

Introduction: Lumbar spondylolisthesis is frequently found in adults as a result of spondylolysis or facet degeneration. The slipped segment produces abnormal positioning of the vertebrae in relation to each other along the spinal column and causes mechanical back pain and compression of neural structures. The initial treatment in most symptomatic patients with lumbar spondylolisthesis is nonoperative supportive care, which consists of a combination of pain medications, bracing, and physical therapy. Surgical intervention is indicated if the symptoms are disabling and they interfere with work despite supportive care, if there is progression of the slippage degree (SD) on serial radiologic examinations, or if there are overt neurological deficits 1,2. Pedicle screw placement is the most popular method in lumbar spinal instrumentation for achieving successful fusion. Recently, to reduce surgical damage to the normal muscular structures during pedicle screw placement, C-arm-guided percutaneous pedicle screw fixation (PPSF) was introduced, and it has become increasingly popular in spinal surgery. Percutaneous transpedicular fixation systems have become more widely used in recent years mainly for the treatment of dorsal, dorsolumbar, and lumbar instability. Aim &amp; Objectives: The present study is aimed at evaluating the functional outcome with percutaneous pedicle screw fixation for spinal fractures&amp; spinal instabilities by free hand technique in patients without neurological deficits. Materials &amp; Methods: The present dissertation is a study of 25 consecutive cases of spinal fractures and spondylolisthesis who attended the orthopaedic emergency or outpatient department of Andhra medical college, Visakhapatnam from 2017 to 2019. All the cases were examined clinically fallowed by radiographic confirmation. Results: In total 25 patients spinal fractures 16 and instability 9, whose mean preoperative ODI scores is 81.04% and the mean postoperative score is 22.6 %. The total postoperative moderate disability patients are15 and minimal disability patients are 10. “PERCUTANEOUS CD FIXATION OF SPINE IN SPINAL FRACTURES/INSTABILITY BY FREEConclusion: HAND TECHNIQUE” is one of the better methods and is suggested for grade 1 &amp; grade 2 spondylolisthesis and spinal fractures, also by which can reduce the morbidity and improve the function.

The Evaluation of The Relationship Between Psoas Muscle Atrophy and Intervertebral Disc and Facet Joint Degeneration in Patients With Lumbar Pain Using Lumbar Spine MRI

Objective: The purpose of the present study was to determine the relationship between psoas muscle lipoatrophy and facet and disc degeneration in patients&#x0D; with low back pain with lumbar spinal Magnetic Resonance Imaging (MRI).&#x0D; Material and Methods: A total of 304 patients who had low back pain were included in this retrospective cross-sectional study. The lumbar MRIs of all patients were evaluated for signs of psoas muscle atrophy. Fat content for each muscle was graded semi-quantitatively (Grade 0-4). The disc and facet joint&#x0D; degenerations of each patient were also graded. Psoas muscle thickness was measured in the mediolateral axial plane parallel to the vertebra.&#x0D; Results: It was found that the mean right psoas muscle thickness score of the patients was 35.9±7.2 mm on average, and the mean left psoas muscle thickness score was 35.8±7.1 mm. It was also found that 41.8% of the right psoas muscle degeneration was grade 1, 41.1% was grade 2, 33.6% of the left psoas muscle degeneration was grade 1, 45.1% was grade 2, 64.1% of the right facet degeneration was grade 1, 23.4% was grade 2, and 53.9% of the left facet degeneration was grade 1, and 30.3% was grade 2.&#x0D; Conclusion: When lumbar spine MRI examinations are evaluated, psoas muscles must also be evaluated in terms of atrophy. Indicating psoas muscle lipoatrophy in patients with low back pain may be useful for better rehabilitation planning.

Level dependent alterations in human facet cartilage mechanics and bone morphometry with spine degeneration.

The zygapophyseal joints of the spine, also known as the facet joints, are paired diarthrodial joints posterior to the intervertebral disc and neural elements. The pathophysiology of facet osteoarthritis (OA), as well as crosstalk between the disc and facets, remains largely understudied compared to disc degeneration. The purpose of this study was to characterize alterations to human facet cartilage and subchondral bone across a spectrum of degeneration and to investigate correlations between disc and facet degeneration. Human lumbar facet articular surfaces from six independent donors were subject to creep indentation mechanical testing to quantify cartilage mechanical properties, followed by microcomputed tomography (µCT) analyses for subchondral bone morphometry. The degenerative state of each articular surface was assessed via macroscopic scoring and via Osteoarthritis Research Society International histopathology scoring. Our data suggest reduced facet cartilage compressive and tensile moduli and increased permeability with increasing degenerative grade, particularly at the lower levels of the spine. µCT analyses revealed spinal level-dependent alterations to the subchondral bone, with an increase in trabecular bone at the L4-L5 level, but a decrease at the upper levels of the lumbar spine with increasing degenerative grade. Cortical bone volume fraction was generally decreased with increasing degenerative grade across spinal levels. Correlation analysis revealed several associations between quantitative measures of disc degeneration and facet OA. This study showed that alterations in the mechanical properties of facet cartilage and in the structural properties of facet subchondral bone correlated with aspects of disc degeneration and were highly dependent on spinal level.