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Lumbar Facet Joint Arthritis Is Associated with More Coronal Orientation of the Facet Joints at the Upper Lumbar Spine

Lumbar Facet Joint Arthritis Is Associated with More Coronal Orientation of the Facet Joints at... Hindawi Publishing Corporation Radiology Research and Practice Volume 2013, Article ID 693971, 9 pages http://dx.doi.org/10.1155/2013/693971 Research Article Lumbar Facet Joint Arthritis Is Associated with More Coronal Orientation of the Facet Joints at the Upper Lumbar Spine 1 1 1 1 Thorsten Jentzsch, James Geiger, Stefan M. Zimmermann, Ksenija Slankamenac, 2 1 Thi Dan Linh Nguyen-Kim, and Clément M. L. Werner Division of Trauma Surgery, Department of Surgery, University Hospital Zur ¨ ich, Ram ¨ istrasse 100, 8091 Zur ¨ ich, Switzerland Institute of Diagnostic and Interventional Radiology, University Hospital Zur ¨ ich, Ram ¨ istrasse 100, 8091 Zur ¨ ich, Switzerland Correspondence should be addressed to o Th rsten Jentzsch; thorsten.jentzsch@usz.ch Received 28 May 2013; Revised 7 September 2013; Accepted 7 September 2013 Academic Editor: David Maintz Copyright © 2013 Thorsten Jentzsch et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. We retrospectively analyzed CT scans of 620 individuals, who presented to our traumatology department between 2008 and 2010. Facet joint (FJ) arthritis was present in 308 (49.7%) individuals with a mean grade of 1. It was seen in 27% of individuals≤40 years and in 75% of individuals≥41 years (𝑃<0.0001 )aswellasin52% of femalesand 49%ofmales (𝑃=0.61 ). Mean FJ orientation ∘ ∘ ∘ ∘ was 30.4 at L2/3, 38.7 at L3/4, 47 at L4/5, and 47.3 at L5/S1. FJ arthritis was significantly associated with more coronal (increased ∘ ∘ degree) FJ orientation at L2/3 (𝑃=0.03 )withacutoffpoint at ≥32 . FJs were more coronally oriented (48.8 )inindividuals≤40 ∘ ∘ ∘ years and more sagittally oriented (45.6 )inindividuals≥41 years at L5/S1 (𝑃=0.01 ). Mean FJ asymmetry was 4.89 at L2/3, 6.01 ∘ ∘ at L3/4, 6.67 at L4/5, and 7.27 at L5/S1, without a significant difference for FJ arthritis. FJ arthritis is common, increases with age, and aeff cts both genders equally. More coronally oriented FJs ( ≥32 ) in the upper lumbar spine may be an individual risk factor for development of FJ arthritis. 1. Introduction their lifetime and up to 5% chronically [10]. Even though etiologies of low back pain are multifactorial [11], FJ arthritis Afunctionalspinalunitconsistsofanteriorlylocatedadjacent is common and affects at least 50% of the population [ 12]. vertebrae separated by an intervertebral disc and posteriorly After Ghormley [ 13] rfi st described a facet syndrome in 1933, located facet (zygapophyseal) joints (FJ) [1]. FJs are composed there has been an ongoing debate [14, 15]about thepossible of an inferior articular process, facing anteriorly, and a association low back pain and FJ pathology [16]. FJs are superior articular process, facing posteriorly, of two adjacent synovial covered joints with hyaline cartilage [17] and inner- vertebrae [2]. Being synovial-lined, diarthrodial, and freely vated by the medial branches of the dorsal rami from two moveable functional units, they transmit shear forces and levels [18, 19]. Recently,ithas been shownthatinflammatory help the intervertebral discs in carrying about 16% of the chemical mediators are increased in degenerated FJs [20]. vertical load [3, 4]. FJ orientation planes differ at various In order to investigate the association of low back pain and levels, with a more sagittal and curved orientation for resis- FJ pathology, most studies [21–25] successfully utilized FJ tance against axial rotation in the upper compared to a more (nerve) blocks and its associated pain relief. u Th s, there is coronal and flat orientation for resistance against flexion convincing evidence that FJ pain plays an important role in and shearing forces in the lower lumbar segments [5, 6]. FJ low back pain [26, 27] and occurs in up to 45% of individuals asymmetry or tropism describes the asymmetry of the left [25]. and right FJ angle [7, 8]. However, controversies still exist in the following issues. Lowbackpainisone of themostcommonhealthprob- In general, study samples have been rather small for FJ arthri- lems [9]. It aeff cts up to 85% of people at least once during tis on CT scans, which is especially true for the prevalence 2 Radiology Research and Practice of FJ arthritis, particularly in younger individuals [28–36]. difference between the right and left FJ angle and categorized Gender predilection has not been reported consistently [12, into four groups determined according to their 50th, 75th, 15, 29, 37]. It also remainsunclear whetherFJarthritis is and 95th percentile, for example, group one includes 50% of associated with FJ orientation and/or FJ asymmetry, and if the sample, group two 25%, group three 20%, and group four so, at which level [1, 6–8, 32, 38–48]. Previous studies [32, 49] 5%. have only reported an increase in FJ arthritis with more All statistical analyses were performed by the Institute for sagittally oriented FJs at the lower lumbar spine. Yet, it is Social and Preventive Medicine, Division of Biostatistics at unknown if changes in FJ orientation at the upper lumbar the University of Zur ¨ ich, using the R program [59]. Several spine lead to FJ orientation at the lumbar spine. er Th efore, different statistical approaches were applied to test the null our goal was to clarify these remaining issues by quantifying hypothesis [60]. This study is an observational study, which the degree of radiographically detectable (1) FJ arthritis on CT means that analysis follows a descriptive and exploratory scans of the lumbar spine from L2-S1 in regards to (2) age, (3) form. er Th efore, 𝑃 values are interpreted as a quantitative gender, (4) FJ orientation, and (5) FJ asymmetry. measure of the evidence against the null hypothesis. As a rough guideline, we assumed weak evidence against the null hypothesis for 𝑃 -values ≥0.01 and <0.1, modest evidence 2. Materials and Methods against the null hypothesis for𝑃 values between≥0.001 and <0.01, and strong evidence against the null hypothesis for𝑃 eTh study has been approved by the institutional review board (ethical committee no. KEK-ZH-Nr.2011-0507). We values<0.001. eTh refore, correction for multiple comparisons retrospectively analyzed CT scans of 620 individuals (2480 has been assessed. The 𝐺 test was used for the following models: FJ arthritis, versus (2) age (categorized), (3) gender functional units), with a mean age of 42.5 (range, 14–94) years, who presented to our traumatology department and and (5) FJ asymmetry. The 𝐺 -test was used to test the asso- underwent a whole body CT scan, including the pelvis and ciation between ordinal outcomes and nominal explanatory lumbar spine, between 2008 and 2010. A dual-source com- variables. Besides the usual properties of a statistical test, the puted tomography scanner (Somatom Den fi ition, Siemens 𝐺 test also provides a decomposition of the total test value 𝐺 into the ordinal levels of the outcome variable, and can Healthcare, Forchheim, Germany) was used [50]. Our study utilized CT scans instead of plain radiographs or magnetic therefore be used to determine the threshold of the ordinal resonance imaging, because they are more accurate in dis- levels. For example, the decomposition of the𝐺 -value for the 4 degrees of FJ arthritis, which is an ordinal measure, playingFJs on axialplanes[51, 52]. FJs of the lumbar spine wereevaluatedbetween thesecondlumbarandthefirstsacral is as follows: 𝐺 =𝐺 0;1+ 𝐺 01;2+ 𝐺 012;3,which 2 2 2 2 level [53]. Axial planes with the largest intersecting set of the means that the total 𝐺 -value can be written as 𝐺 -value 2 2 superior and inferior FJ process were chosen. of a comparison between FJ arthritis 0 and 1, plus a 𝐺 - (1)AssessmentofFJarthritiswascarriedoutaspreviously value of a comparison between FJ arthritis 0 + 1 and 2, plus described in similar studies, where a grading scale described a𝐺 -value of a comparison between FJ arthritis 0 + 1 + 2 by Pathria [29, 54] was used. Grade 0 (normal) indicates and3.Ifthe equation wouldbe100 =10+30 +100 for a normal facet joint, whereas grades 1–3 display increas- a certain explanatory variable, the largest difference occurs between 30 and 100. eTh refore, patients with a degree of ing signs of FJ arthritis with each grade including signs of the lower grade. Grade 1 (mild) shows joint space narrowing, 3 in regard to FJ arthritis show the largest difference with grade 2 (moderate) demonstrates sclerosis, and grade 3 respecttothisexplanatory variable.A𝜒 -test was applied (severe) reveals osteophytes [55](Figure 1). (2) Individuals to test the association between a nominal outcome and a were grouped into those ≤40 and ≥41 years. (3) Gender nominal explanatory variable. eTh 𝜒 -test was used for the was also evaluated. (4) FJ orientation in the axial plane was following models: (4) FJ orientation (categorized) versus age evaluated by measuring the angle between the midline of (categorized) and gender, as well as (5) FJ asymmetry versus the sagittal plane and the midline of the FJ as described by age (categorized) and gender. eTh proportional odds model Schuller et al. [56, 57](Figure 2). FJ orientation (Figure 2)was was used for (1) FJ arthritis versus (4) FJ orientation. We also determined on axial CT planes of the lumbar spine using calculated the cut-off point for FJ arthritis by using the ROC the AGFA Impax viewer. eTh midline of the sagittal planes curves analysis. Afterwards we performed a univariate as well corresponds to a line drawn through the center of the as a multivariate logistic regression analysis by grouping the vertebral body and spinous process. er Th efore, each FJ was patient population according to the cut-off point. Age and compared against this line. The midline of FJs was evaluated gender were defined as potential confounder for the multi- on axial cross-sections where the largest part of the joint, that variateregressionanalysis. is, most parts of the superior and inferior articular facets were visible. The overall FJ orientation was calculated by 3. Results averaging the angles between the right and left side of the FJs. We used absolute angles, indicating that we did not consider (1) Arthritis. Of our 620 individuals, who were evaluated for rotation in one direction as positive and rotation in the radiological FJ arthritis on axial planes of CT scans from L2- opposite direction as negative. The FJ orientation was labeled S1, 308 (49.7%) individuals showed signs of FJ arthritis. eTh ∘ ∘ as coronal if angles were>45 ,sagittalifangleswere≤45 , mean grade of FJ arthritis was 1.310 (50.0%); individuals were and anisotropic if one side was over and the other side under not affected by FJ arthritis (grade 0), 103 (16.6%) individuals 45 [58]. (5) FJ asymmetry was determined as the absolute presented with grade 1, 107 (17.3%) individuals with grade 2, Radiology Research and Practice 3 Grade 0 Grade 1 Grade 2 Grade 3 Figure 1: Grading scale for FJ arthritis. Grade 0 = normal FJ. Grade 1 (mild) = joint space narrowing, grade 2 (moderate) = sclerosis, and grade 3 (severe) = osteophytes. and 98 (15.8%) individuals with grade 3 (Table 1). Two (0.3%) group of FJA with a degree of 3 showed the largest gap in age individualscould notbeevaluated forFJarthritis because (207 = 30 + 58 + 119). This suggests that severe FJ arthritis spondylodesis had been performed or appropriate planes had seemed to be more likely in elderly individuals. not been reconstructed adequately. (3) Gender. er Th e were 202 females (32.6%) and 418 males (67.4%). FJ arthritis did not show significant gender predilec- (2) Age. Separated into two age groups, our study included tion, even if separated into age groups. 52% of females and 330 (53.2%) individuals ≤40 years and 290 (46.8%) indi- 49% of males displayed signs of FJ arthritis (𝑃 = 0.61 ). viduals>40 years. FJ arthritis signicfi antly dieff red between Females presented with a mean FJ arthritis of 1.07, compared age groups, with elderly individuals being more commonly to 0.95 in males. Each grade of FJ arthritis included a similar affected ( 𝑃<0.0001 )(Figure 3). All 4 degrees of FJ arthritis number of females and males. Grade 0 aeff cted 48% of were found in both age groups (≤40 years,>40 years) but females and 51% of males, grade 1 aeff cted 15% of females with different proportions. FJ arthritis was present in 27% of and 17% of males, grade 2 affected 19% of females and 17% of individuals in the age group≤40 years. In contrast, FJ arthritis males, and grade 3 affected 18% of females and 15% of males. was found 75% of individuals in the age group>40 years. Furthermore, FJ arthritis manifested in 95% of individuals in the age group≥65 years, which included 97 individuals. eTh (4) Orientation.MeanFJorientation wasmeasuredas30.4 ∘ ∘ ∘ ∘ 𝐺 0,12; 3-value indicates that comparison of the first 3 groups (SD 7.7 ,range 7.4–66 )atL2/3, 38.7 (SD 9.6 ,range 4.5– ∘ ∘ ∘ ∘ of FJ arthritis with a degree of 0, 1, and 2 to the most severe 73.7 )atL3/4.47 (SD 9.8 ,range 16.2–76.4 )atL4/5and 4 Radiology Research and Practice Table 1: Prevalence of facet joint (FJ) arthritis. Grade Patients (absolute number) Patients (percentage) 0310 50 1 103 16.6 2 107 17.3 398 15.8 betweenFJarthritis andFJorientation couldbeestablished at the other levels. er Th e was a significant difference for FJ orientation in our age groups at L5/S1 (𝑃=0.01 ), where more coronal FJ orientation (48.8 ) manifested in individuals≤40 years and a more sagittal FJ orientation (45.6 ) was present in individuals>40 years. No significant difference was found in FJ orientation and age groups at other levels (30.0 versus ∘ ∘ ∘ Figure 2: Measuring technique for FJ orientation. FJ orientation in 31.00 (𝑃 = 0.61 ) for L2/3, 43.6 versus 42.1 (𝑃 = 0.41 ) the axial plane was evaluated by measuring the angle between the ∘ ∘ for L3/4 and 48.1 versus 45.9 (𝑃 = 0.13 )for L4/5). eTh re midline of the sagittal plane and the midline of the FJ. Coronal FJ were no significant differences for FJ orientation and gender orientation is shown on the left side, whereas sagittal orientation (𝑃=0.13 –0.73). including measurement of FJ orientation is shown on the right side. The red box indicates the value for FJ orientation. eTh blacked out numbers were disregarded because they were created automatically (5) Asymmetry.Themeanvaluesfor FJ asymmetry were ∘ ∘ ∘ ∘ by our software and contained irrelevant information. calculated as 4.89 at L2/3, 6.01 at L3/4, 6.67 at L4/5, and 7.27 at L5/S1. er Th e was no difference between FJ arthritis and FJ asymmetry (𝑃 values = 0.11 for L5/S1, 0.26 for L4/5, 0.10 for L3/4 and 0.17 for L2/3). There were no significant differences in age groups for each level (𝑃=0.35 at L2/3, 0.23 at L3/4, 0.27 80 at L4/5, 0.28 at L5/S1). However, there was modest evidence that FJ asymmetry is more common in females than in males at L5/S1 (𝑃 = 0.01 ) but not at the other levels (𝑃 = 0.47 , 0.91 and 0.33 for L2/3, L3/4 and L5/S1). FJ asymmetry also increased in a craniocaudal fashion. 4. Discussion Our study investigated one of the largest samples of CT scans with regard to FJ arthritis in the literature. As hypothesized we were able to show that (1) radiological appearance of FJ arthritis is a very common entity, affecting nearly half of all individuals, (2) increases with age, (3) does not display gender FJ arthritis (grade) predilection, (4) was signicfi antly associated with coronal, that is, increased degree of FJ orientation at L2/3, and (5) is Figure 3: Grade of FJ arthritis and age. This figure describes the not correlated with FJ asymmetry. increasing grade of FJ arthritis with age. Limitations of our study attribute to the fact that all individuals presented to a trauma department. Even though a selection bias may be assumed, we did not include indi- ∘ ∘ ∘ 47.3 (SD 9.9 ,range 19.6–84.4 ) at L5/S1. FJs of the proximal vidualswithafracture of thelumbarspine.Wewerenot lumbar levels were more sagittally oriented compared to able to check for intra- or interrater reliability, but mea- those at distal lumbar levels, which were more coronally surements were carried out by two trained specialists in oriented (Figures 4 and 5). u Th s, there was a cephalocaudal this field. Furthermore, the measuring technique has been trend of an increasing degree of FJ orientation. described before and did not require validation. We did FJ arthritis was significantly associated with more coro- not pay special attention to degenerative disc disease since nal, that is, increased degree of FJ orientation at L2/3 (mean this has been investigated in previous studies [7, 34, 49]. FJ orientation of 30.1 without FJ arthritis (grade 0) versus Another problem is caused by the parallax effect. It has mean FJ orientation of 32.1 with FJ arthritis (grade 3) (𝑃= been advocated [61, 62] that the spinous process may be 0.03, OR 1.021 (95%-CI 1.002–1.014))) (Figure 4). The cut- an unreliable anatomic midline marker because anatomic off point was ≥32 . This means that more coronally oriented variations, such as scoliosis, in the relationship between FJs, that is,≥32 ,atthislevel were associated with ahigher the anterior vertebral body and posterior spinous process radiological degree of FJ arthritis. No significant association may skew the interpreter’s view on X-rays. However, this Age (years) Radiology Research and Practice 5 L2/3 L5/S1 Normal Facet joint arthritis Figure 4: FJ arthritis and FJ orientation. On the left side, sagittally oriented FJs at L2/3 and coronally oriented FJ at L5/S1 are associated with normal FJs at the lumbar spine. The right side illustrates inversely oriented FJs with arthritic FJs at the lumbar spine, namely, coronals oriented FJs at L2/3 and sagittally oriented FJs at L5/S1. 0123 0123 FJ arthritis (grade) FJ arthritis (grade) FJ arthritis (grade) FJ arthritis (grade) Figure 5: Cephalocaudal change in FJ orientation. eTh re was a steady progress from a sagittal toward a more coronal FJ orientation at the ∘ ∘ lumbar spine in a cephalocaudal fashion, namely, 30 at L2/3 and 47 at L5/S1. ∘ ∘ FJ orientation at L4/5 ( ) FJ orientation at L2/3 ( ) FJ orientation at L3/4 ( ) FJ orientation at L5/S1 ( ) 6 Radiology Research and Practice parallax eect ff is much smaller for more accurate images of with FJ arthritis. Likewise, previous studies [30, 31, 33, 35, 36] CT scans, which we used for our evaluation. The measuring have revealed that FJ arthritis arises at a young age and is technique used in our study has been well established in foundinmorethan50% of individualsover40years.Ina previous studies [6, 32, 38, 42]. Anyhow, this issue does not study by Swanepoel et al. [34], who investigated individuals aeff ct our evaluation of FJ orientation because we calculated under 30 years, macroscopic cartilage fibrillation was more the mean of both sides and did not interprete each side pronounced in FJs than in other joints, such as hip, knee, and independently. We do acknowledge that setting of a wrong ankle. In Eubanks’ et al. study [12], FJ arthritis was present in midline may pose a problem in regard to FJ tropism, but so far 57% of individuals between 20–29 years, 82% between 30–39- no solution to this issue has been presented in the literature. years, 93% between 40–49 years, 97% between 50–59 years, The interesting ndin fi g that the interpedicular midpoint is and100%over60years.Inanancillary to theFramingham the most accurate guide to the coronal midline by Mistry study, Suri et al. [29] investigated 361 individuals and reported and Robertson. [62] could be implemented in future studies. a correlation of FJ arthritis with age (OR 1.09). 89% of Due to the retrospective nature of this study, we were not individuals over 65 years suffered from FJ arthritis. In a able to investigate which individuals showed clinical signs different study of 57 cadaveric specimens of spinal-disease- of FJ arthritis. Anyway, even though there is an ongoing free organ donors, Li et al. [33]statedthatFJarthritis debate [14–16, 21–25] whether radiologic proof of FJ arthritis increasedwithage andnospine wascompletelysparedby is clearly associated with back pain, it was not the purpose of FJ arthritis over the age 42 years. es Th e results all report our study. Due to the cross-sectional design, we were unable the same fact and are not surprising since FJs transmit shear to determine whether more coronally oriented FJs at L2/3 forces, carry about 16% of the vertical load, and tend to be lead to FJ arthritis or the other way around. However, we subject to wear and tear [3, 4]. believe that these changes in FJ orientation go along with FJ arthritis rather than being a manifestation of aging, because (3) Gender. Our study did not nd fi a significant association we did not find a significant association between changes in of FJ arthritis and gender, even though females were slightly FJ orientation at L2/3, and age, or a combined significant more commonly aeff cted (52%) than males (49%). Similarly, association at the other levels. This interesting topic may be in a study by Abbas et al. [37], FJ arthritis did not show gender evaluated in future longitudinal studies. We did not specify predilection in 215 individuals, which was investigated from the exact level or side of FJ arthritis since all levels and sides L3-S1 on CT scans. In a study of 188 individuals by Kalichman seemed to be aeff cted in a similar fashion, with lower levels et al. [15], females were slightly more commonly aeff cted by being slightly more frequently aeff cted [ 12]. Even though our FJ arthritis than men, namely, 67% versus 60%. However, this study included a similar number of individuals under and difference was not significant. According to Suri et al. [ 29] over 40 years, it comprised nearly twice as many males, which females (OR 1.86) were more commonly aeff cted, too. On the may be attributed to the fact that males are injured more often other hand, men had a higher prevalence of FJ arthritis in a and are overrepresented in a trauma population [60]. cadavericstudy of 645spines(𝑃 < 0.001 ) by Eubanks et al. [12], but unfortunately, no percentages were stated. Overall, (1) Arthritis. FJ arthritis was found in almost 50% of individ- there is more evidence that gender cannot be counted on as uals in our study. This is similar to previous studies. Eubanks a risk factor for FJ arthritis. This is surprising, because most et al. [12] studied 647 cadavers and reported the following of the males, especially those presenting to our traumatology prevalence of FJ arthritis: 53% at L1/2, 66% at L2/3, 72% at department, are working in hard labor jobs. Being synovial- L3/4, 79% at L4/5, and 59% at L5/S1. Kalichman et al. [28]also lined, diarthrodial, and freely moveable functional units, they reported a high prevalence of FJ arthritis, namely, 64.5%, in transmit shear forces and help the intervertebral discs in a study 187 individuals from the 3,529 participants enrolled carrying about 16% of the vertical load. eTh refore, most of the in the Framingham Heart Study who were assessed for aortic weight is carried by the intervertebral disc. Even though hard calcification with CT scans. Looking at 361 patients, Suri et al. labor may mainly affect arthritis of the intervertebral disc, a [29], found an even higher prevalence of FJ arthritis, where recent study has shown that estrogen also leads to arthritis of 22% presented with isolated posterior (FJ) arthritis and 57% the intervertebral disc [63]. In conclusion, these two factors showed signs of posterior and anterior arthritis. Our results may balance each other out. Other potential factors that support the fact that FJ arthritis is a common pathology of the cause increased shear forces in women may play a role as spine. The individuals in our study displayed a lower mean well, such as scoliosis, weaker musculature, and carrying age of 42.5 years compared to the mean age of 52.6 years and heavier weights in relation to their muscle strength, including 58.0 years in previously mentioned studies by Kalichman et al. pregnancy and carrying shopping bags [64]. [28]and Suri et al.[29] respectively, whereby Eubanks et al. [12] did not report a mean age. This explains why our results (4) Orientation. Our results point out that increased FJ for FJ arthritis aeff ct a smaller number of individuals. arthritis was significantly associated with a higher degree of FJ orientation, indicating a more coronal FJ orientation, at the (2) Age.WeshowedthatFJarthritis waspresent in 27%of upperlumbarspine,namely, L2/3 (𝑃 = 0.03 ). Interestingly, individuals≤40 years. Our results also illustrated a significant the cut-off point was ≥32 , indicating that more coronally association of FJ arthritis and increasing age (Figure 3). 75% oriented FJs, that is, ≥32 were associated with a higher of our individuals≥41 years and 95%≥65 years presented radiological degree of FJ arthritis at this level. Even though Radiology Research and Practice 7 not significant, the same trend was observed for L3/4 (OR arthritis and FJ asymmetry. This is in line with most previous 1.009), while our results were equivocal for the lower lumbar studies [6, 7, 40], such as by Boden et al. [7], who studied 140 spine. eTh refore, coronally oriented FJs at L2/3 may present a individuals with CT scans. Likewise, Grogan et al. [40]stud- surrogate for FJ arthritis later on in life. ied21cadaversandatotalof104FJswithCTscansanddidnot eTh correlation of FJ arthritis and FJ orientation has only nfi danassociation betweenFJarthritis andFJasymmetry. On the other hand, a single paper by Kong et al. [46]stated been reported forthe lowerpartofthe lumbar spine. A significant association between FJ arthritis and sagittal FJ that FJ arthritis was associated with FJ asymmetry at L4/5 but not at L3/4, and L5/S1 in an MRI study of 300 individuals. orientation of the lower lumbar spine was found in a study Moreover, there was no association of FJ asymmetry and age of CT scans with 188 individuals by Kalichman et al. [6]and a in our study. Previous studies [6, 46, 47]haveyielded the MRI study if 111 individuals by Fujiwara et al. [38]. Likewise, same results. Overall, we could not find evidence for previous arecentCTstudy of 123individuals by Liuetal. [32]linkedFJ hypotheses, which attributed FJ asymmetry to asymmetric arthritis to more sagittally oriented FJs at L4/5 and L5/S1. Our mechanical stress or inborn deformities. Our findings are novel nding fi of increased FJ arthritis with more coronally supported by a study of dried vertebrae of 240 humans by oriented FJs at the upper lumbar spine might be attributed Masharawietal. [48], where FJ asymmetry was considered to the specific function of FJs at different lumbar levels. a normal characteristic of the thoracolumbar spine. Normal FJ orientation planes differ at various levels, with a However, in our study, FJ asymmetry was significantly more sagittal andcurvedorientation forresistanceagainst more common in females than in males at L5/S1, which is in axial rotation in the upper compared to a more coronal and contrast to the study by Kong et al. [46], who did not nd fi flat orientation for resistance against flexion and shearing a meaningful relationship. Interestingly, there was evidence forces in the lower lumbar segments [5, 6]. If the upper that FJ asymmetry increases cephalocaudally, with a mean of lumbar segments display more coronally oriented FJs, they ∘ ∘ 4.89 at L2/3 and 7.27 at L5/S1. This indicates that FJ asymme- are more prone to FJ arthritis because they are not designed try is less common in sagittally oriented and more common to withstand repeating axial rotation. Another theory by in coronally oriented FJs, namely, the lower lumbar levels. Dunlop et al. [65] hypothesizes that aging leads to increased Accordingly, Cassidy et al. [8]andMasharawietal.[44]stated stress in the anteromedial part of the FJ due to repetitive that FJ asymmetry is more commonly found in coronally abrasion during flexion and rotation and therefore changes oriented FJs. This may be explained by the increased load and themorphologyofFJs, resultinginincreased sagittal orien- degenerative changes at the lower lumbar spine [66], which tation [42]. Importantly, inverse orientation of the normal may lead to uncontrolled changes of the FJs. This may affect state, namely, coronally oriented FJs at the upper and sagittaly women more commonly due to changes in estrogen or other oriented FJs at the lower lumbar spine may be independent unknown factors [63]. risk factors for FJ arthritis (Figure 4). In our study, more coronal FJ orientation was present 5. Conclusion in individuals≤40 years, and a more sagittal FJ orientation manifested in individuals≥41 years at L5/S1. This is in line In conclusion, FJ arthritis is common aeff cting about half to previous study by Wang and Yang [42], who noted that of individuals, increases with age, and aeff cts both genders degenerative spondylolisthesis, which has been associated ∘ equally. Coronally oriented FJs (≥32 )inthe upperlumbar with sagittal FJ orientation in several reports [6, 40, 41], spine, namely, at L2/3 may be an individual risk factor was accompanied by a negative correlation of age and and surrogate for development of FJ arthritis in the entire coronally oriented FJs (𝑟 = −0.4555 ) through investigation lumbar spine, which is worth further investigations. Besides, of the orientation of FJs at L4/5 in 300 individuals at different coronal FJ orientation increases craniocaudally, while sagittal age groups. Masharawi et al. [43] did not nd fi an association orientation at the lower lumbar spine increases with age. between FJ orientation and age studying 240 human vertebral FJ asymmetry is not associated with FJ arthritis, is more columns. These FJ changes may be attributed to degenerative common in females at the lower lumbar spine, and also wear and tear, either at the FJs or at the intervertebral disc, increases in a craniocaudal fashion. and resulting traumatic change FJ orientation into a more sagittal alignment [38]. Like previous studies by Wang and 6. Disclosure Yang [42]and Masharawietal. [43], we also did not find an association between gender and FJ orientation. Besides, we Each author certiefi s that he or a member of his or her were able to show a signicfi ant steady progress from a sagittal immediate family has no funding or commercial associations toward a more coronal FJ orientation in a cephalocaudal that might pose a conflict of interest in connection with the ∘ ∘ fashion, namely, 30 at L2/3 and 47 at L5/S1 (Figures 4 and 5). submitted paper. Each author certifies that his institution Thisisinlinewithanancillary CT studyofthe Framingham approved the human protocol for this investigation and that Heart Study with 3529 individuals by Kalichman et al. [6], all investigations were conducted in conformity with ethical whoalsoshowedanincreasingFJO from L3-S1. principles of research. Acknowledgments (5) Asymmetry. Our values for FJ asymmetry are in line with previous studies [40], where FJ asymmetry was commonly The authors would like to thank Ms. Carol De-Simio-Hilton under 7 . 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Lumbar Facet Joint Arthritis Is Associated with More Coronal Orientation of the Facet Joints at the Upper Lumbar Spine

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Copyright © 2013 Thorsten Jentzsch et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Hindawi Publishing Corporation Radiology Research and Practice Volume 2013, Article ID 693971, 9 pages http://dx.doi.org/10.1155/2013/693971 Research Article Lumbar Facet Joint Arthritis Is Associated with More Coronal Orientation of the Facet Joints at the Upper Lumbar Spine 1 1 1 1 Thorsten Jentzsch, James Geiger, Stefan M. Zimmermann, Ksenija Slankamenac, 2 1 Thi Dan Linh Nguyen-Kim, and Clément M. L. Werner Division of Trauma Surgery, Department of Surgery, University Hospital Zur ¨ ich, Ram ¨ istrasse 100, 8091 Zur ¨ ich, Switzerland Institute of Diagnostic and Interventional Radiology, University Hospital Zur ¨ ich, Ram ¨ istrasse 100, 8091 Zur ¨ ich, Switzerland Correspondence should be addressed to o Th rsten Jentzsch; thorsten.jentzsch@usz.ch Received 28 May 2013; Revised 7 September 2013; Accepted 7 September 2013 Academic Editor: David Maintz Copyright © 2013 Thorsten Jentzsch et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. We retrospectively analyzed CT scans of 620 individuals, who presented to our traumatology department between 2008 and 2010. Facet joint (FJ) arthritis was present in 308 (49.7%) individuals with a mean grade of 1. It was seen in 27% of individuals≤40 years and in 75% of individuals≥41 years (𝑃<0.0001 )aswellasin52% of femalesand 49%ofmales (𝑃=0.61 ). Mean FJ orientation ∘ ∘ ∘ ∘ was 30.4 at L2/3, 38.7 at L3/4, 47 at L4/5, and 47.3 at L5/S1. FJ arthritis was significantly associated with more coronal (increased ∘ ∘ degree) FJ orientation at L2/3 (𝑃=0.03 )withacutoffpoint at ≥32 . FJs were more coronally oriented (48.8 )inindividuals≤40 ∘ ∘ ∘ years and more sagittally oriented (45.6 )inindividuals≥41 years at L5/S1 (𝑃=0.01 ). Mean FJ asymmetry was 4.89 at L2/3, 6.01 ∘ ∘ at L3/4, 6.67 at L4/5, and 7.27 at L5/S1, without a significant difference for FJ arthritis. FJ arthritis is common, increases with age, and aeff cts both genders equally. More coronally oriented FJs ( ≥32 ) in the upper lumbar spine may be an individual risk factor for development of FJ arthritis. 1. Introduction their lifetime and up to 5% chronically [10]. Even though etiologies of low back pain are multifactorial [11], FJ arthritis Afunctionalspinalunitconsistsofanteriorlylocatedadjacent is common and affects at least 50% of the population [ 12]. vertebrae separated by an intervertebral disc and posteriorly After Ghormley [ 13] rfi st described a facet syndrome in 1933, located facet (zygapophyseal) joints (FJ) [1]. FJs are composed there has been an ongoing debate [14, 15]about thepossible of an inferior articular process, facing anteriorly, and a association low back pain and FJ pathology [16]. FJs are superior articular process, facing posteriorly, of two adjacent synovial covered joints with hyaline cartilage [17] and inner- vertebrae [2]. Being synovial-lined, diarthrodial, and freely vated by the medial branches of the dorsal rami from two moveable functional units, they transmit shear forces and levels [18, 19]. Recently,ithas been shownthatinflammatory help the intervertebral discs in carrying about 16% of the chemical mediators are increased in degenerated FJs [20]. vertical load [3, 4]. FJ orientation planes differ at various In order to investigate the association of low back pain and levels, with a more sagittal and curved orientation for resis- FJ pathology, most studies [21–25] successfully utilized FJ tance against axial rotation in the upper compared to a more (nerve) blocks and its associated pain relief. u Th s, there is coronal and flat orientation for resistance against flexion convincing evidence that FJ pain plays an important role in and shearing forces in the lower lumbar segments [5, 6]. FJ low back pain [26, 27] and occurs in up to 45% of individuals asymmetry or tropism describes the asymmetry of the left [25]. and right FJ angle [7, 8]. However, controversies still exist in the following issues. Lowbackpainisone of themostcommonhealthprob- In general, study samples have been rather small for FJ arthri- lems [9]. It aeff cts up to 85% of people at least once during tis on CT scans, which is especially true for the prevalence 2 Radiology Research and Practice of FJ arthritis, particularly in younger individuals [28–36]. difference between the right and left FJ angle and categorized Gender predilection has not been reported consistently [12, into four groups determined according to their 50th, 75th, 15, 29, 37]. It also remainsunclear whetherFJarthritis is and 95th percentile, for example, group one includes 50% of associated with FJ orientation and/or FJ asymmetry, and if the sample, group two 25%, group three 20%, and group four so, at which level [1, 6–8, 32, 38–48]. Previous studies [32, 49] 5%. have only reported an increase in FJ arthritis with more All statistical analyses were performed by the Institute for sagittally oriented FJs at the lower lumbar spine. Yet, it is Social and Preventive Medicine, Division of Biostatistics at unknown if changes in FJ orientation at the upper lumbar the University of Zur ¨ ich, using the R program [59]. Several spine lead to FJ orientation at the lumbar spine. er Th efore, different statistical approaches were applied to test the null our goal was to clarify these remaining issues by quantifying hypothesis [60]. This study is an observational study, which the degree of radiographically detectable (1) FJ arthritis on CT means that analysis follows a descriptive and exploratory scans of the lumbar spine from L2-S1 in regards to (2) age, (3) form. er Th efore, 𝑃 values are interpreted as a quantitative gender, (4) FJ orientation, and (5) FJ asymmetry. measure of the evidence against the null hypothesis. As a rough guideline, we assumed weak evidence against the null hypothesis for 𝑃 -values ≥0.01 and <0.1, modest evidence 2. Materials and Methods against the null hypothesis for𝑃 values between≥0.001 and <0.01, and strong evidence against the null hypothesis for𝑃 eTh study has been approved by the institutional review board (ethical committee no. KEK-ZH-Nr.2011-0507). We values<0.001. eTh refore, correction for multiple comparisons retrospectively analyzed CT scans of 620 individuals (2480 has been assessed. The 𝐺 test was used for the following models: FJ arthritis, versus (2) age (categorized), (3) gender functional units), with a mean age of 42.5 (range, 14–94) years, who presented to our traumatology department and and (5) FJ asymmetry. The 𝐺 -test was used to test the asso- underwent a whole body CT scan, including the pelvis and ciation between ordinal outcomes and nominal explanatory lumbar spine, between 2008 and 2010. A dual-source com- variables. Besides the usual properties of a statistical test, the puted tomography scanner (Somatom Den fi ition, Siemens 𝐺 test also provides a decomposition of the total test value 𝐺 into the ordinal levels of the outcome variable, and can Healthcare, Forchheim, Germany) was used [50]. Our study utilized CT scans instead of plain radiographs or magnetic therefore be used to determine the threshold of the ordinal resonance imaging, because they are more accurate in dis- levels. For example, the decomposition of the𝐺 -value for the 4 degrees of FJ arthritis, which is an ordinal measure, playingFJs on axialplanes[51, 52]. FJs of the lumbar spine wereevaluatedbetween thesecondlumbarandthefirstsacral is as follows: 𝐺 =𝐺 0;1+ 𝐺 01;2+ 𝐺 012;3,which 2 2 2 2 level [53]. Axial planes with the largest intersecting set of the means that the total 𝐺 -value can be written as 𝐺 -value 2 2 superior and inferior FJ process were chosen. of a comparison between FJ arthritis 0 and 1, plus a 𝐺 - (1)AssessmentofFJarthritiswascarriedoutaspreviously value of a comparison between FJ arthritis 0 + 1 and 2, plus described in similar studies, where a grading scale described a𝐺 -value of a comparison between FJ arthritis 0 + 1 + 2 by Pathria [29, 54] was used. Grade 0 (normal) indicates and3.Ifthe equation wouldbe100 =10+30 +100 for a normal facet joint, whereas grades 1–3 display increas- a certain explanatory variable, the largest difference occurs between 30 and 100. eTh refore, patients with a degree of ing signs of FJ arthritis with each grade including signs of the lower grade. Grade 1 (mild) shows joint space narrowing, 3 in regard to FJ arthritis show the largest difference with grade 2 (moderate) demonstrates sclerosis, and grade 3 respecttothisexplanatory variable.A𝜒 -test was applied (severe) reveals osteophytes [55](Figure 1). (2) Individuals to test the association between a nominal outcome and a were grouped into those ≤40 and ≥41 years. (3) Gender nominal explanatory variable. eTh 𝜒 -test was used for the was also evaluated. (4) FJ orientation in the axial plane was following models: (4) FJ orientation (categorized) versus age evaluated by measuring the angle between the midline of (categorized) and gender, as well as (5) FJ asymmetry versus the sagittal plane and the midline of the FJ as described by age (categorized) and gender. eTh proportional odds model Schuller et al. [56, 57](Figure 2). FJ orientation (Figure 2)was was used for (1) FJ arthritis versus (4) FJ orientation. We also determined on axial CT planes of the lumbar spine using calculated the cut-off point for FJ arthritis by using the ROC the AGFA Impax viewer. eTh midline of the sagittal planes curves analysis. Afterwards we performed a univariate as well corresponds to a line drawn through the center of the as a multivariate logistic regression analysis by grouping the vertebral body and spinous process. er Th efore, each FJ was patient population according to the cut-off point. Age and compared against this line. The midline of FJs was evaluated gender were defined as potential confounder for the multi- on axial cross-sections where the largest part of the joint, that variateregressionanalysis. is, most parts of the superior and inferior articular facets were visible. The overall FJ orientation was calculated by 3. Results averaging the angles between the right and left side of the FJs. We used absolute angles, indicating that we did not consider (1) Arthritis. Of our 620 individuals, who were evaluated for rotation in one direction as positive and rotation in the radiological FJ arthritis on axial planes of CT scans from L2- opposite direction as negative. The FJ orientation was labeled S1, 308 (49.7%) individuals showed signs of FJ arthritis. eTh ∘ ∘ as coronal if angles were>45 ,sagittalifangleswere≤45 , mean grade of FJ arthritis was 1.310 (50.0%); individuals were and anisotropic if one side was over and the other side under not affected by FJ arthritis (grade 0), 103 (16.6%) individuals 45 [58]. (5) FJ asymmetry was determined as the absolute presented with grade 1, 107 (17.3%) individuals with grade 2, Radiology Research and Practice 3 Grade 0 Grade 1 Grade 2 Grade 3 Figure 1: Grading scale for FJ arthritis. Grade 0 = normal FJ. Grade 1 (mild) = joint space narrowing, grade 2 (moderate) = sclerosis, and grade 3 (severe) = osteophytes. and 98 (15.8%) individuals with grade 3 (Table 1). Two (0.3%) group of FJA with a degree of 3 showed the largest gap in age individualscould notbeevaluated forFJarthritis because (207 = 30 + 58 + 119). This suggests that severe FJ arthritis spondylodesis had been performed or appropriate planes had seemed to be more likely in elderly individuals. not been reconstructed adequately. (3) Gender. er Th e were 202 females (32.6%) and 418 males (67.4%). FJ arthritis did not show significant gender predilec- (2) Age. Separated into two age groups, our study included tion, even if separated into age groups. 52% of females and 330 (53.2%) individuals ≤40 years and 290 (46.8%) indi- 49% of males displayed signs of FJ arthritis (𝑃 = 0.61 ). viduals>40 years. FJ arthritis signicfi antly dieff red between Females presented with a mean FJ arthritis of 1.07, compared age groups, with elderly individuals being more commonly to 0.95 in males. Each grade of FJ arthritis included a similar affected ( 𝑃<0.0001 )(Figure 3). All 4 degrees of FJ arthritis number of females and males. Grade 0 aeff cted 48% of were found in both age groups (≤40 years,>40 years) but females and 51% of males, grade 1 aeff cted 15% of females with different proportions. FJ arthritis was present in 27% of and 17% of males, grade 2 affected 19% of females and 17% of individuals in the age group≤40 years. In contrast, FJ arthritis males, and grade 3 affected 18% of females and 15% of males. was found 75% of individuals in the age group>40 years. Furthermore, FJ arthritis manifested in 95% of individuals in the age group≥65 years, which included 97 individuals. eTh (4) Orientation.MeanFJorientation wasmeasuredas30.4 ∘ ∘ ∘ ∘ 𝐺 0,12; 3-value indicates that comparison of the first 3 groups (SD 7.7 ,range 7.4–66 )atL2/3, 38.7 (SD 9.6 ,range 4.5– ∘ ∘ ∘ ∘ of FJ arthritis with a degree of 0, 1, and 2 to the most severe 73.7 )atL3/4.47 (SD 9.8 ,range 16.2–76.4 )atL4/5and 4 Radiology Research and Practice Table 1: Prevalence of facet joint (FJ) arthritis. Grade Patients (absolute number) Patients (percentage) 0310 50 1 103 16.6 2 107 17.3 398 15.8 betweenFJarthritis andFJorientation couldbeestablished at the other levels. er Th e was a significant difference for FJ orientation in our age groups at L5/S1 (𝑃=0.01 ), where more coronal FJ orientation (48.8 ) manifested in individuals≤40 years and a more sagittal FJ orientation (45.6 ) was present in individuals>40 years. No significant difference was found in FJ orientation and age groups at other levels (30.0 versus ∘ ∘ ∘ Figure 2: Measuring technique for FJ orientation. FJ orientation in 31.00 (𝑃 = 0.61 ) for L2/3, 43.6 versus 42.1 (𝑃 = 0.41 ) the axial plane was evaluated by measuring the angle between the ∘ ∘ for L3/4 and 48.1 versus 45.9 (𝑃 = 0.13 )for L4/5). eTh re midline of the sagittal plane and the midline of the FJ. Coronal FJ were no significant differences for FJ orientation and gender orientation is shown on the left side, whereas sagittal orientation (𝑃=0.13 –0.73). including measurement of FJ orientation is shown on the right side. The red box indicates the value for FJ orientation. eTh blacked out numbers were disregarded because they were created automatically (5) Asymmetry.Themeanvaluesfor FJ asymmetry were ∘ ∘ ∘ ∘ by our software and contained irrelevant information. calculated as 4.89 at L2/3, 6.01 at L3/4, 6.67 at L4/5, and 7.27 at L5/S1. er Th e was no difference between FJ arthritis and FJ asymmetry (𝑃 values = 0.11 for L5/S1, 0.26 for L4/5, 0.10 for L3/4 and 0.17 for L2/3). There were no significant differences in age groups for each level (𝑃=0.35 at L2/3, 0.23 at L3/4, 0.27 80 at L4/5, 0.28 at L5/S1). However, there was modest evidence that FJ asymmetry is more common in females than in males at L5/S1 (𝑃 = 0.01 ) but not at the other levels (𝑃 = 0.47 , 0.91 and 0.33 for L2/3, L3/4 and L5/S1). FJ asymmetry also increased in a craniocaudal fashion. 4. Discussion Our study investigated one of the largest samples of CT scans with regard to FJ arthritis in the literature. As hypothesized we were able to show that (1) radiological appearance of FJ arthritis is a very common entity, affecting nearly half of all individuals, (2) increases with age, (3) does not display gender FJ arthritis (grade) predilection, (4) was signicfi antly associated with coronal, that is, increased degree of FJ orientation at L2/3, and (5) is Figure 3: Grade of FJ arthritis and age. This figure describes the not correlated with FJ asymmetry. increasing grade of FJ arthritis with age. Limitations of our study attribute to the fact that all individuals presented to a trauma department. Even though a selection bias may be assumed, we did not include indi- ∘ ∘ ∘ 47.3 (SD 9.9 ,range 19.6–84.4 ) at L5/S1. FJs of the proximal vidualswithafracture of thelumbarspine.Wewerenot lumbar levels were more sagittally oriented compared to able to check for intra- or interrater reliability, but mea- those at distal lumbar levels, which were more coronally surements were carried out by two trained specialists in oriented (Figures 4 and 5). u Th s, there was a cephalocaudal this field. Furthermore, the measuring technique has been trend of an increasing degree of FJ orientation. described before and did not require validation. We did FJ arthritis was significantly associated with more coro- not pay special attention to degenerative disc disease since nal, that is, increased degree of FJ orientation at L2/3 (mean this has been investigated in previous studies [7, 34, 49]. FJ orientation of 30.1 without FJ arthritis (grade 0) versus Another problem is caused by the parallax effect. It has mean FJ orientation of 32.1 with FJ arthritis (grade 3) (𝑃= been advocated [61, 62] that the spinous process may be 0.03, OR 1.021 (95%-CI 1.002–1.014))) (Figure 4). The cut- an unreliable anatomic midline marker because anatomic off point was ≥32 . This means that more coronally oriented variations, such as scoliosis, in the relationship between FJs, that is,≥32 ,atthislevel were associated with ahigher the anterior vertebral body and posterior spinous process radiological degree of FJ arthritis. No significant association may skew the interpreter’s view on X-rays. However, this Age (years) Radiology Research and Practice 5 L2/3 L5/S1 Normal Facet joint arthritis Figure 4: FJ arthritis and FJ orientation. On the left side, sagittally oriented FJs at L2/3 and coronally oriented FJ at L5/S1 are associated with normal FJs at the lumbar spine. The right side illustrates inversely oriented FJs with arthritic FJs at the lumbar spine, namely, coronals oriented FJs at L2/3 and sagittally oriented FJs at L5/S1. 0123 0123 FJ arthritis (grade) FJ arthritis (grade) FJ arthritis (grade) FJ arthritis (grade) Figure 5: Cephalocaudal change in FJ orientation. eTh re was a steady progress from a sagittal toward a more coronal FJ orientation at the ∘ ∘ lumbar spine in a cephalocaudal fashion, namely, 30 at L2/3 and 47 at L5/S1. ∘ ∘ FJ orientation at L4/5 ( ) FJ orientation at L2/3 ( ) FJ orientation at L3/4 ( ) FJ orientation at L5/S1 ( ) 6 Radiology Research and Practice parallax eect ff is much smaller for more accurate images of with FJ arthritis. Likewise, previous studies [30, 31, 33, 35, 36] CT scans, which we used for our evaluation. The measuring have revealed that FJ arthritis arises at a young age and is technique used in our study has been well established in foundinmorethan50% of individualsover40years.Ina previous studies [6, 32, 38, 42]. Anyhow, this issue does not study by Swanepoel et al. [34], who investigated individuals aeff ct our evaluation of FJ orientation because we calculated under 30 years, macroscopic cartilage fibrillation was more the mean of both sides and did not interprete each side pronounced in FJs than in other joints, such as hip, knee, and independently. We do acknowledge that setting of a wrong ankle. In Eubanks’ et al. study [12], FJ arthritis was present in midline may pose a problem in regard to FJ tropism, but so far 57% of individuals between 20–29 years, 82% between 30–39- no solution to this issue has been presented in the literature. years, 93% between 40–49 years, 97% between 50–59 years, The interesting ndin fi g that the interpedicular midpoint is and100%over60years.Inanancillary to theFramingham the most accurate guide to the coronal midline by Mistry study, Suri et al. [29] investigated 361 individuals and reported and Robertson. [62] could be implemented in future studies. a correlation of FJ arthritis with age (OR 1.09). 89% of Due to the retrospective nature of this study, we were not individuals over 65 years suffered from FJ arthritis. In a able to investigate which individuals showed clinical signs different study of 57 cadaveric specimens of spinal-disease- of FJ arthritis. Anyway, even though there is an ongoing free organ donors, Li et al. [33]statedthatFJarthritis debate [14–16, 21–25] whether radiologic proof of FJ arthritis increasedwithage andnospine wascompletelysparedby is clearly associated with back pain, it was not the purpose of FJ arthritis over the age 42 years. es Th e results all report our study. Due to the cross-sectional design, we were unable the same fact and are not surprising since FJs transmit shear to determine whether more coronally oriented FJs at L2/3 forces, carry about 16% of the vertical load, and tend to be lead to FJ arthritis or the other way around. However, we subject to wear and tear [3, 4]. believe that these changes in FJ orientation go along with FJ arthritis rather than being a manifestation of aging, because (3) Gender. Our study did not nd fi a significant association we did not find a significant association between changes in of FJ arthritis and gender, even though females were slightly FJ orientation at L2/3, and age, or a combined significant more commonly aeff cted (52%) than males (49%). Similarly, association at the other levels. This interesting topic may be in a study by Abbas et al. [37], FJ arthritis did not show gender evaluated in future longitudinal studies. We did not specify predilection in 215 individuals, which was investigated from the exact level or side of FJ arthritis since all levels and sides L3-S1 on CT scans. In a study of 188 individuals by Kalichman seemed to be aeff cted in a similar fashion, with lower levels et al. [15], females were slightly more commonly aeff cted by being slightly more frequently aeff cted [ 12]. Even though our FJ arthritis than men, namely, 67% versus 60%. However, this study included a similar number of individuals under and difference was not significant. According to Suri et al. [ 29] over 40 years, it comprised nearly twice as many males, which females (OR 1.86) were more commonly aeff cted, too. On the may be attributed to the fact that males are injured more often other hand, men had a higher prevalence of FJ arthritis in a and are overrepresented in a trauma population [60]. cadavericstudy of 645spines(𝑃 < 0.001 ) by Eubanks et al. [12], but unfortunately, no percentages were stated. Overall, (1) Arthritis. FJ arthritis was found in almost 50% of individ- there is more evidence that gender cannot be counted on as uals in our study. This is similar to previous studies. Eubanks a risk factor for FJ arthritis. This is surprising, because most et al. [12] studied 647 cadavers and reported the following of the males, especially those presenting to our traumatology prevalence of FJ arthritis: 53% at L1/2, 66% at L2/3, 72% at department, are working in hard labor jobs. Being synovial- L3/4, 79% at L4/5, and 59% at L5/S1. Kalichman et al. [28]also lined, diarthrodial, and freely moveable functional units, they reported a high prevalence of FJ arthritis, namely, 64.5%, in transmit shear forces and help the intervertebral discs in a study 187 individuals from the 3,529 participants enrolled carrying about 16% of the vertical load. eTh refore, most of the in the Framingham Heart Study who were assessed for aortic weight is carried by the intervertebral disc. Even though hard calcification with CT scans. Looking at 361 patients, Suri et al. labor may mainly affect arthritis of the intervertebral disc, a [29], found an even higher prevalence of FJ arthritis, where recent study has shown that estrogen also leads to arthritis of 22% presented with isolated posterior (FJ) arthritis and 57% the intervertebral disc [63]. In conclusion, these two factors showed signs of posterior and anterior arthritis. Our results may balance each other out. Other potential factors that support the fact that FJ arthritis is a common pathology of the cause increased shear forces in women may play a role as spine. The individuals in our study displayed a lower mean well, such as scoliosis, weaker musculature, and carrying age of 42.5 years compared to the mean age of 52.6 years and heavier weights in relation to their muscle strength, including 58.0 years in previously mentioned studies by Kalichman et al. pregnancy and carrying shopping bags [64]. [28]and Suri et al.[29] respectively, whereby Eubanks et al. [12] did not report a mean age. This explains why our results (4) Orientation. Our results point out that increased FJ for FJ arthritis aeff ct a smaller number of individuals. arthritis was significantly associated with a higher degree of FJ orientation, indicating a more coronal FJ orientation, at the (2) Age.WeshowedthatFJarthritis waspresent in 27%of upperlumbarspine,namely, L2/3 (𝑃 = 0.03 ). Interestingly, individuals≤40 years. Our results also illustrated a significant the cut-off point was ≥32 , indicating that more coronally association of FJ arthritis and increasing age (Figure 3). 75% oriented FJs, that is, ≥32 were associated with a higher of our individuals≥41 years and 95%≥65 years presented radiological degree of FJ arthritis at this level. Even though Radiology Research and Practice 7 not significant, the same trend was observed for L3/4 (OR arthritis and FJ asymmetry. This is in line with most previous 1.009), while our results were equivocal for the lower lumbar studies [6, 7, 40], such as by Boden et al. [7], who studied 140 spine. eTh refore, coronally oriented FJs at L2/3 may present a individuals with CT scans. Likewise, Grogan et al. [40]stud- surrogate for FJ arthritis later on in life. ied21cadaversandatotalof104FJswithCTscansanddidnot eTh correlation of FJ arthritis and FJ orientation has only nfi danassociation betweenFJarthritis andFJasymmetry. On the other hand, a single paper by Kong et al. [46]stated been reported forthe lowerpartofthe lumbar spine. A significant association between FJ arthritis and sagittal FJ that FJ arthritis was associated with FJ asymmetry at L4/5 but not at L3/4, and L5/S1 in an MRI study of 300 individuals. orientation of the lower lumbar spine was found in a study Moreover, there was no association of FJ asymmetry and age of CT scans with 188 individuals by Kalichman et al. [6]and a in our study. Previous studies [6, 46, 47]haveyielded the MRI study if 111 individuals by Fujiwara et al. [38]. Likewise, same results. Overall, we could not find evidence for previous arecentCTstudy of 123individuals by Liuetal. [32]linkedFJ hypotheses, which attributed FJ asymmetry to asymmetric arthritis to more sagittally oriented FJs at L4/5 and L5/S1. Our mechanical stress or inborn deformities. Our findings are novel nding fi of increased FJ arthritis with more coronally supported by a study of dried vertebrae of 240 humans by oriented FJs at the upper lumbar spine might be attributed Masharawietal. [48], where FJ asymmetry was considered to the specific function of FJs at different lumbar levels. a normal characteristic of the thoracolumbar spine. Normal FJ orientation planes differ at various levels, with a However, in our study, FJ asymmetry was significantly more sagittal andcurvedorientation forresistanceagainst more common in females than in males at L5/S1, which is in axial rotation in the upper compared to a more coronal and contrast to the study by Kong et al. [46], who did not nd fi flat orientation for resistance against flexion and shearing a meaningful relationship. Interestingly, there was evidence forces in the lower lumbar segments [5, 6]. If the upper that FJ asymmetry increases cephalocaudally, with a mean of lumbar segments display more coronally oriented FJs, they ∘ ∘ 4.89 at L2/3 and 7.27 at L5/S1. This indicates that FJ asymme- are more prone to FJ arthritis because they are not designed try is less common in sagittally oriented and more common to withstand repeating axial rotation. Another theory by in coronally oriented FJs, namely, the lower lumbar levels. Dunlop et al. [65] hypothesizes that aging leads to increased Accordingly, Cassidy et al. [8]andMasharawietal.[44]stated stress in the anteromedial part of the FJ due to repetitive that FJ asymmetry is more commonly found in coronally abrasion during flexion and rotation and therefore changes oriented FJs. This may be explained by the increased load and themorphologyofFJs, resultinginincreased sagittal orien- degenerative changes at the lower lumbar spine [66], which tation [42]. Importantly, inverse orientation of the normal may lead to uncontrolled changes of the FJs. This may affect state, namely, coronally oriented FJs at the upper and sagittaly women more commonly due to changes in estrogen or other oriented FJs at the lower lumbar spine may be independent unknown factors [63]. risk factors for FJ arthritis (Figure 4). In our study, more coronal FJ orientation was present 5. Conclusion in individuals≤40 years, and a more sagittal FJ orientation manifested in individuals≥41 years at L5/S1. This is in line In conclusion, FJ arthritis is common aeff cting about half to previous study by Wang and Yang [42], who noted that of individuals, increases with age, and aeff cts both genders degenerative spondylolisthesis, which has been associated ∘ equally. Coronally oriented FJs (≥32 )inthe upperlumbar with sagittal FJ orientation in several reports [6, 40, 41], spine, namely, at L2/3 may be an individual risk factor was accompanied by a negative correlation of age and and surrogate for development of FJ arthritis in the entire coronally oriented FJs (𝑟 = −0.4555 ) through investigation lumbar spine, which is worth further investigations. Besides, of the orientation of FJs at L4/5 in 300 individuals at different coronal FJ orientation increases craniocaudally, while sagittal age groups. Masharawi et al. [43] did not nd fi an association orientation at the lower lumbar spine increases with age. between FJ orientation and age studying 240 human vertebral FJ asymmetry is not associated with FJ arthritis, is more columns. These FJ changes may be attributed to degenerative common in females at the lower lumbar spine, and also wear and tear, either at the FJs or at the intervertebral disc, increases in a craniocaudal fashion. and resulting traumatic change FJ orientation into a more sagittal alignment [38]. Like previous studies by Wang and 6. Disclosure Yang [42]and Masharawietal. [43], we also did not find an association between gender and FJ orientation. Besides, we Each author certiefi s that he or a member of his or her were able to show a signicfi ant steady progress from a sagittal immediate family has no funding or commercial associations toward a more coronal FJ orientation in a cephalocaudal that might pose a conflict of interest in connection with the ∘ ∘ fashion, namely, 30 at L2/3 and 47 at L5/S1 (Figures 4 and 5). submitted paper. Each author certifies that his institution Thisisinlinewithanancillary CT studyofthe Framingham approved the human protocol for this investigation and that Heart Study with 3529 individuals by Kalichman et al. [6], all investigations were conducted in conformity with ethical whoalsoshowedanincreasingFJO from L3-S1. principles of research. Acknowledgments (5) Asymmetry. Our values for FJ asymmetry are in line with previous studies [40], where FJ asymmetry was commonly The authors would like to thank Ms. Carol De-Simio-Hilton under 7 . 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