Terminology and Legislation referring to Percutaneous Facet Procedures to Treat Low Back Pain in Brazil ­ Current Status

Incongruities in the terminology and in the Brazilian legislation about percutaneous facet procedures (PFPs) for the treatment of chronic lower back pain are frequently the subject of litigations between health professionals and supplementary healthcare providers. The Brazilian Hierarchical Classification of Medical Procedures (CBHPM, in the Portuguese acronym) describes four types of PFPs, while the Brazilian Unified Supplementary Health Terminology (TUSS, in the Portuguese acronym) describes five distinct lumbar PFPs, which correlate with the ones described on the List of Procedures and Events in Health, created by the Brazilian National Agency of Supplementary Health (ANS, in the Portuguese acronym). In the present paper, we review the terminology of the procedures, proposing the unification of the terminology and the abolition of redundancies in the tables. Finally, we developed a single terminology proposal for the PFPs based on their complexity and objectives to be used for the treatment of lower back pain.

Combination of 3.0T magnetic resonance imaging T mapping with texture analysis for evaluating the degeneration of lumbar facet joints / 中南大学学报(医学版)

OBJECTIVES@#Quantitative magnetic resonance imaging has been successfully applied to assess the status of cartilage biochemical components. This study aimed to investigate the performance of 3.0T magnetic resonance imaging T mapping combined with texture analysis for evaluating the early degeneration of lumbar facet joints.@*METHODS@#A total of 38 patients (20 in the asymptomatic group and 18 in the symptomatic group) were enrolled. All patients underwent 3.0T magnetic resonance imaging conventional sequences, water excitation three-dimensional spoiled gradient echo sequence (3D-WATSc), and T mapping scans. The bilateral L and L/S lumbar facet joints were morphological graded using the Weishaupt criteria, T values, and texture parameters derived from T mapping of cartilage. The Kruskal-Wallis test was used to compare the differences of parameters among different groups. Multivariate logistic regression analysis was used to obtain the independent predictive factors for evaluating the early degeneration of lumbar facet joints. Receiver operating characteristic (ROC) curve was performed and the area under curve (AUC) was calculated. Spearman correlation analysis was used to evaluate the correlation of the independent predictors of cartilage T value and texture parameters with the subjects' Japanese Orthopedic Association (JOA) score or Visual Analogue Scale (VAS) score.@*RESULTS@#A total of 148 facet joints were selected, including 70 in Weishaupt 0 (normal) group, 58 in Weishaupt 1 group, and 20 in Weishaupt 2-3 group. T value, entropy, and contrast increased significantly as the exacerbation of facet joint degeneration (all <0.05), while the inverse difference moment, energy, and correlation decreased (all <0.05). Entropy among different groups was significantly different (all <0.05), and the differences of T value, contrast, inverse difference moment, and energy between Weishaupt 0 and Weishaupt 1 groups, or Weishaupt 0 and Weishaupt 2-3 groups were statistically significant (all <0.05). Multivariate logistic regression analysis suggested that T value and inverse difference moment were the independent predictors for evaluating early degeneration of facet joints. The combination of T value with inverse difference moment achieved the best performance in distinguishing Weishaupt 0 from Weishaupt 1 (AUC=0.85), with sensitivity and specificity at 92.7% and 76.5%, respectively. In the symptom group, the cartilage T value combined inverse difference moment was positively correlated with JOA score (=0.475, <0.05) and VAS score (=0.452, <0.05).@*CONCLUSIONS@#3.0T magnetic resonance imaging T mapping combined with texture analysis is helpful to quantitatively evaluate the early degeneration of lumbar facet joints, in which the T value and inverse difference moment show an indicative significance．.

Lumbar facet joint degeneration contributes to degenerative lumbar scoliosis induced by asymmetric stress in rabbits / 南方医科大学学报

OBJECTIVE@#To investigate the role of lumbar facet joint degeneration in the development of degenerative lumbar scoliosis caused by asymmetric stress.@*METHODS@#Thirty-six New Zealand white rabbits were randomly divided into 3 groups (n=12): Group A with aspiration of the nucleus pulposus to induce disc degeneration; Group B with removal of the left capsule from the facet joints at L3/4 to L5/6 to induce degeneration; and Group C with both treatments. Springs were deployed on the left adjacent facets at L3/4, L5/6 and L5/6 to stress the facet joints. Serial radiographs were taken at 3 and 6 months, and the facet joint tissues were sampled at 6 months for Safranin O-fast green staining to assess the severity of cartilage degeneration based on the Mankin score.@*RESULTS@#The Cobb angle differed significantly among the 3 groups (=24.865, =0.000). In all the groups, the Cobb angles at 6 months increased significantly as compared with that at 3 months ( <0.05). The Cobb angles were significantly greater in group C than in the other 2 groups at both 3 and 6 months ( <0.05) but showed no significant difference between Groups A and B (>0.05). The severity of facet joint degeneration also differed significantly among the 3 groups (= 22.009, =0.000), and was the most severe in group C ( <0.05); facet joint degeneration was more severe in group B than in group A ( <0.05).@*CONCLUSIONS@#Facet joint degeneration is an important factor that contributes to the development of degenerative lumbar scoliosis. Disc degeneration and facet joints degeneration can lead to lumbar scoliosis, which in turn aggravates disc degeneration, facet joints degeneration and asymmetric stress, thus forming a vicious circle to further exacerbate lumbar scoliosis.

The Effect of the Pedicle-Facet Angle on Degenerative Cervical Spondylolisthesis

OBJECTIVE: To measure the orientation of the facet joints of cervical spine (C-spine) segments in the sagittal plane, known as the pedicle-facet (P-F) angle, and to use these measurements to evaluate the relationship between the P-F angle and the amount of vertebral anterolisthesis in patients with degenerative cervical spondylolisthesis (DCS). METHODS: A retrospective case-control study was performed including 30 age- and sex-matched patients with DCS and 30 control participants. Anterior-posterior and lateral view radiographs of the C-spine were obtained in a standing position. The P-F angle at all cervical levels and the amount of anterolisthesis at C4-5 were measured from lateral view plain radiographs. RESULTS: The P-F angles at C4-5 were 141.14+/-7.14degrees for the DCS group and 130.53+/-13.50degrees (p=0.012) for the control group, and at C5-6 were 137.46+/-8.53degrees for the DCS group and 128.53+/-16.01degrees for the control group (p=0.001). The mean P-F angle at C4-5 did not correlate with the amount of anterolisthesis (p=0.483). The amount of anterior slippage did correlate with age (p<0.001). CONCLUSION: The P-F angle was intrinsically higher at C4-5, compared to C5-6, in both the DCS and control groups, which might explain the increased likelihood for anterolisthesis of C4. Higher P-F angles in the DCS group may be a predisposing factor to slippage. The P-F angle may interact with age to increase incidence of anterolisthesis with increasing age.

Effects of lumbar facet joints in the pathogenesis of lumbar degenerative spondyiolisthesis / 中国医师进修杂志

[Objective]To study the pathogenesis of lumbar degenerative spondylolisthesis(LDS)through the degeneration degree of lumbar facet joints and the changes of the joint sagittal angle of little zygapophysial joints and the endplate hypozygal angle in patients with LDS and lumbar disc herniation (LDH).[Methods]The image data of 79 patients with lumbar degenerative diseases were collected from October 2009 to November 2011.There were 42 patients with L4-5 LDS(experimental group)and 37 patients in same age with L4-5 LDH(control group).The L4-5 facet joints were graded by Weishaupt ect.lumbar facet joint osteoarthritis imaging grading method.The joint sagittal angle of L4-5 little zygapophysial joints and the L4endplate hypozygal angle were detected by CT.The L4-5 facet joint osteoarthritis grading,joint sagittal angle of lumbar little zygapophysial joints,L4 endplate hypozygal angle and bilateral symmetry between two groups were compared.[Results]There was no grade 0 of facet joint osteoarthritis in both two groups.The numbers of grade 1,2,3 in experimental group were 4,20,18 cases,respectively,while the numbers in control group were 21,14,2 cases.There was significant difference between the numbers of two groups(P ＜ 0.05).The joint sagittal angle of L4-5 little zygapophysial joint,deviation angle of sagittal angle asymmetry and L endphtehypozygal angle in experimental group(26.62°± 1.67°,8.79°± 4.28°,116.92±6.86°)had statistical significance compared with those in control group(45.07° ± 7.32°,5.14° ± 4.28°,104.95° ± 4.97°)(P ＜0.01).The deviation angle of endplate hypozygal angle asymmetry in experimental group had no statistical significance compared with that in control group(P ＞ 0.05).[Conclusions] The sagittal orientation of lumbar facet joint angle and the endplate hypozygal angle increasing have important significance in LDS.

Determination of contact force at facet joint with different sagittal orientation under shearing loads:a finite element analysis / 中国矫形外科杂志

[Objective] The efleet of sagittal orientations of articular facet on the contact force and contact regions of a lumbar spine segment was evaluated.[Methods] [Results]Three-dimensional geometrical and mechanical accurate finite element models of the lumbar L4、5 motion segment representing three sagittal-orientations articular facet were generated and invalidated by an effective CAD method.Contact force and contact regions of the articular facets of three finite element models were predicted under the pure shearing loads.[Result] Under anterior shear condition,the contact force on the facet decreased with the increase of sagittal 0rientation of articular facet.however.in posterior shear load,the contact force on the facet increased with the increase of sagittal orientation.Meanwhile,under both pure shear loading,the percentages of the sagittal and the transversal components are increased with the dectease of the sagittal angle.However,under the salne load condition,there are no difference between the contact regions of the three models with different facet joint angle.[Conclusion]The spatial orientation and geometric forms of the coronal facet articular surfaces are more effective in restricting motion in transversal and sagittal planes while assuming a minor role in resisting axial force or motion than sagittal facet articular surface.It Was presumed that anterior shear force play a more prominent contribution on the degeneration of the facet joint with coronal articular surface compared with posterior shear force.

Radiological research of lumbar facet degenerative diseases / 中国矫形外科杂志

Degeneration of the lumbar facet joints is considered to be one of the main causes of low back pain,which severely impact the life quality of people.This article sums up the research advancement of the lumbar facet joints degeneration of domestic and foreign scholars in recent years,and summarizes the characteristics of the X-ray,CT and MRI and clinical significance of the degeneration of articular process,of which the characteristic of MRI was rarely reported domesticly.The purpose is to provide ideas and references for domestic scholars aiming to further clinical research of related fields in the future.

Risk factors of lumbar facet joints osteoarthritis / 中国矫形外科杂志

The lumbar facet joints osteoarthritis can be a potentially important source of low back pain.The risk factors of lumbar facet joints osteoarthritis has been systematic reviewed.Recent research shows that risk factors for lumbar facet joints osteoarthritis include advanced age(older than 50 years old),male or post-menopause female,relatively more sagittal orientation of the facet joints,a background of intervertebral disk degeneration and L4、5 spinal levels.An up-to-date knowledge of this subject can be helpful in diagnosis and treatment of low back pain.

Contribution of sagittal orientation of facet joints and disc degeneration to degenerative spondylolisthesis in lumbar spine:A finite element research / 国际生物医学工程杂志

Objective To research the connection between the sagittal orientation of facet joints and disc degeneration in lumbar spine and to investigate the contribution of which to development the degenerative spondylolisthesis. Methods A new effective CAD method was used to accurately establish 9 finite element models(FEM)which were assembled respectively with facet-joint angle 65?, 45?, 25?, with normal disc, light degenerative disc and severe degenerative disc. The biomechanical parameters of 9 finite element models were measured under axial compressive load within physiological range. Results Compared with FEMs with facet-joint angle 45? and 25?, anterior displacement of L4 vertebra in FEMs with facet-joint angle 65? was increased, where the maximum von Mises stresses on facet surface, isthmus and the contact force on facet surface in horizontal orientation were obviously increased. Meanwhile, FEMs with facet-joint angle 65? showed a decrease in end-plate bulge and an increase in stress of annular matrix. The stiffness in light degenerative disc FEMs was reduced and the von Mises stresses on facet surface and isthmus was slightly increased compared with the normal disc FEMs. Among all, the FEM with facet-joint angle 65? combined with light degenerative disc showed the poorest resisting anterior shear force. Conclusion Sagittal orientation of facet joints is not only the primary inducement of the degenerative spondylolisthesis but the secondary pathological change of remodeling of the facet-joints induced by the regional stress change. The inherent instability of lumbar motion segment of sagittal orientation of facet joints is influenced by the lumbar disc degeneration. The lumbar disc degeneration has no manifested contribution to the aggravation of the sagittal orientation of facet joints.

Radiological Considerations of Posterior Cervical Lateral Mass Fixation Using Plate and Screw

The aim of this study is to determine whether the posterior cervical fusion methods with the plate-screw system applied to the lateral mass of cervical spine are radiologically safe to patients. The lateral cervical X-rays and CT scans were done on 40 normal adults without cervical problem. Based on Roy-Camille and Magerl's method, the theological trajectory of screw was shown on films and the parameters were measured. The study based on Roy-Camille's method showed less than one percent chance of injury on the facet joint and the mean depth of the screw to be 10.5+/-1.4mm. On the other hand, Magerl's method showed the mean depth of screw to be 11.9+/-1.5mm which is slightly larger than that of Roy-Camille's method and no chance of facet injury occurred. A reduced lateral angle of screw (19.6+/-3.5 degrees) performed with the concept based on Magerl's method resulted a longer depth of screw (13.5+/-2.1mm). Both Roy-Camille and Magerl's methods seemed to be radiologically safe to normal persons. However, the authors recommend the reduced lateral angle (19.6+/-3.5 degrees) of screw based on the Magerl's method more than an original Magerl's methods.

Pigmented Villonodular Synovitis of the Spine: A Case Report

Pigmented villonodular synovitis(PVNS) is a synovial lesion of joints or tendon sheaths, characterized by villous and nodular overgrowth of the synovial membrane. It commonly occurs in synovial joints of the appendicular skeleton, particularly those of the knee and hip, but rarely affecting those of the spine. We report a case of PVNS of the lumbar spine mimicking epidural mass.

Facet Joint Injuries in Acute Cervical Spine Trauma: Evaluation with CT and MRI

PURPOSE: To evaluate injury patterns of facet joints and associated soft tissue injuries in patients withacute traumatic cervical facet joint injuries. MATERIALS AND METHODS: From among patients with cervical spinetrauma, 27 with facet joint injuries, as seen on CT and MRI, were chosen for this study. CT scans were analyzedwith regard to the location of facet joint injury, the presence or absence of facet dislocation or fracture, andother associated fractures. MR images were analyzed with regard to ligament injury, intervertebral disc injury,intervertebral disc herniation, and spinal cord injury. RESULTS: The most common location of facet joint injurywas C6-7 level(n=10), followed by C5-6(n=8). Among these 27 patients with facet joint injuries, 12(44%) hadbilateral injuries and 15(56%) unilateral injuries. Facet fractures were present in 17 cases(63%) and the fractureof inferior facet was more frequent than superi-or. Patterns of fracture were vertical, transverse, or comminuted,but vertical fracture was the most common. Various degrees of dislocation were observed in patients with facetfractures. Fractures other than facet includ-ed pillar(n=11), lamina(n=6), transverse process(n=14), body(n=13),and spinous process(n=3). On MR im-ages, anterior longitudinal ligament injury was found in 8 patients(30%),posterior longitudinal ligament injury in 4(15%), and interspinous ligament injury in 20(74%). Twelvepatients(44%) had spinal cord injuries includ-ing edema(n=8) and hemorrhage(n=4). Among patients with discabnormalities, 11(41%) had intervertebral disc injuries, and traumatic disc herniations were found in nine. CONCLUSION: Traumatic cervical facet joint injuries were manifested as various patterns and frequentlyassoci-ated with other fractures or soft tissue injuries. Analysis of CT and MR findings of these injury patternshelped formulate a therapeutic plan and determine of prognosis.