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Kinematic Magnetic Resonance Imaging to Define the Cervical Facet Joint Space for the Spine in Neutral and Torsion

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Kinematic Magnetic Resonance Imaging to Define the Cervical Facet Joint Space for the Spine in Neutral and Torsion SPINE Volume 39 , Number 8 , pp 664 - 672 ©2014, Lippincott Williams & Wilkins DIAGNOSTICS Kinematic Magnetic Resonance Imaging to Defi ne the Cervical Facet Joint Space for the Spine in Neutral and Torsion Nicolas V. Jaumard , PhD , * † Jayaram K. Udupa , PhD , ‡ William C. Welch , MD , * and Beth A. Winkelstein , PhD * † Study Design. Prospectively acquire magnetic resonance images Conclusion. Quantifi cation of the facet joint space architecture of the neck in normal subjects and patients with radiculopathy to in the cervical spine of patients with radiculopathy is feasible using measure and compare measures of the facet joint space thickness standard magnetic resonance imaging sequences. Measurements of and volume. the facet space thickness and volume, and their changes, from both Objective. The goal was to determine whether there is any pain-free and painful positions, can provide context for localizing difference in facet joint architecture between the 2 populations with potential sources of painful tissue loading. the head in each of neutral and pain-eliciting rotation. Key words: MRI , cervical spine , facet joint , joint space , volume , Summary of Background Data. Degeneration and altered thickness , radiculopathy , pain , axial torsion . mechanics of the facet joint can result in pathological nerve root Level of Evidence: 3 compression and pain. Although lumbar facet joint space thinning Spine 2014;39:664–672 has been reported in the context of low back pain, few studies have quantifi ed the cervical facet joint space, especially in the context of pain. eck pain is a common disability that affects upward Methods. The cervical spine of 8 symptomatic and 10 asymp- of 50% of the general population, with an estimated tomatic subjects was imaged in the sagittal plane in a 3T magnetic annual incidence ranging between 10% and 21% N 1–3 resonance scanner, using a T2-pulse sequence optimized for bone depending on age, sex, and activities. The facet joints are imaging. The facet joint space was identifi ed and segmented in the a potential source of axial and peripheral pain. 4 , 5 Specifi - acquired images. The thickness and volume of the facet joint space, cally, facet joint pain has a prevalence of 54% to 67% in and their changes between positions, were computed from the the patients treated for cervical pain. 6 , 7 Furthermore, facet 3-dimensional representation for all cervical levels on both sides. spondylosis has been associated with cervical radiculopathy, Results. Generally, the facet joint space thickness and volume and facet joint osteoarthritis accounts for up to 45% of the were smaller in the symptomatic subjects than in the asymptomatic chronic low back pain cases. 6 , 8 subjects. The differences were more robust on the left, especially in Cervical radiculopathy is produced by transient and/or neutral and left torsion. The changes in both volume and thickness sustained compression of the cervical nerve root that can from neutral to torsion were also different in sign and magnitude at result from disc herniation, bony trauma, and/or changes in isolated joint levels between the 2 populations. the intervertebral joints. 8 – 11 It has been hypothesized that facet degeneration and reduction of the interfacet distance can also 12 From the * Departments of Neurosurgery , † Bioengineering, and ‡ Medical cause spinal spondylosis and stenosis. The lumbar facet joint Image Processing Group, Department of Radiology, University of gap is smaller in patients with low back pain than in healthy Pennsylvania, Philadelphia. asymptomatic volunteers. 13 In addition, facet cartilage degra- Acknowledgment date: July 24, 2013. First revision date: October 8, 2013. dation has been implicated as contributing to pain; a greater Second revision date: December 19, 2013. Acceptance date: January 2, 2014. incidence of facet joint arthrosis is reported for lumbar steno- The manuscript submitted does not contain information about medical 14 device(s)/drug(s). sis than in healthy controls. Cervical Spine Research Society and the Catherine Sharpe Foundation funds The facet cartilage layers that permit the smooth motion were received to support this work. of the adjacent vertebrae can be eroded because of aging, Relevant fi nancial activities outside the submitted work: grant, grants/grants mechanical injury and wear, and osteoarthritis. 15 – 18 With the pending, and expert testimony. progression of cartilage thinning, the facet joint space also Address correspondence and reprint requests to Beth A. Winkelstein, narrows, which can serve as a radiological marker of facet PhD, Department of Bioengineering, School of Engineering and Applied 13,19 Science, University of Pennsylvania, 210 S. 33rd St, Room 240 Skirkanich joint osteoarthritis. The kinematics of the cervical facet Hall, Philadelphia, PA 19104; E-mail: [email protected] or http:// joints and their articular surfaces are complicated by their spinepain.seas.upenn.edu/ complex anatomy that couples head and neck motions. 4 , 20 DOI: 10.1097/BRS.0000000000000206 As such, head motions infl uence the relative positions of the 664 www.spinejournal.com April 2014 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. SSPINE130897_LRPINE130897_LR 664664 33/22/14/22/14 77:31:31 AMAM DIAGNOSTICS Cervical Facet Joint Architecture by MRI • Jaumard et al opposing articular surfaces in the cervical facet joints, which Procedures adhered to the guidelines of the Committee for could manifest as changes in the joint space. In some patients Research and Ethical Issues of the International Association with cervical radiculopathy, nerve root compression occurs for the Study of Pain. only when there is head motion. It is hypothesized that the All subjects underwent MRI of the cervical spine (C2–C7) change in the joint architecture may be key to understanding using a 3T TimTrio scanner (Siemens Medical Solutions; relationships between neck biomechanics, the facet joint, Malvern, PA) and a standard collar-shaped antenna. The nerve root, and pain. 21 , 22 symptomatic subjects were imaged fi rst with the head/neck Imaging techniques can characterize osteoarthritis in the in the neutral position and then again with the head in the lumbar facets in patients with low back pain. 23 – 25 Radiogra- rotation position producing pain. The asymptomatic subjects phy has proved useful to develop a qualitative assessment to underwent 3 imaging scannings with the head: (1) in neu- screen facet joint osteoarthritis, but it can underestimate the tral position, (2) rotated to the left, and (3) rotated to the degree of degeneration and can be insensitive to mildly dis- right. The head rotation used for the asymptomatic subjects eased joints. 23 Both magnetic resonance imaging (MRI) and approximated the average rotation inducing pain in the symp- computed tomography (CT) provide fi ner resolution and have tomatic subjects. A FLASH 3D pulse sequence with a matrix enabled a refi ned semiquantitative scoring of facet osteoarthri- size of 512 × 512, voxel size of 0.3 × 0.3 × 1 mm, 3 and TE/ tis. 24 , 25 Evaluating the presence of cartilage and bone erosions TR = 4 ms/9 ms, optimized for bone visualization, was used and osteophytes remains qualitative, whereas the narrow- to acquire 120 slices in the sagittal plane over a 7-minute scan ing of the facet joint space has been measured using CT and period. MRI. 24 , 25 Unlike radiography, CT and MRI do not depend on Images were analyzed using customized 3DVIEWNIX the relative orientation of the imaging system and the joint, 23 , 24 software to visualize and measure the facet space volume and providing potential approaches for 3-dimensional (3D) mea- thickness. 27 The digital slices including the left and right facet surements. 23 , 26 Although CT has better bone defi nition than joint spaces at all cervical levels were identifi ed ( Figure 1A ). MRI, concerns regarding radiation exposure and the ability For each slice, the facet joint space was identifi ed as the space to optimize imaging sequences for bone detection make MRI between the subchondral zones of the superior and inferior a potential tool for studying facet joint architecture. 19 Despite articular pillars, consisting of the 2 opposing cartilage layers the potential pathological consequences of facet space nar- and the gap between them. The bony articular pillars were rowing and the availability of high-sensitivity MRI, no study delineated using the semimanual segmentation “live-wire” has examined the feasibility of measuring the changes in facet technique that identifi es the peripheral pixels of a region of joint architecture, including the facet joint space, because of interest, based on a threshold method, for the demarcation changes in the kinematics of the opposing facets between of the facet joint space. 28 The segmented slices were then pain-free and painful head positions. assembled and fi ltered to create and render the facet joint The objective of this study was to measure the volume and space as a 3D object 29 ( Figure 1B ). The volume and thickness thickness of the cervical facet joint space using MRI in sub- of each 3D-reconstructed facet joint space were calculated by jects with cervical radiculopathy and in asymptomatic volun- 3DVIEWNIX. The thickness was measured along the third teers to investigate the potential utility of such an approach. principal axis of inertia of the joint space volume ( Figure 1C ). Measurements were performed using sagittal magnetic reso- For 3 of the asymptomatic subjects (AS2, AS5, and AS8), the nance images acquired with the head in both a pain-free images during head torsion were inadequate for segmenta- neutral position and in a pain-provoking position, for both tion; those subjects were excluded from image analysis for subject groups. Outcomes were compared between the 2 pop- comparison with the symptomatic subjects for head rota- ulations and also between the 2 head positions to evaluate tion. One symptomatic subject (S4) experienced pain only and normalize the changes in facet joint space dimensions in in extension; so, facet space dimensions were absent from both populations.
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