Variation of facet joint orientation and tropism in lumbar degenerative spondylolisthesis and disc herniation at L4-L5: A systematic review and meta-analysis

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Highlights

  • ā€¢

    Patients with DS have more sagittal orientated facet joints.

  • ā€¢

    Patients with DS have more significant facet joint tropism.

  • ā€¢

    No significant correlation was observed between deformity of facet joints and LDH.

  • ā€¢

    The first meta-analysis of the facet joint angle.

Abstract

Although degenerative spondylolisthesis (DS) and lumber disc herniation (LDH) are common causes of back pain, the associations between the lumbar facet joint angle orientation and tropism in these conditions are still contentious. The objective of the meta-analysis was to identify the role of facet joint orientation and tropism on the development of lumbar degenerative disease, including DS and LDH. Electronic searches of PubMed and Embase were conducted up to April 2017. P valueĀ <Ā 0.05 was regarded as significant. Seventeen studies were included in this meta-analysis. Depending on the analysis, patients with DS have more sagittal orientated facet joints compared with control subjects (weighted mean difference [WMD] āˆ’10.5, 95% confidence interval [CI] āˆ’11.71 to āˆ’8.60; PĀ <Ā 0.00001). We also found that DS patients have more remarkable facet joint tropism (WMD 1.84, 95% CI 0.77ā€“2.91; PĀ =Ā 0.0007). No significant correlation was observed between facet joint angle with LDH. There is a possibility that morphological deformity of facet joints could be associated with accelerated degeneration of stabilizing structures and affect the progress of DS. Our conclusion did not support the correlation between LDH and abnormalities of the facet joint. We tend to assume that the mechanics related to biomechanical changes in LDH disease progress might be more sophisticated.

Introduction

Facet joints, also called zygapophyseal joints or apophyseal joint, are situated on the dorsolateral aspect of the spine between the adjacent vertebrae [1]. They play an essential role in balancing the segmental unit of spine [2] and control spinal kinematic function [3]. It is thought that larger sagittal facet joint orientation can limit axial rotation and increase torsional strength. Many of previous studies have attempted to establish the relationship between deformities of facet joints and lumber degenerative changes, but there are still many controversies in this field of research. These degenerative changes include degenerative spondylolisthesis (DS) [4], [5], [6] and lumber disc herniation (LDH) [7], [8], [9]. Facet joint osteoarthritis [10], [11] and spondylolysis [12] have also been reported as the degenerative changes in a few studies.

DS is defined as a lumbar vertebral body slipping forward to the adjacent vertebral body without neural arch defected, due to the unstable influence of progressive change [6], [13], [14]. It develops often at the L4ā€“L5 level and mostly in females older than 40 years [15]. It is assumed that patients with abnormality facet joint angle have less resistance to the shearing force than the normal. This leads to the ligament elasticity decreases and anterior slipping of a vertebra occurs [5]. Another degenerative disease, LDH, is also concerned associated with the abnormality of the facet joint. The intervertebral disc might be noneffective to stress the shear force owing to the existing facet joint tropism [16].

Due to the specific anatomy and great pressure at the L4ā€“L5 level, this region is more vulnerable because of the increased mobility of this segment [17]. Therefore, majority of previous studies involve patients with degenerative changes at the L4-L5 level. This article is intended to accomplish a meta-analysis to evaluate if the facet joint abnormality plays a role in the pathogenesis of DS and LDH at L4-L5. Orientation and tropism were chosen to evaluate the abnormality of the facet joint. We defined the facet joint orientation as the average value between the left facet joint angle degree and the right facet joint angle degree [8]. And we defined the facet joint tropism as the absolute number of the difference value between the left facet joint angle degree and the right facet joint angle degree [5].

Section snippets

Search strategy

We carried out a meta-analysis of most recent radiographic researches following the MOOSE statement. Electronic searches of PubMed and Embase (update to April 25, 2017) were conducted by using the combination of the following terms " facetā€ or " zygapophysealā€ or " apophysealā€, and " orientā€ or ā€œtropismā€ or ā€œangleā€ or ā€œangulationā€ or ā€œasymmetryā€, and ā€œdegeneratedā€ or ā€œdegenerationā€ or ā€œspondylolisthesisā€ or " herniationā€ or " intervertebralā€. No language restriction was applied in this study.

Search results

We extracted 665 references by searching in PubMed and Embase in total. Seventy-nine articles were retrieved after removing duplicates and excluding unrelated studies in the primary screen. After full-text articles assessed, sixty-two studies were excluded. These contained fourteen studies that analyzed facet joint orientation and tropism as dichotomous variables rather than continuous variables, fifteen studies with inappropriate designed, six studies with deficient data, three studies using

Discussion

The character of facet joint abnormality in the progression of lumbar degenerative disease has been studied during the last few decades without firm conclusions. In our meta-analysis, a significant correlation between the facet joint orientation and DS was identified. It indicates that people with a larger sagittal orientation of the lumbar facet joints may have a higher risk of DS, perhaps because their facet joints are not competent for resisting the shear forces [17]. Another hypothesis is

Conclusion

Patients with DS have more sagittal orientated facet joints and more significant facet joint tropism. It is not apparent whether the change of facet joint represents a primary morphological variation or a consequence of secondary reconstruction. No significant correlation was observed between morphological abnormalities of facet joints with LDH. In addition, larger sample, prospective studies with long-term following and normalized measurement are needed.

Source of funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors

Conflicts of interest

The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.

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    Ziyang Liu and Yuchen Duan are co-first authors. They contributed equally to this work.

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