Arthritis, facets and ADR

[Harrison]

Everyone, thanks for making this an interesting and helpful post. Though I am pooped and getting up in a few hours, I spent some time reviewing PubMed on the issue of facet disease and grading systems (big mistake, but good validation of the misdirection of our tax dollars and the NIH).

I am sorry to say this (again), but the spine societies need to get their act together to compensate for this problem that effects TENS of MILLIONS of people in America (TConner: right on!). Though this article is dated, it speaks volumes about the nature and depths of some of the problems we are touching upon in this topic.

Complaints aside, imaging for disease assessments is not part of the current clinical picture. There are a handful of small startups that have some powerful image enhancement software to aid diagnosticians, but IMHO, disease should be left for the pathologists. That is, the geeks that are smart about microscopy, disease pathology, immunohistopathology, hematology. They are conspicuously absent from the diagnostic process of spine patients – both pre and post-op surgery. And that is so wrong!
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Annette Kettler1 and Hans-Joachim Wilke
Institute of Orthopaedic Research and Biomechanics, University of Ulm, Ulm, Germany

Received: 13 October 2004 Revised: 4 April 2005 Accepted: 14 April 2005 Published online: 20 September 2005

Abstract The aim of this literature review was to present and to evaluate all grading systems for cervical and lumbar disc and facet joint degeneration, which are accessible from the MEDLINE database. A MEDLINE search was conducted to select all articles presenting own grading systems for cervical or lumbar disc or facet joint degeneration. To give an overview, these grading systems were listed systematically depending on the spinal region they refer to and the methodology used for grading.

All systems were checked for reliability tests and those recommended for use having an interobserver Kappa or Intraclass Correlation Coefficient >0.60 if disc degeneration was graded and >0.40 if facet joint degeneration was graded. MEDLINE search revealed 42 different grading systems. Thirty of these were used to grade lumbar spine degeneration, ten were used to grade cervical spine degeneration and two were used to grade both.

Thus, the grading systems for the lumbar spine represented the vast majority of all 42 grading systems. Interobserver reliability tests were found for 12 grading systems. Based on their Kappa or Intraclass Correlation Coefficients nine of these could be recommended for use and three could not. All other systems could neither be recommended nor not be recommended since reliability tests were missing. These systems should therefore first be tested before use. The design of the grading systems varied considerably.

Five grading systems were beginning with the lowest degree of degeneration, 37, however, with the normal, not degenerated state. A 5-grade scale was used in six systems, a 4-grade scale in 24, a 3-grade scale in eight and a 2-grade scale in three systems. In 15 cases the normal, not degenerated state was assigned to grade 0 , in another 15 cases, however, this state was assigned to grade 1 . This wide variety in the design of the grading systems makes comparisons difficult and may easily lead to confusion. We would therefore recommend to define certain standards. Our suggestion would be to use a scale of three to five grades, to begin the scale with the not degenerated state and to assign this state to grade 0 .

An erratum to this article can be found at http://dx.doi.org/10.1007/s00586-006-1077-9

[KBear]

Originally Posted by Terry

I started wearing MBT shoes well over a year ago. This stands for Masai Barefoot Technology which forces the person to feel like they are walking in the sand.

For two weeks I went back to wearing my old shoes which place a lot of pounding on the facet joints and started causing pain again.

I went back to the MBT shoes and the pain is lessened again. Coincidence? I think not. The principle is sound where pounding on the lower spine takes place with conventional shoes.

I would encourage people to try these out.

Terry Newton

Where do you get these shoes? I am assuming online?

[2cool4U]

Harrison,

Thanks for the literature confirmation. 42 different systems-Yikes! As you noted, imaging assessment for facet disease isn't part of the routine clinical picture. This won't change until only one or a few classification schemes are developed, but even then, a system would only be useful if each different level of disease reliably corresponds to symptom severity. IMHO, this may never happen.

Annapurna,

I was speaking of primarily bone changes of the facets, as you mentioned because the earlier changes are not easily assessable by MRI due to the sizes of the structures involved. Shoulders and knees are good examples where cartilaginous disease or joint fluid can be readily evaluated.

One of the best ways to improve both of these areas would be, as Harrison mentioned, pathological and histological evaluation, ideally correlated with pre-op imaging findings, which could eventually lead to a classification system. However, I don't think there's a way to get tissue samples from facet joints during surgery or by biopsy. Autopsy studies probably have been done somewhere along the line, but patients would have to be carefully followed while alive and back pain records kept along with imaging records. Something akin to the landmark Framingham heart disease studies, for example. Animal histology studies have likely been done, but clinical correlation to pain levels can't be performed.

I guess these are some of the reasons that medicine remains part art and part science.

[maz]

thanks for that Annapurna, it is strange but it is true about eh heels maybe because I am balancing on my toes more in heels but it is signigifantly reduced and my posture changes in heels so I exect I do hold my shoulders diffrently in heels too. My surgeon is so busy on the NHS its sad he is so overworked but is excellent so I will always stick with him. Once I get him (next consult) I will make it all clear and I did bring the computer and my scans this time but it wasnt the 3 month check and he wouldnt look at my lower half until then anyhow after the double cervical ADR's. The biggest question for me is is it the cyst or is it the facets themselves [I] dont get lower back ache at all so its confusing. Thanks for your input though and thanks Terry where did you get the shoes?? Maz

[soljagirl]

I was walking 4-6 miles per day with my MBTs before the cervical surgery. This was risky on the hilly cobblestone paths I have here, with my spinal cord compromise. One fall away is what I was told. But that's how much I believe in them. I wear them on trains, everywhere. Just standing in them gives you core strengthening.

They're called the World's Littlest Gym. They're as ugly as sin, but they're excellent for alignment, low impact, multifidus strengthening. I remember I used to feel a few twinges of back pain for a couple of minutes after putting them on. That was the realignment happening, because completely pain free afterwards. No orthotics or arch supports needed at all with these shoes.

You're supposed to build up one hour every day. Cheaper on ebay, once you know your Euro size. Just love em. I wouldn't advise wearing them in wet, slippery areas. "Keens" are better for those.

[Terry]

Here is a good place to get the MBT shoes:

http://www.walkerswarehouse.com/mbt-.../mbt-shoes.asp

They also have nifty little videos that shows how the shoes work.

You're right, they're ugly. At my advanced age though, I am more worried about comfort vs. fashion. As far as slippery places I would recommend the YakTraks anyway. Especially in the Winter where we spiney's could do severe damage by falling on our rumps.

Terry Newton