Relationship between asymmetry of lumbar facet joints and direction of lumbar disc herniation in patients aged 12-21 years

doi:10.21203/rs.3.rs-3745808/v1

Background: Lumbar facet joint (FJ) asymmetry is thought to be associated with lumbar disc herniation (LDH), but the relationship between the two is unclear. In addition, the effect of vertebral FJs on LDH in adolescent patients has not been elucidated. The purpose of this study was to measure and compare the angle of lumbar FJs with computed tomography (CT) and to study the relationship between vertebral FJ asymmetry with LDH as well as herniated disc location in adolescent patients (12-21 years old).

Methods: This study retrospectively analysed clinical data from the Department of Orthopaedics at The First Affiliated Hospital of Nanchang University. 149 patients with single- or two-segment LDH composed the case group and 108 adolescent patients with acute abdomen composed the control group aged 12 to 21 years diagnosed from December 2016 to December 2022. The facet joint angle (FJA) of the study subjects at the L3~4, L4~5, and L5~S1 levels was measured lumbar or abdominal CT and recorded. Facet tropism (FT) was defined as a bilateral FJA difference >7°.

Results: Among 149 patients with LDH, 57, 77, and 85 patients had FT at the L3-4, L4-5, and L5-S1 segments, while among the 108 patients without LDH (N-LDH), 25, 29, and 27 patients had FT at the L3-4, L4-5, and L5-S1 segments, respectively. The probability of FT was significantly higher in the experimental group than in the control group (P < 0.05). In the LDH group, FT was present in 31 of 51 protrusions in the L4-5 segment and 56 of 97 protrusions in the L5-S1 segment; while in the N-LDH group, 29 and 27 patients had FT at the L4-5 and L5-S1 segments, respectively. The probability of FT in the experimental group was significantly higher than that in the control group (P< 0.05). In the LDH group, among the 51 cases of L4-5 LDH, there were 18 cases of the central type, 33 cases of the paracentral type, 9 cases of the central type with FT, and 22 cases of the paracentral type with FT. Among the 97 cases of L5-S1 LDH, there were 39 cases of the central type, 58 cases of the paracentral type, 11 cases of the central type with FT, and 45 cases of the paracentral type with FT. By cardinal empirical comparison, vertebral subtotal joint asymmetry was correlated with the location of LDH in the L5-S1 segment (P < 0.05).

Conclusion: FJ asymmetry was significantly associated with LDH in the L4-5 and L5-S1 segments in adolescents, and FJ asymmetry was associated with the location of LDH in the L5-S1 segment in adolescents.

Adolescent lumbar disc herniation

facet tropism

facet joint angle

Lumbar disc herniation (LDH) is a common clinical lumbar lesion, with low back pain and lower limb radicular pain as the main clinical symptoms. While it is mostly seen in middle-aged and elderly patients, it is also rarely encountered in teenagers. However, more recently, we have found that the number of adolescent patients with LDH is increasing. The age of onset of adolescent lumbar disc herniation (ALDH) is 16 to 21 years, with an incidence of 1% to 5%[1,2]. It is generally believed that factors associated with LDH include genetics, trauma, degeneration, inflammation and immunity, and lumbar facet asymmetry. Several studies have found that lumbar facet joint (FJ) asymmetry plays an important role in the development of ALDH.

The vertebral FJs play an important role in spinal stability by enhancing the stability of the motor segments during flexion and extension and preventing excessive[3,4] lumbar spine movement. Over the years, some scholars have speculated that this may be the cause of intervertebral disc degeneration and LDH. In a biomechanical study, Cyron and Hutton[9] found that lumbar FJ asymmetry leads to lumbar spine instability, mainly manifested by joint rotation. They concluded that this unbalanced stress distribution may accelerate the degeneration of the vertebral FJs and discs[8]. In the past, the mainstream view was that trauma is the main cause of ALDH, which is different from the causes of adult LDH. Li and other[10] researchers pointed out that 30% to 60% of patients with ALDH have sustained a waist trauma or sports injury. Compared with that in adults, the lumbar disc in adolescent does not undergo significant degeneration, and the epiphyseal ring is the weakest part of the spine. When subjected to a severe trauma or long-term repeated cumulative injury, epiphyseal ring fracture leads to the loss of anchorage of the annulus fibrosus and its wrapped nucleus pulposus, resulting in protrusion into the spinal canal. In severe cases, the annulus fibrosus will directly rupture and then cause the nucleus pulposus to enter the spinal canal, causing a series of clinical symptoms. Farfan and Sullivan[6] first proposed that lumbar FJ asymmetry is related to the development of LDH. They suggested that FJ asymmetry is associated with the development of LDH because more coronally oriented FJs produce less resistance on the disc, resulting in rotation on the side of the more coronal facet, in turn causing increased torsional stress on the annulus[11].

However, opinions vary. Masharawi Y et al[12] found that vertebral FJ asymmetry is a normal feature in the majority of thoracic vertebrae but that asymmetry in the lumbar spine may be related to a pathological condition[8]. Cassidy found no significant correlation between LDH and vertebral facet asymmetry[11]. Therefore, the relationship between lumbar vertebral FJ asymmetry and LDH remains unclear[1,11,13-16]. Previous studies have not uniformly stipulated the age of the enrolled population and have ignored the relationship between lumbar degeneration and age. At the same time, some studies used normal segments of LDH patients as controls. Therefore, the conclusion about the relationship between LDH and vertebral FJ asymmetry in adolescents lacks rigor and is controversial.

In conclusion, to avoid the deficiencies in the abovementioned related studies, 12- to 21-year-old adolescents with acute abdomen without spine-related diseases were selected as controls to avoid the interference of lumbar spine degeneration caused by increasing age as much as possible. After the determination of and correlation analysis between the experimental and control groups, we discussed whether there is an association between vertebral FJ asymmetry and LDH in adolescent patients and whether lumbar vertebral FJ asymmetry is related to the prominent position of LDH in adolescent patients. The purpose of this study was to provide a new reference concept for the relevant diagnosis and treatment of ALDH patients.

The study was approved by the Ethics Committee of the First Affiliated Hospital of Nanchang University, China. The authors collected clinical data for patients who visited the First Affiliated Hospital of Nanchang University from December 2016 to December 2022. A total of 149 patients between the ages of 12 and 21 years with single-level LDH (L3-L4, L4-L5 or L5-S1) were included in the study. The control group comprised 108 patients between the ages of 12 and 21 admitted to the hospital due to acute abdomen (acute appendicitis, acute cholecystitis, acute pancreatitis, acute intestinal obstruction, or abdominal organ perforation) who underwent a full abdominal computed tomography (CT) scan in the emergency department. These patients had neither LDH nor low back pain before admission. The criteria for inclusion in the experimental group was a diagnosis of LDH with typical CT findings and clinical symptoms, including lower-extremity radicular pain with or without low back pain. The exclusion criteria were as follows: multiple or recurrent disc herniations, associated spondylolisthesis, spina bifida, transitional vertebra, scoliosis, previous surgery, previous trauma, spinal infection or significant facial arthropathy.

The clinical data of all patients were collected through hospital records. Clinical parameters (sex and age) were recorded for both groups, and the corresponding facet joint angles (FJAs) of L3~4, L4~5, and L5~S1 on lumbar and abdominal CT were recorded in the experimental and control groups, respectively, as well as the position of disc herniation (central or lateral protrusion, Figure 1) in the experimental group.

The FJ parameters were measured using partial axial CT images with a slice thickness of 3 mm and a computer-aided design image tool,, according to the method described by Li et al. and Noren[15,17]; measurements were obtained parallel to the endplate and at the incision in the intervertebral disc parallel to the upper and lower vertebral bodies. A line was drawn between the two peaks of each upper joint surface (C and D, F and G). The midline crossed the centre of the lumbar vertebra (O, O = OB) and the midpoint of the base of the spinous process (E) to measure the angle between the midsagittal plane and the line of the lumbar vertebra (α = right vertebral FJA, β = left vertebral FJA). Vertebral FJ asymmetry (FT) refers to the asymmetry of the left or right vertebral FJA, with one FJ being more sagittal than the other[3]. FT was calculated from the absolute value of the difference between the bilateral vertebral FJAs. The FJ direction (facet joint orientation, FJO) was defined as the angle of the facet relative to the sagittal plane and quantified as the mean of the left and right FJAs [（α + β）/2][18]. The angle between the midsagittal plane and the joint line was measured on each side of the lumbar vertebral body (Figure 2).

In this study, FT was defined by an absolute bilateral angular difference value > 7° [4], namely, FJ asymmetry (Figure 2) (Figure 3). To avoid measurement error, 2 spine surgeons independently measured the vertebral FJAs on a bone window CT without knowledge of the patient's symptoms or the purpose of the study. Analysis was performed using the mean of data from 2 observers to minimize observer bias(Figure 3, Figure 4).

Statistical analysis

Pearson's chi-square test was used to analyse the relationship between facet asymmetry and ALDH as well as the position of the disc herniation, and P <0.05 was considered to indicate a significant difference. All analyses were performed using SPSS statistical software (version 26.0, SPSS, Inc.).

Patient characteristics

A total of 257 patients met the inclusion criteria, including 149 (58%) in the LDH group and 108 (42%) in the no LDH (N-LDH) group. The baseline characteristics of the two patient groups are shown in Table 1.

Table1 Baseline characteristics of patients in the LDH and N-LDH groups

Characteristics	Total, n (%) n = 257	LDH group, n (%) n=149 (58)	N-LDH group, n (%) n=108 (42)
Age (years)		19.17±1.80	17.47±2.70
Sex, n (%)
Male	182 (70.80)	103 (69.10)	79 (73.10)
Female	75 (29.20)	46 (30.90)	29 (26.90)
LDH level, n
L3-4		3	0
L4-5		51	0
L5-S1		97	0
L3-4 and L5-S1		1	0
L4-5 and L5-S1		1	0

Herniated and normal discs in different segments

Among 149 patients with LDH, 57, 77, and 85 cases of vertebral FJ asymmetry occurred at the L3-4, L4-5, and L5-S1 level, respectively, among the 108 patients in the N-LDH group, 25, 29 and 27 cases of vertebral FJ asymmetry occurred at the L3-4, L4-5 and L5-S1 level, respectively. The probability of FT in the experimental group was significantly higher than that in the control group (P < 0.05, Table 2).

Table2 Comparison of FT in different segments between the LDH and control groups

LDH level	LDH group (n=149)		Control group (n=108)		P
LDH level	FT	N-FT	FT	N-FT	P
L3-4	57	92	25	83	0.010 *
L4-5	77	72	29	79	0.000 *
L5-S1	85	64	27	81	0.000 *

*P < 0.05

Comparison of FT in corresponding segments in the LDH and control groups

In the LDH group, FT was present in 31 of 51 disc herniations at L4-5 and in 56 of 97 disc herniations at L5-S1. In the N-LDH group, there were 29 and 27 cases of FT at L4-5 and L5-S1, respectively. The probability of FT in the experimental group was significantly higher than that in the control group (P < 0.05, Table 3).

Table3 Comparison of FT in corresponding segments between the LDH and control groups

LDH level	LDH group		Control group		P
LDH level	FT	N-FT	FT	N-FT	P
L4-5	31	20	29	79	0.000 *
L5-S1	56	41	27	81	0.000 *

*P < 0.05

Relationship between FT and disc herniation position in the LDH group

In the LDH group, among 51 cases of L4-5 LDH, there were 18 cases of the central type, 33 cases of the paracentral type, for 9 cases of the central type with FT, and 22 cases of the paracentral type with FT. Among 97 cases of L5-S1 LDH, there were 39 cases of the central type, 58 cases of the paracentral type, 11 cases of the central type with FT, and 45 cases of the paracentral type with FT. The chi-square test showed that FJ asymmetry was significantly correlated with the location of L5-S1 LDH (P < 0.05, Table 4).

Table 4 Relationship between FT and disc herniation position in the LDH group

LDH level	Disc herniation position		Facet joint		P
LDH level	Type	n	Symmetry	Asymmetry	P
L4-5	Central	18	9	9	0.244
L4-5	Paracentral	33	11	22	0.244
L5-S1	Central	39	28	11	0.000 *
L5-S1	Paracentral	58	13	45	0.000 *

*P < 0.05

At present, there have been few reports on the relationship between lumbar FJ asymmetry and LDH, and there is no accepted conclusion. Kalichman et al[19] and Kalichman L and Hunter[20] reported a significant correlation between the lumbar FJA and LDH, and they suggested that severe lumbar FJ asymmetry may increase the risk of LDH. In Kalichman's study, FJs and discs were evaluated by lumbar CT and radiographs [19]. However, Badgley[5] and Vanharanta et al[13] considered that the lumbar FJA does not affect the intervertebral disc and that lumbar FJ asymmetry is congenital and has nothing to do with age. Therefore, the effect of lumbar FJ asymmetry on LDH is still controversial, and there is no unified conclusion. The correlation between lumbar FJ asymmetry and the location of LDH has not been previously reported. Therefore, this paper aimed to analyse the correlation between lumbar FJ asymmetry and LDH as well as the relationship between lumbar FJ asymmetry and the location of LDH by measuring vertebral FJAs and calculating the symmetry of the vertebral FJs on lumbar or abdominal CT.

An appropriate control group is essential for clinical trials. In many studies, vertebral FJs in patients with low back pain or adjacent vertebral FJs in patients with LDH have been used as controls[14,21,22]. The biomechanical nature of lumbar spine movement in patients with low back pain is abnormal, and the vertebral FJs in these patients cannot replace normal vertebral FJs. FJs of adjacent segments in patients with LDH are potential causes of LDH. Different segments play different roles in lumbar biomechanics and range of motion; thus, using adjacent segments as a control is not a rigorous method[23]. In our study, young patients without LDH and low back pain were used as controls to accurately reflect the relationship between LDH and FJ asymmetry. In the present study, the FJs of the same segment as the herniated segment, but not the adjacent segment, in asymptomatic young people were used for comparison with the corresponding segment to obtain more accurate results.

In most studies, the age of subjects in the control and LDH groups differs, which is another reason for the inconsistent results. Most previous studies have been conducted in adults older than 18 and, in some cases, over 80. Kalichman et al[7] and Wang Jixing[24] found that the coronal orientation of lumbar FJs gradually decreased with age. Therefore, degenerative changes should be considered when assessing the pathogenesis of LDH in adults. Due to the influence of degeneration, when young, middle-aged and elderly patients are grouped together for studies, the different proportions of patients in the different age groups will show different results, which will lead to conflicting conclusions.

In the 1990s, Farfan and Sullivan[6], Noren et al[17], and Boden SD et al[25] reported that lumbar FJA asymmetry was a manifestation of congenital structure development and not caused by FJ degeneration. Van Schaik JP et al[26] used CT scans of lumbar FJs to study the trends of change in the FJAs of each lumbar segment and found significant differences in lumbar FJs in some children and adolescents. In 2012, Schmidt H et al[27] used finite element analysis to analyse the load of multiple lumbar intervertebral discs and lumbar FJs and found that the load on lumbar FJs was closely related to LDH. In addition, they also concluded that lumbar FJ asymmetry is inherent in the structure but that increasing age may aggravate the degree of FJ asymmetry. In this study, the control group comprised adolescents without LDH or low back pain, and a certain proportion of these subjects showed FT, which could indirectly verify the previous view. Therefore, lumbar FJ asymmetry is considered a congenital structural feature. However, the degree of asymmetry increases with age. The inclusion of only patients between 12 and 21 years of age in this study helped minimize the interference caused by degenerative factors and provide more accurate results. This study showed that FJ asymmetry was associated with LDH at the L3-4, L4-5, and L5-S1 levels in ALDH patients (aged 12-21 years) and was associated with the location of LDH at the L5-S1 level.

Vertebral FJ asymmetry represents asymmetry of the left and right vertebral FJs, but there is no unified definition for the determination of vertebral FJ asymmetry. Noren et al[17] defined vertebral FJ asymmetry as a bilateral angle difference > 5°. The reference range of FT in most relevant studies is between 5° and 10°[17,28-30], and some scholars have also analysed the collected data and used the average value as the critical value[31,32]. In addition, Boden et al[25] classified vertebral FJ asymmetry into four levels, corresponding to no asymmetry, mild asymmetry, moderate asymmetry and severe asymmetry, with respective angle ranges of 0-6°, 6°-10°, 11°-16° and greater than 16°. Some scholars have performed studies using similar grading methods[33-35]. Some studies have defined FT by a critical value of 10° or 15° to compare the incidence of vertebral FJ asymmetry in adolescents with LDH, with widely varying results. It can be seen that the selection of different cut-off values for FT is one of the important factors of the different results among different studies. If the critical value of vertebral FJ asymmetry is too small, the impact of measurement error on the results of the study cannot be avoided. In contrast, if the critical value is too large, this may lead to a lack or even absence of research objects that can be included in the experimental group.

In this study, vertebral FJ asymmetry was defined as bilateral angular asymmetry > 7°[4,36]. This value is the same as the critical value prescribed by Ening et al[30] and avoids phenomenon that may cause inaccurate results. As in some studies, we found a correlation between minor vertebral asymmetry and disc herniation at all levels. FJ asymmetry occurred in all segments of the lumbar spine, with no significant difference in the incidence among segments of the lumbar spine. These findings are supported by Masharawi et al[37], who considered FJ asymmetry a normal feature of the thoracolumbar spine. Our results suggest that vertebral FJ asymmetry is a common lumbar lesion in people aged 12 to 21 years.

In this study, LDH was diagnosed by clinical manifestations and CT findings. The FJA measurement method has been proven to be a feasible method in previous studies, and the FJA measured on lumbar and abdominal CT (the scanning level needs to pass through the intervertebral disc and be parallel to the lower endplate and the upper vertebral body) is consistent[17]. Although magnetic resonance imaging (MRI) involves no radiation and has fewer contraindications than CT, few healthy young adults are willing to undergo both MRI and CT of the lumbar spine. In contrast, many young patients at our institution undergo abdominal CT for reasons unrelated to LDH or low back pain, such as acute abdominal conditions. Abdominal CT provides excellent resolution for lumbar pathological evaluation. A similar approach has previously been used to study spondylolisthesis[12]. For the measurement of the FJA, CT is more accurate than MRI due to the interference of cartilage on MRI.

Regressive effects can be minimized by using adolescents as subjects. Ishihara et al[38] found that FJ asymmetry is a common imaging feature of ALDH. D.Y. Lee et al[16] found that vertebral FJ asymmetry did not affect LDH development in adolescents or adults. Wang et al. found that FJ asymmetry was associated with LDH at the L4-5 and L5-S1 segments and that irregular changes in FJO at the L3-4, L4-5, and L5-S1 segments were associated with LDH in adolescents[39].

In recent years, an increasing number of scholars have begun to study lumbar FJs. However, they hold different views. Therefore, in this study, the relationship between vertebral FJs and LDH and its location on CT cross-sections was investigated. Statistical analysis showed that vertebral FJ asymmetry was correlated with LDH (P < 0.05) and vertebral FJ asymmetry was correlated with the location of LDH in the L5-S1 segment (P < 0.05). In our study, in addition to finding that FJ asymmetry was correlated with LDH, we found that herniated discs tended to be positions towards the more coronally oriented FJ in a significant number of patients with lumbar FJ asymmetry, which is in line with the findings of Farfan and Sullivan.

From our results, we suggest that FJ asymmetry was significantly associated with LDH in the L4-5 and L5-S1 segments in adolescents, and herniated discs tended to be positions towards the more coronally oriented FJ.

FJ:facet joint; LDH:lumbar disc herniation; CT:computed tomography; FJA:facet joint angle; FT:facet tropism; ALDH:adolescent lumbar disc herniation;

Acknowledgements

Not applicable.

Authors’ contributions

Jianyun Xu collected the data. Kai Xiao and Jinming Wu wrote the manuscript and did the statistical analysis. Yuan Liu and Yingjun Zhong supervised the study and revised the manuscript. All authors read and approved the final manuscript.

Funding

There was no funding for this study.

Availability of data and materials

The data is available upon request from the corresponding author.

Ethics approval and consent to participate

This study was undertaken in accordance with the principles of the Declaration of Helsinki and was approved by the ethics committee of the First Affiliated hospital of Nanchang University. A waiver of informed consent was obtained from ethics committee of the First Affiliated hospital of Nanchang University, since the data were analyzed from the electronic medical record and reported without personal identifiers.

Informed consent statement

A waiver of informed consent was obtained from ethics committee of the First Affiliated hospital of Nanchang University, since the data were analyzed from the electronic medical record and reported without personal identifiers.

Consent for publication

Not applicable.

Competing interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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No competing interests reported.

Relationship between asymmetry of lumbar facet joints and direction of lumbar disc herniation in patients aged 12-21 years

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