|Year : 2022 | Volume
| Issue : 4 | Page : 401-409
Lumbar facet joint stabilization for symptomatic spinal degenerative disease: A systematic review of the literature
Sofia Musso, Felice Buscemi, Lapo Bonossi, Manikon Poulley Silven, Fabio Torregrossa, Domenico Gerardo Iacopino, Giovanni Grasso
Department of Biomedicine, Neurosurgical Unit, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Palermo, Italy
|Date of Submission||07-Sep-2022|
|Date of Acceptance||30-Oct-2022|
|Date of Web Publication||7-Dec-2022|
Department of Biomedicine, Neurosurgical Unit, Neurosciences and Advanced Diagnostics (BiND), University of Palermo, Via Del Vespro 129, Palermo 90100
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: Lumbar spinal degenerative disease (LSDD), unresponsive to conservative therapy, is commonly treated by surgical decompression and interbody fusion. Since facet joint incompetence has been suggested as responsible for the entire phenomenon of spinal degeneration, facet stabilization can be considered as an alternative technique to treat symptomatic spinal degenerative disease. The purpose of this study was to systematically review the literature for studies utilizing lumbar facet joint fixation techniques for LSDD to assess their safety and efficacy.
Methods: A systematic literature review was performed following the preferred reporting items for systematic reviews and meta-analyses statement, with no limits in terms of date of publication. Demographic data, inclusion criteria, clinical and radiological outcome, frequency of adverse events (AEs), and follow-up time were evaluated.
Results: A total of 19 studies were included with a total of 1577 patients. The techniques used for facet arthrodesis were Goel intra-articular spacers in 21 patients (5.3%), Facet Wedge in 198 patients (15.8%), facet screws fixation techniques in 1062 patients (52.6%), and facet joints arthroplasty in 296 patients (26.3%). Clinical outcomes were assessed through the evaluation of pain relief and improvement in functional outcome. Radiological outcomes were assessed by the evaluation of proper positioning of instrumentation, solid bony fusion rate, and preservation of disk height. AE's mainly observed were pseudoarthrosis, reoperation, instrumentation displacement/malpositioning/migration, neurological impairment, deep vein thrombosis, and infections. The mean follow-up time ranged from 6 months to 11.7 years.
Conclusion: Our data demonstrate that facet joint arthrodesis appears to be effective in managing LSDD. These findings, however, are limited by the small sample size of patients. Accordingly, larger series are needed before formal recommendations can be made.
Keywords: Facet fixation, lumbar spinal degenerative disease, neurogenic intermittent claudication, spinal stenosis
|How to cite this article:|
Musso S, Buscemi F, Bonossi L, Silven MP, Torregrossa F, Iacopino DG, Grasso G. Lumbar facet joint stabilization for symptomatic spinal degenerative disease: A systematic review of the literature. J Craniovert Jun Spine 2022;13:401-9
|How to cite this URL:|
Musso S, Buscemi F, Bonossi L, Silven MP, Torregrossa F, Iacopino DG, Grasso G. Lumbar facet joint stabilization for symptomatic spinal degenerative disease: A systematic review of the literature. J Craniovert Jun Spine [serial online] 2022 [cited 2023 Jan 27];13:401-9. Available from: https://www.jcvjs.com/text.asp?2022/13/4/401/362877
| Introduction|| |
Pedicle screw (PS) is considered the gold standard for posterior instrumented lumbar spinal surgery in lumbar spinal degenerative diseases (LSDDs) unresponsive to conservative therapy.,, However, PS fixation method is characterized by some possible complications including PS failure, screw mispositioning, rod breakage, and adjacent segment disease given the restriction of the range of motion (ROM) in lumbar spine., Another compelling argument about PS is the invasiveness of the open procedure, which requires substantial dissection and damage to the paraspinous muscle, thus contributing to spinal stability.,
In order to overcome these critical issues and to guarantee a less invasive and equally efficacious method of fixation, facet fusion techniques have been developed. From a biomechanical point of view, the zygapophyseal joints play a key role in spinal stability: Their alterations are closely related to the pathogenesis of various degenerative conditions of the lumbar spine, which are characterized by low back pain (LBP). Many facet screw fixation techniques have been described. Boucher first described the “transfacet technique” in 1959, while Magerl proposed the “translaminar technique” in 1984. The latter was thought by most surgeons to be provided with greater biomechanical efficacy and, as a consequence, it achieved the greatest popularity among neurosurgeons, even if technically demanding. In recent years, other facet fusion modalities have been explored, leading to the creation of devices that are increasingly customized to fit the individual conformation of the zygapophyseal joints. As a matter of fact, many efforts have been made to combine high fusion rates while preserving the spinal biomechanics and ROM of stabilized vertebral segments to preserve the natural kinematics of lumbar spine.,,,
The aim of this systematic review was to identify and examine studies utilizing different facet joints arthrodesis techniques for the treatment of the LSDD to evaluate the efficacy and safety of this surgical intervention.
| Methods|| |
Using PubMed and MEDLINE databases a systematic literature review was conducted following the preferred reporting items for systematic reviews and meta-analyses guideline. The search strategy was tailored without a backward data limit. We use the following medical subject headings and free-text terms: “facet device,” “facet wedge,” “facet instrumentation,” “facet screw fixation,” “facet fusion,” “lumbar spine surgery,” “arthroplasty” combined using Boolean operators “AND” and “OR.” To avoid the potential omission of relevant studies, we manually screened reference lists of the articles included and previous systematic reviews and meta-analyses regarding facet fusion techniques. Duplicate reports were eliminated using Microsoft Excel 16.37. Details of the search strategy are shown in [Figure 1].
Study selection and inclusion criteria
The research strategy initially relied on title and abstract analysis. The article's full text was retrieved for further investigation if the title and abstract met the inclusion criteria. Three authors (L.B., F.B., and S.M.) independently assessed eligibility, and differences were resolved by discussing and comparing the different points of view of investigators. Only articles published in the English language were included. Finally, each article that met the eligibility criteria underwent a full-text review. Studies that did not have full text available were excluded. Articles that did not evaluate facet fusion techniques were excluded. Articles detailing the use of hybrid surgery (for instance, transpedicular screw fixation in association with transfacet screw fixation) were also rejected. Case reports, technical notes, cadaveric studies, animal studies, biomechanical studies, reviews, and meta-analysis were excluded from the study. The data collection process was conducted without using any automated tools. No ethical approval was required for this study.
Four authors (F.B., L.B., S.M., and P.M.S.) collected data on study characteristics (authors, publication year, study design, and country), patients characteristics (number of patients included, age and sex), kind of pathology, treatment modality and surgical technique used, levels of the lumbar spine treated, clinical and radiological outcomes, adverse events (AEs) and follow-up duration.
| Results|| |
After duplicate removal, 688 articles were selected. Based on the title and abstract screening, we excluded 347 and 225 papers, respectively. Finally, we eliminated other 97 papers due to incompatibility with our eligibility criteria. Hence, 19 published studies were included in this literature review.
Demographic and clinical features
The studies selected included a total of 1577 patients. Eleven studies were retrospective (57.9%) and eight prospective (42.1%) [Figure 2]. In the wide scenario of lumbar degenerative disease, the pathologies treated were various: Lumbar spinal stenosis (LSS), foraminal stenosis, lumbar disk degeneration and herniation, facet joints degeneration, spondylolisthesis, osteoarthritis, instability following surgery of posttraumatic changes, scoliosis. The techniques described to perform facet arthrodesis were the following: Goel intra-articular spacers (5.3%), Facet Wedge (FW) (15.8%), Facet screws fixation techniques (52.6%), and Facet joints arthroplasty (26.3%) [Figure 3]. Screws had been placed in the lumbar (L1–L5) region of the spine and the first sacral vertebra.
|Figure 2: Figure showing the type of the studies recruited for the review|
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|Figure 3: Bar graph showing the techniques for facet arthrodesis in the studies reviewed|
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The outcome was evaluated both clinically and radiologically. The clinical outcome was evaluated by considering pain relief, through Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) scores, and improvement in the functional outcome, according to Macnab's criteria; the radiological outcome was assessed through the evaluation of several parameters: Proper positioning of instrumentation, solid bony fusion rate and preservation of disk height.
Both clinical and radiological outcome were evaluated during the postoperative follow-up time, which among the studies ranged from 6 months to 11 years. The AEs observed included: pseudoarthrosis, reoperation, instrumentation displacement/mispositioning/migration, neurological impairment, deep vein thrombosis, and infections.
Pathologies treated, levels, clinical and radiological outcomes, AEs, and follow-up time are detailed in [Table 1].
| Discussion|| |
LBP is a leading contributor to disabilities worldwide. The elements that constitute the lumbar spine (i.e., soft tissues, vertebrae, zygapophyseal and sacroiliac joints, intervertebral disc, and neurovascular structures) are subject to a variety of stressors and, each of them, alone or in combination, can contribute to the genesis of LBP.
Ravindra et al. in their meta-analysis, tried to estimate the proportion of LSDD in patients suffering from LBP, finding that 6 million individuals (3.63%) worldwide have LSDD and LBP each year, with the highest incidence in Europe (5.7%).
The main accepted view for LSDD pathogenesis identifies deterioration of the disc, due to dehydration or herniation, as the primary event that leads to a cascade of processes responsible for vertical spinal instability, such as the reduction of facet joint space and subsequent facet override, loss of disc space height, bulge of the posterior annulus and the posterior longitudinal ligament, and infolding of the ligamentum flavum. Therefore, various structures of the lumbar spine could be addressed for LBP treatment: Intervertebral discs, facet joints, sacroiliac joints, and nerve roots. Overall, the optimum treatment for LSDD should aim to remove the compression on the neural structures while preserving or restoring the spinal stability. In this regard, various microdecompression (MD) techniques have been introduced although most of them are based on the general concept that the main pathogenetic mechanism underlying LSDD is strictly related to a cascade of processes starting with disc degeneration.,
However, several lines of evidence have suggested that facet can be directly considered as a possible cause of lumbar stenosis. Following the first suggestion goel properly argued that facet damage could start and foster spinal degeneration., Briefly, he suggested that the reduction of the interfacet distance, and the subsequent instability, may play a role in the pathogenesis of the entire spectrum of spondylosis including stenosis of the spinal canal and intervertebral neural foramina, reduction in disc height, bulge of the posterior annulus/posterior longitudinal ligament, invagination, and hypertrophy of the ligamentum flavum.
In this systematic review, the surgical techniques for facet joint arthrodesis, indications, and outcomes were reviewed.
Goel intra-articular spacer
Quite the opposite to the traditional pathogenetic hypothesis, Goel et al. argued that the entire phenomenon of spinal degeneration is secondary to facet incompetence. Facet degeneration and reduction of the interfacet distance can start and foster the entire spectrum of spinal changes that lead to stenosis of the spinal canal and intervertebral neural foramina, and vertebral instability. The primary representation of this degenerative cascade is the lumbar facet hypertrophy seen in canal stenosis, which may reflect the facet overload and the consequent back pain.
In a cadaveric study of 647 lumbar spines, Eubanks et al. found that degenerative changes in lumbar zygapophyseal joints begin in the third decade, with a peak during the seventh decade. The highest grade of degeneration was found at L4–L5 levels.
In this regard, facet distraction can be considered the optimum surgical treatment to restore and fuse the facets in their normal alignment. In a preliminary report, Goel and Shah. recruited 36 patients with single- and multilevel cervical spondylotic radiculopathy and myelopathy, performing an innovative surgery. He proposed the so-called “Goel facet spacers” as an effective tool in the treatment of canal stenosis, by reversing the overriding of the facets, restoring the articular height and the spinal canal and root canal dimension.
After surgical treatment, patients had relief from symptoms of pain, radiculopathy, and myelopathy.
Later, this principle was successfully applied also to the lumbar canal. In a pilot study, Goel et al. employed the intra-articular spacers in 21 patients affected by LSS. Patient outcome was characterized by a good relief from LBP and radiological postoperative findings showed increasing in spinal canal and intervertebral root dimensions, reduction in buckling of ligamentum flavum, and disk bulge extension into the spinal canal. Joint distraction using spacers can be used as a stand-alone method or can be combined with other fixation techniques.
FW ®system (DePuy Synthes, Oberdorf, CH, Switzerland) combines the mechanical friction-based blockade mechanism, by distracting the facets at the diarthrodial surfaces with a titanium implant, and the stability of facet screws that are then inserted to strengthen the system. This minimally invasive approach can be used to immobilize the facet joints at one or two levels, from L1 to S1.
The first prospective study which aimed to compare and analyze clinical outcome of these implants was conducted by Grasso and Landi. They recruited 80 patients and divided them into two groups of 40 patients treated with implants of FWs and MD (Group 1) versus MD alone (Group 2), respectively. The authors collected clinical data (VAS, Zurich Claudication Questionnaire, and ODI preoperatively, and at 3, 6, and 12 months postoperatively. Although significant statistical differences were found in all the groups (from baseline), a statistically better clinical outcome was observed in Group 1 when compared with Group 2 (P < 0.01).
Later, Francaviglia et al. recruited 38 patients affected by herniated disk, spinal canal and foraminal stenosis, and Meyerding grade I degenerative spondylolisthesis to evaluate the safety and efficacy of FW and found that low back VAS score and ODI decreased significantly after surgery. Moreover, in neuroimaging follow-up slippage or signs of adjacent segment degeneration were not detected.
In order to evaluate the feasibility of this surgical technique, Grasso and Goel, in their retrospective study, compared the clinical outcome of patients treated with micro-decompression and arthrodesis with intra-articular spacers versus patients treated with micro-decompression alone. They found a lower rate of re-operation in patients surgically treated with intra-articular spacers than with MD alone (10% vs. 30%) and improvements in functional status, assessed using Macnab's criteria, during the 5th years of follow-up (excellent and good score in 85% of the patients vs. 69.4%).
These studies support the concept that facet distraction and fixation with FW system along with MD of the neural structures is an effective procedure to treat LSDD.
Facet screw fixation techniques
The first surgery for facet joint can be attributed to King in 1948. He placed small screws across the facet joints in conjunction with posterior fusion and found a high rate of solid bony fusion (90.9%) and quite low rate of pseudoarthrosis (10.1%).
Later, other two facet screw fixation techniques emerged. The first was the transfacet pedicle approach described by Boucher in 1959, who employed a longer screw directed toward the pedicle with additional cancellous bone graft, thus leading to a lower rate of pseudarthrosis. The second was the translaminar facet approach described by Magerl in 1984, who used a longer screw inserted from the base of the contralateral side of spinous process, through the lamina, traversing the facet joint and ending at the base of the transverse process. Several studies showed that these two techniques provide a similar degree of spinal stability and lower invasiveness compared to the traditional PS fixation.,,,,,,,,,,,
Zeng et al. analyzed the changes in intervertebral disc height of 29 patients undergoing percutaneous unilateral translaminar facet screw fixation with interbody fusion. No patient experienced significant postoperative complications. This retrospective study showed an augmentation in postoperative intervertebral disc height versus preoperative (P < 0.05).
Jang and Lee. compared percutaneous transfacet screw fixation and PS fixation after anterior lumbar interbody fusion in patients affected by lumbar foraminal stenosis, secondary to degenerative disk disease or degenerative spondylolisthesis, and found an improvement in ODI scale and excellent/good outcome according to Macnab's criteria in patients treated with transfacet screw fixation.
Bochicchio et al. evaluated the effect of percutaneous lumbar transfacet screw placement with a “cross-link” system, called Facet-Link, in 46 patients affected by LSS (with or without mild instability). They found that quality of life (QoL) related questionaries (ODI and SF36) and back/leg VAS improved after surgery. In terms of complications, there were 4 cases of pseudoarthrosis and 4 patients needed further surgeries. Despite that, translaminar screw fixation could be related to different AE, due to the proximity of the facets to nerve roots.
Facet joints arthroplasty
Inflexible spinal fusion can lead to overloading of nonfused segments, increasing like the hood of adjacent segments disease and thus causing pain, wound problems, infections, pseudoarthrosis, and implant failure., Therefore, alternative spinal implants were developed, in order to preserve the ROM.
In patients with intact segmental lumbar disk and symptomatic spinal canal stenosis exclusively caused by facet joint hypertrophy, the concept of “Facet joint Replacement” (FJR) is a promising alternative to monosegmental lumbar fusion. Recently, the intermediate- and long-term results of an FJR in 26 patients affected by spondyloarthropathy and intact segmental lumbar disk have been presented. The dynamic system of FJR showed good results in pain relief, assessed by ODI, VAS back and leg pain scores. This surgical intervention has been shown to improve the patient QoL, and preserve the lumbar spine motion in a follow-up spanning 12 months. In a phase III trial (“A pivotal study of a facet replacement system to treat spinal stenosis” NCT00401518) the primary objective was to evaluate the overall success rate of the anatomic facet replacement system in patients with spinal stenosis when compared to a posterior spinal fusion control. In selected patients, FJR seems to be an alternative to rigid fusion in preventing adjacent level disease, improving back and leg pain, and enhancing patient's QoL.
As well as with total joint replacement, motion preservation can be obtained also with facet joint resurfacing. In this regard, the FENIX facet resurfacing implant aims to restore stability while maintaining motion and alleviating pain. This partial prosthesis is composed by three components: superior facet resurfacing implant, inferior facet resurfacing implant and the translaminar locking screw. The first experience with this implant showed a reduction in pain and need for painkillers in patients affected by proven single segmental bilateral lumbar facet joint osteoarthritis as unique pain generator.
One of the newest concepts of arthrodesis consists in facet fusion devices that fit the facet joint space to prevent facet motion and, thus, instability. Among them, a facet resurfacing device was used and tested in a prospective multicenter study with good results although preliminary. Srour et al. recruited 53 patients diagnosed with facet syndrome or LSS and implanted FFX device, alone or in combination with posterior lumbar interbody fusion (PLIF) (in 15 out of 53 patients). The authors found that all pain and disability scores during the follow-up period remained significantly lower than preoperative scores for all patients, regardless of number of levels involved or if the patient received a PLIF or not. Moreover, a high level of radiologically facet fusion at 1 year was found (86,3%). In 8 cases, the implants were misplaced and in 1 case there was a device migration.
Currently, there is an ongoing multicenter clinical trial that aims to evaluate the safety and efficacy of the zLOCK facet fusion system (“Safety and Efficacy Assessment of Using the zLOCK Facet Stabilization System” NCT05266521) in patients affected by degenerative spondylolisthesis grade 1, mild to moderate stenosis and facets degeneration. This implant is designed to perfectly fits into the facet joints using the body's natural mechanical structure without adding an external scaffold, able to follow the joints changing geometry. The zLOCK implant can be placed in open or percutaneous technique, thus reducing the invasiveness, procedure duration, and shortening the recovery period.
| Conclusion|| |
Developing dynamic constructs that can relieve pain, restore physiological mobility, and endure repetitive loads are a tremendous challenge. In the wide scenario of stabilization techniques, facet arthrodesis is raising growing interest in the latest years, due to the mini-invasiveness, efficacy, and lower risk of injury to neural structures. Accordingly, facet fusion techniques are likely to be an important tool in the actual and future management of degenerative spinal diseases deserving further investigations.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]