Fluid in facet joints

[NJPAIN]

Can't seem to find an answer in the literature:

Is there a "physiologic" or normal amount of fluid in the lumbar facet joints seen on MRI? If so, how does one distinguish that from a "pathologic" amount of fluid warranting the label of "facet joint effusion" possibly indicating altered biomechanics?


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[willabeast]

from experience, not books - if bright T2 on MRI in facet joint, which looks widened, and #22 g needle inserted into joint, and usually get transparent slightly yellow fluid (usually less than 1 ml), very viscous, then you have an inflamed facet joint with fluid in it. normal is no fluid aspirated, not a widened joint, and T2 looks normal.
i had a partner wind up with a post procedure infection once, so make sure you follow up with an ESR if things go downhill.

 

[SSdoc33]

theres fluid in every joint. you just usually cant aspirate any in a "normal" joint. when you see diastasis on MRI, there is usualy some amount of microinstability at that level. intra-articular facets or MBB/RF are reasonable, but if the joints are really wide, they may end up with a fusion.

 

[NJPAIN]

From a radiographic standpoint, is the spectrum between no hyperintense signal and a thin layer of hyperintensity on T2 to be considered "normal". I can't seem to find the reasoning behind one radiologist's facet joint effusion and another's normal joint. Of course there is the obvious spondy with wide joint space and broad bright signal. I'm looking for the dividing line between normal and pathologic. Perhaps it is arbitrary or more Gestalt.


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[willabeast]

From a radiographic standpoint, is the spectrum between no hyperintense signal and a thin layer of hyperintensity on T2 to be considered "normal". I can't seem to find the reasoning behind one radiologist's facet joint effusion and another's normal joint. Of course there is the obvious spondy with wide joint space and broad bright signal. I'm looking for the dividing line between normal and pathologic. Perhaps it is arbitrary or more Gestalt.


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might depend on radiologist. for my purposes (admittedly utilitarian) i would compare the suspicious joint with other joints same patient.
if only L45 joints or joint are hyperintense, and L34, L23, L5S1 all look normal then i would say we have a winner!
i suppose i would miss a systemic problem where all the joints light up, but i always get an ESR as part of my work up, so i doubt i would miss anything too important.
unrelated interesting quote i found recently
//"Before a standing army can rule, the people must be disarmed, as they are in almost every country in Europe. The supreme power in America cannot enforce unjust laws by the sword; because the whole body of the people are armed, and constitute a force superior to any band of regular troops."
- Noah Webster, An Examination of the Leading Principles of the Federal Constitution, October 10, 1787//

 

[NJPAIN]

Interesting, logical approach.


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[epidural man]

Some have looked at this sort of thing.

Attached are some of the findings.

Kim, K. Anthony, and Michael Y. Wang. "MRI‐BASED MORPHOLOGICAL PREDICTORSOF SPECT POSITIVE FACET ARTHROPATHYIN PATIENTS WITH AXIAL BACK PAIN." Neurosurgery 59.1 (2006): 147-156.

Rihn, Jeffrey A., et al. "Does lumbar facet fluid detected on magnetic resonance imaging correlate with radiographic instability in patients with degenerative lumbar disease?." Spine 32.14 (2007): 1555-1560.

 

[ampaphb]

AJNR Am J Neuroradiol. 2014 Mar;35(3):609-14. doi: 10.3174/ajnr.A3731. Epub 2013 Sep 12.
Frequency of discordance between facet joint activity on technetium Tc99m methylene diphosphonateSPECT/CT and selection for percutaneous treatment at a large multispecialty institution.
Lehman VT, Murphy RC, Kaufmann TJ, Diehn FE, Murthy NS, Wald JT, Thielen KR, Amrami KK, Morris JM, Maus TP.

Abstract
BACKGROUND AND PURPOSE:
The clinical impact of facet joint bone scan activity is not fully understood. The hypothesis of this study is thatfacet joints targeted for percutaneous treatment in clinical practice differ from those with reported activity on technetium Tc99m methylenediphosphonate SPECT/CT.

MATERIALS AND METHODS:
All patients with a technetium Tc99m methylene diphosphonate SPECT/CT scan of the lumbar or cervical spine who underwent subsequent percutaneous facet joint steroid injection or comparative medial branch blocks at our institution between January 1, 2008, and February 19, 2013, were identified. Facet joints with increased activity were compared with those treated. A chart review characterized the clinical reasons for treatment discrepancies.

RESULTS:
Of 74 patients meeting inclusion criteria, 52 (70%) had discrepant imaging findings and treatment selection of at least 1 facet joint, whereas 34 patients (46%) had a side (right vs left) discrepancy. Only 92 (70%) of 132 facet joints with increased activity were treated, whereas 103 (53%) of 195 of treated facet joints did not have increased activity. The most commonly documented clinical rationale for discrepancy wasfacet joint activity that was not thought to correlate with clinical findings, cited in 18 (35%) of 52 patients.

CONCLUSIONS:
Facet joints undergoing targeted percutaneous treatment were frequently discordant with those demonstrating increasedtechnetium Tc99m methylene diphosphonate activity identified by SPECT/CT at our institution, in many cases because the active facet joint(s) did not correlate with clinical findings. Further prospective double-blinded investigations of the clinical significance of facet joint activity by use oftechnetium Tc99m methylene diphosphonate SPECT/CT and comparative medial branch blocks are needed.

 

[jonnylingo]

might depend on radiologist. for my purposes (admittedly utilitarian) i would compare the suspicious joint with other joints same patient.
if only L45 joints or joint are hyperintense, and L34, L23, L5S1 all look normal then i would say we have a winner!
i suppose i would miss a systemic problem where all the joints light up, but i always get an ESR as part of my work up, so i doubt i would miss anything too important.
unrelated interesting quote i found recently
//"Before a standing army can rule, the people must be disarmed, as they are in almost every country in Europe. The supreme power in America cannot enforce unjust laws by the sword; because the whole body of the people are armed, and constitute a force superior to any band of regular troops."
- Noah Webster, An Examination of the Leading Principles of the Federal Constitution, October 10, 1787//

Good quote.

 

[Timeoutofmind]

You always get an ESR as part of your work up for axial back pain? Interesting...what else is in your work up?

 

[bedrock]

i always get an ESR as part of my work up

I suppose this is thorough, but in my experience you end up chasing a bunch of slightly elevated ESRs that don't mean anything.

I think getting an ESR is reasonable if there is a clinical reason, but not for every single patient that walks in the door