Lumbar nerve root compression at the intervertebral foramina caused by arthritis of the posterior facets

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✓ The authors report their experience with 12 cases in which the roots of the sciatic nerve were compressed at the intervertebral foramina by degenerative arthritis (arthrosis) of the posterior facets, and in which foraminotomy and facetectomy brought relief of pain. Patients with disc narrowing, spondylolisthesis, and transitional vertebrae place unusual stress on the posterior facets. This may lead to hypertrophy and the development of marginal osteophytes that project downward with eventual constriction of the intervertebral foramen and entrapment of the nerve root. Such alterations are common in patients over 40, and when found in the presence of unremitting sciatic pain without evidence of a herniated disc or other etiology, a causal relationship must be considered.

Article Information

Address reprint requests to: Joseph A. Epstein, M.D., Lake Success Medical Center, 1300 Union Turnpike, New Hyde Park, L.I., New York 11040.

© AANS, except where prohibited by US copyright law.

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    Case 1. A. X-ray film showing collapse of the intervertebral space at L4–5 and prominent asymmetrical hypertrophic alterations of the posterior facets (arrows). B. Myelogram, anteroposterior view, showing bilateral defects in the facets (arrows) immediately above the intervertebral disc. C. Myelogram, lateral view, showing lateral intrusions deforming the column of oil (arrows). D. Myelogram, oblique view, showing facet defects (arrow) causing intrusions in the column of oil.

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    Case 2. A. Spine film showing degenerative osteoarthropathy of the posterior facets at L4–5 (arrows). B. Spine film showing narrowing of the interspace at L4–5 with anterolisthesis of L-4 on L-5 (arrows). C. Myelogram showing nearly complete block at L4–5 with characteristic lateral tapering of the oil column just above the point of obstruction (arrows). D. Myelogram, lateral view, showing dorsal facet encroachment on the column and ventral step deformity of the listhesis (arrows). E. and F. Drawings illustrating laminotomy and foraminotomy with hemifacetectomy and undercutting of the facets to unroof the foramen (arrows) and decompress the roots at L4–5. The underlying disc was excised with the cartilage plates of the vertebrae, and the interspace was packed solidly with bone fragments from the intervening lamina.

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    Case 3. A. Spine film showing transitional L-5 vertebra with large costotransverse process articulating with the sacrum on the left, and changes in the posterior facets at L4–5 on the right (arrows). B. and C. Myelograms showing minimal changes, with indentation in the lateral aspect of the oil column in oblique views. D. and E. Drawings illustrating laminotomy at L4–5. There was marked arthrosis with hypertrophy of the posterior facets (P.F.) and thickening of the joint capsules and investing tissues. The foramen was markedly narrowed, compressing the nerve root after its exit from the canal. Decompression of the L-4 root required excision of the thickened lamina and overlying portion of the facets lateral into the foramen. The dotted line in E indicates the position of the pedicle.

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    Dry specimens of the lumbosacral spine showing transitional L-5 vertebra with the costotransverse process on the left articulating with the sacrum (arrows). Note hypertrophic, degenerative alterations in the posterior facets at L4–5 on the right (arrows). The lumbosacral facets are small, asymmetrical, and rudimentary (hollow arrows), and there is little mobility at this site because of the buttressing effect of the massive costotransverse process united to the sacrum. B. L-4 vertebra, caudal view, shows hypertrophy of the inferior facet on the right with marginal osteophytes intruding into the intervertebral foramen along the dorsal aspect (arrows). The normal funnel-shaped foramen is seen on the left. There is no spur formation along the dorsal aspect of the vertebral body. C. L-5 vertebra, cranial view, showing massive hypertrophy of the superior articular fact on the left with marginal osteophytes intruding into the foramen along its entire length causing stenosis (arrows). In contrast, the foramen on the right shows no alterations associated either with spondylosis or apophyseal arthrosis.

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