[2cool4U]

The topic of facet degeneration and back pain is a complex one. I think part of the problem stems from variability in imaging of the spine before surgery. Some background first: Facet disease is detectable by lumbar CT best, MRI next and regular back X-rays last. Further, it is seen on regular Xrays typically on "oblique" views, which are often not performed pre-op. Usually, lateral flexion/extension (bending) views are done. Generally, back pain patients receive MRI to assess for disc disease, and treatment is then prescribed based on those findings. In most cases, this works well. Regular lumbar spine X-rays generally aren't helpful unless you have had a significant injury or you have advance malignancy or in a few other unusual situations. Some of the medical literature has shown that up to 70% of back X-rays are unnecessary. Most physicians can check their patient's histories, do a physical exam, and then either try conservative treatment or go straight to MRI, skipping regular X-rays. Bone scans, as mentioned by Maddie, aren't used much in the U.S. for back pain, although they are very useful for bone infections, malignancies, stress fractures, and in a few other processes. They offer limited anatomic detail of smaller parts, including the facet joints. This can be offset somewhat by specialized cameras, but their use just isn't widespread here. They are relatively inexpensive, and it may be that they are easier to get in Canada than CT's or MRI's. In the U.S., it seems like every hospital, doctor's office and forward-thinking business professional owns an MRI unit, a CT scanner, or both, but bone scans use injected radioactive material which is regulated by the NRC, so it isn't as easy to buy the equipment and offer the service.

If a patient fails to respond to all of the various conservative treatment options, and everyone here knows what those are, then surgery may be the answer. In traditional fusion surgery, it is really not necessary to evaluate the facets. However, in ADR, as we've read, it can be important. If facet disease is advanced, then the MRI that was done prior to starting PT, etc. may show it. If it is mild or moderate, it may not be visible, as MRI is not as good for bony abnormalities as CT.

However, pre-op CT's are rarely done. Most of the time, they are unnecessary and would simply add to medical costs and expose the patient to unneeded radiation. Indeed, if a discogram is done and is positive, or if facet injections have been tried without success, evaluating the facets with imaging before surgery is probably not needed.

Further complicating all of this is the fact that there is a tremendous variability in the appearance of both disc and bone abnormalities of the spine and actual symptoms experienced by patients. Many (many, many) journal articles have been written on this topic, and definitive research has yet to be performed that allows a high reliability in determining what findings on what studies accurately correlate with what symptoms. Many patients have severe degenerative changes at multiple levels and yet respond to gentle stretching, heat and walking while others can have mild or moderate degeneration at one level and be almost incapacitated.

This is why we all have had X-rays, MRI's, CT's myelograms and discograms, sometimes with conflicting results, and why no surgery has a 100% success rate.

Personal soap box here: In addition, the medical community has a wide variability in approaches to back pain management and physician education for such. We don't have a "Back Pain Awareness" month, and high-profile celebrities don't kick-off large fund-raising campaigns. There is no "Race for the Cure" for back pain, and Oprah doesn't have shows devoted to it. All of this despite overwhelming numbers of people suffering from back pain and billions of dollars spent per year for back care, a considerable amount of which is spent on treatments that may either be unproven or possibly even harmful. 300,000 fusions/year with a success rate of 60% is just unfathomable! Off my soapbox now.

OK, despite that last paragraph of negativity, it looks like ADR may be poised to change some of this. As to whether ADR will relieve all of the symptoms, it depends on how much of the total pain is "discogenic" and whether there is are other "pain generators." This can be a very simple matter of ADR relieving most or even all of the pain, or ADR (or fusion, for that matter) may relieve a variable percentage of the pain, from most to very little. As pre-op screenings improve and physicians are more educated about what to look for before ADR, results should be more reliable to predict . Indeed, this will be absolutely necessary if we want to see ADR succeed as viable surgical technique for the long term.

Wow, only a few posts on this site since I joined, they're all too long! Maybe I should go back to lurking!