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543

NEURORADIOLOGY
Differential Diagnosis of Facet
Joint Disorders
Julia E. C. Anaya, MD
Silmara R. N. Coelho, MD Spinal pain due to facet joint disease is difficult to diagnose since
Atul K. Taneja, MD, PhD the clinical history and physical examination findings are usually
Fabiano N. Cardoso, MD nonspecific. Facet joint disorders have a wide range of causes and,
Abdalla Y. Skaf, MD because of the potential for chronic back pain and disability, an
André Y. Aihara, MD, PhD accurate diagnosis is essential. The most frequent cause of pain in
facet joints is osteoarthritis, which can be assessed at radiography,
Abbreviations: AS = ankylosing spondylitis, CT, or MRI. Ganglion and synovial cysts of the facet joints can
CPPD = calcium pyrophosphate deposition cause compressive symptoms of adjacent structures, especially
disease, FDG = fluorodeoxyglucose, GBCA =
gadolinium-based contrast agent, NSAID = radiculopathy, lower back pain, and sensory or motor deficits.
nonsteroidal anti-inflammatory drug, OA = In ankylosing spondylitis, imaging findings of the facet joints are
osteoarthritis, TGCT = tenosynovial giant cell
tumor useful not only for diagnosis but also for monitoring structural
changes. In septic arthritis of the facet joints, an early diagnosis at
RadioGraphics 2021; 41:543–558
MRI is essential. Gout and metabolic diseases are best evaluated at
https://doi.org/10.1148/rg.2021200079 dual-energy CT, which allows the depiction of crystals. Traumatic
Content Codes: dislocations of facet joints are usually unstable injuries that require
From the Division of Musculoskeletal Radiol- internal reduction, fixation, and fusion and can be well assessed at
ogy, Laboratório Delboni Auriemo, Diagnósticos CT with three-dimensional reconstructions. Facet joint neoplasms
da América SA (DASA), R. Dr. Diogo de Faria
1379, Vila Clementino, São Paulo, SP 04037- like osteoid osteoma, plasmacytoma, tenosynovial giant cell tumor,
005, Brazil (J.E.C.A., S.R.N.C., A.K.T., F.N.C., and osteochondroma are best evaluated at CT or MRI. The authors
A.Y.S., A.Y.A.); Division of Musculoskeletal
Radiology, Alta Diagnósticos, São Paulo, Brazil
provide an overview of key imaging features of the most common
(J.E.C.A., S.R.N.C., A.K.T., A.Y.S.); Muscu- facet joint disorders along with anatomic tips and illustrative cases.
loskeletal Imaging Division, Hospital Israelita Acknowledging key imaging findings for the differential diagnosis of
Albert Einstein, São Paulo, Brazil (A.K.T.); De-
partment of Diagnostic Imaging, Federal Uni- facet joint disorders plays a crucial role in the diagnostic accuracy
versity of São Paulo, São Paulo, Brazil (F.N.C., and proper treatment approach for such entities.
A.Y.A.); Division of Musculoskeletal Radiology,
Hospital do Coração (HCor), São Paulo, Brazil Online supplemental material is available for this article.
(A.K.T., A.Y.S.); and Teleimagem, São Paulo,
Brazil (A.K.T., A.Y.S.). Presented as an educa- ©
RSNA, 2021 • radiographics.rsna.org
tion exhibit at the 2019 RSNA Annual Meeting.
Received April 27, 2020; revision requested June
12 and received July 11; accepted July 16. For
this journal-based SA-CME activity, the authors,
editor, and reviewers have disclosed no relevant
relationships. Address correspondence to Introduction
A.K.T. ([email protected]). Chronic back pain is a common pain syndrome attributed in part
©
RSNA, 2021 to the facet (zygapophysial) joints in up to 82% of cases, which can
lead to disability and have substantial socioeconomic implications
SA-CME LEARNING OBJECTIVES (1–3). Diagnosis and treatment remain difficult because of the large
number and diversity of potential pain generators in the spine. The
After completing this journal-based SA-CME
activity, participants will be able to:
majority of studies present intervertebral disks as the main cause.
„ Identify the anatomy related to facet However, pathologic conditions affecting the facet joints have gained
joint disorders. important attention in chronic back pain syndromes (3).
Describe imaging techniques and select
„ Spinal pain mediated by facet joints is difficult to diagnose since
the best modality to depict each facet clinical history and physical examination findings in most cases are
joint disorder. not specific, which leads to an inefficient use of imaging studies with
Recognize key imaging features of the
„ incidental findings that may be irrelevant in some clinical contexts
most common facet joint pathologic
conditions.
(3). Most guidelines recognize that imaging examinations are essen-
tial for diagnosis and proper treatment if warning signs are present,
See rsna.org/learning-center-rg. when the results are likely to change or guide treatment, and more
rarely, if pain persists beyond 4–6 weeks (3–5).
544  March-April 2021 radiographics.rsna.org

Familiarity with the vascularization of facet

TEACHING POINTS joints is important because it can help explain the
„ Spinal pain mediated by facet joints is difficult to diagnose
pathophysiology of certain diseases. Arterial vascu-
since clinical history and physical examination findings in
most cases are not specific, which leads to an inefficient use
larization is provided by branches of the ascending
of imaging studies with incidental findings that may be irrel- cervical artery (cervical spine), thoracic aorta (tho-
evant in some clinical contexts. racic spine), and abdominal aorta (lumbar spine)
„ Facet joints have lower and upper joint processes that arise (Fig 2). Venous drainage is provided by the internal
vertically from the junction of pedicles and laminae, rep- and external venous plexus, basivertebral veins,
resenting an important portion of the posterior spine and and intervertebral veins. Because of its avalvular
providing structural stability. Together with the intervertebral
nature, the venous plexus may become a path to
disk, they restrict vertebral movement while helping in load
transmission. spread metastases and infections (9–11) (Fig 3).
„ CT improves anatomic assessment of facet joints and is more Articular cartilage surfaces of facet joints are
accurate than MRI to help distinguish bone pathologic con- aneural structures, while capsules, subchondral
ditions. A detailed assessment of their morphology must be bone, and synovium are richly innervated (3,7).
performed in multiple planes because of the obliquity of ar- Each facet joint receives a pair of nerves coming
ticular surfaces. from the medial branch of the spinal nerve with
„ Osteoarthritis (OA) is a progressive degenerative disease that nociceptive, autonomic, and mechanoreceptor
is the most frequent cause of pain in facet joints. According to
fibers (3,7,12). A medial branch runs through
Eubanks et al, signs of OA can already be found in just over
half of adults under 30 years of age and in all elderly people the transverse processes at a lower level in rela-
after 60 years of age, with the prevalence and degree of OA tion to its origin, and the facet joint is innervated
being higher at the L4-L5 level, followed by L3-L4 and L5-S1. by a medial branch at the same level and another
„ A reasonable differential diagnosis can be made for most spi- medial branch at a higher level, a consequence of
nal tumors on the basis of clinical data, patient age, location the presence of a C8 nerve without the presence of
of the spinal and vertebral injury, and radiologic appearance. C8 vertebra. For example, the C6-C7 facet joint
is innervated by the medial branches of C6 and
C7. However, the C7-T1 facet joint is innervated
by the medial branches of C7 and C8. The T1-T2
Anatomy facet joints are innervated by the medial branches
Facet joints have lower and upper joint processes of C8 and T1. This pattern is maintained in the
that arise vertically from the junction of pedicles lumbar spine with the exception of the L5-S1 facet
and laminae, representing an important portion joint, which is innervated by the medial branch of
of the posterior spine and providing structural L4 and the dorsal branch of L5 (12) (Fig 4).
stability. Together with the intervertebral disk, The medial branches of the spinal nerve also in-
they restrict vertebral movement while helping in nervate multifidus muscle, interspinous muscle and
load transmission (6). ligament, and the periosteum of the neural arch
Unlike the intervertebral disk, the facet joints (13). The other two branches of the spinal nerve,
are true synovial joints, composed of two opposite intermediate and lateral, spread to innervate the
articular surfaces covered by a layer of hyaline rest of the paravertebral musculature (3,7). Inflam-
articular cartilage. The joint is surrounded by matory mediators such as prostaglandins and cy-
synovium, synovial folds, and a fibrous capsule, tokines (interleukin-6 and tumor necrosis factor-α)
connecting upper and lower facets and playing an can be found in all of these sites, explaining in part
important role in biomechanics (Fig 1). There is the genesis of back pain in some cases (3).
also production of synovial fluid, the main lubri-
cant of the joint and a nutritional source for the Imaging Techniques
cartilage (6,7). Synovial folds (also called menisci) A wide range of imaging methods may be used to
are composed of fibrous, adipose, or fibroadipose help identify radiologic findings related to painful
tissue and are insinuated between the lower and facet joints (3).
upper facets to increase the contact surface and Anteroposterior and lateral radiographs allow
joint congruence. Finally, the fibrous capsule, depiction of facet joints. However, facet joints are
composed of ligamentous tissue, completely in- visualized most clearly with oblique views, which
volves the joint, regulating its internal environment demonstrate the facet joints with the “Scottie
in relation to nutrients and immune cells (6–8). dog” sign (3).
The entire posterior ligament complex (facet CT improves anatomic assessment of facet
joint capsule, ligamentum flavum, and interspi- joints and is more accurate than MRI to help
nous and supraspinous ligaments) keeps facet distinguish bone pathologic conditions. A
joints and vertebrae in a stable position with each detailed assessment of their morphology must
other (6). Injuries to this complex can result in be performed in multiple planes because of the
subluxation or displacement of the facet (7). obliquity of articular surfaces (3,7).
RG  •  Volume 41  Number 2 Anaya et al  545

Figure 1.  Facet joint anatomy. Drawing shows how

facet joints form the posterolateral articulation con-
necting the posterior arch between vertebral levels,
with the articular cartilage and the meniscus, which are
synovial folds, increasing the contact surface and joint
congruence.

Figure 2.  Drawing depicts how

the facet joint arterial vasculariza-
tion is constructed of branches of
the ascending cervical artery (cer-
vical spine), thoracic aorta (tho-
racic spine), and abdominal aorta
(lumbar spine).

Figure 3.  Drawing demonstrates

the path of facet joint venous
drainage through the internal and
external venous plexus and the ba-
sivertebral and intervertebral veins.

MRI provides excellent soft-tissue resolution, al- The depiction of facet joints at SPECT may
lowing better identification of nonosseous changes, add information on inflammation affecting these
including soft-tissue edema, synovitis, periarticular joints, showing increased uptake (nonspecific).
cysts, and surrounding neural structure impinge- PET/CT and PET/MRI use hybrid techniques
ment. The use of fat-suppressed MRI sequences and can reach higher accuracy rates in many
can demonstrate subchondral bone edema, which pathologic conditions than use of structural im-
is present in the lumbar facet joints in up to 41% aging alone (3).
of patients with back pain. The administration of
gadolinium-based contrast agents (GBCAs) leads Osteoarthritis
to an improved ability to evaluate changes in the Osteoarthritis (OA) is a progressive degenerative
facet joints and surrounding structures, improving disease that is the most frequent cause of pain in
MRI sensitivity and specificity (3,7). facet joints (3,6). According to Eubanks et al (14),
546  March-April 2021 radiographics.rsna.org

Figure 4.  Drawing shows how

the facet joints and their capsules
are well innervated by the medial
branches of the dorsal primary
rami of the spinal nerves (nocicep-
tive and autonomic nerve fibers).

Figure 5.  Evolution of OA in facet joints. a, Axial CT (top) and axial MR (bottom) images show a normal facet joint.
b, Axial CT (top) and axial MR (bottom) images delineate narrowing of the facet joint space and small osteophytes.
c, Axial CT (top) and axial MR (bottom) images depict mild hypertrophy of the articular process. d, Axial CT (top) and axial
MR (bottom) images show moderate osteophytes, moderate hypertrophy of the articular process, and mild subarticular
subchondral cysts. e, Axial CT (top) and axial MR (bottom) images depict large osteophytes, severe hypertrophy of the
articular process, and severe subarticular subchondral cysts.

signs of OA can already be found in just over half Typical imaging characteristics of OA in-
of adults under 30 years of age and in all elderly clude narrowing of the joint space, cartilage
people after age 60 years, with the prevalence and thinning, marginal osteophytes, joint hypertro-
degree of OA being higher at the L4-L5 level, fol- phy, sclerosis, and subchondral cysts (6). Such
lowed by L3-L4 and L5-S1 (6). These authors also findings may also be responsible for narrowing
reported that the incidence seems to be the same of the vertebral canal or intervertebral foramen,
between men and women, with a slight male pre- causing central, subarticular, or foraminal ste-
dilection, and there was no significant difference in nosis, mimicking symptoms of disk herniation
OA rates when considering ethnicity or laterality (6,8) (Fig 6).
(6,14). On the other hand, higher frequency of OA Cross-sectional imaging methods such as CT
is linked to bone mass index and a more sagittal or MRI provide a detailed assessment of joint
orientation of the joint (6). Although there is no morphology, especially because of its oblique
consensus, occurrence of OA is slightly higher in situation. Although CT is more accurate than
the upper facets, probably because of the increased MRI to help identify bone changes, the agree-
pressure of lower facets on upper facets during ment between both is high. Additionally, MRI al-
flexion movements (8). lows better identification of nonosseous changes,
As in all synovial joints, OA involves a continu- including synovitis and periarticular cysts (7).
ous process that begins with loss of cartilage, de- Some studies consider a strong correlation
creased synovial fluid, bone hypertrophy, reduced between facet degeneration or overload and disk
joint space, and changes in ligaments and muscles, degeneration, although facet OA can also occur
ultimately leading to failure of the joint complex without disk degeneration (6).
(3,6). Therefore, it is believed that pain is caused The destabilization between the so-called
by degeneration of the facet joints, leading to in- complex of the three joints (intervertebral disk
flammation of the surrounding tissues (3) (Fig 5). and facet joints) can lead to degenerative insta-
RG  •  Volume 41  Number 2 Anaya et al  547

Ganglion cysts and synovial cysts are often

mentioned as synonyms in the literature. Synovial
cysts are herniations of the synovial membrane of
the joint capsule filled with synovial fluid, which
may or may not communicate with the joint. On
the other hand, ganglion cysts do not have syno-
vial cell lining, being constituted by a collagen
capsule that surrounds a gelatinous liquid rich in
mucopolysaccharides in a higher concentration
than in a synovial cyst (17).
Most cysts are asymptomatic and are found
incidentally (17). However, when present in
facet joints, they can cause compressive symp-
toms of adjacent structures, causing radiculopa-
thy, lower back pain, sensory or motor deficits,
Figure 6.  Axial T2-weighted MR or less commonly, inflammatory changes due to
image shows how facet OA with complications such as rupture, hemorrhage, or
narrowing of the joint space (red infection (17–19).
arrow), cartilage thinning, mar-
ginal osteophytes, and joint hyper- At MRI, cysts typically manifest with hyperin-
trophy (white arrows) reduces the tensity at T2-weighted imaging and hypointensity
size of the vertebral canal and in- at T1-weighted imaging. However, the signal
tervertebral foramen, causing sub- intensity at T1-weighted imaging can be vari-
articular stenosis (dotted circle).
able depending on the protein content, blood, or
calcification deposits (18).
bilities such as spondylolisthesis and scoliosis, the Rosenstock and Vajkoczy (19) proposed a clas-
level most affected by spondylolisthesis being that sification system with details that would facilitate
of L5-S1 (3,8). the selection of surgical approaches involving facet
The fact that lower back pain can originate joint cysts. These include medial facet cysts, which
from facet joints is widely accepted in the lit- compress the dural sac and can be resected by
erature (8). However, the establishment of this ipsilateral laminotomy (Fig 7); lateral facet cysts in
direct relationship can be challenging, as other the intervertebral foramen, which can be resected
changes such as disk degeneration may contrib- using a contralateral approach; mediolateral facet
ute to the genesis of pain (6,8). Although the cysts that compress the dural sac and nerve root
specificity of diagnostic tools has improved in and whose surgical approach can be determined in-
the depiction of facet degenerations, it is im- dividually, depending on the width of the blade and
portant to emphasize that they should not be angulation of the facet joints; and finally, patients
considered synonymous with back pain but as a with facet cysts and associated spondylolisthesis,
possible causal factor (6). where segmental stabilization is indicated (19).
Because of the lack of specificity of imag- Both surgical excision and guided procedures
ing to help diagnose lower back pain caused by such as percutaneous imaging with aspiration or
the facet joint, fluoroscopic-guided facet blocks corticosteroid injection have been used in treat-
performed according to the Spine Intervention ment with good results (17).
Society guidelines have become essential as
diagnostic and therapeutic tools for pain arising Ankylosing Spondylitis
from the facet joints. This diagnostic test focuses Ankylosing spondylitis (AS) is a chronic inflam-
on facet joint blocks, including medial branch matory disease characterized by axial joint inflam-
and intra-articular joint injections with anesthet- mation that is followed by new bone formation,
ics. The test is positive if it relieves the patient’s ankylosis of facet joints, and bridging syndesmo-
pain (7,15,16). phytes at the intervertebral disk spaces, resulting
in impairment of spinal mobility (20–22).
Facet Cysts Between 20% and 50% of patients with AS
Ganglion cysts and synovial cysts represent the have shown ankylosis affecting facet joints in the
most prevalent benign cystic lesions in joints cervical or lumbar spine, and 8% of cervical facet
overall, including facet joints (17). The main joints may be ankylosed even without bridging
predisposing factor is degenerative arthropathy, syndesmophytes at the disks (20). Facet joint
but cysts can also arise secondary to trauma, involvement is associated with longer symptom
rheumatoid arthritis, gout, and systemic lupus duration, greater disease activity, worse spinal
erythematosus (17,18). mobility, and the presence of extra-articular
548  March-April 2021 radiographics.rsna.org

Figure 7.  Facet cyst in a 68-year-old man with

left leg pain and weakness. (a) Axial T2-weighted
MR image depicts a medial left facet synovial cyst
(white arrow) that compresses the dural sac (red
arrow) and nerve root (green arrow). (b) Sag-
ittal T2-weighted MR image shows a facet cyst
(yellow arrow) compressing the dural sac (white
arrow).

Figure 8.  Ankylosing spondylitis. (a) Sagittal reformatted CT image shows diffuse syndesmophytes
and anterior ankylosis (arrow) and vertebral body squaring (loss of normal concavity of the anterior
border) (dashed line). (b) Coronal reformatted CT image depicts diffuse ankylosis of the sacroiliac
joints, which is typical of AS (arrows). (c) Axial CT image at the level of the cervical spine demonstrates
partial ankylosis of the facet joints (arrowheads).

manifestations (inflammatory bowel disease, uve- sclerosis, bone formation, joint space narrow-
itis, and psoriasis) (23). ing, irregularities, and especially, facet joint
Imaging findings of the spine are an important ankylosis. Facet joint fusions are more frequent
part of diagnosis and monitoring structural changes in the thoracolumbar junction than in the lower
in AS. Many sites may be affected, including verte- lumbar spine (24) (Fig 8). MRI is highly specific
bral bodies, vertebral margins, ligaments, interver- for depicting edema and enhancement of bone
tebral spaces, and the facet joint itself (20,23). marrow and joint space and can also add infor-
Radiography offers limited visualization. mation on bone erosion, sclerosis, bridging, and
CT can provide a clear view of bone erosion, ankylosis (21) (Fig 9).
RG  •  Volume 41  Number 2 Anaya et al  549

phy has low sensitivity for depicting spinal gouty

lesions. Specifically, chronic changes can reveal
osteophytes, periarticular erosions, subchondral
cysts, and bone scleroses, and can mimic tumors,
abscesses, tuberculosis, and degenerative spinal
diseases (26,28,30).
CT is helpful in depicting bone erosions
caused by tophi (calcified deposits), which are
present in 50% of cases of tophaceous gout, as
well as soft-tissue involvement (Fig 10). Dual-
energy CT helps in the diagnosis of gout and de-
picts monosodium urate crystals with a sensitivity
of 90% and a specificity of 83% in peripheral
joints. However, dual-energy CT is less sensitive
for spinal lesions and is not able to definitively
exclude such a diagnosis (26,27,30,31).
MRI can occasionally present difficulties in
differentiating gout and tophaceous gout from
other types of lesions such as infections or neo-
Figure 9.  Active AS in a 31-year-old man with severe lower
plasms (29). MRI shows gout tophi with homo-
back pain for 8 months. (a) Sagittal T2-weighted fat-sup- geneous low to intermediate T1-weighted signal
pressed MR image delineates Andersson lesions (localized intensity, low to high T2-weighted signal inten-
vertebral or discovertebral inflammatory lesions of the spine) sity, and homogeneous or peripheral enhance-
(dashed ovals). (b) Sagittal T2-weighted MR image demon-
strates facet joint bone fusion (arrowheads).
ment with normal bone marrow signal intensity
of the adjacent vertebrae.
Nonsteroidal anti-inflammatory drugs
Gout (NSAIDs), colchicine, and corticosteroids, alone
Gout is a metabolic disease that results from or in combination, are recommended in the treat-
monosodium urate crystal deposits in the ment of gout flares. Urate-lowering therapy (al-
synovium and juxta-articular tissues. The peak in- lopurinol and febuxostat) may be used in patients
cidence occurs at 30–50 years of age, affecting pri- with tophi, frequent acute gout flares, chronic
marily middle-aged to elderly men and postmeno- kidney disease, or past urolithiasis (32). De-
pausal women (25–27). Gouty lesions usually compression may be necessary for patients with
involve peripheral joints such as the interphalan- neurologic complications or secondary spinal
geal, ankle, and wrist joints but may also involve instability (26,30).
structures in the axial skeleton such as laminae,
pedicles, vertebral bodies, ligaments, facet joints, Calcium Pyrophosphate Deposition
intervertebral disks, and epidural spaces (28,29). Disease
Gout that is untreated for a prolonged period of Calcium pyrophosphate deposition disease
time (at least 5 years) may lead to tophaceous (CPPD), also known as pseudogout, represents
deposits in variable locations. Deposits in the spine an inflammatory response to the deposition of
are considered rare. However, when affected, most calcium pyrophosphate crystals in hyaline carti-
tophaceous deposits are located in the lumbar seg- lage, fibrocartilage, and periarticular structures
ment, especially in L4-L5 (25,27). (33–35). Its cause is not clear, although some fac-
The physiopathologic mechanism of spinal gout tors are suggested such as increasing age (aging
has been associated with poor vascularity, contrib- of the cartilaginous matrix) and genetic factors
uting to a lower ability to adequately filter crystals (mutation of the ANKH gene). In these muta-
that are deposited in this area. This may be a con- tions, there is an increase in inorganic pyrophos-
sequence of several factors, including hyperlipid- phate secondary to a higher breakdown of ad-
emia, obesity, or poor physical activity (25). enosine triphosphate, which can promote binding
Some patients have mild or no symptoms of pyrophosphate to calcium and consequently,
(back pain), while others present with severe its deposition in cartilages and synovium (34).
symptoms and complications such as neurologic The deposition of crystals leads to chondro-
deficits (spinal cord compression and spinal ste- calcinosis, which can be identified at radiography
nosis) and inflammatory pain (29,30). and occurs more frequently in large joints such as
Imaging studies can show the location of the the knee and hip and, rarely, in the spine, where
lesions (disks, vertebral bodies, spinous process, it most commonly involves the cervical region
facet joints, and ligaments). However, radiogra- (33–35). In the spine, crystals can be found most
550  March-April 2021 radiographics.rsna.org

Figure 10.  Gout in a 56-year-old man. Axial (a)

and sagittal reformatted (b) CT images depict a
mass (tophi) on the facet joints (white arrows),
which has eroded the laminae and spinous pro-
cesses (red arrow). The results of biopsy helped
confirm the diagnosis of gout. (Figure courtesy of
Marcello Henrique Nogueira-Barbosa, MD, PhD,
Faculdade de Medicina de Ribeirão Preto da Uni-
versidade de São Paulo, Ribeirão Preto, SP, Brazil.)

Figure 11.  CPPD in a 79-year-old patient with

neck pain. (a) Coronal reformatted CT image
shows degenerative arthropathy with irregularity
and subchondral sclerosis in the right facet joint,
with some subchondral bone cysts and erosions
(white arrows) and small periarticular calcifica-
tions (red arrow). (b) Axial CT image depicts
small calcifications in the topography of the alar
and transverse ligaments surrounding the dens,
which may correspond to a deposit of calcium
pyrophosphate crystals (arrows).

Figure 12.  CPPD in a 78-year-old patient with

neck pain. Sagittal T2-weighted (a) and contrast-
enhanced T1-weighted (b) MR images with fat
suppression depict low–signal-intensity tissue
within the joint, especially around the odontoid
process and transverse ligament (arrows in a),
along with joint effusion and synovial enhance-
ment (arrows in b).

commonly in the ligamentum flavum, posterior Trauma

longitudinal ligaments, and atlanto-occipital liga- Thoracolumbar spinal fractures include lesions
ments and less frequently can affect the interver- that range from mild apophyseal fractures to
tebral disks (Figs 11, 12) (34,35). We must think neurologic lesions and complex fracture dislo-
about such diagnoses when calcifications are seen cations. Thoracolumbar fractures are the most
in these areas, even when there are no significant common injuries of the spine and represent more
degenerative changes (33). Although uncommon, than 50% of all traumatic spine lesions. However,
there are some reports of lumbar stenosis due to dislocations are rare, constituting less than 3%
the deposition of calcium pyrophosphate in the of cases. Facet dislocations and fractures can be
ligamentum flavum (35). unilateral or bilateral. The dislocations are usually
RG  •  Volume 41  Number 2 Anaya et al  551

Figure 13.  Spinal injury resulting in quadriplegia in a 43-year-old C5-C6, and C6-C7 (42,43). During hyperexten-
man involved in a car accident. (a) Sagittal reformatted CT image sion injuries, the spinous process fractures first,
reveals fracture dislocation of the left facet joint (arrows). (b) Sagit-
tal reformatted CT image depicts right facet dislocation with loss of then the facet joints, and the posterior body is last.
apposition of the facet joints, called the reverse hamburger bun sign Soft-tissue damage may also occur, including dis-
(arrow). (c) Axial CT image shows widening of facet joints (red line) ruption of joint capsules and ligamentum flavum.
and an articular facet fracture (arrow). (Figure courtesy of Mariana S. CT screening with three-dimensional recon-
Silva, MD, Diagnósticos da América SA, São Paulo, SP, Brazil.)
structions has a higher sensitivity (99%) and
specificity (100%) for the depiction of spine injury,
compared with the lower sensitivity (70%) of
plain-film radiography. However, both can show
fracture or loss of apposition of the facet joints, in-
creased interspinous distance, and, in the cervical
spine, anterior vertebral translation of greater than
50% of the anteroposterior vertebral body width
(indicative of bilateral dislocation) or 25% transla-
tion (commonly unilateral dislocation) that can
lead to spinal cord injury. CT is also able to show
soft-tissue abnormalities such as disk herniation or
hematoma (Fig 13) (38,40,42–44).
MRI studies allow the visualization of loss or
incomplete apposition of the facet joint, widen-
ing of facet joints, and articular facet fracture.
MRI findings are indicative of facet fracture-
dislocations and may include subluxation of the
vertebral bodies, asymmetric anterior or posterior
widening of intervertebral disk space, increased
interspinous process distance, disruption of the
posterior column ligament complex (mainly the
supraspinous and interspinous ligaments), and
disruption of the intervertebral disk and ligamen-
tum flavum (36,40,43). MRI might be useful in
the evaluation of soft-tissue injuries, hematomas,
and vascular injury, especially in patients with
neurologic injury with negative CT findings (42)
(Fig 14).

Infectious Arthritis
Septic arthritis of the facet joints is a rare clinical
entity. Its frequency is estimated at 0.2%–4.0% of
all spinal infections and 86%–97% of all the cases
affecting the lumbar spine (45,46). Hematoge-
unstable injuries that require internal reduction, nous spread is the most frequent route of infec-
fixation, and fusion (36–39). There are three tion (72%), although it can occur as a result of
main patterns of thoracolumbar facet disloca- direct inoculation such as surgical intervention,
tions: (a) anterior subluxation of the vertebral spinal injection, acupuncture, or injury (45–47).
body with locked facets, (b) lateral subluxation This infection can result in significant morbid-
of the vertebral body with laterally locked facets, ity and usually affects older (>60 years of age)
and (c) an acute kyphosis with superiorly dislo- or immunocompromised patients such as those
cated facets (39,40). with rheumatoid arthritis, diabetes mellitus, liver
Unilateral cervical facet dislocations represent disease, alcoholism, chronic renal failure, intra-
5% of cervical spine injuries and are often as- venous drug misuse, or corticosteroid therapy
sociated with posterior fractures, ligamentous (45,48,49). The most commonly isolated micro-
avulsions, and annulus fibrosus ruptures, which organism is Staphylococcus aureus (about 70%),
can lead to instability, neurologic deficits, and while others such as Staphylococcus epidermidis,
severe disability (41). Bilateral facet dislocation is group B Streptococcus, Salmonella, and Escherichia
less common and is part of a spectrum of cervi- coli occur less often (45, 50).
cal spine flexion- or distraction-type injuries. The Clinical signs and symptoms are nonspecific,
most common levels for such injuries are C4-C5, and therefore, the differential diagnosis is wide.
552  March-April 2021 radiographics.rsna.org

Figure 14.  Interspinous ligament injury in a

43-year-old man who was involved in a car ac-
cident (same patient as in Figure 13). (a) Sagittal
T2-weighted MR image shows facet dislocation
with loss of apposition of the facet joints, which
is known as the reverse hamburger bun sign (ar-
row). (b) Sagittal T2-weighted fat-suppressed
MR image demonstrates anterior vertebral trans-
lation (red arrow), asymmetric widening of the
intervertebral disk space (white lines), C5-C6 disk
rupture, extrusion with cord compression and
increased signal intensity changes (arrowheads),
and increased interspinous process distance (dot-
ted line) with soft-tissue edema, indicating inter-
spinous ligament injury (white arrow). (Figure
courtesy of Mariana S. Silva, MD, Diagnósticos
da América SA, São Paulo, SP, Brazil.)

Patients present with high fever and severe back up to 38% (Figs 15, 16). Some patients may also
pain that may radiate to the flank, gluteal region, experience remote complications such as endo-
thigh, and calf muscles, which are similar symp- carditis, diskitis, and infections of other joints
toms to those seen in spondylodiskitis, pyelone- (45,50).
phritis, and disk prolapse (45,47,49). Facet joint infectious arthritis is usually man-
Imaging plays an important role in early diag- aged conservatively with intravenous antibiotics,
nosis of infectious arthritis. Standard radiography and surgical intervention is indicated for patients
is rarely useful since the imaging findings are who develop neurologic manifestations or persis-
usually normal and changes are not specific. The tence of epidural abscesses despite appropriate
changes consist of joint space narrowing or wid- antibiotic treatment (46–48,50).
ening, erosions, or subchondral geodes (cavitary
lesions without an epithelial lining), and they are Tumors
seen 3–12 weeks after the onset of the symptoms
(45,49,50). Scintigraphy with technetium 99m– Osteoid Osteoma
methylene diphosphonate (99m Tc-MDP) is 100% Osteoid osteoma is the third most common be-
sensitive to depict infection in facet joints as early nign bone tumor after enchondroma and nonos-
as 3 days from onset but is nonspecific (45,47). sifying fibroma. It usually manifests in patients
CT imaging is 96% sensitive and helps in diagno- under 30 years of age, is seen predominantly in
sis after 2 weeks from onset. CT shows widening males, and has a peak incidence in the 2nd de-
of the joint space and erosive bony changes of cade of life. Osteoid osteomas normally develop
the facet joints and may help depict soft-tissue in long bones, but 10%–25% occur in the spine,
involvement (epidural or paraspinal muscle ab- where the lumbar spine is the most commonly af-
scesses) (45,49,50). fected site (60%), followed by the cervical (27%)
MRI is the standard modality to depict find- and, rarely, the thoracic spine (12%). When the
ings of infectious arthritis because of its high spine is affected, osteoid osteomas are usually
sensitivity and specificity. It can depict alterations found in the posterior elements: the laminae,
as early as after 2 days of infection. MRI helps facet joint, or pedicle (51–54).
identify the widening or destruction of the facet Osteoid osteoma manifests as a dense sclerotic
joint space, intra-articular effusion, synovitis, bone growth with a vascularized nidus that can
and the spread to adjacent muscles, spinal cord, undergo varying degrees of calcification. Lamel-
epidural (potentially responsible for spinal cord lar periosteal reaction can also be seen. These
or nerve root compression) and subarachnoid tumors rarely exceed 1.5–2.0 cm (51,53,54).
spaces, and disk enhancement after injection with Clinically, osteoid osteoma is characterized by
GBCA. It can also be used to monitor response intermittent local pain that worsens at night and
to treatment (45,47–49). Epidural abscess, a can be referred to a nearby joint, creating clinical
major complication, can be seen in up to 25% ambiguity. Pain is typically relieved by aspirin or
of cases, and paraspinal abscess has been seen in NSAIDs (53,55).
RG  •  Volume 41  Number 2 Anaya et al  553

Figure 15.  Septic arthritis. (a) Axial T2-weighted fat-suppressed MR image depicts
bone edema to the left facet joints of L3-L4 (red arrows), with adjacent collections that
are epidural (white arrow) and in the posterolateral paravertebral musculature next
to the facet joint (). These findings indicate septic arthritis of the facet joint with as-
sociated abscesses. (b) Axial contrast-enhanced T1-weighted MR image shows septa
between the abscesses and intense peripheral enhancement in the posterolateral para-
vertebral musculature (arrowheads). An abscess compresses the dural sac, displacing
and grouping the nerve roots of the cauda equina with marked canal stenosis (arrow).
(Figure courtesy of Luis Pecci Neto, MD, Hospital do Coração, São Paulo, SP, Brazil, and
Teleimagem, São Paulo, SP, Brazil.)

the most sensitive method for diagnosis and is

useful to depict osteoid osteoma–typical features,
specifically lytic lesions with a reactive sclerotic
rim and cortical thickening with a central calci-
fied nidus. Osteoid osteoma is frequently sur-
rounded by a thin serpentine low-attenuation
groove in the surrounding bone called the vascu-
lar groove sign (51,53) (Fig 17).
MRI appearances of osteoid osteoma are vari-
able and may show central nidus calcifications
with surrounding sclerosis seen as low signal in-
tensity with T1- and T2-weighted sequences. After
administration of GBCA, diffuse enhancement as
a result of their intrinsic vascularity can be seen
with varying degrees of edema (53,55). A small
nidus is difficult to depict because of the similar
signal intensity of the adjacent cortical bone (55).
Scintigraphy using 99m Tc-MDP and SPECT show
Figure 16.  Epidural abscess (same patient as in Figure 15). the typical finding of a double- density sign (focal
(a) Sagittal contrast-enhanced T1-weighted MR image with fat nidus uptake surrounded by reduced uptake due
suppression demonstrates irregularity and enhancement of the left to sclerotic bone). Although such a sign is sensitive
facet joints of L3-L4 (arrow) with adjacent abscess in the postero-
lateral paravertebral musculature next to the facet joint () and
in the appendicular skeleton, it is less frequently
intense peripheral enhancement (arrowheads). (b) Sagittal con- seen in the spine (51,53,55).
trast-enhanced T1-weighted MR image with fat saturation shows Osteoid osteoma is usually resistant to conser-
an epidural abscess compressing the dural sac (dashed rectangle). vative treatment. Surgical or minimally invasive
(Figure courtesy of Luis Pecci Neto, MD, Hospital do Coração, São
Paulo, SP, Brazil, and Teleimagem, São Paulo, SP, Brazil.)
percutaneous treatments such as ablation are
recommended, aiming to destroy the nidus for
effective pain relief. Recurrence is reported in
Plain radiography shows a round or ovoid lu- about 4.5% of patients (51,52,55).
cent lesion with reactive sclerosis with or without
a visible nidus. Osteoid osteoma is often missed Plasmacytoma and Multiple Myeloma
at plain radiography of the spine, where the small Plasma cell neoplasms represent 1%–2% of all
size of the lesion and superimposed bony struc- human neoplasms and are a group of diseases
tures can obscure the lesion (51,53,55). CT is characterized by proliferation of a single clone of
554  March-April 2021 radiographics.rsna.org

plasma cells, producing a monoclonal immuno-

globulin (56–59).
They can be subdivided into different forms, as
multiple lesions (multiple myeloma) or as a single
lesion (solitary plasmacytoma). Multiple myeloma
is usually located in the bone marrow and is as-
sociated with a wide range of clinical, laboratory,
and radiologic findings. Solitary plasmacytoma is
rare and characterized by a single mass with no
other symptoms than those derived from the pri-
mary lesion (56,60). Solitary plasmacytoma can
manifest as solitary bone plasmacytoma (SBP),
which most frequently occurs in the axial skel-
eton (70% of all solitary plasmacytomas), or as
an extramedullary plasmacytoma (EMP), which
is localized in tissues other than the skeleton. The Figure 17.  Osteoid osteoma in a 24-year-old man with right
mean age at the onset of solitary plasmacytoma is back pain. Axial (a) and sagittal reformatted (b) CT images reveal
between the 5th or 6th decade (10 years younger a lytic lesion (white arrow) with a reactive sclerotic rim (black ar-
row) adjacent to the S1 right facet joint, with a central calcified
than in patients with multiple myeloma), with a nidus (arrowhead).
male-female ratio of 3:1 (58,60–62). Approxi-
mately 50%–55% of patients with SBP and 30%
of patients with EMP develop multiple myeloma
within 10 years after the initial diagnosis, and
close to 100% of patients with SBP develop mul-
tiple myeloma after 15 years (56,63).
Commonly involved sites in multiple myeloma
include the spine, skull, and long bones (proximal
portions of the humerus and femur) (64). EMP
generally develops with lesions in soft tissues,
including the head and neck region (nasal sinuses,
nasopharynx, and oropharynx), gastrointestinal
tract, and lungs (56). SBP most often affects the Figure 18.  Plasmacytoma. (a) Axial CT image (bone window)
pelvic bones and spine (usually vertebral bodies, depicts an extensive lytic bone lesion affecting the facet joints and
transverse process of a thoracic vertebra without sclerotic margins
since the posterior elements of the spine are a (arrows). (b) Axial contrast-enhanced CT image (soft-tissue win-
rare site of solitary plasmacytoma origin) (61). In dow) shows homogeneous enhancement of the soft-tissue injury
decreasing order of frequency, SBP can also affect with a mass effect on the spinal cord (red arrow) and nerve root
the ribs, upper extremities, face, skull, femur, and compression (white arrows).
sternum (58,59). The thoracic vertebrae are more
frequently involved than the lumbar, sacral, or
cervical spine (57). (hyperattenuating) with mass effect and homo-
Most patients present with weakness due to geneous postcontrast enhancement, and spinal
anemia, backache, bone pain with or without a cord or nerve root compression (56,57) (Fig 18).
pathologic fracture in multiple myeloma, and bone Fluorine 18 (18F) fluorodeoxyglucose (FDG)
pain or pathologic fracture in solitary plasmacy- PET or 18F-FDG PET/CT are used for staging,
toma. In cases of vertebral involvement, neurologic restaging, and evaluation of treatment response
disorders (spinal cord compression) and, less com- in multiple myeloma and may be needed in soli-
monly, a palpable mass can be present (57,64). The tary plasmacytoma to help exclude the presence
plasma cell neoplasm diagnosis is currently made of additional lesions (56,60).
on the basis of the results of histologic biopsy and MRI allows better visualization of soft-tissue
immunohistochemical confirmation (56). and bone marrow lesions and is the standard to
Conventional radiography shows that plasma depict epidural mass and spinal cord compression.
cell neoplasms replace trabecular bone while the It shows a T1-isointense or T1-hypointense bone
cortical bone is partly conserved. Lesions are mass and high signal intensity at T2-weighted and
only visible when more than 30% of the trabecu- short inversion time inversion-recovery (STIR)
lar bone is destroyed, which leads to at least 20% imaging, with homogeneous contrast enhance-
of false-negative results (56,57). CT can depict ment. The sharp borders, lack of bony sclerosis,
small lytic bone lesions (<5 mm), which typically and paucity of periosteal reaction are characteristic
do not have sclerotic margins, soft-tissue tumors findings of SBP (56,65) (Fig 19).
RG  •  Volume 41  Number 2 Anaya et al  555

Figure 19.  Plasmacytoma (same patient as in Figure 18). Sagittal T1-weighted (a), T2-weighted fat-
suppressed (b), and contrast-enhanced T1-weighted fat-suppressed (c) MR images delineate a T1-hy-
pointense bone mass affecting the facet joints and transverse process of a thoracic vertebra (white arrows)
with high signal intensity on the T2-weighted image (red arrow), and homogeneous enhancement after
injection of contrast material (), with mass effect and spinal cord compression (green arrow).

Tenosynovial Giant Cell Tumor Its high avidity at FDG PET can mimic more
Tenosynovial giant cell tumor (TGCT) is a aggressive bone lesions, including metastatic dis-
locally aggressive and proliferative benign le- ease (66,68,69). MRI reveals a lesion with low to
sion affecting the synovium of tendon sheaths, intermediate signal intensity at T1-weighted im-
bursae, and joints that can mimic malignant aging and variable signal intensity at T2-weighted
tumors (66–68). It is usually monoarticular, and imaging, reflecting the variable content of hemo-
malignant transformation is uncommon. TGCT siderin, fluid, and hemorrhage, and it often shows
is typically seen in the 3rd decade of life, and the marked heterogeneous contrast enhancement
distribution between men and women is almost (66,69,70) (Fig 20).
equal. Patients may present with localized pain in
the spinal region, radiculopathy, paresthesia, or Osteochondroma
muscle weakness (67,69). Osteochondromas are the most common benign
TGCT can be subdivided into localized and bone tumors, representing 36%–40% of benign
diffuse forms. Localized TGCT usually affects bone tumors. They are typically seen in the ap-
tendons of the hands and feet. Diffuse-type TGCT, pendicular skeleton and rarely found in the spine
also called pigmented villonodular synovitis, affects (1%–4%) (71,72).
the synovium of larger joints such as the knee, hip, Osteochondromas can be present as solitary or
ankle, and elbow (66,68). Although very rare, the hereditary lesions without a genetic component
spinal form of diffuse-type TGCT can arise from or as multiple lesions in the context of hereditary
the synovial membrane of the facet joints and multiple exostosis. The solitary form affects the
bursae. The cervical spine is the most frequently in- spine in 3% of cases, and the hereditary mul-
volved (44%), followed by the lumbosacral (33%) tiple exostosis form in 7%–9%. The causes of
and thoracic (19%) spine. Spinal TGCT may osteochondromas include congenital conditions,
range from 2 to 6 cm, and the majority of tumors trauma, and radiation therapy. They occur more
are typically located in posterior elements, involv- frequently in males (two and a half times more
ing or centered at the facet joints (67,69). than in females) before they reach skeletal matu-
Radiographic findings have varying appear- rity and are usually diagnosed in adulthood as an
ances, including a circumscribed soft-tissue mass incidental finding (71–73).
(approximately 50%), bone erosion (13.9%), The most commonly affected areas are the
periosteal reaction (8.3%), and intralesional cervical (50%) and thoracic spine, and rare cases
calcifications (5.5%). Up to 20% of radiographs have been reported in the sacral and lumbar re-
are normal. Facet joints can be identified as the gions. Osteochondromas arising from facet joints
site of origin in 45% of radiographs, as compared are rare. They may manifest with neurologic
with in 67% of CT images (67,68,70). symptoms if found anteriorly or with pain and
At CT, the lesion is typically characterized by deformity when occurring posteriorly (72,74).
osteolytic and expansive features and sclerotic Plain radiography may show an osseous mass
margins, with hyperattenuation resulting from that is sessile or pedunculated. Continuity be-
the hemosiderin content being rarely calcified. tween the cortex and medulla of the lesion with
556  March-April 2021 radiographics.rsna.org

Figure 20.  TGCT. Sagittal T1-weighted (a), sagittal contrast-enhanced T1-weighted fat-suppressed (b), and
axial contrast-enhanced T1-weighted fat-suppressed (c) MR images reveal a mass involving a right cervical facet
joint, with low signal intensity on T1-weighted images (arrows) and heterogeneous contrast enhancement ().
(Figure courtesy of Mariana S. Silva, MD, Diagnósticos da América SA, São Paulo, SP, Brazil.)

Figure 21.  Osteochondroma. (a) Coronal re-

formatted CT image shows an anterior ossified
mass in continuity with the cortex and medulla
of the right facet joint of a cervical vertebra (ar-
row). (b) Axial CT image demonstrates an ossi-
fied lesion arising from the left articular facet joint
of a thoracic vertebra (arrows). (Figure courtesy
of Mariana S. Silva, MD, Diagnósticos da América
SA, São Paulo, SP, Brazil.)

the original bone serves as a marker that is best benign, with osteoid osteoma mostly affecting the
visualized at CT. CT shows the bone anatomy, lumbar spine, while osteochondroma usually af-
margins, and trabeculation of the lesion better fects the cervical spine (51–54,72–74). In asymp-
than radiography (71,72,74) (Fig 21). tomatic middle-aged patients with a single mass
The growing end of an osteochondroma is in the axial skeleton, plasmacytoma should be con-
characteristically covered by a cartilaginous cap sidered as a possible diagnosis. In cases of patients
that can be visualized at MRI, which can be used over 60 years of age with multiple bone marrow
to help assess malignant degeneration. A thick lesions, which are typically in the spine, skull,
cartilage cap of more than 3 cm during childhood and long bones, multiple myeloma or metastasis
and adolescence and more than 2 cm in adults should be considered as possible causes (56–63).
is probably malignant (74,75). However, a thick- In some cases, the clinical history may be
ened cartilage cap alone is not sufficient for the typical for a specific tumor, such as in young
diagnosis of malignant transformation. Prominent adults with night bone pain that is relieved with
calcifications, soft-tissue invasion, bone erosion, salicylates, which is highly suggestive for osteoid
and tumor invasion of the underlying bone are osteoma (53,55).
also features of malignant transformation (76). For young adult patients with locally aggres-
A reasonable differential diagnosis can be sive tumors involving soft tissues in the poste-
made for most spinal tumors on the basis of clini- rior elements of the cervical spine, one should
cal data, patient age, location of the spinal and remember TGCT, which can mimic malignant
vertebral injury, and radiologic appearance. These lesions (66,68).
imaging findings are summarized in Table E1.
For example, some tumors have a predilection Conclusion
for specific age groups. In patients under 30 years Pathologic conditions of facet joints comprise a
of age, spinal tumors are uncommon and generally wide spectrum of disorders, including OA, cysts,
RG  •  Volume 41  Number 2 Anaya et al  557

AS, infectious arthritis, gout, CPPD, trauma, and 19. Rosenstock T, Vajkoczy P. New classification of facet joint
synovial cysts. Acta Neurochir (Wien) 2020;162(4):929–936.
tumors. Acknowledging and recognizing key im- 20. Maas F, Spoorenberg A, Brouwer E, et al. Radiographic
aging findings in the differential diagnosis of facet damage and progression of the cervical spine in ankylos-
joint disorders​plays a crucial role in diagnostic ing spondylitis patients treated with TNF-α inhibitors:
facet joints vs. vertebral bodies. Semin Arthritis Rheum
accuracy and proper treatment and can improve 2017;46(5):562–568.
clinical and surgical workflows. 21. Chui ETF, Tsang HHL, Lee KH, Lau CS, Wong CH,
Chung HY. MRI inflammation of facet and costover-
Acknowledgments.—The authors would like to thank Mariana tebral joints is associated with restricted spinal mobility
S. Silva, MD, Luis Pecci Neto, MD, and Marcello Henrique and worsened functional status. Rheumatology (Oxford)
Nogueira-Barbosa, PhD, for their contribution in some cases 2020;59(9):2591–2602.
presented and Bruno Salomão for the schematic drawings. 22. Qian BP, Ji ML, Qiu Y, et al. Is There any Correlation
Between Pathological Profile of Facet Joints and Clinical
Feature in Patients With Thoracolumbar Kyphosis Second-
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This journal-based SA-CME activity has been approved for AMA PRA Category 1 Credit . See rsna.org/learning-center-rg.