Introduction: Low back pain (LBP) is a common reason for seeking help from a physician. Despite the understanding of facet pathomorphology, few studies have shown how pre-operative morphometric facet analysis can be used to decide whether decompression versus decompression with instrumented fusion is necessary. Currently many surgeons use the flexion extension plain radiograph to help make this decision. This study analyzes the efficacy of pre-operative facet pathomorphology to decide the optimal surgical approach.

Methods: Included 119 patients (58M, mean age 61) with various degenerative abnormalities of the spine (i.e., stenosis, neural claudication, spondylolisthesis, retrolisthesis, etc.) who underwent minimally invasive decompression with or without minimally invasive instrumented fusion. Morphometric data was gathered from pre-operative MRIs and CTs of the lumbosacral spine and analyzed in terms of facet morphology, disease presentation, and severity of progression. Bilateral superior and inferior facets were measured for length and area; total area was also taken for the joint bilaterally. Non-operative level facets were used for controls.

Results: Facet length and area were found to be significantly longer (2.6 +/- 0.4 cm) than controls (1.6 +/- 0.3 cm) for those patients who required decompression with instrumented fusion, compared to those who required decompression without instrumented fusion. Patients who received decompression without instrumented fusion showed facet levels that were markedly similar to normal levels, showing very little hypertrophy.

Conclusions: Data in this study suggest that patients with elongated facets are appropriate indication for choosing decompression with instrumented fusion. Whereas those patient with facet morphology similar to non-surgical control level can be managed with decompression alone. Thus pre-operative facet analysis can add additional decision making information aside from plain flexion extension radiographs.

Patient Care: This will allow surgeons to choose the safest and more effective method of treatment for their patients.

Learning Objectives: To create a reliable methodology for determining the appropriate surgical procedure for individualized treatment.

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