CASES

1. CASES Dr. Harsha K J 2nd yr resident Dept of Radiology Medical college, Baroda

2. CASE 1

3. 56 yr old male presented with backpain

5. SPINAL CALCIFICATIONS

6. SYNDESMOPHYTE • seen only in the seronegative spondyloarthropathies (Sharpey's fibers) • ossification of annulus fibrosus • thin slender vertical outgrowth extending from margin of one vertebral body to next • near the thoracolumbar junction. • Associated with: • ankylosing spondylitis, • ochronosis

7. syndesmophytes (arrows) in the spine of a patient with ankylosing spondylitis

9. bilateral erosions and sclerosis are noted in the SI joints of this patient with ankylosing spondylitis

10. erosions are noted in the lumbar facet joints of this patient with ankylosing spondylitis

11. OSTEOPHYTE • This is the charectaristic of diarthrodial joint osteoarthritis • Intervertebral disc joints are not synovial joints • However, there are several structures in the intervertebral disc joint which are analogous to structures found in a true synovial joint. • Cartilaginous endplate  articular cartilage • Annulus fibrosus  joint capsule • Nucleus pulposus  synovial fluid of the synovial joint

12. ossification of anterior longitudinal ligament • initially triangular outgrowth several millimeters from edge of vertebral body & tend to be initially oriented horizontally at their attachment to the vertebral bodies • They then often curve slightly and may even form a complete bony bridge across the disc space.

15. Osteophytes are described in any joint • Syndesmophytes are characteristic of spine and not described in any other joint

16. FLOWING ANTERIOR OSSIFICATION • ossification of disk, anterior longitudinal ligament, paravertebral soft tissues • Associated with: • DISH

18. PARAVERTEBRAL OSSIFICATION • initially irregular / poorly defined paravertebral ossification eventually merging with vertebral body • Associated with: • psoriatic arthritis, • Reiter syndrome

19. bony proliferation (arrows) is noted along the anterior margin of the lumbar spine in this patient with Reiter's syndrome

20. AXIAL ARTHROPATHIES • Degenerative disorders • Osteoarthritis • Degenerative nuclear disease • Degenerative annular disease • Diffuse Idiopathic Skeletal Hyperostosis (DISH) • Ankylosing spondylitis • Rheumatoid arthritis • CPPD crystal deposition disease • Psoriatic arthritis • Reiter's syndrome • Enteropathic arthropathy

21. OSTEOARTHRITIS • By definition, osteoarthritis occurs in a synovial joint. • In the spine, therefore, osteoarthritis occurs in • apophyseal (facet) joints, • uncovertebral joints (cervical spine), • costovertebral joints, • sacroiliac joints. • Osteoarthritis may be primary or secondary.

22. Findings include osteophytosis, joint space narrowing, subchondral sclerosis, and subchondral cyst formation. • Besides causing local joint pain, facet osteoarthritis may cause nerve root impingement or compression if the osteophytes are large enough to extend into the lateral recess of the spinal canal.

23. marked osteophytosis and joint space narrowing is noted in the facet joints in this patient with severe osteoarthritis of the lumbar spine -- the osteophytosis is causing significant encroachment on the lateral recesses bilaterally

24. age nucleus tends to become more and more dehydrated, and gradually begins to degenerate intervertebral disc height begins to decrease. increased stress is also placed on the facet joints, leading to the frequent association of osteoarthritis of the facets at the same level. altered pattern of stresses may lead to marginal osteophytosis adjacent to the affected endplates.

25. DEGENERATIVE NUCLEAR DISEASE • with increasing age (arrow), progressive degeneration of the nucleus leads to decreasing disk space height

26. Degenerative annular disease • degeneration of the annulus fibrosus • Also called "spondylosis deformans" or "senile ankylosis".

27. with increasing age (arrow), progressive degeneration of the annulus leads to increasing osteophytosis at the disk space margins -- the height of the disk space is largely preserved

28. marked marginal osteophytosis is noted at each disk space in this patient with predominantly annular degeneration

29. It usually doesn't make a lot of difference to the referring clinician which component of the disk has degenerated. • Therefore, using the term "degenerative disk disease" in one's dictations to refer to these entities.

32. DISH • an idiopathic disorder • DISH is necessarily a diagnosis by exclusion

33. flowing ossification is noted along the anterior margin of the thoracic and lumbar spine in these patients with DISH -- note that the disk spaces are preserved and that at least four contiguous bodies are involved

34. prominent, flowing ossification is noted along the anterior margin of the cervical spine in this patient with DISH -- it is easy to see why such patients often complain of dysphagia

36. Since we often don't have any specific therapy for DISH, is there any reason to try to distinguish it from all of these other disorders ?

37. DISH patients are prone to heterotopic bone formation in surgical sites. • Because of this, some orthopedic surgeons will prophylactically treat DISH patients with radiation or drug therapy prior to performing a total joint arthroplasty, in an attempt to prevent or diminish the development of heterotopic bone formation after surgery.

38. Ankylosing spondylitis • Affects synovial and cartilaginous joints as well as sites of tendon and ligament attachment • Classically, changes are initially noted in the sacroiliac joints and next appear at the thoracolumbar and lumbosacral junctions • Sacroiliitis is the hallmark of ankylosing spondylitis • Although an asymmetric or unilateral distribution can be evident on initial radiographic examination, roentgenographic changes at later stages of the disease are almost invariably bilateral and symmetric in distribution

39. characteristic radiographic features of ankylosing spondylitis include • erosions, • sclerosis, • syndesmophytosis, • ankylosis.

40. bilateral erosions and sclerosis are noted in the SI joints of this patient with ankylosing spondylitis

41. erosions are noted in the lumbar facet joints of this patient with ankylosing spondylitis

42. Rheumatoid arthritis • rheumatoid arthritis predominantly involves the cervical spine, with apophyseal joint erosion and malalignment • Intervertebral disc space narrowing with endplate sclerosis and without osteophytes • Multiple subluxations, especially at the atlanto-axial junction. • Abnormalities of the thoracolumbar spine and sacroiliac joints are infrequent and less prominent than those of ankylosing spondylitis.

43. Other helpful differential findings are the absence of osteoporosis and the presence of bony proliferation and intraarticular bony ankylosis in the seronegative spondyloarthropathies.

44. Psoriatic arthritis • Bilateral sacroiliac joint abnormalities are much more frequent • Widening of the articular space • Ankylosis, is less than that of classic ankylosing spondylitis or the spondylitis associated with inflammatory bowel disease • Paravertebral ossification about the lower thoracic and upper lumbar segments paralleling the lateral surface of the vertebral bodies and the intervertebral discs

45. Features that distinguish paravertebral ossification from the typical syndesmophytosis of ankylosing spondylitis or the spondylitis of inflammatory bowel disease  • usually no osteoporosis(˙≠ RA) • Greater size, • Unilateral or asymmetric distribution, • Location farther away from the vertebral column

46. SI joints • 30-50% of patients with PsA • erosions and sclerosis of SI joints • bilateral lesions are more common than unilateral

47. Lumbar spine showing bilateral sacroiliitis

48. Reiter's syndrome • asymmetric arthritis of the lower extremity, sacroiliitis

49. Enteropathic arthropathy • spondylitis and sacroiliitis of inflammatory bowel disease are identical to those of classic ankylosing spondylitis • H/O inflammatory bowel disease can sometimes help to distinguish these entities • Ulcerative colitis, spondylitis most commonly precedes the onset of colitis • Crohn's disease, the joint abnormalities tend to occur simultaneously with the bowel disease.

50. Peripheral joint abnormalities tend to occur much more frequently with enteropathic arthropathy • usually self limited, and rarely cause lasting deformity of the joint • ankylosing spondylitis, the peripheral joint findings typically include joint space narrowing, osseous erosions, cysts, and bony proliferation