Many types of arthritis can affect the structure and function of the muscles, bones and/or joints, causing symptoms such
Spinal involvement is frequent in rheumatoid arthritis (RA) and seronegative spondyloarthritides (SpA), and its diagnosis is important. Thus, MRI and CT are increasingly used, although radiography is the recommended initial examination. The purpose of this review is to present the typical radiographic features of spinal changes in RA and SpA in addition to the advantages of MRI and CT, respectively. RA changes are usually located in the cervical spine and can result in serious joint instability. Subluxation is diagnosed by radiography, but supplementary MRI and/or CT is always indicated to visualize the spinal cord and canal in patients with vertical subluxation, neck pain and/or neurological symptoms. SpA may involve all parts of the spine. Ankylosing spondylitis is the most frequent form of SpA and has rather characteristic radiographic features. In early stages, it is characterized by vertebral squaring and condensation of vertebral corners, in later stages by slim ossifications between vertebral bodies, vertebral fusion, arthritis/ankylosis of apophyseal joints and ligamentous ossification causing spinal stiffness. The imaging features of the other forms of SpA can vary, but voluminous paravertebral ossifications often occur in psoriatic SpA. MRI can detect signs of active inflammation as well as chronic structural changes; CT is valuable for detecting a
Keywords: Spine, Arthritis, Rheumatoid Arthritis, Spondyloarthropathies
The spine can be involved in most inflammatory disorders encompassing rheumatoid arthritis (RA), seronegative spondyloarthritides (SpA), juvenile arthritides and less frequent disorders such as, arthro-osteitis and SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome.
During the last decade, the diagnostic use of magnetic resonance imaging (MRI) and computed tomography (CT) has increased considerably, although radiography is still the recommended initial examination. It is therefore important to know the characteristic radiographic findings in arthritides in addition to the advantages of supplementary MRI and CT. This review will focus on the different imaging features and be concentrated on the most frequent inflammatory spinal changes seen in RA and SpA, respectively. These two entities display somewhat different imaging features, which are important to recognize.
Rheumatoid arthritis is an autoimmune disease which causes the human body’s own immune system to attack and often destroy the lining of the joints. Although it commonly affects the small joints of the hands and feet, rheumatoid arthritis, or RA, can affect any joint in the human body. The neck, or cervical spine, can be affected more often than the lower back if rheumatoid arthritis affects the joints in the spine.Dr. Alex Jimenez D.C., C.C.S.T.
Involvement in RA is usually located in the cervical spine where erosive changes are predominantly seen in the
Radiography of the cervical spine is mandatory in RA patients with neck pain . It should always include a lateral view in a flexed position compared with a neutral position in addition to special views of the dens area to detect any lesions and/or instability (Fig. 1). A supplementary lateral view during extension can be useful to assess reducibility of
Anterior atlanto-axial subluxation.
Lateral and rotatory atlanto-axial subluxation. Displacement of the lateral masses of the atlas more than 2 mm in relation to that of the axis and asymmetry of the lateral masses relative to the dens, respectively (Fig. 2). Rotatory and lateral subluxation is diagnosed on open-mouth anterior-posterior (AP) radiographs. Anterior subluxation often coexists because of the close anatomical relation between the atlas and the axis.
Posterior atlanto-axial subluxation. The anterior arc of the atlas moves over the odontoid process. This is rarely
Vertical atlanto-axial subluxation is also referred to as
The occurrence of dens erosion can, however, make this measurement difficult to obtain. The Redlund-Johnell method is therefore based on the minimum distance between McGregors line and the midpoint of the inferior margin of the body of the axis on a lateral radiograph in a neutral position (Fig. 3) . Visualisation of the palate may not always be obtained. Methods without dens and/or the palate as landmarks have therefore been introduced . The method described by Clark et al. (described in ) includes assessment of the location of the atlas by dividing the axis into three equal portions on a lateral radiograph. Location of the anterior
Subaxial RA changes also occur in the form of arthritis of the apophyseal and/or uncovertebral joints, appearing as narrowing and superficial erosions by radiography. It can cause instability in the C2-Th1 region, which is mainly seen in patients with severe chronic peripheral arthritis. Anterior subluxation is far more frequent than posterior subluxation. It is defined as at least 3 mm forward slippage of a vertebra relative to the underlying vertebra by radiography including a flexion view (Fig. 6). Changes are particularly characteristic at the C34 and C45 level, but multiple levels may be involved, producing a typical stepladder appearance on lateral radiographs. The condition is serious if the
Discitis-like changes and spinous process erosion may also be detected by radiography in RA, but are relatively rare, whereas concomitant degenerative changes occur occasionally (Fig. 1).
Cross-sectional imaging in the form of CT and MRI eliminates
A diagnostic strategy according to Younes et al.  is recommended (Fig. 9). This includes an indication for radiography in all RA patients with disease duration >2 years as cervical involvement may occur in over 70% of patients and has been reported to be asymptomatic in 17% of RA patients. It is recommended to monitor patients with manifest peripheral erosions accompanied by RF (rheumatoid factor) and antiCCP (antibodies to cyclic citrullinated peptide) positivity every second year and patients with few peripheral erosions and RF negativity at 5-year intervals. MRI is indicated in patients with neurological deficit, radiographic instability, vertical subluxation and
According to European classification criteria [8, 9], SpA is divided
Ankylosing spondylitis is the most frequent and usually the most disabling form of SpA. It has a genetic predisposition in the form of a frequent association with the human leukocyte antigen (HLA) B27 . AS often starts in early adulthood and has a chronic progressive course. It is therefore important to diagnose this disorder. According to the modified New York Criteria , the diagnosis of definite AS requires the following: manifest sacroiliitis by radiography (grade ?2 bilateral or unilateral grade 34 sacroiliitis; Fig. 10) and at least one of the following clinical criteria: (1) low back pain and stiffness for more than 3 months improving with activity, (2) limited movement of the lumbar spine and (3) reduced chest expansion. These criteria are still used in the diagnosis of AS despite the increasing use of MRI to detect the disease early. It is therefore important to know both the characteristic radiographic features and the MR features of AS.
Early radiographic spinal changes encompass erosion of vertebral corners (Romanus lesions) causing vertebral squaring and eliciting reactive sclerosis appearing as condensation of vertebral corners (shiny corners; Fig. 10). These changes are caused by inflammation at the insertion of the annulus fibrosus (enthesitis) at vertebral corners provoking reactive bone formation . Later
Erosive changes within intervertebral spaces (Andersson lesions) have been detected by radiography in approximately 5% of patients with AS , but more frequently by MRI (Fig. 11) .
Persistent movement at single intervertebral spaces may occur in an otherwise ankylosed spine, sometimes caused by non-diagnosed fractures. This can result in pseudo- arthrosis-like changes with the formation of surrounding reactive osteophytes due to excessive mechanical load at single movable intervertebral spaces . The diagnosis of such changes may require a CT examination to obtain adequate visualization (Fig. 13).
One of the life-threatening complications of AS is
Cross-sectional CT or MR imaging can be advantageous in the diagnosis of AS changes. CT providing a clear delineation of osseous structures is the preferred technique for visualizing pseudo-arthrosis and detecting fractures (Figs. 13, 14). CT is superior to MRI in detecting minor osseous lesions such as erosion and ankylosis of the apophyseal,
Characteristic MR findings early in the disease are activity changes mainly consisting of
During the disease course signs of activity can also occur at syndesmophytes, apophyseal joints and interspinous ligaments (Fig. 16). Detection of inflammation at apophyseal joints by MRI, however, demands pronounced involvement histopathologically . The inflammation at vertebral corners is the most valid feature and has been observed related to the development of syndesmophytes by radiography , establishing a link between signs of disease activity and chronic structural changes.
Chronic AS changes detectable by MRI mainly consist of fatty marrow deposition at vertebral corners (Fig. 17), erosion (Fig. 11) and vertebral fusion in advanced disease (Fig. 12). Fatty marrow deposition seems to be an a sign of chronicity being significantly correlated with radiographic changes, in particular, vertebral squaring . Erosions are more frequently detected by MRI than by radiography (Fig. 11)  and can present with signs of active inflammation and/or surrounding fatty marrow deposition compatible with sequels of osseous inflammation. Syndesmophytes, however, may not always be visible by MRI because they may be difficult to distinguish from fibrous tissue unless there is concomitant active inflammation or fatty deposition (Figs. 11, 16) [15, 20].
The possibility of visualizing disease activity by MRI has increased its use to monitor AS, especially during anti-TNF (
orms of SpA
Radiographic changes in reactive and psoriatic arthritis are often characterized by voluminous non-marginal syndesmophytes (
Reactive arthritis is self-limiting in most patients. However, in patients with chronic reactive arthritis and HLA
Axial psoriatic arthritis (PsA) occurs in approximately 50% of patients with peripheral PsA . It differs radiographically from AS by the voluminous paravertebral ossifications and the occurrence of spinal changes without concomitant sacroiliitis in 10% of patients . Axial
In patients with enteropathic arthritis associated with Crohns disease or ulcerative colitis, the spine is often osteoporotic with various accompanying SpA features by radiography, mostly AS-like changes. However, by MRI there may be more pronounced inflammation in the posterior ligaments than seen in the other forms of SpA (Fig. 21).
Rheumatoid arthritis of the spine can cause neck pain, back pain, and/or radiating pain in the upper and lower extremities. In severe cases, RA can also lead to the degeneration of the spine, resulting in the compression or impingement of the spinal cord and/or the spinal nerve roots. As a chiropractor, we offer diagnostic imaging to help determine a patient’s health issue, in order to develop the best treatment program.Dr. Alex Jimenez D.C., C.C.S.T.
Radiography is still valuable in the diagnosis of spinal inflammatory disorders. It is necessary for visualizing instability and is superior to MRI for detecting syndesmophytes. However, MRI and CT can detect signs of spinal involvement before they can be visualized by radiography. MRI adds information about
Computed tomography is particularly valuable in the detection of fracture and minor osseous lesions as well as in the evaluation of pseudo-arthrosis. In conclusion, rheumatoid arthritis most commonly affects the structure and function of your hands, wrists, elbows, hips, knees, ankles and feet, however, people with this chronic inflammatory disease can experience back pain. Imaging the spine in arthritis is fundamental to determine treatment. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
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Additional Topics: Acute Back Pain
Back pain is one of the most prevalent causes of disability and missed days at work worldwide. Back pain attributes to the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments, and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.