Ankylosing Spondylitis

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Ankylosing spondylitis denotes nonspecific inflammatory or rheumatic disorder of the spine clinically characterized by stiffening, pain, fi-brosis, and ankylosis. The disease typically affects the cartilaginous diskovertebral junctions and small accessory vertebral synovial joints, resulting in the "bamboo spine" deformity. The sacroiliac joint involvement is an essential constituent of the disease. The cause is obscure, but many recent studies have confirmed a strong association between this and other SNSA and the histocompatibility antigen HLA-B27. Spon-dylitis and sacroiliitis coexist in various degrees of severity, ranging from full-blown fibrosis with diffuse ankylosis to milder syndromes. This condition was once held to be rare, mainly affecting the male population, but is now recognized as a relatively common disease with Prevalence ranging from 0.5% to 1% of the population and a nearly equal sex distribution. Clinically, the initial chief complaint is back

Fig. 11.1 Usefulness of whole-body scintigraphy in the study of the asymmetrical involvement of SNSA. Anterior whole-body scintigraph of a 37-year-old man with Reit-er's syndrome reveals increased tracer uptake in both hips, the right knee, and the right foot (arrows). Note the asymmetrical and spotty distribution of the lesions in the lower limbs, an important feature of SNSA, particularly Reiter's syndrome

Fig. 11.1 Usefulness of whole-body scintigraphy in the study of the asymmetrical involvement of SNSA. Anterior whole-body scintigraph of a 37-year-old man with Reit-er's syndrome reveals increased tracer uptake in both hips, the right knee, and the right foot (arrows). Note the asymmetrical and spotty distribution of the lesions in the lower limbs, an important feature of SNSA, particularly Reiter's syndrome

Reiter Syndrome

Fig. 11.2A, B Preradiographic diagnosis of Reiter's syndrome. A Mediolateral radiograph of the painful right heel in a 43-year-old man reveals no bony or soft-tissue abnormality (?). B Medial pinhole scintigraph shows very subtle tracer uptake in the posterior plantar aspect of the calcaneus, the sign of an early enthesopathic change in Reiter's syndrome (open arrow). The alteration could not be seen on an ordinary scintigraph (not shown)

pain with stiffening and limited motion of various degrees in about three-quarters of patients. Peripheral joint pain is complained of by 10% to 20% of patients (Sharp 1965) and chest tightness is an important symptom in some patients (Good 1963). The onset is insidious with the first symptom appearing between the ages of 15 and 35 years with the average in the mid-20s. The back pain is aggravated after rest and in the morning but improves after exercise. Sensory and motor symptoms are usually absent. In the early phase, the sacroiliac joint pain

Ankylosing Spondylitis Exercises

Fig. 11.3A, B Classic radiographic and scintigraphic manifestations of sacroiliitis in ankylosing spondylitis. A Anteroposterior radiograph of the sacroiliac joints in a 26-year-old man with ankylosing spondylitis reveals marginal blurring due to subchondral erosions and ebur-nation in the synovial lower compartment of both sacroiliac joints (arrowheads). Note nearly perfect symmetry of the pathology. B Minimally tilted posterior oblique pinhole scintigraphs of both sacroiliac joints (separate acquisitions) show increased tracer uptake localized in the synovial compartment of the joints symmetrically (arrowheads)

Fig. 11.3A, B Classic radiographic and scintigraphic manifestations of sacroiliitis in ankylosing spondylitis. A Anteroposterior radiograph of the sacroiliac joints in a 26-year-old man with ankylosing spondylitis reveals marginal blurring due to subchondral erosions and ebur-nation in the synovial lower compartment of both sacroiliac joints (arrowheads). Note nearly perfect symmetry of the pathology. B Minimally tilted posterior oblique pinhole scintigraphs of both sacroiliac joints (separate acquisitions) show increased tracer uptake localized in the synovial compartment of the joints symmetrically (arrowheads)

may be prominent. However, after ankylosis has been established it ameliorates and sometimes vanishes completely. Sciatica-like pain may be noted in about a half of patients at some stage of the disease (Ogryzlo 1972). The ex-traskeletal manifestations include iritis, spon-dylitic heart disease with cardiomegaly and pericarditis, tuberculosis-like fibrocavitary lung lesions, and intestinal inflammation or renal amyloidosis. It has been emphasized that the disease in a large number of patients with a milder form of the condition may pass undiag-nosed.

Costosternal Joint

Fig. 11.4A, B Low tracer uptake in "bamboo spine" deformity of the advanced ankylosing spondylitis. A Anteroposterior radiograph of the lumbar spine with advanced ankylosing spondylitis in a 41-year-old man shows diffuse, osseous obliteration of the intervertebral spaces, small vertebral joints, and spinous processes, giving rise to the classic "bamboo spine" appearance. B Posterior pinhole scan shows a generalized decrease in tracer uptake due to quiescent metabolism in this stage of the disease. The spine appears "pale" with well-preserved disk spaces, a sign that the disks are not the main structures to be affected in this condition (arrows)

Fig. 11.4A, B Low tracer uptake in "bamboo spine" deformity of the advanced ankylosing spondylitis. A Anteroposterior radiograph of the lumbar spine with advanced ankylosing spondylitis in a 41-year-old man shows diffuse, osseous obliteration of the intervertebral spaces, small vertebral joints, and spinous processes, giving rise to the classic "bamboo spine" appearance. B Posterior pinhole scan shows a generalized decrease in tracer uptake due to quiescent metabolism in this stage of the disease. The spine appears "pale" with well-preserved disk spaces, a sign that the disks are not the main structures to be affected in this condition (arrows)

Pathologically, as the term denotes, the inflammatory process initially involves the joints in the axial skeleton including the sacroiliac joints. In the spine the cartilaginous diskover-

tebral junctions and the synovial apophyseal, costovertebral, and neurocentral joints are affected. The most important feature in this and other SNSA is that, unlike in rheumatoid arthritis, the entheses and not the synovia are the main site of fibrositis (Ball 1971). Enthesopa-thy shows early lymphocytic and macrophage infiltration, suggesting its probable relationship to an immune-mediated pathogenesis. As the disease progresses, chondritis, osteitis, and periostitis may follow. In the final stage the bony ankylosis dominates.

Radiographically, the heralding alterations in the sacroiliac joints are characterized by a broad spectrum of findings, ranging from marginal blurring and bone erosions to eburnation and joint space narrowing. Sacroiliitis is typically bilateral (Fig. 11.3A). Classically, enthe-sopathy first moves from the sacroiliac joints cranially to the thoracolumbar and lumbo-sacral spine and then to the midlumbar, upper thoracic, and cervical level (Wilkinson and By-waters 1958). The vertebral squaring, a characteristic sign of the condition, results from the syndesmophytosis of the annulus fibrosus and longitudinal ligaments. Eventually, the fi-brosed ligaments become ossified, resulting in the "bamboo spine" deformity (Fig. 11.4A). With chronicity, the disease further moves down to the hindfoot, causing Achilles tendinitis and calcaneal spur or "whisker". In contrast to the symmetrical, polyarticular affection of rheumatoid arthritis, the peripheral entheso-pathy and articular change in this disease are asymmetrical and sparse.

Scintigraphic alterations vary according to disease stage. In the early stage, bone scanning shows tracer uptake in the sacroiliac joints, typically, but not always, on both sides. Increased uptake has been described to occur characteristically in the central joints, which include the spinal apophyseal joints and the sternocla-vicular, manubriosternal, and costosternal joints (Lin et al. 1980). Pinhole scanning of the sacroiliac joints demonstrates intense uptake symmetrically. The uptake is localized predominantly to the ilia, reflecting enthesopathy in the thick ventral and dorsal sacroiliac ligament

Fig. 11.5A, B Pinhole scintigraphic manifestations of the individual, vertebral structure involvement in ankylosing spondylitis. A Anteroposterior conventional X-ray tomogram of the midlumbar spine in a 30-year-old woman with ankylosing spondylitis shows narrowing and obliteration of the apophyseal joints (apj), fusion of the spinous processes (sp), and blurring of the vertebral contour. B Posterior pinhole scintigraph shows patchy, intense tracer uptake in the apophyseal joints (apj, lateral arrowheads), the vertebral endplates, the interspinous ligaments (isl, midline arrowheads), and the longitudinal ligaments

Fig. 11.5A, B Pinhole scintigraphic manifestations of the individual, vertebral structure involvement in ankylosing spondylitis. A Anteroposterior conventional X-ray tomogram of the midlumbar spine in a 30-year-old woman with ankylosing spondylitis shows narrowing and obliteration of the apophyseal joints (apj), fusion of the spinous processes (sp), and blurring of the vertebral contour. B Posterior pinhole scintigraph shows patchy, intense tracer uptake in the apophyseal joints (apj, lateral arrowheads), the vertebral endplates, the interspinous ligaments (isl, midline arrowheads), and the longitudinal ligaments as well as arthritis. The main lesions are clearly indicated by more intense uptake surrounded by less intense reactive uptake in the para-arti-

Ankylosing Spondylitis Rays

Fig. 11.6 "Centipede" sign of ankylosing spondylitis in the thoracic spine. Composite posterior pinhole scinti-graph of the thoracic spine in a 22-year-old man with well-established ankylosing spondylitis shows diffuse tracer uptake in the longitudinal and interspinous ligaments, the synovial joints, and the diskovertebral junctions, producing the "centipede" appearance of generalized enthesopathic spondylitis. Compare with the normal thoracic spine (Fig. 4.18)

Fig. 11.6 "Centipede" sign of ankylosing spondylitis in the thoracic spine. Composite posterior pinhole scinti-graph of the thoracic spine in a 22-year-old man with well-established ankylosing spondylitis shows diffuse tracer uptake in the longitudinal and interspinous ligaments, the synovial joints, and the diskovertebral junctions, producing the "centipede" appearance of generalized enthesopathic spondylitis. Compare with the normal thoracic spine (Fig. 4.18)

cular bones (Fig. 11.3B). Associated spinal lesions may or may not be present at this stage. Later, as the spine becomes involved, pinhole scintigraphy shows (a) patchy uptake in the apophyseal joints, (b) horizontal band-like uptake in the diskovertebral junctions, and (c) midline uptake in the spinous processes and interspinous ligaments (Fig. 11.5). Diffuse involvement of the longitudinal ligaments along with the costovertebral joints, the spinous processes, and the interspinous ligaments of the thoracic spine gives rise to the characteristic "centipede" appearance (Fig. 11.6). It is important to note that the characteristic vertebral squaring may be often seen ahead of radiographic change (Fig. 11.7). As a whole, this and

Fig. 11.7A, B Preradiographic demonstration of the vertebral squaring in ankylosing spondylitis. A Lateral pinhole scan of the lumbar spine in a 21-year-old man with ankylosing spondylitis shows the squaring of the L2-L5 vertebral bodies. The vertebral endplates and apophyseal joints also concentrate tracer significantly due to enthe-sopathy (arrows). B Lateral radiograph of the same lumbar spine demonstrates minimal disk space narrowing with endplate thinning (small arrowheads) and the obliteration of the apophyseal joints (large arrowheads), but no squaring of the vertebral bodies

Fig. 11.7A, B Preradiographic demonstration of the vertebral squaring in ankylosing spondylitis. A Lateral pinhole scan of the lumbar spine in a 21-year-old man with ankylosing spondylitis shows the squaring of the L2-L5 vertebral bodies. The vertebral endplates and apophyseal joints also concentrate tracer significantly due to enthe-sopathy (arrows). B Lateral radiograph of the same lumbar spine demonstrates minimal disk space narrowing with endplate thinning (small arrowheads) and the obliteration of the apophyseal joints (large arrowheads), but no squaring of the vertebral bodies other already described scintigraphic features are in good accord with the classic radiographic findings. More classic squaring may be seen in advanced cases. With further progression of the disease, the cervical spine becomes involved, presenting tracer uptake in the intervertebral and interarticular spaces as well as a narrowed atlantoaxial joint. Tracer uptake is markedly reduced in the late stage, reflecting the quieter metabolic state of the disease. As a result, the spine images "pale" and indistinct yet with well-preserved intervertebral spaces (Fig. 11.4B).

With chronicity, the peripheral joints become involved, particularly in females. The hip, sternal joints, glenohumeral joint, knee, hand, foot, and calcaneus are predisposed. The diffused pattern of tracer uptake in this disease is basically the same as that in rheumatoid arthritis, but the distribution is not symmetrical and the involvement is sparse. As mentioned earlier, the comparable alterations in osteoarthri-tis are usually discrete and focal (Fig. 9.5A).

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Arthritis Joint Pain

Arthritis Joint Pain

Arthritis is a general term which is commonly associated with a number of painful conditions affecting the joints and bones. The term arthritis literally translates to joint inflammation.

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