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Rheumatoid arthritis is not common in the thoracic and lumbar spine. However, the high incidence in the cervical spine is well known. One of the most recent studies has indicated the radiographic prevalence rate of rheumatoid arthritis in the cervical spine to be 88.5% (Zik-ou et al. 2005). In contrast, a random sampling study showed rheumatoid arthritis to involve the lumbar spine in only 5% of men and 3% of women (Lawrence et al. 1964). Rheumatoid ar-

Lumbar Spine Ray Women

Fig. 10.40A, B Rheumatoid arthritis in the uppermost cervical spine and skull base. A Anteroposterior conventional X-ray tomogram of the uppermost cervical spine in a 70-year-old woman with rheumatoid spondylitis shows erosions involving the dens (arrowheads) with subluxation to the right (open arrow). The occipitoatlantal joints are markedly narrowed bilaterally (arrows). B Posterior pinhole scintigraph shows intense tracer uptake in both occipitoatlantal joints (arrows) as well as the dens (open arrow). Compare with the normal anatomy in Fig. 4.10

Fig. 10.40A, B Rheumatoid arthritis in the uppermost cervical spine and skull base. A Anteroposterior conventional X-ray tomogram of the uppermost cervical spine in a 70-year-old woman with rheumatoid spondylitis shows erosions involving the dens (arrowheads) with subluxation to the right (open arrow). The occipitoatlantal joints are markedly narrowed bilaterally (arrows). B Posterior pinhole scintigraph shows intense tracer uptake in both occipitoatlantal joints (arrows) as well as the dens (open arrow). Compare with the normal anatomy in Fig. 4.10

Fig. 10.39A, B Not so intense tracer uptake in ankylosed rheumatoid arthritis. A Posteroanterior radiograph of the right sacroiliac joint in a 23-year-old female shows diffuse iliac sclerosis and ankylosis (arrows). B Posterior pinhole scan reveals simply homogeneous tracer uptake of moderate grade with diffuse joint obliteration (arrows). Note that there is no differential uptake in this ankylotic arthritis as there is in florid arthritis (Fig. 10.37)

thritic involvement of the apophyseal joints has been emphasized (Sims-Williams et al. 1977). It is unquestioned that the more realistic incidence of spinal rheumatoid arthritis would be found to be higher if multiple radiographic projections and bone scintigraphy, particularly pinhole scanning, were more regularly used.

Radiographically, the atlantoaxial rheumatoid arthritis reveals irregular erosion of the odontoid process, early widening and later narrowing of the atlantoaxial joints, and occasional subluxation (Fig. 10.40A). Involvement of the lateral masses and the facet joints of the axis and the occipitoatlantal joint is an important accompaniment. Rheumatoid apophysitis of the lumbar and thoracic spine is characterized by erosion, which may result in burring and narrowing or spurious widening of joint spaces (Fig. 10.41A). The oblique view is useful for a clearer presentation of apophysitis.

Pinhole scintigraphy of rheumatoid arthritis in the upper cervical spine shows tracer uptake in the lateral and median atlantoaxial joints around the odontoid process as well as the apo-physeal joints and occipitoatlantal joint (Fig. 10.40B). The eroded dens also accumulates tracer. In the lumbar spine, the apophyse-al and diskovertebral joints show increased uptake. To be anatomically specific, the apo-physeal joint is not in the midline but in the lateral part of the intervertebral space on the posterior scan (Fig. 10.41B) and behind the vertebral body on the lateral scan (Fig. 10.42). Diskovertebral rheumatoid arthritis is indicated by increased uptake (Fig. 10.42). The disk spaces may or may not be narrowed. Lateral pinhole scintigraphy is a sensitive and reliable indicator of rheumatoid arthritis in the lumbar apophyseal joint (Fig. 10.42) and the median (anterior) atlantoaxial joint (Fig. 10.43).

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Arthritis Relief and Prevention

Arthritis Relief and Prevention

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