Intervertebral Osteochondrosis

The spine has five different articulations: the diskovertebral and apophyseal joints in throughout the spine, the costotransverse and costocorporeal joints in the thoracic spine, and the uncovertebral joints in the cervical spine. Of these, the diskovertebral joint is fibrocarti-laginous in type and others are synovial except for the uncovertebral joint that is mixed in type. Based on the principal site of involvement, diskovertebral degeneration can be divided into diskovertebral osteoarthritis and spondylosis deformans. The former osteoar-thritis affects the nucleus pulposus with diffuse condensation of peridiskal bones (endplate-based sclerosis) of the lower lumbar and lum-bosacral vertebrae and the latter the outer or Sharpey's fibers of the annulus fibrosus with osteophytosis. On the other hand, the degenerative change of the apophyseal and costoverte-bral joints is considered to be a classical osteo-arthritis since these joints are synovial.

Radiographically, diskovertebral osteoarth-ritis manifests the narrowing of the intervertebral space, endplate sclerosis, and focal osteo-phytes, most typically in the L4, L5, and S1 vertebrae (Fig. 9.37A). Occasionally, compression fracture may be superimposed on an endplate that is already deformed by osteoarthritis, making the diagnosis extremely difficult (Fig. 9.38B). In contrast, spondylosis deformans is characterized by multiple osteophytes, often prominent, formed in the lateral and anterior edges of the endplates (Fig. 9.39A). The diskovertebral changes such as narrowing of the intervertebral spaces and endplate scleroses are usually inconspicuous.

Pinhole scintigraphic manifestations of dis-kovertebral osteoarthrosis include tracer uptake in the vertebral endplates and marginal spurs with significant diminution of the intervertebral space (Fig. 9.37B). The endplates are affected in pairs in a straight, parallel manner. Compression fractures resemble diskovertebral osteoarthritis, but fractures are rarely paired and not parallel when paired (Fig. 9.38B). Mo-

Osteoarthritis Lumbar Spine

Fig. 9.37A, B Straightness of endplate sclerosis in intervertebral osteochondrosis in the lower lumbar spine. A Anteroposterior radiograph of the lower lumbar spine in a 37-year-old female shows typical endplate based sclerosis in the L4 lower and L5 upper endplates with narrowing of the disk space between (arrow). There are small claw-like spurs at the right lateral edges (arrowheads). B Anterior pinhole scan shows straight tracer uptake in the sclerosed endplates with disk space narrowing (parallel arrows) and spur uptake (arrowheads)

Fig. 9.37A, B Straightness of endplate sclerosis in intervertebral osteochondrosis in the lower lumbar spine. A Anteroposterior radiograph of the lower lumbar spine in a 37-year-old female shows typical endplate based sclerosis in the L4 lower and L5 upper endplates with narrowing of the disk space between (arrow). There are small claw-like spurs at the right lateral edges (arrowheads). B Anterior pinhole scan shows straight tracer uptake in the sclerosed endplates with disk space narrowing (parallel arrows) and spur uptake (arrowheads)

Compression Fracture Vertebrae

Fig. 9.38A,B Arcuate depression of the vertebral endplates in compression fractures of the spine. A Posterior pinhole scintigraph of the lower lumbar spine in a 67-year-old woman with old and new compression fractures of the L4 vertebra shows increased tracer uptake in the centrally depressed upper and lower endplates (open and solid arrows). Note that the tracer uptake is extremely intense in the fresh fracture of the lower endplate (solid arrow), whereas the uptake is minimal in the old fracture of the upper endplate (open arrow). B Near lateral radiograph of the same spine shows compression fractures in the upper and lower endplates of the L4 vertebra (open and solid arrows). Unlike in pinhole scintigraphy, the distinction between old and new fracture is often difficult in radiography. Note that the mature osteophytes in the nonstress areas do not concentrate tracer (arrowheads)

Osteochondrosis Images Areas

Fig. 9.39A, B Different intensities of tracer uptake in old and new osteophytes. A Anterior pinhole scan of the lower lumbar spine in an 80-year-old man with old and new osteophytes reveals little increase in tracer uptake in the prominent old osteophytes in the L2 and L3 vertebrae (arrowheads) but very intense tracer uptake in a "budding" osteophyte in the upper lateral aspect of the L4 vertebra (curved arrow). B Anteroposterior radiograph demonstrates prominent osteophytes in the L2 and L3 vertebrae (arrowheads) and an unimpressive osteophyte in the L4 vertebra (curved arrow)

Osteophyte Cervical Vertebrae

Fig. 9.40A, B Intense tracer uptake in abutting osteophytes. A Posterior pinhole scintigraph of the upper lumbar spine in a 72-year-old man with local pain reveals very intense trace uptake in a structure that protrudes outward from the L2-L3 vertebral junction (arrow). The most intense uptake occurs in the center where two osteophytes meet to fuse. B Anteroposterior radiograph shows a prominent paravertebral osteophyte formed by the two smaller, abutting osteophytes which arise separately from the lateral aspect of the lower endplate of the L1 vertebra and the upper endplate of the L2 vertebra (arrow). A narrow slit-like lucency at the center indicates the incompleteness of fusion (arrow) as confirmed by CT scan (not shown here)

Fig. 9.39A, B Different intensities of tracer uptake in old and new osteophytes. A Anterior pinhole scan of the lower lumbar spine in an 80-year-old man with old and new osteophytes reveals little increase in tracer uptake in the prominent old osteophytes in the L2 and L3 vertebrae (arrowheads) but very intense tracer uptake in a "budding" osteophyte in the upper lateral aspect of the L4 vertebra (curved arrow). B Anteroposterior radiograph demonstrates prominent osteophytes in the L2 and L3 vertebrae (arrowheads) and an unimpressive osteophyte in the L4 vertebra (curved arrow)

Fig. 9.40A, B Intense tracer uptake in abutting osteophytes. A Posterior pinhole scintigraph of the upper lumbar spine in a 72-year-old man with local pain reveals very intense trace uptake in a structure that protrudes outward from the L2-L3 vertebral junction (arrow). The most intense uptake occurs in the center where two osteophytes meet to fuse. B Anteroposterior radiograph shows a prominent paravertebral osteophyte formed by the two smaller, abutting osteophytes which arise separately from the lateral aspect of the lower endplate of the L1 vertebra and the upper endplate of the L2 vertebra (arrow). A narrow slit-like lucency at the center indicates the incompleteness of fusion (arrow) as confirmed by CT scan (not shown here)

reover, tracer uptake is markedly intensified and the disk space is preserved unless the disk is simultaneously involved in fracture. The osteophytes in spondylitis deformans are represented scintigraphically by beak-like uptake of various sizes and intensities at the lateral or anterior edges of the vertebral bodies (Fig. 9.39B). The tracer intensity in osteophytes appears to be related to age and location; the smaller and the less outgrowing the osteophyte, the more intense is the uptake and vice versa. Indeed, as in the knee (Fig. 9.5) and elsewhere, the mature osteophytes that lie in the lateral, nonstressed zones of the spine accumulate tracer only minimally, whereas the small, burgeoning spurs in the weight-bearing axis avidly concentrate tracer (Fig. 9.39B). Interestingly, old osteophytes appear imposing radiographi-cally while fresh ones look unimpressive. Extremely intense uptake in one or two of many osteophytes and endplates occurs as the result of superimposed diseases such as fracture, infection, or metastasis. Thus, when fractured or abutted on another osteophyte, even a mature osteophyte conspicuously concentrates tracer (Fig. 9.40A).

The cervical spine is notorious for diskover-tebral osteoarthritis, uncovertebral osteoarth-ritis, and apophyseal osteoarthritis. As in the lumbar and thoracic spine, diskovertebral oste-oarthritis in the cervical spine is pinhole scinti-graphically indicated by increased tracer upt-

Fig. 9.41A-C Apophyseal and uncovertebral osteoarthritis of the cervical spine. A Posterior spot scintigraph of the cervical spine in a 62-year-old woman with posterior neck and left shoulder pain reveals intense tracer uptake in the left lateral aspect of the lower cervical spine (arrow). B Posterior pinhole scan shows intense tracer uptake in the apophyseal joints of C4-C6 vertebrae (arrowheads) and also modest tracer uptake in C6 and C7 uncovertebral joints (arrows). The latter joints can easily be located at the medial border of the intervertebral foramina (F). C Anteroposterior radiograph shows the obliteration with eburnation of the left apophyseal joints of C4-C6 vertebrae (arrows) and erosions in C6 and C7 uncovertebral joints (arrowheads). Observe the intimate positional relationship between the uncovertebral joints and the intervertebral foramina (F). The radiograph is printed with the right side on the left to match the scinti-graph

Uncovertebral JointsLower Lumbar Spondylotic

Fig. 9.42A, B Vertical alignment and half-astride position of the apophyseal joints in the lower lumbar spine. A Posterior pinhole scintigraph of the midlumbar spine in a 50-year-old woman with known apophyseal osteoarthritis shows intense tracer uptake in L2 and L3 apophyseal joints (arrows). Unlike horizontal alignment in the cervical spine (Fig. 9.41), the apophyseal joints in the lumbar spine are vertically aligned and astride in location. B Coronal CT section through the affected apophyseal joints reveals marked para-articular sclerosis with joint space narrowing on the right (arrowheads) and a vacuum on the left (open arrow). The CT image is printed with the right side on the left to match the scintigraph

Fig. 9.42A, B Vertical alignment and half-astride position of the apophyseal joints in the lower lumbar spine. A Posterior pinhole scintigraph of the midlumbar spine in a 50-year-old woman with known apophyseal osteoarthritis shows intense tracer uptake in L2 and L3 apophyseal joints (arrows). Unlike horizontal alignment in the cervical spine (Fig. 9.41), the apophyseal joints in the lumbar spine are vertically aligned and astride in location. B Coronal CT section through the affected apophyseal joints reveals marked para-articular sclerosis with joint space narrowing on the right (arrowheads) and a vacuum on the left (open arrow). The CT image is printed with the right side on the left to match the scintigraph

Fig. 9.43A, B Osteoarthritis in the lumbosacral apophyseal joint. A Posterior pinhole scintigraph of the lumbosacral region of the spine in a 59-year-old woman with local tenderness shows spotty tracer uptake in the left lumbosacral apophyseal joint (arrow). B Anteroposterior radiograph shows sclerosis in the left lumbosacral apophyseal joint (arrow). The radiograph is printed with the right side on the left to match the scintigraph ake in the sclerosed endplates with narrowed disk space, and such findings are best appreciated on the lateral scan. It is to be noted that osteoarthritis can be confused with infective spondylitis, but radiographic findings basically differ between the two conditions: endplate sclerosis in osteoarthritis (Fig. 9.37A) and endplate lysis in infection (Fig. 6.37B).

The uncovertebral joint of Luschka is the articulation formed between the uncinate processes of the cervical vertebrae, and is found in all but the first two cervical vertebrae. Because this joint borders the medial aspect of the intervertebral foramina, their involvement is readily diagnosed by pinhole scintigraphy (Fig. 9.41B). As shown in this case, the simultaneous involvement of the uncovertebral and apophyseal joints is not uncommon.

Osteoarthritis of the apophyseal and costo-vertebral joints manifests as intense uptake in the respective joint. The uptake in apophyseal osteoarthritis is characterized by its lateral localization in the vertebral column on the posterior or anterior scan. It is laid more or less horizontally in the cervical and midthoracic regions (Fig. 9.41) and vertically in the lower thoracic and upper lumbar regions (Fig. 9.42). For unobstructed, viewing of individual apophyseal joints oblique pinhole scintigraphy is ideal. Apophyseal osteoarthritis may be either solitary or multiple, unilateral or bilateral. The lumbosacral apophyses are most commonly affected, manifesting as classic spotty uptake in the lateral edge(s) of the sacral base (Fig. 9.43). In occasional cases radiographic findings are inconclusive, but scintigraphic evidence is definitive. Indeed, the diagnosis of radiographi-cally dubious osteoarthritis in the false joint between the broad transverse process of the lowermost lumbar vertebra and the lateral part of the transitionalized sacral base can be confirmed by pinhole scintigraphy (Fig. 9.44). It is to be emphasized that planar scan or often radiography is of limited diagnostic value in this condition.

The diagnosis of osteoarthritis of the costovertebral joints, both or either of the costo-transverse and costocorporeal joints, can also

Costocorporeal JointsVertebral Osteochondrosis

Fig. 9.44A, B Pinhole scintigraphic diagnosis of early osteoarthritis in transitionalized lumbosacral joint. A Anterior pinhole scan of the sacrum in a 22-year-old man with disturbing motion pain in the right lumbosa-cral region reveals indeed subtle tracer uptake in the anomalous lumbosacral joint (arrows). Ordinary s cintigraph showed no abnormality (not shown here). B Anteroposterior radiograph reveals borderline para-articular sclerosis in the anomalous joint formed in the transitionalized lumbosacral spine (arrowheads)

Fig. 9.44A, B Pinhole scintigraphic diagnosis of early osteoarthritis in transitionalized lumbosacral joint. A Anterior pinhole scan of the sacrum in a 22-year-old man with disturbing motion pain in the right lumbosa-cral region reveals indeed subtle tracer uptake in the anomalous lumbosacral joint (arrows). Ordinary s cintigraph showed no abnormality (not shown here). B Anteroposterior radiograph reveals borderline para-articular sclerosis in the anomalous joint formed in the transitionalized lumbosacral spine (arrowheads)

be established by pinhole scintigraphic portrayal of increased uptake in the respective joints. To be exact anatomically, the costotransverse joint is located in the paraspinal region and the costocorporeal joint in the immediate juxtaspi-nal region; the former joints lie more laterally

Osteochondrosis Spine

Fig. 9.45A, B Osteoarthritis in the costovertebral (costotransverse and costocorporeal) joints. A Posterior pinhole scintigraph of the lower thoracic spine in a 70-year-old man with local pain shows spotty tracer uptake in the left costotransverse (solid arrow) and costocorporeal (open arrow) joints of the T10 vertebra. The opposite cos-tovertebral joint also shows minimally increased tracer uptake (arrowhead). B Anteroposterior radiograph shows articular narrowing and sclerosis in the costotransverse joints of the T10 vertebra on both sides (arrowheads). Note the more medially located costocorporeal joint with erosions (arrow). The radiograph is printed with the right side on the left to match the scintigraph

Fig. 9.45A, B Osteoarthritis in the costovertebral (costotransverse and costocorporeal) joints. A Posterior pinhole scintigraph of the lower thoracic spine in a 70-year-old man with local pain shows spotty tracer uptake in the left costotransverse (solid arrow) and costocorporeal (open arrow) joints of the T10 vertebra. The opposite cos-tovertebral joint also shows minimally increased tracer uptake (arrowhead). B Anteroposterior radiograph shows articular narrowing and sclerosis in the costotransverse joints of the T10 vertebra on both sides (arrowheads). Note the more medially located costocorporeal joint with erosions (arrow). The radiograph is printed with the right side on the left to match the scintigraph

Radiography Faults

Fig. 9.46A-C Early osteoarthritis in the symphysis pubis. A Anteroposterior radiograph of painful pubic symphysis in a 61-year-old female shows local osteopenia and minimal eburnation with a preserved joint space (arrows). B Fat-suppressed T2-weighted MRI demonstrates subcortical edema in the left pubis (arrow). C Anterior pinhole scan shows intense tracer uptake specifically localized to the para-articular zone of the left pubic bone (arrow)

Fig. 9.46A-C Early osteoarthritis in the symphysis pubis. A Anteroposterior radiograph of painful pubic symphysis in a 61-year-old female shows local osteopenia and minimal eburnation with a preserved joint space (arrows). B Fat-suppressed T2-weighted MRI demonstrates subcortical edema in the left pubis (arrow). C Anterior pinhole scan shows intense tracer uptake specifically localized to the para-articular zone of the left pubic bone (arrow)

Inflammation Pubic Symphisis Mri

Fig. 9.47A, B Chronic osteoarthritis in the symphysis pubis. A Anteroposterior radiograph of painful pubic symphysis in a 72-year-old female shows local osteopenia and prominent eburnation with a narrowed joint space with vacuum shadow. B Anterior pinhole scan shows intense tracer uptake localized to the pubic bone cortices symmetrically, producing a collared neck appearance. This case suggests that the tracer uptake in pubic osteoarthritis may be linked not only to osteosclerosis but also to other causes such as osteopenia

Fig. 9.47A, B Chronic osteoarthritis in the symphysis pubis. A Anteroposterior radiograph of painful pubic symphysis in a 72-year-old female shows local osteopenia and prominent eburnation with a narrowed joint space with vacuum shadow. B Anterior pinhole scan shows intense tracer uptake localized to the pubic bone cortices symmetrically, producing a collared neck appearance. This case suggests that the tracer uptake in pubic osteoarthritis may be linked not only to osteosclerosis but also to other causes such as osteopenia than the latter (Fig. 9.45). As in the osteoarth-ritis of the apophyseal joints, the tracer uptake in costovertebral osteoarthritis is modest at most, and its occurrence is either monarticular or oligoarticular (Fig. 9.45) contrasting with multiple, intense, and usually lateralized tracer uptake in apophyseal joint fractures (Chap. 16). Apophyseal involvement in ankylosing spondylitis and other SNSA is for the most part multiple and symmetrical (Chap. 11).

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Responses

  • pauline
    What is endplate osteophytes?
    5 years ago

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