Costovertebralis arthrosis. Imaging the spine in arthritis—a pictorial review
Metrics details Abstract Spinal involvement is frequent in rheumatoid arthritis RA costovertebralis arthrosis seronegative spondyloarthritides SpAand its diagnosis is important. RA changes are usually located in the cervical spine and can result in serious joint instability.
SpA may involve all parts of the spine. Ankylosing spondylitis is the most frequent form of Costovertebralis arthrosis and has rather characteristic radiographic features.
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 fracture. Introduction The spine can be involved in most inflammatory disorders encompassing rheumatoid arthritis RAseronegative spondyloarthritides SpAjuvenile arthritides and less frequent disorders such as pustulotic 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 costovertebralis arthrosis seen in RA costovertebralis arthrosis SpA, respectively. These two entities display somewhat different imaging features, which are important to recognise. Rheumatoid arthritis Involvement in RA is usually located in the cervical spine where erosive changes are predominantly seen in the atlanto-axial region.
Inflamed and thickened synovium pannus can occur around the odontoid process dens and cause bone erosion and destruction of surrounding ligaments, most seriously if the posterior transverse ligament is involved. Laxity or rupture of the transverse ligament causes instability with a potential risk of spinal cord injury. Cervical RA involvement is a progressive, serious condition with reduced lifetime expectancy [ 1 ], and its diagnosis is therefore important [ 23 ].
Radiography of the cervical spine is mandatory in RA patients with neck pain [ 3 ].
Rib Pain or Costovertebral Joint Dysfunctions
A supplementary lateral view during extension can be useful to assess reducibility of atlanto-axial subluxation possibly limited by pannus tissue between the costovertebralis arthrosis arc of the atlas and dens. The open-mouth view d shows erosion at the base of the dens arrow. The definition of the different forms of instability by radiography is as follows [ 3 ].
Lateral and rotatory atlanto-axial costovertebralis arthrosis Displacement of the lateral masses of the atlas more than 2 mm in relation to that of the axis and costovertebralis arthrosis of the lateral masses relative to the dens, respectively Fig.
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.
What is a costovertebral joint disorder?
AP open-mouth view in a year-old man with RA. There is narrowing of the atlanto-axial joints with superficial erosions black arrow and lateral displacement of the axis with respect to the lateral masses of the atlas white arrow ; in addition signs indicating rotatory displacement with asymmetry of the distance between the dens and the lateral masses of the atlas Full size image Posterior atlanto-axial subluxation The anterior arc of the atlas moves over the odontoid process.
This is rarely seen, but may coexist with fracture of the dens. This line can be difficult to define on radiographs, and vertical subluxation has therefore also been defined costovertebralis arthrosis several other methods. A distance less than 34 mm in men and 29 mm in women indicates vertical subluxation. If the anterior arc of costovertebralis arthrosis atlas is in level with the middle or caudal third of the axis there is slight and pronounced vertical subluxation, respectively.
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A distance less than 15 mm in males and 13 mm in females indicates vertical subluxation [ 4 ] Full size image The occurrence of dens erosion can, however, make this measurement difficult to obtain. Visualisation of the palate may not always be obtained. The method described by Clark et al. Location of the anterior arc of the atlas in level with the middle or caudal third of the axis indicates vertical subluxation Fig. Ranawat et al.
To obtain the diagnosis of vertical fokozódó hátfájás a combination of the Redlund-Johnell, Clark and Ranawat methods has been recommended described in [ 4 ]. If any of these methods suggests vertical subluxation MRI should be performed to visualise the spinal cord Fig. It is mandatory to diagnose vertical subluxation; this can be fatal because of the proximity of the dens to the medulla oblongata and the proximal portion of the spinal cord.
In accordance with this, the anterior arc of the atlas is level with the middle third of the axis. Thus, all measurements indicate vertical subluxation. Supplementary MRI, c costovertebralis arthrosis STIR and d T1-weighted images show erosion of the dens and protrusion of the tip into the occipital foramen causing narrowing of the spinal canal to 9 mm, but persistence of cerebrospinal fluid around alatti csípőfájdalom cord.
There is a 9-mm-thick mass of pannus tissue between the dens and anterior arc black line exhibiting small areas with high signal intensity on the STIR image arrow compatible with slight activity, but signal void fibrous pannus tissue predominates Full size image Fig. MRI of the cervical spine in a year-old woman with advanced peripheral RA, neck costovertebralis arthrosis gyógyszer a rheumatoid arthritis kezelésére clinical signs of myelopathy.
The osseous spinal canal has a width of approximately 7 mm black line. 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. Costovertebralis arthrosis instability may progress over time, especially if the C1—C2 region is stabilised surgically Fig. Osseous changes erosions, etc.
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Additionally, MRI visualises soft tissue structures pannus; spinal cord, etc. CT demonstrates erosion not only at the base of the dens, but also at the tip and at the atlanto-axial and atlanto-occipital joints, which are difficult to visualise by radiography.
The costovertebral joint is found in the thoracic region of the spine. These joints are made by the connection of the head of the rib to the vertebral column. The head of the rib will align with its corresponding vertebrae and the inferior portion of the vertebrae above. Surrounding the joint are ligaments which include: · The Intra-articular ligament - which attaches to the intervertebral disc to the ridge between the 2 facets of the head of the rib.
The post-contrast T1FS images confirm the presence of vascularised enhancing pannus around the dens white arrows and demonstrate improved anatomical delineation compared with the STIR image. There is no sign of spinal cord compression Full size image Fig. MRI in a year-old woman with peripheral erosive RA and neck pain, but normal cervical radiography.
Though this was a giant leap forward there was still a spatial limitation because of the SPECT component of the fused imaging. This limitation was considered fundamental as nuclear medicine is based on a low energy gamma wave.
There is also a subchondral enhancing area in the axis black arrow costovertebralis arthrosis with a pre-erosive lesion Full size image A diagnostic strategy according to Younes et al. 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 subaxial stenosis [ 23 ].
- The ribs articulate with the thoracic vertebrae via two distinctly different joints: costovertebral joint - articulation between the head of the rib and the vertebral body costotransverse joint - articulation between the rib's tubercle and the transverse process of the vertebra Costovertebral Joint The head of a typical rib has two facets separated by a ridge.
Visualisation of the spinal cord is especially important to detect cord injury or risk of injury. According to Younes et al. It should at least include open-mouth and lateral views in neutral and flexed positions.
MRI is indicated in patients with neurological deficit, radiographic instability, atlanto-axial impaction and subaxial stenosis. CT may add information in rotatory and lateral subluxation because of the possibility of secondary reconstruction in arbitrary planes and a clear visualisation of the atlanto-occipital joints [ 6 ] Full size image Seronegative spondyloarthritides According to European classification criteria [ 89 ], SpA is divided into: 1 ankylosing spondylitis AS2 psoriatic arthritis, costovertebralis arthrosis reactive arthritis, 4 arthritis associated with inflammatory bowel disorders enteropathic arthritis and 5 undifferentiated SpA.
Inflammatory changes at the sacroiliac joints always occur in AS and are costovertebralis arthrosis of most other forms of SpA. Spinal changes are also a feature of SpA, especially in the late stages of AS. Ankylosing spondylitis 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 [ 10 ].
AS often starts in early adulthood and has a chronic progressive course. It egyszerű osteochondrosis therefore important to diagnose this disorder. 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.
These changes are caused by inflammation at the insertion of the annulus fibrosus enthesitis at costovertebralis arthrosis corners provoking reactive bone formation [ 12 ].
Later on slim ossifications appear in the annulus fibrosus syndesmophytes Fig. With disease progression the spine gradually fuses because of syndesmophytes crossing the intervertebral spaces in addition to fusion of apophyseal joints, resulting in complete spinal fusion bamboo spine; Fig.
In advanced disease the supra- and interspinous ligaments may ossify and be visible on frontal radiographs as a slim ossified streak Fig. When the ligamentous ossification occurs together with ossification of apophyseal joint capsules, there are three vertical radiodense lines on frontal radiography trolley-track sign. There are additional erosive changes black arrows, c not clearly delineated by radiography and slight oedema at the vertebral corners white arrows, costovertebralis arthrosis.
The interspinous ligaments are ossified, presenting as a slim ossified streak on the frontal radiograph dagger sign; arrows.
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MRI, sagittal T1-weighted images of c the cervico-thoracic and d lumbar region, respectively, shows a general narrowing of the intervertebral discs with costovertebralis arthrosis osseous fusion of the vertebral bodies, especially in the costovertebralis arthrosis region arrows.
Persistent movement at single intervertebral spaces may occur in an otherwise osteochondrosis felnőtteknél 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 [ 14 ]. The diagnosis of such changes may require a CT examination to obtain adequate visualisation Fig. There is surrounding osteophyte formation at this iv space arrows. Supplementary CT, c sagittal and d coronal 2D reconstruction, demonstrates lack of fusion of the vertebral bodies and apophyseal joints at this level arrows.
Fractures may occur after minor trauma because of the spinal stiffness and frequently accompanying osteoporosis. Fractures often occur at intervertebral spaces, but usually involve the ankylosed posterior structures and are thereby unstable Fig. Obvious fractures can be diagnosed by radiography, but fractures may be obscured. It is therefore mandatory to supplement a negative radiography with CT if fracture is suspected in the case of trauma history or a change in spinal symptoms.