Name: El Paso Back Clinic | Spine Specialists - El Paso, TX
Price range: $$

Screening Tests

Back Clinic Screening Tests. Screening tests are typically the first assessment completed and are used to determine if further diagnostic testing might be needed. Because screening tests are the first step towards diagnosis, they are designed to be more likely to overestimate the true incidence of a disease. Designed to be different from diagnostic tests in that they might demonstrate more positive results than a diagnostic test.

This can lead to both true positives as well as false positives. Once a screening test is found to be positive, a diagnostic test is then completed to confirm the diagnosis. Next, we will discuss the assessment of diagnostic tests. Many screening tests are available for physicians and advanced chiropractic practitioners to utilize in their practice. For some tests, there is quite a bit of research demonstrating the benefit of such tests on early diagnosis and treatment. Dr. Alex Jimenez presents appropriate assessment and diagnostic tools used in the office to further clarify and appropriated diagnostic assessments.

Cervical Spine Radiographs in the Trauma Patient

by spinedoctors | Chiropractic, Chiropractic Examination, Chronic Pain, Neck Pain, Research Studies, Screening Tests, Spine Care, Treatments

While computed tomography scanning, or CT scans, of the cervical spine are frequently utilized to help diagnose neck injuries, simple radiographs are still commonly performed for patients who have experienced minor cervical spine injuries with moderate neck pain, such as those who have suffered a slip-and-fall accident. Imaging diagnostic assessments may reveal underlying injuries and/or aggravated conditions to be more severe than the nature of the trauma. The purpose of the article is to demonstrate the significance of cervical spine radiographs in the trauma patient.�

Abstract

Significant cervical spine injury is very unlikely in a case of trauma if the patient has normal mental status (including no drug or alcohol use) and no neck pain, no tenderness on neck palpation, no neurologic signs or symptoms referable to the neck (such as numbness or weakness in the extremities), no other distracting injury and no history of loss of consciousness. Views required to radiographically exclude a cervical spine fracture include a posteroanterior view, a lateral view and an odontoid view. The lateral view must include all seven cervical vertebrae as well as the C7-T1 interspace, allowing visualization of the alignment of C7 and T1. The most common reason for a missed cervical spine injury is a cervical spine radiographic series that is technically inadequate. The �SCIWORA� syndrome (spinal cord injury without radiographic abnormality) is common in children. Once an injury to the spinal cord is diagnosed, methylprednisolone should be administered as soon as possible in an attempt to limit neurologic injury.

Radiographs continue to be used as a first-line imaging diagnostic assessment modality in the evaluation of patients with suspected cervical spine injuries. The aim of cervical spine radiographs is to confirm the presence of a health issue in the complex structures of the neck and define its extent, particularly with respect to instability. Multiple views may generally be necessary to provide optimal visualization.

Dr. Alex Jimenez D.C., C.C.S.T.

Introduction

Although cervical spine radiographs are almost routine in many emergency departments, not all trauma patients with a significant injury must have radiographs, even if they arrive at the emergency department on a backboard and wearing a cervical collar. This article reviews the proper use of cervical spine radiographs in the trauma patient.

Low-risk criteria have been defined that can be used to exclude cervical spine fractures, based on the patient’s history and physical examination.1�6 Patients who meet these criteria (Table 1) do not require radiographs to rule out cervical fractures. However, the criteria apply only to adults and to patients without mental status changes, including drug or alcohol intoxication. Although studies suggest that these criteria may also be used in the management of verbal children,7�9 caution is in order, since the study series are small, and the ability of children to complain about pain or sensory changes is variable. An 18-year-old patient can give a more reliable history than a five-year-old child.

Some concern has been expressed about case reports suggesting that �occult� cervical spine fractures will be missed if asymptomatic trauma patients do not undergo radiography of the cervical spine.10 On review, however, most of the reported cases did not meet the low-risk criteria in Table 1. Attention to these criteria can substantially reduce the use of cervical spine radiographs.

Cervical Spine Series and Computed Tomography

Once the decision is made to proceed with a radiographic evaluation, the proper views must be obtained. The single portable cross-table lateral radiograph, which is sometimes obtained in the trauma room, should be abandoned. This view is insufficient to exclude a cervical spine fracture and frequently must be repeated in the radiographic department.11,12 The patient’s neck should remain immobilized until a full cervical spine series can be obtained in the radiographic department. Initial films may be taken through the cervical collar, which is generally radiolucent. An adequate cervical spine series includes three views: a true lateral view, which must include all seven cervical vertebrae as well as the C7-T1 junction, an anteroposterior view and an open-mouth odontoid view.13

If no arm injury is present, traction on the arms may facilitate visualization of all seven cervical vertebrae on the lateral film. If all seven vertebrae and the C7-T1 junction are not visible, a swimmer’s view, taken with one arm extended over the head, may allow adequate visualization of the cervical spine. Any film series that does not include these three views and that does not visualize all seven cervical vertebrae and the junction of C7-T1 is inadequate. The patient should be maintained in cervical immobilization, and plain films should be repeated or computed tomographic (CT) scans obtained until all vertebrae are clearly visible. The importance of obtaining all of these views and visualizing all of the vertebrae cannot be overemphasized. While some missed cervical fractures, subluxations and dislocations are the result of film misinterpretation, the most frequent cause of overlooked injury is an inadequate film series.14,15

In addition to the views listed above, some authors suggest adding two lateral oblique views.16,17 Others would obtain these views only if there is a question of a fracture on the other three films or if the films are inadequate because the cervicothoracic junction is not visualized.18 The decision to take oblique views is best made by the clinician and the radiologist who will be reviewing the films.

Besides identifying fractures, plain radiographs can also be useful in identifying ligamentous injuries. These injuries frequently present as a malalignment of the cervical vertebrae on lateral views. Unfortunately, not all ligamentous injuries are obvious. If there is a question of ligamentous injury (focal neck pain and minimal malalignment of the lateral cervical x-ray [meeting the criteria in Table 2]) and the cervical films show no evidence of instability or fracture, flexion-extension views should be obtained.17,19 These radiographs should only be obtained in conscious patients who are able to cooperate. Only active motion should be allowed, with the patient limiting the motion of the neck based on the occurrence of pain. Under no circumstance should cervical spine flexion and extension be forced, since force may result in cord injury.

Although they may be considered adequate to rule out a fracture, cervical spine radiographs have limitations. Up to 20 percent11,20,21 of fractures are missed on plain radiographs. If there is any question of an abnormality on the plain radiograph or if the patient has neck pain that seems to be disproportionate to the findings on plain films, a CT scan of the area in question should be obtained. The CT is excellent for identifying fractures, but its ability to show ligamentous injuries is limited.22 Occasionally, plain film tomography may be in order if there is a concern about a type II dens fracture (Figure 1).

While some studies have used magnetic resonance imaging (MRI) as an adjunct to plain films and CT scanning,23,24 the lack of wide availability and the relatively prolonged time required for MRI scanning limits its usefulness in the acute setting. Another constraint is that resuscitation equipment with metal parts may not be able to function properly within the magnetic field generated by the MRI.

Cervical Spine Radiography

Figure 2 summarizes the approach to reading cervical spine radiographs.

Lateral View

Alignment of the vertebrae on the lateral film is the first aspect to note (Figure 3). The anterior margin of the vertebral bodies, the posterior margin of the vertebral bodies, the spinolaminar line and the tips of the spinous processes (C2-C7) should all be aligned. Any malalignment (Figures 4 and 5) should be considered evidence of ligamentous injury or occult fracture, and cervical spine immobilization should be maintained until a definitive diagnosis is made.

Confusion can sometimes result from pseudosubluxation, a physiologic misalignment that is due to ligamentous laxity, which can occur at the C2-C3 level and, less commonly, at the C3-C4 level. While pseudosubluxation usually occurs in children, it also may occur in adults. If the degree of subluxation is within the normal limits listed in Table 2 and the neck is not tender at that level, flexion-extension views may clarify the situation. Pseudosubluxation should disappear with an extension view. However, flexion-extension views should not be obtained until the entire cervical spine is otherwise cleared radiographically.

After ensuring that the alignment is correct, the spinous processes are examined to be sure that there is no widening of the space between them. If widening is present, a ligamentous injury or fracture should be considered. In addition, if angulation is more than 11 degrees at any level of the cervical spine, a ligamentous injury or fracture should be assumed. The spinal canal (Figure 2) should be more than 13 mm wide on the lateral view. Anything less than this suggests that spinal cord compromise may be impending.

Next, the predental space�the space between the odontoid process and the anterior portion of the ring of C1 (Figure 2)�is examined. This space should be less than 3 mm in adults and less than 4 mm in children (Table 2). An increase in this space is presumptive evidence of a fracture of C1 or of the odontoid process, although it may also represent ligamentous injury at this level. If a fracture is not found on plain radiographs, a CT scan should be obtained for further investigation. The bony structures of the neck should be examined, with particular attention to the vertebral bodies and spinous processes.

The retropharyngeal space (Figure 2) is now examined. The classic advice is that an enlarged retropharyngeal space (Table 2) indicates a spinous fracture. However, the normal and abnormal ranges overlap significantly.25 Retropharyngeal soft tissue swelling (more than 6 mm at C2, more than 22 mm at C6) is highly specific for a fracture but is not very sensitive.26 Soft tissue swelling in symptomatic patients should be considered an indication for further radiographic evaluation. Finally, the craniocervical relationship is checked.

Odontoid View

The dens is next examined for fractures. Artifacts may give the appearance of a fracture (either longitudinal or horizontal) through the dens. These artifacts are often radiographic lines caused by the teeth overlying the dens. However, fractures of the dens are unlikely to be longitudinally oriented. If there is any question of a fracture, the view should be repeated to try to get the teeth out of the field. If it is not possible to exclude a fracture of the dens, thin-section CT scans or plain film tomography is indicated.

Next, the lateral aspects of C1 are examined. These aspects should be symmetric, with an equal amount of space on each side of the dens. Any asymmetry is suggestive of a fracture. Finally, the lateral aspects of C1 should line up with the lateral aspects of C2. If they do not line up, there may be a fracture of C1. Figure 6 demonstrates asymmetry in the space between the dens and C1, as well as displacement of the lateral aspects of C1 laterally.

Anteroposterior View

The height of the cervical spines should be approximately equal on the anteroposterior view. The spinous processes should be in midline and in good alignment. If one of the spinous processes is off to one side, a facet dislocation may be present.

Common Cervical Abnormalities

The most common types of cervical abnormalities and their radiographic findings are listed in Table 3. Except for the clay shoveler’s fracture, they should be assumed to be unstable and warrant continued immobilization until definitive therapy can be arranged. Any patient found to have one spinal fracture should have an entire spine series, including views of the cervical spine, the thoracic spine and the lumbosacral spine. The incidence of noncontiguous spine fractures ranges up to 17 percent.27,28 Figures 7 through 9 demonstrate aspects of common cervical spine fractures.

Initial Treatment of Cervical Spine and Cord

If a cervical fracture or dislocation is found, orthopedic or neurosurgical consultation should be obtained immediately. Any patient with a spinal cord injury should begin therapy with methylprednisolone within the first eight hours after the injury, with continued administration for up to 24 hours. Patients should receive methylprednisolone in a dosage of 30 mg per kg given intravenously over one hour. Over the next 23 hours, intravenous methylprednisolone in a dosage of 5.4 mg per kg per hour should be administered. This therapy has been shown to improve outcomes and minimize cord injury,29 although it is not without its problems. The incidence of pneumonia is increased in patients treated with high dosages of methylprednisolone.30

�Sciwora� Syndrome: Unique in Children

A special situation involving children deserves mention. In children, it is not uncommon for a spinal cord injury to show no radiographic abnormalities. This situation has been named �SCIWORA� (spinal cord injury without radiographic abnormality) syndrome. SCIWORA syndrome occurs when the elastic ligaments of a child’s neck stretch during trauma. As a result, the spinal cord also undergoes stretching, leading to neuronal injury or, in some cases, complete severing of the cord.31 This situation may account for up to 70 percent of spinal cord injuries in children and is most common in children younger than eight years. Paralysis may be present on the patient’s arrival in the emergency department. However, up to 30 percent of patients have a delayed onset of neurologic abnormalities, which may not occur until up to four or five days after the injury. In patients with delayed symptoms, many have neurologic symptoms at the time of the injury, such as paresthesias or weakness, that have subsequently resolved.32

It is important to inform the parents of young patients with neck trauma about this possibility so that they will be alert for any developing symptoms or signs. Fortunately, most children with SCIWORA syndrome have a complete recovery, especially if the onset is delayed.33 It is possible to evaluate these injuries with MRI, which will show the abnormality and help determine the prognosis: a patient with complete cord transection is unlikely to recover.3

The treatment of SCIWORA syndrome has not been well studied. However, the general consensus is that steroid therapy should be used.34 In addition, any child who has sustained a significant degree of trauma but has recovered completely should be restricted from physical activities for several weeks.34

Cervical spine radiographs include three standard views, such as the coned odontoid peg view, the anteroposterior view of the entire cervical spine, and the lateral view of the entire cervical spine. Most qualified and experienced healthcare professionals, including chiropractors, offer additional views to visualize the cervicothoracic junction as well as to evaluate the proper alignment of the spine in all patients.�

Dr. Alex Jimenez D.C., C.C.S.T.

About the Authors

MARK A. GRABER, M.D., is associate professor of clinical family medicine and surgery (emergency medicine) at the University of Iowa Hospitals and Clinics, Iowa City. He received his medical degree from Eastern Virginia Medical School, Norfolk, and served a residency in family medicine at the University of Iowa College of Medicine, Iowa City.

MARY KATHOL, M.D., is associate professor of radiology at the University of Iowa Hospitals and Clinics. She is also head of the musculoskeletal radiology section. She received her medical degree from the University of Kansas School of Medicine, Kansas City, Kan., and served a residency in radiology at the University of Iowa College of Medicine.

Address correspondence to Mark A. Graber, M.D., Department of Family Medicine, Steindler Bldg., University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242. Reprints are not available from the authors.

In conclusion,�it is essential to evaluate all views of the cervical spine through imaging diagnostic assessments. While cervical spine radiographs can reveal injuries and conditions, not all neck injuries are detected through radiography. Computed tomography, or CT, scans of the cervical spine are highly accurate in the diagnosis of neck fractures which can help with 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

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.

EXTRA EXTRA | IMPORTANT TOPIC: Chiropractic Neck Pain Treatment

Blank

References

1.�Kreipke DL, Gillespie KR, McCarthy MC, Mail JT, Lappas JC, Broadie TA. Reliability of indications for cervical spine films in trauma patients.�J Trauma. 1989;29:1438�9.

2.�Ringenberg BJ, Fisher AK, Urdaneta LF, Midthun MA. Rational ordering of cervical spine radiographs following trauma.�Ann Emerg Med. 1988;17:792�6.

3.�Bachulis BL, Long WB, Hynes GD, Johnson MC. Clinical indications for cervical spine radiographs in the traumatized patient.�Am J Surg. 1987;153:473�8.

4.�Hoffman JR, Schriger DL, Mower W, Luo JS, Zucker M. Low-risk criteria for cervical-spine radiography in blunt trauma: a prospective study.�Ann Emerg Med. 1992;21:1454�60.

5.�Saddison D, Vanek VW, Racanelli JL. Clinical indications for cervical spine radiographs in alert trauma patients.�Am Surg. 1991;57:366�9.

6.�Kathol MH, El-Khoury GY. Diagnostic imaging of cervical spine injuries.�Seminars in Spine Surgery. 1996;8(1):2�18.

7.�Lally KP, Senac M, Hardin WD Jr, Haftel A, Kaehler M, Mahour GH. Utility of the cervical spine radiograph in pediatric trauma.�Am J Surg. 1989;158:540�1.

8.�Rachesky I, Boyce WT, Duncan B, Bjelland J, Sibley B. Clinical prediction of cervical spine injuries in children. Radiographic abnormalities.�Am J Dis Child. 1987;141:199�201.

9.�Laham JL, Cotcamp DH, Gibbons PA, Kahana MD, Crone KR. Isolated head injuries versus multiple trauma in pediatric patients: do the same indications for cervical spine evaluation apply?�Pediatr Neurosurg. 1994;21:221�6.

10.�McKee TR, Tinkoff G, Rhodes M. Asymptomatic occult cervical spine fracture: case report and review of the literature.�J Trauma. 1990;30:623�6.

11.�Woodring JH, Lee C. Limitations of cervical radiography in the evaluation of acute cervical trauma.�J Trauma. 1993;34:32�9.

12.�Spain DA, Trooskin SZ, Flancbaum L, Boyarsky AH, Nosher JL. The adequacy and cost effectiveness of routine resuscitation-area cervical-spine radiographs.�Ann Emerg Med. 1990;19:276�8.

13.�Tintinalli JE, Ruiz E, Krome RL, ed. Emergency medicine: a comprehensive study guide. 4th ed. New York: McGraw-Hill, 1996.

14.�Gerrelts BD, Petersen EU, Mabry J, Petersen SR. Delayed diagnosis of cervical spine injuries.�J Trauma. 1991;31:1622�6.

15.�Davis JW, Phreaner DL, Hoyt DB, Mackersie RC. The etiology of missed cervical spine injuries.�J Trauma. 1993;34:342�6.

16.�Apple JS, Kirks DR, Merten DF, Martinez S. Cervical spine fractures and dislocations in children.�Pediatr Radiol. 1987;17:45�9.

17.�Turetsky DB, Vines FS, Clayman DA, Northup HM. Technique and use of supine oblique views in acute cervical spine trauma.�Ann Emerg Med. 1993;22:685�9.

18.�Freemyer B, Knopp R, Piche J, Wales L, Williams J. Comparison of five-view and three-view cervical spine series in the evaluation of patients with cervical trauma.�Ann Emerg Med. 1989;18:818�21.

19.�Lewis LM, Docherty M, Ruoff BE, Fortney JP, Keltner RA Jr, Britton P. Flexion-extension views in the evaluation of cervical-spine injuries.�Ann Emerg Med. 1991;20:117�21.

20.�Mace SE. Emergency evaluation of cervical spine injuries: CT versus plain radiographs.�Ann Emerg Med. 1985;14:973�5.

21.�Kirshenbaum KJ, Nadimpalli SR, Fantus R, Cavallino RP. Unsuspected upper cervical spine fractures associated with significant head trauma: role of CT.�J Emerg Med. 1990;8:183�98.

22.�Woodring JH, Lee C. The role and limitations of computed tomographic scanning in the evaluation of cervical trauma.�J Trauma. 1992;33:698�708.

23.�Schaefer DM, Flanders A, Northrup BE, Doan HT, Osterholm JL. Magnetic resonance imaging of acute cervical spine trauma. Correlation with severity of neurologic injury.�Spine. 1989;14:1090�5.

24.�Levitt MA, Flanders AE. Diagnostic capabilities of magnetic resonance imaging and computed tomography in acute cervical spinal column injury.�Am J Emerg Med. 1991;9:131�5.

25.�Templeton PA, Young JW, Mirvis SE, Buddemeyer EU. The value of retropharyngeal soft tissue measurements in trauma of the adult cervical spine. Cervical spine soft tissue measurements.�Skeletal Radiol. 1987;16:98�104.

26.�DeBehnke DJ, Havel CJ. Utility of prevertebral soft tissue measurements in identifying patients with cervical spine fractures.�Ann Emerg Med. 1994;24:1119�24.

27.�Powell JN, Waddell JP, Tucker WS, Transfeldt EE. Multiple-level noncontiguous spinal fractures.�J Trauma. 1989;29:1146�50.

28.�Keenen TL, Antony J, Benson DR. Non-contiguous spinal fractures.�J Trauma. 1990;30:489�91.

29.�Bracken MB, Shepard MJ, Collins WF Jr, Holford TR, Baskin DS, Eisenberg HM, et al. Methylprednisolone or naloxone treatment after acute spinal cord injury: 1-year follow-up data. Results of the second National Acute Spinal Cord Injury Study.�J Neurosurg. 1992;76:23�31.

30.�Galandiuk S, Raque G, Appel S, Polk HC Jr. The two-edged sword of large-dose steroids for spinal cord trauma.�Ann Surg. 1993;218:419�25.

31.�Grabb PA, Pang D. Magnetic resonance imaging in the evaluation of spinal cord injury without radiographic abnormality in children.�Neurosurgery. 1994;35:406�14.

32.�Pang D, Pollack IF. Spinal cord injury without radiographic abnormality in children�the SCIWORA syndrome.�J Trauma. 1989;29:654�64.

33.�Hadley MN, Zabramski JM, Browner CM, Rekate H, Sonntag VK. Pediatric spinal trauma. Review of 122 cases of spinal cord and vertebral column injuries.�J Neurosurg. 1988;68:18�24.

34.�Kriss VM, Kriss TC. SCIWORA (spinal cord injury without radiographic abnormality) in infants and children.�Clin Pediatr. 1996;35:119�24.

The editors of AFP welcome the submission of manuscripts for the Radiologic Decision-Making series. Send submissions to Jay Siwek, M.D., following the guidelines provided in �Information for Authors.�

Coordinators of this series are Thomas J. Barloon, M.D., associate professor of radiology and George R. Bergus, M.D., assistant professor of family practice, both at the University of Iowa College of Medicine, Iowa City.

Close Accordion

Imaging the Spine in Arthritis: a Pictorial Review

by spinedoctors | Arthritis, Arthropathies, Back Pain, Chiropractic, Chiropractic Examination, Chronic Back Pain, Chronic Pain, Lower Back Pain, Neck Pain, Research Studies, Screening Tests, Spine Care, Treatments

Many types of arthritis can affect the structure and function of the muscles, bones and/or joints, causing symptoms such as, pain, stiffness and swelling. While arthritis can commonly affect the hands, wrists, elbows, hips, knees and feet, it can also affect the facet joints found along the length of the spine. One of the most well-known types of arthritis, known as rheumatoid arthritis or RA, is a chronic inflammatory disease of the joints which occurs when the human body’s own immune system attacks the synovium, the thin membrane that lines the joints. According to the article below, imaging the spine in arthritis is fundamental towards its proper treatment.

Abstract

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�fracture.

Keywords:�Spine,�Arthritis, Rheumatoid Arthritis, Spondyloarthropathies

Introduction

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.

�

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 [2, 3].

Fig. 2 Lateral and rotatory atlanto-axial subluxation. AP open- mouth view in a 53-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.

Radiography of the cervical spine is mandatory in RA patients with neck pain [3]. 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 atlanto-axial subluxation possibly limited by pannus tissue between the anterior arc of the atlas and dens.

Anterior atlanto-axial subluxation is the most frequent form of RA instability in the occipito-atlanto-axial region, but lateral, rotatory and vertical subluxation can also occur. The definition of the different forms of instability by radiography is as follows [3].

Anterior atlanto-axial subluxation. Distance between the posterior aspect of the anterior arc of the atlas and the anterior aspect of the dens exceeding 3 mm in a neutral position and/or during flexion (Fig. 1). It may cause stenosis of the atlanto-axial canal presenting as a posterior atlanto-dental interval<14 mm (Fig. 1).

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 seen, but may coexist with fracture of the dens.

Vertical atlanto-axial subluxation is also referred to as atlanto-axial impaction, basilar invagination or cranial�setting, and is defined as migration of the odontoid tip proximal to McRae�s line corresponding to the occipital foramen. This line can be difficult to define on radiographs, and vertical subluxation has therefore also been defined by several other methods. Migration of the tip of the odontoid process >4.5 mm above McGregor�s line (between the postero-superior aspect of the hard palate and the most caudal point of the occipital curve) indicates vertical subluxation (Fig. 3).

Fig. 3 Vertical atlanto-axial subluxation, measurement methods. (a) Lateral normal radiograph in neutral position showing the location of McGregor�s line (black) between the postero-superior aspect of the hard palate and the most caudal point of the occipital curve. Migration of the tip of the dens >4.5 mm above McGregor�s line indicates vertical subluxation. The distance indicated by the white line between McGregor�s line and the midpoint of the inferior margin of the body of axis is used to evaluate vertical subluxation according to Redlund-Johnell and Pettersson�s method. A distance less than 34 mm in men and 29 mm in women indicates vertical subluxation. (b) Sagittal CT�reconstruction of a normal cervical spine showing the location of McRae�s line corresponding to the occipital foramen and the division of the axis into three equal portions used by Clark�s method for diagnosing vertical subluxation. If the anterior arc of the atlas is in level with the middle or caudal third of the axis there is slight and pronounced vertical subluxation, respectively. (c) Ranawat�s method includes determination of the distance between the centre of the second cervical pedicle and the transverse axis of the atlas. A distance less than 15 mm in males and 13 mm in females indicates vertical subluxation [4].

Fig. 4 Vertical subluxation. (a) Lateral radiograph with McGregor�s line (black line; 61-year-old man with RA). The tip of the dens is difficult to define, but measurement according to Redlund-Johnell�s method (white line) results in a distance of 27 mm, which is below the normal limit. In accordance with this, the anterior arc of the atlas is level with the middle third of the axis. (b) Ranawat�s method, the distance between the centre of the second cervical pedicle and the transverse axis of the atlas is below the normal limit (9 mm). Thus, all measurements indicate vertical subluxation. Supplementary MRI, (c) sagittal 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 the 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.

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 McGregor�s line and the midpoint of the inferior margin of the body of the axis on a lateral radiograph in a neutral position (Fig. 3) [4]. Visualisation of the palate may not always be obtained. Methods without dens and/or the palate as landmarks have therefore been introduced [4]. The method described by Clark et al. (described in [4]) includes assessment of the location of the atlas by dividing the axis into three equal portions on a lateral radiograph. Location of the anterior arc of the atlas in level with the middle or caudal third of the axis indicates vertical subluxation (Fig. 3). Ranawat et al. have proposed using the distance between the centre of the second cervical pedicle and the�transverse axis of the atlas at the odontoid process (Fig. 3) [4]. To obtain the diagnosis of vertical subluxation 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 visualize the spinal cord (Fig. 4). Using this combination of methods vertical subluxation will be missed in only 6% of patients [4]. 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. Risk of cord compression/injury occurs, especially in patients with flexion instability accompanied by erosive changes in the atlanto- axial and/or atlanto-occipital joints, causing the vertical subluxation with protrusion of the dens into the occipital foramen (Figs. 4, 5).

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 C3�4 and C4�5 level, but multiple levels may be involved, producing a typical �stepladder� appearance on lateral radiographs. The condition is serious if the subaxial sagittal spinal canal diameter is <14 mm, implying a possibility of spinal cord compression [2]. The instability may progress over time, especially if the C1�C2 region is stabilized surgically (Fig. 6) [5].

Fig. 5 Vertical subluxation with spinal cord compression. MRI of the cervical spine in a 69- year-old woman with advanced peripheral RA, neck pain and clinical signs of myelopathy. (a) Sagittal STIR, (b) sagittal T1 and (c) axial T2 fat-saturated (FS) images show erosion of the dens and protrusion of the tip into the occipital foramen causing compression of the spinal cord, which exhibits irregular signal intensity (white arrows). The osseous spinal canal has a width of approximately 7 mm (black line). There is heterogeneous signal intensity pannus surrounding the dens compatible with a mixture of fibrotic and oedematous pannus tissue (black arrows) in the widened space between the dens and the anterior arc of the atlas.

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 overprojecting structures and can improve the detection of RA changes. Osseous changes (erosions, etc.) can be clearly delineated by CT [6]. Additionally, MRI visualizes soft tissue structures (pannus; spinal cord, etc.), signs of disease activity and sequelae of inflammation in the form of fibrous pannus. These advantages of CT and MRI in patients with atlanto-axial involvement are illustrated in Figs. 7 and 8, including the possibility of detecting signs of arthritis by MRI before the occurrence of erosive changes (Fig. 8) [3].

Fig. 6 Subaxial instability. (a) Flexion view in a 64-year-old woman with advanced peripheral RA showing anterior atlanto-axial instability as well as subaxial instability at multiple levels. (b) Flexion view 2 years later after surgical stabilization of the atlanto-axial region demonstrates progression of the subaxial instability, especially between C3 and C4 (white arrow). There is a characteristic �stepladder� appearance, which also occurred on the initial radio- graphs (a), but is less pronounced.

Fig. 7 Advantages of CT and MRI. (a) Supplementary CT and (b-f) MRI of the patient shown in Fig. 1. 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 visualize by radiography. MRI, (b) sagittal STIR and (c) sagittal T1 of the entire cervical spine and post-contrast T1FS images of the atlanto-axial region, (d) sagittal, (e) coronal and (f) axial. Oedematous voluminous pannus surrounding the dens is seen on the STIR and T1 images (black arrows) in addition to C4/5 and C5/6 disc degeneration with posterior protrusion of the disc at C4/5. The post-contrast T1FS images confirm the presence of vascularized 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.

Fig. 8 Non-radiographic MR findings. MRI in a 41-year-old woman with peripheral erosive RA and neck pain, but normal cervical radiography. (a) Post-contrast axial and (b) coronal TIFS images show signs of active arthritis with synovial contrast enhancement at the left atlanto-axial joint in addition to enhancing pannus tissue at the left side of the dens (white arrows). There is also a subchondral enhancing area in the axis (black arrow) compatible with a pre-erosive lesion.

A diagnostic strategy according to Younes et al. [3] 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 subaxial stenosis [2, 3]. Visualisation of the spinal cord is especially important to detect cord injury or risk of injury. MRI should therefore always be performed in RA patients with neck pain and/or neurological symptoms [3, 7].

�

Seronegative Spondyloarthritides

According to European classification criteria [8, 9], SpA is divided into: (1) ankylosing spondylitis (AS), (2) psoriatic arthritis, (3) 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 part 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 is therefore important to diagnose this disorder. According to the modified New York Criteria [11], the diagnosis of definite AS requires the following: manifest sacroiliitis by radiography (grade ?2 bilateral or unilateral grade 3�4 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 [12]. Later on slim ossifications appear in the annulus fibrosus (syndesmo- phytes) (Fig. 11) [13]. 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. 12). In advanced disease the supra- and interspinous ligaments may ossify and be visible on frontal radiographs as a slim ossified streak (Fig. 12). The occurrence of a single central radiodense streak has, the �dagger sign�. When the ligamentous ossification occurs together with ossification of apophyseal joint capsules, there are three vertical radiodense lines on frontal radiography (trolley-track sign).

Fig. 9 Diagnostic strategy. According to Younes et al. [3] radiography of the cervical spine is indicated in all RA patients with disease duration >2 years. It should at least include open-mouth and lateral views in neutral and flexed positions. Because of the occurrence of asymptomatic cervical involvement in 17% of RA patients, it is recommended to monitor patients with intervals of 2�5 years depending on positivity for the rheumatoid factor. 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].

Erosive changes within intervertebral spaces (Andersson lesions) have been detected by radiography in approximately 5% of patients with AS [14], but more frequently by MRI (Fig. 11) [15].

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 [14]. 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 spinal fracture. Non-fatal fractures have been reported to occur in up to 6% of AS patients, especially in patients with long disease duration [16]. 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. 14). Obvious fractures can visualize 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). The occurrence of cervico-thoracic fractures may cause spinal cord injury and be lethal even following minor trauma [17].

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, costo-vertebral and costo-transversal joints (Fig. 15). MRI can visualize signs of active inflammation in the form of bone marrow and soft tissue oedema and/or contrast enhancement. It has therefore gained a central role in the evaluation of disease activity [15]. MRI can, however, also detect sequelae of inflammation consisting of fatty deposition in the bone marrow and chronic structural changes such as erosion and fusion of vertebral bodies [15].

Characteristic MR findings early in the disease are activity changes mainly consisting of oedema at vertebral corners and/or costo-vertebral joints (Fig. 16) [13]. The inflammatory changes at vertebral corners are characteristic of AS. Based on the occurrence of severe or multiple (?3) lesions in young patients, AS changes can be distinguished from degenerative changes with a high reliability [18].

Fig. 10 Relatively early changes in ankylosing spondylitis (AS). (a) AP radiograph of the sacroiliac joints in a 28-year-old man presenting with typical definite bilateral AS sacroiliitis (grade 3) in the form of bilateral joint erosion accompanied by subchondral sclerosis. (b) Initial spinal changes consisting of erosion of vertebral corners (Romanus lesion) with vertebral squaring corresponding to Th11, Th12, L4 and L5 accompanied by condensation of the vertebral corners�shiny corners (arrows).

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 [19]. The inflammation at vertebral corners is the most valid feature and has been observed related to the development of syndesmophytes by radiography [12], 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 [15]. Erosions are more frequently detected by MRI than by radiography (Fig. 11) [15] 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 (anti-tumour necrosis factor) therapy [21, 22]. Several studies have shown that MR changes are frequent in the thoracic spine (Fig. 16) [15, 23]. It is therefore important to examine the entire spine using sagittal STIR or T2 fat-saturated (FS) and T1-weighted sequences. Supplementary axial slices can be necessary for visualising involvement of apophyseal, costo-vertebral and costo-transversal joints (Fig. 16) [24, 25]. Post-contrast T1FS sequences can sometimes be advantageous as they provide better anatomical delineation [26]. Additionally, dynamic contrast-enhanced MRI may be superior to static MRI in monitoring disease activity during anti-TNF therapy [27]. Whole-body MRI gives the possibility of detecting involvement in other areas without losing important information about spinal and sacroiliac joint involvement [28, 29].

Other Forms of SpA

Radiographic changes in reactive and psoriatic arthritis are often characterized by voluminous non-marginal syndesmophytes (parasyndesmophytes) or coalescing ossification of the paravertebral ligaments in addition to asymmetrical sacroiliitis (Fig. 18) [30].

Reactive arthritis is self-limiting in most patients. However, in patients with chronic reactive arthritis and HLA B27 the axial changes may progress to changes somewhat similar to those seen in AS and can then be regarded as AS elicited by infection [10].

Fig. 11 Syndesmophytes and erosions in AS. (a) Lateral radiograph in a 29-year-old man with the characteristic slim ossification (syndesmophytes) at the periphery of the annulus fibrosus (black arrows) in addition to erosion of the endplates at the intervertebral (iv) space between L3 and L4 (white arrow). Supplementary MRI, (b) sagittal STIR and (c) T1-weighted images show small oedematous areas in the�erosion at iv L3/4 on the STIR image and surrounding fatty marrow deposition on T1 as a sign of previous osseous inflammation. There are additional erosive changes (black arrows, c) not clearly delineated by radiography and slight oedema at the vertebral corners (white arrows, b). Note that the syndesmophytes demonstrated by radiogra- phy are not visible on MRI.

Fig. 12 Advanced AS. (a) AP and (b) lateral radiograph in a 55-year-old man showing vertebral fusion due to syndesmophytes crossing the intervertebral spaces in addition to fusion of the apophyseal joints (bamboo spine). The interspinous ligaments are ossified, presenting as a slim ossified streak on the frontal radiograph (dagger sign; arrows). MRI, sagittal T1- weighted images of (c) the cervico-thoracic and (d) lumbar region, respectively, shows a general narrowing of the intervertebral discs with partial osseous fusion of the vertebral bodies, especially in the lumbar region (arrows). In addition a characteristic AS deformity with reduced lumbar lordosis and thoracic kyphosis.

Fig. 13 Pseudo-arthrosis-like changes in AS. (a) AP and (b) lateral radiograph showing vertebral fusion except at iv Th10/11. 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). (e) 3D reconstruction clearly demonstrates the exuberant surrounding reactive osteophytes.

Fig. 14�Spinal fracture in AS. (a) AP and (b) lateral radiograph of the thoracic spine in a 64-year-old man with advanced AS and increasing back pain over 4 weeks. The lateral view demonstrates a slight malalignment at the anterior aspects of the vertebral bodies of Th9 and Th10, and the iv is irregularly narrowed on the AP view, all�suggesting fracture (arrows). CT, (c) sagittal and (d) coronal reconstruction, shows fracture through the iv space and the posterior structures (arrows). There is widening of the intervertebral space anteriorly in the supine position used for CT compared with the upright position used during radiography.

Axial psoriatic arthritis (PsA) occurs in approximately 50% of patients with peripheral PsA [31]. It differs radiographically from AS by the voluminous paravertebral ossifications and the occurrence of spinal changes without concomitant sacroiliitis in 10% of patients [32]. Axial PsA may be clinically silent [33], and involvement of the cervical spine is frequent (atlanto-axial or apophyseal joint changes). The cervical recognize may include atlanto-axial instability as seen in RA (Fig. 19), but the pathogenesis and thereby imaging findings are different. In PsA radiography and CT usually visualize new bone formation in the region of the dens. This is elicited by osseous inflammation (osteitis) and/or inflammation at ligament/ tendon attachments (enthesitis) detectable by MRI (Fig. 19). Osteitis is often a feature of spinal PsA and can occur together with paravertebral ossification/para- syndesmophytes and erosion of vertebral plates (Fig. 20). , and illustrated MR findings in PsA are based on personal observations and seem to reflect the radiographic changes encompassing a mixture of osteitis, enthesitis and erosion. Unfortunately, there is a lack of�systematic description of spinal changes in PsA by MRI. Some of the patients described under the term SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome may have PsA. SAPHO is a collective term often used for inflammatory disorders primarily presenting with osseous hyperostosis and sclerosis, and they are frequently associated with skin disorders. The most commonly affected site in SAPHO is the anterior chest followed by the spine [34]. The PsA changes shown in Fig. 20 are characterized by hyperostosis and sclerosis, both main features of SAPHO. However, this patient did not have anterior chest involvement.

Fig. 15 CT detection of costo-vertebral changes in AS. Axial CT slices showing erosive changes (a) and ankylosis of costo-vertebral joints (b), respectively (arrows).

Fig. 16 Activity changes in AS by MRI. Sagittal STIR of (a) the cervico-thoracic and (b) the lumbar spine of the patients shown in Fig. 10 obtained 3 years before the radiography. There are multiple high signal intensity areas corresponding to vertebral corners (white arrows). Additionally, osseous oedema of the costo-vertebral joints (a, black arrows) seen on the lateral sagittal slice of the thoracic spine. (c) Axial post-contrast T1FS of an inflamed costo-vertebral joint confirmed the presence of joint inflammation in the form of osseous enhancement in both the vertebra and the rib (arrows) in addition to joint erosion. (d) Midline sagittal post-contrast T1FS shows an�enhancing syndesmophyte. (e) Inflammatory changes at the apophy- seal joint in a 27-year-old man; sagittal STIR image of the lumbar region showing subchondral osseous oedema in the lower thoracic region (white arrows), and both osseous and soft tissue oedema corresponding to the lumbar apophyseal joints (black arrows). Note that the osseous oedema in the pedicle of Th12 extends to the region of the costo-vertebral joint. (f) Coronal post-contrast T1FS of the lumbar spine shows additional enhancement corresponding to the interspinous ligament between L2 and L3 (arrows).

Fig. 17 Chronic changes in AS by MRI. Sagittal T1 (a) the cervico-thoracic and (b) the lumbar spine of the patients shown in Fig. 10. There are multiple fatty marrow depositions at vertebral corners and also posteriorly in thoracic vertebral bodies (b, arrows). This was observed to have developed since the MRI performed 3 years previously (shown in Fig. 16 a-d) and corresponds to areas of previous inflammation.

In patients with enteropathic arthritis associated with Crohn�s 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).

Fig. 18 Psoriatic arthritis (PsA), paravertebral ossifications. (a) AP and (b) lateral radiograph of the lumbar spine in a 48-year-old man with PsA showing voluminous paravertebral new bone forma- tion (arrows) in addition to fusion of the second and third vertebral bodies. There was no concomitant sacroiliitis. (c) AP radiograph of the thoraco- lumbar junction in a female patient with axial PsA demon- strating coalescing paravertebral ossifications (arrows).

Fig. 19 Cervical PsA. (a) Lateral radiographs in the neutral position and (b) during flexion in a 61-year-old woman show atlanto-axial instability with a 4-mm distance between the anterior arc and the dens (white line). Additionally, ankylosis of the apophyseal joints (black arrows) and new bone formation anterior to the C4-7 vertebral bodies (white arrows). CT, (c) axial slice and coronal reconstruction of the dens area, demonstrates new bone formation in the atlanto-axial region (arrows); (d) coronal reconstruction of the lower cervical region shows voluminous new bone formation on the right side of the vertebral bodies (arrows). MRI, (e) sagittal STIR and (f) T1-weighted images, shows homogeneous osseous inflammation corresponding to the dens (arrows) with surrounding irregular oedema compatible with a mixture of osteitis and enthesitis. Note that the anterior new bone formation visualised by radiography is difficult to detect on MRI.

Fig. 20 Lumbar PsA. (a) AP and (b) lateral radiograph in a 50-year- old man show voluminous paravertebral ossifications anteriorly and at the right side of the third lumbar vertebra and adjacent iv spaces. MRI, (c) sagittal STIR, (d) T1 and (e) post-contrast T1-weighted images, demonstrates manifest osseous inflammation (osteitis) in the form of oedema and enhancement of the vertebral body, slight enhancement in the paravertebral new bone formation and erosion of the upper vertebral plate compatible with a mixture of osteitis, enthesitis and erosive changes.

Fig. 21 Enteropathic SpA. Sagittal STIR image of the lumbar spine in a 27-year-old man with ulcerative colitis demonstrates oedema corresponding to the interspinous ligaments (arrows) and spinous processes as signs of inflammation. There are only minimal activity changes corresponding to the vertebral bodies, located to the anterior vertebral corners.

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.

�

Conclusion

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 potential involvement of the spinal cord and nervous roots in addition to signs of disease activity and chronic changes such as fibrous pannus in RA and fatty marrow deposition, erosion and vertebral fusion in SpA. MRI is�therefore widely used to monitor inflammatory spinal diseases, especially during anti-TNF therapy.

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

Additional Topics: Acute Back Pain

�