Degenerative Arthritis
- Spinal Arthritis:
- Spondylosis aka Degenerative disease of the spine represents an evolution of changes affecting most mobile spinal segments beginning with:
- Intervertebral disc (IVD) dehydration (desiccation) and degeneration aka Degenerative Disc Disease (DDD) with an abnormal increase in mechanical stress and degeneration of posterior elements affecting 4-mobile synovial articulations ( true osteoarthritis)
- 2-Facets in the L/S & 2-Facets & 2-Uncovertebral joints in the C/S
- Imaging plays a significant role in the diagnosis, grading, and evaluation of neurological complications (e.g., spondylotic myelopathy/radiculopathy)
- X-radiography with AP, Lateral & Oblique spinal views provides Dx and classification of Spondylosis
- MR imaging may help to evaluate the degree of neurological changes associated with degenerative spinal canal and neural foraminal stenosis
- Spinal motion segment:
- 2-adjacent vertebrae
- IVD (fibrocartilage)
- 2-facets (synovial)
- Pathology: loss of disc height increases mechanical stress on mobile elements
- Ligamentous laxity/local instability
- Spinal osteophytes aka spondylophytes & bony facet/uncinate proliferation
- Disc herniation and often disc-osteophyte complex
- Ligamentum flavum “hypertrophy” or thickening due to buckling
- Loss of normal lordosis with or w/o reversal or kyphosis
- Vertebral canal & neural foraminal stenosis
Neutral lateral cervical radiograph: note mild to moderate disc narrowing and spondylophyte formation at C5-6 & C6-C7 (most common levels affected by cervical spondylosis). Straightening or flattening with mild reversal of cervical lordosis. Some mild facet proliferation is noted at the above levels
- On radiographs: evaluate for disc height (mild, moderate or severe) loss
- End-plate sclerosis & spondylophytes; mild, moderate or severe
- Facet and uncinate irregularity, hypertrophy/degeneration; mild, moderate or severe
- Note degenerative instability aka degenerative spondylolisthesis/retrolisthesis
- Normal or lost lordosis vs. degenerative kyphosis
- Key Dx: correlate with a clinical presentation: neck/back pain with or w/o neurological disturbance ( myelopathy vs. radiculopathy or both)
- Uncinate processes undergo degeneration/proliferation resulting in uncovertebral arthrosis
- Early findings present with mild bone proliferation along the cortical margin (white and black arrows) if compared to normal uncinate (orange arrow)
- Later, more extensive bone proliferation extending into and narrowing vertebral canal and neural osseous foramina (IVF’s) may be noted. The latter may contribute to spinal/IVF stenosis and potential neurological changes
- Posterior oblique views may help further
- AP lower cervical (a) and posterior oblique (b) views
- Note mild uncinated process proliferation with neural foraminal narrowing (arrows)
- Typically if less than a third of IVF becomes narrowed, patients may present w/o significant neurological signs
- Lumbar spondylosis is evaluated with AP and lateral views with additional AP L5-S1 spot view to examine lumbosacral junction
- Typical features include disc height loss/degeneration
- Intra-discal gas (vacuum) phenomenon (blue arrow) along with spondylophytes
- Degenerative spondylolisthesis and/or retrolisthesis (green arrow) may follow disc and facet degeneration and can be graded by the Meyerding classification
- In most cases, degenerative spondylolisthesis rarely progresses beyond Grade 2
- Lumbar facet degeneration seen as bone proliferation/sclerosis and IVF narrowing
- MR imaging w/o gad C is an effective modality to evaluate clinical signs of spondylosis & associated neurological complications with pre-surgical evaluation
- Case: 50-y.o Fe with neck pain. Case b-45-y.o.M (top a b images). MRI reveals: loss of disc hydration or desiccation, spondylophytes and disc herniation w/o neurological changes
- (Bottom images) Left: preoperative and right postoperative MRI slices of the patient presented with clinical signs of cervical spondylotic myelopathy. Note disc herniation, ligam flavum hypertrophy and canal stenosis (left)
- Sagittal MRI slice of lumbar DDD manifested with disc desiccation and posterior herniation effacing thecal sac
- Correlating sagittal and axial slices will be more informative to evaluate canal stenosis and potential degree of neurological involvement (above-bottom images)
- Use the following resources to learn more on MRI evaluation and diagnosis of Degenerative Disc Disease:
- https://radiopaedia.org/articles/intervertebral-disc-disease-nomenclature
- https://ac.els-cdn.com/S1529943014004094/1-s2.0-S1529943014004094-main.pdf?_tid=bab686bc-cf70-4479-a243-b6d2b342461c&acdnat=1535573367_98364d2d06b7c967d3e859e785eb6f13
Diffuse Idiopathic Skeletal Hyperostosis (DISH) aka Forestier disease
- Flowing degenerative ossification of ALL
- M/c Thoracic spine. 2nd m/c-cervical spine
- Dx by imaging only. X-radiography is sufficient
- CT w/o contrast helps with Dx of Fx
- Men>women. Pts>60-y.o. Extensive DISH shows 49% association with type 2DM
- Complications: Chalk (carrot) stick Fx. Unstable 3-column Fx requiring surgical fusion
- Sagittal reconstructed CT scan slice in bone window
- Chalk stick Fx at C5-C6 in the patient with DISH and OPLL
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