Annals ofthe Rheumatic Diseases 1995; 54: 615-625 615

NOW AND THEN Ann Rheum Dis: first published as 10.1136/ard.54.8.615 on 1 August 1995. Downloaded from Commented glossary for rheumatic spinal diseases, based on pathologyf

Robert J Franqois, Frits Eulderink, Eric G L Bywaters

Abstract or the posterior facet joints' and in another3 as Objectives-To redefine and comment on 'dissolution of a vertebra' or as 'a condition terms on a pathological basis, in order to marked by platyspondylia, aplasia of the avoid the confusion due to the use ofterms posterior arch, and separation of the pars with different meanings, to standardise interarticularis'. Thus the simplest and most usage among clinicians, radiologists and common meaning, 'separation of the pars pathologists, and to facilitate literature interarticularis', is not given by either of these searches. two authoritative dictionaries. Methods-Within the Committee of The idea of standardising nomenclature in Pathology ofthe European League against this field arose in 1967, at the VIth European Rheumatism, a study group was set up to Congress of Rheumatology in Lisbon.4 It was analyse the medical literature and taken up again by the Committee on Pathology common practice concerning the nomen- of the European League against Rheumatism clature of rheumatic spinal diseases. The (EULAR): a subgroup was appointed to define group tried to amalgamate the main concepts, list synonyms, and recommend trends in the field, to reconcile etymology, preferred terms. After agreement was reached historical background, morphology, and on a number of items pertaining to the normal common practice. anatomy of the spine,5 a list of terms Results-The group warns against use of concerning pathological changes and diseases the terms 'acquired hyperostosis syn- is now proposed. drome', '(von) Bechterew's disease', The area of investigation is restricted to 'Kuimmel's disease', 'pseudospondylo- rheumatic diseases, excluding fractures, listhesis', 'rheumatoid spondylitis', tumours, and congenital pathology. As part of 'spondylarthropathy' in the sense ofspon- the Committee on Pathology, the working darthritis, and 'spondylosis'. It recom- group approached the problem from a

mends intercorporal or interapophyseal morphological point of view. The Canadian http://ard.bmj.com/ rather than intervertebral (osteo)chon- Vocabulary of signs and symptoms of the drosis, zygapophyseal diverticulum rather musculoskeletal system6 7 has a different and than cyst, disc hernia rather than broader scope. prolapse, spondyloarthritis rather than spondyloarthropathy, marginal rather than anterior spondylitis, and discar- METHOD

throsis. It proposes 'zygarthrosis' to The working party had to represent the on September 26, 2021 by guest. Protected copyright. Laboratoire de designate zygapophyseal osteoarthrosis. mainstreams in the field of spinal pathology. In Rhumatologie, Conclusions-Knowledge of the patho- particular, Anglo-American, French and H6pital Militaire an were Reine Astrid, logical basis of diseases and under- German trends incorporated without B1120 Brussels, standing ofthe original definitions given by omitting the important contributions of other Belgium those who coined new terms make it poss- countries and languages. R J Franqois ible to avoid most of the confusion arising The intention was to compile a glossary to Laboratorium voor from improper use ofspinal terms. be used by pathologists, radiologists, and Pathologie, Rijksuniversiteit, clinicians. Many contacts were made with Leiden, (Ann Rheum Dis 1995; 54: 615-625) interested scientists outside the Committee. The Netherlands The working group aimed to adhere as F Eulderink closely as possible to the following rules: Department of It is common experience that clinicians, 1) to respect the etymological sense of the Rheumatology, University of London, radiologists, pathologists, and other scientists terms; Postgraduate Medical interested in spinal disease use a number of 2) to take account of the historical background School, everyday terms with different meanings, which and to remain faithful to the original definition London, United Kingdom causes considerable confusion. In a recent given by the author who coined the term or E G L Bywaters paper, it appeared that 51 English speaking made it popular; Correspondence to: spine surgeons use 50 different terms for their 3) to give descriptive definitions, accepting Dr R J Francois, four most common diagnoses. 1 only those pathogenetic implications that are 9 avenue de Sumatra, B 1180 Brussels, Belgium. Dictionaries do not solve all problems, as unanimously recognised; tPrepared on behalf ofthe they may differ, and may be incomplete, 4) to avoid using one term in more than one Committee on Pathology of inaccurate, or even totally wrong. For example, meaning; the European League Against Rheumatism. spondylolysis is defined in one dictionary' as 5) if possible, to follow common practice. Accepted for publication 'ankylosis of a vertebral joint' or as It is realised that these rules are partly at odds 13 October 1994 'osteoarthritis of the intervertebral disk space with each other. 616 Franfois, Eulderink, Bywaters

PRESENTATION to the hyaline cartilage at the discovertebral Considering it important that people should interface. understand the original meaning ofthe words they Ann Rheum Dis: first published as 10.1136/ard.54.8.615 on 1 August 1995. Downloaded from use, the authors recall the etymology (Etym) of terms before giving a definition (Del), comments - Intervertebral chondrosis (Com), synonyms (Syn), recommended nomen- Deft Schmorl,'5 considering the whole disc as clature (Rec) and, ifapplicable, the historical (His) (fibro)cartilage, used 'intervertebral chon- source. In rare instances, a new term might be drosis' as a synonym of disc degeneration. proposed (Prop). If useful, French (F) and Com: The three components of the inter- German (D) translations are given. When, within vertebral disc do share a common chondral a definition, a term is used that is defined separ- origin, possessing collagen type II and ately in this list, it is marked by an asterisk (*). glycosaminoglycans. However, Schmorl's definition introduces confusion, in that the same word could be used for degenerative THE GLOSSARY changes of three structures: the hyaline The list contains specific spinal terms and cartilage of the disc, the whole disc, and the general concepts that are particularly hyaline cartilage of the apophyseal joints. In important in spinal pathology. accordance to our rule 4, we do not support Schmorl's nomenclature. People who wish to use it should refer to Schmorl when doing so. Ankylosing spondylitis It would be more accurate to speak of discal or see spondylitis*, ankylosis*. intercorporal (between the bodies) chondrosis instead of intervertebral chondrosis. see also osteochondrosis*. Ankylosis Prop: Intercorporal chondrosis. Etym: Ancient Greek ankylosis, crookedness. Syn: Disc degeneration*; intercorporal Def: Fusion of articulating bones, by dense chondrosis. fibrous tissue (syndesmosis), cartilage (synchondrosis) or bone (synostosis) leading to total loss of movement. Cyst, zygapophyseal or facet joint Com: The concept is widely used in the see diverticulum*, zygapophyseal. adjective 'ankylosing' as in ankylosing spondy- litis* and vertebral ankylosing hyperostosis*. Degeneration Deft Change from a higher to a lower form, Baastrup's syndrome8 especially change of a cell, tissue or organ to Def: Painful condition due to abnormal friction a lower or less functionally active form.

between spinous processes, as a consequence Com: In a tissue or organ, degeneration can be http://ard.bmj.com/ of reduced lumbosacral angle and/or disc accompanied by reactive processes such as height, or of hyperlordosis. inflammation and/or proliferation; in spite of Com: Pathological changes include bursa for- this, a disease can be called degenerative when mation, thinning of interspinous soft tissues, the first or main changes are degeneration. cartilage lining of adjacent processes, with fibril- Degenerative is often opposed to inflam- lation, eventual ebumation, and bone matory; however, it would be unwise to call

sclerosis.9 10 A similar condition in the cervical every non-inflammatory and non-tumoral on September 26, 2021 by guest. Protected copyright. spine was described clinically by Michotte" and condition 'degenerative'. pathologically by Bywaters.'2 see also bursitis*. Degenerative disc disease see disc degeneration*. Bursitis, interspinous Etym: From Latin bursa, purse and the suffix -itist. Diffuse idiopathic skeletal hyperostosis Def: Inflammatory changes in the bursae that (DISH) develop in aging people by synovialisation* of see under hyperostosis*. clefts within the interspinous space.9 12 13 Com: The mechanical variety corresponds to Baastrup's syndrome*. Calcium pyrophos- Disc bulging phate and hydroxyapatite deposits'2 and Deft Protrusion of the whole disc, in contrast rheumatoid changes in adults'2 and to the focal protrusion of a disc herniation. children'2 14 can be seen. t -itis: Suffix to indicate the inflammatory nature of a condition. Chondrosis * -osis: Suffix to indicate either the non-inflammatory Etym: Ancient Greek chondros, cartilage and character of a lesion-most often a degenerative condition-or the widespread nature of a lesion, as in the suffix -osist. chondromatosis. Def: Degeneration* or non-inflammatory In the previous century and in the early 20th century, the of suffix -itis has been used for conditions that are now developmental change cartilage. regarded as degenerative. For example, osteoarthritis Com: In the spine, this would apply to the deformans was the usual term for what we now, better, articular cartilage of the apophyseal joints and call (osteo)arthrosis. Commented glossaryfor rheumatic spinal diseases, based on pathology 617

Diffuse bulging occurs in case of disc disrupture of the endplate, with eventual degeneration*, due to loss of turgor, presence Schmorl nodes*, and changes in the subchon- offissures, or both. dral bone (sclerosis, pseudocysts, erosions, Ann Rheum Dis: first published as 10.1136/ard.54.8.615 on 1 August 1995. Downloaded from eburnation).9 The boundary between disc degeneration* and Disc degeneration discarthrosis is almost impossible to trace. The Deft Degeneration* of disc. former might be used when the changes seem Com: Structural changes include reduced water limited to the intervertebral disc, and the latter and modified proteoglycan content, decreased when bony changes are present. height, brown discolouration, fissuring and In the cervical spine, the term uncodiscar- crumbling. Radiological features of pure disc throsis is applicable, to point to the degeneration are: involvement ofLuschka's joints between uncus - reduced disc height; and the corresponding area of the adjacent - retrolisthesis* due to the obliquity of the vertebral body; uncarthrosis plays an articular facets, but this is only true if the important role in eliciting symptoms because cartilages of the interapophyseal joints are of the osteophytes reducing the intervertebral preserved; foramen. - clefts at the insertion of the annulus fibrosus His: The term discarthrosis was coined by de into the marginal ring, or to a variable extent Seze. He called the variety with advanced throughout the whole disc, visible on plain sclerosis and erosion of the vertebral body radiographs by the vacuum phenomenon or on 'pseudopottque'.20 discograms; Syn: - Erosive intervertebral osteochon- - increased sagittal mobility, that may be seen drosis*21 points to cases with less on flexion and extension views.'6 advanced destruction of the vertebral Disc degeneration is often accompanied or body than de Seze's. followed by bony changes in the vertebral - Disc resorption* was coined by body, mainly osteophytes* and osteosclerosis. Crock22 23 for the variety of disc In the presence of bone changes, the term degeneration* characterised by gross discarthrosis* is pertinent. Some authors might narrowing of a disc space with sclerosis prefer to consider disc degeneration and of the adjacent vertebral bodies. discarthrosis as one continuous process and - Intervertebral osteochondrosis* is, use the term degenerative disc disease."7 according to Schmorl,'5 a synonym for Syn: Degenerative disc disease. discarthrosis; for more accuracy, we recommend replacing intervertebral by intercorporal or discovertebral. Disc hernia(tion) Rec: Discarthrosis. Deft Localised protrusion of part of the disc

beyond its normal boundaries: protrusion of http://ard.bmj.com/ nucleus pulposus and/or annulus fibrosus and/ Discitis or cartilage'8 through a defect in the annulus Deft Infective or sterile inflammation of an and eventually in the perivertebral ligaments, intervertebral disc. or protrusion of disc material into the vertebral Com: The normal disc is avascular, but vessels body through the basal cartilage. will invade the disc after a lesion, allowing Com: Disc prolapse is a less well suited term, inflammation; discitis may also be the

for prolapse is used for other organs, such as extension of a spondylitis*. on September 26, 2021 by guest. Protected copyright. rectum or uterus, to designate a displacement see spondylodiscitis* that occurs without defect of their wall or containing membranes. Syn: Disc hernia into the vertebral body is Discopathy called intravertebral disc hernia, Schmorl's Etym: Ancient Greek diskos, disc and pathos, node*, cartilaginous node. suffering. Deft Any pathological condition of the disc. Com: Should be replaced by a more specific Disc prolapse term (disc degeneration, discitis, etc) whenever see under disc hernia*. possible.

Disc resorption Diverticulum, zygapophyseal see under discarthrosis*. Deft Normal zygapophyseal joints have a cranial and a caudal recess, visible at arthrography.24 Enlargement of these, Discarthrosis especially the cranial one, leads to diverticula Def: Structural and functional failure of the demonstrable by myelography,25 26 computed discal joint, analogous to synovial joint tomography,27 28 arthrography,29 30 and mag- osteoarthrosis, combining disc degeneration* netic resonance imaging.3' 32 In late stages, and bone changes. they could erode the adjacent bone, being seen Com: Starts as disc degeneration. Later or suspected on plain x-ray films. changes are osteophytes*, the more or less Com: The wall of such a diverticulum disappearance of discal tissue, fibrillation and sometimes contains inclusions of calcified chondrocyte clustering in the hyaline cartilage, material33 as a consequence of deterioration of 618 Franfois, Eulderink, Bywaters

the facet joints; this is analogous to what bridges. The prevertebral ossification is of happens in peripheral synovial joints. enthesophytic 42 and sometimes nature,4 Ann Rheum Dis: first published as 10.1136/ard.54.8.615 on 1 August 1995. Downloaded from Syn: - Synovial cyst is often used instead of starts as a ribbon-like calcification.43 diverticulum, but is less correct, in that Aufdermaur44 pointed to the association with cysts are classically closed while Scheuermann's disease. Ossification of the diverticula are connected with the organ posterior longitudinal ligament and of the from which they originate.3 capsule of the facet joints can occur in - Ganglion, another term used in this addition. These aspects are clinically context, is defined as metaplasia of para- important because of the encroachment upon articular connective tissue leading to the the spinal canal at the cervical,45 46 dorsal,47 or formation of a cyst without synovial lumbar48 level. lining, not connected with the synovial Syn: - Vertebral ankylosing hyperostosis fails cavity, and containing mucinous to address the extraspinal localisations. It material.34 3 can be retained to designate the spinal changes or even the whole condition, as Forestier himself had described the Enthesis extraspinal lesions.49 Etym: Ancient Greek (par)enthesis, insertion. - Spondylosis hyperostotica50 51 should Def: Attachment through insertion. In be rejected because of the confusion rheumatology, it serves mainly for attachment around the term spondylosis* (see of tendon, ligament, fascia, or capsule into further). bone; it might also be used for attachment of - DISH is appropriate despite the fact heart valves, iris, etc. that 'skeletal hyperostosis' sounds Com: There are two histological types of pleonastic. enthesis, depending on the chondral or - Arlet and Mazi&res52 coined the term membranous origin ofthe bone tissue receiving hyperostosing disease, which is criticised the insertion: one by calcified cartilage and one by those who do not consider the often by penetrating fibres (Sharpey's fibres).36-38 asymptomatic hyperostosis as a disease. - Other terms stress the metabolic aspects, such as 'spondilopatia iperos- Enthesitis tosica dismetabolica',53 or the import- Etym: Ancient Greek enthesis* and suffix ance of enthesopathies, such as 'diffuse -itis*. enthesopathic hyperostosis'.54 Deft inflammation of an enthesis. Rec: Diffuse idiopathic (skeletal) hyperostosis, vertebral ankylosing hyperostosis, hyperos- tosing disease. Enthesopathy see also under spondylosis* and further in the

Etym: Ancient Greek enthesis* and pathos, discussion. http://ard.bmj.com/ suffering. Deft Any pathology of an enthesis. Com: Enthesopathies include mainly meta- - Acquired hyperostosis syndrome55 bolic, degenerative and inflammatory changes; Def: Synonym of SAPHO*, but including in enthesitis* should be preferred to enthesopathy addition, cases of psoriasis vulgaris. if inflammatory changes are to be designated. Com: To be discarded, because this term might

be confused with diffuse idiopathic hyper- on September 26, 2021 by guest. Protected copyright. ostosis*, to which it is also applicable. Enthesophyte Etym: Ancient Greek enthesis* and phyton, plant, growth. - Synovitis-acne-pustulosis- Deft Osteophyte* at an enthesis. hyperostosis-osteomyelitis syndrome (SAPHO)* Def: see synovitis-acne-pustulosis-hyperostosis- Ganglion, intraspinal osteomyelitis syndrome*. see under diverticulum*. Kummel's disease Hyperostosing disease Def: Clinical syndrome of delayed post- see under hyperostosis*. traumatic vertebral collapse. His: Between 1891 and 1928, Kdmmel56 devoted several papers to a disease caused by Hyperostosis a rather mild trauma of the spine, the pain of Deft Hyperplasia of bone, by interstitial and/or which abated after a few days, to reappear external apposition. some months later after a pain free period. Com: The word is used in vertebral ankylosing Immediately after the initial trauma, no hyperostosis39 or diffuse idiopathic skeletal radiological anomaly is disclosed; in the third hyperostosis (DISH)*40 to name a condition phase, rarefaction and loss of bone tissue lead characterised mainly but not exclusively by to collapse ofthe vertebral body and angulation enthesophytes*. In the spine, the most con- of the spine. spicuous changes are a prevertebral bone layer, Pathological data are available from Schmorl,15 asymmetrical enthesophytes and intervertebral who shows a picture of a necrotic vertebral Commented glossaryfor rheumatic spinal diseases, based on pathology 619

body. This is probably why Resnick and tinning of the intervertebral disc, wedging of Niwayama57 define Kiimmel's disease as the vertebral body, compensatory growth vertebral osteonecrosis. These authors have (increased anteroposterior diameter or localised Ann Rheum Dis: first published as 10.1136/ard.54.8.615 on 1 August 1995. Downloaded from published such a case, with an intraosseous lengthening), absence of bony fusion between vacuum, in their textbook. According to margin and vertebral body (limbus vertebra*). Maldague et al,58 the latter sign is highly Com: Scheuermann62 described the involve- suggestive of ischaemic necrosis. ment ofthe dorsal spine by this condition, with Com: No single aetiology can account for all emphasis on wedging and hyperkyphosis. The cases of delayed post-traumatic vertebral lumbar localisation has been recognised by collapse. Unrecognised fracture, particularly in many authors. osteoporotic patients, ischaemic osteonecrosis, Syn: Scheuermann's disease*. sympathetic neurodystrophy, and tuberculosis are possible causes. Hence the term Kiimmel's syndrome would be better than Kiummel's Osteopenia disease, but the question should be raised of Etym: Ancient Greeek osteon, bone and penia, the usefulness of that concept. poverty. Rec: to be discarded. Def: Radiological concept for any reduction in bone tissue density, whatever the cause (osteoporosis*, hyperparathyroidism, etc). Limbus vertebra Etym: From Latin limbus, border or fringe. Def: Vertebral body with unfused marginal Osteophyte ring, as in juvenile vertebral osteochondrosis*. Etyrm: Ancient Greek osteon, bone and phyton, plant (growth). Def: Any bone outgrowth, but especially spurs Olisthesis around an osteoarthrotic joint. Etym: Ancient Greek olisthesis*, slipping. Com: In peripheral joints, marginal osteophytes Def: Slipping, displacement, as used in are readily distinguished from enthesophytes* spondylolisthesis*. at the insertion of tendons, ligaments, or capsule, because of the free space between the cartilage edge and the attachment of the Osteitis condensans jill capsule. Such free space is lacking at the discal see osteosis condensans ilii*. joint; marginal osteophytes of the vertebral body develop into an insertional area and merit designation as enthesophytes. Osteochondrosis In the spine, Macnab63 distinguished between Deft Degeneration* or non-inflammatory marginal (claw) spurs and traction spurs, developmental change of both cartilage and which are at some distance from the vertebral http://ard.bmj.com/ bone. edge, but this distinction has been Com: In the first sense, and from a questioned.64 Marginal osteophytes associated morphological point of view, osteoarthrosis is with a tear in the annulus fibrosus and a kind of osteochondrosis. probably secondary to some traction on the see intervertebral osteochondrosis*. perivertebral ligaments have been described by The second sense is used to cover a number of Schmorl'5 and Francois.65

heterogeneous conditions affecting the on September 26, 2021 by guest. Protected copyright. immature skeleton,59 including the disco- vertebral junction (juvenile vertebral Osteoporosis osteochondrosis*). Etym: Ancient Greek osteon, bone and porosis, porosity. Def: Increased porosity of bone; local or - Intervertebral osteochondrosis general decrease of trabecular and/or cortical Deft Term used by Schmorl'5 to designate bone volume, as a result of aging, lack of degeneration* of disc and vertebral endplates. gravitational stimulation, hormonal deficiency Com: This denomination has been taken over or excess, and other known and unknown by some authors in the US59 and Europe.2' As factors leading to imbalance between is the case for chondrosis*, the adjective formation and resorption. Bone trabeculae, intervertebral is not accurate enough; the latter although thinner and fewer, do not appear is applicable to both the discovertebral and abnormal by current methods of investigation. zygapophyseal joints; a better denomination Com: When destruction is evident, as in would be intercorporal osteochondrosis. hyperparathyroidism, tumours or infection, Syn: Discarthrosis, intercorporal osteochondrosis. osteolysis should better be used. There is no sharp demarcation between normal and reduced bone density. It is generally accepted - Juvenile vertebral osteochondrosis that spinal osteoporosis is asymptomatic until Def: Postnatal developmental disorder of the the first compression fracture occurs. discovertebral junction60 with focal irregularity or even absence of the osteocartilaginous growth zone and disorganised collagen fibres6' Osteosis condensans 1111 leading to several of the following changes: Def: Triangular or oval bone sclerosis in the irregular endplates with Schmorl's nodes*, iliac bone adjacent to the sacroiliac joint, 620 Franfois, Euldenink, Bywaters

probably due to overload, particularly in Syn: The osteopetrotic variety is also called pregnant women in whom relaxation of the sandwich vertebra. pelvic joints is believed to be an important F: Rachis en maillot de rugby.7 Ann Rheum Dis: first published as 10.1136/ard.54.8.615 on 1 August 1995. Downloaded from aetiological factor. His: Osteitis condensans ilii* was coined by Barsony and Polgar.66 Sandwich vertebra Com: The lesion may also involve the sacral see rugger-jersey**spine. part of the sacroiliac joint. Pathology includes increase of trabecular and cortical bone, marrow fibrosis, and sometimes bone necrosis. SAPHO The articular cartilage is retained. see synovitis-acne-pustulosis-hyperostosis- osteomyelitis syndrome*. Parasyndesmophyte Deft Syndesmophyte* that is inserted at some Scheuermann's disease62 distance from the margin of the vertebral body Deft Juvenile vertebral osteochondrosis* of the and/or extends beyond the vertebral margin. dorsal spine. His: The term was coined by Dihlmann.67 Com: see under osteochondrosis.

Paravertebral ossification (in psoriasis) Schmorl's node70 Deft Paravertebral and paradiscal ectopic bone Deft Cartilaginous node within the vertebral seen in psoriasis and that, unlike syndes- body, in continuity with the intervertebral disc mophytes*, remains unattached to the and associated with an endplate lesion. vertebrae. Com: Can be considered as an intravertebral His: This change was described by Bywaters disc hernia* through a defect or weak place in and Dixon.68 the endplate of the vertebral body or in the subchondral bone; in juvenile vertebral osteochondrosis*, it could merely arise from Pseudospondylolisthesis irregular growth of the endplate also. The see under spondylolisthesis*. frequency of Schmorl nodes does not increase with age.7' In the T1O-L1 area, Schmorl's nodes bear a relationship to disc Pustulotic arthro-osteitis degeneration* 71 Deft Locomotor changes associated with Syn: Cartilaginous node, endplate lesion, pustulosis palmoplantaris. These changes intravertebral disc hernia. include synovitis, sternocostoclavicular hyper- D: Schmorlsches Kn6tchen, Knorpelknotchen. ostosis, chronic sclerosing osteitis of other F: Hernie intraspongieuse, hernie intra- http://ard.bmj.com/ bones, sacroiliitis and spondylitis. somatique/intracorporeale.

Retrolisthesis Spinal rheumatoid arthritis Etym: Latin retro, backwards and ancient Deft Spinal changes due to rheumatoid Greek olisthesis*, slipping. arthritis. Deft Dorsal displacement of a vertebra in His: The histopathology of such changes was on September 26, 2021 by guest. Protected copyright. relation to its distal fellow. analysed in the cervical spine,2 13 72-75 in the Syn: Retrospondylolisthesis3 is more accurate dorsal spine, where the lesions extend from the when used alone; retrolisthesis is accurate costovertebral joints76 and in the lumbar enough when used with specification of the spine.'3 73 involved vertebra. Syn: Rheumatoid spondylitis*,74 but this should be avoided because the same term has been used previously in the USA for many Retrospondylolisthesis years, as a synonym of ankylosing spondylitis*. see retrolisthesis*. Spondarthritis Rheumatoid spondylitis Etym: Conflation of spondylarthritis* and see under spondylitis*. peripheral arthritis, to point to the association of axial and peripheral involvement. Deft Any one of a group of inflammatory Rugger-jersey spine diseases, comprising ankylosing spondylitis*, Deft Peculiar aspect of vertebral bodies, Reiter's disease, reactive arthritis, psoriatic characterised by sclerosis of both subchondral arthritis and spondylitis, arthritis with regions and eventually by atrophy of the ulcerative colitis and Crohn's disease, uveitis, central area,69 giving the spine a striped HLA-B27 linked peripheral arthritis, and appearance. maybe other conditions. Com: Rugger-jersey spine has been described His: The term was coined by the Leeds in hyperparathyroidism, renal osteodystrophy, group.77 certain types of osteopetrosis, and corti- Com: The spondarthritides are characterised costeroid induced osteoporosis. by axial and peripheral arthritis, absence of Commented glossaryfor rheumatic spinal diseases, based on pathology 621

rheumatoid factor, increased frequency of Prop: Zygarthrosis. HLA-B27, overlapping syndromes, familial Rec: Discarthrosis, zygarthrosis. aggregation, and mutual association within Ann Rheum Dis: first published as 10.1136/ard.54.8.615 on 1 August 1995. Downloaded from patients and families. Some authors have advocated inclusion also of Whipple's disease, Spondylitis Behcet's disease, and other diseases, but this Etym: Ancient Greek spondylos, vertebra and should be discouraged for conditions that lack the suffix -itis. the connection with HLA-B27 and do not Def: Inflammation of a vertebra. Qualification exhibit the same inflammatory changes. (ankylosing, infectious, tuberculous, Salmon- Syn: Spondyloarthropathy. The use of the ella, etc) is needed. radical spondylo- makes it clear that spondylo- Com: Note that in 'ankylosing spondylitis', arthropathy is a composed word referring both spondylitis is used in another sense than the to the spine and to another arthropathy; one given here-that of inflammation of however, arthropathy is too vague and does not vertebral joints and eventually of the vertebra. indicate the inflammatory nature of the condition; it applies to any disease involving both the spine and the limbs, such as - Ankylosing spondylitis polyarthrosis, chondrocalcinosis, ochronosis, Def: Inflammatory disease of the axial and to diffuse idiopathic hyperostosis, etc. Spondylo- a lesser extent of the peripheral joints, with arthritis is more accurate. Spondylarthropathy* synovitis,78-81 para-articular bone sclerosis is also used, but should be avoided, because it (osteitis),82 83 enthesitis*,74 and discitis*.13 83 84 has another etymological significance. The inflammatory processes erode fibro- Rec: Spondyloarthritis, spondarthritis. cartilage, hyaline cartilage80 83 and bone, leading to chondro-osseous and fibrous anky- losis, and to squaring ofvertebral bodies.85 The Spondylarthritis disease almost always involves the sacroiliac Etym: Ancient Greek spondylos, vertebra, joints, and is highly linked to HIA-B27. arthron, article or joint and suffix -itis. Syn: Spondylarthritis ankylosans,4 pelvo- Def: Inflammation of spinal joint or joints. spondylitis ossificans,86 spondylitis ankylo- poetica. Eponyms in this case should be avoided, especially that ofvon Bechterew. - Ankylosing spondylarthritis His: von Bechterew (now spelled Bekhterev) Def: Synonym of ankylosing spondylitis*. created considerable confusion in describing, in 1893,87 what he thought to be a genuine disease, distinct from ankylosing spondylitis; in Spondylarthropathy 1899,88 he published two cases of presumed Etym: Ancient Greek spondylos, vertebra, ankylosing spondylitis in order to insist on the arthron, article or joint, pathos, suffering. difference between this disease and his own. http://ard.bmj.com/ Def: Any pathology ofvertebral joints. However, he had been preceded and would be Com: Is also used, incorrectly, for spondarthritis*. followed by numerous authors who did describe accurately ankylosing spondylitis, as stated by different reviewers.89 90 Spondylarthrosis D: Ankylosierende Spondylitis. Etym: Ancient Greek spondylos, vertebra, F: Spondylarthrite ankylosante, pelvi-spondy- arthron, article or joint and the suffix -osis. lite rhumatismale9' (better spelled pelvo- on September 26, 2021 by guest. Protected copyright. Def: Osteoarthrosis of spinal joints. Specify spondylite). zygapophyseal or discal. Com: Originally, this term was used only for interapophyseal joints. The similarity between - Spondylitis deformans the structural and functional failure of apo- Deft Obsolete synonym of spondylosis physeal and discal joints and the relationship deformans*. between both lend support to a common denomination. Moreover, in the very advanced stage ofdisc failure, the whole nucleus pulposus - Marginal (anterior) spondylitis and most of the central part of the annulus Deft Inflammation of the margin of a vertebral fibrosus disappear, a cavity is formed, the basal body due to enthesitis, leading to squaring of cardlages become frayed, and eburnation can the vertebral body, erosion, shining corners or occur-all of which changes are reminiscent of syndesmophytes. diarthrodial joint arthrosis. His: The term anterior spondylitis was Syn: - Discal spondylarthrosis is called introduced by Romanus and Yden in 1952.86 discarthrosis* by de Seze;20 it is a very Com: Since enthesitis is found all along the convenient and short term. margin of the vertebral body,84 the adjective - 'Arthrose posterieure' is a widely used 'marginal' is better suited than the original French synonym for zygapophyseal 'anterior'. spondylarthrosis; it is outdated to that Syn: Romanus lesion. extent that in the anatomical nomen- clature posterior is now replaced by dorsal. It would be useful to have a shorter - Rheumatoid spondylitis term to replace zygapophyseal spondyl- Deft 1. Has been used for decades in the USA arthrosis. We suggest zygarthrosis. as a synonym of ankylosing spondylitis*. 622 Franfois, Euldenink, Bywaters

Since rheumatoid arthritis and anky- for others it includes also disc degener- losing spondylitis are well recognised as ation without vertebral changes. two distinct diseases, the term has been Com: 1. The adjective deformans has no sense, Ann Rheum Dis: first published as 10.1136/ard.54.8.615 on 1 August 1995. Downloaded from discarded. for most pathology induces morpho- 2. Has been used by Ball74 to describe logical changes (that is, deformation). involvement of the spine in rheumatoid 2. Schmorl70 made no distinction arthritis. To avoid confusion, it should be between common osteophytes* and the replaced by spinal rheumatoid arthritis*. osteophytes present in the case of hyper- ostosis* of the spine. As stated previously, hyperostosis and dis- Spondyloarthritis carthrosis*, despite frequent association, see spondarthritis*. are better considered as separate conditions while their causes remain poorly known. Spondyloarthropathy 3. As so many meanings are given to the see spondarthritis*. term spondylosis, without regard to the original definition, and as even the original definition confuses distinct Spondylodiscitis conditions, the study group recommends Deft Combination of spondylitis* and avoidance of the use of the term, or that discitis*. it be defined whenever it is used.

Spondylolisthesis - Spondylosis hyperostotica Etym: Ancient Greek spondylos, vertebra and see under hyperostosis*. olisthesis*, slip. Def: 1. Ventral displacement of the vertebral body due to spondylolysis*, elongation of Syndesmophyte the pars interarticularis, or more complex Etym: Ancient Greek syn, with or together, defects of the neural arch. desmos, ligament and phyton, plant or 2. Ventral displacement of a whole outgrowth. vertebra, secondary to zygarthrosis*. Def: Bony outgrowth replacing the outer part Syn: of 1: Isthmic spondylolisthesis. of the annulus fibrosus, the shorter peri- of 2: Arthrotic spondylolisthesis. In the vertebral ligament, and eventually also the latter sense the term pseudospondyl- deeper part of the longer perivertebral liga- olisthesis has been used; however, it is ment, leading to an intervertebral bridge by not well suited, as the slip is real. means of complex processes involving all kinds of ossification.84 http://ard.bmj.com/ Com: When the syndesmophyte is not inserted Spondylolysis onto the margin of the vertebral body but Etym: Ancient Greek spondylos, vertebra and extends some distance beyond the vertebral lysis, destruction. margin, it may be called a parasyndes- Def: Separation of the isthmus or pars mophyte*.67 When the ossification remains interarticularis. separated from the vertebrae, as has been Syn: Isthmolysis. described in psoriasis,68 the appropriate on September 26, 2021 by guest. Protected copyright. denomination is 'paravertebral ossification'*. His: This term was coined by Forestier and Spondylosis, spondylosis deformans Robert,94 at the suggestion of Sicard, to Def: 1. The term has replaced 'Spondylitis describe the peripheral discal and paradiscal deformans', probably coined by ossifications in ankylosing spondylitis. Rokitansky in his 1844 textbook, without trying to differentiate between inflam- matory and degenerative conditions.89 It Synovialisation was used by Beneke92 and made popular Def: Development of a synovial membrane by Schmorl.93 The latter author's original where none was present, as within the disc'9 or definition is osteophytosis* of the the interspinous space.'0 vertebral body, either the common outgrowths linked to disc degeneration* or those seen in association with Synovitis-acne-pustulosis-hyperostosis- hyperostosis* of the spine. Aufdermaur44 osteomyelitis syndrome* (SAPHO) used the term as a synonym ofForestier's Def: Group of diseases combining skin lesions disease. (acne conglobata or fulminans, hydradenitis 2. In common practice, there is no suppurativa, dissecting cellulitis of the scalp, agreement on the definition. It became pustulosis palmoplantaris) with locomotor apparent, from a small unpublished changes (arthritis, sclerosing osteitis, sterno- inquiry by the authors among spine costoclavicular hyperostosis, recurrent chronic scientists that spondylosis is used by multifocal osteomyelitis, and eventual many as a synonym of spinal arthrosis sacroiliitis and spondylitis).95 96 (mainly of the discal joint, but for some His: The acronym was coined by Chamot et al people of the zygapophyseal joints also); in 1987.95 Commented glossatyfor rheumatic spinal diseases, based on pathology 623

Com: Some authors tend to consider these equal concepts: unlike spondylarthritis,

diseases as spondyloarthritides*. However, spondyloarthritis does not mean arthritis of a Ann Rheum Dis: first published as 10.1136/ard.54.8.615 on 1 August 1995. Downloaded from the link between SAPHO conditions and vertebra, but association of spondylitis and HIA-B27 is weak, if it exists at all. (peripheral) arthritis. Pathological data are scarce; as long as It is also important to be faithful to the morphology has not shown the identity original definition given by an author. For between SAPHO and spondyloarthritis example, Schmorl used 'spondylosis (defor- changes, it is wise to keep them separated. mans)' for osteophytes of the vertebral body- irrespective of the association with hyper- ostosis-and believed that the osteophytes Vertebral ankylosing hyperostosis resulted from discal tears. Rheumatologists see under hyperostosis*. from the UK or the USA, presumably without having read the original papers of Schmorl, began to uge the term spondylosis for all kinds Zygarthrosis of spinal degenerative changes, such as all Def: Osteoarthrosis of the zygapophyseal joint. stages of disc degeneration and eventually His: Coined by the present authors, as a shorter apophyseal osteoarthrosis. Hence, having term for zygapophyseal osteoarthrosis. deviated from its original definition, the term Com: see under spondylarthrosis*. spondylosis should now be discarded because it is too vague and too inclusive. The study group accepted spondylarthrosis DISCUSSION in a broader meaning (osteoarthrosis of Language is man's primary tool both in science apopyseal and discal joints) than the original and elsewhere: hence it should be kept one (apophyseal osteoarthrosis). In this case, accurate. It is not advisable to use terms in some common practice (de Seze's 'discar- another meaning than their original or etymo- throse') prevailed, in addition to the strong logical sense. It is totally unsound to resort, for analogy between peripheral osteoarthrosis and new concepts, to older denominations with a disc degeneration, particularly in the advanced different meaning. Confusion in language leads stage. to confusion in ideas and makes literature DISH is a disease of mature adulthood, searches in data banks cumbersome. developing frequently in spines which are Scientists should refrain from giving a new already the site ofosteoarthritic changes. Many name to an old disease purely to give the aging people exhibit some non-inflammatory impression of a personal discovery. Such enthesophytes, without reaching the fully replacement is advisable only if an earlier term developed stage of DISH. Because of this, is incorrect or too complicated and the new one there is some trend to amalgamate DISH and brings more clarity or simplicity. spinal osteoarthrosis, particularly in the The study group aimed to adhere to five German literature.5' Beneke,92 and after him http://ard.bmj.com/ rules: etymology, history, morphology, clarity, Schmorl,93 termed all types of vertebral common practice. As expected, these rules osteophytes 'spondylitis deformans', later proved partly antagonistic. replaced by 'spondylosis deformans', which Departure from etymology occurred three introduced the confusion. Ott50 coined times. Ankylosis no longer means curvature, 'spondylosis hyperostotica' and Biressi and and common practice prevails when we Mussa4' reported on 'artrosi discosomatica a advocate the sense of fusion of a joint. carattere iperostosante'. There are, however, on September 26, 2021 by guest. Protected copyright. Spondylolysis does not mean dissolution of a several arguments in favour of a dual whole vertebra, but only an interruption of the conception-among others, the existence in isthmus. Rheumatoid spondylitis is etymolo- dogs of pure hyperostosis without associated gically sound when applied to rheumatoid degenerative changes in the intervertebral changes in the spine, but should be avoided, disc,98 and the striking difference between because rheumatoid spondylitis has long been osteoarthrosis and hyperostosis of the same used in the USA to designate ankylosing joint, for example the sacroiliac joints.99 While spondylitis. the controversy remains unresolved, it is wise Another etymological problem is related to to distinguish both conditions. the seronegative arthritides. When the Leeds Another problem in relation to DISH is to group coined spondarthritis, we presume that decide if it should be called a disease, as Arlet they conflated 'spondylitis' and '(peripheral) and Mazieres52 and Forestier and Rotes- arthritis' in much the same way as brunch is the Querol39 have done, in contrast to Smith et al'" conflation of breakfast and lunch. In doing so, or Rothschild et al'Ol who consider it as physio- they did not follow the usual rules of logical aging not giving rise to symptoms. etymology.97 The Greek radical for vertebra is 'spondyl' and is used as such when the second term of the compound name starts with a CONCLUSION vowel. When the second term starts with a A great deal of confusion would disappear if consonant, a connective 'o' is inserted between scientists from the field of rheumatic spinal both members. This is why spondylarthritis has diseases used terms with an exact, universally no connective 'o' and spondylolysis has. If the accepted meaning. Morphologists are able to connective 'o' is used before a vowel, the reach agreement in describing the underlying impression is given that the compound name pathological findings in these diseases; but is a real connection or association between two much remains to be done to unravel their 624 4Franois, Eulderink, Bywaters

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