Review Aseptic spondylodiskitis in rheumatic diseases M. Gumà1, A. Olivé1, R. Pérez2, S. Holgado1, V. Ortiz-Santamaría1, X. Tena1

1Rheumatology Section and 2Radiology ABSTRACT Aseptic diskitis in diffuse idiopathic Service, Hospital Universitari Germans Aseptic diskitis is relatively common. skeletal hyperostosis (Forestier- Trias i Pujol, Barcelona, Spain. S eve ral rheumatic diseases invo l v i n g Rotes’ disease) Mònica Gumà, Resident Rheumatology; the spine may have this complication. DISH is a rheumatic disease that con- Alejandro Olivé, Staff Rheumatology; As this condition mimic infe c t i o u s sists of a proliferative ossification of Ricard Pérez, Staff Radiology; Susana diskitis, it is important to recognize it. the periosteum, ligaments and tendons, Holgado, Staff Rheumatology, Vera Ortiz- Santamaría, Resident Rheumatology; Clinically, it is characterised by verte - predominantly affecting the axial ske- Xavier Tena, Chief Rheumatology. bral pain of an inflammatory nature, leton. Although most common in older Please address correspondence to: occasionally accompanied by fever and patients, the disease has been noted in Alejandro Olivé, MD, Rheumatology an increase in the erythrocyte sedimen - yo u n ger patients. Its fre q u e n cy in Section, Hospital Universitari Germans t ation rat e. Radiologi c a l ly, the de - males is double that for females. DISH Trias i Pujol, C/ Canyet s/n, Badalona, crease in the articular space and the has been found in 6% of individuals 08916 Barcelona, Spain. irregularity of the vertebral plates are over 40, and in 12% of those over 70 E-mail: [email protected] of particular import a n c e. A l t h o u g h (1). Radiologically it can be described Clin Exp Rheumatol 2001: 19: 740-747. uncommon, it is necessary to bear in by the fo l l owing cri t e ri a : ex u b e ra n t © Copyright CLINICAL AND mind this possibility when the etiologi - cacification and ossification in the an- EXPERIMENTAL RHEUMATOLOGY 2001. cal search for a possible infe c t i o u s terior or anterolateral face from at least diskitis proves fruitless. A ME D L I N E four adjacent vertebral bodies; preser- Key words: Aseptic diskitis, pseudo- (1986-2000) and PU B M E D ( 1 9 6 6 - vation of interve rt o b ral disks; and diskitis, aseptic spondylodiskitis, 2000) search of relevant articles was absence of alterations in the sacroiliac pseudoarthrosis. p e r fo rm e d. Descri p t o rs used we re joints (2). aseptic diskitis, spondylodiskitis, pseu - In spite of the high incidence of DISH dodiskitis and pseudoarthrosis. in the populat i o n , ve rt eb ral fra c t u re s after trauma have rarely been reported. Introduction The low frequency of fractures is due Pseudodiskitis or aseptic spondylodis- to the fact that in DISH there are exten- kitis is an entity that behaves clinically s ive regions without ossifi c at i o n , t h e and ra d i o l ogi c a l ly like an infe c t i o u s osseous bri d ge is sometimes incom- diskitis, but has a non-infectious aetiol- ogy. Clinically, it is characterised by ve rt eb ral pain of an infl a m m at o ry Table I. Different causes of aseptic diskitis. n at u re, o c c a s i o n a l ly accompanied by Disease of the spine fever and an increase in the erythrocyte Diffuse idiopathic skeletal hyperostosis s e d i m e n t ation rate (ESR). Radiologi- (DISH) or Forestier-Rotés disease cally, the decrease in the articular space Osteochondrosis and the irreg u l a rity of the ve rt eb ra l plates are of particular importance. Al- Ankylosing though uncommon, it is necessary to Psoriatic arthritis bear in mind this possibility when the SAPHO’s syndrome etiological search for a possible infec- Haemodialized tious diskitis proves fruitless. Several Systemic diseases diseases involving the spine occasion- Sarcoid Behçet’s disease ally simulate infectious diskitis (Table Rheumatoid arthritis I). We begin by detailing DISH and an- Microcrystalline arthritis kylosing spondylitis, in addition to the s p o n dy l o a rt h ro p at h i e s , as they share Cancer some of the etiopat h ogenic theori e s Miscellaneous c o n c e rning this particular complica- Paget’s bone disease Post-surgical tion. The remaining diseases are subse- Foreign body synovitis quently explained.

740 Aseptic spondylodiskitis in rheumatic diseases / M. Gumà et al. REVIEW plete, and there is no participation of distributed in segments. This frequently process. It is postulated that the inflam- the interapophysiary joints. This facili- gives rise to ankylosed zones existing matory entesitis extends from around t ates the spine in DISH being more next to disks or free mobile segments. the intervertebral disk towards the in- flexible (2, 3). In such areas a dynamic overcharge of side of the periosteum and the cortex Paley et al. described two types of frac- the free segments is produced, possibly (20). tures that occur in patients with DISH resulting in microfractures (4). In contrast, the most extensive lesions following a minimal trauma. The first In a recent review of DISH by Mata et (type III) Ð those which radiologically and most frequent fracture crosses the al. (5), some 30 fractures were counted resemble a spondylodiskitiis Ð are ex- vert eb r al body along the ankylosed seg- in the literature (3, 6-8), and a third of plained by the appearance of fractures. ment of the spine: in DISH, an exuber- them presented neurological complica- In AS, as opposed to DISH, the disks ant fo rm ation of bone is pro d u c e d, tions. It is important to emphasize that with their thin syndesmophytes are the which includes the fibrous ring and the both types of fractures and the stress weakest zone in the spine. If a trauma is a n t e rior longitudinal ligament. Th e s e microfractures can simulate infectious present, the line of fracture will cross osseous bridges cause the disk space to diskitis. Quagliano et al. have describ- the disk. This will cause callus forma- be the strongest and largest, leaving the ed 2 patients with DISH whose clinical tion, fibrosis proliferation and destruc- vertebral body as a weaker area. The and radiological characteristics simu- tion of the articular space (20). second type of fracture crosses the final lated spondylodiskitis. Neither of them On the other hand, the theory of the disk of a long fused segment (3) (Fig. p resented neuro l ogical complicat i o n s mobile segment allows us to explain 1). and they were cured with rest and anti- lesions without a prior trauma or frac- Apart from the fractures described by inflammatory drugs (9). ture. Schmorl and Junghans developed Paley, small stress microfractures with- the concept of the mobile segment as out prior tra u m atism have also been Aseptic diskitis in ankylosing c o m p rising the entire system of soft d e s c ri b e d. Stress micro f ra c t u res are spondylitis structures that join two adjacent verte- explained by means of the theory of the is a chronic in- brae (disk, ligaments) (21). The pres- mobile segment. This will be described flammatory disease of unknown aetiol- ence of a relatively mobile segment in a in more detail in the section on anky- ogy which mainly affects the sacroiliac completely rigid spine provokes abnor- losing spondylitis. In DISH, at least in joints and which ossifies and calcifies mal movements and this stress pro- its initial stage s , and occasionally various vertebral ligaments (10). duces an irregular destruction of the throughout the whole process, the ossi- D i s kove rt eb ral lesions in anky l o s i n g ve rt eb ras. It is believed that daily fication is established irregularly and spondylitis (AS) were described for the m ovements of fl exion and ex t e n s i o n first time in 1937 by Anderson (11), transmit mechanical stress, provoking who reported the destruction, with ero- sions and sclerosis, of some of the tho- racic and lumbar vertebral plates. Since Anderson’s initial description of asep- tic diskitis in A S, m a ny other cases have been reported (12-19). It is esti- mated that between 1% and 10% of pa- tients with AS will sustain an aseptic diskitis. Cawley and colleagues (20) suggested that there are three types of erosive and destructive lesions in the diskovertebral union. Type I lesions affect the periph- eral regions of the diskovertebral union and appear in the early phases of the disease.Type II lesions affect the cen- tral zones (Fig. 2). In contrast, type III lesions extend throughout the diskover- tebral union and appear later. Va rious mechanisms have been sug- gested to explain these diskovertebral lesions. The destructive lesions located in the peripheral area as well as in the central zone usually appear in the earli- Fig. 1. DISH, showing increase in the articular est phases of the disease and are consi- Fi g. 2. A n kylosing spondy l i t i s : type I lesion space and erosions in the vertebral plates. showing eripheral erosion. dered to be caused by the inflammatory

741 REVIEW Aseptic spondylodiskitis in rheumatic diseases / M. Gumà et al. m i c ro f ra c t u re s , and that these may diskitis. All cases presented lumbar eve n t u a l ly develop into diskitis. In d i s c o m fo rt , without fever and with these cases, the specimens show elevated acute phase reactants. None a granulation tissue in which inflam- of them presented neurological signs, m at o ry cells are almost ab s e n t , a n d and they all improved after treatment there is evidence of weak callus forma- with antiinflammatory drugs, without tion, rarely reactive bone in the fibrous recurrence of the discomfort. t i s s u e, and oedema in the marrow spaces with scattered perivascular col- Aseptic diskitis in psoriatic arthritis lections of ly m p h o cytes and plasma Ps o ri a tic arth ri t i s , as well as other spon- cells (20). dyloarthropathies, may affect the spine All of these theories continue to be (28). Paravertebral ossification usually debated, as reviewed in Rasker et al. appears in the form of syndesmophytes (19). parallel to the vertebral bodies. Unlike Clinical manife s t ation can va ry fro m AS these syndesmophytes are large r a s y m p t o m atic to medullar compre s- and asymmetrical. Spondylodiskitis is sion, which is exceptional. Type I and estimated to occur in 22% of psoriatic II lesions are clinically silent. On the a rt h ri t i s , though in association with contrary, type III lesions usually mani- other lesions such as syndesmophytes, fest with pain in the spine.The onset is Fig. 3. SAPHO syndrome:osteosclerosis (ivory l i gamentous ossifi c at i o n , ap o p hy s e a l abrupt and is localised in the in vol ve d vertebrae). joint narrowing or fusion, facilitating se gment. Interes t i n g l y enough, the pat- the differential diagnosis with respect t e rn of pain is mechanical. Pat i e n t s The spine may be involved (24). Pain to infectious spondylodiskitis (29). It is observe a clear change in spinal pain and stiff n e s s , u s u a l ly localised, m ay therefore rare that it only produces a from that to which they have become draw attention. In other cases there are decrease in the articular space, sclero- accustomed. Exceptionally, neurologi- no symptoms and lesions can only be sis and osseous ankylosis. Howeve r, cal complications exist due to the pro- detected by a radiography The follow- some cases of aseptic diskitis in pa- l i fe ration of the gra nu l ation tissue ing different types of spinal involve- tients with psoriatic arthritis and suffer- inside the epidural space (22, 23). ment may be observed, often in combi- ing from Cro h n ’s disease have been The prognosis is generally good. Con- nation: described (30). servative treatment including rest, anti- - Pure vertebral osteosclerosis, usually inflammatory drugs, physiotherapy and starting from an anterior corner, in- Osteochondrosis sometimes a corset is sufficient. In cas- volving one or several anterior verte- Osteochondrosis is one of the types of es of instability or neurological com- bral bodies (Fig. 3). degenerative disease that occurs in the p l i c at i o n s , s u rge ry will be necessary - Development of paravertebral ossifi- s p i n e. A geing results in dehy d rat i o n (22, 23). cation with massive bridging, similar and loss of tissue resiliency in the inter- to that seen in DISH. vertebral disc, particularly in the nucle- Aseptic diskitis in the SAPHO -Ve rt eb ra plana (especially in ch i l- us pulposus. Even in the re l at ive ly syndrome dren). early stage of intervertebral osteochon- The acronym SAPHO represents a syn- - Osteosclerosis may be combined with drosis, radiographic findings of the dis- drome characterised by osteoarticular diskitis in a way similar to that ob- ease may be ap p a rent. Pa rt i c u l a rly and cutaneous alterations. The initials served in AS.The frequency of these characteristic is the appearance of lin- stand for each of the characteristics de- lesions is in the range of 9-20%. They ear or circular radiolucent collections Ð fining the syndrome: Synovitis, Acne, are associated with pustulosis palmo- the vacuum phenomena Ð which over- Pustulosis palmoplantaris, Hyperosto- p l a n t a ris though ra re ly with acne. lie the intervertebral discs. The lucent sis and Osteitis (24). The main charac- Two or more foci may be present at areas are produced by gas, principally teristic is a pseudo-infectious osteitis, the same time. Radiologically, there is n i t roge n , a c c u mu l ating in the cl e f t s . which above all involves the anterior a decrease in the disc space and ero- This finding is accentuated in exten- p a rt of the chest and the sacro i l i a c sions in the central or anterior por- sion. Vacuum phenomena are a reliable j o i n t s , and wh i ch is often associat e d tions of the diskove rt eb ral union. indicator of disk degeneration; they are with cutaneous lesions such as pustulo- They are frequently accompanied by rare in the presence of disk . sis palmoplantaris, acne and psoriasis. os t e o p h ytes or hyp e r ostosis that lead As the process of intervertebral osteo- Follow-up of these patients is crucial to changes of reparation more rapidly ch o n d rosis progre s s e s , the interve rt e- and will define if disease is a syndrome than infectious diskitis. Toussirot et bral disk diminishes in height. The car- be l o n g ing to the spondyl o a rt h ro p at h i e s , a l . (27) carried out a re t ro s p e c t ive tilaginous end-plates reveal concomi- or rather a form of psoriatic arthritis study of 25 patients diagnosed with tant degeneration. Radiographically, at (25,26). SAPHO, and found 8 cases of aseptic this stage disk space loss and bone

742 Aseptic spondylodiskitis in rheumatic diseases / M. Gumà et al. REVIEW

This (HS) can ini- tially appear to be vertebral osteochon- dr osis but later becomes cle a r ly destruc - tive and erosive, resembling an infec- tious diskitis (Fig. 5). It is believed that between 5% and 10% of patients in he- m o d i a lysis present such art h ro p at hy, the majority of them after 4 years of dialysis. (37-39). Several factors seem to be related to the pathogenesis: - Crystalline arthropathy: This was the first cause included in the work of Kurtz et al. Hydroxyapatite and pyro- phosphate calcium crystals have been described. It has been linked to the hy p e rp a rat hy roidism that these pa- tients suffe re d, wh i ch pre s u m ably induced crystal deposition. Furt h e r studies will be required in order to c o n fi rm the role of py ro p h o s p h at e calcium deposits in this type of diski- tis (36). - Hyperparathyroidism (HPT): This is Fig. 4. Ostechondrosis:decrease of the articular the factor that has been most closely Fig. 5. Spondyloarthropathy in haemodyalisis: space, sclerosis, bone eburnation and irregularity a s s o c i ated with HS. Such pat i e n t s decrease of the articular space an osseous ero- of the vertebral plates (due to subchondral cysts). frequently suffer from serious HPT. sions in the C6-C7 space. In add i t i o n , subtotal parat hy ro i d e c- eburnation are characteristic.The scle- tomy can rapidly reduce the symp- H oweve r, in hemodialy zed pat i e n t s rosis is generally well defined, is linear toms and pr ogression of the discal le- consulting for vertebral pain, 30% had or triangular in shape, and extends to sion. However, HS can be present in an aseptic diskitis and more than 50% the interve rt eb ral disk. Subch o n d ra l p atients without hy p e rp a rat hy ro i d- presented neurological symptoms (42). condensation of bone in both vertebral ism. Furthermore, there are haemo- Severe cases in which the spinal canal bodies bordering the intervertebral disk dialysed patients with HPT who do is affected, resulting in medullar com- is typical. (31) not suffer from HS. It is probable that pression, have been reported with rela- O s t e o ch o n d rosis may be ap p a rent at HPT predisposes to spondyl o a rt h ro p a - tively frequency. In some cases there- any level in the spine, although abnor- th y, but t h e re are other fa c t o rs in- fore, these patients needed surgical de- malities are particularly prominent in volved (40). compression and verteral stabilisation the lower lumbar and cervical regions - A myloidosis of haemodialysed pa- (45, 46). (31). tients: Currently this would seem to The radiological characteristics of de- be the cause with the greatest degree Post-surgical aseptic diskitis c reased disk space, s cl e rosis and, at of involvement. Various studies have Po s t s u rgical spondylodiskitis is not times, erosions of the vertebral plates found amyloid deposits in particularly frequent, but it has been are similar to the changes caused by taken from patients with HS. Further- well described. It may be post-surgical, i n fectious diskitis, p a rt i c u l a rly wh e n more, the deposits are more frequent p o s t - d i s kograp h i c, or postch e m i o nu- these ch a n ges are produced in short in the cervical spine, as is the case cleolisis. Its presence must be suspect- period of time (32-35) (Fig. 4). In these with HS (41-43). ed when there is an increase in lumbar c a s e s , the vacuum phenomenon ac- Bindi et al. (44) reviewed 100 patients pain after the operation. There are two quires its maximum importance, since on haemodialysis and found that 11% types: infectious diskitis and ‘chemi- its presence in the intervertebral space suffered from HS.The cervical spine cal’ or ‘mechanical’ or ‘aseptic’ diski- almost ex cludes the possibility of was affected in 84%, the lumbar spine tis. The first type is the most frequent, infection (32-35). in 16% and the thoracic spine in 8%. In since the microrganism can be intro- 37% of the cases, tw o segments wer e duced during the operation. It is there- Aseptic diskitis in haemodyalisis in vol v ed at the same time.Thirty-five of fore necessary to seek a possible ethio- Kuntz et al. (36) first described spon- the patients were asymptomatic. Pain logical microrganism. There have been dyloarthropathy suffered by patients in was present in 50% of the cases and studies which emphasize that there are treatment with hemodialysis in 1984. s c i atica and ra d i c u l o p at hy in 15%. almost no clinical or radiological dif-

743 REVIEW Aseptic spondylodiskitis in rheumatic diseases / M. Gumà et al. ferences to distinguish between the two patite crystals in the synovial fluid is Pagetic vertebral block (also called ver- groups. well described.This has been observ- tebral Paget ankylosis or Paget synos- The diagnosis is based on analytic data ed in the shoulder, knee, finger joints tosis) is present in 4.45% and 12% of and biopsy of the involved disc. Data in and elsewhere (55). cases and is more frequent in males favour of a non-infectious diskitis are: - Uric acid crystals: Some 20 cases of over 70 years of age with polyostotic a normal C-re a c t ive protein (ESR is gout involving the spine have been d i s e a s e. Its etiat h oge ny is unknow n . increased during first 2 weeks follow- described.These are patients suffer- Some authors suggest that DISH ing surgery), normal fibrinogen, and a ing from polyarticular chronic topha- (Fo re s t i e r- R o t e s ’ disease) is a factor that h i s t o l ogy with fi b rotic ch a n ges. Th i s ceous gout. Urate deposits may be would favour the progression of Paget’s type of aseptic diskitis has a good prog- found in the epidural space or intra- disease through the vertebral bodies by nosis, with a total recovery following a durally in the ligament flavum, the means of the invasion of the hyperos- few weeks of rest (47, 48). pe d i c les or in the intervert eb r al space. tosic osseous bridges (60). Neverthe- In the latter, radiologically they simu- l e s s , other authors believe that the Microcrystal aseptic diskitis late an infectious diskitis. Clinically cause of the block lies in the aggres- Although crystal diseases are ve ry they can only cause chronic back but siveness of the disease, or in the exis- c o m m o n , spine invo l vement is ve ry this is mostly accompanied by neuro- tence of a previous diskopathy (61). rare. Microcrystal may be deposited in logical deficits such as , In 1995 Marcelli defined Pagetic block the spine and soft tissues. A l t h o u g h p a rap a resis or tetrap a resis. Surgi c a l using the following criteria: a) anterior a s y m p t o m at i c, o c c a s i o n a l ly a mye l o- decompression is therefore necessary or lateral fusion of the vertebral bodies pathy or radiculopathy may be produc- (56-58). with osseous bridges among the plat- e d. Radiologi c a l ly, t h ey simu l ate an forms of two or more Paget vertebrae; infectious diskitis. Pagetic vertebral block b) ra d i o l ogical osseous anky l o s i s - P y ro p h o s p h ate calcium cry s t a l s : Paget’s bone disease is a localised dis- among two or more Paget ve rt eb ra e C h o n d rocalcinosis affects the spine order of bone remodelling. It has been with total or partial disappearance of in 4-10% of cases (49). Most of the s h own that Paget tissue can dire c t ly the intervertebral disks and a decrease time it is asymptomat i c. Pyro p h o s- invade the articular cartilage. When this in the height of the vertebral body; and phate calcium crystals may induce a ex t raosseous invasion of Page t ’s dis- c) anterior convexity of the vertebral d e s t ru c t ive lesion in the ve rt eb ra l ease comes from the toward ankylosis (60). body and in the intervertebrals disks the disc space, the so-called vertebral Pagetic bl o ck may be ra d i o l ogi c a l ly that can be confused with an infec- block is formed (59) (Fig. 6). and clinically confused with an infec- tious diskitis (49-51). These lesions tious diskitis (61, 62) or with a cancer may cause instability and therefore a (63). The vertebral block involves, in truly aseptic diskitis. Pyrophosphate order of frequency, the dorsal, lumbar calcium crystals can also deposit in and cervical spine. It is ver y often symp- the flavum ligament or the atlanto- tomatic and can manifest itself as back occipital ligament (52, 53). Severa l pain or cru ra l gi a , sometimes accom- cases of mye l o p at hy and cerv i c o- panied by neurological complications medullar compression have also been (62,64-66). Treatment is usually with described requiring neurological de- calcitonin or biphosphonates. Very oc- compression (54). c a s i o n a l ly surge ry may be re q u i re d - Hydroxyapatite crystals: In addition (66). to being linked to the spondy l o a r- thropathy of haemodialyzed patients, Aseptic diskitis in cancer hy d rox yap atite may cause asep t i c Cancer disc infiltrations are extremely diskitis (Milwaukee back). There is a rare. The relative preservation of the single reported case of asymptomatic disk is explained by the absence of disk destructive universal diskitis. Pathol- vascularization and by the qualities of ogy examination revealed hydroxya- the cartilaginous plate that inhibit tu- patite crystals. The fact that hydrox- morous proliferation (67). yap atite crystals may be found in However, occasionally cancer disc in- non-inflammatory synovial fluid or in filtration has been described, as well as joints destroyed by other causes neoplasias which, without invading the makes it difficult to establish its etio- d i s k , can ra d i o l ogi c a l ly simu l ate an pathogenical role. However, a chron- infectious diskitis. Lymphoma, and es- ic destructive joint disease accompa- Fig. 6. Paget’s bone disease: increase of the pecially Hodgkin’s disease, is the com- nied by some cartilage loss and bone density and the size of the vertebras. Decrease of monest cause. It manifests in a pure os- the articular space. erosion in association with hydroxya- teosclerotic vertebra (ivory vertebra) or

744 Aseptic spondylodiskitis in rheumatic diseases / M. Gumà et al. REVIEW with a mixed pattern of sclerosis and d e s c ribed 12 symptomatic cases in- REINO JJ (Eds.): Tratado de Reumatología, osteolysis. (67-70) volving the thoracic and lumbar spine, Madrid, Aran 1997; 1697-711. 2. RESNICK D, N I WAYA M A G: D i ffuse idio- The presence of metastasis in other ver- most with histological confirmation. A pathic skeletal hyperostosis. In RESNICK D tebrae or the existence of a known pri- number of these simulated infectious (Ed.): Bone and Joint Imaging. Philadelphia, mary tumor can help in the diagnosis diskitis, and a third of them presented W.B. Saunders Company 1987; 440-51. (70). n e u ro l ogical complications re q u i ri n g 3. PALEY D, SCHWARTZ M, COOPER P, HARRIS WR, LEVINE AM: Fractures of the spine in surgical decompression. diffuse idiopathic skeletal hyperostosis. Clin Aseptic diskitis in sarcoidosis Orthop Rel Res 1991; 267: 22-32. Sarcoidosis is a granulomatous disease Aseptic diskitis in Behçet’s 4. ROTÉS-QUEROL J: Clinical manifestations of of unknown etiology that infiltrates a syndrome d i ffuse idiopathic skeletal hy p e ro s t o s i s (DISH). Br J Rheumatol 1996; 35: 1193-6. multitude of organs, affecting above all Behçet’s syndrome is a disease of un- 5. MATA S, FORTIN PR, FUTZCHARLES MA et young adults, and manifesting mainly known etiology that was first described al.: A controlled study of diffuse idiopathic in the fo rm of bilat e ral hilar adeno- in 1937 as a triad of oral aphthae, geni- s keletal hy p e rostosis. M e d i c i n e 1997; 76: 104-17. p at h i e s , in fi l t r ations in the lung, a n d tal aphthae and uveitis of a recurring 6. HENDRIX RW, MELANY M, MILLER F, ocular and cutaneous lesions. character (80). Arthropathy in the form ROGERS LF: Fracture of the spine in patients The spine is not usually affected by sar- of art h ritis and/or art h ra l gia is an with ankylosis due to diffuse skeletal hyper- coidosis; the ve rt eb ral region most i m p o rtant fe at u re of Behçet’s syn- ostosis: clinical and imaging findings. AJR 1994; 162: 899-904. a ffected is the thoraco-lumbar spine. d ro m e. The fre q u e n cy of art h ritis is 7. MO DY GM, CHARLES RW, RANCHOD HA, The lesions are osteolytic or osteo- ap p rox i m at e ly 50%. The pat t e rn of RUBIN DL: Cervical spine fracture in diffuse sclerotic simulating metastatic cancer. a rt h ritis is usually oligo a rticular and idiopathic skeletal hyperosotosis. J Rheuma - One or several adjacent vertebrae may a s y m m e t rical. The knee is the most tol 1988; 15: 129-31. 8. BURKUS JK, DENIS F: H y p e rextension in- be involved. Unlike in other locations, commonly affected joint, followed by juries of the thoracic spine in diffuse idio- this sarcoidosis is usually symptomatic. the ankle, wrist, and elbow. Although pathic skeletal hyperostosis. Report of four The interve rterbal space is ra re ly any joint can be affected, involvement cases. J Bone Joint Surg Am 1994; 76: 237- affected, but when it does happen the of the spine is unusual (80). 343. 9. QUAGLIANO PV, H AYES CW, PA L M E R W E: differential diagnosis with an infectious Nevertheless, the cervical spine is oc- Vertebral pseudoarthrosis associated with dif- diskitis becomes pra c t i c a l ly impossi- casionally involved Ð atlantoaxial sub- fuse idiopathic skeletal hyperostosis. Skeletal ble, and a biopsy is required (71-76). luxation has been described (81). Fur- Radiol 1994; 23: 353-5. thermore, Rozadilla et al. described a 10. RESNICK D, N I WAYAMA G: A n ky l o s i n g spondylitis. In RESNICK D (Ed.): Bone and Aseptic diskitis in rheumatoid p atient whose X-ray showed image s Joint Imaging. Philadelphia, W.B. Saunders arthritis compatible with cervical aseptic diski- Company 1987; 299-319. When rheumatoid arthritis affects the tis at the moment the diagnosis. The 11. ANDERSON O: Roentgenbilden vid spondy- loarthrtis ankulopoetica. Nord Med 1937; 14: spine, it does so mainly in the cervical patient presented cervical pain without 2000. spine (77). Atloaxoid subluxation is the neurological compromise, and his con- 12. DA N E O V, DI V I T TO R I O S: La spondy l o- most characteristic lesion. Other types dition was controlled with anti-inflam- discite de la spondylarthrite ankylosante. Rev of lesions in the spine are considerably matory drugs (82). Rhum 1970; 37: 155-8. 13. SUTHERLAND RI, M ATHESON D: I n fl a m- less frequent. Destructive lesions in the matory involvement of vertebrae in ankylos- ve rt eb ral bodies and ch a n ges in the Aseptic diskitis induced by a foreign ing spondylitis. J Rheumatol 1975; 2: 296- i n t e rap o p h i s a ry joints, in addition to body 302. aseptic diskitis at different levels of the Gertzbein et al. presented an anecdotal 14. MARTEL W: Spinal pseudoarthrosis, a com- plication of ankylosing spondylitis. Arthritis spine, have nevertheless been described case in which, after a gynaecological Rheum 1978, 21: 485-90. (78-79). These diskovertebral changes operation for a cystocele, ap- 15. GELMAN MI,UMBERJS: Fractures of the tho- may be related to the extension toward peared with fever, although acute phase racolumbar in ankylosing spondylitis. Am J the intervertebral space of the synovitis reactants were not elevated.The pain Roentgenol 1978; 130: 485-91. 16. ESCHELMAN DJ, BEERS GJ, NAIMARK A , that affects neighbouring joints such as was re f ra c t o ry to tre atment. 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