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 Spondyloarthropathies plates are of particular importance. Al- Ankylosing spondylitis 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) – those which radiologically and most frequent fracture crosses the al. (5), some 30 fractures were counted resemble a spondylodiskitiis – 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 Ankylosing spondylitis 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.