Education /spine imaging

1. SERONEGATIVE&SEROPOSITIVE SPONDYLOARTHROPATHIES
BY
DR; SAMEH A RAOUF
PROFESSOR OF RADIO DIAGNOSIS
AIN SHAMS UNIVERSITY

2. OBJECTIVES:
1. Describe the essentials of diagnosis for the
disorders in this category.
2. Review the signs, symptoms and physical
examination and imaging findings commonly
associated with these disorders.

3.  Seronegative = ANA negative, RF negative
 Spondyloarthropathy = vertebral arthritis
 Ankylosing Spondylitis (AS)
 Reiter’s Syndrome & Reactive Arthritis
 Psoriatic Arthritis (Ps A)
 Arthritis associated with IBD (Irritable Bowel Disease
or Enteropathic Arthritis), Crohn’s arthropathy.
 Undifferentiated Spondyloarthropathies (uSpA)
 Juvenile Spondylitis.

4.  Seronegative spondylarthropathy consists of a spectrum
of chronic inflammatory disorders that lack the presence
of rheumatoid factor and are clearly distinct from
rheumatoid arthritis.
 Where as rheumatoid arthritis involves predominantly
the synovial joints, significant abnormalities in the
cartilaginous joints, entheses, as well as synovial
articulations are seen in spondylarthropathic processes.

5.  The seronegative spondyloarthropathies are a
group of arthritic diseases that affect multiple
organ systems and are thought to have a
significant genetic component to their origin.

6.  Axial skeleton involvement
 Prominent sacroiliitis
 Variable peripheral joint involvement
 Inflammatory eye disease
 Uveitis
 Enthesopathy
 HLA-B27

7.  HLA-B27 is the most important predictor of
AS.
 90+% of Caucasians with AS are B27+
 Studies suggest B27 antigen accounts for 20-50% of
the risk for AS
 There are 23 known subtypes of HLA B27 and
not all are associated with disease
 Suggests a structure-function relationship.
 The absence of HLA-B27 expression in an
individual patient does not exclude the
diagnosis of AS.

8.  Ankylosing Spondylitis 90%
 Reactive arthritis 40-80%
 Juvenile Sp A 70%
 IBD 35-75%
 Psoriatic arthritis
 With axial disease 50%
 Peripheral disease 15%
 Undifferentiated Sp A 70%
 Acute anterior uveitis 50%
 Aortic insufficiency, heart block 80%

9.  Young adults
 Peak onset ages 20-40
 overall prevalence is estimated to be as high as
0.2–2%.
 Males>Females (4:1).
 More common in Caucasians

10. Skeletal Axial arthritis (eg, sacroiliitis and spondylitis).
Arthritis of ‘girdle joints’ (hips and shoulders).
Peripheral arthritis uncommon.
Others: enthesitis, osteoporosis, vertebral,
fractures, spondylodiscitis, pseudoarthrosis.
Extraskeletal Acute anterior uveitis.
Cardiovascular involvement.
Pulmonary involvement.
Cauda equina syndrome.
Enteric mucosal lesions.
Amyloidosis, miscellaneous.

11.  Back pain >3months.
 Morning stifnness.
 Tenderness over the SI joints& spinal tenderness 2ry spondyolitis
 Multiple different maneuvers (all unreliable)
 Reduced range of motion of the back.
 Reduced chest expansion owing to costosternal and costovertebral affections.
 Peripheral joints affection e.g. shoulders and hips.
 The lower limbs are more frequently involved than the upper limbs.
 In 20–25% of AS patients, peripheral articular symptoms may precede axial
manifestations.
 Painful tendinopathy occurs in about 10%

12.  Evaluation of other joints
 Particular attention to the large joints
 Lab evaluation
 HLA-B27
 Imaging for AS
 SI joints, others as clinically indicated

13.  Clinical Criteria
 Low back pain, > 3
months, improved by
exercise, not relieved
by rest
 Limitation of lumbar
spine motion, sagittal
and frontal planes
 Limitation of chest
expansion relative to
normal values for age
and sex
• Radiologic Criteria
– Sacroiliitis grade ≥ 2
bilaterally or grade 3 – 4
unilaterally
• Grading
– Definite AS if radiologic
criterion present plus at least
one clinical criteria
– Probable AS if:
• Three clinical criterion
• Radiologic criterion
present, but no signs or
symptoms satisfy clinical
criteria

20.  Sacroiliac Joints and Pelvis
 Sacroiliitis is the hallmark of Ankylosing spondylitis.
 Sacroiliitis is the earliest radiographic sign in 99% of cases of AS
 Although Sacroiliitis alone is a non-specific finding and is not sufficient for the
diagnosis of AS.
 Changes in the sacroiliac joints are considered ubiquitous among patients with AS .
 Both the synovial and ligamentous (superior and posterior) portions of the joint are
involved.
 Classically, the involvement is symmetric and bilateral particularly very early in the
course of the disease.
 unilateral disease may occur.

22. Conventional Radiographic Findings in Ankylosing Spondylitis
 Small erosions lined up one behind the other at corresponding
sites of the ilium and the sacrum resemble a string of beads or
rosary.
 The erosions usually develop earlier on the iliac than on the sacral
side of the joint possibly because the cartilage covering the sacrum
is approximately twice as thick as that covering the ilium .
 Reactive bone proliferation is seen radiographically as sclerosis of
the adjacent cancellous bone with a variable pattern (diffuse, band
shaped,spotty, triangular).

25.  Abnormalities of the spine can be seen at: The disco vertebral
junctions.
 Apophyseal joints, costovertebral joints.
 Posterior ligamentous attachments, and atlantoaxial joints.
 Classically, changes are initially noted at the thoracolumbar and
lumbosacral junctions.
 Spinal extension to the midlumbar, as well as the upper thoracic and
cervical vertebrae, occurs with disease progression but may be
arrested at any stage .

26.  There is a spectrum of:
 Inflammatory and destructive lesions of the spine in
AS.
 This predominantly involves the cartilaginous disco
vertebral junction.
 One of the earliest plain-film findings of spinal
involvement, typically seen at vertebrae T10 through
L2, is the so-called Romanus lesion, also known as
spondylitis anterior

30.  Marginal osteosclerosis.
 Along the spectrum of discovertebral diseases are the more destructive lesions, such as
Andersson lesions.
 Three types are distinguished:
 Type I shows central focal endplate destruction with intraosseous disc
herniation and associated reactive endplate changes, the nature of which
depends on the age of the lesion. In the relatively acute stage, marrow
edema is identified, with enhancement after intravenous gadolinium
contrast administration
 Type-II lesions are located more at the periphery of the discovertebral junction.
 Type-III lesions involving both the central and the peripheral portions may be
difficult to differentiate from infectious spondylodiscitis.

31.  Diagnostic features:
 The absence of an anterior paraspinal soft tissue mass .
 The predominant low signal intensity of the
intervertebral disc on T2-weighted images (with only
possible minor areas of high signal intensity adjacent to
vertebral erosions) indicate a noninfectious Andersson
lesion.

36.  Vertebral bodies initially erode at
corner, reactive sclerosis occurs
below this leading to squared
appearance
 Eventually anulus fibrosus and
longitudinal ligaments become
ossified (syndesmophytes)
 Discs can become calcified, along
with all ligaments including those
between spinous processes 
bamboo spine
Dagger sign,
fused spinous
process ligaments
http://uwmsk.org:8080/EvasMSKTF/

39. Enthesopathy
Erosion
New bone

40.  Magnetic resonance imaging :
 Enable early diagnosis of spinal manifestations of AS by an
increased sensitivity for identification of early-stage Sacroiliitis or
vertebral osteitis.
 Is also superior to other imaging techniques for differential
diagnosis of Andersson lesions vs. infectious spondylodiscitis
and in the evaluation of most acute and chronic spinal
complications of AS.
 MRI has been used to assess the effect drugs in the management
of acute inflammatory lesions

41.  Classical Reiter’s syndrome
 Arthritis, uveitis, urethritis
 “Incomplete Reiter’s”
 Undifferentiated spondyloarthropathy

42.  Peripheral arthritis
 Abrupt onset, asymmetric oligoarthritis
 Lower extremities
 Enthesopathy
 Sausage digits, heel pain (Achilles), plantar pain
 Inflammatory spinal pain
 Evidence of preceding infection
 GU or GI most common

43.  Inflammatory eye disease
 Conjunctivitis, iritis
 Cardiovascular
 Aortic root dilatation, conduction disturbances
 Genital and skin lesions
 Gut mucosal changes
 Association with HIV

44. Reactive Arthritis (Reiter's arthritis)

45. Reactive Arthritis (Reiter's arthritis)

46.  Inflammatory polyarthritis associated with
psoriasis
 May occur prior to the onset of skin disease
 Usually seronegative
 M=F
 Prevalence rate 0.1%

47.  Inflammatory DIP disease
 Asymmetic oligoarthritis with large and small
joints
 Symmetric polyarthritis
 Arthritis mutilans
 Spondyloarthropathy
 Spondylitis and sacroiliitis

48.  Nail pitting
 Skin disease
 Pitting edema
 Inflammatory eye disease

50. Psoriatic Arthritis

51. Psoriatic Arthritis

52.  Bilateral, asymmetrical
 Dramatic joint space loss +/-
ankylosis (arthritis mutilans)
 Bone proliferation, “mouse ears”
 “pencil-in-cup” deformities
 Normal mineralization
 Sausage digits
 Hands > feet > SI > spine
 Usually favors DIP and PIP in hand
 SI involvement usually bilateral,
asymmetrical
 Large bridging bone formation in
spine, similar to reactive arthritis
http://uwmsk.org:8080/EvasMSKTF/
Sausage
digits
http://uwmsk.org:8080/EvasMSKTF/
http://www.hopkins-arthritis.org/arthritis-
info/psoriatic-arthritis/diagnosis.html
Psoriatic Arthritis

53. Psoriatic Arthritis

54. abnormal normal

55.  The appearance of arthritis in patients with inflammatory intestinal disease
(ulcerative colitis, Crohn’s disease, and Whipple’s disease) has been
described since 1950
 These abnormalities have been designated enteropathic arthritis .
 Both the peripheral joints and the axial skeleton (spondylarthropathy) may
be involved enteropathic arthritis.
 The axial skeleton is involved in about 10% of patients.
 Radiological manifestations of enteropathic spondylarthropathy (sacroiliitis
and spondylitis) are indistinguishable from AS.
 Axial involvement is poorly correlated with activity of bowel disease,
whereas a close temporal association exists between exacerbations of
intestinal disease and peripheral joint inflammation

56. arthritis
IBD
Inflammatory
bowel disease
(IBD)

58.  SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis)
 Is considered as a spondylarthropathy associated with different
types of cutaneous pustules.
 The term pustulotic arthro-osteitis (PAO) is more appropriate.

61. • Pathology of Rheumatoid Arthritis:
 RA is the prototype of conditions accompanied by a hyperplastic,
inflammed synovial membrane.
 In RA and related diseases, the synovial lining becomes
hyperemic and thickened, with extensive overgrowth and
formation of villi.
 Inflamed synovial lining in RA eventually grows over the
articular surfaces, eroding and destroying cartilage and
underlying bone.
 The invasive portion of the hyperplastic synovial tissue has been
termed pannus.

62.  MR manifestations of RA and related diseases are nonspecific
, similar changes can be seen in other inflammatory joint
conditions.
 Therefore the goal of those using MRI in these conditions is
not to achieve a specific diagnosis, which may be
accomplished using clinical and laboratory parameters, but
to assess the extent of the early soft tissue and bone
manifestations.

65. Pathogenesis of Rheumatoid Arthritis
Choy, E. H.S. et al. N Engl J Med 2001;344:907-916

66. MRI features Of RA:
 Erosion of the cartilage and bone.
 Tendon or ligamental invasion.
 Synovial pannus :MRI has been used to demonstrate pannus
,and synovial cysts.