Case report: pseudoarthrosis complicating ankylosing spondylitis--appearances on magnetic imaging

Non-infectious thoracic discitis: A diagnostic and management dilemma. A report of two cases with review of the literature

Discitis/ Osteomyelitis is an inflammatory process involving an intervertebral disc and the adjacent vertebral bodies. Infection is the most common cause of discitis, which is often spontaneous and hematogenous in origin. However, many noninfectious processes affecting the spine such as pseudarthrosis in ankylosing spondylitis, amyloidosis, destructive spondyloarthropathy of hemodialysis, Modic changes type 1, neuropathic arthropathy, calcium pyrophosphate dehydrate (CPPD) spondyloarthropathy and gout can mimic infectious discitis/ osteomyelitis. To determine whether a particular patient's spinal process is due to an infectious versus non-infectious cause can be challenging. Although clinical findings and laboratory studies including erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) can be helpful in the diagnosis of bacterial discitis/osteomyelitis due to their high sensitivity; however, their specificity is low. Moreover, both the infectious and non-infectious discitis can appear quite similar on the imaging studies. We present two cases of thoracic discitis with adjacent vertebral osteomyelitis of probable non-infectious etiology. Both were managed with instrumented fusion for stabilization. We also discuss a range of noninfectious causes of discitis/spondylitis and their radiological features which can help differentiate from infectious processes.

Symptomatic pseudarthrosis in ochronotic spine: case report

In this study the authors report the first example of spinal pseudarthrosis in a patient with ochronosis, and they describe the application of posterior-only 360° surgery as an alternative approach to combined anterior-posterior surgery in the management of pseudarthrosis of an ankylosed spine, regardless of its etiology. Spinal involvement in ochronosis produces loss of flexibility and ankylosis of thoracic and lumbar segments. Pseudarthrosis is a serious complication of the diseases that present with ankylosis of the spine. However, its occurrence in ochronotic spine has not been reported previously. Evaluation of progressive paraparesis in a 68-year-old man with ochronosis revealed pseudarthrosis at the T11-12 level. Circumferential dural sac decompression, debridement of the disc space, interbody fusion, and screw-rod fixation were all done via a posterior-only approach. Postoperatively the patient exhibited a marked recovery in terms of pain and neurological status. At the 3-month follow-up, he was able to walk independently. Ochronosis should be included in the etiology of pseudarthrosis. With aggravation of back pain and the appearance of neurological deficits in an already stable patient with any ankylosing disease, pseudarthrosis should be suspected. Furthermore, single-stage, 360°, posterior-only surgery may obviate the need for single-stage or staged anterior-posterior surgical intervention in patients with pseudarthrosis of the thoracic and lumbar spine.

Fracture dislocation of the spine after total hip arthroplasty in a patient with ankylosing spondylitis with early pseudoarthrosis

BACKGROUND CONTEXT

There are no studies suggesting the management of asymptomatic, early pseudoarthrosis with advanced hip and spine deformities in patients with ankylosing spondylitis. Literature advocates the correction of the hip deformity first and that of spine later.

PURPOSE

To highlight the importance of asymptomatic, early pseudoarthrosis lesion in a patient of ankylosing spondylitis with advanced hip and spine deformities.

STUDY SETTING

A 25-year-old female patient suffering from ankylosing spondylitis with 70 degrees of flexion deformity at right hip and rounded kyphosis of thoracolumbar spine was admitted for right total hip arthroplasty.

METHODS

Cementless total hip arthroplasty and flexor tendon release were performed on right hip under general anesthesia and patient was nursed in supine position postoperatively.

RESULTS

The patient developed cauda equina syndrome and loss of sensation below twelfth thoracic segment on the second postoperative day. Radiological evaluation showed a fracture dislocation of the second and third lumbar vertebrae. Retrospective re-examination of preoperative radiographs showed small erosion of the anteroinferior margin of the second lumbar vertebra. Patient's neurological status did not improve after decompression and posterior stabilization of fractured spine.

CONCLUSION

Careful evaluation of the spine in patients with spondyloarthropathy with advanced hip and spine deformities should be done. Any lesion that can potentially destabilize the spine should be treated first before correcting hip deformity.

MRI of the axial skeletal manifestations of ankylosing spondylitis

Magnetic resonance imaging (MRI) is a valuable tool in the imaging and assessment of patients with ankylosing spondylitis. MRI can demonstrate the acute and chronic changes of sacroiliitis, osteitis, discovertebral lesions, disc calcifications and ossification and arthopathic lesions, which characterize the disease, as well as the complications, which include fracture and the rare cauda equina syndrome. This article reviews the range of MRI findings commonly seen within the axial skeleton in patients with this condition.

Spinal fractures and pseudoarthrosis complicating ankylosing spondylitis: MRI manifestation and clinical significance

PURPOSE

To analyze magnetic resonance (MR) patterns of fractures and pseudoarthrosis of the ankylosing spondylitic spine, and related changes in the dura and adjacent soft tissue.

MATERIALS AND METHODS

Sixteen patients with radiographically evident fractures or pseudoarthrosis of the spine were included. Each underwent MR studies. Ten patients among them underwent surgical operations.

RESULTS

Both transdiscal (n = 12) and transvertebral (n = 4) fractures were identified. The levels were located from T9 to L3. Five of 16 patients had pseudoarthrosis. The fractures or pseudoarthrosis had two patterns: low signal on T1-and high signal on T2-weighted images, and low signal on both T1-and T2-weighted images. Disruption of anterior longitudinal ligament (ALL) was identified in 14 patients. Seven patients had vertebral translation, all had disruption of the ALL. Dural adhesions were noted in five patients and manifested as linear epidural enhancements with triangular blunt edges.

CONCLUSION

MR patterns of ankylosing spondylitis are important in evaluating complications of fractures or pseudoarthrosis, as well as changes in dura, soft tissue, and ligaments.

Magnetic resonance imaging in rheumatic disorders of the spine and sacroiliac joints

OBJECTIVE

To review the value of magnetic resonance imaging (MRI) in diagnosis and evaluation of rheumatic diseases of the spine and sacroiliac joints.

METHODS

A review of the literature on MRI of the spine and sacroiliac joints in rheumatoid arthritis (RA), ankylosing spondylitis (AS), infectious spondylodiscitis, infection of the sacroiliac joint (SIJ), gout, calcium pyrophosphate deposition disease, nontraumatic vertebral compression fractures, insufficiency fracture of the sacrum, avascular necrosis of the vertebral body, sarcoidosis, and Paget's disease was performed. The reports were obtained from a Medline search.

RESULTS

In RA, AS, and crystal deposition disease, synovial tissue, atlantoaxial and subaxial subluxations, crystal deposition, and neurologic compromise can be adequately diagnosed with MRI of the cervical spine. Studies on MRI of SIJs in AS indicate that MRI enables early diagnosis of sacroiliitis. In most cases of infectious spondylodiscitis, avascular necrosis of the vertebral body, nontraumatic vertebral compression fractures, and insufficiency fractures of the sacrum characteristic findings on MRI suggest the correct diagnosis. Moreover, soft tissue abnormalities and neurologic compromise can be visualized. In infection of the SIJ, MRI shows findings suggesting an inflammatory process. In Paget's disease, MRI does not provide additional information as compared with plain radiography (PR) or computed tomography (CT).

CONCLUSION

In evaluation of spinal and SIJ abnormalities in many rheumatic diseases, MRI, in addition to PR, can replace conventional tomography, CT, and myelography. Moreover, MRI can visualize soft tissue abnormalities and neurologic compromise without use of intrathecal contrast.

Applications of bone scintigraphy in ankylosing spondylitis

Eighteen bone scintisans performed in 14 patients with ankylosing spondylitis were reviewed. In young patients with low back pain, positive serology, and indeterminate radiographs, quantitative sacroiliac joint assessment and the presence of typical uptake patterns, particularly costovertebral, were useful in suggesting the diagnosis. Scintigraphy was helpful in the early detection of pseudoarthrosis complicating long-standing disease, especially in patients presenting with recurrent back pain. Selective application of bone scintigraphy aids the diagnosis of ankylosing spondylitis and its potential complications.

Posttraumatic spinal osteolysis in ankylosing spondylitis as part of pseudoarthrosis. A case report

A case of ankylosing spondylitis with pronounced osteolysis of the 12th thoracic vertebral body as part of posttraumatic pseudoarthrosis is described. The appearance of posttraumatic osteolysis simulates a malignant lesion, and it is important to consider the diagnosis in cases of osteolytic lesions of unknown origin.

Pseudoarthrosis in ankylosing spondylitis

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