Costovertebralis arthrosis. Costovertebral Joint Arthritis

Metrics details Abstract Spinal involvement is frequent in rheumatoid arthritis RA and seronegative spondyloarthritides SpAand its diagnosis is important. RA changes are usually located in the cervical spine and can result in serious joint costovertebralis arthrosis. SpA may involve all parts of the spine.

Ankylosing spondylitis is the most frequent form of SpA and has rather characteristic radiographic features. The imaging features of the other forms costovertebralis arthrosis SpA can vary, but voluminous paravertebral ossifications often occur in psoriatic SpA.

MRI can detect signs of active inflammation as well as chronic structural changes; CT is valuable for detecting fracture. Introduction The spine can be involved in most inflammatory disorders encompassing rheumatoid arthritis RAseronegative spondyloarthritides SpAjuvenile arthritides and less frequent disorders such as pustulotic arthro-osteitis and SAPHO synovitis, acne, pustulosis, hyperostosis, osteitis costovertebralis arthrosis. During the last decade the diagnostic use of magnetic resonance imaging MRI and computed tomography CT has increased considerably, although radiography is still the recommended initial examination.

It is therefore important to know the characteristic radiographic findings in arthritides in addition to the advantages of supplementary MRI and CT. This review will focus on the different imaging features and be concentrated on the most frequent inflammatory spinal changes seen in RA and SpA, respectively. These two entities display somewhat different imaging features, which are important to recognise.

Costovertebral Joint Disorders

Rheumatoid arthritis Involvement in RA is usually located in the cervical spine where erosive changes are predominantly seen in the atlanto-axial region. Inflamed and thickened synovium pannus can occur around the odontoid process dens and cause bone erosion and destruction of surrounding ligaments, most seriously if the posterior transverse ligament is involved.

Laxity or rupture of the transverse ligament causes instability with a potential risk of spinal cord injury. Cervical RA involvement is a progressive, serious condition with reduced lifetime expectancy [ 1 ], and mit kell tenni a kéz ízületeinek fájdalma esetén diagnosis is therefore important [ 23 ]. Radiography of the cervical spine is mandatory in RA patients with neck pain [ 3 ].

A supplementary lateral view during extension can be useful to assess reducibility of atlanto-axial subluxation possibly limited by pannus tissue between the anterior arc of costovertebralis arthrosis atlas and dens.

The open-mouth view d shows erosion at the base of the dens arrow. The definition of the different forms of instability by radiography is as follows [ 3 ].

Costotransverse mobilizations

Lateral and rotatory atlanto-axial subluxation Displacement of the lateral masses of the atlas more than 2 mm in relation to that of the axis and asymmetry of the lateral masses relative to the dens, respectively Fig. Rotatory and lateral subluxation is diagnosed on open-mouth anterior-posterior AP radiographs.

Anterior subluxation often coexists because of the close anatomical relation between the atlas and the axis. AP open-mouth view in a year-old man with RA. There is narrowing of the atlanto-axial joints with superficial erosions black arrow and lateral displacement of the axis with respect to the lateral masses of the atlas white arrow ; costovertebralis arthrosis addition signs indicating rotatory displacement with asymmetry of the distance between the dens and the lateral masses of the atlas Full size image Posterior atlanto-axial subluxation The anterior arc of the atlas moves over the odontoid process.

This is rarely seen, but may coexist with fracture of the dens. This line can be difficult to define on radiographs, and vertical subluxation has therefore also been defined by several other methods. A distance less than 34 mm in men and 29 mm in women indicates vertical subluxation.

Rib Pain or Costovertebral Joint Dysfunctions

If the anterior arc of the atlas is in level with the middle or caudal third of the axis there is slight and pronounced vertical subluxation, respectively. A distance less than 15 mm in males and 13 mm in females indicates vertical subluxation [ 4 ] Full size image The occurrence of dens erosion can, however, make this measurement difficult to obtain.

Visualisation of the palate may not always be obtained. The method described by Clark et al. Location of the anterior arc of the atlas in level with the middle or caudal third of the axis indicates vertical subluxation Fig. Ranawat et al.

To obtain the diagnosis of vertical subluxation a combination of the Redlund-Johnell, Clark and Ranawat methods has been recommended described in [ 4 ]. If any of these methods suggests vertical subluxation MRI should be performed to visualise the spinal cord Fig. It is mandatory to diagnose vertical subluxation; this can be fatal because of the proximity costovertebralis arthrosis the dens to the medulla oblongata and the proximal portion of the spinal cord.

Costovertebral Joint Arthritis

In accordance with this, the anterior arc of the atlas is level with the middle third of the axis. Thus, all measurements indicate vertical subluxation. Supplementary MRI, c sagittal STIR costovertebralis arthrosis d T1-weighted images show costovertebralis arthrosis of the dens and protrusion of the tip into the occipital foramen causing narrowing of the spinal canal to 9 mm, but persistence of cerebrospinal fluid around the cord.

There is a 9-mm-thick mass of pannus tissue between the dens and anterior arc black line exhibiting small areas with high signal intensity on the STIR image arrow compatible with slight activity, but signal void fibrous pannus tissue predominates Full size image Fig. MRI of the cervical spine in a year-old woman with advanced peripheral RA, neck pain and clinical signs of myelopathy.

The osseous spinal canal has a width of approximately 7 mm black line. It can cause instability in the C2-Th1 region, costovertebralis arthrosis is mainly seen in patients with severe chronic peripheral arthritis. Anterior subluxation is far more frequent than posterior subluxation. It is defined as at least 3 mm forward slippage of a vertebra relative to the underlying vertebra by radiography including a flexion készítmények a nyaki gerinc osteochondrosisának kezelésére Fig.

The instability may progress over time, especially if the C1—C2 region is stabilised surgically Fig. Osseous changes erosions, etc. Additionally, MRI visualises soft tissue structures pannus; spinal cord, etc.

Imaging the spine in arthritis—a pictorial review

CT demonstrates erosion not only at the base of the dens, but also at the tip and at the atlanto-axial and atlanto-occipital joints, which are difficult to visualise by radiography. The post-contrast T1FS images confirm the presence of vascularised enhancing pannus around the dens white arrows and demonstrate improved anatomical delineation compared with the STIR image. There is no sign of spinal cord compression Full size image Fig. MRI in a year-old woman with peripheral erosive RA and neck pain, but normal cervical radiography.

There is also a subchondral enhancing costovertebralis arthrosis in the axis black arrow compatible with a pre-erosive lesion Full size image A diagnostic strategy according to Younes et al.

It is recommended to monitor patients with manifest peripheral erosions accompanied by RF rheumatoid factor and antiCCP antibodies to cyclic citrullinated peptide positivity every second year and patients with few peripheral erosions and RF negativity at 5-year intervals. MRI is indicated in patients with neurological deficit, radiographic instability, vertical subluxation and subaxial stenosis [ 23 ].

Visualisation of the spinal cord is especially important to detect cord injury or risk of injury. According to Younes et al. It should at least include open-mouth and lateral views in neutral and flexed positions. MRI is indicated in patients with neurological deficit, radiographic instability, atlanto-axial impaction and subaxial stenosis. CT may add information in rotatory and lateral subluxation because of the possibility of secondary reconstruction in arbitrary planes and a clear visualisation of the atlanto-occipital joints [ 6 ] Full size image Seronegative spondyloarthritides According to European classification criteria [ 89 ], SpA is divided into: 1 ankylosing spondylitis AS2 psoriatic arthritis, 3 reactive arthritis, 4 arthritis associated with inflammatory bowel disorders enteropathic arthritis and 5 undifferentiated SpA.

Inflammatory changes at the sacroiliac joints always occur in AS and are part of most other forms of SpA. Spinal changes are also a feature of SpA, especially in the late stages of AS. Ankylosing spondylitis Ankylosing spondylitis is the most frequent and usually the most disabling form of SpA.

It has a genetic predisposition in the form of a frequent costovertebralis arthrosis with the human leukocyte antigen HLA B27 [ 10 ]. AS often starts in early adulthood and has a chronic progressive course.

Though this was a giant leap forward there was still a spatial limitation because of the SPECT component of the fused imaging.

It is therefore important to diagnose this disorder. These criteria costovertebralis arthrosis still used in the diagnosis of AS despite the increasing use of MRI to detect the disease early. It is therefore important to know both the characteristic radiographic features and the MR features of Hát térd fájdalom. These changes are caused by inflammation at the insertion of the annulus fibrosus enthesitis at vertebral corners provoking reactive bone formation [ 12 ].

The costovertebral joint is found in the thoracic region of the spine. These joints are made by the connection of the head of the rib to the vertebral column. The head of the rib will align with its corresponding vertebrae and the inferior portion of the vertebrae above.

Later on slim ossifications appear in the annulus fibrosus syndesmophytes Fig. With disease progression the spine gradually fuses because of syndesmophytes costovertebralis arthrosis the intervertebral spaces in addition to fusion of apophyseal joints, resulting in complete spinal fusion bamboo spine; Fig.

In costovertebralis arthrosis disease the supra- and interspinous ligaments may ossify and be visible on frontal radiographs as a slim ossified streak Fig.

When the ligamentous ossification occurs costovertebralis arthrosis with ossification of apophyseal joint capsules, there are three vertical radiodense lines on frontal radiography trolley-track sign.

There are additional erosive changes black arrows, c not clearly delineated by radiography and slight oedema at the vertebral corners white arrows, b. The interspinous ligaments are ossified, presenting as a slim ossified streak on the frontal radiograph dagger sign; arrows.

MRI, sagittal T1-weighted images of c the cervico-thoracic and d lumbar costovertebralis arthrosis, respectively, shows a general narrowing of the intervertebral discs with partial osseous fusion of the vertebral bodies, especially in costovertebralis arthrosis lumbar region arrows. Persistent movement at single intervertebral spaces may occur in an otherwise ankylosed spine, sometimes caused by non-diagnosed fractures.

This can result in pseudo-arthrosis-like changes with the formation of surrounding reactive osteophytes due to excessive mechanical load at single movable intervertebral spaces [ 14 ]. The diagnosis of such changes may require a CT examination to obtain adequate visualisation Fig. There is surrounding osteophyte formation at this iv space arrows.

Supplementary CT, c sagittal and d coronal 2D reconstruction, demonstrates lack of fusion of the costovertebralis arthrosis bodies and apophyseal joints at this level arrows. Fractures may occur after minor trauma because of the spinal stiffness and frequently accompanying osteoporosis. Fractures often occur at intervertebral spaces, but usually involve the ankylosed posterior structures and are thereby unstable Fig.

Obvious fractures can be diagnosed by radiography, but fractures may be obscured. It is therefore mandatory to supplement a negative radiography with CT if fracture is suspected in the case of trauma history or a change in spinal symptoms. The occurrence of cervico-thoracic fractures may cause spinal cord injury and be lethal even following minor trauma [ 17 ].

The lateral view demonstrates a slight malalignment at the anterior aspects of the vertebral bodies of Th9 and Th10, and the iv is irregularly narrowed on the AP view, all suggesting fracture arrows. CT, c sagittal and d coronal reconstruction, shows fracture through the iv space and the posterior structures arrows.

There is widening of the intervertebral space anteriorly in the supine position used for CT compared with the upright position used during radiography Full size image Cross-sectional CT or MR imaging can be advantageous in the diagnosis of AS changes. CT providing a clear delineation of osseous structures is the preferred technique for visualising pseudo-arthrosis and detecting fractures Figs. Costovertebralis arthrosis is superior to MRI in costovertebralis arthrosis minor osseous lesions such as erosion and ankylosis of the apophyseal, costo-vertebral and costo-transversal joints Fig.

It has therefore gained a central role in the evaluation of disease activity [ 15 ]. MRI can, however, also detect sequelae of inflammation consisting of fatty deposition in the bone marrow and chronic structural changes such as erosion and fusion of vertebral bodies [ 15 ]. The inflammatory changes at vertebral corners are characteristic of AS. Hogyan lehet enyhíteni az osteochondrosis the disease course signs of activity can also occur at syndesmophytes, apophyseal joints and interspinous ligaments Fig.

Detection of inflammation at apophyseal joints by MRI, however, demands pronounced involvement histopathologically [ 19 ].

The inflammation at vertebral corners is the most valid feature costovertebralis arthrosis has been observed related to the development of syndesmophytes by radiography [ 12 ], establishing a link between signs of disease activity and chronic structural changes. There are multiple high signal intensity areas corresponding to vertebral corners white arrows. Additionally, osseous oedema of the costo-vertebral joints a, black arrows seen on the lateral sagittal slice of the thoracic spine. Note that costovertebralis arthrosis osseous oedema in the pedicle of Th12 extends to the region of the costo-vertebral joint.

Fatty marrow deposition seems to be an important sign of chronicity being significantly correlated with radiographic changes, in particular vertebral squaring [ 15 ].

Erosions are more frequently detected by MRI than by radiography Fig. Syndesmophytes, however, may not always be visible by MRI because they may be difficult to distinguish from fibrous tissue unless there is concomitant active inflammation or fatty deposition Figs.

Sagittal T1 of a the cervico-thoracic and b the lumbar spine of the patients shown in Fig. There are multiple fatty marrow depositions at vertebral corners and also posteriorly in thoracic vertebral bodies b, arrows. This was observed to have developed since the MRI performed 3 years previously shown in Fig. Several studies have shown that MR changes are frequent in the thoracic spine Fig. Supplementary costovertebralis arthrosis slices can be necessary for visualising involvement of apophyseal, costo-vertebral and costo-transversal joints Fig.

Post-contrast T1FS sequences can sometimes be advantageous as they provide better anatomical delineation [ 26 ]. Whole-body MRI gives the possibility of detecting involvement in other areas without losing important information about spinal and sacroiliac joint involvement [ 2829 ]. Other forms of SpA Radiographic changes in reactive and psoriatic arthritis are often characterised by voluminous non-marginal syndesmophytes parasyndesmophytes or coalescing ossification of the paravertebral ligaments in addition costovertebralis arthrosis asymmetrical sacroiliitis Fig.

There was no concomitant sacroiliitis. However, in patients with chronic reactive arthritis and HLA B27 the axial changes may progress to changes somewhat similar to those seen in AS and can then be regarded as AS elicited by infection [ 10 ].

Axial PsA may be clinically silent [ 33 ], and involvement of the cervical spine is frequent atlanto-axial or apophyseal joint changes. The cervical changes may include atlanto-axial instability as costovertebralis arthrosis in RA Fig. In PsA radiography and CT usually visualise new bone formation in the region of the dens.

The above-mentioned and illustrated MR findings in PsA are based on personal observations and seem to reflect the radiographic changes encompassing a mixture of osteitis, enthesitis and erosion. SAPHO is a collective term often used for inflammatory disorders primarily presenting with osseous hyperostosis and sclerosis, and they are frequently associated with skin disorders.

The PsA changes shown in Fig. However, this patient did not have anterior chest involvement. Additionally, ankylosis krónikus osteochondrosis the apophyseal joints black arrows and new bone formation anterior to the C vertebral bodies white arrows. CT, c axial slice and coronal reconstruction of the dens area, demonstrates new bone formation in the atlanto-axial region arrows ; d coronal reconstruction of the lower cervical region shows voluminous new bone formation on the right side of costovertebralis arthrosis vertebral bodies arrows.

MRI, e sagittal STIR and f T1-weighted images, shows homogeneous osseous inflammation corresponding to the dens arrows with surrounding irregular oedema compatible with a mixture of osteitis and enthesitis.

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Note that the anterior new bone formation visualised by radiography is difficult to detect on MRI Full size image Fig. However, by MRI there may be more pronounced inflammation in the posterior ligaments than seen in the other forms of SpA Fig. Sagittal STIR image of the lumbar spine in a year-old man with ulcerative colitis demonstrates oedema corresponding to the interspinous ligaments arrows and spinous processes as signs of inflammation.

There are only minimal activity changes corresponding to the vertebral bodies, located to the anterior vertebral corners Rheumatoid arthritis kezelés lábujjak size image Conclusion Radiography is still valuable in the diagnosis of spinal inflammatory disorders.

It is necessary for visualising instability and is superior to MRI for detecting syndesmophytes. However, MRI and CT can detect signs of spinal involvement costovertebralis arthrosis they can be visualised by radiography. MRI adds information about potential involvement of the spinal cord and nervous roots in addition to signs of disease activity and chronic changes such as fibrous pannus in RA and fatty marrow deposition, erosion and vertebral fusion in SpA. MRI is therefore widely used to monitor inflammatory spinal diseases, especially during anti-TNF therapy.

Computed tomography is particularly valuable in the detection of fracture and minor osseous lesions as well as in the evaluation of pseudo-arthrosis. Costovertebralis arthrosis 33 21 —