Advices for diagnostics of ankylosing spondylitis / axial spondyloarthritis: A review Part 2. Spinal column involvement

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Abstract

This article, written by a rheumatologist and a radiologist who have been diagnosing ankylosing spondylitis – AS (axial spondyloarthritis) for many years, provides advice on the rational recognition of these diseases. The second part of the article provides information on changes in the spinal column typical of AS / axial spondyloarthritis, which have diagnostic significance and determine the prognosis of the so-called central type of AS.

About the authors

Nikolay V. Bunchuk

"Klinika Sesil'+" LLC

Author for correspondence.
Email: nbunchuk@yahoo.com
ORCID iD: 0000-0002-4728-400X

D. Sci. (Med.)

Russian Federation, Moscow

Antonina V. Levshakova

Hertsen Moscow Oncology Research Institute – branch of the National Medical Research Radiological Centre

Email: nbunchuk@yahoo.com
ORCID iD: 0000-0002-2381-4213

D. Sci. (Med.)

Russian Federation, Moscow

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2. Fig. 1. Patient Sh., 45 years old. Diagnosis – AS, absence of HLA-B27, duration of the disease – 20 years. Radiograph of the lumbar spine in lateral projection: "glossy" corners of the anterior contours of the bodies LIV and LV. The emerging syndesmophyte between LV and LIV.

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3. Fig. 2. Patient Z., duration of AS – 6 years. MRI of the lumbar spine (sagittal plane, T2-FS mode): edema zones are visible in the anterior corners of the bodies LI, LIV and LV (anterior spondylitis) and in the posterior-upper corner LIII (posterior spondylitis).

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4. Fig. 3. A patient with AS, the duration of the disease is 8 years. On the left, on the postmortem radiograph in ThXI–ThXII , signs of anterior spondylitis are visible: "glossy" anterior corners, erosion along the anterior surface of the bodies (upper, lower arrows), on the right – a microscopic picture of the part of the vertebra indicated on the radiograph by the upper arrow. There is an infiltration of bone tissue by inflammatory cells. L – anterior longitudinal ligament (unchanged), C is the cortical layer, S is the spongy bone, O is an osteoid, CW is a fragment of fibrous bone, SW is a fragment of fibrous bone [2].

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5. Fig. 4. Patient G., 40 years old. The diagnosis is AU, the duration of the disease is 20 years. MRI of the thoracic spine (sagittal plane, T2-FS mode): zones of edema in the bodies of ThXI–ThXII vertebrae, adjacent closure plastics are usurated, the height of the disc between them is increased, the signal of its structure is inhomogeneously increased (spondylodiscitis).

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6. Fig. 5. Patient R. Diagnosis – AS. Radiographs of the lumbar spine: a – disk thin non-protruding syndesmophytes typical for AU, connecting the anterior corners of the vertebral bodies; b – symmetrical disc syndesmophytes, ossification of the interosseous ligament ("bamboo stick").

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7. Fig. 6. Radiographs of the spine of different patients. Type I parasindesmophyte is directed cranially (a) or caudally (b), slightly curved, may touch an adjacent vertebra, but does not fuse with it, resembles the shape of a bull's horn. Parasindesmophyte type II (a) is located at the level of the intervertebral space, is short, has smooth contours, does not contact the vertebral bodies (similar to an inset bone). Type III (c) parasindesmophyte is also characterized by the absence of contact with vertebral bodies; it has an irregular elongated shape and is located not only at the level of the gap, but also along neighboring vertebral bodies [Source: Dihlmann W. Diagnostic radiology of the sacroliac joints. Georg Thieme Verlag Stuttgart, NY. 1980].

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8. Fig. 7. Patient P., 55 years old. The diagnosis is SAPHO syndrome (duration – 10 years) with lesions of the sternum, collarbones, thoracic and lumbar spine; palm and foot pustules. A CT scan of the thoracic organs (sagittal plane) was performed: wedge-shaped deformation of ThVI,VII,VIII bodies, their ankylosing, foci of destruction and sclerosis, erosion of the lower end plate ThVIII, anterior osteophytes are visible. There is also osteitis of the sternum handle: contour enlargement (hyperostosis), foci of destruction and osteosclerosis.

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9. Fig. 8. Patient B., 33 years old. Diagnosis – osteomyelitis of the vertebral bodies LI and LII probably of staphylococcal nature: a – x-ray of the lumbar spine: destruction of adjacent sections LI and LII; b – MRI (sagittal plane, T2 mode): discitis in segments ThXII–LI and LII–LIII; c – MRI (axial plane, T2-STIR mode): paravertebral fluid formation. 2.3×1 cm (arrow) in the area of the left iliopsoas muscle (intestine).

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10. Fig. 9. Modic type KM changes. The top row. MRI in the sagittal plane. Type Changes Modic I in bodies LIV and Lv near adjacent end plates against the background of narrowing of the intervertebral space, marginal osteophytes and disc prolapse: a – T1 mode – a signal of reduced intensity in the zone of changes; b – T2-FS mode – a hyperintensive signal in the zone of changes (edema KM). Middle row. MRI in the sagittal plane. Modic II type changes in the anterior sections of the LV and SI bodies near adjacent end plates against the background of narrowing of the intervertebral space and prolapse of the disc. In the zone of changes, there is an increase in signal intensity in T1 (c) mode and T2 (d) mode, a decrease in intensity in T2-FS (e) mode – fatty infiltration of KM. The bottom row. Modic III type changes in the anterior parts of the bodies ThVII and ThVIII: f, g, h – MRI in the sagittal plane. Semicircular zones of isointensive signal in T2 (f), T1 (g) and low intensity signal modes in T2-FS (h); i – CT in sagittal

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