HYPEROSTOSIS AND OSSIFICATION IN THE CERVICAL SPINE

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564 RADIOLOGIC VIGNETTE HYPEROSTOSIS AND OSSIFICATION IN THE CERVICAL SPINE DONALD RESNICK A variety of diseases can produce hyperostosis or ossification in the cervical spine.

1 564 RADIOLOGIC VIGNETTE HYPEROSTOSIS AND OSSIFICATION IN THE CERVICAL SPINE DONALD RESNICK A variety of diseases can produce hyperostosis or ossification in the cervical spine. Included among these are ankylosing spondylitis, psoriatic spondylitis, diffuse idiopathic skeletal hyperostosis (DISH), ossification of the posterior longitudinal ligament (OPLL), sternocostoclavicular hyperostosis (SCCH), juvenile chronic arthritis, and acromegaly. Routine radiography will generally allow accurate diagnosis, especially if one carefully analyzes the lateral projection of the cervical spine. Ankylosing spondylitis Radiographic abnormalities in the cervical spine are not infrequent in patients with ankylosing spondylitis, particularly women, and in disease of long duration (1). A characteristic finding in all spinal segments is the syndesmophyte, representing ossification in the outer fibers of the anulus fibrosus, which leads to thin, vertically-oriented radiodense shadows extending from the corner of one vertebral body to the next (Figure 1). Either the upper or lower portion of the cervical spine can be initially affected, the degree of anterior bone formation is generally limited, and the resulting spinal contour usually remains smooth. The vertebral bodies are of normal size, although osseous resorption along the anterior aspect of the lower cervical vertebral bodies can be a late radiographic From the Veterans Administration Medical Center, La Jolla, California. Address reprint requests to Donald Resnick, MD, Veterans Administration Medical Center, V-114, 3350 La Jolla Village Drive, La Jolla, CA Submitted for publication December 19, 1983; accepted in revised form January 4, finding. The intervertebral discs may appear diminished in height and contain calcification. Apophyseal joint narrowing and bony ankylosis can occur in one or more cervical segments. Additional alterations that may occur include atlantoaxial subluxation and resorption of spinous processes in the lower cervical spine. Psoriatic spondylitis Involvement of the sacroiliac joints and spine is a well-recognized manifestation of psoriatic arthritis (2). Symmetric or asymmetric sacroiliitis is frequently combined with characteristic spinal abnormalities that include the presence of broad, asymmetrically distributed bone formation, termed paravertebral ossification, in the thoracic and lumbar regions. In the cervical spine, osseous excrescences tend to form initially in the lower segment and progress in a cephalic direction. In the lateral projection, the degree of new bone formation is commonly more extensive than that in ankylosing spondylitis (Figure 2). An ill-defined or fluffy mass of new bone can be initially evident, extending across the intervertebral disc. Over a period of time, similar changes at other discal levels combined with bone formation in the anterior aspect of the vertebral body are seen and, with maturation, become better defined or marginated. Involvement of the lower cervical vertebrae, a greater degree of anterior bone formation, and decreased evidence of bony ankylosis of apophyseal joints are findings that favor the diagnosis of psoriatic spondylitis over that of ankylosing spondylitis. Atlantoaxiai subluxation can be evident in patients with either disease. Arthritis and Rheumatism, Vol. 27, No. 5 (May 1984)

RADIOLOGIC VIGNETTE 565 Diffuse idiopathic skeletal hyperostosis DISH (ankylosing hyperostosis of Forestier and Rotes-Querol) is an ossifying diathesis leading to bone formation in spinal and

Although the thoracic and lumbar segments of the vertebral column are more frequently and severely affected than the cervical segment in most patients with DISH, isolated or predominant involvement

2 RADIOLOGIC VIGNETTE 565 Diffuse idiopathic skeletal hyperostosis DISH (ankylosing hyperostosis of Forestier and Rotes-Querol) is an ossifying diathesis leading to bone formation in spinal and extraspinal sites, paraarticular osteophytes, and ligamentous calcification and ossification (3). Although the thoracic and lumbar segments of the vertebral column are more frequently and severely affected than the cervical segment in most patients with DISH, isolated or predominant involvement in the cervical spine can be observed. Alterations are more prominent on lateral radiographs than on frontal radiographs of the spine. Figure 2. Psoriatic spondylitis. New bone formation is seen along the anterior aspect of the lower cervical vertebral bodies. The degree of bonz formation is somewhat more prominent than that in ankylosing spondylitis. The apophyseal joints are not involved. Figure 1. Ankylosing spondylitis. Thin, vertically-oriented outgrowths, termed syndesmophytes, extend between the margins of the vertebral bodies (arrows). The resulting spinal contour is smooth. Apophyseal joint space narrowing and bony ankylosis can be seen. Abnormalities are more common in the lower cervical region (between the fourth and seventh cervical vertebral bodies) than in the upper cervical region. Bony excrescences in this area vary from 1 to 12 mm in thickness (Figure 3). Initially 7 hyperostosis of the cortex along the anterior surface of the vertebral body

566 RESNICK Ossification of the posterior longitudinal ligament OPLL is a condition of unknown etiology occurring in the spine, especially in the cervical region. It Figure 3.

The resulting spinal contour is bumpy at some cervical levels, and the new bone has obliterated the anterior aspect of the vertebral bodies.

3 566 RESNICK Ossification of the posterior longitudinal ligament OPLL is a condition of unknown etiology occurring in the spine, especially in the cervical region. It Figure 3. Diffuse idiopathic skeletal hyperostosis. Exuberant new bone formation along the anterior aspect of the lower cervical spine can be seen. The resulting spinal contour is bumpy at some cervical levels, and the new bone has obliterated the anterior aspect of the vertebral bodies. Radiolucent disc extensions have created areas of interruption of bone formation in the upper cervical spine. is seen. Gradually, elongated bony outgrowths appear at the anterior margin of the vertebra and extend across the intervertebral disc space. Progressive bony deposition can be either smooth and homogeneous or bumpy and irregular, but is usually sharply marginated. A flowing pattern of ossification may result, but this ossification is frequently interrupted by radiolucent disc extensions at the level of the intervertebral disc spaces. Associatcd apophyseal joint narrowing and bony sclerosis and ossification of the ligamenturn are sometimes Ossification and OSteoPhYtosis involving the Posterior aspect ofthe vertebra1 bodies and intervertebral discs are infrequent. Figure 4. Ossification of the posterior longitudinal ligament. Observe a radiodense plaque (arrow) extending along the posterior surface of the second and third cervical levels. A lucency separates the ossified mass from the posterior margin of the second cervical vertebral body. Anteriorly, typical osteophytes can be seen.

RADIOLOGIC VIGNETTE 567 Sternocostoclavicular hyperostosis SCCH is a rare syndrome characterized by hyperostosis and soft tissue ossification between thc clavicle and anterior part of the upper ribs

Although the reported radiographic features in the spine resemble those in ankylosing spondylitis or DISH, there are subtle differences in many patients that allow precise diagnosis.

4 RADIOLOGIC VIGNETTE 567 Sternocostoclavicular hyperostosis SCCH is a rare syndrome characterized by hyperostosis and soft tissue ossification between thc clavicle and anterior part of the upper ribs (5). It is associated with a skin lesion, pustulosis palmaris et plantaris, in a significant number of cases (6). Many patients with SCCH have abnormalities of the spine or sacroiliac joints, or both. Although the reported radiographic features in the spine resemble those in ankylosing spondylitis or DISH, there are subtle differences in many patients that allow precise diagnosis. In addition to the ossified masses in the chest wall, exuberant new bone formation in the cervical spine is distinctive (Figure 5). An ossified plaque along the anterior aspect of the vertebral bodies and interverte- Figure 5. Sternocostoclavicular hyperostosis. Tremendous new bone formation involving the anterior aspect of the entire cervical spine has resulted in obliteration of the anterior margins of both the vertebral bodies and the intervertebral discs. The entire discovertebra1 junction is obliterated. Apophyseal joint ankylosis is prominent. is most frequent in Japanese people and in patients with DISH (4). It is the radiographic appearance, especially as seen on the lateral radiograph of the cervical spine, that establishes the diagnosis of OPLL. A dense ossified strip or plaque of variable thickness (1-5 mm) is evident along the posterior margin of the vertebral bodies and the intervertebral discs (Figure 4). The abnormality is most frequently observed in the midcervical region (C3-C5) although any cervical level (or rarely, a thoracic or lumbar level) may be affected. The ossification is Often separated from the Figure 6. Juvenile chronic arthritis, Findings include widespread body by a thin 'One. Anterior apophyseal joint ankylosis, especially in the upper cervical region, osteophytes are frequently identified (30-50% of Pa- and dwarf-like alterations of the vertebral bodies. Note the small tients) and some patients have DISH. size of the intervening intervertebral discs.

5 568 RESNICK space narrowing and bony ankylosis, and subchondral erosions of the vertebral bodies. Ankylosis of the apophyseal articulations is usually more prominent in the upper cervical region than in the lower region (Figure 6). It is the growth disturbance of both the vertebral bodies and the intervertebral discs that allows accurate diagnosis in most patients. Decreased vertical and anteroposterior diameters of the vertebral bodies are seen at levels of apophyseal joint ankylosis. The adjacent intervertebral discs are also diminished in height or completely obliterated, and they may contain calcification. Syndesmophytes can be seen. The resulting radiographic appearance in juvenile chronic arthritis, consisting of dwarf-like alterations of both the vertebral bodies and the intervertebra1 discs and apophyseal joint ankylosis, is indeed diagnostic. Although apophyseal joint ankylosis is also seen in ankylosing spondylitis, the vertebral bodies are not significantly diminished in size, nor are the intervertebral discs diminutive, because the disease onset Dccurs at a more advanced age. Figure 7. Acromegaly. Subtle changes are apparent. There is a slight increase in the anteroposterior diameter of the vertebral bodies, and osteophytes are present at multiple discal levels. bra1 discs is seen in some cases. The plaque may contain areas of increased radiodensity and appear poorly defined. It obscures the anterior border of the vertebral body and the intervertebral disc. Furthermore, the entire discovertebral junction can be obliterated and bony ankylosis of the apophyseal joints can be observed. When all these abnormalities are present, the diagnosis of SCCH is certain since no other condition leads to identical alterations. Juvenile chronic arthritis Cervical spine abnormalities are observed in many varieties of juvenile chronic arthritis. Findings include subluxation (especially at the atlantoaxial level), erosions of the odontoid process, apophyseal joint Acromegaly Elongation and widening of the vertebral bodies are observed in some patients with acromegaly. The changes are more frequent in the thoracic and lumbar segments than in the cervical region (Figure 7). In addition to an increase in anteroposterior (and lateral) diameter of the vertebral bodies, osteophytes at the discovertebral junction can be seen. The changes resemble those associated with degenerative disease of the intervertebral disc (spondylosis deformans) although in the thoracic and lumbar spine, an increase in height of the intervertebral discs, hypertrophic changes in the apophyseal joints, and increased concavity of the posterior surface of the vertebral bodies are distinctive. REFERENCES 1. Resnick D, Dwosh IL, Goergen TG, Shapiro RF, Utsinger PD, Wiesner KB, Bryan BL: Clinical and radiographic abnormalities in ankylosing spondylitis: a comparison of men and women. Radiology 119: , Killebrew K, Gold RH, Sholkoff SD: Psoriatic spondylitis. Radiology 108:9-16, Resnick D, Shapiro RF, Wiesner KB, Niwayama G, Utsinger PD, Shad SR: Diffuse idiopathic skeletal hyper-

6 RADIOLOGIC VIGNETTE 569 ostosis (ankylosing hyperostosis of Forestier and Rotes- 5. Kesnick D: Sternocostoclavicular hyperostosis. AJR Querol). Semin Arthritis Rheum 7: , : , Resnick D. Guerra J Jr, Robinson CA, Vint VC: Associa- 6. Sonozaki H, Mitsui H, Miyanaga Y, Okitsu K, Igarashi tion of diffuse idiopathic skeletal hyperostosis (DISH) M, Mayashi Y, Matsuura M, Azuma A, Okai K, Kawaand calcification and ossification of the posterior longitu- shima M: Clinical features of 53 cases with pustulotic dinal ligament. AJR 131: , 1978 arthroosteitis. Ann Rheum Dis 40: , 1981

Properties of Purdue. Anatomy. Positioning AXIAL SKELETAL RADIOLOGY FOR PRIVATE PRACTITIONERS 11/30/2018

Properties of Purdue. Anatomy. Positioning AXIAL SKELETAL RADIOLOGY FOR PRIVATE PRACTITIONERS 11/30/2018 AXIAL SKELETAL RADIOLOGY FOR PRIVATE PRACTITIONERS Anatomy Complex Text book is needed Species Contrast Positioning Painful/ non cooperative Sedation General anesthesia Species Contrast 1 Slightly oblique