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331 Cards in this Set
- Front
- Back
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Facet joint arthrosis
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due to biomechanics:
Osteophytosis Subchondral sclerosis Loss of joint space = synovial cysts Degenerative hypertrophy |
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Explain degenerative hypertrophy via facet arthrosis
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Foraminal encroachment (+ uncovertebral joints)
Spinal stenosis = radiculopathy, myelopathy Lateral recess stenosis |
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Facets will adapt to abnormal loading but in lumbar _________ and cervical ______ it's worse
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hyperlordosis
lordosis MOre common in upper to middle segments but disc problems more at C4-C5 |
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Best view for facet joint arthrosis
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AP view
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Synovial cysts are not visualized on
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xrays
But patients do feel them |
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synovial cyst
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outpouching of synovial capsule that bulges out, ie in the cervical spine, in front of the facet or in the back of the facet.
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Worse front of facet or back of facet synovial cyst?
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front = spinal or foraminal stenosis
More common at L4-5 joint************ |
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Content of synovial cyst is fluid. MRI
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high on T1, low on T2
Will see it compressing descending nerve roots |
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tx for synovial cyst
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surgery drain and cut if intractable
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appearance of facet joint arthrosis on xrat
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cloudy!
Degeneration; increased density on AP |
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You can't get uncovertebral joint arthrosis unless
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there is NARROWING of the disc space
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describe uncovertebral joint arthrosis
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Hypertrophy > rounding > osteophytes
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Horizontal radiolucency overlapping superior vertebral body, seen on lateral projection
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PSEUDO-FRACTURE appearance of uncovertebral joint
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Leading cause [w/ facet arthrosis] of cervical spine NEURAL FORAMINAL ENCROACHMENT
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UNCOVERTEBRAL joint arthrosis
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two things that narrow IVF in cervical
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uncovertebral joint arthrosis
facet joint arthrosis |
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What happens to the joints of uncovertebral arthrosis?
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become HORIZONTAL in CERVICAL spine
and compress nerve roots |
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Lumbar spine nerve root only takes up 10% of IVF, but inflammation can cause
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RADICULOPATHY with only the 10% occlusion!
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Ligamentum flavum hypertrophy
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Previously thought to be caused by disc space narrowing and ligament buckling but now proven to represent TRUE hypertrophy
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Ligamentum flavum hypertrophy leads to
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SPINAL CANAL STENOSIS - only in these cases is the LF removed
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What kind of infiltration of the Ligamentum Flavum causes the rate of contracture to be slowed down?
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Fatty infiltration on same side as ligamentum flavum hypertrophy; rate of contracture slowed down w/ fatty atrophy. Delay > chronic back pain; 1st acute LBP then fatty infiltration of multifidi and paraspinal musculature craps out because no innervation and now full of FAT so slow firing = PAIN
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Denervation of spinal nerves
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Think dorsal ramus to multifidus:
Edema FATTY ATROPHY Denervation after a year due to lack of nerve supply; muscle wastes away (cannot really rejeuvenate that mm) = DELAYED contraction due to FAT infiltration so patient keeps hurting themselves |
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MYELOPATHY definition
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Cord inflammation
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Myelopathy is compression of the _____. Changes?
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Cord compression
Leads to ischemic changes and inflammatory changes in cord |
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Types of myelopathy (2)
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DIFFUSE - MYELOMALACIA
CHRONIC - STENOSIS then CYSTIC then PERMANENT w/in 2-6 mo. |
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What is a SYRINX and what syndrome does it cause?
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Formed by duct blockage = SYRINGOMYELIA {loss of motor function is a red flag}
CAUDA EQUINA syndrome |
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Regarding disc calcification, calcified ANNULUS FIBROSIS is called?
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INTERCALARY BONES
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Cervical spinal canal stenosis
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when cord becomes flattened or pushed away
MYELOPATHY - inflammatory changes in cord |
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2 types of MYELOPATHY that result from cord ischemia
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1. MYELOMALACIA = diffuse due to cord ischemia
2. CYSTIC = chronic stenosis becomes cystic then permanent w/in 2-6 mo. |
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MYELOMALACIA
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T2 weighted image can see cord compression caused by ischemia.
If patient has symptoms and evidence of cord compression d/t myelomalacia (myelopathy or neuropathy) then refer out. |
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Imaging side of chronic myelomalacia?
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Irregular area of cord swelling w/ inflammation high signal on T2 becomes CYSTIC = permanent.
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The cord itself becomes cystic
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Chronic stage of myelomalacia (cord inflammation)
Where pt has decrease of pain and temperature, loss of fine dexterity after parasthesias in hands, loss of motor function, decrease in strength = myelopathy |
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syrinx
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central canal blocked in spine
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syringomyelia
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Cape distribution of loss due to syrinx (central canal blocked). Could be due to myelopathy (cord compression)
Can present w/ Chiari malformation |
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Etiology of radiculopathy vs myelopathy
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radiculopathy is due to foraminal stenosis so nerve root involvement at IVF
vs. myelopathy is cord compression so possible syrinx leading to syringeomyelia w/ cape pattern of loss over shoulders |
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Calcification of nucleus pulposis or annulus fibrosis?
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INTERCALARY bones:
d/dx: limbus bone teardrop fracture normal secondary ossification ctr. of vertebral endplate Nucleus pulposis |
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Is disc calcification a big deal?
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no
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Thoracic spine changes d/t degenerative spinal dz
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Costovertebral and costotransverse arthrosis
Hyperkyphosis (ie ankylosing spondylosis) |
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DSD:
SUBLUXATIONS radiographically |
visible intersegmental subluxation (malpositions) are:
ANTEROLISTHESIS RETROLISTHESIS LATEROLISTHESIS ROTATIONS ABNORMAL DISC & FACET WEDGING |
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Most subluxations seen on radiographs are __________ in nature.
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DEGENERATIVE
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Always look at posterior corner of segment _________
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above!
Anterolisthesis caused by facet degeneration - facet arthrosis (bad facets) Retrolisthesis d/t disc narrowing (bad discs) - facets slide backwards |
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Regarding ROTATIONS subluxations, beware of the
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crooked spinous process
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Regarding ABNORMAL DISC & FACET WEDGING, this type of subluxation can form _____________
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SCOLIOSIS
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Which of these is more important in anterolisthesis: disc or facet?
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FACET is anterolisthesis
Anterior slippage of segment above. Narrowing of joint space and remodeling. |
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Which of these is more important in retrolisthesis: disc or facet?
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DISC is retrolisthesis
Loss of disc height allows vertebrae above to slide back. |
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Always evaluate the ______ segment in relation to the _____ segment.
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Top
over bottom ie, where is the top segment (antero, retro, latero) |
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INTERSEGMENTAL INSTABILITY. Patients who have degenerative spinal disease may have facet arthrosis and get degenerative spondylolisthesis so what to do first?
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Take FLEXION/extension films
Instability is a contraindication to adjusting What is too much motion? Every segment should move a little. In CERVICAL spine, more than 3.5 mm from FLEXION to EXTENSION. In LUMBAR spine, more than 4 mm is TOO MUCH. |
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Intersegmental instability of cervical spine LIMIT
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3.5 mm
*more than this in the cervical spine means instability |
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Intersegmental instability of lumbar spine LIMIT
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4 mm
*more than this in the lumbar spine means instability |
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How to describe intersegmental instability on radiograph?
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Need flexion/extension views
How do you measure 3.5 mm? Draw a line along posterior aspect of BELOW vertebra, then draw a line 90 deg. from that along superior endplate of that same body. Make sure you hit the superior corner. From there, draw another parallel line along the back of the ABOVE verterbra and measure the distance between the 2 vertical, parallel lines. |
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If both measurements combined from flexion/extension views in the cervical spine measure more than ____ mm, don't do an adjustment.
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3.5
(add both flex/extend view measurements) |
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In most patients, an anterior translation w/ instability and sx of myelopathy get surgery. The presence of instability in the spine is a very __________ prognostic factor if you wait a long time and do conservative care instead.
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negative (bad outcome)
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At which point is cervical HYPERmobile?
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anything over 2 mm.
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Narrowing of interspinous space in LOWER LUMBAR spine
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BASTRUUP's disease
*WORSE with HYPERlordosis |
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What happens to spinous processes w/ Bastruup's?
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Try to prevent hyperextension. Flattening and sclerosis of sp's w/ accessory bursae on MRI.
CAPPING DEFORMITY |
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Capping deformity
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Bastruup's
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SI degeneration
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evolves w/ time = limited motion by 50 yo.
Fuse progressively throughout life Sx occur 25-35 y.o. Can be pain. Pts w. most pain are in their 20-30's! |
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Imaging for SI degeneration
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*Prominent SCLEROSIS on iliac side, etc.****but always maintain a SMOOTH CORTICAL LINE everywhere (vs. SACROILITIS if not smooth)
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Extremity djd cause
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depends on increased stress in extremity joint due to weight
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Coxofemoral jt djd
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Malum coxae senilis
Non uniform decrease in joint space - superior later aspect Subchondral cysts Osteophytes *may require replacement surgery in severe cases. |
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What is giveaway for coxofemoral djd
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superolateral aspect NON-uniform DECREASE in JOINT SPACE
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Tibiofemoral joint djd
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KNEES
Non-uniform decrease in joint space -MEDIAL > lateral (tibiofemoral jt) -Better seen w/ WEIGHT-BEARING VIEWS Leads to GENU VARUS deformity Osteophytes Subchondral cysts Subchondral sclerosis |
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Patellofemoral joint djd
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Osteophyte formation
Suchondral cyst Severe narrowing of MEDIAL tib-fib joint = NON UNIFORM LOSS OF JOINT SPACE (where, in this case, medial knee more involved than lateral) |
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Patellofemoral djd usually more prominent on _________ side.
Sign? Radiograph view? |
Lateral
Patellar tooth sign (enthesophytes on top face of patella) Sunrise |
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Chondromalacia patella
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early SOFTENING of CARTILAGE due to too much pressure or wrong tracking in adolescents and teens.
Radiographically absent = need MRI MOVIE SIGN = retropatellar pain sitting at movies for 2 hours w/ knees propped on seat in front of you |
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MOVIE SIGN
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retropatellar pain indicative of chondromalacia patellae where pain happens after 2 hours because patella compresses seat in front of them
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Ankle djd
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RARE except POST-trauma (severe trauma or unusual stresses like ballet)
Calcaneus = enthesophytes of ACHILLES TENDON & PLANTAR APONEUROSIS Hallux VALGUS Hallux RIGIDUS (decreased motion of 1st MTP; source of osteoarthritis pain) |
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AC joint djd
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COMMON!
- leads to IMPINGEMENT and SUPRASPINATUS degenerative tear |
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Shoulder/elbow djd
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RARE except for trauma, endocrine or metabolic anomalies (CPPD or acromegaly)
SUPRASPINATUS tears at myotendinous junction - bare/red zone has no/limited vascular supply = acquired tears |
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degenerative enthesophytes at plantar fascia
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enthesophytes are colloquially called 'heel spurs'
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***Precipitating factors for osteoarthritis
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1. Micro or macrotraumas - REPETITIVE
2. CPPD = crystal deposition dz (gout, alkaptonuria) 3. ENDOCRINE = acromegaly |
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Wrist djd
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MOST COMMON = BASAL JOINT
Other joints djd due to post trauma |
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AC djd radiograph
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1. Narrowing of inferior aspect
2. Non-uniform loss of joint space 3. Subchondral sclerosis |
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Which joints always get djd in the hand?
**this is a test question** |
DIPS & PIPS
* DIPS = Heberdeen's nodes ** PIPS = Bouchard's nodes |
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what joint of shoulder should you know well for djd that Dr. Nic likes?
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AC
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What joints almost never affected by djd but almost always affected by RA?
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MCP (2nd and 3rd)
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ERROSIVE osteoarthritis
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bridge between inflammatory and degenerative dz
INFLAMMATORY VARIATION of classic OA ***PERIPHERAL OSTEOPHYTES & CENTRAL EROSIONS**** Middle aged females |
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Where are errosive osteoarthritis sx
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PERIPHERAL OSTEOPHYTES
CENTRAL EROSIONS bilateral, symmetrical, GULL-WING peripheral osteophytes formation w/ central erosion so looks like a gull wing/ V-shaped deformity |
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GULL WING sign
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ERROSIVE arthritis
Lateral osteophytes w/ central erosions = gull wings |
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Where is GULL WING sign
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DIP and PIP most common in hands = can be in feet too
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DISH
aka? epidemiology? |
Diffuse Idiopathic Skeletal Arthrosis
AKA: FORRESTIER'S DISEASE 25% of men over age 50 15% of women over age 50 |
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DISH
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Calcification of LIGAMENTS that occur physiologically with AGE ['bone formers']
No weird labs or lifestyle habits. Just produce more bone. IDIOPATHIC! |
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CF of DISH
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STIFFNESS and mild LBP
DYSPHAGIA in cervical spine due to ALL ossification and OPLL ossification |
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If patient has DISH:
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1. Okay to adjust
2. If no OPLL, do BLOOD GLUCOSE LEVELS to test for co-morbid presentation of DIABETES MELLITUS |
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FLOWING HYPEROSTOSIS
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Calcification of ALL in cervical which BRIDGES MID-BODY TO MID-BODY of each vertebrae
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****Which ligament is most commonly calcified in DISH
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Anterior Longitudinal Ligament*****
Bridges mid-body to mid-body of anterior vertebrae - usually LOWER THORACIC SPINE [T7-11], more commonly on RIGHT because descending aorta pulsations mostly prevent it on left |
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Which side and where is DISH most common?
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RIGHT side LOWER THORACIC [T7-11] with EXTRASPINAL ENTHESOPHYTES
***DISH: CALCIFICATION of ALL |
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What is calcification vs. ossification?
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Calcification is loose disorganized Chaotic laying down of calcium
Ossification is Organized bone that fuses the spine, etc. |
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What is classic radiographic sign of DISH
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FLOWING HYPEROSTOSIS of mid-body to mid-body
vs. bridging ostoephytes that stay at level of disc and/or syndesmophytes |
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How many segments of ALL calcification needed to categorize DISH?
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*4 contiguous segments, preservation of disc spaces, no SI involvement, absence of facet djd
(separates AS from DISH) |
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Diagnostic criteria for DISH
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FLOWING ANTERIOR HYPEROSTOSIS
PRESERVATION OF DISC SPACES 4 CONTIGUOUS SEGMENTS INVOLVED ABSENCE OF FACET DJD NO SACRO-ILIAC INVOLVEMENT |
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Calcification of ALL in DISH can morph into
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ossification
*ie, causing DYSPHAGIA in cervical |
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What radiographic sign is DISH associated directly w/ ALL calcification
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CLEFT SIGN
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Can you get DISH anywhere?
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Yes, any ligaments
Iliolumbar supraspinal intertransverse extremites ligaments etc. |
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EXTREMITES DISH
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myositis ossificans
extraspinal DISH degenerative enthesophytes all synonyms |
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Patients with AS or REITERS prone to
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plantar changes of calcaneus
FLUFFY periostitis Degenerative enthesophtes extraspinal dish |
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OPLL
Most common location> |
Ossification of Posterior Longitudinal Ligament
up to 50% of patients w/ DISH (bullshit) C2-C4 Most common in Japanese population (probably bullshit, too) ***Can lead to SPINAL CANAL STENOSIS |
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Worst outcome of OPLL
***test |
****SPINAL CANAL STENOSIS at C2-C3****
Minimum sagittal space is 12mm develop radiculopathy and myelopathy |
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Causes of Carcot's joint
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Congenital insensitivity to pain
Alcoholism Diabetes mellitus (most common correlation) Neurosyphilis Trauma (paralysis) Syringomyelia Myelomeningocele Leprosy |
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What kind of SHOULDER involvement in NO
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ATROPHIC
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Charcot's is also called:
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NEUROPATHIC ARTHROPATHY
NEUROPATHIC OSTEOARTHROPATHY CHARCOT'S JOINT |
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Charcot's is djd gone
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wild!
6 D's: 1. DIstended joint 2. Density increased 3. Debris 4. Dislocation 5. Disorganization 6. Destruction Painless swelling = BAG OF BONES |
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ATROPHIC VARIETY OF CHARCOT'S JOINT
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LICKED CANDY STICK APPEARANCE
RESORPTION OF BONE TAPERED BONE ENDS *Space pops or Fun Dip! |
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Astro pop radiographic sign
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Licked candy stick sign of Neuropathic Arthropathy/Charcot's joint
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HYPERtrophic foot joints of Charcot's
******Neuropathic osteoarthropathy test question |
1. Lisfranc - amputated feet of soldiers in Napoleon's army
2. Chopart's between mid and hind foot (talonavicular and calcaneocuboid) |
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Neuropathic Osteoarthropathy of SPINE is called
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CHARCOT's JOINT
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IVOC
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vacuum phenomenon seen on radiograph
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syrinx
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CYSTIC dilation of spinal cord creates paresthesias up and down
due to congential causes like arnold chairi malformation |
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How to d/dx between ATROPHIC AND HYPERTROPHIC neuropathic osteoarthropathy
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Atrophic - eroded, licked candy stick
Hypertrophic- 6 D's |
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Synovial osteochondromatosis
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MD speak for SynovioChondroMetaplasia (SCM)
Cartilaginous loose bodies that grow with the synovial fluid |
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80% loose body calcification in joint
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SCM
2 types: PRIMARY - idiopathic, Loose bodies are all SAME SIZE SECONDARY - trauma/degeneration. Loose bodies all DIFFERENT SIZES |
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CF of SCM
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PAIN
SWELLING CREPITUS LOCKING!*** |
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WHere is SCM often found?
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KNEE * HIP
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Loose bodies
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Primary SCM (same size, idiopathic)
Secondary SCM (different size) Loose bodies are INTRA-ARTICULAR OSTEOCHONDRAL BODIES |
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Synovial chondrometaplasia
NEuropathic osteoarthropathy DISH DJD SCM |
all degenerative arthrities
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Inflammatory arthritides general:
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Most can create PANNUS formation.
All involve DIFFERENT JOINTS All heal differently Some fuse, some don't |
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Keys to inflammatory arthritides:
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LOCATION
HOW THEY HEAL |
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SCM
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SYNOVIAL MEMBRANE PROLIFERATION
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CF of Rheumatoid arthritis
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Females 20-60
BILATERALLY SYMMETRICAL (but NOT mirror presentation on both sides) SYNOVIUM INFLAMMATION MORNING STIFFNESS/ PAIN/ TENDERNESS ON MOTION SUBCUTANEOUS NODULES EFFUSIONS OF HEART PERICARDIUM FIBROSIS IN LUNG FIELDS SJOGRENS RAYNAUDS CARPAL TUNNEL SYNDROME |
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RA is worse in the __________
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MORNING, lasting at least 1 hour
*takes a few hours after they get up |
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What can be seen in RA patients
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SUBCUTANEOUS NODULES
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Anything that has a ______________ can get inflamed in RA
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TENDON SHEATH
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How many joints minimum required swollen in RA
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3 or more
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Diagnosis of RA
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need at least 4 diagnostic criteria present for more than 6 weeks
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Lab RA
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+RA factor in 70%******
(these patients look different on xray) Anemia Elevated ESR Elevated C-reactive protein HLA-DR4 |
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Most common locations of RA
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proximal interphalangeal
metacarpophalangeal wrist (MOST COMMON) |
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radiograph RA
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RAT BITE LESIONS
UNIFORM LOSS OF JOINT SPACE DEFORMITIES FIBROUS TO BONY ANKYLOSIS PERIARTICULAR OSTEOPOROSIS |
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MOST COMMON TARGET SITES RA
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*********Hand & wrist********
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Reasons for cervical instability at atlantoaxial joint in RA patient:
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Congenital anomalies (Os Odontoideum)
Trauma Odontoid erosion Transverse ligament rupture Odontoid fx |
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What is AA joint susceptible to in RA:
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BASILAR invagination
facet joint EROSION = FUSION Spinous process EROSION = PENCIL SHARPENING APPEARANCE DIsc narrowing ABSENCE of osteophytes Subluxations = STAIR STEP DEFORMITY |
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STAIR STEP DEFORMITY
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RA = anterolisthesis of up to 5 segments in a row
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Up to 80% of RA patients have ______ spine involvement. Need ________ views to rule out instability.
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Cervical
Stress |
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What is prominent around DENS of RA patient?
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PANNUS formation around dens can erode ligaments (alar and transverse) w/ irregular discovertebral jcns
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HIPS of RA
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AXIAL migration
PROTRUSIO ACETABULI Erosions Femoral head destruction due to EROSION ***small femoral head!** |
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Most common cause of BILATERAL PROTRUSIO ACETABULI*****
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RHEMATOID ARTHRITIS
(small fem head, osteopenia, joint narrowing w/ axial migration) |
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KNEES of RA
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Uniform loss of joint space medial and lateral (unlike osteoarthritis SONK is only medial side)
Joint effusion - prominent inflammation suprapatellar recess - can feel fluid. suprapatellar fossa measuring more than 1cm = joint effusion NO osteophytes Marginal erosions Osteoporosis Subchondral cysts |
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patellar and femoral joint narrowing bilateral
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RA
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Baker's cyst
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popliteal cyst b/w semimembranosus tendon and medial head of gastroc. Puts pressure on MEDIAL side of fossa
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Supraspinous tendon
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first 10 deg of abduction then kicks in after 90.
An RA patient will be very weak in first 10 degrees. |
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Shoulders of RA
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uniform loss of joint space glenohumeral all the way around
Pannus formation Bursa inflamed and leads to supraspinous tendon tear (FULL thickness) Humeral head migrates superiorly b/c of deltoid = NARROWING OF ACROMIO-HUMERAL SPACE |
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Shoulders of RA
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CUFF tear
Clavicular erosions - TAPERED DISTAL CLAVICLE |
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ELBOWs of RA
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90% have a POSITIVE FAT PAD SIGN*****
PANCOMPARTMENTAL LOSS OF JOINT SPACE Marginal erosions BURSITIS -very large OLECRANON bursa; posterior aspect of joint can be inflamed showing the LINEAR FATTY PLANE to be abnormal |
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By definition, JCA is present in patients ____ years of age or less
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16
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Name of Juvenile Chronic Arthritis that is mostly systemic and less arthritic
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Still's Seronegative Systemic
Still's Seronegative Systemic Still's Seronegative Systemic *fever, lymphadenopathy, splenomegaly and hepatomegaly. *reduced growth of joints and bones (bird faces = small jaw) |
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Types of JCA
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Stills Seronegative Systemic
Polyarticular form Pauciarticular or Mono articular form |
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CF of JCA
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Varies
FEMALES 2-5, 9-12 Fever Rash Lymphadenopathy IRidocyclitis Receded, hypoplastic mandible (bird like faces) |
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Target sites of JCA
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CERVICAL spine
HANDS WRIST |
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radiographic JCA
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BALLOONING of epiphyses
EARLY CLOSURE OF GROWTH PLATES IN HANDS & CERVICAL SPINE PERIOSTITIS =more common in juveniles than adults LATE loss of joint space uniformly GROWTH DISTURBANCES like hemophilia presentation such as ballooned epiphyses BONY ANKYLOSIS= fusion! esp facet joints, IPs, carpals, tarsals |
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SERONEGATIVE SPONDYLOARTHROPATHiES
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1. ANKYLOSING SPONDYLITIS
2. ENTEROPATHIC 3. PSORIATIC 4. REITERS 5. |
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PERIARTICULAR OSTEOPENIA in HANDS on CHILD radiograph
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Systemic manifestation of JRA
(not infection b/c only one joint is affected in hands by infection) THICKENING of bones = PERIOSTITIS for kids because loosely attached in kids. Easily widened/displaced. |
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features of JRA different from adult
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PERIOSTITIS
ABSENCE of significant erosion BALLOONING overgrowth of growth plates/epiphysis |
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Ballooning of epiphysis
Flattening or squaring of patella etc looks identical to JRA? |
Hemophilia
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Anklyosis spondylitis aka
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Marie Strumpell's disease
Bechterew's disease |
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describe Ank spondy
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***SACROILIITIS is the #1 sign**
15-35 Males Bilaterally symmetrical (early asymmetrical but becomes uniform) SYNOVIAL INFLAMMATION = high relationship w/ ENTEROPATHIC arthritis ***SI involvement is the beginning = SCLEROSIS on both sides and LOSS OF CORTICAL LINE |
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SI finding of Ank spondy
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SACROILITIS = bilateral, symmetrical SCLEROSIS and LOSS OF CORTICAL LINE
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If you can't figure the SI diagnosis, shoot a
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Ferguson's Angulated SPOT view of lumbosacral
25% tube tilt upward to compensate for L5 S1 disc tilt downward |
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spondylo
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vertebrae
|
|
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R.A.P.E. or P.E.A.R. or R.E.A.P.
|
seronegative spondyloarthropathies:
Psoriatic Enteropathic Ankylosing spondylitis Reactive/Reiters |
|
|
AS doesn't care for _________ joints but loves the _______ joint.
|
synovial = no
SI = yes!! Likes attachments of tendons and ligaments |
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Radiographic findings of AS
|
ROMANUS lesion
SHINY CORNER sign SQUARED bodies SYNDESMOPHYTES (inflammatory joint dz only) CARROT STICK FRACTURE TROLLEY TRACK sign BAMBOO SPINE ANDERSON lesion ENTHESITIS WHISKERING Achilles/Plantar fascia STRING OF PEARLS |
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ANDERSON lesion
|
endplate fracture that creates a pseudo-joint
Ankylosing spondylitis |
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ROMANUS lesion
|
ANNULAR LIGAMENT erosion of AS
|
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MARGINAL SYNDESMOPHYTES
|
ALL of AS
|
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STRING OF PEARLS
|
beaded appearance
|
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GHOST JOINTS
|
no outline
bridging of trabeculae where cortical bone should be AS |
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SYNDESMOPHYTES
|
inflammatory arthritides ONLY
|
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OSTEOPHYTES
|
same as spondylophytes for NON inflammatory osteoarthritis (DJD)
|
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SD
|
Spondylosis Deformans
|
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SD osteophytes
|
HORIZONTAL then BRIDGE
|
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DISH osteophytes
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FLOWING HYPEROSTOSIS connecting MID-BODY to MID-BODY w/ RADIOLUCENCY present
|
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AS and EA osteophytes
|
MARGINAL SYNDESMOPHYTES that are VERTICAL and EGG-SHELL THIN
|
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ENTEROPATHIC ARTHRITIS
|
INFLAMMATORY BOWEL DISEASE
*Cannot distinguish AS from EA on radiograph but AS affects much more of the spine |
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EA patients have positive ________ about 10-20%
|
HLA-B27
|
|
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Bowel problems of EA
|
Ulcerative colitis
Regional enteritis (Crohn's dz) Whipple's Intestinal infections (salmonella, shigella, yersina) |
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PsA
|
DIPs involved in 80% of patients w/ PITTING or onchyolysis or oil stains
*PITTING of nails is a slam dunk for PsA |
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PsA ages
|
20-50 males
|
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Targets for PsA
|
all digits, all fingers
HANDS FEET SI |
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Difference between RA and PsA
|
location
and PsA have a LOT OF BONE PRODUCTION = FLUFFY PERIOSTITIS and MOUSE EARS Very little OSTEOPENIA |
|
|
FLUFFY PERIOSTITIS
|
PsA
Periosteal bone formation WHISKERING at base of distal phalynx EROSIVE MARGINAL CHANGES + FLUFFY PERIOSTITIS = MOUSE EARS! |
|
|
Gull wing vs mouse ears
|
Gull is EROSIVE OSTEOARTHRITIS
vs. Mouse ears are PsA |
|
|
SPINDLE DIGIT
|
Swelling all the way around the finger, aka COCKTAIL SAUSAGE DIGITS
PsA can affect ALL digits and joints |
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|
syndesmophytes of PsA are ___________
|
NON-MARGINAL
*does not touch corner of vertebral body and thicker than eggshell syndesmophytes of AS/EA |
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In PsA changes are BILATERAL but _________
|
ASYMMETRICAL
|
|
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SI of PsA
|
BILATERAL ASYMMETRICAL SACROILITIS
|
|
|
RAY PATTERN
|
PsA
all joints affected in hand in PsA In RA, only the MCP and PIP are RAY patterned |
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|
PENCIL IN CUP deformity
|
PsA
Balancing Pagoda sign |
|
|
OPERA GLASS HAND
|
ARTHRITIS MUTILANS:
'main en lorgnette' TELESCOPING! |
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|
Lab findings for PsA
|
HLA-B27
negative Rheumatoid factor |
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|
REITER'S triad
|
can't see
can't pee can't dance w/ me Urethritis, conjunctivitis, polyarthritis caused by veneral disease or enteric infection (shigella, yersinina, salmonella) Young soldier whoring around |
|
|
REACTIVE ARTHRITIS CF
|
similar to psoriatic arthritis
skin disease KERATODERMA BLENORRHAGICA of hands and feet BALANTITIS CIRCINATA penile lesion |
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|
LOVER'S HEELS
|
clinical description/finding of Reactive/REITERS
PAIN AT calcaneal attachment OF PLANTAR FASCIA OR ACHILLES tendon |
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|
Categorical radiograph of Reactive Arthritis
|
LOVER'S HEELS: bursitis and reactive change at calcaneal attachment of plantar fascia or ACHILLES
|
|
|
Radiographically, Reiter's and ________ cannot be radiographically distinguished.
|
PsA
Non marginal syndesmophytes in spine Bilateral asymmetrical SACROILITIS |
|
|
Reversible subluxations in Hands and elevated ANA, periarticular osteopenia that is REVERSIBLE (common w/ collagen vascular diseases called reversible
subluxations) **Calcificaitons of soft tissues and osteonecrosis (bilateral AVN - fragmentation/sclerosis/bilateral flattening of articular surfaces) |
SLE
|
|
|
SLE onset
|
fever, malaise, skin rash, arthralgia, MALAR RASH
|
|
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SLE
|
Reversible subluxations in Hands and elevated ANA, periarticular osteopenia that is REVERSIBLE (common w/ collagen vascular diseases called reversible subluxations)**Calcificaitons of soft tissues and osteonecrosis (bilateral AVN - fragmentation/sclerosis/bilateral flattening of articular surfaces
|
|
|
Systemic sclerosis
|
Scleroderma
CREST: Calcinosis RAynauds Esophageal Skin calcification Telangiectasia |
|
|
Dilation of small blood vessels
|
telangiectasia
|
|
|
presentation of scleroderma CF
|
vitiligo (tightening of skin)
peripheral pain and swelling supertight ends of fingers mouse like facies dilatation of the esophagus - GERD decreased bowel function pleural/pericardial effusion |
|
|
RADIO scerloderma:
|
HANDS
*ACROOSTEOLYSIS = erosion of distal tufts *SOFT TISSUE CALCIFICATIONS (like SLE, but scleroderma has TAPERING in the DISTAL ASPECT/TUFTS) |
|
|
Osteitis condensans ilii
|
SI joints
women stress reaction on iliac side of SI joints after childbirth may simulate seronegative AS!! but NO EROSIVE CHANGES, no fusion = JUST PLAIN OL' SCLEROSIS |
|
|
Modic changes in spine are due to
|
increased stress
|
|
|
Osteitis PUBIS
|
STRESS related
non-suppurative inflammation pelvic surgery/childbirth/trauma DEGENERATION & SCLEROSIS that resembles INFECTION at pubic symphysis |
|
|
Lumpy bumpy appearance of hand and feet
|
GOUT
( a crystal deposition arthritis) |
|
|
Gout
|
Sodium MONOURATE crystals in
cartilage/synovium/periarticular/subcutaneous *Evokes strong inflammatory reaction Males 4th and 5th decades High purine intake |
|
|
4 stages of GOUT
|
asymptomatic hyperuricemia
Acute gouty arthritis Polyarticular gouty arthritis Chronic tophaceous gout |
|
|
podagra
|
gout attack
BIG toe (1st MTP joint) |
|
|
Gout labs
|
elevated ESR
leukocytosis hyperuricemia joint aspiration |
|
|
radio gout
|
EXTREMITIES
*dense soft tissue TOPHI *OVERHANGING MARGIN sign *Secondary degeneration *most common site 1st MTP = PODAGRA |
|
|
Erosions in gout are
|
CORTICATED
The overhanging margin sign look like little Codman's trianglles |
|
|
Lumpy bumpy CPPD
|
GOUT
|
|
|
big toe classic gout
|
overhanging margin
well corticated erosion (RA likes 5th toe and lots of osteopenia while erosions are non corticated and not lumpy bumpy) |
|
|
OVERHANGING MARGIN sign
|
GOUT
podagra tophi corticated margins lumpy bumpy soft tissue mass |
|
|
CPPD
|
Calcium pyrophosphate dihydrate deposition disease
|
|
|
CPPD Where are deposits?
|
deposit in FIBROCARTILAGE
ie, knees at meniscus |
|
|
CPPD CF
|
pseudogout
over 50 male may be asymptomatic acute inflammed joint bilaterally asymmetric |
|
|
CPPD where
|
knee
symphysis pubis Hand and wrist big joints synovial cartilage hips, spine |
|
|
radio CPPD
|
CHONDROCALCINOSIS = calcification of fibrocartilage
soft tissue swelling LARGE SUBCHONDRAL CYSTS PYROPHOSPHATE ARTHROPATHY |
|
|
CPPD d/dx ****
|
Hyperparathyroidism
Hemochromatosis Wilson's dz Alkaptonuria |
|
|
TRIANGULAR FIBROCARTILAGE
|
IN WRIST
EXAMPLE OF CHONDROCALCINOSIS also in meniscus of knees = CPPD |
|
|
HADD
|
Calcium hydroxyapatite deposition disease
aka CALCIFIC TENDINITIS likes tendons and ligaments!!! |
|
|
MOst common location of HADD and patterns
|
*****SUPRASPINATUS TENDON = external rotation view does not overlap humeral head. BEST VIEW for MOST COMMON SITE OF HADD. Internal rotation is opposite.
INFRASPINATUS = overlaps humeral head on external rotation. Internal rotation is opposite. SUBSCAPULARIS - internal rotation PELLEGRINI-STIEDA femoral attachment of MCL in knee LONGUS COLLI inferior attachment of anterior arch of C1/atlas = MOST IMPORTANT FLEXOR MM OF UPPER CERVICAL SPINE. Tends to calcify . IVD - annulus fibrosis: intercalary bone/ nucleus pulposis |
|
|
HADD patterns
|
SUPRASPINATUS TENDON = external rotation view does not overlap humeral head. Internal rotation is opposite.
INFRASPINATUS = overlaps humeral head on external rotation. Internal rotation is opposite. SUBSCAPULARIS - internal rotation PELLEGRINI-STIEDA femoral attachment of MCL in knee LONGUS COLLI inferior attachment of anterior arch of C1/atlas = MOST IMPORTANT FLEXOR MM OF UPPER CERVICAL SPINE. Tends to calcify . IVD - annulus fibrosis: intercalary bone/ nucleus pulposis |
|
|
HADD others
|
subacromial bursa
|
|
|
OCHRONOSIS/ALKAPTONURIA
|
HOMOGENTISTIC ACID OXIDASE absence so too much acid accumulation in body
BLACK PIGMENTATION of CARTILAGE EXCRETED IN URINE - ALKAPTONURIA HOMOGENTISTIC ACID deposited in tissues = OCHRONOSIS |
|
|
ochronosis
|
HOMOGENTISTIC ACID deposited in tissues = OCHRONOSIS
|
|
|
alkaptonuria
|
blue brown pigmentation of skin
males |
|
|
radio alkaptonuria
|
multiple disc calcification
FUSION OF SPINE w/ calcification of EVERY DISC LEVEL w/ OCHRONOSIS No disease looks like this - AS kind of. |
|
|
synonyms for DJD
|
degenerative arthritis
degenerative arthrosis degenerative disc disease Osteoarthritis Osteoarthrosis |
|
|
Describe DJD generally (osteoarthrosis)
|
Physical and chemical forces
Alter chondrocyte function Alter ground substance (loss of chondroitin sulfate) Fibrillation/Fissures/Flaking/Vascularization Loss of joint space NON-inflammatory secondary changes: subchondral sclerosis, subchondral cysts, articular deformity, synovial hypertrophy, subluxation |
|
|
DJD affects middle aged ___________ and is the degeneration of joint __________.
|
middle aged women
cartilage degeneration |
|
|
DJD:
__________decreases symptoms and reduces ankylosis |
movement!
|
|
|
Primary DJD
|
idiopathic
women w/ no prior history finger DIPS and knees** |
|
|
Secondary osteoarthrosis (djd)
|
Known precipitating factors:
TRAUMA/altered biomechanics CONGENITAL anomalies CPPD |
|
|
CF of osteoarthrosis
|
Males over 45
w/ insidious onset of stiffness, aching and pain that is worse with rest and better as day goes |
|
|
radiography of DJD
|
OSTEOPHYTES
INTRA-ARTICULAR LOOSE BODIES NON-uniform LOSS OF JOINT SPACE SUBCHONDRAL SCLEROSIS {eburnation} SUBCHONDRAL CYSTS/GEODES ARTICULAR DEFORMITY JOINT SUBLUXATION |
|
|
The radiographic correlation of loss of joint space
|
the process of CARTILAGE degredation, as in osteoarthrosis
|
|
|
where is eburnation in djd
|
Eburnation/sclerosis at area of greatest cartilage loss
|
|
|
Most easily recognized sign of djd
|
OSTEOPHYTOSIS/PHYTES
*at joint margins |
|
|
Ad, Nu, Os, Sc, Cy, IaLB, IaD, Sub:
As |
As, Nu, Os, Sc, Cy, IaLB, IaD, Sub:
Asymmetric distribution can be unilateral or bilateral. Often seen in hip. Useful to distinguish from inflammatory arthropathies [ie, RA] which are symmetric. |
|
|
As, Nu, Os, Sc, Cy, IaLB, IaD, Sub
Nu |
As, Nu, Os, Sc, Cy, IaLB, IaD, Sub
NON-uniform loss in joint space due to erosion of cartilage. At regions of greatest intra-articular stress/weight bearing, like spine, hip, knee. Selective compartmental loss of joint space due to fibrillation and cartilage destruction. |
|
|
As, Nu, Os, Sc, Cy, IaLB, IaD, Sub
Os |
As, Nu, Os, Sc, Cy, IaLB, IaD, Sub
Osteophytes = the MOST EASILY RECOGNIZED sign of djd. Bony outgrowth from adj. bone around the CAPSULAR insertion. Bony excresence w/ trabeculae. May bridge to create bony ankylosis. Cartilaginous cap. |
|
|
As, Nu, Os, Sc, Cy, IaLB, IaD, Sub
Sc |
As, Nu, Os, Sc, Cy, IaLB, IaD, Sub
Subchondral SCLEROSIS {eburnation} most prominent where cartilage loss the greatest. Thickened trabeculae. Local compensation. Sclerosis is not present unless loss of joint space. |
|
|
As, Nu, Os, Sc, Cy, IaLB, IaD, Sub
Cy |
As, Nu, Os, Sc, Cy, IaLB, IaD, Sub
Cysts/Geodes subchondral may be confused w/ neoplasm or infection. When seen w/ other signs of joint degeneration, is usually djd. Cysts reside where previously sclerosed bone occurred due to stress. Ovoid geographic loss of bone density 2-20mm in diameter near ARTICULAR surface. Fissured articular plates received synovial fluid and is replaced w/ fibroid or myxoid tissue. Usually in hip. Rarely in spine. |
|
|
As, Nu, Os, Sc, Cy, IaLB, IaD, Sub
IaLb |
As, Nu, Os, Sc, Cy, IaLB, IaD, Sub
IaLb = Intra-articular Loose Bodies/Joint mice are the FLAKING or fragments of CARTILAGE and/or subchondral bone. Especially in KNEE. Synoviochondrometaplasia (osseous and cartilaginous debris) may occur if synovium affected. SMOOTH< ROUND< OVOID but NOT seen on plain film********* |
|
|
As, Nu, Os, Sc, Cy, IaLB, IaD, Sub
IaD |
As, Nu, Os, Sc, Cy, IaLB, IaD, Sub
IaD = Intra-articular Deformity due to denuded subarticular bone from repetitive stress deforms into trabeculae, remodel then fracture until collapse!. Vascular disturbances, necrosis, djd. |
|
|
As, Nu, Os, Sc, Cy, IaLB, IaD, Sub
Sub |
As, Nu, Os, Sc, Cy, IaLB, IaD, Sub
Subluxation of joint due to progressive loss of joint space, capsular and ligamentous laxity, deformation = displacement. |
|
|
synovial fluid intrusion theory
|
the idea of geodes/cysts as the result of joint cartilage cracking under biomechanical deformation leading to fissures, then allowing syn fluid to leak in, plug w/ fibrous tissue and produce a cyst.
|
|
|
d/dx for subchondral cysts
|
DJD (geodes)
Brodie's abcess Chondroblastoma |
|
|
Dead give away radiographically for djd
|
asymmetric loss of joint space
|
|
|
Osteophyte
|
tiny, perpendicular long bone that arises at the joint capsule attachment due to cartilage metaplasia and stress on the capsule's insertion.
*DJD |
|
|
Why does uncovertebral joint osteoarthrosis cause foraminal encroachment?
|
osteophytes of uncinate process = von Luschka = foraminal stenosis of lateral recess
|
|
|
SD
|
Spondylosis Deformans:
Annulus fibrosis No loss of joint space Prominent osteophytes = TRACTION spurs cause bridging ANNULAR vacuum |
|
|
IVOC is ENDPLATE disease in the common vernacular
|
InterVertebral OsteoChondrosis:
NUCLEUS PULPOSIS goes 'away' and so does the disc space! Subchondral cysts and Schmorl's nodes result. PAIN. Nuclear vacuum. |
|
|
Strongest indicator of chronic back pain?
|
***DECREASED disc height
subchondral bone forms at endplates = pain! |
|
|
Describe SD osteophytes
|
Due to microtears of annulus fibrosis
Horizontal Bridge like a magnet man from endplate to endplate. Calcified annular fibers are the bridges. disc space maintained* |
|
|
Describe IVOC osteophytes
|
Dehydration, dessication, collapse all lead to severe narrowing of disc space. THERE IS NO ROOM FOR OSTEOPHYTES. The endplates are practically touching!
*Subchondral cysts after sclerosis, Schmorl's nodes (acquired) |
|
|
Vacuum sign for SD vs. IVOC
|
SD vacuum: right at annular tear/edge
IVOC vacuum: CENTRAL intradiscal gas p973 YR |
|
|
Keinbock's disease
|
LUNATE
osteonecrosis sequela of trauma to wrist Collapse, fragmentation, and sclerosis = SNOWCAPPED appearance |
|
|
TFCC
|
Triangular Fibrocartilage complex
|
|
|
distal ulna and proximal carpal row (luante and triquetrum) plus disc, meniscus, radioulnar ligaments, ulnar collateral ligament, and sheath of ECU tendon.
|
A triangular SIGNAL VOID arises from distal medial radius to ulnar styloid process. Apex towards radius.
TFCC tear pain and popping along ulnar wrist. Most common site for degenerative tears. Bright T2. Avulsion and fluid edema. Asymptomatic. |
|
|
associated w/ tears of posterior horn of medial meniscus of knee
|
BAKER's cyst }{popliteal}{
|
|
|
areas of serpiginous calcification at the metaphysis
|
BONE INFARCTS
can be due to steroids, blood disorders, IBS (ulcerative colitis or Crohn's), SLE or COLLAGEN VASCULAR disorders |
|
|
Myositis ossifican
|
MO
Secondary to traumatic muscle injury in young atheletes Soft tissue mass that undergoes progressive calcification Main d/dx is OSTEOSARCOMA (due to age of person and appearance on film) |
|
|
Osteochondritis Dessicans
|
children/adolescents
unknown origin SMALL NECROTIC AREA in the subchondral bone. May form joint mouse if displaces. MALE KNEES at **MEDIAL femoral condyle*** |
|
|
well-encapsulated eccentric homogenous low signal intensity mass
|
benign
ie, myositis ossificans in a teen instead of osteosarcoma |
|
|
Chondromalacia patellae
|
pathologic softening of patellar cartillage
patella alta and tracking disorder association Progressive basal layer of cartilage 'blister' appearance |
|
|
Osgood-Schlatter dz
|
PARTIAL AVULSION of tibial tuberosity at insertion of patellar tendon
young athletic males w/ anterior knee pain just below patella *a form of tendinitis assoc. w/ incomplete fusion of the tibial apophysis. High signal T2 due to minute fluid accumulation. |
|
|
ABC
|
Benign neoplastic-like lesion.
MC affects axial and proximal appendicular bones. Young people 10-30 Usually primary LONG bones @ METAPHYSIS *expansile/eccentric/soap bubble and contain blood and fibrous tissue **d/dx: GCT, condroblastoma, hemangioma, FD, SBC, osteosarcoma |
|
|
Chondrosarcoma
|
3rd most common primary malignant of bone [MOCE CL]
Axial or proximal appendicular *has a high signal or radiopaque SPOT OF CARTILAGE that looks calcified in the middle of diaphysis "Intramedullary stippled calcification" |
|
|
Malignant fibrous histiocytoma
|
MOST COMMON soft tissue sarcoma of thigh
Occurs late in ADULT life Lower extremities in people over 50 Large soft tissue mass w/ calcification and mixed signal called BOWL OF FRUIT appearance. |
|
|
Osteonecrosis
|
AVN or Ischemic necrosis of bone
In situ death of bone segment AVN of femoral head common When both MEDULLARY BONE & SURROUNDING CORTEX involved, deemed AVN Immediate subchondral regions of prox and dist femur and prox humerus use STIR to see bone marrow EDEMA to suppress fat and increase subtle fluid accumulation |
|
|
synovial cyst
|
degenerative in nature
adjacent to facet joints may cause local back pain may be gas filled = degenerative VACUUM PHENOMENON |
|
|
IVD's are avascular. How are they nourished?
|
diffusion!
metabolic exchange via the vessels that provide the vertebral bodies. Fluid exchange through perforated cartilaginous endplates that sep the disc and adj vertebral spongiosa |
|
|
The biomechanical behavior of the IVD is related to its ________ status.
|
hydration
|
|
|
The fluid in a disc distributes compressive forces in a
|
radial fashion through the annulus fibrosis
As it becomes dehydrated, so does it lose its distributive ability and becomes fibrous and rigid. Results in functionally impaired disc w/ altered load distribution. |
|
|
How does the nucleus pulposus progressively migrate towards the perimeter of the annulus fibrosis?
|
Cartilage FIBRILLATION and annular FISSURING.
These tears allow the np to migrate. when fissures extend to outer margin of annulus, herniation of np may follow. |
|
|
What determines the size and configuration of a disc?
|
Annulus fibrosis:
it is the STRONGEST portion of the disc and firmly binds the vertebrae together |
|
|
Components of annulus fibrosis
|
12-15 concentric lamellar rings that are joined by obliquely oriented fibers extending beyond the lamellae. The inner fibers resemble the nuc. pulposis but the outer 1/3 fibers have a documented NERVE SUPPLY, which explains why narrowing IVF, changes in facet mechanics or bone marrow edema would hurt like a m.f***ker.
|
|
|
What nerve provides sensory to the outer 1/3 of annulus fibrosis?
|
RECURRENT meningeal nerve of von LUSCHKA
|
|
|
3 basic types of disc lesions:
|
1. BULGING = (bulging annulus, disc bulge, ballooning disc)
2. CONTAINED = (protrusion, herniated disc, herniated nuc. pulp, subligamentous disc herniation) 3. NON-contained = (prolapse, extruded, sequestered, free floating, fragmented, ruptured, amputated, wrapped, migrated disc) |
|
|
Bulging disc
|
Circumferential, symmetric bulge of annular fibers.
Letting half air out of inner tube then sitting on it, widening the circumference. Part of natural aging process assoc w/ disc degeneration/dehydration. |
|
|
Contained disc
|
FOCAL migration of NUCLEAR material that is CONTAINED by the OUTER fibers of the annulus fibrosis.
|
|
|
NON-contained disc
|
Nuclear disc material that LEAKS OUT through tear in annulus fibrosis outer fibers.
Usually migrate upward or downward relative to parent disc SEQUESTERED/NON-CONTAINED |
|
|
A bulging disc can compress the epidural veins slightly. Why?
|
Because the round/convex dorsal face [where once was concave} is now infringing on the veins running between the spinal cord and the posterior discal and vertebral borders.
p529 YR |
|
|
Contained paracentral disc herniation means?
|
A focal migration of nucleus pulposis that has exited the annulus fibrosis to one side of the central line of the spinal cord, ie you would get ipsilateral motor fcn and it might press on the spinal nerve root of one side.
|
|
|
Worse pain: radial or concentric tear of annulus?
|
RADIAL
due to von Luschka recurrent meningeal nerve of outer 1/3 of annular fibrosis |
|
|
hard vs. soft disc
|
hard - bulges or herniations w/ adjacent OSTEOPHYTES
soft - no osteophytes |
|
|
Why does the annulus tear with age?
|
Tearing of collagen bridges between annular fibers
|
|
|
Describe a sagittal view of disc derangement BULGING disc:
|
Posterior migration of nucleus pulposis.
Annulus is intact posteriorly but has a CONVEX contour, and may press on epidural veins. Can be greater on one side. |
|
|
Disc herniations that produce myelopathy
|
CONTAINED disc usually LARGE and maintain significant MIDLINE component + congenitally narrowed canal or ligamentous hypertrophy (ie, OPLL). May produce front to back stenosis.
|
|
|
Describe a herniated nucleus pulposis on MRI (gold standard)
|
T1 weighted sagittal cervical spine:
Focal midline herniation w/ compression of subarachnoid space Exacerbation of UE pain on neck extension |
|
|
Sagittal view of disc degrangement CONTAINED DISC HERNIATION
|
Posterior extrusion of nucleus pulposis through annular tears and fissures. This focal protrusion elevates the PLL and increases the convex deformation of the posterior disc margin.
p531 YR |
|
|
Sagittal view of disc derangement NON-contained disc:
|
Non contained nuclear fragment is detached from the herniation and is extruded into the epidural space. Will move cranially or caudally within spinal canal.
p531 YR |
|
|
Increased signal intensity on T1 ENDPLATE but decreased signal intensity of L4/5 and L5/S1 DISCS
|
consistent w/ MODIC type I pattern of marrow degeneration
Inflammation: radiating leg pain and numbness of posterior thigh |
|
|
Hyperintense signal within cord
|
represents cord contusion by disc herniated T1 weighted sagittal
***MRI is the only imaging modality able to detect spinal cord contusions |
|
|
Why does a free disc fragment from a NON-contained disc herniation show high signal intensity on T2 weighted images?
|
Still is hydrated
|
|
|
Modic changes
|
endplate marrow changes described by Michael Modic in 1991:
Narrowing of disc More stress on subchondral bone Marrow changes and subchondral cysts Types I, II, III |
|
|
Type I Modic change
|
SHRINKAGE! Dessication.
EDEMA of MARROW so HIGH on T2-H2o (bright on fat suppressed images) INFLAMMATION + PAIN |
|
|
Type II Modic changes
|
FATTY marrow DEGENERATION (changed from type I edema marrow)
***MOST COMMON type in fat America is fatty marrow degeneration Low signal on T1 AND T2 unless fat suppressed then low signal |
|
|
What is most common Modic change?
|
Type II FATTY MARROW DEGENERATION in fat America
|
|
|
Type III Modic change
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SUBCHONDRAL SCLEROSIS = HEMISPHERICAL SPONDYLOSCEROSIS (say that drunk!)
***rounded appearance to endplates/hemispherical calcified bone of endplates LOW/LOW signal because appears as cortical bone |
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Normal disc characteristics
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Less than 2 mm of endplate margin
asymptomatic because normal! |
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Disc bulge characteristics
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Greater than 2mm
Less than 50% MORE than 2 mm away from endplate margins but less than 50% done lopped over the circumeference Most are asymptomatic. |
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Disc protrusion characteristics
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FOCAL = less than 25% circumference
BROAD BASED = more than 25% of the circumference Most are asymptomatic More than 50% circumference BASE exceeds AP dimension MORE than 50% of circumference |
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Disc extrusion characteristics
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EXCEEDS BASE in A>P
Superior to Inferior MIGRATION w/ SYMPTOMS |
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Disc sequestration characteristics
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SEPARATED FRAGMENT of disc
SYMPTOMATIC! |
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HIZ
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High Zone of Intensity:
**bright spot on MRI to detect annular tear T2 weighted ***Highly specific for annular tear = HIZ MRI finding |
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d/dx cancer mets from djd
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bone scan
MR w/ contrast Lab work correlate history w/ findings |
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What does a NORMAL DISC look like on MRI?
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can see nucleus pulposis via HIGH SIGNAL INTENSITY (hydrated) and annulus should be low signal intensity
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What is the NORMAL shape of a disc?
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ConCAVE! towards spinal canal
EXCEPT L4-L5 (flat) and L5-S1 (convex) |
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Why are annular fibers low signal?
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not much water
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L4 nerve root exists where?
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BELOW pedicles but ABOVE L4-L5 disc
{same for L5 nerve root = it's above the L5-S1 disc} |
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Birdseye view of disc bulge
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bullseye with red ring. disc material (red) is just outside of bullseye (disc) all the way around circumference but less than 2mm out.
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Birdseye of disc protrusion
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bullseye w/ red ring of herniation off to one side, pressing on nerve root but still less than 50% of endplate circumference.
Red ring less than 25% is FOCAL Red ring greater than 25% is BROAD ***stays at SAME level |
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Birdseye of disc EXTRUSION
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bullseye with a mini-me, surrounded by red ring
means A-P diameter is bigger than the base and it HURTS because the extrusion is sitting on a nerve root in the lateral recess |
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Birdseye of disc contained vs. NON-contained
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contained is a bullseye w/ annular fibrosis ALL THE WAY AROUND IT, keeping it contained
NON-contained is a pulposis that is still attached to the mother ship, but has NO annular fibrosis around it. It is about to be set free! |
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Birdseye of disc SEQUESTRATION
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a piece of nucleus pulposis has broken free of the parent and is on its own.
It pisses off the PLL and starts to migrate superiorly or inferiorly. SURGERY is necessary. Major symptoms. |
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surgery for disc sequestration?
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laminectomy
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RA HAND
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1. RADIAL margins of index and middle metacarpal heads (knuckles)
2. SWAN-NECK deformity: hyperex PIP, hyperflex DIP 3. BOUTONNIERE's: opposite - think of typing all the time 4.ULNAR deviation 5. HAYGARTH nodes: MCP/knuckle dislocation leading to ulnar drift 6. HITCHHIKER'S THUMB 7. Dip the SWAN head is DIP SWAN NECK for hand DJD |
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RA in WRIST
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TERRY THOMAS used a ZIG-ZAG paper - he was of SPOTTY character and hung around w/ RATSO down at The Ulnar Sty Bar.
"Ra! Ra! Ra!" Haygarth, the owner, used to yell at them because they were drifters. |
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Terry Thomas used a zig-zag paper to roll a joint. He was of spotty character and hung around w/ Ratso down at the Ulnar Sty Bar. "Ra! Ra! Ra!" Haygarth, the owner, used to yell at them because they were drifters.
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WRIST rheumatoid arthritis:
Terry Thomas sign - scapholunate widening Zig-Zag sign - radial rotation of prox carpals and ulnar drift of MCPs' Spotty carpal sign - holes, dummy Rat bite sign = erosion of styloid process DEAD RINGER for RA Bony ankylosis of midcarpals HAYGARTH nodes - MCP, tendon dislocation w/ ulnar drift |
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RA feet and famous musician
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Daniel LANOIS, who made the soundtrack for Slingblade, plays on his feet and his FIBULAs deviate, he's got fluffy periostitis of the toes and Halux valgus from his cowboy boots. He don't use no waa-waa pedal - he uses a RA-RA pedal.
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Ankylosing spondylitis radiographs
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ROMANUS
SHINY CORNER SQUARED BODIES STRING OF PEARLS/BEADS MARGINAL SYNDESMOPHYTES that are EGG-SHELL THIN (calcified annulus fibrosis fibers) GHOST JOINTS |
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Why are AS syndesmophytes called UNDULATING?
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both sides of spine!
egg-shell thin w/ a vertical pattern margins only The undulating pattern is called ENTHESITIS = erosions at the tendon attachments at corner of vertebrae. When the annular fiber erodes, it's a ROMANUS sign coming off a SHINY CORNER (trumped up bone where calcified annular fibers SQUARE off the vertebral body) TROLLEY TRACK + DAGGER signs (infra and supraspinous calcification into one long line of bone) |
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Pathological radiographic findings of AS that hurt...
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CARROT STICK FRACTURE - ow! a broken syndesmophyte (calcified annular fiber)
Mr. ANDERSON lesion - broken endplate that forms a pseudo-joint ATLANTOAXIAL instability - all the inflammatory arthritides have this (RA, PsA, SLE, EA, Reactive Reiter's, NA, Sceroderma) WHISKERING enthesitis of FLUFFY appearance at cortical margins d/t bone loss |
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Lab findings of AS
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Elevated ESR
Positive HLA-B27 |
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ENTEROPATHIC ARTHRITIS is associated w/ ?
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****************************************************Inflammatory bowel disease**********************************************************************
(ulcerative colitis, Crohn's, Whipple's, Intestinal infections like salmonella/shigella/yerserina terina |
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Psoriatic Arthritis clinical features
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******PITTING of nails 80% of patients
Dry silvery scales Males 20-50 DIPs Worse than RA because all finger joints can be affected |
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PsA targets
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hands
feet SI thoracolumbar cervical similar to RA (atlantoaxial instability) |
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PsA radiographically
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MOUSE EARS - fluffy periostitis w/ less osteopenia
SPINDLE-digit/COCKTAIL SAUSAGE digits, Vienna assumably NON-marginal syndesmophytes because they EXTEND PAST CORNER OF VERTEBRAL BODY BILATERAL Asymmetrical sacroilitis RAY pattern in all joints vs. only ray pattern in RA if MCP and PIP affected PENCIL IN CUP deformity **OPERA GLASS HAND main en lorgnette and arthritis mutilans (dislocations leading to TELESCOPING like intestinal) |
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lab PsA
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HLA-B27 and elevated ESR
HLA up especially if spinal involvement |
