In the appendicular skeleton, one is mostly
concerned with the diarthrodial synovial joints.
While this type of joint is also found in the axial
skeleton (the facet (a.k.a. aphophyseal) joints
and portions of the sacroiliac joints), there are
also many amphiarthrodial joints which are not
synovial (the intervertebral disc joints).
However, there are several structures in the
intervertebral disc joint which are analogous to
structures found in a true synovial joint. The
cartilaginous endplate, the annulus fibrosus, and
the nucleus pulposus are analogous to the
articular cartilage, the joint capsule and the
synovial fluid of the synovial joint.
The different anatomy and physiology of these
joints means that we will see different disorders
affecting this part of the skeleton. However, the
same basic logical principles mentioned in the
last chapter also apply here.

This is, by far, the most common type of arthritis
seen in humans. By definition, osteoarthritis
occurs in a synovial joint. In the spine,
therefore, osteoarthritis occurs in the
apophyseal (facet) joints, the uncovertebral
joints (cervical spine), the costovertebral joints,
and the sacroiliac joints. Osteoarthritis may be
primary or secondary.

marked osteophytosis and joint space narrowing
is noted in the facet joints in this patient with
severe osteoarthritis of the lumbar spine -- the
osteophytosis is causing significant
encroachment on the lateral recesses bilaterally
Degenerative nuclear disease

Another very common disorder is degeneration
of the nucleus pulposus. With age, the nucleus
tends to become more and more dehydrated,
and gradually begins to degenerate. As this
happens, the intervertebral disc height begins to
decrease. When this happens, the altered
pattern of stresses may lead to marginal
osteophytosis adjacent to the affected
endplates. As the disc space decreases in height,
increased stress is also placed on the facet
joints, leading to the frequent association of
osteoarthritis of the facets at the same level.

with increasing age (arrow), progressive
degeneration of the nucleus leads to decreasing
disk space height

Yet another extremely common degenerative
disorder involves degeneration of the annulus
fibrosus. This leads to marginal osteophytosis at
the endplates, especially in the thoracolumbar
spine in many persons over 50 years of age. In
the literature, this entity has been termed
"spondylosis deformans" or "senile ankylosis".
However, both of these terms tend to make the
disease sound a lot worse than it really is. Using
these terms in a film report can lead to calls
from clinicians wondering just what horrible
disease their patients have. Therefore, I prefer
to state "marginal osteophytes are noted at
multiple disc spaces in the spine" in my
dictations. The clinicians know what I'm
describing and they and their patients are not
unduly frightened by the unfamiliar terminology
used for this very familiar process.

with increasing age (arrow), progressive
degeneration of the annulus leads to increasing
osteophytosis at the disk space margins -- the
height of the disk space is largely preserved

In practice, one often sees evidence of
degeneration of both the annulus and the
nucleus. It usually doesn't make a lot of
difference to the referring clinician which
component of the disk has degenerated.
Therefore, I suggest using the term
"degenerative disk disease" in one's dictations to
refer to these entities.

marked marginal osteophytosis is noted at each
disk space in this patient with predominantly
annular degeneration

disk space narrowing is noted at multiple levels
in this patient with degenerative disk disease --
a thin linear area of lucency in the L4-5 disk
space represents gas in the degenerated disk
Diffuse Idiopathic Skeletal Hyperostosis (DISH)

DISH is an extremely common entity of
unknown etiology, which manifests itself by
ossification of the anterior longitudinal ligament,
which produces large flowing bony excrescences
along the spine, especially the anterior aspect.
Inflammatory spondyloarthropathies

This is a disorder of unknown etiology
characterized by synovial inflammation, pannus
formation, and then destruction of bone and
cartilage.

This chronic inflammatory disorder of unknown
etiology principally affects the axial skeleton.
Alterations occur in synovial and cartilaginous
articulations and in sites of tendon and ligament
attachment to bone. Over 90 % of caucasian
patients with ankylosing spondylitis are HLA-B27
positive.

This is the prototypic crystalline arthropathy,
characterized by the deposition of monosodium
urate crystals in the skin, subcutaneous tissues,
and joints. This is most meaningfully classified

as idiopathic gout, encompassing the vast
majority of individuals, or gout associated with
known disorders or enzymatic defects.

characterized by the deposition of calcium
pyrophosphate dihydrate (CPPD) crystals in or
around joints.

clinical patterns that may be associated with
CPPD crystal deposition disease. This pattern,
characterized by intermittent acute attacks of
arthritis, simulates the findings of gout.

pathologically or radiologically evident
calcification of hyaline articular cartilage or
fibrocartilage. In some cases, this calcification
may not indicate deposits of CPPD crystals but
rather accumulations of some other crystal.

describe a peculiar pattern of structural joint
damage occurring in CPPD crystal deposition
disease simulating, in many ways, degenerative
joint disease but characterized by distinctive
features.

This is a disorder characterized by recurrent painful periarticular calcium hydroxyapatite deposits in tendons and soft tissues.

This is a relatively uncommon arthropathy which
occurs in about 2 to 6 % of patients with
psoriasis. Approximately 25 to 60 % of patients
with psoriatic arthritis are HLA-B27 positive.

Reiter's syndrome is a relatively uncommon
arthropathy of uncertain etiology with the classic
triad of urethritis, arthritis, and conjunctivitis. Of
all of the rheumatic diseases, Reiter's syndrome
is most suspect for an infectious etiology. It
appears likely that the disease can be
transmitted in association with either epidemic
dysentery or sexual intercourse. The syndrome
frequently follows an infection of the bowel or
lower genitourinary tract, and it seems likely
that these sites are the portals of entry for the
causative agent. It has been suggested that the
abnormalities of the vertebral column may be
related to organisms extending directly to the
sacroiliac joints and spine via the prostatic
venous plexus or via the venous plexus of
Batson. Implicated organisms include
pleuropneumonia-like organisms (PPLO), the
Bedsonia group of organisms, and viruses,
although to date, no single agent has been
definitely incriminated in this disease.
Approximately 75 to 96 % of patients with
Reiter's syndrome are HLA-B27 positive.

This arthropathy occurs in about 1 - 26 % of
patients with ulcerative colitis or Crohn's
disease. The relationship between inflammatory
intestinal diseases and arthritis is not fully
understood. Infectious, immunologic, and

genetic etiologies have been advanced.
Approximately 90 % of patients with ulcerative
colitis or Crohn's disease who develop
spondylitis or sacroiliitis are HLA-B27 positive.

In a diarthrodial joint, this is the sine qua non of
osteoarthritis. Osteophytes can be seen in both
primary and secondary osteoarthritis. They can
also be seen at various entheses, often due to
altered or increased stress at the entheses
(traction osteophytes). The traction osteophytes
of degenerative annular disease begin several
millimeters from the edge of the vertebral body,
and tend to be initially oriented horizontally at
their attachment to the vertebral bodies. They
then often curve slightly and may even form a
complete bony bridge across the disc space.

Syndesmophytes are generally seen only in the
seronegative spondyloarthropathies. These are
due to inflammation and ossification of the outer
fibers of the annulus fibrosus, known as the
Sharpey's fibers. This is classically seen in
ankylosing spondylitis. In the other seronegative
spondyloarthropathies, one usually sees
paravertebral ossification which forms in the
paravertebral connective tissue at some distance
from the spine. In practice, it may be very
difficult to distinguish osteophytes from
syndesmophytes or paravertebral ossification.

syndesmophytes (arrows) in the spine of a
patient with ankylosing spondylitis
Disc space narrowing

This almost always means degenerative nuclear
disease or infection. These can often be
distinguished by looking at the adjacent
endplates. In degenerative disc disease, the
endplates are often dense, sclerotic, and
associated with osteophytosis. In infection, the
subchondral line of the endplate often becomes
ill-defined and discontinuous.

This is a striking feature of the seronegative
spondyloarthropathies, particularly psoriatic
arthritis. This bony proliferation occurs about
erosions, and probably relates to an
exaggerated healing response of the injured
bone. This proliferation may take the form of
irregular excrescences, subperiosteal deposition
of bone, and intra-articular osseous fusion.

In general, the presence of erosions bespeaks
some type of inflammatory disease, whether the
erosions are due to synovial hypertrophy,
crystalline deposits, or infection.

In general, this is indicative of one of the crystalline arthropathies -- either CPPD or hydroxyapatite.

Stability of the spine is maintained by the spinal
ligaments, articular capsules, and discs. Any
arthropathy which causes degeneration or
destruction of these structures may lead to
instability of the spine and subluxation in several
locations.

Osteoarthritis of the spine looks much like
osteoarthritis elsewhere in the body. Any of the
spinal synovial joints can be affected, including
the facet and uncovertebral joints, the