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DIAGNOSTIC RADIOLOGY

Musculoskeletal and Breast Imaging


PIONEERS OF AIIMS–MAMC–PGI IMAGING COURSE SERIES

Manorama Berry Sudha Suri Veena Chowdhury

PAST EDITORS

Sima Mukhopadhyay Sushma Vashisht


DIAGNOSTIC RADIOLOGY
Musculoskeletal and Breast Imaging
Third Edition

Editors
Veena Chowdhury MD Arun Kumar Gupta MD MNAMS FAMS
Director-Professor and Head Professor and Head
Department of Radiodiagnosis Department of Radiodiagnosis
Maulana Azad Medical College All India Institute of Medical Sciences
New Delhi, India New Delhi, India

Niranjan Khandelwal MD DNB FICR


Professor and Head
Department of Radiodiagnosis
Postgraduate Institute of Medical Education and Research
Chandigarh, India

Associate Editors
Anju Garg MD Anjali Prakash DMRD DNB MNAMS
Director-Professor Professor
Department of Radiodiagnosis Department of Radiodiagnosis
Maulana Azad Medical College Maulana Azad Medical College
New Delhi, India New Delhi, India

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Diagnostic Radiology: Musculoskeletal and Breast Imaging

First Edition : 1998


Second Edition : 2005
Reprint : 2011
Third Edition : 2012

ISBN 978-93-5025-883-5
Printed at
Contributors
Alpana Manchanda MD Deep Narayan Srivastava MD MBA FICR
Professor Professor
Department of Radiodiagnosis Department of Radiodiagnosis
Maulana Azad Medical College All India Institute of Medical Sciences
New Delhi, India New Delhi, India
Anjali Prakash DMRD DNB MNAMS Gaurav Shanker Pradhan DMRD DNB
Professor Professor
Department of Radiodiagnosis Department of Radiodiagnosis
Maulana Azad Medical College Maulana Azad Medical College
New Delhi, India New Delhi, India
Anju Garg MD Jyoti Kumar MD
Director-Professor Associate Professor
Department of Radiodiagnosis Department of Radiodiagnosis
Maulana Azad Medical College Maulana Azad Medical College
New Delhi, India New Delhi, India
Arun Kumar Gupta MD MNAMS FAMS Mahesh Prakash MD
Professor and Head Associate Professor
Department of Radiodiagnosis Department of Radiodiagnosis
All India Institute of Medical Sciences Postgraduate Institute of Medical Education
New Delhi, India and Research, Chandigarh, India

Arun Malhotra DRM PhD Manavjit Singh Sandhu MD


Professor and Head Professor
Department of Nuclear Medicine Department of Radiodiagnosis
All India Institute of Medical Sciences Postgraduate Institute of Medical Education
New Delhi, India and Research, Chandigarh, India

Ashu Seith Bhalla MD Mandeep Kang MD DNB


Additional Professor Additional Professor
Department of Radiodiagnosis Department of Radiodiagnosis
All India Institute of Medical Sciences Postgraduate Institute of Medical Education
New Delhi, India and Research, Chandigarh, India

Atin Kumar MD DNB MNAMS Manphool Singhal MD DNB


Associate Professor Assistant Professor
Department of Radiodiagnosis Department of Radiodiagnosis
All India Institute of Medical Sciences Postgraduate Institute of Medical Education
New Delhi, India and Research, Chandigarh, India
vi Diagnostic Radiology: Musculoskeletal and Breast Imaging

Mukesh Kumar Yadav MD Sanjay Thulkar MD


Assistant Professor Additional Professor
Department of Radiodiagnosis Department of Radiodiagnosis
Postgraduate Institute of Medical Education All India Institute of Medical Sciences
and Research, Chandigarh, India New Delhi, India
Niranjan Khandelwal MD DNB FICR Sapna Singh MD DNB MNAS
Professor and Head Associate Professor
Department of Radiodiagnosis Department of Radiodiagnosis
Postgraduate Institute of Medical Education Maulana Azad Medical College
and Research, Chandigarh, India New Delhi, India
Paramjeet Singh MD Shivanand Gamanagatti MD MNAMS
Professor Associate Professor
Department of Radiodiagnosis Department of Radiodiagnosis
Postgraduate Institute of Medical Education All India Institute of Medical Sciences
and Research, Chandigarh, India New Delhi, India
Punit Sharma MD Smriti Hari MD
Senior Resident Associate Professor
Department of Nuclear Medicine Department of Radiodiagnosis
All India Institute of Medical Sciences All India Institute of Medical Sciences
New Delhi, India New Delhi, India
Raju Sharma MD MNAMS Sumedha Pawa MD
Professor Director-Professor
Department of Radiodiagnosis Department of Radiodiagnosis
All India Institute of Medical Sciences Maulana Azad Medical College
New Delhi, India New Delhi, India
Rakesh Kumar MD PhD Veena Chowdhury MD
Additional Professor Director-Professor and Head
Department of Nuclear Medicine Department of Radiodiagnosis
All India Institute of Medical Sciences Maulana Azad Medical College
New Delhi, India New Delhi, India
Rashmi Dixit MD
Vivek Gupta MD
Professor
Associate Professor
Department of Radiodiagnosis
Department of Radiodiagnosis
Maulana Azad Medical College
Postgraduate Institute of Medical Education
New Delhi, India
and Research, Chandigarh, India
Sameer Vyas MD
Assistant Professor
Department of Radiodiagnosis
Postgraduate Institute of Medical Education
and Research, Chandigarh, India
Preface to the Third Edition
Musculoskeletal radiology has witnessed tremendous strides since Roentgen took the first X-ray of the hand in 1895.
Conventional radiology remains the mainstay in the initial evaluation of trauma and bone tumors. The limited resolution of
X-ray to delineate various components of the musculoskeletal system has now been overcome by advances in cross-
sectional imaging. Magnetic resonance imaging (MRI) and dual energy computed tomography (CT) demonstrate each
detail of ligament, tendon, muscle and bone.
The first edition of Musculoskeletal and Breast Radiology was published in 1998 followed by the second edition in 2005.
The present edition has been designed to provide an integrated approach to musculoskeletal disorders. The first section
deals with all imaging modalities in detail. There is also an updated section on MR imaging. All chapters have been
thoroughly revised. Being a developing nation, infections continue to be a health problem and an entire section is devoted
to it.
The importance of conventional radiography has been emphasized because all radiology services have an X-ray unit and
further the differential diagnosis of various bone lesions should not be made on CT and MRI alone without referring to
recent plain radiographs.
The text is intended to assist in the interpretation of imaging studies and in suggesting the appropriate imaging
technique to clinicians involved in patient care.
The second part of the book contains updated chapters on Breast imaging, including a new one titled A Systematic
Approach to Imaging of Breast Lesions. Breast interventions are being increasingly performed, and a new chapter on the
same has been added. The role of PET-CT in breast cancer is also included as a new chapter.
Dr Sumedha Pawa, the associate editor of the previous edition passed away in October 2011, just as preparations for
this edition were underway. We acknowledge her contribution and wish to place on record our heartfelt thanks to her. We
dedicate this edition to her.
The editors take this opportunity to thank the faculty of the three organizing institutions who have put their collective
experience in this book. We would also like to express our appreciation to Shri Jitendar P Vij (Chairman and Managing
Director), Mr Tarun Duneja (Director-Publishing), Ms Samina Khan and other staff of M/s Jaypee Brothers Medical Publishers
(P) Ltd, New Delhi, India, for their professionalism and dedication towards publication of this book.

Veena Chowdhury
Arun Kumar Gupta
Niranjan Khandelwal
Anju Garg
Anjali Prakash
Preface to the First Edition
There has been a significant increase in the awareness as well as in the actual incidence of detection of disorders related to
the musculoskeletal system and the breast over the years. At the same time, a continuous revolution, occurring in the field
of imaging over these years, has given a new insight in the proper diagnosis, management and follow-up of these disorders.
With the availability of a large number of imaging techniques today, including conventional radiology, computed tomography
(CT), magnetic resonance imaging (MRI), ultrasonography (USG), interventional procedures and radioisotope studies,
each having its own merits and limitations, it has become essential on the part of the present day radiologist to be able to
advise and use the most cost-effective methodology in a given clinical situation. Such a need assumes even a greater
importance in the limited resources situation of a developing country. It is necessary for a radiologist of today to learn the
basic aspects and role of various imaging modalities in a given clinical situation for taking the fullest advantage of these
modalities. The need for a closer cooperation and understanding of each other’s role between the radiologist and a
clinician had never been felt greater before.
The present book on Musculoskeletal and Breast Imaging, the fifth in the series of AIIMS-MAMC-PGI imaging courses,
is a further attempt in this direction. The book has been broadly divided into two sections, i.e. the musculoskeletal disorders
and the breast disorders, each section dealing at length with the relevant imaging techniques and their interpretations in
various disease processes. There are 19 chapters, dealing with all important aspects of these systems.
The multimodality imaging approach to bone, soft tissue and joint diseases is presented while retaining the major
emphasis on conventional radiological findings. There are separate sections devoted to imaging modalities for infections
and inflammations, metabolic bone disorders and tumors. The text is intended to assist in the interpretation of imaging
studies of patients with these disorders and in suggesting the appropriate imaging technique to the clinicians involved in
their care.
The role of mammography in early diagnosis of breast cancer and in helping in breast conservation need not be
overemphasized. The section on breast imaging deals in detail with the role of screening mammography, its relevance as
it pertains to our country, the current status of various other imaging modalities and future directions in the imaging of
breast. The purpose of this book is to provide the reader with essential information in all important aspects of the subspecialty
of musculoskeletal and breast imaging, and we hope that it serves as a compliment to the AIIMS-MAMC-PGI course,
through its concise, comprehensive and current survey on the subject.
We are grateful to all our faculty staff and other eminent teachers for contributing their experiences through their
excellent write-ups in all these volumes providing a balanced view on the modern day practice of Radiology in various
clinical situations. We also thank the series publishers M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India,
Shri Jitendar P Vij (Chairman and Managing Director) and other staff, for timely publication of all these volumes in an
excellent form. But for their active and persistent involvement, such a gigantic task would not have been a reality. We do
sincerely hope that all these volumes, including the present one published under the AIIMS-MAMC-PGI imaging course
series, shall be able to fulfill the desired aims and shall continue to guide the readers in their daily office practice of
radiology. Readers response shall always remain the ultimate guiding spirit in this direction.
Manorama Berry
Veena Chowdhury
Sudha Suri
Sima Mukhopadhyay
Contents

Part One: MUSCULOSKELETAL IMAGING


IMAGING MODALITIES
1. Diagnostic Approach to Focal Bone Lesions: Conventional Radiography,
Computed Tomography and Magnetic Resonance Imaging .................................................................... 3
Shivanand Gamanagatti, Raju Sharma
2. Basic Principles and Current Concepts of Musculoskeletal Magnetic Resonance Imaging .................... 20
Raju Sharma, Shivanand Gamanagatti
3. Nuclear Medicine Imaging for Musculoskeletal Disorders ................................................................... 35
Rakesh Kumar, Punit Sharma, Arun Malhotra
4. Angiography and Interventions in Musculoskeletal Lesions ................................................................ 49
Deep Narayan Srivastava

INFECTIONS/INFLAMMATIONS
5. Tuberculosis of Bones and Joints ......................................................................................................... 64
Gaurav Shanker Pradhan, Veena Chowdhury
6. Nontubercular Bone and Joint Infections ............................................................................................. 80
Manphool Singhal, Niranjan Khandelwal
7. Tuberculosis of the Spine ..................................................................................................................... 94
Rashmi Dixit
8. Noninfective Inflammatory Arthritis ................................................................................................... 113
Mandeep Kang, Mahesh Prakash
9. Nontubercular Infections of the Spine ................................................................................................ 133
Sameer Vyas, Manavjit Singh Sandhu
10. Degenerative Disease of the Spine and Joints .................................................................................... 149
Jyoti Kumar, Sumedha Pawa

METABOLIC BONE DISEASES


11. Skeletal Disorders of Metabolic and Endocrine Origin ........................................................................ 177
Alpana Manchanda, Arun Kumar Gupta
12. Osteoporosis ...................................................................................................................................... 212
Mukesh Kumar Yadav, Vivek Gupta, Niranjan Khandelwal
xii Diagnostic Radiology: Musculoskeletal and Breast Imaging

BONE TUMORS
13. Benign Bone Tumors and Tumor Like Conditions ................................................................................. 229
Mahesh Prakash, Niranjan Khandelwal
14. Malignant Bone Tumors ...................................................................................................................... 244
Anju Garg

MUSCULOSKELETAL MRI
15. Magnetic Resonance Imaging of the Knee .......................................................................................... 276
Sapna Singh
16. Magnetic Resonance Imaging of Hip and Pelvis .................................................................................. 322
Anjali Prakash
17. Magnetic Resonance Imaging of Shoulder and Temporomandibular Joints ......................................... 353
Mahesh Prakash, Paramjeet Singh
18. Magnetic Resonance Imaging in Bone Marrow Disorders.................................................................... 381
Veena Chowdhury

TRAUMA AND SOFT TISSUES


19. Radiological Evaluation of Appendicular Trauma ................................................................................. 406
Atin Kumar, Arun Kumar Gupta
20. Imaging of Soft Tissue Lesions ............................................................................................................ 422
Ashu Seith Bhalla, Sanjay Thulkar

Part Two: BREAST IMAGING


21. A Systematic Approach to Imaging of Breast Lesions ........................................................................... 451
Smriti Hari, Sanjay Thulkar, Arun Kumar Gupta
22. Benign and Malignant Lesions of the Breast ....................................................................................... 482
Smriti Hari, Ashu Seith Bhalla, Sanjay Thulkar
23. Breast Interventions ........................................................................................................................... 508
Sanjay Thulkar, Smriti Hari
24. PET-CT in Management of Breast Cancer ............................................................................................. 526
Rakesh Kumar, Punit Sharma, Arun Malhotra

Index ..........................................................................................................................................................539
P A R T

ONE

MUSCULOSKELETAL
IMAGING
IMAGING MODALITIES
CHAPTER
Diagnostic Approach to Focal Bone
1 Lesions: Conventional Radiography,
Computed Tomography and
Magnetic Resonance Imaging
Shivanand Gamanagatti, Raju Sharma

INTRODUCTION – Periosteal reaction


Focal bone lesions are divided into three broad categories: – Extraosseous extension/soft tissue mass
Benign, malignant (primary and secondary) and non- – Lesion multiplicity
neoplastic. Plain radiographs are initial and most important • Nonaggressive vs aggressive pattern on radiograph is
imaging modality for the diagnosis and should be evaluated not always equivalent to benign vs malignant, e.g.
in systematic manner regardless of the pathology. Computed osteomyelitis can have an aggressive pattern on
tomography (CT) and magnetic resonance imaging (MRI) radiograph.
provide complimentary information that is extremely useful • Do not “over-diagnose” a benign bone tumor and do not
in the work-up of focal bone lesion. CT scan is particularly “under-diagnose” a malignant bone tumor.
useful in evaluating the cortex and matrix. MRI is useful in • Do not misdirect the biopsy approach to the lesion so as
determining the intramedullary extent, soft tissue extent of to convert more conservative operation (compartment
focal bone lesion and also play vital role in detecting skip resection or limb salvage procedure) into more radical
lesions.1 operation (amputation).
• Any skeletal lesion detected on well penetrated
General Principles of focal bone lesion evaluation
radiograph rule out infection, eosinophilic granuloma,
• Prior to the analysis of the radiographic features of focal
subchondral degenerative cyst, lesion related to
bone lesion, certain clinical information, is essential to
metabolic bone disease such as brown tumor, post-
narrow down the differential diagnosis, such as patient’s
age, the location of the lesion and is it solitary or multiple? traumatic changes such as stress fracture or is it normal
• W ithin long bones, plane of the lesion must be variant.
determined with reference to longitudinal (epiphysis, • If the lesion is unchanged from old films (at least 2 years
metaphysis, diaphysis) and transverse (intramedullary, old) then consider for a clinical/radiographic follow-up of
intracortical, surface) planes. Surface (juxtacortical) the patient.
lesions may be parosteal or periosteal. • If there are multiple lesions rule out metastases
• Radiograph is essential for lesion detection and especially in adults or other causes of multiple skeletal
characterization. Radiograph should be systematically lesions such as multiple enchondromas, multiple
assessed for: osteochondromas, fibrous dysplasia, fibrous cortical
– Pattern of bone destruction defects/nonossifying fibromas, sarcoidosis, etc.
– Edge of lesion/zone of transition • If there is solitary lesion, characterize the lesion further
– Cortical response based on age, location, pattern of destruction, margins,
– Matrix mineralization cortical response, matrix, periosteal reaction.
4 Imaging Modalities

Table 1.1 Bone tumors predilection for specific age groups


0-10 10-20 20-30 30-40 40-50 >50

Metastatic Neuroblastoma123456789012
<2Y
123456789012
123456789012
1234567890123456
1234567890123456
1234567890123456
Simple bone cyst 123456789012
123456789012
1234567890123456
1234567890123456
1234567890123456
123456789012 1234567890123456
12345678901234567
1234567890123456
12345678901234567
1234567890123456
123456789012345671234567890123456
12345678901234567
123456789012345671234567890123456
1234567890123456
Fibrous cortical defect 123456789012345671234567890123456
123456789012
12345678901234567
1234567890123456
1234567890121234567890123456
1234567890123456
123456789012 1234567890123456
1234567890121234567890123456
Aneurysmal bone cyst
1234567890121234567890123456
1234567890123456
1234567890123456

Ewing sarcoma

Osteosarcoma
12345678901234567
123456789012345
12345678901234567
123456789012345
12345678901234567
123456789012345
12345678901234567
123456789012345
Giant cell tumor 12345678901234567
123456789012345
12345678901234567
123456789012345
12345678901234567
123456789012345
12345678901234567
123456789012345

Chondrosarcoma

Multiple myeloma

Metastasis

AGE OF THE PATIENT bone cyst is located eccentrically in the medullary cavity
(Fig. 1.1). However, in short or thin tubular bones, such as
Most bone tumors have a predilection for a specific age
the metacarpals, metatarsals, phalanges, and fibula, the
group; therefore, patients age is an important clinical
entire diameter of the bone can be involved, sometimes
information while assessing a bone tumor. Typical peak ages
making it difficult to determine in which part of the bone the
of different lesions are listed in Table 1.1. For example, simple
lesion started. An apophysis (a growth center that does not
bone cysts and chondroblastomas occur in skeletally
contribute to the length of a bone) is the equivalent of an
immature people, while giant cell tumors occur in skeletally
epiphysis (a growth center at the end of a bone that does
mature people. Ewing sarcoma typically occurs in 10 to 20-
contribute to length); thus, one should use the “end-of-bone”
year-old patients, while conventional osteosarcoma has two
differential list for a lesion in such sites as the greater
age peaks, one, arising de novo, in teenagers and the second,
trochanter of the femur and the tibial tubercle (Fig. 1.1).
arising in pagetic or previously irradiated bone, in adults
Similarly, other growth centers such as the patella; the small
older than 50 years. A malignant bone lesion in an adult over
bones of the wrist, hindfoot, and midfoot; and the
40 years old is much more likely to be metastatic carcinoma,
subarticular portions of flat bones, such as those around the
myeloma or metastatic non-Hodgkin’s lymphoma rather than
sacroiliac joints and acetabuli in the pelvis and the glenoid of
a primary bone sarcoma.2
the scapula, are also end-of-bone equivalents.
The differential diagnosis can then be further narrowed
LOCATION OF LESION (FIG. 1.1)
by knowing the age of the patient. For example, a lytic lesion
Most bone tumors, regardless of whether they are benign in the epiphysis of a long bone of an adolescent is likely to be
or malignant, often occur in a characteristic location in the a chondroblastoma, whereas a lytic lesion at the end of a
skeleton (i.e. axial vs appendicular skeleton or long vs flat long bone in a young adult is likely to be a giant cell tumor.
bone). Thus, some tumors (e.g. osteosarcoma) have a Ewing sarcoma and Langerhans cell histiocytosis have a
predilection for sites of rapid bone growth, usually the predilection for the diaphysis of long bones in people younger
metaphyseal region, while other tumors (e.g. Ewing’s than 20 years and a predilection for flat bones such as the
sarcoma) tend to follow the distribution of red marrow. pelvis and skull in people older than 20 years, reflecting the
Furthermore, a lesion in a long bone is usually located normal change in the distribution of red marrow as a person
centrally within the medullary cavity, while an aneurysmal ages.
Diagnostic Approach to Focal Bone Lesions 5

Fig. 1.1: Diagrammatic representation of the locations of various focal bone lesions

Some processes have a predilection for a particular bone circumscribed lytic lesion with a narrow zone of transition.
and location, such as an adamantinoma and osteofibrous The slow growth rate results in sharp demarcation between
dysplasia for the anterior cortex of the tibia, periosteal the destructive lesion and adjacent normal bone. The margin
desmoids for the posterior distal aspect of the femur, and of the lesion represents the true histological margin of
hemangioma for vertebral bodies.2 destruction, however, malignant lesions like metastasis or
myeloma may also demonstrate a similar pattern.
PATTERN OF BONE DESTRUCTION This pattern is further divided into three subtypes:
Three patterns of bone destruction have been described as Type IA — Geographic lesion with sclerotic margin
follows (Figs 1.2A to C):3 Type IB — Geographic lesion with no marginal sclerosis
Type–I — Geographic bone destruction Type IC — Geographic lesion with ill-defined margins
Type–II — Moth-eaten bone destruction
Type–III — Permeative bone destruction Geographic Lesion with Sclerotic Margin
The slow growth of the lesion permits development of a
Geographic Bone Destruction
reactive bone around the lesion so as to accommodate
This type of bone destruction is the least aggressive form transmission of forces. The sclerotic margin may vary in
and suggests a slow growing lesion. It is seen as a well- thickness and is especially thick in lesions occurring in weight-
6 Imaging Modalities

A B C

Figs 1.2A to C: Pattern of bone destruction

bearing bones like femur and tibia. This type of lesion Moth-eaten Bone Destruction
is commonly seen in simple bone cyst (Fig. 1.3A),
This type of lesion is relatively more aggressive, suggesting
enchondroma, chondromyxoid fibroma, Brodie’s abscess, and
more rapidly growing lesion. It is characterized by multiple
fibroxanthoma. Fibrous dysplasia often displays a peripheral
small varying sized lytic lesions that coalesce and involve
thick sclerotic rim resembling a “rind” of orange (Fig. 1.3B).
both cancellous and cortical bone (Fig. 1.3F). In cancellous
In some lesions like Brodie’s abscess (Fig. 1.3C) and
bone, normal trabeculae may be seen in between the lytic
eosinophilic granuloma, the sclerotic rim is rather fuzzy and
lesions while in cortical bone, the lytic lesion starts from
appears to be fading gradually into adjacent cancellous bone.
endosteal surface and extends outwards. This may progress
The sclerotic rim is a mechanical adaptation designed to
to complete cortical destruction with extension into adjacent
accommodate forces transmitted around the space
soft tissues. The lesion has less well-defined margins with
occupying mass.
wide zone of transition and is more extensive on
histopathology, than suggested on a radiograph. This pattern
Geographic Lesion with No Marginal Sclerosis is usually seen in malignant neoplasms like reticulum cell
This type of lesion shows sharp margins with narrow zone of sarcoma, osteosarcoma, chondrosarcoma, fibrosarcoma,
transition, referred to as a punched-out lesion with no round cell tumor (including Ewing’s sarcoma) and also
sclerosis (Fig. 1.3D). The margins seen on radiograph, reflects osteomyelitis.
the true histological edge of the lesion. Giant cell tumor
typically displays this pattern. Many lesions associated with Permeative Bone Destruction
type IA pattern may also show this pattern, e.g. bone cyst, This pattern represents the most aggressive form and
enchondroma and chondroblastoma. suggests a rapidly destructive bone lesion. This type is
characterized by multiple, tiny oval lucent lesions or lucent
Geographic Lesion with Ill-defined Margins
streaks mostly involving cortical bone (Fig. 1.3G). Progressive
This type indicates locally infiltrative process. The margins cortical destruction occurs with exuberant cortical tunneling
are poorly defined suggesting more aggressive pattern than by osteoclasts, and the lesions are ill-defined. The highly
type IB lesions (Fig. 1.3E). The destructive process extends aggressive nature does not allow bone to react and stop its
in the marrow between the trabeculae beyond the further progress. These lesions are much more widespread
radiographic destructive edge. This type of lesion is seen than they appear on a radiograph. This type of lesion is seen
characteristically in giant cell tumor, osteosarcoma, in Ewing’s sarcoma, reticulum cell sarcoma, high grade
chondrosarcoma, fibrosarcoma, aneurysmal bone cyst, chondrosarcoma, fibrosarcoma, angiosarcoma, leukemia
eosinophilic granuloma and osteomyelitis. and metastasis.
Diagnostic Approach to Focal Bone Lesions 7

A B C D E F G

Figs 1.3A to G: Patterns of bone destruction: (A) Type IA – geographic destruction with sclerotic margins in a simple bone cyst seen in the left
iliac bone, (B) Type IA – geographic destruction with thick sclerotic margins, “rind sign”, seen in fibrous dysplasia involving neck of right femur,
(C) Type IA – geographic destruction with sclerotic margin which is fuzzy and facing peripherally, in Brodie’s abscess involving lower end of
humerus, (D) Type IB – geographic destruction with punched-out lesion seen in giant cell tumor involving upper tibia—note its typical eccentric
subarticular position, (E) Type IC – geographic destruction with ill-defined margins seen in another patient of giant cell tumor involving upper
tibia, (F) Type II – moth-eaten destruction seen in osteomyelitis involving left upper femur in a child—also note associated single lamellar
periosteal reaction, and (G) Type III – permeative bone destruction involving upper tibia with osteomyelitis—note the tunneling in the anterior
cortex

Combination and Changing Pattern growing and have well-defined margins. Therefore,
This is characterized by combination of type-I A, B, C, type - assessment of radiographic margin does not always indicate
II or type-III patterns in a single lytic lesion and suggests benign or malignant nature of a lesion.5,6 Aneurysmal bone
more aggressive local growth. This pattern is usually seen in cyst, eosinophilic granuloma, majority of giant cell tumors
some benign lesions, when they become active, undergo and chondromyxoid fibroma may display aggressive
malignant change or fracture. Pressure from tumor growth appearance on radiographs and yet be benign. On the other
or active hyperemia are some of the factors that contribute hand, malignant lesions like plasmacytoma and juxtacortical
to this pattern. A changing pattern is discernible when a osteosarcoma are slow growing and may appear
change in the nature of margin is observed radiographically nonaggressive on plain radiograph. Treatment can also alter
over time. the appearance of malignant bone tumors; following
radiation or chemotherapy they may exhibit significant
MARGIN OF THE LESION sclerosis as well as a narrow zone of transition.3
AND RATE OF GROWTH Inflammatory lesions usually produce marked reactive
bone formation compared with neoplasms. Typically, these
The margin of the lesion relates to the radiographic lesions show a sclerotic margin with sharp inner border and
appearance of the interface between the lesion and adjacent hazy outer border. However, osteoid osteoma also shows
normal bone. This is determined by reaction of the host bone extensive osteosclerosis around the margin of similar nature.
to the lesion and rate of growth of the lesion. Well- Benign tumors or tumor-like conditions and slow growing
marginated lesions have a narrow zone of transition (Fig. malignant tumors usually show sclerotic rim with sharp outer
1.3A) while poorly defined lesions have a wide zone of and inner margins (Fig. 1.3B). While inflammatory lesions
transition (Fig. 1.3G). The aggressiveness and rate of growth show a sclerotic margin with sharp inner border and a hazy
of the lesion can be assessed from its margin. Sharply defined outer border (Fig. 1.3C).
margin or a sclerotic margin suggests slow growth rate, Sometimes, a lesion may demonstrate a scalloped
while ill-defined margins indicate aggressive lesion and rapid margin. This occurs in lesions of cartilage, fibrous tissue, fat
growth rate. Some benign lesions may, however, show a and vascular tissue, where the cells grow in clumps or lobules
rapid growth rate, and some malignant lesions may be slow at different growth rate. The scalloped margin is seen
8 Imaging Modalities

typically in nonossifying fibroma. The assessment of growth CORTICAL RESPONSE


rate on radiographs correlates well with virulence of
organisms, host response, degree of spread of infection in An intact cortex suggests slow growth. It may respond in a
inflammatory lesion and with aggressiveness of the tumors. variety of ways to the presence of a focal lesion. Cortical
However, the radiographic rate of growth is not synonymous trabeculation implies a slow-growing, usually benign lesion,
with actual biological behavior and growth rate of the lesion and is common in simple bone cyst (SBC) and giant cell tumor
as seen in acute osteomyelitis and Ewing’s sarcoma. Both (GCT) (Fig. 1.4A). Endosteal scalloping reects the lobular
these lesions may show similar radiographic appearance of growth pattern of the underlying tumor, and commonly
aggressive pattern of bone destruction. However, such an suggests a chondral (Fig. 1.4B) or brous lesion, but cannot
appearance develops in a relatively short period of time in differentiate benign from malignant. Cortical expansion is a
acute osteomyelitis in contrast to Ewing’s sarcoma which misnomer but implies that endosteal bone removal due to
may take a longer period. Nonetheless, assessment of growth tumor is occurring at a similar speed to periosteal bone
rate may help in narrowing the differential diagnosis. production, again suggesting slow growth. In more

A B

C D E
Figs 1.4A to E: Cortical response: (A) Giant cell tumor showing expansile lytic lesion with intact cortex in lower end of fibula
reaching up to subarticular location suggestive of cortical trabeculation indicating slow growth, (B) Enchondroma showing mildly
expansile intramedullary lytic lesion in proximal phalanx causing endosteal scalloping indicating lobular growth, (C and D)
Aneurysmal bone cyst showing expansile lytic lesion in body of mandible, cortical integrity is not well seen on plain radiograph,
CT section of same patient showing the intact cortex around the expansile lytic lesion, (E) “Saucerization” (arrowhead) of the
medial humeral diaphysis in Ewing’s sarcoma caused by the pressure erosion of the soft mass
Diagnostic Approach to Focal Bone Lesions 9

aggressive lesions, the outer cortical layer may be too thin Osseous matrix is also produced by modulation of
to be seen on plain lms but evident on CT (Figs 1.4C and D). fibroblasts into osteoblasts and occurs in fibrous dysplasia
Destruction of the cortex suggests rapid growth. The and appears diffuse, hazy or poorly defined but not as radio-
most aggressive malignant lesions can occasionally penetrate dense as seen in tumor new bone. Necrosis of fat tissue may
the cortex before destruction is evident radiographically. result in development of bone matrix which appears as
Apparent preservation of the cortex does not preclude clumps of radiodensity.
extension of disease from the medulla. Saucerization,
whereby an extraosseous mass of tumor causes pressure Cartilage Matrix
erosion on the bone’s outer surface, usually occurs with an The cartilage matrix, when sufficiently calcified, is seen as
apparently intact cortex (Fig. 1.4E). Although the soft tissue flecks, punctate (Fig. 1.5C) or flocculated (Fig. 1.5E) in
mass may not be visible, the scalloping of the outer cortex appearance (enchondroma, osteochondroma). When the
implies its presence. These last two entities (penetration of cartilage matrix is sufficiently ossified, it shows appearance
an apparently intact cortex and cortical saucerization) are of arcs (Fig. 1.5D) or rings (Fig. 1.5D) hazy, cloud-like or
most frequently seen with malignant round cell tumors, ivory-pattern. The punctate calcification of cartilage occurs
particularly Ewing’s sarcoma. in disrupted zone of provisional calcification while ring or arc
appearance originates from disrupted enchondral bone
MATRIX MINERALIZATION formation. Both these patterns may exist alone or in
Matrix refers to the acellular intercellular substance combination. The ossified rings in cartilage tumor, suggests
produced by the mesenchymal cells namely osteoblasts, low-grade nature of the tumor.
cartilage cells, fibroblasts and this includes osteoid,
chondroid, myxoid and collagen tissue. Matrix becomes visible PERIOSTEAL REACTION
on the radiograph only when it is mineralized sufficiently Periosteum is like an envelope that separates the bone from
with calcium salts.4 surrounding soft tissues. This consists of two layers, the outer
Evaluation of matrix is valuable for two reasons: fibrous and inner cellular. It is firmly adherent to the
• Identification of particular configuration of matrix helps underlying bone in adults but less so in children. Normally,
in suggesting specific diagnosis. periosteum is not visible and even when it is elevated, it
• It is an indirect indicator of biological activity, e.g. cannot be appreciated on radiograph till mineralization
transition from mineralized to non-mineralized matrix occurs. The periosteal reaction can be stimulated by
on follow-up radiographs indicates increased biologic hyperemia, inflammation or spread of tumor. Its presence is
activity and suggests this as an optimal site for biopsy. an indicator of biologic activity and reflects the duration and
The plain radiographs remain the best modality for intensity of underlying process.5
assessing pattern of matrix mineralization, however, The type of periosteal reaction can be considered under
presence of subtle matrix mineralization can be seen only three subgroups (Fig. 1.6A):
on computed tomography (CT). i. Continuous
ii. Discontinuous or interrupted
Osseous Matrix iii. Complex.
Osseous matrix is produced either by normal or tumor
Continuous Periosteal Reaction
osteoblasts. The presence of bony trabeculae, appearing as
thin interlacing radiodense struts within a lesion, is Continuous periosteal reaction may occur either with intact
pathognomonic of a bone matrix. This occurs in myositis or destroyed underlying cortex. It may be solid, single
ossificans produced by normal osteoblasts, and in low-grade lamellar, multilamellar or parallel spiculated. An underlying
parosteal osteosarcoma produced by tumor osteoblasts. The inflammatory or neoplastic process incites hyperemia that
osseous matrix may appear fluffy, amorphous, hazy (Fig. activates fibroblasts to osteoblasts that produce osteoid and
1.5A) cloud-like or ivory pattern (Fig. 1.5B) on radiograph, mineralized layers of new bone. It takes 10 to 21 days, from
when ossified sufficiently and is seen in high-grade the initial insult, for the periosteum to become
osteosarcoma, parosteal osteosarcoma, and osteoblastoma. radiographically visible.
10 Imaging Modalities

A B C

D E

Figs 1.5A to E: Patterns of matrix mineralization: (A) Cloud-like pattern of osteoid matrix in mid
diaphysis and ivory-like pattern in metaphyseal region of femur in osteosarcoma—note the single
lamellar periosteal reaction along the anterior cortex, (B) Ivory-like pattern of osteoid matrix in a
case of parosteal osteosarcoma involving proximal humerus—note that underlying humeral shaft
can be seen through the tumor new bone in the lower part, (C) Punctate pattern of chondroid
matrix in enchondromas involving multiple bones of hands in Maffucci’s syndrome—note multiple
phleboliths with soft tissue swellings suggestive of cavernous hemangiomas, (D) Flocculent and
arc-like (arrow) pattern of chondroid matrix involving upper third of femur with sarcomatous
change in diaphyseal aclasis, and (E) Extensive flocculent and ring-like (arrow) chondroid matrix
in chondrosarcoma involving left pubic bone, showing mass effect on urinary bladder

Single lamellar periosteal reaction (Fig. 1.6B) is seen as a growth first result in ossified layer of periosteum to be
thin 1 to 2 mm faint radiopaque line from the cortical surface elevated, and later subsequent layers of periosteum are
and usually occurs in osteomyelitis, histiocytosis, some formed as the lesion waxes and wanes during its pro-
benign tumors, and healing fractures. gression. This type of periosteal reaction occurs in
In multilamellated periosteal reaction (Fig. 1.6H), there osteomyelitis, histiocytosis, aneurysmal bone cyst, Ewing’s
are multiple layers of concentric periosteal reaction sarcoma and osteosarcoma. Interruptions in the lamellated
resembling an onion skin. Repeated insults from underlying periosteal reaction, indicates more aggressive behavior of
disease process with alternating periods of rapid and slow the lesion.
Diagnostic Approach to Focal Bone Lesions 11

Solid periosteal reaction (Fig. 1.6C) indicates a slow Codman Angles


process and is almost always associated with benign
The periosteal reaction forms an angular configuration with
pathology. This occurs as a result of ossified matrix filling the
underlying cortex, resembling two sides of an angle (Fig.
spaces between lamellations and cortex. This is seen as
1.6G) and indicates an aggressive pathology. This is formed
marked thickening of the periosteal surface of the cortex on
by elevation of the periosteum by tumor, blood, edema or
plain radiographs. It may be smooth or irregular. Lesions
pus. The angle of the triangle may or may not contain tumor.
that show solid periosteal reaction include osteoid osteoma
This is nonspecific, seen in both benign and malignant lesions.
and eosinophilic granuloma.
Undulating periosteal reaction (Fig. 1.6D) is a variant of Buttresses
solid periosteal reaction, seen in low-grade osteomyelitis,
long-standing varicosities, pulmonary osteoarthropathy, and In this type, solid reactive bone is formed at the lateral
chronic osteitis but rarely in neoplasms. extraosseous margins of slowly growing bone lesions, the
Parallel spiculated continuous periosteal reaction cortex beneath the buttress is frequently intact (Figs 1.6H
represents an underlying malignant pathology. Bony spicules and 1.7).
may appear perpendicular to the cortex—hair on end (Figs
Truncated Lamellae
1.6E and F), fan out in focal divergent manner—sunburst
pattern (Fig. 1.6G), appear to slope in a focal manner (velvet In aggressive neoplasms and virulent infections, the
pattern), or show an unorganized pattern. The direction of lamellations are sometimes interrupted or truncated (Fig.
the spicules is determined by the direction in which the 1.6H), because they are resorbed faster than they can be
tumor grows. This type of periosteal reaction suggests a formed.
more rapid process than lamellated or solid reaction. The
spicules may show uniform, fine velvet-like pattern to long Complex Periosteal Reaction
linear shadows with a gradual reduction in height in each Complex periosteal reaction includes combinations of
direction along the shaft from the mid-zone of the reaction. lamellated, divergent spiculated periosteal reaction,
Hair on end periosteal reaction commonly occurs in Ewing’s buttresses and Codman angles (Fig. 1.6H). More extensive
sarcoma, osteosarcoma, metastasis and thalassemia. These and complex the periosteal reaction, greater is the biologic
spicules are composed of normal reactive bone. Loose areolar activity of the underlying pathology.
tissue between the spicules may be replaced by tumor tissue
in Ewing’s sarcoma, osteosarcoma and metastasis while SOFT TISSUE EXTENSION
these may be replaced by hyperplastic red marrow in
thalassemia (Fig. 1.6F) and sickle cell anemia. Sunburst Normally, the soft tissue shadow of muscle bundles when
appearance is more often seen in osteosarcoma, osteoblastic visualized on a radiograph is sharp with no displacement. It
metastasis and hemangioma (Fig. 1.6G). In osteosarcoma, appears obscured when there is infiltration of intermuscular
the divergent spicules are composed mainly of tumor bone fat planes by inflammation, hemorrhage or tumor. It may
but may also be composed of reactive bone or a combination show displacement by organized hemorrhage or abscess.
of both. In velvet pattern of periosteal reaction, the spicules Presence of fat density in a soft tissue mass suggests a lipoma
are short and sloped. This is seen rarely in chondrosarcoma. (Fig. 1.8A). Presence of phleboliths indicates hemangioma
In unorganized form of periosteal reaction, the spicules are or angiomatous lesion (Fig. 1.5C). In myositis ossificans, focal
seen in various directions and indicate marked aggressive rounded or streak-like areas of amorphous radiodensity are
nature of the lesion, seen in Ewing’s sarcoma as it extends seen with areas of bone formation in the peripheral part as
into soft tissues. the lesion matures. Parosteal osteosarcoma also appears as
an amorphous mass of increased density, but it matures
Interrupted Periosteal Reaction earliest centrally in contrast to myositis ossificans. Both these
lesions may or may not demonstrate a cleavage plane
In this type, continuous mineralization of the periosteal between the mass and underlying bone. Synovial sarcoma
reaction does not occur, resulting in the formation of Codman shows punctate clumps of calcific density and is usually
angles, buttresses or truncated lamellae. present around a joint or along a tendon sheath (Fig. 1.8B).6
12 Imaging Modalities

B C D

E F

A G H

Figs 1.6A to H: Various types of periosteal reaction: (A) Schematic diagram showing various types of periosteal reactions, (B) Single lamellar
periosteal reaction in osteomyelitis involving upper-half of tibia—note type III – permeative bone destruction, (C) Solid periosteal reaction in
stress fracture involving second metatarsal, (D) Undulating periosteal reaction (arrow) in chronic osteomyelitis of tibia, (E) Parallel (hair-on-
end) (arrow) and divergent (sunburst) (arrowhead) spiculated periosteal reaction in diaphyseal osteosarcoma of tibia—note ivory pattern of
osteoid tumor matrix, (F) Hair-on-end periosteal reaction involving the skull vault in thalassemia with marked thickening of outer table in
frontoparietal region, (G) Sunburst periosteal reaction with coarse and striated trabecular pattern seen in hemangioma involving distal femoral
metaphysis in a child, and (H) Complex periosteal reaction in Ewing’s sarcoma of humeral diaphysis—note interrupted multilamellar (onion skin)
reaction, buttress formation (open arrow) in the upper part and Codman angles (arrow) in the lower part of the tumor both on medial and lateral
aspects of bone
Diagnostic Approach to Focal Bone Lesions 13

Soft tissue mass is often associated with primary bone


tumor but less commonly with a secondary deposit. It may
displace adjacent intermuscular fat planes (Fig. 1.8C) and
may or may not erode the contiguous bony cortex.

MULTIPLICITY

Multiplicity of malignant lesions usually indicates metastatic


disease (Fig. 1.9A), multiple myeloma, or lymphoma. Very
rarely, primary malignant bone lesions such as Ewing’s
sarcoma or osteosarcoma, present as multifocal disease.
Benign lesions, which tend to involve multiple sites, are
polyostotic fibrous dysplasia, multiple osteochondromas,
enchondromatosis (Fig. 1.9B), Langerhans’ cell histiocytosis
(Fig. 1.9C), hemangiomatosis, hemophilia pseudotumors
(Fig. 1.9D) and fibromatosis.7

Table 1.2 Examples of septated lesions


Septations Lesions
A B
Coarse, thick Chondromyxoid fibroma
Figs 1.7A and B: Saucerization : (A) “Saucerization” (arrowhead) of
the medial humeral diaphysis in Ewing’s sarcoma—note the buttress Delicate, thin Giant cell tumor
type (arrow) of periosteal reaction in the distal part. (B) Expansile, Delicate, horizontally oriented Aneurysmal bone cysts
lytic, multiseptate lesion in a patient with giant cell tumor of lower end Lobulated Nonossifying fibroma
of radius—note saucerization (arrow) of lateral ulnar cortex due to
soft tissue component of tumor and ridged shell periosteal reaction Striated, radiating Hemangioma

A B C

Figs 1.8A to C: Soft tissue components: (A) Radiograph of hand showing low density lesion in 1st web space (due to presence of fat density)
suggests a lipoma, (B) Radiograph of knee joint showing punctate clumps of calcific density around the joint due to synovial sarcoma,
(C) Radiograph of thigh including knee joint showing lytic destructive lesion in lower end of femur associated with large soft tissue component
displacing the adjacent intermuscular fat planes
14 Imaging Modalities

MISCELLANEOUS

Septations (Table 1.2)


Lytic expansile lesions often show septations which represent
residual normal bone that has not been resorbed or
destroyed. These include aneurysmal bone cyst, giant cell
tumor, nonossifying fibroma, etc. These septations are left
behind by the lobules of growing lesion that advance
asymmetrically at a more rapid rate. The septae are thin in
giant cell tumor (Fig. 1.10A) while they are thick in
A B nonossifying fibroma and chondromyxoid fibroma
(Fig. 1.10B).8

Saucerization
Some tumors invade the cortex of a tubular bone in such a
way that the area of bone destruction resembles a saucer
when the long bone radiograph is viewed in profile. Ewing’s
sarcoma and metastasis may show typical saucerization
configuration. In Ewing’s sarcoma, the tumor breaks through
the cortex, extends subperiosteally and erodes from its
paracortical location to produce saucerization (Fig. 1.7A).
Metastasis also invade subperiosteal region in the same way
as Ewing’s sarcoma or may invade cortex directly. Large
soft tissue masses may erode bone in a similar manner
C
(Fig. 1.7B).8

Figs 1.9A to D: Multiplicity of lesions: (A) Multiple sclerotic lesions


involving pelvis and lumbar spine in elderly patient suggestive of A B
metastases, (B) Multiple intramedullary lytic lesions with chondroid
type of calcification in short bones of hand suggestive of multiple Figs 1.10A and B: Septations: (A) Expansile, lytic, multiseptate lesion
enchondromatosis, (C) Multiple lytic lesions involving long bone both in a patient with giant cell tumor of lower end of radius—note
metaphysis and diaphysis with pathological fracture in a child saucerization of lateral ulnar cortex due to soft tissue component of
suggestive of Langerhan’s cell histiocytosis, (D) Multiple lytic lesions tumor and ridged shell periosteal reaction, and (B) Eccentric expansile
involving tibia and femur in patient with history of bleeding diathesis lytic lesion showing thick septa and ridged shell reaction in
suggestive of hemophilic pseudotumors chondromyxoid fibroma involving lower end of tibia
Diagnostic Approach to Focal Bone Lesions 15

Table 1.3 Benign lesions with aggressive features


Lesion Radiographic Presentation
Osteoblastoma Bone destruction and soft
(aggressive) tissue extension
similar to osteosarcoma
Desmoplastic fibroma Expansive destructive lesion,
frequently trabeculated
Periosteal desmoid Irregular cortical outline, mimics
osteosarcoma or Ewing’s
sarcoma
Giant cell tumor Occasionally aggressive
features – Osteolytic bone
destruction, cortical penetration,
and soft tissue extension
Aneurysmal bone cyst Soft tissue extension, occasio-
nally mimicking malignant tumor
Osteomyelitis Bone destruction, aggressive
periosteal reaction. Occasionally,
features resembling Ewing’s
sarcoma
Pseudotumor of Hemophilia Bone destruction, periosteal
reaction occasionally mimics
Fig. 1.11: Simple bone cyst involving humerus showing “fallen fragment” malignant tumor
(arrow) and “trap-door” (open arrow) signs Myositis ossificans Features of parosteal or
periosteal osteosarcoma
Brown tumor of Lytic bone lesion, resembling
Floating Fragment Sign hyperparathyroidism malignant tumor

The fractured fragment may be seen within a radiolucent


lesion. This fragment changes its location with change in Table 1.4 Lesions that should not be biopsied
extremity position, a characteristic feature seen in Tumors and tumor like lesions Nonneoplastic
unicameral bone cyst. This sign is also known as “fallen conditions
fragment sign” (Fig. 1.11). When the fractured fragment Fibrous cortical defect Avulsion fracture
remains attached at the fracture site, it is seen in the form (healing phase)
of a trapped door due to hydrostatic pressure of the fluid Nonossifying fibroma Bone infarct
contained within the cyst. This is called “trap door sign”. Periosteal (cortical) desmoid Bone island (enostosis)
Both these signs are typical of unicameral bone cyst. Small, solitary focus of Pseudotumor of
fibrous dysplasia hemophilia
BENIGN VERSUS MALIGNANT Myositis ossificans Degenerative and post-
traumatic cysts
Although it is sometimes very difficult to distinguish benign Intraosseous ganglion Brown tumor of
from malignant bone lesions on the basis of plain hyperparathyroidism
radiographys alone, however certain key characteristic Enchondroma in a short, tubular bone Diskogenic vertebral
features may favour one over the other. Benign tumors sclerosis
usually present with well-defined, sclerotic borders, a
geographic type of bone destruction, an uninterrupted solid
periosteal reaction and no soft tissue extension. Malignant an adjacent soft-tissue mass. As noted earlier, it should be
lesions, on the other hand tend to demonstrate poorly kept in mind that some benign tumors can also exhibit
defined borders with a wide zone of transition, a moth-eaten aggressive features (Table 1.3).9
or permeative pattern of bone destruction, an interrupted When all the clinical and radiographic information
periosteal reaction of the sunburst or onion-skin type, and concerning a patient with a bone lesion has been analyzed,
16 Imaging Modalities

the most important diagnostic decision is whether the lesion through the cortex but show no localized bone destruction.
is definitely benign and not to be biopsied, but rather merely These are highly aggressive, Permeative lesions. CT margin
monitored or completely ignored (a “do not touch lesion”) is particularly useful when the tumor margin is not well seen
(Table 1.4), or whether it has an ambiguous and an aggressive on plain radiographs. This applies particularly to lesions in
appearance and should be further investigated via vertebrae and flat bones such ilium, sacrum, and scapula.6
percutaneous or open biopsy. The results of the In the diagnosis of solitary bone lesions CT is typically
histopathologic examination would then determine whether used in order to obtain “radiographic” information, where
further management in a given case would be surgical, conventional radiographs fail due to limited contrast
chemotherapeutic, radiotherapeutic or a combination of resolution, complex skeletal anatomy (e.g. spine, pelvis) (Figs
these. 1.12A and B), or superposition of skeletal elements (e.g.
scapula). Computed tomography has widely replaced
COMPUTED TOMOGRAPHY ANALYSIS conventional tomography, and recently, with the advent of
OF BONE LESIONS multislice techniques, it has developed into a “true”
Computed tomography (CT) provides greater morphological multiplanar modality. Computed tomography is superior to
detail about the bone surrounding a lesion and analysis can radiography in determination of the epicenter of a bone
be applied in the same way as classic radiographic margin lesion (medullary, cortical, periosteal, parosteal). The site of
analysis. A well-defined lesion within the cortex suggests origin can be characteristic for a special entity (e.g. non-
indolent growth while evidence of cortical destruction or ossifying fibroma, periosteal chondroma), and it can
permeation is sign of aggressiveness. As with radiographic influence the growth pattern of the lesion and therefore, it
analysis, CT has a grading system. Lesions contained in bone can determine whether the lesion appears more or less
or by periosteal new bone are grade I and represent indolent aggressive. The biologic activity of a lytic bone lesion is
processes. Lesions that partially or destroy cortex are called mirrored in its pattern of bone destruction. Independent of
grade II. Penetration of the cortex or periosteal new bone the anatomic site of the lesion, CT can define the margins of
shows aggressiveness. Grade III lesions completely penetrate an osseous defect in 360° survey, it can exactly determine

A B

Figs 1.12A and B: Role of CT scan in assessment of focal bone lesion: (A) Axial CT of the lumbar vertebra at the level of the renal
hilum shows marked tumoral destruction of the left half of the vertebral body and the left pedicle, by a proven chondrosarcoma.
Matrix mineralization and residual trabeculae are seen inside. The tumor is extending into the left psoas muscle and is lifting the aorta
and the left renal vain anteriorly (arrowheads). The fat plane with the aorta is obliterated. Posteromedially the mass is extending into
the spinal canal and causing an impression on the theca (arrow). (B) Axial CT section of sacrum showing expansile lytic lesion in
right sacral ala a case of giant cell tumor
Diagnostic Approach to Focal Bone Lesions 17

the width of the zone of transition between normal and Computed Tomography Grading
abnormal bone, and it can detect delicate sclerotic reactions. System of Bone Lesions
The most important advantage of CT over radiography
probably is its superior delineation of cortical alterations, of
which cortical expansion and remodeling, endosteal
scalloping, and focal penetration represent the most
common forms in benign bone lesions. Periosteal reactions
represent another barometer of the biologic activity of bone
tumors and tumor-like lesions. Computed tomography has
the ability to depict periosteal reactions that might be
invisible on radiographs due to superposition or limited
MAGNETIC RESONANCE IMAGING
contrast resolution. Furthermore, CT represents the most
OF BONE LESIONS11,12
valuable imaging modality in detection of subtle matrix
calcifications and therefore can be useful in confirming the Magnetic resonance imaging is exquisitely sensitive to lesions
diagnosis of a bone- or cartilage-forming tumor.10 that replace marrow and destroy bone. It shows the full

A B C

D E F
Figs 1.13A to F: Role of MRI in assessment of focal bone lesion: (A) Coronal T2W MR image showing brightly hyperintense lobulated mass
lesion arising from the right acetabulum in elderly patient suggestive of chondrosarcoma, (B) Coronal STIR MR image showing elongated
hyperintense lesion involving the shaft of humerus in a child suggestive of simple bone cyst, (C) Axial T2W MR image showing expansile lesion
with multiple blood fluid levels suggestive of aneurysmal bone cyst, (D) Sagittal T2W MR image of a patient with biopsy proven case
osteosarcoma showing altered signal intensity involving the metaepiphysis of lower end of femur associated with large soft tissue component
which is extending into knee joint, (E) Coronal T1W image of child with osteomyelitis showing heterogenous signal intensity involving the
diaphysis, metaphysis and epiphysis of lower end of tibia suggestive of aggressive lesion, (F) Sagittal T1W MR image of arm in patient with
known case of osteosarcoma showing altered signal intensity involving upper end of humerus associated with large surrounding soft tissue
component without obvious cortical destruction suggestive of transcortical infiltration
18 Imaging Modalities

extent of lesions and extension into soft tissues. Magnetic marrow edema, the more likely the bone lesion is benign.
resonance imaging is of minor value in the estimation of the Marrow edema may be present around malignant bone
malignant potential of an osseous lesion. Although many tumors, as well, in which case it constitutes the reactive
bone tumors and tumor-like lesions present similar zone of the tumor.
morphology at MRI, some entities can be diagnosed with However, its main role on for preoperative staging of
good reliability. These include chondrogenic tumors tumor extent and involvement of critical structures such as
(Fig. 1.13A), solitary (Fig. 1.13B), and aneurysmal bone cysts joints and neurovascular bundles (Fig. 1.13D).
(Fig. 1.13C), giant cell tumors, lesions containing fatty tissue Magnetic resonance is particularly useful to evaluate
and, to a certain extent, osteoid-osteomas and aggressive lesions such as malignant tumors and infective
osteoblastomas. lesions (Fig. 1.13E). It depicts transcortical infiltration a sign
The differential diagnosis for benign bone lesions of highly aggressive lesions (Fig. 1.13F). Magnetic resonance
surrounded by extensive marrow edema includes osteoid also depicts intratrabecular infiltration sign of infiltrative
osteoma/osteoblastoma, chondroblastoma, Langerhans cell growth in case of malignant bone tumor. It also shows active
histiocytosis, and osteomyelitis. As a general (but not tumor growth in periosteal and endosteal extension at tumor
absolute) guideline, the greater the extent of surrounding margins.

Flow chart 1.1: Assessing focal bone lesion


Diagnostic Approach to Focal Bone Lesions 19

CONCLUSION 2. Miller TT. Bone tumors and tumorlike conditions: analysis


with conventional radiography. Radiology. 2008;246(3):662-
• The guidelines mentioned in chapter usually permit us to 74. Epub 2008 Jan 25.
make correct diagnosis or offer close differentials (Flow 3. Madewell JE, Ragsdale BD, Sweet DE. Radiologic and
chart 1.1). pathologic analysis of solitary bone lesions. I. Internal
margins. Radiol Clin North Am. 1981;19:715-48.
• The pattern of bone destruction, margins, cortical 4. Sweet DE, Madewell JE, Ragsdale BD. Radiologic and
response, location and site of lesion on radiographs helps pathologic analysis of solitary bone lesions. III. Matrix
in differential diagnosis of bone tumor and tumor like patterns. Radiol Clin North Am. 1981;19:785-814.
lesions. 5. Ragsdale BD, Madewell JE, Sweet DE. Radiologic and
• Because of high specificity in detecting lesion features, pathologic analysis of solitary bone lesions. II.
Periosteal reactions. Radiol Clin North Am. 1981;19:749-
radiography is integrated with clinical findings that allows 83.
the differential diagnosis between neoplastic and non- 6. Brown KT, Kattapuram SV, Rosenthal DI. Computed
neoplastic lesions including trauma (healing or stress tomography analysis of bone tumors: patters of cortical
fractures, myositis ossificans), infection (acute destruction and soft tissue extension. Skeletal Radiol.
1986;15:448-51.
osteomyelitis Brodie’s abscess), eosinophilic granuloma
7. Priolo F, Cerase A. The current role of radiography in the
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• Radiography is not sufficient to study the lesions in Eur J Radiol. 1998; 27(suppl 1):S77-S85.
complex anatomical sites such as spine, pelvis, and 8. Moser RP, Madewell JE. An approach to primary bone
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extent of the tumor. In such cases cross-sectional imaging
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35.
pathologist must collaborate to make the diagnosis more
11. Pettersson H, Gillespy T 3rd, Hamlin DJ, et al. Primary
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CHAPTER

Basic Principles and Current


2 Concepts of Musculoskeletal
Magnetic Resonance Imaging
Raju Sharma, Shivanand Gamanagatti

INTRODUCTION quality of MR images.2 Scanners are now available which


allow imaging in the weight bearing, upright position and
MR imaging of the musculoskeletal system has made
also in flexion and extension (Kinematic MRI). This allows
immense progress in the last two decades. The pace of
evaluation of dynamic postural and functional changes in
innovation has been rapid and MR has become a versatile
degenerated disks,3 as well as dynamic evaluation of joints.
and virtually indispensable imaging modality for many
Upright and kinematic MRI may detect minor neural
musculoskeletal applications. Developments such as high
foraminal compromise related to posture. However, these
performance MR systems and optimized coil technology
scanners are open configuration with low magnetic field
have led to improvements in spatial resolution and signal-
strength which may compromise resolution and are
to-noise and better cost-effectiveness of MR studies.1 This
therefore suitable for few niche indications.
in-turn has led to improved diagnosis in shorter period of
Choosing the appropriate coil is important to obtain high
time and better understanding of complex orthopedic
quality images. The smallest coil possible, that allows the
disorders. This chapter aims to briefly outline the basic
required anatomical coverage, should be used to get the
principles of musculoskeletal MRI and highlights the recent
maximum signal. Surface coils that can be placed on or close
advances in this exciting and ever-changing specialty.
to the region of interest should be used. Most new coils are
HARDWARE ISSUES made with a phased array design. These are made of several
smaller coils placed in a series and provide the combined
The basic pre-requisites for optimized MR imaging of the advantage of high resolution images and a wide field of view.
musculoskeletal system are high spatial and contrast Eight channel coils are now available for musculoskeletal
resolution and high sensitivity for the visualization of free applications.
water. Although high-field systems clearly have an advantage
with regard to resolution, musculoskeletal imaging, for most 3T IMAGING
indications, can be done on mid and low-field systems also.
The ultra high-field systems (3 Tesla) are now widely available 3T imaging has many advantages in the musculoskeletal
and provide very high quality images of the musculoskeletal system. Imaging at higher field strengths gives better signal
system. Faster gradients, improvements in surface coil to noise ratio (SNR), resulting in higher resolution images
design, and development of new and faster sequences have and shorter scan times. The SNR at 3T is about twice that at
all contributed to the fact that MRI has become the modality 1.5 T and 3T scanners are already being widely used for
of choice for evaluation of the musculoskeletal system.1,2 musculoskeletal imaging (Fig. 2.1). Research studies are
The use of parallel imaging and motion reduction techniques being conducted at 7T systems also. Not only SNR but also
like PROPELLAR and BLADE have further enhanced the image spatial resolution and the contrast to noise ratio can be
Basic Principles and Current Concepts of Musculoskeletal Magnetic Resonance Imaging 21

Fig. 2.1: Sagittal fat supressed T2W image acquired on a 3 Tesla scanner shows a small detached
ossific fragment in the articular surface of medial femoral condyle with fluid signal intensity
between the fragment and the underlying bone, suggesting osteochondritis dissecans. The
image has a high signal to noise ratio with excellent delineation of anatomy

enhanced on 3T scanners. The collective benefit gives rise to


better delineation of the small intrinsic structures of joints.
Many studies have documented higher accuracy and greater
degree of confidence using 3T imaging, in the diagnosis of
meniscal tears, defects in articular cartilage, triangular
fibrocartilage pathology, etc. However, 3T imaging is unlikely
to replace the need for MR arthrography in lesions like labral
tears.2,4
The sequences and protocols need to be modified for
optimum imaging at 3T. Improved sequence design and
widespread use of parallel imaging are likely to improve the
image quality at 3T even further.

SEQUENCES
Fig. 2.2: Sagittal fat suppressed (FS) proton density (PD) image shows
Many different options are available to image the good delineation of hyaline articular cartilage (gray signal intensity
musculoskeletal system. The aim is to get all the diagnostic along posterior aspect of patella) and cruciate ligaments in the knee.
information necessary in as short a time as possible. This can Anterior cruciate ligament is disrupted with no normal fibers identified,
only be done by adopting a judicious protocol for which it is and there is buckling of PCL, suggesting complete ACL tear
important to know the merits and demerits of the different
types of sequences. It is a good practice to have a standard
most musculoskeletal applications proton density and T2W
protocol tailored to a specific clinical indication for a given
sequences are coupled with fat suppression.
MR scanner. T1W sequence is good for delineation of
anatomy and marrow pathology, proton density sequence
Fast Spin-echo (FSE) Sequences
for meniscal tears, articular cartilage (Fig. 2.2) and ligament
pathology and T2W sequence for detecting soft tissue This group of sequences allows for much more rapid
component of tumors (Figs 2.3A and B), edema, etc. For acquisition of images than the conventional spin-echo (SE)
22 Imaging Modalities

A B

Figs 2.3A and B: Sagittal FS T2W image of the knee gives excellent depiction of the extraosseous and
intraosseous extent of the tumor in a case of osteosarcoma of the distal femoral end. Also note the intra-
articular extension of the tumor

method. This is done by acquiring several samples in the dimensions are nearly isotropic.2 This allows for high-
time in which one sample is obtained in the conventional resolution imaging and is especially useful when evaluating
spin-echo technique. The time saved is directly proportional extremely small structures such as ligaments in the wrist.
to the number of samples also known as the echo train These 3D sequences also provide the ability to create
length.1 This decreases overall imaging time thereby reformatted images in virtually any plane. Ligaments and
decreasing the motion artifacts and increasing the articular cartilage are particularly well demonstrated with
throughput. Alternatively the time saved can be used for these sequences. Dual echo steady state (DESS) is a 3D
obtaining additional signal averages and increasing the steady state GRE sequence with a good signal to noise ratio
matrix size to improve the signal and resolution, respectively. and strong T2 contrast. It is useful for the differentiation of
However, the FSE technique has some disadvantages. synovial fluid and cartilaginous structures. Multiecho data
Firstly the signal intensity of fat remains quite bright on these image combination (MEDIC) is a multiecho GRE sequence
T2W images. As a result pathology in subcutaneous fat or that provides good T2-weighted images and has been found
marrow may be obscured, due to the similarity in the signal useful in joint imaging (Fig. 2.4).
intensity of fat and fluid. This problem can be resolved by GRE sequences are extremely sensitive to susceptibility
combining this technique with fat saturation (Figs 2.3A and effects. This is advantageous when searching for subtle areas
B), which is now routinely employed.1,2 Secondly the FSE of hemorrhage, detecting loose bodies and soft tissue gas.
technique can result in blurring along tissue margins when Conversely drawbacks of this effect include overestimating
long echo train lengths are used. This may result in missing the size of osteophytes in spine imaging and gross artifacts
subtle pathology such as meniscal tears in the knee. when imaging patients with metallic hardware.

Gradient-recalled Echo (GRE) Sequences Fat Suppressed Sequences


These sequences were originally developed to produce T2W Detection of a pathological process is often hindered by the
images in less time than was possible with conventional SE presence of strong signal from neighboring adipose tissue.
techniques. They can be performed either with a 2D or 3D In such cases, suppression of the fat signal offers improved
volume technique. In 3D imaging the signal from an entire conspicuity and sensitivity.1 Fat suppression is commonly
volume of tissue is obtained at one time and this data can be employed with fast spin-echo T2W sequences on which fat is
partitioned into extremely thin slices such that the voxel very bright. It is also frequently coupled with gadolinium
Basic Principles and Current Concepts of Musculoskeletal Magnetic Resonance Imaging 23

Fig. 2.4: Axial FS gradient-echo image (MEDIC) of the shoulder.


Anterior and posterior glenoid labrum are well seen

enhanced images where the hyperintense signal from


enhancing abnormalities may be masked by hyperintense
fat. Fat saturated T1W images are also used with gadolinium
arthrography.
Two main techniques used to accomplish fat suppression
are frequency selective (chemical fat saturation) and short
tau inversion recovery (STIR) imaging. A problem with the
frequency selective fat saturation is the potential for
inhomogeneous suppression of fat signal. It relies on Fig. 2.5: Sagittal STIR image of the whole spine shows hyperintensity
adequate separation of fat and water peaks, which occurs and decreased vertebral height involving multiple vertebrae, suggesting
multiple metastases in a known case of malignancy. There is
only at high-field strength (greater than 1Tesla), and hence
homogeneous suppression of fat
it is not available on mid and low-field scanners.1 The STIR
technique relies on the relaxation properties of fat protons
rather than their resonant frequency. It produces more
homogeneous fat suppression, because it is not as sensitive when they are out of phase there is destructive interference
to field inhomogeneity as the frequency selective technique between fat and water magnetization vectors. At 1.5 T the
(Fig. 2.5). However, STIR sequence should not be used with TE for the in phase image is 4.6 msec or a multiple of 4.6 and
intravenous or intra-articular gadolinium because the the TE for the opposed phase image is 2.3 msec or a multiple
contrast agent has similar relaxation properties to fat protons of 2.3. The fat and water in phase and out phase images can
and therefore its signal intensity may be saturated along be added or subtracted to produce water only or fat only
with fat on the STIR images. images. This two point Dixon technique is sensitive to
A third method of fat suppression is the DIXON technique magnetic field inhomogeneity and to overcome this, a three
or fat water separation technique. This is also based on the point Dixon method has been developed where one in phase
difference in the precessional frequency of protons in fat and two opposed phase images (one at 2.3 msec shorter
and water. However, unlike chemical fat sat it uses a and another sequence with TE 2.3 longer than the nominal
spectrally nonselective radiofrequency pulse, with TEs that TE) are acquired. The three images are analyzed and a phase
capture the phase difference between fat and water protons. map is generated from which fat only, water only and
When fat and water are in phase the signal is maximal and combined images can be created. This technique is called
24 Imaging Modalities

iterative decomposition of fat and water with echo image distortion. Radiologists should be aware of the steps
asymmetric and least square estimation (IDEAL). The Dixon that can be taken to reduce these artifacts. If there is any
technique can be applied to regions of complex anatomy doubt of the MR compatibility of the prosthesis an alternative
and can be used with spin-echo, fast spin-echo as well as imaging modality should be used.
GRE sequences. Its disadvantages include sensitivity to The degree of metal artifact is related to field strength
magnetic field inhomogeneity and potential blurring with and imaging at lower field magnets will decrease the metallic
fast spin-echo sequences.2 artifact. The long axis of the prosthesis should be positioned
parallel to the external magnetic field (B0) to minimize
Role of Contrast artifacts. Other steps that can be taken to reduce metal
Gadolinium-DTPA is a paramagnetic compound and is a T1 artifact are aligning the frequency encoding direction along
contrast agent. For musculoskeletal applications it can be the long axis of the implant, increasing the receiver
administered by the intravenous and intra-articular route. bandwidth and reducing the FOV. Fast spin-echo sequences
Its major application in musculoskeletal MRI is in the setting with long echo train length are least susceptible to metal
of infections (Fig. 2.6), where it can help to distinguish artifacts and should be preferred over gradient-echo
cellulitis from abscess. It is used in evaluating bone tumors sequences.2
to differentiate cystic from solid lesions, for perfusion studies
NORMAL APPEARANCE OF
and for directing biopsy to the enhancing viable tumor rather
MUSCULOSKELETAL TISSUES
than nonenhancing necrotic component.1 Gadolinium is also
useful in imaging postoperative spine to differentiate scar It is useful to know the normal appearance of various tissues
tissue from nonenhancing disk material.2 MR arthrography on different MR sequences and the optimal sequence for
is useful for the diagnosis of subtle pathology like labral tears. each, as this can be applied to any anatomical region. Cortical
bone is dark on all sequences whereas the medullary cavity
Reduction of Metallic Artifact from shows a variable signal depending on whether the marrow
Orthopedic Hardware is hematopoietic or fatty. The distribution of red and yellow
Patients with metallic implants and orthopedic hardware marrow changes with age. STIR, fat suppressed FSE T2 and
frequently need to be imaged. Although they are mostly MR T1W sequences are ideal for imaging marrow pathology,
compatible, they can give rise to significant artifact and whereas GRE sequences are not useful for bony evaluation.
MRI is very sensitive to evaluation of occult osseous trauma
when radiographs are normal and for early diagnosis of
marrow infiltrative disorders and for this purpose STIR
sequence is the most sensitive.2
Articular cartilage is dark grey on STIR and FSE T2W
sequences, and is bright on GRE sequences. Fibrocartilage
like the menisci and glenoid labrum are dark on all sequences.
Meniscal tears are best demonstrated on short TE sequences
like T1 and proton density images.
Tendons are generally dark on all pulse sequences. Useful
sequences are GRE T2*, T1 and FSE T2. Tendons are usually
best imaged in the axial plane. Tears and tendonitis are seen
as hyperintense areas but it is important to know some pitfalls
for this finding. Tendons may show slightly increased signal
intensity close to the site of osseous insertion. This is due to
nontendinous fatty material getting interposed between
Fig. 2.6: Utility of contrast administration. Coronal FS postgadolinium tendon fibers. Another important cause is the magic angle
T1W image shows abnormal synovial enhancement in a case of TB
left hip with multiple rim-enhancing abscesses within the joint cavity phenomenon which can give rise to a hyperintense signal in
and in the surrounding soft tissues the tendons that are oriented at 55° to the main magnetic
Basic Principles and Current Concepts of Musculoskeletal Magnetic Resonance Imaging 25

field B°. However, this bright signal is seen only on the short MORPHOLOGICAL ASSESSMENT
TE images (T1W and proton density) and not on T2W OF CARTILAGE
images.1 Common sites where this artifactual hyperintensity
On spin-echo T1W, Proton density (Fig. 2.2) and T2W
may be seen are the posterior tibial tendon in the ankle,
sequences articular cartilage is of intermediate signal
rotator cuff in the shoulder and posterior cruciate ligament
intensity. 8 With both conventional and advanced MR
in the knee. Changing the position for instance imaging the
techniques several investigators have reported a bilaminar,
ankle in 20° plantar flexion can help to overcome this artifact
and occasionally, a trilaminar appearance of articular
by changing the angle of the tendon with respect to the
cartilage on MRI. However, the laminar signals may not
main magnetic field vector. In addition to hyperintense signal
correspond to the histologic zones. Many MR artifacts like
within the tendon, attention should also be paid to any
truncation, partial volume, chemical shift and magic angle
thickening or fluid around the tendon as is seen in
can contribute to or obscure the laminated appearance.
tenosynovitis.
Routine MR evaluation of a joint includes conventional SE,
Normal synovium is not usually visualized unless it is
FSE and GRE technique.9 Fat suppression methods improve
pathologically thickened. Postgadolinium T1W fat saturated
the contrast between the cartilage and fatty marrow. The
images are useful for delineation of thickened synovium. It
cartilage appears bright due to an increase in the dynamic
may not be possible to distinguish hypertrophied synovium
range. This technique is easily combined with the routine
from synovial fluid on T2W and STIR images. Hypertrophied
sequences to provide high contrast images of the cartilage.
synovium is seen in tubercular and rheumatoid arthritis.
The use of 3D imaging methods in conjunction with FSE and
Muscle is of intermediate signal intensity on all
GRE sequences allows for less than 1 mm slice thickness and
sequences. T1W sequences are good to show the anatomy
greatly improved spatial resolution. Three-dimensional
and detect subacute hemorrhage and fatty atrophy. T2W or
spoiled gradient in the steady state (3D SPGR) or 3D fast
STIR sequences are sensitive for the diagnosis of muscle
low-angle shot (FLASH) has been suggested to be one of the
strain, myositis and intramuscular tumors. These sequences
most useful techniques for assessment of cartilage lesions.
are sensitive but unfortunately nonspecific for muscle
Due to the availability of high-speed gradient MR imaging
pathology.
systems, interest has recently been renewed in steady-state
free precession (SSFP), a rapid GRE imaging technique. SSFP
IMAGING OF ARTICULAR CARTILAGE
has superior signal-to-noise ratio (SNR) compared with other
Articular cartilage imaging has become increasingly GRE techniques and has excellent contrast behavior with
important in the setting of aging population where varying dependence on T1 and T2. Synovial fluid appears
osteoarthritis is a leading cause of chronic disability. Accurate bright due to its long T2. The limitation of this sequence is
assessment of abnormalities has become essential with image degradation due to local magnetic field
advanced surgical and pharmacological treatments proving inhomogeneities at a long TR. 3D dual echo in the steady-
to be useful in the management of cartilage pathology. state (DESS) images have been generated by combining
There are two types of cartilage assessment sequences images from first and second echoes in a steady state. These
based on their usefulness for morphological or compositional images show a high contrast between cartilage and joint
evaluation. To assess the morphology, standard spin-echo fluid.6,10
and gradient echo sequences, fast spin-echo and 3D spin- Chondromalacia, osteoarthritic degeneration,
echo and gradient sequences are available.5,6 These osteochondral defects or inflammatory erosions are the
sequences allow the detection of morphological defects in common cartilage abnormalities seen on MR imaging.8
cartilage and are also used for semiquantitative analysis. To Cartilage degeneration may be superficial or basal. The MR
assess the collagen and proteoglycan content of cartilage grading is mainly based on the depth of the abnormality
matrix, compositional assessment techniques like T2 (partial or full-thickness) which is seen as a focal signal
mapping, d-GEMRIC, T1p mapping, sodium imaging and alteration. Conventional MR techniques show 52 to 95
diffusion weighted techniques are available, but are mostly percent accuracy for lesion detection, which is higher for
used at the research level.2,7 severe lesions. However, use of FSE 3D SPGR and delayed
26 Imaging Modalities

MR arthrography techniques have increased the sensitivity molecules. When anionic molecules like Gd-DTPA enter
to early and surface lesions.10 cartilage they are distributed in areas where the
Direct (joint injection) or indirect (intravenous injection concentration of glycosaminoglycans is low. The
with delayed imaging) MR arthrography is another cartilage concentration of Gd-DTPA can be estimated by measuring
imaging method and is especially useful for detecting T1, T1 mapping of cartilage after administration of Gd-DTPA
superficial lesions. Indirect arthrography with intravenous allows quantitative assessment of glycosamine content. This
administration of diluted gadolinium may be performed technique may become the noninvasive method of assessing
when direct arthrography is inconvenient or not logistically glycosaminoglycan content in cartilage after various methods
feasible. It is based on the concept that intravenous contrast of repair.2,7,11
over time will diffuse into the joint space, so that semi-
arthrographic T1W images can be obtained. MR contrast T1ρ
ρ Mapping
agents do not produce signal themselves but affect the
relaxivity of the surrounding structures; consequently a very This technique assesses both collagen and glycosaminoglycan
low concentration can affect numerous surrounding content and can detect early degenerative changes.
molecules. The advantages are it does not involve a joint However, an additional RF pulse has to be applied after the
injection or fluoroscopic guidance. In addition vascularized magnetization has been tipped in the transverse plane. It is
or inflamed tissue will enhance with this method. It works a more time consuming technique and no large trials have
best in joints like the wrist, ankle and shoulder but not in been done using this method.7,11
large joints like the knee.2
MUSCULOSKELETAL TUMORS
COMPOSITIONAL ANALYSIS MRI has a vital role in the detection, confirmation and
OF CARTILAGE preoperative evaluation of malignant and aggressive benign
The macromolecular network of articular cartilage consists musculoskeletal tumors. Though plain radiographs are the
of collagen and proteoglycans. The collagen provides the initial modality for the diagnosis of bone tumors, MRI is
framework for the tissue and is the main source for tensile indispensable for elucidation of the intra- and extraosseous
and shear strength, whereas glycosaminoglycans provide extent of the tumor, its categorization as intra- or extra-
compressive strength. compartmental, assessment of the neurovascular structures
and the adjacent joint (Figs 2.7 to 2.10).1 MRI is also the
T2 Mapping best technique to detect skip lesions, which are often missed
by other imaging means. The plain radiograph is the modality
T2 of hyaline cartilage is highly sensitive to alterations of most likely to yield a specific diagnosis (Fig. 2.7A), whereas
cartilage matrix. A multiecho sequence is used to measure MRI is crucial for accurate local staging of a malignant tumor.
T2 values and a quantitative color coded map can be In general, musculoskelatal tumors have a nonspecific
generated representing variations in T2 relaxation time appearance on MRI and this modality is not reliable in
within articular cartilage. Areas of early degeneration are determining the histology of bone tumors in most cases.
seen as areas of higher T2 as compared to normal cartilage. Occasionally, it may enable a specific diagnosis on account
T2 maps can be used to monitor the effectiveness of cartilage of pathognomonic signal characteristics, for example
repair.7,11 vertebral hemangioma, soft tissue lipoma (Figs 2.8A and B),
etc. Therefore one should be wary of interpreting the MR
d-GEMRIC
scan in a suspected tumor without reviewing the plain
In this technique the joint is exercised for 10 minutes after radiographs.
the injection of Gd-DTPA and T1 mapping is done 90 minutes Magnetic resonance imaging may detect bone tumors,
after the injection of Gd. The delay is required to allow which are easy to overlook or are not visible on plain
gadolinium to penetrate the full thickness of the articular radiographs (Fig. 2.10). This is particularly true in the pelvis
cartilage. It is based on the fact that ions in the interstitial and sacrum and in patients with hematological malignancies.
fluid of cartilage are distributed on the basis of the In patients with bone pain and a negative plain radiograph,
concentration of negatively charged glycosaminoglycan MRI is more sensitive and specific than nuclear scan.1
Basic Principles and Current Concepts of Musculoskeletal Magnetic Resonance Imaging 27

A B
Figs 2.7A and B: Frontal and lateral radiographs of the knee, (A) show osteosarcoma of the
distal femoral metaphysis with permeative involvement and osteoid pattern of matrix mineralization
extending into the soft tissues. Coronal STIR image, (B) using body coil shows the complete
extent of the tumor, which facilitates optimal surgical management

A B
Figs 2.8A and B: Axial T1W image (A) shows a well-defined hyperintense mass lesion in the left gluteal region which completely
looses signal on coronal fat suppressed image, (B) indicative of fat within, suggesting the diagnosis of soft tissue lipoma. Also
note that the signal intensity of the lesion parallels that of subcutaneous fat

All preoperative imaging of musculoskeletal tumors for planning subsequent sequences. Surface coil images are
should be done before a biopsy is performed as it may aid in then obtained in the coronal or sagittal planes to display the
biopsy planning. Hemorrhage and edema resulting from a extent of the lesion in all three dimensions. The accurate
biopsy may alter the MR appearance and create difficulty in assessment of the craniocaudal extent and exact distance
evaluating the lesion. The tumor should be imaged in at of the proximal and distal margins from a nearby landmark,
least two planes usually parallel and perpendicular to the such as a joint line is crucial for planning a limb-salvage
long axis of the involved bone. The imaging protocol includes procedure and selection of a suitable prosthesis. 1 Axial
an initial large field of view T1W or STIR study using the body images best demonstrate the relationship of the tumor to
coil (Fig. 2.7B). This is useful in detection of skip lesions and the neurovascular bundle (Fig. 2.9). The elucidation of the
28 Imaging Modalities

A B

C D
Figs 2.9A to D: Frontal and lateral radiographs of the elbow (A) show permeative lytic bone destruction with ill-defined margins involving
proximal ulna with Codman’s triangle, cortical breech, soft tissue extension and osseous mineralization, suggesting osteosarcoma. Sagittal
T1W image, (B) clearly demonstrates the intraosseous extent and extension into surrounding soft tissues. Axial T2W (C) and T1W (D) images
depict the extent of tumor, cortical disruption and soft tissue extension with sparing of the neurovascular bundle

intraosseous tumor extent as well as the skip lesions needs fat is best suppressed by a fat saturation technique to further
inclusion of a T1W or STIR sequence. However, overestima- increase the contrast on T2W images. MRI has a high
tion of the tumor extent may occur on STIR images due to negative predictive value for neurovascular or joint
peritumoral edema. The extraosseous extent is exquisitely involvement by the tumor, though joint involvement tends
demonstrated on a T2W sequence (Fig. 2.3) due to the to get over-diagnosed based on MRI. A GRE sequence is
contrast provided by the low-signal muscles. Adjacent bright helpful in clear identification of the neurovascular bundle.12
Basic Principles and Current Concepts of Musculoskeletal Magnetic Resonance Imaging 29

A B
Figs 2.10A and B: Frontal radiograph of the pelvis (A) shows an ill-defined permeative lytic lesion in the right iliac wing. STIR coronal image
(B) clearly shows that there are multiple well-defined hyperintense lesions in bilateral femoral necks also, indicative of bony metastases.
These lesions were not apparent on radiographs. The primary tumor was proven to be Ewing’s sarcoma

USE OF ADVANCED MR TECHNIQUES from nonresponders, and differentiate residual/recurrent


IN TUMOR EVALUATION tumor from radiation necrosis. The former enhance early
and more rapidly whereas post-therapy changes enhance
Conventional MR is unable to provide a specific histologic
later and more slowly.14
diagnosis and is unreliable for differentiating benign from
malignant neoplasms. Neoadjuvant chemotherapy is used
Proton Spectroscopy
in many bone tumors like osteosarcoma and Ewing’s
sarcoma. The evaluation of response to chemotherapy on It can be performed using a single voxel technique with a
routine MR is based on size reduction which is unreliable point resolved spectroscopy sequence (PRESS) and echo time
and may take time. These problems can be addressed by of 135 msec. The choline peak and choline/creatine ratio
using techniques like dynamic contrast enhanced perfusion has been shown to distinguish benign from malignant bone
imaging, proton spectroscopy, diffusion imaging and in and soft tissue tumors (Fig. 2.11B). The voxel should be
phase/opposed phase MR imaging.13,14 placed on areas showing early and intense enhancement.
The caveat is that some metabolically active tumors like
Dynamic Perfusion Imaging giant cell tumor may also show choline peak.13
T1W gradient echo sequence is repeated rapidly a number
Diffusion Weighted Imaging (DWI)
of times after an injection of gadolinium bolus (0.1 mmol/kg)
followed by a saline chase. Timesignal intensity curves are Diffusion can be assessed both qualitatively and
generated in much the same way as is done in breast imaging. quantitatively and is a measure of tumor cellularity and cell
In general malignant tumors show greater enhancement at membrane integrity. It can be used for detection and
a faster rate (Fig. 2.11D) and a rapid wash out as compared characterization of bone tumors as well as assess the
to benign tumors. 13 This technique coupled with response to chemotherapy. DWI sequences are done at
conventional MR, spectroscopy and DWI may help in different b values ranging from 0 to 1000. Typically benign
narrowing the list of differential diagnosis, better assess the lesions lose their signal intensity as b value increases whereas
extent of disease, distinguish responders to chemotherapy cellular tumors retain their signal intensity. The apparent
30 Imaging Modalities

A B

C D

Figs 2.11A to D: Coronal FS postgadolinium image (A) of the elbow showing the placement of voxel for single voxel MR spectroscopy in
enhancing lesion seen in distal humeral metaphysis. There is elevated choline peak (B), suggesting malignant bone tumor. Coronal post-
gadolinium FS T1W image (C) of the elbow showing the placement of region of interest (ROI) for generation of perfusion map of the lesion to
show contrast kinetics. Time signal intensity curve (D) of the same lesion shows rapid uptake and washout of the contrast, indicating malignant
neoplasm
Basic Principles and Current Concepts of Musculoskeletal Magnetic Resonance Imaging 31

diffusion coefficient (ADC) can be used for quantitative pathology is low signal intensity (equal to or less than muscle)
assessment. Low ADC values are seen in cellular tumors on T1W scans (Fig. 2.12A) and variable but usually high signal
because of restricted diffusion. intensity on T2W scans.
DWI can also be used to assess response to chemo- MRI is exquisitely sensitive for detection of metastatic
radiotherapy. Tumor necrosis caused by these modalities disease and surpasses all other imaging techniques in this
increases the ADC value which can be used as a surrogate regard. A common clinical problem is the distinction
marker for response.14 between a metastatic deposits from an acute osteoporotic
collapse, especially in a patient with a known primary tumor.
MARROW IMAGING Both may show a fractured vertebral body with replacement
Conventional radiographic techniques are very insensitive of normal marrow by low signal intensity on T1W scans.
to marrow infiltration and tumors. CT may detect gross Features that suggest tumor are abnormal signal intensity
metastatic disease of the spine but is of limited use in imaging extending into the pedicles and other posterior elements,
primary and metastatic neoplasms in the rest of the skeleton. involvement of the entire vertebral body by the abnormal
Radionuclide bone scanning is insensitive to certain marrow signal intensity, associated soft tissue mass, and multiple
neoplasms such as lymphoma and multiple myeloma. MRI bone lesions. In osteoporotic fractures the abnormal signal
has the major advantage of imaging the bone marrow intensity does not involve the entire vertebral body, but has
directly and its excellent contrast resolution allows the a horizontal line or band separating the abnormal signal
differentiation of normal from infiltrated marrow.1,2 intensity from the normal fatty marrow signal.1 It has been
When diffuse marrow disease is suspected a survey of reported that GRE opposed phase sequence may be helpful
the entire spine, pelvis and proximal femora is performed, based on the fact that some fat is still present in benign
because this is where the bulk of the hematopoietic marrow lesions such as osteoporotic fractures. Hence osteoporotic
exists. For a marrow survey the patient is positioned supine. fractures are supposed to show lower signal intensity than
The phased array coils are used for spine imaging, and the the metastatic lesions. Diffusion weighted images (DWI)
body coil is used for the proximal femora and the pelvis. have also been successfully used for the purpose of this
Sagittal images of the spine and coronal images of the pelvis differentiation.1 The vertebral lesions due to marrow
and femora are most useful. Whole body MRI can now be infiltration by tumor become hyperintense on DWI (Figs
routinely performed for metastatic survey and in marrow 2.12B and C) whereas osteoporotic collapsed vertebra
infiltrative diseases. There is a technique called DWIBS remains hypointense. In and opposed phase images have
(Diffusion weighted imaging with background suppression also been used in this context. Collapse due to osteoporosis
of fat signal) which is ideal for picking up foci of metastatic will retain some normal fatty marrow which will show loss of
disease, lymphoma, etc. and may become a competitive signal on the opposed phase image. On the other hand,
modality for PET-CT. T1W and STIR images are most sensitive metastatic and marrow infiltrative disease replaces the fatty
to marrow pathology.1 marrow completely and hence does not show this signal loss
MRI can distinguish between hematopoietic or red (Figs 2.12D and E).
marrow from yellow marrow. The normal distribution of red MR can also be used to monitor the response of marrow
and yellow marrow and the conversion of red to yellow pathology such as leukemia and metastases to treatment.
marrow occurs in a predictable manner based on age.2 There Serial MRI has been shown to be useful in confirming
is a vast array of marrow disorders that can be detected on remission and detecting relapse in patients with leukemia.
MR imaging although the appearance may be nonspecific
MUSCULOSKELETAL INFECTIONS
and only a differential diagnosis may be offered. However,
MRI is excellent for establishing the presence of disease and Conventional radiographs remain the initial imaging modality
also for directing biopsy to an appropriate site. of choice for suspected osteomyelitis. However, it is
Important categories of marrow pathology include insensitive to the detection of early osteomyelitis. MR
marrow proliferative disorders such as leukemia and imaging scores over radiography, CT and scintigraphy in
myeloma and marrow replacement disorders such as detection of early osteomyelitis. However, the MR
metastases and lymphoma.1 The usual appearance of marrow appearance is nonspecific and similar to infiltrating
32 Imaging Modalities

A B C

D E

Figs 2.12A to E: Sagittal T1W image (A) of lumbosacral spine shows altered signal intensity with partial collapse of L4 vertebra. Diffusion-
weighted images at b 0 s/mm2 (B) and b 400 s/mm2 (C) show retention of signal at higher b value, suggesting restricted diffusion. Sagittal T1W
in-phase (D) and opposed-phase (E) images show suppression of marrow signal in the normal vertebrae. However, L4 vertebra shows no
loss of signal. Diffusion restriction and absence of signal suppression on opposed phase images are markers of malignant vertebral involvement.
This was proven to be metastatic vertebral collapse

neoplasms and stress fractures and the clinical context is further increase the sensitivity for detection of involved
important in reaching the correct diagnosis.15 MR is also areas. Contrast administration is also helpful in dis-
superior to other modalities in delineating the soft tissue tinguishing abscess (Fig. 2.6) from surrounding cellulitis,
involvement. The elucidation of the full extent facilitates increasing the conspicuity of the sinus tracts by causing their
preoperative planning of the maximal degree of walls to enhance and clearly demonstrating the
debridement or the level of the amputation. Fat suppression nonenhancing sequestra within enhancing granulation
techniques combined with gadolinium administration tissue.16
Basic Principles and Current Concepts of Musculoskeletal Magnetic Resonance Imaging 33

In infants and children, involvement of the unossified Tesla), open midfield system (0.5 T) and closed short bore
physis and epiphysis is best shown by MR imaging. magnets (1 to 1.5 T). Improved patient access with open
magnet allows interventions in any desired plane and patient
INFLAMMATORY ARTHRITIS position. To begin with, horizontally open magnets were
used. Recently, experience with vertically open units has
Radiography has been the imaging modality of choice in
also been reported. Vertically open units permit unrestricted
rheumatoid arthritis (RA), primarily because of its
vertical and side access to the patient at the most
reproducibility and feasibility. Currently MRI is being used
homogeneous portion of the magnetic field. The other
widely for recruiting patients into clinical trials as well as
advantage is a horizontally directed main magnetic field
monitoring disease progression over time, because of its
along the long axis of the bore, which ensures that the needle
advantage of simultaneous imaging of key structures other
trajectory is never parallel to the field.19 In closed systems,
than bone (synovium and surrounding soft tissues) that are
instrument manipulation can only be performed with the
important in inflammatory arthritis. MRI is also a useful tool
patient outside the magnet. However, due to higher field
in evaluating patients with early rheumatoid arthritis. It can
strength, image quality as well as the imaging speed is
detect pre-erosive synovitis and can also identify early bone
better.
damage before it becomes apparent on radiography. In early
For instrument visualization the susceptibility artifact
rheumatoid arthritis, wrist and hand involvement is usually
provided by the nonferromagnetic alloys of MR compatible
bilateral. Some authors perform bilateral MR imaging of
needles is used. The size of the artifact is inversely
the wrists or hands. However, it is preferred to study the
proportional to the size of the instrument and directly
dominant or more painful wrist in order to reduce the study
proportional to the field strength and to the angle the
time. The technical recommendations of the OMERACT
instrument makes with the main magnetic field. Typically,
(Outcome Measures in Rheumatoid Arthritis Clinical Trials)
biopsy needles are displayed as dark areas surrounded by a
group for MR imaging studies of RA patients should include
brighter rim.20 Several vendors on the market offer MR
at least the following sequences: (a) imaging in two planes
compatible needles at present. Fine needles of 20 to 24G
(coronal and axial), (b) T1-weighted imaging before and after
with different tip configurations and cutting needles of 14 to
the administration of gadolinium, fat saturated imaging is
18G are commercially available. The overall performance of
preferable after administration), and (c) a fat saturated T2-
a MR compatible needle is inferior to a stainless steel needle
weighted sequence or a STIR sequence.17
due to relatively blunt surfaces and softer alloys. For drainage
procedures MR compatible sets consisting of MR compatible
INTERVENTIONAL MR IMAGING
guidewires, dilators and drainage catheters are available.
Due to restricted patient access on conventional high and Imaging protocol consists of fast localizers in three planes
midfield MR machines and unacceptable speed on the older followed by a fast multislice T2W SE sequence. A post-
low-field systems, MR imaging was not considered as a contrast GRE sequence may be used to select the
guidance tool for interventional procedures earlier. Since appropriate biopsy site. In the closed magnet, needle
the introduction of open magnet designs offering a nearly tracking is done by following a procedure similar to that
free patient access, interest has now focused on used in CT guided interventions. After defining the target
interventional MR. In addition, short bore highfield systems region, a T1W or T2W compatible grid is fixed to the skin of
presently allow satisfactory patient access combined with the patient to aid in selecting needle entry site. The angle
high performance imaging capabilities. A simultaneous and distance from skin to the lesion can be obtained by using
creation of an adequate array of MR compatible instruments standard scanner software. The needle track can be
has made MR interventions viable.18 Percutaneous biopsies controlled step-by-step during advancement of the needle.
and drainage procedures are currently the easiest proce- In the open magnet, a palpating finger may be used instead
dures to be performed under MR control. These do not of a grid for entry site. The instrument can be tracked by
require dedicated hard or software modifications and are continuous repetition of a fast imaging sequence.18
thus attractive and clinically useful. Primary and secondary bone and soft tissue lesions can
Three types of magnets are clinically used for be accessed by MR guided interventional procedures. Due
percutaneous biopsies: open low-field magnets (0.2 to 0.35 to its multiplanar capability, MR allows visualization of the
34 Imaging Modalities

entire planned biopsy pathway including orthogonal and 6. Strickland CD, Kijowski R. Morphologic Imaging of
oblique scans. Lack of ionizing radiation is an obvious Articular Cartilage. Magnetic Resonance Imaging Clinics
of North America. 2011;19(2):229-48.
advantage.20 The unique advantage of MR interventions is
7. Choi JA, Gold GE. MR Imaging of Articular Cartilage
in transcutaneous biopsy of bone marrow lesions of unknown Physiology. Magnetic Resonance Imaging Clinics of North
origin, as their display and localization is possible exclusively America. 2011;19(2):249-82.
on MR. However, the available armamentarium to perform 8. Suh JS, Lee SH, Jeong EK, Kim DJ. Magnetic resonance imaging
MR guided transcortical bone biopsy is limited, though a MR of articular cartilage. Eur Radiol. 2001;11(10):2015-25.
compatible coaxial bone biopsy system has recently been 9. Sonin AH, Pensy RA, Mulligan ME, Hatem S. Grading articular
cartilage of the knee using fast spinecho proton density-
developed.18 Although lesion access by MR is good for weighted MR imaging without fat suppression. American
appendicular skeleton, CT is preferred for biopsy of the axial Journal of Roentgenology. 2002;179(5):1159-66.
skeleton due to superior spatial resolution. 10. Reeder SB, Pelc NJ, Alley MT, Gold GE. Rapid MR imaging
of articular cartilage with steady-state free precession
and multipoint fat-water separation. American Journal
CONCLUSION
of Roentgenology. 2003;180(2):357-62.
The scope of musculoskeletal radiology has widened over 11. Crema MD, Roemer FW, Marra MD, et al. Articular cartilage in
the knee: current MR imaging techniques and applications
the last few years and to a large extent this has been possible in clinical practice and research. Radiographics. 2011;31(1):
because of the exquisite detail provided by the versatile 37-61.
technique of MRI. Highfield MRI, diffusion weighted imaging, 12. Peabody TD, Gibbs CP, Simon MA. Current concepts
dynamic contrast enhanced imaging, MR spectroscopy and review—evaluation and staging of musculoskeletal
other advances have further enhanced the utility of this neoplasms. The Journal of Bone and Joint Surgery
(American). 1998;80(8):1204-18.
modality. However, elegant display of pathology alone does
13. Costa FM, Canella C, Gasparetto E. Advanced magnetic
not suffice, as diagnosis based on images alone, especially resonance imaging techniques in the evaluation of musculo-
MR images, is nonspecific. For the optimal use of this skeletal tumors. Radiol Clin North Am. 2011;49(6):1325-58.
technology the radiologist must couple these images with 14. Garner HW, Kransdorf MJ, Peterson JJ. Posttherapy imaging
an in depth knowledge of pathophysiology and clinical of musculoskeletal neoplasms. Radiol Clin North Am.
perspective so that he can guide the referring clinician 2011;49(6):1307-23.
15. Boutin RD, Brossmann J, Sartoris DJ, Reilly D, Resnick D.
appropriately. ‘Seeing better’ should be coupled with Update on imaging of orthopedic infections. Orthopedic
‘Knowing more’ to make the optimum use of the high tech Clinics of North America. 1998;29(1):41-66.
modality of MRI.21 16. D Towers J. The use of intravenous contrast in MRI of
extremity infection. In: Seminars in Ultrasound, CT, and
MRI. 1997;(18):269-75.
REFERENCES
17. Narváez JA, Narváez J, De Lama E, De Albert M. MR imaging
1. Helms CA, Anderson MW, Major NM, Kaplan P, Dussault of early rheumatoid arthritis. Radiographics. 2010;30(1):
R. Musculoskeletal MRI, 2nd edn. Philadelphia: WB 143-63; discussion 163-5.
Saunders Co; 2009. 18. Adam G, Bücker A, Nolte-Ernsting C, Tacke J, Günther R.
2. Stoller DW. Magnetic resonance imaging in orthopaedics Interventional MR imaging: percutaneous abdominal and
and sports medicine, 3rd edn. Lippincott Williams and skeletal biopsies and drainages of the abdomen. European
Wilkins; 2007. Radiology. 1999;9(8):1471-8.
3. Zou J, Yang H, Miyazaki M, et al. Dynamic bulging of 19. Genant JW, Vandevenne JE, Bergman AG, et al.
intervertebral discs in the degenerative lumbar spine. Interventional Musculoskeletal Procedures Performed
Spine. 2009;34(23):2545. by Using MR Imaging Guidance with a Vertically Open
4. Ramnath RR. 3T MR imaging of the musculoskeletal MR Unit: Assessment of Techniques and Applicability1.
system (Part II): clinical applications. Magnetic Resonance Radiology. 2002;223(1):127.
Imaging Clinics of North America. 2006;14(1): 41. 20. Ghelman B. Biopsies of the musculoskeletal system.
5. Koff MF, Potter HG. Noncontrast MR techniques and Radiologic Clinics of North America. 1998;36(3):567-80.
imaging of cartilage. Radiologic Clinics of North America. 21. Feldman F. Musculoskeletal Radiology: Then and Now.
2009;47(3):495-504. Radiology. 2000;216(2):309.
CHAPTER

3 Nuclear Medicine Imaging for


Musculoskeletal Disorders
Rakesh Kumar, Punit Sharma, Arun Malhotra

INTRODUCTION Three to four hours after intravenous injection about 25


to 35 percent of radiotracer is retained in the normal
Musculoskeletal system is a dynamic organ system, which
adult skeleton, the rest is excreted in the urine via
responds to systemic as well as to localized stress and hence
the kidney. These phosphorus containing complexes avidly
apart from anatomical visualization, it requires physiological
evaluation. Nuclear medicine techniques provide the attach themselves to the hydroxyapatite crystal surface by
physician with the physiologically detailed images that can the process of chemisorptions.1 Thus, they localizes at the
give insight which cannot always be accomplished from plain site of direct and indirect osteoblastic activation.
radiograph or even with computed tomography (CT) and Autoradiographic studies revealed that the 99mTc-labeled
magnetic resonance imaging (MRI). The major advantage phosphonates are mainly taken up in the mineral phase of
of nuclear medicine imaging stems from the fact that skeletal bone at the site of reactive bone formation. This
functional changes appears much before anatomical osteoblastic activation can be seen because of wide array of
changes. Hence, nuclear medicine imaging allows early pathologies, thereby decreasing the specificity. The routine
detection of diseases affecting musculoskeletal system. The bone scintigraphy employs whole body anterior and posterior
present chapter summarizes the nuclear medicine sweep images. In addition dynamic flow and pool images
techniques used for musculoskeletal imaging and their utility are acquired in selected cases.
in various benign and malignant pathologies involving the
musculoskeletal system. SPECT AND SPECT-CT
Given the lack of anatomical information provided by planar
BONE SCINTIGRAPHY
bone scintigraphy, especially in regions of complex anatomy
In spite of newer development in field of nuclear medicine, additional methods are employed. Single photon emission
bone scintigraphy remains the most commonly employed tomography (SPECT) is being routinely used in such a scenario.
method for musculoskeletal imaging. It is done with injection It gives three-dimensional pictures and is beneficial in
of bone seeking radiopharmaceuticals. These compounds patients with normal planar images despite symptoms and
are usually phosphonates labeled with 99mTechnetium in those with equivocal findings.2 Single photon emission
( 99m Tc). The most widely used is 99m Tc-Methylene tomography imaging is most useful for evaluation of the
diphosphonate (MDP). Others are 99mTc-Ethylene hydroxy thoracolumbar spine, skull and pelvis. These areas have
diphosphonate (EHDP) and 99mTc-hydroxy methylene extensive surrounding soft tissue and/or complicated body
diphosphonate (HDP). The presences of p-c-p bonds make contours, and thus superior image contrast provided by
these compounds resistant to hydrolysis by bone SPECT improves lesion detection. The decision to perform
phosphatases, thereby increasing the biological half life. single field-of-view SPECT studies has been guided by
36 Imaging Modalities

suspicious findings on planar imaging or localized clinical with breast cancer being the leading cause in women,
symptoms. However, even with SPECT correlation with prostate cancer in men, followed by lung cancer in both
anatomical imaging is usually needed in many cases. SPECT- sexes. Accurate assessment of skeletal involvement is
CT imaging with hybrid cameras has been introduced to essential for optimal management of these patients.7 Many
overcome this shortcoming and to provide both anatomical patients with bone metastases are and may be identified
and functional information in single setting. during initial staging, routine follow-up, or investigation of
rising tumor markers. For the past few decades, planar bone
PET AND PET-CT scintigraphy has been the most frequently performed
In contrast to routine gamma camera imaging, positron imaging study in the evaluation of metastatic bone disease.
emission tomography (PET) imaging is based on the detection Although scintigraphic findings alone are often nonspecic
of high energy (511 KeV) annihilation photons emitted by for skeletal pathologies, this technique reportedly has an
positron emitting radionuclides. The inherent physics of exquisite sensitivity. Radiographs are found to be negative
positron decay allows tomographic imaging without the need in 30 to 50 percent of patients with positive bone scan. Most
for collimators thereby improving the sensitivity and common pattern of bone metastasis is multiple “hot” lesions
resolution. The lack of anatomical information on PET alone distributed randomly throughout the skeleton.8 A lytic
has been overcome with introduction of hybrid PET-CT. In metastasis usually presents as a photopenic area with
fact, the availability of hybrid PET-CT systems has made PET increased activity at the edge of the lesion. False negative
alone redundant. Although, PET and PET-CT had greatest results in bone scintigraphy are seen in avascular lesions, in
impact in the field of cancer imaging, its application for other the presence of rapidly growing pure osteolytic metastases
areas including musculoskeletal disorders is being actively with no reactive increased osteoblastic activity, or in lesions
investigated. In clinical practice, most PET studies are with low bone turnover (multiple myeloma, thyroid cancer).
performed with 2-[18F] fluoro-2-deoxy- D-glucose (FDG), a Specificity of BS is generally lower, due to a known increased
glucose analogue. It is actively taken up by cells with increased blood flow and metabolic reaction of bone to a variety of
glucose metabolic rate via specific glucose transporters disease processes, including osteoarthritis, trauma, and
(GLUT-1, GLUT-4) and is phosphorylated by hexokinases to inflammation. Therefore, further assessment with other
FDG-6-phosphate, which is retained.3 Nowadays, FDG is imaging modalities, mainly CT and MRI, and in some cases
being increasingly used for imaging primary and secondary histologic confirmation may be required for precise
musculoskeletal tumors as well as infections. Another diagnosis.9
important tracer in context of skeletal imaging is 18F-Flouride. Addition of SPECT has been reported to detect 20 to 50
It can also be used for quantitative studies of skeletal percent more lesions in the spine compared with planar
kinetics.4 Although there are differences between 18F- scintigraphy.10 It increases both the sensitivity and specificity
Fluoride and 99mTc-diphosphonate, it is probable that the of bone scans (BS).11 The use of SPECT for the assessment of
mechanism of uptake in bone is the same, i.e. adsorption suspicious vertebral lesions on planar BS had a negative
onto bony surfaces with predilection for sites of active bone predictive value of 98 percent. The sensitivity and specicity
formation.5 The uptake of 18F-Fluoride is approximately two- of bone SPECT for diagnosis of bone metastases are 87 to 92
fold higher and its blood clearance is signicantly faster and 91 to 93 percent, respectively.12 The decision to perform
compared with the 99mTc-diphosphonates, resulting in an single field-of-view SPECT studies has been guided by
increased bone-to-background ratio. In addition, PET offers suspicious findings on planar imaging or localized clinical
high sensitivity and high resolution, and therefore enables symptoms. Newly developed half-time wholebody SPECT
to perform highly accurate whole-body screening for protocols provide tomographic assessment of the entire
metastases.6 skeleton within an acceptable image acquisition time, with
subsequent improvement in sensitivity and an increased
MUSCULOSKELETAL TUMOR IMAGING detection rate of asymptomatic small skeletal metastases.13
However, even with SPECT correlation with high-quality
Metastasis anatomic images, CT, or MRI, may still be needed for
Skeletal metastasis is the most common malignant bone diagnosis. Hybrid SPECT/CT devices equipped with multi slice
tumor. It affects approximately two-thirds of cancer patients, CT scanners further improves the sensitivity and specicity of
Nuclear Medicine Imaging for Musculoskeletal Disorders 37

BS. It has been shown to be superior to planar BS and SPECT help differentiate benign versus malignant lesions (Figs
for skeletal metastasis of breast and lung cancers.14,15 Foci 3.2A to C)17 18F-Fluoride has shown to highly sensitive for
of increased tracer activity on BS suspicious as representing detecting lytic and sclerotic bone metastasis in breast
malignant bone lesions may not show any morphologic cancer,18 prostate cancer19 and lung cancer.20 There has
abnormality on CT as functional changes precede anatomical been the suggestion that 18F-Fluoride could be more cost
changes, and therefore cannot be conrmed as such. The effective than the bone scan and that a case can be made
presence consensus is to do SPECT-CT of suspicious planar BS for it replacing the bone scan.21 Increased FDG activity at
lesions only if the lesion remains equivocal even after SPECT the sites of skeletal lesions represents active tumor itself,
(Figs 3.1A to E). whereas increased 99mTc-MDP or 18F-Fluoride activity
Several studies have shown the superiority of the represents a blastic activity/reparative process in response
18
F-Fluoride PET over BS for the diagnosis of skeletal to tumor and destroyed bone. Compared with BS or 18F-
metastases; the former demonstrated a higher number of Fluoride, FDG-PET is reported to be more sensitive for lytic
the lesions and a higher contrast between normal and lesions and bone marrow disease but less sensitive for blastic
abnormal bone.16 Although the superb resolution and high lesions.22 It has an additional advantage: the ability to assess
abnormal to normal bone ratio of 18F-Fluoride PET can extraskeletal metastatic disease, including muscle
potentially lower the specificity, hybrid PET-CT imaging should metastasis.23 Recent data almost invariably have shown that

A B E

Figs 3.1A to E: A 37-year-old carcinoma breast patient for staging. Planar bone scintigraphy (A and B) showed a
suspicious focal uptake in left superior pubic rami (arrow). SPECT (C), CT (D) and SPECT (E) images showed lytic
lesion with increased tracer uptake (arrow) suggesting metastasis
38 Imaging Modalities

A C
Figs 3.2A to C: A 60-year-old male with carcinoma prostate and rising PSA. 18F-Fluoride PET MIP images (A and B) shows focal
tracer uptake in bilateral pubic ramii (arrow) suggestive of metastasis. Also noted was tracer uptake in right shoulder (arrowhead).
On PET-CT images (C) this uptake was diagnosed to be degenerative change (arrowhead)

BS is more sensitive than FDG-PET for detection of blastic/ malignancies, FDG-PET has proved an effective modality for
sclerotic lesion, whereas FDG-PET is more sensitive for lytic early assessment of therapeutic response by showing rapid
lesions and bone marrow involvement (Figs 3.3A to D)24 The reduction in FDG uptake by the tumors in responders
lower sensitivity of FDG-PET for detecting sclerotic lesions following chemotherapy.29 The changes in FDG standard
can be complemented by CT, which may obviate the need uptake value (SUV) with therapy showed correlation with
for BS.25 At any rate, it seems generally agreed that the the overall clinical assessment of response as well as with
overall sensitivity of FDG-PET and BS for all lesions is the change in tumor marker value. Flare phenomenon which
comparable, but PET has a higher specificity, resulting in is considered to be a marker of response on BS has also been
an overall higher accuracy. The utility of FDG PET-CT for described on FDG-PET but only associated with antiestrogen
bone metastasis has already been shown in breast cancer, therapy.30
lung cancer, lymphoma, multiple myeloma and
neuroblastoma.26-28 Another, very important advantage of Primary Malignant Tumors
FDG PET-CT is its ability to assess response to therapy in The role of bone scintigraphy in primary malignant bone
bone metastasis. Although BS has been used to assess the tumors is very limited. On three-phase BS, most primary
efficacy of treatment and to follow breast cancer patients, malignant bone tumors are usually highly vascular with
the early response to any treatment cannot be assessed by intense delayed radiotracer uptake that often extends
BS. Moreover, BS may show persistent increased activity beyond the margin of the bone with distorted and ill-defined
even in treated lesions for several weeks to months. In most outline. Although mild variations depending on the type of
Nuclear Medicine Imaging for Musculoskeletal Disorders 39

A B C D

Figs 3.3A to D: A 35-year-old female with known breast cancer underwent PET-CT scan for staging. 18F-FDG wholebody projection image
(A) Shows focal areas of increased radiotracer uptake suggestive of metastases. Lytic sclerotic bone lesions and FDG uptake in multiple
vertebrae in CT, PET and PET-CT sagital sections (B, C and D). There are many lesions showing focal FDG uptake no sclerosis on CT suggestive
of marrow metastases

tumor exist, there is no single pattern specific for individual consistently non-FDG avid.31 Dual-time point PET imaging
tumor. Basically, BS has no role in the initial diagnosis or can be utilized to increase the accuracy of differentiating
assessment of the extent of primary malignant bone tumors benign from malignant soft tissue lesions.32 FDG-PET may
for which MRI is considered the imaging modality of choice. also be used for more accurate staging of histologically
Rather, whole body BS is generally reserved for evaluation confirmed tumors, in therapy response assessment to detect
of metastatic bone disease (Figs 3.4A and B). Although progression or regression of disease ahead of morphological
pulmonary metastases are occasionally identified on BS as change in the tumor and in the early detection of recurrent
focally increased soft tissue uptake, high-resolution CT is best disease. The degree of FDG uptake by tumors pre- and post-
suited for evaluation of pulmonary metastases. therapy correlates well with histological response, often prior
Functional imaging with FDG-PET provides unique to demonstrable changes on anatomical imaging.33 FDG-
information with regard to the metabolic activity of bone PET is also useful for the detection of tumor recurrence and
and soft tissue tumors. This may help characterize has been found to be more sensitive than MR, especially
indeterminate lesions and guide targeted biopsy of the most when MR findings are equivocal.34 SUV on FDG-PET is an
metabolically active area within larger tumors. This aspect important prognostic factor in most musculoskeletal tumors
is particularly important in many soft tissue and bone tumors and has been shown to be a reliable independent prognostic
which are of mixed grade and/or cell type. In one study with indicator.35,36
soft tissue tumors, there was a statistically significant
Benign Tumors
difference in SUV between benign and malignant soft tissue
lesions although there was considerable overlap between Bone scan is a highly sensitive investigation for diagnosis of
the two groups, with only lipomas and hemangiomas were osteoid osteoma. A negative bone scan virtually rules out
40 Imaging Modalities

sensitivity (82-95%) and accuracy (90%) for detecting acute,


uncomplicated osteomyelitis, becoming positive within 28
to 48 hours after the onset of symptoms. Compared with
anatomic modalities, the radionuclide bone scan has the
further advantage of detecting multiple foci of disease which
can be seen especially in children. However, other conditions
(e.g. fractures, neuropathic joints, arthritis) may mimic
osteomyelitis on bone scanning alone, decreasing its
specificity.38 Although adding a fourth phase (24 hours
image) is advocated to increase the specificity, with a high
accuracy of 85 percent, the clinical results are not
impressive.39 In addition in pediatric population, BS can show
reduced radiotracer uptake, which is attributed to increased
pressure on blood vessels, stripping away of periosteum via
the accumulation of pus and interruption of blood supply
due to plugging and thrombosis. This can lead to a false
negative study. About 30 percent of patients with acute
A B osteomyelitis will progress to have subacute or chronic
osteomyelitis (Figs 3.5A to E). Bone scan remains positive
Figs 3.4A and B: A 16-year-old male with osteosarcoma of left femur.
Planar bone scintigraphy (A and B) shows mass in left femoral shaft for months even after successful treatment of acute
with heterogeneous tracer uptake (arrow), consistent with primary osteomyelitis. It is difficult to differentiate healing from
tumor. In addition it showed bone metastasis (arrowhead) and chronic active disease.40
osteogenic pulmonary metastasis
Other radiotracer such as 67Ga-Citrate and 111In-oxine/
99m
Tc-hexamethyl-propylene amine oxime (HMPAO) labeled
the diagnosis of osteoid osteoma. A three-phase bone scan leukocyte imaging has been extensively used in
shows increased blood flow and blood pool and a ‘focal’ area musculoskeletal infection, either alone or in combination
of intense uptake in delayed images.37 Some surgeons have with BS. 67Ga-Citrate localize to the site of infection via
used intraoperative scintigraphic probes to localize osteoid several pathway including increased vascular permeability
osteoma. It addition bone scintigraphy has been used for at site of infection, binding to lactoferrin and direct bacterial
detecting recurrence after radiofrequency ablation of uptake.41 Reported sensitivity for 67Ga-Citrate scintigraphy
osteoid osteoma. Other benign lesions, which can show ranges from 25 to 80 percent, with a specificity of 67
increased uptake, are eosinophilic granuloma, aneurysmal percent.42 It has proven to extremely useful in detecting
bone cyst, chondroblastoma, enchondroma, etc. However, infection in the immunocompromised population. It is usually
there is no specific pattern to make their diagnosis on BS done in combination with BS for musculoskeletal infection.
alone. With the availability of hybrid SPECT-CT such diagnosis However, 67Ga-Citrate scintigraphy suffers from poor image
can be made with greater certainty employing the quality, long scanning time and significantly higher patient
characteristic CT features of many such tumors. radiation dose leading to decline in its use with advent of
better tracers. Labeled leukocytes can overcome some of
INFECTION IMAGING the disadvantages of BS. Its uptake is dependent on the
chemotaxis of labeled leukocytes at the site of infection.
Acute and Chronic Osteomyelitis 111
In-oxine/99mTc HMPAO labeled leukocyte imaging have
Bone scintigraphy is used as a complementary imaging shown increased specificity – up to 80 to 90 percent –
procedure in evaluation of infection. The classic findings are compared to BS for detecting infection, particularly when
increased regional blood flow and blood pool with a complicating conditions are present. As the majority of
corresponding increased uptake on delayed images. This is leukocytes labeled are neutrophils, the procedure is most
different from cellulitis where only increase in blood flow useful for identifying neutrophil mediated inflammatory
and blood pool in the soft tissue with no increased radiotracer processes, such as bacterial infections. It is less useful for
uptake on delayed image is seen. 99mTc MDP has a high those illnesses in which the predominant cellular response is
Nuclear Medicine Imaging for Musculoskeletal Disorders 41

A B E

Figs 3.5A to E: A 35-year-old male with backache. Planar bone scintigraphy (A and B) showed increased
irregular tracer uptake in D6 vertebra (arrow). SPECT (C), CT (D) and SPECT-CT (E) images showed
destructive changes in D6 vertebra with increased tracer uptake along with paravertebral fluid collection
(arrow). The findings were highly suspicious for tuberculosis and confirmed at histopathology

other than neutrophilic, such as tuberculosis.43 Additionally, Diabetic Foot


in contrast to other locations in the skeleton, labeled
Pedal ulcers with or without osteomyelitis is a very common
leukocyte imaging is of limited value for detecting spinal
complication in patients with long-standing diabetes. Foot
osteomyelitis.44 Also their performance requires the
osteomyelitis frequently presents without systemic illness
withdrawal of a large amount of blood (50 cc); it is also
costly, labor intensive and has the inherent limitations related and with no obvious clinical symptoms or signs, besides the
to personnel safety, including the risks of infection and cross ulcer, and imaging studies are often needed to confirm the
contamination from handling blood products. All these diagnosis. Although routinely performed, the accuracy of
factors limit their routine use. Additional use of SPECT-CT three phase BS for pedal osteomyelitis is modest with large
with BS, 67Ga-Citrate and 111In-oxine/99mTc HMPAO labeled prospective study demonstrating a sensitivity of 67 percent
leukocyte improves the specificity of these studies for and specificity of 43 percent.46 With the presence of
detecting osteomyelitis.45 associated Charcot arthropathy the diagnosis becomes more
42 Imaging Modalities

difficult. Addition of SPECT-CT in this scenario appears conventional radionuclide procedures, albeit with higher cost
promising.47 It can show focal bone destruction versus and radiation exposure. It should also be remembered that
arthropathic changes, thereby clinching the diagnosis. FDG is not specific for infection, and increased FDG uptake
Labeled leukocyte imaging may be more sensitive for also is observed in inflammatory arthritis, osteoarthritis,
detecting clinically unsuspected pedal osteomyelitis and is fractures, normally healing bone, and degenerative
useful for monitoring response to medical therapy.48 But a changes.57 For acute and subacute bone and soft tissue
major drawback is the fact that even neuropathic joints may infections, sensitivities of 98 percent and specificities from
accumulate labeled leukocyte, hence not useful when both 75 to 99 percent have been reported with FDG-PET.58 It is
infection and Charcot joint coexists.49 especially useful in cases of chronic infections where BS has
major limitations. It has been shown to be superior to labeled
Prosthetic Infection leukocyte imaging for chronic musculoskeletal infections.59
Its specificity is higher, if recently (<4 months) traumatized
With improving surgical techniques and availability of better
or operated bone is excluded. Though initial results were
prosthetics, the number of patients opting for the same is
excellent, FDG PET-CT appears to be less useful for diabetic
increasing. Although the clinical results of joint replacement
foot infection.60 It is inferior to labeled leukocyte imaging
surgery are usually excellent, these implants do fail. Aspetic
for this purpose. Moreover, altered glucose and insulin
loosening due to mechanical factors and inflammatory
dynamic in these patients makes FDG technically challenging.
reaction to prosthetic components is the most common
Regarding FDG-PET in patients with the suspicion for total
cause for implant failure followed by infection. Infection is
joint replacement infection initial studies showed promising
perhaps the most serious complication of joint arthroplasty
results and reported sensitivities of 90 percent and
surgery, ranging in frequency from ~1 to 2 percent for
specificities of 89 percent in the diagnosis of infected lower-
primary implants to ~3 to 5 percent for revision implants.50
limb prostheses.61 Accuracy of FDG-PET was 96 percent for
Because their treatments are so different, the importance
hip prostheses, 81 percent for knee prostheses, and 100
of distinguishing infection from aseptic loosening of a
percent for other orthopedic devices. However, when
prosthesis cannot be overemphasized. Although BS is
associated with loosening FDG-PET cannot differentiate
sensitive for detecting complications of prosthetic surgery,
between septic and aseptic loosening, as both conditions
it cannot reliably distinguish among the causes for failure.
can cause increased FDG uptake.62 The reason for the
Although routinely advocated, periprosthetic uptake
increased FDG uptake around the prosthesis in aseptic
patterns have not been found to be useful for differentiating
loosening is likely an inflammatory immune reaction to the
infection from aseptic loosening.51 Addition of 67Ga-Citrate
prosthetic material. In a large series, the accuracy of FDG-
scintigraphy to BS only provides moderate improvement in
PET for diagnosing infection of the failed prosthetic joint
accuracy. 52 Labeled leukocyte scintigraphy though
was low, and varied between 47 and 71 percent depending
theoretically presents the advantage of differentiating
on different criteria used to evaluate the images.63 In fact,
aseptic loosening from infection, the actual results has been
it was inferior to combined labeled leukocyte/marrow
variable.53,54 Poor sensitivity is ascribed to the chronicity of
imaging in this series. It should be remembered that image
the process, whereas poor specificity is ascribed to
interpretation in patients with prosthetic devices can be
nonspecific inflammation. Addition of BS or marrow
affected by attenuation-correction-induced artifacts.
scintigraphy might improve the specificity of this test, though
Therefore, it is necessary to examine the nonattenuated-
there is no general consensus.55
corrected scans in these patients because they show less
prominent reconstruction artifacts.64
FDG PET-CT for Musculoskeletal Infection
Experimental studies have shown that mononuclear cells MUSCULOSKELETAL TRAUMA
and neutrophilic granulocytes have increased FDG uptake
Stress Fractures
when activated during the so-called respiratory burst, which
they experience while fighting an infection.56 This forms the Stress fractures are two types: (i) fatigue fractures which
basis for its use in musculoskeletal infections. It provides are caused by repeated abnormal stress on normal bones,
better resolution and shorter test duration compared to bone scan shows fusiform increased radiotracer uptake
Nuclear Medicine Imaging for Musculoskeletal Disorders 43

involving the posterior tibial cortex and (ii) insufficiency Sport Injuries
fractures resulting from normal stress on abnormal bone. The blood pool phase of bone scintigraphy is very important
The later are seen in patients with underlying bone disease in detection of soft tissue injuries. Hyperemia is evident in
such as osteoporosis, osteomalacia, Paget’s disease, fibrous the affected structure with delayed uptake apparent only if
dysplasia, etc. Because clinical assessment usually is not there is necrosis/calcification or close apposition of adjacent
definitive in these injuries, diagnostic imaging is often bony structures, as with tendonitis of the extensor and
required. Plain-film radiography is usually the first abductor pollicis tendons and the adjacent radius or tibialis
examination performed when a stress fracture is suspected. posterior tendonitis and the medial malleolus. SPECT-CT adds
Unfortunately, sensitivity of this method for stress fracture by anatomically localizing the site of involvement. It can in
may be as low as 15 percent.65 Bone scintigraphy, however, addition guide the site of injection, when required.
is extremely sensitive in detecting stress fractures because
it assesses bone metabolism rather than bone anatomy. In METABOLIC BONE DISEASE IMAGING
fact for stress fracture at certain sites such as metatarsal
bones, it is considered to be the reference method. Sacral Metabolic bone disorders represent a heterogeneous group
insufficiency fractures have a classic appearance on BS , highly of skeletal pathologies that can lead to global or focal changes
specific pattern of horizontal uptake in the body of the in bone metabolism. The superior sensitivity of bone
sacrum and vertical uptake in the alae, resulting in the scintigraphy can be valuable for diagnosis, detection of
“Honda,” or “H,” sign.66 Addition of SPECT-CT is likely to complications, and monitoring of treatment response (Figs
improve the accuracy of BS, especially by improving the 3.6A and B). The continuous improvement in gamma camera
anatomical localization. hardware and software with the addition of SPECT, and more
recently, hybrid SPECT-CT, has maintained a role for nuclear
Shin Splints medicine methods in bone disease despite the improvements
seen in morphologic imaging techniques.
The clinical entity shin splint is characterized by exercise
induced pain and tenderness on palpation along the Paget’s Disease
posteromedial border of tibia. It results generally from The initial step in Paget’s disease is increased osteoclastic
unaccustomed biomechanical stress on the tibiae. Shin splints resorption, followed by compensatory osteoblastic activity
are not fractures and can be distinguished from stress and increased bone formation. Most patients with Paget’s
fractures by their linear activity rather than round or fusiform disease have polyostotic disease. Bone scans is a convenient
activity.67 In addition, blood flow and blood pool images are way to evaluate the whole skeleton and has shown a greater
almost always normal. Delayed images of bone scintigraphy sensitivity for detecting affected sites in symptomatic
demonstrate involvement of the posterior tibial cortex, patients in comparison with radiographic skeletal surveys.70
longitudinally oriented uptake involving one-third of the Characteristically, affected bones show intensely increased
length of the bone. activity, extending from the end of a bone and spreading
either proximally or distally, often showing a “V”-shaped
Fractures in Childhood
leading edge. Many different patterns describing vertebral
Very young children may present with failure to move a limb uptake have been reported as being specific for Pagetic
or joint. A history may not be available, especially in preschool involvement, including clover, heart, and Mickey Mouse
children. Bone scans can identify unsuspected sites of signs. 71 Apart from localizing the sites of multifocal
fractures in such children. In addition, it can be useful to involvement, another important use of BS is monitoring
identify child abuse in children at risk. Radiological skeletal response to therapy (bisphosphonate). For this purpose, BS
survey and wholebody scintigraphy does offer is better than measurement of serum alkaline phosphatase
complementary information that is not available from either alone. The bone scan appearances can be unusual after
study alone. 68 More than 50 percent of such cases successful bisphosphonate treatment, resultant heter-
demonstrate diaphyseal injuries.69 Rarely, fracture of the ogeneous uptake sometimes mimicking metastatic disease.
first rib may be the sole manifestation of abuse. Of course, As 18F-Fluoride PET is better suited to assess bone mineral
knowledge of normal BS appearance for the age of child is kinetics, it has also been used to monitor response to
essential for interpreting such a study. bisphosphonate therapy.72
44 Imaging Modalities

Renal Osteodystrophy
Renal osteodystrophy is due to a combination of bone
disorders as a consequence of chronic renal dysfunction, and
often demonstrates the most severe cases of metabolic bone
disease. It may comprise osteoporosis, osteomalacia,
adynamic bone, and secondary hyperparathyroidism in
varying degrees. The most common bone scan appearance
is similar to a superscan from other metabolic bone disorders.
A clue in differentiating this type of scintigraphic pattern
from others is that there may be a lack of bladder activity in
view of renal failure. Quantitative measurements of bone
metabolism in renal osteodystrophy using 18F-Fluoride have
been compared with bone histomorphometry and have
shown a close relationship.74

Osteoporosis and Osteomalacia


Bone scans has no routine clinical role in the diagnosis of
osteoporosis per se but is most often used in established
osteoporosis to diagnose fractures, particularly at sites that
are difficult to image with plain film radiography (e.g.
sacrum, ribs), and may be particularly useful in the diagnosis
vertebral fractures. The characteristic appearance of this
type of fracture is of intense, linearly increased tracer uptake
A B at the affected vertebral level. In addition bone scan is
extremely helpful in assessing the age of the fracture. Also
Figs 3.6A and B: A 29-year-old female presented with multifocal
other causes of bone pain can be reliably excluded in
body ache. Biochemical evaluation showed decreased serum calcium.
Planar bone scintigraphy (A and B) images showed classical features osteoporotic patients on BS. Osteomalacia on the other hand
of metabolic bone disease-increased bone to soft tissue activity, hot shows features similar to other metabolic bone disease. This
calvarium, tie sternum, nonvisualization of kidneys and multiple is probably because of increased osteoid formation. The
pseudofractures detection of pseudofractures with this technique is more
sensitive than that with radiography.75

Bone Dysplasias
Hyperparathyroidism
Fibrous dysplasia is characterized by a slow, progressive,
The diagnosis of hyperparathyroidism is biochemical and BS replacement of the medullary cavity by fibrocollagenous
has no routine role in diagnosis. Bone scans are often used tissue. There is usually intense hyperemia and intense uptake
to help differentiate the causes of hypercalcemia, in with well-delineated margins on BS. Failure of preservation
particular, hyperparathyroidism vs malignancy, so that of the bony outline differentiates fibrous dysplasia from
typical features of metabolic bone disorders may be Paget’s disease. Identification of polyostotic involvement,
recognized. The most common bone scan appearance is which is often asymptomatic, is the main indication for BS.76
similar to a superscan from other metabolic bone disorders, In addition secondary complications in fibrous dysplasia can
and uptake of diphosphonate in areas of ectopic calcification be demonstrated on BS. In several other uncommon
also may be seen. Multiple small focal areas of abnormal congenital dysplasias, skeletal abnormalities are usually
radiotracer uptake in bone scan are suggestive of obvious radiologically. Bone scintigraphy can occasionally
pseudofractures in such patients.73 provide images that are of interest but, more importantly,
Nuclear Medicine Imaging for Musculoskeletal Disorders 45

reflect current physiological activity. The BS findings are


variable depending on type and site of dysplasia. Additionally,
BS might be used for monitoring therapy response.
A
Avascular Necrosis
Avascular necrosis (AVN) is a common condition affecting up
to 30 percent of individuals with underlying medical
conditions requiring steroids. Although the hip is most
commonly involved AVN may affect many other bones, such
as lunate (Kienbock’s disease), navicular (Kohler’s disease)
scaphoid (post fracture) and jaw (post bisphosphonate
therapy). Although MRI is the investigation of choice, a three B C
phase BS provides useful information to diagnose AVN. A
unique advantage of BS is its ability to identify AVN earlier
than MRI (72 hours vs 6 day).77 Up to 85 percent BS may be
normal for first 48 hours, the femoral head then shows
decreased activity (“cold”) for a variable period followed by
increased activity due to reparative process. BS is highly
sensitive (98%) and specific (95%) for the diagnosis of AVN.78 D E
SPECT images improve sensitivity to detect AVN. SPECT-CT
images are very useful especially when evaluating small Figs 3.7A to E: A 42-year-old male presented with swelling and pain
in left hand 3 months after a minor surgery. Three phase bone
bones.
scintigraphy showed increased blood flow (A) and pool (B and C) in
left hand along with classical periarticular uptake in small joints (D and
Complex Regional Pain Syndrome E) in delayed images, suggestive of complex regional pain syndrome
(Reflex Sympathetic Dystrophy) (Reflex sympathetic dystrophy)

The complex regional pain syndrome (CRPS) comprises a


spectrum of sensory, autonomic, and motor features that scintigraphy is in the early detection of subclinical synovitis
predominantly affects the extremities. CPRS I occurs in and monitoring its response to treatment. Scintigraphy is
absence of definable neurological abnormality. Radiological sensitive for the early detection of sacroiliitis, although MRI
changes of bone resorption are late findings and hence three is used routinely. Three phase bone scans is as sensitive as
phase BS has been widely utilized in both the diagnosis and MRI for identifying early rheumatoid arthritis. Bone scans is
monitoring of treatment. The BS pattern of RSD varies very sensitive for the diagnosis of septic arthritis and becomes
significantly, depending upon the stage of the disease. In abnormal much earlier than radiographs. Multiphase BS
early stages, there is increased blood flow and blood pool shows increased flow and blood pool in soft tissue and joint
with increased bone uptake on delayed images (Figs 3.7A and diffuse increased uptake in bones around joints on
to E). A characteristic feature is periarticular uptake of delayed images. This is especially useful in pediatric
radiotracer. In later stages of RSD, bone scan shows normal population.
or even decreased blood flow and blood pool but increased
uptake on delayed images on the affected side.79 In addition FUTURE DIRECTION
patients with BS abnormalities have higher response rate
Further improvement in imaging technology and
(90%) to systemic steroid therapy as compared to those
development of newer radiopharmaceuticals will keep on
without BS findings (36%).80
strengthening and redefining the role of nuclear medicine
imaging. Routine use of SPECT-CT and PET-CT on one had will
JOINT IMAGING
improve the accuracy and on the other hand will broaden
The role of bone scintigraphy is usually complementary to the range of indications with respect to musculoskeletal
anatomical imaging for joint disease. The major role of bone imaging. Another exiting development is hybrid PET-MRI,
46 Imaging Modalities

which when clinically available might revolutionize 10. Gates GF. SPECT bone scanning of the spine. Semin Nucl
musculoskeletal imaging providing high quality images Med. 1998;28:78-94.
11. Savelli G, Mafoli L, Maccauro M, et al. Bone scintigraphy
(anatomical and functional) with less radiation burden. PET and the added value of SPECT (single photon emission
tracers such as 18F-Fluoroestradiol, 18F-Fluorothymidine, 18F- tomography) in detecting skeletal lesions. Q J Nucl Med.
Fluorocholine, etc. will improve the utilization of PET-CT for 2001;45:27-37.
diagnosis, response monitoring and prognostication of 12. Kosuda S, Kaji T, Yokohama H, et al. Does bone SPECT
musculoskeletal tumors. In addition, FDG as well as FDG actually have lower sensitivity for detecting vertebral
metastasis than MRI? J Nucl Med. 1996;37:975-8.
labeled leukocyte PET-CT might gain more and more ground 13. Even-Sapir E, Flusser G, Lerman H, et al. SPECT/multislice
for infection imaging. low-dose CT: A clinically relevant constituent in the
imaging algorithm of nononcologic patients referred for
CONCLUSION bone scintigraphy. J Nucl Med. 2007;48:319-24.
Despite challenges from morphological imaging nuclear 14. Sharma P, Singh H, Kumar R, et al. Bone scintigraphy in
breast cancer: added value of hybrid SPECT-CT and its
medicine imaging techniques continue to have a major role impact on patient management. Nucl Med Commun. 2012;
in a range of neoplastic, infective, inflammatory, metabolic 33(2):139-47.
and traumatic musculoskeletal diseases. In future, with 15. Sharma P, Kumar R, Singh H, et al. Indeterminate lesions
widespread availability of hybrid modalities, its role in on planar bone scintigraphy in lung cancer patients:
musculoskeletal imaging will continue to expand. SPECT, CT or SPECT-CT? Skeletal Radiol. 2011 Oct 16. [Epub
ahead of print]
16. Petren-Mallmin M, Andreasson I, Ljunggren O, et al.
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CHAPTER

4 Angiography and Interventions


in Musculoskeletal Lesions
Deep Narayan Srivastava

With increasing use of CT and MRI in the diagnosis of bone The amount of contrast injection depends on the size and
and soft tissue lesions, angiography is not being used as location of the lesion.
commonly as before, however, if the procedure is used Digital subtraction angiograms (DSAs) are superior to
properly in conjunction with other diagnostic studies, it can conventional angiograms since the superimposed bones,
play a valuable role in the diagnosis and treatment of bone calcifications and also other limb supports in trauma patients
and soft tissue lesions. The role of angiointerventions and can be subtracted resulting in better image quality because
nonvascular musculoskeletal interventions is increasing and of which reliable evaluation of vascular supply of the lesion is
will be discussed. possible.
Magnification angiograms are sometimes required for
TECHNIQUE visualization of tiny vessels.
Diagnostic Angiography Angioembolization
The common femoral artery is the commonly used entry The term embolization refers to the introduction of an
site for percutaneous approach because of its accessibility, embolic agent into a vessel through a selectively placed
the ease of compression against the femoral head for catheter to achieve therapeutic vascular occlusion. The
hemostasis, and the low rate of complications when advent of catheters with hydrophilic coating, micro-
punctured. The left or right femoral artery is punctured by catheters, torque control guide wires and various embolic
Seldinger technique and an arterial sheath is placed. Usually materials has allowed precise and safe delivery of occluding
the contralateral femoral artery is used to approach the agents to anywhere in the body using the blood vessels as a
lesion in lower limb region. Through this arterial sheath roadway. In certain situations, these embolizing materials
angiographic catheter is advanced into the arteries supplying are also injected into the lesion directly under image
the lesion. A wide variety of preshaped 4/5 F angiographic guidance without angiographic route.
catheters are available for selective and superselective The embolization is usually performed using the access
catheterization. The catheter is placed selectively in the used for diagnostic angiography. After the initial diagnostic
major vessel supplying the tumor and angiographic runs are angiography the angiographic catheter is advanced into the
taken with contrast medium injection. Various selective artery supplying the tumor before introduction of embolic
injections are taken depending upon the tumor supply. material. The selective and superselective embolization is a
Visualization of both the arterial and venous circulations safe interventional procedure for any vascular lesion.
is desirable in all cases. The radiographs/frames are obtained Sometimes small caliber catheters like microcatheters (2 to
initially at two frames/second for three to four seconds 3 F) are also used for this. It is also important to weigh the
followed by every 2 seconds for a total of 25 to 30 seconds. risks of the procedure against those of noninterventional
50 Imaging Modalities

and surgical therapies. The embolization should preferably in some benign lesions like giant cell tumor, aneurysmal bone
be performed in angiography suite equipped with C-arm cyst, osteoblastoma, Paget’s disease, benign nerve sheath
mounted image intensifier with digital subtraction tumor and certain hemangiomas (Figs 4.1, 4.2 and 4.4).
angiography of high quality resolution. A portable ultrasound These lesions can easily be differentiated by their clinical
scanner is always useful in the assessment of nonpalpable and plain radiographic features.
arteries, veins and also for direct percutaneous puncture of The presence of a tumor blush does not indicate
lesion. malignancy but may suggest the size and extent of the tumor.
Angiography, however, does not always define the complete
ANGIOGRAPHY IN BONE TUMORS intraosseous extent of the tumor and skip metastases within
the bone are not always seen.2
The role of angiography in bone tumors is limited because of
The angiographic information about the displacement
the following reasons:
or encasement of vessel is important if a radical local
1. If the definitive angiographic features of malignancy are
resection is planned in limb salvage surgeries.
present, it can be assumed that the lesion is malignant,
Early arteriovenous shunting is not a reliable sign of
but a normal arteriogram does not entirely rule out a
malignancy, however, the identification of large abnormal
malignancy.1
draining veins is important to facilitate early ligation and
2. It is often not possible to distinguish between various
prevent tumor embolization during surgery.2
types of bone tumors from the angiographic features
Some bone tumors in which diagnostic angiography is
alone.
sometimes indicated are discussed below.
The angiographic features of malignancy include
neovascularity, pooling or laking of contrast material, tumor
Osteochondroma
stain or blush, encasement and occlusion of vessels, extension
of the tumor vascularity outside the bone, displacement of These bone tumors because of their size and location may
vessels, arteriovenous shunts, abnormal draining veins, cause vascular complications in the form of thrombosis and
tumor invasion of veins, etc. pseudoaneurysms3,4 as well as displacement of vessels.
Neovascularity and pooling of contrast are important Angiography can show all these complications (Figs 4.3A
features of malignancy, however, these may also be present and B). The tumor usually does not show hypervascularity or
abnormal vessels.

A B
Figs 4.1A and B: Ewing’s tumor. (A) Lytic lesion with periosteal Fig. 4.2: Benign nerve sheath tumor. The DSA showing blush of
reaction and soft tissue mass of ulna, (B) Pooling of contrast material contrast (arrows)
is seen on DSA
Angiography and Interventions in Musculoskeletal Lesions 51

Aneurysmal Bone Cyst


Angiography can differentiate aneurysmal bone cyst from
giant cell tumor. On angiography, it is poorly vascularized
tumor, devoid of arteriovenous fistulae and soft tissue
invasion.6 The clinical course and plain radiographic findings
are very useful for the diagnosis of this lesion.

ANGIOGRAPHY IN BONE AND SOFT


TISSUE LESIONS OF VASCULAR ORIGIN
Hemangioma
Hemangiomas can be grouped into four categories: capillary,
A B cavernous, venous hemangiomas and arteriovenous
malformations. Hemangiomas usually involve the soft tissues
Figs 4.3A and B: Multiple osteochondroma. (A) Displacement and (most commonly skeletal muscles) but can also involve
narrowing (arrow) of femoral artery (B) Thrombosis of leg vessels
bones.7 Arteriography can define the extent, degree of
vascularity, source of vascular supply, local recurrence in
follow-up case and differentiate from arteriovenous
Osteoid Osteoma malformations.8 Angiography may show mild to marked
vascularity with coarse, irregular, enlarged arteries and
In the absence of classical roentgenographic findings, pooling of contrast material (Figs 4.4 and 4.5). Arteriovenous
angiography can be helpful when the diagnosis is in doubt.5 shunting may be seen. The osseous hemangiomas may have
The angiographic feature is dense, circumscribed blush in dilated vascular spaces (F igs 4.4A and B). Venous
the early arterial phase which persists in late venous phase. hemangioma is rarely seen on arteriography but is usually
This feature differentiates it from osteomyelitis, Brodie’s seen on venography9 (Figs 4.6A to D). Sometimes it is difficult
abscess and stress fractures that do not have the feature of to ascertain the entire lesion on angiography.10 The MRI is
dense vascular blush. useful in depicting the full extent of the lesion and the
Osteosarcoma relationship to surrounding structures (Figs 4.6A to D).
Angiography sometimes cannot differentiate a benign
Angiography can demonstrate that the tumor is malignant, hemangioma from a malignant vascular tumor.8
and accurately define the degree of soft tissue extension, In cavernous hemangioma, arteriography demonstrates
however, skip areas within the medullary canal are not always normal sized arteries that may show late venous staining on
detected.2 Magnetic resonance imaging (MRI) is useful in delayed films. They do not require treatment as they do not
defining the intraosseous and extraosseous extent of the change with time and rarely bleed, but a common problem
tumor and its anatomic relationship to nearby structures. is local pain due to distention of the lesion or superimposed
thrombosis. The embolization of regional arterial branches
Giant Cell Tumor
is not always useful, but injection of sclerosing agent by direct
Angiography can accurately define the intra as well as puncture technique has shown good results (Fig. 4.5).
extraosseous extent of the tumor because the tumors are Klippel-Trenaunay syndrome (KTS) is a congenital vascular
usually hypervascular and show neovascularity, intense blush abnormality consisting of a cutaneous nevus, varicose veins
and early venous filling. This is of particular importance in and bone and soft tissue hypertrophy affecting one or more
view of the high recurrence rate of the tumor and its ability limbs. Venography is very useful in demonstrating the
to become malignant after treatment. The MRI is useful in characteristic venous anomaly (KT vein), which is a large
the limb salvage surgeries in the assessment of extent of lateral superficial venous channel that often communicates
tumor and the anatomic relationship to nearby structures with profunda femoris or iliac veins (Figs 4.7A to C). MRI
and joint. with its multiplanar imaging abilities has the advantage of
52 Imaging Modalities

A B

Figs 4.4A and B: Angiography shows highly vascular mass with Fig. 4.5: Soft tissue hemangioma leg. Digital subtraction angiography
pooling of contrast in a case of hemangioma of femur (small arrow) shows fine vessels with some pooling of contrast (arrow). This painful
with extraosseous component (large arrows) lesion was successfully treated by percutaneous injection of sclerosing
agent

A B

C D
Figs 4.6A to D: Venous hemangioma (arrow) of axilla with supraclavicular extension. The mass is mildly hyperintense
to muscles on T1WI (A) Hyperintense on T2WI, (B) On DSA, the mass is not vascular with mass effect over axillary
artery with splaying of its lateral thoracic and subscapular branches, (C) No early venous filling seen. Percutaneous
aspiration and injection of contrast shows multiple dilated vascular spaces, (D) The pain disappeared and the size
was reduced after injection of sclerosing agent through the same needle
Angiography and Interventions in Musculoskeletal Lesions 53

A B
Figs 4.8A and B: Arteriovenous malformations of cheek. (A) CT shows
soft tissue vascular mass overlying maxilla, mandible, inferior orbital
margin, (B) On DSA, the mass is supplied by branches of left external
A B C carotid artery with early venous filling
Figs 4.7A to C: Ascending phlebogram showing two Klippel-
Trenaunay veins, one communicating with the popliteal vein (small
arrow), and the other with the superficial femoral vein (large arrow)

demonstrating the full extent of venous malformation and


the status of muscle and soft tissues.9
Arteriovenous malformations (AVMs) tend to grow at
the same rate as the individual, unlike the pattern of rapid
growth and involution seen in hemangioma. The angio-
graphic findings include enlarged, tortuous feeding arteries,
a dense nidus of malformations and early opacification of
draining veins. The AVMs are refractory to treatment.
Mechanically disturbing a stable lesion (after surgical ligation
or proximal embolization of feeding arteries) can result in
significant worsening due to development of new collaterals.
A B
Transcatheter embolization close to nidus of the lesion has
now attained a primary role in the management of AVMs, Figs 4.9A and B: Multiple hemangiomas involving (A) Left foot,
(B) Gluteal muscles (arrows)
but proximal occlusion of feeding vessels by an endovascular
embolic agent or surgical ligation will provide poor clinical
result with recurrence (Figs 4.8A and B).11,12 The angiography Angiosarcoma
can tell about the size, number and location of these lesions
(Figs 4.9A and B). In lesions of extremities, injection of The angiographic features include highly irregular, tortuous
sclerosing agent or alcohol by direct puncture technique is arteries with pooling of contrast,14 arteriovenous shunts and
safe and useful. encasement of vessels.

Hemangiopericytoma ANGIOGRAPHY IN METASTATIC


TUMORS IN BONE AND SOFT TISSUES
These are hypervascular tumors and are seen as a prolonged
dense stain on angiogram.13 There may be displacement of Most metastatic lesions have the same vascular
the major arteries (Fig. 4.10). characteristics that are exhibited by their primary tumors.15
54 Imaging Modalities

intra-arterial chemotherapies, vertebroplasties, radio-


frequency and laser ablation of benign bone lesions.

Aspiration Cytology and Biopsy


The role of aspiration cytology is limited since most lesions
require biopsy. Percutaneous biopsy is less invasive, requires
smaller dose of anesthetics and analgesics, causes minimal
bleeding and biopsy tract contamination, and is a cost-
effective method. However, it is less reliable in obtaining an
adequate representative specimen for grading and further
special studies. For heterogeneous tumors, very myxoid or
cystic lesions and bone tumors without soft tissue
component, a needle core may not give a high diagnostic
yield. The hemangioma and arteriovenous malformations
usually do not require histological confirmation because of
Fig. 4.10: Hemangiopericytoma. A well-demarcated hypervascular characteristic imaging features. For biopsy various size
mass (arrow) with homogeneous blush seen on delayed images trucut needles (11 to 18G) are used. For bone biopsy thick
needles (11G) with diamond tip is preferred. Ultrasound
guidance is always preferred though CT and fluoroscopy is
Angiography cannot distinguish between different types of required for vertebral and other bone lesions.
metastases. It also cannot distinguish a primary osseous or
soft tissue tumor from a secondary growth. Embolization
Preprocedural Preparations
ANGIOGRAPHY IN PERIPHERAL TRAUMA
The patient must be informed about the procedure, benefits,
Angiography has an important role in the management of alternative procedures and potential complications. The
patients with suspected vascular injury both for diagnosis patient should be well hydrated and standby general
and treatment. Angiography is both sensitive and specific anesthesia may be needed for unco-operative patients and
for the diagnosis of vascular injury (active bleeding, children. Severe coagulopathy should be corrected and
pseudoaneurysms and arteriovenous fistula) (Figs 4.11 and sometimes antibiotics are also given. The sedation is given
4.12). Transcatheter embolization is effective, safe and can during the procedure depending upon the type and duration
be a definitive therapy for suitable arterial injuries. In of the procedure.
arteriovenous fistula, early intervention is very useful. Early
intervention in hemodynamically unstable patients with Indications
pelvic fractures is essential to reduce the morbidity of the
The indications of embolization in bone and soft tissue tumors
injury.16 In pelvic fractures, percutaneous embolization of
are as follows :
uncontrolled pelvic hemorrhage is a life-saving technique
1. To control hemorrhage: If there is internal or external
(Figs 4.12A and B). Small aneurysms can be treated by
bleeding from the tumor, angioembolization is sometimes
sonoguided manual compression or coil embolization (Figs
done as an emergency procedure.
4.13 and 4.14). The intra-arterial thrombolytic therapy can
2. To reduce peroperative bleeding: It has been used in
also be used in arterial thrombosis (Figs 4.15A and B).
various soft tissue and bone tumors and hemangiomas
to decrease intraoperative blood loss, which improves
IMAGE GUIDED INTERVENTIONS IN
surgical vision and allows safer and faster surgery.16,17
BONE AND SOFT TISSUE LESIONS
Voigt et al reported the use of Gelfoam embolization in
The commonly used image guided interventions are fine patients with deforming vascular malformations in the
needle aspiration cytology and trucut biopsies, embolizations, craniofacial area. The procedure allows reconstructive
Angiography and Interventions in Musculoskeletal Lesions 55

A B C

D E

F G
Figs 4.11A to G: The DSA in different patients of trauma: (A and B) Fracture femur and fibula with patent arteries, (C) Fracture
femur with thrombosed superficial femoral artery (arrow) with collaterals, (D) Soft tissue injury left shoulder with thrombosed
axillary artery-brachial artery is filling from collaterals, (E) Large pseudoaneurysm from axillary artery, (F) Large pseudoaneurysm
from right superficial femoral artery, (G) Arteriovenous fistula between popliteal artery and vein
56 Imaging Modalities

A B

Figs 4.12A and B: Post-traumatic pelvic bleeding. (A) DSA showing bleeding from right internal iliac artery
trunk, (B) Which stopped after steel coil embolization

A B

Figs 4.13A and B: (A) Ultrasound showing pseudoaneurysm of femoral artery, (B) Developed
after transfemoral arteriography, treated by manual compression

surgery to be carried out with decreased blood loss with palliation of pain in patients with inoperable tumors,
good cosmetic results (Figs 4.16A and B). embolization should be cautiously used.
3. As palliative treatment: In previously treated (surgery 4. To relieve from chronic pain due to tumors: It has been
and/or embolization) cases of recurrent or residual reported that therapeutic arterial occlusion in pelvic
arteriovenous malformations if intravascular access is tumors20 and in metastatic deposits16 gives symptomatic
difficult, direct puncture of the symptomatic lesion can relief of pain. The major vessels of supply are embolized
be performed19 by Chiba needle and alcohol or sclerosing with Gelfoam followed by steel coils to occlude the vessels
agent can be injected directly in tumor bed (nidus) until permanently (Figs 4.17A and B). Embolization with
flow is occluded. The embolization of the soft tissue particles (transcatheter) or percutaneous instillation of
tumors may result in severe, prolonged muscle pain if sclerosing agent has been used to control pain associated
acute muscle ischemia takes place. Therefore, for with a peripheral hemangioma (Fig. 4.5).21
Angiography and Interventions in Musculoskeletal Lesions 57

A B
Figs 4.14A and B: (A) Post-traumatic pseudoaneurysm from superficial temporal artery (arrow). This was treated
by ultrasound guided percutaneous coil embolization, (B) Post-treatment DSA is not showing aneurysm

A B

Figs 4.16A and B: Preoperative embolization of a very large


hemangioma around knee for reconstructive surgery. (A) Pre-
embolization, (B) Post-embolization angiograms

A B
Embolizing Materials
Figs 4.15A and B: (A) Post-traumatic acute thrombosis (arrow) of
brachial artery, (B) Recanalized after intra-arterial thrombolytic infusion There are various types of embolizing materials available.
The selection of the material depends upon the duration,
extent and level of occlusion. The materials can be
5. As a part of treatment: In hemangiomas, angioem- categorized as short, intermediate and long acting or as
bolization decreases the chance of recurrence (Figs 4.18A particulate or liquid agents depending upon the physical
to C).18 A study has shown that this not only decreases properties. The commonly used embolising materials have
the size but also controls a persistent left-to-right shunt.22 been listed in Table 4.1.
58 Imaging Modalities

A B
Figs 4.17A and B: Painful metastatic deposit in the spine treated by therapeutic arterial occlusion.
(A) Pre-embolization, (B) Post-embolization angiograms

A B C
Figs 4.18A to C: (A) Hemangioma submandibular region, (B) Supplied by right facial and lingual arteries,
(C) The common origin of which embolized by steel coils (arrow)

Table 4.1 Commonly used embolizing materials Complications


Type of embolizing agent Examples and duration
The common complications are postembolization syndrome
1. Particulate agents Absorbable (Temporary)
— Autologous blood clot in the form of nausea, vomiting, fever and pain due to tissue
— Gelfoam ischemia. The uncommon complications reported are
Nonabsorbable (Permanent) inadvertent embolization, misplaced or migrated steel coils,
— Polyvinyl alcohol particles abscess formation, spinal cord injury, aneurysm formation
— Microspheres
2. Mechanical agents Nonabsorbable (Permanent) or vessel rupture.
— Steel coils
— Detachable balloons Contraindications
3. Liquid agents Nonabsorbable (Permanent)
— Isobutyl 2-cyanoacrylate
— Ethanol
The contraindications are patients with hemorrhagic
— Sodium tetradecyl sulfate diathesis and puncture site infection.
Angiography and Interventions in Musculoskeletal Lesions 59

Intra-arterial Chemotherapy
Patients with sarcomas not amenable to cure by surgical
resection alone can benefit from preoperative intra-arterial
chemotherapy. Intra-arterial chemotherapy permits limb
sparing resection with less morbidity (Fig. 4.19).23,24 In this
chemotherapeutic drug is injected in tumor bed with the
help of angiographic catheter placed in the artery supplying
the tumor.

Percutaneous Vertebroplasty
Percutaneous vertebroplasty is a well-accepted inter-
ventional procedure for the treatment of painful vertebral
lesions. The technique first introduced in 198425 for a
vertebral hemangioma, has been subsequently used for the
treatment of numerous lesions causing back pain associated
with vertebral involvement like osteoporotic vertebral
collapse, metastatic disease, multiple myeloma and
symptomatic vertebral hemangiomas.

Technique
The procedure consists of instilling acrylic bone cement into
the affected vertebra through a bone biopsy needle by a
Fig. 4.19: Soft tissue sarcoma thigh. Postoperative angiogram was percutaneous approach. The cement consists of poly-
done to look for residual mass and intra-arterial chemotherapy methyl-methacrylate (obtained by mixing liquid monomer

A B C

Figs 4.20A to C: (A) A 30-year-old female with symptomatic D12 vertebral hemangioma, successfully treated with percutaneous vertebroplasty
using polymethyl methacrylate bone cement. T2W pretreatment MR shows D12 vertebral body hemangioma, (B) The vertebroplasty needle is
seen in position with (C) Injected bone cement
60 Imaging Modalities

to the powdered polymer), which is mixed just before the Vertebroplasty is becoming a well-established modality
injection. The cement is injected into the lesion after needle in the management of the aforementioned conditions, and
placement, under fluoroscopic control.26 The cement is relatively safe.28
polymerizes and subsequently sets, affording support to the
vertebra (Figs 4.20A to C). The steps of the procedure are: Percutaneous Treatment
I. Patient is placed in prone position on angiography/ of Disk Herniation
fluoroscopy table.
II. The procedure is performed under sterile conditions. Low backache is one of the major cause of chronic pain and
The skin over the center of the pedicle is anesthetized morbidity. Treatment of herniated disk has evolved from
with local anesthesia. A small skin incision is made and open surgical techniques to minimally invasive or micro-
bone biopsy needle is positioned with its tip in the center therapeutic procedures under local anesthesia. These include
of the mid point of the pedicle. Percutaneous laser disk decompression (PLDD), percu-
III. The needle is advanced under AP and Lat fluoroscopy taneous ozone therapy and percutaneous/endoscopic
till the junction of the anterior and middle third of the nucleotomy.
vertebral body. Approximately 6 ml of PMMA cement In PLDD, laser energy is delivered into nucleus pulposus
is injected. by laser fiber, through a needle. The aim of PLDD is to
IV. Patient is placed in supine position for three hours after vaporize a small portion of the nucleus pulposus. The ablation
the procedure and is discharged after 6 hours. of this small volume results in reduction of intradiskal
pressure, thus reducing the disk herniation29 (Figs 4.21A
Results to D).
In percutaneous ozone treatment, mixture of ozone-
Vertebroplasty results in relief of pain with decrease in oxygen gas is administered into nucleus pulposus through
analgesic use. It provides strength so prevents further the needle. This mixture has a direct effect on the
collapse and pain relief by coagulating the tissue. The relief proteoglycans of the nucleus pulposus, resulting in release
is obtained irrespective of the cause of pain, and is long of water molecules and subsequent degeneration of matrix
lasting.26 and reduction of volume30 (Figs 4.22 A to C).
Both PLDD and percutaneous ozone therapy are not used
Complications for uncontained herniations or sequestered disk. In both the
The incidence of complications is less though various procedures, patient is positioned prone and using either
complications associated with the procedure are as follows: fluoroscopy or CT guidance a lumbar puncture needle (18–
1. Cement leaks outside the vertebra are mostly 21G) is inserted into the center of the disk. After proper
inconsequential, but can cause local or radicular pain, position of the needle, for PLDD, an optical fiber is advanced
neurological damage and pulmonary embolism. through the needle and proper laser energy is given. For
2. Inaccurate needle placement can injure nerve root or ozone treatment, approximated 4 ml ozone-oxygen mixture
spinal cord. is injected with an ozone concentration of 27 µg/ml.31
3. Pain exacerbation may occur due to substantial cement
PERCUTANEOUS ABLATION
leaks.
OF BONE TUMORS
4. Rarely puncture site infection and bleeding may occur.
Percutaneous image guided tumor ablation with thermal
Future Directions energy source such as radiofrequency, laser or microwave
energy is used in the treatment of both benign (osteoid
Although vertebroplasty can give considerable pain relief, it osteoma, osteoblastoma, enchondroma, etc.) and
is not very useful in vertebral body height restoration. A new malignant (metastatic) lesions in place of surgery due to
technique called kyphoplasty27 involves the inflation of a potential benefits such as minimal invasiveness, reduced cost
bone tamp within the vertebral body to restore the height and morbidity.32
of the vertebra, and subsequently placing bone cement for The procedure is performed with CT guidance either
augmentation of strength. under general anesthesia or conscious sedation. A proper
Angiography and Interventions in Musculoskeletal Lesions 61

A B

C D

Figs 4.21A to D: Percutaneous laser treatment of herniated disk. (A) A lumbar puncture needle is placed into the disk under
fluoroscopy, (B and C) Needle position can be checked by doing rotation angiogram and 3D reconstruction image, (D) After
proper position of needle, optical fiber is advanced through the needle and laser energy is deposited

A B C
Figs 4.22A to C: Percutaneous ozone treatment of herniated disk. (A and B) A lumbar puncture needle is placed into the disk under
fluoroscopy, (C) Ozone gas is injected after preparing it from ozone generator machine
62 Imaging Modalities

A B C

D E F
Figs 4.23 A to F: Percutaneous RF ablation of osteoid osteoma. Radiograph of left hip AP view (A), unenhanced axial (B) and coronal (C) CT
images showing a small calcified nidus (small arrow) with surrounding sclerosis (long arrow). After placement of bone biopsy needle (small
arrow) into the lesion under CT guidance the stylet was withdrawn and the RF probe (long arrow) was introduced (D). Axial CT image at the
time of procedure (E) showing tip of the biopsy needle in the lesion. Post-treatment (one week) AP radiograph (F) does not show nidus and
patient is asymptomatic

bone biopsy needle is placed into the lesion with the help of 7. Bliznak J, Staple TW. Radiology of angiodysplasias of the
a hammer or a drill. Radiofrequency probe or laser fiber is limb. Radiology. 1974;10:35.
8. Levin DC, Grodon DH, McSweeney J. Arteriography of
introduced through the cannula and proper energy is
peripheral haemangiomas. Radiology. 1976;121:625.
delivered for ablation (Figs 4.23A to F). 9. Srivastava DN, Gulati M, Thulkar S, et al. Klippel-Trenaunay
syndrome–unusual magnetic resonance features.
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INFECTIONS/INFLAMMATIONS
C H A P T E R

5 Tuberculosis of Bones and Joints

Gaurav Shanker Pradhan, Veena Chowdhury

INTRODUCTION surface of cartilage eroding it in patches, insinuating


between cartilage and subchondral bone, advancing from
Tuberculosis is widely prevalent in our country affecting all
periphery to the center causing loosing and separation of
sections of the society, though it has been controlled to a
cartilaginous tissue as it proceeds causing necrosis of
great extent in the developed world.1 Of all patients
cartilage with erosion of exposed bone. Marginal erosions
suffering from tuberculosis about three percent have skeletal
are characteristic of tuberculosis in weight bearing joints
system involvement.2,3 Most of the skeletal tuberculosis is
such as hip, knee and ankle. Wedge shaped necrotic foci
now caused by bacilli of human type as opposed to bovine
may become evident on either side of joint leading to the
bacilli in the past. Osteoarticular tuberculosis is second in
appearance of ‘kissing sequestra’. Necrosed cartilage,
frequency only to tubercular infection of spine.4
fibrinious material form rice bodies in synovial joints, tendon
sheaths and bursae.5, 6 Abscesses that form may track along
ETIOPATHOGENESIS
fascial planes and result in sinus formation. Plaques of
Osteoarticular tuberculosis begins in the synovium or in the irregular bone, if present in walls of chronic abscess or sinus
metaphyseal spongiosa. Synovial infection can occur by suggest diagnosis of long standing tubercular infection.
contiguous spread or due to hematogenous spread. BCG osteitis that can occur following BCG vaccination
Hematogenous spread can occur from a lung primary or runs a benign course with localization of the Bacillus in
postprimary focus, or from any other visceral, lymph nodal epiphysis and metaphysis with extension across growth plate.
source of infection. Simultaneous involvement of viscera, It resembles chronic osteomyelitis radiologically, but
lymph nodes and parts of skeletal system suggest spread of responds to ATT.
infection through arterial blood supply. Lesion is usually Synovial sheath infections are common with nontypical
destructive and accompanied by pus formation which may Mycobacterium [Other than M. tuberculosis and M. bovis],
get calcified. The metaphyseal lesion may infect the joint with history of trauma [puncture wounds], surgery, immune
through subperiosteal space, through capsule or through compromised status and exposure to contaminated marine
destruction of the epiphyseal plate. In contrast to pyogenic life.
infections, sequestration and periosteitis are not very Tuberculosis has been seen as a late complication of
common. Ischemic necrosis and endarteritis may result in implant surgery usually six to twelve months after operation.
very small sequestrum formation which is usually not This has been attributed to extensive surgery, use of implants
radiologically visible. It may however become visible as a and favorable conditions for circulating mycobacteria like
result of calcification. Marked exudative reaction is however diabetes mellitus, corticosteroids and immune compromised
a common feature. Granulation tissue spreads onto the free status.6,7
Tuberculosis of Bones and Joints 65

Clinical Features Stage of synovitis: In early synovial disease there is soft tissue
swelling and joint widening due to effusion and synovial
Clinical features include insidious onset, low grade fever,
hypertrophy. The first radiological sign may be juxta-articular
anorexia, weight loss and night sweats. The patient may
osteoporosis. Patchy areas of trabecular or bony destruction
present with night pains, painful limitation of movement,
may be evident. In the center of osteolytic lesion or cavity
muscle wasting, regional lymph node involvement and
there may be sequestrum or calcification of the caseous
neurologic symptoms.
tissue, giving appearance of an irregular soft, feathery, coke-
Weight-bearing joints like hip, knee and ankle are
like sequestrum [image en Grelot] (Fig. 5.1). If there is
commonly involved, though any part of the skeleton can get
secondary superadded infection, subperiosteal reaction may
involved by the disease process.8,9
result. As a result of localized hyperemia growth plate may
Radiological Features show overgrowth, especially in childhood.

Tubercular involvement of bone can be broadly divided into Stage of arthritis: Later in the disease, the articular margin
four stages: and bony cortices may be hazy (blurring and fuzzy) giving
i. Inflammatory edema and exudates (predestructive rise to “washed out appearance”. With involvement of
stage). articular cartilage there is narrowing and reduction of joint
ii. Necrosis and cavitation. space. Juxta-articular osteopenia, peripherally located
iii. Destruction and deformation. osseous lesions and gradual narrowing of joint space are
iv. Healing and repair. considered pathognomonic of tubercular osteoarthritis and
Tubercular infection in bones is said to develop two to are referred to as “Phemister Triad” (Fig. 5.2).
three years after primary focus so the diagnosis is usually Early loss of articular joint space is more typically seen in
delayed, in contrast to pyogenic infections which are seen rheumatoid arthritis and thus helps in differentiating from
two to three weeks after clinical presentation. Further tuberculosis.
changes in bone on plain radiograph, are usually appreciable Stage of advanced arthritis: In advanced cases there is
two to four months after onset of disease. The infection collapse of bone, subluxation or dislocation, migration of
originates in the metaphysis and it can cross the growth bone and resultant deformity of joint.10, 11
plate. There is usually no sclerosis and small sequestra are With healing, there is remineralization and cortical and
absorbed. Diaphysial lesions are rare and multiple cystic articular margins become distinct. Fibrous ankylosis may
lucencies are rarer still. occur during healing phase. In contrast to pyogenic arthritis,
Investigations include anteroposterior and lateral views the development of bone ankylosis is uncommon in
of the involved region and radiograph of the chest. tubercular arthritis.

Fig. 5.1: In the center of osteolytic lesion in left femur, there is a Fig. 5.2: Diffuse osteopenia with lytic lesion seen at the lateral articular
small irregular sequestrum picked up on MRI [image en Grelot] margin of tibia with relative preservation of joint spaces in a case of
tuberculosis of left knee
66 Infections/Inflammations

Ultrasonography is helpful in the evaluation of large decreased signal intensity from fat and strikingly
joints, like hip joint to demonstrate joint effusion, synovitis increased signal from fluid and edema. Inversion recovery
and capsular thickening. Synovial thickening can be seen as is an extremely sensitive tool for detecting tissue and
hypoechoic intra-articular soft tissue. Fluid in joint space and marrow pathology. FSE-STIR sequence is used with most
bursal fluid can be anechoic or hypoechoic (thick exudate). of our musculoskeletal protocols.
In tenosynovitis the synovial sheath along tendons is thick 2. The high signal of joint fluid on T2-weighted sequence
and heterogeneous with minimal fluid suggestive of chronic makes it a sensitive method to detect joint effusion.
tenosynovitis. It can in addition indicate presence of 3. Synovial proliferation due to tubercular arthritis may be
associated soft tissue abscess like psoas abscess. It can also hypointense on T2-weighted images and thickened
demonstrate cortical disruption, irregularity of articular synovium enhances vividly after gadolinium. Active
margins and associated soft tissue swelling. Calcification in pannus proliferating into the subarticular bone enhances
abscess, if any can also be seen. Further, evaluation of tendon on the postcontrast scans while chronic fibrosis does not
sheaths and bursal spaces and smaller joints like wrist, hand, enhance.
foot and ankle is also possible. Guided joint fluid aspiration 4. Caseating granulomas with solid centers give a
or synovial biopsy is possible under ultrasound guidance. characteristic hypointense signal to the synovium on
Computed tomography scan is helpful in demonstrating T2-weighted images.
lytic areas and marginal erosions much before plain 5. Chondral lesions and subchondral bone erosions may be
radiographs.12 visible at a stage when the joint space is still well
Swelling in soft tissues, granulation, exudations, abscess preserved.
and early calcification can also be demonstrated much 6. Penumbra sign may be present. A thin intermediate
earlier. Joint space can also be better evaluated by CT scan. signal intensity rim along the periphery of a bone or soft
The predestructive stage can be visualized by MRI and tissue abscess on unenhanced T1-weighted images may
also probably by bone scans. The plain radiographs and CT be seen, due to layer of granulation tissue along its wall.
scan are not likely to detect the stage of inflammatory edema It is useful in identifying soft tissue abscesses.
and exudates. 7. In the pelvis and extremities routine protocols include
Isotope bone scan or magnetic resonance imaging may T1, STIR, and postgadolinium T1-weighted images.
reveal subclinical active lesion in forty percent of patients in Section thickness used in the pelvis is 7 mm and in the
addition to the presenting lesion. Out of technetium-99m, extremities, 4 mm.
gallium-67 and indium-111 isotopes used in skeletal 8. Magnetic resonance imaging can be helpful in detecting
scintigraphy, technetium-99m is the most sensitive, though bone marrow inflammation, intraosseous abscess,
not specific. So a positive scan helps in localizing the sequestrum, cortical destruction, cloaca and sinus tract
suspicious region and is also helpful for follow-up.18 Fluorine formation (Figs 5.4A to C).
fluorodeoxyglucose-positron emission tomography (18F-FDG-
PET) has also been found useful in localizing tubercular disease
and in differentiating soft tissue infection from osseous
infection.4,5,13
Synovial hypertrophy is most commonly seen in
osteoarticular tuberculosis, on magnetic resonance imaging.
Hypointense areas on T2-weighted images suggesting
hemosiderin deposition, rim of synovial lesions on
pregadolinium T1-weighted images and fluid loculations with
enhancing synovial rims and erosions on postgadolinium
images may be helpful in characterizing the lesion as
tubercular when the radiographs are normal (Fig. 5.3).
Certain characteristics that can be helpful on MRI are:
1. Short tau inversion recovery (STIR) imaging, inversion
recovery (TR > 2000 msec; TE > 30 msec; TI = 120–150 Fig. 5.3: Fluid loculations with enhancing synovial rims and erosions
msec) : Fat-saturation technique that results in markedly on postgadolinium images in a case of tuberculosis of right hip
Tuberculosis of Bones and Joints 67

A B C
Figs 5.4A to C: (A and B) Plain X-rays of ankle showing subtle osteolytic lesion in anterior aspect of talus on right side,
(C) MRI showing markedly destructive lesion in anterior aspect of talus with associated soft tissue abnormality

9. Tenosynovitis may be seen in active (hygromatous) and erosion or lytic lesion in the greater trochanter. Tuberculosis
chronic (serofibrinous) phase and bursitis may be seen as of the greater trochanter may involve the overlying
distended bursa or multiple small abscesses.4,9,14 trochanteric bursa without involving the hip joint for a fairly
Computed tomography guided aspirations and needle long period of time.
biopsy for difficult areas like sacroiliac joints may be helpful in Stage of synovitis: The patient may present with irritable hip
obtaining tissues for diagnosis. Repeat imaging can be helpful with plain radiograph being normal (Fig. 5.5). Displacement
in follow-up and if there is deterioration of clinical, laboratory of fat planes and positive obturator sign occur due to flexion
or imaging features then a representative biopsy is mandatory deformity (Reduced obturator foramina size). This is followed
from the area. by onset of soft tissue swelling and deossification.
Skeletal TB involving parts of body other than spine can Radiologically significant osteoporosis appears 12 to 18
be classified according to region of involvement: weeks after onset of symptoms.
1. Tuberculosis of joints—Tubercular arthritis Ultrasound, computed tomography and magnetic
2. Tuberculosis of long and flat bones—Tubercular resonance imaging are more sensitive in this stage to detect
osteomyelitis increased joint space and accumulation of fluid. Investi-
3. Tubercular of short tubular bones—Tubercular dactylitis. gations may be repeated, at three to six weeks interval, to
help in establishing the diagnosis.
TUBERCULOSIS OF JOINTS
Tubercular Arthritis
Hip
Lesions can arise in acetabulum, synovium, femoral epiphysis
or metaphysis (Babcock’s triangle) or spread to the hip from
foci in the greater trochanter or ischium. If there is tubercular
involvement of the upper end of femur (being entirely
intracapsular), the joint is involved early in disease and there
is destruction of articular margins of femoral head and
acetabulum. Hip involvement is seen in about fifteen percent
of cases of osteoarticular tuberculosis.15
Fig. 5.5: Plain X-ray of pelvis showing relatively well-maintained hip
Tubercular lesion may also occur in the greater trochanter joint on left side in an early case of tuberculosis of left hip with hip joint
or the overlying bursa. The lesion may manifest as a surface effusion on ultrasound
68 Infections/Inflammations

Differential diagnosis includes traumatic or nonspecific


transient synovitis, Perthes’, slipped capital femoral epiphysis
and low grade pyogenic infections.
Stage of arthritis: There is deformity of the hip joint. In
addition to osteoporosis localized erosions may be seen in
periarticular region (Fig. 5.6). The destruction of articular
cartilage leads to erosion of acetabular margin and femoral
head with reduction of joint space. Lesions can usually be
picked up on computed tomography before they are
apparent on plain radiographs.7,9
Stage of advanced arthritis: With progression of disease,
there is destruction of articular cartilage, acetabulum,
femoral head, capsule and ligaments. The capsule may also
Fig. 5.6: TB arthritis of left hip showing periarticular osteopenia,
get thickened and contracted (Figs 5.7A to C). The upper indistinct articular surfaces and erosions of femoral head and neck
end of femur may displace upwards and dorsally breaking with relative preservation of joint space
the Shenton’s line and leaving the lower part of acetabulum
empty (Wandering acetabulum) (Fig. 5.8). Bone loss can
lead to bird beak appearance with intrapelvic protrusion. If restriction of mobility. Tenderness may be present in the
femoral head, neck are grossly destroyed and collapsed in medial or lateral joint line and patellofemoral segment of
an enlarged acetabulum, this appearance is called “mortar the joint. The knee joint has the largest intra-articular space
and pestle” appearance (Fig. 5.9). and is involved in about ten percent cases of osteoarticular
Radiological classification for tuberculosis of hip tuberculosis. The initial focus may be in synovium or
(Shanmugasundaram) is useful in assessing relationship subchondral bone of distal femora, proximal tibia or
between various radiological types and functional outcome patella.17
in which various radiological types have been described such In synovial stage, there is osteoporosis, soft tissue swelling
as normal (synovitis stage) wandering acetabulum, due to synovial effusion, thickened synovium and capsule.
There may be distension of suprapatellar bursa on lateral
dislocated hip, Perthes’ type, protrusio acetabuli, atrophic
radiograph of knee. Synovial infection in childhood can lead to
type and mortar and pestle type16 (Figs 5.10A to C).
effusion, osteoporosis, accelerated growth and maturation
resulting in big bulbous squared epiphysis.18 Synovitis can also
Knee
cause widening of the intercondylar notch. Purulent material
Tuberculosis of knee joint can occur in any age group. The can accumulate in the joint space with destruction of articular
most common symptoms are pain on movement of the knee cartilage secondary to the synovitis and metaphyseal and
joint, synovial effusion, palpable synovial thickening and subarticular lesions can occur, both in femur and tibia.

A B C
Figs 5.7A to C: (A) Plain X-ray of pelvis showing erosion of the lateral aspect of femur head and neck with markedly reduced joint space
on left side, (B and C) Altered marrow signal intensity in the left femoral head and neck appearing hypointense on T1 and hyperintense on
STIR MR images
Tuberculosis of Bones and Joints 69

Fig. 5.8: Plain X-ray of pelvis showing destruction and subluxation of Fig. 5.9: Plain X-ray of pelvis showing gross destruction of right
upper end of left femur, being displaced upwards and dorsally resulting femoral head and neck with collapse contained within the enlarged
in “wandering acetabulum” acetabulum giving “mortar and pestle appearance”

A B C

Figs 5.10A to C: (A) There is evidence of irregularity, partial collapse and sclerosis of epiphysis of left femoral head suggestive of Perthes’
type appearance in a case of tuberculosis of left hip joint, (B and C) Flattening of the left femur capital epiphysis in the same case, which
appears diffusely hypointense on T1 and STIR suggestive of sclerosis with marrow signal alteration noted in the left femoral neck

As arthritis sets in, there is loss of definition of articular Ankle and Foot
surfaces, marginal erosions, decreased joint space and
destruction of bones (Fig. 5.11). Swelling, limp and pain may be the early presenting features
In advanced arthritis, there are osteolytic cavities with in tuberculosis of ankle joint. The swelling is evident in front
or without sequestra formation, marked reduction of joint of the joint, around the malleoli and tendoachilles insertion.
space, destruction and deformity of joints. In advanced cases, Marked osteoporosis with or without erosions and osteolytic
there is triple deformity of the knee, that is lateral, posterior lesions may be present in active stage of disease. There may
and superior displacement of tibia on femur. be unsharpness of articular surfaces along with reduction of
The differential diagnosis includes juvenile rheumatoid joint space (Fig. 5.12).
arthritis, villonodular synovitis, osteochondritis dissecans and In long standing cases, gross destruction of bones and
hemophilia. sinus formation can result. The ankle joint can show
Diagnosis is established by radiological examination which pathological anterior dislocation. Rarely, periosteal reaction
can show destructive lesions in the femoral or tibial condyles. may occur.
Biopsy of the synovial membrane and aspiration of the joint In tubercular affliction of foot, common involvement is
fluid followed by smear, culture and guinea pig inoculation seen of calcaneum, subtalar and midtarsal joints, anterior
can confirm the diagnosis. 2/3rds of calcaneum being commonly affected.
70 Infections/Inflammations

Fig. 5.11: Plain X-ray of knee joint showing juxta-articular osteopenia Fig. 5.12: Plain X-ray of ankle joint showing marginal erosions at
with fuzziness of articular margins numerous marginal erosions and subtalar joint with indistinct articular surfaces and loss of joint space
loss of joint space

Talus, metatarsal bones, navicular, cuneiform, cuboid


can all get involved.19 Radiograph can reveal presence of
osteolyic lesion with or without coke-like sequestrum.
Tubercular infection rapidly spreads across the inter-
communicating synovial channels, so multiple bones are
commonly involved (Figs 5.13A and B).
Osteochondritis desicans of talus can simulate a
tuberculous lesion of the ankle.
The foot bones can have isolated tubercular lesions as in
the os calcis or as diaphyseal foci in metatarsal bones
(tubercular dactylitis). A subchondral lesion in the os calcis
A B
leading to talocalcaneal arthritis and peroneal spastic flat
foot is a definite clinical entity. Talonavicular and naviculo- Figs 5.13A and B: MRI of ankle joint in a case of talocalcaneal
tuberculosis showing bony destruction involving talus, multiple
cuneiform lesions and calcaneocuboid joint involvement can collections along with rim enhancement in the subtalar region with
also occur, particularly in diabetes mellitus. The cloaca and sinus tract formation
tarsometatarsal articulation at Lisfranc’s level and the
metatarsophalangeal joint of the great toe can be other pulmonary tuberculosis is high. The classical sites could be
foci of involvement. Lesions very similar to tubercular lesions head of humerus, glenoid, spine of the scapula, acromio-
can occur in Madurella infection. Differential diagnosis clavicular joint, coracoid process and rarely synovial lesion.
should also include a neuropathic change in the foot, It can also be iatrogenic due to steroid injection given for a
secondary to diabetes or leprosy. stiff shoulder with the mistaken diagnosis of frozen shoulder,
particularly in diabetics. In the shoulder joint the initial
Shoulder
tubercular destruction is typically widespread because of
Tubercular disease involving the shoulder joint is rare. It is the small surface contact area of articular cartilage. The
more frequent in adults and the incidence of concomitant clinical presentation is with severe painful restriction of the
Tuberculosis of Bones and Joints 71

shoulder movements, particularly abduction and external articular and head of radius (Fig. 5.16). Rarely the disease is
rotation, and gross wasting of shoulder muscles.20 synovial in origin.
Radiologically, there is osteoporosis with erosion of Radiographic features in articular type include involve-
articular margins (fuzzy) with osteolytic lesion involving head ment of humerus and ulna, osteoporosis, blurring of articular
of humerus, glenoid or both (Fig. 5.14). The lesion may mimic cortex and early diminution of joint space while in the extra-
giant cell tumor. The joint space involvement and capsular articular type, ulna is involved most commonly with
contracture are seen early in the disease. Sinus formation destructive lesions seen in olecranon or coronoid process.9,21
can also occur. In advanced cases, inferior subluxation of the Periostitis may also be seen.
humeral head and fibrous ankylosis may result (Fig. 5.15). Synovial thickening of the radiohumeral segment of the
There is an atrophic type of tuberculosis of the shoulder in articulation can be present, particularly if the synovium is
which the disease runs a benign course without pus formation involved. X-ray examination is highly suggestive. Initially there
called caries sicca and small pitted erosions on the humeral is osteoporosis and blurring of articular cortex. Osteolytic
head may be seen. The classical dry type is more common in lesions may be seen around the elbow joint. In advanced
adults while the fulminating variety with cold abscess or cases there is decreased joint space and subchondral bone
sinus formation is more common in children.21 destruction.20, 21 In infants and children, sequestra may be
Since the joint space is small, multiple and large osseous present. Periosteitis is a common feature and most commonly
destructive lesions are commonly seen. Magnetic resonance affects the ulna. Pathological dislocation of elbow is very
can show synovial lesions as well, besides the osseous lesions. rare. The diagnosis can be confirmed by aspiration or biopsy
Differential diagnosis includes periarthritis of the of synovium from the lateral side.
shoulder, rheumatoid arthritis and post-traumatic shoulder Differential diagnosis includes osteochondritis desicans
stiffness. Aspiration of the shoulder and fine needle aspiration of the humeral condyle and osteoid osteoma of the lateral
biopsy might be necessary to establish the diagnosis. The condyle of the humerus which being intra-articular in location
patient responds well to antitubercular drugs. can be mistaken for tuberculosis of the elbow joint.

Elbow Wrist and Carpus


Tubercular involvement is seen in about two to five percent It is a rare site, usually affecting adults. The anatomical sites
cases. of the lesions may be in the radius or proximal row of carpal
The most frequent sites of involvement are medial and bones—scaphoid, lunate and capitate (Fig. 5.17).
lateral condyles of the humerus, articular surface of Concomitant involvement of the sheaths of volar or dorsal
olecranon usually intra-articular but occasionally extra- tendons might also occur.

Fig. 5.14: Plain X-ray of left shoulder joint showing erosions and Fig. 5.15: Plain X-ray of right shoulder joint showing fuzzy articular
deformity of humeral head and acetabular margin with osteopenia and margins and osteolytic lesions in proximal part of right humerus with
periarticular calcification pathological subluxation of head of humerus
72 Infections/Inflammations

Fig. 5.16: Plain X-ray of right elbow joint showing multiple osteolytic Fig. 5.17: Plain X-ray of right wrist joint showing irregular area of lytic
lesions within the radius, ulna and capitulum destruction seen in distal metaphysis of radius with osteoporosis and
soft tissue swelling

Radiographic features include intense osteoporosis, soft Articular erosion cause widening of the joint space and
tissue swelling, erosions of articular margins and cartilage infection is associated with abscess formation over the back
destructions, periosteal reaction and early appearance of of the joint which may later calcify. Tuberculosis at this
ossification centers. uncommon site is frequently missed.23 The cold abscess can
All carpal bones tend to get involved in adults while more be either intrapelvic or under the gluteus maximus muscle.
localized lesions are seen in children. This is thought to be Diagnosis is established by aspiration of pus or a fine needle
due to thicker articular cartilage in children.22 With cartilage aspiration biopsy. Antituberculosis therapy and protective
destruction, the carpal bones become crowded and adjacent bracing are the treatment of choice.
bones tend to get involved. Intense demineralization is Magnetic resonance imaging is the ideal means of
present in carpus, distal radius and ulna, metacarpals being evaluating the complex anatomy of SI joints. Coronal imaging
usually spared. This serves as a differentiating feature from of the SI joints, parallel to the plane of the sacrum allows
rheumatoid arthritis. direct comparison of one SI joint to the other.23,24
Biopsy of the wrist can be easily done from the dorsal Bone and joint tuberculosis occurs in 1 to 5 percent
route, when in doubt. children who have untreated initial pulmonary tuberculosis.
Spread to the skeletal system occurs during the initial
Sacroiliac Joints infection via the lymphohematogenous route. The skeletal
infection often becomes symptomatic within 1 to 3 years
These are affected more often in young adults than children after the initial infection. Eighty-five percent of patients with
and the involvement is usually unilateral. Sacroiliac (SI) joints tubercular dactylitis are younger than 6 years of age and its
infection is usually associated with tuberculosis of spine. incidence among children with tubercular is reported to be
Tenderness over the sacroiliac joint and compression and 0.65 to 6.9 percent. Tubercular osteitis is one of the
distraction tests are painful. commonest bacterial osteitis.
Radiographic features include irregularity and fuzziness BCG is a vaccine of an attenuated bovine tubercular
of articular surfaces starting at the inferior surface. Sub- Bacillus. Although complications are unusual, generalized
articular erosions may be present causing widening of joint BCG infection and bone and joint infection can occur after
space. Both the sclerosis and erosions predominate on the BCG vaccination. Due to hematogenous spread of BCG
iliac side while punched out lesions may be seen in ilium or infection to the skeleton, it is not usually associated with
sacrum (Figs 5.18A to D). immunologic disorder and has a favorable prognosis.
Tuberculosis of Bones and Joints 73

A B

C D
Figs 5.18A to D: (A) Plain X-ray of pelvis showing large erosions with surrounding
sclerosis at right sacroiliac joint, (B and C) Axial T1W and T2W image shows
hypointensity along iliac blade with hyperintense signal on T2 likely to be marrow
edema with synovial proliferation with altered signal intensity in iliacus muscle, (D) STIR
MR image showing hyperintense synovium in right sacroiliac joint

Radiologically, BCG osteomyelitis affects children are manubrium sterni, sternum and isolated spinous
between 6 months and 6 years of age. It usually affects processes, spine of the scapula, ischium and fibula, but the
epiphysis and metaphysis of tubular bone especially around diagnosis is frequently missed. The lesions tend to be
the knee, ribs, the sternum, the small bones of hand and simultaneous in onset and progression and generally affect
feet. Lesions are more common on same side of the body as persons with low immune resistance. Symmetric, well round,
the vaccine was injected. Solitary lesions predominate and oval cystic lesions, with little or no periosteal reaction initially,
are seen as well defined lytic foci.1,8,23 may be present (Fig. 5.19). In untreated cases, laminated
Diagnosis of osteitis after BCG vaccination is established periosteal reaction may be seen (Figs 5.20A to D). Sequestra
according to criteria proposed by Foucard and Hjelmsted: formation is uncommon in adults, though in children large
1. BCG vaccination in the neonatal period sequestra may be seen as the intraosseous vasculature is more
2. A period of less than 4 years between vaccination and prone to thrombosis. Joint involvement is rare as the lesions are
symptom onset diaphyseal or metphyseal. Disseminated lesions may also present
3. No contact between the child and any adults with TB as bone cysts.24,25 There is no sclerosis, abscess or sinus
4. A consistent clinical profile formation, so it is also called as closed cystic tuberculosis. A firm
5. Histopathology suggestive of TB. diagnosis can only be established by biopsy of the lesion.
TUBERCULOSIS OF LONG AND Antituberculosis regimens with curettage of the lesion are the
FLAT BONES treatment of choice.
Differential diagnosis includes polyostotic fibrous
Tubercular Osteomyelitis dysplasia, eosinophilic granuloma of the bone and
Tubercular osteomyelitis occurs in about 3 percent of patients enchondromatosis.
with bone and joint tuberculosis. In 7 percent of them, the Isolated tubercular involvement of bone is rare (2–3% of
skeletal site of lesions are multiple. The most frequent sites all cases).
74 Infections/Inflammations

thrombosis of intraosseous vasculature in children. Tibia


is the most common bone involved. Joint involvement is
infrequent.
Solitary involvement is predominant although multifocal
involvement can occur. Disseminated skeletal TB is rare,
caused by widespread hematogenous dissemination.
Multiple cystic diaphyseal lesions can occur rarely. The
condition is symmetrical in distribution with simultaneous
onset, progression and regression. Multifocal tuberculous
osteomyelitis also known as osteitis cystica tuberculosa
multiplex.25
Multiple sites of involvement are seen in children, while
in adults, involvement is more often confined to a single
bone. The earliest lesion appears as an eccentric area of
osteolysis in the metaphysis. Little or no surrounding reactive
bone and local osteopenia are salient features.
The radiographic appearance may be somewhat
Fig. 5.19: Plain X-ray of right leg with ankle lateral view showing well-
defined round osteolytic area seen in the shaft of tibia, in a case of different in children as compared to adults. In young patients,
diaphyseal tuberculosis the lesions may be symmetrical and favor metaphyseal
region. They are usually osteolytic and well defined, without
Pathology sclerosis, and may show variable size while in adults, the
Bones are involved as a result of hematogenous spread from lesions are smaller, located in the long axis of bone and may
a primary focus, usually in the lung or the lymphatic system. show well-defined sclerotic margins.
Granulomatous lesion develops within the bone at the site On MRI, early focus of altered marrow signal with
of deposition of the mycobacterium, usually metaphysis irregular margins and cortical invasion with ill defined soft
which is the site of infection. Earliest lesion appears as tissue may be seen. Eccentric lesion with cortical breach
eccentric osteolytic lesion in the shaft near the epiphysis or may show irregular breach or hyperintensity within the
metaphysis. Epiphyseal growth plate offers little resistance cortical black line while small communicating abscesses are
resulting in transphyseal spread of infections. better appreciated on postcontrast T1W images as
Two types of lesions have been described. Caseous enhancing rings of juxtacortical inflammatory tissue and are
exudative type in which there is destruction of bony a strong predictor of tuberculosis.
trabeculae, softening and caseation necrosis followed by
formation of tuberculous pus or cold abscess and granular Flat Bones
type caries sicca where predominantly granulation tissue is
formed with minimal caseation. Ribs
Rib involvement is seen in about two percent cases of bone
Tuberculosis of Long Bones
tuberculosis, adults being generally affected. Nearly one-
Two types of long bone TB occur: third of patients will have pulmonary tuberculosis or
1. Metaphyseal type in which oval or round focus in tuberculosis at other sites. Patients may present with pain,
metaphysis ultimately crosses into the epiphysis and tenderness and fluctuant chest wall swelling. There is bony
further to involve the joint, femur and tibia being the rib expansion with punched out lesions and destruction which
most commonly affected. may be poorly marginated, posterior half of ribs being most
2. Cystic (diaphyseal type), it generally affects children and commonly affected. Associated extrapleural soft tissue
young adults. There is presence of well defined round or abscesses are commonly seen, e.g. cold abscesses tracking
oval lytic areas involving and expanding the diaphysis. from spinal lesion (Fig. 5.21). The abscess may present as
Large sequestra may be seen in diaphysis due to chest wall discharging sinus.5,7
Tuberculosis of Bones and Joints 75

A B

C D

Figs 5.20A to D: (A) Plain X-ray of right thigh showing well-defined round osteolytic area in the shaft of right femur, along with marked
laminated periosteal reaction, (B and C) MR axial and coronal images showing intraosseous abscess in right femur, along with marked laminated
periosteal reaction and, (D) MR spectroscopic image showing prominent lactate peak in a case of diaphyseal tuberculosis

Scapula

Scapula is a rare site for tubercular infection. The infective


focus may be present in acromion, spine, neck, superior or
inferior angle of scapula. Patient presents with pain and
swelling. CT and MRI are helpful in early detection of
lesions.23,24

Sternum

Sternum is uncommonly involved, in about one and a half


percent of cases. An irregular destructive lesion along with
Fig. 5.21: Plain X-ray of chest showing lytic lesion involving anterior presence of retrosternal and presternal soft tissues mass
end of right 3rd rib in a case of rib tuberculosis may be seen. There is paucity of sclerosis or periosteitis.24
76 Infections/Inflammations

Skull Acromioclavicular Joint


Frontal bone is the most common site to be involved in bones Tuberculosis of the acromioclavicular joint is also rare. It is
of cranial vault. Ill-defined lytic lesion may be the only usually seen in region of lateral end and presents with a
radiological feature seen with overlying cold abscess (Potts’ painful swelling.24
Puffy tumor). Button sequestrum can also be sometimes Clavicle may rarely be involved without of adjoining joints.
seen (Fig. 5.22). Facial bones and mandibular involvement is There may be diffuse thickening and honeycombing, multiple
extremely rare.8,9 cystic cavities and sequestra formation like pyogenic
infections. Biopsy may be necessary to confirm diagnosis.
Pelvis
TUBERCULOSIS OF SHORT BONES
Isolated tubercular lesion may occur in iliac bone, ischial
tuberosity and ischiopubic ramus. Ischial tuberosity Tuberculosis of short tubular bones is referred to as tubercular
involvement with the syndrome was earlier recognized as dactylitis. It is primarily a disease of childhood. The disease
“weaver’s bottom” in which the overlying bursa was inflamed tends to affect short tubular bones distal to tarsus and wrist.
with secondary involvement of bone. Concomitant The bones of the hands are more frequently affected than
involvement of sacroiliac joints is common. Radiologically, bones of the feet, proximal phalanx of the index and middle
lytic lesions without surrounding sclerosis or periosteal fingers and metacarpals of the middle and ring fingers being
reaction may be seen. Infection may extend to involve pubic the most frequent locations.
symphysis (Fig. 5.23). Clinical features include soft tissue swelling, which may
be followed by pain and numbness. They quite frequently
present as marked swelling on the dorsum of the hand and
Sternoclavicular Joint
soft tissue abscess is normally a common feature.
Tuberculosis of the sternoclavicular joint is rare. It is usually Monostotic involvement is common, but multiple
seen in region of medial end and presents with a painful peripheral lesions may occur in twenty-five percent cases. It
swelling. Cold abscess and sinus can result as a complication. often follows a benign course without pyrexia and acute
MRI can be a useful modality to detect early erosions and inflammatory signs, as opposed to acute osteomyelitis. Plain
associated soft tissue swelling. Biopsy may be necessary in radiography is the modality of choice for evaluation and
doubtful cases. Differential diagnosis includes rheumatoid follow-up.
arthritis, multiple myeloma, metastasis and low grade The radiographic features of cystic expansion of the short
pyogenic infections.11,14,24 tubular bones have led to the name of “spina ventosa” being

Fig. 5.22: Plain CT scan of cranium showing button Fig. 5.23: Axial CT image showing bilateral pubic bone erosions
sequestrum in the right parietal bone with subcutaneous small cold abscess
Tuberculosis of Bones and Joints 77

A B

Figs 5.24A and B: (A) Plain X-ray of right thumb showing cystic expansile lesion of the proximal shaft of proximal
phalanx of right thumb with pathological fracture, (B) MRI of the same patient showing bone marrow inflammation
along with marked enhancing synovium on postgadolinium images, in a biopsy proven case of tuberculosis

given to tubercular dactylitis of the short bones of the hand. wrist, the classical presentation is a dumb-bell shaped
This condition was first described by Boyer and Nelaton.23 swelling giving cross fluctuation and crepitus, due to melon
The term spina ventosa is derived from spina meaning short seed bodies which are agglutinated protein nodules. The
bone and ventosa meaning expanded with air. spread to these sites is normally from the neighboring bone
Initial bony lesion is in the bone marrow. The disease is or joint but it could be due to hematogenous spread. It can
characterized by bone destruction and fusiform expansion also occur from gravitational spread of the disease from the
of the bone large accompanied with raft fissure swelling. It diseased area.25
is most marked in diaphysis of metacarpals and metatarsals Primary investigation to confirm the diagnosis of
in children. Periosteal reaction and sequestra are uncommon. tenosynovitis and to reveal the degree and extent of tendon
Healing is gradual by sclerosis.24 and tendon sheath involvement is ultrasonography.
Magnetic resonance imaging may demonstrate Sonograms can be quickly obtained along virtually any
intraosseous involvement earlier than the other imaging orientation and very high frequency transducers provide
modalities (Figs 5.24A and B). exquisite special and contrast resolution.
This condition needs to be differentiated from syphilitic In chronic tenosynovitis, tendon and synovial thickening
dactylitis in which there is bilateral and symmetric predominate, with relatively little synovial sheath effusion
involvement, more periostitis, less soft tissue swelling and while in acute suppurative tenosynovitis, synovial sheath
less sequestrations. Chronic pyogenic osteomyelitis and effusion is the predominant feature.25
mycotic lesions in the foot bones have to be differentiated. Magnetic resonance imaging helps in delineating the
The differential diagnosis also includes sarcoidosis, precise extent of soft tissue involvement and any associated
hemoglobinopathies and hyperparathyroidism. 24 osseous or joint involvement. Three stages of tuberculous
Debridement and antitubercular regimen result in complete tenosynovitis have been described:
subsidence of the lesion. 1. The hygromatous stage is characterized by the presence
of fluid inside the tendon sheath without associated
sheath thickening.
Tuberculosis of Tendon Sheaths and Bursae
2. The serofibrinous stage is characterized by thickening of
Any tendon sheath or bursa can be involved in tuberculosis. the flexor tendons and synovium, with multiple tiny
The most common sites are flexor tendon sheaths of hand, hypointense nodules within the hyperintense synovial
subacromial bursa, olecranon bursa and bursae under the fluid on T2W images. These tiny nodules correspond to
medial head of gastrocnemius. In the volar aspect of the the rice bodies.
78 Infections/Inflammations

3. The fungoid stage is characterized by a soft tissue mass correct diagnosis. In advanced cases, diagnosis is not much
involving the tendon and tendon sheath. of a problem and imaging helps in supplementing and guiding
Among bursal infections the most commonly affected therapeutic procedures.
locations are trochanteric, subacromial, subgluteal, and
radioulnar wrist bursa. REFERENCES
Plain radiography may demonstrate local osteopenia due 1. Yochum TR, Row LJ. Infection: non-suppurative
to hyperemia in long-standing bursitis or focal osteolytic bone osteomyelitis (tuberculosis). In: Essentials of Skeletal
destruction (e.g. greater trochanter or the humeral head) Radiology, 2nd edn, W illiams and W ilkins; 1996.
due to local pressure of the enlarged bursa. The wall of the 2. Moore SL, Rafii M. Imaging of musculoskeletal and
distended bursa may contain calcifications, which may be spinal tuberculosis. Radiologic Clinics of North America.
2001;39(2):329-42.
visible on radiographs.8,25 3. Bhan S, Nag HL. Skeletal tuberculosis. In: Surendra K
On MRI, two patterns of involvement have been Sharma: Tuberculosis, 2nd edn: Jaypee Brothers Medical
reported. A uniform distension of the bursa or multiple small Publishers (P) Ltd; 2009. pp. 342-72.
abscesses in the bursa may be seen or low signal intensity 4. Sawlani V, Chandra T, Mishra RN, et al. MRI features of
material within the fluid-filled bursa on T2W images may be Tuberculosis of peripheral joints. Clinical Radiology.
2003;58:755-62.
seen due to the presence of caseous necrosis and fibrotic
5. Grainger and Allison’s Vol 3, 4th edn: Churchill Livingstone
material. Reprinted Edition; 2005. pp. 2069-70.
Antituberculosis regimes coupled with excision of the 6. Adam Greenspan. Orthopedic Imaging—A practical
synovial sheath and bursae are the treatment of choice. approach, 4th edn: Lippincott W illiams and W ilkins;
2004. pp. 798-9.
Atypical Mycobacterial Infection 7. Tuli SM. Tuberculosis of the skeletal system. New Delhi:
Jaypee Brothers Medical Publishers (P) Ltd; 1997.
Infection due to atypical mycobacteria are also seen in 8. David Sutton (Ed). Textbook of Radiology and Imaging
specific clinical setting. Skin and pulmonary diseases are most Vol 2, 7th edn: Churchill Livingstone; 2003. pp. 1166-71.
frequent however skeletal changes may also be noted. The 9. Donald Resnik, Mark J. Kransdorf: Bone and Joint Imaging,
infection may be seen in immunocompromised patients, 3rd edn: Elsevier Saunders; 2005. pp. 758-65.
those with renal transplants or those receiving cortico- 10. Riddley N, Shaikh MI, Remedios, et al. Radiology of
skeletal tuberculosis. Orthopedics. 1998;21(11):1213-20.
steroids. Infection can lead to osteomyelitis, septic arthritis,
11. John Ebnezar. Textbook of Orthopedics, 3rd edn: Jaypee
tenosynovitis and bursitis.20,23,25 Brothers Medical Publishers (P) Ltd; 2006. pp. 499-519.
Radiologically multiple lesions may be seen, metaphysis 12. Morris BS, Varma R, Garg A, et al. Multifocal musculo-
and diaphysis of long bones being usually affected. Discrete skeletal tuberculosis in children: Appearances on
lesions may be present with sclerotic margins but computed tomography. Skeletal Radiology. 2002;31:1-8.
osteoporosis is not marked. Abscesses and sinus tract can 13. Yago Y, Yukihiro M, Kuroki H, Katsuragawa Y, Kubota K.
Cold tubercular abscess identified by FDG PET. Ann Nucl
also be seen. Med. 2005;19:515-8.
14. Griffith JF, Kumta SM, Leung PC, et al. Imaging of musculo-
Tubercular Infection of Prosthetic Joint skeletal tuberculosis: A new look at old disease. Clinical
Prosthetic joint infection may develop due to reactivation of Orthopedics and Related Research. 2002;398:32-9.
tubercular arthritis for which the operation had been 15. Babhulkar SS, Pande S. Tuberculosis of the hip. Clinical
Orthopedics. 2002;398:93-9.
performed.26 Arthrocentesis and specimens are required for
16. Shanmugasundaram TK. A clinicoradiological classi-
establishing the diagnosis. fication of tuberculosis of hip. In: Shanmugasundaram
TK (Ed). Current concepts in bone joint tuberculosis.
CONCLUSION Madras: International Bone and Joint Club; 1983.
It is difficult to diagnose the disease in its earliest stage as 17. Hoffman EB, Allin J, Campbell JAB, et al. Tuberculosis of
the knee. Clinical Orthopedics. 2002;398:100-6.
the clinical and radiologic findings are nonspecific in initial 18. Lee AS, Campbell JAB, Hoffman EB. Tuberculosis of the
stages. We should have a high level of clinical suspicion as knee in children. J Bone Joint Surg Br. 1995;77-B:313-8.
the disease is endemic in our country. At this stage, cross- 19. Dhillon MS, Nagi ON. Tuberculosis of foot and ankle.
sectional imaging and histological examination can lead to Clinical Orthopedics. 2002;398:107-13.
Tuberculosis of Bones and Joints 79

20. Singh NV. Fundamental of Orthopedics, 1st edn: New Age 24. Babhulkar SS, Pande S. Unusual manifestations of
International Publishers; 2011. pp. 236-44. osteoarticular tuberculosis. Clinical Orthopedics. 2002;
21. Malaviya AN, Kotwal PP. Arthritis associated with tuber- 398:93-9.
culosis. Best Practice Res Clin Rheumatol. 2003;17: 25. Boutin RD, Brossmann J, Sartoris DJ, et al. Update on
319-43. Imaging of Orthopedic Infections. Orthopedic Clinics of
22. Gardam M, Lim S. Mycobacterial osteomyelitis and North America. 1998;29(1):41-65.
arthritis. Infect Dis Clin North Am. 2005;19:819-30. 26. Kaya M, Nagoya S, Yamashita, Niiro N, Fujita M.
23. Harisinghani GM, McLoud TC, Shepard JO, et al. Periprosthetic infection of the hip in a patient with no
Tuberculosis from head to toe. Radiographics. 2000;20(2): previous history of tuberculosis. J Bone Joint Surg Br.
449-70. 2006;88:394-5.
CHAPTER

6 Nontubercular Bone
and Joint Infections
Manphool Singhal, Niranjan Khandelwal

INTRODUCTION changes, better visualization of axial skeletal involvement


(e.g. spine, pelvis, sternum) and better delineation of
Osteomyelitis refers to the infection of cortical bone and its
overlapping bony abnormalities like thick periosteal reaction
marrow space. It is classified into three forms: Acute,
or sequestra in chronic osteomyelitis.
subacute and chronic. Subacute osteomyelitis is insidious in
Radionuclide scintigraphy is the most sensitive
presentation as compared to the acute form. Chronic
investigation available for diagnosing acute osteomyelitis
osteomyelitis is a continuous low-grade recurring infection.
though the specificity is not as good. 3 99mTc labeled
The pathogens causing osteomyelitis can be bacteria,
methylene diphosphonate (99mTc-MDP), hydroxymethylene
viruses, mycobacteria or treponemes (Syphilis). Pyogenic
diphosphonate (99mTc-HMDP) and gallium 67 (67Ga) citrate
osteomyelitis is the most common.1,2 Plain radiographs,
are the most commonly used radionuclide agents. The
scintigraphy, ultrasonography (USG), computed tomography
sensitivity and specificity for combined 99mTc 67Ga scanning
(CT) and magnetic resonance imaging (MRI), all play an
are 50 and 78 percent respectively.5 Indium 111 labeled
important role in the diagnosis of osteomyelitis, but overall
leukocyte scanning (111In WBC) has a higher sensitivity and
diagnostic accuracy does not exceed more than 80 to 90
specificity of 83 percent and 94 percent respectively.
percent.3 Presence of previous or chronic osteomyelitis,
Recently introduced Indium 111 labeled polyclonal
adjoining soft tissue infection, fracture, surgery and
immunoglobulin (IgG) has the highest sensitivity and
prosthesis are the factors which make the diagnosis difficult.
specificity of 92 percent and 95 to 100 percent respectively.6,7
Now with the advent of high resolution sonography
IMAGING MODALITIES
equipment ultrasonography (USG) is being increasingly used
Plain radiographs are the first imaging study asked for in the for diagnosis of acute osteomyelitis. Positive findings can be
work-up of osteomyelitis. If cortical irregularity, periosteal detected much earlier than on plain radiographs. Deep soft
reaction, deep soft tissue swelling and demineralization are tissue swelling is the earliest sign which can be detected
detected, additional imaging may not be required to within 2 to 3 days of onset. The other changes include
diagnose osteomyelitis.3 However, only 5 percent of periosteal elevation seen as a hyperechoic line and
radiographs are positive in the early course of disease. Less subperiosteal fluid collection (Fig. 6.1). Cortical breech is
than one-third reveal abnormality by one week while 90 seen as a focal defect in the cortex.8 In a prospective study
percent are positive only by 3 to 4 weeks.4 This delay of 25 patients done to assess the role of ultrasound in acute
constrains the utility of plain radiographs in the early osteomyelitis, the authors found the presence of deep soft
diagnosis of osteomyelitis. tissue swelling periosseous fluid (Fig. 6.2) and periosteal
Computed tomography offers advantages over elevation has positive predictive value of 100 percent in first
conventional radiographs in terms of early detection of bony three days after the onset of symptoms.9
Nontubercular Bone and Joint Infections 81

Fig. 6.1: Acute osteomyelitis: High resolution USG of femur Fig. 6.3: USG-guided percutaneous aspiration of periosteal fluid.
shows periosteal elevation (hyperechoic line) with subperiosteal fluid Note the needle in situ (arrows)
collection (*)

resolution is now the imaging modality of choice for the


early diagnosis of osteomyelitis and overlying soft tissue
involvement.10 It has a sensitivity and specificity of 92 to 100
percent and 89 to 100 percent respectively.11 MRI is better
than scintigraphy in evaluation of axial skeletal osteomyelitis
because of better anatomical delineation.12 In addition, MRI
can distinguish soft tissue infection with periostitis from
osteomyelitis.13 More over the complications of osteomyelitis
like soft-tissue and bone abscesses, physeal involvement,
and septic arthritis can also be diagnosed which can help in
further management such as determining the need for
Fig. 6.2: High resolution ultrasonography (USG) of femur (longitudinal percutaneous or surgical drainage in addition to antibiotic
and transverse) shows periosseous fluid collection in acute therapy.14-16
osteomyelitis
ACUTE OSTEOMYELITIS

Ultrasonography is also an excellent method to detect Acute osteomyelitis is usually hematogenous in origin and
presence of fluid in the joint which may be an indirect sign to generally follows skin infection. Staphylococcus aureus is the
suggest osteomyelitis especially of femur and humerus in an most common offending pathogen. Common age of presen-
infant. In reactivation of chronic osteomyelitis, USG can tation is 2 to 16 years with a male preponderance, the latter
demonstrate abscess or sinus tract formation in soft being attributed to greater exposure to trauma.
tissues which are characteristic of acute osteomyelitis.
Clinical Features
Ultrasonography guidance can also used for percutaneous
aspiration of fluid from the joint or periosteal collection for Clinical features vary in infants, children and adults, being
diagnostic purposes (Fig. 6.3). related to the structural and vascular differences of bone at
Magnetic resonance imaging due to its multiplannar these ages. The blood borne microbial emboli lodge in the
imaging capability, excellent tissue characterization and high metaphysis because of sluggish blood flow in this region. In
82 Infections/Inflammations

Fig. 6.5: Schematic diagram of vascular supply of the


epimetaphyseal region in the infant, child and adult

Fig. 6.4: Chronic osteomyelitis in a child. Radiograph of the right hip


A soft tissue component, subperiosteal abscess and dense
showing diffuse ill-defined lytic areas affecting the entire upper shaft involucrum are more striking in infants than in adults and
of femur with cortical thickening. Note the sparing of epiphysis and children. This has been attributed to less rigid bone of infants
the joint and easy penetration of periosteum by the abscess.

Radiologic Features
children older than one year the epiphyseal plate blocks
extension of the infection (Fig. 6.4), so the infection spreads The earliest radiographic changes are seen 7 to 10 days
laterally into the subperiosteal space or to the joint in which after onset of infection in the form of soft tissue swelling and
synovial reflections extend beyond the epiphysis to small single or multiple osteolytic areas affecting the
metaphysis, such as the shoulder and hip joints. In infants, metaphysis (Fig. 6.6). This is followed by elevation of the
small capillaries cross the epiphyseal growth plate, and thus, periosteum and layered new bone formation after 3 to 6
permit extension of infection to the epiphysis and the joint. weeks. The periosteal reaction is typically lamellar and
In adults, the epiphyseal plate is fused and no longer forms a nodular.2 The dead bone (sequestrum) also forms at 3 to 8
barrier to the spread of infection from metaphysis to the weeks. It appears dense since it does not participate in
adjacent joint. Thus, acute pyogenic arthritis is a frequent normal bone mineral metabolism because of loss of its
complication of osteomyelitis in infants and adults (Fig. 6.5). vascular supply. Osteopenia in the surrounding bone due to
The infarcted bone is reabsorbed by formation of hyperemia, enhances the density of the sequestrum. Once
granulation tissue and the dead cortex usually forms the acute phase has subsided, remodeling reverts the
sequestrum. Reparative new bone formation starts roughly appearance of bone to normal in infants and children but in
10 days after the onset of infection, and new bone is generally adults the sclerosis and cortical irregularity persist.
laid down along both periosteal and endosteal surfaces Patients with sickle cell disease have an unusual
resulting in formation of involucrum. Cloacae appear at the propensity for Salmonella osteomyelitis. This infection is
site of dead periosteum. diaphyseal and difficult to differentiate from a bone infarct.
Neonatal osteomyelitis presents with few clinical signs Localized cortical fissuring or tunneling is a characteristic
despite multiple sites of involvement, and hence, a complete and early feature of this entity.20
skeletal survey is warranted in such cases.17 Premature The bone scintigraphy shows positive findings much
infants requiring umbilical catheterization are at higher risk earlier than plain radiographs, usually within 3 days and
for osteomyelitis.18 Radionuclide bone scintigraphy is sometimes within 24 hours of onset of infection. Traditionally,
advocated in all patients with suspected neonatal “triple phase” bone scanning is done, using technetium 99mTc
osteomyelitis, following initial radiographs.19 agents. The first phase shows the “blood flow”, the second
Nontubercular Bone and Joint Infections 83

the detection, localization, and differentiation of


osteomyelitis, cellulitis and abscess. Cellulitis and
osteomyelitis may have similar soft tissue changes. However,
in cellulitis, the bone is normal.23

LOCALIZED OSTEOMYELITIS
(BRODIE’S ABSCESS)
Localized osteomyelitis or Brodie’s abscess is a limited
osteomyelitis caused either by organisms of low virulence or
high resistance in the host. It occurs most frequently at one
end of the bone, but it may also occur in the diaphysis. It is
seen as a well-circumscribed osteolytic focus surrounded by
a sclerotic margin (Figs 6.8A to C). Occasionally, a meta-
physeal serpiginous channel with sclerotic border marks the
tract of infection. This feature is considered characteristic
of nontubercular etiology like Staphylococcus, Streptococcus
or Haemophilus.2 When the lesion is small, it may be difficult
Fig. 6.6: Acute osteomyelitis of tibia. Radiograph of leg shows small to identify on plain radiographs and CT/MRI may be required.
lucencies in the metaphysis along with thin periosteal reaction
The close differential diagnosis of Brodie’s abscess is an
osteoid osteoma as on imaging both these condition closely
phase shows the “blood pool” of the inflamed region and the simulate each other (T2 hyperintense nidus, sclerotic rim
third phase, which is acquired after 2 to 4 hours, shows the and bone edema), however, on T1-weighted MRI scans a
uptake by bone. Osteomyelitis is “hot” on all phases. ‘penumbra sign’ has been described as a discrete peripheral
However, in patients presenting within 48 hours, the isotope zone of marginally higher signal intensity than the abscess
bone scan may reveal a “cold” spot on account of vasospasm. cavity and surrounding marrow edema/sclerosis, and of lower
A false positive result can occur in degenerative disease, signal intensity than fatty bone marrow, which often
healing fracture and loose prosthesis. But these conditions enhances after contrast. This has been postulated to be due
do not show increased activity in early (I and II) phases, to the presence of active, vascular, inflammatory granulation
unlike osteomyelitis. Deep soft tissue infection with periostitis tissue around the abscess.24
and diabetic osteopathy also cannot be differentiated from
CHRONIC OSTEOMYELITIS
osteomyelitis on the basis of bone scanning alone.3 MRI is
considered superior to bone scan in distinguishing these two Chronic bone infections usually result from inadequately
entities. treated acute osteomyelitis or from infection following
Magnetic resonance imaging is the modality of choice compound bone fractures. Pain, local swelling, discharge
for early diagnosis of osteomyelitis. MRI features of from wound, sinus formation and systemic signs and
osteomyelitis include low signal intensity on T1-weighted symptoms (fever, malaise, nausea and vomiting) may be
image and high-signal intensity on T2-weighted and fluid- present.
sensitive images (fat-suppressed T2-weighted and STIR Conventional radiographs show cloacae, involucrum or
sequences) with post-contrast enhancement (Figs 6.7A to sequestrum (Figs 6.9 and 6.10). There are sclerotic and lucent
C). Intraosseous, subperiosteal, and soft-tissue abscesses if areas admixed with bony thickening and deformities. The
present appear as well-circumscribed areas of focally radiographic impression regarding the activity of infectious
decreased signal intensity on T1-weighted images with process is often equivocal, and one relies heavily on clinical
increased signal intensity equal to that of fluid on fluid findings such as the presence of a sinus tract.25 At times, it is
sensitive sequences and rim enhancement on contrast T1- imperative to review previous films as it may be difficult to
weighted images.14,21,22 differentiate inactive and active chronic osteomyelitis. In
Magnetic resonance imaging has also been shown to be osteomyelitis of the skull, typically no sclerosis is seen (Figs
more sensitive and specific than isotope bone scanning in 6.11A and B).
84 Infections/Inflammations

A B

Figs 6.7A to C: Acute osteomyelitis. Plain X-rays (A) shows smooth periosteal reaction with cortical irregularity
in the lower third of humerus. Postcontrast MR images sagittal (B) and axial (C) shows cortical irregularity with
break in the outline and periosseous fluid collection with increased signal in the adjacent soft tissues

Scintigraphy is more useful in determining activity. low-to-intermediate signal intensity on T1W and high-signal
Routine 99mTc-MDP scanning shows increased uptake, but is intensity on T2W and fluid sensitive images which is in
often non-diagnostic, since even after 1 to 2 years following marked contrast to the low-signal of thickened, surrounding
successful treatment, a positive isotope bone scan is not bone.25,26
uncommon.3 67Ga has been recommended as the optimal Magnetic resonance imaging findings correspond to the
agent. Following successful treatment 67Ga uptake should pathologic features. On MR images the involucrum, manifests
decrease to a normal level. as a well-defined rim of low-signal intensity on all sequences
MRI has been advocated as the imaging modality to surrounding the infected bone marrow.
distinguish regions of active infection from uninvolved Granulation tissue surrounding the infection appears as
marrow or fibrotic regions representing scars from previous hypointense on T1W images, hyperintense on T2W and STIR
infection or trauma.25 Active foci of infection tend to have a images, and shows enhancement after Gd-DTPA.
Nontubercular Bone and Joint Infections 85

A B C

Figs 6.8A to C: Plain X-ray (A and B) axial CT (C) showing Brodie’s abscess in the upper end of tibia

Fig. 6.10: Chronic osteomyelitis. Radiograph of right arm showing


involucrum surrounding distal two-thirds of humerus

A B
Sequestrum is a isolated fragment of devitalized bone
Figs 6.9A and B: Chronic osteomyelitis of the femoral bone. Diaphyseal
lucent areas represent cloacae formation with sequestrum seen as
within an area of active infection shows signal intensity that
radiodense opacities of a sequestrum in all sequences.
86 Infections/Inflammations

A B

Figs 6.11A and B: Chronic osteomyelitis of skull vault. Anteroposterior and lateral skull radiographs
showing multiple lytic areas with no surrounding sclerosis

Sinus tract is identified as a linear or curvilinear area of i. Congenital syphilis, present at birth or in early infancy
low-signal on T1W and high-signal on T2-weighted and STIR ii. Late congenital syphilis
images extending in contiguity from the medullary cavity, iii. Acquired syphilis.
with disruption of the cortex, to the skin.
Soft-tissue inflammation is seen as bright signal on T2W Congenital (Infantile) Syphilis
and STIR images, enhancing after contrast. Sometimes soft-
tissue abscess may also develop (Figs 6.12A to D).25,26 Congenital (infantile) syphilis is a systemic disease due to
transplacental transmission of the spirochetes. Clinical
SCLEROSING OSTEOMYELITIS features include, fever, failure to thrive, saddle nose,
OF GARRE Hutchinson’s teeth, etc. Serologic diagnostic tests include
Sclerosing osteomyelitis of Garre is a rare type of chronic VDRL, FTA and ABS tests. Osseous abnormalities include luetic
osteomyelitis occurring in children and young adults, metaphysitis, diaphysitis and periostitis. Radiologically the
presenting with insidious onset of local pain. Symptoms recur earliest change is in the metaphysis, with widening of the
at intervals for several years and then subside gradually. zone of provisional calcification. The epiphyseal plate appears
There is a predilection for involvement of mandible and shafts wide and dense. The outstanding feature is symmetrical
of long bones. Radiological appearance is of intense sclerosis involvement of multiple bones especially at the upper end of
resulting in thickened bone (Fig. 6.13). Areas of frank bony tibia and lower end of femur. Symmetrical destruction of
destruction are rare. It is distinguished from Ewing’s tumor medial portion of the proximal tibial meta-physis
by the absence of lamellations of periosteal reaction and (Wimberger’s sign) is common and pathognomonic of syphilis
permeative bone destruction. (Fig. 6.14).
The earliest diaphyseal change is focal cortical
SYPHILIS OF BONE destruction. Later there may be extensive destruction of
Syphilis is caused by Treponema pallidum and is of three bone. Periosteal reaction can be solid or lamellated. In the
types: skull, irregular, osteolytic lesions are seen.
Nontubercular Bone and Joint Infections 87

A B

C D

Figs 6.12A to D: (A) Plain X-ray of hip joints reveal erosions along the inferior border of left ischium with
sclerosis. Axial T2W (B), T1W (C) and postcontrast T1 fat saturated (D) MRI images show a large area of lytic
destruction involving the left ischium associated with a large inflammatory tissue which is of high signal on T2W
and hypointense on T1W images involving the gluteal muscles. The marrow of the left ischium also show
increased signal consistent with marrow edema. Few small peripherally enhancing collections are also seen
representing abscesses. The gluteal muscles on the right side also show inflammatory changes

Late Congenital Syphilis


In this condition, syphilitic bony lesions do not become
evident until childhood or early adult life. The lesions are
due to gumma or syphilitic endarteritis. There is minimal
bone destruction which is overshadowed by extensive new
bone proliferation. This results in diffuse thickening of cortical
bone and lamellated periosteal reaction. This lesion causes
typical thickening of the upper half of tibial cortex anteriorly
and is called “Sabre Tibia” (Fig. 6.15).

Acquired Syphilis
Osseous changes in acquired syphilis manifest as dense
osteosclerosis. Long bones and skull are most frequently
involved. The earliest change is periosteal reaction. The
affected bone shows thickened cortex with narrowing of
medullary canal. Gummas cause osteolytic lesion of variable
Fig. 6.13: Chronic sclerosing osteomyelitis of Garre. Long standing
osteomyelitis with endosteal thickening of cortex with obliteration of size and shape. The skull shows predominantly osteolytic
medullary cavity lesions, and outer table is more often involved.
88 Infections/Inflammations

Fig. 6.14: Congenital syphilis. Radiograph of both knees of an infant Fig. 6.15: Sabre tibia. Extensive cortical thickening affecting the
showing symmetrical marginal destruction of medial aspect of tibia shaft of tibia which is widened
and femur in juxtaepiphyseal area and metaphyseal bands

MADURAMYCOSIS
RUBELLA OSTEOMYELITIS
Maduramycosis is a form of chronic osteomyelitis due to
Congenital rubella infection occurs following maternal rubella granulomatous inflammation caused by a wide variety of
in the early months of pregnancy. The characteristic pathogens including fungi or actinomycosis. The infection
radiological feature is metaphyseal lucent bands and occurs by entry of organism through minor trauma to skin,
trabecular irregularity, extending longitudinally from the usually foot (Madura foot). The disease is painless and
epiphysis. It is seen in the upper and lower extremities, presents as swelling, sinus formation and marked deformity
predominantly in the distal end of femur and proximal end (Figs 6.17 and 6.18).
of the tibia (Celery stalk appearance) (Fig. 6.16). Bone Radiologically, periosteal reaction is the most common
changes can be confused with syphilis. Absence of periosteal lesion and is usually lamellated. The disease arises primarily
reaction in congenital rubella helps in differentiating from in soft tissues and secondarily erodes the adjoining cortex
congenital syphilis. and medulla. There is little, if any, osteopenia. The disease is
painless, and characteristically, the sequestrum is absent.
ACTINOMYCOSIS OF BONE
LEPROSY OF BONE
It is a chronic osteomyelitis caused by gram-positive
organism, Actinomyces israelii, which grows in colonies and Leprosy is a chronic granulomatous infection caused by
appear as yellow (Sulphur) granules in pus. They are common Mycobacterium leprae. In lepromatous leprosy, the disease
saprophytes in the gastrointestinal tract and infection occurs predominantly affects the skin, mucous membranes and the
after a dental procedure or trauma to mouth and jaw. The viscera. Bone involvement can rarely occur by direct
most common bones involved are vertebrae and mandible. lepromatous granulation tissue or by endarteritis causing
Radiologically, there is bone destruction without new bone infarcts. In tuberculoid (neural) type, there is predomi-
bone formation. Vertebral osteomyelitis resembles nant involvement of nerves which become thickened and
tuberculosis, although disks are usually spared.2 Ribs respond nodular. The bone changes are secondary to neurotrophic
to actinomycosis by periosteal reaction and thickening, a disturbances causing recurrent trauma and infection which
feature which is most suggestive though, not diagnostic. go unnoticed.
Nontubercular Bone and Joint Infections 89

Radiographically, there is diffuse osteopenia and ill-


defined small osteolytic areas with soft tissue swelling are
seen. Periosteal reaction is rare. In later stages, erosions or
resorption of phalangeal tufts are seen along with soft tissue
atrophy (Figs 6.19A and B). Nonspecific changes including
soft tissue swelling and contractures are also seen.
Calcification of nerves, if observed, is classical of leprosy.
Nasal septal irregularity, thinning and perforation are not
well appreciated on plain radiography, but these
abnormalities are very well demonstrated on CT.

DIABETIC FOOT
Infection is the primary problem requiring hospitalization of
diabetic patient with foot problems often necessitating
amputation. Foot problems account for as much as one-
fourth of hospital admissions among diabetic patients.27 The
Fig. 6.16: Rubella. Radiographs of both lower limbs show the typical
metaphyseal bands and trabecular irregularity in metaphysis extending pathological changes are often a combination of neuropathy,
longitudinally. Note absence of periosteal reaction vasculopathy or infection.

B C

Figs 6.17A to C: Maduramycosis. Plain X-rays (A) and axial CT pre- and postcontrast images
(B and C). There is a large soft tissue swelling in the foot with destruction of 2-4th metatarsals. On
CT, an enhancing soft tissue lesion with secondary destruction of metatarsal shafts is seen
90 Infections/Inflammations

A B
Figs 6.19A and B: Leprosy. Osteopenia with ‘licked candy appearance’
of the metatarsals (A and B). Note the absence of the phalanges of
the 5th toe (B) due to bony resorption

Fig. 6.18: Maduramycosis. Infiltrative destruction of the tarsal and


metatarsal bones with large soft tissue component

Conventional radiographs show either osteomyelitic


changes or neuropathic changes in the foot bones (sensitivity
and specificity 75% each) (Fig. 6.20).28
Scintigraphy can identify early osteopathy at a time when
the conventional radiograph is normal, but its specificity is
very low.28 111In WBC scanning is more specific than 99mTc
bone scan since it is not affected by increased bone turnover
from neuropathy or fracture.29
Magnetic resonance imaging (MRI) can visualize marrow
directly and is found to have the lowest false positive rate
compared to both scintigraphy as well as plain radiography.28 Fig. 6.20: Diabetic foot. There is narrowing of first metatarsophalangeal
In neuroarthropathy, MRI typically shows a specific low signal (Right) and tarsometatarsal joint on left with articular erosion and
marked sclerosis of adjacent bone. Lucencies in soft tissues are due
from within the marrow space on T1W images and T2W to air
images, although there are exceptions. This finding is
consistently different from osteomyelitis where a high signal
HYDATID DISEASE
from the marrow space on T2W images is seen, however,
concurrent infection in the adjacent soft tissues, synovium Bone involvement is rare accounting for 0.5 to 2 percent
and muscles may reveal increased signal on T2W and STIR cases. The most commonly involved bones are the spine,
images which may enhance on post-gadolinium scans (Figs pelvis, femur, tibia, ribs, skull, scapula, humerus and
6.21A to C). Since high signal on T2W images can also be fibula.30,31 The hydatid disease in the bone and joint begins
caused by tumor, trauma or hemorrhage, MRI findings must in childhood and grows at a very slow rate and hence are
be correlated with clinical findings and other imaging studies. seldomly diagnosed in childhood. The bone offers mechanical
Soft tissue infection of foot occurs especially over pressure resistance; hence cyst cannot assume it is typical spherical
points such as metatarsals where organisms enter via shape and enlarges along the path of least resistance. Over
superficial ulceration. Gas may be noted in infective tissues, the time, the trabeculae are absorbed and cortex is
because of gas producing organisms such as E.Coli, without breached, resulting in fracture. Then, the disease spreads
implying the presence of gangrene. to surrounding structures and becomes symptomatic.
Nontubercular Bone and Joint Infections 91

A B C
Figs 6.21A to C: Diabetic foot. (A) Plain radiograph of foot shows dislocation of joints of midfoot and tarsometatarsal joints and with reduced
joint spaces and erosions. The bones show mixed lytic and sclerotic areas, (B) T1W MRI image show dislocated-disorganized joints of foot
with markedly hypointense areas of bony sclerosis, (C) Postcontrast T1W image shows thickened enhancing synovium at tarsometatarsal
joints with enhancing muscles of planter surface

Hydatid disease should be suspected whenever cystic


lesions are seen in the bone especially in the endemic areas.
The bone shows expanded medullary cavity with thinned
out cortex with cortical breech or complete fracture.
Typically, there is no periosteal reaction or new bone
formation. On MRI, the infested bone reveals multiple cysts
which exhibit medium-to-low signal on T1W images and high
signal on T2W images (Figs 6.22A to D).30,31

A B SEPTIC ARTHRITIS
Septic arthritis is usually hematogenous in origin but may
follow local trauma, joint aspiration, soft tissue infection or
periarticular osteomyelitis. Arthroscopic procedures are
complicated by septic arthritis in 0.04 to 3.4 percent of
patients.7 Staphylococcus aureus is the most common
invader followed by N. gonorrhoea, Streptococcus,
Haemophilus and anaerobic organisms.23
Onset of bacterial arthritis is usually abrupt with high
fever, chills and one or more severely tender swollen joints.
Knee joint is most frequently affected (40 to 50%) followed
C D by hip (20 to 25%), shoulder, wrist, elbow and ankle.
Sternoclavicular, sacroiliac and manubriosternal joints are
Figs 6.22A to D: (A) Plain radiograph demonstrates expanded medullary more often involved in intravenous drug abusers.
cavity with endosteal scalloping in right femur and thinned out cortex.
Bone scan is the investigation of choice for early diagnosis
There is pathological fracture neck of femur with proximal migration of
greater trochanter. A large soft tissue shadow is also seen along the
of septic arthritis. Although not specific, bone scanning is
lateral aspect with foci of calcifications, (B) Coronal T1W MR image very sensitive and when negative can rule out the possibility
showing altered marrow signal of medullary cavity (hypointense when of infected joint.8 Computed tomography demonstrates bone
compared to left femur) with a large hypointense lesion along lateral changes much earlier than plain films and is superior in
aspect of upper thigh. Note pathological fracture neck of right femur, demonstrating the extent of infection. Magnetic resonance
(C) Sagittal T2W MR image showing multiple cysts in the medullary
imaging is extremely sensitive in the depiction of joint fluid,
cavity of right femur with small cysts in adductor group of muscles
and large cysts along lateral aspect of thigh, (D) Axial T2W MR image cartilage damage, marrow changes and medullary bone
showing a multi-septated cystic lesion along lateral aspect of femur. destruction, but cannot differentiate infectious from
Note a small cyst in the medullary cavity noninfectious joint effusions.32
92 Infections/Inflammations

A B

Figs 6.23A and B: (A) Plain X-ray of hip joints reveal irregular articular margins of right femoral joint with sclerosis. The femoral
epiphysis is massively destroyed with fuzzy outline, (B) Postcontrast T1W MRI image demonstrate thickened enhancing synovium
with intraosseous abscesses in the femoral epiphysis and bone destruction. Also the marrow shows enhancement in the upper
femur

Radiological patterns are different in adults and infants.


Plain radiographs are usually normal in early course of
disease. Soft tissue swelling is the first radiographic sign of
acute pyogenic arthritis. Hyperemia associated with
pyogenic arthritis causes rapid, juxta-articular osteoporosis
with disappearance of subchondral white line. Periarticular
edema obliterates the adjacent fat planes. At this stage,
effusion is identifiable. Earliest bone change occurs 8 to 10
days after the onset of infection.33 There is loss of definition
of the margins due to osteoporosis with small focal articular
erosions followed by progressive destruction of cartilage
leading to reduction in joint space. Untreated infection can
lead to extensive bone destruction and loss of cortical outline.
Fig. 6.24: USG image in an infant shows joint
In later stages, subluxation or even dislocation can occur.
effusion in hip joint with dependent debris
With healing, sclerotic bone reaction occurs resulting in
irregular articular surface. If the entire cartilage is destroyed,
then bony ankylosis follows (Figs 6.23A and B).34 In pediatric population distinguishing transient synovitis
In infants and children, distention of joint capsule due to from septic arthritis is extremely important and in such cases
fluid can cause joint space widening and even subluxation, the USG may not differentiate as both the conditions
especially of the hip and shoulder. In neonates physiological manifests as synovial thickening, joint effusions and
ossification of femoral head is absent, thus plain radiographs alteration in surrounding soft tissues. MRI can differentiate
are of limited value. Ultrasonography in such cases may these two conditions as in transient synovitis, there are
reveal joint effusion with/without internal echoes (Fig. 6.24). minimal to almost nil marrow changes (High signal changes
Thickened synovial membrane is seen as irregular echogenic in T2W and STIR images which show postcontrast
membrane surrounding the fluid. Joint effusion can also occur enhancement).35
as sympathetic response to adjacent focus of osteomyelitis. Bone changes in gonococcal arthritis are indistinguishable
Arthrocentesis with bacterial cultures is therefore essential from tuberculosis. Destruction is more rapid and serial films
in such cases to document joint infection. are helpful in distinguishing the two. Similarly, Brucellar
Nontubercular Bone and Joint Infections 93

arthritic changes are also indistinguishable from tubercular 15. Jaramillo D, Treves ST, Kasser JR, et al. Osteomyelitis and
joint, however, Brucella involves most commonly sacroiliac septic arthritis in children: appropriate use of imaging
to guide treatment. Am J Roentgenol. 1995;165:399-403.
joints and usually unilaterally.34 Fungal arthritis is most 16. Beltran J, Noto AM, McGhee RB, et al. Infections of
commonly due to Candida, coccidiosis and blastomycosis. the musculoskeletal system: high-field-strength MR
Radiologically, there is soft tissue swelling, periarticular imaging. Radiology. 1987;164:449-54.
osteopenia, relative joint space preservation and bony 17. Brill PW, Winchester P, Krause AN, et al. Osteomyelitis in
a neonatal intensive care unit. Radiology. 1979;13:83-88.
erosions but differentiation from tuberculosis is difficult. 18. Mok M, Reilly RJ, Ash JM. Osteomyelitis in the neonate.
Radiology. 1982;145:677-82.
REFERENCES 19. Bressler EL, Conway JJ, Weiss SC. Neonatal osteomyelitis
examined by bone scintigraphy. Radiology. 1984;152:
1. Greenfield GB (Ed). Cardinal Roentgen Features Radiology 685-8.
of Bone Diseases, 5th edn. Philadelphia: JB Lippincott; 20. Rosen Ra, Morehouse HT, Karp JH, et al. Intracortical
1990. fissuring in osteomyelitis. Radiology. 1981;141:17-20.
21. Connolly SA, Connolly LP, Drubach LA, et al. MRI for
2. Edeiken J (Ed). Roentgen Diagnosis of Disease of Bone
detection of abscess in acute osteomyelitis of the pelvis
(4th edn). Baltimore: W illiams and W ilkins; 1990. pp.
in children. AJR. 2007;189:867-72.
973-1084.
22. Karchevsky M, Schweitzer ME, Morrison WB, et al. MRI
3. Wegener WA, Alavi A. Diagnostic imaging of musculo-
findings of septic arthritis and associated osteomyelitis
skeletal infection. Roentgenography; gallium, in adults. Am J Roentgenol. 2004;182:119-22.
indiumlabeled white blood cell, gammaglobulin, bone 23. Cooper C, Cawley MI. Bacterial arthritis in an English
scintigraphy. Orthop Clin North Am. 1991;22:401-18. Health district. A 10-year-review. Ann Rheum Dis.
4. Wheat J. Diagnostic strategies in osteomyelitis. Am J 1986;45:458-63.
Med. 1985;78:218-24. 24. Gulati Y, Maheshwari AV. Brodie’s abscess of the femoral
5. Markel KD, Brown ML, Dewanjee MK, et al. Comparison of neck simulating osteoid osteoma. Acta Orthop Belg.
indium labeled leukocyte imaging with sequential 2007;73:648-52.
technetium-gallium scanning in the diagnosis of low 25. Quinn SF, Murray W, Clerk RA, et al. MR imaging of chronic
grade musculoskeletal sepsis. A prospective study. J Bone osteomyelitis. J Compt Assist Tomogr. 1988;12:113-7.
Joint Surg. 1985;67:465-76. 26. Mason MD, Zlatkin MB, Esterhai JL, et al. Chronic compli-
6. Rubin RH, Fischman AJ, Callahan RJ, et al. 111In labelled cated osteomyelitis of the lower extremity evaluation
non-specific immunoglobulin scanning in the detection with MR imaging. Radiology. 1989;173:355-9.
of focal infection. N Eng J Med. 1989;321:935-40. 27. Brodsky JW, Schneidler C. Diabetic foot infections. Orthop
7. D Angelo GL, Ogilive Harris DJ. Septic arthritis following Clin North Am. 1991;22:473-89.
arthroscopy with cost benefit analysis of antibiotic 28. Yuh WT, Corson JD, Baraniewski HM, et al. Osteomyelitis
prophylaxis. Arthroscopy. 1988;4:10-4. of the foot in diabetic patients evaluation with plain
8. Esterhai JL Jr, Gelb I. Adult septic arthritis. Ortho Clin film, 99mTc DMP bone scintigraphy and MR imaging. Am J
North Am. 1991;22:503-14. Roentgenol. 1989;152:795-800.
9. Desai RV, Khandelwal N, Gupta S, Suri S, et al. Role of 29. Keenam AM, Tindel NL, Alavi A. Diagnosis of pedal osteo-
ultrasound in acute Osteomyelitis. Asian Oceanian Jr myelitis in diabetic patients using current scintigraphy
Radiology. 2001;6:159-65. techniques. Arch Intern Med. 1989;149:2262-66.
10. Modic MT, Pflanze W, Feiglin DHI, et al. Magnetic 30. Pedrosa I, Saiz A, Arrazola J, et al. Hydatid Cyst: radiologic
and pathologic features and complications. Radio-
resonance imaging of musculoskeletal infections. Radiol
graphics. 2000;20:795-814.
Clin North Am. 1986;24:247-58.
31. Dhatt S, Singhal M, Tripathy SK, et al. Primary hydatidosis
11. Schanwecker DS, Braunstein EM, Wheat LJ. Diagnostic
of femur: a case report and review of literature. Eur J
imaging of osteomyelitis. Infect Disease Clinics North
Orthop Surg Traumatol. 2010;20:401-5.
America. 1990;4:441-63.
32. Tang JSH, Gold RH, Besset LW, et al. Musculo-skeletal
12. Modic MT, Feiglin DH, Piraino DW, et al. Vertebral infection of the extremities. Evaluation with MR Imaging.
osteomyelitis—Assessment using MR. Radiology. 1985; Radiology. 1988;166:205-9.
157:157-66. 33. Manaster BJ. Adult Chronic Hip Pain: Radiographic
13. Unger E, Moldfsky P, Gatenby R, et al. Diagnosis of Evaluation Radiographics. 2000;20:S3-25.
osteomyelitis by MR imaging. Am J Roentgenol. 1988;150: 34. Ediken J (Ed). Roentgen diagnosis of diseases of bone
605-10. (4th edn), Baltimore: William’s and Wilkins. 1990;1:593-
14. Morrison WB, Schweitzer ME, Batte WG, et al. 601.
Osteomyelitis of the foot: relative importance of primary 35. Yang WJ, Im SA, Lim GY, et al. MR imaging of transient
and secondary MR imaging signs. Radiology. 1998;207: synovitis: differentiation from septic arthritis. Pediatr
625-32. Radiol. 2006;36:1154-8.
CHAPTER

7 Tuberculosis of the Spine

Rashmi Dixit

The spine is the most frequent site of osseous involvement lesion not contiguous with the more obvious lesion is seen
by tuberculosis comprising in most series about 50 percent in 4 to 10 percent of cases.4,13
of cases.1,2 The disease was first described by Sir Percival The infection begins in the cancellous area of the
Pott in 1779, hence the name Pott’s disease.3 There has vertebral body commonly in the paradiscal location and less
been a resurgence of the disease in the developed countries often in the centrum or anterior surface. The vertebral body
following the HIV pandemic. becomes soft and gets easily compressed to produce either
Tubercular spondylitis is defined as an infection by wedging or total collapse. Anterior wedging is commonly
Mycobacterium tuberculosis of one or more of the extradural seen in the dorsal spine where the normal kyphotic curve
components of the spine namely the vertebra, intervertebral accentuates the pressure on the anterior part of the
disks, paraspinal soft tissues and epidural space.4,5 It is vertebral body. This produces kyphus with a gibbus
associated with disproportionate amount of morbidity due deformity.6,7 Spread of infection can occur beneath the
to its tendency to produce significant deformity and anterior longitudinal ligament, involving adjacent vertebral
neurologic complications therefore prompt diagnosis and bodies.
treatment are of utmost importance. As infection spreads to the adjacent disk, the disk space
narrows. The intervertebral disk is avascular in adults and
PATHOPHYSIOLOGY spread of infection to the disk can occur by extension through
The spread of tuberculosis to the spine is usually by the subchondral bone via cartilaginous end plate or beneath
hematogenous route, whether by perivertebral arterial or the anterior or posterior longitudinal ligament to involve
venous plexi is still in debate, but the arterial route is the peripheral disk. Disk space narrowing can also occur due
generally considered more important.2 Hematogenous to disk herniation into the weakened vertebral body with
seeding may arise from a primary focus in the lung or other subsequent infection of the herniated disk.6 The inter-
extraosseous foci such as lymph nodes, GIT or any other vertebral disk, however, resists infection by Mycobacterium
viscera which may be active or quiescent.6 tuberculosis probably due to a lack of proteolytic enzymes in
Lower thoracic and lumbar vertebrae are most often the Mycobacterium as compared with pyogenic infection.14
affected followed by middle thoracic and cervical The avascularity of the disk may prevent them from serving
vertebrae.7 The C2-C7 region is reportedly involved in 3 to as an initial site of infection, and it has been suggested that
5 percent of cases8,9 and the atlantoaxial articulation in disk destruction begins only when two vertebral bodies are
less than 1 percent of cases.10-12 Usually two continuous so involved that the disk loses its nutritional support.2 Hence,
vertebrae are involved but several vertebrae may be disk space narrowing occurs later and is less marked in
affected, skip lesions and solitary vertebral involvement tubercular infection as opposed to pyogenic infection.14-16
may also be seen.7 The so-called skip lesion or a second Although the vertebral body is involved more often than the
Tuberculosis of the Spine 95

posterior elements, these latter structures may be affected Late onset paraplegia has a much less favorable prognosis
initially or predominantly in some persons.17,18 than early onset paraplegia.7
A marked exudative lesion due to hypersensitivity
reaction to Mycobacterium results in formation of thick pus LABORATORY INVESTIGATIONS21-24
containing serum, leukocytes, caseous material, tubercle Relative lymphocytosis, a low level of hemoglobin and a
bacilli and bone fragments which tracks through the pre and raised ESR are found in active tubercular disease. The
paravertebral soft tissues forming pre and paravertebral mantoux test is nondiagnostic in an endemic region and may
abscesses. The exudate penetrates ligaments and follows be negative in an immunodeficient individuals. The sensitivity
the path of least resistance along fascial planes, blood vessels of staining for acid-fast bacilli may vary from 25 to 75 percent.
and nerves to distant sites from the original bony lesion as Culture of acid-fast bacilli requires a long incubation period
cold abscess. The abscesses may further extend into the of four to six weeks, although Bactec radiometric culture
spinal canal producing an epidural abscess and cord takes less than two weeks. The serological tests are non-
compression.7 diagnostic in lesions with a low level of bacilli. The
immunoglobulin IgG and IgM titres show significant
CLINICAL FEATURES differences between the initiation of treatment and at three
Tuberculous spondylitis can occur in any age group but months later, but do not correlate with the stage, the
majority of the patients are under thirty years of age at the recovery of the disease or the duration of antituberculous
time of diagnosis. The disease is rare in the first year of life treatment. The polymerase chain reaction is an efficient
but when it occurs, it tends to be more severe with greater and rapid method of diagnosis and can differentiate between
bone destruction and multiple vertebral involvement.7,8 typical and atypical mycobacteria. It analyses the expression
Symptoms and signs vary considerably.4 Some patients may of genes, even from the single cell. A positive result from a
be afebrile and free of systemic symptoms until late stage of polymerase chain reaction is not a substitute for culture and
the disease, others may present with constitutional not indicative of the activity of the disease, since it does not
symptoms before symptoms related to the spine manifest. differentiate live from dead microorganisms and has been
The usual presentation is with persistent spinal pain, local obtained from an ‘ancient’ sample of bone tissue.
tenderness and limitation of spinal mobility.4,7 The ESR is
elevated in more than 80 percent8 of cases and tuberculin IMAGING MODALITIES
skin test is usually positive.19,20 Conventional Radiographs
Paraparesis may be apparent in about 20 to 30 percent
of all patients with spinal tuberculosis.4,7 In the cervical Conventional radiographs are the usual initial investigation,
region the incidence is much higher and over 40 percent but they are often negative in early disease (Figs 7.1A to D).
cases may be associated with quadriparesis.4,8 Paraplegia More than 30 to 50 percent of mineral must be lost before a
may be early onset, which develops during the active phase radiolucent lesion becomes conspicuous on the plain films
of the disease or late onset which may appear many years and this takes about 2 to 5 months.2,7 Plain films are also
after the disease has become quiescent, even without any limited in the evaluation of areas such as craniovertebral
evidence of reactivation. Early onset paraplegia is usually junction, cervicodorsal junction, posterior neural arches and
due to cord compression by epidural abscess or granulation sacrum.
tissue, pathological subluxation or dislocation, sequestered
Nuclear Medicine Scintigraphy
bone or disk fragments. Nonmechanical causes include
inflammatory cord edema due to vascular stasis and toxins Bone scintigraphy using technetium diphosphonate is an
or cord granulation tissue due to passage of tuberculous economical but nonspecific tool for early detection of
inflammation to the meninges and eventually the cord. tuberculous spondylitis.25 Reported sensitivities vary from
Rarely paraplegia may be due to cord infarction due to 87.5 to 95 percent.25 Radiotracer uptake is usually increased
endarteritis Late onset paraplegia can occur due to dural in osseous tuberculous infection and may reveal multiple
fibrosis, severe kyphoscoliotic deformity, spinal canal sites in disseminated disease—a nonspecific finding that may
stenosis, gliosis of cord or sequestra from vertebral body. mimic metastases. 26,27 However, Lifeso and Weaver
96 Infections/Inflammations

A B C D

Figs 7.1A to D: (A) Lateral radiograph L-S spine of a 25-year-old male presenting with low backache
and fever reveals normal vertebrae and disk spaces, (B) T1W, (C) T2W, (D) Postcontrast T1W fat
suppressed sagittal images of the same patient show an area of signal alteration in the anteroinferior
part of L2 vertebral body appearing hypointense on T1W, hyperintense on T2W images and showing
patchy enhancement on the postcontrast images

reported false-negative bone scan findings in 35 percent of incorporation of contrast-enhanced computed tomography
plain film positive lesions.28 The authors noted a high (CECT) in the PET/CT protocol, the complete extent of bone,
incidence of negative Gallium scans as well.29 This may be bone marrow and soft tissue involvement can be delineated.
explained by a purely lytic and avascular early phase of the Moreover, metabolically active disease can be distinguished
disease. False-negative bone scans are seen with from residual fibrotic tissue. As in oncological imaging, PET/
disseminated tuberculosis, cervical spine lesions and isolated CT plays a useful role in determining multiple occult foci of
neural arch lesions. Posterior neural arch lesions are more involvement in a single study. It can also serve as a valuable
readily detectable when cross-sectional nuclear medicine baseline for monitoring response to treatment and providing
imaging is performed.2,26 The pitfalls of limited anatomic information on disease spread. It is also a useful tool to guide
resolution, nonspecificity and false-negative examinations the site of biopsy or other interventional procedures.
limit the use of scintigraphy in tuberculous spondylodiscitis. Tuberculosis can be a common cancer mimick on PET/CT,
Also nuclear imaging techniques do not help distinguish producing uptake patterns that are indistinguishable from
between the different causes of sepsis, but they do help that of malignant processes. Though high standardized
identify a focus of interest. Further imaging of the area in uptake values (SUVs) greater than 2.5 have been attributed
question, along with additional tissue sampling, can then be to malignant lesions, high values (up to 21) have been seen
performed to aid in diagnosis.30 in tuberculosis as well. Several groups have attempted to
FDG-PET and PET-CT 31-35 have high sensitivity for improve the specificity of an 18F-FDG PET by imaging the
detection of chronic osteomyelitis. Tubercular lesions are abnormal sites at dual time points after its administration
found to have increased FDG uptake in regions of active including additional delayed imaging at 90 to 120 minutes.
granulomatous inflammation with cold areas that represent At malignant sites, the FDG uptake continues to increase for
necrosed tissue containing pus. PET/CT can also delineate several hours, which can be demonstrated by the increase
the sinus tracks without the need for contrast instillation in SUVs. On the other hand, in inflammatory lesions, uptake
which is an added advantage of PET/CT. W ith the peaks at approximately 60 minutes after administration and
Tuberculosis of the Spine 97

the SUVs either stabilize or decline thereafter. Hence, Alavi spinal canal are poorly delineated.4,38 In the cervicothoracic
et al35 concluded that imaging at 2 time points after FDG region, epidural involvement may be missed even on CECT,
administration may help distinguish between malignant and without intrathecal contrast enhancement because of beam
inflammatory disorders. However, other authors have found hardening artifacts. For this reason the effect of extradural
equivocal results with dual point time imaging (45 and 120 disease on the thecal sac and its contained spinal cord and
minutes post FDG injection). They found that out of 15 neural elements is difficult to evaluate properly.38
patients a majority showed no reduction, a few showed mild
reduction (up to 20%) and many showed an increase (from Magnetic Resonance Imaging
10 to 40%) in SUV on the delayed images. Another approach The superiority of MR imaging in the detection and staging
to increase the diagnostic accuracy of PET is the combined of inflammatory and infective disorders of the spine is
use of 18F-FDG and C-11 acetate as the latter accumulates in generally accepted making MR the imaging modality of
tumors and not in inflammatory lesions. choice in these conditions.38-40 Magnetic resonance imaging
The exact role of FDG-PET and PET/CT in TB and other is extremely useful to detect disease in areas otherwise
inflammatory diseases is evolving and is not as yet clearly difficult to evaluate on plain films. The major advantages of
defined. With the development of newer and more specific MR imaging include multiplanar capability, the direct
radiotracers like positron emitter labeled antituberculous demonstration of early bone marrow involvement or edema
drug molecules such as INH and rifampicin in the future, and the unsurpassable assessment of spinal canal and neural
PET/CT may play a significant role in establishing an early involvement. Soft tissue and intraosseous abscesses are also
diagnosis and effective monitoring of therapeutic response. well demonstrated on MR imaging.38 Magnetic resonance
imaging has higher sensitivity for early infiltrative disease
Computed Tomography
including endplate changes and marrow infiltration than bone
Technical innovations in last two decades such as multi row scan and plain films.2 Because of its high sensitivity to detect
detector scanners have resulted in faster acquisition and marrow edema, MRI scores over CT in the detection of early
processing times, thinner slice collimation, better resolution,
isotropic voxels and allow high quality 3D-reformatted
images to be produced. Computed tomography remains a
versatile imaging modality for the evaluation of bone and
soft tissue4 and is extremely useful to assess the destruction
of cancellous bone, cortical erosions, presence of bony
fragments and soft tissue calcification.36 The advantages of
a CT examination in cases of tubercular spondylitis include—
early detection of bone and soft tissue changes when plain
films are normal, better anatomic localization and
characterization of lesions, evaluation of areas difficult to
evaluate on plain films such as cranio vertebral junction,
cervicodorsal junction, sacrum and providing guidance for
biopsy and surgical approach.13,37 Computed tomography is
also useful to demonstrate the exact extent of deformity in
chronic cases.36 In spinal disease, CT has a disadvantage
that a routine examination may overlook lesions outside the
chosen scan volume.4 However, much larger volumes can
A B
now be covered with the use of multirow detector scanners
though with an increased radiation burden (Figs 7.2A and B). Figs 7.2A and B: Sagittal reconstructions at bone: (A) and soft tissue,
For specific diagnosis of spondylitis CT is less useful than MR (B) Settings from a multislice CT acquisition for disseminated
tuberculosis reveal reduction of disk space between D4 and D5,
imaging as inflammatory marrow changes in the vertebral
destruction of endplates and a peripherally enhancing prevertebral
body, an early sign of infection are not well depicted on CT abscess due to tubercular involvement. Note the extended coverage
scanning.38 In addition, soft tissue structures within the bony and presence of free fluid in the abdomen (arrow)
98 Infections/Inflammations

disease as the earliest response to vertebral infection is the tuberculosis from other lesions of similar appearance.
accumulation of water in extracellular bone marrow. This is However, an overlap of ADC values was noted with
best depicted on STIR and T1W images.38 The changes at metastatic disease, hence, these must be interpreted in
this stage, however, are nonspecific. association with clinical history and routine MR findings.
Skip lesions are more easily and more often detected by Others found it to be of limited use.43,44 MR imaging does
MR imaging as compared to CT because of its ability to screen have disadvantages. Calcification, the hallmark of tubercular
the entire spine in a single examination. Incidence of infection and small bone fragments are not readily detectable
multilevel noncontiguous vertebral tuberculosis is generally by MRI. Gradient echo (T2*W) images demonstrate
reported to be between 1.1 and 16 percent, but an incidence calcification better than spin-echo images. The low signal of
as high as 71.4 percent has been reported when using whole calcification or bone fragments is more prominent on these
spine MR imaging (Figs 7.3A to D).41 MR is also superior to images and closely matches calcification seen on CT.
CT for detection of epidural, meningial and cord involve- Demonstration of bone fragmentation on T2*W images is
ment.38,42 Planning the surgical approach can be facilitated also considered characteristic of tuberculosis even in the
by MR imaging because of the clear display of the extent of absence of abscess formation.45 Small bone fragments in an
the active infection and its complications including epidural abscess are important to detect when surgical
involvement of neural arch. management is being considered so that they can be
While tuberculosis can be confidently diagnosed when accurately removed. The other disadvantage is that
the characteristic imaging features are present, at times it interventional procedures are difficult to perform with MR
may be difficult to distinguish this from other causes of bone imaging.
marrow edema in early stages and from other conditions
such as metastases and myeloma in atypical cases. Diffusion
IMAGING APPEARANCES
weighted MR imaging has been applied in an attempt to
distinguish between tubercular and neoplastic vertebral Imaging features in tubercular spondylitis consist of the
disease. In one study the authors concluded that DW-MRI vertebral, disk space and the soft tissue changes. Para-
and ADC values may help in the differentiation of spinal vertebral abscesses are an important early feature of Pott’s

A B C D

Figs 7.3A to D: Sagittal T2-weighted images of the cervical (A) and lumbosacral spine, (B) In a case of multifocal
caries spine reveal hyperintense marrow signal in C5 and D8 to D11 vertebrae. A T2 hyperintense epidural soft tissue
is noted at C5 and in the prevertebral region in the lower dorsal spine. Postcontrast images (C and D) reveal abnormal
enhancement in the above vertebrae, and soft tissues. Additional foci of enhancement in C2 and postparaspinal soft
tissues in the lumbar region are also seen. Note the relative preservation of the intervertebral disks
Tuberculosis of the Spine 99

spine. Extension of tubercular spondylodiscitis to the adjacent


soft tissues is common, incidence varying from 55 to 96
percent1,4,46 and rarely may precede any visible vertebral
lesion.6 This extension usually occurs anterolaterally and is
less often observed directly posteriorly in the peridural
space.6,46
Associated changes in the spinal cord and rare variants
of disease such as extraosseous extradural granuloma may
be detected by modern imaging techniques.

CONVENTIONAL RADIOGRAPHS
The radiographic appearances vary depending on the initial
focus of infection within the vertebra. There are mainly four
sites of infection in the vertebra, i.e. paradiscal, anterior
subperiosteal, central and appendiceal.

Paradiscal
This is the most common type of lesion, also called marginal,
intervertebral, subarticular or metaphyseal lesion. The Fig. 7.4: Lateral radiograph L-S spine showing reduction of L3-L4
disk space with erosion of the anteroinferior aspect of L3 vertebral
disease process most often begins in the anterior part of the body—marginal variety of caries
vertebral body either superiorly or inferiorly adjacent to the
endplate.1,28 Two adjacent vertebral bodies are involved in
about 50 percent of cases of tubercular osteomyelitis. There
is demineralization and loss of definition of their dense
margins or endplates. Little or no periosteal reaction or
reactive sclerosis affect the remainder of the vertebra.1,2,18
As infection spreads, the adjacent intervertebral disk
becomes involved with narrowing of the disk space (Fig. 7.4).
Disk space may also narrow due to lack of nutrition and
prolapse of nucleus into the soft necrotic vertebral body.
Rarely the disk space may remain intact for a long time. This
makes the diagnosis difficult, since disk space narrowing
constitutes an important diagnostic feature of infection and
serves to differentiate tuberculosis from fracture, malignant
disease, solitary myeloma and porotic collapse.18
With progressive destruction anterior wedging or
collapse occur resulting in varying degrees of kyphosis.
Scoliosis may occasionally be seen with asymmetric or
unilateral destruction of vertebral bodies and disks and is
virtually confined to the lower thoracic and lumbar
vertebrae. This is not as frequent as kyphosis.6

Central
Fig. 7.5: Lateral radiograph D-L spine showing a lytic area with lack of
The central type of lesion starts in the center of the vertebral
normal trabeculae in the center of D12 vertebral body. There is mild
body. A lytic area with absence of normal trabeculae is seen reduction of vertebral height and minimal sclerosis, adjacent disk
in the central portion away from the disk margin (Fig. 7.5). spaces are, however, normal—central caries
100 Infections/Inflammations

This gradually enlarges and the vertebral body may expand use of cross-sectional imaging as plain films are limited in the
or balloon out like a tumor. In later stages concentric collapse evaluation of the neural arch lesions. Both CT and MR are
occurs, almost resembling a vertebra plana. Paravertebral especially useful in the diagnosis of NAT (Figs 7.7A to C).
shadows may be absent or minimal. The disk space is either Some authors have reported that NAT most commonly affects
not affected or only minimally affected.6,7,18

Anterior Subperiosteal
This type of infection begins at the anterior vertebral margin
underneath the periosteum and spreads beneath the
anterior longitudinal ligament producing subtle anterior
erosions of multiple vertebrae. The clinical symptoms are
severe in relation to the minor radiographic abnormalities
(Figs 7.6 A and B). Disk destruction may be late and anterior
erosions are difficult to detect on plain radiographs.

Appendiceal or Neural Arch Tuberculosis


The neural arch or vertebral arch includes the spinous
process, the laminae, the transverse processes and the
pedicle as well as the lateral masses of the atlas, as
embryologically they are equivalent to the neural arch.
Overall, the neural arch involvement is reported to range
from 2 to 30 percent of cases usually in contiguity with A B
vertebral body involvement.4,13 Isolated involvement of the Figs 7.6A and B: (A) X-ray dorsal spine lateral view in a patient with
neural arch with complete sparing of vertebral bodies and anterior subperiosteal caries shows indistinct the anterior cortices of
intervertebral disks is rare, constituting less than 2 percent multiple dorsal vertebrae, (B) Sagittal T2W MR of the same reveals the
entire extent of pathology with patchy hyperintense signal in multiple
of all the cases of spinal tuberculosis in nonendemic areas
dorsal vertebrae, erosions of the anterior cortices and a large
and 5 to 10 percent in endemic areas.4,47 Neural arch prevertebral abscess. A small ventral epidural collection with dorsal
tuberculosis (NAT) is being increasingly recognized with the displacement of the upper thoracic cord is also noted

A B C

Figs 7.7A to C: X-ray cervical spine lateral view with the shoulders pulled down reveals no abnormality (A) Axial CT sections bone, (B) and
soft tissue, (C) Windows showing lytic lesions involving the left pedicle and posterior body of D1 vertebra. Associated soft tissue extending
into the spinal canal is also seen (arrow)—neural arch tuberculosis
Tuberculosis of the Spine 101

the cervical and upper dorsal spine unlike classical spinal at the dorsolumbar junction has an indistinct converging
tuberculosis which is most common at the lumbodorsal lower border and is referred to as a ‘petering abscess’ (Fig.
junction.47 There is a tendency towards pedicular and 7.9). In the lumbar region the abscess tends to track along
laminar involvement in tubercular spondylitis whereas
pyogenic spondylitis has a predilection for the facet joints.48
The pedicle is usually the most common site of involvement,
the involvement usually being unilateral.49,50 When there is
bilateral involvement of the posterior elements associated
with body involvement gross instability can lead to cord
compression and paralysis. Radiographic findings in NAT
include pedicular or laminar destruction, erosion of the
adjacent ribs in the thoracic region or posterior cortex of
the vertebral body with relative sparing of the intervertebral
disks and a large paraspinal mass.6
Recognition of coexisting posterior and anterior
involvement is essential for presurgical planning. Anterior
stabilization relies on posterior stability, because
decompression can lead to instability, anterior and posterior
stabilization must be performed.2 Cases of isolated NAT
respond well to simple decompression and debridement
followed by chemotherapy.51 Paraplegia associated with NAT Fig. 7.8: Lateral radiograph cervical spine in a patient with caries C5
reportedly has a better prognosis than that with typical vertebra showing reversal of the cervical lordosis, widening of the
spinal tuberculosis.47 prevertebral soft tissues and anterior displacement of the airway due
to an associated abscess
Associated bony changes in tubercular spondylitis seen
on plain films include, unilateral large bridging osteophytes
which may occur due to irritation of the bone by inflam-
matory process with periosteal new bone formation or due
to ossification in ligaments. They are more common in the
lumbar spine as it bears most of the body weight.
Abscess formation associated with tubercular spondylitis
can produce soft tissue opacity on radiographs that appears
out of proportion to the degree of osseous destruction. The
opacity is commonly bilateral and uniform. It may be
globular, which implies pus under tension or fusiform in
morphology. Paravertebral abscess may be minimal in the
central variety of tubercular lesion. An abscess in the cervical
region presents as widening of the prevertebral soft tissues
(Fig. 7.8). In the dorsal spine the posteromedial pleural line
is displaced laterally by a paraspinal abscess and the abscess
produces as typical fusiform shape called the “birds nest”
appearance.7 The aneurysmal effect may be found in Pott’s
disease associated with an anterior paravertebral or
subligamentous abscess between D4 and D10 vertebrae
shallow erosions or gouge defects are found on the anterior
Fig. 7.9: X-ray D-L spine AP view of a patient with tuberculosis D10-
and lateral surfaces of the vertebral bodies probably due to
D11 vertebrae showing a characteristic ‘petering abscess’ with
transmitted aortic pulsations. The intervertebral disks being indistinct inferior margins.Subtle amorphous calcification is seen on
resistant to pressure atrophy are spared.6,7,18,52 An abscess the right side
102 Infections/Inflammations

the psoas producing bulging of the psoas outline. 6,7,52


Calcification in the paraspinal abscesses is considered
pathognomonic of tuberculosis as nontubercular abscesses
rarely calcify. Tuberculous abscesses of the psoas muscle calcify
in two distinct patterns:6 faint amorphous deposits and tear
drop shaped calcification. With healing the calcification tends
to become more dense and in rare instances may be seen to
diminish or disappear on serial radiographs.6
The radiographic appearance of tuberculous spondylitis
in colored races1,52 may be different from the classical caries
spine. In this setting there may be more frequent
involvement of a single vertebral body with conspicuous
preservation of adjacent disks, even when the vertebral body
is totally destroyed. Cervical spine involvement and isolated
involvement of the posterior spinal elements is also more
commonly observed. Sclerotic changes and periosteal
Fig. 7.10: Postcontrast axial CT scan showing characteristic
reaction mimicking nontubercular infection are also more fragmentary destruction of the vertebral body with an associated
frequently observed.1 Cystic and multilocular patterns of multiloculated pre and paravertebral abscess
involvement may be seen probably due to malnourishment
and poor immunological status. However, in general, marked
sclerosis, less destruction and collapse, small or no
paravertebral abscess more rapid clinical course should
suggest a nontubercular etiology of an inflammatory spinal
lesion on conventional radiographs.53

Computed Tomography
Four patterns of bone destruction have been described:13
on CT, i.e. fragmentary—47 percent (Fig. 7.10), osteolytic—
33 percent (Fig. 7.11), subperiosteal—10 percent (Figs 7.12A
and B) and well-defined lytic with sclerotic margins—10
percent. The fragmentary type is the most frequent and
characteristic. This appearance consists of numerous residual
small bone fragments embedded in a soft tissue mass. Similar
appearance has also been described in involved areas of
vertebral appendages.47 The appearance is probably due to
the fact that tuberculous inflammatory exudates lack
proteolytic enzymes required to lyse bone.13 Bone fragments Fig. 7.11: Axial CT scan showing an osteolytic lesion in the anterior
may migrate into the surrounding structures including the vertebral body in a case of caries spine
spinal canal, paravertebral soft tissues and psoas muscles.
These are easily detected by CT. Some authors describe that
the vertebral bodies appear to have ‘exploded’ with There is obliteration of the fat planes around the vertebral
peripheral bony fragments. This is in contrast to pyogenic body early in the evolution of abscess formation.4 Soft tissue
spondylitis that shows multiple small erosions like a ‘pepper abscesses are well-demonstrated on axial scans and
pot’ and no calcification. Disk space narrowing, multilevel multiplanar reconstructions. 4,13 These have been
involvement and kyphosis are also demonstrated and are characterized by their CT attenuation values with high
particularly well seen on multiplanar reconstructions.4,36 attenuation lesions being defined as granulation tissue and
Tuberculosis of the Spine 103

low density lesions defined as abscesses or caseous material. extension of these soft tissue masses with cord compression.
CT is ideally suited to demonstrate small amounts of Small bone fragments which may be present some distance
calcification which are not visible on plain radiographs (Fig. away from the actual site of vertebral destruction may be
7.13).37 easily demonstrated by CT. It is especially important to
The thick nodular rim of increased tissue attenuation of localize such fragments prior to surgical removal.13
an abscess on a precontrast scan represents the hyper- The combination of a multilocular and calcified paraspinal
vascular, hypercellular fibrotic wall of the inflammatory abscess with a thick, well-enhancing irregular rim in the
cavity. Following intravenous contrast administration there presence of vertebral body bony fragmentation is a strong
is usually strong rim enhancement around low attenuation indication of tuberculous rather than pyogenic infection or
multiloculated collection. This is also called the ‘rind sign’.6 neoplasm. CT findings though not always pathognomonic,
Granulation tissue shows a more homogenous enhancement facilitate guided biopsy procedures as well providing material
(Figs 7.14A and B). CT can also demonstrate epidural for histo/cytopathology, AFB staining and culture in equivocal
cases.4,21,54-56

Magnetic Resonance Imaging


T1-weighted images usually show a decreased signal within
the affected vertebral marrow and loss of cortical definition
of the affected vertebrae,4,51 On T2-weighted images a
relative increase in signal intensity is noted within involved
vertebral bodies and disks. Disk involvement has been
A B
reported in 46 to 72 percent of cases and occurs relatively
late compared to pyogenic spondylitis. The internuclear cleft
Figs 7.12A and B: Axial CT scans—bone (A) and soft tissue,
within the disk is a normal finding in patients older than 30
(B) Window settings in a case of subperiosteal caries showing subtle
erosions of the anterior cortex of the D2 vertebra. Associated years and its loss on imaging in combination with a high
collections are noted in the pre and paravertebral soft tissues signal intensity are signs of inflammation (Figs 7.15A
anteriorly.Note another collection in the left posterior paraspinal region and B).4 However, the intervertebral disk when uninvolved,
will not show an increased signal on T2-weighted images.46
Occasionally the disk space is preserved despite extensive
bone destruction, the so-called floating disk sign. In children
the hydrated disks do not seem to form a good barrier to
infection and are involved in most patients imaged.36
Involvement posterior elements is also detected well by MR
imaging and is more common in tuberculosis than pyogenic
infections (Fig. 7.16). Enhanced MR studies may demonstrate
inhomogeneous enhancement in the region of marrow
infiltration.
Paraspinal soft tissue masses are seen in approximately
71 percent of cases on MRI.57 On T1W images loss of the
uniform psoas muscle signal intensity and enlargement of
the affected muscle indicate morphologic alteration of the
paraspinal soft tissue. On T2W images there is an increase in
signal intensity with paraspinal masses appearing
hyperintense (Fig. 7.17).4,45,57 Postcontrast studies reveal
thick rim enhancement around intraosseous and paraspinal
Fig. 7.13: Axial CT section showing a left psoas abscess with a soft tissue abscesses, which is more common in tuberculosis
small speck of calcification than in other spinal infections (Fig. 7.18). More uniform
104 Infections/Inflammations

A B

Figs 7.14A and B: Axial postcontrast CT myelogram (A) with sagittal MPR, (B) In a patient with caries C1-C2 showing
atlantoaxial dislocation with erosions of the right lateral mass of C1 and the dens. A peripherally enhancing abscess is
noted on the right side while homogenously enhancing granulation tissue is seen in the predental space

A B

Figs 7.15A and B: Sagittal T1W (A) and T2W, (B) MR scans of a Fig. 7.16: Postcontrast T1W fat suppressed axial MR section through
patient with tuberculosis L5-S1 show collapse of L5 vertebral body, a thoracic vertebra showing patchy enhancement in the left pedicle,
hypointense marrow signal of L5-S1 and loss of cortical definition on lamina, transverse process and the adjacent rib. Homogenously
the T1W image. The intervening disk space is reduced with hyperintense enhancing granulation tissue is noted in the left paraspinal region and
signal on the T2W image suggesting discitis. A prevertebral abscess dorsal epidural space displacing the cord anteriorly–NAT
lifting up the anterior longitudinal ligament and a small ventral epidural
collection are also seen

enhancement is seen with granulation tissue or phlegmon. vertebral and paravertebral components of tuberculous
Neither an anterior paraspinal phlegmon nor an abscess spondylitis.46 Epidural extension is detected by MRI in about
encases the intercostal arteries in thoracic spinal tuberculosis 61 percent of involved vertebrae.57 The soft tissue masses
as they barely penetrate the anterior longitudinal ligament.58 displace the thecal sac and the spinal cord is distorted. Post-
MR is useful in delineating the communication between contrast fat suppressed T1W sequences are the best to
Tuberculosis of the Spine 105

A B

Fig. 7.17: STIR coronal scan in a patient with lumbosacral caries Figs 7.19A and B: Sagittal T2W (A) and postcontrast fat suppressed
depicts partial collapse and hyperintense signal involving L4-L5 T1W MR, (B) Images in a patient with neural arch tuberculosis D-L spine
vertebrae. There is a disproportionately large psoas abscess on the show nearly homogenously enhancing dorsal epidural granulation tissue
right side lifting up the inferior pole of right kidney with resultant cord compression. Note the abnormal enhancement in
the adjacent spinous processes and interspinous region

The MR imaging features, with high sensitivity and


specificity for diagnosis of spinal tuberculosis59 are disruption
of the endplate, 100 and 81.4 percent respectively,
paravertebral softtissue shadow (96.8%, 85.3%) and a high
signal intensity of the intervertebral disk on the T2-weighted
image (80.6%, 82.4%). The overall sensitivity and specificity
for diagnosis are 100 and 88.2 percent, respectively.

Cord Changes
Conventional radiographs provide little information if any,
on the status of the cord and even CT cannot adequately
assess the cord status. MR imaging on the other hand
because of its superior soft tissue contrast provides invaluable
information about the status of the cord. Cord involvement
often results in neurological deficit or paraplegia.
Paraplegia in patients with active disease may be caused
by mechanical pressure on the cord by tubercular abscesses,
Fig. 7.18: Postcontrast T1W sagittal MR image of a patient with caries granulation tissue, debris, internal gibbus or subluxation. The
spine showing erosion of the spinous process of D3 vertebra with a
large abscess showing thick peripheral rim enhancement spinal cord seems to have some physiologic reserve to with
stand pressure, particularly when pressure develops slowly as
is the case with tuberculosis and 40 to 50 percent reduction in
demonstrate meningeal and epidural inflammatory soft cord diameter is often compatible with good cord function.
tissues, with improved definition of cord and nerve root The midsagittal cord diameter and presence of CSF signal
compromise (Figs 7.19A and B).29,39 Heavily T2W fast spin- anterior to cord at the apex of the deformity at presentation
echo sequences can also be used to provide a myelographic have been shown to correlate with neurological deficit in a
effect showing thecal sac compression.57 recent study. Ambulatory patients had greater cord dimensions
106 Infections/Inflammations

and CSF signal persisting anterior to cord at the apex of the


deformity in this study.60 Unrelieved compression of the spinal
cord results in loss of neurons, gliosis and demyelination of
cord substance in the damaged segment.
Intrinsic changes in the spinal cord such as inflammatory
edema or direct involvement of meninges and spinal cord by
tuberculous infection may also lead to paraplegia .The changes
in the spinal cord may be interpreted as edema of the cord,
myelomalacia, atrophy of the cord and syringomyelia (Fig.
7.20). Edema is seen as hyperintense signal on T2-weighted
images but no signal alteration on T1 while myelomalacia
shows a T1 hypointense signal (higher than that of CSF) as well
and may be associated with thinning of the cord. A syrinx is a
tubular, well-defined fluid filled region within the spinal cord.
It is usually tapered to one, or both ends and can appear
septated. The signal characteristics are typically those of CSF.
Edema of the cord is compatible with good neurological
recovery following treatment, while thinning of the cord with
A B
syrinx or myelomalacia leads to poor cord function. Mild
atrophy of the cord is observed even when there is a successful Figs 7.21A and B: T2 (A) and postcontrast T1W, (B) Sagittal images
neurological outcome.36,61 Rarely a small tuberculoma of the of a patient with tubercular myelitis reveal cord swelling and edema
appearing hyperintense on the T2-weighted image with patchy
cord may be responsible for neurological deficits presenting enhancement on the postcontrast image
as spinal tumor syndrome (Figs 7.21A and B).61

According to some authors MR findings may also be a


useful guide to treatment strategy. Patients ,with neurological
deficit, in whom MR shows a relatively preserved cord with
evidence of myelitis or edema and a predominantly fluid
collection in the extradural space, respond well to conservative
treatment, if mechanical compression is the only cause of the
neurological deficit. Early surgical decompression is indicated
when MRI shows that the extradural compression is due to
granulation tissue or caseous tissue, with little fluid
component compressing the spinal cord, and with features
of edema of the cord, myelitis or myelomalacia.21 Paraplegia
with healed disease21 may occur when the initial lesion has
healed with a residual severe deformity, even after a gap of
10 to 20 years. It is produced by stretching the spinal cord
over an internal anterior bony projection, producing gliosis.
MRI shows severe atrophy of the cord and/or syringo-
hydromyelia, or constricting scarring of and around the dura
(Figs 7.22A and B). Reactivation of the disease is found in 30
Fig. 7.20: Sagittal T2W MR scan of the cervicodorsal spine in a patient to 40 percent of cases on exploration. Symptomatic severe
of caries D4-D5 shows reduction in disk space with altered marrow stenosis of the lumbar canal and ossification of the
signal in the involved vertebrae and associated prevertebral and ventral
epidural collections. The cord is mildly expanded at this level with T2 ligamentum flavum adjacent to severe kyphosis may produce
hyperintense signal due to cord edema an incomplete neurological deficit.
Tuberculosis of the Spine 107

hematogenous. This manifestation is more common in men


than women, in the dorsal epidural space and in the thoracic
segment. Clinically compressive radiculomyelopathy is
evident. On pathologic examination a granulomatous
membrane is found ensheathing and compressing the spinal
cord or cauda equina.6 This variety of disease may be easily
diagnosed by MR imaging. Epidural tubercular lesions appear
to be isointense to cord on T1W images and have mixed
signal intensity on T2W images. Enhancement after
gadolinium will be uniform if the inflammatory process is
phlegmonous in nature or peripherally enhancing if abscess
formation or caseation has occurred (Figs 7.23A to C).5
Epidural tuberculous abscess may occur as primary lesions
or may be seen in association with arachnoiditis, myelitis,
intramedullary tuberculoma, etc.62

A B Post-treatment Follow-up
Figs 7.22A and B: T1W (A) and T2W, (B) Images of the dorsolumbar Conventional Radiographs
spine in an old treated case of tuberculosis spine reveal near complete
destruction of D8 vertebra and partial destruction of the adjacent D7 While on treatment, sequential radiographs can be repeated
and D9 with fatty marrow signal and gross kyphotic deformity. There to assess the degree of healing. However, radiological
is resultant stretching and thinning of the cord but no signal change
suggestive of cord atrophy. Note the fibrofatty proliferation along the evidence of healing is appreciated late on routine radio-
dorsal epidural space appearing hyperintense on both T1 and T2W graphs. It lags behind by about three months.21 Evidence of
images bone destruction or loss of vertebral height may progress till
14 months after starting treatment and should not

ATYPICAL SPINAL TUBERCULOSIS21


The typical paradiscal tubercular lesion is well-described,
easily recognized and treated. Atypical spinal tuberculosis is
defined as compressive myelopathy with no visible or
palpable spinal deformity and without the radiological
appearance of a typical vertebral lesion. Such lesions are
relatively uncommon, and are difficult to diagnose and treat
in the early stages with more chance of neurological compli-
cations. Atypical lesions may present as an intraspinal
tubercular granuloma, involvement of the neural arch,
compressive myelopathy in single vertebral disease, a
concertina collapse of a vertebra or a sclerotic vertebra.
Granulomatous lesions of the epidural, intradural, or
intramedullary spaces present as a compressive myelopathy,
the spinal tumor syndrome, without obvious radiological A B C
signs. Tubercular granuloma should be considered in the Figs 7.23A to C: Extraosseous extradural granuloma: Sagittal T2W
differential diagnosis of spinal tumor syndrome in zones (A) T1W, (B) and postcontrast, (C) MR images show normal vertebral
endemic for tuberculosis. and intervertebral disk morphology and signal intensity pattern. A long
Extraosseous extradural granuloma is a rare variant that segment, crescentic dorsal epidural abscess showing heterogenous
signal on T1W and T2W images with irregular peripheral contrast
leads to a extradural granulomatous lesion in the absence of enhancement (arrows) causing anterior displacement of thecal sac is
bone involvement. The route of infection is most likely seen
108 Infections/Inflammations

necessarily be considered an adverse feature.63 Soft tissue PET/CT65


paravertebral masses may also progress while on treatment
A few recent studies suggest that 18F-FDG-PET may be useful
reaching a maximum size within 1.5 months, although they
for discriminating residual and nonresidual spinal infection
may take up to 15 months to resolve. Although MRC trials
after treatment.
(Multicenter randomized controlled trials of Medical
Research Council, UK) have shown persistent changes in plain
radiological appearances of the vertebral column up to three
years after completion of treatment, these changes were
attributed to new bone formation and ankylosis.64 Signs of
healing include static lesion or regression of a lesion on serial
radiographs, well-defined outlines of the lesion, evidence of
sclerosis (Fig. 7.24) and fusion of adjacent vertebral bodies
forming a large block of osseous mass. Increased density of
the vertebral body in association with healing can lead to
the appearance of an ivory vertebra. The phenomenon is
usually evident in the lumbar region (Fig. 7.25).6 Calcific
debris which progresses to fusion on serial films may be seen
as early as 3 weeks, although it can take up to 27 months for
any evidence of fusion to appear.63 Fusion of contiguous
vertebrae has long been regarded as the surest sign of
healing of spinal tuberculosis although there is no actual
proof of this (Fig. 7.26).63
In the absence of reliable serological and immunological
markers of healing, the ‘healed status’ is achieved if there is
clinical and radiological evidence of healing with no
recurrence after two years.21 It is, however, well known Fig. 7.25: X-ray D-L spine AP view showing sclerosis of D12 vertebra
that reactivation of disease may occur years later. giving the appearance of ivory vertebra in a patient with healing caries

Fig. 7.24: Lateral radiograph D-L spine in a case of healing tuberculosis Fig. 7.26: Lateral radiograph of the cervical spine shows fusion of
shows reduced disk space between D12 and L1 vertebrae with multiple cervical vertebral forming a large osseous block in a patient
sclerosis adjacent to the vertebral end plates with healed tuberculosis of the cervical spine
Tuberculosis of the Spine 109

Computed Tomography active disease. Reactivation may present with an isolated


psoas abscess without evidence of bony lesions.
Features of resolution such as increase in vertebral bone
The exact role of MR in the follow-up of spinal tuberculosis
density, with reduction in the size of paraspinal soft tissue
is not defined.
masses as edema and inflammatory exudate subside are
readily apparent on sequential CT examinations.4 The
inflammatory reaction in the bone marrow, however, is not
well depicted (Figs 7.27A and B).38

Magnetic Resonance Imaging40,48,57


Post-therapy follow-up can also be done with MR. The earliest
sign of healing is a reduction in the amount of inflammatory
soft tissue. Increasing soft tissue mass, bony destruction or
an alteration in signal intensity do not indicate failed
treatment. A high-signal intensity rim on the T1W sequences
at the edge of the osseous lesion represents healing (Fig.
7.28). A progressive sequential increase in signal intensity
on T1W images has been found to correlate well with
resolving symptoms and clinical signs (Fig. 7.29). Reduction
in gadolinium enhancement and eventual loss of
enhancement are useful signs of healing. However,
persistent or increasing enhancement are not necessarily
indicative of either deterioration or treatment failure. MR
imaging is also useful in the detection of reactivation of old Fig. 7.28: Sagittal T1W MR image of the cervicodorsal spine of a
patient after 3 months of ATT shows erosions of the posterior cortex
tubercular spondylitis. The change of signal from low signal of D7-D8 vertebrae. These lesions show marginal hyperintense signal
in healed tuberculosis to high signal on T2W images suggests signifying healing lesions

A B

Figs 7.27A and B: Sagittal and coronal CT reconstructions of the Fig. 7.29: Sagittal T1W MR of the dorsal spine in a patient with healed
lumbar spine of a patient on ATT showing sclerosis of the inferior caries spine shows kyphosis with complete absence of disk space
body and end plate of L1 vertebra with reduced L1-L2 disk space between multiple dorsal vertebrae which appear hyperintense on the
suggestive of healing disease T1W image due to fatty replacement
110 Infections/Inflammations

In a study66 where follow-up MR spine examinations were Clinical findings usually allow a differentiation of infection
performed between 6 and 12 months after starting ATT, a from degenerative spondylosis, but vertebral infection with
significant proportion of patients had radiological evidence radicular pain may be misdiagnosed as degenerative disease
of persistent disease activity in the form of infective discitis, if the patient is afebrile. With degenerative disease, the disk
vertebral body abscess, vertebra body edema or multifocal space is usually not markedly narrowed and on MR imaging
intraosseous abscess with persistent cord compression. Both disk dessication is manifested as low signal intensity on T2W
the British and American Thoracic Societies, based on the images. After intravenous contrast infected disks enhance
evidence of the MRC trials, advocate short course strongly whereas degenerated disks only occasionally
chemotherapy (six months) for adult uncomplicated fully enhance to a small degree.17
sensitive spinal TB. However, the authors felt that in a When infection is considered, a history of chronicity and
significant proportion of patients, longer durations of insidious progression suggests tubercular rather than
treatment (more than 6 months) may be required as their pyogenic infection. In tuberculosis, lack of sclerotic and
MR scans were abnormal even though there was apparent reactive changes with prominent osteoporosis are seen on
disease resolution clinically. plain films. On MR imaging relative preservation of disk,
In another study 67 where parallel follow-up of the clinical with involvement of multiple contiguous vertebrae,
(weight, analgesic intake and neurological status), involvement of entire body, loss of cortical definition, more
laboratory, and imaging outcome of nineteen patients frequent involvement of posterior elements, a well-defined
treated for spinal tuberculosis was done it was suggested paraspinal region with abnormal signal intensity,
that the laboratory inflammatory syndrome, i.e. elevated disproportionally large paraspinal masses, especially with
CRP and ESR should disappear after 3 months of treatment calcification or a thick rim of enhancement, subligamentous
and that patients should recover their previous clinical status spread to three or more vertebral levels and presence of
after 6 months of treatment. On MRI, all epidural abscesses skip lesions favor a tubercular etiology. However,
disappeared within 9 months, but importantly, many lesions differentiation from pyogenic infection can at times be
remained visible by MRI at the end of treatment, i.e. 12 difficult.1,17
months (15% of initial paravertebral abscesses and 25% of Like tuberculosis the course of brucellosis is indolent.
vertebral edematous signals) despite the favorable clinical Characteristic features of brucellar spondylitis include gas
outcome with a mean follow-up of 25 months. The authors within the disk, only minimal associated paraspinal soft tissue
suggested that the persistence of MRI abnormalities after mass, absence of gibbus deformity and predilection for the
12 months of treatment does not require further treatment lower lumbar spine. On MR images, vertebral body
in patients who have a favorable clinical and laboratory morphology and cortical margins are intact despite evidence
outcome. MRI alone cannot determine when treatment of osteomyelitis.
should be stopped. Repeat MRI is probably not necessary in Sarcoidosis can produce findings identical to those of
patients who have a clinical and laboratory improvement tuberculosis including multifocal vertebral lesions with
during treatment.67 paraspinal masses.1
Although both these studies have evaluated only a limited When a solitary vertebra is involved, differentiation from
number of patients they highlight the fact that there is metastatic disease in adults and from eosinophilic granuloma,
currently no guidance on soft tissue or vertebral changes in children may be difficult. Spinal lesions such as lymphoma
noted on MR spine examination, during the course of, or that affect consecutive vertebrae or neoplasms such as
after antituberculous therapy. Furthermore, time course multiple myeloma and chordoma that involve contiguous
studies of the MR changes of spinal TB need to be performed vertebrae and disks can add to the diagnostic difficulty.1,2,4
to achieve consensus on the interpretation and use of this Bizarre infections such as fungal disease and spinal
powerful modality in the follow-up of spinal TB patients.66 echinococcosis cannot be easily distinguished from tuber-
culosis or neoplasms.
DIFFERENTIAL DIAGNOSIS The morphologic and pathophysiologic changes en-
The differential diagnosis of tubercular spondylodiscitis countered in spinal tuberculosis are the most severe among
includes pyogenic and fungal infections, degenerative disk infective spondylitides and are also the most varied.
disease, brucellosis, neoplasms, etc. Conventional radiographs are the usual initial imaging
Tuberculosis of the Spine 111

investigation. However, early in the disease and in atypical 14. Chapman M, Murray RO, Stoker DT. Tuberculosis of the
cases such as isolated NAT, plain films may be negative and if bones and joints. Semin Roentgenol. 1979;14:266-82.
15. Weaver P, Lifeso RM. The radiological diagnosis of tuber-
the clinical suspicion of tubercular infection is strong MR culosis sof the adult spine. Skell Radiol. 1984;12:178-88.
imaging which is the technique of choice should be 16. Kahn DS, Pritzker KPH. Pathophysiology of Bone infection.
considered. The wider availability of CT, high sensitivity and Clin Orthop. 1973;96:12-9.
ability to assist in diagnosis by accurately targeting lesions 17. Sharif HAS, Aideyan OA, Clark DC, et al. Brucellar and
for guided biopsy make it a useful alternative diagnostic tool tuberculous spondylitis: Comparative imaging features.
Radiology. 1989;155:419-25.
for early diagnosis when MR is not available. 18. Golding FC. Tuberculosis of Bone. In: A textbook of X-ray
A delay in diagnosis may lead to irreversible neurologic diagnosis by British Authors. Shanks CS Kerly P (Eds), 3rd
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Hence, a multidisciplinary approach to tubercular spondylitis 19. Jalleh RD, Kuppuswamy L, Mahayiddin AA, et al. Spinal
is essential to ensure prompt assessment of the location, tuberculosis—A five year review of cases at the National
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CHAPTER

8 Noninfective Inflammatory
Arthritis
Mandeep Kang, Mahesh Prakesh

INTRODUCTION world’s adult population. It is a progressive, chronic, systemic


Noninfective inflammatory arthritides comprise a group of inflammatory disease affecting primarily the synovial joints
different, mostly systemic disorders that have one impor- which can lead to considerable disability and morbidity.
tant feature in common; inflammatory granulation tissue Rheumatoid arthritis may develop at any age, but the peak
eroding and destroying articular cartilage. The noninfective age of onset is between the 4th and 6th decades. Women
inflammatory arthritides include rheumatoid arthritis are three times more likely to be affected than men.3 The
(seropositive) and the seronegative spondyloarthropathies etiology is unknown but appears to be multifactorial. There
namely, ankylosing spondylitis, psoriatic arthropathy, Reiter’s is a genetic predisposition with over 70 percent of patients
syndrome and enteropathic arthritis. Although radiologic expressing HLA-DR4. A role for factors like smoking and
manifestations of the arthropathies reflect pathologic infectious agents has also been suggested in the etiology.4
alterations, joints can react to disease only in limited ways Although any synovial joint in the body may be affected, the
and therefore, different pathologic conditions may exhibit classical presentation is of a symmetrical polyarthritis
similar radiologic features. Many of these are nonspecific, affecting the small joints of the hands and feet. However, it
but certain combinations are more likely than others to occur may be asymmetrical in 20 to 25 percent of cases.1 Large
in a particular disease; thus one may consider the “predictive joints which are commonly involved include the ankle, knee
value” of a radiologic feature relative to the clinical and shoulder. The axial skeleton is later and less often
condition.1 A systematic approach with evaluation of various affected, with the exception of the cervical spine.
radiological abnormalities helps in arriving at the correct Characteristically, joints which communicate with one
diagnosis. Various features to be evaluated include: another tend to be affected together, e.g. uniform tricom-
a. Distribution of affected joints partmental involvement in the knee joint and simultaneous
b. Presence of soft tissue swelling involvement of the distal radioulnar and radiocarpal joints.2
c. Bone density Over the past couple of decades, there has been a
d. Cartilage space narrowing paradigm shift in the management of RA which has resulted
e. Reactive bone formation in significantly improved prognosis. Presently, the manage-
f. Site and character of erosions ment involves two main strategies, to start treatment as
g. Subarticular cystic lesions early as possible and to frequently assess disease activity to
h. Presence of soft tissue calcification monitor response to therapy. New biologic therapies have
i. Joint deformities.2 also emerged such as the antitumor necrosis factor drugs to
supplement the conventional disease modifying
RHEUMATOID ARTHRITIS antirheumatic agents.5
Rheumatoid arthritis (RA) is the most common inflammatory The spectrum of disease manifestations of RA is protean.
arthritis affecting approximately 0.5 to 1 percent of the The 1987 diagnostic criteria of the American College of
114 Infections/Inflammations

Table 8.1 The traditional diagnostic criteria (1987) of the sonography and MR imaging can detect disease earlier than
American College of Rheumatology for the conventional radiography and CT. Secondly, in the present
diagnosis of RA
scenario, RA is treated aggressively with disease modifying
• Morning stiffness in and around joints that lasts at least drugs, hence osseous changes are delayed.4
1 hour before maximal improvement
• Soft tissue swelling of at least three joints that is observed by
Radiographic Features
a physician
• Swelling (arthritis) of the metacarpophaloangeal, proximal The earliest changes include joint space widening and soft
interphalangeal or wrist joints tissue swelling.
• Symmetrical swelling (arthritis)
• Subcutaneous rheumatoid nodules
Joint space widening is the earliest but a transient radio-
• A positive test for rheumatoid factor
graphic abnormality, sometimes lasting for only a few weeks.
• Radiographic signs: Erosions or periarticular osteopenia in
This finding is due to edema and swelling of the synovium
hand or wrist joints and joint effusion. Joint space widening is best detected at
the metacarpophalangeal (MCP) joints, especially in the 5th
digit.11
Rheumatology are commonly used for the diagnosis of this
disease (Table 8.1).6 However, these criteria are not readily Soft tissue swelling represents a combination of joint effusion,
applicable in patients with early disease, hence in recent synovial edema, and proliferation and tenosynovitis which
years, the role of imaging like MR and ultrasound has gained invariably precedes cartilaginous and osseous changes. In
in importance.7,8 the hand, periarticular fusiform swelling may be seen over
the proximal interphalangeal (PIP) and 2nd and 5th MCP
Pathophysiology joints. Soft tissue swelling over the 3rd and 4th MCP joints
may be appreciated as a local increased density. Soft tissue
The rheumatoid factors are anti-gamma-globulin antibodies swelling over the ulnar styloid may be better detected on
which are elaborated by the synovium in response to
radiographs rather than clinical examination and is due to
unknown antigens. These antibodies are believed to be the
involvement of the extensor carpi ulnaris sheath. Soft tissue
initiating factor that triggers RA. Immune complex deposi- swelling over the radial styloid may be seen due to
tion in the synovium activates the complement system with involvement of the radiocarpal joint.12 In the feet, the soft
invasion by neutrophils and macrophages. This leads to tissue changes are less evident radiographically but may be
synovial proliferation, pannus formation and ultimate seen over the 1st and 5th metatarsal heads. There may be
cartilage and subchondral bony destruction. In advanced
blurring and obliteration of the pre-Achilles fat pad and
cases, there may be fibrous ankylosis which may be followed
blurring and thickening of the Achilles tendon.2
by bony ankylosis.9, 10 In the knee, there may be lateral bulging of the fat lines
Rheumatoid factors (RF) are found in the serum and over the distal femur on AP radiographs. On lateral views,
synovial fluid in 70 to 80 percent of patients with a clinical there is distension of the suprapatellar bursa with blurring
diagnosis of RA. They may be found in the synovial fluid even of its surrounding fat lines. In the elbow, the anterior and
when the serum is negative. However, they may also be
posterior fat lines are displaced away from the joint on the
found in the synovial fluid of patients with non-rheumatoid
lateral view.12
disorders, therefore, only high titres of RF in a joint effusion Osteopenia in RA is of two types: Local juxta-articular
suggest RA. Early in the course of the disease, the rheumatoid osteopenia is due to synovial inflammation and hyperemia
factors may initially be negative and later become positive.3 and is seen early in the course of the disease. Generalized
osteopenia is due to limitation of movement due to pain,
Imaging
muscle wasting or steroid therapy and is therefore seen late
The radiologic features of RA may be divided into “early” in the disease.2 Osteopenia is seen more often as the disease
and “late” changes. The detection of early changes is progresses and 80 percent of patients demonstrate
important because new disease modifying therapies are osteopenia by 2 years after onset of symptoms. It is a
more effective when used before severe disability has precursor of erosive disease and may mask early erosions.
occurred. Since early changes are nonosseous in nature, Assessment of osteopenia may be difficult and comparison
Noninfective Inflammatory Arthritis 115

characteristic that the presence of exuberant periosteal


reaction should suggest an alternate diagnosis.2
Erosions are the most important diagnostic feature of
RA but may not be seen when the patient presents initially.
Their incidence rises from less than 40 percent at 3 months
from symptom onset to 90 to 95 percent at 10 years of
disease.12 The detection of erosions indicates irreversible
joint damage. The earliest sites of cortical surface erosions
are at the bare areas of bone between the edge of the
articular cartilage and the attachment of the joint capsule
and therefore their distribution is related to the anatomy of
the joint.13
In the hands, erosions usually involve the wrist, MCP and
PIP joints. The DIP joints are usually spared. Erosions involve
a larger area on the proximal side of the PIP joints due to the
larger bare areas on this side of the joint. At the MCP joints,
the erosions develop first and most extensively in the
Fig. 8.1: X-ray hand reveals the early changes of rheumatoid arthritis metacarpal heads and are most evident at the radiovolar
with classical juxta-articular osteopenia and uniform narrowing of aspect of the 2nd and 3rd MCP joints. The 5th metacarpal
the distal radioulnar, radiocarpal and intercarpal joints. Subluxations
may demonstrate the earliest erosions on its lateral aspect.
at the 1st MCP and IP joints cause the classical “Hitch-hiker’s”
deformity In the interphalangeal (IP) joint of the thumb, erosions
generally develop at the ulnar side of the volar aspect of the
base of the distal phalanx. The ulnar styloid is commonly
between normal and abnormal joints in the same patient is eroded due to inflammation in the prestyloid recess. There
helpful. However, it is subjective and there may be inter- may be large erosions of the radius at the distal radioulnar
observer as well as intraobserver variability in the assess- joint. Erosions occur throughout the carpus and may be
ment. Generalized or solitary terminal phalangeal sclerosis followed by fusion. However, bony ankylosis is uncommon in
may be seen in up to 35 percent of patients with RA and other joints in adult rheumatoid arthritis.3
other arthropathies and may be seen before any other In the feet, erosions appear earlier and are most often
abnormality.12 seen at the 5th MTP joint. The metatarsal heads erode before
Joint space narrowing is due to destruction of the the bases of the proximal phalanges, particularly on the
articular cartilage and is virtually always uniform (Fig. 8.1). medial plantar aspect, although the lateral aspect of the
It may be more apparent than real in the presence of flexion 5th metatarsal head may be eroded. A characteristic site
deformities, and an oblique view may be required to assess for erosion in the tarsus is at the posterosuperior aspect of
the space. Uniform narrowing with an intact subchondral the calcaneum above the insertion of the Achilles tendon.
cortex is however not specific for RA as it may also be seen in However, tarsal erosions are less often seen in RA as
the seronegative spondyloarthropathies or connective tissue compared to the seronegative spondyloarthropathies.12
diseases. Presence of uniform narrowing on the other hand Bone erosions may also develop at extra-articular sites
is an important feature of RA that helps to differentiate it including the upper posterior ribs and ischial margins.2
from osteoarthritis in which the joint space narrowing is Radiologically, early marginal erosions appear as cortical
characteristically nonuniform or segmental.1 defects or an indistinctness of the subchondral cortex. This
Subperiosteal bone apposition is uncommon in adult RA erasure or loss of the cortical white line is first seen on the
and is almost always subtle. When present, it may be seen radial aspect of the 4th and 5th metacarpal heads. If seen
at the site of capsular or tendon attachments and probably en face, erosions appear entirely within the bone giving a
reflects the effect of tenosynovitis. This relative lack of cystic appearance (Fig. 8.2). Some may be deep or pocketed.
periosteal reaction, despite advanced and often dramatic Erosive change is less common in the large joints. There
joint destruction is a hallmark of the disease and is so may be a superficial surface irregularity in the presence of
116 Infections/Inflammations

bone. Invariably, there is destruction of the adjacent joint


cartilage. Pseudocysts may attain sizes up to 2 to 3 cm, are
usually oval to round, with regular outlines or slightly
scalloped margins.13

Late Changes
Alignment deformities at joints may result from local synovitis
weakening the capsule and tendonitis preventing normal
musculotendinous actions causing subluxations and
dislocations. Tendons may also rupture in the region of eroded
bone. Thus, rotator cuff tears result in upward subluxation
of the eroded humeral head. Subluxation at the MCP joints
leads to ulnar deviation which is seen in 50 percent of patients
with chronic disease. There is also increasing palmar flexion
due to ulnar deviation of extensor tendons. Other classical
Fig. 8.2: Rheumatoid arthritis-magnified view of the CMC joints deformities in the hands are the “boutonnière” deformity
demonstrates multiple erosions in the bases of the metacarpals due to flexion at the PIP joint with extension at the DIP joint.
and trapezium giving a cystic appearance
The reverse is seen with the “swan-neck” deformity due to
PIP joint extension and DIP joint flexion. Flexion at the 1st
MCP joint with hyperextension at the interphalangeal joint
results in the “Hitch-hiker’s thumb”. There may also be
dislocation of the carpus causing a bayonet deformity at the
wrist.3
In the feet, there may be lateral deviation of the toes,
especially hallux valgus (Fig. 8.4). The hallux sesamoids sublux
between the 1st and 2nd metatarsal heads and the
transverse arch flattens due to ligamentous laxity.12
Severe erosive change leads to marked destruction and
narrowing of the joint spaces with extreme irregularity and
destruction of the subchondral bone (Fig. 8.5). In the hands,
the bone ends are often reciprocally eroded and there may
be telescoping of the fingers. There is resultant arthritis
Fig. 8.3: X-ray both knee joints in a case of RA reveals diffuse multilans which may also be seen in other conditions such as
osteopenia with uniform narrowing of the joint spaces. Note the erosive OA and multicentric reticulohistiocytosis.2
lack of irregularity of the articular margins
Gross loss of bone at the femoral head results in a “bird’s
beak” appearance. There may be pointing of the adjacent
diffuse joint narrowing (Fig. 8.3). In the hip, the medial joint bone ends at the acromioclavicular joints with resorption of
space is characteristically involved with medial migration of the distal clavicles.
the femoral head causing protrusio acetabuli. This is in Stress fractures may occur due to normal stress on bone
contrast to OA which generally involves the superior with decreased elastic resistance. Giant synovial cysts may
compartment of the hip joint.1 develop, particularly originating from the knee joint and
Rarely, large intraosseous defects or pseudocysts may presenting in the calf. They may also occur around the
be seen in patients with massive synovial proliferation. It is shoulder, elbow and hip where they may protrude into the
hypothesized that these form due to the high intra-articular pelvis. Rheumatoid arthritis can attack any synovial joint
pressure which exceeds the intraosseous pressure resulting and there may be involvement of the laryngeal joints,
in migration of synovial fluid into the underlying subchondral sternomanubrial or temporomandibular joints.2
Noninfective Inflammatory Arthritis 117

Pulmonary involvement may lead to pleural effusions,


pulmonary nodules (30%) or interstitial fibrosis (predomi-
nantly lower lobe). Pulmonary nodules are usually associated
with subcutaneous nodules over the extensor surfaces of
the elbows or other joints. Secondary osteoarthritis may
complicate RA in weight bearing joints. Reactive sclerosis
and new bone formation is not marked in these joints.12

Axial Skeleton Involvement

The spondylitis of RA is distinctive in that it has a predilection


for the cervical region. Thoracic or lumbar involvement is
distinctly uncommon. Osteoporosis, disk narrowing and end
Fig. 8.4: X-ray of the forefoot shows more advanced changes of plate irregularity are seen with only a little reactive new
RA with gross erosions of the metatarsal heads with subluxations
bone formation in the upper cervical vertebrae in contrast
at the MTP and IP joints with hallux valgus
to osteoarthritis which involves the lower cervical vertebrae.
Facet joint erosions may lead to subluxations at multiple
levels in the upper cervical spine giving a step ladder
appearance.3
Atlantoaxial (AA) subluxation is seen in up to 20 to 25
percent of patients with chronic RA and is primarily due to
laxity of the transverse ligament (which is responsible for
maintaining the integrity of the AA joint) with or without
erosion of the odontoid. Separation between the anterior
border of the odontoid and the posterior surface of the
anterior arch of the atlas in flexion of more than 2.5 mm in
adults or 4 mm in children is considered diagnostic of AAD
(Figs 8.6A and B). Although it can be visualized on plain
radiographs, 3D CT and MR give a better depiction of both
the soft tissue and bony involvement (Figs 8.7A to D).13 The
eroded odontoid may at times fracture. Resorption of bone
Fig. 8.5: Magnified view of the wrist joint demonstrating late changes
of RA with severe osteopenia, gross destruction of the distal ends at nonarticular surfaces occurs at the spinous processes
of the radius and ulna with ankylosis of the carpal bones which become short, sharp and tapered.2

A B

Figs 8.6A and B: Sagittal reformatted 3D CT images of the craniovertebral junction in (A) Extension and (B) Flexion
show increase in the atlantoaxial distance on flexion with erosion of the odontoid peg due to RA
118 Infections/Inflammations

A B

C D
Figs 8.7A to D: MR of the craniovertebral junction in a case of RA with AAD: (A) T1 and (B) T2-
weighted images in neutral position reveal erosion of the odontoid with pannus which appears
hypointense on T1 and hyperintense on T2-weighted sequences. Hyperintense signal is seen within
the cord at this level due to ischemia/edema, (C) Postgadolinium, there is significant enhancement of
the pannus, (D) T2-weighted image in flexion demonstrates compression of the cord due to posterior
displacement of the odontoid peg

Occasionally, the sacroiliac joints exhibit minimal erosions trated the ability of USG to detect early synovial inflammation
with joint space narrowing, however reactive sclerosis as in the form of synovial thickening and joint effusion. Power
seen in ankylosing spondylitis, is typically absent. Rarely, there doppler has the capability to detect and measure changes in
may be ankylosis of the SI joints. the vascularity of the synovium due to inflammation (Figs
8.8A and B). Ultrasonography contrast agents have the
OTHER IMAGING MODALITIES potential to increase the sensitivity of power doppler by
increasing the signal from the synovial vessels.
Ultrasonography The joint margins can be assessed for the presence of
With the advent of high resolution linear transducers, erosions. It has been demonstrated that USG is more
(7.5 MHz and higher), ultrasonography (USG) may be used sensitive than conventional radiography for detection of
for detection and monitoring of joint and soft tissue inflam- erosion in the small joints of the hands and feet.14 The internal
mation and bone damage. A number of studies have demons- structure of the tendons can be assessed and their integrity
Noninfective Inflammatory Arthritis 119

A B

Figs 8.8A and B: (A) Ultrasound image of the carpal bones shows diffuse synovial thickening in a case of RA. (B) Power
Doppler in another case shows synovial thickening extending along the tendon sheaths with increased vascularity

or rupture demonstrated by dynamic scanning. Leakage of cervical spine abnormalities, particularly for the evaluation
synovial fluid may also be demonstrated, e.g. a ruptured of atlantoaxial subluxation.13
Baker’s cyst which needs to be differentiated from other
causes of calf pain, such as deep vein thrombosis or muscle Radionuclide Scanning
tear. USG can also be used to monitor response to therapy.
Following treatment, USG can detect reduction in the Scanning with 99mTc-MDP is highly sensitive for detection of
synovial inflammation and vascular flow parameters.15 the inflammatory changes of arthritis but shows poor
Several studies have compared power doppler with MR specificity. In RA, isotopes are at least 70 percent more
imaging for the detection of early arthritis. A prospective sensitive than conventional films and may be used to monitor
study that followed 60 patients showed that USG was more response to therapy.9 Findings include increased flow in the
sensitive than MR in detecting synovitis.16 In another study, synovium in the early or blood pool phase and increased
sonography was found to be a valuable tool, however, CEMR uptake in the delayed 3 hours scans.
was superior in evaluating synovial proliferation and
erosions.17 Disadvantages of USG include the user dependent Magnetic Resonance Imaging (MRI)
nature of the modality and the long time required to evaluate Over the last two decades, MR has come to be considered
multiple joints. to be the best imaging modality for RA, despite being
expensive and time consuming. The Outcome Measures in
Computed Tomography
Rheumatoid Arthritis Clinical Trials (OMERACT) MR imaging
Computed tomography (CT) is not frequently used routinely study group is an international, multidisciplinary group set-
in RA as it is inferior to MR and USG for the detection of early up for the purpose of standardizing techniques and defini-
disease along with the disadvantage of using ionizing tions of joint pathologies in RA.5 According to their recom-
radiation. It can demonstrate the presence of erosions, mendations, a MR scan for RA should include at least the
particularly in the carpal and tarsal bones. It can also show following: (i) Imaging in two planes (axial and coronal)
joint space narrowing or ankylosis. A recent study has (ii) T1-weighed sequences before and after gadolinium and
reported comparable performance of CT with MR for the (iii) A fat saturated T2-weighted or a short inversion recovery
evaluation of synovitis and tenosynovitis using contrast (STIR) sequence. MR is also a useful imaging modality for
enhanced CT with digital masking of the bone.18 However, the follow-up of RA to evaluate progression or remission.
its main use lies in the diagnosis and management of upper The typical progression in RA from the stage of synovitis
120 Infections/Inflammations

followed by bone marrow edema and finally bony erosion


are well demonstrated on MRI.5

Synovial Imaging
Magnetic resonance is considered to be the gold standard
for synovial imaging. Inflammatory changes within the soft
tissues of the joints which precede the development of
erosions and which are not detectable on plain radiographs
are well demonstrated on MR.19 It has been reported that
using the enhancement of MCP and PIP joints as a positive
diagnostic criteria, RA could be diagnosed with a sensitivity
of 96 percent and accuracy of 44 percent.7 The OMERACT
group defines synovitis as an area in the synovial compart- Fig. 8.9: Coronal STIR image shows ill defined areas of high signal
intensity in the carpal bones due to bone marrow edema
ment with increased contrast enhancement whose thickness
exceeds the width of the normal synovium.5 Magnetic
resonance depicts irregular thickening of the synovium which bone erosions. It is currently considered as a forerunner of
is of intermediate signal intensity (SI) compared to darker erosions. Some studies have shown the high association of
fluid on T1 and high signal intensity on T2-weighted spin bone marrow edema at baseline with erosions 1 year and 6
echo sequences. Fat suppressed T2-weighted sequences years later.20
more clearly delineate disease extent. Postgadolinium, there
can be significant rapid enhancement of the inflamed Erosions
synovium unlike joint effusion which does not enhance in the
early phase. Images obtained more than 10 minutes after On MR, erosions are seen as a focal loss of normal SI from
gadolinium show diffusion of gadolinium into the synovial cortical or subchondral bone on T1 and focal regions of high
joint fluid resulting in increased signal intensity. 5 Active SI on T2-weighted or STIR images (Figs 8.10A and B). Erosions
synovitis is best visualized on postcontrast fat suppressed replace marrow fat and contain inflamed synovium which
T1-weighted images and there is indirect evidence enhances with gadolinium and are thus easily differentiated
suggesting that the degree of postcontrast enhancement from other interosseous fluid filled cystic lesions.21
correlates with the degree of inflammation. 13 Fibrotic In early RA, MR can identify bone erosions in 45 to 72
pannus and pannus with hemosiderin deposition shows low percent of patients with disease of less than 6 months
SI on T1 and T2-weighted images and do not enhance on duration, compared with 8 to 40 percent on radiography.5,8
postgadolinium images. This is important as MR can assist in making an early diagnosis
Quantification of synovial volume has been shown to play of RA, allowing treatment to be instituted early in the course
an important role in the diagnosis and follow-up of RA. The of disease. It is also important to identify those patients in
baseline synovial volume has been found to correlate whom progressive disease is not seen as these patients do
significantly with the number of new bone erosions at 1 year not require aggressive treatment protocols. In one study,
follow-up.5,19 82 percent of patients without erosions at baseline MR
imaging had no radiographic erosions at 2-year follow-up.5
Bone Marrow Edema
Tendons and Ligaments
Bone marrow edema has been reported to be a distinctive
finding in RA, especially in the early phase. It manifests as ill Rheumatoid arthritis can involve the ligaments or tendons
defined, high SI on fat suppressed, T2-weighted and STIR directly which results in predisposition to rupture. Increased
images with enhancement following gadolinium (Fig. 8.9). signal on T2-weighted spin echo and STIR sequences indicates
It has been found in 39 to 75 percent of patients with RA tendon involvement and may be due to erosion, invasion by
with disease duration of less than 1 year.5 It is usually found pannus or partial tear. Thinning or thickening of the tendon
in the subchondral bone and can be seen alone or surrounding is also abnormal.
Noninfective Inflammatory Arthritis 121

recognized as a characteristic feature of RA. They may


contain collagen, fibrinogen, fibrin, fibronectin, mononuclear
cells, blood cells and amorphous material.4

Large Joints
Though involvement of large joints usually occurs after
established disease elsewhere, MRI is more sensitive in
picking up early change. In the glenohumeral joint, rotator
cuff tears, joint effusion, giant synovial cysts and early erosions
are best evaluated on MR imaging. Similarly, involvement of
the hip joint with detection of joint effusion, pannus, erosions
and articular cartilage destruction is well depicted on MRI
A
(Figs 8.11A and B).19

SCORING SYSTEMS FOR RA


Radiographic images demonstrate the structural damage
in the patient at a given point in time. Radiographic abnor-
malities were initially used to develop an index of damage
that was used to assign patients to four stages. However, by
the early 1960’s, it was realized that assigning a single score
for all radiographic abnormalities lacked sensitivity for
detecting disease progression and various scoring systems
B were developed which separately rated the severity of
erosion and joint space narrowing. Larsen developed a global
Figs 8.10A and B: Patient with RA: (A) X-ray both hands PA view
shows diffuse loss of the joint spaces at the radiocarpal, intercarpal scoring method that incorporated erosions, osteoporosis and
and CPC joints, (B) T1-weighted coronal image demonstrates multiple soft tissue swelling in a single score. Various modifications of
erosions in the carpal bones, distal ulna and radius the global or composite methods have been extensively used
to describe the course of articular damage in RA and evaluate
response to therapy.22 However, the scoring methods are
Tenosynovitis can be diagnosed by the presence of fluid not precise measurements, they reflect individual readers
in the tendon sheath, tendon sheath thickening or enhance- and the error of individual scores is considerable. Also, the
ment. The extensor carpi ulnaris is the most frequently expected progression of structural damage in untreated RA
involved tendon.21 Tenosynovitis of the flexor tendons of the is impossible to determine. None of the attempts to describe
wrist results in an increase in carpal tunnel volume, which course so far have taken into account the effect of treatment.
leads to mechanical pressure and compression of the median Development of an accurate, easily reproducible and easily
nerve which can also be inflamed resulting in Carpal-Tunnel carried out quantitative measurement of bony erosion and
syndrome. Axial images are most useful for assessing the cartilage destruction is required.
anatomic characteristics of the Carpal-Tunnel. On MRI at present, the most frequently used method is
the OMERACT rheumatoid arthritis magnetic resonance
Intraosseous cysts show low SI on T1 and high SI on T2-
imaging score (RAMRIS). In this, the synonitis is assessed in
weighted images and may not enhance in the immediate
three wrist regions: distal radioulnar joint, radiocarpal joint
postcontrast phase.4
and the intercarpal, carpometacarpal and MCP joints on a
Intra-articular loose bodies are frequently seen due to the scale of 0 to 3. A score of 0 is normal, while score of 1 (mild),
destructive inflammatory process and include cartilaginous 2 (moderate) or 3 (severe) reflect the maximum volume of
and osseous fragments. A subset of loose bodies is called enhancing synovium. Similarly, bone marrow edema is scored
“rice bodies” as they resemble polished rice. They are now from 0 to 3 based on the volume 0: no edema, volume 1:
122 Infections/Inflammations

A B

Figs 8.11A and B: (A) X-ray pelvis of a patient with RA shows uniform loss of joint space with irregularity of the articular
surface in bilateral hip joints. Note the medial migration of the femoral heads, (B) Coronal T2-weighted image better
demonstrates the erosions. Note the bone marrow edema manifesting as ill defined hyperintense signal

1 to 33 percent, volume 2: 34 to 66 percent and volume 3: Juvenile-onset Adult Type (Seropositive)


67 to 100 percent of bone that is edematous. Erosions in the Rheumatoid Arthritis
carpal bones, distal radius and ulna and the bases of the
Seropositive JRA accounts for 5 to 15 percent of JIA. The
metacarpal bones are scored separately. The scores range
onset is during adolescence and there is a strong female
from 0 to 10 on the basis of the volume of erosion in the
preponderance. It is a peripheral erosive polyarthritis which
assessed bone in increments of 10 percent. The maximum
is nearly identical with adult RA. Large joints such as the
score in the wrist is 150.23 However, using the RAMRIS score
knee and hips may be affected.
is difficult, requiring years of dedicated work, is subject to
high interobserver variability and is not practical in clinical Seronegative Chronic Arthritis
practice.
Scoring methods have been effective in establishing In this subgroup, systemic or articular symptoms and signs
benefit from drug treatment and will continue to examine develop in the absence of positive serology for rheumatoid
the benefit of new drugs in the years to come. Development factor:
of a simple, easy to use, accurate and reproducible method a. Classic systemic disease represents 20 percent of children
would be a powerful tool for both the physician and the with JIA. It occurs in children under the age of 5 years.
clinical investigator. Both sexes are equally affected. These children present
with an acute febrile onset with anemia,
JUVENILE IDIOPATHIC hepatosplenomegaly, lymphadenopathy, anorexia,
ARTHRITIDES (JIA) weight loss and chronic recurrent arthralgias. Erosive
arthritis is uncommon.
A number of separate disorders can lead to chronic arthritis b. Pauciarticular type is the most common type of JIA
in children, however there is as yet no uniformly accepted accounting for nearly half the cases. Four or less joints
classification for these diseases. The International League are involved, usually the large joints such as the knee,
of Associations of Rheumatologists (ILAR) task force did elbow and ankle. It typically affects young girls.
attempt to establish classification criteria24 however they c. Polyarticular type represents approximately 20 percent
are not in universal use. of JIA. It may occur at any age and is commoner in
Noninfective Inflammatory Arthritis 123

A B C
Figs 8.12A to C: A 12-year-old boy with JIA: (A) X-ray of the pelvis shows mild narrowing of the joint spaces in bilateral hips, (B) Coronal T2-
weighted image demonstrates the presence of joint effusion and ill defined hyperintense signal in the acetabulum signifying bone marrow
edema, (C) Coronal T1-weighted image shows bone erosions in bilateral hip joints

females. It is symmetric and involves the large and small The most distinctive radiographic findings are seen as a
joints as well as the cervical spine. Growth retardation is result of altered growth patterns. There is accelerated bone
common due to premature fusion of the epiphyses and maturation with early fusion of epiphyses and bone
there may be associated mandibular hypoplasia with shortening secondary to hyperemia.10 This results in large
antegonial notching. expansile (ballooned) epiphyses while the adjacent
Generally, the prognosis in JIA is good with fewer than metaphysis and diaphysis appear gracile and constricted.3
20 percent children having progressive destructive disease. Muscle atrophy is generally a prominent feature (Fig. 8.13).
The pathophysiology is virtually identical to the adult form In the carpus and tarsus, the bones show accelerated
with synovial inflammation and increased production of maturation, crowding with joint space narrowing and an
joint fluid with effusion. Pannus is less extensive than adult abnormal angular shape (squashed carpi). The cervical spine
RA but still produces significant cartilage and bony
destruction.3,10,25

Radiologic Features
The knee is the most common joint to manifest radiographic
abnormalities followed by the ankle, wrist, hand, elbow, hip,
shoulder, cervical spine, sacroiliac (SI) joints and sterno-
clavicular joint.25 Early changes include soft tissue swelling
and osteopenia which may be juxta-articular or diffuse. In
early stages, it is probably due to hyperemia, but later, disuse
atrophy and steroids contribute to it. Band-like metaphyseal
lucent zones (growth arrest lines) may be evident.
Pathological fractures may occur.10 Periostitis appears within
weeks after the onset of symptoms and is usually seen along
the shafts of the proximal phalanges, metacarpals and
metatarsals.3
Later, there is uniform loss of joint space and articular
erosions (Figs 8.12A to C). Progressive destruction can lead
to bony ankylosis. Fusion at the carpometacarpal joint of the Fig. 8.13: Juvenile rheumatoid arthritis—X-ray knee joint AP view
reveals diffuse osteopenia with large squared femoral condyles,
index and middle fingers is characteristic as are multiple widening with irregularity of the intercondylar notch and subchondral
fused cervical vertebrae.3 lucencies. Note the reduction in the soft tissue bulk
124 Infections/Inflammations

is often affected with erosions at the apophyseal joints with or without spondylitis. A classification criteria for the
(usually at C2-3) leading to ankylosis. The associated vertebral entire group of SSA has been developed. These criteria are
bodies fail to develop. AAD is said to occur rarely in children inflammatory spinal pain or synovitis, together with at least
with seronegative disease. The intervertebral disks are one of the following: positive family history, urethritis,
narrowed and fusion may occur. There may be ankylosis of inflammatory bowel disease, psoriasis, acute diarrhea,
the SI joints. Late in the course of the disease, secondary alternating buttock pain, enthesopathy or radiographically
degenerative changes may occur.12 evident sacroiliitis.30
Radiographs are useful for diagnosis, staging and follow-
up and for exclusion of other causes of pain such as fractures, ANKYLOSING SPONDYLITIS
tumors or congenital disorders. However, they mostly depict Ankylosing spondylitis (AS) is a chronic, progressive inflamma-
late manifestations and indirect signs of synovial disease. tory arthritis principally affecting the synovial joints of the
Ultrasound is a quick, safe and radiation free modality which spine and adjacent soft tissues as well as the SI joints,
can directly image the synovium for evidence of proliferation although peripheral joints such as the hips, shoulders and
or hypervascularity.26 It can also depict joint effusion or knee may also be involved.3 There is a strong association
provide guidance for aspiration to exclude septic arthritis. with HLA-B27 with more than 90 percent of patients with
In a study on 30 patients, USG was found to be more sensitive AS having this antigen. It has been shown that AS will develop
than clinical assessment for the detection of synovial effusion in 0.6 to 1.3 percent of persons who are positive for HLA-
and thickening in cases of JIA.27 In another study, it was B27. Sixty-five percent of patients of psoriasis with spondylitis
found that power doppler sonography was highly accurate or inflammatory bowel disease with spondylitis also have
in monitoring the therapeutic response in cases of JIA.28 HLA-B27 and it has been postulated that the antigen is
Magnetic resonance remains the imaging modality of essentially related to spinal changes.12
choice for evaluating the early changes of JIA because of its The disease is common in males (4:1) though recently it
ability to allow direct visualization of nonossified portions of has been realized that women may be more commonly
epiphyseal cartilage.10 It clearly depicts joint effusion, affected than thought earlier. Women are more likely to
cartilage changes, synovial proliferation, bony erosion or have clinical manifestations without radiographic evidence
synovial cysts. With long standing JIA of the knee, synovial of disease. The onset of disease is generally between 15 and
proliferation over the meniscal surfaces leads to meniscal 35 years.10
attenuation with eventual meniscal hypoplasia or The classical clinical description of AS is of an insidious
atrophy.25,29 onset with low back pain persisting for more than 3 months.
Radiographic evidence of synovitis may be seen in trauma Back stiffness is worse after periods of inactivity and there
induced synovitis, septic arthritis or tubercular arthritis. may be pain over the gluteal and sacroiliac regions.
These disorders are monoarticular in contrast to JIA and Radiographic evidence of sacroiliitis is required for the
history of trauma or acute onset may serve to differentiate definitive diagnosis of AS, but may take several years to
them from JIA. If tubercular arthritis involves multiple large appear. Various extra-articular features may be present of
joints, it may be indistinguishable from JIA. In hemophilic which the most common is acute anterior uveitis. Others
arthropathy, repetitive bleeding into the joint induces include aortitis, aortic regurgitation, pulmonary fibrosis,
synovial inflammation and hypertrophy with a radiologic cardiac conduction defects, arachnoiditis and amyloidosis.31
picture closely resembling JIA. Pulmonary involvement can result in cavitation with fibrosis
in bilateral lung apices mimicking tuberculosis.10
SERONEGATIVE
SPONDYLOARTHROPATHIES Pathophysiology
Seronegative spondyloarthropathies (SSA) are a group of Histologically, the synovitis of AS is identical to that of RA.
seronegative arthritic diseases affecting multiple organ There is a predisposition to develop ankylosis via cartilage
systems with clinical and radiological overlap and a significant metaplasia, endochondral ossification, fibrosis and formation
genetic component. They are characterized by the absence of woven bone. The enthesopathy consists of destruction of
of rheumatoid factor, peripheral arthropathy and sacroiliitis ligaments, tendons and local bone with inflammatory
Noninfective Inflammatory Arthritis 125

A B
Figs 8.14A and B: Sacroiliitis in ankylosing spondylitis: (A) X-ray pelvis AP view shows mild irregularity with sub-articular
sclerosis in both SI joints, (B) Axial CT section of the SI joints of the same patient shows irregularity of the articular surfaces with
subarticular sclerosis which is more marked in the iliac blades

infiltrate. This heals by deposition of new bone at the tendon/ The modified New York criteria for grading sacroiliitis
ligament interface causing bone proliferation at nonarticular established in 1994 are:32
sites, syndesmophytes and capsular ossification.12 It has been Grade 0 - Normal findings
suggested that there is a genetic predisposition which allows Grade 1 - Suspicious changes
an antigen or other triggering factor to reach the synovium Grade 2 - Minimal abnormality (small localized
and incite an inflammatory response. This response includes erosions or sclerosis without alteration in
activated lymphocytes which liberate tumor necrosis factor joint width)
alpha (TNFα) and other cytokines leading to destruction of Grade 3 - Unequivocal abnormality
tissue.31 Grade 4 - Total ankylosis
Joint changes are assessed using prone views with
Radiologic Features cephalad angulation or oblique views. However, CT is more
sensitive than radiographs in depicting small and early
Sacroiliac Joints erosions and joint space changes.31 Recently, it has been
The classic sacroiliitis is bilateral and symmetrical. In about suggested that dynamic CEMR may be even more sensitive
10 percent of cases, the sacroiliitis may be unilateral than CT in detecting sacroiliitis.33 Magnetic resonance
or asymmetrical at presentation but eventually becomes findings include erosions, subchondral sclerosis, bone
bilaterally symmetrical. Changes occur in both the synovial marrow edema, intra-articular hyperintensity on T2 and T2*-
and ligamentous (superior and posterior) parts of the SI weighted images and enhancement within the joint cavity
joints. The earliest radiographic findings are a loss of or (Figs 8.15A and B). Radionuclide scanning shows nonspecific
blurring of the subchondral cortex. This is followed by small increased uptake in the presence of active sacroiliitis.
(rat-bite) erosions which are worse along the iliac aspect of
Spine
the joint. These cause widening of the joint space with hazy
margins (Figs 8.14A and B). This is followed by larger erosions, Spinal involvement classically starts at the dorsolumbar or
subjacent sclerosis and joint space narrowing as irregular lumbosacral junction with subsequent progressive
new bone bridges the joint space with eventual ankylosis involvement of the rest of the spine in an ascending manner.
and resolution of the sclerosis.1,2,10,12 In females, the cervical region may be initially affected.
126 Infections/Inflammations

A B

Figs 8.15A and B: Ankylosing spondylitis: (A) T1 and (B) T2-weighted coronal images show irregularity of the
cortex, discrete sub-chondral erosions, irregular thinning of the articular cartilage and reactive sub-articular
bone marrow edema and fatty change

Erosions initially occur at the vertebral margins at the site of


attachment of the outer fibers of the annulus fibrosus
(Romanus lesions) with adjacent sclerosis (shiny corner sign).
In adolescents, these erosions can be large mimicking an
infectious process (erosive spondylitis). Healing of these
erosions or laying down of bone beneath the anterior
longitudinal ligament causes “squaring” of the vertebral
bodies, best appreciated on lateral radiographs of the lumbar
spine. Exuberant new bone formation may even cause
anterior convexity of the vertebral body (barrel shaped
vertebrae).3,12,31
A B
As the disease progresses, there is syndesmophyte
formation along the anterior and anterolateral aspects of Figs 8.16A and B: Ankylosing spondylitis: X-rays lumbosacral spine
(A) AP and (B) lateral views reveal the classical appearance of the
the body due to ossification in the annulus. Syndesmophytes bamboo spine on the lateral view and the dagger and tram-track signs
are paravertebral in location and vertically oriented in on the AP view with bilateral ankylosis of the SI joints
contrast to the osteophytes seen in degenerative disease
which are horizontally directed. The syndesmophytes seen
in AS are classically marginal, symmetrical, fine and delicate. intensity on T1WI which is hyperintense on T2WI and
Ankylosis of multiple vertebrae by syndesmophytes gives the enhances postcontrast.31
bamboo spine appearance. Similar ossifications may be seen Spinal fractures are common in the spine through the
in the interspinous ligaments and facet joints resulting in the porotic bone just beneath the endplates. Two categories
dagger and tram-track signs respectively (Figs 8.16 A and have been described, the traumatic fractures and stress
B). Facet joint ankylosis is the major factor causing loss of fractures. Traumatic fractures occur after spinal fusion even
spinal mobility.1-3,10 with trivial trauma and are of the unstable category with
Studies have shown than MR can detect active enthesitis involvement of all three columns. Stress fractures typically
in the spine before Romanus lesions are seen on radiographs. occur near the cervicothoracic and thoracolumbar junctions,
Magnetic resonance shows an abnormal area of low signal with development of sclerotic pseudoarthrosis with
Noninfective Inflammatory Arthritis 127

destruction of the disk and vertebral endplates (Andersson Enthesopathies at tendinous and ligamentous insertions
lesion) resembling an infective discitis.12,31 can cause erosions with marked sclerosis.3 These can be
Cauda equina syndrome can result from arachnoiditis commonly seen at the iliac crest, ischial tuberosity (ischial
with large posterior dural diverticula causing osseous defects whiskering) and the calcaneum.
in the laminae. CT and MR imaging may show peripheral
clumping of nerve roots, prominent arachnoid diverticulae, PSORIATIC ARTHROPATHY (PA)
laminar erosions and dural calcifications.12,31 Psoriasis is a chronic inflammatory disease of the skin which
Atlantoaxial subluxation can occur but it is much less may be associated with a chronic inflammatory arthritis in 5
common than RA. There may be dramatic resorption of bone to 8 percent of cases. The incidence is highest between 20
from the anterior aspects of the lower cervical vertebral and 39 years in males and 40 to 59 years in females with an
bodies.2 equal male-to-female ratio. The etiology is unknown.
Histologically, a chronic synovitis may cause joint destruc-
Peripheral Joints tion with inflammation of the tendon and ligamentous
Ankylosing spondylitis is the only seronegative spondylo- insertion sites (enthesitis).31
arthropathy where large joint involvement is not so Skin lesions are usually seen on extensor surfaces, scalp
uncommon. In general, the arthropathy resembles RA with and lumbosacral areas and are sharply demarcated, dry,
a few differences. Shaggy periostitis and ankylosis are more erythematous plaques with a silvery scale. Clinically, patients
common, whereas osteoporosis, erosions and joint space with PA can be broadly classified into three groups:3,12,31
narrowing are less prominent.12 a. Mono or oligoarthritis with enteritis
The hip joints are involved in up to 50 percent of patients b. Peripheral polyarthritis resembling RA and
with AS. Radiographic changes include concentric joint space c. Predominant axial disease resembling AS with or without
narrowing, axial migration, cuff like osteophytes on the peripheral joint disease. This is rare, occurring in only 5
femoral head and protrusio acetabuli with eventual joint percent of patients.
fusion (Figs 8.17A to C). The shoulder is the next commonly The skin lesions precede the arthritis in 70 percent of
involved joint and shows narrowing of the acromio-clavicular patients, however arthritis may precede skin lesions in
and glenohumeral joint spaces and a hatchet deformity on 15 percent of cases. In another 15 percent, the two appear
the humeral head due to enthesitis of the rotator cuff concomitantly.12 The joints commonly involved are the knee,
tendon.31 Small joint involvement is rare and is characterized DIP and PIP joints of the hands and feet, MTP and MCP joints
by an asymmetric distribution, subtle erosions and and the ankles. Sacroiliitis may be seen in 35 to 50 percent
proliferative bone changes at the involved joints. and spondylitis in 30 to 40 percent of cases.34

A B C
Figs 8.17A to C: A 32-year-old male with ankylosing spondylitis: (A) X-ray pelvis shows bilateral sacroiliitis with rat-bite erosions and fuzzy,
irregular margins. Note the narrowing of the joint space with erosions in the left hip joint, (B) Coronal STIR image shows bilateral sacroiliitis with
bone marrow edema, (C) Coronal T2-weighted fat saturated image demonstrates the narrowing of the left hip joint space, erosions and bone
marrow edema
128 Infections/Inflammations

Radiologic Features the hands and feet associated with extensive bone
resorption.12
The radiologic features are quite characteristic and the
The sacroiliac joints may be involved in up to 50 percent
diagnosis can be strongly suggested based on the presence
of patients with PA and the involvement is usually bilateral.
of bone erosions and prominent bone proliferation which is
It may be symmetric or asymmetric and ankylosis is relatively
the most distinguishing feature in this condition.
uncommon. Involvement of the spine may occur in the
The hands and feet are most commonly involved in PA. A
absence of sacroiliitis and is more common in males than
fusiform soft tissue swelling is seen involving the entire digit
females. It is characterized by coarse, asymmetric
(sausage digit). The involvement may be unilateral, if
paravertebral ossification (non-marginal syndesmophytes)
bilateral, it is asymmetric. All the joints of a single row may
in the dorsolumbar region in contrast to the symmetric, fine
be affected. The bone density is preserved. Bone erosion
marginal syndesmophytes seen in AS.1,3 These may be
typically begins at the margins of the joint and proceeds
unilateral with skip areas. The anterior surface of the
along the articular surface (surface erosion) or progresses
vertebral bodies is spared and squaring of the bodies is
along the joint capsule away from the joint along the
distinctly uncommon. There may be diffuse, ill defined,
metaphysis (enthesitic erosion).31 This leads to a pencil like
paravertebral ossification. Isolated cervical involvement may
tapering of the ends of the small bones. The joint space may
be seen with apophyseal fusion and AAD.31
be widened due to fibrous tissue deposition and bone
Magnetic resonance frequently shows signal changes in
resorption due to severe surface erosions resulting in the
the soft tissue and bone marrow related to the enthesitis
“pencil in cup” appearance. The enthesitic erosions along
reflecting inflammatory changes.35
with bone proliferation may give an irregular outline to the
metaphyses or may widen the end of bone (mouse-ears sign)
REITER’S SYNDROME
(Figs 8.18A and B).3 Nail changes may be associated with
resorption of the terminal tufts or the distal phalanges may Reiter’s syndrome (RS) is a sexually transmitted disease
become sclerotic. Calcaneal erosions with fluffy periosteal commonly affecting young men which is characterized by
reaction may be seen at both the posterosuperior and arthritis, uveitis and conjunctivitis. In Europe, a similar
posterior plantar aspects. Periosteal reaction along the syndrome occurs in association with bacillary dysentery.3,12
diaphysis of the short tubular bones is common. In the Skeletal involvement may eventually occur in up to
advanced stages, there may be “arthritis mutilans” which is 80 percent of cases. There is a peripheral asymmetric
a term used to describe severe destruction of the joints of arthritis with a predilection for the joints of the lower limbs

A B
Figs 8.18A and B: X-rays of the hands—magnified views reveal: (A) Fusiform soft tissue swelling with gross
erosive changes at the DIP and PIP joints. Note the subperiosteal bone apposition causing widening of the bone
ends, (B) Erosive changes at the PIP and DIP joints with a “pencil-in-cup” appearance. These features are
characteristic of psoriasis
Noninfective Inflammatory Arthritis 129

especially the feet where erosions occur at the heels, MTP CRYSTAL DEPOSITION ARTHROPATHY
joints and IP joint of the great toe. The DIP joints are rarely
involved (in contrast to PA). Periostitis may be fine and Gout
lamellar in acute cases or fluffy and irregular in chronic cases. Gout is a metabolic disorder characterized by recurrent
Reactive calcaneal spurs occur in 20 percent of patients.2,12 episodes of arthritis which results from a disturbance of urate
Sacroiliitis may develop in about 50 percent of cases and metabolism with the deposition of monosodium urate (MSU)
may be unilateral or asymmetrical in contrast to AS where it crystals in the joints and soft tissues. Primary gout is caused
is classically bilaterally symmetrical (Figs 8.19A to C). Ankylosis by inborn defects of either purine metabolism or the renal
is also less common. Coarse, asymmetric syndesmophytes tubular secretion of urate. Secondary gout is caused by
similar to those seen in psoriatic arthropathy may occur, acquired disorders that result in increased turnover of nucleic
especially in the thoracolumbar region but occur less acids (e.g. myeloproliferative disorders), by acquired defects
frequently.1,3 in renal excretion of urates or due to certain drugs like
cyclosporine.36
ENTEROPATHIC Men in the age group of 40 to 50 years are commonly
SPONDYLOARTHROPATHY affected however gout also occurs in postmenopausal
This group comprises arthritides associated with inflam- women. Four stages are seen clinically:37
matory intestinal diseases such as ulcerative colitis, regional a. Asymptomatic gout—presence of hyperuricemia.
enteritis (Crohn’s disease) and Whipple’s disease. HLA-B27 is b. Acute gouty arthritis—episodes of monoarticular
present in most patients with spinal involvement.3 There peripheral acute arthritis, involving the 1st MTP joint of
are two distinct types of joint involvement: the great toe in 75 percent of cases. Later, the arthritis
a. A spondylitis and sacroiliitis which is indistinguishable from may be polyarticular and chronic and a phase of chronic
ankylosing spondylitis may be seen in 6 percent of patients gouty arthritis results.
with inflammatory bowel disease and may even precede c. Intercritical gout—is the symptom free period between
the development of bowel disease. Syn-desmophyte acute attacks.
formation, squaring of vertebral bodies and apophyseal d. Chronic tophaceous gout—is characterized by the
ankylosis is seen similar to AS. The sacroiliitis is bilateral deposition of monosodium urate crystals (tophi) in
and symmetric. These changes do not correlate with the tendons, ligaments, cartilage, bone and other soft tissues
activity of the gut disease and may continue to worsen including synovium or in the subcutaneous tissues in a
even if the gut disease becomes quiescent. para-articular location.
b. A peripheral asymmetrical arthropathy with nonspecific Definitive diagnosis involves the demonstration of MSU
features of soft tissue swelling and local periostitis. The crystals in the synovial fluid which are needle shaped and
activity of the arthropathy approximates the activity of show strong negative birefringence under polarized light
the bowel disease.12 microscopy.3

A B C

Figs 8.19A to C: A 32-year-old male with Reiter’s arthropathy: (A) X-ray pelvis shows bilateral sacroiliitis with narrowing and irregularity of
the right hip joint, (B) Coronal T2-weighted fat saturated image shows fluid in bilateral hip joints with erosions and narrowing of the left hip joint,
(C) Axial T2-weighted fat saturated image shows asymmetric ankylosis of the sacroiliac joints
130 Infections/Inflammations

Fig. 8.21: X-ray both feet shows advanced changes of gout with
multiple soft tissue tophi, some of which are calcified. Gross
Fig. 8.20: X-ray of the first MTP joint shows well defined periarticular erosions are seen in both 1st MTP joints. Note the
periarticular erosions with overhanging edges classical of gout saucerization of the left 1st proximal phalanx due to overlying soft
tissue tophi

Imaging
a low to intermediate SI on T1 and a low (if calcified) or high
Gout has several characteristic radiographic features, but
SI on T2-weighted images.36
these are seldom seen these days as it takes 4 to 6 years for
gout to cause radiographically evident disease and most
CPPD CRYSTAL DEPOSITION DISEASE
patients are correctly diagnosed and treated successfully
before that.1 Calcium pyrophosphate dihydrate (CPPD) crystal deposition
The classic findings are the presence of sharply margi- disease is characterized by acute, subacute or chronic joint
nated, round to oval erosions, which are oriented in the long inflammation with deposition of CPPD crystals in hyaline and
axis of the bone, often with sclerotic borders or overhanging fibrocartilage and other soft tissue structures. CPPD crystals
edges (Fig. 8.20). These are initially periarticular in location, are weakly birefringent on polarized light microscopy. The
but may later extend into the joint. There is a predilection disease may cause intermittent acute attacks of arthritis
for the 1st MTP joint, however other joints such as the ankles, when it is called pseudogout.2
knee, elbow and wrist joint may also be affected. Spinal The classic triad consists of pain, cartilage calcification
involvement is unusual but the sacroiliac joints may be and joint destruction. Chondrocalcinosis can occur in any
involved in 5 to 13 percent of cases. The bone density is joint but commonly involves the medial and lateral
preserved till the late stages of the disease. Punctuate bone compartments of the knee, the triangular cartilage and
sclerosis owing to intraosseous deposition of tophi may be lunotriquetral ligament in the wrist and the symphysis pubis
seen resembling enchondromas.12 There is uneven articular (Fig. 8.22). When CPPD crystals occur in the soft tissues such
space narrowing due to cartilage destruction. Para-articular as the rotator cuff, they cannot be differentiated from
tophi cause asymmetric “lumpy-bumpy” soft tissue swellings calcium hydroxyapatite crystals which occur in calcific
which frequently show fluffy calcification in the presence of tendonitis.1
renal disease (Fig. 8.21). These tophi may saucerise the The arthropathy of CPPD is a degenerative joint disease
underlying bone. Chondrocalcinosis may be seen because up caused by the crystals eroding the cartilage. However, CPPD
to 40 percent of patients with gout have concomitant CPPD has a tendency to involve the shoulder, elbow, wrist and the
deposition disease. Nephrolithiasis may be seen in 20 percent patellofemoral compartment of the knee, sites which are
of cases.1 not usually involved by degenerative joint disease.
On MR, an inflamed joint will show joint effusion and Occasionally, CPPD arthropathy may accelerate and severe
para-articular edema with enhancement of the para- destruction occurs to such an extent that it mimics a
articular structures postcontrast. Tophaceous deposits have neuropathic joint.2
Noninfective Inflammatory Arthritis 131

10. Resnick D. Rheumatoid arthritis and the seronegative


spondyloarthropathies: Radiographic and pathologic
concepts. In: Resnick B (Ed): Diagnosis of bone and joint
disorders. Philadelphia: WB Saunders; 2002. pp. 837-90.
11. Renner WR, Weinstein AS. Early changes of rheumatoid
arthritis in the hand and wrist. Radiol Clin North Am.
1988;26:1185-93.
12. Renton P. Diseases of joints. In: Sutton D (Ed): Textbook
of Radiology and Imaging, 7th edn. Churchill Livingstone.
2002;2:1201-45.
13. Resnick D. Rheumatoid arthritis. In: Resnick D (Ed):
Diagnosis of bone and joint disorders. Philadelphia: WB
Saunders; 2002. pp. 891-987.
14. Wakefield RJ, Gibbon WW, Conaghan PG, et al. The value
of sonography in the detection of bone erosions in
Fig. 8.22: Magnified view of the knee joint demonstrating patients with rheumatoid arthritis: a comparison with
chondrocalcinosis conventional radiography. Arthritis Rheum. 2000;43:2762-
70.
15. Brown AK, Wakefied RJ, Conaghan PG, Karini Z, O’ Connor
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6. Arnett FC, Edworthy SM, Block DA, et al. The American carpus at presentation predicts radiographic joint
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Arthritis Rheum. 1991;34:1218.
CHAPTER

9 Nontubercular Infections
of the Spine
Sameer Vyas, Manavjit Singh Sandhu

INTRODUCTION be approximately 3 to 13 percent. Myelography,


discography chemonucleolysis, vertebroplasty, and
Spinal infections result from several infectious pathologic
kyphoplasty are other known causes of spinal infection.
agents with wide and varied clinical presentations.1-6 Several
Vertebral bodies and intervertebral disks are most
factors can make people more vulnerable to spinal
frequently affected with primary or secondary involvement
infections, including immunodeficiency secondary to
of the epidural space, posterior elements, and paraspinal
human immunodeficiency virus (HIV) infection or intra
soft tissues. The pathogenesis of spinal infections can be
venous drug abuse, old age, chronically debilitated
explained on the basis of the vascular anatomy of the
individuals, the widespread use of broad-spectrum
vertebral column. The vasculature of the vertebral bodies
antibiotics, the use of corticosteroids and immuno-
and intervertebral disks changes significantly with age. The
suppressive drugs and parenteral alimentation. The recent
most accepted hypothesis is that vertebral osteomyelitis
development of medical technologies has enhanced the
results from hematogenous spread from an infected
ease of detection and the options for definitive
microembolus in the arterial system becoming lodged in
management of spinal infections. Ironically, technologic
one of the metaphyseal arteries resulting in infarction and
advances have also promoted the occurrence of spinal
subsequent infection. Osteomyelitis is most frequent at the
infections by increasing the number of patients with
endplates because of the greater number of arteries in this
iatrogenic immunosuppression, enhancing the life
location. Anterior subchondral vertebral region is the usual
expectancy of patients with chronic medical illnesses, and
site of infection within the vertebra corresponding to the
increasing the complexity of spinal procedures and
area rich in arterial supply.1 Also pre-existing foci of infection
therefore the potential for infectious complications.7,8
within the body and a high incidence of streptococcal
and tubercular spinal infection favor the theory of
PATHOGENESIS OF SPINAL INFECTIONS hematogenous route of infection. The early infectious lesion
The pathogens can reach the spine by four principal routes occurs in the anterosuperior subchondral region of the
of spread: (a) the arterial hematogenous route from distant vertebral body and subsequently extends through the
septic foci; (b) the venous hematogenous route; (c) endplate. Further dissemination may occur via sub-
contiguous spread from neighboring infected organs such ligamentous spread of infection with resulting anterior
as the oropharynx, pleural space of the lung, and thoracic vertebral body scalloping or rupture of anterior longitudinal
or abdominal wall; and (d) direct inoculation (iatrogenic ligament (Fig. 9.1).
during surgery or interventional procedures).1,3,6 Iatrogenic The pathogenesis of disk space infection differs in the
spinal infections constitute 2.5 percent of all spinal adults and in children. In children, the intervertebral disks
infections. The infection risk of open surgery is reported to receive nutrition by blood vessels that pass through the
134 Infections/Inflammations

Fig. 9.1: Pathophysiology of vertebral osteomyelitis—the focus of


infection usually begins in the anterosuperior subchondral region
and subsequently extends to involve the adjacent disk and vertebral
body. Anterior subligamentous spread may also occur

cartilaginous endplates of adjacent vertebral bodies. Hence,


any infection involving the vertebral endplates easily
extends to the adjacent disk space, whereas this is not so
Fig. 9.2: Bacterial osteomyelitis involving the cervical vertebrae:
in the mature adult spine, where the nutrition of the nucleus plain X-ray cervical spine lateral view showing anterior erosion of
pulposus occurs primarily by the process of diffusion.1 C5 vertebra, prevertebral soft tissue mass and early loss of disk
space height between C4 and 5
IMAGING OF SPINAL INFECTIONS
The various modalities available for evaluation of patients
radiographic features at times make it difficult to
with suspected spinal infection are plain radiography,
differentiate infective spinal conditions from other non-
radioisotope scanning, computed tomography, myelography
infective causes such as spondylodiscitis degenerative
or CT myelography, and magnetic resonance imaging. A wise
changes and metastases.2,5 The plain radiographic features
selection of the modalities is essential for timely patient
of spinal infection (Figs 9.2 to 9.4) may include
management, as untreated spinal infections can lead to
demineralization, loss of definition of endplate margins,
crippling and even life-threatening situations. Comparison
narrowing of intervertebral disk space, associated soft tissue
of various imaging modalities in infections is illustrated in
swelling (paraspinal or epidural soft tissue masses), and
Table 9.1.
eventually destructive changes of the vertebral end plate
Plain Radiography: Plain radiographs are often done first and the vertebral body (spinal deformity, frank vertebral
in patients with suspected spinal pathology. Unfortunately destruction).1,5,6 Paraspinal extension of the infective
the changes on plain radiographs appear quite late (2–8 process may be appreciated as widened retropharyngeal
weeks) after the onset of infection. It is possible to suggest or retrotracheal space in the cervical region, displacement
a positive diagnosis if changes are present on plain of paraspinal lines in the dorsal region and evidence of
radiographs, however, there is a significant overlap of unilateral or bilateral paravertebral psoas abscesses in the
findings on radiographs between various infections. Atypical lumbar region.9-12

Table 9.1 Comparison of imaging modalities in infections


Advantages Disadvantages
Plain radiograph Readily available 30–50% loss of bone density before becomes abnormal
Inexpensive Poor sensitivity
CT Detects bony changes and Lacks sensitivity of MRI
surrounding extent
MRI Evaluation of the bone marrow, Hard to distinguish trauma/neoplasm from infection/new
and neural structures from old disease
Radionuclide scanning Scans whole skeleton, Expensive
sensitive earlier in disease than Long acquisition time, hard to distinguish overlying
radiograph and CT soft-tissue infections
Nontubercular Infections of the Spine 135

A B C
Figs 9.3A to C: X-ray dorsal spine anteroposterior (A) and lateral view (B) showing contiguous endplate
destruction at D8-9 intervertebral disk space and decrease in height of D9 vertebral body, features suggestive
of pyogenic spondylodiscitis. The follow-up X-ray dorsal spine anteroposterior view (C) demonstrating healing
as evidenced by ankylosis of two adjacent vertebrae

fusion. Limitation of plain radiographs is most evident when


it comes to differentiate between chronic vertebral
osteomyelitis, discogenic degenerative end plate changes,
and the presence of superimposed infection in the setting
of chronic degenerative disk disease.2,9
Radioisotope Scanning: Radionuclide imaging frequently
is part of the diagnostic work-up of musculoskeletal
infection.13-18 Isotope scanning is a very sensitive technique
for early diagnosis of spinal lesions which is ubiquitously
available and relatively inexpensive. Radionuclides most
commonly used for detecting inflammatory changes of the
spine are technetium-99m (99mTc) phosphate complexes,
gallium 67 (67Ga) citrate, and indium 111 (111In)-labeled
white blood cells. A three-phase Technetium-99m
diphosphonate bone scan can be valuable in the diagnosis
of vertebral osteomyelitis and is positive within hours to
days after the onset of infection. It shows increased activity
Fig. 9.4: Case of infective spondylodiscitis in middle aged female,
in all phases.
X-ray cervical spine lateral view showing decreased disk space at
C4-C5 level with destruction of anterior vertebral body of C4 vertebra Radionuclide imaging is sensitive to infection, but this
and large prevertebral abscess is a highly nonspecific tool and cannot differentiate infection
from other causes of increased uptake like trauma (healing
Healed or healing processes may be seen on plain fractures), sterile inflammatory reactions, loosened
radiographs as areas of sclerosis, reactive new bone prosthetic devices, arthritis or tumor. Combined, or
formation, spur formation, bony bridging or vertebral sequential, bone (Technetium-99m) and gallium imaging is
136 Infections/Inflammations

the dual tracer technique used for diagnosing complicating


osteomyelitis and can differentiate infection from increased
bone mineral turnover. Gallium-67 scans are specifically
used to localize areas of inflammation.14 67Ga binds to
leukocytes which migrate to the area of inflammation. These
leukocytes bind to various proteins at the site of the
pathology. A Gallium scan is usually obtained in conjunction
with a Technetium scan. If Gallium scan is congruent or
hotter than 99mTc scan, infection is implied and if 67Ga scan
is non-congruent or colder it implies that no infection is
present. The overall accuracy of sequential bone/gallium
imaging is about 65 to 80 percent. The Gallium-67 combined
with 99mTc MDP is useful in the diagnosis of vertebral
osteomyelitis and has an accuracy similar to that of MRI.13
The combined accuracy of technetium and gallium scan has
been reported to be as high as 94 percent.8 Labeled
leukocyte imaging is not useful for detecting spinal
osteomyelitis in contrast to other areas in the skeleton, A B
because 50 percent or more of all cases of vertebral Figs 9.5A and B: NCCT lumbar spine sagittal (A) and coronal (B)
osteomyelitis present as nonspecific areas of decreased, or reformat images showing better depiction of bony changes. There
absent, activity. The radionuclide study takes time to is superior endplate destruction of the L3 vertebra with involvement
perform (hours to days). of the L2-3 intervertebral disk
Single photon emission computed tomography (SPECT)/
CT has been found to be very useful in musculoskeletal
infection. The three dimensionality of a focal process can features that CT can pick-up. Identification of pre- or
be further enhanced by the use of (SPECT).13,15 SPECT may paravertebral soft tissue mass and extent of spread into
reveal abnormalities not seen on the planar images. SPECT/ the epidural space with subsequent thecal sac deformity
CT provided precise anatomic localization and delineation can be well appreciated on CT. Chronic stages of infection
of the extent of the infection. The CT component of the may reveal extensive osseous destruction, sequestrum and
test improved specificity by excluding active bone infection marked heterotropic bone formation. Paravertebral
and by identifying bone abnormalities, other than infection, abscesses with psoas involvement are easily identified after
responsible for increased tracer uptake. contrast administration. Intravenous contrast-enhanced CT
FDG-PET is a promising alternative to bone and gallium may show ring enhancement of an epidural abscess causing
imaging for diagnosing spinal osteomyelitis. It may be posterior displacement of the dural sac. The use of helical
especially useful and superior to MRI for distinguishing true and multislice CT scans with reformatted images in the
infectious spondylodiscitis from severe granulation-type sagittal and coronal planes has proved to be extremely
degenerative disk disease, and in patients who had previous useful.9 CT may also be used to guide various diagnostic
surgery and suffered from high-grade infection in com- and therapeutic procedures.
bination with a paravertebral abscess and in those patients
Myelography/CT Myelography: In these days, the use of
with low-grade spondylitis or discitis. The specificity of the
myelography is limited and is used where MR is unavailable
test, however, was adversely affected by the presence of
or contraindicated. Encroachment on the spinal canal due
spinal implants.18
to any infectious process may lead to thecal sac abnormality
Computed tomography: CT entails a much better evaluation which can be identified by these techniques. Myelography
of the extent of bone destruction (Figs 9.5A and B). is an invasive investigation with its complications related
Involvement of vertebral body and the posterior elements to the puncture site such as infection and CSF leakage with
is easily identified by cross-sectional imaging. Destruction additional risk of exacerbating cord compression and
of disk space and presence of disk space gas are additional contaminating additional spinal compartments. Thus,
Nontubercular Infections of the Spine 137

myelography alone or with CT is not the preferred imaging 2. Viral infections, e.g. human immunodeficiency virus
modality in patients with suspected spinal infection. (HIV), cytomegalovirus and herpes simplex.
3. Fungal, e.g. coccidioidomycosis, cryptococcosis, blasto-
Magnetic resonance imaging (MRI): MRI is the imaging
mycosis, aspergillosis, candidiasis.
modality of choice for infective lesions of the spine because
4. Parasitic, e.g. hydatid disease, cysticercosis.
changes on MRI precede any other radiographic changes,
detects marrow inflammation and has superior spatial
Pyogenic Bacterial Infections
resolution in imaging the spinal cord and nerve roots.19-28
MRI has high sensitivity in early stages and with its known Suppurative infections of the spine comprise only 2 to 5
multiplanar capabilities and better soft tissue contrast, MRI percent of all osteomyelitis. A higher incidence is seen in
provides a much better definition of the paravertebral and the debilitated, diabetics and in elderly. Staphylococcus
epidural extension of the disease.25 Several MR imaging aureus accounts for more than half the cases of infection.
patterns and SI alterations have been described to be Other organisms responsible for infection include
indicative of spinal infection including decreased disk height, Streptococcus, Pneumococcus, gram-negative organisms
disk hypointensity on T1-weighted MR images, disk like E. coli, Pseudomonas, Salmonella (in sickle cell disease)
hyperintensity on T2-weighted MR images, disk and Klebsiella. Spine is a common site for infection in IV
enhancement, effacement of the nuclear cleft, and erosion drug abusers (mainly by Pseudomonas) along with sacroiliac
of the vertebral endplates on T1-weighted MR images.20,21 and sternoclavicular joints involvement.
Use of I/V gadolinium-DTPA allows better definition of Hematogenous spread is common. Blood-borne
the extent of spinal inflammatory lesions. Also pathogens may reach the spine either by antegrade flow
paramagnetic contrast better defines the paravertebral and through the nutrient arterioles of the vertebral bodies or
intraspinal extension of disease. MRI is also a valuable tool by retrograde flow through the paravertebral Batson venous
in evaluation of postoperative spinal infections. MR imaging plexus. There is usually a history of recent primary infection
has a reported sensitivity of 96 percent and an accuracy of of the skin, urinary tract or the upper respiratory tract,
94 percent in vertebral infections.9 Although MRI is an recent surgery or instrumentation. Patients typically present
excellent diagnostic tool it may overlook vertebral with severe back pain which is constant and aggravated by
osteomyelitis in the absence of a localized study site, in the movement. Other symptoms include fever, malaise and local
early course of disease, and in the presence of sclerosis. 17 tenderness. Development of neurological symptoms usually
In addition to the diagnostic capabilities of various indicates the spread of infection to the epidural space.
modalities CT and fluoroscopy can be used to guide Lower lumbar spine involvement may lead to hip pain and
percutaneous aspiration or biopsy in patients of suspected contractures. Uncommonly, even radicular pattern of pain
spinal infections. US/CT-guided catheter drainage of large may be seen. Examination reveals local tenderness and
paraspinal/psoas abscesses can also be undertaken. restriction of movement. ESR is invariably raised. Diagnosis
of spinal infection can be established with positive blood
TYPES OF INFECTIONS cultures (less than 25% of cases), percutaneous needle
Vertebral bodies and intervertebral disks are most frequently biopsy sampling of the infected vertebral body or disk
affected with primary or secondary involvement of the performed under fluoroscopic or CT guidance (in 68% to
epidural space, posterior elements, and paraspinal soft 86% of cases) and an open surgical biopsy procedure can
tissues. In Asia and Africa, tuberculosis has been and still is be performed in cases in which percutaneous biopsy
the leading cause of spinal infections, mostly affecting the sampling fails, is nondiagnostic, or cannot be performed.
younger population. A small percentage of cases can be Spinal osteomyelitis is most common in lumbar region
attributed to nontubercular bacteria, fungal and parasitic (48%), followed by the thoracic spine (35%) and is less
causes.8 common in the cervical spine (6.5%) and sacrum. Infection
The various nontubercular infections of the spine can involves the vertebral body rather than the appendages.
be grouped under the following sub-headings: Radiological findings on plain radiographs usually lag
1. Bacterial (pyogenic) and nonpyogenic (e.g. brucellosis, behind the symptoms by 2 to 8 weeks. Infection usually
actinomycosis, nocardiosis). starts anteriorly in the subchondral area of the vertebral
138 Infections/Inflammations

body, thus, the earliest finding is rarefaction of the


endplates. Later frank erosions, scalloping and destruction
of vertebral endplates is noted. Following this, there is loss
of disk space height as the infection spreads to involve the
adjacent vertebrae. In most patients, only two vertebrae
are involved. Rarely, the infection is confined to one
vertebral body. Vertebral destruction occurs and collapse
may result with accompanying soft tissue swelling in pre-
and paravertebral location. Reparative process can begin as
early as 4 to 6 weeks after the onset of radiologic change
and is heralded by increasing sclerosis, reactive new bone
going on to spur formation, bony bridging or ankylosis of the
adjacent vertebrae. Rarely, ivory vertebrae and soft tissue A B C
calcification may be found. Radionuclide scanning may be Figs 9.6A to C: MRI lumbar spine sagittal (A), coronal (B) T2W
used to localize the exact site of infection and to search for and T1 images show abnormal signal intensity (arrow) of L3
vertebra, contiguous L2-L3 intervertebral disk and surrounding soft
multifocal lesions.14
tissue in a case of pyogenic spondylodiscitis. In addition there is
Computed tomography (CT) plays a minor role in cases loss of intra-nuclear cleft
with bony or soft tissue components. CT findings of vertebral
osteomyelitis include: (i) detection of erosion or bone
destruction and fragmentation, and (ii) presence of adjacent
soft tissue swelling with obliteration of fat planes around the
vertebral body. CT diagnosis may be problematic if soft tissue
lesions are seen in the absence of fragmentation or if
fragmentation is seen without associated soft tissue swelling
as in the case of previously treated or inactive discitis or
hypertrophic degenerative disease. Diagnosis of vertebral
osteomyelitis can also be difficult if pathognomonic features
of other specific disease entities are present like acute vertebral
fractures, metastatic or degenerative disease. Intradiscal or
vertebral gas is an extremely uncommon finding in spinal
infection and may be detected in clostridial or streptococcal
infections. At about 10 to 12 weeks, an osteoblastic response
may occur with sclerotic new bone formation. This is more a
feature of pyogenic than tubercular osteomyelitis. Vertebral
body ankylosis or fusion may be seen with the process of
A B
healing. However, if the therapy is inadequate, collapse with
spinal deformity resulting in instability of the vertebral column Figs 9.7A and B: MRI lumbar spine sagittal T2W (A) and T1 fat
may occur. saturated post contrast (B) images show destruction of L1-L2
intervertebral disk and contiguous vertebral bodies with T2
Magnetic resonance scanning is the imaging modality hyperintense soft tissue that is showing peripheral contrast
of choice for evaluation of patients with vertebral enhancement and having intraspinal epidural extension in a case
osteomyelitis.22-27,29,30 The findings on MR are characteristic of pyogenic spondylodiscitis
and occur early in the disease. A constellation of findings
of MR (Figs 9.6 to 9.8) indicates pyogenic infection and helps weighted images and high signal intensity on T2-
to differentiate it from some of the other disease processes weighted images), but usually at one of the vertebral
like TB.30 These include the following: body metaphyses. These signal alterations mainly
1. The vertebra usually show homogeneous areas of represents edema and often precede the destructive
altered signal intensity (low signal intensity on T1- changes.
Nontubercular Infections of the Spine 139

A B C

Figs 9.8A to C: T1W sagittal image (A) of the lumbosacral spine shows a decreased signal
from L4 and L5 vertebrae with reduced intervening disk space. T2W image (B) show increased
signal intensity involving more than half of the L5 vertebral body. Contrast enhanced T1W
sagittal image (C) showing enhancement of the osseous lesion as well as the inflammatory
epidural mass (arrow)

2. The intervertebral disk usually show hyperintensity on other nonpyogenic granulomatous infections involving the
T2-weighted imaging, with abnormal configuration spine, based on clinical and imaging features as described
(absence of the internuclear cleft). The height of the in Table 9.2.22,23,31
intervertebral disk may be reduced.
3. Loss of a margin between disk and vertebral bodies on Pyogenic Disk Space Infections
T2-weighted images. In adults, since the disk is avascular, hematogenous infection
4. Diffuse and homogeneous enhancement is seen in the is rare. Most infections occur by contiguous spread from
affected marrow and disks. vertebral osteomyelitis or by direct inoculation of bacteria
5. Variable extension of the process into the paraspinal into the disk at the time of surgery or percutaneous
region. The presence of epidural extension and procedures like discography, percutaneous discectomy and
associated meningeal inflammation can be better chemonucleosis. Staphylococcus aureus is the most
demonstrated with contrast. common organism implicated and presentation is usually
6. Osseous and extra-axial abscesses showing restricted with back pain. Erythrocyte sedimentation rate (ESR) is
diffusion on diffusion-weighted imaging. elevated, but this is not a very useful marker especially in
Magnetic resonance imaging may able to differentiate postoperative cases where ESR remains elevated even up
tuberculous spondylitis from pyogenic spondylitis.22,23 A to 6 months.
well-defined paraspinal abnormal signal, a thin and smooth Radiographic features include decreased disk space
abscess wall, subliga-mentous spread to three or more height and reactive sclerosis of adjacent endplates. Isotope
vertebral levels, and multiple vertebral or entire body scanning may show increased uptake but it may also be
involvement were more suggestive of tuberculous due to recent surgery or percutaneous manipulation. MRI
spondylitis than pyogenic spondylitis. Diffusion-weighted has become the modality of choice for evaluating disk space
magnetic resonance imaging has limited usefulness for infection. Septic discitis demonstrates disk space narrowing
differentiating spinal infection and malignancy.24 It is also on MRI. The vertebral endplates are indistinct and show
possible to differentiate between pyogenic infection and low SI on T1WI. On T2WI and proton density images, the
140 Infections/Inflammations

Table 9.2 Differentiating features of infectious spondylitides


Features Tubercular Pyogenic Brucella
Associated with pulmonary site Yes No –
Site of predilection Dorsolumbar Lower lumbar Lower lumbar
Onset of symptoms Insidious Acute Acute
Progression Slow Rapid Rapid
Multifocal involvement Yes No Infrequent
Vertebral body height Destroyed Destroyed Preserved
Posterior elements May be involved Spared Spared
Subligamentous spread Common May be seen No
Disk destruction Late Early Early
Intradiscal gas Infrequent May be seen Frequently
Paraspinal and epidural extension Common Common Uncommon
Paraspinal mass Large Small Small
Enhancement of paraspinal mass Peripheral Patchy Patchy
Calcification in paraspinal mass Yes No No
Spinal deformity Common Uncommon No
Bone sclerosis No* Yes* Yes
*Caucasians show a greater tendency to new bone formation in pyogenic infection. This is not so in Asians and Blacks where
such changes are seen in tuberculosis and vice versa.

vertebral endplates may be of increased signal intensity but present. Infection may also be distributed along the course
the major finding in the disk space is an abnormal high of the ascending and descending nutrient branches of the
signal.32 posterior spinal artery. The direction and extent of flow
Paraspinal soft tissue thickening and edematous changes through the valveless venous plexus are significantly
in the paraspinal musculature are also seen. In fact the influenced by changes in intra-abdominal pressure, which
earliest MR finding in pyogenic septic discitis is obliteration may account for the contamination of the spine that may
of fat planes between the paraspinal musculature and the be observed in a child with urinary tract and other pelvic
outer margin of the disk. Diagnosis is usually confirmed by infections.33
percutaneous disk aspirates which can be cultured for Infection of spine may also occur secondary to spread
organisms. from a contiguous contaminated source or from direct
implantation. Subligamentous spread of infection with
Spinal Infections in Children subsequent bony invasion is more characteristic of
Infections of the spine in children consist of osteomyelitis tuberculosis than pyogenic infection. Direct implantation
and the so-called spondyloarthritis or discitis. The hallmark of organisms can occur during punctures of the spinal canal.
of radiographic diagnosis is disk space narrowing with Postoperative infection may develop following laminectomy
destruction of the two adjacent vertebral body surfaces.33 or other instrumentation such as scoliosis repair. The
Localization of infection to the osseous and articular cervical spine may be infected by direct extension from
structures of the vertebral column is not as common in prevertebral abscesses, especially those associated with
children as adults. The most common route of sharp foreign bodies in the pharynx.
contamination of the spine is by a hematogenous pathway, Vertebral and disk infections account for approximately
either by an arterial route or Batson’s paravertebral venous 2 to 4 percent of all cases of osteomyelitis with equal
system. The arterial pathway can be implicated by the incidence in boys and girls. The symptoms include fever;
localization of early infection in the subchondral region of malaise; weight loss; back pain, which may be intermittent
the vertebral body, where numerous arterial loops are or constant; or hip contracture, which occurs secondary to
Nontubercular Infections of the Spine 141

psoas muscle irritation. The erythrocyte sedimentation rate the disk spaces and disks (increased on T2WI) with reduction
(ESR) is elevated, but serum leukocyte count may be normal in disk height seen best on sagittal images.34
and organisms may not be recovered from blood cultures.
Magnetic resonance imaging is the modality of choice Differential Diagnosis of Spinal Infection
for early diagnosis of vertebral osteomyelitis. MR imaging Spinal infections may be mimicked by degenerative and
is more sensitive in the detection of vertebral osteomyelitis inflammatory spinal diseases. 1,2,25 Conditions such as
than either conventional radiography or CT scan and nuclear diskogenic vertebral body degeneration in the inflammatory
scintigraphic studies. Soft tissue extension from spinal phase (Modic type 1 degeneration); acute cartilaginous
osteomyelitis in the form of epidural abscess or node; ankylosing spondylitis; neuropathic spine; dialysis-
paravertebral abscess is well demonstrated by MR imaging related spondyloarthropathy; and neoplasm may lead to
and enhanced CT scan. Following treatment, a radiodense alterations in signal intensity that may be mistaken for
“ivory” vertebra may be seen. The affected disk space may infection. Lack of abnormally increased signal intensity of
remain relatively intact, or complete bony ankylosis may an associated disk on T2-weighted images and a lack of soft-
occur. tissue involvement are characteristic findings of Modic type
1 degeneration and conversely endplate destruction,
Childhood Disk Infection or Discitis increased disk signal intensity on T2-weighted images, or a
Until about 7 years of age, profuse anastomoses exist paravertebral or epidural abscess are indicative of infectious
between the intraosseous spinal arteries, preventing spondylitis. Acute cartilaginous node may be distinguished
devascularization and infarction of large portions of the by concentric ring of high signal intensity around the node
metaphysis when septic emboli occlude a metaphyseal on T2-weighted images, involvement of only one endplate
artery. This tends to limit the extent of metaphyseal and and no diffuse signal intensity abnormality of the disk.
osseous infection to the cartilaginous endplate at either end Ankylosing spondylitis can be differentiated by presence of
of the vertebra. Hence, hematogenous spread to the spinal ankylosis and fracture that extends into the posterior
pediatric spine tends to be limited to the disk space. column (Andersson lesion). Neuropathic spine is
Additionally, the pediatric disk retains vascularity, unlike in characterized by vacuum phenomenon, facet involvement,
adults, and occasionally blood-borne pathogens may lodge lower signal intensity of disk and bone marrow on T2-
directly in the disk space in children, without any weighted images whereas in dialysis-related spondylo-
involvement of the metaphyseal endplates.1 This is different arthropathy vertebral marrow shows hypointense signal on
from the adult form of infection and has a good prognosis. both T1 and T2WI.
Natural course of the disease is slow and self-limiting
Postoperative Spondylodiscitis
following medical therapy. The posterior elements of the
vertebrae are not involved and paravertebral soft tissue Postoperative spondylodiscitis is an infrequent complication
masses are absent.The mean age at presentation is 6 to 8 of lumbar disk surgery.1 The typical clinical presentation is
years. Diagnosis is often delayed due to nonspecific nature recurrent pain after initial postoperative relief, muscle
of complaints. Clinically there may be low-grade fever, spasm and fever. The most probable cause is intraoperative
malaise and irritability, and the child might refuse to walk, contamination rather than hematogenous spread, although
stand or sit. ESR is frequently elevated. either may occur. The imaging findings appear several weeks
Radionuclide 99mTc or gallium scan is useful modality after the initial symptoms. MR may be helpful earlier, but it
which shows an increased uptake in the affected area, and is usually not possible to reliably diagnose infection until 3
this is positive well before the plain radiographic changes weeks after surgery. The disk space infection can be
appear. Plain films show decreased disk space height and diagnosed in the postoperative spine by triad of
at a later stage vertebral endplates might be eroded or intervertebral disk space enhancement, annular
irregular with or without sclerosis. Seventy-five percent of enhancement, and vertebral body enhancement when
the discitis are seen in lumbar or dorsal region, rarely in found in conjunction with appropriate laboratory findings
the cervical spine. At times two levels may be involved. MRI such as an increased ESR.1 Contrast enhancement and signal
detects the lesion early and shows abnormal signal from changes in the intervertebral disk or the vertebral end plates
142 Infections/Inflammations

can be seen both in the setting of discitis and in normal


postoperative asymptomatic patients. MR imaging may be
useful for the exclusion rather than the confirmation of
postoperative spondylodiscitis by showing absence of signal
changes in the vertebral endplates, contrast enhancement
of the disk, or enhancing paravertebral soft tissues.

Epidural Space Infections


The frequency of epidural abscess has been increasing.
Epidural abscess usually manifests itself by intense pain,
which could be localized over the infected level or be spread
diffusely over the spine. The pain could be even more
disabling than the concomitant neurologic deficit. The
epidural space can become infected either by contiguous
spread of an infective process from the surrounding bone,
intervertebral disk or adjacent soft tissue abscesses or by
direct inoculation of organisms into the epidural space
Fig. 9.9: Sagittal MRI scan in a patient with a large epidural
following use of indwelling epidural catheters. At times
abscess in the dorsal spine showing peripheral enhancement
hematogenous spread of microorganisms may occur. following gadolinium administration with hypointense central areas
Unchecked epidural infections can be dangerous often representing purulent contents
leading to cord compression and paralysis. Hence, it is
important to diagnose and treat this entity early.
Contrast enhanced MRI provides the best evaluation of rods of Brucella species. Brucellosis is a zoonosis disease that
such patients. Besides its ability to distinguish the cord from affects animals as the primary host (e.g. camels, sheep, goats)
the thecal sac, it offers easy identification of paraspinal soft and humans as the secondary host. The organisms are
tissues and extension and involvement of the bone marrow. usually transmitted by the consumption of uncooked meat
T1W images can show a soft tissue mass displacing the or unpasteurized dairy products.35 Vertebral infection
thecal sac away from the bone. On T2W images, epidural occurs in about 6 to 12 percent of cases of brucellosis. The
abscesses are defined clearly on sagittal planes as presenting signs and symptoms of spinal brucellosis are
hyperintense extradural lesions. The epidural abscess and nonspecific and similar to those associated with other forms
the dural sac are usually separated by hypointense stria of spinal osteomyelitis. The symptom onset of spinal
corresponding to the leptomeninges. Gadolinium brucellosis tends to be subacute, and the radiologic
enhancement in epidural abscesses is of two types, a manifestations are nonspecific, with some similarity to cases
peripheral enhancement with a central hypointense area of tuberculosis.36 The main problem in the diagnosis is its
corresponding with the true abscess with fluid contents differentiation from other infective processes particularly
(Fig. 9.9) and a second, homogeneous enhancement tuberculosis which is the most common cause of spinal
corresponding with the inflammatory tissue without infection in India. However, the proliferative changes
purulent contents. Fat suppression techniques improve the associated with bony repair in brucellosis are not seen in
sensitivity further by eliminating the possible confusion tuberculous infection, and deformities of the spine, which
between high signal of fat and similar signal from are common in TB, are rarely seen with brucellosis.
gadolinium. Radionuclide bone scans are highly sensitive in
demonstrating areas of involvement in patients with
Nonpyogenic Bacterial Infections Brucella infection who have musculoskeletal complaints.
Spine is the most common site for skeletal brucellosis. Spinal
Brucellosis
infection with brucellosis can be focal or diffuse. In the focal
Brucellosis or undulant fever is a granulomatous form, the osteomyelitis is located in the anterior aspect of
nontubercular infection which is caused by gram-negative the vertebral endplate (classically superior endplate of L4
Nontubercular Infections of the Spine 143

vertebra) at the discovertebral junction. In the diffuse form, and are associated primarily with pulmonary infection in
the infective process involves initially the entire vertebral immunocompromised patients. Spinal involvement is rare
body and ultimately extends to involve the neighboring disks with nonspecific radiological findings–there are only about a
and vertebrae. The lower lumbar spine is most frequently dozen cases reported in the literature–and occurs both by
affected. direct extension of intrathoracic infections and through
Plain radiographs mainly show a focal lesion at the hematogenous spread.
superior endplate with a maintained vertebral body
architecture. Associated sclerosis is frequently seen. Disk Viral Infections
space reduction with presence of gas in disk is a hallmark
of brucellosis not seen in tuberculosis. Paravertebral soft Spinal Infections in AIDS
tissue abscesses are less commonly associated and spinal The most frequent causative agent of bacterial spinal
deformity is rare when compared with tuberculosis. infections in patients with HIV is S. aureus, as in immuno-
Computed tomography confirms the presence of focal competent patients. The manifestations may be isolated
or diffuse disease in brucellosis. Findings of bone sclerosis, or a combination of osteomyelitis, discitis, epidural spinal
localized endplate destruction simulating Schmorl’s nodes, phlegmon or abscess, paraspinal abscess, or myelitis. The
loss of muscle/fat plane and disk space gas when seen point presence of complete prevertebral soft tissue involvement,
to a Brucella infection, whereas large paraspinal abscesses absence of posterior elements involvement, diffuse bone
with enhancing rim, calcification, or bone fragments suggest destruction, and absence of marginal sclerosis are signs of
tubercular nature of infection. On MR, the above findings pyogenic spondylodiscitis, whereas nonpyogenic infection
are further corroborated with evidence of an intact manifestations are the presence of focal lytic bone
vertebral morphology, normal posterior elements and a involvement, marginal sclerosis, and paraspinal soft tissue
focal lesion which shows a decreased SI on T1W images masses.38
and moderately increased SI or T2W images. Disk Use of gadolinium-enhanced T1-weighted images is
destruction is early. There is only a moderate extension into recommended in the investigation of spinal infections
the paraspinal and epidural space by granulation tissue and/ because it increases the conspicuity of epidural disease and
or edema and spinal deformity is infrequent. is essential for the detection and delineation of intradural
disease. In cases of spondylodiscitis, the involved disk and
Actinomycosis: Actinomyces species are gram-positive, adjacent vertebral bodies typically show enhancement to
filamentous bacteria that are most commonly associated with various degrees. Homogeneous enhancement of epidural
chronic draining infections. Spinal involvement is rare and or paraspinal soft tissue masses is consistent with the
generally the result of contiguous spread from adjacent sites presence of a phlegmon, whereas ring enhancement is seen
of infection, especially the lungs and sinuses. Vertebral with abscesses.
destruction with deformity is uncommon with Actinomyces
infection.37 Fungal Infections
Actinomycotic infection of the spine is caused by
anaerobic organisms and is usually seen in debilitated Fungal infections of the spine are infrequent and tend to
persons. Mandible and spine are most commonly affected. occur in patients with predisposing conditions or, rarely, as
Osseous involvement results from extension of soft tissue a consequence of iatrogenic interventions. Examples of
infection. Radiological manifestations include lytic lesions comorbid conditions usually seen in patients with fungal
with surrounding sclerosis involving several vertebrae and spinal infections include prolonged corticosteroid
frequently sparing the disks. Posterior elements and ribs are administration, immunosuppression after organ transplan-
frequently involved, with associated paravertebral abscesses tation, severe systemic illness associated with malnutrition
which are not as large as seen in tuberculosis and do not and multiple antibiotic use, HIV infection, diabetes, alcohol
show calcification. Presence of sinus tracts leading to the skin or intravenous drug abuse, and parenteral nutrition.
along with above findings suggests the diagnosis.37 Fungal infections of the spine include aspergillosis,
coccidioidomycosis, cryptococcosis, Candida and blasto-
Nocardiosis: Nocardia are filamentous, branching, gram- mycosis. Following inhalation of spores, these involve the
positive aerobic bacteria. They are normally found in the soil spine by a hematogenous route. Radiologically, each fungal
144 Infections/Inflammations

infection does not have any distinctive features of its own. Actinomycosis, Echinococcus and Coccidioidomycosis may
Most of them resemble tubercular infection, but a few also spare the intervertebral disk. The pathogenesis of
characteristic features have been described for some of the absence of hyperintensity within the intervertebral disk is
infections. unclear and may be multifactorial. The imaging findings may
reflect an absence of fungal invasion, an altered inflammatory
Aspergillosis reaction within the infected disk, or an intrinsic characteristic
Aspergillus, a ubiquitous species of fungus, is usually of either the disk before infection (e.g. degenerated disk) or
pathogenic only in patients with impaired immune defences. of the invading fungi (e.g. paramagnetic elements).41
Aspergillus typically invades the spine from a contiguous
Cryptococcosis (Torulosis)
site of infection (usually pulmonary), but can also be spread
hematogenously. Though rare, Aspergillus vertebral Cryptococcosis is a serious disease of worldwide distribution
infections have been reported in immunocompetent hosts caused by Cryptococcus neoformans, an organism that has
as well.39 Differentiation must be made from tuberculosis, an unusual predilection for the central nervous system. This
which can closely mimic aspergillosis of the spine, using fungus can be recovered from soil, pigeon droppings, fruit,
serologic testing. The radiographic features, including and human intestinal tract and skin. The disease is generally
osseous and disk space destruction and a paraspinal mass, acquired by the respiratory route through inhalation of
resemble those of tuberculosis.39 aerosolized spores. The development of Cryptococcus
infection in patients with compromised immune defences
Coccidioidomycosis is well known. Patients undergoing renal transplantation
Coccidioidomycosis is caused by Coccidioides immitis, a are particularly susceptible.
filamentous fungus which infects the lung primarily and Disseminated cryptococcal infection may result in osseous
disseminates throughout the body in about 0.5 percent of involvement in 5 to 10 percent of patients and spine is
patients. Osseous involvement is seen in 10 to 50 percent commonly involved. Radiologically, nonspecific well-defined
of which spine is the most common site.40 Plain radiographs osteolytic areas with sclerotic margins are seen involving the
usually reveal multiple erosive defects involving vertebral vertebral body and posterior elements (Figs 9.10A to C).
bodies and appendages. Disk space is usually preserved and Again, multifocal involvement and large paraspinal soft
spinal deformity is uncommon. Paraspinal masses and tissue abscesses may be present making the picture at times
adjacent rib involvement is common. Differentiation from indistinguishable from tuberculosis.39
tuberculosis can be made by the presence of skull lesions,
Blastomycosis
which, although common in coccidioidomycosis, are rare
in tuberculosis.39 This infection caused by Blastomyces dermatitidis enters
Lumbar spine is commonly affected. MR appearances of the body by a skin wound or the respiratory tract. Skeletal
the lesion are that of hypo to hyperintense SI on T1WI and changes can occur because of hematogenous seeding, or
on T2WI the lesions are almost always hyperintense. by direct extension from an overlying cutaneous lesion. The
Following gadolinium injection, the lesions which are hypo- commonly affected osseous sites are the vertebrae, the ribs,
to isointense on T1W sequence show enhancement.40 Ring the tibia, the carpus, and the tarsus. The radiologic features
enhancement may be seen in intraosseous abscesses. are not specific.
Presence of paraspinal masses, epidural spread and All age groups can be affected, but the disease appears
subligamentous spread are similar to those seen in to have a predilection for those in the second through fifth
tuberculosis. decades of life. The infection may be self-limited or may
The absence of hyperintensity within the intervertebral progress to dissemination. Disseminated disease produces
disks on T2-weighted images and the preservation of the generalized symptoms of fever, malaise, anorexia, and night
intranuclear cleft are findings associated with nonpyogenic sweats. Secondary osseous involvement is common, with
or TB spondylitis.41 These are, however, nonspecific findings the spine being a prime target. Vertebral involvement
that have been reported in cases of pyogenic disease as well. produces a destructive lesion often associated with a large
Other nonpyogenic infections caused by Nocardia, paraspinal mass. The lower thoracic and lumbar spine is
Nontubercular Infections of the Spine 145

A B C

Figs 9.10A to C: T2 (A), T1 (B) sagittal, and T2 (C) coronal MR imaging in a case of cryptococcosis of the
dorsal spine showing multiple contiguous vertebral involvement of the upper dorsal spine with vertebral
destruction and prevertebral, epidural and posterior paraspinal abscesses with compression of the adjacent
cord and relatively preserved disk spaces

most often the site of the infection. Blastomycosis of the more widespread changes of osteomyelitis.30 Granulomas
spine must be distinguished from tuberculosis and usually are not apparent at surgery. Aspiration of synovial
coccidioidomycosis. In tuberculosis the posterior elements fluid or biopsy of synovial membrane with isolation of
of the vertebral body are not infected, whereas in Candida confirms the diagnosis.39
coccidioidomycosis and blastomycosis all bony elements of
the spine may be involved.39 Also blastomycosis frequently Parasitic Infections
involves the adjacent ribs and unlike coccidioidomycosis or
Echinococcosis or Hydatid
actinomycosis, the disk space is frequently involved in
blastomycosis. Additionally, blastomycosis has a greater Echinococcosis occurs throughout South America, the
tendency to produce cutaneous fistulae.30 The definitive Arabian Peninsula, Australia, New Zealand, Indian
diagnosis is typically made through positive cytology or subcontinent and East Africa. The principal host is the dog,
histologic examination of biopsy specimens. whereas sheep and humans are the intermediate hosts.
Ingestion of ova and absorption by the bowel is the major
Candidiasis (Moniliasis) route of transmission. Echinococcosis or hydatid disease of
the bones is rare, accounting for approximately 0.5 to 4
Of the various Candida species, Candida albicans is most percent of all patients.30 Spinal involvement by hydatid
commonly associated with human disease. Candida disease is seen in about half of these patients. In the spine,
infection of the musculoskeletal system occurs typically in sacrum and lower dorsal vertebra are commonly involved.
intravenous drug addicts and when host resistance is The primary infection from the medullary cavity in the
depressed. Infants, children, and adults can be affected. vertebral body spreads to involve the pedicles and
Osteomyelitis can occur in one or more sites. Common laminae.42 Hydatid disease in the bones differs from disease
patterns of distribution include involvement of a single long elsewhere in the soft tissues in that the cysts are always
bone, the sternum, or two consecutive vertebral bodies. multilocular. Growth occurs along the line of least resistance
Usually, the lumbar spine is the region affected. particularly along the intertrabecular spaces with the
Radiographic findings include soft tissue swelling, joint formation of diverticulated cysts that may form by
space narrowing, irregularity of subchondral bone, and exogenous vesiculation. Enlargement of the larvae results
146 Infections/Inflammations

in dilatation of the bony spaces of spongiosa and resorption hydatid disease. CT is superior to MR in demonstrating
of cancellous bone. Expansion is relatively slow with a calcified lesions.
smooth well-defined sclerotic margin. Erosion through the On MR, cysts demonstrate inhomogenous low signal
periosteum into the adjacent soft tissues proceeds without intensity on T1W images and high signal on T2W images
subperiosteal new bone formation. Extension into (Figs 9.11A to D). T2W images are not helpful in
extradural space or paraspinal tissues may occur. Contiguous differentiating quiescent from active stage of the cysts. MRI
involvement of the rib is a feature. may demonstrate intradural extension to better advantage
Spinal hydatid has been classified into: (i) primary cyst than CT without the need for subarachnoid contrast.
in the cord, (ii) intradural cyst, (iii) extradural cyst, (iv)
hydatid disease of the vertebrae, and (v) paravertebral Cysticercosis
hydatid disease. Mid dorsal and lumbosacral levels are most
commonly affected. Plain film findings include a uni- or Cysticercosis is caused by the pork tapeworm T. solium.
multiloculated lytic expansile bone lesion with marginal Humans are an intermediate host for these worms and are
sclerosis involving the vertebral body, posterior elements infested by eating raw or poorly cooked infected pork or
and even the adjacent ribs with paraspinal soft tissue mass. contaminated vegetables. Embryos penetrate the intestinal
Disk space is preserved as the disease propagates beneath wall and travel to the subcutaneous tissues, muscles,
the periosteum and ligaments.39 The findings are at times viscera, and the central nervous system. Intramuscular cysts
nonspecific and indistinguishable from other benign cystic and calcifications can be clinically palpated. On conventional
bone lesions or metastatic disease. radiographs and CT, dead calcified cysticerci can be
CT signs are nonspecific and often reveal bone lysis identified in the paravertebral muscles and soft tissues as
extending into the posterior elements, adjacent vertebrae, small linear rice shaped calcifications measuring
disk space and epidural space, creating a picture of approximately 5 to 8 mm with long axis running parallel to
spondylitis. However, costal involvement and lack of the paravertebral muscle fibers. CT scan can also reveal
enhancement following contrast administration suggest innumerable, round, low attenuating cysts, 5 to 7 mm in

A B D

Figs 9.11A to D: MRI lumbosacral spine parasagittal T2W (A), T1W (B), axial T2W (C), T1W (D)
images show large multiloculated, cystic, expansile lesion involving posterior arch elements of L5 and
sacrum demonstrating a having both osseous and extraosseous components. The cysts show peripheral
T2 hypointense wall and central fluid signal in a case of spinal hydatid
Nontubercular Infections of the Spine 147

A B C

Figs 9.12A to C: MRI sagittal T2W (A), T1W (B), and postcontrast T1W (C) images
show intramedullary ring enhancing lesion with T2 hypointense rim and associated cord
edema in a case of intramedullary neurocysticercosis

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CHAPTER

10 Degenerative Disease
of the Spine and Joints
Jyoti Kumar, Sumedha Pawa

INTRODUCTION pulposus, outer annulus fibrosus, and hyaline cartilaginous


endplates. The ligaments consist of the anterior and posterior
Degenerative joint disease is the most common and
longitudinal ligaments (ALL, PLL), ligamentum flavum (LF)
widespread form of arthritis. Degenerative joint disease is a
and interspinous ligaments. Since involvement of one site
general term to describe degenerative alterations in any
predisposes the other sites to degenerative changes owing
type of articulation, i.e. synovial, cartilaginous or fibrous. It
to altered biomechanical forces, patients often present with
is a disease of the whole joint in which all articular structures
degenerative changes in multiple sites.1,2
are affected. Osteoarthritis (OA) has a greater predilection
for involving certain joints while sparing others. For example, Imaging Modalities
it is highly prevalent in the spine and knees. Imaging
Magnetic resonance imaging (MRI) is often the modality of
evaluation of OA has become especially important because
choice in evaluation of spine because of its superior soft tissue
of the prevalence of the condition, the increased life span of
contrast. Computed tomography (CT) demonstrates superior
the population, and the newer treatments that are being
spatial resolution and improved conspicuity of osseous and
developed.
calcified structures.3
Complimentary tests in evaluation of degenerative spine
DEGENERATIVE DISORDERS
include radiography, discography, conventional myelography,
OF THE SPINE
CT myelography, and nuclear scintigraphy. Plain films are
Degenerative diseases of the spine are a ubiquitous collection inexpensive, widely available and give a panoramic view of
of conditions that represent some of the most common the entire spine. Bones can be directly visualized and
indications for advanced imaging studies. Degenerative functional information regarding alignment and stability can
changes may arise in the vertebrae, intervertebral disks, be obtained with upright dynamic films in flexion-extension
facet joints and ligaments. Degeneration at various sites is and lateral bending. Myelography is reserved only for
linked to each other since the main common pathogenetic patients with contraindications to MRI or in whom subtle
factor is chronic overload. The intervertebral articulation instability is suspected but not confirmed by other
consists of a three-joint complex consisting of the examinations. Discography is reserved for selected patients
amphiarthrodial endplate-disk-endplate joint of the anterior before intervention or when the diagnosis of discogenic pain
column and the two diarthrodial facet joints of the posterior must be confirmed.2
column supported by ligaments and muscle groups. In the Weight bearing CT or MRI may be done by axial loading
cervical spine, uncovertebral joints (joints of Luschka) are performed in supine position. A hydraulic compressor is
the other lateral articulations between the vertebral bodies. placed below a patient’s feet and over the shoulders to apply
The intervertebral disk space consists of the inner nucleus a variable axial load. This simulates static mechanical forces
150 Infections/Inflammations

acting on the spine in the upright position. Dedicated upright fibrocartilage and collagen and attaches to the cartilaginous
open MR scanners can determine axial load by gravity, endplate. The collagen in the inner annulus is less plentiful
patient’s weight and spine morphology without artificial than in the outer ring. The annular fibers become
stimulation. Dynamic flexion extension is also possible in these progressively more compact centrifugally. The outermost
units.2 Dynamic plain films, weight bearing CT or MRI have fibers are the densest, known as Sharpey’s fibers. The nucleus
been used for the study of spinal stenosis. Previously occult pulposus converts much of the axial force into radial force
abnormalities, including disk herniation, ligamentous and functions to spread the load evenly over the adjacent
infolding, subluxations may all be demonstrated using endplate. Cartilaginous endplates are composed of hyaline
kinematic MRI. Functional information regarding vertebral cartilage. These are usually not well discernible on imaging.
stability may also be provided on dynamic examination. Surrounding the cartilaginous endplate is a ring of dense
bone, the ring apophysis that fuses to the vertebra in the
Pathophysiology second decade of life. Fetal and infantile disk is well
Pathogenetic mechanisms are multiple and chronic overload vascularized but these branches soon atrophy and the adult
is the most important factor. The other causes are sequelae disk becomes avascular. It obtains its nutrition by diffusion
of acute trauma, metabolic, toxic, genetic, vascular or from vertebral endplates.3
infectious. The distribution of axial load determines the The normal intervertebral disks are of slightly lower signal
common sites of spine degeneration. In the cervical spine, it intensity than bone marrow on T1-weighted images and
is C5-C6 and C6-7 levels as these are the sites of lordosis with higher T2 signal. The annulus is seen as a peripheral
inversion. The dorsal spine is rarely involved as it is less mobile region of low signal intensity on T2W images and nucleus
and less involved in dynamic load. In the lumbar spine, L4-5 pulposus is hyperintense. A horizontal internuclear cleft of
and L5-S1 are the sites of highest dynamic and static overload fibrous tissue containing collagenous, elastic and reticular
and hence most predisposed to degenerative changes.2 fibers may normally be seen on T2WI in over 90 percent of
In patients with degenerative changes of the spine, there patients over 30 years of age and is considered a
are multiple mechanisms that act in combination to produce paraphysiologic change.1,2 On T1WI, the distinction between
pain.4 These are: the nucleus and annular fibers is less discernible (Figs 10.1A
i. Biochemical mediators of inflammation resulting from to C), similar to CT.
disk degeneration and herniation.
ii. Mechanical compression of nerves by bone, ligament Degenerative Disk Changes
or disk material. The intervertebral disk undergoes marked changes with
iii. Instability or abnormal motion with associated disk aging, which must be distinguished from degenerative
degeneration and facet arthropathy. changes in the disk. The incidence of degeneration increases
iv. Disruption of free nerve endings in the outer annular with age, but most disks in normal aging individuals do not
fibers. show changes in height and morphology that characterize
degenerating disks. With aging, small concentric and
Anatomy of Intervertebral Disk transverse tears may develop in the annulus. The composition
The intervertebral disk has an inner nucleus pulposus and an of the intervertebral disk may change with decrease in
outer annulus fibrosus and is bordered by cartilaginous glycosaminoglycans and increase in collagen; and hence a
endplates. The nucleus pulposus consists of hydrated decrease in affinity for water. Therefore, aging can reduce
proteoglycans supported by network of elastin and collagen the signal intensity of the disk by a few percent. However,
type 2 fibers. Over time, the gelatinous proteoglycans is loss of high signal intensity on T2WI or loss of disk height
replaced by fibrocartilage. The nucleus is eccentrically cannot be entirely attributed to aging.5
located and more closely related to the posterior surface of Degenerating disks may undergo dehydration, fissures,
the intervertebral disk. The annulus is composed of outer bulging and herniations. On MR, the earliest appearance of
and inner layers. The outer layer consists of dense collagen degeneration of the nucleus is dessication, manifest as low
type 1 fibers and is anchored to the vertebral endplates by signal intensity on T2-weighted images instead of high signal
perivertebral ligaments. The inner annulus is composed of of normally hydrated disks (Fig. 10.2). Although it is usually
Degenerative Disease of the Spine and Joints 151

A B C
Figs 10.1A to C: Sagittal T1-weighted (A) T2-weighted (B) and axial T2-weighted (C) MR images of
lumbosacral spine show normal intervertebral disk that is slightly lower signal intensity than bone marrow
on T1-weighted images and with higher T2 signal. The annulus is seen as a peripheral region of low signal
intensity on T2W images (arrow) and nucleus pulposus (N) is hyperintense. A horizontal internuclear cleft
is seen on T2W sagittal image

fibrocartilage in the nucleus pulposus and replacement by


dense fibrous tissue and cystic spaces. The disk becomes
more and more fibrous and disorganized with no clear
distinction between nucleus and annulus.4 Negative pressure
produced by abnormal spaces pulls in gas, predominantly
nitrogen resulting in vacuum disk phenomenon (Figs 10.3A
and B). The disk may show linear or patchy low signal
intensity either due to gas or sometimes, calcification. When
occasionally fluid may be pulled instead of nitrogen, there
may be paradoxical high signal appearance of the disk on
T2WI instead of the low signal intensity of dessicated disk.
Associated disk narrowing and endplate changes and
osteophytes are pointers that this seemingly hydrated disk
is a degenerated disk. With progress of degeneration, disk
calcification may occur. This can appear as increased or
decreased signal on T1WI. Paradoxical high signal on T1WI
may be seen depending on the amount and state of
Fig. 10.2: Sagittal T2-weighted MR image of lumbosacral spine shows calcium.4,6
decreased T2 signal of L4/5 disk with loss of differentiation between Annular disruption is a critical factor in degeneration.
nucleus and annulus fibrosus suggestive of disk desiccation. Note Annular fiber degeneration may result in tears: (1) Type 1
made of transitional vertebra
circumferential or concentric tears, (2) Type 2 radial tears
and (3) Type 3 transverse tears. Concentric tears are tears
asymptomatic, it suggests disk overload and is a precursor that run longitudinally along the plane of collagen fibers and
to further degenerative abnormalities. 1,2 There is precede annular bulging. These are seen as focal
progressive loss of disk height. The one morphological feature hyperintense areas in the external aspect of the annulus.
that characterizes disk degeneration is annular radial tears. Transverse tears are ruptures of Sharpey’s fibers adjacent to
Development of annular radial tears results in shrinkage of the ring apophyses and can be seen in normally hydrated
152 Infections/Inflammations

disk. Radial tears are linear rupture of the annulus fibers discography in detecting radial tears.5 On MRI, radial tears
extending from the nucleus pulposus traversing the entire appear as hyperintense transverse band into the annulus on
inner-to-outer dimension of the annulus and correlate with MRI (Figs 10.4A and B).1,2 These high intensity zones (HIZ)
shrinkage and disorganization of the nucleus. This can may enhance suggesting ingrowth of granulation tissue.
progress to more severe disruption and disk herniation. However, presence of HIZ or even their enhancement is no
Megnetic resonance is less sensitive than cryomicrotomy or more thought to be correlated with the acuity of the tear.

A B
Figs 10.3A and B: Axial CT (A) and sagittal multiplanar reformatted CT (B) images show
vacuum phenomenon seen as air within multiple intervertebral disks. Note also made of marked
hypertrophy of the left facet joint seen on the axial image and wedge compression fracture of
L1 vertebra on the sagittal image

A B

Figs 10.4A and B: Sagittal (A) and axial (B) T2-weighted MR images of lumbosacral spine
depict disk desiccation with annular tear seen as high intensity zone at L5/S1 level
Degenerative Disease of the Spine and Joints 153

Disk Herniation remodeling because of osteoporosis or even partial volume


averaging.6
Herniation is the term used most commonly to describe the Disk herniation can be classified into disk protrusion and
displacement of disk material. It can involve displacement disk extrusion. When the greatest distance between the
of the nucleus pulposus, endplate cartilage, fragmented edges of the disk material beyond the disk space is less than
apophyseal bone or annular tissue beyond the normal the distance of the edges at the disk base in all planes, it is
confines of the disk space. referred to as disk protrusion. The disk protrudes through a
To bring uniformity to reporting of disk degeneration, defect in the inner annulus but the outer annular fibers are
North American Spine Society, American Society of Spine intact. Protrusions may be classified as focal or broad, based
Radiology, and American Society of Neuroradiology on their degree of disk involvement. It is termed a focal
combined their committees, yielding a consensus paper on protrusion when it involves less than 25 percent of the disk
nomenclature of disk degeneration.7 circumference, whereas the term broad-based protrusion is
Disk herniation is localized displacement of the disk used when it involves between 25 and 50 percent of the disk
material, involving less than 50 percent of the circumference circumference (Figs 10.6A and B).1,2,8
of the disk. In contrast, disk bulge by definition is not When the distance between the edges of the disk
herniation and is the term used when there is a smooth material beyond the disk space is greater than the distance
circumferential extension of the disk margin beyond the between the edges of the base in at least one plane, it is
boundary of the adjacent vertebral endplates in greater than called disk extrusion (Figs 10.7A to C). The extruded disk
50 percent of the disk circumference. This is usually less than suggests complete rupture of the annulus fibrosus. Disk
3 mm beyond the edges of the vertebral body. The annulus extrusions may be further classified into migrated or
fibrosus is grossly intact, although weakened due to tears in sequestrated disks. The disk that displaces away from the
the oblique collagen bridges between the concentric annular site of extrusion but still maintains continuity with the parent
fibers. The concentric fibers are intact. On MR, there is disk is known as a migrated disk. Sequestrations are disk
uniform circumferential extension of the outer disk margin. extrusions that get detached from the parent disk. This is
There is usually loss of height of the involved disk space and clinically very relevant as a sequestered disk may be a
desiccation of the nucleus pulposus (Figs 10.5A and B).1,2,8 contraindication to minimally invasive therapies such as a
Apart from degeneration, disk bulge has several etiologies- microdiscectomies, percutaneous radiofrequency ablations,
normal variation, ligamentous laxity, vertebral body or the use of intradiscal steroids.1,2,8

A B
Figs 10.5A and B: Axial T1 (A) and T2-weighted (B) images at L4-5 level show diffuse disk bulge with ligamentum
flavum hypertrophy resulting in canal and lateral recess stenosis. Note that ligamentum flavum are better discernible on
T1 rather than T2-weighted image
154 Infections/Inflammations

A B
Figs 10.6A and B: Sagittal (A) and axial T2-weighted (B) MR images depict broad based disk
protrusion at L5/S1 level. On the sagittal image, the herniated disk is seen to lie within the confines
of the disk margins

A B C

Figs 10.7A to C: Sagittal T1 (A), sagittal T2 (B) and axial T2-weighted (C) MR images reveal
markedly decreased disk space between L5/S1 with disk extrusion that is seen to extend beyond
the confines of the disk space on the sagittal image. On the axial image, the extruded disk is seen
to impinge on the traversing S1 nerve root on the right side. Note made of type 2 endplate marrow
changes seen as bright signal on both T1 and T2-weighted sagittal images

Other descriptions of intervertebral disk herniations may posteriorly by the PLL. This terminology is used when PLL
also be described according to their relationship with the can be seen as a distinct structure. Normally, it may be
posterior longitudinal ligament. They may be categorized difficult to distinguish the PLL from the outer annulus and
as subligamentous (disk herniation is ventral to the PLL), the dura. The relationship to PLL is related to the sagittal
transligamentous (disk has extended through the PLL), or location of the abnormality. In the midline, PLL is firmly
extraligamentous (disk has herniated in a region not bounded attached to the posterior vertebral body and no potential
Degenerative Disease of the Spine and Joints 155

space exists between the two. In the paramidline location show spontaneous reduction in size. This may be due to
the PLL narrows and is not firmly attached to the vertebral dehydration, fragmentation and phagocytosis of the disk
body and a potential space exists between the two, known material. This is greatest in extrusions and sequestrations.2,9
as the anterior epidural space. This is the space where disk Radiology is also involved in interventional techniques
fragments are frequently trapped.8 for therapeutic purpose, e.g. automated discectomy,
In the axial plane, it is classified into various zones as percutaneous laser disk decompression, intradiscal oxygen-
central, subarticular (lateral recess), foraminal and ozone injection. Their success rates range from 70 to 80
extraforaminal (far lateral). The medial edge of the facet percent with minimal potential complications.2
articulations and the borders of the pedicles or the neural
formina are used for anatomic landmarks, although they Endplate Changes
may be difficult to interpret on axial images as they are These are a reflection of abnormal stresses—loading or
curved structures.8 motion stresses. According to Michael Modic, endplate
The axial classification is useful as it describes the changes can be classified into three categories.4
herniation relative to the various exiting and traversing Modic type 1 changes (vascular pattern) correspond to
nerves. Lumbar disk herniations generally produce symptoms active inflammation, showing decreased signal on T1WI and
involving the nerve root inferior to the level of herniation as high signal on T2WI. Type 2 changes (fatty pattern) reflect
it compresses the transiting inferior root. However, an fatty infiltration and show bright signal on both T1 and T2
extraforaminal or foraminal disk herniation may compress weighted images (Figs 10.7A and B). Type 3 changes (sclerotic
the exiting root at the same level. In the cervical spine, disk pattern) are seen in advanced chronic stage, and correspond
herniations tend to involve the nerve root at the same level. to bone sclerosis. This is seen as decreased signal on both T1
This information is important to determine whether patient’s and T2-weighted images. These changes are also apparent
symptoms are attributable to MR imaging findings, for on radiographs and CT (Fig. 10.3A).1,2 Sometimes, more than
preoperative planning and to avoid surgery at the incorrect one type of Modic change can be seen at the same level.
spinal level.1 The relationship with degenerative disk disease is
Magnetic resonance is the most frequently used probably caused by multiple factors—common
technique for evaluation of disk herniation as it has high biomechanical factors, raised mechanical stresses on the
inherent soft tissue contrast. Contrast MRI is usually not endplates induced by disk dehydration and disk metabolism
required and is more used in postoperative examinations to changes. Endplate alterations can also induce disk changes
differentiate residual and recurrent herniations from scar as disk is an avascular structure supplied by metabolite
tissue. It may also be used sometimes in the preoperative diffusion from endplate cartilage. The relative lack of blood
setting to detect annular tears and inflammatory processes supply and sparse cell population within the nucleus results
that may accompany acute disk dessication-like facet joint in limited ability to recover from metabolic or mechanical
synovitis and radiculitis. It may also help to differentiate injury.2
herniation from neurinoma. Computed tomography is unable Type 1 may progress to type 2 changes or rarely may
to detect early disk dessication. It can detect advanced revert to normal. Type 1 and type 2 changes may occasionally
changes like disk space narrowing and sclerotic endplate progress to type 3 changes. Type 1 Modic changes have
changes. Computed tomography is more sensitive than MR been positively correlated with back pain. According to Chung
for detecting the presence of transdiscal gas, predominantly et al10 asymptomatic type 1 changes when present are
nitrogen. This is known as the vacuum phenomenon and is generally focal, involve the anterosuperior endplate and
very specific for disk degeneration and is only rarely involve midlumbar spine. In contrast, in symptomatic
encountered in infective discitis.1 Computed tomography is individuals, these are confluent changes superior and inferior
also more accurate in detection of discal calcification and to a degenerated disk, and usually seen in the lower lumbar
posterior osteophytes which may have therapeutic spine.
implications. On MRI, bright T1 signal may be found with Sometimes type 1 changes may be so extensive that the
mild to moderate intradiscal calcium deposition.1,2 imaging appearance may simulate infective etiology.
Imaging studies with 6 to 12 months follow-up have However, in infectious process, there is hyperintensity of
demonstrated that nearly 63 percent of disk herniations may the disk on T2WI with enhancement, paraspinal or epidural
156 Infections/Inflammations

inflammation and erosion or destruction of endplate. Disease of Facets, Uncovertebral


Subchondral enhancement may be seen in both cases.1,2 Joints and Ligaments
Sclerotic type 3 changes can be rounded and mimic blastic
metastatic disease on radiographs and CT. However, the The facet or zygoapophyseal joints are synovium lined joints.
degenerative endplate changes are seen abutting the They are oriented nearly in the sagittal plane in the cervical
endplate and there are associated features of disk spine and approximately 40 degrees in the sagittal plane in
degeneration like disk narrowing and vacuum phenomenon.6 the lumbar spine. Like other synovial joints, these are
Focal herniations of disks through cartilaginous endplates predisposed to arthropathy with alterations of articular
may produce Schmorl’s nodes. In most cases, these are cartilage. Facetal joint changes may be primary or secondary
remote occurrences of no clinical consequence. However, to disk degeneration. The latter is believed to be the main
some of them may be traumatic in etiology and can be inciting factor for facet osteoarthritis. Secondary to disk
related to episodes of sudden pain when MR may show degeneration, increased loading on facets and increased
endplate edema representing endplate fracture.1 mobility at a segment can contribute to facet arthropathy.
Most Schmorl’s nodes occur after axial loading and result Facet tropism (asymmetry) and more sagittal orientation of
in extrusion of nucleus pulposus through the endplate rather facets greater than 45 degrees are other hypothesized
than biomechanically stronger annulus fibrosus. Additional causes. It has been postulated that facetal joint degeneration
predisposing factors are intrinsic abnormalities of the is more likely associated with patient symptoms as this is less
endplate due to vascular channels or notochordal remnant frequently found in asymptomatic individuals compared to
defects. Patients with straight rather than concave endplates disk degeneration. Patients usually present with axial pain.
are also more predisposed due to less favorable axial computed tomography is more sensitive in detecting early
loading.3 changes than MRI. The imaging findings include joint space
On CT, Schmorl’s nodes are seen as focal indentations in narrowing, subchondral sclerosis and cyst formation,
the endplate in continuity with the intervertebral disk. There osteophyte formation, vacuum phenomenon and
may be surrounding endplate sclerosis. On MR, we can see hypertrophy of the articular processes (Figs 10.8A and B). In
direct continuity of the disk material into the region of the addition, MR imaging can demonstrate edema in the
endplate defect. In acute/subacute cases, there may be adjacent posterior elements and soft tissues.1
increased T2 signal, typically following the contour of the In the lumbar spine, facetal degeneration is accompanied
endplate which may also demonstrate enhancement.3 by ligamentum flavum hypertrophy contributing to

A B

Figs 10.8A and B: Axial CT image (A) depicts right facet arthrosis seen as erosions, sclerosis and decreased joint
space. T2-weighted axial image (B) of another patient with facet arthritis shows increased fluid within the right facet
joint with accompanying paraspinal muscle atrophy
Degenerative Disease of the Spine and Joints 157

secondary spinal canal stenosis. This is due to fibrosis and present at all levels and not seen in the infants. These joints
loss of elasticity of the ligament. These ligaments are best are lined with cartilage, which is presumably continuous with
assessed on T1-weighted images as these are difficult to the adjacent cartilaginous endplate. These are clinically
differentiate from cortical bone on T2WI (Figs 10.5 and 10.9). important as degeneration of these joints plays an important
In the lumbar spine, posterior paraspinal muscle atrophy role in foraminal stenosis and nerve root compromise in the
also frequently accompanies facet joint degeneration (Fig. cervical spine.3
10.8B).1,3 Narrowing of the intervertebral disk may lead to
Juxta-articular cysts may also be seen accompanying facet abnormal contact between spinous processes, leading to
degeneration, most commonly at L4/5, frequently with degeneration of the spinous processes and interspinous
degenerative spondylolisthesis. These may represent synovial ligaments. This may result in interspinous pseudoarthrosis
cysts, ganglion cysts or cysts of the ligamentum flavum. It is and cyst formation and has been termed Baastrup’s
often difficult to differentiate between these entities by phenomenon. There is localized tenderness that is
radiologic, pathologic or surgical means. Anterior cysts are exacerbated with extension and relieved with flexion,
more likely to be associated with symptoms than posterior anesthetic injections or surgical excision. Redundant
cysts as the former project into the spinal canal or neural interspinous ligaments, interspinous bursae, or hypertrophic
foramina.3 degeneration may extend anteriorly, contributing to spinal
On MRI, these cysts are generally high signal intensity canal stenosis.3
on T2WI. Some portions may be low SI on T2WI due to
calcification or gas. Adjoining facet joints may show increased Spondylosis Deformans and
amount of fluid within. These may be treated surgically or Intervertebral Osteochondrosis
percutaneously, while spontaneous regression is also Degeneration of the disk affects both the nucleus and the
known.1,3 annulus simultaneously. The imaging appearance depends
In the cervical spine, in addition, uncovertebral joints on the predominant component.
can undergo degeneration (Figs 10.10 A to C). These develop Spondylosis deformans essentially affects the annulus
between the uncinate processes of the lower vertebrae and fibrosus and adjacent apophyses. The classic sign of
the lateral margin of the superior vertebrae and are found spondylosis deformans is osteophytosis. Osteophytes are bony
from C2-3 level to C6-7 level. These are variable joints, not spurs that originate on the anterolateral aspect of the

A B
Figs 10.9A and B: Axial (A) and sagittal T2W (B) MR images show facetal degenerative
changes more marked on the left in the axial image with evidence of ligamentum flavum
hypertrophy resulting in narrowing of the spinal canal at L3-L4 and L4-L5 levels
158 Infections/Inflammations

A B C

Figs 10.10A to C: Coronal reformatted CT image (A) shows normal uncovertebral joints in cervical spine. Coronal reformatted CT
image in another patient with extensive spinal degenerative changes (B) depicts marked arthrosis involving uncovertebral joints as
well as endplate changes. Axial CT image (C) of the same patient depicts uncovertebral arthrosis with neural foraminal narrowing

vertebral bodies a few millimeters from the margins of the


disk space (Figs 10.11A and B). Increased vertebral motility
due to weakening and radial degeneration of annular fibers
and resultant traction on Sharpey’s fibers stimulates
osteogenesis. Initially, osteophytes have a triangular
horizontal extension (in contrast to syndesmophytes in
seronegative arthropathies which are vertically oriented).
In more advanced cases, osteophytes become hooked and
grow more vertically. These may fuse together on either
side of the disk space to form bridging osteophytes. The
mucoid matrix of the disk becomes fibrous; however disk
height is normal or only slightly decreased and the disk
margins are regular. Posterior osteophytes, although less
common, are clinically more relevant because of possible
compression of neural structures. They have a triangular
shape with marginal location. Large posterior osteophytes
may result in spinal stenosis, with compressive myelopathy, A B
especially in the cervical region.1-3 Figs 10.11A and B: Lumbar spine AP and lateral radiographs depict
Spondylosis deformans is considered a paraphysiological marginal osteophytes at L2, L3 and L4 levels with relatively preserved
change as it is found in 60 percent of women and 80 percent disk spaces
of men after the age of 50 years. They may be considered
pathologic when severe or symptomatic.2 Plain films are In contrast to spondylosis, vertebral osteochondrosis is a
adequate for the diagnosis of spondylosis. Computed pathological process, although not always symptomatic. It
tomography and MRI, although can depict osteophytes are involves primarily the nucleus pulposus and vertebral end
useful for other associated degenerative changes or to plates. There is accompanying fissuring of the annulus
establish relationship between osteophytes and neural fibrosus. Early disk changes seen on sagittal FSE T2WI include
structures. loss of normal T2 hypointensity within nucleus. Late changes
Degenerative Disease of the Spine and Joints 159

include further decreasing signal within the nucleus pulposus, In severe lumbar canal stenosis, sometimes “redundant
loss of distinction between nucleus pulposus and annulus nerve roots” is seen as enlarged and swollen cauda equina.
fibrosus, disk space narrowing, disk bulges, vacuum This may be due to radicular venous congestion, ischemia
phenomenon and endplate changes. Posterior osteophyte and edema.2
formation may also occur at this stage. 2 Computed Myelopathy is the most serious complication of canal
tomography can detect later changes, including disk stenosis. It is thought that continuous pinching of the cord
calcification, gas within disk space and also aid in can result in chronic hypoperfusion and result in
differentiating oseophytes from degenerated disk.3 demyelination and neuronal death. Increased intramedullary
signal on T2WI is seen (Fig. 10.12) that indicates the presence
Complications of Degenerative of edema, chronic ischemia, myelomalacia or rarely
Spinal Disease syringomyelic cavitation. Enhancement on T1WI may confirm
the abnormality. Low signal on noncontrast T1WI suggests a
Spinal and Foraminal Stenosis poor prognosis. However, it must be remembered that
Lumbar canal stenosis is the most common acquired disorder absence of abnormal signal does not rule out myelopathy, as
in elderly population, caused by degenerative changes and clinical and electrophysiological criteria may be more
primarily manifesting after the 6th decade of life. Congenital sensitive. ADC maps and diffusion tensor imaging may
stenosis presents earlier in life with multilevel involvement improve the sensitivity in detecting subtle changes, but
and fewer degenerative changes.1 decrease the specificity.3
Congenital stenosis is seen in patients with disorders such Facet hypertrophy, PLL thickening or disk herniation can
as achondroplasia and mucopolysaccharidosis or may be lead to encroachment of lateral recesses. This is best
idiopathic. It is usually related to short pedicles, short laminae evaluated on axial images and is found most commonly at
or sagittal orientation of facet joints. Any superimposed L4-5 level. The normal sagittal diameter of the lateral recess
pathological process is much more likely to cause is > 5 mm; when this space is less than 4 mm, it is considered
symptomatic compression. Acquired stenosis is most stenotic.2,3
commonly due to degenerative changes and usually involves Disk and facet degeneration can also project into the
the cervical and lumbar spine. The central canal may be neural foramina, causing their narrowing. Remodeling of
narrowed anteriorly by degenerated disk, posterior bulging
of posterior longitudinal ligament or posterior osteophytes
and posteriorly by facet joints and ligamentum flavum.1,3
Other less common causes of acquired spinal canal stenosis
include ossification of the PLL (OPLL) and /or LF (OLF) and
epidural lipomatosis.
Although absolute measurements may not be clinically
relevant in all cases, the diagnosis of spinal canal stenosis
should be considered if the anteroposterior diameter of the
cervical and lumbar canals is less than 12 mm and in the
thoracic region if it is less than 10 mm. Stenosis may also be
considered if the ratio between canal sagittal diameter and
vertebral body sagittal diameter is <0.8. More than objective
canal measurements, it is the subjective evaluation of canal
morphology and relationship between containing and
contained structures that correlates better with patient’s
symptoms. Epidural fat is reduced or disappears. Multiple
anterior and posterior notches can be observed on the dural
Fig. 10.12: Sagittal T2-weighted image of the cervical spine shows
sac, with disappearance of the subarchnoid space and
multiple disk bulges and posterior longitudinal ligament thickening
narrowing of the spinal cord. The stenosis is severe if CSF signal resulting in thecal sac indentation with hyperintense signal within the
is completely effaced on axial T2WI or CT myelogram images.1,2 cord suggesting myelopathy
160 Infections/Inflammations

the endplates secondary to disk degeneration results in wider


and shorter vertebral body and this may also cause narrowing
of the spinal canal, lateral recesses and neural foramina.
Loss of disk height may result in anterosuperior slippage of
the facet joint and narrow the craniocaudal diameter of the
foramen and hence, contributing to neural foraminal
narrowing. In the cervical spine, neural foraminal narrowing
is most commonly caused by uncovertebral osteophytes.
Lumbar neural foramina are well seen on both axial and
sagittal MR images whereas cervical neural foramina are
best evaluated on axial MR images.1,3 On sagittal MRI,
foramen is seen as an ovoid structure, filled with cerebrospinal
fluid and fat. Mild narrowing is seen as a “keyhole”
appearance. Moderate narrowing effaces the inferior
portion of the foramen at the level of the disk. Severe
narrowing results in effacement of the fat in the foramen.
There may be loss of fat around the exiting nerves and thecal
sac. There may be effacement of contrast or CSF around Fig. 10.13: Coronal reformatted CT image reveals laterally directed
nerve roots in the lumbar cistern. Inflammatory changes osteophytes on the concavity of scoliosis with vacuum phenomenon
at multiple levels
around the entrapped nerve may enhance on gadolinium
administration. It must be remembered that correlation with
symptoms of radiculopathy is essential to diagnose nerve Segmental Instability
root impingement.3 Disk degeneration can lead to narrow disk space and buckling
Computed tomography is the gold standard for evaluation of ligamentum flavum which can further result in an unstable
of bony abnormalities, and is accurate for identifying vertebral segment. Resultant malalignment may result in
posterior osteophytes and calcification of ligaments. anterolisthesis, posterolisthesis, rotolisthesis (rotational
Magnetic resonance imaging depicts the disk pathology and spondylolisthesis) or lateral spondylolisthesis. Degenerative
nervous structures clearly.2 rotolisthesis occurs classically secondary to disk degeneration
Spinal cord or nerve root compression is a dynamic and results in canal and foraminal stenosis. It may also
phenomenon that worsens in erect position or with certain occur secondary to asymmetric facet degeneration.
movements. The stenosis can become more evident or Anterolisthesis occurs mostly at L4-5 level, secondary to facet
sometimes, may only be evident during weight bearing or degeneration. In patients with degenerative scoliosis, lateral
dynamic examination.2,3 and rotolisthesis is often encountered.3 Posterolisthesis,
which is associated with facet and disk degeneration, is
Scoliosis and Kyphosis
frequent at more mobile spine segments such as the cervical
Asymmetric degenerative disk changes can result in and upper lumbar spine.2 The typical sites of degenerative
degenerative scoliosis (Fig. 10.13). This tends to produce a spondylolisthesis are L3-4 and L4-5, because of more sagittal
positive feedback loop that tends to accelerate the orientation of facet joints.
degenerative changes on one side. Compared to idiopathic Spondylolisthesis may also result from pars interarticularis
scoliosis, degenerative scoliosis is usually short segment and defects (spondylolysis) and the most common is the isthmic
most often occurs in the lumbar spine. Also, loss of lumbar type of spondylolysis. This is most commonly seen at L5 and
lordosis and spinal and foraminal stenosis are more common L4 vertebrae and is a defect in pars interarticularis which is
with degenerative scoliosis. Thoracic kyphosis in adults is considered a fatigue fracture. Other less common causes of
frequently secondary to asymmetric degeneration in the spondylolisthesis are acute trauma, congenital dysplasias,
anterior portions of the disks.3 tumors and iatrogenic causes. Spondylolisthesis due to pars
Degenerative Disease of the Spine and Joints 161

defect may be distinguished from degenerative may be diagnosed as loss of alignment of one or more vertebral
spondylolisthesis on imaging. The former depicts canal lines. Other radiographic signs are vertebral slippage,
widening at the involved level (Figs 10.14A to C) whereas variations in pedicle length, narrowing of neural foramina,
the latter demonstrates canal narrowing at the affected and loss of disk height. Conventional MRI has a limited role. It
level because of slippage of the posterior arch and facet may show displacement and pseudobulging of disk at the
hypertrophy.1,2 involved level. Axial loaded CT or MRI or upright MRI can
Secondary to segmental instability, hypertrophy of the provide functional information regarding vertebral stability.2
ligaments, facet osteoarthritis, and osteophyte formation,
may develop which have an additive effect on narrowing of Clinical Implications
the spinal canal and foramina. These osteophytes may aid in Clinical features and imaging findings need to be always
stabilizing the spinal segment, which may be shown on evaluated together to plan appropriate therapeutic strategy
kinematic MR imaging.3 as symptoms and imaging findings do not always correlate
Vertebral body movement may be seen on flexion, well. Roudsari and Jarvik11 concluded that imaging is not
extension and lateral bending radiographs where instability necessary with low backache in patients who have no signs

C B
Figs 10.14A to C: Axial (A) and sagittal reformatted CT (B) images reveal lysis of pars interarticularis of
L4 with spondylolisthesis of L4 over L5 resulting in widening of the AP diameter of the spinal canal. T2-
weighted axial MR image (C) of another patient shows break involving pars interarticularis of L4 with
widening of spinal canal
162 Infections/Inflammations

or symptoms of systemic disease and who have no clinical It is also valuable in treatment planning for chondral
suspicion for serious spine problems. However, if there is no lesions and in following cartilage reconstructions
clinical improvement after medical/noninvasive therapy at longitudinally. It may reduce the need for more costly
one month follow-up, imaging must be cosidered. Spinal and invasive diagnostic arthroscopy. Whenever accurate
stenosis and radiculopathy should also be evaluated by evaluation of surface changes is needed, arthrographic
imaging if symptoms persist for more than one month. techniques may be done. MR imaging and MR
arthrography is being increasingly done to obtain detailed
DEGENERATIVE DISEASE OF JOINTS information about the status of the degenerated joints
prior to prosthetic replacement. MR imaging reliably
Prevalence and Incidence of shows the whole spectrum of osteoarthritic changes
Osteoarthritis accurately.
Osteoarthritis has a predilection for certain joints while 3. Computed tomography: CT provides excellent contrast
sparing others. For example, in the hands, the distal resolution and has the advantage of allowing excellent
interphalangeal, proximal interphalangeal, and carpo- display of the bones of the affected joint. CT
metacarpal joints are frequently affected, whereas the wrists arthrography, an excellent tool for measuring cartilage
are rarely affected. Other frequently affected joints include thickness, may be done when MR arthrography is not
knee, hip and metatarsophalangeal joint. The ankles and possible (e.g. not available, claustrophobia, metallic
elbows are usually spared.12 implants). It has the inconvenience of radiation exposure
Approximately 32.5 percent of adults aged 30 years and and is limited to evaluation of surface lesions only. DECT
older have radiographic evidence of osteoarthritis in the is a promising technique with potential application in
hand in at least one joint.13 According to data from the evaluation of tendons, ligaments and can aid in reduction
Framingham study, radiographic knee osteoarthritis occurs of metal artifacts.15
in at least 33 percent of persons aged 60 years and older.14 4. Radionuclide scintigraphy: 99mTechnetium scintigraphy
Another feature of osteoarthritis is the higher prevalence is a very sensitive method that reveals increased indicator
and more often generalized distribution in women than in uptake in very early stages of OA and allows evaluation
men. For most joints, before the age of 50 years, men have of compartment distribution. Because of the poor
a higher prevalence of the disease than do women. After specificity of these changes, scintigraphy is used only as
age of 50 years, women have a much higher prevalence of a screening method and for follow-up studies.
disease than do men. The reasons for this gender difference
may be related to the hormone deficiency that develops in Pathogenesis
women around age of 50 years.12 The joints are used over and over again. Whether this use
constitutes a dynamic trophic and healthy effect on joints or
Imaging Modalities an injurious effect depends on the activities involved and the
1. Conventional radiography: It is the initial examination vulnerability of the underlying joint. Most daily activities,
performed in routine evaluation of degenerative even if performed repeatedly over many years, do not
arthritis. It is a sensitive and cost-effective modality, produce sufficient injury to a joint to cause osteoarthritis.
therefore appropriate for large scale studies and follow- Joints become susceptible to injury and subsequent
up of patients. However, it does not directly demonstrate osteoarthritis when local factors in the joint combine with
the articular cartilage and soft tissues of the joint. systemic vulnerabilities.12
2. Magnetic resonance imaging: MR imaging provides Hyaline articular cartilage loss is a signature event in
excellent soft tissue contrast. With its ability to osteoarthritis. Articular cartilage is a complex structure that
differentiate tissues according to their biochemical consists of a gel extracellular matrix composed of 80 percent
properties and to obtain images in multiple planes, MRI water and 20 percent solids that include collagens (mainly
is the optimal modality to assess pathologic conditions of type II), proteoglycans, and noncollagenous proteins.14 The
joints. MR imaging allows direct visualization of the unique biomechanical properties of articular cartilage in
articular cartilage, inflamed synovium, other soft tissues response to mechanical loading result from the flow of water
like joint-capsule, menisci, and ligaments noninvasively. through the intercellular matrix. Mature chondrocytes
Degenerative Disease of the Spine and Joints 163

seldom divide but remain metabolically active, synthesizing that occur as part of aging make the joint susceptible to
and turning over matrix proteoglycans. A complex network disease.
of cytokines and growth factors secreted by synovial lining There is a higher percentage of hand and hip
cells and by chondrocytes controls the level of matrix osteoarthritis due to inheritance than knee osteoarthritis.18
synthesis and degradation. Aggrecan is a macromolecule It is likely that multiple genes confer an increased risk for
consisting of small highly negative charged glyco- osteoarthritis. It is increasingly likely that the genetic
saminoglycan chains that are forced into close proximity predisposition to osteoarthritis will be based on a variety of
and electrostatic repulsion by the collagen II chains physiologic vulnerabilities, including alterations in minor
interwoven through the matrix. The electrostatic repulsion collagens within cartilage, changes in enzymes or their
of aggrecan gives cartilage its compressive stiffness. In early activators within cartilage, variations in cytokines, or growth
osteoarthritis, despite an increased production of aggrecan factor profiles in cartilage and genes that dictate joint shape
and matrix in general, the net concentration of aggrecan in and structure.12
cartilage falls as degradation outweighs synthesis. Osteoporosis and osteoarthritis are inversely
Eventually, superficial fibrillation and cracking of the matrix associated—persons with high-bone density are at high-risk
occur, which are followed by focal disintegration and for osteoarthritis.19 A part of, but not all, of this relationship
ulcerations of cartilage.16 between high-bone density and osteoarthritis is explained
Deep to cartilage loss is an increased quantity of by obesity causing osteoarthritis and also being strongly
subchondral bone. Bone grows into the calcified cartilage. At associated with high-bone density. Attrition and perhaps even
the joint margins, chondral structures form at sites of tension, low-bone density are associated with the progression of
and endochondral ossification occurs in these structures, osteoarthritis, and it seems likely that high-bone density
producing chondro-osteophytes, so called “osteophytes”. contributes only to the initial occurrence of disease and not
Osteophytes form in areas of low stress, increasing the surface necessarily to its progression.20
area of the articular cartilage, thereby, decreasing the stresses Inconsistent data exist on the relationship of estrogen
that are experienced by the joint and increase joint stability. deficiency to osteoarthritis in women. Women have a high-
They commonly form at the margins of the joint where risk for osteoarthritis after about age of 50 years, much
increased vascularization of subchondral bone stimulates higher than the risk for men. Studies have been inconsistent
endochondral ossification.12,16 Synovial hypertrophy and regarding whether estrogen replacement therapy eliminates
fibrosis are seen in most joints affected by osteoarthritis, and that risk. Preliminary data suggest that nutritional
local synovitis affects 20 to 30 percent of diseased joints. deficiencies may increase the occurrence or progression of
Synovial involvement in osteoarthritis may contribute to osteoarthritis, including low-level intakes of vitamin C,
disease by serving as the source of cytokines such as interleukin- vitamin E, and vitamin D.21
1 that may turn off chondrocyte-mediated cartilage matrix
synthesis and trigger synthesis of degradative enzymes, by Local Joint Vulnerabilities
secreting excess synovial fluid that makes the joint-lax and Factors that affect joint shape are likely to have an
vulnerable to injury.12 important role in causing osteoarthritis, especially in the
A sound knowledge of the pathophysiology of hip. Developmental abnormalities occurring during infancy
degenerative arthritis is important for understanding disease or childhood that leave a hip-joint misshapen and that
progression and its timely management. increase local stresses to cartilage in that hip-joint
The causes of OA include systemic factors, such as predispose to hip osteoarthritis in early adulthood. The
genetics, estrogen use and bone density, and biomechanical three types of congenital and developmental abnormalities
factors that affect the joints, including muscle weakness, that are most commonly implicated are congenital
obesity, joint-laxity, and alignment.17 dysplasia, Legg-Perthes disease, and a slipped capital
femoral epiphysis. Although these abnormalities are rare
Systemic Risk Factors
in childhood, milder forms may be more common and may
Osteoarthritis is a disease of aging, but age alone does not account for a large percentage of osteoarthritis of the hips
cause osteoarthritis; rather, the vulnerabilities of the joint in adults.22
164 Infections/Inflammations

A major injury to a joint can cause permanent damage osteoarthritis. In men, such jobs may account for as much
to many of the structures within a joint and can serve as the osteoarthritis as obesity.27
incipient lesion of osteoarthritis.12 Most studies of runners have suggested that they are
An important interplay occurs between systemic and local not at especially high-risk for knee osteoarthritis. This may
joint vulnerabilities. Injury to the knee in an adolescent is not be true for nationally competitive professional runners
unlikely to cause osteoarthritis quickly, if at all. In contrast, who are more likely to have hip osteoarthritis.24
older joint is more vulnerable to major injury than the younger
joint.23 Limb malalignment markedly increases the risk of Radiographic—Pathologic Correlation
progression of knee osteoarthritis.16 Altman et al28 defined OA as “a heterogeneous group of
conditions that lead to joint symptoms and signs which are
Extrinsic Factors Acting on the Joint associated with defective integrity of articular cartilage, in
addition to related changes in the underlying bone and at
Obesity: Persons who are overweight have a higher
the joint margins”. The need to separate idiopathic (primary)
prevalence of knee osteoarthritis. Weight probably increases
OA from OA that is related to an underlying condition
the risk for knee osteoarthritis by increasing the amount of
(secondary) was stressed. Articular degeneration occurs
mechanical load across a joint. Indeed, every pound of weight
without a pre-existing insult in primary OA, or as a result of
is multiplied threefold to sixfold in terms of its effect on knee
previous injury or underlying condition in secondary OA.29
loading. Although, obesity markedly increases the risk for
The most typical pattern of OA is the presence of
knee osteoarthritis, its relationship to hip osteoarthritis is
reparative changes in both the stressed and nonstressed
not as strong.24 By distributing the weight-bearing load more
aspects of the joint. In the stressed segment of the joint,
broadly, hip-joints may be protected against the effects of
cartilage damage is evidenced by thinning of the cartilage
being overweight.
rim and development of erosions and ulceration. Such
Muscle weakness: As a consequence of disease, persons with damage is followed by hypervascularity of the articular
osteoarthritis have weakness in the muscles that bridge, cartilage. The radiologic picture is characterized by joint
the diseased joint. Affected persons become relatively space loss. Subchondral infraction, compression and necrosis
inactive, leading to muscular atrophy. Also, direct neurologic of bone trabeculae lead to bone sclerosis on radiographs.30,31
messages transmitted by a swollen joint through afferent Other subchondral changes, such as formation of cystic lesions
impulses inhibit the maximal contraction of muscles bridging as a result of either synovial fluid intrusion or bone contusion,
joints, leading to apparent weakness. This weakness most occur in the stressed segment.31-33
likely accounts for much of the disability and may increase In the nonstressed segment, reparative changes lead to
the risk of progression. osteophytosis. 34 Osteophyte formation is the most
characteristic feature in OA. They commonly form at the
Joint Overuse from Occupations and Athletics margins of the joint where increased vascularization of
subchondral bone stimulates endochondral ossification.15
The normal joint is built to withstand the considerable
Osteophytes can be classified as marginal, central,
dynamic loading that occurs with daily activities. It provides
periosteal, and capsular or synovial depending on their origin.
healthy trophic influences to cartilage and other joint
Marginal and central osteophytes develop through
structures.25 When activity is excessive or when normal
endochondral ossification after vascularization of
activity acts on a vulnerable joint, joint injury and eventually
subchondral bone marrow. Periosteal osteophytes form from
osteoarthritis occur. Two examples are athletic and
a process resembling appositional bone growth due to
occupational activities.
stimulation of periosteal membrane; capsular osteophytes
Prolonged continuous activity may injure the joint when
develop in reaction to capsular traction forces.
it is past the point where joint protective mechanisms are
effective.24,26 Subchondral sclerosis: It is believed to be caused by
Particular types of activities that occur in a variety of redistribution of stress that results from progressive cartilage
jobs pose a high-risk of later development of osteoarthritis. loss. Subchondral sclerosis occurs at these sites as a result of
Examples include jobs that require regular knee bending deposition of new bone on pre-existing trabeculae and
and lifting or carrying heavy loads, which predispose to knee trabecular microfractures with callus formation.
Degenerative Disease of the Spine and Joints 165

Subchondral cysts: They appear between thickened Fragmentation of the cartilaginous or osseous surface,
subchondral trabecula. Cysts often are multiple, and, especially in advanced disease can lead to the formation of
histologically, can contain myxoid and adipose tissue, intra-articular bodies, which may be either embedded on
occasional cartilage with surrounding fibrous components the surface or loose in the joint cavity. Depending on their
and are bordered by peripheral sclerotic bone.35 Proposed size and location, intra-articular bodies can cause joint
theories of the pathogenesis of cyst formation include bony inflammation with clinical symptoms and acceleration of
microcontusions that leads to extension of synovial fluid into osteoarthritis.
the subchondral bone through tiny gaps in the articular The radiographic appearance of OA in different joints
surface,36 or the proliferation of myxomatous tissue within varies, being dependant on anatomic relationships and the
the bone narrow.35 stress to which each joint is subjected. The two weight-
bearing joints that are affected most frequently by OA, are
Radiologically, the marginal osteophytes represent lips of
the hip and the knee.
new bone around the joint edges (Fig. 10.15). Osteophytes
of the central type lead to new bone formation in the center
HIP OSTEOARTHRITIS
of the joint and therefore may produce an irregular contour
of the joint surface. Radiographs of periosteal osteophytes Radiographic Views
reveal an area of thickened cortex. This type is most common
at the medial aspect of the femoral neck, where it is called Standard views performed include a supine anteroposterior
buttressing. Capsular osteophytes extend along the direction (AP) view of the pelvis, an AP view of the hip, and a frog
of capsular pull. lateral view of the hip with the patient rolled towards the
Besides the articular surface itself, other articular affected side.37 In the anteroposterior view, the femur
structures such as ligamentous and capsular tissue—may should be placed in 15 to 20 degrees of internal rotation to
undergo severe degenerative changes, including thickening, best visualize the femoral neck. In the frog-leg view the
disruption and distortion, which lead radiographically to femur is in 45 degrees of abduction. The superior aspect of
deformation, malalignment and subluxation of the joint. the joint space is visualized but with a different projection of
Degenerative lesions also occur in intra-articular the femoral head. Neither anteroposterior nor frog-leg views
fibrocartilaginous tissue such as menisci in the knee or the allow assessment of the anterior and posterior part of the
labra in hip and shoulders. joint space. Therefore, anterior and posterior oblique views
(between 30 and 45 degrees) are additionally recommended.
All of these views except the frog-leg view can also be
obtained under weight-bearing conditions, which provides
more accurate measurement of the joint space.
The “false profile” view that was first described by
Lequesne and Laredo38 in 1961 has been proposed as a more
sensitive view for diagnosing cartilage space narrowing than
conventional AP views. The “false profile” view is an oblique
lateral view of the hip obtained in the erect position. A recent
series compared cartilage space narrowing that is seen on
conventional AP radiographs and “false profile” radiographs.
Of the cases with doubtful or no narrowing seen on the AP
view, nearly 75 percent showed detectable narrowing on
the “false profile” view. It is recommended in addition to
conventional AP views, to help detect early cartilage space
narrowing in patients who have a clinical suspicion of OA.38

Radiographic Appearance
Fig. 10.15: AP radiograph of the knee shows marginal osteophytes,
seen as lips of new bone near the lateral edge of knee-joint and tibial In 1991, the American College of Rheumatology
spiking in a case of degenerative arthritis subcommittee on criteria for OA summarized the findings
166 Infections/Inflammations

from a multicenter study and suggested clinical and


radiographic criteria for reporting OA in symptomatic
patients.39 These included: (1) cartilage space narrowing;
(2) osteophytosis; (3) subchondral cysts; (4) subchondral
sclerosis; (5) femoral neck buttressing; and (6) femoral head
remodeling. Of these, cartilage space narrowing was the
most sensitive, but least specific. Medial femoral neck
buttressing, when seen, was the most specific. Osteophytosis
had the best overall balance of high sensitivity and specificity
in detecting hip OA. When using radiographs to assess
progression of hip OA, combining cartilage space narrow-
ing with subchondral cysts or subchondral sclerosis produces
the best sensitivity.40
Asymmetric joint space narrowing: It is the most reliable
sign of OA in the hip-joint. Distinctive patterns of nonuniform
loss of articular cartilage lead to the classic patterns of
femoral head migration which can be categorized into three
Fig. 10.16: AP radiograph of the right hip joint shows marked reduction
different patterns: (i) superior migration; (ii) medial
in joint space on the right side, more along the superior joint space
migration; and (iii) axial migration. with osteophytes, subchondral sclerosis and cysts. Note made of
cortical buttressing on medial femoral neck
Superior Migration Pattern
Buttressing can occur on the medial as well as lateral side of
Superior migration is the most common pattern and is seen in
the femoral neck. The differential diagnosis of the superior
78 percent of patients who have OA.41 This can be subdivided
migration patterns is quite limited and includes calcium
into superolateral and superomedial types. The superolateral
pyrophosphate dihydrate (CPPD) crystal deposition disease
type is characterized by unilateral and asymmetric changes,
and osteonecrosis, both associated with secondary
including narrowing of the superior joint space, which causes
degenerative changes.
the femoral head to move superiorly. In more advanced
disease, flattening of the superolateral aspect and lateral Medial Migration Pattern
displacement of the femoral head lead to widening of the
inferomedial joint space. In the pressure zone on the lateral Medial migration of the femoral head can be observed in
and outer aspect of the femoral head and acetabulum, about 22 percent of all patients with osteoarthritis.41 This
sclerosis, cyst formation and osteophytes also can be seen. In pattern frequently shows bilateral and symmetric changes
the femoral neck, medially thickening of the cortex and is more common in women than in men. Radio-
(buttressing) accompanies these findings (Fig. 10.16). graphically, joint space loss in the medial aspect with
Superomedial migration in most cases occurs bilaterally consequent widening of the lateral aspect of the joint space
and in contrast to the superolateral pattern, is more is the most typical finding. Some cases also reveal acetabular
frequent in men than women. After superior movement of protrusion. Osteophytes develop on the lateral and medial
the femoral head with narrowing of the superior joint space sides of femur and acetabulum, and cystic lesions are mostly
and progressive head deformity, broad based osteophytes small. Buttressing can occur on the medial side of the femoral
begin to fill in the apparently widened medial part of the neck. For the medial migration pattern, Paget’s disease and
joint space. The femoral head flattens progressively at the osteomalacia with additional degenerative changes are
superior aspect. These changes produce apparent included in the differential diagnosis.
displacement of the femoral epiphysis. Other findings in this
Axial Migration Pattern
particular migration pattern are osteophytes and cystic
lesions on the lateral and outer aspects of the femoral head Concentric loss of joint space is the characteristic finding in
and acetabulum in association with subchondral sclerosis. the axial migration pattern but it is not specific (Fig. 10.17).
Degenerative Disease of the Spine and Joints 167

of subchondral sclerosis that are visible on radiographs are


smaller than areas of low signal that are identified on MR
imaging.
Subchondral cysts: Cystic spaces appear between thickened
subchondral trabecula. They vary from 2 to 15 mm and are
often multiple. They can contain myxoid and adipose tissue,
occasional cartilage with surrounding fibrous components,
and are bordered by peripheral sclerotic bone.35 Subchondral
cysts in the acetabulum have been referred to as “Eggers”
cysts.15
The term “intraosseous ganglion” is used to describe
acetabular lesions that contain gelatinous fluid. The
combination of a mass and erosion of the adjacent
superolateral acetabulum is characteristic, although non-
specific for paralabral cysts (ganglia). A more specific finding
is gas within the soft tissue mass, apparently due to nitrogen
tracking from the joint. MR imaging showed these juxta-
Fig. 10.17: AP radiograph of the right hip joint shows marked reduction
in joint space on the right side, with axial migration of the femoral head
acetabular soft tissue masses to have intermediate signal
and accompanying osteophytes intensity on T1 and proton density images and high signal
intensity on T2-weighted images. The signal intensity of the
fluid within the ganglion may be greater on T1-weighted
This pattern is infrequent and may cause problems in images than that of the joint fluid because of the cyst’s
differential diagnosis, as diffuse and symmetric joint space greater protein content.42
loss is also present in various other abnormalities, such as
Osteophytosis: Marginal osteophytes occur at the periphery
rheumatoid arthritis and infection. The presence of
of the femoral head or the margins of the fovea. Central or
osteophytes and sclerosis as well as the absence of erosions
interior osteophytes extend from the subarticular surface.
and osteoporosis adjacent to the joint may be helpful for
On radiographs they appear as flat or button-like osseous
differentiation. Even if osteophytes and sclerosis are
projections that cause contour deformities of the articular
combined with axial migration of the femoral head, other
surface. They may be misdiagnosed as intra-articular bodies.
primary diseases such as ankylosing spondylitis, CPPD crystal
Central osteophytes form at the acetabular fossa and
deposition disease, and secondary OA superimposed on
partially or completely enclose it. Periosteal or synovial
rheumatoid arthritis, Paget’s disease or osteonecrosis must
osteophytes form as osseous outgrowths from periosteum
be excluded.36
or synovial membranes. This is most apparent in the medial
Uniform loss of cartilage indicates a primary disorder of
femoral neck where production of cortical thickening or a
cartilage rather than loss secondary to abnormal mechanical
line of new bone formation occurs which is termed
stress. This disorder could be either an inflammatory process
“buttressing”.43,44 Buttressing bone is believed to be due to
or a deposition process. Inflammatory disease will usually
altered stress loads on the femoral neck, possibly from
cause erosive changes and aggressive destruction of
increased neck shaft angle or decreased femoral neck
cartilage. Some inflammatory arthropathies may lead to
diameter. It is most commonly seen with OA and less often
new bone proliferation in the form of ossification of
with avascular necrosis. Identification of this finding makes
ligamentous attachments or ankylosis. Deposition
the diagnosis of inflammatory arthritis unlikely, since it is
arthropathies usually cause slow degeneration of cartilage
rarely seen in patients who have RA or psoriasis.39,43
and secondary osteoarthritic changes.
Osteophytes, sclerosis and cystic lesions are not specific
Subchondral sclerosis: It occurs at these sites because of finding for OA. These changes also can be seen in CPPD crystal
deposition of new bone on pre-existing trabeculae and deposition disease and neuropathic osteoarthropathy, most
trabecular microfractures with callus formation. The areas commonly combined with marked collapse of the femoral
168 Infections/Inflammations

head, and in ankylosing spondylitis, which shows a include anteroposterior (AP) standing, posterior-anterior
characteristic femoral osteophyte extending across the (PA), lateral, and tangential patellar views. The
femoral head-neck border. anteroposterior radiograph is obtained with the patient
There may be some difficulty in differentiating between supine with the central ray directed 5 degrees in a cephalad
medial osteophytes and loose articular bodies in the direction. The lateral view may be obtained with the knee-
acetabular fossa. A linear radiodense shadow favors osteo- flexed (20–35 degrees) or as a cross table radiograph with
phytes, whereas a circular intra-articular shape makes a the knee fully extended. All three joint space compartments
loose body much more likely than an osteophyte. can be assessed with these two views. The tunnel view (a
frontal view with the knee flexed about 50 degrees) provides
Rapid Destructive Osteoarthritis additional information about the intercondylar tubercles and
Rapid destructive osteoarthritis (RDO) is an uncommon the posterior surface of the femoral condyles.1 The non-
subset of hip OA that results in striking bone and cartilage weight bearing tunnel view may demonstrate cartilage loss
loss, usually within a matter of weeks to months. Pain is that is not visible on routine PA, oblique and lateral views or
severe and progressive. Rapid destructive osteoarthritis on standing views.50
(RDO) most often affects elderly women and is usually For accurate assessment of joint space loss, weight-
unilateral. It is postulated that RDO is likely multifactorial bearing radiographs may be helpful. These views reliably
and results from increased levels of bone resorptive enzymes show the extent of joint space loss and the degree of
or the use of anti-inflammatory drugs or intra-articular angulation and subluxation (varus or valgus).51 Complete
corticosteroids.45,46 Watanabe, et al postulated that RDO is evaluation of the femoropatellar joint, however, requires
triggered by mechanical factors, such as insufficiency additional views: (i) The Merchant view is obtained with the
fractures caused by osteopenia, posterior pelvic tilt, and patient in the supine position with the knee-flexed in a
mild acetabular dysplasia, and progresses to end-stage 45 degrees angle. The tube should be angled 30 degrees
disease by inflammation that is due to granulation tissue.47 toward the floor; (ii) Sunrise view—the patient lies in the
Lequesne48 noted rapid destructive osteoarthritis to be prone position with the knee-flexed 90 degrees or more and
defined by cartilage space narrowing of at least 2 mm per the X-ray beam strikes the articular surface tangentially and
year, whereas in the commonly seen form of OA, cartilage so provides information about the joint space. In this view
space narrowing of 0.8 mm is noted yearly. Rapid, marked the patella is deeply situated within the intercondylar fossa
bone loss from the femoral head and acetabulum occurs.49 (Figs 10.18A to C).
Osteophytes are small or absent and buttressing bone is The standing view of the legs is an important study for
absent; cyst like changes and sclerosis are typical features. the evaluation of osteoarthritic deformity and is especially
Radiographic evidence of osteoporosis may be present. The valuable for planning osteotomy correction. The view is
radiographic features may mimic osteonecrosis with obtained using a long cassette to include the hips to the
secondary OA, RA, seronegative arthropathies, infection, ankles. The patient stands with weight equally distributed
or neuropathic arthropathy. on both legs and the patellae directed forward. In a normal
Treatment of RDO is joint replacement. Exclusion of individual, the mechanical axis (a line drawn from the center
septic arthritis and neuropathic arthropathy is of critical of the femoral head to the center of the ankle) passes just
importance preoperatively.15 medial to the center of the knee-joint. The distance from
the mechanical axis to the center of the knee helps quantify
KNEE OSTEOARTHRITIS the deformity in millimeters and is termed the ‘mechanical
axis deviation’.15
Radiographic Views
Radiographic Findings
A large array of radiographic examinations are available for
evaluating the three compartments of the knee. Generally, The knee-joint can be divided into three compartments: the
the goal is to provide a tangential view of the weight bearing lateral femorotibial, medial femorotibial and patellofemoral
joint so that the thickness of the cartilage space can be compartments. In most cases only one or two of these
assessed. Standard radiographs for evaluation of knee OA compartments show evidence of osteoarthritic changes.
Degenerative Disease of the Spine and Joints 169

A C
Figs 10.18A to C: AP (A), lateral (B) and sunrise (C) views of both knees depict marginal osteophytes involving
femorotibial articulation. Degenerative changes are more marked at patellofemoral compartment with osteophytes,
subchondral sclerosis and asymmetric reduction in joint space

Involvement of all three compartments is rare. Most


commonly the medial femorotibial part is involved either
alone or along with the patellofemoral compartment.

Cartilage Space
Asymmetric joint space loss of varying severity is the cardinal
feature (Fig. 10.19). The normal cartilage space on a standing
view is 3 mm or more. Ahlback52 defined cartilage space
narrowing on standing views as a cartilage space of less
than 3 mm, or less than half the width of the same area in
the opposite normal knee, the other compartment of the
same knee, or by the presence of cartilage space narrowing
on weight bearing as compared with nonweight-bearing
views. Buckland-Wright et al53 classified cartilage space
narrowing (on macroradiographic studies), based on the
cartilage space width, as mild (3 mm), moderate (between
3 mm and 1.5 mm), and marked (<1.5 mm). Fig. 10.19: AP radiograph of the knee shows marginal osteophytes
with marked reduction in medial joint space with subchondral sclerosis
Osteophytes and cysts

Four areas of knee osteophyte formation have been


Subchondral Sclerosis
described, marginal, intercondylar, tibial spine, and internal.
Marginal osteophytes are frequently seen at the femoral Cartilage space narrowing is accompanied by subchondral
and tibial margins of the joint as well as in advanced cases at cysts and sclerosis at femoral and tibial locations, most
the intercondylar tubercles. The central type of osteophytes, commonly at the tibial plateau.
most common at the femoral condyles, can be Increased stress across a compartment may be
misinterpreted as intra-articular bodies. associated with subchondral sclerosis. A technique called
170 Infections/Inflammations

“fractal signature analysis” has been used to study the Malalignment


structure of the subchondral bone on 5 × microfocal radio-
In advanced osteoarthritis, angulation and subluxation at
graphs.54 The structure of the medial tibial subchondral bone
the knee-joint can occur. Varus and valgus deformities are
was altered in patients who had OA; the abnormality
diagnosed on weight-bearing films. If a line is drawn through
correlated with the degree of cartilage space narrowing.
the midpoints of the femoral head and the talotibial joint, it
Sclerosis in the subchondral bone of the tibia and femur
should bisect the knee-joint between the intercondylar
suggest severe cartilage loss and should suggest the severity
tubercles. If the axis lies medial to the intercondylar tubercles,
of the disorder, even when the cartilage space does not
the more frequent varus deformity is present; if it lies lateral,
seem to be narrowed.
a valgus deformity is present. Varus alignment is more often
The patellofemoral compartment is affected frequently
seen in patients who have OA than in those who have RA.
in OA, most commonly in combination with involvement of
Varus alignment increased the risk of medial OA progression;
the medial femorotibial compartment (Figs 10.20A and B).
valgus alignment increased the risk of lateral progression.16
Osteoarthritis related changes in the patellofemoral space
Additional signs include small joint effusions, intra-
rarely occur in isolation; if such changes are seen, other
articular bodies of different sizes and bone proliferation.
underlying processes should be excluded.
Sclerosis and flattening of the fabella are signs of sesamoid
The patellofemoral findings include joint space loss with
involvement.
deformity at the patellar articular surface in severe cases and
osteophytes, which can involve an extensive area at the superior
Differential Diagnosis
and inferior aspects of the posterior patellar surface (Fig. 10.18).
Other abnormalities are increased sclerosis at the Distribution of abnormalities among the three joint
dorsopatellar surface and subchondral cystic lesions. Two compartments of the knee can be helpful in establishing
more changes which are nonspecific and found also in other the differential diagnosis. Unicompartmental or
diseases, frequently occur in osteoarthritis: (i) In severe bicompartmental disease is more typical of OA than is tricom-
patellofemoral compartment disease, a scalloped cortical partmental involvement. Pathologic changes in the medial
defect of the anterior femoral surface as a result of femorotibial compartment usually indicate OA, whereas the
mechanical attrition produced by the patella in a fully lateral femorotibial space also can be affected in rheumatoid
extended knee; (ii) Bone proliferation at the site of osseous arthritis and CPPD crystal deposition disease.34
attachment of the quadriceps tendon. Radiographically Symmetric involvement of both femorotibial spaces more
known as the “tooth sign”, this finding consists of hyperostotic frequently is observed in rheumatoid arthritis, ankylosing
changes at the anterior-superior surface of the patella.55 spondylitis and joint infection. Entities such as

A B
Figs 10.20A and B: AP (A) and lateral (B) radiographs of both knees show degenerative arthritis involving medial
femorotibial and patellofemoral compartments in the knee-joint
Degenerative Disease of the Spine and Joints 171

hyperparathyroidism, CPPD crystal deposition disease for example, is not influenced by the presence of cartilage
and chondromalacia patellae may produce isolated space narrowing. Cartilage space narrowing was assessed
femoropatellar disease.56 separately for men and women.
The differential diagnosis of sclerosis, cysts and Altman et al 61 developed an atlas of individual
osteophytes includes CPPD crystal deposition disease (large radiographic features in OA.
cystic lesions, fragmentation and deformity) and gout
(erosions without joint space loss).57 SHOULDER OSTEOARTHRITIS
Osteoarthritis of the shoulder may be primary or secondary
Radiographic Grading of Osteoarthritis
to other disorders such as RA, chronic rotator cuff tear,
Radiographic grading of OA typically includes assessment of trauma, CPPD arthropathy, avascular necrosis, or congenital
osteophytes and cartilage space narrowing. Other features malformations. Primary OA was believed to be rare so that
such as sclerosis and cyst formation, have lower reprodu- an underlying cause should be sought in most cases. Phillips
cibility.58 Clinical and laboratory assessment also may be and Kattapuram, however, noted that primary OA may not
included.38 be as rare as many observers have stated.62
Of the features of OA, cartilage space width is the most Radiographic evaluation of the shoulder includes a
sensitive radiographic measurement for detection of change 40 degrees posterior oblique, external rotation view, internal
overtime. The reproducibility of cartilage thickness rotation AP, and scapular lateral (“Y”) views. These may be
measurement is critical to the follow-up of subjects. supplemented by outlet views (Y view with 10 degrees caudal
Reproducibility in measuring cartilage space relates to angulation), AP angled views for impingement, and axillary
several factors, including variations in patient positioning on views.
follow-up visits and measurement technique. Ravaud The normal alignment of the humeral head with relation
et al59 evaluated the reproducibility of measuring the medial to the glenoid on posterior oblique images places the medial
compartment cartilage space in healthy subjects and epiphyseal-metaphyseal junction of the humerus at about
osteoarthritic patients. The reproducibility was greatest if the inferior aspect of the glenoid rim. Thus, an arc normally
patient positioning techniques were used with fluoroscopy. can be drawn from the medial aspect of the humerus to the
The assessment of cartilage space narrowing of the lateral aspect of the scapular border. The degree of upward
tibiofemoral articulation has higher intraobserver displacement of the humerus could be classified by degrees
reproducibility than the assessment of sclerosis and cyst depending on the position of the humeral baseline to the
formation. Greatest interobserver reproducibility was found glenoid. Normally, the acromiohumeral distance is at least
for evaluation of osteophytes.59 7 mm and the glenohumeral cartilage space measures about
Amongst some specific grading systems, the Kellgren and 4 mm.63
Lawrence system was the first standardized method for Radiographic findings of primary OA are similar to
assessing knee OA on radiographs.60 This system uses a global osteoarthritic findings in large joints elsewhere. Formation
score. Radiographic features that were believed to be of osteophytes occur along the articular margin of the
indicative of OA included osteophytes from the joint margins humeral head and the line of attachment of the labrum to
or tibial spines, periarticular ossicles (usually at the proximal the glenoid. The osteophytes predominate along the anterior
interphalangeal or distal interphalangeal joints), cartilage and inferior aspects of the humeral articular margin and the
space narrowing with sclerosis of subchondral bone, lower two-thirds of the glenoid circumference (Fig. 10.21).
subchondral “pseudocystic areas”, and altered shape of bone Marginal osteophytes develop around the anatomic neck
ends. Critics of this method noted that greater emphasis was and may be prominent medially. In addition, articular
placed on osteophytes than on cartilage space narrowing.58 eburnation of the humeral head causes subchondral sclerosis,
Nagaosa et al58 developed an atlas of line drawings of which can be associated with bony erosions. Eventually, the
the knee to be used for grading OA in that joint. This atlas humeral head becomes flat and enlarged and subluxes
included osteophytes and cartilage space narrowing as posteriorly which results in secondary posterior glenoid
separate criteria. The use of line drawings (rather than erosion. Computed tomography may be useful in
radiographs) allows only one of these abnormalities to be preoperative planning to assess glenoid bone stock and the
presented on each illustration so that analysis of osteophytes, degree of posterior bone loss.64,65
172 Infections/Inflammations

HAND AND WRIST OSTEOARTHRITIS


Osteoarthritis of the hand is most often seen in middle-aged,
postmenopausal women. In descending order, the most
common areas of involvement are the distal interphalangeal
(DIP) joints, the base of the thumb, the proximal
interphalangeal (PIP) joints, and the metacarpophalangeal
(MCP) joints.70 There is a relative symmetry of distribution in
both hands.71 Clinically apparent bony nodules about the
DIP joint are called Heberden’s nodes; similar features about
the PIP joints are called Bouchard’s nodes. Most
investigators consider these nodes to be palpable
osteophytes.72 Hallmarks of OA of the hand are cartilage
space narrowing, subchondral sclerosis, osteophytosis, and
subluxation. Cyst formation is rare. Erosion and ankylosis
are not typically present.
According to the American College of Rheumatology
Fig. 10.21: AP radiograph of left shoulder shows osteophytes with subcommittee, combining radiographic findings by rows of
subchondral sclerosis and cysts in patient with degenerative changes joints was more sensitive and specific for diagnosing OA of
the hand than evaluating individual joints.73
ROTATOR CUFF TEAR ARTHROPATHY
Interphalangeal Joints
Neer et al66 postulated that the condition arose from a series
of nutritional and mechanical factors that begin with rotator Multiple joint involvement of the DIP and PIP rows are
cuff tear. The condition is the end-stage of a series of characteristic features of OA; DIP joint involvement is
degenerative changes in the glenohumeral joint. The significantly more common than PIP joint involvement.70 The
degenerative changes in the rotator cuff lead to instability highest incidence of hand OA is in the second DIP joint. DIP
and wear and tear of the glenohumeral joint and arthritis. joint involvement may occur in the absence of PIP
Basic calcium-phosphate crystals are generated that induce involvement; however, it is rare to see solitary PIP changes.
synovial hyperplasia and secretion of enzymes with Cartilage loss results in characteristic apposition of the
subsequent destruction of collagen—containing structures. subchondral bone with undulating osseous contours. The
The clinical syndrome is usually seen in elderly women and is wavy contours of the base of the distal phalanx resemble
bilateral in more than half of the cases.67 the wings of a seagull—the gull wing sign (Fig. 10.22).74 The
Characteristic features of cuff tear arthropathy include osteophytes are marginal with narrow, spike-like bony
elevation of the humeral head with articulation between the growths extending proximally from the distal phalanx in the
humerus and acromian, rounding of the greater tuberosity, DIP joint and extending proximally from the base of the
cartilage space narrowing and osteophytes formation at the middle phalanx in the PIP joint.36 There is a predilection for
glenohumeral articulation, soft tissue swelling, and dorsal and volar osteophyte formation, that are, therefore,
calcification with a distended subacromial bursa sometimes more apparent with steep oblique and lateral views of the
visible.63 Humeral subluxation may be associated with glenoid, hand.
acromial, or coracoid wear. CT may be useful to document The osteophytes are continuous with the adjacent
the degree of bone erosion and subluxation. Magnetic cortical and cancellous bone, and, therefore, should not be
resonance is the investigation of choice. confused with the irregular new bone formation that is seen
Medical treatment of cuff-tear arthropathy may be used in psoriatic arthritis.74 Subluxation of the joint line usually
in mild cases; the use of prostaglandins to inhibit the effects occurs in the radial and ulnar directions and produces a
of basic calcium-phosphate crystal is being explored. Surgical characteristic zigzag appearance. In contrast, in RA, dorsal
treatment usually consists of hemiarthroplasty.68,69 or volar subluxation is seen.
Degenerative Disease of the Spine and Joints 173

Degenerative changes that are seen in isolation at the


trapezioscaphoid joint, however, suggest other causes,
including CPPD and RA.
Base of thumb OA can be diagnosed with a high degree
of accuracy with standard AP, lateral, and oblique views
along with Eaton and Littler’s basal joint stress view. This
view provides clearer visualization of all trapezial facets. It
is a PA 30 degrees oblique view of both thumbs under stress;
the patient pushes the radial sides of both thumbs together.
It has been postulated that chronic loading leads to
Fig. 10.22: PA radiograph of both hands depict degenerative changes
progressive instability and laxity of the trapezial ligaments,
involving multiple DIP joints. Note is made of Gullwing sign at DIP of which leads to trapezial tilt away from the trapezoid. This
right index finger along with radial subluxation. Ulnar subluxation is tilt causes abnormal shear forces on the trapeziometacarpal
seen at left little finger DIP which produces a characteristic zigzag joint, which possibly leads to OA.76
appearance

Metacarpophalangeal Joints
Thumb Base
Osteoarthritic changes in the second through fifth MCP joints
The base of the thumb consists of four trapezial articulations: are classically associated with other arthropathies, such as
trapeziometacarpal, trapezioscaphoid, trapezial-index RA, CPPD, and hemochromatosis or with certain occupations
metacarpal, and trapeziotrapezoid. Radiographic changes where there is repetitive stress on these joints. Although
of OA of the wrist essentially involve only the changes in the MCP joints are common, they are less
trapeziometacarpal joint or, less often, the trapezioscaphoid prominent than changes that are seen in the interphalangeal
joint (Fig. 10.23). If degenerative changes are seen at joints. Cartilage space narrowing seen with OA in the MCP
trapezioscaphoid joint, 84 percent of these patients have joints tends to be uniform. Marginal osteophytes are smaller
coexisting involvement of the trapeziometacarpal joint.75 than in the interphalangeal joints and subchondral cysts are
generally small.

Erosive (Inflammatory) Osteoarthritis


Erosive OA is seen predominantly in the hands of
postmenopausal women. Large joint involvement is rarely
reported in the shoulder, hips, knees, spine and
metatarsophalangeal joints.
The distribution of joint involvement is nearly identical
to noninflammatory OA of the hand with bilateral
involvement of the interphalangeal joints, and, to a lesser
degree, the trapeziometacarpal, trapezioscaphoid, and MCP
joints. The central erosions that are most commonly seen in
the interphalangeal joints are characteristic of erosive OA.
Eventually, there may be intra-articular bony ankylosis of
one or more interphalangeal joints. Clinical evaluation should
distinguish this from rheumatoid arthritis and psoriatic
arthritis.77,78
Fig. 10.23: Standard PA radiograph of the wrist shows joint space
narrowing and osteophyte formation that involves the trapezium— FOOT AND ANKLE OSTEOARTHRITIS
1st metacarpal joint with less severe involvement of the trapezoidal-
index metacarpal-joint. Notice the radial subluxation of the first Osteoarthritis of the ankle is usually secondary to previous
metacarpal fractures or ligamentous injury,79 often with interruption of
174 Infections/Inflammations

the ankle mortise. Chronic repetitive stresses, from Natural history of back pain is also poorly understood
occupational or sports activities, and tarsal coalition or and causes of low backache remain unknown in majority of
surgical fusion of adjacent joints may lead to OA of the ankle. cases. Nonspecific imaging findings may often be
Radiographic findings include asymmetric cartilage space encountered in asymptomatic subjects and findings seen in
loss, subchondral sclerosis, and cystic changes and symptomatic patients do not necessarily correlate with
osteophytosis. Weight-bearing views have been suggested symptoms.1 The diagnosis should always be based on
to better demonstrate cartilage space loss.79 A bony combined information from clinical findings and imaging
excrescence form the dorsal aspect of the talus near the studies for determining appropriate patient management
head-neck junction is believed to be due to capsular traction strategy.
and can be seen in athletes; it is not an indicator of OA.
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METABOLIC BONE DISEASES
CHAPTER

11 Skeletal Disorders of Metabolic


and Endocrine Origin
Alpana Manchanda, Arun Kumar Gupta

Metabolic bone disease encompasses a diverse group of • Disorder with no defect in mineralization and osteoid
disorders associated with altered calcium and phosphorus formation but decreased bone mass—Osteoporosis
homeostasis.1,2 Although many of these disorders are quite • Miscellaneous—Fluorosis, heavy metal poisoning,
common, they may be difficult to distinguish on the basis hypervitaminosis. Table 11.1 lists the metabolic profile
of history, physical examination and imaging studies. 1,2 with reference values.
To the clinician, metabolic bone disease is often silent
until the patient presents with fracture, the ultimate RICKETS AND OSTEOMALACIA
complication of many metabolic disorders. Other patients Rickets in children and osteomalacia in adults are a group
may however present with a clinical history of back pain of bone disorders in which there is incomplete minerali-
and a nonspecific radiologic finding of generalized osteo- zation of normal osteoid tissue. Both conditions usually
penia.3 At this stage prior to fracture, accurate diagnosis is result from an abnormality in vitamin D metabolism. The
crucial. Understanding their diverse manifestations on biochemical and histological abnormalities are identical in
imaging studies may allow early diagnosis. the two conditions while skeletal manifestations differ
The manifestations of endocrine derangements in the depending upon the age of the patient at the time of onset
skeletal system depend on the age of the patient at the of disease.
time of presentation. In general, skeletal manifestation in Vitamin D is a steroid hormone which in normal
childhood and infancy consist of disturbances in growth and individuals is produced by skin exposure to sunlight and
maturation and in adulthood, disturbances in maintenance obtained from the diet.4 To attain its active form, vitamin D
and metabolism. must undergo two hydroxylations, first in the liver and
second in the kidneys (Fig. 11.1). The primary function of
DISORDERS OF METABOLIC ORIGIN vitamin D is to maintain calcium and phosphate homeo-
stasis, thereby ensuring normal mineralization of the skele-
The most common types of metabolic bone diseases are
ton. The target areas for vitamin D action include bone,
acquired disorders; nonetheless, rare forms frequently are
gastrointestinal tract, kidneys, and parathyroid gland.1,4,5
genetically based and cause intrinsic alterations in the bone
cell population. Table 11.1 Metabolic profile–reference values
The various metabolic bone disorders may be grouped 1. S calcium 8.7–10.2 mg/dl
according to their underlying defects: 2. Ionized calcium 4.5–5.3 mg/dl
• Defect in osteoid formation—Scurvy 3. S phosphorus 2.4–4.1 mg/dl
4. Alkaline phosphatase 223–635 U/L
• Defect in mineralization—Rickets/Osteomalacia 5. Vitamin D >25 ng/ml
• Disorder with increased bone resorption—Hyperpara- 6. S parathormone 8–51 pg/ml
thyroidism 7. S ascorbic acid <0.6 mg/100 ml
178 Metabolic Bone Diseases

Fig. 11.1: Pathway for activation of vitamin D3

Causes tation.1,4,5 In the first six months of life, rickets can present
with tetany or convulsions. In most children with rickets,
Rickets and osteomalacia occur due to many causes
skeletal growth is stunted and they present with swollen,
(Table 11.2), most common being due to dietary deficiency
tender joints. With advanced disease, they may present with
of vitamin D called vitamin D deficient rickets or nutritional
irritability, weakness, and bony deformities. The most
rickets. Many abnormalities in vitamin D metabolism can
notable clinical finding are soft tissue swelling occurring
potentially result in rickets and osteomalacia. These include
around the growth plates due to hypertrophied cartilage.
malabsorption syndromes, hepatobiliary diseases, renal
Clinically, enlargement of wrists and costal cartilage are
diseases, drugs and neoplasms.1,4
most suggestive of the disease with a specificity of
81 percent and 64 percent respectively.6
Table 11.2 Causes of rickets and osteomalacia In adults, findings of osteomalacia are more subtle.
Abnormalities of vitamin D metabolism Initial symptoms include fatigue, malaise or bone pain. With
1. Deficiency conditions
advanced disease, proximal muscle weakness and abnormal
• Dietary deficiency of vitamin D
• Lack of exposure to ultraviolet light gait may be present.1,5 Typical manifestations of osteo-
2. Absorption defects malacia consist of bone pain especially in the hips and
• Gastrointestinal malabsorption muscle weakness.
• Biliary atresia
• Small bowel bypass surgery
3. Hepatic diseases Biochemical Findings
• Cirrhosis
• Hepatitis On laboratory evaluation, the serum calcium and phospho-
4. Anticonvulsant therapy rus may be normal or slightly reduced while serum alkaline
5. Renal insufficiency phosphatase levels are increased.
• Type I VDDR
• Type II VDDR
Pathology of Rickets and Osteomalacia
Rickets and osteomalacia secondary to phosphate loss
1. X-linked hypophosphatemia, genetic (Vitamin D resistant There is remarkable similarity in the biochemical and
rickets) histologic abnormalities in rickets and osteomalacia. The
2. Primary hypophosphatemic rickets, acquired
characteristic changes of rickets are identified in the growth
3. Renal tubular acidosis
• Type I (distal) RTA plates prior to closure while abnormalities of osteomalacia
• Type II (proximal) RTA are seen in the mature areas of trabecular and cortical bone.
4. Tumor associated phosphate deficiency In order to understand the changes of rickets, the
5. Chemotherapeutic drug induced rickets
general structure and organization of growth plate is
Miscellaneous discussed briefly. The growth plate is a complex structure
1. Metaphyseal chondrodysplasia (Schmid type)
which is located at the ends of long bones and situated
2. Hypophosphatasia
3. Atypical axial osteomalacia between the epiphysis and metaphysis.4 Although it is
adjacent to the epiphysis, functionally it is part of the shaft.
Histologically, the cellular arrangement of the normal
Clinical Features
growth plate is characterized by order, with progressive
Clinical findings of rickets and osteomalacia are highly increase in the number and size of cartilaginous cells from
variable and depend on the etiology and severity of the the epiphysis to metaphysis. The normal epiphysis has four
disorder, as well as the age of patient at the time of presen- zones. From the epiphyseal ossification center towards the
Skeletal Disorders of Metabolic and Endocrine Origin 179

gnomic of osteomalacia and may be found in other active


metabolic states associated with high bone turnover.
However, there is an increase in both the number and width
of the osteoid seams in osteomalacia.

Radiological Features
Although there is a significant overlap between rickets and
osteomalacia, their radiologic findings are quite different
and hence, they will be discussed separately.

RICKETS
In the earliest stage, rachitic changes are not detectable
radiologically. Biochemical and histologic changes develop
several weeks prior to the appearance of the conclusive
changes in the radiographs.7
The most common and nonspecific radiologic finding in
patients of rickets is osteopenia.1,4,5 Characteristic changes
occur at the open growth plate.5 These changes are best
seen in those areas showing most active growth. The distal
ends of radius and ulna are the optimal site for the demons-
tration of the earliest lesion.7 Significant changes are often
seen in the ulna when the radius appears to be normal as
Fig. 11.2: Structure of the growth plate showing
the distal ulnar growth plate grows more rapidly than the
normal cellular organization
distal radius. Therefore, the ulna is a more sensitive indicator
shaft the various zones are—the resting zone, proliferating of rickets at the wrist.
zone, hypertrophic zone and zone of primary and secondary Radiographic abnormalities reflect the disordered
spongiosa. The hypertrophic zone is further subdivided into proliferation of cartilaginous cells in the zone of hypertrophy
zones of maturation, degeneration and provisional along with the deficient mineralization in the zone of
calcification (Fig. 11.2). provisional calcification.4,5 The zone of provisional calcifi-
In rickets, there is disorganization of the growth plate cation is a band of calcification which marks the end of the
and adjacent metaphysis. The resting and proliferative zones radiolucent growth plate and beginning of the radiographi-
of the cartilaginous growth plate are not significantly altered cally calcified metaphysis.
from the normal pattern. However, the zone of maturation As the rachitic changes are more advanced at the fastest
is grossly abnormal with a disorganized increase in the growing growth plates, radiographs of the most active sites
number of cells and a loss of normal columnar pattern. This should be undertaken. In order of decreasing activity, the
cell mass results in an increase in length and width of the most active growth plates are costochondral junction of the
growth plate. Overall, there is diminished quantity of middle ribs, the distal femur, the proximal humerus, both
calcified osteoid and an increase in uncalcified osteoid ends of tibia, and the distal ulna and radius.
which casts increased radiolucency on the radiographs. The characteristic radiologic features of rickets seen at
Osteomalacia results from insufficient, delayed or the end of long bones in order of occurrence are:
defective mineralization of cortical and spongy bone. 1. Widening of the growth plate is the earliest specific
Histologically, it is characterized by abnormal quantities of radiologic change which occurs as a result of increase
inadequately mineralized bone matrix called osteoid, in cartilaginous cell mass.4
coating the surfaces of trabeculae and lining the haversian 2. Irregular metaphyseal margins (paint brush meta-
canals in the cortex. These layers of osteoid are often physes) occurs due to fraying and disorganization of the
referred to as osteoid seams. Osteoid seams are not patho- spongy bone in the metaphyseal region.
180 Metabolic Bone Diseases

irregular, indistinct borders and shows delayed


appearance of ossification centers.
5. The shafts of long bones may appear normal when
changes are first detected in the metaphysis. Rarefaction
of the shaft becomes evident a few weeks later due to
loss of mineral content. The cortex becomes thin with a
coarse texture.
A B 6. Skeletal deformities are the most common complication
detected radiologically, appearance and location of
Figs 11.3A and B: Rickets: X-ray bilateral wrists and knees AP
view: Typical changes of active rickets consisting of fraying, which depend on age and the part in which disease
irregularity of distal radius and ulnar metaphysis and distal femoral develops.4
and proximal tibial metaphysis with widening of the growth plates i. Skull: It is particularly affected in the early months
at the wrists and knees. The adjacent epiphysis and diaphysis are of life as it has to accommodate the rapidly
osteopenic
growing brain. There is excess osteoid deposition
in frontal and parietal regions and posterior
flattening due to supine posture of the infant. This
3. Further progression of the disease leads to widening and results in squared configuration of the skull known
cupping of the metaphysis (Figs 11.3 A and B). This can as “craniotabes” (Fig. 11.4A).
be explained by the protrusion of the bulky mass of ii. Long bones: In early childhood, more rapid
cartilaginous cells in the zone of hypertrophy into the growth occurs in the long bones and bowing
poorly mineralized metaphysis. Cupping of the distal end deformities of arms and legs are common which
of the ulna in younger infants is not necessarily abnormal can be related to the sitting position assumed by
as it has been observed in some nonrachitic infants infants and children. Bowing also is a result of
during the first months of life.7 Cupping is common in displacement of the growth centers owing to the
both ends of the fibula and the distal ends of the ulna assymetrical musculotendinous pulls on the
and tibia. Metaphyseal cupping is however never found weakened growth plate9 (Fig. 11.4B). Bulbous
in the bones of the elbow.8 enlargement of the costochondral junctions,
4. Similar process occurs on the epiphyseal side of the particularly those of the middle ribs can be seen
growth plate. The defective maturation and minerali- (rachitic rosary Fig. 11.4C), which can indent the
zation results in an epiphysis that is osteopenic and has pleural surface or even the thymic shadow.6

A B C
Figs 11.4A to C: Skeletal deformities in rickets: (A) Squared configuration of the skull in the neonatal period-“Craniotabes”,
(B) Marked anterior bowing of the tibia and fibula with rachitic changes. The visualized bones are osteopenic, (C) “Rachitic
rosary”: Widened anterior ends of ribs due to hypertrophy of costochondral junction
Skeletal Disorders of Metabolic and Endocrine Origin 181

A B
Figs 11.5A and B: X-ray wrists of two infants with rickets.The bones Fig. 11.6: Healing rickets: X-ray B/L wrists showing reappearance
are markedly osteopenic with fracture of distal ends of radius in of the dense zone of provisional calcification at the metaphysis
both

iii. Spine: Scoliosis and vertebral end plate defor- iii. Recalcification of the subperiosteal osteoid may
mities may develop in older children as the effects produce a thick envelope of cortex that surrounds the
of weight bearing become more important. shaft. This thick, opaque envelope along the shaft may
Scoliosis coupled with bending deformities of long be of uniform density or lamellated.
bones results in an overall decrease in height of iv. Epiphyseal ossification center which were ill-defined
the child. and osteopenic in the active stage of rickets become
iv. Pelvis: The protrusion of the hip and spine into sharply defined in the healing stage. In severe cases,
the soft pelvis produces a triradiate configuration the ossification centers may become invisible during
of the pelvis. Such a pelvic deformity may cause the active stage of rickets and reappear when they
considerable difficulty during parturition. are recalcified during healing, erroneously suggesting
v. Fractures: In long standing cases of rickets, trivial a rapid advance in skeletal maturation.
trauma may result in fracture of the weakened When the patient is on intermittent or inadequate
undermineralized bone (Figs 11.5A and B). treatment, the process of calcification and repair is irregular.
In severe malnutrition, rickets may be associated with Radiologically, patchy sclerosis of the metaphysis is seen,
scurvy and protein deficiency. sometimes with alternating sclerotic and lucent bands.

Signs of Healing Rickets Sequelae

Radiological evidence of healing is seen within 2 to 3 Complete healing and restoration of normal structures is
weeks of adequate therapy and total recalcification is the rule in rickets even when severe changes are present
usually complete in two months. 10 The signs of healing during the active stage.7
rickets are: Central rarefaction of ossification centers and cortical
i. Reappearance of the dense zone of provisional thickening of tubular bones may remain for a long time.
calcification. This is the first evidence of healing and Bowing and angulation deformities are not uncommon due
is seen radiologically as a transverse line of increased to weakened bones.
density which appears beyond the visible end of shaft
with a metaphysis interposed between the two Etiologic Considerations of Rickets
radiolucent areas (Fig. 11.6). Further mineralization Once the radiographic diagnosis of rickets is made, an
of the osteoid unites this with the metaphysis. attempt must be made to determine a possible etiology.
ii. Increase in cupping of the healing metaphysis is seen The causes can be:
as compared to the cupping seen in the active stage I. Abnormalities of vitamin D metabolism
of rickets. II. Secondary to renal tubular loss of phosphate
182 Metabolic Bone Diseases

III. Conditions in which there is no known abnormality subligamentous; presence of brown tumors; soft tissue and
of vitamin D metabolism or calcium-phosphorus vascular calcification. Increased bone density or
homeostasis. osteosclerosis is either focal or diffuse (Fig. 11.7A) and is
commonly seen in the spine but also occurs in the pelvis
ABNORMALITIES OF VITAMIN D ribs, skull and tubular bones. The characteristic appearance
METABOLISM of the spine is called “rugger jersey spine” because of its
resemblance to the striped jersey worn by rugby players
Renal Osteodystrophy
and is caused by increased bone deposition in the vertebral
Renal osteodystrophy is a term which is used to describe endplates (Fig. 11.7B).
the bony changes in patients with chronic renal insuffi-
ciency. In children, end stage renal disease is commonly due Hereditary Vitamin D—
to loss of renal parenchyma because of structural abnor- Dependent Rickets (VDDR)
malities of the urinary tract. While, in adults, chronic
Vitamin D—dependent rickets should be considered when
glomerulonephritis is the main cause.
rickets presents in early infancy and other usual causes such
Due to chronic renal disease there is phosphate reten-
as inadequate vitamin D intake, intestinal malabsorption,
tion along with impaired ability to form 1, 25 dihydroxy
liver disease or kidney disorders have been excluded.
vitamin D3 . Low levels of vitamin D and an excess of
Two forms have been described which involve problems
phosphate stimulate an excess parathyroid hormone
with the formation or function of 1,25(OH)2 D3.
resulting in secondary hyperparathyroidism.
Radiographic changes in renal osteodystrophy, there-
Type I VDDR
fore, reflect a combination of different processes including
rickets/osteomalacia, secondary hyperparathyroidism and Type I disorder results from a deficiency (genetic defect) of
osteosclerosis. Radiological changes in rickets have already the renal enzyme 1-alpha-hydroxylase, which converts 25
been described. The characteristic radiological changes in (OH)D3 to 1,25(OH)2D3. Therefore, the blood levels of
secondary hyperparathyroidism consists of bone resorption 25(OH)D 3 are normal while those of 1,25(OH) 2D 3 are
which may be subperiosteal, intracortical, endosteal or decreased.

A B
Figs 11.7A and B: Renal osteodystrophy: (A) X-ray B/L knees showing knock knee deformity
and patchy sclerosis at the distal femoral and proximal tibial metaphysis with slight widening of
the growth plate, (B) Characteristic “rugger jersey spine” appearance in a patient of chronic
renal failure with nephrolithiasis in the left kidney
Skeletal Disorders of Metabolic and Endocrine Origin 183

Clinical presentation is early, often by 3 months of age, Clinical Features


with most patients being symptomatic by one year of age.
Clinical features include bowing of legs, limb deformities,
The disease is differentiated from X-linked hypophospha-
short stature and premature fusion of cranial sutures
temic rickets by the presence of convulsions and muscular
leading to skull deformities. Dental abnormalities are also
weakness. Rachitic bone changes may be severe, rapidly
seen.
progressive and accompanied by pathologic fractures.4
Healing occurs with physiologic doses of 1,25 dihydroxy Biochemical Findings
vitamin D3. This disorder is also known as pseudovitamin D
It is characterized by low serum phosphorus, normal serum
deficiency rickets as patients with this condition respond
calcium, normal parathyroid hormone (PTH) and elevated
to large doses of vitamin D or physiologic doses of 1,25
levels of alkaline phosphatase.
(OH)2D with resolution of the clinical, biochemical and
radiographic abnormalities. Radiological Features
Radiographically, the rachitic changes may be mild to
Type II VDDR
moderate with bowing of long bones seen, particularly in
In this type of VDDR serum levels of 1,25(OH)2D3 are the lower limbs. Coarsening of trabecular pattern is seen
elevated, thereby indicating an end organ resistance to with increasing age. In adults, generalized increase in bone
1,25(OH)2D3. It is also known as calcitrol resistant rickets density, especially of the axial skeleton is characteristic. The
(CRR) and is a rare autosomal recessive disorder charac- spine and pelvis may show changes in the form of calcifi-
terzied by severe rickets, growth retardation, severe dental cation and ossification in the paravertebral ligaments,
changes and alopecia from early infancy. The diagnosis of ligamentum flavum, iliolumbar and sacroiliac ligaments. The
type II VDDR should be suspected from the unusual spinal changes may resemble those of ankylosing spondylitis
association of severe rickets and alopecia. or diffuse idiopathic skeletal hyperostosis (DISH). However,
the sacroiliac joints in X-linked hypophosphatemia show no
RICKETS AND OSTEOMALACIA bone erosions in contrast to that seen in ankylosing
SECONDARY TO PHOSPHATE LOSS spondylitis. The appendicular skeleton also shows multiple
sites of new bone formation at various muscle and ligament
A number of rachitic and osteomalacic syndromes have
attachments. Osteoarthritis is common, particularly in the
been identified of both congenital and acquired origin which
ankle, knees, wrists and sacroiliac joints.
share one or several renal tubular abnormalities. Rickets or
The above radiographic findings in the axial and
osteomalacia results from hypophosphatemia secondary to
appendicular skeleton are distinctive and the diagnosis may
impaired renal tubular resorption of phosphate resulting
be suggested prior to the clinical recognition of the disorder.
in phosphate loss. These disorders were described by
Albright, Fanconi and associates who also reported that
Renal Tubular Acidosis
rickets was resistant to vitamin D therapy in these patients.4
Renal tubular acidosis (RTA) comprises a group of tubular
X-linked Hypophosphatemia transport defects characterized by inability to appropriately
acidify the urine with resultant metabolic acidosis. The
X-linked hypophosphatemia (or familial vitamin D—
underlying abnormalities consist of an impairment of
resistant/refractory rickets) is the most common form of
bicarbonate resorption or excretion of hydrogen ions or a
renal tubular rickets and osteomalacia. It is genetically
combination of both. Detailed biochemical tests are
transmitted in an X-linked dominant trait. The syndrome is
essential for reaching at a correct diagnosis in RTA.11
characterised by lifelong hypophosphatemia. The basic
defect lies in impaired reabsorption of phosphate from
Type I (Distal) RTA
proximal tubules.4 In addition, the conversion of 25(OH)D3
to 1,25(OH)2D3 is also impaired. Serum calcium levels are It is characterized by persistent severe metabolic acidosis
in the normal range while the serum inorganic phosphate with continuous bicarbonaturia and is an important cause
levels are persistently low. Rickets generally develops of severe rachitic abnormalities. 11 In untreated cases
between 12 and 18 months of age. nephrocalcinosis/renal calculi are formed.
184 Metabolic Bone Diseases

Type II (Proximal) RTA glomerular abnormalities may also occur. Any part of the
This type of RTA may occur in children in an isolated form nephron may be damaged by ifosfamide. The major cause
or as part of global proximal tubular dysfunction called of rickets and osteomalacia is hyperphosphaturia with
Fanconi’s syndrome. In this condition, phosphaturia of resultant hypophosphatemia.
tubular origin is associated with glycosuria, various
SYNDROMES WITH THE RADIOGRAPHIC
aminoacidurias, in addition to bicarbonaturia. Unlike type I
APPEARANCE OF RICKETS OR
RTA, children with type II RTA do not progressively accumu-
OSTEOMALACIA BUT WITHOUT
late acid.11 Rachitic deformities and nephrocalcinosis are
ABNORMALITIES OF VITAMIN D
uncommon in isolated proximal RTA but are common in
METABOLISM OR RENAL TUBULAR
Fanconi’s syndrome.
DYSFUNCTION (PHOSPHATE LOSS)
Tumor Associated Rickets and Hypophosphatasia
Osteomalacia
Hypophosphatasia is a rare disorder that is genetically
Tumor associated rickets and osteomalacia (also termed transmitted that may resemble rickets both clinically and
oncogenic osteomalacia) is a syndrome characterized by radiologically. However, the serum calcium and phosphorus
hyperphosphaturia, with resultant hypophosphatemia, levels are normal. The characteristic diagnostic features are:
decreased levels of 1,25(OH)2D3 (refractory to vitamin D3 i. Defective skeletal mineralization, resembling rickets
administration) and various neoplasms. radiologically.
The syndrome is more common in adults than children.
ii. Low serum alkaline phosphatase level (in contrast to
The tumors are benign, of connective tissue origin, located
rickets in which it is increased).
either in soft tissues or bones. They are typically vascular
iii. Increased amounts of phosphoethanolamine, an
and often show foci of new bone formation.
amino acid, in the blood and urine.
Patients with this syndrome frequently have generalized
muscle weakness and proximal myopathy. Radiographic A wide spectrum of clinical severity is noted with most
changes of rickets and osteomalacia may be advanced at patients being diagnosed in infancy and childhood. The most
the time of initial presentation. severely effected neonates usually die soon after birth.
The cause of rickets in association with these tumors Radiologically, there is reduced mineralization. Fractures
has been attributed to the secretion of a humoral agent with deformity and shortening may suggest a dwarfing
termed ‘phosphatonin’ which directly inhibits the absorp- syndrome. Radiographic changes at the growth plate may
tion of phosphates in the proximal tubule.12 The tumors be seen soon after birth, are similar to those of rickets but
are usually small, benign and of vascular origin (hemangio- show characteristic multiple radiolucent extensions into the
pericytoma), but there is now known to be a wide spectrum metaphysis that represent uncalcified bone matrix.4 Coarse
of tumors, some of which may be malignant.13 trabecular pattern, bowing deformities with or without
Biochemically, serum calcium is normal with marked healing fractures may be present. Wormian bones and
decrease in serum phosphate. These patients are resistant craniosynostosis may be present.
or refractory to vitamin D. However, resection of the tumor
results in the reversal of metabolic, clinical and osseous Metaphyseal Chondrodysplasia
abnormalities. (Schmid Type)
It is a disorder in which there is generalized symmetric
Chemotherapeutic Drug Induced Rickets
disturbance of enchondral bone formation, primarily at the
High doses of a chemotherapeutic agent, ‘Ifosfamide’ used metaphysis.4 It is manifested in childhood as short stature,
in the treatment of solid tumors, especially in children have bowing of the long bones and has a benign course. The
been known to result in Fanconi syndromes with hypophos- radiographs show widening of the growth plate. Multiple,
phatemic rickets.12 This complication is seen as a result of small, bony projections extend from the metaphysis into
nephrotoxic metabolites of the drug and may be irrever- the growth plate. In contrast to the usual rickets, the meta-
sible.12 Renal toxicity is predominantly tubular, although physis is well mineralized and may show increased density.4
Skeletal Disorders of Metabolic and Endocrine Origin 185

There is absence of Looser’s zones. The serum calcium,


phosphorus and alkaline phosphatase levels are normal.
Spontaneous improvement occurs and patients do not
respond to vitamin D therapy.

Atypical Axial Osteomalacia


It is a rare condition in which the radiographic abnormalities
are confined to the axial skeleton, with sparing of appendi-
cular sites. A dense, coarse trabecular pattern is most
marked in the cervical region. The lumbar spine, pelvis and
ribs are also involved. Looser’s zones have not been
identified in this condition.12 The biochemical findings are
normal with no response to vitamin D therapy.

OSTEOMALACIA
The term osteomalacia literally means “soft bones”.
A B
Radiological Changes
Figs 11.8A and B: X-ray lumbosacral spine AP and lateral views
The radiological findings of osteomalacia are often reveal marked diffuse osteopenia with reduced vertebral height with
nonspecific.4 Correlation with appropriate laboratory and biconcave appearance giving cod fish appearance. The sacral spine
is acutely kyphotic : Osteomalacia
clinical data are often required for reaching at a correct
diagnosis. The major skeletal changes observed are:
i. Osteopenia: It is the most common radiologic sign due Looser’s zones are considered to be either
to decreased bone mineral content.4 It is usually insufficiency type stress fracture or due to vascular
uniform involving all the bones. pulsations acting on the softened bone.6,12 However,
ii. Coarse indistinct trabecular pattern: It is in in contrast to fatigue type stress fractures, pseudo-
combination with generalized osteopenia suggests fractures do not necessarily involve weight bearing
osteomalacia.4 An overall decrease in number of bony bones and may remain unaltered over long periods
trabeculae within all the bones enhances the contrast of time. True fractures may develop later at these sites
of the remaining trabeculae giving a coarse, mottled because they represent areas of weakened bone12
appearance (Figs 11.8A and B). (Fig. 11.10). In addition, Looser’s zones show mild to
iii. Cortical involvement: The cortices of long bones moderate sclerosis with an absence of callus.
become thin, with indistinct definition, especially on Radiolucent areas similar to pseudofractures may be
the endosteal surface. seen in bones affected by Paget’s disease and fibrous
iv. Pseudofractures or Looser’s zones: These are a more dysplasia.12,14
specific but less common manifestation of osteomala- The terms Milkman’s fracture, increment fracture
cia. 14 Looser’s zones are linear areas of under and Umbauzonen have also been used to describe
mineralized osteoid that occur in a bilateral and osteomalacic pseudofractures.4,6 Pseudofractures
symmetric distribution14,15 (Figs 11.9A and B). They occur at sites of increased stress and therefore,
are oriented at right angles to the cortex.10 The accelerated bone turnover. The osteoid which is laid
characteristic sites include: down in the replacement process is inadequately
— Axillary margins of scapula mineralized, which accounts for its radiolucent
— Superior and inferior pubic rami appearance (Fig. 11.11).4,12
— Inner margins of the proximal femur Pseudofractures may be identified by radionuclide
— Posterior margins of the proximal ulna bone scan or MR imaging before being evident on
— Ribs.4,15 radiographs.12
186 Metabolic Bone Diseases

A B
Figs 11.9A and B: (A) Chest radiograph showing typical appearance of Looser’s zone in bilateral lateral and
medial borders of scapulae and ribs, (B) X-ray pelvis (AP) showing characteristic appearance of Looser’s zones
in bilateral superior pubic rami and mild right protusio acetabuli with resultant asymmetric shape of the pelvic
cavity

Fig. 11.10: X-ray pelvis (AP) in a 28 years female with sudden


onset pain over right thigh following trivial trauma reveals fracture
of upper end of the right femur. The visualized bones are osteopenic Fig. 11.11: Radiograph bilateral legs (AP) showing Looser’s zone
with coarse trabecular pattern. Looser’s zones are seen in bilateral in upper 1/3rd bilateral fibula with surrounding sclerosis. There is
superior and inferior ramii : Osteomalacia osteoporosis with cortical thinning of the bones

Bone scintigraphy has been found to be more ment of sacrum thereby producing a triradiate shape
sensitive than blood biochemistry and radiographic of the pelvis11 (Figs 11.12A and B). Both the femur
findings in the detection of osteomalacia. The typical and tibia show bowing deformity, vertebral bodies
features of osteomalacia seen on whole body may develop a biconcave shape and kyphoscoliosis is
scintigraphy are widening of mandible, rachitic rosary not an uncommon finding. Basilar invagination of the
sign, the tie sign of the sternum, pseudofracture sign skull may occur.11
and prominent epiphysis of the knees.16 Radiographs of the spine in osteoporosis (characterized
v. Bony deformities: These occur mainly in weight by decrease bone mass but there is no defect in minerali-
bearing joints. In the pelvis, there is medial acetabular zation) and osteomalacia may appear to be similar but they
migration (protrusio acetabulae) and inferior displace- can be differentiated on the basis of coarse and indistinct
Skeletal Disorders of Metabolic and Endocrine Origin 187

A B
Figs 11.12A and B: Pelvis AP in two different patients of osteomalacia: (A) Looser’s zones in bilateral symmetric distribution in
inner margins of proximal femora and superior and inferior pubic rami, (B) Severe osteomalacic changes with triradiate pelvis
due to bilateral protrusio acetabuli and inferior displacement of sacrum. The visualized bones are markedly osteoporotic. Old
healed Looser’s zones are seen in B/L superior and inferior pubic rami

trabeculae in osteomalacia while the trabeculae are thin Secondary HPT


and sharp in osteoporosis. Also, the spinal deformity in
Secondary HPT is associated with abnormalities in function
osteomalacia is uniform unlike osteoporosis wherein it is
of the parathyroid glands induced by a sustained hypo-
nonuniform.4
calcemic stimulus. The most common cause is chronic renal
failure. Occasionally, malabsorption states and dietary
HYPERPARATHYROIDISM abnormalities leading to hypocalcemia may be respon-
Hyperparathyroidism (HPT) is a pathological state charac- sible.19
terized by excessive production of parathyroid hormone.
In the normal state, parathyroid hormone promotes release Tertiary HPT
of calcium into the blood from the bone. It also stimulates Tertiary HPT occurs in patients with long standing secondary
extensive bone remodeling. Alterations of parathyroid HPT who develop autonomous parathyroid function and
function cause a breakdown in calcium homeostasis leading hypercalcemia.
to characteristic pathologic and radiologic abnormalities.17
Hyperparathyroidism is divided into primary, secondary Pathophysiology
and tertiary types.
The clinical, pathological and radiological manifestation of
HPT can be understood by understanding the inter-related
Primary HPT
roles of parathyroid hormone (PTH) and vitamin D in the
Primary HPT is characterized by increased parathyroid regulation of calcium metabolism.
hormone secretion occurring as a result of abnormality in Parathyroid hormone influences many tissues in the
one or more of the parathyroid glands. The cause in most human body and is essential for the proper transport of
cases is a single parathyroid adenoma (90% of cases); less calcium and other ions in bone, intestine and kidney. The
common causes include double adenomas (4%), hyperplasia synthesis and secretion of PTH is regulated by the ionized
of multiple glands (6%), and parathyroid carcinoma (<1%).18 serum calcium level. The normal serum calcium levels are
Hyperplasia of the parathyroid glands can occur as an maintained within a normal physiologic range by the
isolated finding or as part of multiple endocrine neoplasia intestines and kidneys which balance intake and excretion.
(MEN) syndromes. Ninety-nine percent of the elemental calcium is bound to
188 Metabolic Bone Diseases

the skeleton, and PTH works to increase the serum calcium Clinical Features
by increasing the resorption with liberation of calcium and
phosphorus. The clinical features of primary HPT relates to hypercalcemia
In the kidneys, PTH inhibits resorption of phosphate in which results from:
the proximal and distal tubules. This causes decrease in the a. increased intestinal absorption of calcium
plasma phosphate concentration which in turn helps to b. increased bone turnover
maintain the serum calcium level. PTH also increases the c. increased tubular resorption of calcium.
renal tubular reabsorption of calcium. Patients may present with tiredness, lethargy, polyuria,
Parathyroid hormone has no documented direct effect anorexia or nausea, or to bone or renal complication.
upon intestinal calcium absorption. PTH along with a The true incidence of primary HPT is not known but
decreased serum calcium and phosphate stimulate biochemical screening identifies the condition in unsus-
synthesis of 1,25 dihydroxy vitamin D; the primary mediator pected persons. It is found at all ages from birth to old age,
of intestinal calcium and phosphorus absorption and also with the highest incidence between 20 and 60 years, with
acts on bone to produce resorption. Thus, functioning renal women being affected two to four times more often than
tissue is critical to the metabolism of both PTH and vitamin men.10
D and is a major target organ for the action of these There appears to be a relationship between the severity
hormones (Fig. 11.13). of the disease and the type of symptoms that predominate.
Therefore, there exists a negative feedback loop Patients with renal calculi are younger, have a chronic course
between serum calcium and PTH. An abrupt fall in serum and are associated with hyperplasia of the parathyroid
calcium will actively stimulate PTH secretion. Other factors gland. Those with bone changes have a subacute progres-
affecting PTH secretion include Al, Mg and Li levels and the sive course characterized by a marked elevation in serum
secretion of histamine, cortisol, calcitonin and cyclic AMP calcium levels, and these patients generally have
(Fig. 11.14). adenomas.19

Fig. 11.13: Overview of vitamin D metabolism


Skeletal Disorders of Metabolic and Endocrine Origin 189

Fig. 11.14: Role of PTH and calcitonin in the regulation of calcium metabolism

Nephrolithiasis is the most common clinical manifesta- Table 11.3 Differential diagnosis of hypercalcemia
tion, followed by hypertension, peptic ulcers, pancreatitis, Malignancy
psychiatric disorders and bone pain.20 • Solid tumors (primarily breast cancer)
• Hematologic disorders
• Myeloma
Biochemical Findings • Lymphoma
• Leukemia
In most cases the diagnosis of hyperparathyroidism can be Enocrinological disorders
made on the basis of clinical symptomatology and labora- • Primary hyperparathyroidism
tory tests. Sustained elevation of serum calcium and serum • Multiple endocrine neoplasias (types I and II)
• Ectopic hyperparathyroidism (malignancy predominantly
parathormone levels are the most accepted means for the lung cancer)
establishment of diagnosis of primary HPT.17 Multiple • Secondary hyperparathyroidism (renal failure)
measurements of serum calcium are often recommended • Hyperthyroidism
• Hypoadrenalism
due to the variations in the amount of circulating para-
Drugs
thyroid hormone at any given time. Also, hypercalcemia is • Vitamin A intoxication
a feature of other disease states such as malignancy, • Vitamin D intoxication
endocrinological disorders, secondary to drugs, granuloma- • Thiazides
• Calcium
tous disorders, etc. (Table 11.3). Ten to twenty percent of • Milk alkali syndrome
patients with malignancy have levated serum calcium levels • Dialysis
(normal ref range = 9–11 mg%) with majority of these Granulomatous disorders
patients having direct involvement of the skeleton by a • Sarcoidosis
• Tuberculosis
malignant lesion.21 • Histoplasmosis
The term pseudohyperparathyroidism is referred to the • Berylliosis
syndrome consisting of hypercalcemia of malignancy in the • Rheumatoid arthiritis
absence of demonstrable skeletal metastasis or primary Pediatric disorders
• Infantile hypercalcemia
hyperparathyroidisim. • Hypophosphatasia
Elevated urinary cyclic AMP and elevated alkaline Miscellaneous
phosphatase levels signify increase in bone turnover and • Immobilization
skeletal involvement. • Paget’s disease
190 Metabolic Bone Diseases

In secondary HPT, the plasma calcium levels are normal evaluation shows osteoclastic activity.17 Bone resorption is
or low and the serum inorganic phosphate levels are high a hallmark of HPT and is one of the effects of increased PTH
(chronic renal failure) or low (intestinal malabsorption). production. The bone resorption is due to increased
osteoclastic activity and can be detected on the subperio-
Radiological Approach steal, intracortical, endosteal, subchondral and trabecular
The value of radiological studies in primary and secondary surfaces. Overall cortical bone is affected more severely than
HPT lies not in the initial diagnosis, but in assessing the cancellous bone. These changes are reflected radiologically
severity of the condition, and in noninvasive localization of by poor definition of cortical surfaces, increased cortical
the parathyroid glands prior to surgery as well as in the striations (“tunneling”), cortical thinning, and distortion and
follow-up of the patient.19 blurring of trabecular bone.19

Subperiosteal Resorption
Radiological Findings
Subperiosteal resorption of cortical bone is considered
The skeletal changes in hyperparathyroidism are characteri- pathognomic of HPT.17,19 Although it may be seen at various
stic and reflect the histologic changes of increased skeletal sites, the earliest and best recognized changes are
resorption of cortical and cancellous bone with substitutive seen in the hands.22 The earliest site of subperiosteal
fibrosis. Conventional radiography can assess the extent of resorption is the radial aspect of middle phalanges of middle
bone involvement and the presence of bone changes is an and index fingers (Figs 11.15A and B). Some authors have
accepted indication for parathyroid surgery in primary cited the earliest radiographic evidence of superiosteal
HPT.19 The bone changes of primary and secondary HPT are resorption to occur in the terminal tufts of the fingers.19,22
identical, except for the associated changes of renal Loss of fine cortical outline around the tufts results in a
osteodystrophy in secondary HPT. mesh like or woven appearance, with significant erosion of
tufts being more obvious in advanced cases. A distinctive
BONE RESORPTION pattern of band-like appearance of acroosteolysis may be
The incidence of bone lesions varies from 30 to 40 percent.19 seen in the terminal phalanges of the hands (less commonly
The initial bone changes may not be seen on radiographic the feet), consisting of band-like radiolucent areas that may
or gross pathologic examination, although, microscopic separate the tuft and the base of the phalanx separately.

A B

Figs 11.15A and B: Hyperparathyroidism: (A) Hands showing resorption of the subperiosteal bone on the
radial aspect of the middle phalanges of the index and middle fingers with magnified view, (B) Showing minimal
resorption of the tufts of terminal phalanges as well
Skeletal Disorders of Metabolic and Endocrine Origin 191

Fig. 11.16: Pantomogram showing extensive subperiosteal


resorption with loss of lamina dura in a patient with parathyroid
adenoma

Fig. 11.17: Anteroposterior and lateral radiograph of leg shows


Other sites of subperiosteal resorption include the resorption of anterior tibial cortex, intracortical striations and brown
medial aspect of the proximal end of tibia, humerus and tumor with pathological fractures: HPT
femur; superior and inferior margins of the ribs and lamina
dura surrounding the teeth22 (Fig. 11.16). Loss of lamina
dura once considered pathognomic of HPT is now Richardson et al quantified the degree of intracortical
considered as nonspecific as it may accompany dental tunneling in the metacarpal shafts and found it to be a
sepsis, fibrous dysplasia, Paget’s disease, osteomalacia and sensitive indicator of the extent of bone disease in
other endocrine disorders.17,22 Subperiosteal resorption HPT.19,22,23 This method known as the “cortical striation
may also occur in the marginal areas of joints, particularly index” requires detailed magnification radiographs.19,22 A
in the hands and feet, and may mimic erosive changes of grading system is used to determine the degree of cortical
rheumatoid arthritis or other inflammatory arthropathies. striation present in the first and second metacarpal of each
A feature to differentiate the erosions in HPT from that of hand.
rheumatoid arthritis is that they are located slightly away Grade 0 — solid cortex with up to one striation.
from the joint margin and are almost always associated with Grade 1 — mild increase in striations.
typical subperiosteal resorption of the adjacent phalangeal Grade 2 — increased striations, but with involvement of
tufts. less than 50 percent of the cortex.
Grade 3 — extensive striations throughout the cortex.
Intracortical Bone Resorption The second and third metacarpal of each hand are
Intracortical bone resorption or tunneling is one of the graded separately. In normal individuals the “mean cortical
index” is one or less than one. Increased striations are seen
hallmarks of rapid bone resorption wherein groups of
in patients with primary HPT, renal osteodystrophy and
osteoclasts tunnel through the Volkman’s and haversian
osteomalacia. The importance of cortical striation measure-
canals.19 This finding is also not specific for HPT and may
be seen in hyperthyroidism, acromegaly and disorders ment in patients with HPT is in monitoring the response to
causing rapid osteoporosis. They are radiographically seen treatment.19
as tiny linear striations within the cortex parallel to the long
Endosteal Bone Resorption
axis of the bone, best seen in the tubular bones of the hand
and feet, especially in the cortex of the second metacarpal. It leads to cortical thinning, scalloping and irregularity of
Intracortical resorption of bone is almost always associated the endosteal surface, especially in the bones of the hand.
with subperiosteal resoprtion (Fig. 11.17). Endosteal bone resorption may occur more commonly in
192 Metabolic Bone Diseases

conjunction with subperiosteal and intracortical resorption


rather than an isolated finding.

Subchondral Bone Resorption


Subchondral bone resorption is a common manifestation
of hyperparathyroidism, particularly in the joints of the axial
skeleton, such as the sacroiliac, sternoclavicular, acromio-
clavicular joints, pubic symphysis and discovertebral
junctions causing surface irregularity and increase in joint
space. 19,22 The changes are most severe in the distal
clavicles. The peripheral joints may also show subchondral
bone resorption, and these changes may mimic infective
arthritis.
Fig. 11.18: Osteoporosis with loss of definition of inner and outer
Subphyseal Bone Resorption tables of the skull causing a classical mottled appearance of the
skull vault :”salt and pepper skull”
In children with primary or secondary HPT, irregular radio-
lucent areas may appear in the mataphysis adjacent to the
growth plate. This finding is reminiscent of the abnor- characteristic of primary hyperparathyroidism, but seen
malities accompanying rickets.21 with increasing frequency in secondary hyperparathy-
roidism as well. 22 They represent hemorrhage and
Subligamentous and Subtendinous deposition of breakdown products of hemoglobin. Brown
Bone Resorption tumors may cause swelling, pathological fracture and bone
Resorption of bone occurs at sites of tendon and ligament pain in the skeletal system. Histologically, the cavities are
attachment to bone. The frequently involved sites are filled with fibrous tissue and osteoclasts with necrosis and
femoral trochanter, ischial and humeral tuberosities, elbow, hemorrhagic liquefaction. Radiographically brown tumors
inferior surface of calcaneus and inferior aspect of distal are seen as lytic, expansile, cystic lesions which are often
end of clavicle. multiple. They appear as well defined lesions of the axial or
appendicular skeleton, and are frequently eccentric or
Trabecular Bone Resorption cortical in location (Figs 11.19A and B). The common sites
of involvement are the mandible, clavicle, ribs, pelvis and
Trabecular resorption occurs throughout the skeleton in
tubular bones.17,19,23 Other manifestation of HPT are
HPT, especially in the advanced stages of the disease, though
generally present, although occasionally a brown tumor may
changes in the skull vault are characteristic.17,19 Osteoclasts
be the only finding radiologically. With removal of the
on the surface of bone dissect through the center of
parathyroid adenoma, brown tumors may demonstrate
trabecula giving a stippled, mottled, granular appearance
healing with sclerosis.19,23
termed radiologically as “salt and pepper skull” 17,19
The presence of multiple osteolytic lesions in an elderly
(Fig. 11.18). The definition of outer and inner table is lost.
patient with complaints of bone pain is suggestive of a
Focal areas of osseous thickening in the cranial vault may
mitotic/metastatic etiology. However, other etiologies such
be observed on radiographs as well-defined or poorly
as multiple myeloma or brown tumor should be considered
defined radiopaque areas.
and serum phosphate, calcium and PTH levels and serum
protein electrophoresis should also be checked.
BROWN TUMORS
Brown tumors with hemorrhagic or cystic component
They are also known as osteitis fibrosa cystica or Von in weight bearing bones are associated with a higher risk of
Recklinghausen disease of the bone. Brown tumors are pathological fracture. MR imaging can aid in determining
cystic lesions within bone and are an end result of extensive hemorrhage and cystic component and indirectly in
bone resorption.17 They have initially been described estimation of fracture risk.24
Skeletal Disorders of Metabolic and Endocrine Origin 193

A B
Figs 11.19 A and B: (A) X-ray bilateral hands in primary HPT showing multiple, well defined, expansile lytic lesions in
lower end of radius, head and distal ends of 3rd and 5th metacarpals of right hand, (B) A large well defined, oval lytic
lesion with sclerotic rim in left iliac bone with multiple smaller ill defined lesions in bilateral ischium: Brown tumors

It has been seen that there is a risk of pathological subperiosteal resorption of the phalanges and occur on the
fracture when the brown tumor involves more than two- ulnar aspect of metacarpal heads unlike rheumatoid
thirds of the cortex of the long bone, especially in the arthritis.
weight-bearing area. Preventive internal fixation is indicated Another feature that is more common in primary hyper-
if the tumor involves more than two-thirds of the cortex of parathyroidism is chondrocalcinosis or calcification in
the weight-bearing long bone.25 hyaline cartilage or fibrocartilage. This occurs due to calcium
In the past, advanced cases of hyperparathyroidism pyrophosphate dihydrate (CPPD) crystal deposition. It may
presenting with severe bone resorption was not an also occur in chronic renal disease, although its frequency
uncommon finding. However, use of more sophisticated is much lower than in primary HPT. Radiologically, chondro-
diagnostic techniques along with an increased awareness calcinosis is seen in 18 to 40 percent patients with primary
of this condition, have led to an earlier diagnosis, when the HPT.17,22 Chondrocalcinosis may be seen in hyaline cartilage
degree of bone resorption is somewhat limited.17 Fine detail and fibrocartilage of the knee, symphysis pubis and
and magnification skeletal radiography in primary HPT will triangular cartilage of the wrist.20 The deposition of crystals
not only detect mild disease but will also reveal intracortical, may lead to episodes of pseudogout. In contrast, soft tissue
endosteal and trabecular resorption.17 and vascular calcification is more common in secondary HPT
The combined effect of all the patterns of bone resorp- than in primary HPT.
tion is generalized osteopenia in a majority of patients.17,22
On radiographs, osteopenia is frequently a subjective OSTEOSCLEROSIS
finding that is difficult to interpret and is identifiable only
after 30 to 50 percent of mineral content is lost. This Increased bone density or osteosclerosis may be seen due
difficulty can be overcome by using quantitative bone to stimulation of osteoblastic activity by PTH in addition to
mineral analysis which will indicate not only the degree and its osteoclastic activity. The bone sclerosis can be either
rate of bone loss in the disease but also partial recovery of focal or diffuse.22 In patients with secondary HPT a diffuse
the loss that is seen after successful parathyroidectomy.17 increase in bone density is seen while in patients of primary
HPT bone sclerosis is localized or patchy. Focal bone sclerosis
is apparent in the metaphyseal regions of the long bones,
JOINT DISORDERS
the skull or the vertebral endplates. In the evaluation of
Erosive arthropathy of the hands, wrists and shoulders may hyperparathyroidism, one must keep in mind that osteo-
occur in patients with HPT, simulating rheumatoid arthritis. sclerotic changes may also occur as a manifestation of
These changes are almost always associated with typical healing, either spontaneous or as a result of treatment.26
194 Metabolic Bone Diseases

RENAL OSTEODYSTROPHY
Renal osteodystrophy is a term applied to the bone changes
present in patients with chronic renal failure. In chronic renal
failure, secondary HPT often co-exists with rickets, osteo-
malacia, osteosclerosis and osteoporosis as part of
spectrum of findings called renal osteodystrophy. The
skeletal changes of primary and secondary HPT are identical,
except for associated changes of renal osteodystrophy seen
in secondary HPT. Table 11.4 highlights the features
differentiating primary from secondary HPT.
The most common cause is chronic glomeruloneph-
ritis.27 It can also result from bilateral chronic pyelonephritis,
often associated with vesicoureteric reflux. In both
conditions small contracted kidneys are an evidence of the
end stage renal disease. The findings in renal
osteodystrophy in children and adults are distinctive.
The most common finding in secondary HPT of renal
osteodystrophy is subperiosteal resorption although other Fig. 11.20: Renal osteodystrophy: Diffuse increase in bone density
manifestations may be seen. The osseous resorption has of the pelvis and lumbar vertebrae with coarsened trabecular pattern
shown to increase from 10 percent in the early stage of
disease to 50 to 70 percent after 3 to 9 years of dialysis.27
Conversely, following parathyroidectomy bone resorption
has shown to regress. Calcification of arteries, articular
cartilage and periarticular tissues also occurs in renal
osteodystrophy.
Osteosclerosis may occasionally be the only manifesta-
tion of renal osteodystrophy. It has a predilection for the
axial skeleton (Fig. 11.20), with deposition of bone in the
subchondral areas of the vertebral bodies. This results in
the appearance of radiodense bands across the superior
and inferior vertebral margins known as “rugger jersey”

Table 11.4 Primary versus secondary HPT


Primary HPT Secondary HPT
• Consists of skeletal • Skeletal features of HPT
features of HPT only with features of renal
osteodystrophy (rickets/ Fig. 11.21: Typical features of renal osteodystrophy in form of
osteomalacia and osteosclerosis of the axial skeleton with osteomalacic changes in
osteosclerosis) the pelvis
• Skeletal changes are • More florid
less florid
• Sclerosis rarely seen • Commonly seen spine appearance. Other sites of osteosclerosis include the
• Brown tumors are • Less common pelvis, ribs and clavicles (Fig. 11.21). It also involves the
more common metaphysis of long bones and the skull.
• Chondrocalcinosis • Less common
Osteopenia has been reported in up to 85 percent of
more common
• Soft tissue and vascular • More common patients in renal osteodystrophy and is the end result of
calcification are less effect of osteomalacia, bone resorption and a decrease in
common bone quantity (osteoporosis).27
Skeletal Disorders of Metabolic and Endocrine Origin 195

In children, metaphyseal changes resembling rickets are Following parathyroidectomy the subperiosteal
seen. This together with cortical erosions can give rise to resorption resolves, bone turnover decreases and bone
the “rotting fencepost” appearance, particularly in the density improves. Patients with nephrolithiasis develop
femoral neck. Slipped capital epiphysis may also be seen as fewer newer stones and renal function improves. Patients
a complication, most commonly involving the proximal with peptic ulcer disease improve and symptoms of
femur. depression, weakness and fatigue often disappear.19
Preoperative localization of abnormal parathyroid is not
RENAL LESIONS routinely advocated by all surgeons due to a high success
rate of 90 to 95 percent in localising the lesion in previously
Renal tubular dysfunction results from the direct effect of
unoperated patients.28 However, imaging can assist the
parathyroid hormone on the kidney and is corrected by
surgeon in preoperatively identifying a persistent or ectopic
parathyroidectomy. Renal calculi have been reported in
parathyroid adenoma or parathyroid hyperplasia, thereby
50 percent patients. These calculi are often small and the
increasing surgical success from 60 to 90 percent.28
patient often presents with a renal colic.
PREOPERATIVE LOCALIZATION
NEPHROCALCINOSIS
TECHNIQUES
This is less common than renal calculi. Deposition of calcium
The noninvasive tests for parathyroid localization are:
is generally in the region of the renal pyramids (Fig. 11.22),
• High resolution ultrasound
but forms no diagnostic pattern. Uremia is a major cause
• High resolution computed tomography (HRCT)
of death in untreated HPT.
• Magnetic resonance imaging (MRI)
PARATHYROID LOCALIZATION • Dual isotope thallium-201 chloride - technetium-99m
subtraction scanning
The standard treatment for primary hyperparathyroidism • Technetium-99m sestamibi scintigraphy
is surgical removal of the abnormal parathyroid gland or • Single photon emission computed tomography (SPECT)
glands.19,28 This is because untreated HPT leads to bone loss, • Parathyroid digital subtraction angiography
renal calculi and nephrocalcinosis. The presence of bone • Selective venous sampling.
changes is an accepted indication of parathyroid surgery in
The success of all these techniques, except venous
primary HPT.19
sampling depends to a varying degree on the size of the
abnormal gland.

ANATOMICAL AND PATHOLOGICAL


CONSIDERATION IMPORTANT
FOR LOCALIZATION
Embryology and Anatomy
In the majority of population (84%), the parathyroid glands
are four in number—two superior and two inferior. The
glands are symmetrical, with the superior parathyroid
glands usually lying posterior to the junction of upper and
middle thirds of the thyroid and the inferior parathyroid
glands just below the lower poles of the thyroid. Three to
five percent population have 5 glands, and 1 to 3 percent
have 3 glands. Supernumerary glands are seen
approximately 3 to 5 percent of time.29
Fig. 11.22: Ultrasound of the right kidney shows medullary The superior parathyroid glands are derived from the
nephrocalcinosis in a patient of secondary HPT fourth branchial pouch along with the lateral lobes of the
196 Metabolic Bone Diseases

thyroid. The inferior glands arise from the third branchial is often guided by rapid intraoperative PTH testing. A greater
pouch along with thymus gland. These embryologic than 50 percent drop in the serum PTH to normal or near-
relationships help to explain the normal and variable normal levels 10 minutes after parathyroid resection is
anatomic location of the superior and inferior parathyroid suggestive of a single parathyroid adenoma as the cause of
glands. The superior parathyroid glands being closely related primary HPT.18 Thus, the primary benefit of preoperative
to the thyroid gland undergo minimal descent and their imaging studies is the accurate determination of
position are relatively constant.18 >90 percent glands are uniglandular disease to help select patients most
located deep in relation to the mid portion of the superior appropriate for unilateral and minimally invasive
pole of the thyroid near the cricothyroid junction.29 approaches.
The incidence of ectopic parathyroid glands is A National Institute of Health consensus panel on
20 percent. Ectopic superior parathyroids may be found primary hyperparathyroidism revised parathyroid surgery
within the thyroid gland (1 to 2%), in retrotracheal or guidelines for asymptomatic patients in 2002. Surgery is
retroesophageal location (1% cases), within the carotid indicated if one or more of the following factors are present:
sheath (1% of cases) or may descend into the postero- a serum calcium level 1.0 mg/dl above the upper limit of
superior mediastinum (5% of cases). The inferior the normal range; a 24-hour urinary calcium level of more
parathyroid glands along with the thymus decend a greater than 400 mg; creatinine clearance reduced by 30 percent;
distance and therefore are more variable in location but a bone mineral density T-score of less than -2.5 SD measured
most commonly are located inferior, posterior or lateral to at any site; age of less than 50 years; and undesirability or
the lower thyroid pole (69%). Ectopic inferior parathyroid impossibility of medical surveillance.29
glands are more common and can lie anywhere from the
angle of the mandible to the pericardium, i.e. along the Parathyroid Imaging
path of migration of the thymus.30 They can be found more High resolution sonography and 99mTc-sestamibi scinti-
inferiorly in the neck, in the thymic tongue or in the cervical graphy are the main imaging techniques for preoperative
portion of the thymus gland (29%). Ref. Persistent hypercal- location of parathyroid adenomas, with similar sensitivities
cemia after parathyroid surgery can be due to mediastinal and specificities for solitary adenoma detection by these
parathyroid glands in as many as one-third of cases. techniques.
Localization accuracy improves when both sonography
Surgical Treatment and scintigraphy are obtained preoperatively. Contrast-
Definitive treatment of primary hyperparathyroidism enhanced CT and MRI can also effectively locate parathyroid
involves the surgical excision of hyperfunctioning parathy- adenomas but are less commonly used for preoperative
roid glands. In the past, this was achieved with bilateral location and are more commonly used in the setting of
neck exploration and removal of the enlarged gland or failed parathyroidectomy, for the detection of suspected
glands. Improved presurgical imaging localization, ectopic (mediastinal) glands.29
intraoperative PTH assays, and hand-held gamma detectors
Sonographic Evaluation
have made the selective excision of hyperfunctioning
parathyroid glands possible.18 Ultrasonography is the modality of choice for preoperative
Over the past decade, the development of minimally localization of the pathological gland in all patients of proven
invasive techniques to parathyroid surgery has made HPT. Transducers of 12 to 15 MHz are used for imaging giving
accurate preoperative localization of parathyroid disease a tissue resolution of 1 to 2 mm. Solid lesions can be
absolutely critical for effective surgical treatment. differentiated from blood vessels. High resolution sono-
Currently practiced minimally invasive techniques graphy is an established procedure with a sensitivity of
include unilateral open parathyroidectomy, video-assisted 80 percent and specificity of 90 percent in detecting cervical
parathyroidectomy, and videoscopic parathyroidectomy. All parathyroid adenomas.19
of these techniques involve a more focused approach Normal parathyroid glands are 2 to 7 mm in length,
wherein the procedure is limited to the abnormal para- 2 to 4 mm in width, and 0.5 to 2 mm in thickness and weigh
thyroid gland, thereby reducing the operating time substan- 35 to 55 mg.30 They are normally not visible on ultrasound,
tially.29 The extent of minimally invasive parathyroidectomy CT or MRI.
Skeletal Disorders of Metabolic and Endocrine Origin 197

Most cases of primary hyperparathyroidism are caused parathyroid adenomas in all imaging studies except when
by a single parathyroid adenoma (90%). Hyperplasia of all local invasion of neighboring structures is present.19
four glands (6%), double adenomas (4%) and rarely When parathyroid gland enlargement is not found in
parathyroid carcinoma are the other causes. Adenomas are the region of the thyroid, the entire neck from mandible to
considerably larger, having a mean mass of greater than suprasternal notch should be examined sonographically,
10 times the normal parathyroid gland and are thus often including the retrotracheal region via a lateral approach.28
identified at cross-sectional imaging.27 However, ectopic parathyroid glands in the neck may be
At sonography, parathyroid adenomas are typically seen missed on ultrasonographic evaluation. Ultrasonography
as homogeneously hypoechoic solid masses. This is due to cannot be used to identify mediastinal parathyroid adeno-
the compact cellularity of the gland that is characteristic of mas. Rarely, parathyroid adenomas may be intrathyroid in
adenomas at sectioning.29 They may sometimes have a location. These are completely surrounded by thyroid tissue
hyperechoic capsule. The echogenicity of vast majority of and are oriented with their greatest dimension in the
parathyroid adenomas is substantially less than that of cephalocaudal direction. Sonographicaly, they are well
thyroid tissue; normal thyroid parenchyma having a visualized because they are hypoechoic in contrast to the
characteristic sonographic appearance of homogeneous echogenic thyroid parenchyma. However, percutaneous
medium to high level echoes. Around 90 percent of adeno- biopsy may often be required to reliably differentiate an
mas are found at the poles of the thyroid gland and are intrathyroid adenoma from a thyroid nodule.
easily discernable sonographically (Figs 11.23A and B). Gray-scale imaging should be supplemented by color
Imaging of the lower poles can be enhanced by asking the and power Doppler imaging to look for feeding vessels and
patient to swallow, which momentarily raises the thyroid vascularity of suspected adenomas seen at initial gray-scale
gland in the neck. They are usually oval or bean shaped, imaging. As per recent literature, color and power Doppler
but larger adenomas can be multilobulated. imaging commonly show a characteristic extrathyroidal
Parathyroid carcinomas are usually larger than feeding vessel (typically a branch off the inferior thyroidal
adenomas, on an average measuring more than 2 cm as artery), which enters the parathyroid gland at one of the
compared to 1 cm for adenomas. Carcinomas generally have poles. Internal vascularity is also commonly seen in a
a lobulated contour, heterogeneous echotexture and cystic peripheral distribution. The artery feeding the adenoma
components. However, they may be indistinguishable from tends to branch around the periphery of the gland before

A B
Figs 11.23A and B: (A) Transverse ultrasound scan reveals a hypodense mass posteroinferior to the right lobe of thyroid
in a patient with parathyroid adenoma, (B) Contrast enhanced computed tomography (CECT) also shows a hypodense
solid mass in the same location
198 Metabolic Bone Diseases

penetrating deeper, resulting in a characteristic arc or rim adenoma. However, these sonographic features are
of vascularity. In addition, color Doppler sonography of the inconsistent and it may not be always possible to
overlying thyroid gland may show an area of asymmetric differentiate abnormal parathyroid glands from lymph-
hypervascularity that may help to locate an underlying adenopathy and thyroid masses.
adenoma. When gray-scale and Doppler imaging fail to
show an abnormal parathyroid gland, graded compression Percutaneous Aspiration/Biopsy
of subcutaneous tissues and strap muscles may show a
relatively incompressible gland which may help differentiate Fine needle aspiration cytology of the parathyroid masses
an adenoma from surrounding soft tissue. This technique has increased the specificity of sonography by reliably
is often helpful in detection of ectopic glands in the lower differentiating parathyroid pathology from thyroid nodule
neck.29 and cervical lymph nodes. In addition to the cytologic or
Hyperplasia is also a more difficult diagnosis to make histologic analysis of the specimen, the aspiration can be
sonographically because the single gland size is generally diluted with 1 ml of saline and analyzed for parathyroid
much smaller than an adenoma. However, similar to hormone (PTH) by radioimmunoassay.19
adenomas, compact cellularity may render hyperplastic Although PTH aspiration is rarely necessary for routine
glands hypoechoic relative to the overlying thyroid. cases, this procedure can be particularly helpful in cases in
which prior thyroid or parathyroid surgery has distorted
Pitfalls in Interpretation neck anatomy or when preoperative confirmation of
unusual-appearing or ectopic glands is needed. A theoretic
Normal cervical structures such as perithyroid veins, complication of the procedure is seeding of abnormal
esophagus and longus colli muscles of the neck can simulate parathyroid tissue along the biopsy track, resulting in an
parathyroid adenomas, producing false positive results entity known as parathyromatosis. This has been described
during neck sonography. Performing real time sonography in cases of recurrent hyperparathyroidism after parathy-
in multiple planes, color Doppler flow imaging and use of roidectomy in which the capsule of the parathyroid gland
certain maneuvers by the patient help to differentiate the was disrupted during the procedure.
above normal structures from a suspected parathyroid Although it is primarily used as a therapy to treat tertiary
adenoma. Pathologic structures that are potential causes hyperparathyroidism (most often in the setting of renal
of false positive results include thyroid nodules and cervical failure), sonographically guided parathyroid ablation with
lymph nodes. ethanol is a potential treatment option for patients with
Several features may help in distinguishing lymph nodes primary hyperparathyroidism. The procedure involves
from adenomas. An echogenic fatty hilum usually indicates placement of the needle in the parathyroid gland and slowly
a benign lymph node. At color Doppler examination, lymph injecting a volume of ethanol equal to approximately
nodes are supplied by small hilar vessels, whereas a polar, 50 percent of the volume of the gland until the absence of
peripheral distribution of color flow is commonly seen with blood flow to the gland is confirmed on color Doppler
parathyroid adenomas. sonography.29
Concomitant thyroid disease also contributes to
imaging pitfalls. Enlarged multinodular thyroid gland can
Contrast Enhanced Computed
limit the sonographic evaluation of parathyroid adenomas.
Tomography
Anatomy is distorted and posterior nodules may mimic
parathyroid disease. Posterior thyroid nodules can have a Contrast enhanced computed tomography (CECT) has a
similar sonographic appearance to intracapsular para- sensitivity of up to 87 percent in detecting parathyroid
thyroid glands, although the typical vascular pattern of a adenoma. It is superior to sonography in patients with failed
parathyroid adenoma is uncommonly seen in thyroid parathyroidectomy, in cases of altered anatomy and in
nodules.29 delineating ectopic mediastinal parathyroid masses, thereby
Thyroid nodules more often show a heterogeneous aiding in operative planning. Computed tomography has the
echotexture with calcification and or cystic changes;28 while advantage of larger field of view and ability to image all
parathyroid adenomas are of a homogeneous, hypoechoic areas of neck and mediastinum. The advent of spiral CT has
echogenicity. A hyperechoic capsule favors a parathyroid enabled excellent visualization of neck vasculature and their
Skeletal Disorders of Metabolic and Endocrine Origin 199

A B

Figs 11.24A and B: Axial CT section (A) and coronal reconstruction, (B) shows a solid mass posterior to the
left lobe of thyroid extending to the inferior part of neck in a patient of multiple parathyroid adenomas

separation from other neck structures 19 (Figs 11.24A Parathyroid Scintigraphy


and B).
Nuclear medicine computer subtraction images of thallium
and technetium can aid in the localization of the abnormal
Magnetic Resonance Imaging
parathyroid gland. This technique relies on the differential
Magnetic resonance imaging (MRI) is less commonly used uptake of the two isotopes by the thyroid and parathyroid
for preoperative localization than sonography and glands. Thallium-201 chloride accumulates in tissues with
scintigraphy though it has similar sensitivity to other high blood flow which includes both thyroid and parathyroid
techniques in the detection of abnormal parathyroid tissue. glands as well as in thyroid nodules and parathyroid
MR imaging is the accepted modality for localizing adenomas. Technetium-99m accumulates only in the
parathyroid lesion in persistent or recurrent hyper- thyroid. Digital images are produced with each isotope. The
parathyroidism, despite previous parathyroidectomies with technetium scan is then subtracted from the thallium
a sensitivity of 88 percent.30 Magnetic resonance imaging leaving an image of only the parathyroid concentration of
has an equally high sensitivity when the gland is in the thallium.
mediastinum.30 The primary disadvantage of nuclear medicine techni-
On MR scans, parathyroid adenomas are soft tissue ques is limited spatial resolution. The maximum resolution
masses that are of low to medium signal intensity on T1- of thallium-technetium scanning is 7 to 8 mm and it is very
weighted images, are medium to high signal intencity on difficult to detect glands weighing less than 500 mg with
T2-weighted images and show moderate enhancement on this technique.28
gadolinium enhanced images. Approximately 10 to The radiopharmaceutical of choice for imaging para-
35 percent of enlarged glands do not have high signal thyroid enlargement is 99mTc sestamibi. 99mTc sestamibi has
intensity on T2-weighted images. This may be due to fat replaced 201Tl for parathyroid scintigraphy because of
content, hemorrhage or fibrosis. The size of the gland is superior image quality, more favorable dosimetry, and
the most important factor affecting detection on MRI.30 improved detection sensitivity with its use. Three general
The typical signal intensities of abnormal parathyroid techniques of radionuclide scintigraphy are commonly used
gland on T1-weighted and T2-weighted images may not be for the detection and visualization of hyperfunctioning
distinguishable from lymph nodes. This differentiation is parathyroid glands: single-phase dual isotope subtraction
more often based on topography and shape of the imaging, dual-phase single-isotope imaging, and a combi-
structures. A location medial to the carotid sheath is mostly nation of the two. In dual isotope subtraction imaging
due to parathyroid while nodes are located laterally.19 technique, one radiopharmaceutical (99mTc sestamibi) is
200 Metabolic Bone Diseases

used for visualization of the hyperfunctioning parathyroid scanning is when ordinary sestamibi scans are inconclusive
gland and the thyroid gland, and a second (123I or 99mTc or when a more detailed anatomic localization is required
pertechnetate) is used for visualization of the thyroid gland such as when patients are being reoperated.19
only. The second set of images is then digitally subtracted
from the first set. Evidence of residual radioactivity on the HYPOPARATHYROIDISM
subtraction image represents a hyperfunctioning para- The most common cause of hypoparathyroidism is excision
thyroid gland. Disadvantages of this subtraction method or trauma to the parathyroid glands during thyroid surgery.17
include the necessity of two radionuclide injections and of It can also occur as idiopathic hypoparathyroidism in which
a cooperative and immobile patient, identically positioned the parathyroid glands are absent or atrophied.
for the two studies. In addition, there is an increased It usually occures in childhood, with girls being affected
likelihood of artifacts on images obtained with digital more commonly than boys. The disorder may be charac-
subtraction. Dual agent studies with 99mTc sestamibi and terized by the presence of circulating antibodies to the
iodine 123 or 99mTc pertechnetate subtraction have parathyroid, adrenal and thyroid glands, supporting the
produced a sensitivity of 95 percent for adenomas and 64 concept that idiopathic hypoparathyroidism may be part
to 80 percent for hyperplastic glands.28 The single-isotope of a generalized autoimmune disease.
dual-phase imaging technique was proposed on the basis Rare forms of hypoparathyroidism are seen after
of the frequently observed difference between the rate of radiation damage to the gland and as a response of an infant
99m
Tc sestamibi washout from the thyroid gland and the to hyperparathyroidism in the mother owing to trans-
rate of washout from hyperfunctioning parathyroid glands, placental transport of calcium with suppression of fetal
which is typically slower. This technique requires a single parathyroid activity.
injection of 99m Tc sestamibi, followed by imaging at
approximately 10 to 15 minutes and 1.5 to 3 hours after Clinical Presentation
the injection. Increased mitochondrial content in Patients with hypoparathyroidism usually present with
parathyroid adenomas is believed to be responsible for the neuromuscular dysfunction precipitated by hypocalcemia.14
observed sestamibi concentration. Due to the high Premature closure of the growth plate may lead to short
sensitivity of sestamibi scintigraphy (82 to 100%), it is stature. Dental abnormalities may occur in the form of delay
generally considered the standard initial imaging modality or failure of tooth eruption.
to detect a parathyroid adenoma.
Biochemical Findings
Single Photon Emission Computed Laboratory findings in hypoparathyroidism consist of
Tomography decreased serum levels of parathyroid hormone (PTH) and
Single photon emission computed tomography (SPECT) is a calcium with elevated phosphate levels.
technique whereby images of diseased glands which have
absorbed a radioactive marker can be obtained. It increases Radiological Findings
the sensitivity and specificity by 2 to 3 percent over routine 1. The most common finding in hypoparathyroidism is
sestamibi scanning. SPECT can be performed anytime within bony sclerosis, which may be focal or generalized.14,17
the first several hours after a patient is injected with Localized osteoslerosis is more common, reported in 23
sestamibi. SPECT is used with increasing frequency as it percent of patients while generalized osteosclerosis is
provides three dimensional information (lateral, supero- seen in 9 percent.21 Bones involved more commonly are
inferior and anteroposterior). The major reason for the pelvis, proximal femur, vertebral bodies.
superiority of SPECT is the improved contrast resolution 2. Other findings include calvarial thickening, hypoplastic
(target to background). The fusion of CT images with SPECT dentition.
images, either by using software or by performing the 3. Band like areas of increased radiodensity in the
studies sequentially on hybrid SPECT/CT imaging systems, metaphysis of long bones may also be seen in hypopara-
has the advantage of combining the physiologic three- thyroidism.
dimensional information from SPECT and anatomic 4. The abnormalities in the spine resemble those of diffuse
information from CT. The most important use for SPECT idiopathic skeletal hyperostosis (DISH) including
Skeletal Disorders of Metabolic and Endocrine Origin 201

calcification and ossification of the anterior longitudinal


ligament and spinal osteophytes. The sacroiliac joints
are generally spared. This feature along with lack of
erosive arthropathy differentiates it from ankylosing
spondylitis.
5. Subcutaneous calcification may be seen around the hip
and shoulder joints.
6. Calcium deposition in the basal ganglia a characteristic
finding and occasionally also seen in the cerebrum and
cerebellum. It is also a feature of pseudohypo-
parathyroidism. It is also seen in infectious disorders
such as toxoplasmosis and cytomegalic inclusion Fig. 11.25: Shortening of fourth and fifth metacarpal bones seen in
disease, in Fahr’s syndrome (ferrocalcinosis), after both hands in a patient of pseudohypoparathyroidism (PHP) along
radiation therapy and exposure to toxic substances such with shortening of the middle phalanges of the fifth fingers
as carbon monoxide.21

PSEUDOHYPOPARATHYROIDISM fifth metacarpals. Normally the line does not intersect


the third metacarpal bone or just contacts its distal
Pseudohypoparathyroidism (PHP) is an inherited disorder aspect. The sign is considered positive if the line inter-
that manifests as end-organ resistance to parathyroid sects the third metacarpal, indicating disproportionate
hormone rather than from defecient secretion of the shortening of the fourth and fifth metacarpal bone.
hormone. This may be due to a defect in the adenyl-cyclase- Other congenital conditions with positive metacarpal
cyclic AMP system in the renal tubules and bones. It is sign are basal cell nevus syndrome, multiple epiphyseal
transmitted as an autosomal dominant trait and shares dysplasia, Beckwith-Wiedemann syndrome as well as
many features with hypoparathyroidism. acquired conditions such as juvenile chronic arthritis,
sickle cell anemia with infarction, trauma and neonatal
Clinical Findings hyperthyroidism. This sign may be unreliable in diag-
The patients are usually short, obese, mentally retarded and nosing PHP and PPHP as the third metacarpal may also
may have brachydactyly.14,17 be short in these conditions.21
Pseudohypoparathyroidism is more frequent in women Other radiological findings in PHP are similar to those
than men and is usually diagnosed in the second decade of of hypoparathyroidism and consist of bony sclerosis, soft
life. tissue calcification, dense metaphyseal bands, calvarial
thickening and basal ganglia calcification. Basal ganglia
Biochemical Findings calcification is more common than in idiopathic hypo-
parathyroidism (Fig. 11.26).27
Hypocalcemia and hyperphosphatemia are seen similar to
2. Soft tissue calcification and ossification. This occurs in
that in hypoparathyroidism. However, the levels of serum
approximately 55 percent of patients with PHP and is
parathyroid hormone (PTH) are elevated.
seen commonly in the hands and feet. The calcifications
may be present at birth and are superficial in location
Radiological Findings
and usually periarticular in distribution.
1. The best known sign of PHP is shortening of the fourth 3. Radiographic findings of secondary hyperparathyroidism
metacarpal. Although not specific for PHP as it is also may be seen in some patients with PHP.
seen in pseudopseudohypoparathyroidism (PPHP), this 4. In addition to short metacarpals, metatarsals; phalanges
is a characteristic finding (Fig. 11.25). may be short and exostoses and cone shaped epiphysis
The metacarpal sign has been used to determine may be seen. The exostoses are frequently located
whether this shortening is present. To use the sign a centrally and project at right angles to the bone and
line is drawn tangential to the heads of the fourth and differ from the appearance of multiple hereditary
202 Metabolic Bone Diseases

Table 11.5 Endocrine profile–reference values


1. S cortisol Fasting (8 am–12 noon) : 5–25 μg/dl
12 noon–8 pm : 5–15 μg/dl