Chapter 20 - Inflammatory Diseases of the Spine

Question 1

Cervical spine manifestations of RA

Answer 1

atlantoaxial subluxation that progresses toward superior. migration of the odontoid

Pannus formation posterior to dens

Question 2

Risk factors for more significant cervical findings in RA?

Answer 2

Significant peripheral joint findings, male gender, corticosteroid use

Question 3

Symptoms of c-spine manifestations of RA

Answer 3

• C2 nerve compression: occipital headaches, referred pain in face, ears, mastoid (greater occipital nerve irritation)
• vertebrobasilar insufficiency - vertigo, nausea, vomiting, dysphagia, dysarthria

Question 4

Laboratory workup for RA

Answer 4

• RF (igG) is sensitive but. not specific
• anti-CCP very specific

Question 5

Radiographic evaluation in RA for c-spine issues

Answer 5

lateral XRs are most helpful
- posterior ADI (<14 associated with neurologic compromise and usually requires surgery)
- Anterior ADI (anything >3.5mm is abnormal)

Question 6

Indications for surgery in c-spine RA

Answer 6

myelopathy symptoms should be addressed surgically BEFORE the reach stage III (ranawat classification)
- stage I: no neurologic deficits
- stage II: subjective weakness, hyperreflexia, or dysesthesias
- stage III: objective weakness, hyperreflexia, or dysesthesias (IIIA - ambulatory, IIIB - non-ambulatory)

Question 7

Indications for surgery in minimally symptomatic RA

Answer 7

1. SAC (aka posterior ADI)<14mm

patients with a SAC 10-14mm will get at least one ranawat class better than pre-op

patients with SAC <10 exhibit little to no neurologic recovery

Question 8

Contraindication for C1-C2 transarticular screw

Answer 8

Abberant/enlarged foramen transversarium prohibiting pedicle screw placement

Question 9

What is the potential complication of bicortical C1 lateral mass screws?

Answer 9

Internal carotid perforation/injury iwth anterior cortex breach

Question 10

Spinal manifestations of AS:

Answer 10

inflammation of annulus fibrosis, leading to formation of bridging syndesmophytes

Question 11

AS Lab findings

Answer 11

HLA-B27 positive

Question 12

Differences between AS and RA

Answer 12

RA affects synovial joints
AS affects entheses - where ligaments and tendons attach to bone

Question 13

Characteristic finding in psoriatic arthritis

Answer 13

Destruction of the interphalangeal joints

Question 14

What is the potential complication of bicortical C1 lateral mass screws?

Answer 14

Internal carotid perforation/injury with anterior cortex breach

Question 15

Radiographic markers of AS

Answer 15

• earliest stage: iliac side erosion of the SI joints
• marginal thin flowing syndesmophytes -> bamboo spine (ossification of the annulus fibrosis)

Question 16

Treatment for AS

Answer 16

new studies demonstrate promise regarding THFa inhibitors in AS, short duration of symptoms and positive CRP at initiation of treatment associated with best response/improvement in sx

Question 17

Spinal manifestations of psoriatic arthritis:

Answer 17

1. synovial destruction in the c-spine similar to RA
2. discovertebral erosions and axial ankylosis - non-contiguous and asymmetric pattern. BOTH marginal and non-marginal syndesmophytes

Question 18

Non-spinal manifestations of psoriatic arthritis

Answer 18

Achilles tendinopathy
Plantar fasciitis
Dactilitis (sausage-like swelling of the digits)

Question 19

Define Reiter’s syndrome

Answer 19

post-infectious arthritis (most commonly chlamydia or salmonella enteritis)

triad:
large joint infammatory arthritis
uveitis
urethritis

Question 20

Radiographic spinal manifestations of Reiter’s syndrome

Answer 20

Asymmetric sacroilitis, non-marginal syndesmophytes

Question 21

Diffuse Idiopathic Skeletal Hyperostosis (Dish)

Answer 21

enthesopathy of spine, shoulder elbow, knee and calc

Question 22

Radiographioc manifestations of DISH

Answer 22

no SI involvement, large, non-marginal syndesmophytes. MUST have 4 contiguous segments involved to be classified as DISH