Kickas.org Forums Ankylosing Spondylitis General Discussion #1 AS Web Support Group Degenerative Disk Disease

Hello
..haven't been here in ages...I don't actually have AS, but a reactive arthritis..that turned chronic...I finally after 20yrs have a sacroiliac xray that shows narrowing of both joints but I've had neck pain since my 30's that the MRI is just now showing the damage..the question I have is about that...I have arthritis in my C-spine and Thoracic spine, and tenderness now in my rib cage..but the rheumy says that the spinal arthritis is just wear and tear arthritis...I seem to remember that women's spines don't show the fusing like men and never show up on MRI's or xrays as being spondyarthritis. I hope that made sense..it bothered me that the doctor said that the cspine arthritis wasn't connected when my neck was so bad whenever I would have a flare. What needs to occur before they associate it with AS?

Thanks

Hi Susie - Looks like AS is 'always' a bit of a tough nut to DX 'and' get it right! let alone being a woman into the bargain... The following might help you:

http://www.springerlink.com/content/978-1-4419-0297-9

Chapter
Clinical Assessment in the Spondyloarthropathies
Ruth Wittoek and Herman Mielants
DOI: 10.1007/978-1-4419-0298-6_1
PDF (2.2 MB)
1-16

Thhe above covers clinical assessment, really taking thhe various protocols, i.e. the BATH etc (can never remember the names of the other two!) Theh protocols are useful in DX AS but are not the be-all end-all of arriving at a DX. Again, will see what I can haul out for you to go check out and no doubt, others will soon be responding to your questions.

Chapter
Imaging in Spondyloarthritis
Walter P. Maksymowych
DOI: 10.1007/978-1-4419-0298-6_2
PDF (1.7 MB)

Maksymowych has written an excellent article on imaging, ou search most of out with a google - the info posted above refers to a chapter in a book, published 2009. Will see if I can find a link for you to the complete paper, as opposed to a synopsis.

As far as MRIs go, saggital STIR imaging will show up enthesis and damage that the standard MRI will not show up. The radiologist will need to be looking for squaring of the vertebrae; Romanus lesions; shiny corners; enthesisis. Considered pretty much a sure fire DX 'of' AS, together with other elements, the 'clinical' picture of DX like, stiffness in the morning, better after exercise than after rest, etc etc. Also that maddening gut involvement. Rib cage involvement, think we can all of us say 'yes' to rib involvement...!

Will be back on-line later to update info for you.

Molly C (France)
Keeping on Keeping on

Good paper on Imaging:
http://radiographics.rsna.org/content/25/3/559.full
Spinal Changes in Patients with Spondyloarthritis: Comparison of MR Imaging and Radiographic Appearances

Hi Susie, I'm so thankful for Molly, queen of research. She will be able to supply you with a lot of information. I will just add this as myself and many others here suffer more than one autoimmune deseases. Osteoarthritis can cause just as much spinal damage as AS, in different ways so it's not uncommon to have both. If you suspect AS, familiar background or symptoms of AS, find a doc that will work with you to find a diagnosis.
Cindy

Hey Molly, here's a question for you. What are Romanus Lesions?
I have 3 more "Lesions" on my spinal cord that showed up on my last MRI. I no sooner get rid of one and 2 or 3 more show up.
Cindy

Hello Cindy (heigh, you are too kind hon, only doin what I love to do, diggin, leaving no stone unturned - an prob boring ridgid any number of people off into the bargain! <LOL>)- Romanus lesions, named after R. Romanus, who noted these 'lesions' in spondy patients. Facinating. See the link I posted above to Imaging, very good paper, excellent overview of imaging in spondyloarthritis:

http://radiographics.rsna.org/content/25/3/559.full
Spinal Changes in Patients with Spondyloarthritis: Comparison of MR Imaging and Radiographic Appearances.

References (section):
Romanus R, Yden S. Destructive and ossifying spondylitic changes in rheumatoid ankylosing spondylitis. Acta Orthop Scand 1952; 22: 88–99.Medline22.&#8629;JevticV, Kos-Golja M, Rozman B, McCall I.

Marginal erosive discovertebral “Romanus” lesions in ankylosing spondylitis demonstrated by contrast enhanced Gd-DTPA magnetic resonance imaging. Skeletal Radiol 2000; 29: 27–33.CrossRefMedline

Check out fig. 5c : (here's the text)
Figure 5c. Arthritis of the zygapophyseal joints in a 32-year-old patient with ankylosing spondylitis. (a) Lateral radiograph of the thoracic spine shows a posterior shiny corner at T9–10. (b) Sagittal T1-weighted fast spin-echo image shows circumscribed loss of signal intensity in the area of the vertebral arch (arrows) and zygapophyseal joints. (c) Sagittal contrast-enhanced fat-saturated T1-weighted image shows pronounced enhancement of the vertebral arch, articular processes, and adjacent soft tissue (arrows), (...more)

And fig. 2a:
Figure 2a. Spondylitis (inactive Romanus lesions) in a 39-year-old patient with ankylosing spondylitis. (a) Lateral radiograph of the lumbar region shows syndesmophytes (arrows) at L3 through S1 and a shiny corner at the superior endplate of L5. (b) On the corresponding T1-weighted fast spin-echo image, the syndesmophyte at L5 (lower long arrow) is barely visible. (...more)

(snip...) "The underlying anatomic structure is the epiphyseal ring in juvenile patients; in adults, it is fused with the vertebral body. Later in the course of the disease, sclerotic changes of the edges of the vertebral endplates appear, findings referred to as “shiny corners.” MR imaging allows for the detection of Romanus lesions in both early and late spondyloarthritis. In active disease, these lesions are depicted as reduced signal intensity of the rim of the endplate on T1-weighted MR images and as increased signal intensity on STIR images (Fig 1) and represent bone marrow edema or osteitis (22). The condition is designated anterior spondylitis when the changes involve only the anterior vertebral edge, posterior spondylitis when they involve the posterior edge, and marginal spondylitis when combined changes are seen. The changes described occur exactly at the site of attachment of the anulus fibrosus to the vertebral endplate. Because such a junction of bone and ligamentous structure is an enthesis by definition, anterior or posterior spondylitis can be regarded as an enthesitis."

See also fig. 4a and 4b - which covers pretty much my own fracture..!

This is assuredly one of the best papers I have come across. Think in fact it is a 'must read' for all spondy persons, so that they can be informed as to 'what' those spinal changes are and...how best these changes may be viewed: MRI Saggital STIR imaging, AND the new, uMRI: Multi Positional Upright MRI The uMRI permits of the 'loading' of the body, I refer to it a bit like to 'loading' of a supportive wall, IF the cement is good the loading will be firm and strong, if defective, will show up nicely but ONLY when that wall is shown as loaded as opposed to prone imaging. OK. A bit on the simplistic side, but ya get the picture!

Will forever thank (thanks to a wonderful KA member who introduced me to her) that excellent rhuematologist I was consulting with in the UK. Terrific lady. Wish I had as good a rheumy over here...

Hope this is helpful - will post more as I dig em out

Thanks Molly! you too Cindy..
I just read an article that says you can get degenerative arthritis in your 20's..sounds odd to me...I think all arthritis is inflammatory..why else would your bones start eroding at 20..next infants will have osteoarthritis for no reason *rolls eyes here*
I'm off to read

This is a useful one: Pulmonary Involvement in Ankylosing Spondylitis
http://www.ncbi.nlm.nih.gov/pubmed/16926649?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.
Pubmed_ResultsPanel.Pubmed_SingleItemSupl.Pubmed_Discovery_RA&linkpos=5&log$=relatedreviews&logdbfrom=pubmed

And see the 'Related Articles' on the upper right hand side.
Worth investigatng.

(Annoying that these links are soooo long. Hope you can pick em up!)


http://www.ncbi.nlm.nih.gov/pubmed/9236678?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_SingleItemSupl.Pubmed_Discovery_RA&linkpos=1&log$=relatedarticles&logdbfrom=pubmed

Br J Rheumatol. 1997 Jun;36(6):677-82.

"Lung findings on high-resolution computed tomography in idiopathic ankylosing
spondylitis--correlation with clinical findings, pulmonary function testing and
plain radiography."

Useful synopsis to check out - note the recommendation of CT scans as the plain radiographs did NOT pick up the lung problems (much like to the plain radiographs NOT picking up changes that the Saggital STIR MRI images 'do' pick up!)

Hi Susie,

ReA that turns into a chronic case is AS. I can't remember the percentage but around 5-10% of ReA will develop into AS. It does not seem likely (to me) that your spinal arthritis is wear & tear of degenerative osteoarthritis. ReA is in the spondyloarthropathy family and your c-spine arthritis is connected!

Women's spines do show fusing like men, unfortunately, and it can show on both MRI and standard x-ray. Inflammation prior to damage will show on a nuclear bone scan. I don't think I've ever posted this publicly, but for the sake of women with AS, these are my own results from standard x-ray:

Exam date: Oct 25 2006
(RAD) PELVIS AP
Clinical History: Ankylosing Spondylitis
Findings:
Pelvis.
There is complete fusion of the SI joints bilaterally. Osteitis is seen
at the symphysis pubis with joint space narrowing superiorly. There are
moderate-to-severe degenerative changes of the hip joints bilaterally with
concentric joint space narrowing worse on the left. Subchondral cysts are
noted in the left hip joint. Degenerative changes are seen at the
lumbrosacral junction.

Exam date: Oct 25 2006
(RAD) THORACIC SPINE 2 Views
Clinical History: Ankylosing Spondylitis
Cervical spine, thoracic and lumbar spine.
Findings:
Cervical spine.
There is ankylosis involving the posterior elements of C2--C4 vertebral
bodies. There is narrowing of the facet joints throughout the cervical
spine. There is normal alignment however. No atlantoaxial abnormalities
noted.

Thoracic spine.
Syndesmophytes are seen throughout the mid and lower thoracic spine
anteriorly. No fractures seen. Vertebral body heights are maintained.
There is generalized osteopenia.

Lumbar spine.
There is generalized osteopenia.
The SI joints are fused bilaterally. There is narrowing of the
intervertebral disc space at the L4-L5 and L3-L4 levels. No
syndesmophytes are seen. There is facet joint arthropathy throughout the
lumbar spine. Degenerative changes are seen in the lumbrosacral junction.

I've had AS for 29 yrs now but at the time these were taken I was 26 yrs in. When I asked why I wouldn't have syndesmophytes within my lumbar also, my rheumy said matter of factly, "Well, you do." She said it just wasn't captured on the x-ray but would show on MR imaging. We didn't bother with MRI, (I didn't need it, I already knew what was going on) but MRI is the gold standard which can be very helpful for dx, or in earlier less-obvious stages. I hope this dispels the myth that women don't suffer AS with fusion. We do.

Good luck in getting the help you need and deserve!
mig

http://www.springerlink.com/content/978-1-4419-0297-9

What I would suggest is to take each of these
chapter/content headings - there are 23 of
them - use them as a google to check into
other available papers within the context of
the title.

Think you will be amazed at the wealth of
information available.

Hi Susie - Mig is right on. There can indeed be fusing in women with AS. The President of the French SA Association, has complete fusion of her spine. She was fused in a bamboo position and underwent an op, pretty much the same op as Ineptwill (Alan) underwent. She is now straight up and down, with rods and screws.

As for Mig's X-ray results, mine of the cervical and thoracic spine are very similar (don't have scans of anywhere else - radiologist was saving money that day!) Only I have fractures, bone marrow oedema, Romanus lesions, shiny corners - the rest are as Mig.

Now these findings are prob similar for many spondy women.

As Mig correctly points out, a nuclear bone scan is very useful,
superb for showing up inflammation, light up like to Blackpool Tower! Otherwise see if you can get an MRI Saggital STIR imaging done (my findings did not show up with the standard MRI imaging, my consultant was fairly sure of an AS DX for me, so she sent me back for the S. STIR scans which showed up the problems, including the fractures.)