RHEUMATOID
ARTHRITIS
OF A. W.
Froi;i
We
report
thoracic
and
seven
comprised
various
instability,
major
presented,
enabling
spondylitis. though
We less
cases
lumbar
Pri,zce.v.s
of
with
occurred.
of paravertebral root
distinction
submit
common
that
than
be
subcervical
rheumatoid
of the
thoracic
and
lumbar
regions.
dial facet joints are composed tissues so it was not unexpected
of that
made
rheumatoid Lawrence
erosions,
arthritis
erosive
pure
accounts of ankylosing to the present study.
Definite a
are
rheumatoid
is generally
spondylitis
rheumatoid
Case
and
believed,
spine.
CASE
target al. , in
rotatory
features
spondylosis than
lesions
and
radiological
is commoner
of the
Pathological
anteroposterior
degenerative
spondylitis
involvement
in four.
Specific
diarthroci
in whom
discitis,
collapse.
of the cervical
spine has attention involve-
SPINE
To;t,i
is presented
vertebral
between
rheumatoid
The
Cape
rheumatoid
and
involvement
Rheumatoid arthritis aflecting the cervical been well described in the literature. but scant has been paid to the less common rheumatoid ment
joint
LUMBAR
MEYERS
corroboration
compression, to
L.
AND
Hospital,
seropositive
combinations a
0.
Ort/iopaedic
Histological
lumbar
nerve
THORACIC
HEYWOOD,
A lice
patients
vertebrae
B.
THE
I. A
man
and
are
not
relevant
REPORTS
spondylitis aged
60
years
had
suffered
from
active
detailed study published in 1964, found an increased mcidence of lumbar facet joint erosions and anteroposterior instability in 50 rheumatoid subjects when compared with 50 controls. Their radiological study also showed
seropositive rheumatoid arthritis for 10 years when chest pain necessitated radiological investigation. A lytic lesion of the third rib was demonstrated, as well as collapse ofthe fifth thoracic vertebra (Fig. I). He died of
that
rheumatoid valvular disease. Histological examination
the mean
disc
width
was
less in the
rheumatoid
sub-
jects than in the control group. Bywaters (1981) reported on autopsy findings in thoracic spines of I 14 rheumatoid arthritis subjects. In eight subjects who had not had complaints relating to their thoracic spines he found discitis associated joints.
with
rheumatoid
erosion
(Fig. 2) showed rounding chronic rheumatoid
of the costovertebral
rib lesion
A search of the literature has revealed reports of eight patients with rheumatoid arthritis complicated by abnormalities in the thoracic and lumbar spinal regions and in whom histological proof of spinal involvement was obtained. Table I summarises these cases together with four ofour own which we describe in this paper. We
also present three whom radiological nosis
of rheumatoid
seven
patients The
without clinical
white
literature
of the lumbar
contains
several with
histological
corroboration
B. Heywood. MChOrth. FRCSEd. Department ofOrthopaedic Surgery 0. L. Meyers, MD. FCP(SA). Professor and Rheumatology Princess Alice Orthopaedic hospital. White Town 7945. South Africa. for reprints
should
he sent
1986 British Editorial Society 0301 620X 86 3059 S2.00 (.
362
other
All
and
are
Prokssor head
and
Head
of
A. W.
Retreat. B. 1-leywood.
Surgery
of Cape
the
affected
vertebra
arthritis.
thigh third
showed
Bacterial
culture
was
with surtypical of negative.
The
features. Case 2. A man aged 58 had a history of seropositive rheumatoid arthritis involving peripheral joints for IS years. The disease had been quiescent for three years on chloroquine therapy when he developed pain in the left
similar
and
with a reduced knee jerk and hypo-algesia in the lumbar dermatome. Radiographs showed minor displacement at L2/3 L3/4 (Fig. 3). There was a destructive lesion in L4
and
erosion
sclerosis.
of
the
Needle growth.
men
areas
showed
L3--4
biopsy
no bacterial sclerosis,
really
of Department
Road.
Joint
of
vertebral
which
to Professor
of Bone
reports
destructive
A. W.
Requests
spine.
(Caucasian).
spondylitis” and
histological proof but in features suggest the diag-
involvement
were
“rheumatoid lesions
cases and
of
areas of fibrinoid necrosis inflammatory cell infiltration
disc of the
space disc
Histology of focal
with and
of an open
bone
surrounding
vertebra
necrosis
yielded
biopsy
speci-
alternating
with
by a chiefly polymorphonuclear cellular reaction (Fig. 4). A second bacterial culture, Weil- Felix, Widal and Brucella agglutinin tests were negative. Clinical and radiological deterioration (Fig. 5) led to myelography nine months later. and a partial block
surrounded
was
demonstrated
At operation bacteriological laminectomy from
at the L2- 3 level (Fig. 6). histological findings and negative
the and
tests were posterolateral
L2 to L4 and
this
THE
was
JOURNAL
confirmed fusion followed OF
BONE
.
Decompressive were performed
three AND
weeks JOINT
later SURGERY
by
RHEUMATOII)
ARTHRITIS
OF THE
THORACI(
ANI)
LUMBAR
363
SPINE
Case I Figure I -Collapse of the fifth thoracic vertebra i n i 6t)et i-old riit Ic rheunii 101(1 patient. Figure 2 I Iistological section of autops specimen of the collapsed vertebra. Areas (.)t fibrinoid necrosis are surrounded in flaiiiittorv cell i n fill ral ion. chieil round cells. Note also the area of Focal hone necrosis.
Fig.
Fig.
6
I
Fig.
Fig.
7
2
Fig.
8
Case 2. l:Ig(lre 3 Minor spondylolisthesis of L2 on L3 and destructive erosions with retrolisthesis at the LI 4 disc space. Facet joint damage is present Lt both levels. Note that osteophytosis is minimal. Figure 4-Photomicrograph of the biopsy specimen taken from disc and adjacent hone at the L3 4 level. Areas of focal bone necrosis are surrounded by an inflammatory cell reaction, chiefly polymorphonuclear. Figure 5-Increasing erosion and collapse of the L3 and L4 vertebrae and the intervening disc space over a period of nine months. Figure 6 Myelogram shosing i narrowed segi1ent in the dye column opposite the L3 vertebra. Figures 7 and 8---Radiographs three years after decompressive Iani,nccloni and poslerolateral fusion. In spite ofpartial exlrusion ofthe anterior strut graft. fusion appears to have occurred from L2 to L4.
VOL.
68
B. No.
3. MA\
l9t6
364
A. W.
lig.
It. HEYW(X)D.
0.
1.. MEYERS
[:ig.
9
I
10
Fig.
II
‘
a’
#{149}
#{149}
Fig.
12
I /
V.,
. .
:i
0’ 4
‘‘
.
.
Case 3. Figures 9 and I()-Nlarkcd anterolateral subluxation of the body of L4 on L5. A strong rotational element is present. Figure I I-Myelogram showing a subtotal block of the dye column at the level of the subluxation. Figure 12- Flistological
.
section. #{149}‘l(
showing
non-specific
inflammatory
cellular
reaction.
‘‘
I ‘“‘
a4.k1#{149}1
#{149}
#{149}‘.
anterior
.
.
w#{149}
)‘‘i
fusion
incorporating
an
iliac
from L2 to L4. Three years after operation the graft appeared radiologically united, stable and all pain had settled. Case 3. A man aged 53. with a I 5-year positive polyarticular costeroid medication, history of low hack The right anklejerk
rheumatoid presented pain radiating and kneejerk
the
crest
strut
graft
(Figs 7 and 8) the spine was history
of sero-
arthritis and on cortiwith a three-month down the right thigh. were absent. and plain
radiographs (Figs 9 and 10) demonstrated thesis of L4 5 with a marked lateral and to
%I
spondylolisrotational shift
left.
Myelography showed almost complete at the L4 5 level (Fig. I I). At operation. the paravertebral joints showed insta-
obstruction
hility. loss ofarticular synoviuii. Histological (Fig. tration.
12) showed Culture
cartilage and examination a
was
non-specific negative.
The
hypertrophic of this inflammatory fourth and
bar laniinae were renoved. No granulation tiiaterial was found in the spinal canal
pinkish material fifth
tissue or disc but the cauda
was compressed by the lamina and inferior of’ L4 vertebra. and the L4 nerve root was kinked the pedicle of the vertebra. After decompression,
equilla
terolateral fusion later the fusion was a pseudarthrosis hut
no nerve
root
was
infillum-
facets around pos-
was done from L3 to L5. Four years radiologically solid at L4, 5 hut there at L3/4. He still had low back pain symptoms.
4. A woman
Case
positive
aged
rheumatoid
hack
pain
50 with a I 0-year history arthritis had a complaint
for six months.
and narrowing ofthe sions of the end-plates
Radiographs
showed
of seroof low sclerosis
LI 2 disc with a suggestion of eroa year after her first presentation.
Figures 13 to 16 show the evolution of the lesion over two years. A technetium bone scan showed increased uptake at the level ofinvolvement. Culture from a needle biopsy
produced
no organisms.
Microscopy trabeculae
rotic
(Fig. 17) revealed and fibrous tissue
bone with some with a predominantly
nec-
polymorphonuclear cellular exudate. Weil-Felix. Widal and Bruce/la agglutinin tests were negative. No antibiotics were given. Two years later she is painfree and the radiograph shows better definition of the sclerotic endplates
hut
Probable
early
retrolisthesis
rheumatoid
is now
developing.
spondylitis
woman aged 74. with a I 5-year history of seropositive rheumatoid arthritis in partial remission on chrysotherapy. complained of increasing low back pain for three years. The radiographs showed spondylolisCase
thesis L5
5.
A
of L3 on L4 with some lateral subluxation (Figs 18 and 19). Both disc spaces were
sclerotic
and
showed
gations werejustified supportive therapy. THE
minor
erosions.
since
her
JOURNAL
pain
OF
BONE
No was
AND
of L4 on narrow and
further controlled
JOINT
investiwith
SURGERY
RHEUMATOII)
Fig.
ARTHRITIS
13
Fig.
OF THE
THORACIC
14
ANI)
Fig.
Fig.
LUMBAR
365
SPINE
IS
Fig.
17
(ise 4. 1 igures I 3 tO I 6 Serial radiograplis over a two-year period shoing ftirl rapid loss of disc space culminating in early retrolisthesis. Note tl#{236}e loss of definition of the end-plates. unlike degenerative disease. especiall in the 1983 picture (Fig. 14). Note also the gas shadows in the disc space. similar to degenerative disease. Figure 1 7---E-Iistological section ofend-plate bone showing necrotic trabeculae surrounded by fIbrous tissue s ith a cellular reaction. predominantly polymorphonuclear.
Fig.
IS
Case 5. Radiographs showing retrolisthesis sertebra is also displaced laterally. Note
VOL.
68 B.
No.
3. sI..\V
956
Fig. of L2 3 and the osteophylic narrowing.
spondylolisthesis build-up on the
19
of L3 4. The third right. the side of the
lumbar greatest
16
366
A.
Case
for
aged 63 years, obstructive lung
6. A man
chronic
on corticosteroid disease and
W. B. HEYW(X)D,
0.
L. MEYERS
therapy seropositive
rheumatoid
arthritis. presented with multiple joint and increasing hack ache. Radiographs of the cervical spine showed atlanto-axial instability. In the lumbar spine the lateral view showed a characteristic ragged and finely eroded appearance of the end-plates and retrolisthesis of L3 on L4 (Fig. 20). He refused ilivolVeillent
further
investigations
trolled
by wearing
Probable
and
degenerative
Case
7.
A
woman
his
were
symptoms
partly
con-
a corset. and
aged
rheumatoid
78.
with
arthritis
aggressive
seropositive
rheumatoid arthritis of 22 years’ duration, presented with moderate iiechanical low back pain. Radiographs (Figs 22 and 24) showed lumbar scoliosis with wedging, displacement and rotation of the body of L2. In addition to the characteristic “soft” . woolly and eroded appearance space
of’ the end-plates margins. there
of the three is pronounced
central lumbar osteophytosis
disc and
sclerosis.
Fig.
20
Case 6. Irregularity. sclerosis. blurring and erosion of the L2 3 and L3 4 disc spaces together with soiie retrolisthesis of the body of L3.
A typical
degenerative lumbar disc (Fig. 21) compared with rheumatoid discitis in Case 7 (Fig. 22). Contrast the smooth, “hard” sclerotic margins of the degenerative end-plates with the rheumatoid ones which arc vague and blurred with a “moth-eaten” appearance from inflammatory erosion. The osteophytes seen in the rheumatoid vertebral i1argins do not affect the diagnosis. Fig.
21
Fig.
22
A
degenerative scoliotic lumbar scoliosis (Fig. 23) trasted with a rheumatoid with similar deformity (Fig. Note the blurred outline of the plates in the latter.
THE
JOURNAL
OF BONE
midconspine 24). end-
AND
JOINT
SURGERY
