rheumatoid arthritis of the thoracic and lumbar spine - The Bone

thoracic and lumbar vertebrae occurred. Histological corroboration is presented in four. Pathological lesions comprised various combinations of parave...

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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