Radiology

Prepared by, hassan jama hassan

1. Pott’s Diseas
2. Spondylosis
3. 3. Diffuse Idiopathic Skeletal Hyperostosis (DISH

1.Pott’s Diseas

Definition, Tuberculosis (TB) of the spine (Pott’s disease) is the most common site of bone
infection in TB; hips and knees are also often affected. The lower thoracic and upper lumbar
vertebrae are the areas of the spine most often affected.

Pathogenesis Of Pott’s Disease

Pott’s disease results from haematogenous spread of tuberculosis from other sites, often
pulmonary. The infection then spreads from two adjacent vertebrae into the adjoining disc
space. If only one vertebra is affected, the disc is normal, but if two are involved the
intervertebral disc, which is avascular, cannot receive nutrients and collapses. The disc tissue
dies and is broken down by caseation, leading to vertebral narrowing and eventually to
vertebral collapse and spinal damage). A dry soft tissue mass often forms and superinfection
is rare.

Radiological features
Radiographic changes associated with potts disease present relative late
The following are radiographic changes characteristics of spinal tuberculosis on plain
radiography
 Lytic destruction of anterior portion of vertebral body
 Increased anterior wedging
 Collapse of vertebral body
 Reactive sclerosis of on progressive lytic process
Additional radiographic finding may include the following;
 Vertebral end plate may osteoporotic
 Intervertabral disks may be shrunk or destroyed
 2. Spondylosis
Spondylosis (spinal osteoarthritis) is a degenerative disorder that may cause loss of
normal spinal structure and function. Although aging is the primary cause, the
location and rate of degeneration is individual. The degenerative process of
spondylosis may impact the cervical, thoracic, and/or lumbar regions of the spine
affecting the intervertebral discs and facet joints.
Spondylosis often affects the following spinal elements:

Pathology

Intervertebral Discs and Spondylosis

As people age certain biochemical changes occur affecting tissue found throughout
the body. In the spine, the structure of the intervertebral discs (anulus fibrosus,
lamellae, nucleus pulposus) may be compromised. The anulus fibrosus (e.g. tire-like)
is composed of 60 or more concentric bands of collagen fiber termed lamellae. The
nucleus pulposus is a gel-like substance inside the intervertebral disc encased by the
anulus fibrosus. Collagen fibers form the nucleus along with water, and
proteoglycans.

The degenerative effects from aging may weaken the structure of the anulus fibrosus
causing the 'tire tread' to wear or tear. The water content of the nucleus decreases with
age affecting its ability to rebound following compression (e.g. shock absorbing
quality). The structural alterations from degeneration may decrease disc height and
increase the risk for disc herniation.

Facet Joints (or Zygapophyseal Joints) and Spondylosis

The facet joints are also termed zygapophyseal joints. Each vertebral body has four
facet joints that work like hinges. These are the articulating (moving) joints of the
spine enabling

extension, flexion, and rotation. Like other joints, the bony articulating surfaces are
coated with cartilage. Cartilage is a special type of connective tissue that provides a
self-lubricating low-friction gliding surface. Facet joint degeneration causes loss of
cartilage and formation of osteophytes (e.g. bone spurs). These changes may cause
hypertrophy or osteoarthritis, also known as degenerative joint disease.
Bones and Ligaments
Osteophytes (e.g. bone spurs) may form adjacent to the end plates, which may
compromise blood supply to the vertebra. Further, the end plates may stiffen due to
sclerosis; a thickening/hardening of the bone under the end plates.

Ligaments are bands of fibrous tissue connecting spinal structures (e.g. vertebrae) and
protect against the extremes of motion (e.g. hyperextension). However, degenerative
changes may cause ligaments to lose some of their strength. The ligamentum flavum
(a primary spinal ligament) may thicken and/or buckle posteriorly (behind) toward the
dura mater (a spinal cord membrane).

Cervical Spine and Spondylosis

The complexity of the cervical anatomy and its wide range of motion make this spinal
segment susceptible to disorders associated with degenerative change. Neck pain from
spondylosis is common. The pain may spread (radiate) into the shoulder or down the
arm. When a bone spur (osteophyte) causes nerve root compression, extremity (e.g.
arm) weakness may result. In rare cases, bone spurs that form at the front of the
cervical spine, may cause difficult swallowing (dysphagia).

Thoracic Spine and Spondylosis

Pain associated with degenerative disease is often triggered by forward flexion and
hyperextension. In the thoracic spine disc pain may be caused by flexion - facet pain
by hyperextension.

Lumbar Spine and Spondylosis

Spondylosis often affects the lumbar spine in people over the age of 40. Pain and
morning stiffness are common complaints. Usually multiple levels are involved (e.g.
more than one vertebrae).

The lumbar spine carries most of the body's weight. Therefore, when degenerative
forces compromise its structural integrity, symptoms including pain may accompany
activity. Movement stimulates pain fibers in the anulus fibrosus and facet joints.
Sitting for prolonged periods of time may cause pain and other symptoms due to
pressure on the lumbar vertebrae. Repetitive movements such as lifting and bending
(e.g. manual labor) may increase pain
Bilateral chronic sacroiliitis. Frontal radiograph shows complete fusion of both
sacroiliac joints.

X-Rays and Other Tests

Radiographs (x-rays) may indicate loss of vertebral disc height and the presence of
osteophytes, but is not as useful as a CT Scan or MRI.

The CT Scan may be used to reveal the bony changes associated with spondylosis. An
MRI is a sensitive imaging tool capable of revealing disc, ligament, and nerve
abnormalities.

Discography seeks to reproduce the patient's symptoms to identify the anatomical

source of pain. Facet blocks work in a similar manner. Both are considered
controversial.
The physician compares the patient's symptoms to the findings to formulate a
diagnosis and treatment plan. Further, the results from the examination provide a
baseline from which the physician can monitor and measure the patient's progress.

Radiographic Appearance

Plain radiography of the spine may show generalised degenerative changes,

osteophytic lipping, narrowed intervertebral spaces and poor alignment of the normal
spinal curves.
CT and MRI may be needed to show disc bulging and prolapse

Romanus lesions. Lateral radiograph shows anterior corner erosions at the T12
and L1 vertebral bodies. The typical shiny corner sign (or Romanus lesion) is
present (arrows).

3. Diffuse Idiopathic Skeletal Hyperostosis (DISH

General Considerations

o More common in Caucasian males aged 50-75 years

o Ossification of anterior longitudinal ligament with or without
osteophytes is the primary pathology
o DISH is an enthesopathy – there is reaction at the sites of tendinous
insertions (entheses)
o Laminated, flowing ossification
o Should involve four contiguous vertebral bodies
o Ossification is usually quite thick
o Disc height is maintained in affected area
o Does not have ankylosis of SI joints
 Involvement of SI joints excludes DISH
o Involves lower thoracic spine most often, but also cervical and lower
lumbar spine most frequently
 Left side of spine in thoracic area tends to not have ossification
because of pulsations of aorta
• Clinical Findings
o Back stiffness or, less frequently, back pain
 Stiffness is worse in the morning
 o Large osteophytes have also been reported to compress or obstruct a
number of structures, including:
 Bronchus
 IVC
 Esophagus
 Increased incidence of calcification in surgical scars
 Associated with
• Hyperostosis frontalis interna
• Ossification of the posterior longitudinal ligament
(OPLL)
• Ossification of the vertebral arch ligaments (OVAL)
• Imaging Findings
o Conventional radiography is usually study of choice
o Flowing ossification along anterior aspect of vertebral bodies, but
separated from them and the body
o Should involve 4 levels
o Ossification may thicken as disease becomes more chronic
o “Whiskering” at the sites of tendinous insertion (entheses)
 Pelvic involvement
• Iliac crests
• Ischial tuberosities
• Iliolumbar ligaments
• Lesser trochanter
 Deltoid tuberosities of humerus
 Olecranon spurs
o Also may have ossification of the
 Achilles tendon
 Plantar aponeurosis
 Triceps tendon
• DDX:
o Ankylosing spondylitis
 Has involvement of SI joints
 Syndesmophytes are thinner
o Degenerative disc disease
 Osteophytes form only at corners of vertebral bodies
 Narrowing and desiccation of disc
o Acromegaly
 May produce osteophytes but they are not flowing
o Fluorosis may produce osteophytes, whiskering and ligamentous
ossification
 But all bones are uniformly increased in density
 Diffuse Idiopathic Skeletal Hyperostosis (DISH). There is flowing ossification
(black arrows)
that spans more than four contiguous vertebral bodies while the disc height is
maintained and
the flowing ossification is separated from the anterior aspect of the vertebral body
(blue arrows).