LEV any xrays of the neck and spine? | Arthritis Information

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LEV, you are so good at sharing pics of xrays and they are so informative. DO you know where I can find xrays of the neck and upper spine? I searched but cannot find any.

 Jode,

I hope these are helpful and at least informative, you may want to click on the anatomy link in blue between lines below. Hope that things are looking better for you and that the sun is beginning to warm you inside.

LEV

Introduction

There are many different types of rheumatological diseases that affect the spine. A rheumatological disease is a problem that affects the entire body as a whole - such as the relatively well known rheumatoid arthritis. When a rheumatological disease affects the spine, the resulting conditon is called a spondyloarthropathy. The term is made up of Greek words: "Spondylo" means "vertebra," "arthro" means "joint" and "pathos" means "disease."

The most common diseases in the spondyloarthropathies include:

  • Ankylosing Spondylitis
  • Psoriatic Arthritis
  • Reactive Arthritis
  • Enteropathic Arthritis
  • Rheumatoid Arthritis

This guide will help you understand

  • which parts of the spine are affected
  • what causes these diseases
  • what the most common symptoms are
  • what tests your doctor may recommend
  • what treatment options are available

Anatomy

What parts of the spine are involved?

This group of diseases cause damage by creating inflammation that attacks the connective tissues of the body. In most cases, the cause of these diseases is unknown. There is increasing evidence that the underlying cause may be a combination of genetics and infection. A person born with certain genes may react differently to certain types of infections. Once that person is exposed to certain infections, the body responds by defending itself. The way the body defends itself against infection is through an inflammatory response. This is normal. What is not normal is that long after the infection
is gone, the inflammation continues. This chronic inflammation causes damage to many of the connective tissue structures in the body and leads to the symptoms.

There are several rheumatological diseases that can affect the spine. The rheumatological diseases that affect the spine primarily affect the connective tissues. One of the most common rheumatological diseases is rheumatoid arthritis (RA). RA primarily attacks the synovial joints.

Most of the joints in the body are synovial joints - such as the knee, hip and shoulder. A synovial joint is where two bones come together to form a connection that needs to be flexible - the two bones need to move against one another. The ends of the bones are covered with articular cartilage. Articular cartilage is a white, shiny material that is very slippery. It provides shock absorption and allows the bones to glide against one another easily. The synovial joint is completely enclosed by a joint capsule made up of tough connective tissue on the outside and a thin layer of tissue on the inside called the synovial lining. The joint is water tight. Inside the joint there is a small amount of fluid called synovial fluid. Articular cartilage does not have any blood vessels. The synovial fluid brings nutrients to the articular cartilage as it lubricates the joint.

In RA, the synovial lining of the joint is affected. The normally thin tissue of the synovial lining becomes inflamed and thickened. This material begins to produce inflammatory chemicals that damage the articular cartilage and bone underneath. The joint is slowly destroyed until bone rubs against bone. There are synovial joints between each vertebra in the spine and between the skull and the first cervical vertebra. It is easy to see why RA affects the spine.

In some rheumatological diseases, the inflammatory process affects other connective tissue structures. One structure that is commonly affected is where ligaments and tendons attach to the bone. This area is called an entheis. There are entheses located all over the body - wherever tendons and ligaments need to attach to bone. There are also many entheses in the spine itself, such as where the intervertebral disc attaches to the vertebra. Many of the rheumatological diseases that affect the spine seem to attack these areas of the spine. It is unclear why this occurs.

Related Document: A Patient's Guide to Lumbar Spine Anatomy

Causes

What causes this problem?

The cause, or causes, of all of these rheumatological diseases is still unknown. There is increasing evidence that the underlying cause in many of these conditions is a combination of a person's genetic makeup and how that person responds to certain types of infections.

For many years, doctors have been aware that people with these diseases have a higher percentage of a gene called HLA-B27. The HLA-B27 gene plays a role in determining how the cells of the body react against infection. Not everyone with this gene will develop a rheumatological disease, but the vast majority of people with the diseases have the gene. Recently, more research has shown that there are a number of variations of the HLA-B27 gene. This further complicates a very complex situation in trying to understand what role genetics plays in the cause of these diseases.

There are also a number of different infections that have been found to be related to the development of the rheumatological diseases. When patients with these diseases are studied, there seems to be certain bacterial infections that are more likely to precede the development of the rheumatological disease. The infection may be over, but the body continues to mount an inflammatory response that instead attacks the connective tissue
structures of the body itself.

The current evidence suggests that people with certain genes are more likely to react to certain types of infections by developing a rheumatological disease.

Related Document: A Patient's Guide to Rheumatoid Arthritis

Symptoms

What does the condition feel like?

Most of these diseases cause pain and stiffness as the primary symptoms affecting the spine. The pain and stiffness is worse in the morning and improves with activity. The flexibility of the spine decreases as time passes and the disease progresses.

In the diseases that affect the synovial joints, destruction of the joints can result in instability of the spine and may cause pressure on the spinal nerves or spinal cord. In the
diseases that affect the entheses, the spine more commonly develops large bone spurs and may fuse together and become stiff. Instabilty occurs only if the stiff spine is fractured.

Because these diseases are systemic, meaning that they affect the entire body, the symptoms also affect the entire body. The symptoms include pain in areas that are affected, such as the other synovial joints, and the other entheses of the body. Some of the diseases may include a skin rash, such as psoriasis. Several of the spondyloarthropathies affect the eyes, causing inflammation of the iris. Inflammation of the urethra (the tube from the bladder to the outside) can cause pain when urinating – called urethritis.

Diagnosis

How do doctors diagnose the problem?

The diagnosis requires a careful history followed by a thorough physical examination. Many patients have someone directly related to them that suffers from the same disease. Your doctor may ask questions about symptoms of recent infections such as diarrhea, burning with urination, difficulty with vision and eye pain.

The laboratory evaluation is very useful in the diagnosis. Tests may be ordered to look for signs of infection, chronic inflammation, rheumatoid arthritis and the presence of the
HLA-B27 gene.

X-rays can be very useful to show the changes in the spine, joints and pelvis that are common with many of these diseases. X-rays are usually the first test ordered before any of the more specialized tests. In the early stages the x-rays may be negative, but as time passes, the changes may appear and confirm the diagnosis.

Other radiological imaging tests may be useful. A bone scan can show the sites of inflammation before the changes appear on x-rays. A bone scan is a special test where radioactive tracers are injected into your blood stream. The tracers then show up on special x-rays of your back. The tracers build up in areas where bone is undergoing a rapid repair process, such as a healing fracture or the area surrounding an infection or tumor. Usually the bone scan is used to locate the problem. Other tests such as the computed tomography (CT) scan or magnetic resonance imaging (MRI) scan are then used to look at the area in detail.

If there are symptoms suggesting the spinal nerves or spinal cord are in danger, an MRI scan may be recommended to look at the spine more closely. The MRI scan uses magnetic waves to create pictures of the lumbar spine in slices. The MRI scan shows the lumbar spine bones as well as the soft tissue structures such as the discs, joints and nerves. MRI scans are painless and don't require needles or dye.

Treatment

What treatment options are available?

There is no cure for any of these diseases. The goal of treatment is to manage the pain and, when possible, to slow the progression of the damage to the underlying structures.

Remaining as active as possible is critical to maintaining your function. A physical therapy program can teach you how to maximize your function and retain as much flexibility as possible. Learn all you can about what you can do to control your symptoms and remain as healthy as possible.

RADIOGRAPHIC FINDINGS:

Within the Wrist: Early RA will demonstrate erosions in the distal radioulnar joint, ulnar styloid, radial styloid, and triquetro-pisiform joint (the latter are best seen on ball-catcher's view). Typically, the next erosions and joint space narrowing will occur in the carpal bones and MCP joints. Ligamentous rupture can lead to wrist instability resulting in ulnar translocation of entire carpus, scapholunate instability, and dorsal and volar flexion carpal instability (DISI and VISI).

Within the Elbow: Diffuse involvement of joint with extensive erosion in olecranon articulation and joint space narrowing with trochlea of humerus seeming to "dig into" olecranon. Joint effusion and olecranon bursitis may also occur.

Within the Shoulder: Glenohumeral joint space narrowing with marginal erosions within the humeral head. Ligamentous/tendinous injury results in rotator cuff degeneration with a "high-riding" humeral head. Also look for lysis of the lateral clavicle and erosion at the insertion of the coracoclavicular ligament.

Within the Spine: The cervical spine is commonly affected; particularly look for C1-C2 involvement which can have catastrophic consequences. For instance, pannus formation near the odontoid can cause erosions in the odontoid and ligamentous laxity of the transverse ligaments. The latter results in increased predental space (greater than 2.5-3 mm which is upper limit of normal in adults) which can result in canal stenosis. Alternatively, the pannus itself can proliferate and directly compress the spinal cord. Also, ligamentous destruction can result in atlantoaxial impaction (ie. dens goes up into the foramen magnum along with Mr. Cord--Mr. Cord doesn't like that). Other findings include erosions within the facet joints.

And courtesy of Dr. Richardson: 

 

Within the Hip: Axial joint space narrowing leading to protrusio deformity at the severe end of the spectrum, diffuse osteoporosis, lack of osteophyte formation unless secondary OA occurs. In contradistinction, OA usually results in superolateral (ie. weight-bearing) acetabular joint space narrowing, normal bone density and osteophyte formation.

Within the Knee: Joint space narrowing, osteoporosis, marginal erosions, without osteophyte formation unless there is secondary OA (do you see a recurring theme?). There may be a joint effusion with fluid tracking into the semimembranosus-gastrocnemius bursa (AKA Baker's or popliteal cyst). Occasionally there will also be patellar tendon rupture.

Within the Feet: MTP joint erosions early on, particularly of the 5th MTP. Toe deformities that result include lateral deviation at the MCPs and hammer toes. Also look for retrocalcaneal bursitis with erosions in the posterior calcaneus; the retrocalcaneal fluid can obliterate the pre-Achilles fat pad (AKA Krager's fat pad).

Thanks for doing that.

THANKYOU LEV!Thanks Lev, very informative!
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