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MRI in Non-infectious Inflammation and Arthropathies

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Abstract

The non-infectious inflammatory disorders and arthropathies of the spine include several diseases broadly classified as rheumatoid arthritis (RA); the seronegative spondyloarthropathies (SpAs) including ankylosing spondylitis (AS), psoriatic arthritis (PsA), reactive arthritis (ReA), and enteropathic arthropathy (EnA); the synovitis-acne-pustulosis-hyperostosis-osteitis (SAPHO) group of syndromes; diffuse idiopathic skeletal hyperostosis (DISH); the crystal-induced arthropathies, including gout, calcium pyrophosphate deposition disease (CPPD), and calcium hydroxyapatite deposition disease (Ca-HADD); and the relatively uncommon disorders of primary synovial and chondrocyte neoplasia: pigmented villonodular synovitis (PVNS) and synovial osteochondromatosis (SOC), respectively.

RA, the SpAs, and each of the crystal arthropathies are associated with non-infectious spondylodiscitis, which are indistinguishable from one another. The SpAs also typically result in non-specific sacroiliitis and enthesitis, which result in fusion and syndesmophyte formation, respectively. The anterior vs posterior involvement of the spine, the appearance of the syndesmophytes, and the laterality of the sacroiliitis are potentially distinguishing features between the different SpAs.

In addition, RA characteristically results in inflammatory pannus at the dens, resulting in erosion and potential instability with basilar invagination. Among the crystal arthropathies, erosions from gout are due to the underlying tophus deposition, which can involve any portion of the spine. CPPD in particular has a predilection for the dens, where it can cause erosion and instability, similar to RA, while Ca-HADD exhibits a predilection for the longus coli muscle anterior to C1 and C2. DISH results in vertebral osteophytes and segmental fusion, similar in appearance to PsA, but is not associated with the inflammation and ankylosis of the SpAs. PVNS and SOC very rarely involve the spine and can have a variety of appearances; MRI is needed for evaluation of neurologic complications, and CT is often needed for characterization of the neoplastic process and osseous complications.

MRI, preferably with intravenous gadolinium contrast, is best suited to demonstrate the earliest characteristic inflammatory manifestations of these diseases and is also helpful in diagnosing and differentiating infectious spondylodiscitis. MRI evaluation, not necessarily with intravenous contrast, is needed for evaluating the neural structures and any potential neurologic complications. MRI is not well suited for the diagnosis of thin syndesmophytes typical of AS or calcifications associated with gout, CPPD, or Ca-HADD. Correlation with laboratory data and radiographs or CT of the spine and extremities is often helpful in reaching a diagnosis.

Finally, the SpAs and DISH can be associated with potentially neurologically catastrophic fractures due to the biomechanical limitations resulting from fused vertebral segments. The imaging findings of such fractures can be quite subtle, and MRI evaluation is critical in detecting potential neurologic injuries.

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Acknowledgment

Figures 6.18, 6.19, 6.20, 6.21, and 6.27 are courtesy of Dr. Alessandra J. Sax. The author acknowledges and thanks Dr. Alessandra J. Sax for assistance in preparing and providing the images.

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Dheer, S. (2020). MRI in Non-infectious Inflammation and Arthropathies. In: Morrison, W., Carrino, J., Flanders, A. (eds) MRI of the Spine. Springer, Cham. https://doi.org/10.1007/978-3-030-43627-8_6

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  • DOI: https://doi.org/10.1007/978-3-030-43627-8_6

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