1. Medical college, Baroda
CASES
Dr. Harsha K J
2nd yr resident
Dept of Radiology
Medical college, Baroda

2. CASE 1

3. 56 yr old male presented with backpain

5. SPINAL CALCIFICATIONS

6. SYNDESMOPHYTE
seen only in the seronegative spondyloarthropathies (Sharpey's fibers)
ossification of annulus fibrosus
thin slender vertical outgrowth extending from margin of one vertebral body to next
near the thoracolumbar junction.
Associated with:
ankylosing spondylitis,
ochronosis

7. syndesmophytes (arrows) in the spine of a patient with ankylosing spondylitis

9. bilateral erosions and sclerosis are noted in the SI joints of this patient with ankylosing spondylitis

10. erosions are noted in the lumbar facet joints of this patient with ankylosing spondylitis

11. OSTEOPHYTE
This is the charectaristic of diarthrodial joint osteoarthritis
Intervertebral disc joints are not synovial joints
However, there are several structures in the intervertebral disc joint which are analogous to structures found in a true synovial joint.
Cartilaginous endplate  articular cartilage
Annulus fibrosus  joint capsule
Nucleus pulposus  synovial fluid of the synovial joint

12. ossification of anterior longitudinal ligament
initially triangular outgrowth several millimeters from edge of vertebral body & tend to be initially oriented horizontally at their attachment to the vertebral bodies
They then often curve slightly and may even form a complete bony bridge across the disc space.

13. Radiographic appearance
Type
Mechanism
Radiographic appearance
Marginal
Endochondral ossification due to vascularizatoin of subchondral bone marrow
Outgrowth at the margins (nonpressure segments) of the joint producing lips of bone
Central
Encochondral ossification due to vascularization of subchonddral bone marrow)
Outgrowth at the central areas of the joint producing bumpy contour
Periosteal (synovial)
Intramembranous type of ossification due to stimulation of periosteal (synovial) membrane with appositional bone formation
Thickening of intraarticular "cortices" producing buttressing
Capsular
Capsular traction
Lips of bone extending along the direction of capsular pull

15. Osteophytes are described in any joint
Syndesmophytes are characteristic of spine and not described in any other joint

16. FLOWING ANTERIOR OSSIFICATION
ossification of disk, anterior longitudinal ligament, paravertebral soft tissues
Associated with:
DISH

18. PARAVERTEBRAL OSSIFICATION
initially irregular / poorly defined paravertebral ossification eventually merging with vertebral body
Associated with:
psoriatic arthritis,
Reiter syndrome

19. bony proliferation (arrows) is noted along the anterior margin of the lumbar spine in this patient with Reiter's syndrome

20. AXIAL ARTHROPATHIES Degenerative disorders Ankylosing spondylitis
Osteoarthritis
Degenerative nuclear disease
Degenerative annular disease
Diffuse Idiopathic Skeletal Hyperostosis (DISH)
Ankylosing spondylitis
Rheumatoid arthritis
CPPD crystal deposition disease
Psoriatic arthritis
Reiter's syndrome
Enteropathic arthropathy

21. OSTEOARTHRITIS
By definition, osteoarthritis occurs in a synovial joint.
In the spine, therefore, osteoarthritis occurs in
apophyseal (facet) joints,
uncovertebral joints (cervical spine),
costovertebral joints,
sacroiliac joints.
Osteoarthritis may be primary or secondary.

22. Findings include osteophytosis, joint space narrowing, subchondral sclerosis, and subchondral cyst formation.
Besides causing local joint pain, facet osteoarthritis may cause nerve root impingement or compression if the osteophytes are large enough to extend into the lateral recess of the spinal canal.

23. marked osteophytosis and joint space narrowing is noted in the facet joints in this patient with severe osteoarthritis of the lumbar spine -- the osteophytosis is causing significant encroachment on the lateral recesses bilaterally

24. intervertebral disc height begins to decrease.
age
nucleus tends to become more and more dehydrated, and
gradually begins to degenerate
intervertebral disc height begins to decrease.
increased stress is also placed on
the facet joints, leading to the frequent
association of osteoarthritis of
the facets at the same level.
altered pattern of stresses
may lead to marginal
osteophytosis
adjacent to the affected
endplates.

25. DEGENERATIVE NUCLEAR DISEASE
with increasing age (arrow), progressive degeneration of the nucleus leads to decreasing disk space height

26. Degenerative annular disease
degeneration of the annulus fibrosus
Also called "spondylosis deformans" or "senile ankylosis".

27. with increasing age (arrow), progressive degeneration of the annulus leads to increasing osteophytosis at the disk space margins -- the height of the disk space is largely preserved

28. marked marginal osteophytosis is noted at each disk space in this patient with predominantly annular degeneration

29. It usually doesn't make a lot of difference to the referring clinician which component of the disk has degenerated.
Therefore, using the term "degenerative disk disease" in one's dictations to refer to these entities.

32. DISH an idiopathic disorder
DISH is necessarily a diagnosis by exclusion

33. flowing ossification is noted along the anterior margin of the thoracic and lumbar spine in these patients with DISH -- note that the disk spaces are preserved and that at least four contiguous bodies are involved

34. prominent, flowing ossification is noted along the anterior margin of the cervical spine in this patient with DISH -- it is easy to see why such patients often complain of dysphagia

36. Since we often don't have any specific therapy for DISH, is there any reason to try to distinguish it from all of these other disorders ?

37. DISH patients are prone to heterotopic bone formation in surgical sites.
Because of this, some orthopedic surgeons will prophylactically treat DISH patients with radiation or drug therapy prior to performing a total joint arthroplasty, in an attempt to prevent or diminish the development of heterotopic bone formation after surgery.

38. Ankylosing spondylitis
Affects synovial and cartilaginous joints as well as sites of tendon and ligament attachment
Classically, changes are initially noted in the sacroiliac joints and next appear at the thoracolumbar and lumbosacral junctions
Sacroiliitis is the hallmark of ankylosing spondylitis
Although an asymmetric or unilateral distribution can be evident on initial radiographic examination, roentgenographic changes at later stages of the disease are almost invariably bilateral and symmetric in distribution

39. characteristic radiographic features of ankylosing spondylitis include
erosions,
sclerosis,
syndesmophytosis,
ankylosis.

40. bilateral erosions and sclerosis are noted in the SI joints of this patient with ankylosing spondylitis

41. erosions are noted in the lumbar facet joints of this patient with ankylosing spondylitis

42. Rheumatoid arthritis
rheumatoid arthritis predominantly involves the cervical spine, with apophyseal joint erosion and malalignment
Intervertebral disc space narrowing with endplate sclerosis and without osteophytes
Multiple subluxations, especially at the atlanto-axial junction.
Abnormalities of the thoracolumbar spine and sacroiliac joints are infrequent and less prominent than those of ankylosing spondylitis.

43. Other helpful differential findings are the absence of osteoporosis and the presence of bony proliferation and intraarticular bony ankylosis in the seronegative spondyloarthropathies.

44. Psoriatic arthritis
Bilateral sacroiliac joint abnormalities are much more frequent
Widening of the articular space
Ankylosis, is less than that of classic ankylosing spondylitis or the spondylitis associated with inflammatory bowel disease
Paravertebral ossification about the lower thoracic and upper lumbar segments paralleling the lateral surface of the vertebral bodies and the intervertebral discs

45. Features that distinguish paravertebral ossification from the typical syndesmophytosis of ankylosing spondylitis or the spondylitis of inflammatory bowel disease 
usually no osteoporosis (˙≠ RA)
Greater size,
Unilateral or asymmetric distribution,
Location farther away from the vertebral column

46. SI joints 30-50% of patients with PsA
erosions and sclerosis of SI joints
bilateral lesions are more common than unilateral

47. Lumbar spine showing bilateral sacroiliitis

48. Reiter's syndrome
asymmetric arthritis of the lower extremity, sacroiliitis

49. Enteropathic arthropathy
spondylitis and sacroiliitis of inflammatory bowel disease are identical to those of classic ankylosing spondylitis
H/O inflammatory bowel disease can sometimes help to distinguish these entities
Ulcerative colitis, spondylitis most commonly precedes the onset of colitis
Crohn's disease, the joint abnormalities tend to occur simultaneously with the bowel disease.

50. Peripheral joint abnormalities tend to occur much more frequently with enteropathic arthropathy
usually self limited, and rarely cause lasting deformity of the joint
ankylosing spondylitis, the peripheral joint findings typically include joint space narrowing, osseous erosions, cysts, and bony proliferation

55. CASE 3
A 28 yr old lady with past h/o LSCS came with bleeding PV

57. Accreta = abnormal adhesion of the placenta with absence of the decidua basalis (the stratum spongiosum, in particular)
Increta = invasion of the myometrium
Percreta = invasion through the serosa of the uterus

58. 80% of cases
5% of cases
15% of cases

59. Estimating the risk of anterior and central placenta accreta
predisposing factors for placenta accreta are repeated cesarean section, other surgical procedures such as myomectomy, dilation and curettage, multiparity, placenta previa, miscarriage
Estimating the risk of anterior and central placenta accreta
No previous C/S: 1%– 5% One previous C/S: 30% Two or more C/S: 40% and higher Other risk factors include maternal age >35 years, endometrial defects (Ascherman syndrome), and submucous leiomyomata.

60. criteria included
diffuse and focal intraparenchymal placental lacunar flow,
bladder/uterine serosa hypervascularity,
prominent subplacental venous complex,
loss of subplacental Doppler vascular signals

61. cases of fundal or posterior placenta accreta, it may be difficult to make the diagnosis at US because the location is far from the transducer
US may also be limited in detection and evaluation of the degree of extrauterine extent.
MR imaging is helpful as a complement to US in such cases

62. MR imaging shows the placenta in a gravid uterus as moderately hyperintense on T2-weighted images and allows differentiation between the placenta and the hypointense myometrium
Images obtained perpendicular to the boundary plane between the placenta and myometrium may be most useful for evaluation of the depth of placental invasion into the myometrium.

63. Placenta accreta and increta are suggested by thinning, irregularity, or focal disruption of the subjacent myometrium
Placenta percreta is suggested by extension of the placenta transmurally through the myometrium
When irregularity or disruption of the normal bladder wall is seen, invasion of the bladder may be present.
findings of placenta percreta may be similar to those of invasive gestational trophoblastic tumor

64. When the zonal structure of the uterus is intact at MR imaging and US, placenta percreta may be more likely.
The level of ß-hCG may be helpful in the differentiation.

65. Placenta accreta is very rarely recognised before birth, and is very difficult to diagnose. While it can lead to some vaginal bleeding during the third trimester

66. Placenta accreta

68. Coronal RARE MR image (single shot/60) shows an absent myometrial-placental interface in a posterolateral location (arrowhead) surrounded by a normal myometrial-placental interface (arrows). This region was not well identified with US. A fibroid (F) is present in the right lateral aspect of the uterus

69. PLACENTA INCRETA

71. Placenta percreta

74. Placenta percreta in a 31-year-old woman with a history of two cesarean sections. At 28 weeks gestation, the patient was referred for evaluation of a placenta that appeared abnormal at US. Coronal T2-weighted images (a obtained posterior to b) show disruption of the normally continuous low-signal-intensity bladder dome (arrow), an appearance consistent with placenta percreta

75. ABNORMALITY IN PLACENTAL CONTOUR H/O PREDISPOSED CONDITIONS
TAS
ABNORMALITY IN PLACENTAL CONTOUR
H/O PREDISPOSED CONDITIONS
TVS
MRI

76. Look for placenta in partially filled bladder may rule out placental invasion in majority of cases
Doppler may add a bit of more information

77. SIGNS

78. Ivory Phalanx Sign
increased density throughout the osseous structures of the involved digit in a person with psoriatic arthritis.
Sclerosis of an entire phalanx, typically the great toe, is likely the result of bony proliferation as an exaggerated healing response to injured bone in patients with seronegative spondyloarthropathy

79. Sausage Digit
X-ray of the hand with diffuse fusiform soft-tissue swelling of the entire 3rd digit.
This sign refers to fusiform soft-tissue swelling involving an entire, single digit within the hand.
The appearance of a sausage digit (cocktail sausage) is classically associated with the single-ray pattern of involvement seen in some patients with psoriatic arthritis, and may be the initial manifestation of the disease

80. BITE SIGN.
Seen in AVN
A rapid progression of change in a joint secondary to steroid injections.
Transition of a joint from one of minor alterations(such as narrowing, sclerosis) to one of significant bony fragmentation and collapse.
Gouged-out areas of bony destruction may be similar to small animal bites, hence the bite sign.

81. THANKYOU