X-ray diagnosis of osteoarthritis

In recent years significantly increased the role of X-ray studies in spinal osteochondrosis. It is primarily undertaken to determine the capabilities of the secondary effects of changes in the spinal segment, the spinal cord, vessels and roots, and to exclude primary bone changes and lesions of different etiology (malformations, tumors, etc.). However, often in the analysis of X-ray data, there are certain difficulties in the correct interpretation, in particular the nature and level of correlation of radiological findings and clinical manifestations. The basis for this are basically two reasons. Firstly, changes in bone and ligamentous apparatus PDS backbone arising from intervertebral disc degeneration often become available later radiological control the onset of clinical signs. Secondly, clearly defined on radiographs degenerative dystrophic changes of the spine is not always accompanied by appropriate clinical pathology or proceed with minimal clinical manifestations. In this regard, crucial radiographic signs of osteoarthritis, conditional on those or other neurological or vascular disorders.

In the analysis of X-ray in the first place should be considered the greatest manifestations of osteochondrosis in the PDS. For example, if the radiographic signs of osteoarthritis are determined only by the front or the anterolateral aspect of the vertebral bodies, the impact on the formation of the nerve is not expected. In contrast, when there are changes in the posterior and posterolateral spine may cause clinical symptoms.

In the thoracic region of the spine due to the presence of physiological kyphosis and associated power distribution of stresses that the formation of osteophytes usually occurs in the anterolateral spine, and prevents pain.

Severe lordosis in the cervical and lumbar spine with a predominant load on the rear sections of the intervertebral disc results in more frequent protrusion of the latter in the posterior and posterolateral areas with the subsequent formation of posterior and posterolateral herniations and osteophytes, which often cause one or the other clinical symptoms.

Note that cervical spine radiographs must be visible region of the skull base and two first thoracic vertebra. The C7-Th area, often the clinical significance is the identification of cervical ribs and the transverse processes of hypertrophied vertebral bodies.

On radiographs of the lumbar spine must be captured sacrum, ileosacral joints, as well as the iliac wings.

The course and the direction of the X-ray examination of the patient depends on the clinical picture. It is necessary to emphasize the importance of implementing a number of cases, the X-ray to the patient when standing and sitting, which allows to carry out research into the conditions of physiological stress.

On the lateral radiograph revealed the following features.

Narrowing the gap between the vertebrae, intervertebral, indicating a reduction in the height of the intervertebral disc as a result of the collapse, sucking or squeezing out of his degenerate masses.

ATTENTION! Severe narrowing of intervertebral gap is too late symptom of osteoarthritis.

Clinical importance of reducing the height of the intervertebral gap, even without the presence of hernias or posterolateral osteophytes may be due to offset obliquely standing VCP articular processes so that processes in the underlying vertebra pressed intervertebral foramen, which taper in the craniocaudal and oblique in size. It is also possible small displacement of adjacent vertebral bodies relative to each other. Often this is accompanied by the development of degenerative changes in the small joints - spondyloarthrosis and reactive yellow ligament changes with secondary effects on the spinal cord.

• In severe cases of degenerative disc disease occurs sclerosis, subchondral bone, detectable on radiographs as a marginal sclerosis of the vertebral bodies. Independent clinical significance of this radiological symptom of osteoarthritis is not, and can only be an indication of a degenerative process.
• Do not have clinical significance and cartilaginous vertebral hernia (hernia Shmorlja). They often develop in the aging process of the body in the thoracic and lumbar spine, and are rarely seen in the cervical region.
• The clinical significance is the identification of the rear or posterolateral osteophytes, are often the cause of spinal cord compression, or roots, especially at the cervical level, where due to the relative narrowness of the spinal canal and intervertebral foramen conditions are such that even a small osteophyte or dorsal bulging disc can affect the spinal cord or roots. It is well established that in the cervical spine cause compression are often not herniated disc, namely, back and posterolateral osteophytes. At the level of the lumbar compression of the cauda equina roots often occurs due to loss of the rear protrusion or disc. It is known that the spinal canal is wider than in the cervical spine, and under the influence of heavy loads degenerated intervertebral disc, probably, it is a great opportunity Snack prolapses posteriorly.
• Identify and front osteophytes, can be seen as the reaction of the anterior longitudinal ligament in the form of its calcification.

On radiographs FASD:

1. thoracic and lumbar spine can be determined and osteophytes on the lateral surface of the vertebral bodies, often multiple. The clinical significance of the first minimum and only indicates the presence of a degenerative process at this level. The ratio of the lateral to the anterior osteophytes departments vertebral body drastically reduces their clinical significance (N.S.Kosinskaya);
2. cervical spine often reveals uncovertebral effects of osteoarthritis, which is one of the earliest signs of degenerative disc disease, often defined in the initial stages, when only functional X-ray examination confirms the presence of changes in the intervertebral discs. This is due to the increased load on them in Lyushka joints. Radiologically determined uncovertebral manifestations of osteoarthritis often have impacts on the vertebral artery and the spinal nerve.

• determine the clinical significance is the identification of the displacement of the vertebral body, which can affect the spinal cord and roots, even in the absence of posterolateral osteophytes or hernias. It should be remembered that the displacement of the vertebrae in the lumbar spine may also occur in the absence of degenerative disc disease at anomalies of the vertebrae, static, etc. changes Moreover, osteochondrosis can thus often develop secondarily.
• flatness of lordosis in the cervical and lumbar spine in middle and old age, especially straightening it at the level of individual segments, it is an early symptom of osteoarthritis.
• The angular kyphosis of the cervical or lumbar spine in a physiological position of the patient is always an indication of the presence of intervertebral disc disease.
• Osteoarthritis of the small joints of the spine (spondylarthritis) often detects smiling at the same level as the degenerative-dystrophic changes of intervertebral discs. However, the coincidence of the extent of damage of the joints and intervertebral discs is not marked (I.L.Tager); Sometimes in severe osteochondrosis phenomenon spondyloarthrosis small, often absent, and vice versa.

For spondyloarthrosis characteristic changes in the form of newly formed osteophytes, joint space narrowing, increasing its length, the presence of multiple sclerosis subchondral bone layer. Often formed with the base neoarthrosis arches, Pommer nodules as small defects in the end plate with clear contours and sclerotic reaction around.

Spondyloarthrosis clinical significance lies in the fact that it is almost always a reactive changes of yellow ligament, the narrowing of the spinal canal with the impact on the spinal cord. Changes in the articular processes of the vertebrae also cause a decrease in anteroposterior size of the intervertebral foramen with the influence on the nerve roots; they can directly influence and formed by spondyloarthrosis osteophytes. Perhaps the influence of the past on the vertebral artery.

• intervertebral foramen with osteochondrosis may be narrowed due to convergence of the vertebral bodies, posterolateral osteophytes, osteophytes at uncovertebral arthrosis in the cervical and spondyloarthrosis. In the lumbar spine intervertebral foramen often narrows the posterolateral disc herniation. Narrowing of the intervertebral foramen of the cervical spine directly to disc herniation - a rare phenomenon, since it hindered the promotion of bundles uncovertebral joints.

Typical features in the X-ray pattern deforming spondylosis are:

1. Systematic destruction - osteophytes develop in several vertebrae (can be detected on radiographs FASD). Large osteophytes, developing only one vertebra, argue against a purely degenerative and static-degenerative origin of deformation and is more common in post-traumatic spondylosis.
2. Messy and uneven defeat. When deforming spondylosis osteophytes on different vertebrae have different values.
3. Defeat the two (cranial and caudal) vertebrae halves. Develop as osteophytes toward cranial and caudal to the side of the disc. This feature is often detected on radiographs only two (frontal and lateral) projections.
4. Knitted vertebrae in deforming spondylosis develops due to the merger of osteophytes. This fusion occurs asymmetrically, and not necessarily at the disk level. Often growing two "beak" towards each other to form a kind of joint (nonartrosis osteophytes), which, in turn, develop secondary osteophytes.
5. Discs (intervertebral gap) in the "pure" forms of deforming spondylosis without combination with osteochondrosis not narrowed. On the other hand, the projection intervertebral gap seems even more expanded, and have a clearly defined type of lenticular lenses. This is explained by the fact that the vertebral body increased in diameter and extended in the X-ray "corners" because of bone growths.
6. The vertebral bodies in deforming spondylosis usually without signs of osteoporosis. Lack of osteoporosis is partly due to the fact that the spine as if enclosed in a "bag" of ossification, as well as the fact that the function of the spine to the development of osteophytes knitted saved.

For embodiments of the spine structure should primarily include quantitative deviations. However, the total number of vertebrae in humans varies only within a small range, and mainly in the area of the sacrum and coccyx. Most susceptible to similar variations in the so-called transitional departments: head-neck, neck and chest, thoracic-lumbar and lumbosacral.

At the same time there are changes in the shape (mostly temples and their processes), which give the last cervical vertebra thoracic form (the development of cervical ribs). Similarly, the last thoracic vertebra may have only rudimentary developed ribs, not much different from the transverse processes of the 1st lumbar vertebra and the 1st lumbar vertebra may have a rudimentary ribs. In transitional lumbosacral may experience partial or total transformation of the last vertebra of the type or sacral 1st sacral lumbar by type. For these options accepted terms: dorsalization, sacralization and lumbalization.

Cervical ribs. It is known that almost 7% of all people have those or other options such as cervical ribs, usually at the VII cervical vertebra, and often bilateral than unilateral. There is, though rarely, development of cervical several ribs on the neck vertebrae.

Lumbosacral. Of all the parts of the spine transitional lumbosacral undoubtedly the most variable. Variations are observed in the number of vertebrae (instead of the normal number 5 can be observed 4 and 6) forms the transverse processes, mainly in the lumbar spine in the posterior part of vertebral arches (cleft and variations seam arches L5 and sacral vertebrae) and finally in relation to the articular processes of the lumbar vertebrae and the 1st sacral.

However, it should be emphasized that the analysis of the anomalies of the spine, and options on radiographs should be comprehensive. You can not, for example, identifying cleft arches of the 1st sacral vertebra, not to pay any attention to the condition of the bodies of the lumbar vertebrae, disks and processes arches firstly, because options are often accompanied by arches variants processes; secondly, because in addition to the embodiment of the bow can be found changes such as, for example, low back pain, arthritis of the intervertebral joints and others. Experience has shown that the identification of easily detectable, but few meaningful options is to view other hard to identify, but more clinically important changes acquired.

In severe, recurrent, refractory to conventional treatment ischialgia in which the X-ray examination indicates sacralization, spina bifida, spondylolisthesis, osteophytes, or changes of rheumatic type, you should not come to the conclusion that they are the cause of ischialgia. Intra spongios disc herniation indicate the possibility of a general disease of the intervertebral discs.

From all these combined features of some accidental, others can only emphasize congenital anomalies, indicating the place of least resistance to the lumbar segment of the spine.

Several authors (Laskasas, Piso, Yungans) turned all their attention to the angle between the L4 vertebra, and the L5 respectively with the sacral bone.

Sacrovertebral angle does not exceed 118 °. Yungansa angle defined by the median axis of the vertebral bodies L5-S1, is open at 143 °, and the sacral spinal disc - 20 °.

Traumatic cervical boundary. there are several types of anomalies and variations among them in the field of transitional traumatic cervical spine: a) assimilation of the atlas, and b) the "manifestation" of the atlas.

When I assimilate cervical vertebra fused with the occipital bone in the area of one or both of the side of the masses. There may also be knitted arches of the atlas with the lateral part of the free masses. Along with assimilation goal formation often found in the posterior arch of the atlas, and very rarely - in front (V.A.Dyachenko). The opposite condition - "a manifestation of the atlas," ie, the appearance of unusual protrusions on the edges of the foramen magnum, resembling rudimentary atlas. Practical value of such an option has not.

Anomalies and variants of the articular processes of the spine are generally reduced to the following points.

• Variant position of the articular facets in relation to the sagittal plane of the body that called Putti "anomaly tropism" articular facets. For example, in the articular facet normal lumbar spine are in a plane close to the sagittal plane, in the case of the "abnormality tropism" we find that the facet on one or both sides are in a frontal plane. Inverse correlation observed in the joints between L5 and S1, where facets normally located in the frontal plane.

Under the "tropism" is meant a morphological variant of the lumbar spine in which the intervertebral joint plane to the right is asymmetric with respect to the plane of the intervertebral joints left.

The phenomena of tropism is most often seen in the lumbosacral spine. Imperfect built intervertebral joints with additional injury or static spine overloads can serve as a place of deforming arthrosis and determining pain in the lumbar spine.

• Rotating the long axis of the facets relative to the longitudinal axis of the body.
• The anomaly values articular process or only the articular facets.
• The wedge-shaped joint.
• Cross the gap dividing process at COP base and the top of the (additional ossification nucleus).
• Lack of articular processes.
• Spondylosis.
• Hypoplastic joint transitional vertebra with the sacrum. It should be pointed out that all the above isolated anomalies and variations articular processes cx relate mainly to the lumbar spine.

Transition sacrococcygeal border

The sacrum is usually composed of 5 vertebrae, embodying four pairs of sacral holes. At the lower end of the sacrum bays are peculiar to fit with a corresponding 1st and coccygeal vertebra form a fifth pair of apertures; thus sacrum includes another vertebra.

For the most part I and II coccygeal vertebrae are connected by the joint, and I coccyx and last sacral bone may be connected. X-rays often can determine bony fusion between the last sacral and 1 coccygeal vertebra.

Radiographic studies have to distinguish the following morphological forms coccyx (I.L.Tager): a) committed; b) unilaterally assimilated; c) the right to assimilate.

The perfect shape of the coccyx is characterized primarily by the presence of a separate 1st coccygeal vertebra with horns and transverse processes and separate, decreasing in size the remaining vertebrae. At the same time the last vertebrae can be deformed and fused together.

Unilateral assimilation - when the 1st coccygeal vertebrae on one side only accepted form of sacral vertebrae, only one side is soldered to the sacrum to form the fifth sacral holes on the side of knitted. There is a different fusion degree: or complete bone knitted full bone closure sacral hole and clearance side portions coccygeal vertebra type lower edge of the sacrum or the side portions coccygeal vertebrae adjacent to the side of the sacrum, but separated by a gap of a few millimeters, the linear slit or even after the gap.

At a bilateral assimilation 1st coccygeal vertebra completely converted into the sacrum, forming a fifth pair of sacral holes. Coccyx thus consists of one or two vertebrae of the oval tracks. In these cases also notes varying degrees of assimilation: along with a complete bony fusion of the coccyx to the observed shape is not quite yet able to join the side portions of the 1st coccygeal vertebra with the sacrum, separated by a narrow gap, or even after it.

Offset vertebrae

Clinically, G.I.Turnerom (1926) has been studied experimentally and radiological spondylolisthesis. It is known that the offset vertebra can not occur without disturbing its fixation to the intervertebral disc. Essentially, every case of bias should be considered as a "looseness" disc and spondylolisthesis - as' intervertebral disc disease." There are three degrees of spondylolisthesis:

• Grade 1 - displaced vertebra slid anteriorly moderately, partial exposure of the surface of the 1st sacral vertebra;
• 2nd degree - significant exposure of the upper surface of the sacrum, V vertebra strongly inclined anteriorly;
• 3rd degree - the entire upper facet of the sacrum is exposed;
• 4th degree - vertebra is displaced in a small basin.

Since the first studies were devoted to spondylolisthesis, there have been numerous attempts to systematize. The most widespread classification Meyerdinga (1932), which distinguished between 4 degrees displacement of the vertebrae based spondylography. The offset to the j-consistent part of the vertebra of I degree from j to S - II degree, from S to s - III degree, and from s and beyond - IV degree. Junge and Kuhl (1956) proposed to add to the classification Meyerdinga V degree - total displacement with respect to the underlying vertebra. Newman, Wiltse, Macnab (1976) proposed a classification, which is based on etiopathogenic factor (dysplastic spondylolisthesis degenerative pathological traumatic spondylolisthesis).

Offered V.V.Dotsenko et al. (2002) Clinical classification spondilolis-prostheses can serve as a complement to the existing radiological and etiopathogenetically.

Stable offset:

• lumbodynia missing or not constant;
• patient activity slightly decreased or normal;
• no need to take analgesics;
• the patient does not need an external immobilization;
• There are no radiological signs of instability.

Unstable displacement:

• lumbodynia constant;
• Patient activity is reduced;
• severe drug dependence;
• the need for external immobilization;
• radiographic signs of instability.

Compression neurological syndrome (moderate):

• intermittent radicular syndrome amenable to conservative treatment;
• There are no signs of "loss" root function;
• patient activity normal or slightly reduced.

Compression neurological syndrome (severe):

• persistent radiculopathy on the displaced vertebra level, not amenable to conservative treatment;
• increase in syndrome "Drop" function chums or roots;
• Patient activity is reduced.

Spondylolysis - a gap in the vertebral arch between the articular process and not m the junction of the bow with the body of the vertebra, as wrongly interpreted by some authors (normally up to 8 years of age there is a layer of cartilage between the vertebral bodies and arches). Spondylolysis slots are located as shown by observations V.A.Dyachenko, now under the articular facet of the upper articulated process and are often cross-oblique direction - from the inside and from the top, outwards and downwards. In other cases, the gap cross crosses shackle, under the base of the upper articular process and its facet. Surfaces are ear-shaped slits, triangular shape; they are smooth, without spines, the surface articulated symmetrical, bilateral.

Spondylolysis detected in most cases only one vertebra, two-rarely detected in the radiological and practice in patients over the age of 20-30 years.

Spondylolisthesis combined with spondylolysis in males are 5-6 times more often than women, and are usually detected after the age of 30 years.

When expressed displacement degrees of spondylolisthesis I degree diagnosis is made by clinical examination: body shortened in the lumbar spine, the ribs are close to scallops iliac bones of the sacrum is palpated spinous process V lumbar vertebra, above which is determined by a deep depression. This keeps the sacrum upright. Transverse folds of skin (especially in women) hanging on the abdomen and in the lumbar region. Determined voltage long muscles. If there is an increased lumbar lordosis torso somewhat deflected backward. According V.D.Chaklinu most severe spondylolisthesis also accompanied by scoliosis.

In severe cases of spondylolisthesis with clinical examination can often determine the shortening of the waist to the presence of transverse folds in the lumbar region above the iliac crest. This shortening is formed not so much due to displacement of the vertebrae, as due to the rectification of the pelvis, approaching the iliac crest to the lower ribs.

Often reveal spondylolisthesis reduction in low-lumbar spine mobility division, which is explained as a loss of the movable segment of the spine due to lesions of the intervertebral disc and muscle contracture of the lumbar region.

With neurological complaints by patients to reduce pain in the lumbar region, manifested in the form of lumbar radiculitis (lumbago) or lumbar ischialgia. Pain sometimes occur suddenly after an overload or sudden movements.

Pseudospondilolistesis observed in the majority of cases in older obese women and much less frequently in men (10: 1). Offset vertebra with moderate. As a rule, appears biased IV lumbar vertebra on V. At clinical examination conspicuous sharp hyperlordosis and lumbar muscle strain.

ATTENTION! Based on clinical data alone, without X-ray examination, diagnosis of this type of spondylolisthesis is practically impossible, as, indeed, it is impossible for mild degrees of spondylolisthesis.

Currently distinguished:

• Fixed (functionally), spondylolisthesis, ie anterior displacement of a vertebra is that "fixed" by the presence of spondylolysis gap in combination with osteochondrosis or no spondylolysis - interarticular extension of the bow, combined with osteochondrosis;
• fixed or unfixed spondylolisthesis, which is the spinal osteochondrosis combined with local deforming arthrosis of the articular disc corresponding to this pair;
• functional displacement due to the presence of osteoarthritis, but without radiographically visible deformation of the bow and its joints.

Offset vertebrae posteriorly known under different names - retrospondilolistez, retroposition. The cause of the rear displacement of the vertebrae, most experts believe degenerative disc lesion. It is not excluded traumatic and inflammatory etiology bias.

In the mechanism of the rear displacement Brocher a major role to considerable thrust backward from the yellow ligaments and powerful extensor of the back, which are antagonists of the anterior longitudinal ligament.

At clinical examination, there is no objective evidence that would reveal the posterior displacement of the vertebrae. Only the X-ray examination allows finally to establish the diagnosis. The pictures in the rear projection parts such offsets are not detected, for that indispensable side shots where shaped ledges violation of a line drawn through the dorsal contours of vertebrae is determined by the bias level.

Unlike "pseudospondilolistesis" arthritic joints in arches at the rear offsets are not detected. Offset vertebrae posteriorly is a severe form of pathological shifts and give the highest percentage of disability.

Rear bias often located in the zone II-III lumbar vertebra. Invaluable assistance has functional radiography, making it possible to objectively document not only the presence of posterior displacement, but also the degree of "looseness" in the relevant PDS spine.

Therefore, as in the front displacements, back bias can occur at any level of the lumbar spine, but the ratio of the static spine and posterior displacement level are opposite to those of " pseudospondilolistesis ". So, when hyperlordosis forward move lower, and posterior - upper lumbar vertebrae; when gipolordoze - return ratio. This leads to the conclusion that the level of displacement of the vertebrae and the offset direction (forward or backward) is entirely dependent on the characteristics of the static thoraco-lumbar spine.

The study of the X-ray shows that the displacement of the vertebrae posteriorly occur in the transition zone kifolordosis: it is here that the greatest point of the vertical load is posterior portions of disks in which degenerative changes (low back pain) occur due to prolonged compression. But because in the transition zone vertebrae and discs are arranged so that their ventral dorsal sections above are, naturally, only the posterior vertebral slippage may occur at this level. This applies to cases hyperlordosis and to cases gipolordosis.

From the standpoint of sliding mechanism should also be noted that the articular processes because of their location at a certain angle backward can not shift to resist posterior vertebra, which is further reinforced thanks to the constant thrust experienced by vertebrae yellow ligaments at extensor movements.

In assessing posterior displacement should take into account the possibility of so-called false retroposition. In such cases, we are talking about increasing the size of the anteroposterior spine in relation to the underlying. This increase can be seen in turn as true (for example, after compression fracture consolidation, with Paget's disease, hemangioma, etc..) Or false - by marginal osteophytes rear.

ATTENTION! False retroposition can cause pronounced neurological syndrome, as they are always accompanied by degenerative changes of the disc.

Clinical and radiographic observations highlight two more groups of vertebral displacement: Stair and combined offset.

When the ladder spondylolisthesis occurs at the same time the displacement of the two (or possibly more) of the vertebrae in one direction - forward or backward.

Combined offset characterized by the simultaneous displacement of the two vertebrae in opposite directions.

The diagnosis of osteoarthritis is made by the presence of multiple radiographic signs listed above. The clinic for a comprehensive assessment of the identified radiological changes is advisable to use the following criteria.

Criteria, reflecting the amortization violation disk function: narrowing of intervertebral gap seal deputies boiler rooms-plates of the vertebral bodies, the presence of the front or rear growths (osteophytes), skewness of the vertebral bodies in front of the edge rims, calcification of the fibrous ring, the development of osteoarthritis and neoarthrosis. For the cervical spine is quite pathognomonic sign of osteoarthritis is to change the hook processes, their deformation, education uncovertebral arthrosis.

The criteria reflect a violation of the motor function of the spinal segment, which is most clearly identified and specified during functional tests: abnormal mobility or immobility ( "Unit") of one or more segments. Signs of fixation on radiographs are straightening of physiological curvatures or local angular kyphosis, lordosis, scoliosis, the displacement of the spinous processes, and in advanced cases - convergence of the transverse processes of the vertebral bodies, the local "block" (a symptom of "spacer"), as well as areas of calcification disk triangular shape facing the tip of crack in the intervertebral. Often signs of immobility, coupled with signs of hypermobility in the PDS (pseudospondilolistesis, subluxation by Kovács et al.).

To assess the stages and severity of osteochondrosis Zekeriya classification can be recommended:

• Stage 1 - a slight lordosis changes in one or more segments;
• Stage 2 - changes in the average severity of: straightening of lordosis, slight thickening of the disk, is moderately pronounced front and rear deformation of the hook exostosis or processes of the cervical spine;
• Stage 3 - expressed changes, ie the same, but with a significant narrowing of the intervertebral foramen;
• 4th stage - considerably expressed osteochondrosis with narrowing of the intervertebral foramen and spinal canal, massive exostoses directed backward - toward the spinal canal.

ATTENTION! Not always the clinical symptoms may be caused by changes in X-ray revealed bone spine PDS.

In clinical practice, radiologists, neurologists, orthopedists, traumatologists, rheumatologists and other specialists working with this category of patients, cases mismatch radiological symptoms of spine lesion with the severity of clinical manifestations.