commented - annals of the rheumatic diseases · def: inflammatory changes in the bursae that...

Annals of the Rheumatic Diseases 1995; 54: 615-625

NOWAND THEN

Commented glossary for rheumatic spinaldiseases, based on pathologyf

Robert J Franqois, Frits Eulderink, Eric G L Bywaters

AbstractObjectives-To redefine and comment onterms on a pathological basis, in order toavoid the confusion due to the use oftermswith different meanings, to standardiseusage among clinicians, radiologists andpathologists, and to facilitate literaturesearches.Methods-Within the Committee ofPathology ofthe European League againstRheumatism, a study group was set up toanalyse the medical literature andcommon practice concerning the nomen-clature of rheumatic spinal diseases. Thegroup tried to amalgamate the maintrends in the field, to reconcile etymology,historical background, morphology, andcommon practice.Results-The group warns against use ofthe terms 'acquired hyperostosis syn-drome', '(von) Bechterew's disease','Kuimmel's disease', 'pseudospondylo-listhesis', 'rheumatoid spondylitis','spondylarthropathy' in the sense ofspon-darthritis, and 'spondylosis'. It recom-mends intercorporal or interapophysealrather than intervertebral (osteo)chon-drosis, zygapophyseal diverticulum ratherthan cyst, disc hernia rather thanprolapse, spondyloarthritis rather thanspondyloarthropathy, marginal ratherthan anterior spondylitis, and discar-throsis. It proposes 'zygarthrosis' todesignate zygapophyseal osteoarthrosis.Conclusions-Knowledge of the patho-logical basis of diseases and an under-standing ofthe original definitions given bythose who coined new terms make it poss-ible to avoid most of the confusion arisingfrom improper use of spinal terms.

(Ann Rheum Dis 1995; 54: 615-625)

It is common experience that clinicians,radiologists, pathologists, and other scientistsinterested in spinal disease use a number ofeveryday terms with different meanings, whichcauses considerable confusion. In a recentpaper, it appeared that 51 English speakingspine surgeons use 50 different terms for theirfour most common diagnoses. 1

Dictionaries do not solve all problems, asthey may differ, and may be incomplete,inaccurate, or even totally wrong. For example,spondylolysis is defined in one dictionary' as'ankylosis of a vertebral joint' or as'osteoarthritis of the intervertebral disk space

or the posterior facet joints' and in another3 as'dissolution of a vertebra' or as 'a conditionmarked by platyspondylia, aplasia of theposterior arch, and separation of the parsinterarticularis'. Thus the simplest and mostcommon meaning, 'separation of the parsinterarticularis', is not given by either of thesetwo authoritative dictionaries.The idea of standardising nomenclature in

this field arose in 1967, at the VIth EuropeanCongress of Rheumatology in Lisbon.4 It wastaken up again by the Committee on Pathologyof the European League against Rheumatism(EULAR): a subgroup was appointed to defineconcepts, list synonyms, and recommendpreferred terms. After agreement was reachedon a number of items pertaining to the normalanatomy of the spine,5 a list of termsconcerning pathological changes and diseasesis now proposed.The area of investigation is restricted to

rheumatic diseases, excluding fractures,tumours, and congenital pathology. As part ofthe Committee on Pathology, the workinggroup approached the problem from amorphological point of view. The CanadianVocabulary of signs and symptoms of themusculoskeletal system6 7 has a different andbroader scope.

METHODThe working party had to represent themainstreams in the field of spinal pathology. Inparticular, Anglo-American, French andGerman trends were incorporated withoutomitting the important contributions of othercountries and languages.The intention was to compile a glossary to

be used by pathologists, radiologists, andclinicians. Many contacts were made withinterested scientists outside the Committee.The working group aimed to adhere as

closely as possible to the following rules:1) to respect the etymological sense of theterms;2) to take account of the historical backgroundand to remain faithful to the original definitiongiven by the author who coined the term ormade it popular;3) to give descriptive definitions, acceptingonly those pathogenetic implications that areunanimously recognised;4) to avoid using one term in more than onemeaning;5) if possible, to follow common practice.It is realised that these rules are partly at oddswith each other.

Laboratoire deRhumatologie,H6pital MilitaireReine Astrid,B1120 Brussels,BelgiumR J FranqoisLaboratorium voorPathologie,Rijksuniversiteit,Leiden,The NetherlandsF EulderinkDepartment ofRheumatology,University ofLondon,Postgraduate MedicalSchool,London,United KingdomE G L BywatersCorrespondence to:Dr R J Francois,9 avenue de Sumatra,B 1180 Brussels, Belgium.

tPrepared on behalf of theCommittee on Pathology ofthe European League AgainstRheumatism.Accepted for publication13 October 1994

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PRESENTATIONConsidering it important that people shouldunderstand the original meaning ofthe words theyuse, the authors recall the etymology (Etym) ofterms before giving a definition (Del), comments(Com), synonyms (Syn), recommended nomen-clature (Rec) and, if applicable, the historical (His)source. In rare instances, a new term might beproposed (Prop). If useful, French (F) andGerman (D) translations are given. When, withina definition, a term is used that is defined separ-ately in this list, it is marked by an asterisk (*).

THE GLOSSARYThe list contains specific spinal terms andgeneral concepts that are particularlyimportant in spinal pathology.

Ankylosing spondylitissee spondylitis*, ankylosis*.

AnkylosisEtym: Ancient Greek ankylosis, crookedness.Def: Fusion of articulating bones, by densefibrous tissue (syndesmosis), cartilage(synchondrosis) or bone (synostosis) leading tototal loss of movement.Com: The concept is widely used in theadjective 'ankylosing' as in ankylosing spondy-litis* and vertebral ankylosing hyperostosis*.

Baastrup's syndrome8Def: Painful condition due to abnormal frictionbetween spinous processes, as a consequenceof reduced lumbosacral angle and/or discheight, or of hyperlordosis.Com: Pathological changes include bursa for-mation, thinning of interspinous soft tissues,cartilage lining of adjacent processes, with fibril-lation, eventual ebumation, and bonesclerosis.9 10 A similar condition in the cervicalspine was described clinically by Michotte" andpathologically by Bywaters.'2see also bursitis*.

Bursitis, interspinousEtym: From Latin bursa, purse and the suffix-itist.Def: Inflammatory changes in the bursae thatdevelop in aging people by synovialisation* ofclefts within the interspinous space.9 12 13Com: The mechanical variety corresponds toBaastrup's syndrome*. Calcium pyrophos-phate and hydroxyapatite deposits'2 andrheumatoid changes in adults'2 andchildren'2 14 can be seen.

to the hyaline cartilage at the discovertebralinterface.

- Intervertebral chondrosisDeft Schmorl,'5 considering the whole disc as(fibro)cartilage, used 'intervertebral chon-drosis' as a synonym of disc degeneration.Com: The three components of the inter-vertebral disc do share a common chondralorigin, possessing collagen type II andglycosaminoglycans. However, Schmorl'sdefinition introduces confusion, in that thesame word could be used for degenerativechanges of three structures: the hyalinecartilage of the disc, the whole disc, and thehyaline cartilage of the apophyseal joints. Inaccordance to our rule 4, we do not supportSchmorl's nomenclature. People who wish touse it should refer to Schmorl when doing so.It would be more accurate to speak of discal orintercorporal (between the bodies) chondrosisinstead of intervertebral chondrosis.see also osteochondrosis*.Prop: Intercorporal chondrosis.Syn: Disc degeneration*; intercorporalchondrosis.

Cyst, zygapophyseal or facet jointsee diverticulum*, zygapophyseal.

DegenerationDeft Change from a higher to a lower form,especially change of a cell, tissue or organ toa lower or less functionally active form.Com: In a tissue or organ, degeneration can beaccompanied by reactive processes such asinflammation and/or proliferation; in spite ofthis, a disease can be called degenerative whenthe first or main changes are degeneration.Degenerative is often opposed to inflam-matory; however, it would be unwise to callevery non-inflammatory and non-tumoralcondition 'degenerative'.

Degenerative disc diseasesee disc degeneration*.

Diffuse idiopathic skeletal hyperostosis(DISH)see under hyperostosis*.

Disc bulgingDeft Protrusion of the whole disc, in contrastto the focal protrusion of a disc herniation.

ChondrosisEtym: Ancient Greek chondros, cartilage andthe suffix -osist.Def: Degeneration* or non-inflammatorydevelopmental change of cartilage.Com: In the spine, this would apply to thearticular cartilage of the apophyseal joints and

t -itis: Suffix to indicate the inflammatory nature of acondition.* -osis: Suffix to indicate either the non-inflammatorycharacter of a lesion-most often a degenerativecondition-or the widespread nature of a lesion, as inchondromatosis.In the previous century and in the early 20th century, thesuffix -itis has been used for conditions that are nowregarded as degenerative. For example, osteoarthritisdeformans was the usual term for what we now, better,call (osteo)arthrosis.

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Diffuse bulging occurs in case of discdegeneration*, due to loss of turgor, presenceof fissures, or both.

Disc degenerationDeft Degeneration* of disc.Com: Structural changes include reduced waterand modified proteoglycan content, decreasedheight, brown discolouration, fissuring andcrumbling. Radiological features of pure discdegeneration are:- reduced disc height;- retrolisthesis* due to the obliquity of thearticular facets, but this is only true if thecartilages of the interapophyseal joints arepreserved;- clefts at the insertion of the annulus fibrosusinto the marginal ring, or to a variable extentthroughout the whole disc, visible on plainradiographs by the vacuum phenomenon or ondiscograms;- increased sagittal mobility, that may be seenon flexion and extension views.'6Disc degeneration is often accompanied orfollowed by bony changes in the vertebralbody, mainly osteophytes* and osteosclerosis.In the presence of bone changes, the termdiscarthrosis* is pertinent. Some authors mightprefer to consider disc degeneration anddiscarthrosis as one continuous process anduse the term degenerative disc disease."7Syn: Degenerative disc disease.

Disc hernia(tion)Deft Localised protrusion of part of the discbeyond its normal boundaries: protrusion ofnucleus pulposus and/or annulus fibrosus and/or cartilage'8 through a defect in the annulusand eventually in the perivertebral ligaments,or protrusion of disc material into the vertebralbody through the basal cartilage.Com: Disc prolapse is a less well suited term,for prolapse is used for other organs, such asrectum or uterus, to designate a displacementthat occurs without defect of their wall orcontaining membranes.Syn: Disc hernia into the vertebral body iscalled intravertebral disc hernia, Schmorl'snode*, cartilaginous node.

Disc prolapsesee under disc hernia*.

Disc resorptionsee under discarthrosis*.

DiscarthrosisDef: Structural and functional failure of thediscal joint, analogous to synovial jointosteoarthrosis, combining disc degeneration*and bone changes.Com: Starts as disc degeneration. Laterchanges are osteophytes*, the more or lessdisappearance of discal tissue, fibrillation andchondrocyte clustering in the hyaline cartilage,

disrupture of the endplate, with eventualSchmorl nodes*, and changes in the subchon-dral bone (sclerosis, pseudocysts, erosions,eburnation).9The boundary between disc degeneration* anddiscarthrosis is almost impossible to trace. Theformer might be used when the changes seemlimited to the intervertebral disc, and the latterwhen bony changes are present.In the cervical spine, the term uncodiscar-throsis is applicable, to point to theinvolvement ofLuschka's joints between uncusand the corresponding area of the adjacentvertebral body; uncarthrosis plays animportant role in eliciting symptoms becauseof the osteophytes reducing the intervertebralforamen.His: The term discarthrosis was coined by deSeze. He called the variety with advancedsclerosis and erosion of the vertebral body'pseudopottque'.20Syn: - Erosive intervertebral osteochon-

drosis*21 points to cases with lessadvanced destruction of the vertebralbody than de Seze's.- Disc resorption* was coined byCrock22 23 for the variety of discdegeneration* characterised by grossnarrowing of a disc space with sclerosisof the adjacent vertebral bodies.- Intervertebral osteochondrosis* is,according to Schmorl,'5 a synonym fordiscarthrosis; for more accuracy, werecommend replacing intervertebral byintercorporal or discovertebral.

Rec: Discarthrosis.

DiscitisDeft Infective or sterile inflammation of anintervertebral disc.Com: The normal disc is avascular, but vesselswill invade the disc after a lesion, allowinginflammation; discitis may also be theextension of a spondylitis*.see spondylodiscitis*

DiscopathyEtym: Ancient Greek diskos, disc and pathos,suffering.Deft Any pathological condition of the disc.Com: Should be replaced by a more specificterm (disc degeneration, discitis, etc) wheneverpossible.

Diverticulum, zygapophysealDeft Normal zygapophyseal joints have acranial and a caudal recess, visible atarthrography.24 Enlargement of these,especially the cranial one, leads to diverticulademonstrable by myelography,25 26 computedtomography,27 28 arthrography,29 30 and mag-netic resonance imaging.3' 32 In late stages,they could erode the adjacent bone, being seenor suspected on plain x-ray films.Com: The wall of such a diverticulumsometimes contains inclusions of calcifiedmaterial33 as a consequence of deterioration of

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the facet joints; this is analogous to whathappens in peripheral synovial joints.Syn: - Synovial cyst is often used instead of

diverticulum, but is less correct, in thatcysts are classically closed whilediverticula are connected with the organfrom which they originate.3- Ganglion, another term used in thiscontext, is defined as metaplasia of para-articular connective tissue leading to theformation of a cyst without synoviallining, not connected with the synovialcavity, and containing mucinousmaterial.34 3

EnthesisEtym: Ancient Greek (par)enthesis, insertion.Def: Attachment through insertion. Inrheumatology, it serves mainly for attachmentof tendon, ligament, fascia, or capsule intobone; it might also be used for attachment ofheart valves, iris, etc.Com: There are two histological types ofenthesis, depending on the chondral ormembranous origin of the bone tissue receivingthe insertion: one by calcified cartilage and oneby penetrating fibres (Sharpey's fibres).36-38

EnthesitisEtym: Ancient Greek enthesis* and suffix-itis*.Deft inflammation of an enthesis.

EnthesopathyEtym: Ancient Greek enthesis* and pathos,suffering.Deft Any pathology of an enthesis.Com: Enthesopathies include mainly meta-bolic, degenerative and inflammatory changes;enthesitis* should be preferred to enthesopathyif inflammatory changes are to be designated.

EnthesophyteEtym: Ancient Greek enthesis* and phyton,plant, growth.Deft Osteophyte* at an enthesis.

Ganglion, intraspinalsee under diverticulum*.

Hyperostosing diseasesee under hyperostosis*.

HyperostosisDeft Hyperplasia of bone, by interstitial and/orexternal apposition.Com: The word is used in vertebral ankylosinghyperostosis39 or diffuse idiopathic skeletalhyperostosis (DISH)*40 to name a conditioncharacterised mainly but not exclusively byenthesophytes*. In the spine, the most con-spicuous changes are a prevertebral bone layer,asymmetrical enthesophytes and intervertebral

bridges. The prevertebral ossification is ofenthesophytic nature,4 42 and sometimesstarts as a ribbon-like calcification.43Aufdermaur44 pointed to the association withScheuermann's disease. Ossification of theposterior longitudinal ligament and of thecapsule of the facet joints can occur inaddition. These aspects are clinicallyimportant because of the encroachment uponthe spinal canal at the cervical,45 46 dorsal,47 orlumbar48 level.Syn: - Vertebral ankylosing hyperostosis fails

to address the extraspinal localisations. Itcan be retained to designate the spinalchanges or even the whole condition, asForestier himself had described theextraspinal lesions.49- Spondylosis hyperostotica50 51 shouldbe rejected because of the confusionaround the term spondylosis* (seefurther).- DISH is appropriate despite the factthat 'skeletal hyperostosis' soundspleonastic.- Arlet and Mazi&res52 coined the termhyperostosing disease, which is criticisedby those who do not consider the oftenasymptomatic hyperostosis as a disease.- Other terms stress the metabolicaspects, such as 'spondilopatia iperos-tosica dismetabolica',53 or the import-ance of enthesopathies, such as 'diffuseenthesopathic hyperostosis'.54

Rec: Diffuse idiopathic (skeletal) hyperostosis,vertebral ankylosing hyperostosis, hyperos-tosing disease.see also under spondylosis* and further in thediscussion.

- Acquired hyperostosis syndrome55Def: Synonym of SAPHO*, but including inaddition, cases of psoriasis vulgaris.Com: To be discarded, because this term mightbe confused with diffuse idiopathic hyper-ostosis*, to which it is also applicable.

- Synovitis-acne-pustulosis-hyperostosis-osteomyelitis syndrome(SAPHO)*Def: see synovitis-acne-pustulosis-hyperostosis-osteomyelitis syndrome*.

Kummel's diseaseDef: Clinical syndrome of delayed post-traumatic vertebral collapse.His: Between 1891 and 1928, Kdmmel56devoted several papers to a disease caused bya rather mild trauma of the spine, the pain ofwhich abated after a few days, to reappearsome months later after a pain free period.Immediately after the initial trauma, noradiological anomaly is disclosed; in the thirdphase, rarefaction and loss of bone tissue leadto collapse ofthe vertebral body and angulationof the spine.Pathological data are available from Schmorl,15who shows a picture of a necrotic vertebral

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body. This is probably why Resnick andNiwayama57 define Kiimmel's disease asvertebral osteonecrosis. These authors havepublished such a case, with an intraosseousvacuum, in their textbook. According toMaldague et al,58 the latter sign is highlysuggestive of ischaemic necrosis.Com: No single aetiology can account for allcases of delayed post-traumatic vertebralcollapse. Unrecognised fracture, particularly inosteoporotic patients, ischaemic osteonecrosis,sympathetic neurodystrophy, and tuberculosisare possible causes. Hence the term Kiimmel'ssyndrome would be better than Kiummel'sdisease, but the question should be raised ofthe usefulness of that concept.Rec: to be discarded.

Limbus vertebraEtym: From Latin limbus, border or fringe.Def: Vertebral body with unfused marginalring, as in juvenile vertebral osteochondrosis*.

OlisthesisEtym: Ancient Greek olisthesis*, slipping.Def: Slipping, displacement, as usedspondylolisthesis*.

in

Osteitis condensans jill

see osteosis condensans ilii*.

OsteochondrosisDeft Degeneration* or non-inflammatorydevelopmental change of both cartilage andbone.Com: In the first sense, and from amorphological point of view, osteoarthrosis isa kind of osteochondrosis.see intervertebral osteochondrosis*.The second sense is used to cover a number ofheterogeneous conditions affecting theimmature skeleton,59 including the disco-vertebral junction (juvenile vertebralosteochondrosis*).

- Intervertebral osteochondrosisDeft Term used by Schmorl'5 to designatedegeneration* of disc and vertebral endplates.Com: This denomination has been taken overby some authors in the US59 and Europe.2' Asis the case for chondrosis*, the adjectiveintervertebral is not accurate enough; the latteris applicable to both the discovertebral andzygapophyseal joints; a better denominationwould be intercorporal osteochondrosis.Syn: Discarthrosis, intercorporal osteochondrosis.

- Juvenile vertebral osteochondrosisDef: Postnatal developmental disorder of thediscovertebral junction60 with focal irregularityor even absence of the osteocartilaginousgrowth zone and disorganised collagen fibres6'leading to several of the following changes:irregular endplates with Schmorl's nodes*,

tinning of the intervertebral disc, wedging ofthe vertebral body, compensatory growth(increased anteroposterior diameter or localisedlengthening), absence of bony fusion betweenmargin and vertebral body (limbus vertebra*).Com: Scheuermann62 described the involve-ment of the dorsal spine by this condition, withemphasis on wedging and hyperkyphosis. Thelumbar localisation has been recognised bymany authors.Syn: Scheuermann's disease*.

OsteopeniaEtym: Ancient Greeek osteon, bone and penia,poverty.Def: Radiological concept for any reduction inbone tissue density, whatever the cause(osteoporosis*, hyperparathyroidism, etc).

OsteophyteEtyrm: Ancient Greek osteon, bone and phyton,plant (growth).Def: Any bone outgrowth, but especially spursaround an osteoarthrotic joint.Com: In peripheral joints, marginal osteophytesare readily distinguished from enthesophytes*at the insertion of tendons, ligaments, orcapsule, because of the free space between thecartilage edge and the attachment of thecapsule. Such free space is lacking at the discaljoint; marginal osteophytes of the vertebralbody develop into an insertional area and meritdesignation as enthesophytes.In the spine, Macnab63 distinguished betweenmarginal (claw) spurs and traction spurs,which are at some distance from the vertebraledge, but this distinction has beenquestioned.64 Marginal osteophytes associatedwith a tear in the annulus fibrosus andprobably secondary to some traction on theperivertebral ligaments have been described bySchmorl'5 and Francois.65

OsteoporosisEtym: Ancient Greek osteon, bone and porosis,porosity.Def: Increased porosity of bone; local orgeneral decrease of trabecular and/or corticalbone volume, as a result of aging, lack ofgravitational stimulation, hormonal deficiencyor excess, and other known and unknownfactors leading to imbalance betweenformation and resorption. Bone trabeculae,although thinner and fewer, do not appearabnormal by current methods of investigation.Com: When destruction is evident, as inhyperparathyroidism, tumours or infection,osteolysis should better be used. There is nosharp demarcation between normal andreduced bone density. It is generally acceptedthat spinal osteoporosis is asymptomatic untilthe first compression fracture occurs.

Osteosis condensans 1111Def: Triangular or oval bone sclerosis in theiliac bone adjacent to the sacroiliac joint,

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probably due to overload, particularly inpregnant women in whom relaxation of thepelvic joints is believed to be an importantaetiological factor.His: Osteitis condensans ilii* was coined byBarsony and Polgar.66Com: The lesion may also involve the sacralpart of the sacroiliac joint. Pathology includesincrease of trabecular and cortical bone,marrow fibrosis, and sometimes bone necrosis.The articular cartilage is retained.

ParasyndesmophyteDeft Syndesmophyte* that is inserted at somedistance from the margin of the vertebral bodyand/or extends beyond the vertebral margin.His: The term was coined by Dihlmann.67

Paravertebral ossification (in psoriasis)Deft Paravertebral and paradiscal ectopic boneseen in psoriasis and that, unlike syndes-mophytes*, remains unattached to thevertebrae.His: This change was described by Bywatersand Dixon.68

Pseudospondylolisthesissee under spondylolisthesis*.

Pustulotic arthro-osteitisDeft Locomotor changes associated withpustulosis palmoplantaris. These changesinclude synovitis, sternocostoclavicular hyper-ostosis, chronic sclerosing osteitis of otherbones, sacroiliitis and spondylitis.

RetrolisthesisEtym: Latin retro, backwards and ancientGreek olisthesis*, slipping.Deft Dorsal displacement of a vertebra inrelation to its distal fellow.Syn: Retrospondylolisthesis3 is more accuratewhen used alone; retrolisthesis is accurateenough when used with specification of theinvolved vertebra.

Retrospondylolisthesissee retrolisthesis*.

Rheumatoid spondylitissee under spondylitis*.

Rugger-jersey spineDeft Peculiar aspect of vertebral bodies,characterised by sclerosis of both subchondralregions and eventually by atrophy of thecentral area,69 giving the spine a stripedappearance.Com: Rugger-jersey spine has been describedin hyperparathyroidism, renal osteodystrophy,certain types of osteopetrosis, and corti-costeroid induced osteoporosis.

Syn: The osteopetrotic variety is also calledsandwich vertebra.F: Rachis en maillot de rugby.7

Sandwich vertebra**see rugger-jersey spine.

SAPHOsee synovitis-acne-pustulosis-hyperostosis-osteomyelitis syndrome*.

Scheuermann's disease62Deft Juvenile vertebral osteochondrosis* of thedorsal spine.Com: see under osteochondrosis.

Schmorl's node70Deft Cartilaginous node within the vertebralbody, in continuity with the intervertebral discand associated with an endplate lesion.Com: Can be considered as an intravertebraldisc hernia* through a defect or weak place inthe endplate of the vertebral body or in thesubchondral bone; in juvenile vertebralosteochondrosis*, it could merely arise fromirregular growth of the endplate also. Thefrequency of Schmorl nodes does not increasewith age.7' In the T1O-L1 area, Schmorl'snodes bear a relationship to discdegeneration* 71Syn: Cartilaginous node, endplate lesion,intravertebral disc hernia.D: Schmorlsches Kn6tchen, Knorpelknotchen.F: Hernie intraspongieuse, hernie intra-somatique/intracorporeale.

Spinal rheumatoid arthritisDeft Spinal changes due to rheumatoidarthritis.His: The histopathology of such changes wasanalysed in the cervical spine,2 13 72-75 in thedorsal spine, where the lesions extend from thecostovertebral joints76 and in the lumbarspine.'3 73Syn: Rheumatoid spondylitis*,74 but thisshould be avoided because the same term hasbeen used previously in the USA for manyyears, as a synonym of ankylosing spondylitis*.

SpondarthritisEtym: Conflation of spondylarthritis* andperipheral arthritis, to point to the associationof axial and peripheral involvement.Deft Any one of a group of inflammatorydiseases, comprising ankylosing spondylitis*,Reiter's disease, reactive arthritis, psoriaticarthritis and spondylitis, arthritis withulcerative colitis and Crohn's disease, uveitis,HLA-B27 linked peripheral arthritis, andmaybe other conditions.His: The term was coined by the Leedsgroup.77Com: The spondarthritides are characterisedby axial and peripheral arthritis, absence of

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rheumatoid factor, increased frequency ofHLA-B27, overlapping syndromes, familialaggregation, and mutual association withinpatients and families. Some authors haveadvocated inclusion also of Whipple's disease,Behcet's disease, and other diseases, but thisshould be discouraged for conditions that lackthe connection with HLA-B27 and do notexhibit the same inflammatory changes.Syn: Spondyloarthropathy. The use of theradical spondylo- makes it clear that spondylo-arthropathy is a composed word referring bothto the spine and to another arthropathy;however, arthropathy is too vague and does notindicate the inflammatory nature of thecondition; it applies to any disease involvingboth the spine and the limbs, such aspolyarthrosis, chondrocalcinosis, ochronosis,diffuse idiopathic hyperostosis, etc. Spondylo-arthritis is more accurate. Spondylarthropathy*is also used, but should be avoided, because ithas another etymological significance.Rec: Spondyloarthritis, spondarthritis.

SpondylarthritisEtym: Ancient Greek spondylos, vertebra,arthron, article or joint and suffix -itis.Def: Inflammation of spinal joint or joints.

- Ankylosing spondylarthritisDef: Synonym of ankylosing spondylitis*.

SpondylarthropathyEtym: Ancient Greek spondylos, vertebra,arthron, article or joint, pathos, suffering.Def: Any pathology of vertebral joints.Com: Is also used, incorrectly, for spondarthritis*.

SpondylarthrosisEtym: Ancient Greek spondylos, vertebra,arthron, article or joint and the suffix -osis.Def: Osteoarthrosis of spinal joints. Specifyzygapophyseal or discal.Com: Originally, this term was used only forinterapophyseal joints. The similarity betweenthe structural and functional failure of apo-physeal and discal joints and the relationshipbetween both lend support to a commondenomination. Moreover, in the very advancedstage of disc failure, the whole nucleus pulposusand most of the central part of the annulusfibrosus disappear, a cavity is formed, the basalcardlages become frayed, and eburnation canoccur-all of which changes are reminiscent ofdiarthrodial joint arthrosis.Syn: - Discal spondylarthrosis is called

discarthrosis* by de Seze;20 it is a veryconvenient and short term.- 'Arthrose posterieure' is a widely usedFrench synonym for zygapophysealspondylarthrosis; it is outdated to thatextent that in the anatomical nomen-clature posterior is now replaced bydorsal. It would be useful to have a shorterterm to replace zygapophyseal spondyl-arthrosis. We suggest zygarthrosis.

Prop: Zygarthrosis.Rec: Discarthrosis, zygarthrosis.

SpondylitisEtym: Ancient Greek spondylos, vertebra andthe suffix -itis.Def: Inflammation of a vertebra. Qualification(ankylosing, infectious, tuberculous, Salmon-ella, etc) is needed.Com: Note that in 'ankylosing spondylitis',spondylitis is used in another sense than theone given here-that of inflammation ofvertebral joints and eventually of the vertebra.

- Ankylosing spondylitisDef: Inflammatory disease of the axial and toa lesser extent of the peripheral joints, withsynovitis,78-81 para-articular bone sclerosis(osteitis),82 83 enthesitis*,74 and discitis*.13 83 84The inflammatory processes erode fibro-cartilage, hyaline cartilage80 83 and bone,leading to chondro-osseous and fibrous anky-losis, and to squaring ofvertebral bodies.85 Thedisease almost always involves the sacroiliacjoints, and is highly linked to HIA-B27.Syn: Spondylarthritis ankylosans,4 pelvo-spondylitis ossificans,86 spondylitis ankylo-poetica. Eponyms in this case should beavoided, especially that ofvon Bechterew.His: von Bechterew (now spelled Bekhterev)created considerable confusion in describing,in 1893,87 what he thought to be a genuinedisease, distinct from ankylosing spondylitis; in1899,88 he published two cases of presumedankylosing spondylitis in order to insist on thedifference between this disease and his own.However, he had been preceded and would befollowed by numerous authors who diddescribe accurately ankylosing spondylitis, asstated by different reviewers.89 90D: Ankylosierende Spondylitis.F: Spondylarthrite ankylosante, pelvi-spondy-lite rhumatismale9' (better spelled pelvo-spondylite).

- Spondylitis deformansDeft Obsolete synonymdeformans*.

of spondylosis

- Marginal (anterior) spondylitisDeft Inflammation of the margin of a vertebralbody due to enthesitis, leading to squaring ofthe vertebral body, erosion, shining corners orsyndesmophytes.His: The term anterior spondylitis wasintroduced by Romanus and Yden in 1952.86Com: Since enthesitis is found all along themargin of the vertebral body,84 the adjective'marginal' is better suited than the original'anterior'.Syn: Romanus lesion.

- Rheumatoid spondylitisDeft 1. Has been used for decades in the USA

as a synonym of ankylosing spondylitis*.

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Since rheumatoid arthritis and anky-losing spondylitis are well recognised astwo distinct diseases, the term has beendiscarded.2. Has been used by Ball74 to describeinvolvement of the spine in rheumatoidarthritis. To avoid confusion, it should bereplaced by spinal rheumatoid arthritis*.

Spondyloarthritissee spondarthritis*.

Spondyloarthropathysee spondarthritis*.

SpondylodiscitisDeft Combinationdiscitis*.

of spondylitis* and

for others it includes also disc degener-ation without vertebral changes.

Com: 1. The adjective deformans has no sense,for most pathology induces morpho-logical changes (that is, deformation).2. Schmorl70 made no distinctionbetween common osteophytes* and theosteophytes present in the case of hyper-ostosis* of the spine. As statedpreviously, hyperostosis and dis-carthrosis*, despite frequent association,are better considered as separateconditions while their causes remainpoorly known.3. As so many meanings are given to theterm spondylosis, without regard tothe original definition, and as even theoriginal definition confuses distinctconditions, the study group recommendsavoidance of the use of the term, or thatit be defined whenever it is used.

SpondylolisthesisEtym: Ancient Greek spondylos, vertebra andolisthesis*, slip.Def: 1. Ventral displacement of the vertebral

body due to spondylolysis*, elongation ofthe pars interarticularis, or more complexdefects of the neural arch.2. Ventral displacement of a wholevertebra, secondary to zygarthrosis*.

Syn: of 1: Isthmic spondylolisthesis.of 2: Arthrotic spondylolisthesis. In thelatter sense the term pseudospondyl-olisthesis has been used; however, it isnot well suited, as the slip is real.

Spondylolysis

Etym: Ancient Greeklysis, destruction.Def: Separation ofinterarticularis.Syn: Isthmolysis.

spondylos, vertebra and

the isthmus or pars

Spondylosis, spondylosis deformansDef: 1. The term has replaced 'Spondylitis

deformans', probably coined byRokitansky in his 1844 textbook, withouttrying to differentiate between inflam-matory and degenerative conditions.89 Itwas used by Beneke92 and made popularby Schmorl.93 The latter author's originaldefinition is osteophytosis* of thevertebral body, either the commonoutgrowths linked to disc degeneration*or those seen in association withhyperostosis* of the spine. Aufdermaur44used the term as a synonym of Forestier'sdisease.2. In common practice, there is noagreement on the definition. It becameapparent, from a small unpublishedinquiry by the authors among spinescientists that spondylosis is used bymany as a synonym of spinal arthrosis(mainly of the discal joint, but for somepeople of the zygapophyseal joints also);

- Spondylosis hyperostoticasee under hyperostosis*.

SyndesmophyteEtym: Ancient Greek syn, with or together,desmos, ligament and phyton, plant oroutgrowth.Def: Bony outgrowth replacing the outer partof the annulus fibrosus, the shorter peri-vertebral ligament, and eventually also thedeeper part of the longer perivertebral liga-ment, leading to an intervertebral bridge bymeans of complex processes involving all kindsof ossification.84Com: When the syndesmophyte is not insertedonto the margin of the vertebral body butextends some distance beyond the vertebralmargin, it may be called a parasyndes-mophyte*.67 When the ossification remainsseparated from the vertebrae, as has beendescribed in psoriasis,68 the appropriatedenomination is 'paravertebral ossification'*.His: This term was coined by Forestier andRobert,94 at the suggestion of Sicard, todescribe the peripheral discal and paradiscalossifications in ankylosing spondylitis.

SynovialisationDef: Development of a synovial membranewhere none was present, as within the disc'9 orthe interspinous space.'0

Synovitis-acne-pustulosis-hyperostosis-osteomyelitis syndrome* (SAPHO)Def: Group of diseases combining skin lesions(acne conglobata or fulminans, hydradenitissuppurativa, dissecting cellulitis of the scalp,pustulosis palmoplantaris) with locomotorchanges (arthritis, sclerosing osteitis, sterno-costoclavicular hyperostosis, recurrent chronicmultifocal osteomyelitis, and eventualsacroiliitis and spondylitis).95 96His: The acronym was coined by Chamot et alin 1987.95

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Commented glossatyfor rheumatic spinal diseases, based on pathology

Com: Some authors tend to consider thesediseases as spondyloarthritides*. However,the link between SAPHO conditions andHIA-B27 is weak, if it exists at all.Pathological data are scarce; as long asmorphology has not shown the identitybetween SAPHO and spondyloarthritischanges, it is wise to keep them separated.

Vertebral ankylosing hyperostosissee under hyperostosis*.

ZygarthrosisDef: Osteoarthrosis of the zygapophyseal joint.His: Coined by the present authors, as a shorterterm for zygapophyseal osteoarthrosis.Com: see under spondylarthrosis*.

DISCUSSIONLanguage is man's primary tool both in scienceand elsewhere: hence it should be keptaccurate. It is not advisable to use terms inanother meaning than their original or etymo-logical sense. It is totally unsound to resort, fornew concepts, to older denominations with adifferent meaning. Confusion in language leadsto confusion in ideas and makes literaturesearches in data banks cumbersome.

Scientists should refrain from giving a newname to an old disease purely to give theimpression of a personal discovery. Suchreplacement is advisable only if an earlier termis incorrect or too complicated and the new onebrings more clarity or simplicity.The study group aimed to adhere to five

rules: etymology, history, morphology, clarity,common practice. As expected, these rulesproved partly antagonistic.

Departure from etymology occurred threetimes. Ankylosis no longer means curvature,and common practice prevails when weadvocate the sense of fusion of a joint.Spondylolysis does not mean dissolution of awhole vertebra, but only an interruption of theisthmus. Rheumatoid spondylitis is etymolo-gically sound when applied to rheumatoidchanges in the spine, but should be avoided,because rheumatoid spondylitis has long beenused in the USA to designate ankylosingspondylitis.Another etymological problem is related to

the seronegative arthritides. When the Leedsgroup coined spondarthritis, we presume thatthey conflated 'spondylitis' and '(peripheral)arthritis' in much the same way as brunch is theconflation of breakfast and lunch. In doing so,they did not follow the usual rules ofetymology.97 The Greek radical for vertebra is'spondyl' and is used as such when the secondterm of the compound name starts with avowel. When the second term starts with aconsonant, a connective 'o' is inserted betweenboth members. This is why spondylarthritis hasno connective 'o' and spondylolysis has. If theconnective 'o' is used before a vowel, theimpression is given that the compound nameis a real connection or association between two

equal concepts: unlike spondylarthritis,spondyloarthritis does not mean arthritis of avertebra, but association of spondylitis and(peripheral) arthritis.

It is also important to be faithful to theoriginal definition given by an author. Forexample, Schmorl used 'spondylosis (defor-mans)' for osteophytes of the vertebral body-irrespective of the association with hyper-ostosis-and believed that the osteophytesresulted from discal tears. Rheumatologistsfrom the UK or the USA, presumably withouthaving read the original papers of Schmorl,began to uge the term spondylosis for all kindsof spinal degenerative changes, such as allstages of disc degeneration and eventuallyapophyseal osteoarthrosis. Hence, havingdeviated from its original definition, the termspondylosis should now be discarded becauseit is too vague and too inclusive.The study group accepted spondylarthrosis

in a broader meaning (osteoarthrosis ofapopyseal and discal joints) than the originalone (apophyseal osteoarthrosis). In this case,some common practice (de Seze's 'discar-throse') prevailed, in addition to the stronganalogy between peripheral osteoarthrosis anddisc degeneration, particularly in the advancedstage.DISH is a disease of mature adulthood,

developing frequently in spines which arealready the site of osteoarthritic changes. Manyaging people exhibit some non-inflammatoryenthesophytes, without reaching the fullydeveloped stage of DISH. Because of this,there is some trend to amalgamate DISH andspinal osteoarthrosis, particularly in theGerman literature.5' Beneke,92 and after himSchmorl,93 termed all types of vertebralosteophytes 'spondylitis deformans', laterreplaced by 'spondylosis deformans', whichintroduced the confusion. Ott50 coined'spondylosis hyperostotica' and Biressi andMussa4' reported on 'artrosi discosomatica acarattere iperostosante'. There are, however,several arguments in favour of a dualconception-among others, the existence indogs of pure hyperostosis without associateddegenerative changes in the intervertebraldisc,98 and the striking difference betweenosteoarthrosis and hyperostosis of the samejoint, for example the sacroiliac joints.99 Whilethe controversy remains unresolved, it is wiseto distinguish both conditions.Another problem in relation to DISH is to

decide if it should be called a disease, as Arletand Mazieres52 and Forestier and Rotes-Querol39 have done, in contrast to Smith et al'"or Rothschild et al'Ol who consider it as physio-logical aging not giving rise to symptoms.

CONCLUSIONA great deal of confusion would disappear ifscientists from the field of rheumatic spinaldiseases used terms with an exact, universallyaccepted meaning. Morphologists are able toreach agreement in describing the underlyingpathological findings in these diseases; butmuch remains to be done to unravel their

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aetiopathogenesis and for some, even thefundamental early changes remain unknown.The authors thank Professor Max Aufdermaur, MD, from thePathologisches Laboratorium, Kantonsspital, Luzem, Switzer-land for reading the manuscript and helping with the Germanmedical literature. They are also indebted to ProfessorReneLagier, MD, from theDepartement de Pathologie, Universitede Gen&ve, Switzerland, for many useful comments, discussionsand suggestions.

Supported by the Comite de Concertation pour la RechercheScientifique des ForcesArmees Belges (project G52).

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