vertebral sclerosis in adults - annals of the rheumatic...

Annals of the Rheumatic Diseases, 1978, 37, 18-22

Vertebral sclerosis in adultsA. S. RUSSELL,' J. S. PERCY,1 AND B. C. LENTLE2

'From the Rheumatic Disease Unit, Department of Medicine, University of Alberta, Edmonton, and the2Department ofNuclear Medicine, W. W. Cross Cancer Institute, Edmonton, Alberta

SUMMARY Narrowing of the intervertebral disc space with sclerosis of the adjacent vertebral bodiesmay occur as a consequence of infection, neoplasia, trauma, or rheumatic disease. Some patientshave been described with backache and these radiological appearances without any primary cause

being apparent. The lesions were almost always of 1 or, at most, 2 vertebrae and most frequentlyinvolved the inferior margin of L4. We describe 3 patients with far more extensive vertebral involve-ment and present the clinical, radiological, scintiscan, and histological findings. The only patientwe have seen with the better known, isolated L4/5 lesion was shown on biopsy to have staphylococcalosteomyelitis. For this reason we would still recommend a biopsy of all such sclerotic vertebrallesions if they occur in the absence of other rheumatic disease.

Sclerosis of one or more vertebrae is a relativelynonspecific radiological finding and may reflectunderlying neoplasia as well as chronic infection orpossible trauma. There have been recent descriptionsof sclerosis of one vertebral body occurring inassociation with reduction in height of the adjacentdisc space (Williams et al., 1968; Martel et al., 1976).Sometimes the adjacent vertebra may be involvedand lytic areas may be present adjacent to, or sur-rounded by, the sclerosis. These lesions are associatedwith pain and have been attributed to low gradeinfection, particularly when they are seen in children(Williams et al., 1968; Spiegel et al., 1972). Frankbacterial infection following surgical interferencewith intervertebral discs can produce similar radio-logical changes, and the term 'discitis' has beenused to describe these lesions as well as those occur-ring in children. Similar radiological appearancesmay be seen in patients with ankylosing spondylitis(Cawley et al., 1972) and, more rarely, in those withrheumatoid artlritis (Seaman and Wells, 1961).

Martel et al. suggested that in adults most ofthese lesions are initiated by vertebral and platefractures and are not due to a primary inflammatorylesion of the intervertebral disc, implying thereforethat the term 'discitis' maybeinappropriate (Martel elal., 1976; Martel, 1977). In a recent review of 17 adultpatients with no other rheumatic disease the scleroticlesions predominantly involved the inferior aspect ofL4 and extended across only 1 disc space (Martel etal., 1976).Correspondence to Dr A. S. Russell, Department of Medi-cine, 9-112 Clinical Sciences Building, University of Alberta,Edmontont, Alberta, Canada T6G 2G3.

We have recently seen 3 patients who have ver-tebral sclerosis and disc space narrowing but of amore sensitive nature than has been previouslydescribed. Nonmarginal syndesmophytes were alsopresent in 1 patient. The single adult patient seenduring this 2-year period which an infected vertebrallesion is also recorded for comparison.

Patients and methods

Bone scans were performed with 99m technetiumstannous pyrophosphate (TcPP) as previouslydescribed (Russell et al., 1975). All showed abnormalspinal uptake. The sacroiliac/sacrum (SI/S) ratioswere within normal limits except in case 2, where theratio was 1 * 51 and 1 * 37/1. None had changes outsidethe axial skeleton. All patients had normal sacro-iliac radiographs. All patients had a complete bloodcount, erythrocyte sedimentation rate, and serumcalcium, phosphate, and alkaline phosphatasemeasured. Apart from the ESR these were all nor-mal. Tests were performed for antibodies to Bru-cella abortus, Francisella tularensis, salmonellae,Yersinia enterocolitica selected serotypes, Yer-sinia pseudotuberculosis types I, II, and Ill. Thesewere negative. Mantoux tests were negative to 100TU. HLA typing was performed, no patient pos-sessed HLA B27.

CASE 1This woman developed backache when aged 37,and 3 years later a ganglioneuroma of the right S1nerve root was removed with a partial laminectomyof L5-S1. Preoperative radiological investigation

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Vertebral sclerosis in adults 19

showed lumbar vertebral sclerosis and early syndes-mophytes on the right side. Her low back symptomsimproved, but 2 years later in 1975 she developed aconstant pain in the mid-dorsal spine.

Examination revealed the residual signs of aright SI nerve root lesion and a smooth dorsalkyphosis with midline tenderness from D5 to DlI.Symmetrical plaques 3 to 5 cm across resemblingnummular psoriasis were present over the limbs.Biopsy of these lesions failed to provide histologicalconfirmation of psoriasis. Routine blood tests wereall normal except for an ESR of 48. Cerebrospinalfluid (CSF) was normal. Radiological examinationof the spine showed a fusion Cl and C2 of probablecongenital origin. Diffuse sclerosis of D7-D1O waspresent, with reduction of the intervertebral discspaces (Figs. 1 and 2). Mild but similar changesoccurred in L2-L4, and in addition large right-sided

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Fig. 2 Case 1 Tomograph of mid-dorsal spine.

non-marginal syndesmophytes were present (Fig. 3).A bone scan with TcPP showed increased uptakein the corresponding areas, with normal SI/S ratios.

She was treated symptomatically with indo-methacin and physiotherapy and her symptomsimproved, though they were not completely relieved.Her ESR 3 months later was 26 mm/h. Two years

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....later the bone scan was normal, but radiographs

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of the vertebral bodies D6/7 with reduction in theheight of the intervening and adjacent discs (Fig. 4).

Fig. 1 Case 1. Tomograph of mid-dorsal spine. A bone scan with TcPP showed increased uptake



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20 Russell, Percy, Lentle

months. She continues to complain of some pain inher mid-dorsal spine, although this is less severe thanit was initially.

CASE 3This 47-year-old man had had lumbar and dorsalbackache for 4 years. It increased in severity overthe preceding year despite the use of anti-inflam-matory analgesics. He had developed pain radiatinganteriorly across both sides of the chest and hadincreasing stiffness of the lumbar spine. There was amild tenderness over the mid-dorsal and lumbarspine and forward flexion was restricted. Examina-tion was otherwise normal. All blood tests werenormal except for an ESR of 26 mm/h. Routineradiological examination was not seen to be ab-normal, but a bone scan with TcPP showed increaseduptake centred over D6-D9. Tomograms showedincreased bone density of these 4 vertebrae, withirregularity and narrowing of the intervening discspaces. A myelogram was normal, and the CSF was

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11.~~~~~~~~~~~~~~~~.Fig. 3 Case 1. Tomograph of lumbar spine showingright-sided nonmarginal syndesmophytes.

in the mid-dorsal spine, but the sacrum/sacroiliacratios were also increased (1 *51/1 * 37). An openbiopsy of the body of D6 showed sclerotic boneassociated with an increase in paravertebral fattytissue containing small collections of histocytic cells.Aerobic and anaerobic cultures were sterile. Threevmonths later the ESR had fallen to 22 mm/h, and -both this and her radiological and scintiscan find-ings have remained unchanged over the ensuing 18 Fig. 4 Case 2. Tomograph of mid-dorsal spine.



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Vertebral sclerosis in adults 21

also normal. A normal biopsy was obtained fromthe D8 vertebra and the D8/9 disc. Symptomatictreatment was complicated by the presence of achronic peptic ulcer. One year later his symptomshad virtually disappeared and the bone scan hadreturned to normal. The radiological appearancesremained unchanged.

CASE 4This 34-year-old man developed an acute low backpain while using a meat grinder. After 5 months hewas put in an exercise and intermittent lumbartraction, with improvement. The pain recurred aftersome weeks, and he was transferred for furtherassessment. There was no abnormality on physicalexamination. Investigations showed an ESR of 41mm/h, a globulin level of 4'9 g/100 ml and an IgGof 2955 mg/100 ml. All other blood tests were normal.Initial radiological examination of the lumbo-sacral spine with myelography had been normal buthe subsequently developed vertebral sclerosis anddisc space narrowing at the L4/5 level (Figure 5). A

s..pn.'

Fig. 5 Case 4. Plain radiograph of lumbar spine.

repeat myelogram showed no other abnormalitybut the CSF obtained had 85 WBC and 25 RBC/mm3 and the CSF protein was mildly increased at54 mg/100 ml. A bone scan showed increased ver-tebral uptake at the level of the L4/5. A biopsy ofdisc and bone were performed and showed osteo-myelitis of both L4 and L5 with sequestrumformation. Cultures grew Staphylococcus aureus sen-sitive to penicillin. His symptoms resolved on longterm treatment with this antibiotic.

Discussion

Vertebral sclerosis with irregularity of the vertebralend plates and reduction in height of the adjacentdisc is a complication of ankylosing spondylitis(Cawley et al., 1972) and is also seen, although morerarely, in patients with rheumatoid arthritis (Sea-man and Wells, 1961). We have excluded suchpatients from this report. Seventeen patients wererecently described with the above radiologicalfeatures (Martel et al., 1976). In contrast to ourpatients, all were aged over 40 years and all lesionsinvolved the lumbar spine. In 12 they involved theinferior margin of L4, and in 4 only the single ver-tebra showed an abnormal radiological appearance.In young children a similar but more acute lesionmay be seen, and the lower lumbar area is againthe commonest site. Two adjacent vertebrae aregenerally involved, and there is marked reduction inheight of the intervening disc space. The lesionprobably has an infective cause. The only one of ourpatients, case 4, with relatively restricted vertebraldisease as described by Martel et al. (Martel et al.,1976; Martel, 1977) did have a lesion of L4/5 but wasshown on biopsy to have a Staphylococcus aureusosteomyelitis. An infective lesion was clearly shownto be present in 7 of 15 patients recently reported withsimilar vertebral changes (McCain et al., 1978). Itwould therefore seem to be important to examinethese lesions by biopsy even when seen at L4/5.None of the other biopsies showed any specificchanges. Case 2, with slight histocytic infiltration,has not shown any progression over the intervening2 years. The 3 noninfected patients showed muchmore extensive involvement than previously des-cribed with, in case 1, the formation of asymmetricalnonmarginal syndesmophytes.The bone scan showed a focal area of increased

uptake at the site of the lesions. This is of courseentirely nonspecific from a diagnostic point of viewbut indicates that the process was associated withosteoblastic activity (Gates, 1977). In case 3 itshowed an abnormality not readily apparent oninitial routine radiographs but one that was vis-ualised by tomography. We have previously reported



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22 Russell, Percy, Lentle

the appearance of these discovertebral lesions on abone scan in patients with ankylosing spondylitisand have shown the bone scan in this clinical situationto be abnormal before the radiological appearancesof vertebral sclerosis develop (Lentle et al., 1977).

It is certainly possible that the radiologicalappearances we have noted are due to interverte-bral disc herniation and are simply more extensivethan those described by Martel et al. However, noneof their patients with sclerotic lesions were under 40years of age nor did any of the lesions involve thedorsal spine. We have no convincing alternativeexplanations, but despite the negative biopsies theraised ESR did suggest an inflammatory basis forthese lesions. We would like to draw attention tothese radiological appearances and to their appar-ently benign nature.

References

Cawley, M. I. D., Chalmers, T. M., Kellgren, J. H., andBall, J. (1972). Destructive lesions of vertebral bodies inankylosing spondylitis. Annals of the Rheumatic Diseases,31, 345-358.

Gates, G. F. (1977). Scintigraphy of discitis. Clinics inNuclear Medicine, 2, 20-25.

Lentle, B. C., Russell, A. S., Percy, J. S., and Jackson, F. I.(1977). Scintigraphic findings in ankylosing spondylitis.Journal of Nuclear Medicine, 18, 524-528.

Martel, W. (1977). A radiologically distinctive cause, of lowback pain. Arthritis and Rheumatism, 20, 1014-1018.

Martel, W., Seeger, J. F., Wicks, J. D., and Washburn, R. L.(1976). Traumatic lesions of the discovertebral junction inthe lumbar spine. American Journal of Roentgenology, 127,457-464.

McCain, G. A., Ralph, E. D., Austin, T. W., Harth, M.,Bell, D. A., and Disney, T. F. (1978). Abstract. Annals ofthe Royal College ofPhysicians and Surgeons of Canada, 11,92.

Russell, A. S., Lentle, B. C., and Percy, J. S. (1975). Investi-gation of sacroiliac disease: Comparative evaluation ofradiologic and radionuclide techniques. Journal of Rheu-matology, 2, 45-51.

Seaman, W. B., and Wells, J. (1961). Destructive lesions of thevertebral bodies in rheumatic disease. American Journal ofRoentgenology, Radium Therapy, and Nuclear Medicine, 86,241-250.

Spiegel, P. G., Kengla, K. W., Isaacson, A. S., and Wilson,J. C. (1972). Intervertebral disc-space inflammation inchildren. Journal of Bone and Joint Surgery, 54A, 284-296.

Williams, J. L., Moller, G. A., and O'Rourke, T. L. (1968).Pseudo-infections of the intervertebral disc and adjacentvertebrae? American Journal of Roentgenology, 103, 611-615.



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