Bamboo Spine - X-Ray Findings of Ankylosing Spondylitis Revisited

PICTORIAL ESSAY
Bamboo spine – X-ray findings of ankylosing

spondylitis revisited
Antoinette Reinders, MB ChB
Matthys J van Wyk, MB ChB, FCRad Diag (SA)
Department of Diagnostic and Interventional Radiology, University of the Free State, Bloemfontein
Corresponding author: A Reinders (antoinette.reinders@gmail.com)
Pathology and imaging characteris-

Ankylosing spondylitis is a debilitating disease that is one of the sero- tics
negative spondylarthropathies, affecting more males than females in In this pictorial essay, we focus on the characteristic axial skeleton
the proportion of about 6:1 in the age group 15 - 35 years of age. Early imaging findings of AS, as it presents on conventional X-ray:1
radiographic findings include bilateral sacro-iliitis and early axial • florid anterior spondylitis (Romanus lesions)
(lower lumbar spine) ankylosis. Typical X-ray findings are florid • florid diskitis (Andersson lesions)
spondylitis (Romanus lesions), florid diskitis (Andersson lesions),
early axial ankylosis, enthesitis, syndesmophytes and insufficiency
fractures. Typical radiological abnormalities are pointed out on
conventional X-rays and reviewed for early diagnosis and prompt
treatment of patients at risk.
S Afr J Rad 2012;16(3):111-113. DOI:10.7196/SAJR.684
Ankylosing spondylitis (AS) is one of the sero-negative spondylo-

arthropathies.1 This group of arthritides is characterised by specific
skeletal imaging findings and, biochemically, by the absence of
rheumatoid factor or nodules, and the presence of the HLA-B27 gene.
These spondylo-arthropathies can be divided into 5 major groups: (i)
ankylosing spondylitis, (ii) reactive arthritis/Reiter’s syndrome, (iii)
arthritis associated with inflammatory bowel disease, (iv) psoriatic
arthritis and (v) undifferentiated spondylo-arthropathy.1
AS is a debilitating disease, affecting mostly white men, with a
male:female ratio of about 6:1 within the age group 15 - 35 years of age.
Early lumbar axial ankylosis and spinal involvement is more marked
in male patients than female, with early radiographic signs of hip
involvement.2-4
Classic joint involvement includes: bilateral sacro-iliac, thoraco-
lumbar and lumbo-sacral joints (early) and cervical spine (late).5 The
peripheral skeleton is involved in 10 - 20% of cases, with apical fibrosis
of the lung parenchyma reported in only 1% of AS patients.6 Additional
cardiac manifestations, such as aortic valve and root abnormalities, and
with conduction and rhythm abnormalities, have also been reported in
2 - 10% of patients.6
Genetic susceptibility has been mentioned as a causative factor, with
96% of patients testing positive for the HLA-B27 gene.1 Associated
diseases include: ulcerative colitis, iritis and aortic insufficiency.
Prognosis depends on age at first presentation, as well as the radiological
grade, as defined by either the Bath Ankylosing Spondylitis Radiology
Index (BASRI) – for cervical and lumbar spine and hips – or the
Fig 1. Lateral lumbar spine view. Note the ‘squaring’ of the lumbar vertebrae
Modified New York Criteria for the Extent of Sacro-iliitis, with lumbar (open arrowhead), together with the central radio-dense region in the vertebral
and bilateral sacro-iliac joint involvement being marked in the early endplate of the 5th lumbar vertebra, superiorly (white arrowhead). This is
years of the disease.6 known as an Andersson lesion.
SAJR September 2012 Vol. 16 No. 3 111

PICTORIAL ESSAY
• insufficiency fractures of the ankylosed spine Insufficiency fractures

• syndesmophytes These can be referred to as ‘non inflammatory Andersson lesions’ and
• enthesitis of the interspinal ligaments are a not uncommon complication of advanced disease.1 They can
• ankylosis. be classified into 2 basic categories: (i) spontaneous or (ii) following
minimal trauma.7 The fractures are typically 3-column, involving
Romanus lesions (florid anterior spondylitis) either the disc space or juxta-articular endplate. The second category
It is best to describe these lesions in terms of a disco-vertebral unit typically occur near the cervico-thoracic or thoraco-lumbar junctions.
(DVU). This ‘unit’ comprises the superior half of the inferior vertebrae, Delay in treatment can cause pseudoarthrosis, which can be seen on
plus the intervertebral disc, plus the inferior half of the superior conventional X-rays as subchondral sclerosis and vertebral endplate
vertebrae.1 Typical Romanus lesions are situated at the attachment of erosions.7
the annulus fibrosis to the vertebral endplate, and can be in the anterior,
posterior or marginal regions of the DVU. Irregularities and erosions Syndesmosphytes
of the vertebral endplates are characteristic of acute inflammation. These are paravertebral ossifications that resemble an osteophyte, but
Post-inflammatory changes are known as ‘shiny corners’, which appear run in the vertical rather than the horizontal plane (Fig. 2).8 They
as sclerotic lesions in the same anatomical location on the vertebral are not due to calcification of the anterior longitudinal ligament but
endplate.1 When these lesions are present, ‘squaring’ of the vertebrae rather ossification of the anterior portion of the annulus fibrosis of the
can be appreciated, with progressive loss of the lumbar lordosis (Fig. 1). intervertebral disc. The lesions are preceded by a Romanus lesion, and
are symmetrical and marginal. About 15% of affected patients show
Andersson lesions (florid diskitis) evidence of syndesmophytes.1
These appear as irregularities and erosions of the vertebral endplates
(Fig. 1), not related to the anterior or posterior edge but rather to the
central portions of the intervertebral discs. These are better visualised
by MR images of the spine, but can be seen on conventional X-ray and
are indicative of active inflammation.1
Fig. 3. Antero-posterior view of the thoracic and lumbar spine. Note the
calcification of the interspinous ligaments secondary to enthesitis, with the
Fig. 2. Lateral cervical spine X-ray. The white arrowhead indicates classic dagger sign (white arrowheads) stretching into the pelvis. The trolley
syndesmophytes, representing calcification of the anterior portion of the track sign can also be seen in the lower lumbar spine and thoracic spine (open
annulus fibrosis. Calcification of the interspinous ligaments can also be seen arrowheads), lateral to the calcified interspinous ligaments, representing the
(open arrowhead). calcified apophyseal joint capsules.
112 SAJR September 2012 Vol. 16 No. 3

PICTORIAL ESSAY
Ankylosis
Ankylosis of several of the joints causes structural abnormalities of
the axial skeleton. Marked ankylosis is seen at the sacro-iliac joints
(Fig. 4) and facet joints of the thoracic spine, and costovertebral
and costotransverse joints1 that causes an exaggerated kyphosis with
decreased chest expansion during inhalation and increased susceptibility
to respiratory tract infections.
Conclusion
AS is a debilitating disease with very specific radiological abnormalities
that can, if detected early, be successfully managed by medical and
physical therapy. It remains the role of the radiologist to keep a look-out
for early radiological abnormalities in susceptible patients.
1. Hermann KGA, Althoff CE, Schneider U, et al. Spinal changes in patients with spondylarthritis:
Comparison of MR imaging and radiographic appearances. RadioGraphics 2005;25:559-570.
2. Boonen A, Van der Cruyssen B, de Vlam K, et al. Spinal radiographic changes in ankylosing spondylitis:
association with clinical characteristics and functional outcome. J Rheumatol 2009;36(6):1249-1255.
3. Atagunduz P, Aydin SZ, Bahadir C, et al. Determinants of early radiographic progression in ankylosing
spondylitis. J Rheumatol 2010;37(11):2356-2361.
Fig. 4. Antero-posterior view of the pelvis. The open arrowheads indicate 4. Cansu DU, Calisir C, Savas Yavas U, et al. Predictors of radiographic severity and functional disability in
marked ankylosis of the hips and sacro-iliac joints. turkish patients with ankylosing spondylitis. Clin Rheumatol 2011;30(4):557-562.
5. Jang HJ, Ward MM, Rucker AN, et al. Ankylosing spondylitis: Patterns of radiographic involvement – a
re-examination of accepted principles in a cohort of 769 patients. Radiology 2011;258(1):192-198.
Enthesitis (trolley track and dagger signs)9 6. Momeni M, Taylor N, Tehrani M, et al. Cardiopulmonary manifestations of ankylosing spondylitis. Int
Ossification of the supraspinous and interspinous ligaments produces J Rheumatol 2011;1:1-6.
7. Hong SH, Ja-Young C, Joon Woo L, et al. MR imaging assessment of the spine: infection or an imitation?
a characteristic single or double radio-dense sign on the AP view of
RadioGraphics 2009;29:599-612.
the spine (Fig. 3). The trolley track sign derives from the 2 lateral lines 8. Helms CA. Arthritis. In: Brant WE, Helms CA, eds. Fundamentals of Diagnostic Radiology. 3rd ed.
of ossification representing the apophyseal joint capsules, and the Philadelphia: Lippincott Williams & Wilkins, 2007:1136-1140.
9. Olivieri I, Ciancio G, Scarano E, et al. The extension of the ankylosing spondylitis “dagger sign” into the
dagger sign from the central line of ossification visible on the AP view.
sacrum. J Rheumatol 2000;27(12):2944-2945.
Enthesitis precedes ossification of the ligaments.9

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PICTORIAL ESSAY

Bamboo spine – X-ray findings of ankylosing

Corresponding author: A Reinders (antoinette.reinders@gmail.com)

Pathology and imaging characteris-

S Afr J Rad 2012;16(3):111-113. DOI:10.7196/SAJR.684

Ankylosing spondylitis (AS) is one of the sero-negative spondylo-

SAJR September 2012 Vol. 16 No. 3 111

• insufficiency fractures of the ankylosed spine Insufficiency fractures

112 SAJR September 2012 Vol. 16 No. 3

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