Localized Destructive Lesions in Rheumatoid Spondylitis

The ordinary roentgenologic manifestations of rheumatoid spondylitis have been well described (1–4). Clinicians and roentgenologists are especially interested in recognizing the early phases of the disease, when treatment is often efficacious; little improvement can ordinarily be effected when the condition is far advanced. For that reason, little has been written concerning the late stages of the disease, except for descriptions of operative procedures that have been used to correct extensive deformity. The so-called bamboo spine, in which the spinal column is completely ankylosed as the result of ossification of the vertebral ligaments, is easily recognized. It is usually stated that in these cases the vertebral bodies are osteoporotic and the intervertebral disks are narrowed but that neither structure is directly involved or affected by the disease (5). This investigation was initiated by the observation that certain patients show striking destructive changes involving the intervertebral disks and adjacent vertebral bodies which, though closely resembling some type of infection, such as tuberculosis, brucellosis, or a pyogenic condition, constitute in reality just another manifestation of rheumatoid spondylitis. Over a period of ten years (1947 through 1956), 10 patients with far advanced rheumatoid spondylitis and roentgenologic evidence of involvement of an intervertebral disk and adjacent bodies have been seen at the Mayo Clinic. This low incidence would indicate the rarity of this association. The localized destructive lesions in all 10 patients were similar roentgenologically, and biopsy of the affected area in 2 showed chronic inflammatory lesions. From this it is believed that involvement of the intervertebral disk and adjacent bodies represents destruction by a chronic inflammatory process resulting from the spondylitis. In all cases the lesions failed to show the progression that would be expected of other infectious or granulomatous processes; in 1 patient there was evidence of spontaneous healing without specific treatment. All the patients were men. The average age at onset of symptoms was twenty-four years. In all instances, the disease had been in progress for at least ten years before exaggerated localized pain in the back led to further investigation. Roentgen examination then revealed the lesions affecting the intervertebral disk and adjacent vertebral bodies. As already noted, the specimens in the 2 cases in which biopsy was performed were considered histologically compatible with rheumatoid inflammation. Needle biopsy was done in another case but did not provide sufficient material for diagnosis. Results of cultures and smears for bacteria and fungi were negative in these 3 cases. Characteristic roentgenographic features were destruction of the intervertebral disk and the margins of the adjacent vertebrae.