Aseptic discitis in patients with ankylosing spondylitis: a retrospective study of 14 cases

doi:10.1016/j.jbspin.2004.05.015

Joint Bone Spine

Volume 72, Issue 3, May 2005, Pages 248-253

https://doi.org/10.1016/j.jbspin.2004.05.015 Get rights and content

Abstract

Objectives. – To determine whether patients with ankylosing spondylitis (AS) and discitis exhibit specific characteristics as compared to patients who have AS without discitis.

Methods. – We retrospectively collected clinical, laboratory, and imaging data from the charts of 79 patients with AS admitted to a rheumatology department.

Results. – Of the 79 patients, 14 (18%) had discitis that was not due to infection or trauma. Mean age at the diagnosis of AS was 40 years and mean duration of AS at admission was 10 years, with no difference between the two groups. In three patients, discitis was the inaugural manifestation of AS. Two patients had discitis at two levels. The lumbar and thoracolumbar segments were the most common sites of discitis. Symptoms of discitis were present in 10 of the 14 patients. Stage III sacroiliitis was significantly more common in the patients with discitis. None of the patients experienced neurological compromise.

Conclusion. – The frequency of aseptic discitis in patients with AS is probably overestimated as a result of inclusion and exclusion biases. Discitis usually occurs at an advanced stage of AS under the form of an erosive condition related to both mechanical factors and osteoporosis. Inaugural or early discitis can occur, however, as a result of the inflammatory process.

Introduction

Aseptic discitis is an uncommon manifestation of ankylosing spondylitis (AS) first described by Andersson in 1937. Destructive lesions of the disk and adjacent vertebral bone occur in the absence of infection or trauma. This pattern is characteristic of AS [1]. Studies conducted using modern imaging techniques and pathological examination of the entheses have rekindled interest in aseptic discitis as a manifestation of AS. Nevertheless, few data are available on aseptic discitis in AS. The studies reported by Marie-Bonnin [2] in 1986 and Bouvier et al. [3] in 1987 (43 patients) are among the most recent and largest case-series. Discitis is defined primarily on the basis of imaging features as a variable combination of disk-space narrowing, erosions in the adjacent endplates, and peripheral sclerosis. The objectives of the present study in a population with AS were to look for specific characteristics of patients with discitis as compared to those without discitis, to compare our findings with results in the literature, and to discuss available evidence on the pathophysiology of discitis associated with AS.

Section snippets

Patients and methods

We reviewed the medical records of all the patients with AS admitted to the rheumatology department of the Besançon Teaching Hospital, Besançon, France, over a 6-year period. We selected the patients who met the modified New York criteria for AS [4]. With this criteria set, the diagnosis is definite in patients who have radiological evidence of grade II to IV sacroiliitis on both sides, or grade III or IV sacroiliitis on one side with at least one of the three following clinical criteria: low

Results

Of the 79 AS patients with valuable medical records who were admitted during the study period, 14 had radiological evidence of discitis.

Discussion

The prevalence of discitis in our series was 18%, as compared to only 5–10% in earlier studies by Rasker et al. [5], and Agarwal et al. [6] Cawley et al. [7] reported radiological abnormalities in up to 28% of patients, but they seem to have included Romanus lesions. The high prevalence in our study may be ascribable to selection bias: our study patients were admitted to a rheumatology department, suggesting that they possibly represented a subset with severe AS. In some studies, aseptic

Conclusion

The occurrence of aseptic discitis in patients with AS is probably underestimated, in part because screening is not performed and in part because the symptoms may be ascribed to the underlying joint disease. In AS patients, discitis is associated with clinical signs reflecting advanced disease and with a significantly greater likelihood of stage III radiological sacroiliitis. One or more levels may be involved. Discitis may be the inaugural manifestation of AS. The outcome is usually favorable.

References (24)

T. Hunter
The spinal complications of ankylosing spondylitis
Semin. Arthritis Rheum.
(1989)
A. Marie-Bonnin
Les spondylodiscites de la pelvispondylite rhumatismale
(1986)
M. Bouvier et al.
Évolution des spondylodiscopathies de la spondylarthrite ankylosante
Rev. Rhum.
(1987)
Wendling D. Spondylarthrite ankylosante. EMC, APP LOC, 14-230-A-10,...
J.J. Rasker et al.
Spondylodiscitis in ankylosing spondylitis, inflammation or trauma? A description of six cases
Scand. J. Rheumatol.
(1996)
A.K. Agarwal et al.
Variable histopathology of discovertebral lesion (spondylodiscitis) of ankylosing spondylitis
Clin. Exp. Rheumatol.
(1990)
M.I.D. Cawley et al.
Destructive lesions of vertebral bodies in ankylosing spondylitis
Ann. Rheum. Dis.
(1972)
A. Bartha et al.
Spondylodiscitis in ankylosing spondylitis
Ann Rheum Dis
(2002)
Y. Kabasakal et al.
The epidemiology of spondylodiscites in ankylosing spondylitis. A controlled study
Br. J. Rheumatol.
(1996)
M. Bouvier et al.
Les formes pseudopottiques et pseudodystrophiques des spondylodiscites de la SPA
Rev. Rhum.
(1980)

P. Louyot et al.

La spondylodiscite de la spondylarthrite ankylosante

Rev. Rhum.

(1963)

P. Jobanputra et al.

Discovertebral destruction in ankylosing spondylitis complicated by spinal cord compression

Ann. Rheum. Dis.

(1988)

Cited by (42)

Ankylosing spondylitis complicating with a thoracolumbar Andersson lesion: A case report
2023, Asian Journal of Surgery
Management of Andersson lesions of spine: A systematic review of the existing literature
2022, Journal of Clinical Orthopaedics and Trauma
Citation Excerpt :
It is either an erosive or sclerotic process extending either into the disc or adjacent bone. The incidence of Andersson lesion in patients with ankylosing spondylitis has been reported in the literature from 5% to 28% with male preponderance.2 Most of these lesions are seen at the junctional regions; thoracolumbar junction being most commonly involved region with one or more levels involved.
Andersson lesions also termed as aseptic spondylodiscitis, spinal pseudoarthrosis are known to occur in patients with ankylosing spondylitis. Trauma as well as inflammation has been cited as factors responsible for the causation of these lesions. A variety of surgical approaches have been described in the literature such as anterior, posterior, combined anterior and posterior, with or without reconstruction of the anterior column defect. Controversy still exists regarding the optimal management these lesions.
To address the optimal method of management, levels of instrumentation, requirement of fusion and anterior instrumentation and general epidemiological profile of the patients with Andersson lesions.
An electronic search for studies on the surgical management of Andersson lesions of spine was performed. Quality assessment of the included articles was done by two independent authors according to the criteria used by researchers previously in systematic reviews.
Males were found to have an increased incidence with the thoracolumbar junction being the most common level. Posterior approach was the most favoured with reconstruction of the gap in the anterior column. Posterior osteotomy with correction of deformity was done commonly for an optimal healing environment. Instrumenting 2–3 levels above and below the lesion is favoured by most.
Conservative management for Andersson lesions can be employed in the setting of acute trauma and stable fractures involving a single column. Surgical management of these lesions with a posterior long segment fixation and anterior column reconstruction is the favoured treatment in majority of the cases.
Comparative analysis and differentiation between SAPHO syndrome and spondyloarthropathies using whole-spine MRI
2021, Clinical Radiology
Citation Excerpt :
The WS-MRI-based study of Kim et al. showed that the incidence of Andersson lesions was as high as 11.1% in SpAs.19 In this study, 42.9% and 18.2% of the two groups showed spondylodiscitis, higher than those reported in the literature.20–22 It is believed that WS-MRI can help locate more lesions than conventional MRI.
To determine the imaging characteristics of SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteitis) syndrome and seronegative spondyloarthropathies (SpAs) on whole-spine magnetic resonance imaging (WS-MRI) and evaluate the role of WS-MRI in the diagnosis and differentiation of the two diseases.
Twenty-eight patients with SAPHO and 44 with SpAs were included. All patients were symptomatic and clinically diagnosed with SAPHO or SpAs, and all underwent WS-MRI for comparison of imaging characteristics.
The mean age of the SAPHO patients was 48.7 ± 12.7 years, while that of the SpA patients was 34.7 ± 12.3 years (p<0.001). WS-MRI showed that the frequency of cervical, thoracic, and lumbar spine involvement was 53.6% versus 52.3%, 75% versus 88.6%, and 60.7% versus 63.6%, respectively (p=0.70, 0.13, and 0.80). The frequency of sacroiliac joint involvement was 7.1% and 100% (p<0.001). Continuous spinal involvement accounted for 50% versus 43.2%, 60.7% versus 84.1%, and 39.3% versus 40.9% in the cervical, thoracic, and lumbar vertebrae, respectively (p=0.03). WS-MRI showed that bone marrow oedema of spinal anterior corner was observed in 50% versus 75% (p=0.03). Vertebral body and posterior attachment involvement accounted for 85.7% versus 93.2% and 14.3% versus 34.1% (p=0.3, 0.06). The frequency of bone erosion in mobile spine was 75% and 36.4%, respectively (p=0.02). The frequency of intervertebral disc, endplate, anterior thoracic wall, and paraspinal soft-tissue swelling was 42.9% versus 18.2%, 53.6% versus 22.7%, 85.7% versus 42.2%, and 50% versus 11.4% (p=0.02, 0.00).
Factors differentiating the two groups at WS-MRI were bone marrow oedema of the spinal anterior corner, bone erosion, and swelling of the intervertebral disc, endplate, anterior thoracic wall, and paraspinal soft-tissue.
Andersson Lesion Occurring in the Lumbosacral Segment of a Young Man: A Case Report and Literature Review
2020, World Neurosurgery
Citation Excerpt :
In 1972, Cawley et al.2 divided ALs into localized and extensive lesions. The prevalence of discovertebral lesions complicating AS was reported range from 1.5% to >28%.3,4 AL can lead to chronic back pain, neurological dysfunction, and progressive kyphosis.
Andersson lesion (AL) is not a rare complication of ankylosing spondylitis (AS), but it seldom occurs in single lumbosacral segments or young people. We present a case of a young patient with AS and AL between L5 and S1.
A 30-year-old man with a history of AS presented with AL between L5 and S1. Surgery performed under O-arm navigation was successful. At 6-month follow-up, the patient’s pain was reduced, and his function had improved.
AL rarely occurs in the lumbosacral region or in young people and can be misdiagnosed as spinal tuberculosis. Surgical treatment of AL aims to relieve spinal nerve compression, reconstruct spinal stability, and restore sagittal balance. In view of the ambiguous anatomic landmark of patients with AS, we recommend surgery assisted with O-arm navigation, which clearly showed the entry point and guaranteed the accuracy of pedicle screw placements.
Computed Tomography and MR Imaging in Spondyloarthritis
2017, Radiologic Clinics of North America
Citation Excerpt :
Arthritis of the zygapophyseal and costovertebral/costotransverse joints can be observed in patients with SpA and AS in particular; it is usually associated with periarticular bone marrow edema, erosions, and joint effusion, and affected joints may undergo ankylosis at late phases (Fig. 6). The 2 central features of AS that promote the pathologic remodeling of the spine are inflammation and new bone formation; however, osteoporosis also occurs because of an uncoupling of the bone formation and bone resorption processes.25–27 Ankylosis and bone resorption promote weakening of the spine as well as increased risk of vertebral fractures, even from trivial trauma.28
Clinical features of axial spondyloarthritis
2015, Rheumatology: Sixth Edition

View all citing articles on Scopus

View full text

Original articleAseptic discitis in patients with ankylosing spondylitis: a retrospective study of 14 cases

Abstract

Introduction

Section snippets

Patients and methods

Results

Discussion

Conclusion

Semin. Arthritis Rheum.

Les spondylodiscites de la pelvispondylite rhumatismale

Évolution des spondylodiscopathies de la spondylarthrite ankylosante

Rev. Rhum.

Spondylodiscitis in ankylosing spondylitis, inflammation or trauma? A description of six cases

Scand. J. Rheumatol.

Variable histopathology of discovertebral lesion (spondylodiscitis) of ankylosing spondylitis

Clin. Exp. Rheumatol.

Destructive lesions of vertebral bodies in ankylosing spondylitis

Ann. Rheum. Dis.

Spondylodiscitis in ankylosing spondylitis

Ann Rheum Dis

The epidemiology of spondylodiscites in ankylosing spondylitis. A controlled study

Br. J. Rheumatol.

Les formes pseudopottiques et pseudodystrophiques des spondylodiscites de la SPA

Rev. Rhum.

La spondylodiscite de la spondylarthrite ankylosante

Rev. Rhum.

Discovertebral destruction in ankylosing spondylitis complicated by spinal cord compression

Ann. Rheum. Dis.

Original article
Aseptic discitis in patients with ankylosing spondylitis: a retrospective study of 14 cases