Figure 1
X-ray of cervical spine (a) with close up view of the C6-7 disc (b)
Clinical History
A man who suffers from chronic renal failure presented with signs of cervical cord compression.
Imaging Findings
The patient has had end stage renal disease and has been on maintenance haemodialysis for over 15 years. He presented with increasing difficulty in walking of few months in duration. On examination the power of both upper and lower limbs were normal. Propriaception was decreased in both lower limbs. He had hyperactive reflexes with ankle clonus and upgoing plantars bilaterally. X-ray (fig 1) and MRI (fig 2) of the cervical spine were obtained.
Discussion
The possible causes of the progressive discovertebral lesions in patients with
chronic renal failure are many, including osteitis fibrosa caused by severe
secondary hyperparathyroidism and deposition of iron, aluminum, calcium
oxalate, hydroxyapatite, calcium pyrophosphate, or amyloid resulting from
[beta] 2-microglobulin. Destructive spondyloarthropathy (DSA) is thought to be due to amyloid deposition. Ohashi et al (1) speculated that qualitative and quantitative changes of degenerating collagen predisposed to the accumulation of amyloid in the lower cervical and lumbar spine. Ito et al (2) reported the distribution map of amyloid deposits in the spinal components, including intervertebral discs, ligaments, facet joints, and vertebral bodies. Amyloid is densely deposited at the enthesis of collagen fibers to the bone at the facet joints and in peripheral tears of the annulus fibrosis. The capsular fibres as well as the annular fibres are disrupted by amyloid deposition, which may eventually lead to posterior ligamentous laxity and spinal instability. In
addition to ligamentous laxity, vertebral endplates are destroyed by penetration
of amyloid granulation into the adjacent vertebral bodies. Around the amyloid
granulation, osteoclast activity is enhanced with no evidence of new bone
formation. These destructive changes of the three-joint complex of the spine
finally cause severe slipping and segmental instability. Besides these
destructive changes, amyloid or calcium deposits in the spinal canal and
ligamentum flavum cause spinal canal stenosis leading to spinal cord or cauda
equina compression.
Imaging (plain radiograph and cross section) appearances reflect the pathological changes (3,4). Kuntz et al (5) in 1984 was the first to describe the radiological features of DSA of the cervical spine: disc space narrowing, vertebral erosions, and irregular endplate destruction with minimal osteophyte formation in the absence of a microbial infection or prevertebral mass. Radiographic features may simulate those of an infectious process. The absence of high signal intensity on T2-weighted images on MR generally helps to eliminate the diagnosis of an infection (4).
The cervical spine is the area most frequently involved in DSA. The initial clinical symptoms are usually neck pain and associated brachialgia, probably caused by root compression. Signs of cord compression or myelopathy may also be present.
When patients have neurological symptoms surgical treatment may be considered. Our patient had a successful cervical spinal decompression and fusion which helped to relieve pain and to improve neurological deficits.
Imaging (plain radiograph and cross section) appearances reflect the pathological changes (3,4). Kuntz et al (5) in 1984 was the first to describe the radiological features of DSA of the cervical spine: disc space narrowing, vertebral erosions, and irregular endplate destruction with minimal osteophyte formation in the absence of a microbial infection or prevertebral mass. Radiographic features may simulate those of an infectious process. The absence of high signal intensity on T2-weighted images on MR generally helps to eliminate the diagnosis of an infection (4).
The cervical spine is the area most frequently involved in DSA. The initial clinical symptoms are usually neck pain and associated brachialgia, probably caused by root compression. Signs of cord compression or myelopathy may also be present.
When patients have neurological symptoms surgical treatment may be considered. Our patient had a successful cervical spinal decompression and fusion which helped to relieve pain and to improve neurological deficits.
Differential Diagnosis List
Destructive spondyloarthropathy
Final Diagnosis
Destructive spondyloarthropathy
References
[1]
Ohashi K, Hara M, Kawai R, Ogura Y, Honda K, Nihei H, Mimura N.
Cervical discs are most susceptible to beta 2-microglobulin amyloid deposition in the vertebral column.
Kidney Int. 1992 Jun;41(6):1646-52. (PMID: 1501421)
[2]
Ito M, Abumi K, Takeda N, Satoh S, Hasegawa K, Kaneda K.
Pathologic features of spinal disorders in patients treated with long-term hemodialysis.
Spine. 1998 Oct 1;23(19):2127-33. (PMID: 9794059)
[3]
Leone A, Sundaram M, Cerase A, Magnavita N, Tazza L, Marano P.
Destructive spondyloarthropathy of the cervical spine in long-term hemodialyzed patients: a five-year clinical radiological prospective study.
Skeletal Radiol. 2001 Aug;30(8):431-41. (PMID: 11479748)
[4]
Theodorou DJ, Theodorou SJ, Resnick D.
Imaging in dialysis spondyloarthropathy.
Semin Dial. 2002 Jul-Aug;15(4):290-6. (PMID: 12191028)
[5]
Kuntz D, Naveau B, Bardin T, Drueke T, Treves R, Dryll A.
Destructive spondylarthropathy in hemodialyzed patients. A new syndrome.
Arthritis Rheum. 1984 Apr;27(4):369-75. (PMID: 6712753)
Case information
| URL: | https://www.eurorad.org/case/2328 |
| DOI: | 10.1594/EURORAD/CASE.2328 |
| ISSN: | 1563-4086 |
Figure 2
MRI of cervical spine: sagittal T1-weighted image (a) and T2-weighted image (b).
The C7 disc is destroyed with erosions and irregularity of the end plates and loss of volume of the adjacent vertebral bodies especially C6. No perivertebral soft tissue mass is present.
C6-7 disc destruction and end plates erosions are well seen. A high signal within the disc space and subtle oedema of the adjacent vertebral bone marrow are visualized. Ligamentum flavum hypertrophy, minimal retrolythesis of C6 on C7 and a degree of canal stenosis with cord compression are noted.
X-ray of cervical spine (a) with close up view of the C6-7 disc (b)
MRI of cervical spine: sagittal T1-weighted image (a) and T2-weighted image (b).
The C7 disc is destroyed with erosions and irregularity of the end plates and loss of volume of the adjacent vertebral bodies especially C6. No perivertebral soft tissue mass is present.
C6-7 disc destruction and end plates erosions are well seen. A high signal within the disc space and subtle oedema of the adjacent vertebral bone marrow are visualized. Ligamentum flavum hypertrophy, minimal retrolythesis of C6 on C7 and a degree of canal stenosis with cord compression are noted.