Rheumatoid Spondylitis: Correlation of Clinical and Roentgenographic Features

Abstract

Rheumatoid (ankylosing) spondylitis predominantly affects males of military age. For this reason it constitutes an important and frequent cause of chronic back disability in soldiers. At the Army Rheumatism Center, Army and Navy General Hospital, 1,084 instances of the disease were observed during a twenty-two-month period; these constituted 18.1 per cent of 6,000 consecutive admissions for rheumatic conditions of all types (1). Few examples of true “poker back” deformity or “bamboo spine” have been encountered among soldiers; such an occurrence usually led to rejection at the time of induction. The majority of soldiers with rheumatoid spondylitis have been observed during the early or relatively early phases of the disease. This has allowed an unusual opportunity for the study of the early diagnostic features; these features have been outlined elsewhere (2). It is during the early stages of rheumatoid spondylitis that the best results may be expected from roentgen therapy to the spine, corrective and preventive postural exercises, orthopedic appliances, and other therapeutic measures. To direct such procedures intelligently, it is important to know in each case the degree of extension, the severity, and rate of progression of the disease. Generally such information can be obtained by a correlated study of the clinical and roentgenographic features. Clinical Features The clinical picture of rheumatoid spondylitis is dependent upon such qualifying factors as the severity of the disease, the degree of spinal extension, the activity of the process at various levels of the spine, the duration of the disease, and the amount of extra-articular soft-tissue involvement. The disease may be mild, moderate, or severe; the intensity of symptoms, rate of progression, and amount of constitutional reaction will vary accordingly. The sacroiliac joints may be involved alone or, at the other extreme, the synovial joints of the entire spine may be affected. The process may be active in one area and “burned out” or quiescent at another level. Associated soft-tissue reaction in the muscles, ligaments, or spinal nerve roots may give rise to symptoms at levels higher than the actual joint involvement. The following is a summary of the clinical features of the disease, especially those which reflect involvement of the various regions of the spine. Sacroiliac Involvement: Because the disease almost invariably begins in the sacroiliac joints, the symptoms and findings referable to the lower back at onset may be considered as expressions of sacroiliac involvement. In approximately 75 per cent of cases the early symptoms consist of aching and stiffness of the lower back, which qualitatively exhibit the characteristics of “fibrositis,” that is, are most pronounced on arising in the morning, are accentuated by physical inactivity and ameliorated by mild exercise, are subject to fluctuations with weather changes, and are relieved temporarily by local heat and salicylates.