Cornered!

A pictorial review of the radiological features in

Ankylosing Spondylitis.

Poster No.: C-1747

Congress: ECR 2016
Type: Educational Exhibit
Authors: 1 1 2 3 1
L. Sammut , N. Bonanno , R. Grech , A. Mizzi ; Msida/MT,
2 3
Dublin 9/IE, ATTARD/MT
Keywords: MR, CT, Conventional radiography, Musculoskeletal bone,
Education, Education and training
DOI: 10.1594/ecr2016/C-1747

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Page 1 of 38
Learning objectives

The purpose of this exhibit is:

1. Modality-based description of the distinguishing imaging features of Ankylosing

Spondylitis of the spine, supplemented with a collection of images.

2. To highlight the role of magnetic resonance imaging in the detection of early cartilage
changes and bone marrow oedema of the sacroiliac joints.

3. An educational tool for the radiologists-in-training.

Background

Ankylosing spondylitis (AS, derived from the Greek ankylos, meaning stiffening of
a joint; spondylos, meaning vertebra; -itis, meaning inflammation) is a distinct disease
entity characterized by inflammation of multiple articular and para-articular structures
frequently resulting in bony ankylosis. AS is classified as a chronic and progressive form
of seronegative arthritis, and has a strong genetic predisposition.

AS has a predilection for the axial skeleton, affecting particularly the sacroiliac and spinal
facet joints and the paravertebral soft tissues.

Extraspinal manifestations of the disease include peripheral arthritis, iritis, pulmonary

(1,2)
involvement, and systemic upset.

This pictorial presentation offers a selection of spinal manifestations of AS as portrayed

by different imaging modalities namely plain radiography, computed tomography (CT),
magnetic resonance imaging (MRI) and bone scintigraphy.

Findings and procedure details

Imaging is an integral part of the work-up and management of AS.

Page 2 of 38
For decades, conventional radiography has been the primary imaging modality in AS.
However, advances in CT and MRI have exponentially increased the amount and latitude
of information obtainable by imaging.

Imaging is used for multiple reasons such as establishing or confirming the diagnosis,
determining extent of disease, monitoring change in disease (e.g. activity and structural
damage), providing prognostic information or selecting patients for specific therapies.

Conventional Radiography

Radiographs are the single most important imaging technique for the detection,
diagnosis, and follow-up monitoring of patients with AS.

Overall bony morphology and subtle calcifications and ossifications may be demonstrated
well radiographically. The diagnosis may be reliably made if the typical radiographic
features of AS are present.

Radiographs are limited in detecting early sacroiliitis and in demonstrating subtle changes
(3)
in the posterior vertebral elements.

Sacroiliac joints

Sacroiliitis occurs early in the course of AS and is regarded as a hallmark of the

(4)
disease.

• Radiographically, the earliest sign of sacroiliitis is indistinctness of the joint.

The joints initially widen before they narrow.
• Subchondral bony erosions on the iliac side of the joint are subsequently
seen; these are followed by subchondral sclerosis and bony proliferation.
• With eventual bony fusion, the sclerosis resolves.
• At the end stage, the sacroiliac joint may be seen as a thin, dense line, or it
may not be visible at all.
• Sacroiliitis typically is symmetrical, although it may be asymmetrical in the
(4)
early stages of the disease. Fig. 1 on page 21

Page 3 of 38
Fig. 1: Early and Late Sacroilitiis (a) Antero-posterior radiograph of the sacroiliac joints in a 30-year old male

demonstrating early signs of unilateral sacroiliitis. There is indistinctness of the right joint margins and a discrete

focus of subchondral sclerosis (red arrow). The left sacroiliac joint is radiographically unremarkable at this early

stage of the disease. (b) Antero-posterior radiograph of the sacroiliac joints in a 55-year old male with established

AS, demonstrating complete fusion of both sacroiliac joints (red arrowheads). This is a case of chronic, bilateral

sacroiliitis. The sacroiliac joints are seen as a thin, dense line. Knowledge Tip! Radiographically, the earliest sign of

sacroiliitis is blurring of joint margins. The joints initially widen before they narrow. Sacroiliitis typically is symmetrical,

although it may be asymmetrical in the early stages of the disease.

References: Medical Imaging Department, Mater Dei Hospital, Malta

Spine

• In the spine, the early stages of spondylitis are manifested as small

erosions at the corners of the vertebral bodies. The areas are surrounded

Page 4 of 38
 by reactive sclerosis and have been termed the shiny corner sign, or
Romanus lesion.
• Another characteristic feature of AS is squaring of the vertebral bodies.
This is caused by a combination of corner erosions with new periosteal bone
formation along the anterior aspect of the vertebral bodies. This feature
is best seen in the lumbar spine, with loss of the normal concave anterior
cortex of the vertebral body. Fig. 2 on page 22
• Syndesmophyte (bony spur) formation follows, in which ossification of the
outer fibres of the annulus fibrosis leads to bridging of the corners of one
vertebra to another. Syndesmophytes are the hallmark of spinal disease
in AS. Syndesmophytes are radiographically visible on the anterior and
lateral aspects of the spine. They appear as thin, vertically-oriented bony
projections. Fig. 2 on page 22
• Posterior interspinous ligament ossification, combined with linking of the
spinous process, produces an appearance of a solid midline, vertical, dense
line on frontal radiographs - the 'dagger spine' appearance. Fig. 3 on page
23
• Vertebral fusion. Progressive growth of syndesmophytes will bridge
the intervertebral disc causing ankylosis and extensive bone formation
produces a smooth, undulating spinal contour - the 'bamboo spine'. Fig. 3 on
page 23 Fig. 4 on page 24
• Calcifications of the disc may occur at single or multiple levels; they
are usually associated with apophyseal joint ankylosis and adjacent
syndesmophytes. Fig. 5 on page 26
• In established AS, fractures usually occur at the thoracolumbar and
cervicothoracic junctions. Upper cervical spine fractures and atlantoaxial
subluxation are rarely seen. Fractures typically are transverse, extend from
anterior to posterior, and frequently pass through the ossified disk. These
are termed chalk stick fractures.
• Pseudoarthrosis is radiographically depicted as disco-vertebral destruction
with adjacent sclerosis. The changes, referred to as the Andersson lesion,
may resemble infection of the disc, although pseudoarthrosis usually
develops secondary to a previously undetected fracture or at an unfused
segment. Therefore, an important imaging feature is the involvement of
the posterior elements, seen as a linear, hypodense area with sclerotic
(4)
borders.

Page 5 of 38
Fig. 2: The syndesmophytes. Anteroposterior and lateral radiographs of the thoracolumbar spine in a 45-year

old male showing squaring of the vertebral bodies (red arrow) and syndesmophyte formation (red arrowheads).

Knowlegde Tip! Vertebral body squaring is caused by a combination of corner erosions and periosteal new

bone formation along the anterior aspect of the vertebral body. This is followed by syndesmophyte formation.

Syndesmophytes represent ossification of the outer fibers of the annulus fibrosus.

References: Medical Imaging Department, Mater Dei Hospital, Malta

Page 6 of 38
Fig. 3: Bamboo or Dagger Spine? (a) Frontal radiograph showing complete fusion
of the lumbar vertebral bodies by marginal syndesmophytes giving the appearance
of a "bamboo spine". (b), (c) Frontal radiographs of the thoracolumbar spine showing
diffuse syndesmophytic anklylosis and supraspinous and interspinous ligament
calcification giving rise to a "dagger spine" appearance. Knowledge Tip! Look for
undulating continuous lateral spinal borders on frontal radiographs that resemble a
bamboo stem for the "bamboo spine". Look for the central vertical radiodense line on
frontal radiographs for the "dagger sign".
References: Medical Imaging Department, Mater Dei Hospital, Malta

Page 7 of 38
Fig. 4: Vertebral Fusion. The cervical spine exhibits extensive formation of vertical
anterior and posterior syndesmophytes that have bridged the anterior vertebral corners

Page 8 of 38
causing ankylosis. Early sclerosis of the facet joints is noted, best appreciated from C2
downwards.
References: Medical Imaging Department, Mater Dei Hospital, Malta

Fig. 5: Calcification of the Discs. Anteroposterior and lateral radiographs of a 53-year

old gentleman depicts multilevel disc calcification (red arrows), as well as bridging
syndesmophytes (red arrowheads). Knowledge Tip! Calcification of the disc may occur
at single or multiple levels; they are usually associated with apophyseal joint ankylosis
and adjacent syndesmophytes.
References: Medical Imaging Department, Mater Dei Hospital, Malta

Page 9 of 38
Fig. 6: Lateral thoracic spine radiograph in a 62-year old male with widespread
ankylosis giving rise to a severe kyphotic deformity. Knowledge Tip! The combination
of a fixed thoracic kyphosis, loss of lumbar lordosis and compensated extension of the
cervical spine is known as the "question mark posture" of established AS.

Page 10 of 38
References: Medical Imaging Department, Mater Dei Hospital, Malta

Computed Tomography

CT is useful in selected patients in whom AS is suspected and in whom initial sacroiliac

joint radiographs findings are normal or equivocal. CT is superior to plain radiography
in identifying features such as joint erosions, subchondral sclerosis and bony ankylosis.
However, some normal variations of the sacroiliac joint may simulate the features of
(5,6,7)
inflammation. CT is also beneficial in the evaluation of complications. Fig. 7 on page
28

Fig. 7: Axial CT prior to CT-guided infiltration of the sacroiliac joints as a measure of pain relief. The CT shows

bilateral sacroiliac joint involvement as evidenced by multiple subchondral erosions and sclerosis. Knowledge Tip!

Page 11 of 38
The primary value of CT in AS is its ability to detect and clearly define erosion of bone at any joint or enthesis, and

for documenting fractures.

References: Medical Imaging Department, Mater Dei Hospital, Malta

CT supplements bone scintigraphy in evaluating areas of increased uptake, particularly

in the spine. Fractures, Andersson lesions, spinal canal stenosis, and facet inflammatory
disease are detected well using CT, particularly on reformatted coronal, sagittal, or
oblique images.

Other useful applications of CT include the assessment of atlantoaxial joint instability,

costovertebral disease, manubriosternal disease, and paraspinal muscle atrophy. It also
(4)
yields more information on fracture morphology than do the other modalities. Fig. 8 on
page 28 Fig. 9 on page 30 Fig. 10 on page 30 Fig. 11 on page 31

Page 12 of 38
Fig. 8: CT sagittal reconstructions of the thoracolumbar spine in a 41-year old
gentleman demonstrating the typical "shiny corner sign" (red arrows) which results from
the healing and sclerosis of Romanus lesions at the vertebral end plates. Knowledge
Tip! In the spine, the early stages of spondylitis are manifested as small erosions at
the corners of the vertebral bodies (Romanus lesions). The areas are surrounded by
reactive sclerosis and have been termed the "shiny corner sign".

Page 13 of 38
References: Medical Imaging Department, Mater Dei Hospital, Malta

Fig. 9: Sagittal CT of the cervical spine in a 49-year old gentleman showing

discrete erosions and densities of anterior vertebral end-plates (red arrows) and
presence of posterior syndesmophytes (red arrows). This represents end-stage
Romanus spondylitis. Knowledge Tip! Syndesmophytes are characteristic of
spondyloarthropathies. They differ from osteophytes by their initial vertical, rather than
horizontal, orientation. Osteophytes are bony projections that form along joint margins;
a syndesmophyte is a bony growth originating inside a ligament.
References: Medical Imaging Department, Mater Dei Hospital, Malta

Page 14 of 38
Fig. 10: The sagittal CT image of a 63 year-old gentleman who sustained minimal
trauma to the back confirms simultaneous three-column fractures at T10 and T11
levels and other signs of AS. Corresponding T1- and T2-weighted MR images showing
altered signal intensity of the T10 and T11 vertebral bodies with horizontally oriented
three-column fractures (red arrows), with consequent spinal cord compression at
this level (red arrowheads). Knowledge Tip! "Chalkstick" fractures of a fused spine,
classically seen in AS; these fractures are known as "chalkstick" fractures because of
how brittle the spine becomes in AS, and can occur with minimal trauma. They usually
occur at the cervicothoracic or thoracolumbar junctions.
References: Medical Imaging Department, Mater Dei Hospital, Malta

Page 15 of 38
Fig. 11: CT sagittal reconstructed image showing established cervical AS with
extensive ossification of the ALL and PLL with multilevel fusion. A fracture is seen
through an anterior syndesmophyte bridging between the C3 and C4 vertebral bodies
(red arrow head). There is also a fracture through the C7 vertebral body disrupting
its inferior end plate (red arrow). Knowledge Tip! For patients with established AS,
fractures usually occur at the thoracolumbar and cervicothoracic junctions. Upper
cervical spine fractures and atlano-axial subluxation are rarely seen.
References: Medical Imaging Department, Mater Dei Hospital, Malta

Magnetic Resonance Imaging

Page 16 of 38
MRI may have a role in the early diagnosis of sacroiliitis. Yu et al. postulated MRI to be
more sensitive than either plain radiography or CT in the detection of early cartilaginous
(8)
changes and bone marrow oedema of the sacroiliac joints. Fig. 12 on page 32

Fig. 12: (a) Axial and (b) Coronal Short tau inversion recovery (STIR) sequence
images of the sacroiliac joints showing extensive bilateral changes of sacroiliitis with
bone marrow oedema evident on the sacral side of the joint bilaterally and on the right
iliac side of the joint posteriorly with subchondral cyst formation and bony sclerosis.
References: Medical Imaging Department, Mater Dei Hospital, Malta

Although sensitive in the detection of sacroiliitis, MRI is not specific for diagnosing AS
as the cause of sacroiliitis.

Detection of synovial enhancement on MRI has been found to correlate with disease
activity. MRI findings of vertebral corner inflammatory or fatty lesions may also be used
(4)
to predict development of new radiographic syndesmophytes. Fig. 13 on page 33
Fig. 14 on page 34

Page 17 of 38
Fig. 13: (a) Sagittal T1 weighted sequence of the thoracic spine shows focal area
of T1 hyperintesities (red arrows) which correspond to the abnormalities seen on
the T2 sequence. This represents focal fatty marrow due to chronic inflammation.
Appearances are in keeping with Romanus lesions. The most frequent pattern of
signal intensity lesions correspond to Modic type II changes. (b) Sagittal T2 weighted
sequence of the thoracic spine. There are multiple sharply marginated triangular T2
hyper intense 'corner' abnormalities (red arrows). No associated osteophyte formation
or Schmorl's nodules are seen. © Sagittal STIR sequence demonstrates hyperintense
vertberal corners (red arrows) affecting multiple thoracic vertebrae.
References: Medical Imaging Department, Mater Dei Hospital, Malta

Page 18 of 38
Fig. 14: Sagittal T1-weighted (a) and T2-weighted (b) sequences of the thoracic spine
of a 48-year old gentleman. There are multiple, sharply marginated, triangular 'corner'
abnormalites which are hyperintense on both T1 and T2 weighted sequences (red
arrows). These represent focal fatty marrow due to chronic inflammation. Appearances
are in keeping with Romanus lesions.
References: Medical Imaging Department, Mater Dei Hospital, Malta

MRI has been found to be superior to CT in the detection of cartilage changes, bone
erosions, and subchondral bone changes. MRI is also sensitive in the assessment of
activity in relatively early disease. Affected sites include the discovertebral junction and
the peripheral joints. In general, areas of increased T2 signal correlate with the presence
(9)
of oedema or vascularized fibrous tissue.

In established disease, MRI detects pseudoarthrosis, cauda equina syndrome, and

spinal canal stenosis. In the setting of fractures or pseudoarthrosis, MRI is useful in the
(10)
assessment of spinal canal compromise and cord injury. Fig. 10 on page 30

Page 19 of 38
Nuclear Imaging

Bone scintigraphy is applicable in the assessment of patients with suspected AS in whom

radiographic findings are normal or equivocal.

• Qualitative assessment of the accumulation of radionuclides in the sacroiliac

region may be difficult because of normal uptake in the location.
• Quantitative analysis may be more useful in these patients. Ratios
of sacroiliac joint-to-sacral uptake of 1.3:1 or more are considered
(11,12)
abnormal. Fig. 15 on page 34

Page 20 of 38
Fig. 15: Quantitative scintigraphy scan of a 51-year old patient with established AS
showing increased sacroiliac joint uptake, with a sacroiliac joint-to-sacral uptake ratio
that exceeds 1.5:1 on each side.
References: Medical Imaging Department, Mater Dei Hospital, Malta

An increase in bone scintigraphic uptake may also be useful in the evaluation of

active disease. Sites affected include the peripheral joints and entheses. An important
application is in patients with long-standing disease who develop new pain, with or
without recent history of trauma. Focal areas of uptake may indicate a fracture or
pseudoarthrosis. Application of single-photon emission CT (SPECT) scintiscans may
help to better localize the structures involved. In these patients, the sites of increased
scintigraphic uptake must be correlated with further imaging by radiography or computed
tomography.

Scintigraphy has high sensitivity but low specificity in the diagnosis of sacroiliitis. Several
factors potentially affect calculation of the sacroiliac joint-to-sacrum ratio. Factors include
a prominent sacral tubercle that may produce increased uptake in the sacrum, and the
influence of age and sex on radionuclide uptakes in the sacroiliac joints and sacrum.
In patients with advanced disease, scintigraphy results may be falsely negative as the
radionuclide uptake may not appear abnormal.

Although sensitive in the detection of active disease in the spine, increased radionuclide
accumulation is not specific for the diagnosis of AS.

Abnormal radionuclide uptake in the sacroiliac joints and other spinal locations may not be
(4)
specific for AS. Correlation with other radiologic and clinical findings is thus important.

Images for this section:

Page 21 of 38
Fig. 1: Early and Late Sacroilitiis (a) Antero-posterior radiograph of the sacroiliac
joints in a 30-year old male demonstrating early signs of unilateral sacroiliitis. There is
indistinctness of the right joint margins and a discrete focus of subchondral sclerosis
(red arrow). The left sacroiliac joint is radiographically unremarkable at this early stage
of the disease. (b) Antero-posterior radiograph of the sacroiliac joints in a 55-year old
male with established AS, demonstrating complete fusion of both sacroiliac joints (red
arrowheads). This is a case of chronic, bilateral sacroiliitis. The sacroiliac joints are seen
as a thin, dense line. Knowledge Tip! Radiographically, the earliest sign of sacroiliitis is
blurring of joint margins. The joints initially widen before they narrow. Sacroiliitis typically
is symmetrical, although it may be asymmetrical in the early stages of the disease.

© Medical Imaging Department, Mater Dei Hospital, Malta

Page 22 of 38
Fig. 2: The syndesmophytes. Anteroposterior and lateral radiographs of the
thoracolumbar spine in a 45-year old male showing squaring of the vertebral bodies
(red arrow) and syndesmophyte formation (red arrowheads). Knowlegde Tip! Vertebral
body squaring is caused by a combination of corner erosions and periosteal new
bone formation along the anterior aspect of the vertebral body. This is followed by
syndesmophyte formation. Syndesmophytes represent ossification of the outer fibers of
the annulus fibrosus.

© Medical Imaging Department, Mater Dei Hospital, Malta

Page 23 of 38
Fig. 3: Bamboo or Dagger Spine? (a) Frontal radiograph showing complete fusion of
the lumbar vertebral bodies by marginal syndesmophytes giving the appearance of a
"bamboo spine". (b), (c) Frontal radiographs of the thoracolumbar spine showing diffuse
syndesmophytic anklylosis and supraspinous and interspinous ligament calcification
giving rise to a "dagger spine" appearance. Knowledge Tip! Look for undulating
continuous lateral spinal borders on frontal radiographs that resemble a bamboo stem for
the "bamboo spine". Look for the central vertical radiodense line on frontal radiographs
for the "dagger sign".

© Medical Imaging Department, Mater Dei Hospital, Malta

Page 24 of 38
Fig. 4: Vertebral Fusion. The cervical spine exhibits extensive formation of vertical
anterior and posterior syndesmophytes that have bridged the anterior vertebral corners

Page 25 of 38
causing ankylosis. Early sclerosis of the facet joints is noted, best appreciated from C2
downwards.

© Medical Imaging Department, Mater Dei Hospital, Malta

Fig. 5: Calcification of the Discs. Anteroposterior and lateral radiographs of a 53-year

old gentleman depicts multilevel disc calcification (red arrows), as well as bridging
syndesmophytes (red arrowheads). Knowledge Tip! Calcification of the disc may occur
at single or multiple levels; they are usually associated with apophyseal joint ankylosis
and adjacent syndesmophytes.

© Medical Imaging Department, Mater Dei Hospital, Malta

Page 26 of 38
Fig. 6: Lateral thoracic spine radiograph in a 62-year old male with widespread ankylosis
giving rise to a severe kyphotic deformity. Knowledge Tip! The combination of a fixed
thoracic kyphosis, loss of lumbar lordosis and compensated extension of the cervical
spine is known as the "question mark posture" of established AS.

Page 27 of 38
© Medical Imaging Department, Mater Dei Hospital, Malta

Fig. 7: Axial CT prior to CT-guided infiltration of the sacroiliac joints as a measure of

pain relief. The CT shows bilateral sacroiliac joint involvement as evidenced by multiple
subchondral erosions and sclerosis. Knowledge Tip! The primary value of CT in AS is
its ability to detect and clearly define erosion of bone at any joint or enthesis, and for
documenting fractures.

© Medical Imaging Department, Mater Dei Hospital, Malta

Page 28 of 38
Fig. 8: CT sagittal reconstructions of the thoracolumbar spine in a 41-year old gentleman
demonstrating the typical "shiny corner sign" (red arrows) which results from the healing
and sclerosis of Romanus lesions at the vertebral end plates. Knowledge Tip! In the
spine, the early stages of spondylitis are manifested as small erosions at the corners of
the vertebral bodies (Romanus lesions). The areas are surrounded by reactive sclerosis
and have been termed the "shiny corner sign".

Page 29 of 38
© Medical Imaging Department, Mater Dei Hospital, Malta

Fig. 9: Sagittal CT of the cervical spine in a 49-year old gentleman showing discrete
erosions and densities of anterior vertebral end-plates (red arrows) and presence of
posterior syndesmophytes (red arrows). This represents end-stage Romanus spondylitis.
Knowledge Tip! Syndesmophytes are characteristic of spondyloarthropathies. They differ
from osteophytes by their initial vertical, rather than horizontal, orientation. Osteophytes
are bony projections that form along joint margins; a syndesmophyte is a bony growth
originating inside a ligament.

© Medical Imaging Department, Mater Dei Hospital, Malta

Page 30 of 38
Fig. 10: The sagittal CT image of a 63 year-old gentleman who sustained minimal trauma
to the back confirms simultaneous three-column fractures at T10 and T11 levels and
other signs of AS. Corresponding T1- and T2-weighted MR images showing altered
signal intensity of the T10 and T11 vertebral bodies with horizontally oriented three-
column fractures (red arrows), with consequent spinal cord compression at this level (red
arrowheads). Knowledge Tip! "Chalkstick" fractures of a fused spine, classically seen
in AS; these fractures are known as "chalkstick" fractures because of how brittle the
spine becomes in AS, and can occur with minimal trauma. They usually occur at the
cervicothoracic or thoracolumbar junctions.

© Medical Imaging Department, Mater Dei Hospital, Malta

Page 31 of 38
Fig. 11: CT sagittal reconstructed image showing established cervical AS with extensive
ossification of the ALL and PLL with multilevel fusion. A fracture is seen through an
anterior syndesmophyte bridging between the C3 and C4 vertebral bodies (red arrow
head). There is also a fracture through the C7 vertebral body disrupting its inferior end
plate (red arrow). Knowledge Tip! For patients with established AS, fractures usually
occur at the thoracolumbar and cervicothoracic junctions. Upper cervical spine fractures
and atlano-axial subluxation are rarely seen.

© Medical Imaging Department, Mater Dei Hospital, Malta

Page 32 of 38
Fig. 12: (a) Axial and (b) Coronal Short tau inversion recovery (STIR) sequence images of
the sacroiliac joints showing extensive bilateral changes of sacroiliitis with bone marrow
oedema evident on the sacral side of the joint bilaterally and on the right iliac side of the
joint posteriorly with subchondral cyst formation and bony sclerosis.

© Medical Imaging Department, Mater Dei Hospital, Malta

Page 33 of 38
Fig. 13: (a) Sagittal T1 weighted sequence of the thoracic spine shows focal area of
T1 hyperintesities (red arrows) which correspond to the abnormalities seen on the T2
sequence. This represents focal fatty marrow due to chronic inflammation. Appearances
are in keeping with Romanus lesions. The most frequent pattern of signal intensity
lesions correspond to Modic type II changes. (b) Sagittal T2 weighted sequence of the
thoracic spine. There are multiple sharply marginated triangular T2 hyper intense 'corner'
abnormalities (red arrows). No associated osteophyte formation or Schmorl's nodules
are seen. © Sagittal STIR sequence demonstrates hyperintense vertberal corners (red
arrows) affecting multiple thoracic vertebrae.

© Medical Imaging Department, Mater Dei Hospital, Malta

Fig. 14: Sagittal T1-weighted (a) and T2-weighted (b) sequences of the thoracic spine
of a 48-year old gentleman. There are multiple, sharply marginated, triangular 'corner'
abnormalites which are hyperintense on both T1 and T2 weighted sequences (red
arrows). These represent focal fatty marrow due to chronic inflammation. Appearances
are in keeping with Romanus lesions.

© Medical Imaging Department, Mater Dei Hospital, Malta

Page 34 of 38
Fig. 15: Quantitative scintigraphy scan of a 51-year old patient with established AS
showing increased sacroiliac joint uptake, with a sacroiliac joint-to-sacral uptake ratio that
exceeds 1.5:1 on each side.

© Medical Imaging Department, Mater Dei Hospital, Malta

Page 35 of 38
Conclusion

This poster clearly portrays the role of imaging in the diagnosis and management of
patients with AS. Identification of characteristic imaging features of AS is the basis for
diagnosis. This presentation will serve as a teaching tool and reference for the general
radiologist, and of course for radiologists-in-training.

Personal information

Lara Sammut

Basic Specialist trainee

Medical Imaging Department,

Mater Dei Hospital, Malta

lara.sammut@gov.mt

Nathania Bonanno

Basic Specialist trainee

Medical Imaging Department,

Mater Dei Hospital, Malta

nathania.bonanno@gov.mt

Reuben Grech

Consultant Radiologist

Medical Imaging Department,

Mater Dei Hospital, Malta

reubengrech@yahoo.com

Adrian Mizzi

Page 36 of 38
Consultant Radiologist

Medical Imaging Department,

Mater Dei Hospital, Malta

adrian.mizzi@gov.mt

References

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W.P. (2011) Focal fat lesions at vertebral corners on magnetic resonance
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Page 37 of 38
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