Weekly Case

Title : Case 588

Age / Sex : 62 / M

Chief complaint : Lower back pain for several months. End-stage renal disease

What is your impression?

Two weeks later, you can see the final diagonosis with a brief discussion of this case (Please submit only one answer).

Courtesy : 
Lee Young-Hwan, Daegu Catholic university Medical Center


Answer: Destructive spondyloarthropathy



Marked narrowing of intervertebral disc space at L3-4 level on plain radiography

MR images show destruction of intervertebral disc space at L3-4 level with irregularity of adjacent endplates and prominent erosions.

T2-weighted image shows lesions of predominantly low signal intensity.

Heterogeneous enhancement on Gd-enhanced images.

No significant paravertebral inflammation or edema


Differential Diagnosis:

Infectious spondylitis

Neuropathic spondyloarthropathy


CPPD deposition disease




Patients with chronic renal disease and on hemodialysis may develop many different musculoskeletal abnormalities, including secondary hyperparathyroidism, osteomalacia, osteosclerosis, osteoporosis, amyloidosis, a variety of crystal deposition diseases, destructive osteoarthropathy, and destructive spondyloarthropathy.


Destructive spondyloarthropathy is considered a serious complication of chronic hemodialysis, and is characterized by rapidly progressive radiographic abnormalities, including loss of intervertebral disk space, erosion of subchondral bone in the adjacent vertebral bodies, and new bone formation.


Destructive spondyloarthropathy affects middle-aged and elderly patients with chronic renal disease who have been undergoing maintenance hemodialysis. The prevalence of the condition has been reported to range from 5 to 25.3% in different series, and it depends on age and the duration of hemodialysis. Destructive spondyloarthropathy shows a predilection for the lower portion of the cervical spine, although the craniocervical junction, and occasionally the thoracic and lumbar spine may also be affected.


Beta2-microglobulin amyloidosis is a major cause of destructive spondyloarthropathy. Amyloid deposits accumulate at intervertebral discs, facet joints, and the ligamentum flavum in spine lesions


Destructive spondyloarthropathy is characterized by erosions of the anterosuperior and/or anteroinferior corners of the vertebral body, severe narrowing of the intervertebral disk space, and erosions and cysts of adjacent vertebral plates with minimal osteophyte formation. As the disease progresses, vertebral body collapse, subluxation, or listhesis may occur.


Single, or usually multiple, spinal levels are involved. But destructive changes are limited in one or sometimes two disc levels. It was thought that once the destructive changes had occurred, axial and shearing loads were concentrated to the involved level and destruction progressed in limited disc levels.


MRI findings include low signal intensity in the affected intervertebral discs and adjacent vertebral endplates on both T1- and T2-weighted MR images. Enhancement of the affected spinal segments is seen and may be due to reactive inflammation around deposits of beta-2 microglobulin amyloid.


Early vertebral abnormalities may simulate those of early ankylosing spondylitis, with erosions of the anterosuperior or anteroinferior corners of the vertebral bodies involved. As the disease progresses, destructive lesions may simulate infection.


It may be difficult to differentiate changes secondary to destructive spondyloarthropathy from infectious spondylitis. In infectious spondylitis, structures that are involved show increased signal intensity on T2-weighted and STIR images. But, other studies of destructive spondyloarthropathy have reported abnormal high signal intensity in the affected structures on T2-weighted MR images. In most cases, however, low signal is present in T2-weighted images and allows exclusion of an infection. And absence of paraspinal inflammatory change and no clinical or laboratory evidence of infection may be helpful to its differentiation.




  1. J. TD, J. TS, Donald R. Imaging in the Dialysis Patient: Imaging in Dialysis Spondyloarthropathy. Seminars in Dialysis 2002;15(4):290-6

  2. Kiss E, Keusch G, Zanetti M, Jung T, Schwarz A, Schocke M, et al. Dialysis-Related Amyloidosis Revisited. AJR American Journal of Roentgenology 2005;185(6):1460-1467

  3. Kaplan P, Resnick D, Murphey M, Heck L, Phalen J, Egan D, et al. Destructive noninfectious spondyloarthropathy in hemodialysis patients: A report of four cases. Radiology 1987;162:241-244

  4. Hayami NHoshino JSuwabe TSumida KMise KHamanoue S, et al. Destructive spondyloarthropathy in patients on long-term peritoneal dialysis or hemodialysis. Ther Apher Dial 2015;19:393-398

Correct Answer
Total applicants 29 Correct answers 17
Name Institution
이혜란 전문의
전인환 전문의
김기욱 국군대전병원, 전문의
김창현 전문의
한유비 전문의
권소이 전문의
이영선 전문의
김동수 전공의
손상욱 군의관, 전문의
이준영 전공의
이은채 전문의
김형민 전문의
김미선 전문의
이승민 전문의
박상옥 안산21세기병원, 전문의
석지현 전문의
이지현 삼성서울병원, 전문의