Todays pelvis and hip XR was notable for the severe bilateral SIJ erosions.
The left hip (lateral view not included) is mildly narrowed with small
osteophytes.
[image: XR pelvis now.JPG]
I found an old AP pelvis XR from 2008 which shows milder erosions on the
right side (not reported) and normal hips
[image: XR pelvis 2008.JPG]
She has scoliosis and severe multilevel DDD and facet arthrosis.
Lumbar CT from March 2022 (alas, no mention of the SIJs in the report)
[image: CT Cor.JPG]
[image: CT ax1.JPG]
[image: CT ax2.JPG]
This confuses me. There is degenerative vacuum…not what I expect in
inflammatory sacroiliitis, but I have not seen such dramatic erosions in
SIJ DJD. Is this Erosive OA? Does that happen in the SIJs?
Calling on you arthritis mavens….please help.
Hilary
PS In the unlikely event that you missed the recent Case Session on MSK
Intervention, IT WAS AMAZING…here is the link to the video on our website ocadmsk.com/videos/
PPS In the unlikely event that you have not yet registered for our website,
maybe do that at ocadmsk.com
6 thoughts on “79F chronic worsening hip pain, XR and prior CT. Please help.”
hilary.umans
I found this most helpful, from Rob Lambert:
Age 79 – severe disease, but age 65 there is only mild disease.
Severe progression of inflammatory sacroiliitis after age 50 is very
unusual. Of course you can have severe disease, but the progression is
usually worst between age 20-60.
However, over age 60 other things may start to affect the SIJ including
crystalline arthropathies such as CPPD and gout.
In a biomechanically unstable pelvis, severe degenerative arthropathy is
possible too.
So my differential Dx is:
1. CPPD
2. Erosive OA – primary
3. Erosive OA – secondary – to mechanically unstable pelvis
4. Erosive OA – secondary – to previous mild inflammatory sacroiliitis
5. Gout
I think it is very unlikely to be:
6. Hyperparathyroidism
7. Inflammatory sacroiliitis (without OA)
8. Amyloid
[gallery]
hilary.umans
Sharing Don Resnick’s comments, and an article he attached:
Rob’s comments, as always, are great. I agree with some of his differential
diagnostic considerations, although my order may have been a bit different.
Almost all of the cases of chronic renal disease with
hyperparathyroid-induced subchondral erosions about the sacroiliac joints
had evidence of significant similar abnormalities about the symphysis
pubis and other changes of hyperparathyroid bone disease, so I agree that
hyperparathyroidism is an unlikely cause of the SI changes in your elderly
woman.
CPPD disease is an interesting choice. I am attaching a paper by Bill
Martel, a study to which I often refer when dealing with CPPD disease of
the axial skeleton. I remember his emphasis on the presence of vacuum
phenomena in the abnormal sacroiliac joints of the patients he describes in
this article. I have seen many examples of changes in the sacroiliac joints
in persons with this disease, although I personally have not encountered
bone erosions / sclerosis as severe as the cases in his article or in your
patient, but I gather it is possible. Also, in all of the cases that I have
encountered with significant SI joint changes in CPPD disease, there was
chondrocalcinosis in the symphysis pubis and about the hips (such as the
labrum), although the resolution of your submitted images prevents me from
checking there. Finally, as CPPD crystal deposition is so common in elderly
persons, often asymptomatic, the discovery of such crystals on radiographs
does not always indicate it is the cause of accompanying structural joint
changes in the sacroiliac joint or elsewhere.
Unfortunately the L spine images don’t include the pubic
symphysis….resolution is awful, but here’s the Cor Scout. The symphysis
looks wide and maybe eroded (was normal in 2008)…but on this lousy image
I can’t see chondrocalcinosis, for what it’s worth.
[image: image.png]
[gallery]
hilary.umans
The conversation re CPPD of the SIJ continued and I wanted to share the
additional comments and beautiful images contributed by Jean-Denis Laredo,
who is our newest OCADer (wecome!)
See the images attached….they are strikingly similar to the images of the
initial case I posted….
Based on these additional images Jean-Denis shared, Don Resnick commented:
Over the years, we must have sectioned joints from over 1000 cadavers. Lots
of CPPD in so many joints, including cartilage and ligaments of SI joints.
But rarely did we encounter such bad structural disease in the SI joints.
It was the Martel article on CPPD disease that opened my eyes to more
severe sacroiliac joint abnormalities.
Rob Lambert replied:
Well I do think it is quite rare. However, with the internet, we are now
seeing rare conditions a little more often.
If manifestations of disease only occur in 1:1,000,000 of the population,
then there would be 300 in the USA and 40 in Canada and eventually someone
will see an example and send it around.
It seems the main DDx of the original case remains CPPD vs Erosive OA.
The similarity to the attached case is compelling and suggests that we
should favor CPPD….but understanding just how rare it is (as per Rob) I
think Erosive OA probably remains in the differential.
That said, I can’t recall reporting Erosive OA of the SI Joints. How rare
is that????
Rob? Jean-Denis? Don? Anyone?????
Hilary
[gallery]
ocad-msk
Hi,
I confirm such erosive CPPD SIJ arthritis is very uncommon.
We have seen only two such cases over the two last decades.
Concerning the differential diagnosis, chondrocalcinosis is diffuse over the whole spine, in IV disks, posterior arches and ligaments. In both cases, disk disease mimicking spine infection with fluid-like SI and gadolinium enhancement was also present at one or two levels. Biopsy was performed to rule out infection
For Hilary : Yes, I have cases of (very) erosive degenerative disease of the SIJ. Instability of the pelvic girdle involving at least one SIJ and the pubic symphysis is usually present in such cases
The conversation re CPPD of the SIJ continued and I wanted to share the additional comments and beautiful images contributed by Jean-Denis Laredo, who is our newest OCADer (wecome!)
See the images attached….they are strikingly similar to the images of the initial case I posted….
Based on these additional images Jean-Denis shared, Don Resnick commented:
Over the years, we must have sectioned joints from over 1000 cadavers. Lots of CPPD in so many joints, including cartilage and ligaments of SI joints. But rarely did we encounter such bad structural disease in the SI joints. It was the Martel article on CPPD disease that opened my eyes to more severe sacroiliac joint abnormalities.
Rob Lambert replied:
Well I do think it is quite rare. However, with the internet, we are now seeing rare conditions a little more often.
If manifestations of disease only occur in 1:1,000,000 of the population, then there would be 300 in the USA and 40 in Canada and eventually someone will see an example and send it around.
It seems the main DDx of the original case remains CPPD vs Erosive OA.
The similarity to the attached case is compelling and suggests that we should favor CPPD….but understanding just how rare it is (as per Rob) I think Erosive OA probably remains in the differential.
That said, I can’t recall reporting Erosive OA of the SI Joints. How rare is that????
Rob? Jean-Denis? Don? Anyone?????
Hilary
Sharing Don Resnick’s comments, and an article he attached:
Rob’s comments, as always, are great. I agree with some of his differential diagnostic considerations, although my order may have been a bit different.
Almost all of the cases of chronic renal disease with hyperparathyroid-induced subchondral erosions about the sacroiliac joints had evidence of significant similar abnormalities about the symphysis pubis and other changes of hyperparathyroid bone disease, so I agree that hyperparathyroidism is an unlikely cause of the SI changes in your elderly woman.
CPPD disease is an interesting choice. I am attaching a paper by Bill Martel, a study to which I often refer when dealing with CPPD disease of the axial skeleton. I remember his emphasis on the presence of vacuum phenomena in the abnormal sacroiliac joints of the patients he describes in this article. I have seen many examples of changes in the sacroiliac joints in persons with this disease, although I personally have not encountered bone erosions / sclerosis as severe as the cases in his article or in your patient, but I gather it is possible. Also, in all of the cases that I have encountered with significant SI joint changes in CPPD disease, there was chondrocalcinosis in the symphysis pubis and about the hips (such as the labrum), although the resolution of your submitted images prevents me from checking there. Finally, as CPPD crystal deposition is so common in elderly persons, often asymptomatic, the discovery of such crystals on radiographs does not always indicate it is the cause of accompanying structural joint changes in the sacroiliac joint or elsewhere.
Todays pelvis and hip XR was notable for the severe bilateral SIJ erosions. The left hip (lateral view not included) is mildly narrowed with small osteophytes.
[XR pelvis now.JPG]
I found an old AP pelvis XR from 2008 which shows milder erosions on the right side (not reported) and normal hips
[XR pelvis 2008.JPG]
She has scoliosis and severe multilevel DDD and facet arthrosis.
Lumbar CT from March 2022 (alas, no mention of the SIJs in the report)
[CT Cor.JPG]
[CT ax1.JPG]
[CT ax2.JPG]
This confuses me. There is degenerative vacuum…not what I expect in inflammatory sacroiliitis, but I have not seen such dramatic erosions in SIJ DJD. Is this Erosive OA? Does that happen in the SIJs?
Calling on you arthritis mavens….please help.
Hilary
PS In the unlikely event that you missed the recent Case Session on MSK Intervention, IT WAS AMAZING…here is the link to the video on our website ocadmsk.com/videos/
PPS In the unlikely event that you have not yet registered for our website, maybe do that at ocadmsk.com<ocadmsk.com>
[gallery]
kghermann
Dear Hilary, Jean-Denis, and Don, dear OCADers,
I must admit that I spontaneously thought of joint changes in secondary
hyperparathyroidism in the sacroiliac joint, which Hilary had posted. After
all, that would be much more common than erosive CPPD.
We have collected some cases with blatant SIJ changes in the context of
secondary hyperparathyroidism, of which I attach two.
Further, I attach for information a publication from our group where we had
recently looked for erosive changes on CT in patients with renal disease
but without back pain. Erosions were more common in HPT.
OCAD is a great group for discussion, I really enjoy the postings. Thank
you Hilary and Philip for the administration!
Age 79 – severe disease, but age 65 there is only mild disease.
Severe progression of inflammatory sacroiliitis after age 50 is very
unusual. Of course you can have severe disease, but the progression is
usually worst between age 20-60.
However, over age 60 other things may start to affect the SIJ including
crystalline arthropathies such as CPPD and gout.
In a biomechanically unstable pelvis, severe degenerative arthropathy is
possible too.
So my differential Dx is:
1. CPPD
2. Erosive OA – primary
3. Erosive OA – secondary – to mechanically unstable pelvis
4. Erosive OA – secondary – to previous mild inflammatory sacroiliitis
5. Gout
I think it is very unlikely to be:
6. Hyperparathyroidism
7. Inflammatory sacroiliitis (without OA)
8. Amyloid
[gallery]
Rob’s comments, as always, are great. I agree with some of his differential
diagnostic considerations, although my order may have been a bit different.
Almost all of the cases of chronic renal disease with
hyperparathyroid-induced subchondral erosions about the sacroiliac joints
had evidence of significant similar abnormalities about the symphysis
pubis and other changes of hyperparathyroid bone disease, so I agree that
hyperparathyroidism is an unlikely cause of the SI changes in your elderly
woman.
CPPD disease is an interesting choice. I am attaching a paper by Bill
Martel, a study to which I often refer when dealing with CPPD disease of
the axial skeleton. I remember his emphasis on the presence of vacuum
phenomena in the abnormal sacroiliac joints of the patients he describes in
this article. I have seen many examples of changes in the sacroiliac joints
in persons with this disease, although I personally have not encountered
bone erosions / sclerosis as severe as the cases in his article or in your
patient, but I gather it is possible. Also, in all of the cases that I have
encountered with significant SI joint changes in CPPD disease, there was
chondrocalcinosis in the symphysis pubis and about the hips (such as the
labrum), although the resolution of your submitted images prevents me from
checking there. Finally, as CPPD crystal deposition is so common in elderly
persons, often asymptomatic, the discovery of such crystals on radiographs
does not always indicate it is the cause of accompanying structural joint
changes in the sacroiliac joint or elsewhere.
[gallery]
symphysis….resolution is awful, but here’s the Cor Scout. The symphysis
looks wide and maybe eroded (was normal in 2008)…but on this lousy image
I can’t see chondrocalcinosis, for what it’s worth.
[image: image.png]
[gallery]
additional comments and beautiful images contributed by Jean-Denis Laredo,
who is our newest OCADer (wecome!)
See the images attached….they are strikingly similar to the images of the
initial case I posted….
Based on these additional images Jean-Denis shared, Don Resnick commented:
Over the years, we must have sectioned joints from over 1000 cadavers. Lots
of CPPD in so many joints, including cartilage and ligaments of SI joints.
But rarely did we encounter such bad structural disease in the SI joints.
It was the Martel article on CPPD disease that opened my eyes to more
severe sacroiliac joint abnormalities.
Rob Lambert replied:
Well I do think it is quite rare. However, with the internet, we are now
seeing rare conditions a little more often.
If manifestations of disease only occur in 1:1,000,000 of the population,
then there would be 300 in the USA and 40 in Canada and eventually someone
will see an example and send it around.
It seems the main DDx of the original case remains CPPD vs Erosive OA.
The similarity to the attached case is compelling and suggests that we
should favor CPPD….but understanding just how rare it is (as per Rob) I
think Erosive OA probably remains in the differential.
That said, I can’t recall reporting Erosive OA of the SI Joints. How rare
is that????
Rob? Jean-Denis? Don? Anyone?????
Hilary
[gallery]
I confirm such erosive CPPD SIJ arthritis is very uncommon.
We have seen only two such cases over the two last decades.
Concerning the differential diagnosis, chondrocalcinosis is diffuse over the whole spine, in IV disks, posterior arches and ligaments. In both cases, disk disease mimicking spine infection with fluid-like SI and gadolinium enhancement was also present at one or two levels. Biopsy was performed to rule out infection
For Hilary : Yes, I have cases of (very) erosive degenerative disease of the SIJ. Instability of the pelvic girdle involving at least one SIJ and the pubic symphysis is usually present in such cases
Wishes
Jean-Denis
________________________________
De : ocad-msk@googlegroups.com <ocad-msk@googlegroups.com> de la part de hilary umans <hilary.umans@gmail.com>
Envoyé : lundi 12 septembre 2022 15:42:01
À : ocad-msk@googlegroups.com
Objet : Re: 79F chronic worsening hip pain, XR and prior CT. Please help.
The conversation re CPPD of the SIJ continued and I wanted to share the additional comments and beautiful images contributed by Jean-Denis Laredo, who is our newest OCADer (wecome!)
See the images attached….they are strikingly similar to the images of the initial case I posted….
Based on these additional images Jean-Denis shared, Don Resnick commented:
Over the years, we must have sectioned joints from over 1000 cadavers. Lots of CPPD in so many joints, including cartilage and ligaments of SI joints. But rarely did we encounter such bad structural disease in the SI joints. It was the Martel article on CPPD disease that opened my eyes to more severe sacroiliac joint abnormalities.
Rob Lambert replied:
Well I do think it is quite rare. However, with the internet, we are now seeing rare conditions a little more often.
If manifestations of disease only occur in 1:1,000,000 of the population, then there would be 300 in the USA and 40 in Canada and eventually someone will see an example and send it around.
It seems the main DDx of the original case remains CPPD vs Erosive OA.
The similarity to the attached case is compelling and suggests that we should favor CPPD….but understanding just how rare it is (as per Rob) I think Erosive OA probably remains in the differential.
That said, I can’t recall reporting Erosive OA of the SI Joints. How rare is that????
Rob? Jean-Denis? Don? Anyone?????
Hilary
Sharing Don Resnick’s comments, and an article he attached:
Rob’s comments, as always, are great. I agree with some of his differential diagnostic considerations, although my order may have been a bit different.
Almost all of the cases of chronic renal disease with hyperparathyroid-induced subchondral erosions about the sacroiliac joints had evidence of significant similar abnormalities about the symphysis pubis and other changes of hyperparathyroid bone disease, so I agree that hyperparathyroidism is an unlikely cause of the SI changes in your elderly woman.
CPPD disease is an interesting choice. I am attaching a paper by Bill Martel, a study to which I often refer when dealing with CPPD disease of the axial skeleton. I remember his emphasis on the presence of vacuum phenomena in the abnormal sacroiliac joints of the patients he describes in this article. I have seen many examples of changes in the sacroiliac joints in persons with this disease, although I personally have not encountered bone erosions / sclerosis as severe as the cases in his article or in your patient, but I gather it is possible. Also, in all of the cases that I have encountered with significant SI joint changes in CPPD disease, there was chondrocalcinosis in the symphysis pubis and about the hips (such as the labrum), although the resolution of your submitted images prevents me from checking there. Finally, as CPPD crystal deposition is so common in elderly persons, often asymptomatic, the discovery of such crystals on radiographs does not always indicate it is the cause of accompanying structural joint changes in the sacroiliac joint or elsewhere.
Todays pelvis and hip XR was notable for the severe bilateral SIJ erosions. The left hip (lateral view not included) is mildly narrowed with small osteophytes.
[XR pelvis now.JPG]
I found an old AP pelvis XR from 2008 which shows milder erosions on the right side (not reported) and normal hips
[XR pelvis 2008.JPG]
She has scoliosis and severe multilevel DDD and facet arthrosis.
Lumbar CT from March 2022 (alas, no mention of the SIJs in the report)
[CT Cor.JPG]
[CT ax1.JPG]
[CT ax2.JPG]
This confuses me. There is degenerative vacuum…not what I expect in inflammatory sacroiliitis, but I have not seen such dramatic erosions in SIJ DJD. Is this Erosive OA? Does that happen in the SIJs?
Calling on you arthritis mavens….please help.
Hilary
PS In the unlikely event that you missed the recent Case Session on MSK Intervention, IT WAS AMAZING…here is the link to the video on our website ocadmsk.com/videos/
PPS In the unlikely event that you have not yet registered for our website, maybe do that at ocadmsk.com<ocadmsk.com>
[gallery]
I must admit that I spontaneously thought of joint changes in secondary
hyperparathyroidism in the sacroiliac joint, which Hilary had posted. After
all, that would be much more common than erosive CPPD.
We have collected some cases with blatant SIJ changes in the context of
secondary hyperparathyroidism, of which I attach two.
Further, I attach for information a publication from our group where we had
recently looked for erosive changes on CT in patients with renal disease
but without back pain. Erosions were more common in HPT.
OCAD is a great group for discussion, I really enjoy the postings. Thank
you Hilary and Philip for the administration!
Cheers,
Kay.
[gallery]