Pelvo-Spondylitis in Rheumatoid Arthritis

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Abstract
Attention has recently been focused on the clinical differences between rheumatoid arthritis and ankylosing spondylitis and the justification for considering these as related diseases has been seriously questioned (1, 2). Cervical spondylitis frequently occurs in adults with classical rheumatoid arthritis, and the sacroiliac joints may be affected as well (3, 4). Erosions of the ischial tuberosities (4) and symphysis pubis have also been noted in some of these patients. It seemed pertinent, therefore, to determine whether such lesions are common in rheumatoid arthritis and whether they bear any resemblance to the lesions of ankylosing spondylitis. Anatomy The sacroiliac joints are true diarthroses (5–7). They possess a hyaline articular cartilage (which is two to three times thicker on the sacral than on the iliac surface), a joint cleft, synovial membrane, and fibrous capsule. Normally they have slight motion, but osteoarthritic changes are frequent as early as the fourth decade, and a resultant immobility is therefore common, especially in males; it is for this reason that these joints are sometimes spoken of as amphiarthroses. Such osteoarthritic fusion tends to be superficial and is easily differentiated pathologically from the solid intra-articular bony union of ankylosing spondylitis (7). Accurate radiologic evaluation of these joints is difficult because of their variable and peculiar morphology (8). Their articular surfaces are crescentic or ear-shaped in outline and often present reciprocal, interlocking depressions and ridges. The sacral surface is slightly convex, while the iliac side is concave. The direction of the articular cleft can vary considerably within the joint but is roughly oblique, from front to back, so that in the anteroposterior view the anterior margin is usually projected lateral to the posterior contour. The extent of the articular surface is shown in Figure 1. Accessory sacroiliac joints have also been described (9). In a symphysis the two opposed bony surfaces are coated with hyaline cartilage, united with fibrocartilage, and reinforced by ligamentous bands. There is no joint cavity, but a small cleft may be seen. Examples are found in the symphysis pubis, the joints between vertebral bodies, and the sternomanubrial joint (10), although the last named is often regarded as a synchondrosis because replacement of cartilage by bone frequently occurs late in life. It is of interest, in connection with the ischial erosions in rheumatoid arthritis, that an inconstant synovial bursa may be seen adjacent to the ischial tuberosity and the latter serves as an attachment for the sacrotuberous ligament and a number of tendons. Method of Study Frontal and lateral roentgenograms of the spine and frontal films of the pelvis were obtained from patients with rheumatoid arthritis and ankylosing spondylitis.

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