9 Neurogenic and Metabolic Bone Diseases
Neurogenic Osteoarthropathy
Definition
Severe destructive atrophic/hypertrophic arthropathy
Pathology
Increased osteoclastic resorption due to increased blood flow to the subchondral region, caused by neurogenic dysfunction
Causes
Frequent:
– Syringomyelia
Rare:
– Spinal trauma
– Diabetes mellitus
– Tabes dorsalis
– Amyloidosis
– Disseminated encephalitis
– Myelomeningocele
– Alcoholism
– Intra-articular corticosteroid injection
Clinical Findings
Depends on underlying condition
Joint swelling (with or without pain)
Joint hypermobility (instability)
Diagnostic Evaluation
(→ Method of choice)(Fig. 9.1)
Recommended views
Anteroposterior (AP)
Axial
Findings
Increased sclerosis
Effusion
Fragmentation
Joint destruction
Dislocation/subluxation
No juxta-articular osteoporosis
(→ Supplementary method)
Indications
In the early stage, detection of effusion (not diagnostic)
(→ Supplementary method)
Evaluation of underlying disease (e.g., syringomyelia, myelomeningocele)
Differential diagnosis:
– Atrophic type: septic joint
– Hypertrophic type: massive osteoarthritis
Goals of Imaging
Seventy of joint destruction
Differentiation from other diseases (causes)
Extra-articular manifestations?
Fig. 9.1 
Neurogenic osteoarthropathy (Charcot joint)
Massive deformity of the joint-forming bones with numerous osteochondral fragments (advanced stage of the disease).
Therapeutic Principles
Therapy of underlying condition
Fig. 9.2 
CPPD crystal arthropathy
A | Chondrocalcinosis with punctate superficial calcifications of the articular cartilage and small calcifications in the disk of the AC joint. |
B | Delicate stripe-like calcifications in the joint capsule and/or supraspinatus tendon and/or subacromial/subdeltoid bursa. |
Fig. 9.3 
CPPD crystal arthropathy, conventional radiograph
A Delicate linear calcification at the insertion of the supraspinatus tendon.
Calcium Pyrophosphate Dihydrate Crystal Arthropathy
Definition
A joint disease caused by calcium pyrophosphate dihydrate (CPPD) crystal deposition, usually multiarticular and symmetrical
Occurs in middle and old age, no gender preference
Pathology
Numerous, also larger cystic lesions
Severe progressive bone destruction
No erosions
CPPD deposition in:
– Cartilage (chondrocalcinosis)
– Synovia and synovial fluid
– Joint capsule
– Tendons, primarily the supraspinatus tendon
– Subacromial/subdeltoid bursa
– Ligaments
Clinical Findings
Ranging from asymptomatic to symptoms of acute arthritis or chronic progressive arthritis with acute pain attacks
Diagnostic Evaluation
(→ Method of choice)
Recommended views
AP
Axial
High-resolution film
Punctate calcifications in hyaline cartilage and/or in the disk of the acromioclavicular (AC) joint in chondrocalcinosis
Linear calcifications in joint capsule, supraspinatus tendon, and subacromial bursa
In pyrophosphate arthropathy, numerous, also larger cysts to severe destructive arthropathy, with or without chondrocalcinosis and soft-tissue calcifications
(→ Supplementary method)
Findings
Localization of calcifications in the supraspinatus tendon or bursa
Determination of tendon degeneration or tear
Bursal fluid
(→ Supplementary method) (Fig. 9.4a, b)
Indications
Documenting the extent of the synovitis and the therapeutic response
Visualization of the extent of cartilage and bone destruction
Recommended sections
Paracoronal
Parasagittal
Axial
Recommended sequences
T1-weighted spin-echo (SE)
Short time inversion recovery (STIR)
Intravenous injection of Gd-DTPA
Findings
Synovial thickening with strong enhancement on T1 weighting after administration of Gd-DTPA
Hyperintense effusion in bursa and joint on STIR sequence
Calcifications signal void on all sequences
Degenerative changes in the supraspinatus tendon hyperintense on all sequences
Defects in hyaline articular cartilage
Subchondral cysts hypointense on T1 weighting and hyperintense on STIR sequence
Goals of Imaging
Localization of calcifications
Detection of cystic and destructive bone changes
Therapeutic Principles
Conservative
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Colchicine
Intra-articular corticosteroids
Surgical
Arthroplasty in severe destructive arthropathy
Fig. 9.4 a 
CPPD crystal arthropathy, paracoronal section, T1-weighted SE sequence
A | Supraspinatus tendon showing altered signal with hyperintense areas and thickening at the insertion. |
B | On the bursa-facing surface of the supraspinatus tendon, a small signal-void area consistent with a calcification. |
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