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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6009_Библиотеки_им_академика_М_И_Перельмана.pdf
Spondylolysis
KEY FACTS
TERMINOLOGY
• Defects in pars interarticularis thought to result from
repetitive stress injury
○ Pars is junction of pedicle, lamina, and facet
IMAGING
• Most common at L5: 80-90%
• Discontinuity in neck of "Scotty dog" on oblique plain films
• Elongation of spinal canal at level of pars defects on axial
imaging
• Incomplete ring sign on axial imaging
TOP DIFFERENTIAL DIAGNOSES
• Acute traumatic fracture of posterior elements
Degenerative Diseases and Arthritides
• Facet arthropathy with marrow edema
• Septic facet with marrow edema
• Bone tumor with marrow edema
• Pedicle stress fracture
• Congenital defect with pars cleft
(Left) Coronal oblique
radiograph shows a thin
lucency in the right L5 pars
interarticularis with adjacent
bony sclerosis. (Right) Lateral
radiography shows a defect
and mild angulation in the L5
pars interarticularis . There
is disc height loss at L5-S1
with associated sclerotic
endplate changes.
PATHOLOGY
• Repeated microfractures of pars interarticularis lead to
fatigue fracture
CLINICAL ISSUES
• 6-8% in general population, 10-20 years old
• Symptoms of chronic low back pain
• Conservative measures in grade 1-2 spondylolisthesis
• Wide variety of practice patterns for treatment
○ Epidural or pars steroid injection
○ Surgical intervention
– Fail conservative treatment
– Have worsening slippage
○ No consensus on optimum surgical strategy
– Laminectomy/fusion
– Transforaminal lumbar interbody fusion/posterior
lumbar intervertebral fusion
– Anterior lumbar interbody fusion with posterior
instrumentation
220
(Left) Sagittal bone CT
reformation shows a chronicappearing L5 pars defect with
smooth corticated margins
without anterolisthesis ſt.
(Right) Sagittal T1WI MR
shows grade I anterolisthesis
of L5 on S1 with severe disc
degeneration and loss of disc
height. There is a widened
canal sign with increased
distance between the
posterior margin of L5 and the
spinous process ſt, indicating
bilateral spondylolysis. Note
the degenerative endplate
changes at L2-L3 and L3-L4.
Spondylolysis
IMAGING
General Features
• Best diagnostic clue
○ Bony defect or cortical discontinuity in pars
interarticularis (PI)
• Location
○ Most common at L5: 80-90%
○ L4 2nd most common
• Morphology
○ Horizontal orientation on axial imaging
Radiographic Findings
• Radiography
○ Radiolucent band in PI on oblique views of lumbar spine
(discontinuity in neck of "Scotty dog")
○ Oblique lucency at base of laminae on lateral view
○ Contralateral pedicle and lamina hypertrophy and
sclerosis
– Unilateral spondylolysis; best seen on frontal lumbar
spine
○ Variable degree of spondylolisthesis
○ Disc height loss at level below spondylolysis
○ Secondary degenerative sclerotic endplate changes and
spurring
CT Findings
• Bone CT
○ Incomplete ring sign on axial imaging
– Disruption of ring formed by vertebral body and arch
○ May simulate facet joints
– Extrafacet sign; horizontal vs. oblique orientation;
irregular vs. smooth bony cortex
○ Pars defects well seen on oblique reformation
○ Variable spondylolisthesis and foraminal narrowing on
sagittal reformation
– Disc space loss; degenerative endplate changes
○ Canal may be widened even without spondylolisthesis
MR Findings
• T1WI
○ Focally decreased signal in PI on sagittal and axial
imaging; similar appearance on T2WI
• T2WI
○ Hyperintensity may be present within pars defects and
adjacent marrow of pedicle
• STIR
○ Marrow edema adjacent to pars defects and pedicle
• Elongation of spinal canal
• MR sensitivity: 57-86%; MR specificity: 81-82%
Nonvascular Interventions
• Myelography
○ Neural foraminal narrowing with anterolisthesis and disc
height loss
Nuclear Medicine Findings
• Bone scan
○ Foci of increased radiotracer uptake in posterior
elements; suggests bone healing; SPECT is better but still
relatively high false-positives and false-negatives
Degenerative Diseases and Arthritides
Imaging Recommendations
• Best imaging tool
○ Axial thin-section CT with bone algorithm (sagittal and
oblique reformation)
DIFFERENTIAL DIAGNOSIS
Acute Traumatic Fracture of Posterior Elements
• History of acute trauma
Facet Arthropathy With Marrow Edema
• Hypertrophied facet and ligamentum flavum
Septic Facet With Marrow Edema
• Clinical findings of fever, elevated WBC, and sedimentation
rate
Bone Tumor With Marrow Edema
• Osteoid osteoma typical
• Metastatic disease
Pedicle Stress Fracture
• Stress reaction may show adjacent marrow edema
Congenital Defect With Pars Cleft
• Hypoplasia of spinal accessory process
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Commonly asymptomatic; chronic low back pain,
particularly in children and adolescents
○ Other symptoms: Back spasm; hamstring tightness;
radiculopathy and cauda equina syndrome; gait
disturbance
Treatment
• Conservative measures in patients with grade 1 and 2
spondylolisthesis
○ Antiinflammatory medications; epidural steroid injection;
brace/physical therapy
• Surgical intervention: Fail conservative treatment; have
worsening slippage; preserve neural function and prevent
instability
• Wide variety of practice patterns for treatment; 50% of
surgeons agreed on surgical treatment in 1 study
• No consensus on optimum surgical strategy
○ Laminectomy/fusion; transforaminal lumbar interbody
fusion/posterior lumbar intervertebral fusion; anterior
lumbar interbody fusion (ALIF) with posterior
instrumentation
DIAGNOSTIC CHECKLIST
Consider
• L5-S1 isthmic spondylolysis stand-alone ALIF failure has
been reported; unique axial load and shear stresses;
supplementary posterior fixation recommended
Image Interpretation Pearls
• Look for integrity of PI on sagittal MR
221
Adult Rheumatoid Arthritis
KEY FACTS
IMAGING
• Erosions of dens, uncovertebral joints, facet joints
• Atlantoaxial instability in 20-86% patients with rheumatoid
arthritis (RA)
• Atlantoaxial subluxation in 5% of cervical RA
• Cranial settling occurs in 5-8% of RA patients
• Lower cervical spine: Facet and uncovertebral joint
erosions, instability
• Neutral, flexion, and extension lateral radiographs
performed for evaluation of instability
○ Normal: 2 mm between inner margin anterior ring of C1
and dens
Degenerative Diseases and Arthritides
○ High correlation to neurologic symptoms with distance ≥
9 mm
• Pannus is mass-like and surrounds and erodes dens, facet
joints, uncovertebral joints
○ Low signal on T1WI
○ Heterogeneous signal on T2WI, STIR
(Left) Axial and sagittal
graphics show erosion of dens
by hypertrophied synovial
tissue (pannus). The pannus
has eroded the transverse
ligament of the dens ,
resulting in instability. The
spinal cord is compressed.
(Right) Coronal CT
reconstruction illustrates
erosive changes at the right
C1-C2 joint and lateral
subluxation of C1 with respect
to C2 ſt. Inflammatory
synovial proliferation and
destruction of surrounding
bone also affect the
uncovertebral joints in the
subaxial spine st.
○ Enhances avidly with gadolinium
TOP DIFFERENTIAL DIAGNOSES
• Seronegative spondyloarthropathy
• Calcium pyrophosphate dihydrate deposition (CPPD)
disease
• Juvenile chronic arthritis
• Osteoarthritis
• Degenerative disc disease
CLINICAL ISSUES
• 50-60% of RA patients have involvement of cervical spine
• Never involves spine before hands &/or feet
• May develop radiculopathy, myelopathy
• Instability → significant morbidity, mortality
DIAGNOSTIC CHECKLIST
• Calcifying mass with odontoid erosions is notRA
○ Indicates crystalline arthropathy, usually CPPD
222
(Left) Lateral view from a
bone scan shows focal marked
uptake at the C1-C2 junction
in this patient with
rheumatoid arthritis (RA).
(Right) Sagittal NECT scan
shows upward translocation
of the odontoid ſt and
widened atlantodental
interval . The skull and C1
have remained together with
the ligamentous laxity and
disruption at C1-C2 (coupled
with the C1 lateral mass
collapse), allowing C2 to
migrate cephalad into the
foramen magnum with
brainstem compression (not
shown).
TERMINOLOGY
Abbreviations
• Rheumatoid arthritis (RA)
Adult Rheumatoid Arthritis
Degenerative Diseases and Arthritides
• May cause "pseudopannus" at dens
Gout
• Rare in spine
IMAGING
General Features
• Location
○ Cervical spine: ~ 50-60% of RA patients
– C1-odontoid articulations, occipital condyles, facets
Radiographic Findings
• Radiography
○ Erosions of dens, uncovertebral joints, and facet joints
○ Neutral, flexion, and extension lateral radiographs to
evaluate for instability
○ C1-C2 instability
– Normal: < 2 mm between anterior ring of C1 and dens
□ Neurologic symptoms present if distance ≥ 9 mm
– Atlantoaxial instability in 20-86% of patients
○ Basilar impression: Decreased distance occiput to C2
– Used synonymously with cranial settling
– Bony erosions of occipital condyles/C1 lateral masses
where cranium moves downward relative to dens
□ Dens may protrude through foramen magnum
○ Instability may also be present at lower levels of cervical
spine
CT Findings
• Bone CT
○ Odontoid erosions
○ Pannus around dens may be seen; never calcifies
MR Findings
• Pannus
○ Low signal intensity on T1WI
○ Contrast-enhanced T1WI MR may be able to discriminate
between joint effusion and various forms of pannus
• Subluxations may lead to spinal stenosis
○ Myelopathic changes are common
Imaging Recommendations
• Best imaging tool
○ Cervical spine radiographs in flexion/extension
○ Plain radiographs of hands &/or feet
○ Thin-section bone algorithm CT
○ MR imaging in patients with cord symptoms
DIFFERENTIAL DIAGNOSIS
Seronegative Spondyloarthropathy
• Corner erosions of anterior cortex vertebral bodies
Calcium Pyrophosphate Dihydrate Deposition
Disease
• Inflammatory mass around odontoid with calcification
Juvenile Idiopathic Arthritis
• Fusion of vertebral bodies, facet joints, erosions
Osteoarthritis
• Osteophytes and joint narrowing
PATHOLOGY
General Features
• Laboratory findings
○ ESR, C-reactive protein (CRP) elevated
○ Autoantibodies, such as rheumatoid factor (RF) and
anticitrullinated protein antibody (ACPA)
Staging, Grading, & Classification
• 2010 American College of Rheumatology/European League
Against Rheumatism criteria
○ Target population: Patients with at least 1 joint with
clinical synovitis not explained by other disease
○ Joint involvement
○ Serology
– Presence of RF, ACPA
○ Acute-phase reactants
– CRP, ESR
○ Duration of symptoms
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Morning pain and stiffness
○ Radiculopathy
Demographics
• Gender
○ 3x more common in women
Natural History & Prognosis
• Increased morbidity and mortality with CVJ instability
• Neurologic symptoms poor prognostic sign as mortality
rate increases dramatically
Treatment
• Medical treatment
○ Corticosteroids
○ Disease-modifying agents slow disease progression
– Tumor necrosis factor inhibitors, methotrexate (MTX),
cyclosporine
– Biological treatment, such as infliximab, for failure of
initial MTX treatment
• Surgical indications for atlantoaxial instability
○ Pain, myelopathy, cord compression, symptomatic
vertebral artery compromise
○ Atlantodental interval > 8-10 mm
○ C1-C2 transarticular surgical fusion for atlantoaxial
subluxation
• Surgical indications for basilar impression
○ Lower cranial neuropathy (C9-C12)
○ Myelopathy, pain, symptomatic vertebral artery
compromise, deformity
○ Severe compression of cervicomedullary junction
• Transoral odontoidectomy for cord compression
223
(Left) Sagittal CT
demonstrates superior
migration of the dens ſt.
Cranial settling may lead to
compression of the brainstem
by the dens with compression
of the autonomic centers with
labile blood pressures,
arrhythmias, or sudden death.
(Right) Sagittal NECT shows
cranial settling with upward
translocation of the odontoid
process ſt relative to the
foramen magnum. There are
also odontoid erosions st and
Degenerative Diseases and Arthritides
increased atlantodental
interval .
(Left) Sagittal CT
reconstruction exhibits
erosions along the posterior
margin of the dens ſt and
widening of the anterior
atlantodental interval (AADI)
st. (Right) Sagittal T1WI MR
depicts widening of the AADI
ſt related to the
inflammatory pannus and
erosive changes of the
posterior dens st, consistent
with known RA.
Adult Rheumatoid Arthritis
224
(Left) Sagittal NECT (bone
window) shows extensive
erosive changes of the
anterior arch of C1 ſt and
odontoid process . The
odontoid is malpositioned and
touching the clivus. (Right)
Sagittal T1WI MR shows a
large amount of the pannus
both ventral and dorsal to the
odontoid ſt with effacement
of the thecal sac and posterior
displacement of cord st.
Adult Rheumatoid Arthritis
Degenerative Diseases and Arthritides
(Left) Sagittal radiograph in
the flexed position illustrates
marked widening of the AADI
ſt. Inflammatory destruction
via synovitis of the atlantal
transverse ligament leads to
anteroposterior instability of
the atlantoaxial joint. (Right)
Sagittal radiograph in the
same patient shows a
decrease in the AADI with the
neck extended. However,
posterior atlantodental
interval (PADI) has been
shown to be a more reliable
predictor of whether
neurologic symptoms will
develop. MR is recommended
when PADI is ≤ 14 mm.
(Left) Sagittal CT
demonstrates marked erosive
change of the dens st. Erosion
of the odontoid process
frequently coincides with the
development of anterior
atlantoaxial subluxation.
Widening of the AADI is also
noted ſt. There is narrowing
of the PADI and the space
for the cord is markedly
narrowed. (Right) Axial NECT
displays abnormal soft tissue
widening the predental space
. There are erosive changes
along the margin of the dens
. The pannus is the main
cause of bone destruction.
(Left) Initial MR shows rapid
development cranial settling &
severe inflammatory response
surrounding C1-C2 articulation
with a ventral and dorsal soft
tissue mass ſt but a relatively
preserved relationship of C2
with the foramen magnum.
Large disc extrusion is seen at
C5 . (Right) Follow-up MR 6
months later (a further
example of rapid development
cranial settling) shows rapid
progression of cranial settling
with upward translocation of
the odontoid process through
the foramen magnum with
severe cervicomedullary cord
compression ſt.
225
Juvenile Idiopathic Arthritis
KEY FACTS
TERMINOLOGY
• Spectrum of idiopathic inflammatory arthropathies
occurring in childhood
IMAGING
• Cervical spine subluxations, fusions, and growth
disturbance
• Bony overgrowth due to hyperemia may also be seen
• Cranial settling and basilar invagination are common
• Involves discs, facets, and uncovertebral, costovertebral
and costotransverse joints
• Progresses to ankylosis
○ Fused vertebrae are small in anteroposterior dimension
Degenerative Diseases and Arthritides
if fused early in childhood
• Pannus on MR: Rounded, periarticular mass
○ ↓ signal on T1WI; intermediate, heterogeneous signal on
T2WI, STIR
• Synovitis: Effusions in facets and sacroiliac joints
(Left) Lateral radiograph
shows fusion of the posterior
elements and vertebral bodies
from C2-C6 ſt. Fusion
occurred at a young age and
the vertebral bodies across the
fused section ceased to grow,
resulting in small body size in
the fused portion . (Right)
Sagittal NECT of the cervical
spine shows multiple fused
vertebral bodies ſt that also
involve the posterior elements
. The fusion extends to the
craniocervical junction st.
There is severe disc
degeneration below the fusion
site .
TOP DIFFERENTIAL DIAGNOSES
• Congenital spinal fusion
• Physiologic cervical spine subluxations
• Down syndrome
• Osteogenesis imperfecta
• C1-C2 osteomyelitis
PATHOLOGY
• Rheumatoid factor is negative
CLINICAL ISSUES
• Vague, pauciarticular pain
• Limited neck movement
DIAGNOSTIC CHECKLIST
• Diagnosis is often delayed due to subtle imaging findings
and nonspecific symptoms
• Sacroiliac joints normally wide in children; diagnose juvenile
ankylosing spondylitis only if inflammatory changes seen
226
(Left) Coronal CT shows
erosions along the dens ſt,
C1-C2 facet joint st, and C3C4 uncovertebral joint .
Joint space narrowing and
growth disturbances are key
radiologic manifestations of
juvenile idiopathic arthritis.
(Right) Sagittal CT shows
superior migration of the dens
into the foramen magnum st.
Erosive changes of the dens,
clivus ſt, and subaxial facet
joints are seen.
Neurogenic (Charcot) Arthropathy
KEY FACTS
Degenerative Diseases and Arthritides
TERMINOLOGY
• Destructive arthropathy occurring when pain and
proprioception are impaired while joint mobility is
maintained
IMAGING
• Almost always in lumbar spine
• Vertebral endplate destruction
• Facet joint destructive arthropathy
• Preserved bone density
• Nonunited fractures
• Bony debris around vertebrae
• Vertebral subluxations
• Soft tissue mass, which may be large
• Heterogeneous enhancement
○ Both of affected vertebrae and soft tissue mass
TOP DIFFERENTIAL DIAGNOSES
• Pyogenic infection
• Atypical infection: Tuberculosis, fungi
• Soft tissue sarcoma
• Bone tumor
• Degenerative disc disease with instability
CLINICAL ISSUES
• Instability of spine
• Spine deformity
• Treated with rigid internal fixation and fusion of affected
spinal levels
• Treatment
○ Rigid internal fixation and fusion of affected spinal level
○ Can also be treated with bracing but success limited
DIAGNOSTIC CHECKLIST
• Distinction between neuropathic joint and infection is 1 of
most difficult problems radiographically
• Only 2 processes can destroy joint in 1 month: Infection and
neurogenic arthropathy
(Left) Sagittal graphic shows
arthropathy centered at 3
adjacent discs with endplate
erosions, bony debris, and
deformity. (Right) Sagittal
NECT shows a Charcot joint
with pseudoarthrosis at L2-L3
ſt and remodeling of adjacent
vertebral bodies with
extensive hypertrophic bone
production about the posterior
elements st. Note the
posterior retrolisthesis of the
spinal canal at the L2-L3 level
. Note also the linear
calcification involving the dura
in the lower thoracic spine
from arachnoiditis .
(Left) Axial NECT shows the
typical massive bone
production associated with
neuropathic pseudoarthrosis.
(Right) Sagittal T1 C+ MR in a
paraplegic with cord
transection shows
heterogeneous enhancement
and destructive arthropathy at
L2-L3 with posterior
subluxation, with central fluidfilled areas ſt surrounded by
enhancing reparative tissues.
L3-L4 is affected to a lesser
extent. The striking soft tissue
abnormalities seen on MR of
Charcot arthropathy often
raise concern for infection or
sarcoma.
227
Hemodialysis Spondyloarthropathy
KEY FACTS
TERMINOLOGY
• Destructive spondyloarthropathy
• Discocentric destructive arthritis in patient on long-term
hemodialysis
IMAGING
• Vertebral and endplate destruction in patient on long-term
hemodialysis,± vertebral collapse
○ Cervical, thoracic, or lumbar spine
○ Often involves multiple levels
• Endplate destruction with sharply marginated erosions
• Amorphous material in disc, spinal canal, &/or prevertebral
soft tissues
Degenerative Diseases and Arthritides
○ Usually lower signal intensity than infection on T2WI,
STIR
TOP DIFFERENTIAL DIAGNOSES
• Infection
• Neuropathic joint
(Left) Coronal graphic shows 2
types of hemodialysis
arthropathy: Crystal
deposition ſt and amyloid
deposition , both of which
may cause endplate erosions.
(Right) Lateral radiograph
shows severe bone destruction
ſt centered at the C4-C5 disc
st with smaller, punched-out
erosions at C5-C6 and C6C7. This patient was on
hemodialysis and had chronic,
worsening neck pain and
findings consistent with cord
compression.
• Gout
• Calcium pyrophosphate deposition disease
PATHOLOGY
• 2 types of arthropathy associated with hemodialysis
○ Amyloid deposition: β-2 microglobulin
○ Crystal deposition: Hydroxyapatite
CLINICAL ISSUES
• Indolent
• May result in spinal instability
• Back pain, radiculopathy, cord compression
• Fusion for stabilization
DIAGNOSTIC CHECKLIST
• Specimen must be sent for crystal analysis in saline or
ethanol; formalin dissolves crystals
• History is key to making diagnosis
228
(Left) Sagittal T1WI MR shows
severe bone destruction
centered at the C4-C5 disc st
with smaller, punched-out
erosions at C5-C6 and C6C7. This patient was on
hemodialysis and had chronic,
worsening neck pain and
findings consistent with cord
compression. Soft tissue
posteriorly could represent
discs or crystal deposition.
(Right) Sagittal STIR MR of the
same patient shows severe
cord compression. Of note,
discs and masses remain very
low signal intensity, unlike
pyogenic infection.
Hemodialysis Spondyloarthropathy
TERMINOLOGY
Synonyms
• Destructive spondyloarthropathy (DSA)
Definitions
• Discocentric destructive arthritis in patient on long-term
hemodialysis
IMAGING
General Features
• Best diagnostic clue
○ Vertebral and endplate destruction in patient on long-
term hemodialysis,± vertebral collapse
• Location
○ Cervical, thoracic, or lumbar spine
○ Often involves multiple levels
Radiographic Findings
• Radiography
○ Endplate destruction
○ Soft tissue mass
– May contain amyloid
– May contain crystals with visible calcification
CT Findings
• Sharply marginated endplate erosions
• Soft tissue mass
○ ± calcifications
○ Vertebral body collapse
MR Findings
• Vertebral endplate destruction
• Abnormal signal intensity in vertebral bodies
○ High signal intensity on T2WI, STIR mimics infection
• Amorphous material in disc, spinal canal, &/or prevertebral
soft tissues
○ Usually lower signal intensity than infection on T2WI,
STIR
Nuclear Medicine Findings
• Bone scan
○ Positive 3-phase bone scan
Imaging Recommendations
• Best imaging tool
○ MR
○ Differentiation from active infection may require biopsy
DIFFERENTIAL DIAGNOSIS
Infection
• Endplate destruction, adjacent soft tissue abscess
• High signal intensity in disc on T2WI, STIR
• Calcifications absent
Neuropathic Joint
• Lumbar spine
• Bone debris, subluxations prominent
Gout
• Imaging appearance may be identical
Degenerative Diseases and Arthritides
Calcium Pyrophosphate Deposition Disease
• Disc, ligamentum flavum linear calcifications
• Endplate destruction, erosions
PATHOLOGY
General Features
• Etiology
○ 2 types of arthropathy associated with hemodialysis
– Amyloid deposition: β-2 microglobulin
□ Less common today due to advances in
hemodialysis
– Crystal deposition: Hydroxyapatite
• Associated abnormalities
○ Adynamic bone disease
– Absolute or partial parathyroid hormone deficit
associated with low or absent bone remodeling
– Patients often present with bone fractures and
collapse, myopathy
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Asymptomatic unless severe
○ Other signs/symptoms
– Back pain, radiculopathy, cord compression
Demographics
• Epidemiology
○ Uncommon, incidence increases with length of time on
dialysis
Natural History & Prognosis
• Indolent, may result in instability
Treatment
• Options, risks, complications
○ Fusion for stabilization
DIAGNOSTIC CHECKLIST
Consider
• Specimen must be sent for crystal analysis in saline or
ethanol; formalin dissolves crystals
Image Interpretation Pearls
• History is key to making diagnosis
SELECTED REFERENCES
1. Rizzo MA et al: Neurological complications of hemodialysis: state of the art. J
Nephrol. 25(2):170-82, 2012
2. Spinos P et al: Surgical management of cervical spondyloarthropathy in
hemodialysis patients. Open Orthop J. 4:39-43, 2010
3. Yamamoto S et al: Recent progress in understanding dialysis-related
amyloidosis. Bone. 45 Suppl 1:S39-42, 2009
4. Sarraf P et al: Non-crystalline and crystalline rheumatic disorders in chronic
kidney disease. Curr Rheumatol Rep. 10(3):235-48, 2008
5. Theodorou DJ et al: Imaging in dialysis spondyloarthropathy. Semin Dial.
15(4):290-6, 2002
6. Leone A et al: Destructive spondyloarthropathy of the cervical spine in long-
term hemodialyzed patients: a five-year clinical radiological prospective
study. Skeletal Radiol. 30(8):431-41, 2001
229