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DECEMBER 2020 | The Surgical Technologist | 553 Imaging Radiography (X-Ray) The radiographic hallmarks of RA in the thoracolumbar spine include erosion and fusion of apophyseal and facet joints along with erosions of spinous processes. 36,37 General radiological lumbar lesions were not more prevalent among RA patients compared with population controls, though vertebral fractures were more frequent in RA patients. 38 Disc space narrowing and severity of endplate erosion were correlated with higher RA severity scores (Larsen grades). 4,38 Larsen grade of the wrist was also found to be higher in patients with lumbar facet ero- sion, compared to patients without these lesions. 4 This is likely because facet joints are synovial joints consisting of fibrocar- tilage that are very similar to peripheral joints and as such undergo similar inflammatory reactions resulting from RA. 39 Abnormal radiologic findings in the lumbar spine have been reported in 57 % of patients with RA. In particular, the most frequent radiographic findings (Figure 2) are disc space nar- rowing (37 % ), scoliosis (28 % ), spondylolisthesis/retrolisthesis (23 % ), endplate erosion (20 % ), facet erosion (20 % ), and osteo- phyte formation (5 % ). 4 In another study, 21 % of RA patients had vertebral fractures, and the vertebral fractures increased to 33 % in patients treated with corticosteroids. 33 These findings are generally consistent with other existing literature. 40,41 In assessing for evidence of spondylolisthesis in patients with RA, Sugimura et al 42 found 36.7 % of patients with RA had radio- graphic evidence of lumbar spondylolisthesis, with significant associations with higher serum CRP levels and history of joint surgery. Of note, Lee et al 43 described significant relationships between certain sagittal parameters and clinical outcomes in patients with RA. The study included 120 RA patients and 60 controls, and found that the C7/sacrofemoral distance ratio (C7/SFD) significantly predicted the visual analogue scale (VAS) for back pain ( P ¼ .005), and the spinosacral angle (SSA) significantly predicted the Korean Oswestry Disability Index (KODI) and Scoliosis Research Society scores ( P ¼ .038 and P ¼ .044, respectively) in RA patients. 43 The authors also reported that the mean C7/SFD ratio was more positive and the SSA lower in RA patients than in matched controls, speculating that spinal misalignment and pelvic abnormalities are closely related in RA. Magnetic Resonance Imaging (MRI) MRI is increasingly being used for RA research and in clinical practice because of its capability in detecting early inflamma- tory changes in bones and joints without exposing patients to ionizing radiation. This ability to identify the key pathological features of RA much earlier than would be seen on radiography is advantageous in earlier treatment of the disease, especially Figure 2. (A) Anteroposterior Lumbar radiograph demonstrating scoliosis with an apex at L2-L3. (B) Lateral radiograph demonstrating focal kyphosis and erosive endplate changes at L2-L3. Joo et al 769