Detection Is Just the Beginning
One same-day whole-body radiographic survey (plus DXA), read two ways — a conventional report beside a RheumaView™ structured radiographic report at three rendering depths.
RV-005 · SP-MIX(CS·TS·LS·SI·PEL·HW·FA) · Single-Date · Mixed coverage · Radiograph + DXAWhy this is a representative case
This is a single-timepoint study with no prior imaging available for comparison, so longitudinal change cannot be assessed here. It is presented as a multi-region, mixed axial/peripheral survey with paired DXA — chosen to show how one dataset can be rendered at controlled depths rather than to demonstrate progression over time. See how case complexity scales below.
New patient — establishing care
New patient transferring from a previous rheumatologist to establish care; outside medical records are not available. Reported history of many years of arthritis, probably psoriatic, with fibromyalgia, and multiple years of treatment with various DMARDs including advanced therapy — never taken consistently (non-compliance, fear of side effects, perceived lack of efficacy). Both axial and peripheral pain. This context frames the imaging request; it does not alter the report text.
DIAGNOSTIC IMAGING — RADIOLOGY REPORT
Conventional radiographic interpretation
| Patient | De-identified |
| Sex / Age | Female · 68 years |
| Exam | Radiographs — cervical, thoracic, lumbar spine; pelvis (hips and sacroiliac joints); both hands, both wrists, both feet, both ankles |
| Date of service | 2026 |
| Indication | Long-standing inflammatory arthritis, query psoriatic. Multiple DMARDs over the years, never sustained. Axial and peripheral pain. Evaluate. |
| Comparison | None available. |
| Technique | Multiple radiographic projections as above, including AP/lateral and dedicated coned/oblique views where obtained. |
FINDINGS
Cervical spine: Straightening of the normal cervical lordosis. Multilevel degenerative change at the lower cervical levels with disc space narrowing and anterior osteophytes; uncovertebral and facet degenerative changes. The odontoid is intact and the atlantoaxial relationship is preserved on the views provided. No fracture or destructive bony lesion. Dental amalgam noted.
Thoracic spine: Vertebral body heights and alignment are maintained. Mild degenerative change with minor anterior endplate spurring. No acute compression deformity. Visualized lung fields are grossly unremarkable within the limits of a bone technique. Overlying external monitoring leads are noted.
Lumbar spine: Alignment is preserved without spondylolisthesis. Disc space narrowing with endplate spurring at the lower lumbar levels and facet arthrosis. No fracture or aggressive osseous lesion. Overlying bowel gas. Vascular calcification projected anteriorly.
Pelvis, hips and sacroiliac joints: The hip joint spaces are maintained bilaterally without significant degenerative change. No fracture or focal bony lesion. The pubic symphysis is unremarkable. The sacroiliac joints are partially obscured by overlying bowel gas; no definite erosion, sclerosis or ankylosis is appreciated on these projections, and evaluation is limited.
Both hands: Erosive and degenerative changes, most pronounced at the distal interphalangeal joints bilaterally, with joint space narrowing, subchondral irregularity, marginal osteophytes and small marginal erosions. Lesser involvement of the proximal interphalangeal joints. The metacarpophalangeal joints are relatively preserved. Periarticular osteopenia. No acute fracture. Soft tissues are unremarkable.
Both wrists: The carpal joint spaces are largely maintained. Minor degenerative change at the first carpometacarpal/scaphotrapezial region. No definite erosion or carpal collapse. No fracture.
Both feet: Forefoot degenerative changes, most marked at the first metatarsophalangeal joints bilaterally, with joint space narrowing and marginal irregularity; hallux valgus angulation. Changes also at the first interphalangeal joints. Minor changes at the lesser metatarsophalangeal joints. Periarticular osteopenia. No acute fracture.
Both ankles: The ankle mortises are preserved. No significant joint space narrowing. Small posterior and plantar calcaneal spurs. No fracture or aggressive lesion.
IMPRESSION
- Multilevel degenerative changes of the cervical, thoracic and lumbar spine, most pronounced in the lower lumbar region.
- Erosive and degenerative arthropathy of the hands, distal interphalangeal predominant, bilateral.
- Degenerative changes of the forefeet (first metatarsophalangeal predominant), with minor degenerative change of the wrists and minor degenerative/enthesophytic change of the ankles.
- No significant osseous abnormality of the hips. Sacroiliac joints incompletely evaluated on the available projections; no definite abnormality identified.
- Diffuse osteopenia. No acute fracture.
Electronically signed by the interpreting radiologist.
Patient: De-identified
DOB: xx/xx/1957
Age: 68 years
Sex: Female
Study date: 2026-xx-xx
Modality: Radiographs
Declared / Examined Regions: Cervical spine, thoracic spine, lumbar spine, sacroiliac joints/pelvis/hips, bilateral hands/wrists, bilateral feet/ankles.
Regions / projections obtained:
Cervical spine: AP, lateral, open-mouth odontoid, right
oblique, left oblique.
Thoracic spine: AP, lateral.
Lumbar spine: AP, lateral, right oblique, left oblique,
spot lateral lumbosacral view.
Sacroiliac joints / pelvis / hips: AP pelvis, AP
sacroiliac joints, bilateral oblique sacroiliac views, focused right hip
AP view, focused left hip AP views.
Right hand/wrist: PA, oblique, lateral, focused
PA/oblique wrist views.
Left hand/wrist: PA, oblique, lateral, focused
PA/oblique wrist views.
Right foot/ankle: AP/dorsoplantar foot, oblique foot,
lateral foot, frontal ankle view.
Left foot/ankle: AP/dorsoplantar foot, oblique foot,
lateral foot, frontal ankle view.
Shared / overlapping projection note: AP pelvic
projections contribute to both sacroiliac joint and hip
assessment.
Comparison: No comparison studies available.
Findings
Cervical spine
Mild straightening of cervical lordosis. Vertebral body heights are maintained. Mild disc space narrowing at C3-C4. Mild disc space narrowing with small endplate osteophytes at C4-C5. Moderate disc space narrowing with endplate osteophytes at C5-C6. Mild-to-moderate disc space narrowing with small endplate osteophytes at C6-C7. Mild multilevel uncovertebral and facet hypertrophic change in the mid/lower cervical spine with mild bilateral lower cervical osseous foraminal narrowing, greatest at approximately C5-C6/C6-C7. Atlantodental alignment is preserved. No odontoid erosion, atlantoaxial malalignment, syndesmophytes, bridging ankylosis, or other convincing inflammatory axial spondyloarthropathy pattern.
Thoracic spine
Mild thoracic dextrocurvature. Vertebral body heights are maintained without compression deformity. Mild multilevel mid thoracic and moderate lower thoracic degenerative disc/endplate spondylosis with disc space loss, endplate sclerosis, and osteophytic spurring. No definite anterior vertebral corner erosions, syndesmophytes, ankylosing bridge, or flowing ossification pattern meeting radiographic criteria for DISH.
Lumbar spine
Mild lumbar levocurvature. Vertebral body heights are maintained. Marked multilevel degenerative disc disease with vacuum phenomenon, endplate sclerosis, and osteophytic spurring, greatest from L2-L3 through L5-S1 and maximal at L4-L5. Mild low-grade multilevel degenerative listhesis/retrolisthesis. Lower lumbar facet arthropathy, greatest at L4-L5 and L5-S1. No pars defect identified on the provided oblique views. No convincing inflammatory corner erosions, syndesmophytes, ankylosing change, or vertebral compression fracture.
Sacroiliac joints
Mild bilateral inferior-predominant subchondral sclerosis and small degenerative irregularity/osteophytic change. Sacroiliac joint spaces remain visible bilaterally. No definite erosions, pseudowidening, partial ankylosis, or complete ankylosis. Pattern favors mild bilateral degenerative sacroiliac arthrosis rather than radiographic inflammatory sacroiliitis.
Pelvis / hips
Mild degenerative change of the pubic symphysis. Mild bilateral hip osteoarthritis with slight superolateral joint space narrowing and small acetabular/femoral head-neck osteophytic spurring. No erosive hip arthropathy, protrusio, or femoral head collapse. Small chronic-appearing calcific/enthesopathic focus adjacent to the left greater trochanter, compatible with chronic gluteal insertional enthesopathic/calcific tendinous change.
Right hand / wrist
Mild diffuse osteopenic appearance. Mild radiocarpal and distal radioulnar degenerative change. Mild-to-moderate first carpometacarpal osteoarthritis with mild adjacent triscaphe degenerative change. Mild degenerative change at the thumb MCP joint and moderate thumb IP osteoarthritis. Scattered interphalangeal arthropathy, greatest at the DIP joints. There is central erosive-remodeling change at the third DIP with gull-wing configuration. Additional milder degenerative narrowing/remodeling in other DIP joints and mild multifocal PIP osteoarthritis. MCP joints are relatively preserved without convincing inflammatory-type MCP joint space loss or marginal erosive MCP pattern. No pencil-in-cup deformity, acro-osteolysis, fluffy periostitis, or carpal collapse.
Left hand / wrist
Mild diffuse osteopenic appearance. Mild radiocarpal and distal radioulnar degenerative change. Mild-to-moderate first carpometacarpal osteoarthritis with mild adjacent triscaphe degenerative change. Mild degenerative change at the thumb MCP joint and moderate thumb IP osteoarthritis. Scattered interphalangeal arthropathy, greatest at the DIP joints. There are central erosive-remodeling changes at the second and third DIP joints with gull-wing morphology, favoring erosive osteoarthritis. Additional mild multifocal PIP osteoarthritis. MCP joints are relatively preserved without convincing inflammatory-type MCP joint space loss or marginal erosive MCP pattern. No pencil-in-cup deformity, acro-osteolysis, fluffy periostitis, or carpal collapse.
Right foot / ankle
Mild diffuse osteopenic appearance. Mild hallux valgus with mild bunion change. Mild first MTP osteoarthritis and mild hallux IP osteoarthritis. Mild scattered lesser toe interphalangeal osteoarthritis. Mild bunionette-type prominence at the fifth metatarsal head. Mild midfoot/tarsometatarsal degenerative change. Mild tibiotalar degenerative spurring without advanced joint space loss. Plantar and posterior calcaneal enthesophytes are present. No convincing marginal erosions, inflammatory periostitis, acro-osteolysis, destructive ray remodeling, or other radiographic post-inflammatory destructive forefoot pattern.
Left foot / ankle
Mild diffuse osteopenic appearance. Mild hallux valgus. Mild first MTP osteoarthritis and mild hallux IP osteoarthritis. Mild scattered lesser toe interphalangeal osteoarthritis. Mild bunionette-type prominence at the fifth metatarsal head. Mild midfoot/tarsometatarsal degenerative change. Mild tibiotalar degenerative spurring without advanced joint space loss. Small plantar and posterior calcaneal enthesophytes are present. No convincing marginal erosions, inflammatory periostitis, acro-osteolysis, destructive ray remodeling, or other radiographic post-inflammatory destructive forefoot pattern.
Impression
Multiregional predominantly degenerative arthropathy involving the cervical, thoracic, and lumbar spine, sacroiliac joints, hips, hands/wrists, and feet/ankles. Dominant axial abnormality is marked multilevel lumbar degenerative disc disease with associated lower lumbar facet arthropathy, greatest from L2-L3 through L5-S1 and maximal at L4-L5.
Mixed hand pattern: bilateral osteoarthritis with greatest involvement of the DIP joints, thumb IP joints, and first carpometacarpal joints, plus central erosive-remodeling interphalangeal change (gull-wing pattern) involving the right third DIP and left second and third DIP joints, favoring an erosive osteoarthritis component.
Mild bilateral degenerative sacroiliac arthrosis without convincing radiographic erosive sacroiliitis or ankylosis.
Mild bilateral hip, forefoot, midfoot, and ankle osteoarthritis with mild chronic calcaneal enthesopathic change bilaterally and small chronic left greater trochanteric enthesopathic/calcific change.
No convincing radiographic destructive psoriatic arthropathy identified on this examination. Specifically, no definite psoriatic-type marginal erosive MCP/MTP pattern, no pencil-in-cup deformities, no acro-osteolysis, no convincing inflammatory periostitis, no syndesmophyte-dominant axial ankylosis, and no radiographic sacroiliac ankylosis.
Mild diffuse osteopenic appearance. No acute osseous abnormality identified on the provided radiographs.
EMR Summary
Pattern: degeneration-predominant multiregional arthropathy with mixed hand phenotype. Dominant structural abnormality is marked lumbar spondylodegenerative disease. Hands show bilateral OA greatest at DIP, thumb IP, and first CMC joints, with superimposed erosive OA-type central gull-wing remodeling at the right 3rd DIP and left 2nd-3rd DIPs. SI joints show mild symmetric degenerative arthrosis without erosive sacroiliitis. Feet/ankles show mild OA and chronic calcaneal enthesophytes without convincing destructive inflammatory forefoot pattern. No convincing radiographic destructive PsA pattern identified. No priors for progression assessment.
Patient: De-identified
DOB: xx/xx/1957
Age: 68 years
Sex: Female
Study date: 2026-xx-xx
Modality: Radiographs
Declared / Examined Regions: Cervical spine, thoracic spine, lumbar spine, sacroiliac joints/pelvis/hips, bilateral hands/wrists, bilateral feet/ankles.
Regions / projections obtained:
Cervical spine: AP, lateral, open-mouth odontoid, right
oblique, left oblique.
Thoracic spine: AP, lateral.
Lumbar spine: AP, lateral, right oblique, left oblique,
spot lateral lumbosacral view.
Sacroiliac joints / pelvis / hips: AP pelvis, AP
sacroiliac joints, bilateral oblique sacroiliac views, focused right hip
AP view, focused left hip AP views.
Right hand/wrist: PA, oblique, lateral, focused
PA/oblique wrist views.
Left hand/wrist: PA, oblique, lateral, focused
PA/oblique wrist views.
Right foot/ankle: AP/dorsoplantar foot, oblique foot,
lateral foot, frontal ankle view.
Left foot/ankle: AP/dorsoplantar foot, oblique foot,
lateral foot, frontal ankle view.
Comparison: No comparison studies available.
Findings
Mild straightening of cervical lordosis. Mild multilevel cervical spondylosis, greatest at C5-C6, with additional milder disc degeneration at C3-C4, C4-C5, and C6-C7 and mild lower cervical uncovertebral/facet hypertrophic change with mild bilateral lower cervical foraminal narrowing. Mild thoracic dextrocurvature with mild-to-moderate multilevel thoracic degenerative disc/endplate spondylosis, greatest in the lower thoracic spine. Marked multilevel lumbar degenerative disc disease with vacuum phenomenon, endplate sclerosis, osteophytic spurring, mild low-grade degenerative listhesis/retrolisthesis, and lower lumbar facet arthropathy, greatest from L2-L3 through L5-S1 and maximal at L4-L5. No convincing syndesmophytes, ankylosing bridge, inflammatory corner erosions, or vertebral compression fracture.
Mild bilateral inferior-predominant degenerative sacroiliac arthrosis without definite erosions or ankylosis. Mild degenerative change of the pubic symphysis. Mild bilateral hip osteoarthritis with slight superolateral joint space narrowing and small marginal osteophytes. Small chronic-appearing calcific/enthesopathic focus adjacent to the left greater trochanter.
Bilateral hands show mild diffuse osteopenic appearance, mild radiocarpal/distal radioulnar degenerative change, mild-to-moderate first carpometacarpal osteoarthritis with mild adjacent triscaphe degeneration, mild thumb MCP degeneration, and moderate thumb IP osteoarthritis. Scattered interphalangeal arthropathy is greatest at the DIP joints. Central erosive-remodeling change with gull-wing morphology is present at the right third DIP and left second and third DIP joints, favoring erosive osteoarthritis. Additional milder multifocal PIP osteoarthritis is present. MCP joints are relatively preserved without convincing inflammatory-type MCP joint space loss or marginal erosive MCP pattern. No pencil-in-cup deformity, acro-osteolysis, fluffy periostitis, or carpal collapse.
Bilateral feet/ankles show mild diffuse osteopenic appearance, mild hallux valgus, mild first MTP and hallux IP osteoarthritis, mild scattered lesser toe interphalangeal osteoarthritis, mild bunionette-type prominence at the fifth metatarsal heads, mild midfoot/tarsometatarsal degenerative change, mild tibiotalar degenerative spurring, and bilateral plantar/posterior calcaneal enthesophytes. No convincing marginal erosions, inflammatory periostitis, acro-osteolysis, or destructive ray remodeling.
Impression
Multiregional predominantly degenerative arthropathy involving the cervical, thoracic, and lumbar spine, sacroiliac joints, hips, hands/wrists, and feet/ankles. Dominant axial abnormality is marked multilevel lumbar degenerative disc disease with associated lower lumbar facet arthropathy, greatest from L2-L3 through L5-S1 and maximal at L4-L5.
Mixed hand pattern with bilateral osteoarthritis greatest at the DIP joints, thumb IP joints, and first carpometacarpal joints, plus central erosive-remodeling interphalangeal change with gull-wing morphology at the right third DIP and left second and third DIP joints, favoring an erosive osteoarthritis component.
Mild bilateral degenerative sacroiliac arthrosis without convincing radiographic erosive sacroiliitis or ankylosis.
Mild bilateral hip, forefoot, midfoot, and ankle osteoarthritis with bilateral chronic calcaneal enthesopathic change and small chronic left greater trochanteric enthesopathic/calcific change.
No convincing radiographic destructive psoriatic arthropathy identified on this examination. No definite psoriatic-type marginal erosive MCP/MTP pattern, no pencil-in-cup deformities, no acro-osteolysis, no convincing inflammatory periostitis, no syndesmophyte-dominant axial ankylosis, and no radiographic sacroiliac ankylosis.
Mild diffuse osteopenic appearance. No acute osseous abnormality identified.
Patient: De-identified
DOB: xx/xx/1957
Age: 68 years
Sex: Female
Study date: 2026-xx-xx
Modality: Radiographs
Declared / Examined Regions: Cervical spine, thoracic spine, lumbar spine, sacroiliac joints/pelvis/hips, bilateral hands/wrists, bilateral feet/ankles.
Regions / projections obtained:
Cervical spine: AP, lateral, open-mouth odontoid, right
oblique, left oblique.
Thoracic spine: AP, lateral.
Lumbar spine: AP, lateral, right oblique, left oblique,
spot lateral lumbosacral view.
Sacroiliac joints / pelvis / hips: AP pelvis, AP
sacroiliac joints, bilateral oblique sacroiliac views, focused right hip
AP view, focused left hip AP views.
Right hand/wrist: PA, oblique, lateral, focused
PA/oblique wrist views.
Left hand/wrist: PA, oblique, lateral, focused
PA/oblique wrist views.
Right foot/ankle: AP/dorsoplantar foot, oblique foot,
lateral foot, frontal ankle view.
Left foot/ankle: AP/dorsoplantar foot, oblique foot,
lateral foot, frontal ankle view.
Shared / overlapping projection note: AP pelvic
projections contribute to both sacroiliac joint and hip
assessment.
Comparison: No comparison studies available.
Findings
Mild straightening of cervical lordosis. Mild multilevel cervical spondylosis with disc degeneration at C3-C4, C4-C5, C5-C6, and C6-C7, greatest at C5-C6, with mild lower cervical uncovertebral/facet hypertrophic change and mild bilateral lower cervical foraminal narrowing. Mild thoracic dextrocurvature with mild-to-moderate multilevel thoracic degenerative disc/endplate spondylosis, greatest in the lower thoracic spine. Marked multilevel lumbar degenerative disc disease with vacuum phenomenon, endplate sclerosis, osteophytic spurring, mild low-grade listhesis/retrolisthesis, and lower lumbar facet arthropathy, greatest from L2-L3 through L5-S1 and maximal at L4-L5. No convincing syndesmophytes, ankylosing bridge, inflammatory corner erosions, or vertebral compression fracture.
Mild bilateral inferior-predominant degenerative sacroiliac arthrosis without definite erosions or ankylosis. Mild degenerative change of the pubic symphysis. Mild bilateral hip osteoarthritis with slight superolateral joint space narrowing and small marginal osteophytes. Small chronic-appearing calcific/enthesopathic focus adjacent to the left greater trochanter.
Bilateral hands show mild diffuse osteopenic appearance, mild radiocarpal/distal radioulnar degenerative change, mild-to-moderate first carpometacarpal osteoarthritis with mild adjacent triscaphe degeneration, mild thumb MCP degeneration, and moderate thumb IP osteoarthritis. Scattered interphalangeal arthropathy is greatest at the DIP joints, with additional mild multifocal PIP osteoarthritis and relative MCP preservation. Central erosive-remodeling change with gull-wing morphology is present at the right third DIP and left second and third DIP joints, favoring erosive osteoarthritis. No pencil-in-cup deformity, acro-osteolysis, fluffy periostitis, or carpal collapse.
Bilateral feet/ankles show mild diffuse osteopenic appearance, mild hallux valgus, mild first MTP and hallux IP osteoarthritis, mild scattered lesser toe interphalangeal osteoarthritis, mild bunionette-type prominence at the fifth metatarsal heads, mild midfoot/tarsometatarsal degenerative change, mild tibiotalar degenerative spurring, and bilateral plantar/posterior calcaneal enthesophytes. No convincing marginal erosions, inflammatory periostitis, acro-osteolysis, or destructive ray remodeling.
Impression
Multiregional predominantly degenerative arthropathy involving the cervical, thoracic, and lumbar spine, sacroiliac joints, hips, hands/wrists, and feet/ankles; dominant axial abnormality is marked multilevel lumbar degenerative disc disease with associated lower lumbar facet arthropathy, greatest from L2-L3 through L5-S1 and maximal at L4-L5.
Mixed hand pattern with bilateral osteoarthritis greatest at the DIP joints, thumb IP joints, and first carpometacarpal joints, plus central erosive-remodeling interphalangeal change with gull-wing morphology at the right third DIP and left second and third DIP joints, favoring an erosive osteoarthritis component.
Mild bilateral degenerative sacroiliac arthrosis without convincing radiographic erosive sacroiliitis or ankylosis.
Mild bilateral hip, forefoot, midfoot, and ankle osteoarthritis with bilateral chronic calcaneal enthesopathic change and small chronic left greater trochanteric enthesopathic/calcific change.
No convincing radiographic destructive psoriatic arthropathy identified on this examination. No definite psoriatic-type marginal erosive MCP/MTP pattern, no pencil-in-cup deformities, no acro-osteolysis, no convincing inflammatory periostitis, no syndesmophyte-dominant axial ankylosis, and no radiographic sacroiliac ankylosis.
Mild diffuse osteopenic appearance. No acute osseous abnormality identified.
Research Analytic Addendum
Patient: de-indentified
DOB: xxxx-xx-xx
Age: 68 years
Sex: Female
Study date: 2026-xx-xx
Modality: Radiographs and DXA
Regions / views / projections:
Cervical spine: AP, lateral, open-mouth odontoid, right
oblique, left oblique.
Thoracic spine: AP, lateral.
Lumbar spine: AP, lateral, right oblique, left oblique,
spot lateral lumbosacral view.
Sacroiliac joints / pelvis / hips: AP pelvis, AP
sacroiliac joints, bilateral oblique sacroiliac views, focused right hip
AP view, focused left hip AP views.
Right hand/wrist: PA, oblique, lateral, focused
PA/oblique wrist views.
Left hand/wrist: PA, oblique, lateral, focused
PA/oblique wrist views.
Right foot/ankle: AP/dorsoplantar foot, oblique foot,
lateral foot, frontal ankle view.
Left foot/ankle: AP/dorsoplantar foot, oblique foot,
lateral foot, frontal ankle view.
DXA: AP spine L1-L4; bilateral femoral neck and total
femur analysis with supplemental regional hip parameters.
1. Integrated Structural Summary
This dataset shows a degeneration-dominant multiregional structural phenotype with the greatest burden in the lumbar spine, additional multilevel cervical and thoracic spondylosis, mild bilateral degenerative sacroiliac arthrosis, mild bilateral hip osteoarthritis, bilateral hand osteoarthritis with superimposed erosive osteoarthritis at selected DIP joints, and mild bilateral foot/ankle osteoarthritis with chronic calcaneal enthesopathic change.
The key update versus the prior undercalled version is that the interphalangeal pattern is not purely nonerosive OA. There are central erosive-remodeling DIP changes with gull-wing morphology involving the right third DIP and left second and third DIP joints, favoring an erosive osteoarthritis component. This is structurally distinct from classic marginal inflammatory erosions and should be preserved as a mixed-pattern hand phenotype rather than collapsed into generic degeneration.
There remains no convincing radiographic destructive psoriatic arthropathy on the current survey. Specifically, no definite psoriatic-type marginal MCP/MTP erosive pattern, no pencil-in-cup deformities, no acro-osteolysis, no convincing inflammatory periostitis, no radiographic erosive sacroiliitis, and no syndesmophyte-dominant axial ankylosing pattern are identified.
Bone-density data show no osteoporosis, but there is mild focal osteopenic reduction at the left femoral neck. The AP lumbar spine DXA values are likely artifactually elevated by marked multilevel lumbar degenerative change, especially at L3-L4; hip-based density values are the more reliable skeletal-density anchor.
2. Region-by-Region Structural Table
| Region | Dominant pattern | Burden | Key structural features | Inflammatory / post-inflammatory signal |
|---|---|---|---|---|
| Cervical spine | Degenerative | 2/3 | Mild straightening; greatest degeneration at C5-C6; additional C3-C4, C4-C5, C6-C7 disc loss/spurring; mild lower cervical hypertrophic foraminal narrowing | No convincing inflammatory axial change |
| Thoracic spine | Degenerative | 1–2/3 | Mild thoracic dextrocurvature; lower thoracic-predominant disc/endplate spondylosis | No convincing inflammatory axial change |
| Lumbar spine | Degenerative/mechanical | 3/3 | Marked multilevel DDD with vacuum phenomenon, endplate sclerosis, osteophytes, mild listhesis/retrolisthesis, lower lumbar facet arthropathy | No convincing inflammatory axial change |
| SI joints | Degenerative arthrosis | 1/3 | Mild bilateral inferior-predominant sclerosis/irregularity; preserved joint spaces | No erosive sacroiliitis or ankylosis |
| Hips | Degenerative | 1/3 | Mild bilateral superolateral narrowing and small acetabular/femoral head-neck spurs | No erosive hip arthropathy |
| Pubic symphysis | Degenerative | 1/3 | Mild degenerative change | No inflammatory change identified |
| Left greater trochanter | Enthesopathic/calcific | 1/3 | Small chronic calcific/enthesopathic focus | Chronic insertional change |
| Right hand/wrist | Mixed OA + erosive OA | 2/3 | DIP-predominant OA; thumb IP and first CMC OA; mild wrist OA; gull-wing central erosive remodeling at 3rd DIP | Erosive OA footprint at selected DIP |
| Left hand/wrist | Mixed OA + erosive OA | 2/3 | DIP-predominant OA; thumb IP and first CMC OA; mild wrist OA; gull-wing central erosive remodeling at 2nd and 3rd DIPs | Erosive OA footprint at selected DIP |
| Right foot/ankle | OA + enthesopathic overlay | 1–2/3 | Mild first-ray and lesser IP OA; mild midfoot OA; mild ankle spurring; plantar/posterior calcaneal enthesophytes | No convincing destructive inflammatory forefoot pattern |
| Left foot/ankle | OA + enthesopathic overlay | 1–2/3 | Mild first-ray and lesser IP OA; mild midfoot OA; mild ankle spurring; plantar/posterior calcaneal enthesophytes | No convincing destructive inflammatory forefoot pattern |
3. Axial Quantitative Structural Analysis
Cervical spine by level
| Level | Disc-space loss | Osteophytes/endplate spurring | Facet/uncovertebral hypertrophy | Net burden |
|---|---|---|---|---|
| C2-C3 | 0 | 0 | 0 | 0 |
| C3-C4 | 1 | 0–1 | 0–1 | 1 |
| C4-C5 | 1 | 1 | 1 | 1 |
| C5-C6 | 2 | 2 | 1–2 | 2 |
| C6-C7 | 1–2 | 1 | 1 | 1–2 |
Cervical totals
Evaluable disc levels with degenerative change: 4/5
Maximal degenerative burden: C5-C6
Lower cervical foraminal narrowing burden: 1/3
Syndesmophytes: 0
Atlantoaxial erosive/instability pattern: 0
Thoracic spine
| Feature | Estimate |
|---|---|
| Coronal curvature burden | 1/3 |
| Mid thoracic degenerative burden | 1/3 |
| Lower thoracic degenerative burden | 2/3 |
| Compression deformities | 0 |
| Syndesmophytes / inflammatory bridges | 0 |
| DISH-type flowing ossification | 0 |
Lumbar spine by level
| Level | Disc-space loss | Vacuum phenomenon | Endplate sclerosis | Osteophytes | Facet-associated burden | Net burden |
|---|---|---|---|---|---|---|
| L1-L2 | 1 | 1 | 0–1 | 1 | 0 | 1 |
| L2-L3 | 2 | 2 | 2 | 2 | 1 | 2 |
| L3-L4 | 2 | 2 | 2 | 2 | 1 | 2 |
| L4-L5 | 2–3 | 2 | 2–3 | 2 | 2 | 3 |
| L5-S1 | 2 | 2 | 1–2 | 1–2 | 2 | 2 |
Lumbar totals
Degenerated visible lumbar levels: 5/5
Vacuum-positive levels: 5/5
Maximal burden level: L4-L5
Lower lumbar facet burden: 2/3
Listhesis/retrolisthesis burden: 1/3
Pars defects: 0
Inflammatory corner erosions: 0
Syndesmophytes: 0
Sacroiliac joint structural table
| SI feature | Right | Left | Interpretation |
|---|---|---|---|
| Joint-space preservation | 1 | 1 | Joint spaces maintained |
| Inferior subchondral sclerosis | 1 | 1 | Mild degenerative |
| Degenerative irregularity/osteophytic change | 1 | 1 | Mild |
| Definite erosions | 0 | 0 | Not seen |
| Pseudowidening | 0 | 0 | Not seen |
| Partial ankylosis | 0 | 0 | Not seen |
| Complete ankylosis | 0 | 0 | Not seen |
Axial inflammatory/post-inflammatory footprint
Syndesmophytes: 0
Axial ankylosing bridges: 0
SI erosions: 0
SI ankylosis: 0
Definite post-inflammatory structural axial footprint: not demonstrated radiographically
4. Pelvis / Hip / Enthesis Quantification
| Feature | Right | Left | Interpretation |
|---|---|---|---|
| Hip joint-space narrowing | 1 | 1 | Mild bilateral |
| Hip marginal osteophytes | 1 | 1 | Mild bilateral |
| Erosive hip change | 0 | 0 | None |
| Femoral head contour collapse | 0 | 0 | None |
| KL-style hip OA estimate | 1–2 | 1–2 | Mild bilateral OA |
| Greater trochanteric calcific/enthesopathic focus | 0 | 1 | Left-sided chronic insertional change |
| Pubic symphysis degeneration | 1 | 1 | Mild |
5. Hand / Wrist Structural Analytics
Overall hand pattern
Distribution: DIP > thumb IP / first CMC > PIP >> MCP
Pattern class: mixed osteoarthritis + erosive osteoarthritis
Inflammatory marginal MCP pattern: not convincing
Psoriatic destructive remodeling pattern: not convincing
Right hand / wrist compartment table
| Compartment | Burden | Pattern type | Notes |
|---|---|---|---|
| DIP joints overall | 2/3 | OA / erosive OA | 3rd DIP shows central erosive-remodeling gull-wing change |
| PIP joints overall | 1/3 | OA | Mild multifocal |
| MCP joints overall | 0–1/3 | Minimal degenerative | Relative preservation; no convincing inflammatory erosive pattern |
| Thumb IP | 2/3 | OA | Moderate |
| Thumb MCP | 1/3 | OA | Mild |
| First CMC | 2/3 | OA | Mild-moderate |
| Triscaphe | 1/3 | OA | Mild |
| Radiocarpal | 1/3 | OA | Mild |
| DRUJ | 1/3 | OA | Mild |
| Marginal inflammatory erosions | 0 | — | Not convincing |
| Pencil-in-cup / acro-osteolysis | 0 | — | Absent |
Left hand / wrist compartment table
| Compartment | Burden | Pattern type | Notes |
|---|---|---|---|
| DIP joints overall | 2/3 | OA / erosive OA | 2nd and 3rd DIPs show central erosive-remodeling gull-wing change |
| PIP joints overall | 1/3 | OA | Mild multifocal |
| MCP joints overall | 0–1/3 | Minimal degenerative | Relative preservation; no convincing inflammatory erosive pattern |
| Thumb IP | 2/3 | OA | Moderate |
| Thumb MCP | 1/3 | OA | Mild |
| First CMC | 2/3 | OA | Mild-moderate |
| Triscaphe | 1/3 | OA | Mild |
| Radiocarpal | 1/3 | OA | Mild |
| DRUJ | 1/3 | OA | Mild |
| Marginal inflammatory erosions | 0 | — | Not convincing |
| Pencil-in-cup / acro-osteolysis | 0 | — | Absent |
Erosive change classification table
| Joint | Laterality | Erosive pattern | Confidence | Comment |
|---|---|---|---|---|
| 3rd DIP | Right | Central erosive-remodeling | High | Gull-wing configuration; favors erosive OA |
| 2nd DIP | Left | Central erosive-remodeling | High | Gull-wing configuration; favors erosive OA |
| 3rd DIP | Left | Central erosive-remodeling | High | Gull-wing configuration; favors erosive OA |
Hand totals
Hands with relative MCP preservation: 2/2
Hands with selected DIP erosive OA foci: 2/2
Definite DIP joints with gull-wing erosive remodeling: 3
Definite marginal inflammatory MCP erosions: 0
Psoriatic pencil-in-cup joints: 0
Acro-osteolysis sites: 0
Interpretive consequence:
The erosive component in the hands is best classified as erosive
OA/post-erosive remodeling in selected DIP joints, not as a
classic RA-type marginal erosion pattern and not as a convincing
destructive psoriatic pattern.
6. Foot / Ankle Structural Analytics
Right foot / ankle
| Compartment / feature | Burden | Pattern |
|---|---|---|
| Hallux valgus | 1/3 | Mild deformity |
| 1st MTP OA | 1/3 | Mild OA |
| Hallux IP OA | 1/3 | Mild OA |
| Lesser toe IP OA | 1/3 | Mild OA |
| Midfoot/TMT OA | 1/3 | Mild OA |
| Tibiotalar spurring/OA | 1/3 | Mild OA |
| Plantar calcaneal enthesophyte | 1/3 | Chronic enthesopathic |
| Posterior calcaneal/Achilles enthesophyte | 1/3 | Chronic enthesopathic |
| Marginal inflammatory erosions | 0 | Not convincing |
| Inflammatory periostitis | 0 | Not convincing |
| Acro-osteolysis | 0 | Absent |
Left foot / ankle
| Compartment / feature | Burden | Pattern |
|---|---|---|
| Hallux valgus | 1/3 | Mild deformity |
| 1st MTP OA | 1/3 | Mild OA |
| Hallux IP OA | 1/3 | Mild OA |
| Lesser toe IP OA | 1/3 | Mild OA |
| Midfoot/TMT OA | 1/3 | Mild OA |
| Tibiotalar spurring/OA | 1/3 | Mild OA |
| Plantar calcaneal enthesophyte | 1/3 | Chronic enthesopathic |
| Posterior calcaneal/Achilles enthesophyte | 1/3 | Chronic enthesopathic |
| Marginal inflammatory erosions | 0 | Not convincing |
| Inflammatory periostitis | 0 | Not convincing |
| Acro-osteolysis | 0 | Absent |
Foot totals
Feet with first-ray OA: 2/2
Feet with calcaneal enthesophytes: 2/2
Definite marginal MTP erosions: 0
Definite destructive inflammatory forefoot remodeling: 0
7. Enthesopathy Inventory
| Site | Side | Burden | Comment |
|---|---|---|---|
| Plantar calcaneal insertion | Right | 1/3 | Mild chronic enthesophyte |
| Plantar calcaneal insertion | Left | 1/3 | Mild chronic enthesophyte |
| Achilles insertion | Right | 1/3 | Mild chronic enthesophyte |
| Achilles insertion | Left | 1/3 | Mild chronic enthesophyte |
| Greater trochanteric gluteal insertion | Left | 1/3 | Small chronic calcific/enthesopathic focus |
Enthesopathic site count: 5
Global enthesopathy burden: 1/3
8. Destructive / Post-Inflammatory / PsA-Specific Audit
| Structural feature | Count |
|---|---|
| Definite marginal inflammatory erosions (hands/feet/SI) | 0 |
| Definite central erosive OA-type DIP lesions | 3 |
| Pencil-in-cup joints | 0 |
| Acro-osteolysis sites | 0 |
| Convincing inflammatory periostitic sites | 0 |
| Carpal collapse patterns | 0 |
| Destructive forefoot ray remodeling sites | 0 |
| SI erosive joints | 0 |
| SI ankylosed joints | 0 |
| Syndesmophytes | 0 |
| Ankylosing axial bridges | 0 |
Mixed-pattern interpretation
This case should not be simplified to “degenerative
only,” because the hands do contain an erosive OA
component.
It should also not be overstated as destructive PsA,
because the specific radiographic hallmarks of destructive psoriatic
remodeling are not demonstrated.
9. Symmetry and Distribution Metrics
| Region | Symmetry score |
|---|---|
| Hands | 3/3 |
| Wrists | 3/3 |
| Feet/ankles | 3/3 |
| Hips | 3/3 |
| SI joints | 3/3 |
Minor asymmetry notes
Right calcaneal enthesophytes are slightly more conspicuous.
Left greater trochanteric calcific focus is unilateral.
Left femoral neck density is lower than right.
Distribution metrics
Axial burden: 3/3
Peripheral burden: 2/3
Enthesopathic burden: 1/3
Destructive inflammatory burden: 0–1/3
Symmetry preservation index: high
Approximate domain weighting:
Axial: 60–65%
Peripheral: 35–40%
Approximate degenerative/post-inflammatory erosive OA : destructive inflammatory ratio:
~6:1, with the erosive DIP component preserved inside the non-psoriatic mixed OA domain.
10. DXA Summary
Primary DXA values
| Site | BMD (g/cm²) | T-score | Z-score | Interpretation |
|---|---|---|---|---|
| AP Spine L1-L4 | 1.354 | +1.4 | +1.9 | Raw normal/elevated, likely artifact-inflated |
| L1 | 1.192 | +0.5 | +1.0 | Normal |
| L2 | 1.263 | +0.5 | +1.0 | Normal |
| L3 | 1.479 | +2.3 | +2.8 | Likely spuriously elevated |
| L4 | 1.442 | +2.0 | +2.5 | Likely spuriously elevated |
| Femoral Neck Left | 0.825 | -1.3 | -0.6 | Osteopenic |
| Femoral Neck Right | 0.854 | -1.0 | -0.4 | Threshold-adjacent low-normal |
| Neck Mean | 0.840 | -1.2 | -0.5 | Mild reduction |
| Total Femur Left | 0.947 | -0.4 | 0.0 | Normal |
| Total Femur Right | 0.930 | -0.6 | -0.2 | Normal |
| Total Femur Mean | 0.939 | -0.5 | -0.1 | Normal |
Supplemental hip DXA
| Site | Left | Right | Mean / comment |
|---|---|---|---|
| Wards BMD | 0.556 | 0.671 | Mean 0.613 |
| Wards T-score | -2.7 | -1.8 | Reduced, supplemental only |
| Trochanter BMD | 0.761 | 0.723 | Mean 0.742 |
| Trochanter T-score | -0.1 | -0.7 | Mean approx. -0.4 |
| Upper Neck BMD | 0.598 | 0.635 | Mean 0.617 |
| Upper Neck T-score | -2.0 | -1.3 | Mean approx. -1.7 |
| Lower Neck BMD | 1.033 | 1.066 | Mean 1.050 |
| Shaft BMD | 1.135 | 1.131 | Mean 1.133 |
| Hip axis length (mm) | 109.6 | 113.8 | Right > left by 4.2 mm |
DXA deltas / asymmetry
Right-left femoral neck BMD difference: +0.029 g/cm²
Left-right total femur BMD difference: +0.017 g/cm²
Right-left hip axis length difference: +4.2 mm
Bone-density interpretation
Osteoporosis: not demonstrated
Osteopenia: left femoral neck
Most reliable density anchors: femoral necks and total femur
Lumbar AP spine likely overestimates true density because of marked degenerative confounding
Spine-hip discordance
| Comparison | Difference |
|---|---|
| Spine T-score minus neck mean T-score | 2.6 |
| Spine T-score minus total femur mean T-score | 1.9 |
| L3 T-score minus left femoral neck T-score | 3.6 |
| L4 T-score minus left femoral neck T-score | 3.3 |
These discordances are large and support degenerative inflation of AP lumbar DXA.
11. Composite Indices
| Composite index | Score |
|---|---|
| Degenerative Structural Burden Index | 3/3 |
| Axial Mechanical Burden Index | 3/3 |
| Peripheral OA Index | 2/3 |
| Erosive OA Hand Index | 2/3 |
| Enthesopathy Index | 1/3 |
| Destructive PsA Structural Index | 0–1/3 |
| Axial Inflammatory Structural Index | 0/3 |
| Bone Fragility Signal Index | 1/3 |
| Symmetry Preservation Index | 3/3 |
Mechanical pain-generator weighting estimate
| Contributor | Estimated weight |
|---|---|
| Lumbar spine | 35–40% |
| Cervical spine | 10–15% |
| Hands | 15–20% |
| Feet/midfoot/first ray | 10–15% |
| Hips | 5–10% |
| Enthesopathic foci | 5–10% |
12. Clinicoradiographic Interface
Clinical history includes longstanding psoriasis/PsA, morning stiffness, synovitis, dactylitis, toe swelling, and axial tenderness. The radiographic record shows:
high degenerative burden,
a real erosive OA component in selected DIP joints,
mild chronic enthesopathic change,
but no convincing destructive psoriatic structural pattern.
Important reconciliation point
The newly recognized DIP erosive changes do not reclassify the case as destructive PsA. Their morphology is central erosive-remodeling / gull-wing, which favors erosive OA rather than the more typical marginal destructive or proliferative psoriatic pattern.
Radiographically underrepresented domains
Plain radiographs remain limited for:
active synovitis
tenosynovitis
soft-tissue dactylitis
marrow edema
early/non-radiographic sacroiliitis
noncalcified enthesitis
Clinicoradiographic discordance estimate
Moderate: clinical inflammatory activity may exceed structurally visible inflammatory damage on plain films.
13. Coverage / Missingness
| Domain | Status |
|---|---|
| Cervical spine radiographs | Complete |
| Thoracic spine radiographs | Complete |
| Lumbar spine radiographs | Complete |
| SI/pelvis/hips radiographs | Complete |
| Hands/wrists radiographs | Complete |
| Feet/ankles radiographs | Complete |
| DXA spine | Present |
| DXA hips | Present |
| Knees | Not imaged |
| MRI | Not provided |
| Ultrasound | Not provided |
Potentially informative but not available for inflammatory activity:
dedicated knee radiographs
musculoskeletal ultrasound for synovitis/enthesitis
MRI SI joints or symptomatic axial segments
targeted higher-resolution evaluation of symptomatic dactylitic digits/toes
14. Follow-Up Anchors
Structural progression targets
| Target | Current status |
|---|---|
| DIP erosive OA joints | Right 3rd DIP; left 2nd and 3rd DIPs |
| MCP inflammatory erosions | 0 |
| MTP inflammatory erosions | 0 |
| Psoriatic proliferative remodeling | 0 |
| SI erosive change | 0 |
| SI ankylosis | 0 |
| Syndesmophytes | 0 |
| Lumbar degenerative progression | Advanced baseline present |
| Hip OA progression | Mild baseline present |
Bone-density follow-up anchors
| Target | Current value |
|---|---|
| Left femoral neck | BMD 0.825, T-score -1.3 |
| Right femoral neck | BMD 0.854, T-score -1.0 |
| Total femur mean | BMD 0.939, T-score -0.5 |
15. Final Integrated Research Synthesis
This comprehensive structural and densitometric profile demonstrates a degeneration-dominant, symmetric, multiregional musculoskeletal phenotype. The dominant abnormality is marked lumbar spondylodegenerative disease. The hands show a mixed pattern composed of bilateral OA centered at the DIP joints, thumb IP joints, and first CMC joints, with a superimposed erosive osteoarthritis component manifested by central gull-wing erosive-remodeling change at the right third DIP and left second and third DIP joints. Mild bilateral degenerative SI arthrosis, mild bilateral hip OA, mild forefoot/midfoot/ankle OA, bilateral calcaneal enthesophytes, and small chronic left greater trochanteric enthesopathic/calcific change are also present. The overall study does not show convincing radiographic destructive psoriatic arthropathy or radiographic axial inflammatory spondyloarthropathy. DXA shows no osteoporosis, but does show mild focal osteopenic reduction at the left femoral neck; AP lumbar spine density is likely artifactually elevated by degenerative change and should not be used as the primary density anchor. Overall, the imaging record remains weighted much more strongly toward degenerative/mechanical disease with selected erosive OA-type interphalangeal remodeling than toward a destructive psoriatic structural phenotype.
DEXA extracted data
Study date: 2026-xx-xx
Patient: Female, age 68
Impression
Low bone mass (osteopenia).
Lowest reported region: left femoral neck, T-score -1.3.
No osteoporosis by reported T-scores.
AP Spine (L1-L4)
BMD: 1.354 g/cm²
T-score: +1.4
Z-score: +1.9
Individual lumbar levels
L1: BMD 1.192, T-score +0.5, Z-score +1.0
L2: BMD 1.263, T-score +0.5, Z-score +1.0
L3: BMD 1.479, T-score +2.3, Z-score +2.8
L4: BMD 1.442, T-score +2.0, Z-score +2.5
Femoral neck
Left: BMD 0.825, T-score -1.3, Z-score -0.6
Right: BMD 0.854, T-score -1.0, Z-score -0.4
Mean: BMD 0.840, T-score -1.2, Z-score -0.5
Total femur
Left: BMD 0.947, T-score -0.4, Z-score 0.0
Right: BMD 0.930, T-score -0.6, Z-score -0.2
Mean: BMD 0.939, T-score -0.5, Z-score -0.1
Supplemental hip subregions
Trochanter
Left: BMD 0.761, T-score -0.1, Z-score -0.5
Right: BMD 0.723, T-score -0.7, Z-score -1.0
Mean: BMD 0.742, T-score -0.4, Z-score -0.8
Intertrochanter
Left: BMD 1.140
Right: BMD 1.092
Mean: BMD 1.116
Ward’s
Left: BMD 0.556, T-score -2.7, Z-score -1.4
Right: BMD 0.671, T-score -1.8, Z-score -0.5
Mean: BMD 0.613, T-score -2.2, Z-score -0.9
Upper neck
Left: BMD 0.598, T-score -2.0, Z-score -1.3
Right: BMD 0.635, T-score -1.3, Z-score -0.6
Mean: BMD 0.617, T-score -1.7, Z-score -1.1
Lower neck
Left: BMD 1.033
Right: BMD 1.066
Mean: BMD 1.050
Shaft
Left: BMD 1.135
Right: BMD 1.131
Mean: BMD 1.133
Hip geometry
Hip axis length: left 109.6 mm, right 113.8 mm, mean 111.7 mm
Classification summary
Normal: AP spine, total femur
Osteopenia: left femoral neck
Borderline osteopenic / threshold: right femoral neck
The images — read both ways
Cervical spine 5 views
Thoracic spine 3 views
Lumbar spine 4 views
Pelvis / SI joints / hips 5 views
Right hand & wrist 5 views
Left hand & wrist 5 views
Right foot & ankle 4 views
Left foot & ankle 4 views
How case complexity scales
Foundational
Single date, single modality, focused region(s). Establishes the structured baseline and descriptor discipline.
Longitudinal
Multiple timepoints of the same modality. Adds temporal comparison and baseline anchoring across studies.
Multi-modality
More than one modality on the same case — here radiographs combined with DXA across a mixed axial and peripheral survey. Domains compound across modalities.This case