Magnetic resonance imaging guided corticosteroid injection of sacroiliac joints in patients with spondylarthropathy. Are multiple injections more beneficial?

Pan American League of Associations for Rheumatology recommendations for the management of axial spondyloarthritis

Axial spondyloarthritis (axSpA) comprises a spectrum of chronic inflammatory manifestations affecting the axial skeleton and represents a challenge for diagnosis and treatment. Our objective was to generate a set of evidence-based recommendations for the management of axSpA for physicians, health professionals, rheumatologists and policy decision makers in Pan American League of Associations for Rheumatology (PANLAR) countries. Grading of Recommendations, Assessment, Development and Evaluation-ADOLOPMENT methodology was used to adapt existing recommendations after performing an independent systematic search and synthesis of the literature to update the evidence. A working group consisting of rheumatologists, epidemiologists and patient representatives from countries within the Americas prioritized 13 topics relevant to the context of these countries for the management of axSpA. This Evidence-Based Guideline article reports 13 recommendations addressing therapeutic targets, the use of NSAIDs and glucocorticoids, treatment with DMARDs (including conventional synthetic, biologic and targeted synthetic DMARDs), therapeutic failure, optimization of the use of biologic DMARDs, the use of drugs for extra-musculoskeletal manifestations of axSpA, non-pharmacological interventions and the follow-up of patients with axSpA.

Ultrasound guided corticosteroids sacroiliac joint injections (SIJIs) in the management of active sacroiliitis: a real-life prospective experience

INTRODUCTION

Active sacroiliitis represents the hallmark of axial spondyloarthritis (axSpA) and manifests as inflammatory low back pain associated with morning stiffness (MS). Sometimes, the combination of non-steroidal anti-inflammatory drugs (NSAIDs) and biological disease modifying drugs (bDMARDs) proves unsatisfactory in achieving a remission.

MATERIALS AND METHODS

We enrolled patients affected with active sacroiliitis confirmed via magnetic resonance imaging (MRI) and treated with a corticosteroid sacroiliac joint injection (SIJI) via ultrasound guidance. After SIJI, we evaluated visual-analogue scale (VAS) and MS pain changes. As controls, we selected axSpA patients starting bDMARDs.

RESULTS

We enrolled 26 patients (mean age 55 ± 14 years; 25 females and 1 male; > 95% treated with NSAIDs; 46% on bDMARDs; 75.82 ± 123 months) and examined a total of 47 treated joints. We detected a 48% reduction in VAS pain after 24 h. Moreover, we observed a significant reduction (p < 0.0001) of VAS pain between the baseline and every subsequent follow-up visit. Further, a significant difference in VAS pain compared to the baseline in the controls was observed starting from week 12. There was a significant reduction in MS after 1 week due to SIJIs, while in the controls the first significant change from the baseline in MS was detected after 12 weeks. The efficacy of infiltrative therapy lasted up to 6 months: persistent VAS as well as MS pain reduction was observed.

CONCLUSIONS

US-guided SIJI represents an effective and safe technique for patients who have active sacroiliitis yet are ineligible for biologic treatment or who experience unsatisfactory disease control despite receiving therapy.

MRI-guided sacroiliac joint injections in children and adults: current practice and future developments

Common etiologies of low back pain include degenerative arthrosis and inflammatory arthropathy of the sacroiliac joints. The diagnostic workup revolves around identifying and confirming the sacroiliac joints as a pain generator. Diagnostic sacroiliac joint injections often serve as functional additions to the diagnostic workup through eliciting a pain response that tests the hypothesis that the sacroiliac joints do or do not contribute to the patient's pain syndrome. Therapeutic sacroiliac joint injections aim to provide medium- to long-term relief of symptoms and reduce inflammatory activity and, ultimately, irreversible structural damage. Ultrasonography, fluoroscopy, computed tomography, and magnetic resonance imaging (MRI) may be used to guide sacroiliac joint injections. The populations that may benefit most from MRI-guided sacroiliac joint procedures include children, adolescents, adults of childbearing age, and patients receiving serial injections due to the ability of interventional MRI to avoid radiation exposure. Most clinical wide-bore MRI systems can be used for MRI-guided sacroiliac joint injections. Turbo spin echo pulse sequences optimized for interventional needle display visualize the needle tip with an error margin of < 1 mm or less. Published success rates of intra-articular sacroiliac joint drug delivery with MRI guidance range between 87 and 100%. The time required for MR-guided sacroiliac joint injections in adults range between 23-35 min and 40 min in children. In this article, we describe techniques for MRI-guided sacroiliac joint injections, share our practice of incorporating interventional MRI in the care of patients with sacroiliac joint mediated pain, discuss the rationales, benefits, and limitations of interventional MRI, and conclude with future developments.

Efficacy and Safety of Intra-articular Sacroiliac Glucocorticoid Injections in Ankylosing Spondylitis

BACKGROUND/AIMS

To assess the efficacy and safety of intra-articular sacroiliac glucocorticoid injection in ankylosing spondylitis (AS).

METHODS

Patients with AS undergoing fluoroscopy-guided intra-articular sacroiliac glucocorticoid injection were enrolled between 2012 and 2018. Efficacy was assessed by numeric pain rating scale, acute phase reactants, Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index, and Ankylosing Spondylitis Disease Activity Score (ASDAS). Patients who started biologics within 3 months despite the intervention were compared with those not starting biologics, hence: the nonbiologic group.

RESULTS

A total of 96 patients were treated, with a total of 107 injections. After intervention, there were significant decreases in numeric pain rating scale (7.8 ± 1.8 vs. 3.3 ± 2.2, p < 0.001) and acute phase reactants level (erythrocyte sedimentation rate [ESR] 23.0 mm/h [10.0-47.0 mm/h] vs. 13.0 mm/h [4.0-27.0 mm/h], p < 0.001; C-reactive protein [CRP] 1.0 mg/dL [0.2-2.7 mg/dL] vs. 0.2 mg/dL [0.2-0.9 mg/dL], p < 0.001). Disease activity scores also decreased for BASDAI (6.2 ± 1.8 vs. 4.5 ± 2.5, p = 0.001), Bath Ankylosing Spondylitis Functional Index (5.5 [4.1-7.0] vs. 1.8 [0.5-4.1], p = 0.001), ASDAS-CRP (2.9 ± 1.0 vs. 2.3 ± 1.3, p = 0.046), and ASDAS-ESR (3.7 ± 1.1 vs. 2.4 ± 1.3, p < 0.001). However, 12 patients (12.5%) started biologics within 3 months. These patients showed higher ESR (91.0 mm/h [IQR 21.0-113.0 mm/h] vs. 21.5 mm/h [IQR 9.5-43.0 mm/h], p = 0.010), CRP (8.0 mg/dL [IQR 1.11-17.1 mg/dL] vs. 0.8 mg/dL [IQR 0.2-1.8 mg/dL], p = 0.002), BASDAI (7.4 ± 1.2 vs. 5.9 ± 1.8, p = 0.027), and ASDAS-CRP (4.0 ± 0.5 vs. 2.8 ± 1.0, p = 0.004) than the nonbiologic group. There was no serious adverse event.

CONCLUSIONS

Intra-articular sacroiliac glucocorticoid injection can be a safe and effective treatment option for active sacroiliitis in AS.

The Value of 3 Tesla Field Strength for Musculoskeletal Magnetic Resonance Imaging

ABSTRACT

Musculoskeletal magnetic resonance imaging (MRI) is a careful negotiation between spatial, temporal, and contrast resolution, which builds the foundation for diagnostic performance and value. Many aspects of musculoskeletal MRI can improve the image quality and increase the acquisition speed; however, 3.0-T field strength has the highest impact within the current diagnostic range. In addition to the favorable attributes of 3.0-T field strength translating into high temporal, spatial, and contrast resolution, many 3.0-T MRI systems yield additional gains through high-performance gradients systems and radiofrequency pulse transmission technology, advanced multichannel receiver technology, and high-end surface coils. Compared with 1.5 T, 3.0-T MRI systems yield approximately 2-fold higher signal-to-noise ratios, enabling 4 times faster data acquisition or double the matrix size. Clinically, 3.0-T field strength translates into markedly higher scan efficiency, better image quality, more accurate visualization of small anatomic structures and abnormalities, and the ability to offer high-end applications, such as quantitative MRI and magnetic resonance neurography. Challenges of 3.0-T MRI include higher magnetic susceptibility, chemical shift, dielectric effects, and higher radiofrequency energy deposition, which can be managed successfully. The higher total cost of ownership of 3.0-T MRI systems can be offset by shorter musculoskeletal MRI examinations, higher-quality examinations, and utilization of advanced MRI techniques, which then can achieve higher gains and value than lower field systems. We provide a practice-focused review of the value of 3.0-T field strength for musculoskeletal MRI, practical solutions to challenges, and illustrations of a wide spectrum of gainful clinical applications.

The Role of Sacroiliac Joint Steroid Injections in the Treatment of Axial Spondyloarthritis

Objectives

This study aims to investigate the effects of fluoroscopy-guided sacroiliac joint steroid injection in patients with acute bilateral sacroiliitis diagnosed with axial spondyloarthritis (axSpA) and how those injections affect the current need for nonsteroidal anti-inflammatory drug (NSAID) usage.

Patients and methods

We retrospectively evaluated 43 patients (28 males, 15 females; mean age, 31.7±6.3 years; range, 18 to 44 years) fulfilling the Assessment of SpondyloArthritis international Society 2009 criteria for axSpA between June 2015 and May 2016. One group included 22 patients (injection group) treated with sacroiliac joint steroid injection (triamcinolone acetonide) and the other group included 21 patients (non-injection group) not receiving the injection. All 43 patients in both groups were treated with indomethacin peroral. Pre-treatment, first week and first, third and sixth month follow-up examinations were evaluated.

Results

A ≥50% reduction in the numeric rating scale score compared with the baseline was considered as significant pain relief. The mean pain relief rates in patients receiving injections were higher at all inspections. This difference was statistically significant at first week (p<0.05). When groups were compared, no difference was found in the Bath Ankylosing Spondylitis Disease Activity Index scores (p>0.05). There was no statistically significant difference between the two groups when indomethacin dose was evaluated cumulatively for six months (p>0.05).

Conclusion

Fluoroscopy-guided sacroiliac joint steroid injections can be recommended in patients with active sacroiliitis, particularly in those with severe axial pain, for rapid analgesia in the initial term. It was concluded that steroid injections applied to the sacroiliac joint did not affect disease activity. It is noteworthy that there is a trend to reduce the use of NSAIDs in patients receiving these injections, although it does not make a statistically significant difference in the long term.

Image-guided Sports Medicine and Musculoskeletal Tumor Interventions: A Patient-Centered Model

The spectrum of effective musculoskeletal (MSK) interventions is broadening and rapidly evolving. Increasing demands incite a perpetual need to optimize services and interventions by maximizing the diagnostic and therapeutic yield, reducing exposure to ionizing radiation, increasing cost efficiency, as well as identifying and promoting effective procedures to excel in patient satisfaction ratings and outcomes. MSK interventions for the treatment of oncological conditions, and conditions related to sports injury can be performed with different imaging modalities; however, there is usually one optimal image guidance modality for each procedure and individual patient. We describe our patient-centered workflow as a model of care that incorporates state-of-the-art imaging techniques, up-to-date evidence, and value-based practices with the intent of optimizing procedural success and outcomes at a patient-specific level. This model contrasts interventionalist- and imaging modality-centered practices, where procedures are performed based on local preference and selective availability of imaging modality or interventionalists. We discuss rationales, benefits, and limitations of fluoroscopy, ultrasound, computed tomography, and magnetic resonance imaging procedure guidance for a broad range of image-guided MSK interventions to diagnose and treat sports and tumor-related conditions.

Local sacroiliac injections in the treatment of spondyloarthritis. What is the evidence?

Local sacroiliac injections represent an available treatment option in spondyloarthritis (SpA). There is no synthetic data about efficacy of this procedure in SpA. The aim of this review is to analyze the available data of the literature of local sacroiliac injections in SpA.

METHODS

A Pubmed search of papers published after 1990 was performed.

RESULTS

Pubmed search retained 15 publications in spondyloarthritis, 12 with corticosteroids (total of 468 injections in 268 patients), including 2 small-sized controlled studies, and 3 with TNF blockers (24 patients in open studies). With steroids, the two controlled studies (with a total number of 30 patients only) demonstrated significant results over placebo. In open studies, good response was reported in more than 80% of the cases, with a mean duration of improvement over 8 months. Reduction of sacroiliac inflammation on MRI was also found in several studies after injection. There is no consensus about the technique of injection or the type of steroid injected. No particular safety concern was reported. Many limitations have to be considered in the interpretation of these results.

CONCLUSION

This kind of procedure should be kept in the therapeutic armament in the current setting of costly targeted systemic treatments of spondyloarthritis. However, definition of a clear position in the treatment strategy needs further well-conducted studies.

Evidence-based diagnosis and treatment of the painful sacroiliac joint

Sacroiliac joint (SIJ) pain refers to the pain arising from the SIJ joint structures. SIJ dysfunction generally refers to aberrant position or movement of SIJ structures that may or may not result in pain. This paper aims to clarify the difference between these clinical concepts and present current available evidence regarding diagnosis and treatment of SIJ disorders. Tests for SIJ dysfunction generally have poor inter-examiner reliability. A reference standard for SIJ dysfunction is not readily available, so validity of the tests for this disorder is unknown. Tests that stress the SIJ in order to provoke familiar pain have acceptable inter-examiner reliability and have clinically useful validity against an acceptable reference standard. It is unknown if provocation tests can reliably identify extra-articular SIJ sources of pain. Three or more positive pain provocation SIJ tests have sensitivity and specificity of 91% and 78%, respectively. Specificity of three or more positive tests increases to 87% in patients whose symptoms cannot be made to move towards the spinal midline, i.e., centralize. In chronic back pain populations, patients who have three or more positive provocation SIJ tests and whose symptoms cannot be made to centralize have a probability of having SIJ pain of 77%, and in pregnant populations with back pain, a probability of 89%. This combination of test findings could be used in research to evaluate the efficacy of specific treatments for SIJ pain. Treatments most likely to be effective are specific lumbopelvic stabilization training and injections of corticosteroid into the intra-articular space.

Ultrasound-guided sacroiliac joint injection in patients with established sacroiliitis: precise IA injection verified by MRI scanning does not predict clinical outcome

OBJECTIVE

IA injections of SIJs with corticosteroids are often performed in patients suffering from low back pain due to active sacroiliitis. However, SIJ injections are technically demanding, and therefore the clinical outcome of ultrasound-guided corticosteroid SIJ injections was analysed in relation to the accuracy of the injection.

METHODS

Ultrasound-guided injections were performed with 40 mg triamcinolone and 0.78 mg gadolinium in 20 SIJ of 14 consecutive patients suffering from active sacroiliitis. Immediately following SIJ injection, MRI scanning was initiated to verify the correct placement of the drug. Clinical outcome of the intervention was determined using a numerical pain rating scale (NRS) at Days 1 and 28.

RESULTS

Despite ultrasound guidance, only 8 injections (40%) were exactly positioned into the SIJ space, whereas the other 12 injections (60%) missed the SIJ. However, there were no significant differences observed in the clinical outcome between the IA-injected group and the peri-articular-injected group. There was similar pain relief observed in both groups 24 h and 28 days following the intervention [IA injection group: mean NRS-baseline: 6.8 (range 4-9), NRS-24 h: 4.3 (range 1-7) and NRS-day 28: 3.5 (range 1-5); peri-articular injection group: mean NRS-baseline: 7.0 (range 5-10), NRS-24 h: 4.1 (range 1-10) and NRS-day 28: 4.5 (range 1-8)].

CONCLUSION

These results demonstrate that IA SIJ injections remain technically challenging despite ultrasound guidance. However, peri-articular deposition of triamcinolone appears sufficient for pain and symptom control in patients suffering from active sacroiliitis.

[Concepts of in-patient gradual diagnostics for patients with lumbar back-pain]

Concepts for treating back pain by considering recent advancements in understanding chronic pain have been increasingly discussed over the last years. In general, any kind of therapy requires a most accurate diagnosis; however, in cases of lumbar back pain matching clinical observations with known structural pathologies is not always straight forward. Here, we suggest a concept of in-patient gradual diagnosis of patients with back pain that includes stepwise structural and functional components. We emphasize that in addition to the specific (classifiable) factors causing back pain (e.g. compression of lumbar nerve roots, facet joint associated pain syndrome, sacroiliacal dysfunction, segmental instability) also unspecific (non-classifiable) causes as well as disease-associated and/or determining bio-psychological or social factors need to be considered. With this study, we aim to introduce the procedure and assess the value of in-patient gradual diagnostics. We will describe different approaches, which we will evaluate for specific indications.

[Inflammatory spine disease as a cause of back pain]

PURPOSE

The aim of this review is to evaluate the role of inflammatory spine disease in patients with chronic back pain. The contribution of imaging modalities for the diagnostic evaluation of back pain is discussed.

MATERIAL AND METHODS

A systematic literature search based on the classification of seronegative spondyloarthropathies and rheumatoid arthritis was performed. The results of this search and the experiences in a large collective of rheumatological patients are analyzed.

RESULTS

The prevalence of rheumatoid arthritis (1-2%) is comparable to that of spondyloarthropathies (1.9%). The etiology of these entities is not fully elucidated. Magnetic resonance imaging is increasingly used for early detection and surveillance of therapy with TNF-alpha antagonists.

DISCUSSION

Bone marrow edema, which is only detectable with MRI, represents an early sign of inflammation. Therapy with TNF-alpha antagonists is based on clinical and laboratory criteria, and signs of inflammation in MRI. MRI is useful for assessment of the effectiveness of anti-inflammatory therapy.