Early axial spondyloarthritis

Performance of Fully Automated Algorithm Detecting Bone Marrow Edema in Sacroiliac Joints

This study evaluates the performance of a fully automated algorithm to detect active inflammation in the form of bone marrow edema (BME) in iliac and sacral bones, depending on the quality of the coronal oblique plane in patients with axial spondyloarthritis (axSpA). The results were assessed based on the technical correctness of MRI examination of the sacroiliac joints (SIJs). A total of 173 patients with suspected axSpA were included in the study. In order to verify the correctness of the MRI, a deviation angle was measured on the slice acquired in the sagittal plane in the T2-weighted sequence. This angle was located between the line drawn between the posterior edges of S1 and S2 vertebrae and the line that marks the actual plane in which the slices were acquired in T1 and STIR sequences. All examinations were divided into quartiles according to the deviation angle measured in degrees as follows: 1st group [0; 2.2], 2nd group (2.2; 5.7], 3rd group (5.7; 10] and 4th group (10; 29.2]. Segmentations of the sacral and iliac bones were acquired manually and automatically using the fully automated algorithm on the T1 sequence. The Dice coefficient for automated bone segmentations with respect to reference manual segmentations was 0.9820 (95% CI [0.9804, 0.9835]). Examinations of BME lesions were assessed using the SPARCC scale (in 68 cases SPARCC > 0). Manual and automatic segmentations of the lesions were performed on STIR sequences and compared. The sensitivity of detection of BME ranged from 0.58 (group 1) to 0.83 (group 2) versus 0.76 (total), while the specificity was equal to 0.97 in each group. The study indicates that the performance of the algorithm is satisfactory regardless of the deviation angle.

The usefulness of bone SPECT/CT imaging with volume of interest analysis in early axial spondyloarthritis

Background

The role of conventional bone scintigraphy in diagnosing early axial spondyloarthritis (SpA) is yet controversial. Single positron emission computed tomography (SPECT) plus CT is an imaging modality that adds better anatomical information to scintigraphy of the sacroiliac (SI) joint. Our aim was to investigate the usefulness of bone SPECT/CT with volume of interest (VOI) analysis in early axial SpA patients.

Methods

Twenty patients (male: female ratio = 12:8; age range = 17–65 years) presenting with inflammatory back pain meeting the Amor criteria of early axial SpA were recruited from a single center in South Korea. Bone scintigraphy was performed 180 min after intravenous injection of 1110 MBq of Tc-99 m-HDP, followed by bone SPECT/CT. The ratio between the entire SI joint and sacrum (SIS ratio) was measured by both bone SPECT/CT and bone scintigraphy. Data from 13 controls were also evaluated. Receiver operating characteristic (ROC) curve was plotted for further analysis, and the correlation between the SIS ratio and SI joint grade by plain radiography was assessed.

Results

The SIS ratio of early axial SpA patients vs. control subjects was significantly increased in bone SPECT/CT (p < 0.001). However, no significant difference was detected in bone scintigraphy. ROC curve analysis showed a significant difference in the area under curve (AUC) of bone SPECT/CT vs. bone scintigraphy (0.862 vs. 0.523, respectively; p < 0.001). With a cut-off SIS ratio of 1.50, ROC curve analysis showed a sensitivity of 80.0% and specificity of 84.6% in bone SPECT/CT. The SIS ratio measured in SPECT/CT, but not that measured in bone scintigraphy, was significantly increased with a higher grade of SI joint changes in plain radiography (p = 0.014).

Conclusion

Bone SPECT/CT is more useful than conventional bone scintigraphy in identifying sacroiliitis in early axial SpA patients, even with mild SI joint changes in plain radiography. By combining CT, we can accurately delineate the sacrum and SI joint uptake with our VOI method.

Characterization of individuals with sacroiliac joint bridging in a skeletal population: analysis of degenerative changes in spinal vertebrae

The aim of this study was to characterize the individuals with sacroiliac joint bridging (SIB) by analyzing the degenerative changes in their whole vertebral column and comparing them with the controls. A total of 291 modern Japanese male skeletons, with an average age at death of 60.8 years, were examined macroscopically. They were divided into two groups: individuals with SIB and those without bridging (Non-SIB). The degenerative changes in their whole vertebral column were evaluated, and marginal osteophyte scores (MOS) of the vertebral bodies and degenerative joint scores in zygapophyseal joints were calculated. SIB was recognized in 30 individuals from a total of 291 males (10.3%). The average of age at death in SIB group was significantly higher than that in Non-SIB group. The values of MOS in the thoracic spines, particularly in the anterior part of the vertebral bodies, were consecutively higher in SIB group than in Non-SIB group. Incidence of fused vertebral bodies intervertebral levels was obviously higher in SIB group than in Non-SIB group. SIB and marginal osteophyte formation in vertebral bodies could coexist in a skeletal population of men. Some systemic factors might act on these degenerative changes simultaneously both in sacroiliac joint and in vertebral column.

Imaging in rheumatology: reconciling radiology and rheumatology

Imaging in rheumatology was in the past largely confined to radiographs of the hands and sacroiliac joints (SIJs) helping to establish the diagnosis and then monitoring disease progression. Radiographs are not very sensitive for early inflammation in inflammatory rheumatic disorders and the demand on imaging services was therefore limited. However, over the last 10-15 years new drugs and new technologies have brought new challenges and opportunities to rheumatology and radiology as specialties. New drug treatments allow more effective treatment, preventing many complications. Early diagnosis and disease monitoring has become the challenge for the rheumatologist and radiologist alike. The best possible patient outcome is only achieved if the two specialties understand each other's viewpoint. This article reviews the role of imaging-in particular radiography, magnet resonance imaging, computer tomography, ultrasound and nuclear medicine-for the diagnosis and monitoring of rheumatological disorders, concentrating on rheumatoid arthritis, inflammatory spondylarthropathies and gout. Teaching Points • New drugs for the treatment of inflammatory disorders has led to greatly improved outcomes. • Imaging often allows for earlier diagnosis of inflammatory disorders. • Early diagnosis and treatment can often prevent the development of crippling disease manifestations. • Tailored imaging examinations are best achieved by consultation of rheumatologist and radiologist.

Primary bone marrow oedema syndromes

MRI scanning in patients with rheumatological conditions often shows bone marrow oedema, which can be secondary to inflammatory, degenerative, infective or malignant conditions but can also be primary. The latter condition is of uncertain aetiology and it is also uncertain whether it represents a stage in the progression to osteonecrosis in some patients. Patients with primary bone marrow oedema usually have lower limb pain, commonly the hip, knee, ankle or feet. The diagnosis is one of exclusion with the presence of typical MRI findings. Treatment is usually conservative and includes analgesics and staying off the affected limb. The natural history is that of gradual resolution of symptoms over a number of months. Evidence for medical treatment is limited, but open-label studies suggest bisphosphonates may help in the resolution of pain and improve radiological findings. Surgical decompression is usually used as a last resort.

Differential diagnosis and management of ankylosing spondylitis masked as adhesive capsulitis: a resident's case problem

STUDY DESIGN

Resident's case problem.

BACKGROUND

Ankylosing spondylitis is a potentially debilitating seronegative spondyloarthropathy, with inflammatory low back pain as the most commonly reported symptom. In the absence of low back pain, identification of other diagnostic criteria or associated impairments and joint involvement, such as involvement of the hip or shoulder, may be beneficial.

DIAGNOSIS

A 32-year-old man with right shoulder pain and decreased range of motion was referred with a diagnosis of adhesive capsulitis. He had been managed by multiple healthcare providers for 3 years before being referred to a physical therapist. Glenoid labral pathology was evident on prior magnetic resonance imaging, which had led to a persistent focus on the shoulder. The evaluation by the physical therapist revealed significant mobility deficits in the cervical, thoracic, and lumbar spine. Radiographs and laboratory tests were ordered and a referral was made to rheumatology after the initial physical therapy assessment. The diagnostic work-up confirmed the diagnosis of ankylosing spondylitis and led to multidisciplinary management of the disease.

DISCUSSION

Low back pain is often the primary symptom of ankylosing spondylitis later in the disease process. Earlier indicators of ankylosing spondylitis, such as severely impaired mobility and spine stiffness, may help guide detection in the absence of spinal pain. In this case, an appropriate diagnosis led to improvement in the management strategy of what might have appeared to be unrelated shoulder pain. Early differential diagnosis is important, as emerging interventions show promise when used earlier in the disease process.

A historical perspective of the spondyloarthritis

PURPOSE OF REVIEW

The history of ankylosing spondylitis, the main representative of the spondyloarthritides, is dating back to several thousand years BC and recently proven for medieval skeleton by HLA-B27 typing with modern molecular techniques. In modern time, the history of spondyloarthritis (SpA) is characterized by fluctuation between lumping and splitting. Actually, the recent advent of new classification criteria demands to discuss the consequences and clinical implications in the historical context of the development of the concept of SpA including the controversy of lumping and splitting.

RECENT FINDINGS

The new Assessment of SpondyloArthritis International Society classification criteria for axial and peripheral SpA are primarily developed to provide support for clinical trials with biologicals and other treatment modalities, which intend to cover the whole spectrum, especially early clinical manifestations of spondyloarthritides. New insights into genetics and the evolving etiological role of Chlamydia in SpA including the most recent finding of the effective combination antibiotic therapy are major advances in the evolving history of SpA.

SUMMARY

The concept of SpA is well accepted for the classification, diagnosis, and therapeutic management of a high proportion of individuals with inflammatory rheumatic conditions. For further advances research technologies are now available to enlarge the current body of clinical, immunologic, and genetic studies using pivotal microbiologic research and new antimicrobial therapeutic strategies.

MR imaging assessment of inflammatory, crystalline-induced, and infectious arthritides

The role of magnetic resonance imaging in evaluating patients with inflammatory arthritides has evolved with the recent introduction of drugs capable of modifying disease activity and natural history. In conditions like rheumatoid arthritis, active synovitis and bone marrow inflammation precede and predict bone and cartilage erosion. These imaging findings identify patients who can be treated early and aggressively to prevent future morbidity. Similarly, in gout and other crystalline disorders, specific diagnosis aided by imaging may lead to earlier medical and surgical management. Infected joints need the most rapid identification to institute immediate therapy and prevent irreversible cartilage destruction.