Msk imaging sacro iliac c cyteval
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SACRO-ILIAC JOINT IMAGING
Pr Catherine Cyteval Montpellier-France
Montpellier
• Size and shape of the human ear • Articular surface:S1-S3
• « Key stone in an Arch »
Diarthrodial joint
Face – RD Face – RA 15°
Oblique
Sacoiliac joint : X Rays
Sacral part : hyalin + fibrocartilage ( 2 - 5 mm ) Iliac part: fibrocartilage ( 1 - 2 mm )
• synovial joint capsule only present on the anterior aspect
Mr C
36 year-old
Left Coxalgia for two months
Inflammatory syndroma
bilateral sacroiliitis
Physiopathology - spondyloarthitis
actives Lesions Inflammation (Enthesitis Synovitis)
Edema MRI Non radiographic SpA
actives Lesions Inflammation (Enthesitis Synovitis)
Edema
Syndesmophyts
Erosions
Sclerosis
Ankylosis
chronic Lesions
Destruction
Repair
MRI
Xrays, CT, MRI ankylosing Spondylarthritis
Non radiographic SpA
Sacro iliac Joint –active Lesions
Ax Coro
Anywhere in the joint but especially around the foot
Physiopathology - spondyloarthitis
actives Lesions Inflammation (Enthesitis Synovitis)
Edema
Syndesmophyts
Erosions
Sclerosis
Ankylosis
chronic Lesions
Destruction
Repair
MRI
Xrays, CT, MRI ankylosing Spondylarthritis
Non radiographic SpA
Fatty areas
erosions
sclerosis
T1
Sacroiliac Joint –structural Lesions in MR
ankylosis T1
Sacroiliac Joint –structural Lesions in MR
• Stade I - Broaden joint
• Stade II - stamps
• Stade III - cloody
• Stade IV - Fusion
X rays and CT only show chronic lesions FORESTIER CLASSIFICATION
Sacroiliac Joint –structural Lesions
FORESTIER CLASSIFICATION
Sacroiliac Joint –structural Lesions
• Stade I - Broaden joint
• Stade II - stamps
• Stade III - cloody
• Stade IV - Fusion
FORESTIER CLASSIFICATION
Sacroiliac Joint –structural Lesions
Stade I - Broaden joint
Stade II - stamps Stade III - cloody Stade IV - Fusion
• Grade I - Pseudo – élargissement
• Grade II - Timbre – poste
• Grade III - Aspect marécageux
• Grade IV - Fusion
FORESTIER CLASSIFICATION
Sacroiliac Joint – Structural Lesions
Several diagnostic criteria based on clinical and radiological signs
AMOR ESSG European
Spondylarthropathy Study Group
New York modifié
ASAS Assessment of
SpondyloArthritis international
Society
Sacro-iliite IRM ou radiographique
SpA Diagnostic
Existence of an X-ray, at least, sacroiliitis grade 2 bilaterally or grade 3 unilateral
AMOR ESSG European
Spondylarthropathy Study Group
New York modifié
ASAS Assessment of
SpondyloArthritis international
Society
SPA Diagnostic
Existence of an X-ray, at least, sacroiliitis grade 2 bilaterally or grade 3 unilateral
MRI (Or Xray) Sacroiliitis
2009 ASAS Criteria axial spondyloarthritis
chronic Lombalgia and < 45 year-old
MRI or Xray
Sacroiliitis + 1 élément HLA B27 +
+ 2 éléments
And
or
arthritis enthesitis
uveitis dactylitis
Psoriasis
Enthérocolopathy
family history
AINS good Reponse
High CRP
HLA B27
Our patient axial spondyloarthritis
chronic Lombalgia and < 45 year-old
MRI or Xray
Sacroiliitis + 1 élément HLA B27 +
+ 2 éléments
And
or
arthritis enthesitis
uveitis dactylitis
Psoriasis
Enthérocolopathy
family history
AINS good Reponse
High CRP
HLA B27
inflammatory lesions / ASAS criterias
sub chondral Œdema on 2 concecutive slices or 2 localisations on the same slice (STIR)
(Rudwaleit M et al. Ann. Rheum.Dis.2008)
ASAS 2009
Not in account enthesitis
sacro-iliac interosseous Ligament
chronic Lesions
T1
sacro-tuberal Ligament
ASAS 2009
• Aseptic Osteitis (SAPHO): Unilateral Massive, sacral and iliac sclerosis
Specificity ? inflammatory Signal in 11% of the control patients
Aydin et al. Ann Rheum Dis 2012
Edema and fatty infiltration in 27% of the control patients U Weber et al; Arthritis & Rheum; octobre 2010
Diagnostic value of MRI
retrospective study : 110 p. (28 SPA) Abnormality in 21% of the control patients
C Cyteval Skeletal Radiology 2013
SI MR+ in 75% SpA patients Weber U et al Eular 2013 OP 273
Sensitivity ?
• Will they have an interest in stopping the NSAID before MRI?
• If the MRI is the first SI - – Should we repeat the MRI SI later? – Should we do an MRI of the spine (or after a
negative MRI SI)?
Questions
A. Larbi – J Malghem 2010
Evolution of edema with anti TNF
Faut-il arrêter les AINS avant l’IRM?
20 patients with SpA treated by NSAIDs (etoricoxib) • MRI lumbar spine and SI to S0 and S6 (20 patients) • 15/20 patients (71%) had lesions on MRI S0 (63 lesions in total) • 12/20 (60%) responders
Jarre4 SJ et al. Ann Rheum Dis 2009
• SI : S0 : 11 MRI + (25 lesions) à S6 : 9 MRI + (22 lesions)
• Spine: A S0 : 11 MRI + (38 lesions) à S6 : 9 MRI + (36 lesions)
Low impact of etoricoxib on inflammatory lesions in MRI, even if clinical improvement
Should we stop NSAIDs before the MRI?
INFAST Study Design Part I: Treatment Phase • 2:1 randomization • IV infusions: weeks 0, 2, 6, 12, 18, and 24 Anti TNF+ AINS Placebo + AINS
Screening /Washout
M0 MRI
M6 MRI
ET=early termination; IFX=infliximab (anti TNF); IV=intravenous; NPX=Naproxen (AINS); PBO=placebo.
Should we stop NSAIDs before the MRI?
105 p
51 p
Characteristic
Anti TNF+ AINS
a
(N=105) M0
Anti TNF+ AINS
M6
Placebo+ AINS
b
(N=51) M0
Placebo+ AINS
M6
Gender,male 69% 78%
Age,years,mean(SD) 31.7(8.51) 30.7(7.34)
Years since symptom onset,mean(SD)
1.76(0.896) 1.91(1.439)
Spine SI joint Spine or SI joint Patients with readable MRIs and active Lesions ats creening
59% 88% 91%
40% 72.4% 21.9%
59% 90% 94%
54.9% 93.9% 100%
BASFI=Bath Ankylosing Spondylitis Functional Index; HLA=human leukocyte antigen. aFor disease characteristics, N=106. bFor disease characteristics, N=52.
Should we stop NSAIDs before the MRI?
Should we stop NSAIDs before the MRI?
Seems that the response is NO
Should we repeat the MRI SI later?
Van den Berg ACR2012 (SPACE)
– 68 patients with recent inflammatory back pain (38% men, age 34.9 ± 10.3 years)
– MRI SI M0, M24
– 44 with negative MRI at baseline ◊ 15% became +
– 24 with positive MRI at baseline ◊ 30% became-
Should we repeat the MRI SI later?
157 subjects with chronic back pain <2 years, beginning before age 45
90 with a diagnosis of SpA MRI M0 and M3
– MRI - : 71/90 5/71 MRI + M3 – MRI + : 19/90 4/19 MRI-M3
diagnosis became + in only 2 patients
Van Onna et al. Ann Rheum Dis 2011;70:1981-‐1985
Extended report
Ann Rheum Dis 2011;70:1981–1985. doi:10.1136/annrheumdis-2011-200025 1983
The likelihood of a positive MRI is negligible (<5%) in the case of an HLA-B27-negative patient with a negative MRI at base-line. The likelihood is close to 90% in the case of an HLA-B27-positive patient with a positive MRI at baseline. The likelihood is intermediate in patients with either HLA-B27 positivity but a negative MRI at baseline (27%) or a positive MRI but nega-tive HLA-B27 status at baseline (49%).
DISCUSSIONIn this cohort of patients with early IBP, almost two-thirds of the patients had a negative MRI at baseline. Interestingly, in only a minority of these patients (15%), the MRI status changed dur-ing follow-up. A negative MRI at baseline in combination with a negative HLA-B27 status had a likelihood of 95% of fi nding a negative MRI in the next 2 years. This fi nding may be of clinical relevance, because it suggests that in HLA-B27-negative patients with a negative MRI sacroiliitis can be excluded with a high level of certainty.
A similar conclusion can be drawn from the group of patients with a positive MRI. One can conclude that if sacroiliitis is detected by MRI, there is a high likelihood that sacroiliitis remains present in HLA-B27-positive patients (88%). This fi nd-ing therefore adds to the credibility of MRI as a pivotal measure in the axial spondyloarthritis criteria. It is of note that there was no use of biological agents in this cohort of patients with early IBP during this 2-year period.
In general, both male gender and HLA-B27 positivity inde-pendently determined the likelihood of a positive MRI at any time point. This is not surprising, because spondyloarthritis and in particular AS is strongly associated with HLA-B27 and has an overall male predominance. In this study it was found that HLA-B27-positive male patients with IBP have the highest chance of a positive MRI at any time.
patients, 39 (89%) completed either one or two follow-up MRI. In six of these 39 patients (15%), the MRI became positive at 1 or 2 years follow-up. In one HLA-B27-positive patient of these six patients the MRI remained positive at 2 years follow-up, in one HLA-B27-negative patient the MRI became negative again at 2 years follow-up, in two HLA-B27-negative patients the MRI became positive at 2 years follow-up and in two HLA-B27-positive patients no MRI were available at 2 years follow-up.
Twenty-four patients (35%) had a positive MRI at baseline, of which 16 (66%) patients were HLA-B27 positive. In total, 23 of these 24 patients completed either one or two follow-up MRI. The MRI became negative in seven of these 23 patients (30%) during follow-up at one or at both assessments. Five of these seven patients were HLA-B27 negative, and in three of them the MRI was only weakly positive at baseline. In the remaining two patients, a strongly positive MRI was detected at baseline, but the MRI became negative during follow-up. In two HLA-B27-positive patients with a negative MRI at 1 year follow-up, the MRI was positive again at 2 years follow-up.
Factors determining a positive MRIIn the GEE analysis, both male gender (OR 3.0, 95% CI 1.1 to 8.2, p=0.035) and HLA-B27 positivity (OR 5.1, 95% CI 1.9 to 13.6, p<0.001) independently determined the likelihood of a posi-tive MRI at any time point. CRP did not contribute to explain-ing variation in the model. The effects of these determinants are visualised in an absolute manner in fi gure 1, showing that the likelihood of a positive MRI in HLA-B27-negative women with IBP is only approximately 10% compared with HLA-B27-positive men with IBP in whom this likelihood is close to 70%.
Likelihood of a positive MRI during follow-upThe likelihood of fi nding a positive MRI if the baseline MRI is either negative or positive was also investigated. Both HLA-B27 status (OR 8.1, 95% CI 2.3 to 28.3, p<0.001) and MRI status at baseline (OR 22.0, 95% CI 6.1 to 79.6, p<0.001) appeared to be strongly and independently contributory to a positive MRI of the sacroiliac joints over time. Figure 2 shows the likelihood of a positive MRI in relation to HLA-B27 status.
Table 2 MRI status over time according to the ASAS/OMERACT MRI working group defi nition in 68 patients with early infl ammatory low back pain who were included in the ESpAC
MRI availability
No of patients Baseline 1 Year 2 Years HLA-B27 positive
9 + + + 85 + + NA 42 + – + 21 + + – 02 + – – 02 + NA + 12 + NA – 01 + NA NA 126 – – – 62 – – + 07 – – NA 31 – + + 11 – + – 02 – + NA 25 – NA NA 3
+, positive MRI; –, negative MRI.ASAS, Assessment of SpondyloArthritis Society; ESpAC, Early Spondyloarthritis Cohort; HLA-B27, human leucocyte antigen B27; NA, not available; OMERACT, Outcome Measures in Rheumatoid Arthritis Clinical Trials.
Figure 1 Likelihood of a positive MRI at any time point in patients with short-standing infl ammatory back pain assessed at baseline, 1 year and 2 years of follow-up in function of HLA-B27 status and gender. HLA-B27, human leucocyte antigen B27.
17_annrheumdis-2011-200025.indd 198317_annrheumdis-2011-200025.indd 1983 9/23/2011 9:07:28 PM9/23/2011 9:07:28 PM
group.bmj.com on April 15, 2013 - Published by ard.bmj.comDownloaded from
Predictors "positivation" if initially normal MRI: Male, B27
Van Onna et al. Ann Rheum Dis 2011;70:1981-‐1985
Should we repeat the MRI SI later?
Should we repeat the MRI SI later?
Seems that the response is NO for female Possible for male
Rudwaleit-‐ Song -‐ACR 2010 -‐ (519)
Should make sacroiliac and / or spine MRI?
Patients avec atteinte axiale symptomatique(n=362)
SA axiale non-radiologique (n = 160)
SA axiale radiologique = SA (n = 202)
Males 43,8 % 63,5 %
Âge (ans) [DS] 36,3 (10,3) 39,1 (11,3)
Duration of the ilness (ans) [DS] 5,7 (6,8) 11,2 (10,0)
BASDAI (0-10) [DS] 4,1 (2,0) 4,3 (2,0)
HLA B27+ 78,0 % 86,9 %
MRI ac've sacroilii's Active MRI inflammatory lesions spinal
Active MRI inflammatory lesions spinal (without sacroiliitis)
77,8 % (112/144)
76,7 % (132/172)
28,8 % (17/59)
56,3 % (54/96)
10,0 % (6/60)
6,8 % (3/44)
p = 0,978
p = 0,004
p = 0,569
No X Rays sign of sacroilii's
Sacroilii's seen on X Rays
0 10 20 30 40 50 60 70 80 90 %
Whatever the clinical, sacroiliac MRI seems to be the most profitable review. Only 6.8% of non-radiological axial SA have isolated spinal inflammatory lesions without sacroiliitis
Should make sacroiliac and / or spine MRI?
• Reading MRI of the spine in addition to the SI increases the number of non-radiographic forms that are ultimately recognized positive MRI compared to reading only SI
Sog IH et al. Arthritis Rheum 2008
• It increases quite significantly the number of false positives (mechanical or healthy)
• In addition it allows to diagnose other causes of lumbar pain
Protocole
• Sacro iliac joint : – coronal T1- STIR – Axial STIR
• Spine from T7 to L5: – Sagittal STIR (or Fat sat T2)
• 37 year old woman with inflammatory low back pain rate
• Bilateral - Symmetrical • often iliac + / - Sacral • Osteosclerosis > 10 mm • dense - clear limits • normal spacing
Iliac densification
• Female 58 years buttock pain with inflammatory rhythm
Osteoarthritis
• Multiple pregnancies.. Elderly… Weight • Location middle 1/3 , anterior • Common - Bilateral asymmetric - Spurs • Check the pubic symphysis
upper1/3
Middle 1/3
Inf 1/3
Front
Middle
Back
Hyperostosis
Sacro-iliac(s)?
Inflam. Rh.
SPA
Psoriasis
SAPHO
(Entérocolopathy)
Osteoarthritis
17 years old male with low back pain
Sacro-iliac(s)?
Inflam. Rh.
Infectious
drugs HyperParaTh
Teenager: Pseudo-enlargment
When growth has not finished
Osteoarthritis
< 20 years
<45 y ears
>45 years
• 67 years old woman with Kidney insufficiency for 17 years
2rd hyperparathyroidism
Sacro-iliac(s)?
Inflam. Rh.
Osteoarthritis
SPA
Psoriasis
SAPHO
(Entérocolopathy)
Teenager: Pseudo-enlargment
HyperParaTh
• C Noémie • 24 year-old • A week after delivery • Inflammatory left buttock pain • infl Sd ++++
C.Noémie
sept 2011
oct 2011
infectious Sacroiliitis staph
infectious Sacroiliitis Unilateral
Effusion
Infectious sacro-iliitis
• Unilateral • Soft tissus +++ • Effusion
on X rays and CT scan Patterns appear later
1
Sacro-iliac(s)?
Inflam. Rh.
Osteoarthritis
Infectious
Teenager: Pseudo-enlargment
HyperParaTh
< 20 years
<45 years
>45 years
Kidney insufficiency
26 year-old female
fracture
Sacro-iliac(s)?
Inflam. Rh.
Osteoarthritis
Infectious
Teenager: Pseudo-enlargment
HyperParaTh
Para articular bone < 20 years
<45 years
>45 years
Kidney insufficiency
Para articular Decalcification Hemochromatosis
Sacro-iliac(s)?
Inflam. Rh.
Osteoarthritis
Infectious
Teenager: Pseudo-enlargment
HyperParaTh
Para articular bone < 20 years
<45 years
>45 years
Kidney insufficiency
Mr B., 20 years old Inflammatory Low back pain
?
Sacro-iliac(s)?
Inflam. Rh.
Osteoarthritis Infectious
SPA
Psoriasis
SAPHO
(Entérocolopathy)
Teenager: Pseudo-enlargment
HyperParaTh
Para articular bone
Sacro-iliac(s)?
Inflam. Rh.
Osteoarthritis Infectious
SPA
Psoriasis
SAPHO
(Entérocolopathy)
Teenager: Pseudo-enlargment
HyperParaTh
Para articular bone
SPA Mr B ?
Sacro-iliac(s)?
Inflam. Rh.
Osteoarthritis Infectious
SPA
Psoriasis
SAPHO
(Entérocolopathy)
Teenager: Pseudo-enlargment
HyperParaTh
Para articular bone
Roaccutane (isotrétinoïne): 8 months in 2007 and 4 months in 2010 !!!
Isotrétinoïne and bones
• Sacroiliitis : seldom
*E. Eksioglu et al., Sacroiliitis and polyneuropathy during isotrtinoin treatment 2007 *Elias et al.,Acne fulminans and bilateral seronegative sacroiliitis triggered by isotretinoin 1991 *Bachmeyer et al., Isotretinoin induced bilateral sacroiliitis 2003
• Diffuse Idiopathic Skeletal Hyperostosis like *J. DiGiovanna et al., Isotretinoin effects on bone
Hyperostosis and calcification of tendons and ligaments Bone bridges along the anterior longitudinal ligament (6 vertebrae at least)
Mr S. (26 ans) Roaccutane for 7 years
Sacro-iliac(s)?
Inflam. Rh.
Osteoarthritis Infectious
SPA
Psoriasis
SAPHO
(Entérocolopathy)
Teenager: Pseudo-enlargment
drugs HyperParaTh
Para articular bone < 20 years
<45 years
>45 years
Traps • Accessory Sacroiliac Joint
Thank you