Msk imaging sacro iliac c cyteval

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