SACRO-ILIAC JOINT
IMAGING

Montpellier

Pr Catherine Cyteval
Montpellier-France
Diarthrodial joint

•  Size and shape of the human ear
•  Articular surface:S1-S3
•  « Key stone in an Arch »
Sacoiliac joint : X Rays

Face – RD

Face – RA 15°

Oblique
• synovial joint capsule only present on the anterior aspect

Sacral part : hyalin + fibrocartilage ( 2 - 5 mm )
Iliac par...
Mr C
36 year-old
Left Coxalgia for two
months
Inflammatory syndroma
bilateral sacroiliitis
Physiopathology - spondyloarthitis

actives Lesions
Non radiographic SpA

Inflammation
(Enthesitis
Synovitis)

Edema

MRI
Sacro iliac Joint

–active Lesions

Non radiographic SpA

Edema

Destruction

actives Lesions

Inflammation
(Enthesitis
Sy...
Physiopathology - spondyloarthitis

Non radiographic SpA

Edema

Destruction

actives Lesions

Inflammation
(Enthesitis
Sy...
Sacroiliac Joint

–structural Lesions in MR

erosions

T1

Fatty areas

sclerosis
Sacroiliac Joint

T1

–structural Lesions in MR

ankylosis
Sacroiliac Joint

–structural Lesions

X rays and CT only show chronic lesions

FORESTIER CLASSIFICATION

•  Stade I - Bro...
Sacroiliac Joint

–structural Lesions

FORESTIER CLASSIFICATION

•  Stade I - Broaden joint
•  Stade II - stamps
•  Stade ...
Sacroiliac Joint

–structural Lesions

FORESTIER CLASSIFICATION

Stade I - Broaden joint
Stade II - stamps
Stade III - clo...
Sacroiliac Joint

– Structural Lesions

FORESTIER CLASSIFICATION

•  Grade I - Pseudo – élargissement
•  Grade II - Timbre...
SpA Diagnostic

Several diagnostic criteria based on
clinical and radiological signs

AMOR

ESSG
European
Spondylarthropat...
SPA Diagnostic

AMOR

ESSG
European
Spondylarthropathy
Study Group

New York
modifié

Existence of an X-ray, at least, sac...
2009 ASAS Criteria

axial spondyloarthritis
chronic Lombalgia and < 45 year-old
And
MRI or Xray
Sacroiliitis + 1 élément

...
Our patient

axial spondyloarthritis
chronic Lombalgia and < 45 year-old
And
MRI or Xray
Sacroiliitis + 1 élément

arthrit...
inflammatory lesions / ASAS criterias
sub chondral Œdema on 2 concecutive slices or 2
localisations on the same slice (STI...
ASAS 2009
ASAS 2009

enthesitis

Not in account

chronic Lesions

T1

sacro-tuberal Ligament
sacro-iliac interosseous Ligament
•  Aseptic Osteitis (SAPHO):
Unilateral
Massive, sacral and iliac sclerosis
Diagnostic value of MRI
Sensitivity ?
SI MR+ in 75% SpA patients
Weber	
  U	
  et	
  al	
  Eular	
  2013	
  OP	
  273	
  
...
Questions

• 

Will they have an interest in stopping the
NSAID before MRI?

•  If the MRI is the first SI –  Should we re...
Faut-il arrêter les AINS avant l’IRM?
Evolution of edema with anti TNF
A. Larbi – J Malghem 2010
Should we stop NSAIDs before the MRI?

20 patients with SpA treated by NSAIDs (etoricoxib)
•  MRI lumbar spine and SI to S...
Should we stop NSAIDs before the MRI?

INFAST Study Design
Part I: Treatment Phase
Screening
/Washout

•
•

	
  
	
  
	
  ...
Should we stop NSAIDs before the MRI?

Characteristic

Gender,male

Anti TNF+
AINS

Anti TNF+
AINS

a

Placebo+
AINS

Plac...
Should we stop NSAIDs before the MRI?

Seems that the response is NO
Should we repeat the MRI SI later?
–  68 patients with recent inflammatory back pain (38% men, age
34.9 ± 10.3 years)

–  ...
Should we repeat the MRI SI later?

157 subjects with chronic back pain <2 years, beginning before age 45
90 with a diagno...
Should we repeat the MRI SI later?

Downloaded from ard.bmj.com on April 15, 2013 - Published by group.bmj.com

Extended r...
Should we repeat the MRI SI later?

Seems that the response is NO for female
Possible for male
Should make sacroiliac and / or spine MRI?
Patients avec atteinte axiale
symptomatique(n=362)

SA axiale nonradiologique (...
Should make sacroiliac and / or spine MRI?

•  Reading MRI of the spine in addition to the SI increases the number of nonr...
Protocole
•  Sacro iliac joint :
–  coronal T1- STIR
–  Axial STIR

•  Spine from T7 to L5:
–  Sagittal STIR (or Fat sat T...
•  37 year old woman with inflammatory low back
pain rate
Iliac densification
• 
• 
• 
• 
• 

Bilateral - Symmetrical
often iliac + / - Sacral
Osteosclerosis > 10 mm
dense - clear ...
•  Female 58 years buttock pain with inflammatory
rhythm
Osteoarthritis
• 
• 
• 
• 

Multiple pregnancies.. Elderly… Weight
Location middle 1/3 , anterior
Common - Bilateral asymm...
upper1/3

Front

Middle

Middle 1/3

Back
Inf 1/3
Hyperostosis
Inflam. Rh.
SPA
Psoriasis
SAPHO

Sacro-iliac(s)?

(Entérocolopathy)

Osteoarthritis
17 years old male with low back pain
Inflam. Rh.
<45 y ears

HyperParaTh

drugs

Sacro-iliac(s)?
Osteoarthritis
Teenager:

>45 years

Pseudo-enlargment

< 20 y...
•  67 years old woman with Kidney
insufficiency for 17 years
2rd hyperparathyroidism
Inflam. Rh.
HyperParaTh
SPA
Psoriasis
SAPHO

Sacro-iliac(s)?

(Entérocolopathy)

Osteoarthritis
Teenager:
Pseudo-enlargmen...
• 
• 
• 
• 
• 

C Noémie
24 year-old
A week after delivery
Inflammatory left buttock pain
infl Sd ++++
C.Noémie

sept 2011

oct 2011
infectious Sacroiliitis staph
Effusion
Unilateral

infectious Sacroiliitis
Infectious sacro-iliitis
•  Unilateral
•  Soft tissus +++
•  Effusion
on X rays and CT scan
Patterns appear later

1
Inflam. Rh.
<45 years

HyperParaTh
Kidney insufficiency

Sacro-iliac(s)?
Infectious

Osteoarthritis
Teenager:
Pseudo-enlar...
26 year-old female

fracture
Inflam. Rh.
<45 years

HyperParaTh
Kidney insufficiency

Sacro-iliac(s)?
Infectious

Osteoarthritis
Teenager:
Pseudo-enlar...
Para articular Decalcification

Hemochromatosis
Inflam. Rh.
<45 years

HyperParaTh
Kidney insufficiency

Sacro-iliac(s)?
Infectious

Osteoarthritis
Teenager:
Pseudo-enlar...
Mr B., 20 years old
Inflammatory Low back pain
?
Inflam. Rh.
HyperParaTh
SPA
Psoriasis
SAPHO

Sacro-iliac(s)?

(Entérocolopathy)

Osteoarthritis

Infectious

Teenager:
Pse...
Inflam. Rh.
HyperParaTh
SPA
Psoriasis
SAPHO

Sacro-iliac(s)?

(Entérocolopathy)

Osteoarthritis

Infectious

Teenager:
Pse...
SPA

?

Mr B
Inflam. Rh.
HyperParaTh
SPA
Psoriasis
SAPHO

Sacro-iliac(s)?

(Entérocolopathy)

Osteoarthritis

Infectious

Teenager:
Pse...
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 t...
•  Diffuse Idiopathic Skeletal Hyperostosis like
Hyperostosis and calcification of tendons and ligaments
Bone bridges alon...
Mr S. (26 ans)
Roaccutane for 7 years
Inflam. Rh.
<45 years

HyperParaTh

drugs

SPA
Psoriasis
SAPHO

Sacro-iliac(s)?

(Entérocolopathy)

Osteoarthritis

Infect...
Traps
•  Accessory Sacroiliac Joint

Thank you
Msk imaging sacro iliac c cyteval
Msk imaging sacro iliac c cyteval
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Msk imaging sacro iliac c cyteval

  1. 1. SACRO-ILIAC JOINT IMAGING Montpellier Pr Catherine Cyteval Montpellier-France
  2. 2. Diarthrodial joint •  Size and shape of the human ear •  Articular surface:S1-S3 •  « Key stone in an Arch »
  3. 3. Sacoiliac joint : X Rays Face – RD Face – RA 15° Oblique
  4. 4. • synovial joint capsule only present on the anterior aspect Sacral part : hyalin + fibrocartilage ( 2 - 5 mm ) Iliac part: fibrocartilage ( 1 - 2 mm )
  5. 5. Mr C 36 year-old Left Coxalgia for two months Inflammatory syndroma
  6. 6. bilateral sacroiliitis
  7. 7. Physiopathology - spondyloarthitis actives Lesions Non radiographic SpA Inflammation (Enthesitis Synovitis) Edema MRI
  8. 8. Sacro iliac Joint –active Lesions Non radiographic SpA Edema Destruction actives Lesions Inflammation (Enthesitis Synovitis) Erosions chronic Lesions Sclerosis Repair Ax MRI Syndesmophyts Xrays, CT, MRI Coro ankylosing Spondylarthritis Ankylosis Anywhere in the joint but especially around the foot
  9. 9. Physiopathology - spondyloarthitis Non radiographic SpA Edema Destruction actives Lesions Inflammation (Enthesitis Synovitis) Erosions chronic Lesions MRI Sclerosis Repair Syndesmophyts Xrays, CT, MRI ankylosing Spondylarthritis Ankylosis
  10. 10. Sacroiliac Joint –structural Lesions in MR erosions T1 Fatty areas sclerosis
  11. 11. Sacroiliac Joint T1 –structural Lesions in MR ankylosis
  12. 12. Sacroiliac Joint –structural Lesions X rays and CT only show chronic lesions FORESTIER CLASSIFICATION •  Stade I - Broaden joint •  Stade II - stamps •  Stade III - cloody •  Stade IV - Fusion
  13. 13. Sacroiliac Joint –structural Lesions FORESTIER CLASSIFICATION •  Stade I - Broaden joint •  Stade II - stamps •  Stade III - cloody •  Stade IV - Fusion
  14. 14. Sacroiliac Joint –structural Lesions FORESTIER CLASSIFICATION Stade I - Broaden joint Stade II - stamps Stade III - cloody Stade IV - Fusion
  15. 15. Sacroiliac Joint – Structural Lesions FORESTIER CLASSIFICATION •  Grade I - Pseudo – élargissement •  Grade II - Timbre – poste •  Grade III - Aspect marécageux •  Grade IV - Fusion
  16. 16. SpA Diagnostic Several diagnostic criteria based on clinical and radiological signs AMOR ESSG European Spondylarthropathy Study Group New York modifié Existence of an X-ray, at least, sacroiliitis grade 2 bilaterally or grade 3 unilateral ASAS Assessment of SpondyloArthritis international Society Sacro-iliite IRM ou radiographique
  17. 17. SPA Diagnostic AMOR ESSG European Spondylarthropathy Study Group New York modifié Existence of an X-ray, at least, sacroiliitis grade 2 bilaterally or grade 3 unilateral ASAS Assessment of SpondyloArthritis international Society MRI (Or Xray) Sacroiliitis
  18. 18. 2009 ASAS Criteria axial spondyloarthritis chronic Lombalgia and < 45 year-old And MRI or Xray Sacroiliitis + 1 élément arthritis enthesitis uveitis dactylitis or HLA B27 + + 2 éléments Psoriasis AINS good Reponse Enthérocolopathy High CRP family history HLA B27
  19. 19. Our patient axial spondyloarthritis chronic Lombalgia and < 45 year-old And MRI or Xray Sacroiliitis + 1 élément arthritis enthesitis uveitis dactylitis or HLA B27 + + 2 éléments Psoriasis AINS good Reponse Enthérocolopathy High CRP family history HLA B27
  20. 20. 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)
  21. 21. ASAS 2009
  22. 22. ASAS 2009 enthesitis Not in account chronic Lesions T1 sacro-tuberal Ligament sacro-iliac interosseous Ligament
  23. 23. •  Aseptic Osteitis (SAPHO): Unilateral Massive, sacral and iliac sclerosis
  24. 24. Diagnostic value of MRI Sensitivity ? SI MR+ in 75% SpA patients Weber  U  et  al  Eular  2013  OP  273   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 retrospective study : 110 p. (28 SPA) Abnormality in 21% of the control patients C Cyteval Skeletal Radiology 2013
  25. 25. Questions •  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)?
  26. 26. Faut-il arrêter les AINS avant l’IRM? Evolution of edema with anti TNF A. Larbi – J Malghem 2010
  27. 27. Should we stop NSAIDs before the MRI? 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 • 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 Jarre4  SJ  et  al.  Ann  Rheum  Dis  2009  
  28. 28. Should we stop NSAIDs before the MRI? INFAST Study Design Part I: Treatment Phase Screening /Washout • •                 2:1 randomization IV infusions: weeks 0, 2, 6, 12, 18,      and 24  Anti TNF+ AINS    Placebo + AINS M0    MRI 105 p 51 p M6    MRI ET=early termination; IFX=infliximab (anti TNF); IV=intravenous; NPX=Naproxen (AINS); PBO=placebo.
  29. 29. Should we stop NSAIDs before the MRI? Characteristic Gender,male Anti TNF+ AINS Anti TNF+ AINS a Placebo+ AINS Placebo+ AINS b (N=105) M0 M6 69% (N=51) M0 M6 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 59% 88% 91% 40% 72.4% 21.9% Patients with readable MRIs and active Lesions ats creening BASFI=Bath Ankylosing Spondylitis Functional Index; HLA=human leukocyte antigen. aFor disease characteristics, N=106. bFor disease characteristics, N=52. 59% 90% 94% 54.9% 93.9% 100%
  30. 30. Should we stop NSAIDs before the MRI? Seems that the response is NO
  31. 31. Should we repeat the MRI SI later? –  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- Van  den  Berg  ACR2012  (SPACE)  
  32. 32. 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 –  MRI + : 19/90 5/71 MRI + M3 4/19 MRI-M3 diagnosis became + in only 2 patients Van  Onna  et  al.  Ann  Rheum  Dis  2011;70:1981-­‐1985
  33. 33. Should we repeat the MRI SI later? Downloaded from ard.bmj.com on April 15, 2013 - Published by group.bmj.com Extended report ccording to the ASAS/OMERACT MRI tients with early inflammatory low back SpAC 1 Year 2 Years HLA-B27 positive + + – + – NA NA NA – – – + + + NA + NA + – – + – NA – + NA + – NA NA 8 4 2 0 0 1 0 1 6 0 3 1 0 2 3 s Society; ESpAC, Early Spondyloarthritis Cohort; 7; NA, not available; OMERACT, Outcome cal Trials. d either one or two follow-up MRI. 5%), the MRI became positive at 1 HLA-B27-positive patient of these ed positive at 2 years follow-up, in nt the MRI became negative again wo HLA-B27-negative patients the ars follow-up and in two HLA-B27- Figure 1 Likelihood of a positive MRI at any time point in patients with short-standing inflammatory 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. Predictors "positivation" if initially normal MRI: Male, B27 The likelihood of a positiveVan  Onna  et  al.  Ain the case MRI is negligible (<5%) nn  Rheum  Dis  2011;70:1981-­‐1985    
  34. 34. Should we repeat the MRI SI later? Seems that the response is NO for female Possible for male
  35. 35. Should make sacroiliac and / or spine MRI? Patients avec atteinte axiale symptomatique(n=362) SA axiale nonradiologique (n = 160) SA axiale radiologique = SA (n = 202) 43,8 % 63,5 % 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) 78,0 % 86,9 % Males Âge (ans) [DS] HLA B27+ %   90   80   70   60   50   40   30   20   10   0   p  =  0,978   77,8  %   76,7  %   (112/144)   (132/172)   No  X  Rays  sign  of  sacroilii's   p  =  0,004   56,3  %   (54/96)   28,8  %   (17/59)   MRI  ac've  sacroilii's   Active MRI inflammatory lesions spinal Sacroilii's  seen  on  X  Rays   p  =  0,569   6,8  %   (3/44)   10,0  %   (6/60)   Active MRI inflammatory lesions spinal (without sacroiliitis) 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 Rudwaleit-­‐  Song  -­‐ACR  2010  -­‐  (519)  
  36. 36. Should make sacroiliac and / or spine MRI? •  Reading MRI of the spine in addition to the SI increases the number of nonradiographic 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
  37. 37. Protocole •  Sacro iliac joint : –  coronal T1- STIR –  Axial STIR •  Spine from T7 to L5: –  Sagittal STIR (or Fat sat T2)
  38. 38. •  37 year old woman with inflammatory low back pain rate
  39. 39. Iliac densification •  •  •  •  •  Bilateral - Symmetrical often iliac + / - Sacral Osteosclerosis > 10 mm dense - clear limits normal spacing
  40. 40. •  Female 58 years buttock pain with inflammatory rhythm
  41. 41. Osteoarthritis •  •  •  •  Multiple pregnancies.. Elderly… Weight Location middle 1/3 , anterior Common - Bilateral asymmetric - Spurs Check the pubic symphysis
  42. 42. upper1/3 Front Middle Middle 1/3 Back Inf 1/3
  43. 43. Hyperostosis
  44. 44. Inflam. Rh. SPA Psoriasis SAPHO Sacro-iliac(s)? (Entérocolopathy) Osteoarthritis
  45. 45. 17 years old male with low back pain
  46. 46. Inflam. Rh. <45 y ears HyperParaTh drugs Sacro-iliac(s)? Osteoarthritis Teenager: >45 years Pseudo-enlargment < 20 years When growth has not finished Infectious
  47. 47. •  67 years old woman with Kidney insufficiency for 17 years 2rd hyperparathyroidism
  48. 48. Inflam. Rh. HyperParaTh SPA Psoriasis SAPHO Sacro-iliac(s)? (Entérocolopathy) Osteoarthritis Teenager: Pseudo-enlargment
  49. 49. •  •  •  •  •  C Noémie 24 year-old A week after delivery Inflammatory left buttock pain infl Sd ++++
  50. 50. C.Noémie sept 2011 oct 2011 infectious Sacroiliitis staph
  51. 51. Effusion Unilateral infectious Sacroiliitis
  52. 52. Infectious sacro-iliitis •  Unilateral •  Soft tissus +++ •  Effusion
  53. 53. on X rays and CT scan Patterns appear later 1
  54. 54. Inflam. Rh. <45 years HyperParaTh Kidney insufficiency Sacro-iliac(s)? Infectious Osteoarthritis Teenager: Pseudo-enlargment < 20 years >45 years
  55. 55. 26 year-old female fracture
  56. 56. Inflam. Rh. <45 years HyperParaTh Kidney insufficiency Sacro-iliac(s)? Infectious Osteoarthritis Teenager: Pseudo-enlargment < 20 years >45 years Para articular bone
  57. 57. Para articular Decalcification Hemochromatosis
  58. 58. Inflam. Rh. <45 years HyperParaTh Kidney insufficiency Sacro-iliac(s)? Infectious Osteoarthritis Teenager: Pseudo-enlargment < 20 years >45 years Para articular bone
  59. 59. Mr B., 20 years old Inflammatory Low back pain
  60. 60. ?
  61. 61. Inflam. Rh. HyperParaTh SPA Psoriasis SAPHO Sacro-iliac(s)? (Entérocolopathy) Osteoarthritis Infectious Teenager: Pseudo-enlargment Para articular bone
  62. 62. Inflam. Rh. HyperParaTh SPA Psoriasis SAPHO Sacro-iliac(s)? (Entérocolopathy) Osteoarthritis Infectious Teenager: Pseudo-enlargment Para articular bone
  63. 63. SPA ? Mr B
  64. 64. Inflam. Rh. HyperParaTh SPA Psoriasis SAPHO Sacro-iliac(s)? (Entérocolopathy) Osteoarthritis Infectious Teenager: Pseudo-enlargment Para articular bone
  65. 65. Roaccutane (isotrétinoïne): 8 months in 2007 and 4 months in 2010 !!!
  66. 66. 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
  67. 67. •  Diffuse Idiopathic Skeletal Hyperostosis like Hyperostosis and calcification of tendons and ligaments Bone bridges along the anterior longitudinal ligament (6 vertebrae at least) *J. DiGiovanna et al., Isotretinoin effects on bone
  68. 68. Mr S. (26 ans) Roaccutane for 7 years
  69. 69. Inflam. Rh. <45 years HyperParaTh drugs SPA Psoriasis SAPHO Sacro-iliac(s)? (Entérocolopathy) Osteoarthritis Infectious >45 years Teenager: Pseudo-enlargment < 20 years Para articular bone
  70. 70. Traps •  Accessory Sacroiliac Joint Thank you

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