SPA spondyloarthritis imaging

1. Spondyloarthritis (Spa)
JFIM
14th
edi-on
HANOI
2015
Pr
Jean
Denis
LAREDO
Hôpital
Lariboisière
-­‐
Paris

2. ü Ankylosing spondylitis
ü Reactive arthritis
ü Psoriatic arthritis
ü Inflammatory bowel disease-related arthritis
ü Undifferentiated spondyloarthritis
ü SAPHO syndrome
Spondyloarthritis (Spa)

3. • No
biological
diagnos-c
test
• Diagnosis
needs
first
to
rule
out
tumor
and
infec-on
Spondyloarthritis (Spa)

4. Case
1
• 19
y-­‐o
chinese
woman
• Long
history
of
back
pain
diagnosed
as
Scheuermann’s
disease

7. Typical
Spa
• Romanus
lesions

9. Spa
1. Marginal
ostei-s/vertebral
enthesi-s

10. 1

11. Erosive
ConstructiveE C
Enthesitis:
Early phase Intermediate phase Late phase

12. Erosive
ConstructiveE C
Synovial Joints

13. Case
2
• 52
yo
man
• Back
pain
day
and
night
• CRP
:
17

14. T1
T2
fat
Sat

15. T1
T2
fat
Sat

16. Cas
2
T1
T2
fat
Sat

17.
CAS
N°
2
:
Disc
osteoarthri,s
with
Modic
1
mimicking
“Romanus
lesions”

18. Message
Magne3c
Romanus
:
non-­‐specific
Increase
specificity
with
many
lesions
in
many
sites

22. Sacroiliitis active :
definition according ASAS/OMERACT
Rudwaleit
M.
Ann
Rheum
Dis
2009;68(10):1520-­‐1527

23. Sensibilité
82%
Spécificité
84%
Rudwaleit
M,
ARD
2009

24. Recent
(<5y)
Spa
Posi-ve
Sacroiliac
joint
MRI:
only
30%
Look
for
other
sites
of
involvement

27. Right
Lec

28. Right
Lec

29. Case
3
• 26y-­‐o
woman
with
back
pain
and
anterior
thoracic
pain
night
and
day
for
many
years
• Cardiologist
:
normal
heart

30. Cliché
1
STIR

31. Cliché
2
STIR

32. Cliché
3
STIR

33. Cliché
5

34. Cliché
5

35. Cliché
4
STIR

36. Mise au point sur la sémiologie radiologique
Anatomie-­‐radiologique
de
l’ar3cula3on
costo-­‐vertébrale

37. T2
Fat
Sat

38. T2
Fat
Sat

39. Case
3
• 26y-­‐o
woman
with
back
pain
and
anterior
thoracic
pain
night
and
day
for
many
years
• Cardiologist
:
normal
heart

40. Cliché
6

41. Cliché
6

42. Cliché
6

43. Cliché
6

44. Cas
3
Erosive
E+C
Constructive

45. Suspicion
of
Spa
Look
for
other
sites
of
involvement
Carefully
listen
to
the
pa-ent
Perform
full
body
imaging
:
bone
scin-graphy

46. Anterior thoracic wall involvement

47. Spa
1. Marginal
ostei-s/vertebral
enthesi-s
2. Other
distant
lesions:
• Bone
scin-graphy
or
PET-­‐scan
• MRI
of
the
thoracolumbar
spine
and
pelvis
• Anterior
thoracic
wall

48. Case
4
• 19
yo
man
• Hip
pain
at
night
improved
by
NSAID
• RBC
sedimenta-on
rate
57
• CRP
62mm
• Referred
for
Laser
therapy
for
osteoid
osteoma

50. T1
T1G

51. Cas 4

59. SAPHO
Syndrome
Skin
disease
(acne)
+
Bone
disease
• Syndrome
• Arthri-s
• Pustulosis
• Hyperostosis
• Ostei-s

60. SAPHO
Syndrome
• Mysterious
disease
• Close
to
spondyloarthri-s
but
different:
No
HLA
B27
an-gen
• Caricatural
Spa:
increased
erosion
and
increased
bone
contruc-on
• Mimics
bone
tumor
and
joint
infec-on

61. Case
5:
57
y-­‐o
man
with
back
pain
at
night

62. Case
5:
57
y-­‐o
man
with
back
pain
at
night

63. Marginal
ostei-s/vertebral
enthesi-s:
Progressive
extension
around
the
vertebra

64. Erosion
Construc-on

65. SAPHO
Sd:
Clinical
clues
1. Cutaneous
lesions

66. Case
report:
33
y-­‐o
main
with
back
pain
at
night
T11,
T12
&
L1
bone
sclerosis
• 1st
bone
biopsy
:
no
tumor.
An--­‐tuberculous
treatment
• Second
biopsy
:
no
tumor,
no
infec-on.
Working
diagnosis:
SAPHO
syndrome

67. STIR
T1
Ini-al
MRI
T1
T1
Gado
FS
1-­‐year
follow-­‐up
MRI
3rd
biopsy:
epidermoid
carcinoma
Case
report:
33
y-­‐o
main
with
back
pain
at
night

68. SAPHO
Syndrome
• No
biological
diagnos-c
test
• Diagnosis
needs
first
to
rule
out
tumor
and
infec-on

69. Important
message
• SAPHO
&
Spa:
no
marginal
ostei-s
:
danger

70. Dossier
JB
Thorel,
Lorient
• 45
y-­‐o
woman
• December
2009:
small
(<1cm)
breast
carcinoma
• Bone
scin-graphy:
increased
uptake
at
T11-­‐T12
• PET-­‐scan
:
normal
Case
6

71.
scan
T1
Case
6
:
45
y-­‐o
woman

72.
Scan
T1
T2

73.
Scan
T1
T2
T1+G

74. Case
6
:
57
y-­‐o
man

75. Anterior
hyperostosis
of
the
vertebral
body

77. Spa
&
SAPHO
Syndrome:
Clinical
clues
1. Cutaneous
lesions

78. Spa
&
SAPHO
Syndrome
:
Radiological
clues
1. Marginal
ostei-s/vertebral
enthesi-s
2. Other
distant
lesions
3.
Hyperostosis
with
increased
size
of
the
bone

79. The
bread
theory
to
explain
all
bone
diseases

80. 1.
Diseases
ea-ng
both
the
crust
and
the
inside
of
the
bread

81. 1.
Diseases
ea-ng
both
the
crust
and
the
inside
of
the
bread
Bone
metastases

82. 2.Diseases
ea-ng
the
inside
only

83. 2.Diseases
ea-ng
the
inside
only
Myeloma,
Plasmacytoma,
Giant
Cell
Tumor

84. Diseases
ea-ng
the
crust
only

85. Diseases
ea-ng
the
crust
only
Spondyloarthri-s,
SAPHO
Syndrome

86. Case
1:
19
y-­‐o
chinese
woman
• Hip
joint
arthri3s
• Hip
joint
aspira3on:
no
microorganism
• Long
history
of
back
pain
diagnosed
as
Scheuermann’s
disease

97. Typical
Spa
• Romanus
lesions
• Costovertebral
arthri-s
• Sacroilii-s
• Hip
arthri-s

98. Message
Spa:
Coexistence
of
lesions
of
different
age

99. Cas
4
• 39
y-­‐o
man
with
acute
permanent
back
pain

102. Case
4:
facet
joint
staphylococcus
infec-on

103. Message
• Be
careful
with
very
subtle
MR
findings
• Spa
diagnosis
requires
clear-­‐cut
MR
findings

104. SAPHO
Sd:
Clinical
clues
1. Cutaneous
lesions
2. Non-­‐steroid
an--­‐inflammatory
drugs
very
effec-ve
on
pain
3.
No
clinical
&
biological
inflamma-on

105. SAPHO
Syndrome
:
Radiological
clues
?

106. Case
3:
57
y-­‐o
man
with
back
pain
at
night

108. Case
1
T1
T1
T1
Gado
STIR

109. T1
T1
T1
gado
T1
gado

110. T1
Gado
Fat
Sat
T1
Gado
Fat
Sat

111. Case
1:
61
y-­‐o
man
with
back
and
bunock
pain
at
night

112. SAPHO
Syndrome
:
Radiological
clues
1.
Marginal
ostei-s/vertebral
enthesi-s

113. Marginal
ostei-s/vertebral
enthesi-s
32-­‐y-­‐o
man
with
neck
pain

114. Marginal
ostei-s/vertebral
enthesi-s
Gad-­‐E.
T1-­‐W.
T1-­‐W.

115. Marginal
ostei-s/vertebral
enthesi-s
71%
T2
57-­‐y-­‐o
woman
with
back
pain

116. Marginal
ostei-s/vertebral
enthesi-s
71%
T1
T1
Gado
T2

117. T1
T1
Gado
T1
Gado
STIR
Case
1

118. Case
report
:
16
y-­‐o
man
Posterolateral
thoracic
pain
for
2
weeks,
maximal
when
waking
up.
Improved
with
NSAID
Severe
acne
No
biological
inflamma-on:
VS
6,
CRP
1.4

119. Case
report
:
16
y-­‐o
man

120.
T2
STIR
Case
report
:
16
y-­‐o
man

121. STIR
images
Case
report
:
16
y-­‐o
man

122. Case
report
:
16
y-­‐o
man

123. Genre
10F/3H
Age
at
first
symptoms
(years)
17-­‐53
(median
:
32
;
Q1
:21
;
Q3
:43)
Age
at
diagnosis
(years)
17-­‐64
(median
:
38
;
Q1
:29,5
;
Q3
:48)
Age
at
first
spine
MRI(years)
17-­‐63
(median
:
33
;
Q1
:28
;
Q3
:44)
Cutaneous
involvement
7
(54%)
Palmo-­‐Plantar
Pustulosis
5
(39%)
Severe
acne
2
(15%)
Other
(extra-­‐vertebral)
bone
lesions
9
(69%)
Sacro-­‐iIiac
joint
involvement
2
(15%)
Anterior
thoracic
wall
3
(23%)
Sacro-­‐iliac
&
Anterior
thoracic
wall
1
(8%)
Ostei3s
2
(15%)
Peripheral
joint
&
Anterior
thoracic
wall
1
(8%)

124. Spondyloarthropathies
Erosive
E+C
Constructive

125. SAPHO
Erosive
Bone
destruc-on
Vertebral
collapse
Disc
space
infec-on
E+O
Ossifiant
Bone
sclerosis
Hyperostosis

126. Case
3:
57
y-­‐o
man
with
back
pain
at
night

127. Erosion
Sclerosis

128. Pa-ente
de
28
ans
2509051472
• Sacro-­‐iliite
droite
depuis
2008
• Talalgie
droite
et
arthralgies
des
mains
• Scia-que
S1
droite
depuis
2010,
d’horaire
inflammatoire
• Psoriasis
personnel
et
chez
les
deux
parents
• HLA
B27-­‐
• Résistante
aux
AINS
et
à
2
an--­‐TNF
• Surtout
très
gênée
par
la
scia-que
S1
droite
Karine
Loua-,
Caroline
Rey-­‐Jouvin,
Anne
Miquel,
Saint-­‐Antoine

129. 2509051472

131. SAPHO
Syndrome
:
Radiological
clues
1. Marginal
ostei-s/vertebral
enthesi-s
2. Other
distant
lesions
3.
Hyperostosis
with
increased
size
of
the
bone

132. 50
y-­‐o
woman
• Back
pain
at
night
for
5
years,
much
improved
by
indometacin
• Sedimenta-on
rate
62
to
96,
normal
CRP
• HLA
B27
absent
• No
other
abnormality
• 2
percutaneous
+
1
surgical
biopsy
:
bone
sclerosis

133. 50
y-­‐o
woman

134. 50
y-­‐o
woman

135. Spinal
MR
follow-­‐up
of
SAPHO
syndrome
(Emilie
Dodré,
Caroline
Parlier-­‐Cuau)
• 14
pa-ents
fullfilling
SAPHO
syndrome
criteria
• follow-­‐up
4-­‐157
months
(median
17
months)

136. Evolution of Romanus spondylitis
regression extension

137. Evolution of SAPHO syndrome
extension

139. Marginal
ostei-s/vertebral
enthesi-s:
Progressive
extension
around
the
vertebra

140. Follow-­‐up
in
spinal
SAPHO
syndrome
– 14
pa-ents/27
lesions
– 17months
(mean
FU)
– Extension
:
20/27
(74%)
– 3
types
of
extension
:
• Within
the
same
vertebra
(52%)
• Adjacent
vertebra
(22%)
• Distant
vertebra
(11%)

141.
Pa3ent
11,
progression
par
con3guïté
de
part
et
d’autre
de
l’érosion
ini3ale
A-­‐ajeinte
ini3ale
:
séquence
T2
;
B-­‐Evolu3on
à
6
mois
:
séquence
T1
Fat
Sat
après
injec3on
de
gadolinium

142. Progression
des
érosions
cor-cales
• 75
érosions
ini-ales
• 31/75
(41%)
érosions:
progression
de
proche
en
proche
– 4
types
de
progression

143. Progression
along
the
vertebral
endplate
13
(42%)

144. Progression
along
the
anterior
cortex
1
(3%)

145. Progression
along
the
vertebral
endplate
and
anterior
cortex
5
(16%)

146.
Picture
frame
progression
12
(39%)

147. Résultats
Evolu3on
des
anomalies
de
signal
des
CV
EVOLUTION
DES
ANOMALIES
DE
SIGNAL
DES
FOYERS
LESIONNELS
(21/27
(78%))
Extension
au
sein
du
foyer
18
(67%)
Progression
œdème
11
(41%)
Progression
mixte,
œdème
et
condensa3on
6
(22%)
Progression
condensa3on
isolée
1
(4%)
Modifica3on
de
signal
3
(11%)
Dispari3on
de
l’œdème
et
appari3on
de
graisse
2
(7%)
Dispari3on
de
l’œdème
et
appari3on
d’une
condensa3on
1
(4%)

148. SAPHO
syndrome
is
a
progressing
disease
to
adjacent
bone
• Progressing
MR
findings
in
66%
of
the
cases
(mean
follow-­‐up:
17
months)
Bone
marrow
edema
41%
Vertebral
height
loss
26%
Disc
space
involvement
48%
Soc
-ssue
thickening
11%

149. Evolu3on
des
anomalies
discales
• 13
foyers
sur
27
(48%):
ajeinte
discale
évolu3ve
– 37%
(10/27)
–
appari-on
ou
majora-on
de
la
perte
de
hauteur
– 11%
(3/27)
–
perte
de
hauteur
associée
à
des
anomalies
de
signal
(PDC
ou
Hypersignal
T2)
Evolu3on
sur
5
mois

150. Tuméfac3on
des
3ssus
mous
• Présente
sur
l’IRM
ini-ale:
8
foyers
/
27
(30%)
• Progression
pour
3
des
27
foyers
ini3aux
(11%)
– Taille:
9
(+1mm),
13
(+3mm),
15
mm
(+8mm)
• Pas
de
nécrose
(zone
avasculaire)
• Pas
de
masse
intracanalaire
+6mois

151.
Suivi
20
mois
Vertebral
height
loss
(26%)
Evolu3on
sur
20
mois

152. Evolu3on
over
20
months:
+22°
Kyphosis
Increased
thoracic
kyphosis
:
4/13
pa3ents
(31%)

153. Conclusion
1
• SAPHO
syndrome:
No
diagnos-c
test
First
rule
out
tumor
and
infec-on
• Diagnos-c:
convergence
of
posi-ve
and
nega-ve
criteria