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![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)](https://image.slidesharecdn.com/msk-imaging-sacro-iliac-c-cyteval-min-131129100118-phpapp01/85/Msk-imaging-sacro-iliac-c-cyteval-35-320.jpg)
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Msk imaging sacro iliac c cyteval
- 1. SACRO-ILIAC JOINT IMAGING Montpellier Pr CatherineCyteval Montpellier-France
- 2. Diarthrodial joint • Sizeand shape of the human ear • Articular surface:S1-S3 • « Key stone in an Arch »
- 3. Sacoiliac joint :X Rays Face – RD Face – RA 15° Oblique
- 4. • synovial joint capsuleonly present on the anterior aspect Sacral part : hyalin + fibrocartilage ( 2 - 5 mm ) Iliac part: fibrocartilage ( 1 - 2 mm )
- 5. Mr C 36 year-old LeftCoxalgia for two months Inflammatory syndroma
- 6.
- 7. Physiopathology - spondyloarthitis activesLesions Non radiographic SpA Inflammation (Enthesitis Synovitis) Edema MRI
- 8. Sacro iliac Joint –activeLesions 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. Physiopathology - spondyloarthitis Nonradiographic SpA Edema Destruction actives Lesions Inflammation (Enthesitis Synovitis) Erosions chronic Lesions MRI Sclerosis Repair Syndesmophyts Xrays, CT, MRI ankylosing Spondylarthritis Ankylosis
- 10. Sacroiliac Joint –structural Lesionsin MR erosions T1 Fatty areas sclerosis
- 11. Sacroiliac Joint T1 –structural Lesionsin MR ankylosis
- 12. Sacroiliac Joint –structural Lesions Xrays and CT only show chronic lesions FORESTIER CLASSIFICATION • Stade I - Broaden joint • Stade II - stamps • Stade III - cloody • Stade IV - Fusion
- 13. Sacroiliac Joint –structural Lesions FORESTIERCLASSIFICATION • Stade I - Broaden joint • Stade II - stamps • Stade III - cloody • Stade IV - Fusion
- 14. Sacroiliac Joint –structural Lesions FORESTIERCLASSIFICATION Stade I - Broaden joint Stade II - stamps Stade III - cloody Stade IV - Fusion
- 15. Sacroiliac Joint – StructuralLesions FORESTIER CLASSIFICATION • Grade I - Pseudo – élargissement • Grade II - Timbre – poste • Grade III - Aspect marécageux • Grade IV - Fusion
- 16. SpA Diagnostic Several diagnosticcriteria 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. SPA Diagnostic AMOR ESSG European Spondylarthropathy Study Group NewYork 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. 2009 ASAS Criteria axialspondyloarthritis 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. Our patient axial spondyloarthritis chronicLombalgia 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. 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.
- 22. ASAS 2009 enthesitis Not inaccount chronic Lesions T1 sacro-tuberal Ligament sacro-iliac interosseous Ligament
- 23. • Aseptic Osteitis(SAPHO): Unilateral Massive, sacral and iliac sclerosis
- 24. Diagnostic value ofMRI 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. Questions • Will they havean 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. Faut-il arrêter lesAINS avant l’IRM? Evolution of edema with anti TNF A. Larbi – J Malghem 2010
- 27. Should we stopNSAIDs 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. Should we stopNSAIDs 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. Should we stopNSAIDs 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. Should we stopNSAIDs before the MRI? Seems that the response is NO
- 31. Should we repeatthe 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. Should we repeatthe 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. Should we repeatthe 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. Should we repeatthe MRI SI later? Seems that the response is NO for female Possible for male
- 35. Should make sacroiliacand / 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. Should make sacroiliacand / 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. Protocole • Sacro iliacjoint : – coronal T1- STIR – Axial STIR • Spine from T7 to L5: – Sagittal STIR (or Fat sat T2)
- 38. • 37 yearold woman with inflammatory low back pain rate
- 39. Iliac densification • • • • • Bilateral -Symmetrical often iliac + / - Sacral Osteosclerosis > 10 mm dense - clear limits normal spacing
- 40. • Female 58years buttock pain with inflammatory rhythm
- 41. Osteoarthritis • • • • Multiple pregnancies.. Elderly…Weight Location middle 1/3 , anterior Common - Bilateral asymmetric - Spurs Check the pubic symphysis
- 42.
- 43.
- 44.
- 45. 17 years oldmale with low back pain
- 46. Inflam. Rh. <45 years HyperParaTh drugs Sacro-iliac(s)? Osteoarthritis Teenager: >45 years Pseudo-enlargment < 20 years When growth has not finished Infectious
- 47. • 67 yearsold woman with Kidney insufficiency for 17 years 2rd hyperparathyroidism
- 48.
- 49. • • • • • C Noémie 24 year-old Aweek after delivery Inflammatory left buttock pain infl Sd ++++
- 51. C.Noémie sept 2011 oct 2011 infectiousSacroiliitis staph
- 52.
- 53. Infectious sacro-iliitis • Unilateral • Soft tissus +++ • Effusion
- 54. on X raysand CT scan Patterns appear later 1
- 55. Inflam. Rh. <45 years HyperParaTh Kidneyinsufficiency Sacro-iliac(s)? Infectious Osteoarthritis Teenager: Pseudo-enlargment < 20 years >45 years
- 56.
- 57. Inflam. Rh. <45 years HyperParaTh Kidneyinsufficiency Sacro-iliac(s)? Infectious Osteoarthritis Teenager: Pseudo-enlargment < 20 years >45 years Para articular bone
- 58.
- 59. Inflam. Rh. <45 years HyperParaTh Kidneyinsufficiency Sacro-iliac(s)? Infectious Osteoarthritis Teenager: Pseudo-enlargment < 20 years >45 years Para articular bone
- 60. Mr B., 20years old Inflammatory Low back pain
- 61.
- 62.
- 63.
- 64.
- 65.
- 66. Roaccutane (isotrétinoïne): 8 monthsin 2007 and 4 months in 2010 !!!
- 67. 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
- 68. • Diffuse IdiopathicSkeletal 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
- 69. Mr S. (26ans) Roaccutane for 7 years
- 71. Inflam. Rh. <45 years HyperParaTh drugs SPA Psoriasis SAPHO Sacro-iliac(s)? (Entérocolopathy) Osteoarthritis Infectious >45years Teenager: Pseudo-enlargment < 20 years Para articular bone
- 72. Traps • Accessory SacroiliacJoint Thank you