What rheumathologist expect from radiologist in spinal MRI studies: Imaging findings in Spondiloarthritis

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1 What rheumathologist expect from radiologist in spinal MRI studies: Imaging findings in Spondiloarthritis Poster No.: C-2383 Congress: ECR 2015 Type: Educational Exhibit Authors: B. Gutierrez, V. Familiar Carrasco, E. Fontoira Moyer, A. Cabeza Carreto, A. I. UTRERA GARCIA DE SALAZAR, S. Mancheva Maneva; Madrid/ES Keywords: Inflammation, Oedema, Acute, Imaging sequences, Education, Contrast agent-intravenous, MR, Musculoskeletal spine DOI: /ecr2015/C-2383 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 24

2 Learning objectives 1. To illustrate MRI findings in spondyloarthritis with special emphasys in spine 2. To show the proper imaging protocol to avoid missing early an subtle inflammatory signs Page 2 of 24

3 Background Seronegative Spondyloarthropaties (SpA) are a group of chronic inflammatory disorders non associated with rheumatoid factors that affect mainly axial skeleton ( sacroiliac joints and spine - although there can be also peripheral disease-) Their prevalence is between 0,9 and 1,5% and they share clínical and radiological manifestations as well as closely association with histocompability antigen HLA-B27. Nowadays early diagnosis is vital to prevent non reversible structural changes in Spondyloartropathy and MRI plays an important role for this aim. Spondyloarthropathies comprises a group of diseases: -Ankylosing spondylitis -Psoriatic arthritis -Enteropatic spondyloarthritis -Reactive arthritis -Undifferenciated spondyloarthritis. The main clinical manifestation in Spondyloarthropaties is inflammatory back pain ( onset of back pain before 40 years old, insidious in onset; pain that improves with exercise but not with rest; nocturnal pain), but other typical associated features includes: Enthesitis ( Achilles Tendon, plantar fascia); Uveitis, dactylitis, psoriasis inflammatory bowel disease, response to NSAIDs, arthritis (hip/shoulder) or family history of spondyloarthropathy. HLA B27 testing is helpful in supporting the diagnosis in a patient with classic inflammatory back symptoms or other associated features when radiographic changes are not yet present. Laboratory data has limited utility. Although elevations in inflammatory markers such as erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) are often present, these are nonspecific. Page 3 of 24

4 Radiographic imaging in early disease can be normal but MRI with STIR images of the axial spine and sacroiliac joints are more sensitive for early inflammatory changes and bone marrow edema. Recently, tumor necrosis factor (TNF) -inhibitors, have been used with succes in inititial states changing the course disease and avoiding structural damage. Therefore, to improve patients outcomes early diagnosis and treatment is neccesary. Because early inflammation is missed by radiography, MRI plays an important role in the diagnosis of early SpA. The new classification criteria for axial SpA include sacroiliac inflammation on MRI as a major criterion for the classification of SpAs. Thatswhy the Assessment in SpondyloArthritis international Society-Outcome Measures in Rheumatology (ASAS/OMERACT) MRI working group developed a definition of 'a positive MRI for the SI joints' for patients with SpA. But spondylitis may also occur before or without sacroiliitis, so a definition of a 'positive MRI' for spinal inflammation was also considered necessary, despite it is not yet included as a criterion for the diagnosis of SpA Page 4 of 24

5 Findings and procedure details PROCEDURE DETAILS At our institution we perfom MRI studies of selected anatomic areas depending on patient s symptoms ( lumbar, dorsal or cervical). The MR imaging protocol we use for spinal studies of SpA includes the following sequences: -Sagital T1 and T2-weighted turbo spin-echo sequence -Sagital short inversion time inversion-recovery (STIR). When considered neccesary axial STIR image is added. -Axial, Sagital and Coronal fat-suppressed, postcontrast T1-weighted turbo spin-echo sequence. We administrate a paramagnetic contrast medium (Gadolinium) in selected patients with high suspicious of inflammatory spondiloarthritis. IMAGING FINDINGS It is important to know the phisiopathology of disease to understand the imaging findings ( Note: Although the following phisiopathology is explained related to entheseal structures at the intervertebral disc, in general terms it can be applied to other locations with inflammatory disease- SpA- including sacroiliac joints.) Phisiopathology: Inflammation is detected as edema in acute phase, whereas in postinflammatory phase this lesions may turn into fatty infiltration and also destruction of the attachment of annulus fibrosus to bone, resulting in a superficial erosion at the anterior and / or posterior edges of the vertebral endplates (called Romanus lesions). Osseous erosion produces reactive bone formation resulting in marginal sclerosis ( "shiny cornes" that are identified in lateral thoracolumbar plain films). Healing of the erosion is associated with formation of syndesmophytes and ossification of annulus fibrosuslongitudinal ligament complex ( tipical findings of the chronic phase). 1. INFLAMMATORY LESIONS The majority of active MRI lesions can be resumed in : Page 5 of 24

6 -bone edema ( or osteitis) -enthesitis The main location of these lesions is entheseal structures at the intervertebral disc, but there are another locations. The distribution pattern of lesions are: -corner inflammatory lesions (spondylitis) -central inflammatory lesions (spondylodiscitis) -inflammatory lesions in the lateral spinal segment: -insertion sites of spinal ligaments (enthesitis) -costovertebral, costotransverse and zygoapophyseal (facet) joints (arthritis) (Many authors defend that these joints may develope secundary arthritis due to it s close relation with affected entheseal structures) Description of inflammatory changes 1.SPONDYLITIS ( Anterior/ posterior) ( Fig. 1 on page 11, Fig. 2 on page 11 ) Enthesitis at the insertion of the insertion of the annulus fibrosus-longitudinal ligament complex. These lesions are depicted as bone marrow edema at corners of vertebral bodies ( low signal intensity in T1, high signal in STIR and enhancement in postcontrast images) (Although many authors use the term "Romanus lesion" for these lesions, the ASAS working work dissaproved it) 2.INFLAMMATORY SPONDYLODISCITIS ( Fig. 3 on page 12, Fig. 4 on page 13) Inflammatory involvement of the intervertebral disks by spondyloarthritis is known as spondylodiskitis or "Andersson lesion" (non-infectoius disease) At MR imaging, these lesions are depicted as bone marrow edema (low signal intensity in T1, high signal in STIR and enhancement in postcontrast images) at cortical plate adjacent to intervertebral disk (one or boht). They are often hemispherically shaped, and don t spread to surrounding soft tissues. 3. ENTHESITIS OF SPINAL LIGAMENTS ( Fig. 5 on page 13, Fig. 6 on page 14 ) Page 6 of 24

7 Inflammation of suprsapinal, interspinal and ligament flava usually associated with bone marrow edema at adjacent bone. At MR imaging, these lesions are depicted as soft tissue edema ( in ligaments and adjacent mucles also) and reactive bone edema in affected areas (low signal intensity in T1 and high signal in STIR. Postcontrast sequences are better to evalute the extent of lesion). 4. ARTHRITIS OF THE SYNOVIAL JOINTS OF THE SPINE ( Fig. 7 on page 15 ) Arthritis of the zygapophyseal joints (facet joints),costovertebral joints, and costotransverse joints is similar to primary arthritis of peripheral joints,although many authors defend that these joints may develope secundary arthritis cause it close relation with affected entheseal structures. MRI findings are depicted as joint effusion, synovitis, erosions, and bone marrow edema ( low signal intensity in T1, high signal in STIR and enhancement in postcontrast images). Joint ankylosis can be also detected at late stages. These abnormalities are usually not detected on sagital MR images therefore additional transverse or coronal MR images are recommended. 2. STRUCTURAL CHANGES Structural chronic changes may present as: -bone marrow alteration ( fatty depositions) -bony destruction (erosions) -bony proliferation (syndesmophytes and ankylosis) Description and location of structural changes: 1. FATTY DEPOSITION ( Fig. 8 on page 16 ) Circumscribed areas of fatty bone marrow degeneration, usually seen at vertebral corners and endplates, but also at spinous apophysis, pedicles and other locations. At MRI these lesions are depicted as focal lesions that follows fat signal intensity in all sequences (high signal intensity in T1 and T2, and low signal in STIR images). Page 7 of 24

8 Some authors called them inactive Romanus lesions 2. EROSIONS ( Fig. 9 on page 17 ) Bone destruction that mostly occur at vertebral corners and endplates At MRI it is depicted as cortical line disruption with hypointense margins in all sequences. 3. SYNDESMOPHYTES ( Fig. 10 on page 18 ) Bony outgrowths of the anterior vertebral edges they have lower or higher signal intensity on STIR images, depending on stage of disease. They are more vertically located compared with spondylophytes in degenerative diseases of spine Conventional radiography appears to be superior in the depiction of syndesmophytes than MRI 4. ANKYLOSIS ( Fig. 11 on page 19 ) Bony fusion throuhg the disc or/and at the attachment sites of the annulus fibrosus (bridging syndesmophytes) The newly formed bone has the same signal intensity as normal bone on MR images. Vertebral ankylosis is clearly depicted by both conventional radiography and MR imaging. NECESSARY SPINAL MRI FINDINGS TO CONSIDER "POSITIVE" THE DIAGNOSIS OF SpA The ASAS/OMERACT working group established in 2010 the following points: - A "positive" spinal MRI for inflammation was defined as the presence of anterior/ posterior spondylitis in three or more sites. - Evidence of fatty deposition at several vertebral corners was found to be suggestive of SpA, especially in younger adults - Spondylodiscitis occurs frequently but has low specificity - Other inflammatory lesions ( facet joint lesions...) are not yet well studied. Page 8 of 24

9 DIFFERENTIAL DIAGNOSIS BASED ON MR IMAGING FINDINGS 1. DEGENERATIVE DISC DISEASE ( ACTIVATED OSTEOCHONDROSIS MODIC I) ( Fig. 12 on page 20 ) Sometimes it is impossible to distinguish between inflammatory spondylodiscitis and activated osteochondrosis cause both diseases share almost all imaging findings. Clinical history and patient s age may hep in diagnosis The following table compare and analize these two entities: INFLAMMATORY SPONDYLODISCITIS DISC DEHYDRATED/ +/HERNIATIATED DEGENERATIVE DISC DISEASE +++ ANY L4-L5, L5-S LEVEL OTHER INFLAMMATORY FINDINGS ( spondylitis, enthesitis) 2.INFECTIOUS SPONDYLODISKITIS (Fig. 13 on page 20) Is an acute vertebral osetomyelitis caused by haematogenous spread into vertebral body. At MRI infectious spondylodiskitis is depicted as subchondral or extensive bone marrow edema in the vertebral body (low signal intensity in T1, high signal in STIR and enhancement in postcontrast images). INFLAMMATORY SPONDYLODISCITIS INFECTIOUS SPONDYLODISCITIS T2 HIGH SIGNAL IN THE DISC (FLUID IN DISC SIGN) SOFT TISSUE INFLAMMATION RELATED TO THE AFFECTED VERTEBRA Page 9 of 24

10 ABSCESSES (PARAVERTEBRAL, EPIDURAL) STRESS REACTION / SPONDYLOLYSIS / BONE CONTUSION ( Fig. 14 on page 21 ) Edema in lateral spinal segments may also be detected in other conditions as trauma/ spondylolylisis or stress ( athletes and patients with scoliosis can produce unilateral pedicle overload ) 4.DISH ( Fig. 15 on page 22 ) Spinal ossification in diffuse idiopathic skeletal hyperostosis ( DISH) can simulate Ankylosing Spondylitis (AS) but while ossification in AS develops in a vertical direction, DISH presents more voluminous multisegmental ossification with preservation of the height of the intervertebral spaces and Sharpey fibers. This preservation produces a lucency - "T" or "Y" shaped- between the ossified longitudinal ligament and vertebral endplates ( typical radiographic finding in DISH) Page 10 of 24

Images for this section: Fig. 1: 25 years old patient with ankylosing spondylitis (positive HLA B27), with sacroiliac and lumbar inflammatory pain.

11 Images for this section: Fig. 1: 25 years old patient with ankylosing spondylitis (positive HLA B27), with sacroiliac and lumbar inflammatory pain. As is it showed in Figure 2, this patient had also active sacroiliitis, so this finding is highly suspicious of anterior spondylitis Page 11 of 24

12 Fig. 2: Sacroiliac findings in the same patient described in figure 1 Page 12 of 24

Fig. 3: 74 years old patient with positive HLA B 27 and lumbar inflammatory pain Fig. 4: 29 years old patient with recurrent lumbar inflammatory pain.

13 Fig. 3: 74 years old patient with positive HLA B 27 and lumbar inflammatory pain Fig. 4: 29 years old patient with recurrent lumbar inflammatory pain.clinical history, age patient and the presence of enthesitis supports the diagnosis of Andersson lesion and help in differential diagnosis with Modic I changes ( degenerative discal pathology) Page 13 of 24

14 Fig. 5: 41 years old patient with ankylosing spondylitis and chronic lumbalgia. MR was performed to evaluate inflammatory activity for changing treatment Page 14 of 24

15 Fig. 6: 53 years old patient with seronegative spondyloarthropathy and inflammatory lumbar pain Page 15 of 24

16 Fig. 7: 34 years old patient with inflammatory spondylitis (positive HLA-B27). Several uveitis in recent years and dorsal inflammatory pain in the last month. Page 16 of 24

17 Fig. 8: 68 years old patient with positive HLA B27 spondyloarthritis and chronic lumbar pain Page 17 of 24

18 Fig. 9: 65 years old patient diagnosed of ankylosing spondylitis with chronic lumbar pain. MRI is performed to detect active lesions that allow a different treatment Page 18 of 24

19 Fig. 10: Psoriatic spondylitis with dorsal and sacroiliac pain in a 43 years old patient Page 19 of 24

20 Fig. 11: 60 years old patient with avanced ankylosis spondylitis Fig. 12: 43 years old patient with non inflammatory lumbar pain Page 20 of 24

21 Fig. 13: 72 years old patient with intense lumbar pain and fever Page 21 of 24

22 Fig. 14: 20 years old patient with right paravertebral lumbar pain. The patient referred a focal direct contusion while he was playing football Fig. 15: 68 years old patient with chronic lumbar pain Page 22 of 24

23 Conclusion SpA s patients outcome improves with early treatment, thus MRI plays an important role in early diagnosis. Early and subtle spinal MRI signs of spondyloarthropaties are often overlooked and can be challenging to recognise if radiologist doesn t suspect inflammatory disease. Radiologist must be familiriazed with the imaging findings and with the proper MRI protocol to avoid performing non diagnostic studies Page 23 of 24

24 References 1. Schueller-Weidekamm C, Mascarenhas VV, Sudol-Szopinska I, et al. Imaging and Interpretation of Axial Spondylarthritis:The Radiologist's Perspective-Consensus of thearthritis Subcommittee of the ESSR. Semin Musculoskelet Radiol 2014;18: Banegas-Illescas ME, López-Menéndez C, Rozas-Rodríguez ML, et al. Nuevos criterios ASAS para el diagnóstico de espondiloartritis. Diagnóstico de sacroileítis por resonancia magnética. Radiología 2014;56(1): Kay-Geert AH, Xenofon B, Désirée H, et al. Descriptions of spinal MRI lesions and definition of a positive MRI of the spine in axial spondyloarthritis: a consensual approach by the ASAS/OMERACT MRI study group. Ann Rheum Dis 2012;71: Kay-Geert AH, Althoff CE, Udo Schneider U, et al. Spinal Changes in Patients with Spondyloarthritis: Comparison of MR Imaging and Radiographic Appearances. RadioGraphics 2005; 25: Jevtic C. Magnetic resonante imaging appereances of different discovertebral lesions. Eur. Radiol 2001;11: Brower AC. Arthritis in Black and White. Madrid: Editorial Marbán; Page 24 of 24

Ankylosing spondylitis: A Pictorial Review

Ankylosing spondylitis: A Pictorial Review Poster No.: P-0009 Congress: ESSR 2012 Type: Scientific Exhibit Authors: J. Acosta Batlle, B. Palomino Aguado, M. D. Lopez Parra, S. 1 2 3 2 4 1 2 Hernandez Muñiz,