MRI IN ASSESSMENT OF THE SYSTEMIC MANIFESTATIONS OF RHEUMATOLOGICAL DISEASE

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1 British Journal of Rheumatology 1996;35(suppl. 3):40-44 MRI IN ASSESSMENT OF THE SYSTEMIC MANIFESTATIONS OF RHEUMATOLOGICAL DISEASE F. KAINBERGER,* S. TRATTNIG,* C. CZERNY,* G. SEIDL,* H. KRITZt and H. DVfflOF* *Department of Diagnostic Radiology, Section Osteoradiology, and MR-Institute, University of Vienna, and Ludwig-Boltzmann-Institutjur radiologisch-physikalische Tumordiagnostik and f Rehabilitation Center Engelsbad, Badenl'Austria SUMMARY Magnetic resonance imaging (MRI) has emerged as complementary imaging modality to conventional radiography. The same diagnostic rules that are used in the interpretation of the routine radiographs should be applied to the analysis of MR images with the macroscopic spread of the disease as a main diagnostic clue. MRI has been shown to be a sensitive tool in detecting early arthritic changes and erosions, inflammation in periarticular tendons and tendon sheaths, and in juxtaarticular bursae. MRI plays a pivotal role in diagnosis of arthritis of the craniocervical junction and its complications. It also has been used effectively to detect insufficiency fractures and osteonecrosis. MRI may be important in diagnosing early arthritis, in specifying the differential diagnosis of rheumatic disease, and in selecting subgroups of patients to provide tailored therapeutic regimens. KEY WORDS: Arthritis, rheumatoid, Atlas and axis, Fractures, insufficiency, Joints, temporomandibular, Magnetic resonance (MR), Tendons. INTRODUCTION WITH ITS high contrast-resolution of soft tissue structures, MRI has emerged as an imaging modality that is complementary to conventional radiography. In RA virtually all joints of the appendicular skeleton and of the vertebral column have been investigated with MRI [1]. From plain film analysis it is well known that the specificity of the abnormalities is, in part, based on their distribution. The same diagnostic rules that are used in the interpretation of routine radiographs should be applied on the analysis of MR images with the macroscopic spread of the disease as a main diagnostic clue [2-4]. PERIPHERAL JOINTS Erosions of the articular bones are distinctive radiograph findings in patients with RA and are associated with a poor prognosis [5]. In several studies MRI was shown to be a sensitive tool in detecting early arthritic changes and erosions not visible on conventional plain films [6, 7]. Moore et al. described the MRI features of a rheumatoid arthritic geode [3]. Development of such a cyst from before X-ray diagnosis to its coalescence with the wrist joint was observed. The authors concluded that these juxta-articular cysts are not merely an intrusion of the synovial cavity into the bone marrow but start as isolated structures beneath the subchondral bone. According to preliminary results of Giovagnoni et al [8], MRI might play a role in the differentiation of RA and the 'rheumatoid-like' form of psoriatic arthropathy. Correspondence to: F. Kainbergw; Univ.-KJinik fur Radiodiagnostik, AKH, Wftehringer Guertel 18-20, A-1090 Vienna/Austria. Important signs for differentiating these two entities were tendon sheath effusion and the number and location of soft-tissue swelling and subchondral erosions. These results again stress the importance of the distribution of MR findings in the differential diagnosis of rheumatic diseases. TENDONS AND TENDON SHEATHS Inflammation of tendon sheaths is a well-known manifestation of RA. Changes in periarticular tendons and tendon sheaths are, in part, characteristic and can assist in diagnosis [9, 10]. Pierre-Jerome et al. [11] conducted a comparative study looking at soft-tissue changes in the carpal tunnel. Results were correlated with neurophysiological studies and showed a tendency for lower median nerve function in patients with tenosynovitis. Sinus-tarsi syndrome is a clinical entity characterized by pain in the lateral part of the hindfoot and the feeling of instability [12]. Although the incidence as a sequelae of rheumatic disease is not known exactly, it is assumed that ~30% of this entity occurs in patients with RA, seronegative spondylarthropathies or gout [12, 13]. Pannus forms in the posterior subtalar joint with destructive changes of the intraosseous ligament, the neighbouring tendons and the bone. With MRI, the onset and extent of these abnormalities are visualized to better advantage than with plain film radiography [12]. A case of a spontaneous Achilles tendon rupture occurring after a 2-year history of seropositive RA was reported by Matsumoto et al [14]. Histologica] section of the ruptured Achilles tendon revealed the existence of rheumatoid granulation within the tendon tissue. These facts suggested that tendon inflammation was a possible cause of Achilles tendon rupture in this patient withra. C 19% British Society for Rheumatology 40

2 KAINBERGER ETAL: IMAGING OF ARTICULAR INVOLVEMENT 41 BURSITIS AND FORMATION OF SYNOVIAL CYSTS Juxta-articular bursae may contain a considerable synovial volume, and may therefore be involved in inflammatory disease to the same or to an even higher degree than the joint itself. Soft-tissue imaging with high-resolution sonography or MRI offers the opportunity to detect and quantify the extent of Baker's cyst, subacromial-subdeltoid bursitis, iliopsoas bursitis or other forms of synovial cysts. Sonography should be the first imaging modality used to visualize synovial cysts. MRI, including the technique of magnetization transfer contrast, is a helpful imaging tool if fibrous strands, excessive synovial proliferation or complications lead to an unusual appearance. CRANIOCERVICAL JUNCTION Several types of subluxation develop at the occipitoatlantoaxial junction. Each type, including anterior, vertical, lateral and posterior displacement, is equally apparent on MR images [15]. The sensitivity of myelopathy correlates better with the MR imaging findings than those noted with conventional radiography [16]. Contrast-enhanced T\ -weighted spin-echo imaging can discriminate between joint effusion and the form and FIG. 1 Typical manifestation of RA of the knee. Pannus forms in the synovia covering the anterior cruciate ligament (a) T\- weighted " " T i (b) T\ -weighted after administration of Gd-DTPA.

3 42 MRI IN ASSESSMENT OF RA extension of pannus in patients with RA in this region [17]. Although the advantages of MR imaging of the cervical spine in patients with RA are obvious, the technique appears to be less effective in the evaluation of the apophyseal joints and spinous processes [18]. TEMPOROM ANDIBULAR JOINT MR imaging has been used effectively to assess the temporomandibular joint. Rheumatic joints showed moderate or intense soft-tissue enhancement along the disk and articular surfaces, and therefore differed significantly in their appearance from non-rheumatic disease [19]. modality in RA and related diseases because of its easy access, low cost and the possibility of surveying the inflammatory lesions. However, with MRI many of the 'blind spots' of imaging algorithms may be illuminated. Despite the high sensitivity of MRI in showing early bone and soft-tissue lesions, its availability is restricted, due to its high cost and limited distribution. This situation may change in the future MRI may be important in diagnosing early arthritis, in specifying the differential diagnosis of rheumatic diseases, and in selecting subgroups of patients to provide tailored therapeutic regimens to better advantage. REFERENCES BONE: INSUFFICIENCY FRACTURES AND ISCHAEMIC NECROSIS Insufficiency fractures are a common cause of pain but are often overlooked in patients with RA [20]. Bone scintigraphy is recommended for diagnosis. With the increasing number of MRI investigations in the field of rheumatology, radiologists should be aware of the different forms of stress reactions of the bone. The value of MRI in diagnosing osteonecrosis is well appreciated [21]. Zizic [22] reported 28% of intracapital trabecular fractures in patients with painful hips due to RA. In systemic lupus erythematosus patients, the mean maximal daily dose of prednisone was significantly greater in patients with osteonecrosis than in those without bony complications [22]. CONCLUSION Plain-film radiography is still the main imaging 1. Rcsnick D, Niwayama G: Rheumatoid arthritis. In: Resnick D, Niwayama G (eds) Diagnosis of bone andjoint disorders, 3rd cdn. WB. Saunders, Philadelphia, Kieft GJ, Dijkmans BAC, Bloem JL, Kroon HM. Magnetic resonance imaging of the shouler in patients with rheumatoid arthritis. Ann Rheum Dis 1990;49:7-l Moore EA, Jacoby RK, Ellis RE, Fry ME, Pittard S, Vennart W Demonstration of a geode by magnetic resonance imaging: a new light on the cause of juxtaarticular bone cysts in rheumatoid arthritis. Ann Rheum Dis 199O;49: Poleksic L, Zdravkovic D, Jablanovic D Watt I, Back G. Magnetic resonance imaging of bone destruction in rheumatoid arthritis: comparison with radiography. Skeletal Radiol 1993^2: Fleming A, Crown JM, Corbett M. Progostic value of early features in rheumatoid arthritis. Br Med J 1986^: Fbley-Nolan D, Stack JP, Redmond RU. Magnetic resonance imaging in the assessment of rheumatoid FIG. 2 Fifty-six-year-old female with long-standing RA. Pannus formation (large arrow) in the sinus tarsi with dorsal extension in the posterior talocalcaneal joint and involvement of the adjacent tendon sheaths (small arrow).

4 KAINBERGER ETAL: IMAGING OF ARTICULAR INVOLVEMENT 43 (a) Fio. 3 Two types of rheumatoid pannus in the atlantoaxial junction of different patients. Both lead to compression of the spinal canal, (a) Pannus covers the dens and extends dorsally with compression of the spinal cord, (b) Pannus form within the anterior atlantodental joint with dorsal sutduxation of the dens. arthritis a comparison with plain film radiographs. Br J Rheumatol : Rominger MB, Bernreuter WK, Kcnney P, Morgan SL, Blackburn WD, Alarcon GS. MR imaging of the hands in early rheumatoid arthritis: preliminary results. Radiographics 1993;13: Giovagnoni A, Grassi W, Terilli F, Blasetti P, Pad E, Ercolani P, Cervini C MRI of the hand in psoriatic and rhenmatical arthritis. Eur Radiol 1995^: Rubens DJ, Blebea JS, Totterman SMS, Hooper MM. Rheumatoid arthritis: evaluation of wrist extensor tendons with clinical examination versus MR imaging a preliminary report. Radiology 1993;187: Sanchez RB, Quinn SF. MRI of inflammatory synovial processes. Magnt Res Imag 1989^7: Pierre-Jerome C, Bekkelund SI, Husby G, MeHgren SL. Bilateral fast MRI of the carpal tunnel in rheumatoid arthritis. ESMRMB, 11th Annual Scientifc Meeting, Vienna 1994, Abstract Book Trattnig S, Breitenseher M, Haller J, Heinz-Peer G, Kukla C, Imhof H. Sinus-tarsi-syndrome MRI diagnosis. Radiologe : Kjaergaard-Andersen P, Soballe K, Andersen K, Pilgaard S. Sinus tarsi syndrome: presentation of seven cases and review of the literature. J Foot Surg 1989^8: Matsumoto K, Hukada S, Nishioka J, Asajima S. Rupture (b)

5 44 MRI IN ASSESSMENT OF RA of the Achilles tendon in rheumatoid arthritis with histologic evidence of enthesitis. A case report. Gin Orthop 1992;280: Reynolds H, Carter SW, Murthagh FR, Silbiger M, Rechtine GR. Cervical rheumatoid arthritis: value of flexion and extension views in imaging. Radiology 1987;164: Yamashita Y, Takahashi M, Sakamoto, Kojima R. Atlantoaxial subluxation. Radiography and magnetic resonance imaging correlated to myelopathy. Ada Radio! [Diag] 1989;3O: Stiskal MA, Neuhold A, Szolar DH, Saeed M, Czerny C, Leeb B, Smolen J, Czembirek H. Rheumatoid Arthritis of the craniocervical region by MR imaging, detection and characterisation. AJR 1995; 165: Bundschuh C, Modic MT, Kearney F, Morris R, Deal C. Rheumatoid arthritis of the cervical spine: surface-coil MR imaging. Am J Rheumatol 1988;151: Smith H-J, Larheim TA, Aspestrand F. Rheumatic and nonrheumatic disease in the temporomandibular joint gadolinium-enhanced MR Imaging. Radiology 1992; 185: Wei N. Stress fractures of the distal fibula presenting as monarticular flares in patients with rheumatoid arthritis. Arthritis Rheum 1994;7: Kramer J, Hofmann S, Imhof H. The non-traumatic femur head necrosis in the adult. II: radiologic diagnosis and staging. Radiologe 1994^4: Zizic TM. Osteonecrosis. Curr Opin Rheumatol. 1991; 3:481-9.