MRT av spondylartrit. Spondylartropatier. Diagnostik. Modern behandling. Spondylartropatier karaktäriseras av
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1 MRT av spondylartrit Mats Geijer SUS Lund Magnetic resonance imaging (MRI) in diagnosis of axial spondylarthritis Part Course Directors: Lars Erik Kristensen, Department of Rheumatology, Skåne University Hospital, Malmö Mats Geijer, Consultant Radiologist, Department of Radiology and Physiology, Skåne University Hospital, Lund Date 9 december 04 Location Göteborg ENB04007PSE0 Spondylartropatier Grupp av överlappande sjukdomstillstånd Ankyloserande spondylit / Mb. Bechterew Reaktiv artrit (Campylobacter, Yersinia, Shigella, Chlamydia spp.) Enteropatisk spondylit (Mb. Crohn, ulcerös colit) Psoriasisartrit Odifferentierad spondylartropati Spondylartropatier karaktäriseras av Sacroiliit och (ascenderande) spondylit Sacroiliitis is the hallmark of ankylosing spondylitis Perifer artrit (juxtaartikulär > intraartikulär) Entesopati (senfästen, kapselfästen) Familjär disposition Association med HLA-B7 Smygande debut med svår klinisk diagnos Tidigare svår radiologisk tidigdiagnos Tidigare endast symptomatisk behandling Nu bra radiologi Nu bra behandling 4 Modern behandling Sjukgymnastik NSAID DMARD Corticosteroider Sulfasalazin Metotrexat Biologiska läkemedel TNFα-blockerare (tumornecrosis factoralpha) Infliximab - Remicade Adalimumab Humira Receptorprotein Etanercept- Enbrel Diagnostik Anamnes och status BASMI (Bath Ankylosing Spondylitis Metrology Index) BASFI (Bath Ankylosing Spondylitis Functional Index) Laboratorieprover? Radiologisk utredning kotpelare och sacroiliacaleder Röntgen Magnetisk resonanstomografi Datortomografi 5 6
2 Kliniska symptom AS 7 8 Patologi CT of sacroiliitis Inflammation i enteser Ligamentfästen, senfästen Diskkapsel circumferentkring disken Ledkapslar (facettleder, costovertebralleder, costotransversalleder) Benresorption (apofysit, leddestruktion) Bennybildning (syndesmofyter, hypertrofa pålagringar) Ankylos Four cases of ankylosing spondylitis; from mild to severe disease Psoriatic arthritis Reactive arthritis 9 Pathologic findings: Erosions, sclerosis, ankylosis Magnetic resonance imaging (MRI) Anatomic sites for inflammatory changes Since990 High sensitivity and specificity Active inflammation Juxta-articular bone marrow Effusion Contrast enhancing inflammatory tissue Disk, surrounded by capsule and ligaments Costo-vertebral joints Costo-transverse joints Chronic post-inflammatory changes Fatty metaplasia of bone marrow Erosions Sclerosis Ankylosis Facet joints (not shown on image)
3 Anatomic sites for inflammatory changes Normal variants and non-inflammatory disease With increasing age Accessory sacroiliac joints DISH (Diffuse idiopathic skeletal hyperostosis, Mb Forestier Rotes-Querol) Costo-vertebral joints -0 Costo-transverse joints Ribs 0 articulate at disk level Ribs articulate on vertebral body Costo-vertebral joints - Normal variants and non-inflammatory disease Stress-related Inflammatory and post-inflammatory sacroiliitis 5 4 OCI (Osteitis condensans ilii) Radiography Same patient on both images CT Inflammation Enthesitis (inflammation of the entheses insertion points for ligaments and joint capsules) Post-inflammatory reparative and/or destructive changes Fatty conversion of bone marrow 4 Sclerosis and new bone formation Erosions 5 Ankylosis Enthesitis (radiographic Romanus lesions, corner lesions on MRI) Enthesitis (radiographic Romanus lesions, corner lesions on MRI)
4 Enthesitis (radiographic Romanus lesions, corner lesions on MRI) Enthesitis (radiographic Romanus lesions, corner lesions on MRI) Enthesitis (radiographic Romanus lesions, corner lesions on MRI) Enthesitis (radiographic Romanus lesions, corner lesions on MRI) MRI: Examination protocol for.5 or T Spin-echo (SE) -weighted sequence. Bone marrow Used for anatomy, and for chronic changes such as fatty metaplasia of bone marrow, sclerosis, and erosions. Bright pelvic veins Dark subcutaneous fat Signal information from fat. Erosions Bright subcutaneous fat Used to detect active inflammation with bone marrow. All signal from fat is extinguished, and signal is derived exclusively from water. MRI: Examination protocol for.5 or T (Short tau inversion recovery) sequence
5 Additional sequences are optional MRI: Examination protocol for.5 or T SE -weighted with fat saturation or proton density (PD) with fat saturation may show erosions better Scan planes, anatomy Oblique coronal sections Parallel to the anterior border of the sacrum (about S level), mm thick Intravenous gadolinum contrast has not been shown to have added value in diagnosis Oblique axial sequences Perpendicular to the sacrum, -4 mm thick Inflammatory pathologic changes Oblique coronal Oblique coronal SE Enthesitis with bone marrow Fatty metaplasia of bone marrow Erosions 4 Ankylosis 4 Oblique coronal and SE Oblique axial (or TSE T fs) MRI protocol for axial SpA Small areas of fatty infiltration or tous high signal may be seen in healthy individuals. According to the ASAS classification criteria there should be minimum areas of clearly present bone marrow highly suggestive of SpA or in contiguous sections MRI protocol for axial SpA Costovertebral joint Sequences Scan orientation, anatomy active inflammation, bone marrow Sagittal scanning Two scans to cover entire spine (cervico-thoracic + thoracolumbar) SE anatomy, postinflammatory fatty replacement of bone marrow Wider scanning than for regular lumbar spine MRI in order to cover area for costo-vertebral and costo-transverse joints Oblique axial Recommended standard examination protocol Costo-transverse joint 5
6 Midline Active corner lesions and sacroiliitis Healthy Small areas with bone marrow or fatty infiltration is a common finding in healthy individuals. At least tous or 5 fatty infiltration areas are needed for diagnosis of AS on MRI. With diagnosis Far lateral Differential diagnosis Sacroiliac joints in the same patient. Ankylosis, fatty infiltration, small areas of bone marrow Ankylosis Fatty infiltration Bone marrow Arthritis expanding into soft tissues with abscess formation. fs Gd T Before treatment February 6 March 6 Infectious (septic) sacroiliitis After 6 weeks After treatment, healing of soft tissue infection but increasing bone marrow changes Stürzenbecher et al. MR im aging of septic sacroiliitis. Skeletal Radiol. 000;9: Differential diagnosis Sacral insufficiency fracture, 74-year-old female The diagnosis of AS can often be found in prior studies T fs July 0 MRI of the SI joints, sacroiliitis Erosions Fatty replacement Bone marrow MRI of the lumbar spine, missed sacroiliitis T July 5 Bone marrow Fracture line Bone marrow 6
7 The diagnosis of AS can often be found in prior studies The diagnosis of AS can often be found in prior studies Sacroiliac joint radiography four years before: Missed diagnosis (right-sided sacroiliitis, suspicious on the left) Three years before: Pelvis and hip radiography. Missed diagnosis (right-sided sacroiliitis, suspicious on the left) Sacroiliitis with sclerosis and erosions Våga ställa diagnos! The diagnosis of AS can often be found in prior studies Sclerosis Polytrauma five years before: Missed diagnosis (unilateral sacroiliitis rightsided sacroiliitis, suspicious on the left) Samtidigt: Erosions -årig kvinna. Ryggproblem ett par år. SI-leder? Exakt ett år tidigare 7
8 Jämför CT och MRT Ytterligare 7 månader tidigare. Bilateralt benmärgsödem - sacroiliit Rekommenderad läsning MRT: Sieper J., et al. The Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to assess spondyloarthritis. Ann Rheum Dis 009; 68 ():-44. Datortomografi: Geijer M. Clinical utility and evaluation of radiology in diagnosing sacroiliitis (Thesis). Gothenburg University Röntgenundersökning: Braum L, Hermann K-GA. Utility of imaging in the diagnosis and assessment of axial spondyloarthritis. Int J Adv Rheumatol 00; 8:7-5. Vill ni veta mer? ENB040905PSE0 8
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