AXIAL SPONDYLARTHROPATHIES Dr. AYSENUR OKTAY Med School Ege Univ, - PowerPoint PPT Presentation

AXIAL SPONDYLARTHROPATHIES Dr. AYSENUR OKTAY Med School Ege Univ, Radiology Izmir, TR

Axial skeleton: SIJ/ spine � Romatoid arthritis � Seronegative spondylarthropaties � AS � PsA � Reactive arthritis � Spondylitis associated with IBD � Undifferenciated SpA � Juvenile chronic arthritis

Inflammatory changes in SpA � Enthesitis/ subchondral osteitis/ synovitis � � arthropathy, enthesopathy, extraskeletal findings � � may exist in any combination in individual patients Inflammation of bone at sites of ligament insertions = Enthesitis

Garg N. Best Prac & Research Clin Rheumatol 28 (2014) 663-672

Rudwaleit M. J Arthritis Rheum 52 (2005) 1000-1008

Imaging � Initial diagnosis � Assessment of involvements � Follow-up of the diesease � Estimation of prognosis � Detection of complications

SIJ Loss of sharpness of subchondral line/ synovial/ on iliac side Histology: synovitis/ subchondral inflammation Erosions/ sclerosis/ pseudo-widening Histology: cartilage-bone destruction/ fibrosis/ proliferative bony changes

SIJ Total ankylosis/ ligament ossification osteoporosis Changes in synovial and ligamentous portion

Spine � Discovertebral/ apophyseal/ costovertebral/ atlantoaxial joints � Small erosions � Shiny corners (Romanus lesions) � Squaring of vertebral bodies

Spine � Sindesmophyte formation François RJ Ossification, outer layer annulus fibrosus deep layers of longitudinal lig.

Spine � Discovertebral erosion and destruction Andersson lesions Discovertebral inflammation İ ntraosseous discal displacement

Early detection and treatment of SpAs � Biologic agents blocking (TNF-a), and possibly interleukin � Studies since 2008 -- anti-TNF therapy also highly effective in nonradiographic axSpA � ASAS consensus recommendation on use of anti-TNF agents in AS was extended to patients with nr-axSpA → objective verification of disease activity is more important now

ASAS classification criteria for axial SpA Inflammatory back pain ≥ 3 months With age at onset <45 HLA-B27 Sacroiliitis on imaging and and ≥ 2 SpA features ≥ 1 SpA features Sacroiliitis on imaging: MRI: active (acute) inflammation Radiography: findings according to mNew York criteria SpA features: Inflammatory back pain Psoriasis Arthritis NSAID response Enthesitis Family history Uveitis Inflammatory bowel Dactilitis Elavated CRP

ASAS classification Positive MRI Bone marrow edema -2 lesions on same SIJ slice -1 lesion in same SIJ quadr on at least two consecutive slices Enthesitis Synovitis Capsulitis

T1 STIR (ESSR) arthritis subcommittee consensus paper: +C is of diagnostic importance should be applied in doubtful cases T1+C fs Schueller-Weidekamm C, et al. Semin Musculoskelet Radiol (2014)

Diagnostic value of pelvic enthesitis Jans L. Eur Radiol (2014) 24:866–871

T1+C fs

Sacroiliitis: Structural lesions Erosions Subchondral sclerosis Periarticular fat deposition Ankylosis T1 T1 STIR

Cartilage sequences T2 GRE T1 fat sat 3D FLASH DESS

Acute inflammatory lesions in spine ‘Corner sign’ ant/post spondylitis in at least three sites Sensitivity 44%-67% Specifity 81%-97% Hermann KGA. Ann Rheum Dis 2012;71:1278–1288 Canella C. AJR 2013; 200:149-157 T1 STR

spondylodiscitis ‘Andersson lesions’ 33% in patients with SpA 59% specificity Canella C. AJR 2013; 200:149-157 T1 T1+C

Spondylitis: Structural lesions Fat deposition at vertebral corners Erosions Syndesmophytes Ankylosis T1

Spondylitis occurs in 50-67% of AS Rarely - in spine alone 36 E

Monitoring 13.09.2012 STIR 22.01.2013

Imaging research on SpA � Development of a definition of what constitutes a positive MRI for classification of axial SpA * Incorporating structural lesions in the SIJs / inflammatory lesions in the spine *WSM (whole spine MR) and whole body MRI to assess inflammatory lesions outside the SIJs � Development / validation of MRI based quantifying and scoring Weckbach et al. Semin Musculoskelet Radiol 2012 methodologies * Diffusion-w MRI /dynamic CE MRI for inflammatory changes *Methodologies for scoring structural change

Imaging research on SpA � Development of a definition of what constitutes a positive MRI for classification of axial SpA * Incorporating structural lesions in the SIJs / inflammatory lesions in the spine *WSM (whole spine MR) and whole body MRI to assess inflammatory lesions outside the SIJs � Development / validation of MRI based quantifying and scoring methodologies * Diffusion-w MRI /dynamic CE MRI for inflammatory changes *Methodologies for scoring structural change

Thank you