1. SACRO-ILIAC JOINT
IMAGING
Montpellier
Pr Catherine Cyteval
Montpellier-France

2. Diarthrodial joint
• Size and 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 capsule only present on the anterior aspect
Sacral part : hyalin + fibrocartilage ( 2 - 5 mm )
Iliac part: fibrocartilage ( 1 - 2 mm )

5. Mr C
36 year-old
Left Coxalgia for two
months
Inflammatory syndroma

6. bilateral sacroiliitis

7. Physiopathology - spondyloarthitis
actives Lesions
Non radiographic SpA
Inflammation
(Enthesitis
Synovitis)
Edema
MRI

8. Sacro iliac Joint
–active Lesions
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
Non radiographic 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 Lesions in MR
erosions
T1
Fatty areas
sclerosis

11. Sacroiliac Joint
T1
–structural Lesions in MR
ankylosis

12. Sacroiliac Joint
–structural Lesions
X rays 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
FORESTIER CLASSIFICATION
• Stade I - Broaden joint
• Stade II - stamps
• Stade III - cloody
• Stade IV - Fusion

14. Sacroiliac Joint
–structural Lesions
FORESTIER CLASSIFICATION
Stade I - Broaden joint
Stade II - stamps
Stade III - cloody
Stade IV - Fusion

15. Sacroiliac Joint
– Structural Lesions
FORESTIER CLASSIFICATION
• Grade I - Pseudo – élargissement
• Grade II - Timbre – poste
• Grade III - Aspect marécageux
• Grade IV - Fusion

16. SpA Diagnostic
Several diagnostic criteria 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
New York
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
axial spondyloarthritis
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
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

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. ASAS 2009

22. ASAS 2009
enthesitis
Not in account
chronic Lesions
T1
sacro-tuberal Ligament
sacro-iliac interosseous Ligament

23. • Aseptic Osteitis (SAPHO):
Unilateral
Massive, sacral and iliac sclerosis

24. Diagnostic value of MRI
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 have an 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 les AINS avant l’IRM?
Evolution of edema with anti TNF
A. Larbi – J Malghem 2010

27. Should we stop NSAIDs 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 stop NSAIDs 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 stop NSAIDs 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 stop NSAIDs before the MRI?
Seems that the response is NO

31. Should we repeat the 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 repeat the 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 repeat the 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 repeat the MRI SI later?
Seems that the response is NO for female
Possible for male

35. 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)

36. Should make sacroiliac and / 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 iliac joint :
– coronal T1- STIR
– Axial STIR
• Spine from T7 to L5:
– Sagittal STIR (or Fat sat T2)

38. • 37 year old 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 58 years 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. upper1/3
Front
Middle
Middle 1/3
Back
Inf 1/3

43. Hyperostosis

44. Inflam. Rh.
SPA
Psoriasis
SAPHO
Sacro-iliac(s)?
(Entérocolopathy)
Osteoarthritis

45. 17 years old male with low back pain

46. Inflam. Rh.
<45 y ears
HyperParaTh
drugs
Sacro-iliac(s)?
Osteoarthritis
Teenager:
>45 years
Pseudo-enlargment
< 20 years
When growth has not finished
Infectious

47. • 67 years old woman with Kidney
insufficiency for 17 years
2rd hyperparathyroidism

48. Inflam. Rh.
HyperParaTh
SPA
Psoriasis
SAPHO
Sacro-iliac(s)?
(Entérocolopathy)
Osteoarthritis
Teenager:
Pseudo-enlargment

49. •
•
•
•
•
C Noémie
24 year-old
A week after delivery
Inflammatory left buttock pain
infl Sd ++++

51. C.Noémie
sept 2011
oct 2011
infectious Sacroiliitis staph

52. Effusion
Unilateral
infectious Sacroiliitis

53. Infectious sacro-iliitis
• Unilateral
• Soft tissus +++
• Effusion

54. on X rays and CT scan
Patterns appear later
1

55. Inflam. Rh.
<45 years
HyperParaTh
Kidney insufficiency
Sacro-iliac(s)?
Infectious
Osteoarthritis
Teenager:
Pseudo-enlargment
< 20 years
>45 years

56. 26 year-old female
fracture

57. Inflam. Rh.
<45 years
HyperParaTh
Kidney insufficiency
Sacro-iliac(s)?
Infectious
Osteoarthritis
Teenager:
Pseudo-enlargment
< 20 years
>45 years
Para articular bone

58. Para articular Decalcification
Hemochromatosis

59. Inflam. Rh.
<45 years
HyperParaTh
Kidney insufficiency
Sacro-iliac(s)?
Infectious
Osteoarthritis
Teenager:
Pseudo-enlargment
< 20 years
>45 years
Para articular bone

60. Mr B., 20 years old
Inflammatory Low back pain

61. ?

62. Inflam. Rh.
HyperParaTh
SPA
Psoriasis
SAPHO
Sacro-iliac(s)?
(Entérocolopathy)
Osteoarthritis
Infectious
Teenager:
Pseudo-enlargment
Para articular bone

63. Inflam. Rh.
HyperParaTh
SPA
Psoriasis
SAPHO
Sacro-iliac(s)?
(Entérocolopathy)
Osteoarthritis
Infectious
Teenager:
Pseudo-enlargment
Para articular bone

64. SPA
?
Mr B

65. Inflam. Rh.
HyperParaTh
SPA
Psoriasis
SAPHO
Sacro-iliac(s)?
(Entérocolopathy)
Osteoarthritis
Infectious
Teenager:
Pseudo-enlargment
Para articular bone

66. Roaccutane (isotrétinoïne):
8 months in 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 Idiopathic Skeletal 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. (26 ans)
Roaccutane for 7 years

71. Inflam. Rh.
<45 years
HyperParaTh
drugs
SPA
Psoriasis
SAPHO
Sacro-iliac(s)?
(Entérocolopathy)
Osteoarthritis
Infectious
>45 years
Teenager:
Pseudo-enlargment
< 20 years
Para articular bone

72. Traps
• Accessory Sacroiliac Joint
Thank you