David Salonen

Assessment of radiographic progression in the spines of patients with ankylosing spondylitis treated with adalimumab for up to 2 years

IntroductionAnkylosing spondylitis (AS) is a chronic rheumatic disease associated with spinal inflammation that subsequently leads to progression of structural damage and loss of function. The fully human anti-tumor necrosis factor (anti-TNF) antibody adalimumab reduces the signs and symptoms and improves overall quality of life in patients with active AS; these benefits have been maintained through 2 years of treatment. Our objective was to compare the progression of structural damage in the spine in patients with AS treated with adalimumab for up to 2 years versus patients who had not received TNF antagonist therapy.MethodsRadiographs from patients with AS who received adalimumab 40 mg every other week subcutaneously were pooled from the Adalimumab Trial Evaluating Long-Term Efficacy and Safety for Ankylosing Spondylitis (ATLAS) study and a Canadian AS study (M03-606). Radiographic progression from baseline to 2 years in the spine of adalimumab-treated patients from these two studies (adalimumab cohort, n = 307) was compared with an historic anti-TNF-naïve cohort (Outcome in AS International Study [OASIS], n = 169) using the modified Stoke AS Spine Score (mSASSS) method.ResultsmSASSS results were not significantly different between the adalimumab cohort and the OASIS cohort, based on baseline and 2-year radiographs. Mean changes in mSASSS from baseline to 2 years were 0.9 for the OASIS cohort and 0.8 for the adalimumab cohort (P = 0.771), indicating similar radiographic progression in both groups. When results for patients in the OASIS cohort who met the baseline disease activity criteria for the ATLAS and Canadian studies (OASIS-Eligible cohort) were analyzed, there was no significant difference in mean change in mSASSS from baseline to 2 years between OASIS-Eligible patients and adalimumab-treated patients; the mean changes in mSASSS were 0.9 for the OASIS-Eligible cohort and 0.8 for the adalimumab cohort (P = 0.744).ConclusionsTwo years of treatment with adalimumab did not slow radiographic progression in patients with AS, as assessed by the mSASSS scoring system, when compared with radiographic data from patients naïve to TNF antagonist therapy.Trial registrationCanadian study (M03-606) ClinicalTrials.gov identifier: NCT00195819; ATLAS study (M03-607) ClinicalTrials.gov identifier: NCT00085644.

Low-dose Infliximab (3 mg/kg) Significantly Reduces Spinal Inflammation on Magnetic Resonance Imaging in Patients with Ankylosing Spondylitis: A Randomized Placebo-controlled Study

Objective. To evaluate the influence of low-dose infliximab (IFX) on spinal inflammation scored by magnetic resonance imaging (MRI). The dose recommended for rheumatoid arthritis (3 mg/kg) is also clinically effective for ankylosing spondylitis (AS), although effects on spinal inflammation as defined by MRI have yet to be described in a placebo-controlled trial. Methods. In a 12-week double-blind period, patients were randomized 1:1 to receive either IFX 3 mg/kg at 0, 2, and 6 weeks, or placebo. Spinal inflammation in discovertebral units (DVU) was measured by the Spondyloarthritis Research Consortium of Canada (SPARCC) MRI Index at baseline and 12 weeks by 3 readers blinded to timepoint and treatment allocation. We also compared reliability and discrimination of the SPARCC MRI index based on evaluation of the entire spine (23 DVU score) compared to assessment of only the 6 most severely affected DVU (6 DVU score). Results. At Week 12, patients treated with IFX experienced mean reductions of 55.1% and 57.2% in the 6 DVU and 23 DVU SPARCC scores, respectively, compared with a mean increase of 5.8% and decrease of 3.4% in 6 DVU and 23 DVU scores, respectively, for patients taking placebo (p < 0.001). A large treatment effect (Guyatt’s effect size ≥ 1.7) and high reliability was evident and comparable between 6 DVU and 23 DVU scoring methods. Conclusion. Treatment with low-dose IFX leads to a large treatment effect on spinal inflammation as measured by MRI. Scoring for inflammation of only the most severely affected regions of the spine by MRI is comparable to assessment of the entire spine.

ROTATOR CUFF EVALUATION: IMAGING AND DIAGNOSIS

A variety of disorders can lead to disease and pathology of the rotator cuff tendons. The most important information is obtained during a careful history and physical examination. With the judicious use of various diagnostic modalities, evaluation of the cause of the rotator cuff disease is possible.

Is the Madrid Sonographic Enthesitis Index Useful for Differentiating Psoriatic Arthritis from Psoriasis Alone and Healthy Controls

Objective. To assess the usefulness of the MAdrid Sonographic Enthesitis Index (MASEI) in classifying patients as having psoriatic arthritis (PsA) and comparing entheseal abnormalities between patients with PsA, psoriasis alone (PsC), and healthy controls (HC). Methods. Patients with PsC were assessed to exclude inflammatory arthritis. The MASEI scoring system was used to quantify the extent of ultrasonographic (US) entheseal abnormalities. The total MASEI score was categorized into items that reflected inflammatory abnormalities (MASEI-inflammatory) and chronic damage (MASEI-damage). Nonparametric tests were used to compare MASEI scores across the groups. A cutoff point of MASEI ≥ 20 was used to calculate the sensitivity and specificity of the MASEI to classify patients as having PsA. Results. Patients with PsA (n = 50), PsC (n = 66), and HC (n = 60) were assessed. Total MASEI scores were higher in patients with PsA than in those with PsC, and both those groups were higher than HC (p < 0.0001). MASEI-inflammatory showed a similar trend (p < 0.0001). MASEI-damage was higher in patients with PsA compared to both patients with PsC and HC (p < 0.0001); however, no difference was observed between patients with PsC and HC. No significant difference in MASEI scores was found across the 3 groups in patients with a body mass index > 30. The sensitivity of the MASEI score to correctly classify patients as having PsA was 30% and the specificity was 95% when compared to HC and 89% when compared to PsC. Conclusion. The severity of US entheseal abnormalities is highest in patients with PsA followed by PsC and is lowest in healthy controls. MASEI can specifically classify patients as having PsA.

Trunnionosis: the latest culprit in adverse reactions to metal debris following hip arthroplasty

The imaging findings of periprosthetic soft tissue lesions (pseudotumours) have been typically defined in the context of newer second-generation metal-on-metal hip arthroplasty. More recently, similar findings have been described in the setting of non-metal-on-metal prostheses. Although uncommon, wear and corrosion between the metal surfaces at the head-neck (‘trunnionosis’) and neck-stem interfaces are the potential culprits. With modular junctions containing at least one cobalt chromium component frequently present in hip arthroplasty prostheses, the incidence of this mode of adverse wear may be higher than previously thought (irrespective of the specific bearing couple used). In the present report, we described a case of a severe adverse local tissue reaction secondary to suspected corrosion at the head-neck taper in a metal-on-polyethylene total hip arthroplasty and reviewed the literature. Knowledge of this topical entity should help radiologists facilitate early diagnosis and ensure early management of this potentially serious complication.

Significance of Clinical Evaluation of the Metacarpophalangeal Joint in Relation to Synovial/Bone Pathology in Rheumatoid and Psoriatic Arthritis Detected by Magnetic Resonance Imaging

Objective. Rheumatologists base many clinical decisions regarding the management of inflammatory joint diseases on joint counts performed at clinic. We investigated the reliability and accuracy of physically examining the metacarpophalangeal (MCP) joints to detect inflammatory synovitis using magnetic resonance imaging (MRI) as the gold standard. Methods. MCP joints 2 to 5 in both hands of 5 patients with rheumatoid arthritis (RA) and 5 with psoriatic arthritis (PsA) were assessed by 5 independent examiners for joint-line swelling (visually and by palpation); joint-line tenderness by palpation (tender joint count, TJC) and stress pain; and by MRI (1.5 Tesla superconducting magnet). Interrater reliability was assessed using kappa statistics, and agreement between examination and corresponding MRI assessment was assessed by Fisher’s exact tests (p < 0.05 considered statistically significant). Results. Interrater agreement was highest for visual assessment of swelling (κ = 0.55–0.63), slight-fair for assessment of swelling by palpation (κ = 0.19–0.41), and moderate (κ = 0.41–0.58) for assessment of joint tenderness. In patients with RA, TJC, stress pain, and visual swelling assessment were strongly associated with MRI evaluation of synovitis. Visual swelling assessment demonstrated high specificity (> 0.8) and positive predictive value (= 0.8). For PsA, significant associations exist between TJC and MRI synovitis scores (p < 0.01) and stress pain and MRI edema scores (p < 0.04). Assessment of swelling by palpation was not significantly associated with synovitis or edema as determined by MRI in RA or PsA (p = 0.54–1.0). Conclusion. In inflammatory arthritis, disease activity in MCP joints can be reliably assessed at the bedside by examining for joint-line tenderness (TJC) and visual inspection for swelling. Clinical assessment may have to be complemented by other methods for evaluating disease activity in the joint, such as MRI, particularly in patients with PsA.

Validation of Digital Radiology Measurement Tools for Quantitative Spinal Imaging

Background/Objective: Digital imaging tools for linear and angular measurements facilitate measurement requirements compared to conventional techniques. However, the accuracy of these measurements, especially in spinal trauma, has not been assessed. The objective of this study was to validate current onscreen measurement tools available on picture archiving and communication systems (PACS) for distance and angular measurements in cervical spine plain digital radiographs and computed tomographic (CT) images. Method: A cervical spine sawbone was prepared with radio-opaque markers at known distances and angles. This model was then imaged with digital plain radiographs (spine model at a fixed [24 cm] and variable distance from the X-ray receiver) and CT (1-mm slice thickness) at 4 centers. Using 4 different commercially available digital imaging viewing programs, linear and angular measurements were performed by a musculoskeletal radiologist and 5 spinal surgeons. Results: At only 24 cm (distance from the ana...

MRI of the glenoid labrum with gross anatomic correlation

The objective of this pictorial essay is to illustrate the magnetic resonance image (MRI) appearance of the glenoid labrum and the perilabral structures with and without instillation of intraarticular contrast material. Ten cadaveric shoulder specimens underwent axial MRI using various MR pulse sequences. The shoulders then were transversely sectioned, and the gross morphology of the labrum and perilabral structures was evaluated and correlated with the MR images. The contrast-enhanced sequences allowed for improved anatomic visualization of the structures evaluated.

Development and Validation of the Spondyloarthritis Radiography Module for Calibration of Readers Using the Modified Stoke Ankylosing Spondylitis Spine Score

To develop and validate a reference image module aimed at calibration of readers using the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS) to assess radiographic progression in spondyloarthritis.

Use and abuse of magnetic resonanceimaging in sports medicine

Abstract MRI (magnetic resonance imaging) is a non-invasive imaging modality used in the evaluation of musculoskeletal injury. It has provided a specific advantage in the athletic population given the numerous soft-tissue injuries which are encountered. The work-up of the injured athlete, however, must include a careful history, complete physical examination and appropriate use of plain radiographs. The MRI should be used as an adjunct and not as a substitute for thorough clinical evaluation. The future management of sport-related musculoskeletal injury will undoubtedly be shaped by MRI and its related technologies.