Monique Reijnierse

Clinical indications for musculoskeletal ultrasound: A Delphi-based consensus paper of the European society of musculoskeletal radiology

AbstractObjectiveTo develop clinical guidelines for musculoskeletal ultrasound (MSKUS) referral in Europe.MethodsSixteen musculoskeletal radiologists from seven European countries participated in a consensus-based interactive process (Delphi method) using consecutive questionnaires and consensus procedure meetings at several European radiology meetings. The evaluation of musculoskeletal diseases was established by literature reviews, followed by consensus on clinical utility in three consensus meetings. This involved a thorough, transparent, iterative approach which including interview, questionnaire, Delphi and standard setting methodologies. European MSK radiologists with a special interest in MSKUS formed two different expert groups who worked on reaching a consensus in the first two meetings. The third meeting resolved questions that did not achieve a consensus level of 67% using the first two questionnaires.ResultsOn expert consensus, the use of MSKUS is indicated to detect joint synovitis, fluid and septic effusion for potential aspiration, and poorly indicated to detect loose bodies. Recommendations for most appropriate use of musculoskeletal ultrasound are reported in six areas relevant to musculoskeletal ultrasound: hand/wrist, elbow, shoulder, hip, knee and ankle/foot.ConclusionA comprehensive evidence-based, expert consensus-defined educational framework on clinical ultrsound is presented. This should facilitate referrals for this important imaging technique throughout Europe.Key Points• Musculoskeletal ultrasound is indicated for detecting joint synovitis, effusions and fluid collections. • Musculoskeletal ultrasound is poor at detecting loose bodies. • Musculoskeletal ultrasound is relevant for most joints.

Pain in hand osteoarthritis is associated with inflammation: the value of ultrasound

Objectives To investigate the association of ultrasound (US) features—grey scale (GS) synovitis, synovial thickening, effusion and power Doppler signal (PDS)—with symptoms in hand osteoarthritis (HOA). Methods Fifty-five consecutive patients (mean age 62 years, 87% women) with HOA, fulfilling the American College of Rheumatology criteria, were assessed for pain upon palpation and filled in Australian/Canadian Osteoarthritis Index (AUSCAN) scores, visual analogue scale pain and Short Form-36 (SF-36). US was performed in all metacarpophalangeal, proximal interphalangeal, distal interphalangeal, first interphalangeal and first carpometacarpal joints, and features were semiquantitatively scored (0–3). Generalised estimating equations were used to calculate OR (95% CI) for the association between US features and pain per joint adjusted for relevant confounders. The association between US features summated scores and self-reported outcomes was studied by linear regression analysis. Results GS synovitis, effusion, synovial thickening and PDS were shown in 96%, 91%, 73% and 86% of patients, respectively. US features were dose-dependently associated with pain upon palpation (OR 4.5 (95% CI 2.2 to 9.0), 4.4 (2.0 to 9.4), 4.9 (2.2 to 11.0) and 4.1 (2.2 to 7.9)). GS synovitis was associated with AUSCAN pain, stiffness and SF-36, and effusion with AUSCAN pain. Conclusions GS synovitis, effusion, synovial thickening and PDS are associated with pain in HOA, suggesting a role for inflammation. Further follow-up studies are warranted.

MR imaging of edema accompanying benign and malignant bone tumors

To evaluate the incidence, quantity, and presentation of intra- and extraosseous edema accompanying benign and malignant primary bone lesions, the magnetic resonance (MR) studies of 63 consecutive patients with histologically proven primary bone tumors were reviewed. MR scans were assessed for the presence and quantity of marrow and soft tissue edema and correlated with peroperative findings, resected specimens and follow-up data. The signal intensity and enhancement of tumor and edema prior to and after intravenous administration (if any) of gadolinium-labled diethylene triamine pentaacetate (Gd-DTPA) was analyzed. Marrow edema was encountered adjacent to 8 of 39 malignant tumors and 14 of 24 benign lesions. Soft tissue edema was found accompanying 28 of 39 malignancies and 10 of 24 benign disorders. On unenhanced T1-weighted MR images tumor and edema were difficult to differentiate. Tumor inhomogeneity made this differentiation easier on T2-weighted sequences. In 36 patients the contrast medium Gd-DTPA was used. Edema was present in 27 of these patients and the respective enhancement of tumor and edema could be compared. Edema always enhanced homogeneously, and in most cases it enhanced to a similar degree as or more than tumor. Marrow and, more specifically, soft tissue edema is a frequent finding adjacent to primary bone tumors. The mere presence and quantity of marrow and soft tissue edema are unreliable indicators of the biologic potential of a lesion. Unenhanced MR scans cannot always differentiate between tumor and edema, but the administration of Gd-DTPA is of assistance in differentiating tumor from edema. Awareness of marrow and/or soft tissue edema adjacent to bone lesions is of importance because edema can be a pitfall in the diagnostic work-up and staging prior to biopsy or surgery.

Comparison of dixon and T1-weighted MR methods to assess the degree of fat infiltration in duchenne muscular dystrophy patients

To compare different lipid multipeak spectral models to the single‐peak model in Dixon‐based fat‐water separation and to evaluate differences between visually scored magnetic resonance (MR) images and quantitatively assessed fat fractions in muscle of Duchenne muscular dystrophy patients.

Defining active sacroiliitis on MRI for classification of axial spondyloarthritis: update by the ASAS MRI working group

Objectives To review and update the existing definition of a positive MRI for classification of axial spondyloarthritis (SpA). Methods The Assessment in SpondyloArthritis International Society (ASAS) MRI working group conducted a consensus exercise to review the definition of a positive MRI for inclusion in the ASAS classification criteria of axial SpA. Existing definitions and new data relevant to the MRI diagnosis and classification of sacroiliitis and spondylitis in axial SpA, published since the ASAS definition first appeared in print in 2009, were reviewed and discussed. The precise wording of the existing definition was examined in detail and the data and a draft proposal were presented to and voted on by the ASAS membership. Results The clear presence of bone marrow oedema on MRI in subchondral bone is still considered to be the defining observation that determines the presence of active sacroiliitis. Structural damage lesions seen on MRI may contribute to a decision by the observer that inflammatory lesions are genuinely due to SpA but are not required to meet the definition. The existing definition was clarified adding guidelines and images to assist in the application of the definition. Conclusion The definition of a positive MRI for classification of axial SpA should continue to primarily depend on the imaging features of ‘active sacroiliitis’ until more data are available regarding MRI features of structural damage in the sacroiliac joint and MRI features in the spine and their utility when used for classification purposes.

Magnetic resonance imaging of skeletal muscles in sporadic inclusion body myositis

OBJECTIVE To analyse whether MRI of upper and lower extremity muscles in a large patient group with sporadic IBM (sIBM) is of additional value in the diagnostic work-up of sIBM. METHODS Thirty-two sIBM patients were included. Magnetic resonance (MR) parameters evaluated in 68 muscles of upper and lower extremity were muscle atrophy, fatty infiltration and inflammation. These findings were correlated with disease duration, weakness and serum creatine kinase (sCK) levels. RESULTS Fatty infiltration was far more common than inflammation. Muscles most frequently infiltrated with fat were the flexor digitorum profundus (FDP), anterior muscles of the upper leg and all muscles of the lower leg, preferentially the medial part of the gastrocnemius. The rectus femoris was relatively spared compared with other quadriceps muscles as well as the adductors of the upper leg. Inflammation was common in general, but individually sparse, present in 78% of the patients with a median of two inflamed muscles per patient. A statistically significant correlation was found between the amount of fatty infiltration and disease severity, disease duration and sCK. CONCLUSION We provide a detailed description of the MRI in sIBM and show a distinct pattern of muscle involvement. Relatively severe affliction of the medial compartment of the gastrocnemius, combined with relative sparing of the rectus femoris or involvement of the FDP can be indicative of sIBM. MRI can contribute to the diagnosis in selected patients with clear clinical suspicion, but lacking the mandatory set of muscle biopsy features.

Percentage of patients with spondyloarthritis in patients referred because of chronic back pain and performance of classification criteria: experience from the Spondyloarthritis Caught Early (SPACE) cohort

Objectives. The objectives of the study are to describe the Spondyloarthritis Caught Early (SPACE) cohort, present the performance of various SpA classification criteria and compare patients fulfilling the imaging arm with patients fulfilling the clinical arm of the Assessment of Spondyloarthritis international Society (ASAS) axSpA criteria on demographics, presence of SpA features and level of disease activity. Methods. Patients with back pain (53 months but 42 years, onset <45 years) visiting the rheumatology outpatient clinic of the Leiden University Medical Center were included in the SPACE cohort. Patients were classified according to the modified New York (mNY), ESSG, Amor and ASAS axSpA criteria. The sensitivity and specificity of criteria were tested against a rheumatologist’s diagnosis. Results. In total, 157 patients were included; 92 patients fulfilled any criteria, 11 fulfilled the mNY (sensitivity 16.9%, specificity 100%), 68 the ESSG (sensitivity 64.6%, specificity 71.7%), 48 the Amor (sensitivity 47.7%, specificity 81.5%) and 60 the ASAS axSpA criteria (sensitivity 84.6%, specificity 94.6%). Of those 60 patients, 30 fulfilled the imaging arm and 30 the clinical arm. Patients in the imaging arm are statistically significantly more often male, have a longer symptom duration and less often a positive family history for SpA than patients fulfilling the clinical arm. Patients in both arms are very similar regarding all other SpA features and level of disease activity. Conclusion. The inclusion criteria of the SPACE cohort yield the same high numbers of SpA patients compared with referral strategies like inflammatory back pain, HLA-B27+ or sacroiliitis, yet are easier to apply. The ASAS axSpA criteria outperformed the other criteria; 38.2% fulfilled the ASAS axSpA criteria. Patients fulfilling the clinical arm of the ASAS axSpA reflect a group of patients similar to those fulfilling the imaging arm.

ASAS modification of the Berlin algorithm for diagnosing axial spondyloarthritis: results from the SPondyloArthritis Caught Early (SPACE)-cohort and from the Assessment of SpondyloArthritis international Society (ASAS)-cohort

Objective To compare the original Berlin algorithm for diagnosing axial Spondyloarthritis (axSpA) with two modifications in the SPondyloArthritis Caught Early (SPACE)-cohort and the Assessment of SpondyloArthritis international Society (ASAS) axSpA criteria validation (ASAS)-cohort. Methods Patients in the SPACE-cohort (back pain ≥3 months, ≤2 years, onset <45 years) and the ASAS-cohort (undiagnosed chronic back pain) were diagnosed according to three algorithms: original (inflammatory back pain (IBP) mandatory), modification 1 (IBP defined by ≥3/5 IBP-features instead of ≥4/5) and modification 2 (IBP deleted as obligatory entry criterion, added as SpA-feature). Diagnosis by rheumatologist, ASAS axSpA criteria and likelihood ratio product were used as external standards to test the performance of the algorithms. Results SPACE-cohort: Compared to the diagnosis by rheumatologist (either axSpA or no-axSpA), the original algorithm agreed in 120 patients (76.4%). Agreement decreased using modification 1 (119 patients; 75.8%), increased using modification 2 (125 patients; 79.6%). Sensitivity increased from 66.2% (original) to 72.3% (modification 1) and 78.5% (modification 2). Specificity decreased more using modification 1 (83.7% to 78.3%) than when using modification 2 (83.7% to 79.6%). ASAS-cohort: Compared to the diagnosis by rheumatologist (either axSpA or no-axSpA), the original algorithm agreed in 484 patients (70.7%). Agreement increased using modification 1 (520 patients; 75.9%) and modification 2 (548 patients; 80.0%). Sensitivity increased from 65.3% (original) to 77.9% (modification 1) and 79.6% (modification 2). Specificity decreased more using modification 1 (79.2% to 72.2%) than when using modification 2 (79.2% to 75.6%). Conclusions ASAS accepted a modified algorithm for diagnosing axSpA in which IBP is excluded as obligatory entry criterion and added as SpA-feature.

Are magnetic resonance flexion views useful in evaluating the cervical spine of patients with rheumatoid arthritis

Abstract  Objective. To determine whether MR imaging in flexion adds value relative to imaging in the neutral position with respect to displaying involvement of the subarachnoid space, brainstem and spinal cord. Design and patients. T1-weighted MR images of the cervical spine in 42 rheumatoid arthritis patients with cervical spine involvement were obtained and analyzed prospectively. We assessed changes between images obtained in the neutral position and following active flexion, especially horizontal atlantoaxial and subaxial motion, presence or absence of brainstem compression, subarachnoid space involvement at the atlantoaxial and subaxial level and the cervicomedullary angle. Vertical atlantoaxial subluxation and the amount of pannus were correlated with motion and change in subarachnoid space. Results. The flexion images showed horizontal atlantoaxial motion in 21 patients and subaxial motion in one patient. The flexion view displayed brainstem compression in only one patient. Involvement of the subarachnoid space increased at the atlantoaxial level in eight (19%) patients (P=0.004) and at the level below C2 in five (12%) patients (P=0.03). There were no patients with a normal subarachnoid space in neutral position and compression in the flexed position. The cervicomedullary angle changed significantly with flexion. Vertical atlantoaxial subluxation and the amount of pannus did not show a significant correlation with motion or subarachnoid space involvement. Conclusion. MR imaging in the flexed position shows a statistically significant narrowing of the subarachnoid space at the atlantoaxial level and below C2. Cord compression is only observed on flexion views if the subarachnoid space in neutral position is already decreased. MR imaging in the flexed position might be useful, since subarachnoid space involvement may be an indicator for the development of neurologic dysfunction.

Agreement Between Clinical Practice and Trained Central Reading in Reading of Sacroiliac Joints on Plain Pelvic Radiographs: Results From the DESIR Cohort

To investigate the degree of agreement between local rheumatologists/radiologists and central trained readers (external standard) on the presence/absence of sacroiliitis on radiographs of the sacroiliac (SI) joints.