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New ASAS Criteria for the Diagnosis of Spondyloarthritis: Diagnosing Sacroiliitis by Magnetic Resonance Imaging 9

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New ASAS Criteria for the Diagnosis of Spondyloarthritis: Diagnosing Sacroiliitis by Magnetic Resonance Imaging 9 Document downloaded from http://www.elsevier.es, day 10/02/2016. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited. Radiología. 2014;56(1):7---15 www.elsevier.es/rx UPDATE IN RADIOLOGY New ASAS criteria for the diagnosis of spondyloarthritis: ଝ Diagnosing sacroiliitis by magnetic resonance imaging ∗ M.E. Banegas Illescas , C. López Menéndez, M.L. Rozas Rodríguez, R.M. Fernández Quintero Servicio de Radiodiagnóstico, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain Received 17 January 2013; accepted 10 May 2013 Available online 11 March 2014 KEYWORDS Abstract Radiographic sacroiliitis has been included in the diagnostic criteria for spondy- Sacroiliitis; loarthropathies since the Rome criteria were defined in 1961. However, in the last ten years, Diagnosis; magnetic resonance imaging (MRI) has proven more sensitive in the evaluation of the sacroiliac Magnetic resonance joints in patients with suspected spondyloarthritis and symptoms of sacroiliitis; MRI has proven imaging; its usefulness not only for diagnosis of this disease, but also for the follow-up of the disease and Axial spondy- response to treatment in these patients. In 2009, The Assessment of SpondyloArthritis inter- loarthropathies national Society (ASAS) developed a new set of criteria for classifying and diagnosing patients with spondyloarthritis; one important development with respect to previous classifications is the inclusion of MRI positive for sacroiliitis as a major diagnostic criterion. This article focuses on the radiologic part of the new classification. We describe and illustrate the different alterations that can be seen on MRI in patients with sacroiliitis, pointing out the limitations of the technique and diagnostic pitfalls. © 2013 SERAM. Published by Elsevier España, S.L. All rights reserved. PALABRAS CLAVE Nuevos criterios ASAS para el diagnóstico de espondiloartritis. Diagnóstico Sacroileítis; de sacroileítis por resonancia magnética Diagnóstico; Resumen La sacroileítis radiográfica ha formado parte del diagnóstico de las Imagen por resonancia espondiloartropatías desde su inclusión en los criterios de Roma en 1961. Sin embargo, magnética; en la última década, la resonancia magnética (RM) ha demostrado ser más sensible para Espondiloartropatías valorar las articulaciones sacroilíacas en los pacientes con sospecha de espondiloartritis y axiales síntomas de sacroileítis, no solo para diagnosticarla, sino también para seguir la evolución de la enfermedad y el tratamiento de estos pacientes. El grupo The Assessment of Spondy- loArthritis international Society (ASAS) desarrolló en el ano˜ 2009 unos criterios para clasificar y diagnosticar a los pacientes con espondiloartritis, entre los que destacaba la inclusión de un estudio de RM positivo para sacroileítis como criterio diagnóstico mayor. ଝ Please cite this article as: Banegas Illescas ME, López Menéndez C, Rozas Rodríguez ML, Fernández Quintero RM. Nuevos criterios ASAS para el diagnóstico de espondiloartritis. Diagnóstico de sacroileítis por resonancia magnética. Radiología. 2014;56:7---15. ∗ Corresponding author. E-mail address: marux [email protected] (M.E. Banegas Illescas). 2173-5107/$ – see front matter © 2013 SERAM. Published by Elsevier España, S.L. All rights reserved. Document downloaded from http://www.elsevier.es, day 10/02/2016. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited. 8 M.E. Banegas Illescas et al. Este artículo incide en la parte radiológica de esta clasificación. Se describen e ilustran las diferentes alteraciones que podemos encontrarnos en los estudios de RM en pacientes con sacroileítis, resaltando las limitaciones y potenciales errores diagnósticos. © 2013 SERAM. Publicado por Elsevier España, S.L. Todos los derechos reservados. Introduction Table 1 ASAS Categorization Criteria for spondyloarthritis in patients under 45 years old of age with lower back pain of Under the term spondyloarthritis (SpA) we include a hetero- 3 months duration. geneous group of chronic rheumatic inflammatory diseases that can affect the axial skeleton predominantly. We can Radiological diagnosis of HLA B27 + 2 or more features distinguish five (5) different groups: ankylosing spondyli- sacroiliitis + 1 or more of spondyloarthritis tis (AS), arthritis and reactive SpA (formerly known as features of Reiter’ Syndrome), arthritis associated with inflammatory spondyloarthritis bowel syndrome, psoriatic arthritis and non-radiological Features of Radiological diagnosis 1 axial SpA. They all share clinical manifestations (the most spondyloarthritis of sacroiliitis important, the inflammatory lower back pain), and radio- --- Low inflammatory --- Active (acute) inflammation logical manifestations (sacroiliitis) accompanied by familial pain in the MRI highly suggestive aggregation and a strong association with the antigen HLA --- Arthritis of scaroiliitis due to SpA 1 B27. Overall prevalence of these entities is estimated --- Enthesitis --- Radiological sacroiliitis 2 between 0.23 and 1.8%. --- Uveítis defined according to the New Traditionally and given the high frequency of joint --- Dactilitis York criteria (grade >2 bilateral 1 affectation---over 90%, X-raying the sacroiliac joints (SJ) has ---Psoriasis or grade 3 --- 4 unilateral) 3 been essential to diagnose, categorize and monitor SpA. ---Crohn/colitis Thus the radiographic sacroiliitis is part of the diagnostic ---Goof response 4 criteria of AS since they were established in Rome in 1961, to NSAID and part of the diagnostic criteria of SpA since they were ---Family history of 5 published by Amor et al. in 1990. The signs that can be spondyloarthropathy seen in an X-ray translate into structural changes only vis- --- H L A B27 ible too late which in turn can delay the diagnosis of the ---High CRP levels 1,6 disease between 6 and 8 years since symptom onset. Nevertheless there have been important innovations dur- ing the last ten years for the early management of SpA due to the development of new biological therapies with <45 years old with lower back pain of 3 or more months anti-tumour necrosis factor (anti-TNF) antagonists and the duration. Criteria comprise 2 sections: one ‘‘radiological growing relevance of magnetic resonance (MR) as elective section’’ and one ‘‘clinical section’’. To qualify for the modality for an early diagnosis of the disease, to evaluate radiological section a sacroiliitis on a simple radiography 3,7---12 the therapeutic effects and establish prognosis. Nev- or MRI and at least one of the characteristic traits of SpA ertheless none of the diagnostic categorizations---not even detailed in Table 1 needs to be confirmed. To qualify for the the Roman criteria or the European Spondyloarthropathy clinical section the patient needs to have a positive HLA B27 Study Group (ESSG) classification included MR as a diagnos- and at least two of the characteristic traits of SpA without 13 tic criteria. Back in 2009 the international panel of experts radiologic sacroiliitis being mandatory. known as the Assessment in SpondyloArthritis international ASAS criteria were validated in an international cohort Society (ASAS) developed a series of criteria for the catego- trial with a sensibility and specificity close to 82.9 and 84.4%, rization and early diagnosis of axial SpA (the MR-established respectively as opposed to Amor et al. criteria (sensibility 14 sacroiliitis was among these criteria ). 82.9% and specificity 77.5%) and ESSG (sensibility 85.1% and The purpose of this study is to introduce this catego- 15 specificity 65.1%), both adjusted for MRI. It is important to rization with special attention to radiological issues and highlight that diagnosis in the radiological section showed a describe through images the different lesions we can see in 15 66.2 sensibility and 9733% specificity. an MRI in patients with sacroiliitis. We will also talk about the In an effort to establish common criteria to diagnose limitations of this categorization as well as about mistakes sacroiliitis through MRI the ASAS/Outcome Measures in made during diagnosis. Rheumatology Network (OMERACT) group made up of 8 rheumatologists and 2 radiologists collected the signs of SpA The ASAS Categorization: findings in magnetic reported on MRI studies and established which would be 14 resonance and definition of sacroiliitis necessary to diagnose sacroiliitis associated with SpA. The lesions found in sacroiliac joints (SJ) on the MRI were cat- ASAS criteria to diagnose axial SpAs were published back in egorized into 2 big groups: active (or acute) inflammatory 14 2009 (Table 1). These criteria will be applied to patients lesions and structural lesions. Document downloaded from http://www.elsevier.es, day 10/02/2016. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited. New ASAS criteria for the diagnosis of spondyloarthritis: Diagnosing sacroiliitis by magnetic resonance imaging 9 Figure 1 (a) T1-weighted coronal oblique image where we can see one periarticular hypointensity with greater affectation of the iliac margin of the right sacroiliac joint (arrow). (b) On the STIR sequence we have one hyperintense zone compatible with bone oedema. Active inflammatory lesions sequences (Fig. 1). The intraforaminal sacral bone consti- tutes the intensity of the reference bone signal. T1-weighted Four types of inflammatory lesions in sacroiliitis associated sequence enhancement with fat suppression after
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