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Magnetic Resonance Imaging of the Shoulder in Patients with Rheumatoid Arthritis

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Magnetic Resonance Imaging of the Shoulder in Patients with Rheumatoid Arthritis Annals ofthe Rheumatic Diseases 1990; 49: 7-11 7 SCIENTIFIC PAPERS Ann Rheum Dis: first published as 10.1136/ard.49.1.7 on 1 January 1990. Downloaded from Magnetic resonance imaging of the shoulder in patients with rheumatoid arthritis G J Kieft, B A C Dijkmans, J L Bloem, H M Kroon Abstract than physical examination combined with plain To evaluate the ability of magnetic resonance radiographs. imaging (MRI) to detect shoulder abnor- malities 18 patients (36 shoulders) with rheu- matoid arthritis (RA) and shoulder complaints Patients and methods were studied. Osseous abnormalities of the PATIENTS glenoid and humeral head were readily Eighteen consecutive patients with definite or detected with MRI. The imaging planes used classical RA, according to the American Rheu- were not suitable for the evaluation of matism Association criteria,9 who had visited acromioclavicular joint involvement. Mag- the outpatient clinic of the department of netic resonance imaging depicted soft tissue rheumatology and had shoulder complaints abnormalities that were not clearly visualised were included in the study. All patients gave by plain film radiography, such as involve- their informed consent to participation in the ment of rotator cuff tendons and subacromial study. The table gives the clinical details of bursae, joint effusion, and muscular atrophy. these patients. This group included seven Magnetic resonance imaging appears to be a female and 11 male patients with median age 63 sensitive method for evaluation of gleno- years (range 42-79) and median duration of humeral joint changes in patients with RA. disease five years (range 1-23); one patient was seronegative and 17 were seropositive. Accord- ing to x rays of the wrists, hands, and forefeet The shoulder is one of the more common sites five patients had non-erosive and 13 had erosive of involvement of rheumatoid arthritis (RA). disease. Fifteen of the 18 patients had been or Rheumatoid arthritis not only affects the syno- were being treated with disease modifying vium within the glenohumeral joint but can also drugs. The motion of30 shoulders was restricted involve the distal third of the clavicle, bursae, for anteflexion or abduction or both (table). rotator cuff tendons, and surrounding http://ard.bmj.com/ muscles.' 2 Clinically, shoulder arthritis can often go METHODS unrecognised. There are several reasons for Plain radiographs were taken in the antero- this: the onset of the disease in the shoulder is posterior (arm in exorotation) and axial views. often insidious, the shoulder joint is deeply The radiographs were evaluated in concert by seated, and synovial tissue swelling often escapes two of the authors (BACD, HMK), one radio- notice as it is difficult to detect unless suspected. logist, and one rheumatologist without know- on September 25, 2021 by guest. Protected copyright. It is important to recognise shoulder involve- ledge of the results of the MRI studies. Involve- ment early and if possible, to prevent further ment of the glenohumeral joint, major tubero- damage by conservative treatment-for sity, and acromioclavicular joint was graded by example, by careful physiotherapy with active the scoring method described by Kellgren'0: and passive movements, before irreversible grade 0 no abnormalities, grade 1 dubious changes have occurred. erosions, grade 2 definite but mild erosions, Radiography can be helpful in determining grade 3 more destructive changes, and grade 4 the extent of shoulder involvement in RA. severe erosions. Radiographic assessment of the stage of the Magnetic resonance imaging studies of the Department of disease is based on the presence of bone shoulders were performed with a 0 5 tesla Diagnostic Radiology, erosions, joint space narrowing, and osteo- superconductive magnet MRI system (Gyroscan University Hospital, Leiden, The Netherlands porosis. Joint erosions, not specifically the S5 Philips, Best, The Netherlands). A flexible G J Kieft shoulder, usually occur within the first two 'wrap around' surface coil was used. Multiple J L Bloem years of the disease.3 Joint space loss and images in the transverse and oblique planes- H M Kroon osteoporosis are not specific for RA.3 4 that is, perpendicular to the glenoid surface, Department of resonance has Rheumatology, Magnetic imaging(MRI) proved were obtained. The oblique plane has been University Hospital, its usefulness in the evaluation of the musculo- described in detail.8 Spin echo pulse sequences Leiden, The Netherlands skeletal system.5 6 Owing to its superior soft with relative TI weighting (600, 30) (repetition B A C Dijkmans tissue contrast, tomographic nature, and multi- time ms, echo time ms) and relative T2 weight- Correspondence to: planar imaging, MRI is particularly valuable for ing by the dual echo technique (2000, 50-100) Department of Diagnostic Radiology, Building 1: assessment of the synovium, cartilage, muscles, were used in all examinations. To keep the C2-S, PO Box 9600, tendons, and ligaments.7 8 scanning time within acceptable limits two 2300 RC Leiden, The Netherlands. This study was undertaken to determine excitations were used in all cases. The total Accepted for publication whether MRI can provide more information scanning time for both shoulders was less than 3 March 1989 about shoulder involvement in patients with RA one hour. A 250 mm field of view and 5 mm 8 Kieit, Dijkmans, Bloem, Kroon Clinical, radiographic and magnetic resonance imaging (MRI) findings in 18 patients with rheumatoid arthritis 8 9 10 Patient number 2 3 4 6 7 Ann Rheum Dis: first published as 10.1136/ard.49.1.7 on 1 January 1990. Downloaded from Sex F M M M M.Ni M .Ni Age (years) 77 63 75 53 79 57 76 42'N 7 Duration of RA (years) 1 19 12 2 l 12 I 2 - Seropositive/negative + Erosive/non-erosive E NE E NE E 14 NE 1' E Anteflexion (degrees) 170 170 160 170 160, 170 90 110 180 160 170 170 180 180 180 180 17(0 170 170 160 Abduction (degrees)' 90/90 90 90 8090 70 40 90 80 80 80 9() 90 90 90 80 80 90 90 Glenohumeral involvement Radiography 00 00 00 33 00 00 (() 00 20 02 2I MRI 02 02 00 42 0(0 20 0(0 12 2 0 22 Acromioclavicular joint involvement - Radiographs 1 2 00 00 2 3 00 1 0 00 0 0 0 00 (02 MRI 20 20 00 10 30 00 (10 3 1( 0(1 (10 Minor and major tubercle involvement t Radiographv 00 1(0 10 4A4 0(0 1 1 2 0 I I 0 2 2 MRI 32 20 20 44 22 22 22 12 322 22 Cartilage destruction Radiographv _+ + t-- MRI _~~~~__ ~ ~~~~~~~__ + +-_ _-_ + + Soft tissue abnormality detected with MRIR. Rotator cuff tendon destruction -t -t Rotator cuff muscle atrophy Effusion or pannus + -rt- t Lvmph nodes *Values given for right shoulder,left shoulder. tGrade 0=no abnormalities; grade 1=dubious erosions; grade 2=definite but mild erosions; grade 3=more destructive changes; grade 4 severe erosiolls. TOwing to osteosvnthetic material this area could not be evaluated in this patient. %-absent; +=present; + + severe. thick contiguous sections were chosen in synovial fluid is not visible on magnetic reson- combination with a 154 x 256 acquisition matrix ance images; when it is abnormal (pannus and a 512x 512 display matrix. formation) it has a low signal intensity on T1 Figure 1 shows the magnetic resonance and low or high signal intensity on T2 weighted images of the shoulder of a normal volunteer. images."" Normal hyaline articular cartilage Patient positioning proved simple. A comfort- has an intermediate signal intensity on TI and able neutral humeral position with the patient T2 weighted images. Cartilage disease was supine was chosen. The images were interpreted diagnosed when the articular cartilage had by two of the authors (GJK, JLB), both thinned focally or diffusely. radiologists, in concert without knowledge of In a final session the radiographs and mag- the clinical history or radiographic findings. netic resonance images were reviewed together The findings for 110 subjects without RA, who by two of the authors (GJK, BACD) to establish had undergone MRI of the shoulders for a whether or not the magnetic resonance images variety of other reasons, as well as the findings provided additional information. http://ard.bmj.com/ for 10 normal volunteers and two cadaveric shoulders served as controls.8 " Magnetic resonance images were evaluated by the scoring Results system used for the radiographs. Bone erosions Magnetic resonance images of adequate tech- were defined as marginal osseous defects with a nical quality were obtained in all cases. A low or non-homogeneous signal intensity on T1 metallic artefact was present in one shoulder. weighted images. 12 Joint effusion was diag- and thus the region of the tuberosities and the on September 25, 2021 by guest. Protected copyright. nosed when the joint capsule was distended by lateral part of the rotator cuff tendons in this material that was identified by its low signal shoulder could not be evaluated. Other artefacts intensity on T1I weighted images and high signal were minimal; if present they were attributable intensity on T2 weighted images. 4 Normal to motion. Figure 1: Magnetic resonance images ofa normal left shoulder (37year old healthy man). (a) Ti weighted (repetition time (TR) 600 ms, echo time (TE) 30 ms) image ofthe supraspinatus tendon and muscle taken in the oblique plane; (b) T2 weighted (TR 2000, TE 100) image in the same plane; the relative intensities ofthe normal musculoskeletal tissues remain the same; note the normal subdeltoid bursa (arrows); (c) TI weighted (TR 600, TE 30) transverse image at the level ofthe coracoid process. I =humeral head; 2= acromion; 3=glenoid cavity; 4=coracoid process; 5=supraspinatus muscle; 6=supraspinatus tendon; 7 =infraspinatus muscle; 8=subscapular muscle; 9=deltoid muscle; 10= trapezius muscle; II = acromioclavicularjoint; 12 = tendon ofthe long head of biceps muscle.
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