Can Imaging Be Used for Inflammatory Arthritis Screening?

Abstract

This article reviews the utility of imaging in the diagnostic work-up of suspected and undifferentiated axial and peripheral inflammatory arthritis. Radiographic findings, that is, late damage but not early inflammation, are part of the classification criteria for rheumatoid arthritis (RA), ankylosing spondylitis, spondyloarthritis (SpA), and psoriatic arthritis (PsA), and they are generally part of the early examination program in arthritis.

Computed tomography visualizes calcified tissue with high resolution but is rarely used unless radiography is unclear and MRI unavailable.

MRI and ultrasonography (US) allow sensitive visualization and assessment of peripheral inflammatory and destructive joint and soft tissue involvement, and MRI is by far the best available method for detecting inflammation in the spine and sacroiliac joints in early SpA. Thus MRI/US can contribute to an earlier diagnosis of RA, PsA, and SpA.

MRI and US are part of the recent American College of Rheumatology/European League against Rheumatism 2010 classification criteria for RA (can be used to count involved joints), and MRI is part of the SpondyloArthritis International Society criteria for axial and peripheral SpA.

Thus radiography, MRI, and/or US should be used in clinical practice to contribute to the diagnostic work-up in suspected, but not definite, inflammatory joint disease and early unclassified inflammatory joint disease, and they are also useful in establishing a specific diagnosis of RA. Radiography and particularly MRI are essential in establishing an early diagnosis of axial SpA.

Keywords

undifferentiated arthritis - rheumatoid arthritis - spondyloarthritis - radiography - magnetic resonance imaging - ultrasonography

• References

• 1 O'Dell JR. Treating rheumatoid arthritis early: a window of opportunity?. Arthritis Rheum 2002; 46 (2) 283-285
• 2 Smolen JS, Landewé R, Breedveld FC , et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs. Ann Rheum Dis 2010; 69 (6) 964-975
• 3 Singh JA, Furst DE, Bharat A , et al. 2012 update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken) 2012; 64 (5) 625-639
• 4 Braun J, van den Berg R, Baraliakos X , et al. 2010 update of the ASAS/EULAR recommendations for the management of ankylosing spondylitis. Ann Rheum Dis 2011; 70 (6) 896-904
• 5 van der Heijde D, Østergaard M. Assessment of disease activity and damage in inflammatory arthritis. In: Bijlsma JWJ, , ed. The EULAR Compendium on Rheumatic Diseases. London, UK: BMJ Publishing Group; 2009: 182-201
• 6 Resnick D. Diagnosis of Bone and Joint Disorders. Philadelphia, PA: WB Saunders; 2002
• 7 van der Linden S, Valkenburg HA, Cats A. Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria. Arthritis Rheum 1984; 27 (4) 361-368
• 8 Berens DL. Roentgen features of ankylosing spondylitis. Clin Orthop Relat Res 1971; 74: 20-33
• 9 Resnick D, Niwayama G, Goergen TG. Comparison of radiographic abnormalities of the sacroiliac joint in degenerative disease and ankylosing spondylitis. AJR Am J Roentgenol 1977; 128 (2) 189-196
• 10 Hermann KG, Althoff CE, Schneider U , et al. Spinal changes in patients with spondyloarthritis: comparison of MR imaging and radiographic appearances. Radiographics 2005; 25 (3) 559-569; discussion 569–570
• 11 Døhn UM, Ejbjerg BJ, Court-Payen M , et al. Are bone erosions detected by magnetic resonance imaging and ultrasonography true erosions? A comparison with computed tomography in rheumatoid arthritis metacarpophalangeal joints. Arthritis Res Ther 2006; 8 (4) R110
• 12 Døhn UM, Ejbjerg B, Boonen A , et al. No overall progression and occasional repair of erosions despite persistent inflammation in adalimumab-treated rheumatoid arthritis patients: results from a longitudinal comparative MRI, ultrasonography, CT and radiography study. Ann Rheum Dis 2011; 70 (2) 252-258
• 13 Østergaard M, McQueen F, Wiell C , et al. The OMERACT psoriatic arthritis magnetic resonance imaging scoring system (PsAMRIS): definitions of key pathologies, suggested MRI sequences, and preliminary scoring system for PsA Hands. J Rheumatol 2009; 36 (8) 1816-1824
• 14 Brown AK, Conaghan PG, Karim Z , et al. An explanation for the apparent dissociation between clinical remission and continued structural deterioration in rheumatoid arthritis. Arthritis Rheum 2008; 58 (10) 2958-2967
• 15 Gandjbakhch F, Conaghan PG, Ejbjerg B , et al. Synovitis and osteitis are very frequent in rheumatoid arthritis clinical remission: results from an MRI study of 294 patients in clinical remission or low disease activity state. J Rheumatol 2011; 38 (9) 2039-2044
• 16 Jimenez-Boj E, Nöbauer-Huhmann I, Hanslik-Schnabel B , et al. Bone erosions and bone marrow edema as defined by magnetic resonance imaging reflect true bone marrow inflammation in rheumatoid arthritis. Arthritis Rheum 2007; 56 (4) 1118-1124
• 17 McQueen FM, Gao A, Østergaard M , et al. High-grade MRI bone oedema is common within the surgical field in rheumatoid arthritis patients undergoing joint replacement and is associated with osteitis in subchondral bone. Ann Rheum Dis 2007; 66 (12) 1581-1587
• 18 Hetland ML, Ejbjerg B, Hørslev-Petersen K , et al; CIMESTRA study group. MRI bone oedema is the strongest predictor of subsequent radiographic progression in early rheumatoid arthritis. Results from a 2-year randomised controlled trial (CIMESTRA). Ann Rheum Dis 2009; 68 (3) 384-390
• 19 Hetland ML, Stengaard-Pedersen K, Junker P , et al; CIMESTRA study group. Radiographic progression and remission rates in early rheumatoid arthritis—MRI bone oedema and anti-CCP predicted radiographic progression in the 5-year extension of the double-blind randomised CIMESTRA trial. Ann Rheum Dis 2010; 69 (10) 1789-1795
• 20 Haavardsholm EA, Bøyesen P, Østergaard M, Schildvold A, Kvien TK. Magnetic resonance imaging findings in 84 patients with early rheumatoid arthritis: bone marrow oedema predicts erosive progression. Ann Rheum Dis 2008; 67 (6) 794-800
• 21 Bøyesen P, Haavardsholm EA, Østergaard M, van der Heijde D, Sesseng S, Kvien TK. MRI in early rheumatoid arthritis: synovitis and bone marrow oedema are independent predictors of subsequent radiographic progression. Ann Rheum Dis 2011; 70 (3) 428-433
• 22 Eshed I, Bollow M, McGonagle DG , et al. MRI of enthesitis of the appendicular skeleton in spondyloarthritis. Ann Rheum Dis 2007; 66 (12) 1553-1559
• 23 Totterman SM. Magnetic resonance imaging of psoriatic arthritis: insight from traditional and three-dimensional analysis. Curr Rheumatol Rep 2004; 6 (4) 317-321
• 24 Hermann KG, Bollow M. Magnetic resonance imaging of the axial skeleton in rheumatoid disease. Best Pract Res Clin Rheumatol 2004; 18 (6) 881-907
• 25 Maksymowych WP, Landewé R. Imaging in ankylosing spondylitis. Best Pract Res Clin Rheumatol 2006; 20 (3) 507-519
• 26 Wiell C, Szkudlarek M, Hasselquist M , et al. Ultrasonography, magnetic resonance imaging, radiography, and clinical assessment of inflammatory and destructive changes in fingers and toes of patients with psoriatic arthritis. Arthritis Res Ther 2007; 9 (6) R119
• 27 Arnett FC, Edworthy SM, Bloch DA , et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum 1988; 31 (3) 315-324
• 28 Aletaha D, Neogi T, Silman AJ , et al. 2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Ann Rheum Dis 2010; 69 (9) 1580-1588
• 29 Koevoets R, Machado P, Bombardier C, van der Heijde DM. The value of conventional radiographs in undifferentiated arthritis: a systematic review. J Rheumatol Suppl 2011; 87: 26-30
• 30 van Aken J, van Dongen H, le Cessie S , et al. Comparison of long term outcome of patients with rheumatoid arthritis presenting with undifferentiated arthritis or with rheumatoid arthritis: an observational cohort study. Ann Rheum Dis 2006; 65: 20-25
• 31 van Gaalen FA, Linn-Rasker SP, van Venrooij WJ , et al. Autoantibodies to cyclic citrullinated peptides predict progression to rheumatoid arthritis in patients with undifferentiated arthritis: a prospective cohort study. Arthritis Rheum 2004; 50: 709-715
• 32 Jansen LM, van Schaardenburg D, van der Horst-Bruinsma IE , et al. One year outcome of undifferentiated polyarthritis. Ann Rheum Dis 2002; 61: 700-703
• 33 van der Helm-van Mil AH, le CS, van DH , et al. A prediction rule for disease outcome in patients with recent-onset undifferentiated arthritis: how to guide individual treatment decisions. Arthritis Rheum 2007; 56: 433-440
• 34 Duer A, Østergaard M, Hørslev-Petersen K , et al. Magnetic resonance imaging and bone scintigraphy in the differential diagnosis of unclassified arthritis. Ann Rheum Dis 2008; 67: 48-51
• 35 Watt I. Basic differential diagnosis of arthritis. Eur Radiol 1997; 7 (3) 344-351
• 36 van der Linden S, Valkenburg HA, Cats A. Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria. Arthritis Rheum 1984; 27 (4) 361-368
• 37 Feldtkeller E, Khan MA, van der Heijde D, van der Linden S, Braun J. Age at disease onset and diagnosis delay in HLA-B27 negative vs. positive patients with ankylosing spondylitis. Rheumatol Int 2003; 23 (2) 61-66
• 38 Rudwaleit M, van der Heijde D, Landewé R , et al. The development of Assessment of SpondyloArthritis International Society classification criteria for axial spondyloarthritis (part II): validation and final selection. Ann Rheum Dis 2009; 68 (6) 777-783
• 39 Dougados M, van der Linden S, Juhlin R , et al. The European Spondylarthropathy Study Group preliminary criteria for the classification of spondylarthropathy. Arthritis Rheum 1991; 34 (10) 1218-1227
• 40 Taylor W, Gladman D, Helliwell P, Marchesoni A, Mease P, Mielants H. CASPAR Study Group. Classification criteria for psoriatic arthritis: development of new criteria from a large international study. Arthritis Rheum 2006; 54 (8) 2665-2673
• 41 Wallace SL, Robinson H, Masi AT, Decker JL, McCarty DJ, Yü TF. Preliminary criteria for the classification of the acute arthritis of primary gout. Arthritis Rheum 1977; 20 (3) 895-900
• 42 Gerster JC, Landry M, Dufresne L, Meuwly JY. Imaging of tophaceous gout: computed tomography provides specific images compared with magnetic resonance imaging and ultrasonography. Ann Rheum Dis 2002; 61 (1) 52-54
• 43 Nicolaou S, Yong-Hing CJ, Galea-Soler S, Hou DJ, Louis L, Munk P. Dual-energy CT as a potential new diagnostic tool in the management of gout in the acute setting. AJR Am J Roentgenol 2010; 194 (4) 1072-1078
• 44 Duer A, Østergaard M, Hørslev-Petersen K, Vallø J. Magnetic resonance imaging and bone scintigraphy in the differential diagnosis of unclassified arthritis. Ann Rheum Dis 2008; 67 (1) 48-51
• 45 Tamai M, Kawakami A, Uetani M , et al. A prediction rule for disease outcome in patients with undifferentiated arthritis using magnetic resonance imaging of the wrists and finger joints and serologic autoantibodies. Arthritis Rheum 2009; 61 (6) 772-778
• 46 Narváez J, Sirvent E, Narváez JA , et al. Usefulness of magnetic resonance imaging of the hand versus anticyclic citrullinated peptide antibody testing to confirm the diagnosis of clinically suspected early rheumatoid arthritis in the absence of rheumatoid factor and radiographic erosions. Semin Arthritis Rheum 2008; 38 (2) 101-109
• 47 Tamai M, Kawakami A, Uetani M , et al. Early prediction of rheumatoid arthritis by serological variables and magnetic resonance imaging of the wrists and finger joints: results from prospective clinical examination. Ann Rheum Dis 2006; 65 (1) 134-135
• 48 Solau-Gervais E, Legrand JL, Cortet B, Duquesnoy B, Flipo RM. Magnetic resonance imaging of the hand for the diagnosis of rheumatoid arthritis in the absence of anti-cyclic citrullinated peptide antibodies: a prospective study. J Rheumatol 2006; 33 (9) 1760-1765
• 49 Boutry N, Hachulla E, Flipo RM, Cortet B, Cotten A. MR imaging findings in hands in early rheumatoid arthritis: comparison with those in systemic lupus erythematosus and primary Sjögren syndrome. Radiology 2005; 236 (2) 593-600
• 50 Klarlund M, Østergaard M, Jensen KE, Madsen JL, Skjødt H, Lorenzen I. The TIRA Group. Magnetic resonance imaging, radiography, and scintigraphy of the finger joints: one year follow up of patients with early arthritis. Ann Rheum Dis 2000; 59 (7) 521-528
• 51 Sugimoto H, Takeda A, Masuyama J, Furuse M. Early-stage rheumatoid arthritis: diagnostic accuracy of MR imaging. Radiology 1996; 198 (1) 185-192
• 52 Sugimoto H, Takeda A, Hyodoh K. Early-stage rheumatoid arthritis: prospective study of the effectiveness of MR imaging for diagnosis. Radiology 2000; 216 (2) 569-575
• 53 Mori G, Tokunaga D, Takahashi KA , et al. Maximum intensity projection as a tool to diagnose early rheumatoid arthritis. Mod Rheumatol 2008; 18 (3) 247-251
• 54 Zampogna G, Parodi M, Bartolini B , et al. Dynamic contrast-enhanced magnetic resonance imaging of the wrist in early arthritis [in Italian]. Reumatismo 2008; 60 (4) 254-259
• 55 Machado PM, Koevoets R, Bombardier C, van der Heijde DM. The value of magnetic resonance imaging and ultrasound in undifferentiated arthritis: a systematic review. J Rheumatol Suppl 2011; 87: 31-37
• 56 Duer-Jensen A, Hørslev-Petersen K, Hetland ML , et al. Bone edema on magnetic resonance imaging is an independent predictor of rheumatoid arthritis development in patients with early undifferentiated arthritis. Arthritis Rheum 2011; 63 (8) 2192-2202
• 57 Østergaard M. Clarification of the role of ultrasonography, magnetic resonance imaging and conventional radiography in the ACR/EULAR 2010 rheumatoid arthritis classification criteria—comment to the article by Aletaha et al [e-letter]. Ann Rheum Dis. Available at: http://ard.bmj.com/content/69/9/1580.short/reply#content-block . Accessed December 2, 2010
• 58 Aletaha D, Hawker G, Neogi T , et al. Re: Clarification of the role of ultrasonography, magnetic resonance imaging and conventional radiography in the ACR/EULAR 2010 rheumatoid arthritis classification criteria—comment to the article by Aletaha et al [e-letter]. Ann Rheum Dis. Available at: http://ard.bmj.com/content/69/9/1580.short/reply#content-block . Accessed January 11, 2011
• 59 Duer-Jensen A, Hørslev-Petersen K, Bak L , et al. Using MRI synovitis to count involved joints in the ACR/EULAR 2010 RA criteria increases their sensitivity and specificity. Ann Rheum Dis 2012; 71 (Suppl) S601
• 60 Rudwaleit M, Jurik AG, Hermann KG , et al. Defining active sacroiliitis on magnetic resonance imaging (MRI) for classification of axial spondyloarthritis: a consensual approach by the ASAS/OMERACT MRI group. Ann Rheum Dis 2009; 68 (10) 1520-1527
• 61 Weber U, Lambert RG, Pedersen SJ, Hodler J, Østergaard M, Maksymowych WP. Assessment of structural lesions in sacroiliac joints enhances diagnostic utility of magnetic resonance imaging in early spondylarthritis. Arthritis Care Res (Hoboken) 2010; 62 (12) 1763-1771
• 62 Weber U, Lambert RG, Østergaard M, Hodler J, Pedersen SJ, Maksymowych WP. The diagnostic utility of magnetic resonance imaging in spondylarthritis: an international multicenter evaluation of one hundred eighty-seven subjects. Arthritis Rheum 2010; 62 (10) 3048-3058
• 63 Bennett AN, Rehman A, Hensor EM, Marzo-Ortega H, Emery P, McGonagle D. Evaluation of the diagnostic utility of spinal magnetic resonance imaging in axial spondylarthritis. Arthritis Rheum 2009; 60 (5) 1331-1341
• 64 Weber U, Hodler J, Kubik RA , et al. Sensitivity and specificity of spinal inflammatory lesions assessed by whole-body magnetic resonance imaging in patients with ankylosing spondylitis or recent-onset inflammatory back pain. Arthritis Rheum 2009; 61 (7) 900-908
• 65 Kim NR, Choi JY, Hong SH , et al. “MR corner sign”: value for predicting presence of ankylosing spondylitis. AJR Am J Roentgenol 2008; 191 (1) 124-128
• 66 Bennett AN, Rehman A, Hensor EM , et al. The fatty Romanus lesion—a non-inflammatory spinal MRI lesion specific for axial-spondyloarthropathy. Ann Rheum Dis. Available at: http://ard.bmj.com/content/early/2010/04/07/ard.2009.112094.full.pdf . Accessed August 9, 2009
• 67 Hermann KG, Baraliakos X, van der Heijde DM , et al; Assessment in SpondyloArthritis international Society (ASAS). Descriptions of spinal MRI lesions and definition of a positive MRI of the spine in axial spondyloarthritis: a consensual approach by the ASAS/OMERACT MRI study group. Ann Rheum Dis 2012; 71 (8) 1278-1288
• 68 Scirè CA, Montecucco C, Codullo V, Epis O, Todoerti M, Caporali R. Ultrasonographic evaluation of joint involvement in early rheumatoid arthritis in clinical remission: power Doppler signal predicts short-term relapse. Rheumatology (Oxford) 2009; 48 (9) 1092-1097
• 69 Freeston JE, Wakefield RJ, Conaghan PG, Hensor EM, Stewart SP, Emery P. A diagnostic algorithm for persistence of very early inflammatory arthritis: the utility of power Doppler ultrasound when added to conventional assessment tools. Ann Rheum Dis 2010; 69 (2) 417-419
• 70 Filer A, de Pablo P, Allen G , et al. Utility of ultrasound joint counts in the prediction of rheumatoid arthritis in patients with very early synovitis. Ann Rheum Dis 2011; 70 (3) 500-507
• 71 Klauser A, Halpern EJ, Frauscher F , et al. Inflammatory low back pain: high negative predictive value of contrast-enhanced color Doppler ultrasound in the detection of inflamed sacroiliac joints. Arthritis Rheum 2005; 53 (3) 440-444
• 72 Delle Sedie A, Riente L, Filippucci E , et al. Ultrasound imaging for the rheumatologist XXVI. Sonographic assessment of the knee in patients with psoriatic arthritis. Clin Exp Rheumatol 2010; 28 (2) 147-152
• 73 Galluzzo E, Lischi DM, Taglione E , et al. Sonographic analysis of the ankle in patients with psoriatic arthritis. Scand J Rheumatol 2000; 29 (1) 52-55
• 74 Milosavljevic J, Lindqvist U, Elvin A. Ultrasound and power Doppler evaluation of the hand and wrist in patients with psoriatic arthritis. Acta Radiol 2005; 46 (4) 374-385
• 75 D'Agostino MA, Said-Nahal R, Hacquard-Bouder C, Brasseur JL, Dougados M, Breban M. Assessment of peripheral enthesitis in the spondylarthropathies by ultrasonography combined with power Doppler: a cross-sectional study. Arthritis Rheum 2003; 48 (2) 523-533
• 76 D'Agostino MA, Aegerter P, Bechara K , et al. How to diagnose spondyloarthritis early? Accuracy of peripheral enthesitis detection by power Doppler ultrasonography. Ann Rheum Dis 2011; 70 (8) 1433-1440
• 77 Grassi W, Meenagh G, Pascual E, Filippucci E. “Crystal clear”-sonographic assessment of gout and calcium pyrophosphate deposition disease. Semin Arthritis Rheum 2006; 36 (3) 197-202
• 78 Rudwaleit M, Jurik AG, Hermann KG , et al. Defining active sacroiliitis on magnetic resonance imaging (MRI) for classification of axial spondyloarthritis: a consensual approach by the ASAS/OMERACT MRI group. Ann Rheum Dis 2009; 68 (10) 1520-1527