Advices for diagnostics of ankylosing spondylitis/axial spondyloarthritis: A review
- Authors: Bunchuk N.V.1, Levshakova A.V.2
-
Affiliations:
- „Klinika Sesil'+“ LLC
- Hertsen Moscow Oncology Research Institute – branch of the National Medical Research Radiological Centre
- Issue: Vol 25, No 11 (2023): Neurology and rheumatology
- Pages: 755-765
- Section: Articles
- URL: https://bakhtiniada.ru/2075-1753/article/view/253989
- DOI: https://doi.org/10.26442/20751753.2023.11.202461
- ID: 253989
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Abstract
The article written by a rheumatologist and a radiologist who have long-term experience in diagnostics of ankylosing spondylitis (axial spondylitis), provides advices on rational recognition of these diseases. The first part of the article discusses adequate visualization of the sacroiliac joints and the need for thoughtful consideration of radiological and MRI signs of sacroiliitis, neither of which, taken alone, is pathognomonic. An optimal, from the authors' point of view, algorithm for conducting visualization studies of sacroilial joints is proposed. Numerous situations simulating sacroiliitis are analyzed.
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##article.viewOnOriginalSite##About the authors
Nikolay V. Bunchuk
„Klinika Sesil'+“ LLC
Author for correspondence.
Email: nbunchuk@yahoo.com
ORCID iD: 0000-0002-4728-400X
D. Sci. (Med.), „Klinika Sesil'+“ LLC
Russian Federation, MoscowAntonina V. Levshakova
Hertsen Moscow Oncology Research Institute – branch of the National Medical Research Radiological Centre
Email: nbunchuk@yahoo.com
ORCID iD: 0000-0002-2381-4213
D. Sci. (Med.), Hertsen Moscow Oncology Research Institute – branch of the National Medical Research Radiological Centre
Russian Federation, MoscowReferences
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Fig. 1. Patient V., 29 years old. Stress fractures of the sacrum that developed in the 9th month of pregnancy. MRI (coronal projection, STIR mode): in both lateral masses of the sacrum there are large areas of increased signal intensity (bone marrow edema), against which fracture lines can be traced (indicated by arrows).
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Fig. 2. Patient N., 22 years old, duration of axSpA 9 months. CT scan (coronal projection): erosions (“jagged” contour) and wide subchondral sclerosis of the ilium (unilateral definite sacroiliitis) are visible in the right SIJ.
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Fig. 3. Patient B., 22 years old, diagnosed with AS, disease duration 36 months. CT scan of the sacroiliac joints (coronal projection): wide subchondral sclerosis in the iliac bones, on the right, small erosions in the upper part and areas of widening of the gap in the lower part of the joint, on the left, multiple erosions and areas of widening of the gap (bilateral definite sacroiliitis).
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Fig. 4. Patient P., diagnosis of AS, disease duration 12 months: a – CT scan of the sacroiliac joints (coronal projection) showed wide subchondral sclerosis of the iliac bones, marginal erosion of the ilium and sacrum, widening of the joint space on both sides (bilateral definite sacroiliitis) ; b – on the radiograph of the sacroiliac joints of the same patient (taken shortly before the CT scan), changes (subchondral sclerosis, suspected widening of the gap in the middle part of the left joint) are not visible as clearly as on the CT scan.
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Fig. 5. Scheme by W. Dihlmann of radiological changes in the SIJ, characteristic of sacroiliitis in patients with AS (borrowed from [15]): a – blurred contour of the anterior auricular surfaces of the sacrum and ilium; b – blurred structure of the subchondral sections of the articulating bones; c – pseudo-expansion of the joint space, resembling a garland of light bulbs; d – pseudo-expansion of the joint space with preserved cortical plate (a kind of osteolysis); a strip-like zone of increased transparency is noted parallel to the joint space; e – before small erosions appear on the edges of the articular surfaces, they can be detected slightly away from it in the form of oval or round radiolucent zones that do not deform the contour; f – “string of beads” or “rosary”; g - unilateral changes resembling the edge of a saw or postage stamp; large isolated erosions, sequestration and a combination of small and larger rounded zones of subchondral osteolysis may be observed; h – spotted sclerosis of cancellous bone (tiger pattern, aspect tigré), spherical areas of compaction (dappled horse color, aspect pommelé) or diffuse subchondral sclerosis; i – compaction of cancellous bone in the form of a strip next to the subchondral layer; j – triangular-shaped area of sclerosis, similar to condensing osteitis of the ilium; k – intra-articular bone “bridges” and narrowing of the gap; l – types of ossification of the joint capsule, including the “star sign”.
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Fig. 6. Patient M. 25 years old. Diagnosis of AS, HLA-B27+, duration of pain in the lower back 3 years: a – on the radiograph only areas of subchondral sclerosis of the iliac bones on both sides are visible (stage I of sacroiliitis); b – CT scan (coronal projection) showed wide zones of subchondral sclerosis on both sides, a few erosions (stage II sacroiliitis); c – MRI (coronal projection, T2 STIR mode): areas of bone marrow edema (light areas in the subchondral parts of the ilium and sacrum on the right), erosion of the ilium in the area of edema (active sacroiliitis according to the ASAS classification).
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Fig. 7. Patient P. 24 years old. Diagnosis of AS, HLA-B27+, duration of pain in the lower back 1 year: a – radiograph: wide zone of subchondral sclerosis in the left ilium (stage I of sacroiliitis); b – CT (coronal projection): multiple erosions of the iliac bones with pseudo-widening of the gap of both joints, wide subchondral sclerosis of the iliac bones (stage III sacroiliitis); c – MRI (coronal projection, T2 STIR mode): numerous areas of periarticular bone marrow edema (light areas) and erosion in the ilium and sacrum on both sides (active sacroiliitis according to ASAS classification).
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Fig. 8. Microscopic examination of a SIJ biopsy in a patient with early AS. From the side of the subchondral bone, a bundle of connective tissue penetrates into the cartilage (indicated by an arrow) (borrowed from [19]).
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Fig. 9. Destruction of the manubriosternal joint in patient Sh., 45 years old. Diagnosis of AS, HLA-B27, disease duration 20 years, duration of lesion of the manubriosternal joint 1 year.
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Fig. 10. Patient B., diagnosis of AS. MRI of the SIJ (coronal projection, T2 FatSat mode): multiple areas of bone marrow edema (indicated by arrows) mainly in the subchondral areas. The changes meet the criteria for “active” sacroiliitis according to the ASAS classification [22].
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Fig. 11. MRI of the SIJ (axial projection, T2 FatSat mode): technical aliasing artifacts (occur in case of incorrectly selected phase encoding). Areas of irregular linear and semilunar shape are visible, overlapping the left SIJ and soft tissues in the scanning area (indicated by arrows), which complicates visualization.
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Fig. 12. MRI of the SIJ (in axial projection, T2 FatSat mode): insufficient fat suppression, as evidenced by the persistence of a hyperintense signal from adipose tissue in the right gluteal region (indicated by an asterisk). An area of hyperintense signal in the right lateral mass of the sacrum mimics bone marrow edema (indicated by the arrow).
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Fig. 13. MRI of the SIJ (coronal projection, T2 FatSat mode): artifacts from vascular pulsation in the form of vertically directed lines make it difficult to visualize the SIJ. One may suspect areas of bone marrow edema in the bodies of both iliac bones and the lateral masses of the sacrum, but it is not possible to reliably assess these changes against the background of artifacts.
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Fig. 14. Patient A. 20 years old, duration of pain in the lower back for 5 years. MRI of the SIJ in the coronal projection: a – in T2 FatSat mode, in the left lateral mass of the sacrum at the level of the upper parts of the joint, an area of bone marrow edema is noted, and an impression is also created of an increased signal from the adjacent soft tissues (indicated by arrows); b – in T1 mode, neoarthrosis is clearly visualized between the left transverse process of the LV vertebra and the left lateral mass of the sacrum (arrow) – left-sided sacralization of the LV with signs of edema.
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Fig. 15. Patient K. 32 years old. Complaints of pain in the lower back for 5 years, arose after childbirth: on CT scan of the sacroiliac joints in the coronal (a) and axial (b) planes in the subchondral parts of the bodies of both iliac bones and the lateral mass of the sacrum, zones of wide sclerosis are observed (indicated arrows), the width of the joint spaces is not changed, the endplates of the bones are clear, without usuration - bilateral condensing osteitis of the ilium and sacrum.
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Fig. 16. Patient 36 years old. Complaints of back pain. On a CT scan of the SIJ (left) in the axial projection in the subchondral part of the body of the right ilium, a wide zone of sclerosis is noted (indicated by an arrow), the right joint gap is somewhat unevenly narrowed, smooth, there are anterior osteophytes on both sides. An MRI of the same patient in the axial projection shows a zone of reduced signal intensity (indicated by an arrow), corresponding to the area of sclerosis identified on the CT scan.
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Fig. 17. Osteoarthritis of the SIJ in a 39-year-old female patient with scoliosis and inflammatory pain in the sacral area. CT scan shows unevenness of the articular surfaces, their local narrowing (mainly on the left), bilateral subchondral sclerosis of the iliac bones and marginal osteophytes (on the left), no erosions were detected (borrowed from [22]).
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Fig. 18. Patient G., diagnosis of “diffuse idiopathic skeletal hyperostosis”: a – the x-ray shows a narrowing of the right joint gap and areas of subchondral sclerosis in the lower and upper parts of both joints, the left joint gap is not visible in places; b – CT showed that the SIJ gap is intact on both sides, there are no erosions or subchondral sclerosis, and ossification of the capsule is noted in the upper part of the joints.
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Fig. 19. Patient S. Diagnosis of “diffuse idiopathic skeletal hyperostosis”: a – on the x-ray of the thoracic spine in a direct projection, closing and non-closing convex spondylophytes are visible, more pronounced along the right contour (a typical feature of Forestier’s disease is the effect of aortic pulsation); b – on the radiograph in the lateral projection, a continuously ossified, significantly thickened anterior longitudinal ligament is visible adjacent to the surface of the vertebral bodies (the shape of the vertebral bodies, the intervertebral spaces are intact); c – its size and location are better determined on a CT scan of one of the thoracic vertebrae.
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Fig. 20. Purulent sacroiliitis in patient N., 29 years old, 1 month after the onset of the disease: a – MRI revealed widespread bone marrow edema on both sides of the left SIJ, as well as swelling of the iliacus muscle on the left (indicated by arrows); b – CT scan shows destruction of the left SIJ (osteomyelitis).
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