Spine injections: the rationale for CT guidance.

Back pain is one of the most common medical problems and is associated with high socioeconomic costs. Imaging-guided spinal injections are a minimally invasive method to evaluate where the back pain is originating from, and to treat patients with radicular pain or spinal stenosis with infiltration of corticosteroids. CT-guided spine injections are a safe procedure, characterized by precise needle placement, excellent visualization of the relevant anatomical structures, and low radiation exposure for the patient and the interventional radiologist. In this review article, the variety of applications of CT-guided injections (focused on nerve roots and epidural injections) and the optimal injection procedure as well as risks and side effects are discussed.

Intraarticular Steroid Injection in Hip and Knee with Fluoroscopic Guidance: Reassessing Safety.

Background Intraarticular corticosteroid (IACS) injections are frequently performed for hip and knee osteoarthritis (OA); however, there are conflicting data about the benefits and complications of IACS injections and a lack of large studies with follow-up. Purpose To determine the number of patients with complications after hip and knee IACS injections in a large study sample with long-term follow-up. Materials and Methods This retrospective single-center case series included patients who received a corticosteroid injection in the hip (n = 500) or knee (n = 500) and who underwent clinical and radiologic follow-up (conventional radiography, fluoroscopy, CT, or MRI) between 1 and 12 months after injection (January 2016 to May 2020). General descriptive statistics and the χ2 test were applied. P < .05 was indicative of a significant difference. Results Of the 1000 patients (mean age, 57 years ± 16 [SD]; 545 women), 10 patients (1%) developed severe complications. Four patients developed osteonecrosis; three, insufficiency fractures; and three, rapid progressive OA. All 10 complications occurred between 2 and 9 months after injection: six (60%) in the hip and four (40%) in the knee. Of the included 1000 patients, 545 (54%) were women, but they had nine of the 10 (90%) complications (P = .02). Conclusion Intraarticular steroid injection had a substantially lower complication rate than that reported in previous smaller studies. The rate of severe complications was disproportionally higher in women than in men. © RSNA, 2022 See also the editorial by Jennings in this issue.

MRI of the Elbow: How to Do It.

The diagnostic cascade for elbow complaints starts with the physical examination and radiographs that already can clarify or rule out many causes. Depending on the suspected pathology, additional imaging is necessary. Magnetic resonance imaging (MRI) has the advantage of accurately demonstrating a broad spectrum of diseases. The main indication for noncontrast MRI of the elbow is chronic epicondylitis. For magnetic resonance (MR) arthrography, it is suspected chondral and osteochondral abnormalities. Indirect MR arthrography is an option when direct arthrography is not practicable. MR arthrography of the elbow with traction is feasible, with promising results for the assessment of the radiocapitellar cartilage.

Influence of pregnancy/childbirth on long-term bone marrow edema and subchondral sclerosis of sacroiliac joints.

OBJECTIVE: To investigate long-term effects of pregnancy/childbirth on bone marrow edema (BME) and subchondral sclerosis of sacroiliac joints (SIJ) in comparison to MRI changes caused by spondyloarthritis (SpA) and assess the influence of birth method and number of children on SIJ-MRI changes. MATERIALS AND METHODS: This is a retrospective cohort study with 349 women (mean age 47 ± 14 years) suffering low back pain. Four subgroups were formed based on SpA diagnosis and childbirth (CB) history. Two musculoskeletal radiologists scored the presence of BME and sclerosis on SIJ-MRI using the Berlin method. Further, an 11-point "global assessment score" representing the overall confidence of SpA diagnosis based on MRI was evaluated in addition to the ASAS (Assessment of Spondyloarthritis International Society) criterion of "positive MRI" for sacroiliitis. RESULTS: CB did not correlate with BME score (p = 0.38), whereas SpA diagnosis was associated with a higher BME score (r = 0.31, p < 0.001). Both CB (r = 0.21, p < 0.001) and SpA diagnosis (r = 0.33, p < 0.001) were correlated with a higher sclerosis score. CB was not associated with a higher confidence level in diagnosing SpA based on MRI (p = 0.07), whereas SpA diagnosis was associated with a higher score (r = 0.61, p < 0.001). Both CB (phi = 0.13, p = 0.02) and SpA diagnosis (phi = 0.23, p < 0.001) were significantly associated with a positive ASAS criterion for sacroiliitis. In non-SpA patients with CB, number of children (p = 0.001) was an independent predictor of sclerosis score, while birth method yielded no significant effect (p = 0.75). CONCLUSION: Pregnancy/CB has no impact on long-term BME on SIJ, however, may cause long-term subchondral sclerosis-similar to SpA-associated sclerosis. Number of children is positively correlated with SIJ sclerosis. Birth method yields no effect on SIJ sclerosis.

Diagnostic utility of perilesional muscle edema in myositis ossificans.

OBJECTIVES: To investigate the value of extensive perilesional muscle edema for the differentiation between myositis ossificans (MO) and malignant intramuscular soft tissue tumors on MRI. MATERIALS AND METHODS: Two blinded readers analyzed MR examinations of 90 consecutive patients with intramuscular soft tissue masses (group 1: MO, n = 20; group 2: malignant tumors, n = 70). Extent of edema around lesions was graded (0, none; 1, minimal edema; 2, moderate edema; 3, extensive edema). Edema-lesion ratio (ELR = ratio of the maximal diameter of the edema and the maximal diameter of the central lesion) was calculated. ROC analysis, Mann-Whitney U test, and Kappa test were used. RESULTS: A total of 70% and 60% of patients with MO had edema grade 3 (reader 1/reader 2), 30%/40% edema grade 2. For the patients with malignant tumors, it was 2.9%/1.4% (edema grade 3) and 16%/23% (edema grade 2). Interrater reliability was substantial (kappa = 0.66). Extent of edema was significantly higher for patients of group 1 (p < 0.0001, both readers). Mean ELR was 3.60 (group 1) and 1.35 (group 2), with statistically significant differences (p < 0.0001). Grade 3 edema showed a sensitivity/specificity of 70%/97.1% (reader 1) and 60%/99% (reader 2) for diagnosing MO. For ELR > 2.0, sensitivity was 90% and specificity 91% for diagnosing MO. CONCLUSIONS: Extensive perilesional muscle edema on MRI of more than double the size of the central lesion is highly specific, but not pathognomonic for myositis ossificans in the early/intermediate stage in the differentiation to malignant intramuscular soft tissue lesions.

Pincer-type MRI morphology seen in over a third of asymptomatic healthy volunteers without femoroacetabular impingement.

BACKGROUND: In daily routine, pincer femoroacetabular impingement (FAI) findings are often seen without a clinical diagnosis of pincer FAI. PURPOSE: To assess the presence of pincer FAI MRI findings in asymptomatic volunteers with negative impingement test versus patients with clinically confirmed FAI. STUDY TYPE: Case-control study. POPULATION: Sixty-three asymptomatic volunteers and 63 matched patients with FAI were included. FIELD STRENGTH/ SEQUENCE: A coronal T1 -weighted turbo spin-echo sequence as well as a 3D oblique transverse water-excitation true fast imaging sequence at 1.5T. ASSESSMENT: The volunteers underwent standard MRI of the hip, and patients underwent MR arthrography of the symptomatic hip using the same MR sequences. Measurements of cranial acetabular version, acetabular depth, and lateral center-edge angle were performed independently by three fellowship-trained musculoskeletal radiologists. STATISTICAL TESTS: Descriptive statistics, Mann-Whitney U-test, Unpaired t-test, receiver operating characteristics (ROC), Intraclass correlation coefficient (ICC). RESULTS: Forty-one percent (26/63, reader 1), 32% and 37% (20 and 23/63, reader 2/3) of asymptomatic volunteers had at least one positive MR finding for pincer-FAI. Patients with pincer or mixed-type FAI had cranial retroversion of the acetabulum of -0.2° ± 7.1 (mean ± standard deviation) for reader 1 and -0.3° ± 5.5/-0.2° ± 4.8 for reader 2 / reader 3, while asymptomatic volunteers had an anteversion of 6.2° ± 6.4 (reader 1) and 3.2° ± 4.9/3.1° ± 6.5 (readers 2/3): This difference was statistically significant (P ≤ 0.002), but there was a large overlap between the groups. Acetabular depth measurements were very similar for patients with either pincer or mixed-type FAI (5.1-5.3 mm ± 3.1) and volunteers (5.2-6.1 mm ± 2.6), without a statistically significant difference (P ≤ 0.50). Lateral center-edge angle was also similar in patients with either pincer or mixed-type FAI (32.1-35.1° ± 9.1) and volunteers (30.7-33.2° ± 6.5), without a statistically significant difference (P ≤ 0.28). DATA CONCLUSION: There is a large overlap in pincer-type MRI findings between patients with symptomatic FAI and asymptomatic volunteers. More than a third of volunteers exhibited at least one positive pincer-type MRI finding. LEVEL OF EVIDENCE: 1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;49:1296-1303.

Postpartum Bone Marrow Edema at the Sacroiliac Joints May Mimic Sacroiliitis of Axial Spondyloarthritis on MRI.

OBJECTIVE: The objective of our study was to compare MRI findings in the sacroiliac joints of postpartum women (as a model of mechanical changes) and women with known axial spondyloarthritis (as an inflammatory model). SUBJECTS AND METHODS: For this prospective multicenter age-matched, case-control study, sacroiliac joint MRI examinations of 30 healthy women (mean age, 34.0 years) in the early postpartum period (mechanical group) and 30 age-matched women (mean age, 33.8 years) with known axial spondyloarthritis (retrospective inflammatory group) were compared. Blinded to clinical information, readers assessed MR images using the following scoring systems: Spondyloarthritis Research Consortium of Canada (SPARCC) MRI index, Berlin method, Assessment of Spondyloarthritis International Society (ASAS) criteria, and SPARCC MRI structural score. Descriptive statistics as percentages of the different findings (i.e., bone marrow edema [BME], erosion, fatty bone marrow replacement, backfill, ankylosis) and scores between groups and between delivery modes were compared. RESULTS: In the postpartum group, 63.3% (19/30) of women showed BME around the sacroiliac joints compared with 86.7% (26/30) of women in the spondyloarthritis group (based on ASAS criteria). Erosions were uncommon in the postpartum group (10.0% [3/30] postpartum vs 56.7% [17/30] spondyloarthritis). Fatty bone marrow replacement, backfill, and ankylosis were not seen in the postpartum group. In subjects with positive MRI findings for sacroiliitis based on ASAS criteria, the SPARCC MRI index (mean ± SD, 13.6 ± 14.5 vs 13.0 ± 10.7; p = 0.818) and Berlin method (4.5 ± 3.0 and 5.5 ± 3.5, p = 0.378) were not different between the postpartum and spondyloarthritis groups. Scores were not different between birth modalities. CONCLUSION: Pregnancy-induced BME at the sacroiliac joints, as a result of prolonged mechanical stress, was present in 63.3% of women who underwent MRI during the early postpartum period and may mimic sacroiliitis of axial spondyloarthritis.

Is there an Added Value of T1-Weighted Contrast-Enhanced Fat-suppressed Spin-Echo MR Sequences Compared to STIR Sequences in MRI of the Foot and Ankle?

OBJECTIVES: To prospectively compare T1-weighted fat-suppressed spin-echo magnetic resonance (MR) sequences after gadolinium application (T1wGdFS) to STIR sequences in patients with acute and chronic foot pain. METHODS: In 51 patients referred for MRI of the foot and ankle, additional transverse and sagittal T1wGdFS sequences were obtained. Two sets of MR images (standard protocol with STIR or T1wGdFS) were analysed. Diagnosis, diagnostic confidence, and localization of the abnormality were noted. Standard of reference was established by an expert panel of two experienced MSK radiologists and one experienced foot surgeon based on MR images, clinical charts and surgical reports. Patients reported prospectively localization of pain. Descriptive statistics, McNemar test and Kappa test were used. RESULTS: Diagnostic accuracy with STIR protocol was 80% for reader 1, 67% for reader 2, with contrast-protocol 84%, both readers. Significance was found for reader 2. Diagnostic confidence for reader 1 was 1.7 with STIR, 1.3 with contrast-protocol; reader 2: 2.1/1.7. Significance was found for reader 1. Pain location correlated with STIR sequences in 64% and 52%, with gadolinium sequences in 70% and 71%. CONCLUSIONS: T1-weighted contrast material-enhanced fat-suppressed spin-echo magnetic resonance sequences improve diagnostic accuracy, diagnostic confidence and correlation of MR abnormalities with pain location in MRI of the foot and ankle. However, the additional value is small. KEY POINTS: • Additional value of contrast-enhanced MR over standard MR with STIR sequences exists. • There is slightly more added value for soft tissue than for bony lesions. • This added value is limited. • Therefore, application of contrast material cannot be generally recommended.

Frequency of Arthritis-Like MRI Findings in the Forefeet of Healthy Volunteers Versus Patients With Symptomatic Rheumatoid Arthritis or Psoriatic Arthritis.

OBJECTIVE: The objective of the present study is to evaluate arthritis-like findings on MRI studies of the forefeet of healthy volunteers versus patients with symptomatic rheumatoid arthritis (RA) or psoriatic arthritis (PsA). MATERIALS AND METHODS: Two observers analyzed MR images of the forefeet of 31 healthy volunteers, 30 patients with symptomatic RA, and 30 patients with symptomatic PsA, to identify MRI patterns of RA or PsA (e.g., bone marrow edema [BME], erosions, tenosynovitis, joint effusion, periarticular soft-tissue edema, or bony proliferations) on the basis of the Outcome Measures in Rheumatoid Arthritis Clinical Trial RA MRI scoring system and the PsA MRI scoring system. The Mann-Whitney test with Bonferroni correction was used for statistical analysis. RESULTS: Reader 1 found BME in 14 healthy volunteers (45%), whereas reader 2 found BME in 10 volunteers (32%). Tenosynovitis was observed by reader 1 in three healthy volunteers (10%). Joint effusion was found by reader 1 in seven healthy volunteers (23%) and by reader 2 in three volunteers (10%); the mean intensity grades for these findings were low (range, 1-1.33). Erosions, soft-tissue edema, and bony proliferations were not found in the forefeet of healthy volunteers. Reader 1 and reader 2 observed all arthritis-like features on the MR images of patients with RA. The percentages of patients with RA who had such MRI features, as identified by reader 1 and reader 2, respectively, were as follows: BME, 83% and 80%; erosions, 40% and 40%; tenosynovitis, 33% and 17%; effusion, 87% and 53%; soft-tissue edema, 20% and 27%; and bony proliferations, 3% and 3%. The percentages of patients with PsA who were found to have arthritis-like findings on MR images, as determined by reader 1 and reader 2, respectively, were as follows: BME, 70% and 67%; erosions, 20% and 20%; tenosynovitis, 57% and 50%; effusion, 70% and 37%; and soft-tissue edema, 60% and 53%. Bony proliferations were observed by reader 2 only in 7% of patients with PsA. The mean minimum intensity grade was 1 (for tenosynovitis in patients with RA, as observed by reader 2), whereas the maximum intensity grade was 2.53 (for erosions in patients with RA, as observed by reader 1). Tenosynovitis and soft-tissue edema were observed more frequently in patients with PsA than in patients with RA (p = 0.001-0.059). CONCLUSION: On the forefoot of healthy volunteers, mild BME is a common finding, and tenosynovitis and joint effusion are occasional findings. The frequency and intensity of arthritis-like findings on MRI are similar in patients with RA and PsA, with the exception of tenosynovitis and soft-tissue edema, which are more frequently observed in patients with PsA than in patients with RA.

Enthesitis of lumbar spinal ligaments in clinically suspected spondyloarthritis: value of gadolinium-enhanced MR images in comparison to STIR.

OBJECTIVE: To compare detection of spinal ligament enthesitis between gadolinium-enhanced fat-saturated T1-weighted gadolinium-enhanced fat-saturated T1-weighted (T1+Gd) and STIR sequences in patients with suspected spondyloarthritis. MATERIALS AND METHODS: Sixty-eight patients (37 males, 42 ± 14 years) with a sacroiliac-joint (SIJ) and lumbar spine MRI for suspected spondyloarthritis were prospectively included. Sagittal T1+Gd and STIR images of the lumbar spine were assessed by two readers for enthesitis of interspinous/supraspinous ligaments, and for capsulitis of facet-joints between T12-S1. Patients' MRI were grouped according to ASAS (Assessment of SpondyloArthritis international Society) criteria in positive (group A) or negative (group B) SIJs. Enthesitis/capsulitis were compared between groups. Interreader agreement was assessed. RESULTS: Enthesitis/capsulitis per patient was statistically significantly more frequent with T1+Gd compared to STIR (p ≤ 0.007), except for interspinous ligaments for reader 1 (p = 0.455). Interspinous enthesitis, supraspinous enthesitis, and capsulitis were present with T1+Gd(STIR) in 64.7 %(72.1 %), 60.3 %(17.7 %), and 61.8 %(29.4 %) for reader 1, and 51.5 %(41.2 %), 45.6 %(7.4 %), and 91.2 %(45.5 %) for reader 2. There were 76.5 %(52/68) patients in group A and 23.5 %(16/68) in group B. Total number of enthesitis/capsulitis on T1+Gd was statistically significantly higher in group A than B (4.96 vs. 2.94, p = 0.026; 8.12 vs. 5.25, p = 0.041 for reader 1 and 2, respectively). Interreader agreement showed mixed results for interspinous/supraspinous/capsulitis but was higher on T1+Gd (ICC = 0.838/0.783/0.367; p ≤ 0.001) compared to STIR (ICC = 0.652/0.298/0.224; p ≤ 0.032). CONCLUSION: In patients with suspected spondyloarthritis, enthesitis/capsulitis in the lumbar spine are common findings and more frequently/reliably detected with T1+Gd than STIR. In patients with positive SIJ-MRI, the total number of enthesitis/capsulitis in T1+Gd was higher compared to patients with negative SIJ-MRI.

Does spinal MRI add incremental diagnostic value to MRI of the sacroiliac joints alone in patients with non-radiographic axial spondyloarthritis?

OBJECTIVE: To assess the incremental diagnostic value of spine MRI evaluated separately from and combined with sacroiliac joint (SIJ) MRI in non-radiographic axial spondyloarthritis (nr-axSpA) compared with SIJ MRI alone. METHODS: The study sample comprised two independent cohorts A/B of 130 consecutive patients aged ≤50 years with back pain, newly referred to two university clinics, and 20 healthy controls. Patients were classified according to clinical examination and pelvic radiographs as having nr-axSpA (n=50), ankylosing spondylitis (n=33), or non-specific back pain (n=47). Four readers assessed SIJ and spine MRI separately 6 months apart, and 1-12 months later both scans simultaneously using standardised modules. Readers recorded presence/absence of SpA and their level of confidence in this conclusion on a 0-10 scale (0=definitely not; 10=definite). We analysed differences between SIJ MRI versus spine MRI alone, and SIJ MRI alone versus combined MRI, descriptively by the number/percentage of subjects according to the mean of four readers. RESULTS: In cohorts A/B, 15.8%/24.2% of patients with nr-axSpA having a negative SIJ MRI were reclassified as being positive for SpA by global evaluation of combined scans. However, 26.8%/11.4% of non-specific back pain controls and 17.5% of healthy volunteers with a negative SIJ MRI were falsely reclassified as having SpA by combined MRI. Low confidence in a diagnosis of SpA by SIJ MRI increased to high confidence by combined MRI in 6.6%/7.3% of patients with nr-axSpA. CONCLUSIONS: Combined spine and SIJ MRI added little incremental value compared with SIJ MRI alone for diagnosing patients with nr-axSpA and enhancing confidence in this diagnosis.

Candidate lesion-based criteria for defining a positive sacroiliac joint MRI in two cohorts of patients with axial spondyloarthritis.

OBJECTIVE: To determine candidate lesion-based criteria for a positive sacroiliac joint (SIJ) MRI based on bone marrow oedema (BMO) and/or erosion in non-radiographic axial spondyloarthritis (nr-axSpA); to compare the performance of lesion-based criteria with global evaluation by expert readers. METHODS: Two independent cohorts A/B of 69/88 consecutive patients with back pain aged ≤50 years, with median symptom duration 1.3/10.0 years, were referred for suspected SpA (A) or acute anterior uveitis plus back pain (B). Patients were classified according to rheumatologist expert opinion based on clinical examination, pelvic radiography and laboratory values as having nr-axSpA (n=51), ankylosing spondylitis (n=34) or non-specific back pain (n=72). Four blinded readers assessed SIJ MRI, recording the presence/absence of SpA by concomitant global evaluation of T1-weighted spin echo (T1SE) and short τ inversion recovery (STIR) scans and, thereafter, whether BMO and/or erosion were present/absent in each SIJ quadrant of each MRI slice. We derived candidate lesion-based criteria based on the number of SIJ quadrants with BMO and/or erosion and calculated mean sensitivity and specificity for SpA. RESULTS: For both cohorts A/B, global assessment showed high specificity (0.95/0.83) compared with the Assessment in SpondyloArthritis international Society (ASAS) definition (0.76/0.74). BMO ≥3 (0.89/0.84) or ≥4 (0.92/0.87) showed comparably high specificity to global assessment. Erosion ≥2 and/or BMO ≥3 or ≥4 were associated with comparably high sensitivity to global assessment without affecting specificity. These combined criteria showed both higher sensitivity and specificity than the ASAS definition. CONCLUSIONS: Lesion-based criteria for a positive SIJ MRI based on both BMO and/or erosion performed best for classification of axial SpA, reflecting the contextual information provided by T1SE and STIR sequences.

Hip MRI: how useful is intraarticular contrast material for evaluating surgically proven lesions of the labrum and articular cartilage?

OBJECTIVE: The objective of our study was to prospectively compare the diagnostic performance of MR arthrography and conventional MRI with surgical correlation in the same patient for detecting labrum and articular cartilage defects. SUBJECTS AND METHODS: Twenty-eight patients (mean age, 31.8 years) underwent MR arthrography, conventional MRI, and subsequent hip surgery, which served as the reference standard. Labrum and cartilage defects were evaluated at MRI by two independent readers. A McNemar test and kappa statistics were used for statistical analysis. RESULTS: At surgery, 31 labral tears were identified. MR arthrography had an advantage over conventional MRI for detecting labral tears at the anterosuperior quadrant (sensitivity of MR arthrography, 81% and 69% for readers 1 and 2, respectively; sensitivity of conventional MRI, 50% for both readers); this difference in performance between MR arthrography and conventional MRI was statistically significant for reader 1 (p = 0.02) but not for reader 2 (p = 0.2). Interobserver agreement for labral tears was higher for MR arthrography (κ = 0.81) than for conventional MRI (κ = 0.63). Surgery showed 31 acetabular cartilage defects and nine femoral cartilage defects. MR arthrography had an advantage over conventional MRI for detecting acetabular cartilage defects (sensitivity of MR arthrography, 71% and 92% for readers 1 and 2, respectively; sensitivity of conventional MRI, 58% and 83%), whereas there was no advantage to using MR arthrography for detecting femoral cartilage defects with statistically significant difference for the acetabular cartilage or femoral cartilage. Interobserver agreement was slightly higher for MR arthrography (κ = 0.50) than for conventional MRI (κ = 0.40) for assessing the acetabular cartilage and was almost identical for the femoral cartilage (κ = 0.62 and 0.63, respectively). CONCLUSION: MR arthrography was superior to conventional MRI for detecting labral tears and acetabular cartilage defects and showed a higher interobserver agreement. For femoral cartilage lesions, both modalities yielded comparable results.

Ligaments of the Lisfranc joint in MRI: 3D-SPACE (sampling perfection with application optimized contrasts using different flip-angle evolution) sequence compared to three orthogonal proton-density fat-saturated (PD fs) sequences.

PURPOSE: To compare the detection rate and visibility of the ligaments in the Lisfranc joint with a single 3D (-SPACE) MR sequence and three orthogonal PD fat-saturated sequences. MATERIALS AND METHODS: Thirty-one asymptomatic feet and 15 patients with posttraumatic pain in the Lisfranc joint were evaluated with a 3D-SPACE-sequence (0.5 mm section thickness, acquisition time 10:22 min, secondary reformations) and three orthogonal PD fs sequences (2 mm section thickness, 9:20 min). The Lisfranc-ligament, the dorsal and plantar tarsometatarsal ligaments (TMT), the dorsal, interosseous, and plantar intermetatarsal ligaments (IMT) (24 ligaments for each foot) were assessed. RESULTS: In asymptomatic feet, 692 ligaments were detected with the SPACE sequence, thereof 90.6 % exhibited normal signal, and most (96.9 %) were completely visible on one single image. A total of 659 ligaments were detected with the PD fs sequence, thereof 86.6 % yielded normal signal, and 28.5 % were completely visible on one single image. In patients, 327 ligaments were detected with SPACE, thereof 50.6 % appeared completely visible with high signal. On PD fs, 308 ligaments were detected, 42.2 % of the ligaments had high signals. CONCLUSIONS: The ligaments of the Lisfranc joint are better detected with a single 3D-SPACE sequence and secondary reformations than with three orthogonal PD fs sequences.

Detection and quantification of glenohumeral joint effusion: reliability of ultrasound.

OBJECTIVES: To evaluate reliability of ultrasound for detection and quantification of glenohumeral joint effusion. METHODS: With institutional review board approval and informed consent ultrasound of 30 consecutive patients before and after MR arthrography of the shoulder was performed. Presence and width of any anechoic collection was noted within various locations (biceps tendon sheath, subscapular recess (neutral position and internal rotation), posterior glenohumeral joint recess (neutral position and external rotation)). Injected fluid (8-12 ml) into the glenohumeral joint served as gold-standard. Widths of anechoic collections were correlated (Spearman rank correlation) with injected fluid. RESULTS: Glenohumeral anechoic collection was consistently seen in the posterior glenohumeral joint recess with the arm in external rotation (100%, 30/30), and in the biceps tendon sheath (97%, 29/30). Ultrasound was not sensitive at other locations (7%-17%). Mean width in anterior-posterior direction of anechoic collection in the posterior glenohumeral joint recess was 7 mm (range: 3-18 mm), 2 mm (range: 1-7 mm) in the biceps tendon sheath. Significant correlation (R = 0.390, p = 0.033) was found between width of anechoic collection and injected fluid in the posterior glenohumeral joint recess. CONCLUSIONS: Glenohumeral joint effusion can be detected and quantified most reliably in the posterior glenohumeral joint recess with the arm in external rotation.

Dynamic imaging and function of partial supraspinatus tendon tears.

PURPOSE: It was the purpose of this study to identify and document normal and abnormal supraspinatus tendon function in vivo using real-time ultrasound. METHODS: We defined 4 groups of 20 individuals each: partial tear (group 1), full-thickness tear (group 2), successfully repaired tear (group 3), and healthy asymptomatic controls (group 4). Except for group 4, all patients underwent magnetic resonance arthrography to confirm the diagnosis. All underwent ultrasound imaging of the supraspinatus tendon with the adducted arm at rest and under maximal isometric abduction. Tendon deformation was dynamically assessed and measured with tendon thickness changes at 0.5, 1, 1.5, and 2 cm from the tendon insertion. The clinical assessment consisted of absolute and relative Constant score, subjective shoulder value, and strength measurements. RESULTS: Without muscle contraction, the tendons of the 4 groups were not of significantly different thickness, with the least variation at 1.5 cm from the insertion site. On contraction, the normal tendon thickness significantly increased at a distance of 2 cm, whereas it did not for the full-thickness and partial supraspinatus tears. Thus contraction of the muscle resulted in measurable deformation of the tendon. CONCLUSIONS: Partially torn supraspinatus tendons can be functionally incompetent, leading to a biomechanical deformation of the musculotendinous unit that is not different from that of a unit with a full-thickness tendon tear. The dynamic sonographic finding of a successful repair of a supraspinatus tendon is similar to that of a normal tendon, even though the previously injured muscle appears unable to generate the same strength as a normal muscle. LEVEL OF EVIDENCE: Level III, case-control study.

Elbow stiffness: effectiveness of conventional radiography and CT to explain osseous causes.

OBJECTIVE: The purpose of our study was to evaluate the effectiveness of conventional radiography and CT for explaining the osseous causes of elbow stiffness. MATERIALS AND METHODS: Two independent readers analyzed loose bodies and osteophytes on conventional radiography and CT (or CT arthrography) of the elbow in 94 consecutive patients (71 men, 23 women; mean age, 41 years; range, 18-68 years). Arthroscopic or surgical correlation was available in 58 (62%) patients. In all 94 patients, the expected restriction of motion was measured on images and correlated (Pearson's correlation) with the clinical restriction of motion. Kappa statistics were performed for interobserver agreement. RESULTS: Accuracy for detecting loose bodies was 67% with conventional radiography and 79% with CT. Differences in accuracy were most pronounced for detecting loose bodies in the posterior joint space (64% for conventional radiography vs 79% for CT). Accuracy for detecting osteophytes was 69% with conventional radiography and 76% with CT. Expected restriction of motion on conventional radiography correlated significantly with clinical restriction for only one reader for flexion (R = 0.21, p = 0.04). Expected restriction of extension on CT correlated significantly with clinical restriction of motion by both readers (R = 0.34 and 0.33, p = 0.001 and 0.001, respectively). Expected restriction of flexion on CT correlated significantly by one reader (R = 0.24, p = 0.02). Interobserver agreement with regard to detection of both loose bodies and osteophytes was higher for CT (kappa = 0.83 and 0.76) than for conventional radiography (0.64 and 0.60). CONCLUSION: CT is more effective than conventional radiography in explaining the osseous causes of elbow stiffness.

TASCI-transcutaneous tibial nerve stimulation in patients with acute spinal cord injury to prevent neurogenic detrusor overactivity: protocol for a nationwide, randomised, sham-controlled, double-blind clinical trial.

INTRODUCTION: Neurogenic lower urinary tract dysfunction (NLUTD), including neurogenic detrusor overactivity (NDO) and detrusor sphincter dyssynergia, is one of the most frequent and devastating sequelae of spinal cord injury (SCI), as it can lead to urinary incontinence and secondary damage such as renal failure. Transcutaneous tibial nerve stimulation (TTNS) is a promising, non-invasive neuromodulatory intervention that may prevent the emergence of the C-fibre evoked bladder reflexes that are thought to cause NDO. This paper presents the protocol for TTNS in acute SCI (TASCI), which will evaluate the efficacy of TTNS in preventing NDO. Furthermore, TASCI will provide insight into the mechanisms underlying TTNS, and the course of NLUTD development after SCI. METHODS AND ANALYSIS: TASCI is a nationwide, randomised, sham-controlled, double-blind clinical trial, conducted at all four SCI centres in Switzerland. The longitudinal design includes a baseline assessment period 5-39 days after acute SCI and follow-up assessments occurring 3, 6 and 12 months after SCI. A planned 114 participants will be randomised into verum or sham TTNS groups (1:1 ratio), stratified on study centre and lower extremity motor score. TTNS is performed for 30 min/day, 5 days/week, for 6-9 weeks starting within 40 days after SCI. The primary outcome is the occurrence of NDO jeopardising the upper urinary tract at 1 year after SCI, assessed by urodynamic investigation. Secondary outcome measures assess bladder and bowel function and symptoms, sexual function, neurological structure and function, functional independence, quality of life, as well as changes in biomarkers in the urine, blood, stool and bladder tissue. Safety of TTNS is the tertiary outcome. ETHICS AND DISSEMINATION: TASCI is approved by the Swiss Ethics Committee for Northwest/Central Switzerland, the Swiss Ethics Committee Vaud and the Swiss Ethics Committee Zürich (#2019-00074). Findings will be disseminated through peer-reviewed publications. TRIAL REGISTRATION NUMBER: NCT03965299.

Do Patients With Skin Psoriasis Show Subclinical Axial Inflammation on Magnetic Resonance Imaging of the Sacroiliac Joints and Entire Spine?

OBJECTIVE: To explore potential subclinical involvement of the axial skeleton by magnetic resonance imaging (MRI) of the sacroiliac (SI) joints and the entire spine in patients with skin psoriasis without clinical evidence of peripheral or axial inflammation. METHODS: Twenty patients with skin psoriasis but no clinical evidence of peripheral or axial inflammation and 22 healthy controls underwent standardized dermatologic and rheumatologic clinical examination and unenhanced 1.5T MRI of the SI joint and the entire spine. Two blinded readers globally assessed the presence or absence of SI joint inflammation simultaneously on T1-weighted and short tau inversion recovery MRI sequences with a confidence estimate. Bone marrow edema, fat metaplasia, erosion, and ankylosis of the SI joint, and vertebral corner inflammatory lesions and fat lesions were recorded using standardized modules. The prevalence of each lesion type was calculated in both groups, averaged across 2 readers. The number of subjects with lesions in the SI joint and spine (≥1, 2, 3, 4, or 5 lesions) as concordantly assessed by both readers was recorded. RESULTS: The median duration of skin psoriasis was 23.0 years, the median age of patients was 48.5 years, and 25.0% of patients and 9.1% of healthy controls were concordantly classified by both readers as having SI joint inflammation (P = 0.23). The prevalence of bone marrow edema and structural lesions was comparable across patients and controls, both on SI joint and spine MRI. CONCLUSION: In this controlled study, patients with skin psoriasis but no clinical arthritis or spondylitis showed limited evidence of concomitant subclinical axial involvement by SI joint and spine MRI. These findings do not support routine screening for subclinical axial inflammation in patients with longstanding skin psoriasis.

Validation of a Knowledge Transfer Tool According to the OMERACT Filter: Does Web-based Real-time Iterative Calibration Enhance the Evaluation of Bone Marrow Lesions in Hip Osteoarthritis?

OBJECTIVE: To assess reliability and feasibility of using a Web-based interface and interactive online calibration tool for magnetic resonance imaging (MRI) scoring of bone marrow lesions (BML) in osteoarthritis (OA), applied to the Hip MR Inflammation Scoring System (HIMRISS). METHODS: Seven readers new to HIMRISS (3 radiologists, 4 rheumatologists) scored coronal short-tau inversion recovery MRI from a hip OA observational study obtained pre- and 8-week poststeroid injection (n = 40 × 2 scans × 2 hips = 160 hips). By crossover design, Group B (4 readers) scored 20 patients (40 hips) using conventional spreadsheet-based methods and then another 20 using a Web-based interface and an online real-time iterative calibration (RETIC) training module. Group A (3 readers) reversed the order, scoring the first 20 subjects by the new method and the final 20 conventionally. Outcomes included ICC and reader survey. RESULTS: Interobserver reliability for BML status was high by both spreadsheet and Web-based methods (0.84-0.90), regardless of the order in which scoring was performed. Reliability of change scores was moderate and improved with training. Improvement was greater in readers who began with the spreadsheet method and then used the Web-based method than in those who began with the Web-based method, especially at the acetabulum. Readers found Web-based/RETIC scoring more user-friendly and nearly 50% faster than traditional spreadsheet methods. CONCLUSION: HIMRISS offers reliable BML scoring in OA, whether by conventional spreadsheet-based scoring or by a Web-based interface with interactive feedback. The new method allowed faster readings, provided a consistent training environment that helped inexperienced readers achieve reliability equivalent to that of conventional methods, and was preferred by the readers.