[Imaging of inflammatory back pain]. / Tulehduksellisen selkäkivun kuvantamis- diagnostiikka.

We recommend magnetic resonance imaging of the sacroiliac joints as the first line imaging method in suspected inflammatory back disorder. Plain X-ray can be taken from those over 35 years of age. A nonconclusive finding in plain X-ray should be verified by MR imaging. For the present, diagnostic criteria for spondylarthritis do not take into account spinal changes. Typical spinal findings can, however, be helpful in making treatment decisions. In case the spinal region MR imaging should be utilized if possible, because radiography is particularly insensitive for thoracic spine. After a confirmed diagnosis, the inflammatory nature of the condition can usually be assessed clinically.

The thoracic and lumbar spine in severe juvenile idiopathic arthritis: magnetic resonance imaging analysis in 50 children.

OBJECTIVE: To determine the prevalence of vertebral fractures as a complication of juvenile idiopathic arthritis (JIA). STUDY DESIGN: This cross-sectional study evaluated the prevalence and characteristics of spinal abnormalities in 50 children (aged 7.0-18.7 years) with treatment-resistant JIA by magnetic resonance imaging. Vertebral deformities, endplate irregularities, intervertebral disc involvement, spinal canal, neural foramina, and back muscles were analyzed and correlated with clinical characteristics and bone mineral density. RESULTS: Magnetic resonance imaging revealed various abnormalities in 31 patients (62%). Vertebral compression was seen in 28%, disc degeneration in 46%, protrusions in 14%, prolapses in 4%, endplate changes in 26%, and anterior vertebral corner lesions in 16%. Two patients (4%) had mild spinal canal narrowing without medullar involvement; none had neural root compression. Six patients (12%) had mild back muscle atrophy. No correlation was observed between spinal fractures or other vertebral changes and disease activity or duration, pain or bone mineral density; patients with spinal fractures tended to have a higher recent glucocorticoid exposure (P=.086). CONCLUSION: Children with severe JIA have a high prevalence of compression fractures and other vertebral, endplate, and disc abnormalities in the thoracic and lumbar spine.

Prevalence of vertebral compression fractures and associated factors in children and adolescents with severe juvenile idiopathic arthritis.

OBJECTIVE: Vertebral fractures occur in patients with juvenile idiopathic arthritis (JIA), but data on their frequency and causes are scarce. Our cross-sectional study evaluated prevalence of compression fractures and associated factors in a high-risk pediatric population with severe JIA. METHODS: Children and adolescents with a history of treatment-resistant polyarticular-course JIA for ≥ 5 years or systemic arthritis for ≥ 3 years were recruited. Clinical examination, dietary recall, laboratory measurements, bone mineral density (BMD) measurement by dual-energy X-ray absorptiometry, and spinal radiography were performed. RESULTS: Our study included 50 patients (41 girls), of whom 6 (12%) had systemic arthritis, with a median age of 14.8 years (range 7.0-18.7 yrs) and median disease duration of 10.2 years (range 3.9-16.8 years). Ninety-four percent had used systemic glucocorticoids (GC); the median total duration of GC treatment was 7.1 years (range 0-15.5 yrs). The median weight-adjusted cumulative GC dose for the preceding 3 years was 72 mg/kg (range 0-911 mg/kg). The median bone age-corrected lumbar spine and whole-body areal BMD Z-scores were -0.8 and -1.0, respectively. Twenty-two percent had vertebral fractures, mostly thoracic. Compression fractures were associated with high disease activity, high body mass index (BMI), and high recent cumulative GC dose, but not with disease duration or BMD. Thirty percent had sustained at least 1 peripheral low energy fracture. Twenty-six percent were deemed to have significantly compromised bone health. CONCLUSION: Severe JIA is associated with a significant risk of vertebral compression fractures. Associated factors include high disease activity, high BMI, and high recent GC exposure. Further studies are needed to establish optimal prevention and treatment guidelines.

[Strong metatarsal pain and localized bone lesions in a physically active male (clinico-pathological conference report)]. / Liikuntaa harrastaneen miehen voimakas jalka- teräkipu ja paikalliset luustomuutokset.

With the exception of a previous history of pulmonary sarcoidosis, a previously healthy 38-year old man developed a sudden unilateral metatarsal pain and gradually progressing osteoporotic, partly lytic metatarsal bone lesions. The patient received a bisphosphonate treatment. Clinical and radiological situation began to improve during the follow-up observation. The diagnosis was based on clinical picture.

Ability of ultrasound imaging to detect erosions in a bone phantom model.

OBJECTIVES: The authors examined the validity, interobserver reliability and interscanner variation in detecting bone erosions with ultrasonography using a custom-made phantom. METHODS: 21 bovine bones were used. Artificial erosions were made into 15 bones and six bones were left as controls. In the processed bones the numbers of erosions, their depths and widths varied between 1-7, 1-4 and 1.5-5 mm, respectively. Each bone was coated with polyvinyl alcohol cryogel to mimic overlying soft tissue and to hide the erosions. Four musculoskeletal sonography experts scanned the 21 blind-coded phantoms using one of the three sets of ultrasound equipment. Finally, quality assurance measurements of the ultrasound equipment was carried out using two additional bone samples. RESULTS: The sonographers detected the erosions successfully with ultrasound. The mean correlation coefficient for a correct result in terms of the number of erosions detected was 0.88 (range 0.75-0.975). The overall Cohen's kappa coefficient for interobserver agreement was 0.683 in terms of discrimination between healthy bones and bones with erosions. The different sets of equipment showed that their overall performance was equal. CONCLUSIONS: The sonographers had good correlations with the number of erosions and they were successful in separating healthy bones from bones with erosions. It seems that neither depth nor width is crucial but that in experimental conditions a 1.5 mm erosion width was the limit for the resolution with current ultrasound equipment. Ultrasound is a valid and reliable method of detecting cortical bone erosions in vitro, when the round erosion is at least 1 mm deep and 1.5 mm wide.

A 30-year result of deforming arthritis in systemic lupus erythematosus.

Symmetric non-erosive polyarthritis is the most common clinical feature in systemic lupus erythematosus (SLE). We report on a 42-year follow-up of a 71-year-old woman who first had polyarthritis in 1963 at the age of 29 and continuously since 1975. SLE was diagnosed in 2000 at the age of 66 as anti-dsDNA (56 kIU/l), and antinuclear antibodies (1:2,560) turned positive. In 2005 hand and feet radiographs revealed severe Jaccoud's arthritis with subluxations but without erosions.

Bone oedema predicts erosive progression on wrist MRI in early RA--a 2-yr observational MRI and NC scintigraphy study.

OBJECTIVES: To investigate if disease assessment by contrast-enhanced dynamic and static magnetic resonance imaging (MRI) and quantitative nanocolloid (NC) scintigraphy gives useful additional information in early rheumatoid arthritis (RA). METHODS: Twenty-seven patients with early RA (disease duration < or =12 months) were followed up for 1 yr and 24 of them for 2 yrs with contrast-enhanced MRI and NC scintigraphy of the wrist joint. Synovial inflammation was assessed by measuring time-dependent enhancement rates (E-rate) from dynamic MRI scans and technetium(99m)-labelled nanocolloid ((99m)Tc-NC) uptake from scintigraphy scans. Synovial membrane hypertrophy, bone oedema and erosions were semiquantitatively scored according to the Outcome Measures in Rheumatology Clinical Trials RA-MRI scoring system from static MR images. Response to the treatment was evaluated based on whether or not > or = 50% improvement was achieved in the tender and swollen joint scores and the Health Assessment Questionnaire score, with normal C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) levels. Progression of the erosion score on wrist MRI was evaluated as the outcome. RESULTS: The baseline MRI bone oedema score (rho= 0.67), MRI synovitis score (rho= 0.57), ESR (rho= 0.56), CRP (rho= 0.48), E-rate (rho= 0.47) and (99m)Tc-NC uptake (rho= 0.45) were related with the change in the MRI erosion score from baseline to 2 yrs (rho= Spearman's correlation). In the multivariate logistic regression model, the bone marrow oedema score was the only baseline variable that predicted erosive progression at 2 yrs' follow-up (OR 4.2, 95% CI 1.3-13.8). The median (interquartile range) change in the erosion score from baseline to 2 yrs was 0 (0, 0) and 4 (2, 5) in the patients with (n= 9) and without (n= 15) a persistent clinical response over the 2 yrs, respectively (P= 0.001). The non-responders who presented with erosive progression from 1 yr to 2 yrs had higher MRI synovitis scores, bone oedema scores, E-rate and (99m)Tc-NC uptake at 1-yr follow-up than the non-responders without progressive bone damage. CONCLUSION: The degree of local synovial inflammation at baseline, evaluated by dynamic and static MRI and quantitative NC scintigraphy, is closely related to the progression of wrist joint erosions during the first 2 yrs of the disease. Furthermore, at follow-up, if no persistent clinical response is achieved, these imaging methods may help to predict future erosiveness and help in clinical therapeutic decision making.