6
Magnetic resonance imaging of peripheral joints in rheumatic diseases

https://doi.org/10.1016/j.berh.2004.06.001Get rights and content

Abstract

The need for better methods than the conventional clinical, biochemical and radiographical examinations in the management of inflammatory joint diseases is evident, since these methods are not sensitive or specific to early pathologies and subtle changes. Magnetic resonance imaging (MRI) offers improved sensitivity to early inflammatory and destructive changes in peripheral joints in rheumatoid arthritis (RA) and, even though less well documented, in other inflammatory joint diseases. Good evidence is available that MRI bone erosions represent true bone abnormalities and are predictors of radiographical outcome in RA. Similarly, there is solid evidence for MRI synovitis representing true synovial inflammation and being of considerable practical, clinical and radiological significance in RA.

Describing the encouraging current knowledge regarding MRI for diagnosis, monitoring and prognosis, this chapter discusses the potential for the use of MRI in the clinical management of patients with suspected and diagnosed inflammatory joint diseases, as well as research priorities and clinical situations where the use of MRI could be suggested.

Section snippets

MRI hardware

MRI of the peripheral joints can be performed using whole-body MR-units or dedicated extremity MR-units (E-MRI). Most studies have used whole-body MR-units. Low-field E-MRI has been commercially available for a few years19., 20. and as machines are getting continuously smaller, transportable units are now available21, increasing the potential for widespread rheumatological use. The advantages of E-MRI compared with whole-body units include markedly lower costs, more comfortable patient

MRI in the diagnosis of inflammatory joint diseases

The ability of MRI to contribute to the process of diagnosing RA or other inflammatory joint diseases can be divided into two fundamentally different aspects: first, the ability to correctly detect various joint pathologies, e.g. synovitis or erosions; second, the ability to correctly diagnose specific types of arthritides, e.g. RA or PsA, i.e. a differential diagnostic value.

Monitoring of therapy

Since MRI directly visualises both the inflammatory and the destructive aspects of arthritic disease with unprecedented detail, it has the potential for accurate monitoring of treatment efficacy.

MRI assessment methods are quantitative (measuring), semiquantitative (scoring) or qualitative (presence or absence), and the setting and question asked markedly influence which method should be chosen (Table 4). The quantitative synovitis methods estimate the inflammatory activity of the joint by

MRI in the prognosis of the clinical and radiological disease course

There is solid evidence that MRI findings (synovitis, bone oedema and MR imaged bone erosions) predict subsequent radiographical erosive progression.44., 45., 60., 79. A study of established RA wrists found a positive predictive value for high synovial membrane volumes of 80% for erosive progression the following year, while the negative predictive value of low volumes was 100%.60 Accordingly, a recent 1-year study of 40 early RA patients found no erosive progression in joints without synovitis.

Why and when to use MRI in routine clinical practice

Considering the described evidence on the validity and predictive value of MRI (Table 2, Table 3) and the obvious shortcomings of conventional methods, it appears to be justified to recommend the introduction of MRI for specific indications in the routine clinical management of patients with diagnosed or suspected inflammatory joint diseases. Clinical situations where the use of MRI can be suggested include clinical presentations in suspected but not definite arthritis, in early unclassified

Future perspectives and research priorities

MRI has multiple potential applications in RA clinical trials. In human phase I/II studies it could be useful for the sensitive assessment of a compound's anti-inflammatory effectiveness (‘proof of concept’ studies) and for pre-trial selection of the patients most likely to progress. In phase III/IV studies, the superior sensitivity of MRI for structural joint damage may allow reductions in trial size and length due to more sensitive separation of responders from non-responders. In the future,

Summary

The obvious need in the management of inflammatory joint diseases for better diagnostic, monitoring and prognostic methods than conventional clinical examination, laboratory tests and radiography, has increased the interest in new imaging modalities such as magnetic resonance imaging (MRI).

MRI allows the detailed assessment of inflammatory and destructive manifestations of rheumatic diseases, including synovitis, tenosynovitis, enthesitis, bone marrow oedema and bone erosion. Good evidence is

Acknowledgements

The Danish Rheumatism Association is acknowledged for financial support. Photographer Susanne Østergaard is acknowledged for excellent technical assistance.

References (91)

  • A.C. Brower

    Use of the radiograph to measure the course of rheumatoid artrhitis. The gold standard versus fool's gold

    Arthritis & Rheumatism

    (1990)
  • F.M. McQueen et al.

    Magnetic resonance imaging of the wrist in early rheumatoid arthritis reveals a high prevalence of erosion at four months after symptom onset

    Annals of the Rheumatic Diseases

    (1998)
  • M. Backhaus et al.

    Arthritis of the finger joints. A comprehensive approach comparing conventional radiography, scintigraphy, ultrasound, and contrast-enhanced magnetic resonance imaging

    Arthritis & Rheumatism

    (1999)
  • D.J. Rubens et al.

    Rheumatoid arthritis: evaluation of wrist extensor tendons with clinical examination versus MR imaging—a preliminary report

    Radiology

    (1993)
  • M.B. Rominger et al.

    MR imaging of the hands in early rheumatoid arthritis: preliminary results

    Radiographics

    (1993)
  • A. Corvetta et al.

    MR imaging of rheumatoid hand lesions: comparison with conventional radiology in 31 patients

    Clinical and Experimental Rheumatology

    (1992)
  • C. Jorgensen et al.

    Sensitivity of magnetic resonance imaging of the wrist in very early rheumatoid arthritis

    Clinical and Experimental Rheumatology

    (1993)
  • M. Østergaard et al.

    Scoring of synovial membrane hypertrophy and bone erosions by MR imaging in clinically active and inactive rheumatoid arthritis of the wrist

    Scandinavian Journal of Rheumatology

    (1995)
  • V. Jevtic et al.

    Distinctive radiological features of small hand joints in rheumatoid arthritis and seronegative spondyloarthritis by contrast-enhanced (Gd-DTPA) magnetic resonance imaging

    Skeletal Radiology

    (1995)
  • D. McGonagle et al.

    Characteristic magnetic resonance imaging entheseal changes of knee synovitis in spondylarthropathy

    Arthritis & Rheumatism

    (1998)
  • D. McGonagle et al.

    The relationship between synovitis and bone changes in early untreated rheumatoid arthritis. A controlled magnetic resonance imaging study

    Arthritis & Rheumatism

    (1999)
  • M. Klarlund et al.

    Magnetic resonance imaging, radiography, and scintigraphy of the finger joints: one year follow up of patients with early arthritis

    Annals of the Rheumatic Diseases

    (2000)
  • A. Savnik et al.

    MRI of the arthritic small joints: comparison of extremity MRI (0.2 T) vs high-field MRI (1.5 T)

    European Radiology

    (2001)
  • H. Lindegaard et al.

    Low field dedicated magnetic resonance imaging in untreated rheumatoid arthritis of recent onset

    Annals of the Rheumatic Diseases

    (2001)
  • O.M. Troum et al.

    Identification of wrist and metacarpophalangeal joint erosions using portable in-office high resolution magnetic resonance imaging compared to conventional X-ray

    Arthritis & Rheumatism

    (2003)
  • B. Ejbjerg et al.

    Optimized low-cost low-field dedicated extremity MRI can provide similar information on wrist and MCP joint synovitis and bone erosions as expensive conventional high-field MRI arthritis—a comparison with ‘conventional’ high-field MRI

    Annals of the Rheumatic Diseases

    (2002)
  • N. Nakahara et al.

    Gadolinium-enhanced MR imaging of the wrist in rheumatoid arthritis: value of fat suppression pulse sequences

    Skeletal Radiology

    (1996)
  • P.A. Rinck et al.

    Magnetic Resonance in Medicine. The Basic Textbook of the European Magnetic Resonance Forum

    (1993)
  • M. Østergaard et al.

    OMERACT Rheumatoid Arthritis Magnetic Resonance Imaging Studies. Core set of MRI acquisitions, joint pathology definitions, and the OMERACT RA-MRI scoring system

    The Journal of Rheumatology

    (2003)
  • M. Østergaard et al.

    Reducing costs, duration and invasiveness of magnetic resonance imaging in rheumatoid arthritis by omitting intravenous gadolinium injection—does it affect assessments of synovitis, bone erosions and bone edema?

    Annals of the Rheumatic Diseases

    (2003)
  • C.G. Peterfy et al.

    MR imaging of the arthritic knee: improved discrimination of cartilage, synovium, and effusion with pulsed saturation transfer and fat-suppressed T1-weighted sequences

    Radiology

    (1994)
  • P. Conaghan et al.

    New approaches to imaging of early rheumatoid arthritis

    Clinical and Experimental Rheumatology

    (1999)
  • V. Jevtic et al.

    The value of contrast enhanced magnetic resonance imaging in evaluation of drug therapy in rheumatoid arthritis—a prospective study on hand joints in 65 patients

    Acta Phalmacologica

    (1993)
  • H. Sugimoto et al.

    Early stage rheumatoid arthritis: prospective study of the effectiveness of MR imaging for diagnosis

    Radiology

    (2000)
  • B. Ostendorf et al.

    Magnetic resonance imaging and miniarthroscopy of metacarpophalangeal joints: sensitive detection of morphologic changes in rheumatoid arthritis

    Arthritis & Rheumatism

    (2001)
  • H. König et al.

    Rheumatoid arthritis: evaluation of hypervascular and fibrous pannus with dynamic MR imaging enhanced with gd-DTPA

    Radiology

    (1990)
  • M. Østergaard et al.

    Magnetic resonance imaging-determined synovial membrane and joint effusion volumes in rheumatoid arthritis and osteoarthritis: comparison with the macroscopic and microscopic appearance of the synovium

    Arthritis & Rheumatism

    (1997)
  • K. Gaffney et al.

    Quantitative assessment of the rheumatoid synovial microvascular bed by gadolinium-DTPA enhanced magnetic resonance imaging

    Annals of the Rheumatic Diseases

    (1998)
  • B. Partik et al.

    Patterns of gadopentetate-enhanced MR imaging of radiocarpal joints of healthy subjects

    American Journal of Roentgenology

    (2002)
  • A.L. Tan et al.

    Role of metacarpophalangeal joint anatomic factors in the distribution of synovitis and bone erosion in early rheumatoid arthritis

    Arthritis & Rheumatism

    (2003)
  • B. Ejbjerg et al.

    Magnetic resonance imaging of wrist and finger joints in healthy subjects occasionally shows changes resembling erosions and synovitis as seen in rheumatoid arthritis

    Arthritis & Rheumatism

    (2004)
  • A. Giovagnoni et al.

    MRI of the hand in psoriatic and rheumatical arthritis

    European Radiology

    (1995)
  • A. Offidani et al.

    Subclinical joint involvement in psoriasis: magnetic resonance imaging and X-ray findings

    Acta Dermato Venereologica

    (1998)
  • F.M. McQueen et al.

    Magnetic resonance imaging of the wrist in early rheumatoid arthritis reveals progression of erosions despite clinical improvement

    Annals of the Rheumatic Diseases

    (1999)
  • A. Savnik et al.

    MRI of the wrist and finger joints in inflammatory joint diseases at 1-year interval: MRI features to predict bone erosions

    European Radiology

    (2002)
  • Cited by (31)

    • Imaging in Pediatric Rheumatic Diseases

      2015, Textbook of Pediatric Rheumatology
    • Imaging the Laboratory Mouse in vivo

      2012, The Laboratory Mouse
    • MR imaging features of foot involvement in patients with psoriasis

      2008, European Journal of Radiology
      Citation Excerpt :

      Clinical and radiological changes in the foot should be evaluated with care, as they provide valuable diagnostic and prognostic information to guide treatment in patients with inflammatory arthritis [1,11]. It has been well recognized that MR imaging is more sensitive than clinical examination in the detection of inflammatory changes such as synovitis, tenosynovitis, and enthesopathy and also bone erosions earlier than conventional radiography [12]. Therefore, we performed MR imaging to evaluate possible foot abnormalities in patients with psoriasis.

    View all citing articles on Scopus
    View full text