Abstract
Involvement of the sacroiliac joints is the first predominant finding of all seronegative spondylarthropathies (SpA) subsets, such as ankylosing spondylitis, psoriatic arthritis, and undifferentiated SpA. Although conventional radiography is indicated in the initial evaluation of sacroiliac joints diseases, it is often insensitive for demonstrating the early changes of sacroiliitis, so other imaging techniques typically are often necessary to clarify the pathology and for establishing the early diagnosis of seronegative SpA. Other imaging modalities, including computed tomography (CT), magnetic resonance imaging (MRI), ultrasonography (US), and bone scintigraphy have improved visualization of inflammatory changes at the sacroiliac joints (SIJ). CT scans are indicated for disease processes in which bony destruction or ossification may occur. MRI has been proposed as an imaging method to detect sacroiliitis earlier. MRI can identify both inflammation and structural changes caused by inflammation, while radiographs show only structural changes. MRI may be particularly useful in making a diagnosis of SpA. Musculoskeletal US has an increasing and relevant role in the evaluation of SpA mainly for its ability to assess joint and periarticular soft tissue involvement and in particular for its capacity to detect enthesitis. US assessment in general is safe, noninvasive, and comparably cheap, showing itself as a complimentary tool to clinical evaluation in SpA; nevertheless, it is very user dependent. Bone scintigraphy is at most of limited diagnostic value for the diagnosis of established AS, including the early diagnosis of probable/suspected sacroiliitis. The main aim of this study is to introduce the clinical and radiological aspects of the SIJ involvement in SpA, particularly the contribution of the different imaging techniques.
Similar content being viewed by others
References
De Angelis R, Salaffi F, Grassi W (2007) Prevalence of spondyloarthropathies in an Italian population sample: a regional community-based study. Scand J Rheumatol 36:14–21
Salaffi F, De Angelis R, Grassi W (2005) MArche Pain Prevalence Investigation Group (MAPPING) Study. Prevalence of musculoskeletal conditions in an Italian population sample: results of a regional community-based study. I. The MAPPING study. Clin Exp Rheumatol 23:819–828
Brandt J, Bollow M, Haberle J et al (1999) Studying patients with inflammatory back pain and arthritis of the lower limbs clinically and by magnetic resonance imaging: many, but not all patients with sacroiliitis have spondyloarthropathy. Rheumatology 38:831–836
Dougados M, van der Linden S, Juhlin R et al (1991) The European Spondyloarthropathy Study Group preliminary criteria for the classification of spondylarthropathy. Arthritis Rheum 34:1218–1227
Amor B, Dougados M, Mijiyawa M (1990) Criteria of the classification of spondylarthropathies. Rev Rhum Mal Osteoartic 57:85–89
van der Linden S, Valkenburg HA, Cats A (1984) Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria. Arthritis Rheum 27:361–368
Feldtkeller E, Bruckel J, Khan MA (2000) Scientific contributions of ankylosing spondylitis patient advocacy groups. Curr Opin Rheumatol 12:239–247
van Tubergen A, Heuft-Dorenbosch L, Schulpen G et al (2003) Radiographic assessment of sacroiliitis by radiologists and rheumatologists: does training improve quality? Ann Rheum Dis 62:519–525
Rudwaleit M, van der Heijde DM, Khan MA, Braun J, Sieper J (2004) How to diagnose axial spondylarthritis early. Ann Rheum Dis 63:535–543
Szanto E, Lindvall N (1978) Quantitative 99mTc pertechnetate scanning of the sacroiliac joints. A follow-up study of patients with suspected sacroiliitis. Scand J Rheumatol 7:93–96
Dequeker J, Goddeeris T, Walravens M, De Roo M (1978) Evaluation of sacroiliitis: comparison of radiological and radionuclide techniques. Radiology 128:687–689
Goldberg RP, Genant HK, Shimshak R, Shames D (1978) Applications and limitations of quantitative sacroiliac joint scintigraphy. Radiology 128:683–686
Song IH, Carrasco-Fernández J, Rudwaleit M, Sieper J (2008) The diagnostic value of scintigraphy in assessing sacroiliitis in ankylosing spondylitis: a systematic literature research. Ann Rheum Dis 67:1535–1540
Geijer M, Sihlbom H, Göthlin JH, Nordborg E (1998) The role of CT in the diagnosis of sacroiliitis. Acta Radiol 39:265–268
van der Heijde D, Bellamy N, Calin A, Dougados M, Khan MA, van der Linden S (1997) Preliminary core sets for endpoints in ankylosing spondylitis. Assessment in Ankylosing Spondylitis Working Group. J Rheumatol 24:2225–2229
Salvarani C, Olivieri I, Cantini F et al (2004) Recommendations for the appropriate use of anti-TNF-alpha therapy in patients with psoriatic arthritis. Italian Rheumatology Society. Reumatismo 56:133–138
Braun J, Davis J, Dougados M, Sieper J, van der Linden S, van der Heijde D (2006) ASAS Working Group. First update of the international ASAS consensus statement for the use of anti-TNF agents in patients with ankylosing spondylitis. Ann Rheum Dis 65:316–320
Wanders A, Landewé R, Spoorenberg A et al (2004) What is the most appropriate scoring method for ankylosing spondylitis? A comparison of the available methods based on the Outcome Measures in Rheumatology Clinical Trials Filter. Arthritis Rheum 50:2622–2632
Salaffi F, Carotti M, Garofalo G, Giuseppetti GM, Grassi W (2007) Radiological scoring methods for ankylosing spondylitis: a comparison between the Bath Ankylosing Spondylitis Radiology Index and the modified Stoke Ankylosing Spondylitis Spine Score. Clin Exp Rheumatol 25:67–74
MacKay K, Brophy S, Mack C, Doran M, Calin A (2000) The development and validation of a radiographic grading system for the hip in ankylosing spondylitis: the Bath Ankylosing Spondylitis Radiology Hip index. J Rheumatol 27:2866–2872
Averns HL, Oxtoby J, Taylor HG, Jones PW, Dziedzic K, Dawes PT (1996) Radiological outcome in ankylosing spondylitis: use of the Stoke Ankylosing Spondylitis Spine Score (SASSS). Br J Rheumatol 35:373–376
Creemers MC, Franssen MJ, van’t Hof MA, Gribnau FW, van de Putte LB, van Riel PL (2005) Assessment of outcome in ankylosing spondylitis: an extended radiographic scoring system. Ann Rheum Dis 64:127–129
Battafarano DF, West SG, Rak KM, Fortenbery EJ, Chantelois AE (1993) Comparison of bone scan, computed tomography, and magnetic resonance imaging in the diagnosis of active sacroiliitis. Semin Arthritis Rheum 23:161–176
Blum U, Buitrago Tellez C, Mundinger A et al (1996) Magnetic resonance imaging (MRI) for detection of active sacroiliitis—a prospective study comparing conventional radiography, scintigraphy, and contrast enhanced MRI. J Rheumatol 23:2107–2115
Yu W, Feng F, Dion E, Yang H, Jiang M, Genant HK (1998) Comparison of radiography, computed tomography and magnetic resonance imaging in the detection of sacroiliitis accompanying ankylosing spondylitis. Skeletal Radiol 27:311–320
Fenton P (1996) Magnetic resonance imaging of the sacroiliac joints: worth the cost? J Rheumatol 23:2020–2021
Yazici H, Turunc M, Ozdogan H, Yurdakul S, Akinci A, Barnes CG (1987) Observer variation in grading sacroiliac radiographs might be a cause of ‘sacroiliitis’ reported in certain disease states. Ann Rheum Dis 46:139–145
Battistone MJ, Manaster BJ, Reda DJ, Clegg DO (1998) Radiographic diagnosis of sacroiliitis: are sacroiliac views really better? J Rheumatol 25:2395–2401
Lawson TL, Foley WD, Carrera GF et al (1982) The sacroiliac joints: anatomic, plain roentgenographic, and computed tomographic analysis. J Comput Assist Tomogr 6:307–314
Dale K, Vinje O (1985) Radiography of the spine and sacroiliac joints in ankylosing spondylitis and psoriasis. Acta Radiol 26:145–159
Puhakka KB, Jurik AG, Egund N et al (2003) Imaging of sacroiliitis in early seronegative spondylarthropathy. Assessment of abnormalities by MR in comparison with radiography and CT. Acta Radiol 44:218–229
Carrera GF, Foley WD, Kozin F et al (1981) CT of sacroiliitis. Am J Roentgenol 136:41–46
Jurik AG, Hansen J, Puhakka KB (2002) Effective radiation dose from semicoronal CT of the sacroiliac joints in comparison with axial CT and conventional radiography. Eur Radiol 12:2820–2825
Puhakka KB, Jurik AG, Schiøttz-Christensen B et al (2004) MRI abnormalities of the sacroiliac joints in early spondylarthropathy: a 1-year follow-up study. Acta Rheumatol 335:332–338
Braun J, Sieper J, Bollow M (2000) Imaging of sacroiliitis. Clin Rheumatol 19:51–57
Iovane A, Midiri M, Finazzo M et al (1998) Magnetic resonance imaging of seronegative sacroiliitis. Radiol Med 96:185–189
Braun J, Brandt J, Listing J et al (2002) Treatment of active ankylosing spondylitis with infliximab: a randomised controlled multicentre trial. Lancet 359:1187–1193
Muche B, Bollow M, Francois RJ et al (2003) Anatomic structures involved in early- and late-stage sacroiliitis in spondylarthritis: a detailed analysis by contrast-enhanced magnetic resonance imaging. Arthritis Rheum 48:1374–1384
Puhakka KB, Melsen F, Jurik AG et al (2004) MR imaging of the normal sacroiliac joint with correlation to histology. Skeletal Radiol 33:15–28
Puhakka KB, Jurik AG, Schiøttz-Christensen B et al (2004) MR imaging of early seronegative spondylarthropathy. Abnormalities associated to clinical and laboratory findings. Rheumatology 43:234–237
Bozgeyik Z, Ozgocmen S, Kocakoc E (2008) Role of diffusion-weighted MRI in the detection of early active sacroiliitis. AJR 191:980–986
Bredella MA, Steinbach LS, Morgan S, Ward M, Davis JC (2006) MRI of the sacroiliac joints in patients with moderate to severe ankylosing spondylitis. AJR 187:1420–1426
Maksymowych WP, Inman RD, Salonen D et al (2005) Spondylarthritis research Consortium of Canada MRI index for assessment of sacroiliac joint inflammation in ankylosing spondylitis. Arthritis Rheum 53:703–709
Baraliakos X, Landewe R, Braun J (2006) MRI in ankylosing spondylitis. Future Rheumatol 1:423–431
Gašperšic N, Serša I, Jevtic V, Tomšic M, Praprotnik S (2008) Monitoring ankylosing spondylitis therapy by dynamic contrast-enhanced and diffusion-weighted magnetic resonance imaging. Skeletal Radiol 37:123–131
Brandt J, Haibel H, Cornely D et al (2000) Successful treatment of active ankylosing spondylitis with the anti-tumor necrosis factor alpha monoclonal antibody infliximab. Arthritis Rheum 43:1346–1352
Davis JC Jr, van der Heijde D, Braun J et al (2003) Recombinant human tumor necrosis factor receptor (etanercept) for treating ankylosing spondylitis: a randomized, controlled trial. Arthritis Rheum 48:3230–3236
Braun J, Baraliakos X, Golder W et al (2003) Magnetic resonance imaging examinations of the spine in patients with ankylosing spondylitis, before and after successful therapy with infliximab: evaluation of a new scoring system. Arthritis Rheum 48:1126–1136
Rudwaleit M, Baraliakos X, Listing J, Brandt J, Sieper J, Braun J (2005) Magnetic resonance imaging of the spine and the sacroiliac joints in ankylosing spondylitis and undifferentiated spondylarthritis during treatment with etanercept. Ann Rheum Dis 64:1305–1310
Hanly JG, Mitchell MJ, Barnes DC, MacMillan L (1994) Early recognition of sacroiliitis by magnetic resonance imaging and single photon emission computed tomography. J Rheumatol 21:2088–2095
McGonagle D, Gibbon W, Emery P (1998) Classification of inflammatory arthritis by enthesitis. Lancet 352:1137–1140
McGonagle D, Gibbon W, O'Connor P, Green M, Pease C, Emery P (1998) Characteristic magnetic resonance imaging entheseal changes of knee synovitis in spondylarthropathy. Arthritis Rheum 41:694–700
Alcalde M, Acebes JC, Cruz M, González-Hombrado L, Herrero-Beaumont G, Sánchez-Pernaute O (2007) A sonographic enthesitic index of lower limbs is a valuable tool in the assessment of ankylosing spondylitis. Ann Rheum Dis 66:1015–1019
Balint PV, Kane D, Wilson H, McInnes IB, Sturrock RD (2002) Ultrasonography of entheseal insertions in the lower limb in spondyloarthropathy. Ann Rheum Dis 61:905–910
D'Agostino MA, Said-Nahal R, Hacquard-Bouder C, Brasseur JL, Dougados M, Breban M (2003) Assessment of peripheral enthesitis in the spondylarthropathies by ultrasonography combined with power Doppler: a cross-sectional study. Arthritis Rheum 48:523–533
Lehtinen A, Taavitsainen M, Leirisalo-Repo M (1994) Sonographic analysis of enthesopathy in the lower extremities of patients with spondylarthropathy. Clin Exp Rheumatol 12:143–148
Kamel M, Eid H, Mansour R (2004) Ultrasound detection of knee patellar enthesitis: a comparison with magnetic resonance imaging. Ann Rheum Dis 63:213–214
Kamel M, Eid H, Mansour R (2003) Ultrasound detection of heel enthesitis: a comparison with magnetic resonance imaging. J Rheumatol 30:774–778
Olivieri I, Barozzi L, Padula A et al (1998) Retrocalcaneal bursitis in spondyloarthropathy: assessment by ultrasonography and magnetic resonance imaging. J Rheumatol 25:1352–1357
Spadaro A, Iagnocco A, Baccano G, Ceccarelli F, Sabatini E, Valesini G (2008) Sonographic detected joint effusion compared to physical examination in the assessment of sacroiliac joint in spondylarthritis. Ann Rheum Dis. doi:10.1136/ard.2008.093351
Arslan H, Sakarya ME, Adak B et al (1999) Duplex and color Doppler sonographic findings in active sacroiliitis. Am J Roentgenol 173:677–680
Wakefield RJ, Balint PV, Szkudlarek M et al (2005) OMERACT 7 Special Interest Group. Musculoskeletal ultrasound including definitions for ultrasonographic pathology. J Rheumatol 32:2485–2487
Unlu E, Pamuk ON, Cakir N (2007) Color and duplex Doppler sonography to detect sacroiliitis and spinal inflammation in ankylosing spondylitis. Can this method reveal response to anti-tumor necrosis factor therapy? J Rheumatol 34:110–116
Klauser A, Halpern EJ, Frauscher F et al (2005) Inflammatory low back pain: high negative predictive value of contrast-enhanced color Doppler ultrasound in the detection of inflamed sacroiliac joints. Arthritis Rheum 53:440–444
Goei The HS, Lemmens AJ, Goedhard G et al (1985) Radiological and scintigraphic findings in patients with a clinical history of chronic inflammatory back pain. Skeletal Radiol 14:243–248
Galanski M, Nagel HD, Stamm G (2000) Radiation exposure dosage in CT studies: results of a nationwide inquiry. Rofo 172:M164–168
Braun J, Bollow M, Remlinger G et al (1998) Prevalence of spondylarthropathies in HLA-B27 positive and negative blood donors. Arthritis Rheum 41:58–67
Braun J, Sieper J (1996) The sacroiliac joint in the spondyloarthropathies. Curr Opin Rheumatol 8:275–287
Braun J, Bollow M, Sieper J (1998) Radiologic diagnosis and pathology of the spondyloarthropathies. Rheum Dis Clin North Am 4:697–735
Braun J, van der Heijde D (2002) Imaging and scoring in ankylosing spondylitis. Best Pract Res Clin Rheumatol 16:573–604
Helliwell PS, Hickling P, Wright V (1998) Do the radiological changes of classic ankylosing spondylitis differ from the changes found in the spondylitis associated with inflammatory bowel disease, psoriasis, and reactive arthritis? Ann Rheum Dis 57:135–140
Guglielmi G, De Serio A, Leone A, Cammisa M (2000) Imaging of sacroiliac joints. Rays 25:63–74
Ory PA, Gladman DD, Mease PJ (2005) Psoriatic arthritis and imaging. Ann Rheum Dis 64(Suppl 2):ii55–57
De Filippis LG, Caliri A, Lo Gullo R et al (2005) Ultrasonography in the early diagnosis of psoriasis-associated enthesopathy. Int J Tissue React 27:159–162
Ozcakar L, Cetin A, Inanici F, Kaymak B, Gurer CK, Kolemen F (2005) Ultrasonographical evaluation of the Achilles' tendon in psoriasis patients. Int J Dermatol 44:930–932
De Simone C, Guerriero C, Giampetruzzi AR, Costantini M, Di Gregorio F, Amerio P (2003) Achilles tendinitis in psoriasis: clinical and sonographic findings. J Am Acad Dermatol 49:217–222
Taylor W, Gladman D, Helliwell P, Marchesoni A, Mease P, Mielants H (2007) CASPAR Study Group. Classification criteria for psoriatic arthritis: development of new criteria from a large international study. Arthritis Rheum 56:699–700
Gladman DD, Shuckett R, Russell ML, Thorne JC, Schachter RK (1987) Psoriatic arthritis (PSA)—an analysis of 220 patients. Q J Med 62:127–141
Torre Alonso JC, Rodriguez Perez A, Arribas Castrillo JM, Ballina Garcia J, Riestra Noriega JL, Lopez Larrea C (1991) Psoriatic arthritis (PA): a clinical, immunological and radiological study of 180 patients. Br J Rheumatol 30:245–250
Williamson L, Dockerty JL, Dalbeth N, McNally E, Ostlere S, Wordsworth BP (2004) Clinical assessment of sacroiliitis and HLA-B27 are poor predictors of sacroiliitis diagnosed by magnetic resonance imaging in psoriatic arthritis. Rheumatology 43:85–88
Battistone MJ, Manaster BJ, Reda DJ et al (1999) The prevalence of sacroiliitis in psoriatic arthritis: new perspectives from a large, multicenter cohort. A Department of Veterans Affairs Cooperative Study. Skeletal Radiol 28:196–201
Taccari E, Spadaro A, Riccieri V (1996) Correlations between peripheral and axial radiological changes in patients with psoriatic polyarthritis. Rev Rhum Engl Ed 63:17–23
Sieper J, Rudwaleit M, Braun J et al (2002) Diagnosing reactive arthritis: role of clinical setting in the value of serologic and microbiologic assays. Arthritis Rheum 46:319–327
Bissoli E, Sansone V (1994) Sacroiliitis in seronegative arthritis. The anatomicopathological aspects and imaging methods compared. Radiol Med 88:198–208
Gran JT, Husby G (1992) Joint manifestations in gastrointestinal diseases. 1. Pathophysiological aspects, ulcerative colitis and Crohn's disease. Dig Dis 10:274–294
Protzer U, Duchmann R, Höhler T et al (1996) Enteropathic spondylarthritis in chronic inflammatory bowel diseases: prevalence, manifestation pattern and HLA association. Med Klin (Munich) 91:330–335
Palm O, Moum B, Ongre A, Gran JT (2002) Prevalence of ankylosing spondylitis and other spondyloarthropathies among patients with inflammatory bowel disease: a population study (the IBSEN study). J Rheumatol 29:511–515
De Vlam K, Mielants H, Cuvelier C et al (2000) Spondyloarthropathy is underestimated in inflammatory bowel disease: prevalence and HLA association. J Rheumatol 27:2860–2865
Mester AR, Makó EK, Karlinger K et al (2000) Enteropathic arthritis in the sacroiliac joint. Imaging and differential diagnosis. Eur J Radiol 35:199–208
Olivieri I (1996) Undifferentiated seronegative spondyloarthropathy in females. Br J Rheumatol 35:395–396
Olivieri I, Padula A, Pierro A, Favaro L, Oranges GS, Ferri S (1995) Late onset undifferentiated seronegative spondyloarthropathy. J Rheumatol 22:899–903
Olivieri I, Padula A, Pierro A, Barozzi L, Ferri S, Pavlica P (1997) Iliolumbar ligament ossification in undifferentiated seronegative spondyloarthropathy. Clin Rheumatol 16:212–214
Mau W, Zeidler H, Mau R et al (1988) Clinical features and prognosis of patients with possible ankylosing spondylitis. Results of a 10-year follow-up. J Rheumatol 15:1109–1114
Disclosures
None
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Guglielmi, G., Scalzo, G., Cascavilla, A. et al. Imaging of the sacroiliac joint involvement in seronegative spondylarthropathies. Clin Rheumatol 28, 1007–1019 (2009). https://doi.org/10.1007/s10067-009-1192-1
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10067-009-1192-1