Espondioloartritis 2014
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Este documento describe los cambios radiológicos y de resonancia magnética que ocurren en la columna vertebral de pacientes con espondiloartritis, incluyendo espondilitis anterior, posterior y marginal, discitis, fracturas por insuficiencia, artritis apofisaria, entesitis y sindesmofitos. También explica el protocolo de RM para evaluar estas condiciones y clasificar los cambios según el sistema Modic.
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Espondioloartritis 2014
- 1. Espondiloartritis Dr. Orlando Morales Ballesteros Residente de cuarto año Imagenología diagnóstica y terapéutica Spinal Changes in Patients with Spondyloarthritis: Comparison of MR Imaging and Radiographic Appearances RadioGraphics. 2005;25:559–570●
- 2. Espondiloartritis • Espindiloartritis seronagativas (HLA-B27) • TNF-a* • 5 subgrupos: – Espondilitis anquilosante. – Artritis reactiva (Sx. Reiter) postinfecciosa – Artritis psoriasica. – Artritis asociada a enfermedad digestiva inflamatoria (Crohn, CUCI) – Indiferenciadas
- 3. Espondiloartritis Cambios: – Espondilitis anterior, posterior y marginal (tempranos) – Discitis, anquilosis, fracturas por insuficiencia en columna anquilosada. – Sindesmofitos* – Artritis apofisaria y costovertebral, entesitis de los ligamentos intervertebrales.
- 4. Protocolo RM • T1 TSE Sagital • STIR • Matriz de 512 pixeles • 1.5 Tesla • Gadolinio* (Entesitis, séptico) – Supresión grasa T1
- 5. Espondilitis anterior y posterior • Irregularidades y erosiones en los bordes de los platos discales (Edema) • Lesión de Romanus • “Esquinas brillantes” – Activas ó inactivas • Inserción del anillo fibroso (Entesis) “MR Corner Sign”: Value for Predicting Presence of Ankylosing Spondylitis. AJR:191, July 2008
- 6. Espondilitis anquilosante • S: 44% E: 96% • VPP: 92% VPN: 63% – 61% esquinas anteriores – Toracolumbar (T12-L1, L1-L2) – Modic II – Cambios degenerativos* (L4-L5) “MR Corner Sign”: Value for Predicting Presence of Ankylosing Spondylitis. AJR:191, July 2008
- 7. • Espondilitis anterior • Espondilitis posterior • Espondilitis marginal “MR Corner Sign”: Value for Predicting Presence of Ankylosing Spondylitis. AJR:191, July 2008
- 9. Espondilodiscitis • Compromiso inflamatorio de los discos intervertebrales por espondiloartritis (reumática) • Lesión de Andersson (1937) • 8% de los pacientes con espondilitis anquilosante • Hiper STIR, Hipo T1 Tardia
- 12. Fractura por insuficiencia • Lesión no inflamatoria – Distinguir de Andersson (inflamatoria) • Fractura por insuficiencia en columna anquilosada (Estrés) • Espontánea o trauma mínimo • Daño osteoporótico previo secundario a espondilitis anquilosante
- 13. Fractura por insuficiencia • Transdiscal • Transvertebral
- 18. Artritis sinoviales • Artritis facetaria; costovertebral, costotransversas • Similar a la artritis periférica • Derrame articular, Sinovitis, Erosiones, Edema óseo • Evolución a la anquilosis • Articulaciones borrosas (Rx)
- 22. Entesitis • Estabilidad de la columna vertebral por múltiples ligamentos • Comprometidos en la espondiloartritis – Ligamentos interespinales – Ligamentos supraespinosos • Hiper STIR; Refuerzo al C+ • Asociado con osteitis adyacente
- 24. Sindesmofitos y Anquilosis • Sindesmofitos; difícil detección por RM. • 15% de las vértebras • Rx convencional • Alta o baja intensidad (STIR); depende de la etapa
- 25. Sindesmofitos y Anquilosis • Anquilosis; – Bordes o porción central del cuerpo vertebral – Extensión de hueso a través del disco – Secuela de la lesión de Andersson
- 30. Clasificación de los cambios • Modic • Tres lesiones – Inflamatorias agudas (1) – Postinflamatorias, degeneración grasa (2) – Anquilosis (3) • Valoración de la articulación sacroiliaca • Efectividad del tratamiento
- 36. What??
Notas del editor
- Figure 4. Insufficiency fracture (noninflammatory Andersson lesion) in a 60-year-old patient with a long history of ankylosing spondylitis.(a)Lateral radio-graph of the lumbar spine shows gross bony destruction of the T12-L1 disk with irregular contours of the endplates and increased sclerosis of adjacent vertebral bodies (large arrow). Ankylosis of inferior articular segments (small arrows) and barreling of L3 through L5 are seen. Radiographic features Early diagnosis is best made with bone scan or MRI, as plain films may initially appear normal. Plain film initially normal periosteal reaction progressing to callus formation in diaphyseal fractures linear sclerosis and cortical thickening more common in metaphyseal and epiphyseal fractures 2 MRI MRI is as sensitive as bone scanning but is of higher specificity, both in isolating the exact anatomic location and in distinguishing fractures from tumours or infection. T1 low marrow signal enhancement can be prominent T2 : high marrow signal with extension into adjacent soft tissues Bone scan Increased activity at site of fracture.
- (b)Sagittal contrast-enhanced T1-weighted fast spin-echo image shows subacute hematoma with low signal intensity and marginal contrast enhancement (arrowheads), indicative of peripheral revascularization at T12-L1 (large arrow). Ankylosis of the superior and inferior segments is seen (small arrows). The fracture extends to the posterior elements. (Fig 4a and 4b re-printed, with permission, from reference 23.) 564 May-June 2005 RGfVolume 25● Number 3 Rad
- Figure 6. Acute insufficiency fracture of vertebral body. A 47-year-old lupus patient under corticoid therapy. Sagittal MRI T1-weighted (A) and FSE T2-weighted (B) images demonstrate partial T12 upper plateau collapse (arrows). The edema becomes better characterized on the STIR sequence (C), associated with a local reactional inflammatory process with contrast uptake on the T1-weighted image (D). http://www.rb.org.br/detalhe_artigo.asp?id=2161&idioma=English
- Spine: Pedicle stress/insufficiency fractures Clinical: 70 y/o female with acute on chronic back pain. Dx: Acute pedicle stress/insufficiency fractures at the L4 and L5 levels without spondylolisthesis. These are likely insufficiency fxs given age.
- Magnetic resonance imaging of the axial skeleton in rheumatoid disease
- Figure 5. Arthritis of the zygapophyseal joints in a 32-year-old patient with ankylosing spondylitis.(a)Lateral radiograph of the thoracic spine shows a posterior shiny corner at T9–10.
- (b)Sagittal T1-weighted fast spin-echo image shows circumscribed loss of signal intensity in the area of the vertebral arch (arrows) and zygapophyseal joints.(c)Sagittal con-trast-enhanced fat-saturated T1-weighted image shows pronounced enhancement of the ver-tebral arch, articular processes, and adjacent soft tissue (arrows), findings suggestive of ar-thritis of apophyseal joints. Marginal spondylitis is seen (arrowheads).
- (d)Transverse con-trast-enhanced fat-saturated T1-weighted turbo spin-echo image shows enhancement near the costovertebral joint (arrow), a finding indicative of synovitis with concomitant osteitis of the adjacent rib and vertebral portions (arrowheads)
- Figure 6. Enthesitis in a 47-year-old patient with ankylosing spondylitis.(a)Sagittal unen-hanced T1-weighted fast spin-echo image shows thickening of the supraspinal ligament from C7 through T3 (arrows).(b)Sagittal contrast-enhanced fat-saturated T1-weighted turbo spin-echo image shows pronounced enhancement in the area of the interspinal and supraspinal ligaments (arrows), a finding indicative of enthesitis. (Patient was positioned on a gel cushion to improve signal-to-noise ratio.)
- Espondilitis anquilisante Fases tardias; RM papel importante en detectar cambios tempranos.
- Figure 7. Ankylosis and syndesmophytes in a 36-year-old patient with ankylosing spondylitis.(a)Lateral radio-graph of the lumbar spine shows anterior syndesmophytes at L3–4 and L4–5 (arrows) and a defect of the epiphyseal ring at the anterior edge of L3 (arrowhead). Beginning ossification of intervertebral spaces L1–2 and L2–3 is evident.
- (b)On the T1-weighted turbo spin-echo image, syndesmophytes are not seen.(c)Sagittal contrast-enhanced fat-saturated T1-weighted turbo spin-echo image shows enhancement in the area of the epiphyseal rings at L4–5 (arrow-heads), a finding representing a Romanus lesion. Subtle enhancement (arrow) of intervertebral disk L4–5 (an early Andersson lesion) is also seen.
- The Andersson lesion in ankylosing spondylitis
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- Figura 2. Respuesta al tratamiento con adalimumab. Sacroileítis bilateral en resonancia basal que desaparece a los 6 meses de comenzar el tratamiento con adalimumab. RM basal a 13 pacientes con espondilitis anquilosante, puntuando los hallazgos con el sistema ASSpiMRI-a. Tras 6 meses de tratamiento con adalimumab se repitió la RM. Todos los pacientes mostraron mejora en las puntuaciones del ASSpiMRI-a y de las imágenes inflamatorias en articulaciones sacroilíacas
- Marked subchondral sclerosis, erosions, subchondral cyst formation of both sacroiliac joints (SI).
- Title: Juvenile Spondylarthropathy: Sacroileitis Description: A 9 year-old boy with a 6 week history of left-sided hip pain and inability to walk was evaluated for possible septic arthritis. A coronal CT scan (left) showed erosion and sclerosis of the left sacroiliac joint. Coronal MR image (right) demonstrated marrow edema, erosion, and effusion of the joint. Joint aspirate was sterile, HLA-B27 was present consistent with juvenile spondylarthropathy.
- Sacroileítis bilateral en paciente con espondilitis anquilosante