SciELO, LILACS and PubMed starting from descriptors Espondiloartropatias, Fisioterapêutica da Dor Crônica nas Espondiloartropatias Soronegativas. Espondiloartropatiassoronegativas Sombra Silva Espondiloartropatias soronegativas (EAS) •Introdução –. Resumo: Sacroiliíte é o processo inflamatório não-infeccioso das articulações sacroilíacas, sendo critério diagnóstico das espondiloartropatias soronegativas.
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Sacroiliitis, Spondyloarthropathy, X-ray, Computed tomography, Magnetic resonance imaging Descritores: Sacroiliitis is a non-infectious inflammatory process involving the sacroiliac joint, and is soronegaitvas diagnostic criterion for seronegative spondyloarthropathies.
Imaging methods are of great value for confirming the diagnosis of this condition. The present study is a review of espondiloartdopatias included in didactic files and in the literature to illustrate the anatomy, techniques, and main imaging findings in x-ray, computed tomography and magnetic resonance imaging for determining the diagnosis of sacroiliitis, also approaching main differential diagnoses.
Seronegative spondyloarthropathies are basically subdividedand differentiated by their espondiloartropatiaz features, and are classifiedinto five different entities: Most frequently, spondyloarthropathies occur in youngpatients, the early diagnosis being critical for establishment ofan appropriate therapy aiming at improving prognosis and workingcapacity of the patients 3.
The objective of the soronegatvias study was to review anddemonstrate the main aspects in sacroiliac joints imagingevaluation, especially on CT and MRI.
The studies were performed in equipmentof different brands. X-rays images were obtained in anteroposterior views with caudal and oblique inclinations. The current protocol for CT studies esponidloartropatias of axial and coronal oblique images acquisition in 3. The protocol for MRI also consists of axial and coronal oblique views in 4.
Later, T1-weighted sequences with fat saturation are performed, before and after gadolinium injection Figure 2. It was not a purpose of this study a systematic analysis ofeach case separately. The sacroiliac joint presents a complex two-compartmentanatomy.
The synovial portion of the sacroiliac joint isvertically oriented, while the ligamentous portion presentshorizontal-oblique orientation 4,5. The normal joint space of the sacroiliac joint measures 2. Conventional x-ray still remains as the imaging method mostutilized in the clinical practice.
An international consensusstill remains to be reached regarding the best technique and viewfor radiographic evaluation of the sacroiliac epsondiloartropatias. The main limitation of the x-ray film is the low sensitivityfor detecting abnormalities in the early stages of the disease. Radiographic signs in sacroiliitis appear only three to sevenyears after the initial symptoms onset, presenting withalterations soroneagtivas in the chronic phase of thedisease 1,2,8.
The main radiographic signs are: Assessing a patient with suspected sacroiliitis, we may classify the sacroiliac joint into five radiographic grades modified New York criterion: Scintigraphy presents high sensitivity for sacroiliitis, butspecificity is low.
This study must be interpreted in combinationwith other radiological study, and is of higher value in cases ofunilateral alterations. The most significant indication would befor localizing another disease as a cause of lumbarpain 1,6,8. Imaging methods like CT and MRI are extremely useful,especially in the absence of alterations, or when they areminimal on plain x-ray grades 0 to 2 1. The evaluation of sacroiliitis by CT, in comparison with theconventional x-ray, has shown to be more espondioartropatias, with a betterand earlier detection of bone alterations, principally because ofits capability to perform sequential slices, so avoidingstructures overlapping 6,7,9,10, The CT shows higher sensitivity for detecting minimal boneerosions esponxiloartropatias joint space narrowing, however presents the samediagnostic capacity of plain x-rays in cases ofankylosis 2.
The most frequent findings of sacroiliitis on CT are: Joint space narrowing is characterized by a thickness of less than 2. Bone erosions are small cortical defects on the synovial portion of the joint Figure 7. These soroneagtivas latter findings can be seen in both sides of the joint, however, they are frequently seen at the iliac side because this side presents lower thickness and some cartilaginous clefts.
Esppndiloartropatias focal or complete fusion of the joint characterizes ankylosis observed in more advanced stages of the disease 4,5 Figure 8. Alterations in the ligamentous portion are rare, when comparedwith the synovial portions.
CT is better than MRI for detectingbone formation in the enthesis of thistopography 3. CT is comparable to MRI for detecting bone erosion, but issuperior for evaluating bone sclerosis and ankylosis, and isindicated especially for detecting chronicalterations 1. CT is a method of excellence in demonstrating bone details,besides serving as a guidance tool in percutaneous biopsies,arthrocentesis, and for intra-articular injection ofsteroids 6,11, Structures comprising the sacroiliac joint are better demonstrated by MRI, and are seen as follows: Theseerosions are better demonstrated on T1-weighted fat-saturatedsequences.
On T1-weighted fat-saturated sequences, after intravenous gadolinium injection, a significant enhancement of sacroiliac joint and surrounding bone marrow soronegarivas be observed, and this finding is highly suggestive of sorobegativas active disease Figure 12.
Type I lesions werecharacterized by low-intensity on T1-weighted, and high-intensitysignals on T2-weighted sequences and on images acquired aftergadolinium injection.
Type II lesions were characterized bylow-intensity signal in all of the sequences. This observationhas suggested that MRI is able to differentiate lesions with highhydric contents inflammatory edema from those with fibroustissue or sclerosis, i.
Type II lesions are associated with fatcollections The study developed by Hanly et al.
Abordagem Fisioterapêutica da Dor Crônica nas Espondiloartropatias Soronegativas.
This theory ishistopathologically corroborated by another study, by espondiloarteopatias ofopen biopsy in patients with initial stage of disease, where theearliest finding was subchondral inflammation.
The sequence withhighest sensitivity and specificity in detecting periarticularbone marrow edema is the STIR sequence, since, differently fromthe conventional T2-weighted spin-echo sequence, it saturates defat, differentiating it from fluid 6,8, For differentiating them, it is important to observe thesite of the edema, i.
The use of dynamic post-contrast sequence in the evaluation ofinflammatory processes has been reported in several studies, butthis has not been easily done in the dailypractice 3. On theother hand, Battafarano et al. The main disadvantages of MRI are: The main differential radiographic diagnosis of sacroiliitis is condensing iliac osteitis, that usually presents bilaterally and symmetrically in female, asymptomatic patients, manifesting on images as sclerosis of the ventro-caudal portions espondiloarrropatias the sacroiliac joint 14 Figure Other relevant differential radiographic diagnoses includemetabolic diseases like hyperparathyroidism and gout.
Usually, incases of hyperparathyroidism the condition manifests bilaterallyand symmetrically, either in its primary form or in its secondaryforma renal osteodystrophycharacterized by subchondral bonereabsorption with irregularity on the bone surface, sometimeswith adjacent sclerosis and widening of the joint space.
Sacroiliitis: imaging evaluation
In casesof chronic tophaceous gout, the condition may manifestsymmetrically or asymmetrically, sometimes unilateral,characterized by large, destructive erosion with a sclerotichalo, but with espondiloartropatiass join space In the evaluation of the sacroiliac joint, the patient ‘s age should be taken into consideration, since osteoarthrosis is frequent in elder, asymptomatic patients. These alterations are characterized by marginal osteophytes, subchondral sclerosis, and soroengativas articular fusion 1,3 Figure Erosion, subchondral cysts and ankylosis are rarely seen in the degenerative process 4.
Early in the initial phase of the process, periarticular subchondral bone marrow edema can be seen representing fibrous, vascularized tissue 8. Fat deposition also may be seen in normal elder individuals, and soronegtaivas patients with degenerative disease 16 Figure Other important differential diagnosis is infectioussacroiliitis, particularly the pyogenic type. Infectioussacroiliitis is quite rare, prevailing in injectable drugs usersand in individuals with skin, pulmonary soronnegativas genitourinaryinfections, and have as its most frequent etiologic agent the Staphylococcus aureus.
The skronegativas of infectioussacroiliitis is difficult, many times delayed because of itsinsidious clinical presentation with non-specific and poorlylocalized signs, frequently simulating abdominal syndromes,lumbar discopathies or lumbosciatalgia. CT and MRI allow anearlier diagnosis, but are not able to define the etiologicagent.
Generally, radiographic alterations can be observed onlytwo or three weeks after the first symptoms onset, while oncontrast-enhanced MRI, alterations can be observed within esponddiloartropatias tothree days, showing MRI highersensitivity 2,6, CT findings in the infectious process are the same of those observed in the sacroiliitis of spondyloarthropathies, except for the juxtarticular bone demineralization, considered as the earliest finding, besides signs suggestive of soft tissues involvement and unilaterality of the process MRI, besides determining alterations in the affected sacroiliac joint and in the contiguous soronegativws, also clearly demonstrates the involvement of adjacent soft tissues or collections, frequently posteriorly to the iliopsoas muscle, these findings being highly suggestive of infectious involvement, and not seen in spondyloarthropathies 6,12,13,15, The intravenous gadolinium injection can more accurately define these soft tissues involvement 12,13,16 Figures 17 and The conventional soronegativsa remains as the method of choice in theprimary evaluation and follow-up of patients with sacroiliitis.
The MRI plays an essential role in better demonstrating earlyalterations and inflammatory activity of this process. On theother hand, CT is superior in quantifying chronicalterations. Braun J, van der Heijde D. Imaging and scoring in ankylosing spondylitis. Best Pract Res Clin Rheumatol ; Magnetic resonance imaging in rheumatic disorders of the spine and sacroiliac joints.
Semin Arthritis Rheum ; Imaging of sacroiliitis in early seronegative spondylarthropathy.
Assessment of abnormalities by MR in comparison with radiography and CT. Computed tomography findings in patients with sacroiliac pain. Clin Orthop Espondikoartropatias Res ; J Comput Assist Tomogr ;6: MR imaging of the normal sacroiliac joint with correlation to histology.
Espondiloartropztias of bone scan, computed tomography, and magnetic resonance imaging in the diagnosis of active sacroiliitis. Early recognition of sacroiliitis by magnetic resonance imaging and single photon emission computed tomography. Magnetic resonance imaging MRI for detection of active sacroiliitis: Use of dynamic magnetic resonance imaging to detect sacroiliitis in HLA-B27 positive and negative children with juvenile arthritides.
STIR sequence in infectious sacroiliitis in three patients. Clin Imaging ; Magnetic resonance imaging of sacroiliac joint inflammation. Early detection of sacroiliitis on magnetic resonance imaging and subsequent development of sacroiliitis on plain radiography.
A prospective, longitudinal study. Bone and joint imaging.
Anterior uveitis associated to systemic diseases
Osteomyelitis and pyogenic infection of the sacroiliac joint. MRI findings and review. Cristiano Montandon Avenida Ismerino S. Received March 4, Accepted after revision May 2, Espondkloartropatias are better demonstrated on T1-weighted fat-saturatedsequences; d subchondral sclerosis characterized by zones withlow-intensity signal on T1- and T2-weighted images; e subchondral bone marrow edema characterized by low-intensity signal on T1- and high-intensity signal on T2- especially the T2-weighted fat-saturated and STIR sequences.