A Rheumatologist’s Guide to Interpreting Imaging in Spondyloarthritis Vivek Arya, Ashish Sharma, Abhinetri KSV
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Authors Ashish Sharma MBBS MD (Internal Medicine) Fellowship Rheumatology Consultant Department of Rheumatology Fortis Hospital Noida, Uttar Pradesh, India Vivek Arya MBBS MD (Internal Medicine) Consultant Department of General Medicine and Rheumatology North Devon District Hospital Barnstaple, UK Abhinetri KSV MBBS MD (Radiodiagnosis) Consultant Department of Radiology Fortis Flt Lt Rajan Dhall Hospital New Delhi, India Foreword Ashok Kumar
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A Rheumatologist's Guide to Interpreting Imaging in Spondyloarthritis
First Edition: 2020
Printed at
Contributors Foreword
Diagnostics of spondyloarthritis have come a long way. The driving force behind this development is obviously the availability of highly effective anti-TNF drugs. The classical ‘bamboo-spine’ is encountered uncommonly in present day practice owing to diagnosis of spondyloarthritis at a much earlier stage. Imaging plays a crucial role in early diagnosis.
Dr Ashish Sharma is a bright young rheumatologist with keen interest in medical imaging. At the same time, he is an excellent rheumatologist. Dr Vivek Arya is an eminent Professor of General Medicine and consultant rheumatologist in the UK. Dr Abhinetri is an astute radiologist with special interest in musculoskeletal imaging. The three authors have produced this book in which they have illustrated a variety of radiographs, MRIs and CT scans of patients with spondyloarthritis. Many of the imaging features, which we seldom see (or notice!), have been nicely presented in the form of high quality pictures.
Spondyloarthritis is far beyond sacroiliac joints, is a fact this book brings out very well, including changes in the ligaments, which can easily be seen on plain radiographs. Although MRI is very sensitive in identifying acute changes in spondyloarthritis, it also picks up nonspecific changes, which need proper interpretation. The authors provide a balanced approach, which utilizes plain radiography and MRI optimally. I frequently come across anxious patients coming to me for a second opinion, with an MRI report (which looks quite scary!). It is very unusual to find an absolutely ‘normal’ MRI report. Overindulgence in MRI frequently leads to erroneous diagnoses. That is why it is very important for rheumatologists to have a basic understanding of MRI, so that they can interpret the films themselves, keeping in view all the clinical parameters.
The authors have explained the science of MRI in very simple manner and have thoroughly explained various findings on MRI in patients with spondyloarthritis. This will definitely help clinicians in broadening their horizon to look beyond sacroiliac joints and to interpret the findings themselves, rather than relying on the MRI report! This book will help our radiology colleagues too in better understanding non-traumatic, musculoskeletal imaging, where the experience in radiology is relatively suboptimal.
CT scan is just an extension of plain radiographs and has limited utility in spondyloarthritis. Chronic structural changes are better visualized on CT. Fractures of the spine occur frequently in patients with spondyloarthritis because of the high prevalence of spinal osteoporosis in them. Such occult fractures are a frequent cause of disabling pain in AS patients and are better picked-up on CT. Not uncommonly, clinicians interpret spinal pain as evidence of active AS and miss the occult fracture of spine.
I am sure this book will be an excellent guide for clinicians in interpreting imaging in patients with spondyloarthritis. The book demonstrates how to get the best out of both plain radiography and MRI in diagnosing spondyloarthritis. MRI has a definite role in non-radiographic spondyloarthritis. It should be interpreted in a mature way, taking into consideration the clinical features and acute phase reactants. The book has the potential to create a healthy change in the manner spondyloarthritis imaging is utilized and interpreted in clinical practice. In addition, it is also a valuable resource for both clinicians and rheumatologists.
Ashok Kumar MBBS MD FRCP (London)
Director and Head
Department of Rheumatology
Fortis Flt Lt Rajan Dhall Hospital
Vasant Kunj, New Delhi
Formerly, Professor and Head of Rheumatology
Department of Medicine, AIIMS
New Delhi, India
This book is meant for the practicing rheumatologist. It will also be useful for postgraduate students and internists with an interest in Rheumatology. It intends to familiarize clinicians involved in the care of patients with spondyloarthritis (SpA) with various common and uncommon imaging features of these disorders. In addition, it will serve as a reference for comparison of imaging features observed by clinicians in their day-to-day practice.
We have presented various imaging features of SpA on radiographs, MRI and CT scans. Besides hip, knee and ankle joints, other peripheral joints have not been included, like interphalangeal joints, which are commonly involved in psoriatic arthritis. Moreover, various mimics of SpA on imaging have not been included, as they are out of the scope of this book.
Imaging in SpA is not just about the sacroiliac joints. Many other features are to be looked into, as described in the book. Plain radiographs are an excellent modality for detecting structural changes. Moreover, structural progression can be easily monitored by radiographs due to their easy reproducibility in terms of cost and radiation exposure. MRI is very helpful in detecting active inflammation. Moreover, inflammation at various entheseal sites and the presence of chronic changes (fatty metaplasia, erosions, sclerosis, and ankylosis) can be very helpful in making a correct diagnosis of SpA in cases where classification criteria for SpA are not met but the clinical suspicion is high.
Clinico-radiological correlation is indispensable for making a correct diagnosis, which is best possible if the imaging plates are read by the treating physicians themselves.
Our aim is not to make rheumatologists into radiologists or to do away with the role of a radiologist in interpreting imaging related to SpA. Far from it, this is a collaborative work involving both rheumatologists and a consultant radiologist.
The purpose is to make it easier for a rheumatologist to understand the report given by a radiologist in this context and to participate with a basic understanding during multidisciplinary meetings involving radiology colleagues. The ultimate aim is to ensure better patient care through shared understanding of imaging findings.
We hope the reader will enjoy reading this book as much as we have enjoyed writing it!
Ashish Sharma
Vivek Arya
Abhinetri KSV