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Seminars in Arthritis and Rheumatism Aug 2021Psoriatic arthritis (PsA) is a heterogenous, chronic, inflammatory musculoskeletal disease that can lead to peripheral and axial damage and loss of function. Axial... (Review)
Review
Psoriatic arthritis (PsA) is a heterogenous, chronic, inflammatory musculoskeletal disease that can lead to peripheral and axial damage and loss of function. Axial involvement occurs in 25% to 70% of patients with PsA, varying greatly depending on its definition, with the key manifestations being sacroiliitis and/or spondylitis. However, there are no agreed-upon classification or diagnostic criteria for axial involvement in PsA and no consensus on treatment paradigms, which complicates management of PsA. There have only been a few studies assessing biologics in patients with PsA with axial involvement, and most treatment plans are based on evidence from patients with axial spondyloarthritis. Rheumatologists therefore face many challenges in the management of axial PsA, including diagnosis, differential diagnosis, and choice of appropriate treatment. In this review, we summarize the clinical presentation, imaging characteristics, differential diagnoses, treatment options, and prognosis of axial PsA, with the aim of increasing rheumatologists' knowledge of this phenotype of PsA and thereby aiding its optimal management.
Topics: Arthritis, Psoriatic; Humans; Prognosis; Rheumatologists; Sacroiliitis; Spondylarthritis
PubMed: 34198146
DOI: 10.1016/j.semarthrit.2021.06.006 -
Advances in Orthopedics 2022Sacroiliitis is an inflammation of one or both of the sacroiliac (SI) joints, most often resulting pain in the lower back that can extend down the legs. Pain arising... (Review)
Review
INTRODUCTION
Sacroiliitis is an inflammation of one or both of the sacroiliac (SI) joints, most often resulting pain in the lower back that can extend down the legs. Pain arising from the SI joint can be difficult to diagnose and treat due to the intricate surrounding ligamentous structure, nerve innervation, and its role in transferring weight from the upper body to the lower limbs. SI joint dysfunction accounts for up to 25% of cases of lower back pain and has a debilitating effect on patient functionality. This review aims to provide comprehensive coverage of all aspects of SI joint pain, with a specific focus on differential diagnosis and treatment.
METHODS
Current literature on SI joint pain and inflammation, other etiologies of lower back pain, and new treatment options were compiled using the databases PubMed and Cochrane and used to write this comprehensive review. There were no restrictions when conducting the literature search with regard to publication date, study language, or study type.
RESULTS
The diagnosis protocol of SI joint pain arising from sacroiliitis usually begins with the presentation of lower back pain and confirmatory diagnostic testing through fluoroscopy joint block. Reduction in pain following the anesthetic is considered the golden standard for diagnosis. The treatment begins with the conservative approach of physical therapy and analgesics for symptom relief. However, refractory cases often require interventional methods such as corticosteroid injections, prolotherapy, radiofrequency ablation, and even SI joint fusion surgery.
CONCLUSION
SI joint pain is a complex problem that can present with varying patterns of pain due to uncertainty regarding its innervation and its prominent surrounding structure. It is therefore especially important to obtain a thorough history and physical on top of diagnostic tests such as a diagnostic block to properly identify the source of pain. Conservative treatment options with physical therapy and analgesics should be attempted first before interventional strategies such as ablation, injections, and prolotherapy can be considered. SI joint fusion surgery is a solution to cases in which previous methods do not provide significant relief.
PubMed: 36620475
DOI: 10.1155/2022/3283296 -
Skeletal Radiology Sep 2022In 2009, the Assessment of SpondyloArthritis international Society (ASAS) published a definition of 'active sacroiliitis on magnetic resonance imaging (MRI) for... (Review)
Review
In 2009, the Assessment of SpondyloArthritis international Society (ASAS) published a definition of 'active sacroiliitis on magnetic resonance imaging (MRI) for classification of axial spondyloarthritis'. This new definition of an 'ASAS-positive MRI' was integral to new classification criteria for axial spondyloarthritis that were published in the same year. The ASAS MRI definition had the considerable advantage of simplicity and the definition gained popularity as guidance for interpreting MRI of the sacroiliac joints in clinical practice. However, classification criteria are not designed for use in clinical practice with the consequence that overreliance on the presence of bone marrow edema, which is the principal determinant of an 'ASAS-positive MRI', may result in a tendency to overcall inflammatory sacroiliitis in the clinical setting. This article aims to inform the reader about the rationale behind the ASAS definition of a positive MRI and ASAS classification criteria, their proper use in research and why they should not be used in clinical practice. The article also contains guidance for an updated imaging protocol and interpretation of images including typical imaging findings, differential diagnosis, and common pitfalls.
Topics: Axial Spondyloarthritis; Humans; Magnetic Resonance Imaging; Sacroiliac Joint; Sacroiliitis; Spondylarthritis
PubMed: 35199195
DOI: 10.1007/s00256-022-04018-4 -
BMJ Case Reports Aug 2023A man in his early 70s presented with stiffness and aching in the shoulder and pelvic girdles. His C reactive protein level was elevated at 116 mg/L, leading to an...
A man in his early 70s presented with stiffness and aching in the shoulder and pelvic girdles. His C reactive protein level was elevated at 116 mg/L, leading to an initial diagnosis of polymyalgia rheumatica. Treatment with prednisone at 20 mg/day provided limited improvement and relapses recurred despite concomitant immunosuppressive agents. Extensive investigations failed to reveal an underlying aetiology.Five years later, gross painless haematuria led to the detection of an invasive papillary urothelial carcinoma. A review of the staging CT scan revealed findings compatible with bilateral erosive sacroiliitis, which had developed since his initial presentation. Radical cystoprostatectomy provided temporary relief but after a further 9 months, symptoms relapsed, and metastatic spread was discovered.Paraneoplastic sacroiliitis is a rare clinical entity; and to the best of our knowledge, this is the first reported case associated with a solid tumour.
Topics: Male; Humans; Carcinoma, Transitional Cell; Sacroiliitis; Urinary Bladder Neoplasms; Autoantibodies; Cystectomy
PubMed: 37652573
DOI: 10.1136/bcr-2022-252572 -
Current Opinion in Rheumatology Jul 2023Imaging is used in the diagnosis of peripheral and axial disease in juvenile spondyloarthritis (JSpA). Imaging of the joints and entheses in children and adolescents can... (Review)
Review
PURPOSE OF REVIEW
Imaging is used in the diagnosis of peripheral and axial disease in juvenile spondyloarthritis (JSpA). Imaging of the joints and entheses in children and adolescents can be challenging for those unfamiliar with the appearance of the maturing skeleton. These differences are key for rheumatologists and radiologists to be aware of.
RECENT FINDINGS
In youth, skeletal variation during maturation makes the identification of arthritis, enthesitis, and sacroiliitis difficult. A great effort has been put forward to define imaging characteristics seen in healthy children in order to more accurately identify disease. Additionally, there are novel imaging modalities on the horizon that are promising to further differentiate normal physiologic changes versus disease.
SUMMARY
This review describes the current state of imaging, limitations, and future imaging modalities in youth, with key attention to differences in imaging interpretation of the peripheral joints, entheses, and sacroiliac joint in youth and adults.
Topics: Adult; Adolescent; Humans; Child; Magnetic Resonance Imaging; Spondylarthritis; Sacroiliitis; Sacroiliac Joint; Arthritis, Juvenile
PubMed: 37067983
DOI: 10.1097/BOR.0000000000000942 -
Modern Rheumatology Mar 2021Non-radiographic axial spondyloarthritis (nr-axSpA) is a subgroup of axial spondyloarthritis (axSpA) without fulfilling the modified New York criteria of sacroiliac... (Review)
Review
Non-radiographic axial spondyloarthritis (nr-axSpA) is a subgroup of axial spondyloarthritis (axSpA) without fulfilling the modified New York criteria of sacroiliac joint radiographs for ankylosing spondylitis (AS). AS and nr-axSpA share various demographic and clinical features and disease burden, although sex and objective inflammatory findings such as elevated serum C-reactive protein level are slightly different between AS and nr-axSpA. Recently, diagnostic guidance for nr-axSpA in Japan was proposed for epidemiological studies of a population with a low prevalence of HLA-B27 positivity and the use of molecular targeted agents suitable for the unique medical care system in Japan. A biological agent targeting interleukin-17 was approved for nr-axSpA by the Pharmaceutical and Medical Devices Agency (PMDA) in August 2020. Some other biological agents will be also available for Japanese patients with nr-axSpA in the near future.
Topics: Antirheumatic Agents; Biomarkers; Clinical Trials as Topic; Humans; Spondylarthritis
PubMed: 32996809
DOI: 10.1080/14397595.2020.1830512 -
Current Rheumatology Reports Jul 2021To provide an overview of recent studies on pathogenesis, diagnosis, and management of juvenile spondyloarthritis (JSpA). (Review)
Review
PURPOSE
To provide an overview of recent studies on pathogenesis, diagnosis, and management of juvenile spondyloarthritis (JSpA).
RECENT FINDINGS
Recent studies show differences in gut microbiome in patients with JSpA in comparison to healthy controls. There is increased recognition of the impact of the innate immune system on disease pathology. Normative reference on MRI of sacroiliac (SI) joints in children is now available. However, there is significant variability in interpretation of MRI of SI joints in children and a need for standardization. NSAIDs, physical therapy, and Tumor Necrosis Factor Inhibitors (TNFi) remain the mainstay of management for patients with JIA who have polyarthritis, sacroiliitis, and/or enthesitis as per recent ACR guidelines. Newer therapeutic options beyond TNFi are needed to manage patients who fail TNFi. This review highlights some of the recent advances in our knowledge of JSpA pathophysiology, diagnosis, and treatment. It also identifies areas in need of further research and standardization to improve our understanding and outcomes in JSpA.
Topics: Arthritis, Juvenile; Child; Humans; Magnetic Resonance Imaging; Sacroiliac Joint; Sacroiliitis; Spondylitis, Ankylosing
PubMed: 34255209
DOI: 10.1007/s11926-021-01036-4 -
Arthritis & Rheumatology (Hoboken, N.J.) Jun 2020
Topics: Arthritis, Juvenile; Humans; Rheumatology; Sacroiliitis; United States
PubMed: 32103641
DOI: 10.1002/art.41238 -
Annals of the Rheumatic Diseases Nov 2019The Assessment of SpondyloArthritis international Society (ASAS) MRI working group (WG) was convened to generate a consensus update on standardised definitions for MRI...
OBJECTIVES
The Assessment of SpondyloArthritis international Society (ASAS) MRI working group (WG) was convened to generate a consensus update on standardised definitions for MRI lesions in the sacroiliac joint (SIJ) of patients with spondyloarthritis (SpA), and to conduct preliminary validation.
METHODS
The literature pertaining to these MRI lesion definitions was discussed at three meetings of the group. 25 investigators (20 rheumatologists, 5 radiologists) determined which definitions should be retained or required revision, and which required a new definition. Lesion definitions were assessed in a multi-reader validation exercise using 278 MRI scans from the ASAS classification cohort by global assessment (lesion present/absent) and detailed scoring (inflammation and structural). Reliability of detection of lesions was analysed using kappa statistics and the intraclass correlation coefficient (ICC).
RESULTS
No revisions were made to the current ASAS definition of a positive SIJ MRI or definitions for subchondral inflammation and sclerosis. The following definitions were revised: capsulitis, enthesitis, fat lesion and erosion. New definitions were developed for joint space enhancement, joint space fluid, fat metaplasia in an erosion cavity, ankylosis and bone bud. The most frequently detected structural lesion, erosion, was detected almost as reliably as subchondral inflammation (κappa/ICC:0.61/0.54 and 0.60/0.83) . Fat metaplasia in an erosion cavity and ankylosis were also reliably detected despite their low frequency (κappa/ICC:0.50/0.37 and 0.58/0.97).
CONCLUSION
The ASAS-MRI WG concluded that several definitions required revision and some new definitions were necessary. Multi-reader validation demonstrated substantial reliability for the most frequently detected lesions and comparable reliability between active and structural lesions.
Topics: Adult; Female; Humans; Joint Diseases; Magnetic Resonance Imaging; Male; Middle Aged; Reproducibility of Results; Rheumatology; Sacroiliac Joint; Sacroiliitis; Spondylarthritis
PubMed: 31422357
DOI: 10.1136/annrheumdis-2019-215589