CT-guided intraarticular corticosteroid injection into the sacroiliac joints in patients with spondyloarthropathy: indication and follow-up with contrast-enhanced MRI.

PURPOSE: Our goal was to prospectively study the therapeutic efficacy of CT-guided intraarticular corticosteroid instillation of inflamed sacroiliac joints (SIJs) in patients with spondyloarthropathies and to evaluate the role of MRI as a procedure for establishing the indication and for therapeutic follow-up. METHOD: A total of 103 CT-guided corticosteroid injections of the SIJs were performed in 66 patients with inflammatory back pain (IBP): 37 bilateral, 29 unilateral. All patients did not respond to an immediately preceding 4 week nonsteroidal antiinflammatory therapy. Forty milligrams of a crystalline long-acting corticoid was instilled in each joint. All 66 patients underwent continuous clinical follow-up at 10 to 12 week intervals after corticosteroid injection to a maximum of 18 months. The degree of subjective complaints before and after the intervention was recorded using a analogue scale (0 = no pain, 10 = unbearable pain). Dynamic contrast-enhanced (Gd-DTPA, 0.1 mmol/kg body wt) MRI with quantitative determination of contrast enhancement was performed in all patients before the therapeutic intervention and in 38 patients at 8 +/- 4 months. RESULTS: Sixty-one of the 66 study patients (92.5%) showed a statistically significant abatement of subjective complaints from 8.8 +/- 1.3 to 3.3 +/- 2.3 (p < 0.01) at 1.7 +/- 1.1 weeks after intervention, and this improvement lasted for 10 +/- 5 months. The percentage contrast enhancement at dynamic MRI likewise showed a significant reduction from 100.3 +/- 48% before to 44.3 +/- 36.1% after intraarticular cortisone administration (p < 0.01). CONCLUSION: CT-guided intraarticular corticosteroid instillation in the SIJs may be regarded as an effective therapy for florid sacroiliitis. The severity of inflammation and the response to therapy can be determined quantitatively by dynamic MRI.

Computed tomography guided corticosteroid injection of the sacroiliac joint in patients with spondyloarthropathy with sacroiliitis: clinical outcome and followup by dynamic magnetic resonance imaging.

OBJECTIVE: To evaluate computed tomography (CT) guided corticosteroid injections of inflamed sacroiliac (SI) joints in patients with spondyloarthropathies (SpA), and to evaluate dynamic magnetic resonance imaging (DMRI) of the SI joints in serial examinations of these patients, who had different degrees of inflammatory back pain. METHODS: We examined and treated 30 patients with ankylosing spondylitis (n = 9) or undifferentiated SpA (n = 11) (14 women and 16 men, mean age 36.5 +/- 13.4 years, mean disease duration 5.4 +/- 4.0 years) who had severe inflammatory back pain for more than 3 months. All patients had DMRI of the SI joints before and 4-6 months after a CT guided injection of 40 mg triamcinolone acetonide into SI joints (n = 54; 24 patients received injections in both joints). Enhancement of the contrast agent gadolinium-DTPA was quantified by calculating the enhancement of the contrast agent gadolinium-DTPA was quantified by calculating the enhancement gradient Fenh. A subjective index with a visual analog scale (0 = no pain, 10 = very severe pain) was used for assessment of back pain. Followup visits were done every 3 months for a maximum of 18 months. RESULTS: There was significant improvement of inflammatory back pain and sacroiliitis at 5.2 +/- 1.3 months after therapy in 25/30 patients (83.3%). The differences between the Fenh values before (98.2 +/ 56.1) and after (44.3 +/- 31.2) therapy and of the subjective pain index (8.5 +/- 1.5 and 3.0 +/- 2.3, respectively) were statistically significant. Subjective improvement lasted a mean of 8.9 +/- 5.3 months. CONCLUSION: CT guided corticosteroid injection of inflamed SI joints is a useful option in therapy for sacroiliitis in patients with SpA. Different degrees of inflammation in the SI joints can be quantitatively assessed by DMRI.

Use of immunohistologic and in situ hybridization techniques in the examination of sacroiliac joint biopsy specimens from patients with ankylosing spondylitis.

OBJECTIVE: To investigate mechanisms involved in inflammation and new bone formation in the sacroiliac (SI) joints of patients with ankylosing spondylitis (AS). PATIENTS AND METHODS: Computed tomography-assisted biopsy of the SI joint was performed in 5 patients with AS with a mean disease duration of 4.5 years and radiographic stage 2-3 disease. Immunohistologic studies were performed with the alkaline phosphatase-anti-alkaline phosphatase technique, and cytokine messenger RNA (mRNA) was detected by in situ hybridization. RESULTS: Dense cellular infiltrates with varying amounts of CD3+ cells (mean +/- SD 53.3 +/- 24.1%), CD4+ cells (29.7 +/- 17.6%), CD8+ cells (15.8 +/- 11.4%), CD14+ cells (23.6 +/- 16.9%), CD45RO+ cells (48.4 +/- 23.6%), and CD45RA+ cells (4.5 +/- 2.9%) were found in the synovial portion of the SI joints of all 5 patients. In these infiltrates a high amount of tumor necrosis factor alpha (TNF alpha) mRNA and, near the site of new bone formation, a lower amount of transforming growth factor beta (TGF beta) mRNA, were detected, while no message for interleukin-1 was found in the 3 patients examined by this technique. CONCLUSION: The presence of T cells and macrophages was demonstrated in cellular infiltrates in the SI joints of 5 patients with active AS. The finding of abundant TNF alpha message in these joints could have implications regarding potential immunotherapeutic approaches to this disease. TGF beta might be involved in new bone formation in AS.