THE RADIOGRAPHIC DISSECTION OF CHRONIC RHEUMATIC ARTHRITIS

An appraisal of magnetic resonance imaging of the wrist in rheumatoid arthritis

OBJECTIVES

To evaluate the role of magnetic resonance imaging (MRI) in the diagnosis, staging, and follow-up of the rheumatoid wrist.

METHODS

A Medline search was performed to identify all publications from the years 1985 to 1999 concerning MRI of the wrist in patients with rheumatoid arthritis (RA). Additional papers were retrieved by scanning the references to the Medline-listed articles. Details of the MRI technique, as well as clinical data, were analyzed and compared.

RESULTS

A total of 55 papers were identified. There were considerable variations in imaging sequence, section type, and slice thickness. Erosions and synovitis were the conditions that mostly profited from the adoption of MRI. Although the visualization of erosions was better detailed with MRI than with conventional radiography, erosions were only rarely related to clinical and laboratory parameters. Another advantage was that synovitis imaging, which can be enhanced by contrast agents, was amenable to quantitation. The extent of the synovial surface and the rate of contrast enhancement in a series of consecutive, rapidly acquired images were the most common measures.

CONCLUSIONS

MRI of the rheumatoid wrist is a useful technique to ascertain the criteria for diagnosis and progression of RA, and to monitor the effects of treatment. Implementation of a standardized protocol could further increase its value.

Radiological evaluation of erosions: a quantitative method for assessing long-term remittive therapy in rheumatoid arthritis

1 The most reliable method for evaluating possible remission-inducing properties in a drug is to measure how well it prevents the appearance of new erosions in serial X-rays of the hands. 2 I have reviewed the literature on the development, over the last 25 years, of a standard method for quantitatively assessing the progress of erosions radiologically. 3 The only drugs thus far shown to be genuinely remission-inducing are cyclophosphamide, high-dose penicillamine, and (most consistently over several decades) gold-thiols, all drugs with life-threatening toxicity. 4 The search for a non-steroidal drug with remission-inducing properties is crucial in our efforts to find a safe drug to control the progression of rheumatoid arthritis.

Methods of assessing radiographic change in rheumatoid arthritis

The first attempt at standardization in the evaluation of rheumatoid arthritis was reported by Steinbrocker in 1949. Subsequently, Kellgren in the late 1950s, Sharp in 1971, and Larsen in 1973 reported detailed techniques for semiquantitative evaluation of radiographic changes and indicated that joint films may be the most accurate and reproducible basis for assessing the severity and progression of rheumatoid arthritis. High-resolution magnification radiography, achieved by optical magnification of fine-grain film or direct radiographic magnification, has proved particularly valuable for the reliable and sensitive evaluation of articular abnormalities in arthritis. Studies have supported the clinical usefulness of these techniques in assessing early rheumatoid arthritis. A semiquantitative radiographic approach recently used in a multicenter clinical trial is illustrated herein. Results indicate a high interobserver correlation for grades of erosion and joint-space narrowing. The sensitivity with which observers graded the findings, however, varied among observers despite the use of reference standards. There was poor correlation among observers for assessing changes in grade with time so that evaluation of clinical response was limited. Observations from this analysis provide the basis for improved methods in the design of clinical therapeutic trials.

Radiographic changes in early rheumatoid disease

We have studied the radiological features in 94 patients with early rheumatoid disease followed prospectively for 5 years. The changes appeared very early and occurred in up to 71-3% of patients. Erosive changes occurred in the feet much more commonly than in the hands and considerably earlier. Erosive changes were present before there was joint-space loss. Frequent x-ray examination of feet and hands in the first 2 years after presentation is required if we are to identify patients at risk for serious joint damage.