Tc-99m HIG Scintigraphy in Detection of Active Inflammation in Ankylosing Spondylitis

Quantitative scintigraphy in discriminating sacroiliac joint physiological and pathological uptake

Background

Bone scintigraphy is a highly sensitive diagnostic nuclear medicine imaging technique that uses a radiotracer to evaluate the distribution of active bone formation in the skeleton related to malignant and benign diseases, as well as physiological processes. Subjective increase of the radioactivity at the sacroiliac joint in cancer patients could indicate physiological, metastatic, or inflammatory (sacroiliitis) cause. In this single-center study, we aimed to settle the normal sacroiliac index (SII) in males and females and if it differs from side to other, as a more accurate quantitative method than qualitative one, and assess its validity in discriminating the cause in pathological increase.

Results

Sacroiliac index can differentiate physiological uptake at the SIJ from pathological uptake with a highly significant value (P < 0.001). Using SII at a cutoff value 1.17 had 100% sensitivity and specificity in differentiating between the two conditions. The normal SII in our institute ranged from 0.9 to 1.14 with no significant difference between right and left SIJs. The mean SII was 1.33 ± 0.11 in patients with ankylosing spondylitis (AS) and 1.38 ± 0.1 in metastatic cases with no significant difference in SII between the two diseased groups (P = 0.49).

Conclusion

Bone scintigraphy is widely used in our institute and qualitative assessment of SIJ uptake is sometimes confusing. In this study, we assessed the normal SII range in physiological uptake and assessed a cutoff value (which is lower than other races) above which any increase in SIJ uptake is considered pathological. We could not confirm a cutoff value to discriminate between AS and metastatic affection of SIJ.

A Narrative Review of the Classification and Use of Diagnostic Ultrasound for Conditions of the Achilles Tendon

Enthesitis is a cardinal feature of spondyloarthropathies. The Achilles insertion on the calcaneus is a commonly evaluated enthesis located at the hindfoot, generally resulting in hindfoot pain and possible tendon enlargement. For decades, diagnosis of enthesitis was based upon patient history of hindfoot or posterior ankle pain and clinical examination revealing tenderness and/or enlargement at the site of the tendon insertion. However, not all hindfoot or posterior ankle symptoms are related to enthesitis. Advanced imaging, including magnetic resonance imaging (MRI) and ultrasound (US), has allowed for more precise evaluation of hindfoot and posterior ankle conditions. Use of US in diagnosis has helped confirm some of these cases but also identified other conditions that may have otherwise been misclassified without use of advanced imaging diagnostics. Conditions that may result in hindfoot and posterior ankle symptoms related to the Achilles tendon include enthesitis (which can include retrocalcaneal bursitis and insertional tendonopathy), midportion tendonopathy, paratenonopathy, superficial calcaneal bursitis, calcaneal ossification (Haglund deformity), and calcific tendonopathy. With regard to classification of these conditions, much of the existing literature uses confusing nomenclature to describe conditions in this region of the body. Some terminology may imply inflammation when in fact there may be none. A more uniform approach to classifying these conditions based off anatomic location, symptoms, clinical findings, and histopathology is needed. There has been much debate regarding appropriate use of tendonitis when there is no true inflammation, calling instead for use of the terms tendinosis or tendonopathy. To date, there has not been clear examination of a similar overuse of the term enthesitis in conditions where there is no underlying inflammation, thus raising the need for more comprehensive taxonomy.

The Role of Imaging in Diagnosing Axial Spondyloarthritis

Imaging has a central role in the diagnosis, management, and follow-up of patients with axial spondyloarthritis (axSpA). For the early diagnosis of axSpA, magnetic resonance imaging is of utmost relevance. While no novel imaging techniques were developed during the past decade, improvements to the existing modalities have been introduced. This report provides an overview of the applications and limitations of the existing imaging modalities.

Chiropractic Care in the Management of Inactive Ankylosing Spondylitis: A Case Series

Objective

This report describes chiropractic management for 3 cases of inactive ankylosing spondylitis (AS).

Clinical Features

A 25-year-old woman presented with chronic, mechanical neck pain and stiffness that was ultimately diagnosed as AS. A 23-year-old man presented with chronic low back and left hip pain that was diagnosed as AS. A 31-year-old man with low back pain presented with a known diagnosis of AS. Physical examination in 2 cases failed to identify systemic findings associated with AS. In the third case, examination revealed a history of ulcerative colitis. Laboratory examination of case 2 yielded a positive HLA-B27, but cases 1 and 3 were HLA-B27 negative. The acute reactants were negative in all 3 patients, indicating an inactive phase of disease. All 3 patients underwent spinal imaging including sacroiliac joint radiography. In case 3, magnetic resonance imaging of the sacroiliac joints was performed. All 3 imaging examinations revealed bilateral, symmetric sacroiliitis.

Interventions and Outcome

Patients were managed by both a medical rheumatologist and a doctor of chiropractic. Chiropractic care ranged from instrument-assisted spinal manipulation to diversified spinal and soft tissue manipulation and Cox flexion-distraction. Patients were given home stretches and rehabilitation exercises. All 3 patients experienced some relief of their symptoms including pain reduction and improved activities of daily living.

Conclusion

These 3 patients displayed differences and commonalities in clinical, laboratory, and imaging features. Chiropractic manipulation and rehabilitation seemed to be beneficial in reducing symptomatology and improving musculoskeletal function for these 3 patients. These findings suggest the potential for collaborative or integrative management in similar cases.

Radionuclide Methods in the Diagnosis of Sacroiliitis in Patients with Spondyloarthritis: An Update

Sacroiliitis, inflammation of the sacroiliac joint (SIJ), is the hallmark of ankylosing spondylitis and spondyloarthritis (SpA) in general. The arsenal of recommended diagnostic modalities for imaging of the SIJ is scanty and, in practice, includes only conventional X-rays and magnetic resonance imaging (MRI). This review suggests that bone scintigraphy, particularly single-photon emission computed tomography (SPECT) with calculation of indices, or SPECT in combination with low-dose computed tomography (CT) can be a sensitive and specific tool for the diagnosis of sacroiliitis and can be used as part of the individualized approach to the diagnosis of axial SpA. In addition, [¹⁸F]fluoride positron emission tomography (PET)/CT imaging and immunoscintigraphy, using labeled monoclonal anti-cytokine antibodies, are promising methods of current scientific interest in this field.