Comparative analysis of low-field magnetic resonance imaging in patients with rheumatoid arthritis treated with certolizumab pegol or infliximab

OBJECTIVES

The aim is to clarify the differences in magnetic resonance imaging (MRI) findings between rheumatoid arthritis (RA) patients treated with certolizumab pegol (CZP) and infliximab (IFX).

METHODS

The study included RA patients who received CZP or IFX and were examined with low-field MRI (compacTscan; compact magnetic resonance imaging) at the beginning and again within 6 months of treatment initiation. Comparisons were made regarding background, clinical course, and differences in MRI findings following initiation of tumour necrosis factor inhibitors between the CZP and IFX treatment groups. MRI findings were evaluated by scoring erosion, bone marrow oedema (BME), and synovitis.

RESULTS

Ten cases in CZP and 18 cases in IFX group were compared. The biologic disease-modifying antirheumatic drug-naïve rate in the IFX group was significantly higher than that in the CZP group. After 6 months, disease activities were significantly decreased from baseline in both groups. Erosion score did not change significantly in both groups after 6 months. BME score was significantly decreased in the CZP group after 6 months, whereas in the IFX group, there was no significant change. Synovitis score was significantly decreased in both groups after 6 months.

CONCLUSIONS

The findings of our study suggest that, in patients with RA, CZP might improve BME more effectively than IFX.

Management of lumbar bone stress injury in cricket fast bowlers and other athletes

Background

Recent guidelines (including a special series in The Lancet) have emphasised a minimal role for imaging when assessing low back pain in adults, as the majority of patients will have non-specific findings on imaging that do not correlate well with pain.

Objective

To assess whether the diagnosis of lumbar bone stress injuries in young athletes should be considered an exception to the recommendation to avoid imaging for low back pain in adults.

Method

Narrative review.

Results

Early lumbar bone stress injury diagnosis has been available via traditional MRI sequences (and its precursor Single Photon Emission Computed Tomography (SPECT)) for 25-30 years. MRI assessments using bone window sequences (such as Volumetric Interpolated Breath-hold Examination (VIBE)) have allowed a better understanding of the diagnosis and prognosis of lumbar bone stress injury in young athletes. MRI with bone sequences has allowed non-radiating scans to serially follow the healing of unilateral stress fractures. In the majority of cases, non-chronic unilateral fractures can heal; however, this takes three-six months rather than the six-ten weeks that would be the typical unloading period if using symptoms (only) as a guide. The use of MRI to provide evidence of bony healing (as opposed to fibrous union, which creates the pars defect that predisposes to further bone stress lesions) can lead to better long-term outcomes in athletes. There is evidence to flag this as a structural lesion which is both painful and, more importantly, can heal/resolve if managed correctly. Therefore it represents an important 'specific' diagnostic subset within adult low back pain.

Conclusion

Structural (rather than functional) management of bone stress injuries in high-demand athletes, such as cricket pace bowlers, is in contrast to the recommendation of functional management for general back pain in adults. Structural management is justified when there are demonstrable superior outcomes of having better structure. Although this has not yet been shown in randomised trials of elite athletes, apparent lengthier Test cricket careers of pace bowlers who do not have pars defects suggest better athletic outcomes if bony healing is achieved. For lower demand young adults, or athletes with established bilateral pars defects, functional management may be more pragmatic.

Bone marrow lesions of the femoral head: can radiomics distinguish whether it is reversible?

Purpose

Contrary to the self-limiting nature of reversible bone marrow lesions, irreversible bone marrow lesions require early surgical intervention to prevent further morbidity. Thus, early discrimination of irreversible pathology is necessitated. The purpose of this study is to evaluate the efficacy of radiomics and machine learning regarding this topic.

Material and methods

A database was scanned for patients who had undergone MRI of the hip for differential diagnosis of bone marrow lesions and had had follow-up images acquired within 8 weeks after the first imaging. Images that showed resolution of oedema were included in the reversible group. The remainders that showed progression into characteristic signs of osteonecrosis were included in the irreversible group. Radiomics was performed on the first MR images, calculating first- and second-order parameters. Support vector machine and random forest classifiers were performed using these parameters.

Results

Thirty-seven patients (seventeen osteonecrosis) were included. A total of 185 ROIs were segmented. Fortyseven parameters were accepted as classifiers with an area under the curve value ranging from 0.586 to 0.718. Support vector machine yielded a sensitivity of 91.3% and a specificity of 85.1%. Random forest classifier yielded a sensitivity of 84.8% and a specificity of 76.7%. Area under curves were 0.921 for support vector machine and 0.892 for random forest classifier.

Conclusions

Radiomics analysis could prove useful for discrimination of reversible and irreversible bone marrow lesions before the irreversible changes occur, which could prevent morbidities of osteonecrosis by guiding the decisionmaking process for management.

DCNAS-Net: deformation convolution and neural architecture search detection network for bone marrow oedema

Background

Lumbago is a global disease that affects more than 500 million people worldwide. Bone marrow oedema is one of the main causes of the condition and clinical diagnosis is mainly made by radiologists manually reviewing MRI images to determine whether oedema is present. However, the number of patients with Lumbago has risen dramatically in recent years, which has brought a huge workload to radiologists. In order to improve the efficiency of diagnosis, this paper is devoted to developing and evaluating a neural network for detecting bone marrow edema in MRI images.

Related work

Inspired by the development of deep learning and image processing techniques, we design a deep learning detection algorithm specifically for the detection of bone marrow oedema from lumbar MRI images. We introduce deformable convolution, feature pyramid networks and neural architecture search modules, and redesign the existing neural networks. We explain in detail the construction of the network and illustrate the setting of the network hyperparameters.

Results and discussion

The detection accuracy of our algorithm is excellent. And its accuracy of detecting bone marrow oedema reached up to 90.6\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\%$$\end{document}%, an improvement of 5.7\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\%$$\end{document}% compared to the original. The recall of our neural network is 95.1\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\%$$\end{document}%, and the F1-measure also reaches 92.8\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\%$$\end{document}%. And our algorithm is fast in detecting it, taking only 0.144 s per image.

Conclusion

Extensive experiments have demonstrated that deformable convolution and aggregated feature pyramid structures are conducive for the detection of bone marrow oedema. Our algorithm has better detection accuracy and good detection speed compared to other algorithms.

Efficacy and safety of secukinumab in patients with spondyloarthritis and enthesitis at the Achilles tendon: Results from a Phase 3b trial

Objective

ACHILLES aimed to demonstrate efficacy of secukinumab on Achilles’ tendon enthesitis in spondyloarthritis (SpA) patients.

Methods

Patients ≥18 years (n = 204) with active PsA or axial SpA and heel enthesitis were randomized 1:1 to secukinumab 150/300 mg or placebo up to week 24, and thereafter placebo patients were switched to secukinumab.

Results

At week 24, a higher, yet statistically non-significant (P = 0.136), proportion of patients in secukinumab vs placebo reported resolution of Achilles tendon enthesitis in affected foot (42.2% vs 31.4%; odds ratio [OR] = 1.63; 95% CI: 0.87, 3.08). Proportion of patients reporting resolution of enthesitis based on Leeds Enthesitis Index was higher with secukinumab vs placebo (33.3% vs 23.5%; OR = 1.65; 95% CI: 0.85, 3.25) at week 24. Mean change from baseline in heel pain at week 24 was higher in secukinumab patients vs placebo (−2.8 [3.0] vs −1.9 [2.7]). Greater improvements with secukinumab were observed in heel enthesopathy activity and global assessment of disease activity. Imaging evaluation by local reading confirmed heel enthesitis on MRI at screening for all patients. Based on central reading, 56% presented with bone marrow oedema and/or tendinitis; according to Heel Enthesitis MRI Scoring System (HEMRIS) post hoc analysis, 76% had signs of entheseal inflammation while 86% had entheseal inflammation and/or structural changes.

Conclusion

A substantial proportion of patients showed no signs of inflammation on the centrally read MRIs despite a clinical diagnosis of heel enthesitis, thus highlighting that the discrepancy between the clinical and imaging assessments of enthesitis requires further investigation. Although ACHILLES did not meet the primary end point, the study reported clinically meaningful improvements in patient-related outcomes.

Trial registration

clinicaltrials.gov, NCT02771210

Magnetic resonance characterisation of primary Raynaud's phenomenon

The objective findings of phalangeal T2-weighted hyperintense and T1-weighted hypointense bone marrow signal on MRI without features of seronegative arthropathy or osteomyelitis may assist clinicians in making a diagnosis in the appropriate clinical context.

The association between change in bone marrow lesion size and change in tibiofemoral cartilage volume and knee symptoms

OBJECTIVE

To describe the association between change in subchondral bone marrow lesions (BMLs) and change in tibiofemoral cartilage volume and knee symptoms in patients with symptomatic knee OA.

METHODS

In total, 251 participants (mean 61.7 years, 51% female) were included. Tibiofemoral cartilage volume was measured at baseline and 24 months, and BML size at baseline, 6 and 24 months. Knee pain and function scores were evaluated at baseline, 6 and 24 months. Change in total and compartment-specific BML size was categorized according to the Least Significance Criterion. Linear mixed-effects models were used to evaluate the associations of change in BMLs over 6 and 24 months with change in cartilage volume over 24 months and knee symptoms over 6 and 24 months.

RESULTS

Total BML size enlarged in 26% of participants, regressed in 31% and remained stable in 43% over 24 months. Compared with stable BMLs in the same compartment, enlarging BMLs over 24 months were associated with greater cartilage loss (difference: -53.0mm3, 95% CI: -100.0, -6.0), and regressing BMLs were not significantly associated with reduced cartilage loss (difference: 32.4mm3, 95% CI: -8.6, 73.3) over 24 months. Neither enlargement nor regression of total BML size over 6 and 24 months was associated with change in knee pain and function over the same time intervals.

CONCLUSIONS

In subjects with symptomatic knee osteoarthritis and BMLs, enlarging BMLs may lead to greater cartilage loss but regressing lesions are not associated with reduced cartilage loss while neither is associated with change in knee symptoms.

Power and spectral Doppler ultrasound in suspected active sacroiliitis: a comparison with magnetic resonance imaging as gold standard

OBJECTIVES

The objectives of this study were to study with Power Doppler US (PDUS) the SI joints (SIJs) of patients with suspected active sacroiliitis, to describe SIJ flows with spectral wave analysis (SWA) on Doppler US, and to correlate US data with both clinical characteristics and presence of SIJ bone marrow oedema (BME) in subsequent MRI.

METHODS

A total of 42 patients (32 females and 10 males, mean age 46.8 years) with recent onset of inflammatory back pain (IBP) were included. Every patient underwent US examination with a convex 1-8 MHz probe [scoring PDUS signals with a three-point scale and describing flows in SWA calculating the mean Resistive Index (RI)] and subsequent MRI of the SIJs.

RESULTS

PDUS signals were detected in 34 patients and 62 SIJs. In 29 patients and 56 SIJs, MRI revealed BME. A definite diagnosis of SpA was made in 32 patients. PDUS signals were more frequent (P < 0.0001) in patients with a final diagnosis of SpA, yielding a higher PDUS score (P = 0.0304). PDUS grading correlated with both BME grading (r = 0.740, P = 0.0001) and AS DAS (ASDAS) (r = 0.6257, P = 0.0004), but not with inflammatory reactants nor anthropometric data. Mean RI were, respectively, 0.60 and 0.73 (P < 0.0001) in patients with or without diagnosis of active sacroiliitis. The most inclusive RI cut-off resulted <0.70 [positive predictive value (PPV) 94%, accuracy 90%, P = 0.0001]. The best Likelihood Ratio (5.471) for RI to detect pathologic cases was obtained with a cut-off of <0.60 (PPV 96%).

CONCLUSIONS

PDUS and SWA of SIJs demonstrate good diagnostic accuracy for active sacroiliitis compared with MRI.

Bone marrow oedema syndrome of the foot and ankle in a paediatric population: a retrospective case series with serial MRI evaluation

PURPOSE

By means of a case series we wanted to describe and correlate the clinical and imaging features of bone marrow oedema syndrome (BMOS) of the foot and ankle in children.

METHODS

A retrospective data study was performed on patients born on or after 01 January 2001 who underwent multiple MRI scans of the foot and ankle for pain symptoms. Six patients who presented with increased signal intensity on T2-weighted MR imaging without any underlying causes or concomitant pathology were included.

RESULTS

All patients, three boys and three girls with a mean age of 11 years (8 to 14), displayed patchy areas of increased signal intensity on T2-weighted and turbo inversion recovery magnitude (TIRM) images. On average, six tarsal bones were involved (4 to 8). In all patients, treatment consisted of rest and/or protected weight-bearing. The mean time for symptoms to improve during treatment was 6 months (1 to 16). The mean duration of treatment was nine months (3 to 16). In all patients clinical and imaging symptoms were strongly correlated and regressed in time.

CONCLUSION

BMOS as a pathological entity should be considered in paediatric patients with foot and ankle pain without a clear underlying cause, and characteristic T2-weighted and TIRM signal intensity increase on MRI images. As BMOS is transient and self-limiting, conservative treatment is advised while the oedema regresses. An early diagnosis of this pathology could prevent unnecessary diagnostic investigations and invasive treatments.

LEVEL OF EVIDENCE

IV.

Bone marrow oedema-type signal in the proximal phalanx of Thoroughbred racehorses

This study focused on 8 Thoroughbred racehorses showing bone marrow oedema-type signal in the proximal sagittal groove of the proximal phalanx, with the aim of understanding its clinical significance. Standing magnetic resonance imaging played an important role in assessing osseous abnormalities that were not radiographically identifiable. Further, a histopathological result from one of the cases showed there was oedema surrounding adipose tissues with increase in density of trabecular scaffolding. This may indicate presence of osseous injury within the area of decreased elasticity due to subchondral bone modeling. This study suggests that detection of osseous abnormality based on bone marrow oedema-type signal, and application of appropriate care following injury would contribute to prevent deterioration of stress-related fractures of the proximal phalanx.

Magnetic resonance imaging scans are not a reliable tool for predicting symptomatic acromioclavicular arthritis

BACKGROUND

We investigated whether magnetic resonance imaging (MRI) scans can accurately diagnose arthritis of the acromioclavicular joint (ACJ) because it has recently been suggested that bone marrow oedema on MRI scans is a predictive sign of symptomatic ACJ arthritis.

METHODS

The MRI scans of 43 patients (50 shoulders) who underwent ACJ excision for clinically symptomatic ACJ arthritis were compared to a control group of 43 age- and sex-matched patients (48 shoulders) who underwent an MRI scan for investigation of shoulder pain but did not have clinical symptoms or signs of ACJ arthritis. The scans were evaluated by an experienced musculoskeletal radiologist, who was blinded to the examination findings.

RESULTS

Bone marrow oedema was present in only 15 (30%) shoulders in the ACJ excision group, although this was higher than the six shoulders in the asymptomatic group (p = 0.03). Forty-one (82%) shoulders in the symptomatic group had grade III/IV ACJ arthritis compared to 31 (65%) in the asymptomatic group (p = 0.05). However, 44 out of 48 (92%) shoulders in the asymptomatic group had signs of osteoarthritis on MRI scans.

CONCLUSIONS

In contrast to recent reports, the present study shows that MRI is not helpful in making the diagnosis of ACJ arthritis. A focused history and clinical examination should remain the mainstay for surgical decision making.

LEVEL OF EVIDENCE

Level 3.

A Rare Case of Spinal Sarcoidosis Presenting as Multiple Bone Marrow Oedematous Lesions

Sarcoidosis is a systemic disorder that most commonly affects the lungs. Bone involvement is rare, and spinal involvement is even more rare. The presence of focal lesions of the vertebrae is highly suspicious of advanced malignancy. However, malignant metastatic spread to the spine involves the vertebral cortex rather than the bone marrow itself, a distinction that is often missed and therefore misleading. We describe here a middle-aged woman with multiple focal oedematous lesions of the bone marrow suspected of being advanced malignancy but finally diagnosed as a rare case of spinal sarcoidosis.

Dimethyl fumarate-associated transient bone marrow oedema syndrome

BACKGROUND

Dimethyl fumarate (DMF) is a commonly used and effective treatment for relapsing and remitting multiple sclerosis. Its use results in impairment of the transcription factor nuclear factor erythroid-derived 2 (E2)-related factor (Nrf2), which is involved in both immunomodulation and bone health. DMF has not previously been reported to cause bone marrow complications, though other fumarates including tenofovir have. The mechanism of fumarate-associated bone toxicity remains unclear with altered osteoblastic gene expression and function suggested.

METHODS

We present a case of a 54-year-old female with relapsing remitting multiple sclerosis (RRMS) treated for 30 months with DMF who developed relapsing atraumatic lower limb bone pain.

RESULTS

Serial imaging revealed multifocal areas of bone marrow oedema and trabecular fractures. The patient was diagnosed with transient bone marrow oedema syndrome. Management consisted of cessation of therapy and treatment with the pro-osteobalstic agent denosumab.

CONCLUSION

In this instance of DMF-associated bone marrow oedema, cessation of DMF and treatment with denosumab resulted in symptomatic improvement. DMF therapy may potentially result in bone marrow oedema due to inhibition of common upstream signalling pathways, including the Nrf2 signalling pathway.

The role of Iloprost on bone edema and osteonecrosis: Safety and clinical results

INTRODUCTION

Iloprost is a commercially available prostaglandin I₂ (PGI₂) analogue that is shown to have antithrombotic, vasodilatative and antiproliferative effects. A number of clinical studies have shown that Iloprost can be effective in the management of bone marrow oedema and the treatment of avascular necrosis. The aim of this manuscript is to present our current understanding on the effect of Iloprost on the treatment of these conditions.

AREAS COVERED

The authors offer a comprehensive review of the existing literature on the experimental and clinical studies analysing the effect of Iloprost on bone, bone marrow oedema and avascular necrosis.

EXPERT OPINION

The available data from the clinical studies suggest that Iloprost has limited effect in advanced stages of avascular necrosis. However, literature suggests that Iloprost administration can be a viable option in the management of bone marrow oedema and early stages of osteonecrosis. Despite these promising results its effect on bone homeostasis needs further elucidation. Moreover, further data on its safety, dosage and efficiency through randomized multicenter studies are desirable in order to reach final conclusions.

[MRI diagnostics of bone marrow oedema and its significance for the forensic medical evaluation of the injuries to bones and articulations]

The objective of the present study was the analysis of the publications in the literature dealing with radiological methods employed for the diagnostics of injuries to and diseases of the bones and articulations as well as the role of bone marrow oedema in the development of these conditions in the specific context of the problems facing forensic medical expertise. The main results of the domestic and foreign authors concerning MRI-based investigations into the nature of injuries and other pathological changes in bones and articulations during different periods after their development are discussed with the major emphasis placed on diagnostics of bone marrow oedema. Magnetic resonance visualization of this diagnostic feature and the related manifestations of the above conditions in many cases provides an indisputable evidence of the damage whereas the discovery of its distribution to and localization in the bone structures makes it possible to elucidate the sources of this condition, such as a blow, torsional stress, stretching, etc., and its underlying mechanisms. The character and the mode of distribution of the signal from a bone marrow oedema under various conditions of visualization allow to carry out differential diagnostics of the damage prescription period of up to 1.5 months.

Aetiology and pathogenesis of bone marrow lesions and osteonecrosis of the knee

Bone marrow lesions (BML) of the knee are a frequent MRI finding, present in many different pathologies including trauma, post-cartilage surgery, osteoarthritis, transient BML syndromes, spontaneous insufficiency fractures, and true osteonecrosis.

Osteonecrosis (ON) is in turn divided into spontaneous osteonecrosis (SONK), which is considered to be correlated to subchondral insufficiency fractures (SIFK), and avascular necrosis (AVN) which is mainly ascribable to ischaemic events.

Every condition has a MRI pattern, a different clinical presentation, and specific histological features which are important in the differential diagnosis.

The current evidence supports an overall correlation between BML and patient symptoms, although literature findings are variable, and very little is known about the natural history and the progression of these lesions.

A full understanding of BML will be mandatory in the future to better address the different pathologies and develop appropriately-targeted treatments.

Cite this article: Marcacci M, Andriolo L, Kon E, Shabshin N, Filardo G. Aetiology and pathogenesis of bone marrow lesions and osteonecrosis of the knee. EFORT Open Rev 2016;1:219-224. DOI: 10.1302/2058-5241.1.000044.

Bone marrow oedema assessment by magnetic resonance imaging in rheumatoid arthritis wrist and metacarpophalangeal joints: the importance of field strength, coil type and image resolution

OBJECTIVE

The aim of this study was to examine the influence of different MRI unit field strengths, coil types and image resolutions on the OMERACT RA MRI scoring system (RAMRIS) of bone marrow oedema (BME) and image quality.

METHODS

Forty-one patients and 12 healthy controls participated in this cross-sectional study. Coronal short tau inversion recovery (STIR) and T1-weighted sequences were obtained at 0.23, 0.6, 1.5 and 3T using flex coils (Flex). Additional STIR sequences were obtained with phased array extremity coils (Extr) (at 0.6 and 1.5T) and higher resolution (at 1.5T). In otal, 338 STIR image sets were anonymized and scored according to RAMRIS and parameters of image quality were measured.

RESULTS

The BME sum scores were similar overall when comparing the different MRI units, coil types and voxel sizes, yet significantly higher at the higher resolution of 1.5T Extr compared with 0.23T Flex (P = 0.004), 0.6T Flex (P = 0.03), 1.5T Flex (P = 0.05) and 3T Flex (P = 0.001). Mean differences were relatively minor (0-3.5). Intrareader reliability of BME scores was high [intraclass correlation coefficient ≥ 0.90 for all except 0.23T (0.81) and percentage exact agreement 81-88%]. The smallest detectable difference was better at 0.6, 1.5 and 3T (9-29% of maximum value) than at 0.23T (40%). Image quality was lowest at 0.23T.

CONCLUSION

No major, consistent differences were found between BME scores using STIR sequences obtained at different field strengths, coil types and image resolutions, suggesting that these are equally suited for assessment of BME in RA. However, parameters of image quality and intrareader reliability (favouring 0.6, 1.5 and 3T) should be considered when selecting the MRI acquisition strategy.

Primary bone marrow oedema syndromes

MRI scanning in patients with rheumatological conditions often shows bone marrow oedema, which can be secondary to inflammatory, degenerative, infective or malignant conditions but can also be primary. The latter condition is of uncertain aetiology and it is also uncertain whether it represents a stage in the progression to osteonecrosis in some patients. Patients with primary bone marrow oedema usually have lower limb pain, commonly the hip, knee, ankle or feet. The diagnosis is one of exclusion with the presence of typical MRI findings. Treatment is usually conservative and includes analgesics and staying off the affected limb. The natural history is that of gradual resolution of symptoms over a number of months. Evidence for medical treatment is limited, but open-label studies suggest bisphosphonates may help in the resolution of pain and improve radiological findings. Surgical decompression is usually used as a last resort.