Is there any role for Nuclear Medicine in the investigation of Spondyloarthropathies in the era of MRI?

1. NUCLEAR MEDICINE IMAGING IN
SPONDYLOARTHROPATHIES:
FROM SACROILIAC JOINT UPTAKE
RATIO TO HYBRID IMAGING
John T. Koutsikos, MD, PhD
Department of Nuclear Medicine
401 General Military Hospital,
Athens, Greece

2. INTRODUCTION
Spondylarthropathies (SpA) as a group have seronegative, inflammatory arthritis with
a relationship to HLA B27, characterized by involvement of the spine, peripheral
arthtitis and enthesitis.
Represent a variety of diagnoses, including ankylosing spondylitis (AS), reactive
arthritis, psoriasic arthritis (PsA), and enteropathic arthritis.
It is now more important than ever to diagnose and treat SpA early, since new
therapeutic agents have yielded tremendous responses not only in advanced disease
but also in the early stages of the disease.

3. IMAGING I
Imaging of the sacroiliac joints (SIJ) has an important role in the diagnosis, classification
and monitoring of patients with SpA.
Conventional radiography was given an outstanding role in the development of
classification New York (NY) criteria in 1961 and modified NY criteria in 1984.
However, radiographic sacroiliitis reflects structural changes which may appear late in
the disease process at least in a subset of patients. It has low specificity especially for
patients at the early stages of the disease.
To enable earlier diagnosis, highly reliable and sensitive imaging techniques are needed.

5. IMAGING II
Magnetic resonance imaging (MRI) is used as a sensitive imaging modality for the
detection of sacroiliitis in early SpA.
MRI detects (early) inflammation such as bone marrow edema/osteitis, synovitis,
enthesitis and capsulitis associated with SpA
MRI has become a pivotal imaging tool for early diagnosis of axial SpA (recently
included as a major criterion in the ASAS classification criteria)

9. SCINTIGRAPHY I
 Four decades ago several reports about the diagnostic role of scintigraphy to detect
sacroiliitis were promising

13. SCINTIGRAPHY II
 Four decades ago several reports about the diagnostic role of scintigraphy to detect
sacroiliitis were promising
Bone scintigraphy was the method of choice and quantification of SIJ index has been
used as a diagnostic procedure to detect early sacroiliitis.

16. SCINTIGRAPHY III
Bone scintigraphy was the method of choice and quantification of SIJ index has been
used as a diagnostic procedure to detect early sacroiliitis.
However, data about the diagnostic value of bone scan to detect acute inflammatory
changes in the SIJ are conflicting and many studies suggest that scintigraphy of the SIJ is
at most of limited diagnostic value for the diagnosis of established SpA, including the
early diagnosis of probable/suspected sacroiliitis.

19. BONE SPECT
Single photon emission computed tomography (SPECT) of the bone, compared with planar
scintigraphy increases image contrast and improves lesion detection and localization.
Studies have documented the unique diagnostic information provided by SPECT in
patients with back pain.
In several studies bone SPECT appears to be an excellent diagnostic tool for active
sacroiliitis.

21. 2009 SNM Annual Congress

22. RADIOGRAPHIC SUSPICIOUS CHANGES IN THE SACROILIAC
JOINTS: THE ROLE OF BONE SINGLE PHOTON EMISSION
COMPUTED TOMOGRAPHY (SPECT) SCINTIGRAPHY
T. Pipikos1, J. Koutsikos1, S. Bakalis1, S. Episkopopoulou1, K.
Athanasiou1, G. Koniaris1, D. Kassimos2;
1 Nuclear Medicine dept., 2 Rheumatology dept.,
401 General Military Hospital, ATHENS, GREECE

23. AIM
To evaluate the role of bone single
photon emission computed tomography
(SPECT) scintigraphy in the detection of
sacroiliitis in patients with SpA and
suspicious changes of sacroiliitis on X-
ray.
X-ray, MRI, and SPECT of the sacroiliac
joints of 46 SpA patients (41 males, 5
females, mean age 28.2 y.o.) were
evaluated retrospectively.
Fourteen patients were classified as
grade 1
MRI detected features of sacroiliitis in
10/14 patients (71%)

24. SPECT FINDINGS
SPECT was (+)ve in all 10 MRI identified pts, as well as in one more male
with increased CRP and ECR.
In a 2-year follow up period, ankylosing spondylitis was established for this
patient.

26. (-)VE SPECT

27. (+)VE SPECT

28. SCINTIGRAPHY II
Other radiopharmaceuticals such as Ga-67, radiolabelled leucocytes, In-111 chloride,
99mTc labelled liposomes were demonstrated to accumulate in inflamed area in arthritis
However these agents have not been used in routine clinical practice.
99mTc labeled nonspecific polyclonal human immunoglobulin (HIG) accumulates in
infection and sterile inflammatory processes. HIG being a nonspecific marker of
inflammation and infection may help to detect active inflammation in SpA.

29. HIG SCINTIGRAPHY

30. HIG SCINTIGAPHY
EANM Annual Congress 2007

38. PET-CT
Inflammation tracers
glucose analogue F-18 FDG
macrophage tracer C-11 PK11195
Bone tracer
F-18 Fluoride