Pitfalls in MR morphology of the sterno-costo-clavicular region using whole-body MRI

doi:10.1016/j.crad.2013.02.007

Clinical Radiology

Volume 68, Issue 8, August 2013, Pages 785-791

https://doi.org/10.1016/j.crad.2013.02.007 Get rights and content

Aim

To analyse the imaging findings at the sterno-costo-clavicular (SCC) joint region using whole-body (WB) magnetic resonance imaging (MRI) in healthy individuals to minimize misinterpretation as changes due to spondyloarthritis (SpA).

Materials and methods

As part of a cross-sectional study of 122 SpA patients, 75 healthy individuals (42/33 males/females; median age 30.3 years; range 17.7–63.8 years) were scanned using sagittal and coronal WB short tau inversion recovery (STIR) and T1-weighted MRI sequences. The SCC region was analysed independently by seven readers for bone marrow oedema (BMO), erosions, subchondral fat signal intensity (FSI), and joint fluid accumulation.

Results

SCC changes simulating inflammation were reported by four or more of the seven readers in 15 (20%) healthy individuals (12 male/three female; median age 32.1 years; range 20.2–48 years). Thirteen individuals (17%) had changes at the manubriosternal joint (MSJ); five had BMO, one BMO + erosion, four erosion, two erosion + FSI, and one FSI only. Changes at the sternoclavicular joint occurred in three individuals (4%) encompassing erosion, erosion + FSI + BMO, and joint fluid accumulation, respectively. One patient had both MSJ and sternoclavicular joint changes.

Conclusions

Findings mimicking inflammatory changes occurred in healthy individuals, particularly in the MSJ. Awareness of this is important in recognition of SCC inflammation in SpA.

Introduction

Inflammatory involvement of the sterno-costo-clavicular (SCC) region in patients with spondyloarthritis (SpA) is a well-known1, 2, 3 but often a neglected disease manifestation, except in patients primarily presenting with hyperostotic and/or sclerotic SCC changes, such as SCC hyperostosis and pustulotic arthro-osteitis.³ Conventional magnetic resonance imaging (MRI) of the SCC region is, therefore, rarely performed routinely even in the presence of SCC pain in SpA patients. The increasing use of whole-body (WB) MRI in the diagnosis of SpA offers an opportunity to evaluate inflammation of the SCC region in addition to the entire spine and the sacroiliac joints.4, 5, 6, 7, 8, 9 Frequent involvement of the SCC joints in SpA has been confirmed by WB MRI, being present in 72 (59%) of 122 SpA patients.⁶ SCC involvement was more frequent in ankylosing spondylitis compared with SpA patients not fulfilling the modified New York criteria for ankylosing spondylitis,¹⁰ occurring in 65% and 37% of the patients, respectively. The manubriosternal joint (MSJ) was the most frequently affected SCC joint both in ankylosing spondylitis and in patients with other forms of SpA.⁶ However, in the same study 15 of 75 (20%) healthy controls were found to have changes in the SCC region by WB MRI simulating SpA lesions.⁶ These findings in healthy individuals have not been analysed in detail.

The purpose of this study was to analyse and describe the SCC findings in healthy individuals using WB MRI to minimize misinterpretation as SpA changes.

Section snippets

Patients

As part of a controlled, cross-sectional study of 122 consecutive SpA patients at a University Hospital, a control group of 75 healthy volunteers was recruited from the staff of the hospital.⁶ The control subjects had no clinical sign of SpA, notably psoriasis, inflammatory bowel disease, reactive arthritis, uveitis and enthesitis, and did not have clinically relevant back pain according to the Nordic questionnaire.¹¹ The control group represents the present study group and encompassed 42 males

Results

Changes in the SCC region simulating inflammation were reported by the majority of readers in 15 (20%) healthy individuals (12 male/3 female); median age 32.1 years (range 20.2–48 years). MRI lesions compatible with erosion were observed in 12%, FSI in 5.3%, and BMO in 9.3% of the individuals, respectively, whereas BMO was the most frequent finding in the SpA patients (Table 1).

Nearly all lesions observed in healthy individuals occurred at the MSJ (8% for BMO, 9.3% for erosion, 4% for FSI),

Discussion

The present study on WB MRI of the SCC region showed changes simulating erosion, FSI and/or BMO in 20% of healthy individuals. Nearly all lesions observed in healthy persons occurred at the MSJ. The MSJ was also the most frequently affected joint in SpA patients by WB MRI, but the low frequency of SClJ changes in healthy individuals was in contrast to the findings in SpA where BMO, erosion, and FSI at the SClJ occurred in 23.8%, 11.5%, and 10.7% of the patients, respectively. Signs simulating

Acknowledgements

The present work was supported by the Walter L. and Johanna Wolf Foundation, Zurich, Switzerland, and the Foundation for Scientific Research at the University of Zurich, Switzerland. Both funding bodies played no role in study design, in the collection and interpretation of data, or in the decision to submit the manuscript for publication.

References (20)

S. Weckbach et al.
Whole-body MR imaging in psoriatic arthritis: additional value for therapeutic decision making
Eur J Radiol
(2011)
I. Kuorinka et al.
Standardised Nordic questionnaires for the analysis of musculoskeletal symptoms
Appl Ergon
(1987)
B. Fournié et al.
Prospective study of anterior chest wall involvement in ankylosing spondylitis and psoriatic arthritis
Rev Rhum Engl Ed
(1997)
A.G. Jurik
Seronegative anterior chest wall syndromes. A study of the findings and course at radiography
Acta Radiol
(1992)
A.G. Jurik
Clinical problems. Seronegative arthritis and sternocostoclavicular syndromes
U. Weber et al.
Validation of whole-body against conventional magnetic resonance imaging for scoring acute inflammatory lesions in the sacroiliac joints of patients with spondylarthritis
Arthritis Rheum
(2009)
U. Weber et al.
Assessment of active spinal inflammatory changes in patients with axial spondyloarthritis: validation of whole body MRI against conventional MRI
Ann Rheum Dis
(2010)
U. Weber et al.
Anterior chest wall inflammation by whole-body magnetic resonance imaging in patients with spondyloarthritis: lack of association between clinical and imaging findings in a cross-sectional study
Arthritis Res Ther
(2012)
U. Weber et al.
Whole body MR imaging in ankylosing spondylitis: a descriptive pilot study in patients with suspected early and active confirmed ankylosing spondylitis
BMC Musculoskelet Disord
(2007)
I.H. Song et al.
Poor agreement between enthesitis on whole body MRI and enthesitis on clinical examination in patients with early axial SpA—results from the ESTHER trial at baseline
Arthritis Rheum
(2011)

There are more references available in the full text version of this article.

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Les articulations sterno-claviculaires (SCC) sont probablement trop rarement examinées par les rhumatologues, alors qu’elles peuvent être d’une grande aide dans le raisonnement diagnostique. Leur situation anatomique, à l’interface entre le thorax et l’épaule, peut égarer l’analyse sémiologique. Toute douleur de l’épaule ou de la paroi thoracique antérieure doit faire rechercher une pathologie de l’articulation SCC, par la recherche d’une tuméfaction ou rougeur locale, et la pression sur l’articulation. L’imagerie (radiographie, scanner, IRM, scintigraphie, échographie) est parfois rendue difficile d’interprétation du fait des structures adjacentes et de la fréquence des anomalies non spécifiques de cette articulation. La richesse en enthèses de cette région en fait le lit des atteintes des spondyloarthrites, bien connues et démontrées. L’atteinte dans le SAPHO, impressionnante par l’hyperostose et l’ostéite caractéristique, ne doit pas faire négliger les atteintes plus discrètes rencontrées dans les spondylarthrites ankylosantes ou les rhumatismes psoriasiques. Cependant, d’autres atteintes inflammatoires sont possibles : les atteintes infectieuses, à pyogènes ou à germes atypiques ou à croissance lente, mais aussi, de manière plus rare, les atteintes dans le cadre de la polyarthrite rhumatoïde ou des arthrites microcristallines. Enfin, les atteintes arthrosiques sont fréquentes après 50 ans, mais rarement symptomatiques.
Sternoclavicular joints (SCC) are probably too rarely considered by the rheumatologists. However, they can be of great help in the diagnostic reflection. Their anatomical location, between the chest and the shoulder joint, can mislead the semiology analysis. Every patient presenting with shoulder pain must have an examination of the SCC, by looking for local swelling or redness, and pressuring the joint. Imaging (X-rays, CT-scan, MRI, scintigraphy, ultrasonography) can be hard to interpret because of the adjacent structures and the frequency of non-specific abnormalities of this joint. There are lots of entheses in this region, which explains the frequent and demonstrated correlation of SCC pathology with spondyloarthritis. In SAPHO syndrome, hyperostosis and osteitis are very impressive. However, one must not neglect the more discreet SCC symptoms encountered in ankylosing spondylitis and psoriatic arthritis. Other inflammatory conditions are possible in the SCC: septic arthritis (by pyogenic or atypical germs), and more rarely, rheumatoid arthritis or microcrystalline arthritis. Finally, osteoarthritis of the SCC is common over the age of 50, but rarely symptomatic.
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MRI findings for unilateral sternoclavicular arthritis: differentiation between infectious arthritis and spondyloarthritis
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Whole-body magnetic resonance imaging in inflammatory arthritis: Systematic literature review and first steps toward standardization and an omeract scoring system
2017, Journal of Rheumatology

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Pitfalls in MR morphology of the sterno-costo-clavicular region using whole-body MRI

Aim

Materials and methods

Results

Conclusions

Introduction

Section snippets

Patients

Results

Discussion

Acknowledgements

Eur J Radiol

Appl Ergon

Prospective study of anterior chest wall involvement in ankylosing spondylitis and psoriatic arthritis

Rev Rhum Engl Ed

Seronegative anterior chest wall syndromes. A study of the findings and course at radiography

Acta Radiol

Clinical problems. Seronegative arthritis and sternocostoclavicular syndromes

Validation of whole-body against conventional magnetic resonance imaging for scoring acute inflammatory lesions in the sacroiliac joints of patients with spondylarthritis

Arthritis Rheum

Assessment of active spinal inflammatory changes in patients with axial spondyloarthritis: validation of whole body MRI against conventional MRI

Ann Rheum Dis

Anterior chest wall inflammation by whole-body magnetic resonance imaging in patients with spondyloarthritis: lack of association between clinical and imaging findings in a cross-sectional study

Arthritis Res Ther

Whole body MR imaging in ankylosing spondylitis: a descriptive pilot study in patients with suspected early and active confirmed ankylosing spondylitis

BMC Musculoskelet Disord

Poor agreement between enthesitis on whole body MRI and enthesitis on clinical examination in patients with early axial SpA—results from the ESTHER trial at baseline

Arthritis Rheum