Postpartum Bone Marrow Edema at the Sacroiliac Joints May Mimic Sacroiliitis of Axial Spondyloarthritis on MRI

Agten, Christoph A.; Zubler, Veronika; Zanetti, M.; Binkert, Christoph A.; Kolokythas, Orpheus; Prentl, Elke; Buck, Florian M.; Pfirrmann, Christian W. A.

doi:10.2214/ajr.17.19404

Cited by 49 publications

(43 citation statements)

References 23 publications

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“…Concern has arisen that since the introduction of the ASAS axSpA classification criteria misclassification or overtreatment might occur more frequently, particularly in nr-axSpA [ 34 , 35 ]. There is increasing evidence that several imaging abnormalities might mimic mild sacroiliitis on MRI and some of these are more frequent in women (such as bone more edema following pregnancy or associated with osteitis condensans ilii) [ 36 – 38 ]. We were not able to evaluate the extent of this potential imaging misinterpretation, as MRIs were not available for central scoring.…”

Section: Discussionmentioning

confidence: 99%

Differences between men and women with nonradiographic axial spondyloarthritis: clinical characteristics and treatment effectiveness in a real-life prospective cohort

et al. 2020

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Background Sex differences with regard to clinical manifestations and response to tumor necrosis factor inhibitors (TNFi) have been delineated for the radiographic form of axial spondyloarthritis (axSpA). More limited evidence for a differential effectiveness of treatment in genders exists for the nonradiographic disease state (nr-axSpA). The aim of the study was to compare demographics, clinical parameters, and response to TNFi in women versus men with nr-axSpA. Methods We compared disease characteristics of 264 women and 231 men with nr-axSpA at inclusion in the prospective Swiss Clinical Quality Management Cohort. Response to a first TNFi was assessed in 85 women and 78 men without diagnosed co-morbid fibromyalgia. The primary outcome was the proportion of patients achieving the 40% improvement in the Assessment of SpondyloArthritis international Society criteria (ASAS40) at 1 year. Additional response outcomes were evaluated as secondary outcomes. Patients having discontinued TNFi were considered non-responders. Logistic regression analyses were adjusted for baseline differences, which might potentially mediate the effect of sex on treatment response. Results Compared to men, women had a longer diagnostic delay, a higher level of perceived disease activity, and more enthesitis and were in a lower percentage HLA-B27 positive. An ASAS40 response was achieved by 17% of women and 38% of men (OR 0.34; 95% CI 0.12, 0.93; p = 0.02). A significantly lower response rate in women was confirmed in the adjusted analysis (OR 0.19; 95% CI 0.05, 0.62; p = 0.009) as well as for the other outcomes assessed. Conclusion Despite only few sex differences in patient characteristics in nr-axSpA, response rates to TNFi are significantly lower in women than in men.

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Section: Discussionmentioning

confidence: 99%

Differences between men and women with nonradiographic axial spondyloarthritis: clinical characteristics and treatment effectiveness in a real-life prospective cohort

et al. 2020

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“…Both SIJ were evaluated regarding BME and subchondral sclerosis using the established semiquantitative "Berlin method," which has been used in various studies and shown its capability to accurately assess SIJ-MRI findings similar to other more detailed scoring systems such as the Spondyloarthritis Research Consortium of Canada (SPRCC) MRI index or SPRCC MRI structural score [4,9,18,19]. The "Berlin method" is based on global grading of the cartilaginous portion of the SIJ [19][20][21]: Each SIJ was divided into 4 quadrants (upper ilium, lower ilium, upper sacrum, lower sacrum), respectively, and each quadrant was graded separately as follows: BME/sclerosis not present: score = 0; < 33% of quadrant area: score = 1; ≥ 33 to <66% of quadrant area: score = 2; and ≥ 66% of quadrant area: score = 3 (Fig.…”

Section: Image Analysismentioning

confidence: 99%

“…due to lumbar disc herniation [6][7][8], as well as mechanical stress on the pelvic girdle, e.g. caused by pregnancy/childbirth or physical activity in athletes can cause subchondral BME and subchondral sclerosis of the SIJ which may be indistinguishable from axSpA [9][10][11][12][13][14][15]. This often poses a diagnostic dilemma in female patients with a history of pregnancy and childbirth, because overcalling these findings would lead to unnecessary treatment and costs, whereas to consider them as always normal after childbirth may delay treatment and reduce patient outcome in cases of actual axSpA.…”

Section: Introductionmentioning

confidence: 99%

Influence of pregnancy/childbirth on long-term bone marrow edema and subchondral sclerosis of sacroiliac joints

et al. 2021

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Objective To investigate long-term effects of pregnancy/childbirth on bone marrow edema (BME) and subchondral sclerosis of sacroiliac joints (SIJ) in comparison to MRI changes caused by spondyloarthritis (SpA) and assess the influence of birth method and number of children on SIJ-MRI changes. Materials and methods This is a retrospective cohort study with 349 women (mean age 47 ± 14 years) suffering low back pain. Four subgroups were formed based on SpA diagnosis and childbirth (CB) history. Two musculoskeletal radiologists scored the presence of BME and sclerosis on SIJ-MRI using the Berlin method. Further, an 11-point “global assessment score” representing the overall confidence of SpA diagnosis based on MRI was evaluated in addition to the ASAS (Assessment of Spondyloarthritis International Society) criterion of “positive MRI” for sacroiliitis. Results CB did not correlate with BME score (p = 0.38), whereas SpA diagnosis was associated with a higher BME score (r = 0.31, p < 0.001). Both CB (r = 0.21, p < 0.001) and SpA diagnosis (r = 0.33, p < 0.001) were correlated with a higher sclerosis score. CB was not associated with a higher confidence level in diagnosing SpA based on MRI (p = 0.07), whereas SpA diagnosis was associated with a higher score (r = 0.61, p < 0.001). Both CB (phi = 0.13, p = 0.02) and SpA diagnosis (phi = 0.23, p < 0.001) were significantly associated with a positive ASAS criterion for sacroiliitis. In non-SpA patients with CB, number of children (p = 0.001) was an independent predictor of sclerosis score, while birth method yielded no significant effect (p = 0.75). Conclusion Pregnancy/CB has no impact on long-term BME on SIJ, however, may cause long-term subchondral sclerosis—similar to SpA-associated sclerosis. Number of children is positively correlated with SIJ sclerosis. Birth method yields no effect on SIJ sclerosis.

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“…55,56 In a recent study, MRI of the SIJs in otherwise healthy women in the early postpartum period was compared with a control group of patients with axSpA. 57 In 63.3% of the early postpartum women, BME was found at the SIJs and could not be differentiated from acute sacroiliitis secondary to axSpA. However, no structural changes (i.e., erosions, fatty bone marrow replacement) were found.…”

Section: Mechanical Stressmentioning

confidence: 99%

Top-Ten Tips for Effective Imaging of Axial Spondyloarthritis

Reijnierse

Eshed

Gaalen

2019

Semin Musculoskelet Radiol

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Axial spondyloarthritis (axSpA) is a chronic inflammatory condition that encompasses ankylosing spondylitis as well as nonradiographic axSpA and can lead to chronic pain, structural damage, and disability. The disease is strongly associated with the presence of human leukocyte antigen-B27. Early diagnosis of axSpA is significant due to new treatment regimens leading to reduction of inflammation and potentially delaying disease progression. Imaging of the sacroiliac joints and the spine plays an important role in the early diagnosis of spondyloarthritis. In the current review, the top-ten tips for the effective imaging of axSpA are presented to help both radiologists and rheumatologists in using imaging properly and effectively in their clinical practice.

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Postpartum Bone Marrow Edema at the Sacroiliac Joints May Mimic Sacroiliitis of Axial Spondyloarthritis on MRI

Cited by 49 publications

References 23 publications

Differences between men and women with nonradiographic axial spondyloarthritis: clinical characteristics and treatment effectiveness in a real-life prospective cohort

Differences between men and women with nonradiographic axial spondyloarthritis: clinical characteristics and treatment effectiveness in a real-life prospective cohort

Influence of pregnancy/childbirth on long-term bone marrow edema and subchondral sclerosis of sacroiliac joints

Top-Ten Tips for Effective Imaging of Axial Spondyloarthritis

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