Imaging in rheumatoid arthritis – why MRI and ultrasonography can no longer be ignored

Implementing the modern treatment strategy in rheumatoid arthritis (RA), i.e. early initiation and optimal adjustments of aggressive therapies, requires methods for early diagnosis and sensitive monitoring of the disease process. In rheumatoid arthritis clinical trials and routine management, conventional radiography is the pivotal method for diagnosing and monitoring structural joint damage. However, it is insensitive to bone damage at its earliest stages and totally incapable of capturing the primary feature of rheumatoid disease, the synovitis. In comparison with radiography, magnetic resonance imaging (MRI) offers assessment of bone damage with improved sensitivities to early pathology and to change. In addition, detailed assessment of soft tissue changes, including synovitis and tenosynovitis, is possible and MRI findings are of prognostic value for the long‐term radiological outcome. Ultrasonography (US) is less validated than MRI, but available data suggests that US offers comparable information on both inflammatory and destructive changes in RA finger and toe joints. Issues of reliability, standardization and documentation limit its value in clinical trials, This article reviews current knowledge on conventional radiography, computed tomography, MRI and US for assessment of peripheral joints in RA. The rationale is provided for MRI being the new gold standard for assessment of RA joints and US becoming a routine bedside tool for improved joint assessments and injections by rheumatologists. Pursuing the goal of improving patient care and disease outcome, rheumatologists can no longer afford to ignore MRI and US as means to measure disease activity and joint damage in rheumatoid arthritis.

[1]  W. Schmidt.  Value of sonography in diagnosis of rheumatoid arthritis , 2001, The Lancet.

[2]  M Ostergaard,et al.  Magnetic resonance imaging-determined synovial membrane volume as a marker of disease activity and a predictor of progressive joint destruction in the wrists of patients with rheumatoid arthritis. , 1999, Arthritis and rheumatism.

[3]  R. Adler,et al.  Power Doppler sonography of synovitis: assessment of therapeutic response--preliminary observations. , 1996, Radiology.

[4]  J. O'dell,et al.  Treating rheumatoid arthritis early: a window of opportunity? , 2002, Arthritis and rheumatism.

[5]  R. Yood,et al.  Guidelines for the management of rheumatoid arthritis: 2002 Update. , 2002, Arthritis and rheumatism.

[6]  W. Grassi,et al.  Sonographic imaging of normal and osteoarthritic cartilage. , 1999, Seminars in arthritis and rheumatism.

[7]  O. Tervonen,et al.  Evaluation of humeral head erosions in rheumatoid arthritis: a comparison of ultrasonography, magnetic resonance imaging, computed tomography and plain radiography. , 1998, British journal of rheumatology.

[8]  M. Liang,et al.  The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. , 1988, Arthritis and rheumatism.

[9]  M Ostergaard,et al.  Quantitative assessment of the synovial membrane in the rheumatoid wrist: an easily obtained MRI score reflects the synovial volume. , 1996, British journal of rheumatology.

[10]  P. Emery,et al.  Imaging the joints in early rheumatoid arthritis. , 2001, Best practice & research. Clinical rheumatology.

[11]  A. Fischman,et al.  Use of magnetic resonance imaging and positron emission tomography in the assessment of synovial volume and glucose metabolism in patients with rheumatoid arthritis. , 1995, Arthritis and rheumatism.

[12]  O. Henriksen,et al.  Synovial volume--a marker of disease severity in rheumatoid arthritis? Quantification by MRI. , 1994, Scandinavian journal of rheumatology.

[13]  S. Seltzer,et al.  Computed tomography of the hindfoot with rheumatoid arthritis. , 1985, Arthritis and rheumatism.

[14]  Henrik S. Thomsen,et al.  MRI of the wrist and finger joints in inflammatory joint diseases at 1-year interval: MRI features to predict bone erosions , 2002, European Radiology.

[15]  J. B. Kneeland,et al.  Quantification of the volume of articular cartilage in the metacarpophalangeal joints of the hand: accuracy and precision of three-dimensional MR imaging. , 1995, AJR. American journal of roentgenology.

[16]  M. Østergaard,et al.  Power Doppler ultrasonography for assessment of synovitis in the metacarpophalangeal joints of patients with rheumatoid arthritis: a comparison with dynamic magnetic resonance imaging. , 2001, Arthritis and rheumatism.

[17]  D. Blake,et al.  Quantitative assessment of the rheumatoid synovial microvascular bed by gadolinium-DTPA enhanced magnetic resonance imaging , 1998, Annals of the rheumatic diseases.

[18]  F. McQueen,et al.  Magnetic resonance imaging of the wrist in early rheumatoid arthritis reveals progression of erosions despite clinical improvement , 1999, Annals of the rheumatic diseases.

[19]  W. Grassi,et al.  Finger tendon involvement in rheumatoid arthritis , 1995 .

[20]  H. Sugimoto,et al.  Early-stage rheumatoid arthritis: diagnostic accuracy of MR imaging. , 1996, Radiology.

[21]  E. Krupinski,et al.  Ultrasonographic imaging of the hand and wrist in rheumatoid arthritis , 1995, Skeletal Radiology.

[22]  O. Henriksen,et al.  Changes in synovial membrane and joint effusion volumes after intraarticular methylprednisolone. Quantitative assessment of inflammatory and destructive changes in arthritis by MRI. , 1996, The Journal of rheumatology.

[23]  C F Beaulieu,et al.  Future of MR imaging of articular cartilage. , 2001, Seminars in musculoskeletal radiology.

[24]  E. Paleolog.  Angiogenesis in rheumatoid arthritis , 2002, Arthritis research.

[25]  W. Grassi,et al.  Guidelines for musculoskeletal ultrasound in rheumatology , 2001, Annals of the rheumatic diseases.

[26]  M Ostergaard,et al.  Magnetic resonance imaging-determined synovial membrane and joint effusion volumes in rheumatoid arthritis and osteoarthritis: comparison with the macroscopic and microscopic appearance of the synovium. , 1997, Arthritis and rheumatism.

[27]  G. Marchal,et al.  Staging and follow‐up of rheumatoid arthritis of the knee. Comparison of sonography, thermography, and clinical assessment. , 1988, Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine.

[28]  K. Kaarela.  Prognostic factors and diagnostic criteria in early rheumatoid arthritis. , 1985, Scandinavian journal of rheumatology. Supplement.

[29]  P. Taylor.  VEGF and imaging of vessels in rheumatoid arthritis , 2002, Arthritis research.

[30]  H. Tony,et al.  Evaluation of pannus and vascularization of the metacarpophalangeal and proximal interphalangeal joints in rheumatoid arthritis by high-resolution ultrasound (multidimensional linear array). , 1999, Arthritis and rheumatism.

[31]  A. Giovagnoni,et al.  MRI of the hand in psoriatic and rheumatical arthritis , 1995, European Radiology.

[32]  M. Østergaard,et al.  Magnetic Resonance Imaging of Soft Tissue Changes in Rheumatoid Arthritis Wrist Joints , 2001, Seminars in musculoskeletal radiology.

[33]  Richard W. Martin,et al.  A comparison of etanercept and methotrexate in patients with early rheumatoid arthritis. , 2000, The New England journal of medicine.

[34]  N Stewart,et al.  Magnetic resonance imaging of the wrist in early rheumatoid arthritis reveals a high prevalence of erosions at four months after symptom onset , 1998, Annals of the rheumatic diseases.

[35]  D Loreck,et al.  Prospective two year follow up study comparing novel and conventional imaging procedures in patients with arthritic finger joints , 2002, Annals of the rheumatic diseases.

[36]  H. Genant,et al.  MRI in Rheumatoid Arthritis at OMERACT 2002: Suggested 'core set' of MRI acquisitions, definitions of important joint pathologies, and scoring system (OEMRACT 2002 RAMRIS) , 2002 .

[37]  P. Emery.  The Roche Rheumatology Prize Lecture. The optimal management of early rheumatoid disease: the key to preventing disability. , 1994, British journal of rheumatology.

[38]  B. Manger,et al.  Joint and connective tissue ultrasonography--a rheumatologic bedside procedure? A German experience. , 1995, Arthritis and rheumatism.

[39]  D. Burstein,et al.  MRI Techniques in Early Stages of Cartilage Disease , 2000, Investigative radiology.

[40]  W. Grassi,et al.  Sonographically guided procedures in rheumatology. , 2001, Seminars in arthritis and rheumatism.

[41]  K J Wolf,et al.  Rheumatoid arthritis: evaluation of hypervascular and fibrous pannus with dynamic MR imaging enhanced with Gd-DTPA. , 1990, Radiology.

[42]  D. Resnick.  Diagnosis of Bone and Joint Disorders , 1987 .

[43]  Ultrasonography in Arthritis of the Knee , 1995, Acta radiologica.

[44]  M Ostergaard,et al.  Quantification of synovistis by MRI: correlation between dynamic and static gadolinium-enhanced magnetic resonance imaging and microscopic and macroscopic signs of synovial inflammation. , 1998, Magnetic resonance imaging.

[45]  John D. Isaacs,et al.  The value of sonography in the detection of bone erosions in patients with rheumatoid arthritis: a comparison with conventional radiography. , 2000, Arthritis and rheumatism.

[46]  A. Giovagnoni,et al.  MR imaging of rheumatoid hand lesions: comparison with conventional radiology in 31 patients. , 1992, Clinical and experimental rheumatology.

[47]  V. Jevtič,et al.  Distinctive radiological features of small hand joints in rheumatoid arthritis and seronegative spondyloarthritis demonstrated by contrast-enhanced (Gd-DTPA) magnetic resonance imaging , 1995, Skeletal Radiology.

[48]  W. Grassi,et al.  Sonographic imaging of tendons. , 2000, Arthritis and rheumatism.

[49]  J L Lamarque,et al.  Sensitivity of magnetic resonance imaging of the wrist in very early rheumatoid arthritis. , 1993, Clinical and experimental rheumatology.

[50]  H. Bliddal,et al.  Quantitative ultrasonography in rheumatoid arthritis: evaluation of inflammation by Doppler technique , 2001, Annals of the rheumatic diseases.

[51]  Désirée van der Heijde,et al.  Plain X-rays in rheumatoid arthritis: overview of scoring methods, their reliability and applicability. , 1996 .

[52]  Marcin Szkudlarek,et al.  Interobserver agreement in ultrasonography of the finger and toe joints in rheumatoid arthritis. , 2003, Arthritis and rheumatism.

[53]  I. Watt.  Basic differential diagnosis of arthritis , 1997, European Radiology.

[54]  Neal Stewart,et al.  OMERACT Rheumatoid Arthritis Magnetic Resonance Imaging Studies. Exercise 3: an international multicenter reliability study using the RA-MRI Score. , 2003, The Journal of rheumatology.

[55]  H. Sugimoto,et al.  Assessment of disease activity in rheumatoid arthritis using magnetic resonance imaging: quantification of pannus volume in the hands. , 1998, British journal of rheumatology.

[56]  I. McInnes,et al.  Ultrasound guided versus conventional joint and soft tissue fluid aspiration in rheumatology practice: a pilot study. , 2002, The Journal of rheumatology.

[57]  Michael J. Green,et al.  The relationship between synovitis and bone changes in early untreated rheumatoid arthritis: a controlled magnetic resonance imaging study. , 1999, Arthritis and rheumatism.

[58]  H. Genant,et al.  Interreader agreement in the assessment of magnetic resonance images of rheumatoid arthritis wrist and finger joints--an international multicenter study. , 2001, The Journal of rheumatology.

[59]  U. Mödder,et al.  Magnetic resonance imaging and miniarthroscopy of metacarpophalangeal joints: sensitive detection of morphologic changes in rheumatoid arthritis. , 2001, Arthritis and rheumatism.

[60]  M. Østergaard,et al.  Magnetic resonance imaging, radiography, and scintigraphy of the finger joints: one year follow up of patients with early arthritis , 2000, Annals of the rheumatic diseases.

[61]  A Woolf,et al.  The links between joint damage and disability in rheumatoid arthritis. , 2000, Rheumatology.

[62]  Neal Stewart,et al.  OMERACT Rheumatoid Arthritis Magnetic Resonance Imaging Studies. Summary of OMERACT 6 MR Imaging Module. , 2003, The Journal of rheumatology.

[63]  J. Ridgway,et al.  Comparative assessment of leflunomide and methotrexate for the treatment of rheumatoid arthritis, by dynamic enhanced magnetic resonance imaging. , 2002, Arthritis and rheumatism.

[64]  C G Peterfy,et al.  Magnetic resonance imaging in rheumatoid arthritis: current status and future directions. , 2001, The Journal of rheumatology.

[65]  A. Larsen,et al.  Radiographic Evaluation of Rheumatoid Arthritis and Related Conditions by Standard Reference Films , 1977, Acta radiologica: diagnosis.

[66]  H. Genant,et al.  Magnetic resonance imaging in rheumatoid arthritis: summary of OMERACT activities, current status, and plans. , 2001, The Journal of rheumatology.

[67]  S. van der Linden,et al.  Determination of the minimal clinically important difference in rheumatoid arthritis joint damage of the Sharp/van der Heijde and Larsen/Scott scoring methods by clinical experts and comparison with the smallest detectable difference. , 2002, Arthritis and rheumatism.

[68]  R N Maini,et al.  Infliximab and methotrexate in the treatment of rheumatoid arthritis. Anti-Tumor Necrosis Factor Trial in Rheumatoid Arthritis with Concomitant Therapy Study Group. , 2000, The New England journal of medicine.

[69]  H. Vacher,et al.  Where is imaging going in rheumatology? , 2000, Bailliere's best practice & research. Clinical rheumatology.

[70]  D. M. van der Heijde,et al.  How to read radiographs according to the Sharp/van der Heijde method. , 2000, The Journal of rheumatology.

[71]  C Rigon,et al.  Long-term sonographic follow-up of rheumatoid and psoriatic proliferative knee joint synovitis. , 1996, British journal of rheumatology.

[72]  D Loreck,et al.  Arthritis of the finger joints: a comprehensive approach comparing conventional radiography, scintigraphy, ultrasound, and contrast-enhanced magnetic resonance imaging. , 1999, Arthritis and rheumatism.

[73]  F. Arnett.  Revised criteria for the classification of rheumatoid arthritis. , 1990, Orthopedic nursing.

[74]  S. van der Linden,et al.  Randomised comparison of combined step-down prednisolone, methotrexate and sulphasalazine with sulphasalazine alone in early rheumatoid arthritis , 1997, The Lancet.

[75]  C. Kneitz,et al.  High resolution ultrasound detects a decrease in pannus vascularisation of small finger joints in patients with rheumatoid arthritis receiving treatment with soluble tumour necrosis factor alpha receptor (etanercept). , 2002, Annals of the rheumatic diseases.

[76]  C. Peterfy,et al.  Imaging of the disease process , 2002, Current opinion in rheumatology.

[77]  E. Rostrup,et al.  Dynamic magnetic resonance imaging of the metacarpophalangeal joints in rheumatoid arthritis, early unclassified polyarthritis, and healthy controls , 2000, Scandinavian journal of rheumatology.

[78]  W. Grassi,et al.  Ultrasonography in rheumatology: an evolving technique , 1998, Annals of the rheumatic diseases.

[79]  M. Østergaard,et al.  Contrast-enhanced power Doppler ultrasonography of the metacarpophalangeal joints in rheumatoid arthritis , 2002, European Radiology.

[80]  J. Braun,et al.  Entheses and enthesitis: a histopathologic review and relevance to spondyloarthritides , 2001, Current opinion in rheumatology.

[81]  A C Brower,et al.  Use of the radiograph to measure the course of rheumatoid arthritis. The gold standard versus fool's gold. , 1990, Arthritis and rheumatism.

[82]  P. Gideon,et al.  Effect of intraarticular osmic acid on synovial membrane volume and inflammation, determined by magnetic resonance imaging. , 1995, Scandinavian journal of rheumatology.

[83]  Paul Bird,et al.  OMERACT Rheumatoid Arthritis Magnetic Resonance Imaging Studies. Exercise 4: an international multicenter longitudinal study using the RA-MRI Score. , 2003, The Journal of rheumatology.

[84]  J. Ilonen,et al.  Only high disease activity and positive rheumatoid factor indicate poor prognosis in patients with early rheumatoid arthritis treated with “sawtooth” strategy , 1998, Annals of the rheumatic diseases.

[85]  U. Brodin,et al.  Patients with rheumatoid arthritis benefit from early 2nd line therapy: 5 year followup of a prospective double blind placebo controlled study. , 1995, The Journal of rheumatology.

[86]  O. Henriksen,et al.  The accuracy of MRI-determined synovial membrane and joint effusion volumes in arthritis. A comparison of pre- and post-aspiration volumes. , 1995, Scandinavian journal of rheumatology.

[87]  M. Østergaard,et al.  Low field dedicated magnetic resonance imaging in untreated rheumatoid arthritis of recent onset , 2001, Annals of the rheumatic diseases.

[88]  P. Algra,et al.  Comparison of sonography and magnetic resonance imaging for the diagnosis of partial tears of finger extensor tendons in rheumatoid arthritis. , 2000, Rheumatology.

[89]  L. Pallwein,et al.  The value of contrast-enhanced color Doppler ultrasound in the detection of vascularization of finger joints in patients with rheumatoid arthritis. , 2002, Arthritis and rheumatism.

[90]  W. Grassi,et al.  Intralesional therapy in carpal tunnel syndrome: a sonographic-guided approach. , 2002, Clinical and experimental rheumatology.

[91]  Henrik S. Thomsen,et al.  MRI of the arthritic small joints: comparison of extremity MRI (0.2 T) vs high-field MRI (1.5 T) , 2001, European Radiology.

[92]  Rene Westhovens,et al.  COBRA combination therapy in patients with early rheumatoid arthritis: long-term structural benefits of a brief intervention. , 2002, Arthritis and rheumatism.

[93]  D. M. van der Heijde,et al.  Plain X-rays in rheumatoid arthritis: overview of scoring methods, their reliability and applicability. , 1996, Bailliere's clinical rheumatology.

[94]  H K Genant,et al.  How many joints in the hands and wrists should be included in a score of radiologic abnormalities used to assess rheumatoid arthritis? , 1985, Arthritis and rheumatism.

[95]  W E Palmer,et al.  Quantification of inflammation in the wrist with gadolinium-enhanced MR imaging and PET with 2-[F-18]-fluoro-2-deoxy-D-glucose. , 1995, Radiology.

[96]  M. Zanetti,et al.  [Sonography of the musculoskeletal system]. , 1997, Therapeutische Umschau. Revue therapeutique.

[97]  H. Sugimoto,et al.  Early-stage rheumatoid arthritis: prospective study of the effectiveness of MR imaging for diagnosis. , 2000, Radiology.

[98]  F. McQueen,et al.  A 1-year follow-up study of dynamic magnetic resonance imaging in early rheumatoid arthritis reveals synovitis to be increased in shared epitope-positive patients and predictive of erosions at 1 year. , 2000, Rheumatology.

[99]  M. Adkins.  Diagnosis of Bone and Joint Disorders , 1997 .

[100]  C. Kneitz,et al.  High resolution ultrasound detects a decrease in pannus vascularisation of small finger joints in patients with rheumatoid arthritis receiving treatment with soluble tumour necrosis factor α receptor (etanercept) , 2002 .

[101]  P. Tugwell,et al.  OMERACT conference on outcome measures in rheumatoid arthritis clinical trials: introduction. , 1993, The Journal of rheumatology.

[102]  M. Walther,et al.  Correlation of power Doppler sonography with vascularity of the synovial tissue of the knee joint in patients with osteoarthritis and rheumatoid arthritis. , 2001, Arthritis and rheumatism.

[103]  O. Henriksen,et al.  Quantitative assessment of synovial inflammation by dynamic gadolinium-enhanced magnetic resonance imaging. A study of the effect of intra-articular methylprednisolone on the rate of early synovial enhancement. , 1996, British journal of rheumatology.

[104]  G. Alarcón,et al.  High-resolution ultrasound for the study of target joints in rheumatoid arthritis. , 2002, Arthritis and rheumatism.

[105]  M. A. van 't Hof,et al.  Biannual radiographic assessments of hands and feet in a three-year prospective followup of patients with early rheumatoid arthritis. , 1992, Arthritis and rheumatism.

[106]  Stanley B. Cohen,et al.  Treatment of rheumatoid arthritis with anakinra, a recombinant human interleukin-1 receptor antagonist, in combination with methotrexate: results of a twenty-four-week, multicenter, randomized, double-blind, placebo-controlled trial. , 2002, Arthritis and rheumatism.

[107]  M. Østergaard,et al.  Finger joint synovitis in rheumatoid arthritis: quantitative assessment by magnetic resonance imaging. , 1999, Rheumatology.