Musculoskeletal Imaging • Pictorial Essay

Lacout et al.
CT and MRI of Spondyloarthropathy

Musculoskeletal Imaging
Pictorial Essay

CT and MRI of Spine and

Sacroiliac Involvement in
Spondyloarthropathy
1
Alexis Lacout OBJECTIVE. Spondyloarthropathies are rheumatoid diseases that predominantly af-fect
Benoît Rousselin the axial skeleton, causing pain, stiffness, and ankylosis. The aims of this article are to
Jean-Pierre Pelage illustrate the different stages of the diseases from early inflammatory involvement to anky-
losis using CT and MRI and to discuss the role of imaging in the management of affected
Lacout A, Rousselin B, Pelage JP patients.
CONCLUSION. CT and MRI are the most sensitive techniques in the detection of axial
involvement, permitting earlier diagnosis and optimized treatment.
American Journal of Roentgenology 2008.191:1016 -1023.

pondyloarthropathy is a general S term for a

Keywords: ankylosing spondylitis, CT, MRI,
sacroiliac joint, spondyloarthropathy
DOI:10.2214/AJR.07.3446
Received November 20, 2007; accepted after
revision April 29, 2008.
1
All authors: Service de Radiologie, Hôpital Ambroise
Paré, 9 Ave. Charles de Gaulle, 92104 Boulogne,
France. Address correspondence to A. Lacout.
AJR 2008; 191:1016–1023
0361–803X/08/1914–1016
© American Roentgen Ray Society
group of chronic in-flammatory rheumatic
diseases that predominantly affect the ax
ial skeleton, causing pain and stiffness [1].
Five subgroups can be distinguished, includ-
ing ankylosing spondylitis, reactive arthri-tis
(Reiter’s syndrome), psoriatic arthritis,
arthritis associated with chronic inflamma-
tory bowel disease, and undifferentiated
spondyloarthropathies [2]. These afflictions
have in common that they are seronegative
for rheumatoid factor and often are associ-
ated with the presence of HLA-B27 [3, 4].
Schematically, unlike rheumatoid arthritis,
which affects the synovial membrane, spon-
dyloarthropathies principally involve the
enthesis [5].
Although radiographs have been widely
used in the past, CT and MRI are more sensi-
tive and specific for assessing involvement of
the spine and sacroiliac joint [2, 4–7].
Furthermore, CT and MRI may help in iden-
tifying the different stages of enthesitis and
therefore help in optimizing the management
of patients [2]. These different stages include
inflammatory involvement with bone ero-
sions, fatty postinflammatory degeneration,
sclerotic changes, and bone formations in
succession (Fig. 1).
Imaging
Rachidian Involvement
Rachidian involvement consists of inflam-
matory changes of the insertions of the verte-
bral ligaments (enthesitis) [5]. Histopatho-
logic examinations of enthesitis can reveal
erosive lesions with infiltrating macrophages
and lymphocytes [8, 9]. The marrow spaces in
the immediate vicinity of the enthesis may
show edema, lack of hemopoietic tissue, and
plasma cell infiltration [8]. With imag-ing, the
successive stages of the disease from early
inflammatory involvement to fat-ty
postinflammatory changes, bone forma-tions,
and ankylosis can be identified [2]. These
different stages may be present in the same
patient [4].
The earliest inflammatory changes are best
observed with MRI and consist of the
inflammatory appearance of the ligaments and
of their insertions (enthesitis) [2, 10].
However, CT appears to be more sensitive for
depicting chronic changes such as ero-sions,
sclerotic changes, and bone formations located
at the same sites [4]. Depending on the specific
site of the inflammatory involve-ment, four
different entities can be distin-guished:
spondylitis (Romanus spondylitis),
spondylodiskitis (Andersson aseptic spondy-
lodiskitis), arthritis of the zygapophyseal
joints, and true ligamentous inflammatory
involvement [2, 8, 10].
Romanus spondylitis consists of inflam-
matory changes involving the edges of the
vertebral endplates. Involvement of the ante-
rior edges is secondary to enthesitis of the
anterior longitudinal ligament, whereas in-
volvement of the posterior edges is second-
ary to enthesitis of the posterior longitudinal
ligament. MRI can show hyperintense
edematous corners on T2- and T1-weighted

1016 AJR:191, October 2008


sequences with IV administration of gadolin-
ium (Fig. 1). Inflammatory bone erosions of
the edges of the vertebral endplates may be
observed later on CT [2, 10] (Figs. 2 and 3).
Andersson aseptic spondylodiskitis con-
sists of inflammatory changes involving the
diskus and adjacent vertebral endplates,
which appear hyperintense on T2- and T1-
weighted sequences after gadolinium admin-
istration (Fig. 3). As observed in Romanus
lesions, bone erosions of the vertebral end-
plates may be observed later on CT [2, 10].
Arthritis of the posterior joint may occur,
with bone marrow edema, effusion, and ero-
sions and may undergo ankylosis at the end
stage. MRI best depicts early inflammatory
changes [2, 10] (Fig. 3). The costovertebral
and costotransverse joints may also be in-
volved [2].
Although ligamentous lesions are most
commonly confined to the bone insertions,
they can also involve other parts of the liga-
American Journal of Roentgenology 2008.191:1016-1023.
ment, corresponding to true ligamentous in-
flammation [8]. True ligamentous inflamma-
tory involvement may be observed in the
course of the disease using MRI [2, 10]. Fat-
saturated T1-weighted sequences with ad-
ministration of gadolinium are more sensi-
tive than T2-weighted or STIR sequences in
the detection of this type of involvement. All
the vertebral ligaments may be affected,
most often the interspinal and the supraspi-
nal ligaments (Figs. 3 and 4). Inflammation
of the bone marrow adjacent to their inser-
tions may be also seen [2, 10].
Later in the course of the disease, inflam-
mation may decrease and inflammatory
zones may be replaced by fatty postinflam-
matory bone marrow [2]. MRI may show
fatty infiltration at either edge of the verte-
bral endplates representing postinflamma-
tory changes after Romanus spondylitis or
Andersson spondylodiskitis [2] (Fig. 5).
The last stage of spinal involvement con-
sists of sclerotic changes, bone formations,
and ankylosis (Fig. 6). CT may be the best
imaging tool for diagnosis, although MRI
may also detect such changes [4]. However,
in these cases, radiographs may often be suf-
ficient [4]. Syndesmophytes, consisting of
bone outgrowth forming an osseous bridge
between two adjacent vertebrae, are charac-
teristic of spondyloarthropathies [4] (Fig. 7).
These bone formations are different from os-
teophytes because their initial directions are
not horizontal but vertical. Syndesmophytes
(end stage of Romanus spondylitis) are re-
sponsible for the development of peripheral
AJR:191, October 2008
CT and MRI of Spondyloarthropathy
spinal ankylosis. Ankylosis may also be cen-
tral, secondary to bone formations passing
through the disk (end stage of Andersson
spondylodiskitis). Ankylosis of the zygapophy-
seal joints may also be observed [2] (Fig. 6).
Insufficiency vertebral fractures may oc-
cur in spondyloarthropathies and are known
as Andersson fractures. These fractures may
be characterized by ankylosis and
osteoporo-tic changes [2, 4, 11].
Sacroiliac Joint Involvement
Because the sacroiliac joints are predomi-
nantly made of fibrous connective tissues
(fibrocartilage) and contain very little syn-
ovial fluid, these articulations may be con-
sidered entheses [5, 12]. These features may
explain why sacroiliac joints are spared dur-
ing rheumatoid arthritis and also explain
their characteristic involvement during spon-
dyloarthropathies.
Sacroiliitis may be unilateral or bilateral.
The different stages of sacroiliac involve-
ment on CT and MRI are similar to those
observed in the spine [2, 13]. The early in-
flammatory changes of the joint are best de-
tected with MRI, although erosions,
sclerotic changes, and ankylosis are also
well depicted using CT [4, 6, 7, 13].
The earliest signs of sacroiliitis are identi-
fied using MRI. Subchondral bone edema is
associated with increased signal in fat-satu-
rated fast spin-echo T2-weighted or STIR
sequences and with contrast-enhancement in
fat-saturated fast spin-echo T1-weighted se-
quences after administration of gadolinium [6,
7, 13] (Figs. 8 and 9). Inflammatory en-
hancement of the fibrous connective tissue of
the joint may also be present [6, 7, 13] (Fig.
10). CT may initially depict subchondral de-
mineralization followed by bone erosions
[14] (Fig. 3). Early diagnosis of either sacro-
iliac or spinal inflammatory involvement
helps in initiating early treatment such as
physiotherapy, nonsteroidal antiinflammato-
ry drugs, or, anti-TNF (tumor necrosis fac-
tor) agents, which, for example, may prevent
the end stage of ankylosis [4].
Later in the course of the disease, inflam-
mation usually decreases and subchondral
edema is progressively replaced by fatty
postinflammatory bone marrow, which ap-
pears hyperintense on T1-weighted sequenc-
es [13] (Fig. 11).
The final stage of sacroiliac involvement
consists of subchondral sclerosis followed
by fusion of the joint with ankylosis. At this
stage, MRI may show sclerotic changes, hy-
pointense on T1- and T2-weighted sequenc-
es, and fusion of the articulation [13] (Fig.
12). However, in cases in which radiographs
and MRI are equivocal, CT may be the best
imaging technique for depicting subchondral
density and sacroiliac ankylosis [4] (Figs. 3,
13, and 14).
Conclusion
Although radiographs are usually first ob-
tained for the detection of axial involvement
in spondyloarthropathies, CT and MRI are
more sensitive and specific, allowing earlier
diagnosis and optimized management of af-
fected patients. Because earlier treatment
may be associated with a better prognosis,
radiologists should be familiar with the wide
spectrum of imaging findings, particularly
during the early stages of inflammation.
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10. Hermann KG, Bollow M. Magnetic resonance im-
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11. Geusens P, Vosse D, van der Linden S. Osteoporo-sis
and vertebral fractures in ankylosing spondyli-tis.
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12. Puhakka KB, Melsen F, Jurik AG, Boel LW,
Vesterby A, Egund N. MR imaging of the normal
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sacroiliac joint with correlation to histology. Davis JC. MRI of the sacroiliac joints in patients 14. Geijer M, Sihlbom H, Göthlin JH, Nordborg E.
Skeletal Radiol 2004; 33:15–28 with moderate to severe ankylosing spondylitis. The role of CT in the diagnosis of sacro-iliitis.
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Changes best depicted on MRI Changes best depicted on CT

Appearance of
syndesmophytes
and ankylosis

ofdisease

Fatty postinflammatory Sclerotic changes

infiltration
Stages

Inflammatory Appearance of
bone erosions
signal of the
bone marrow
American Journal of Roentgenology 2008.191:1016-1023.

Andersson Romanus
spondylodiskitis spondylitis

Fig. 1—Diagram shows different stages of rachidian involvement in spondyloarthropathies. Early inflammatory Fig. 2—31-year-old woman with ankylosing
changes are best shown on MRI (bone marrow edema), although more chronic changes are best depicted on CT spondylitis: Romanus anterior and posterior
(bone erosions, sclerotic changes, syndesmophytes). Pattern of sacroiliac joint involvement is similar. spondylitis of thoracic spine. Gadolinium-enhanced
sagittal fat-saturated fast spin-echo T1-weighted
image shows hyperintense changes at anterior and
posterior edges of vertebral endplates (arrows).

A B C
Fig. 3—29-year-old man with ankylosing spondylitis: Romanus anterior spondylitis, Andersson spondylodiskitis, zygapophyseal joint arthritis,
true ligamentous inflammation, and sacroiliac joint involvement.
A, Sagittal fast spin-echo T1-weighted image shows circumscribed hypointensity of anterior edges of vertebral endplates secondary to both
edema and sclerotic changes (arrows).
B, Sagittal STIR-weighted image shows florid hyperintense Romanus lesions (arrows).
C, Gadolinium-enhanced sagittal fat-saturated fast spin-echo T1-weighted image confirms vertebral inflammatory changes (arrows) and shows discrete
enhancement of interspinal and supraspinal ligaments (arrowheads).
(Fig. 3 continues on next page)

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 CT and MRI of Spondyloarthropathy
American Journal of Roentgenology 2008.191:1016-1023.

D E F

G H
Fig. 3 (continued)—29-year-old man with ankylosing spondylitis: Romanus anterior spondylitis, Andersson spondylodiskitis, zygapophyseal
joint arthritis, true ligamentous inflammation, and sacroiliac joint involvement.
D, CT scan (sagittal reformation) shows sclerotic changes and erosions of vertebral endplates (arrows).
E, Sagittal STIR-weighted sequence shows hyperintensity of vertebral endplates adjacent to intervertebral disk, corresponding to Andersson aseptic
spondylodiskitis (arrows). Hyperintensity of bone marrow around zygapophyseal joints corresponds to arthritis (arrowheads).
F, Coronal CT scan of sacroiliac joints shows multiple subchondral erosions (arrows) and sclerosis (arrowheads).
G and H, Frontal (G) and lateral (H) radiographs of lumbar spine show discrete erosions and densities of anterior vertebral endplates (arrows, G) and
presence of lateral syndesmophytes (arrowheads, H).

AJR:191, October 2008 1019

 Lacout et al.

A B C
Fig. 4—55-year-old woman with spondyloarthropathy (precise diagnosis not yet established) and
ligamentous inflammation.
A–C, Gadolinium -enhanced sagittal (A), coronal (B ), and axial (C) fat-saturated fast spin-echo
American Journal of Roentgenology 2008.191:1016-1023.

T1-weighted images of L3–L4 level of lumbar spine show strong enhancement of yellow
ligaments (thin arrows) and of interspinal and supraspinal ligaments (thick arrows, B and C ),
corresponding to inflammatory involvement. D, Sagittal fat-saturated fast spin-echo T2- weighted
image shows discrete hyperintensity of interspinal and supraspinal ligaments (arrows), less visible
than with gadolinium-enhanced fat-saturated fast spin-echo T1-weighted sequences.

Fig. 5—45-year-old
man with ankylosing
spondylitis:
postinflammatory
fatty vertebral
changes after
Romanus spondylitis.
Sagittal fast spin-echo
T1-weighted image
of thoracic spine
shows circumscribed
hyperintensity of
anterior edges of
vertebral endplates
corresponding to fatty Fig. 6—73-year-old woman with ankylosing spondylitis: postinflammatory
infiltration of bone vertebral sclerotic changes after Romanus spondylitis; ankylosis of
marrow long after zygapophyseal joints. Sagittal vertebral CT scan shows sclerotic change of
florid inflammatory anterior edge of vertebral endplates corresponding to postinflammatory Romanus
Romanus spondylitis involvement (arrows). Bone constructions and ankylosis of zygapophyseal joints
(arrows). (arrowhead) are also seen.

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 CT and MRI of Spondyloarthropathy

Fig. 7—80-year-old woman with

ankylosing spondylitis: syndesmophytes.
A and B, Sagittal (A) and coronal (B) CT scans of
thoracic and lumbar spine show syndesmophytes
corresponding to osseous bridge between two
adjacent vertebrae (arrows).

A B

Fig. 8—21-year- old woman with spondyloarthropathy

associated with Crohn’s disease: unilateral sacroiliitis.
Coronal STIR-weighted sequence of sacroiliac joints
shows hyperintensity of right iliac subchondral bone
American Journal of Roentgenology 2008.191:1016-1023.

marrow (arrowhead).

A B
Fig. 9—54-year-old man with ankylosing spondylitis: bilateral sacroiliitis.
A and B, Coronal STIR (A) and gadolinium-enhanced fat-saturated T1-weighted (B) images of sacroiliac joints show hyperintensity of subchondral bone marrow (arrows).

AJR:191, October 2008 1021

 Lacout et al.

A B
Fig. 10—18-year-old man with ankylosing spondylitis: bilateral sacroiliitis.
A, Gadolinium-enhanced coronal fat-saturated fast spin-echo T1-weighted image of sacroiliac joints shows enhancement of connective fibrous tissues ( arrows).
American Journal of Roentgenology 2008.191:1016-1023.

Hyperintensity of right iliac subchondral bone marrow (arrowhead) is also seen.

B, Radiograph of sacroiliac joint failed to detect sacroiliitis.

A B
Fig. 11—25-year-old man with ankylosing spondylitis: postinflammatory fatty infiltration after acute sacroiliitis.
A and B, Coronal T1-weighted (A) and STIR-weighted (B) sequences show T1 hyperintensity and STIR hypointensity of subchondral bone marrow of right joint,
finding indicative of fatty infiltration (arrows). STIR-weighted image shows no hyperintensity that would indicate active inflammatory involvement.

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 CT and MRI of Spondyloarthropathy

A B
Fig. 12—35-year-old woman with ankylosing spondylitis: postinflammatory sacroiliac sclerotic changes after acute sacroiliitis.
A and B, Axial (A) and gadolinium-enhanced fat-saturated (B) T1-weighted images of sacroiliac joints show subchondral hypointensity indicative of
sclerotic changes (arrows).
American Journal of Roentgenology 2008.191:1016-1023.

Fig. 13—35-year-old woman with ankylosing

spondylitis: postinflammatory sacroiliac sclerotic
changes after acute sacroiliitis. Axial CT scan
shows condensations of subchondral bone marrow
of joints (arrows) predominant on left side.

A B
Fig. 14—53-year-old woman with ankylosing spondylitis: sacroiliac joint ankylosis.
A and B, Axial CT scan (A) and volume reformation, frontal view (B) of sacroiliac joints show complete ankylosis with homogeneous osseous bridge
passing through articulations (arrowheads).

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