The usefulness of magnetic resonance imaging of the hand and wrist in very early rheumatoid arthritis
© Drosos et al.; licensee BioMed Central Ltd. 2011
Received: 21 January 2011
Accepted: 9 June 2011
Published: 9 June 2011
Magnetic resonance imaging (MRI) was used to study the hand and wrist in very early rheumatoid arthritis (RA), and the results were compared with early and established disease.
Fifty-seven patients fulfilling the new American College of Rheumatology criteria for RA, 26 with very early RA (VERA), 18 with early RA (ERA), and 13 with established RA (ESTRA), (disease duration < 3 months, < 12 months, and > 12 months, respectively) were enrolled in the study. MRI of the dominant hand and wrist was performed by using fat-suppressed T2-weighted and plain and contrast-enhanced T1-weighted sequences. Evaluation of bone marrow edema, synovitis, and bone erosions was performed with the OMERACT RA MRI scoring system.
Edema, erosions, and synovitis were present in VERA, and the prevalence was 100%, 96.15%, and 92.3%, respectively. Significant differences in edema and erosions were found between VERA and ESTRA (P < 0.05). No significant difference was found in synovitis.
Edema, erosions, and synovitis are findings of very early RA. MRI, by detecting these lesions, may play an important role in the management of these patients.
Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease characterized by prominent joint manifestations. Inflammation of the synovial membrane leads to the formation of a highly cellular inflammatory tissue, the pannus, which, by eroding cartilage and bone, leads to joint destruction and ankylosis . Articular involvement of the hand and wrist has been considered a very frequent presenting finding . The presence of marginal erosions, seen on conventional radiographs of the hand and wrist, has been viewed as a specific and relatively sensitive diagnostic finding . Conventional radiographs cannot assess synovitis, bone edema, and early marginal erosions [3–8]. Bone edema, erosions, and synovitis have been detected by magnetic resonance imaging (MRI) in patients with disease duration of < 1 year [3, 4, 8–15]. Bone edema and erosions are considered red flags for progression of bone damage in the future, and thus, modern concepts in RA imply that treatment with conventional disease-modifying antirheumatic drugs (DMARDs) and particularly biologic DMARDs, should ideally be started before erosive disease is detected [16–20]. Nevertheless, no studies have evaluated with MRI the hand and wrist of patients with disease duration of less than 3 months.
The purpose of this study was to assess with MRI in very early RA (VERA) the prevalence and severity of hand and wrist involvement and to compare the involvement with early RA (ERA) and established RA (ESTRA).
Materials and methods
Statistical analysis was performed with SPSS base 15 for Windows. Interobserver variability was evaluated by using the Pearson correlation coefficient. Analysis of variance (ANOVA), followed by the least significant difference test, was used to study differences between groups. A P value less than 0.05 was considered statistically significant.
Clinical data in 57 patients with very early, early and established rheumatoid arthritis
VERA (n= 26)
ERA (n= 18)
ESTRA (n= 13)
Age, mean (SD), yr
Disease duration, mean (SD), mo
Disease activity score for 28 joint indices, mean (SD)
C-reactive protein, mean (SD)
Rheumatoid factor positivity
Anticitrullinated cyclic peptide positivity
Prevalence of edema, erosions, and synovitis (evaluated with the OMERACT RA MRI scoring system)
Analysis of variance with total score for bone edema, erosions and synovitis
Distribution of edema, erosions and synovitis in hand and wrist joints
No significant correlation was found between the imaging findings and the clinical (duration of morning stiffness (min), grip strength (mm Hg), total joint count with tenderness or swelling, number of swollen joints, number of tender joints and pain score on VAS (cm)) and laboratory findings (CRP, ESR, RF, anti-CCP, and DAS-28).
In this study, the OMERACT RA MRI scoring system was applied to look for differences in bone edema, erosions, and synovitis between VERA, ERA, and ESTRA, and the major findings were (a) the presence of bone edema, erosions, and synovitis at the very early stages of RA; and (b) a significant difference in bone edema and erosions between VERA and ESTRA.
MRI is being used largely in the assessment of hand and wrist involvement of patients with RA [3, 5–7, 13–16]. Most of the studies have been performed in patients with late early and established disease. Only one study evaluated patients with disease duration less than 4 months . This study demonstrated an incidence of bone erosions of 45%, but half of the patients were receiving DMARDs. The present study demonstrated a very high incidence of bone erosions (96%) in a treatment-naïve population evaluated at a very early stage of RA. The lack of treatment and the evaluation of the MCP joints, which are characteristically affected in early RA , may probably explain the difference in incidence of bone erosions. Previous studies, by demonstrating very early the presence of anti-CCP antibodies and RF, have suggested that the disease process in RA starts long before the onset of symptoms . This study, by demonstrating bone erosions in VERA, reinforces this hypothesis. Another interesting finding of this study was the presence of bone edema in all patients with VERA. Bone edema is a pre-erosive lesion that represents true inflammation and can be seen on MRI alone or surrounding bone erosions . Bone edema can be present at any stage of RA and has been associated with more-aggressive disease [26, 27]. Lack of treatment that could decrease the aggressiveness of the disease process might probably explain the presence of bone edema in all patients with VERA.
In this study, the presence of synovitis was independent of the disease duration, and the incidence was high in all groups. In the VERA group, the incidence of synovitis and bone erosions was almost similar. The exact nature of the relation between synovitis and bone damage remains unclear. The synovium seems to be the prime target in the inflammatory course of RA. Conaghan et al  showed that in ERA, synovitis appears to be the primary abnormality, and bone damage occurs as a late effect in proportion to the level of synovitis but not in the absence of synovitis. Bone erosions are caused by direct invasion of pannus into bone but also by pro-osteoclastogenic imbalance, which is cytokine driven. The pathogenic mechanism in the very early period of RA may be different from that in established disease. Current theories of the immunopathogenesis of RA suggest that abnormally sensitive to tumor necrosis factor (TNF)-α bone marrow stem cells could travel via the systematic circulation to the subchondral bone marrow, where they initiate inflammatory and pre-erosive changes or could travel to the synovial membrane, where they promote synovial hyperplasia and inflammatory synovitis. It seems that bone marrow edema represents a true inflammation in the bone and is a pre-erosive lesion that can be reversible. Irreversibility of bone edema with increasing disease chronicity is probably due to organization of the inflammation with formation of dense vascularized infiltration and activation of osteoclasts. Thus, in contrast to radiographic erosions that reflect bone damage that has already occurred, bone marrow edema represents early inflammatory infiltrates in the subchondral bone [27–29].
In the current study, a significant difference in edema and erosions was demonstrated between VERA and ESTRA. This is in agreement with previous studies, which, by using hand radiographs, showed that up to 60% of the patients develop joint erosions at the end of the 1 year from disease onset . The present study did not reveal any relation between the MRI findings in ERA and disease activity. A recent study performed in a 3-T MR unit by using a dynamic contrast-enhanced T1-weighted sequence demonstrated a correlation between synovitis and DAS-28. This study was performed in a small series of patients, and only synovitis was evaluated . Further studies are needed in larger series of patients to assess the usefulness of 3-T MRI in the detection of hand-wrist lesions in patients with ERA.
In conclusion, bone edema, erosions and synovitis are very early MRI findings of RA. MRI of the hand and wrist on clinical diagnosis of RA is useful to assess the degree of involvement.
analysis of variance
citrullinated cyclic peptide
disease activity score of 28 joint indices
disease-modifying antirheumatic drugs
early rheumatoid arthritis
erythrocyte sedimentation rate
established rheumatoid arthritis
magnetic resonance imaging
tumor necrosis factor
visual analogue scale
very early rheumatoid arthritis.
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