Duplex and Sonographic Sacroiliitis

HaUl Arslan1 M. Emin Sakarya1 Burhan Adak2 Ozkan Unal1 Mehmet Sayarlioglu3
OBJECTIVE. graphic findings SUBJECTS sacroiliacjoints

Color Doppler Findings in Active

The aim of this study in active sacroiliitis.

was to describe

the duplex

and color

Doppler

sono20 vol-

AND METHODS. Forty-one in 10 patients with osteoarthritis,

joints in 21 patients and 30 sacroiliacjoints

with active sacroiliitis, of 15 asymptomatic

unteers were investigated on duplex and color Doppler sonography. We investigated whether a vessel was present around the posterior portions of sacroiliac joints with color Doppler sonography. When sonography RESULTS. 41 joints 0.97 ferent .001). patients

an artery was detected, the resistive in all groups and also after treatment Vascularization with of eight around active of the 21 patients sacroiliitis, The mean with

index (RI) was measured using duplex in the patients with active sacroiliitis. portions nine joints RI values with active sacroiliitis, of sacroiliac of six patients

Doppler

the posterior

joints with 0.91

was seen in osteoarthri

tis, and 13 joints 0.07 after therapy. from those In addition, with

volunteers.

were 0.62 sacroiliitis

0.13,

0.09,

and

0.03, respectively.

In the patients

active

the mean RI value

was 0.91

The RI values

for the patients

were significantly

dif(p < in the in-

of the patients with osteoarthritis the RI values were significantly sacroiliitis (p

<

(p < .001) and of the volunteers different before and after treatment portions of sacroiliac joints

active

.001). around the posterior

CONCLUSION.

Vascularization

creased and RI values decreased in patients with active sacroiliitis. Color and duplex Doppler sonography were able to reveal these changes and can be used in the diagnosis of active sacroiliitis and follow-up after treatment. Thus, RI values cal symptoms in patients with active sacroiliitis. may be a quantitative indicator for clini-

S
flammatory spondylitis,

acroiliitis volvement

is an inflammatory inof one or both sacroiliac

tis. The purpose of our study was to investigate the duplex and color Doppler sonographic findings

joints spondyloarthropathies.

and is the key symptom of all A group of related in-

in active

sacroiliitis.

joint diseases, such as ankylosing psonatic arthritis, reactive arthriarthritis, and undifferentiated are considered among Sacroiliac joints may also rheumatoid Reiters can arthritis, syndrome pyo[1]. easily and

Subjects

and Methods

tis, enteropathic spondyloarthropathies, these abnormalities. be involved genic Received March 9, 1998; accepted after revision
March 8, i999.

in gout, sacroiiitis

arthritis,

Chronic

be diagnosed

Department of Radiology, YUzUncU61University, Tip Fakultesi Hastanesi, Radyoloji Anabilim Dali, Maras Cad. Van 65200,Turkey. Address correspondence to H.Arslan. 2Physical Medicine and Rehabilitation, YUzUncUYil
University, Van 65200, Turkey.

with different radiologic methods. The current imaging techniques applied to the sacroiliac joints are conventional radiography, tomogra[2-4]. phy, scintigraphy, CT, and MR imaging

3lntemal Medicine, YUz#{252}ncU Yil University, Van 65200,Turkey.

AJR1999;173:677-680

Chronic sacroiliitis may show periods of activation during the course of the disease. MR imaging may be a reliable indicator
[5].

in

the

0361-803X199/1733-677

diagnosis of active sacroiliitis did not encounter any study

Ray Society

However, we on the use of duin sacroilii-

American

Roentgen

plex and color Doppler

sonography

Between March 1996 and June 1998, 38 patients with sacroiliitis underwent sacroiliac CT, of whom 21 had both laboratory and clinical evidence of active sacroiliitis. These patients were examined with color and duplex Doppler sonography. On CT, sacroiliitis was diagnosed as the presence of two or more of the following findings: sacral subchondral sclerosis, loss ofjoint space, and erosions or intraarticular osseous ankylosis [6]. Physical examinations revealed focal sacroiliac tenderness, low back pain, and pain during Patricks test [7]. For Patricks test, the patient lies supine on the table and the examiner flexes, abducts, and externally rotates the patients leg. To stress the sacroiliac joint, the examiner extends the range of motion by placing one hand on the flexed knee joint and the other hand on the anterior superior iliac spine of the opposite side and presses on each of these points. If the patient complains of increased pain,

AJR:i73,September 1999

677

Arsian

et al.

there may be an abnormality in the sacroiliac joint. The Westergren method for erythrocyte sedimentation rate and the level of C-reactive protein were
high in the laboratory data of the patients with ac-

tive sacroiliitis. In addition to 41 sacroiliac joints of 21 patients with active sacroiliitis, 20 sacroiliac joints of 10 patients with osteoarthritis and 30 sacroiiacjoints of 15 asymptomatic volunteers were investigated with duplex and color Doppler sonography. The patients with active sacroiiitis consisted of 12 males and nine females, who ranged in age from 17 to 39 years (mean, 27 5 years). The patients with osteoarthritis were six men and four women, who ranged in age from 45 to 73 years (mean, 62 4 years), and the asymptomatic volunteers consisted of seven men and eight women, who ranged in age from 20 to 29 yeaz-s (mean, 25 3 years). The abnormalities seen in the 21 patients with active sacroiliitis were caused by ankylosing spondylitis (n = 13), psoriatic arthritis (n = 5), Reiters syndrome (n = 2), and tubeitulous arthritis (n = I). Bilateral sacroiliacjoints were involved in 20 patients. On the other hand, one patient with tuberculosis sacroiliitis had unilateral involvement. Although asymptomatic volunteers underwent only duplex and color Doppler sonography, all patients with active sacroiliitis and those with osteoarthritis underwent CF and duplex and color Doppler sonography within 3 days. CT was performed in the axial plane angulated 20#{176} cranially using a W450 scanner (Hitachi Medical, Tokyo, Japan). Imaging was performed with 5-mm contiguous slices through each sacroiliac joint with the gantry angled to the joint after the review of a preprocedural topogram. These studies were performed by two radiologists 270A experienced scanner in Doppler (Toshiba, Tokyo, imaging Japan). with We an SSA

Fig. 1.-23-year-old man with healthy sacroiliac joint imaged in prone position. A, Gray-scale sonogram shows spinous process in midline (double arrow). Posterior portions of sacroiliac joints are seen as hypoechoic cleft areas (single arrows) 2-3 cm from spinous process. B, Axial CT scan obtained at same level as A shows sacrum and spinal process in midline (thin arrow). Bilateral sacroiliac joints (thick arrows) from posterior aspect corresponding to A are seen on both sides.

Vmas

and

Vmjn

were

the

maximum

and

minimum

flow rates recorded during one cardiac cycle. The RI value was calculated as the average of at least two measurements for each patient. The same measurements were repeated 3 weeks after therapy. Data of the patients are shown in Table 1 . The resuits before and after treatment were compared and

those of the study and control groups were compared. At the end of the study, the mean RI value was calculated for the whole group of 21 patients

before therapy and then compared with the mean RI value after therapy. Twenty of the patients received antiinflammatory treatment. Surgical drainage of pelvic abscess and antituberculosis treatment were performed in a patient with tuberculosis sacroiliitis. The symptoms that regressed after treatment were focal sacroiliac tenderness, low back pain, and pain during Patricks test. In addition, the Westergren method for erythrocyte sedimentation rate and the level of C-reactive

Findings

on Duplex

Doppler

Sonography

in 21 PatIents

with Sacrolllltis

Resistive
Patient

Index Value After Treatment Right

-

used a 3.75-MHz high-resolution curved array transducer and a color video printer (CP15E; Mitsubishi, Tokyo, Japan) to record representative duplex and color Doppler sonograms on print film. A pulse repetition frequency between 3000 and 5500 Hz was used, with appropriate adjustments ofcolor gain (between 100 and 120 dB) and wall filter settings (between 29 and 96 Hz). The standard duplex and color Doppler sonographic examinations of the sacroiliac joint included multiple transverse sections. The patients were examined in the prone position. The transducer was settled to the sacral region from the postenor aspect in the transverse position. Landmarks were seen in the gray-scale sonograms and CT scans (Fig. 1). Other parts of sacroiliac joints cxcept the posterior aspect were not seen in this cxamination because of the oblique position of the joints. Initially, we tried to observe vessels inside or around the posterior portions of the sacroiliac joint with color Doppler sonography. If arteries were present both inside and around the joint, only the inside measurements were considered. Each duplex and color Doppler sonographic examination lasted approximately 15-20 mm. When an artery was found, the resistive index (RI) was measured on duplex and color Doppler sonography. The RI value was defined as [Vmas _ Vminl Vmas, where

Before Treatment No. 1 2 3 4 5 6 7 8 9 10 ii 12 13 14 15 16 17 18 i9 20 21

Note-Dash (-I

Cause of Sacroiliitis

Age (yr) 24 23 29 27 17 25 18 26 20 35 39 24 31 33 35 31 29 28 26 24

Sex Male Male Female Female Male Female Male Male Female Male Female Male Male Male Male Female Male Female Female Male Female

Right
-

Left 0.50 0.51 0.76 0.54 0.31 0.49 0.52 0.62 0.85 0.70 0.68 0.70 0.75 0.67 0.90 0.50 0.57 0.65 0.82 0.69 0.62

Left 0.87 0.90 1.0 0.85 0.87 0.91 0.88 0.95 i.O 0.82 0.95 0.75 1.0 0.98 1.0 0.95 0.85 0.90 0.86 0.93 1.0 Tuberculosis Ankylosing Ankylosing sacroiliitis spondylitis spondylitis

0.47 0.56 0.60 0.58 0.55 0.56 0.65 0.53 0.50 0.55 0.75 0.63 0.70 0.48 0.49 0.51 0.60 0.85 0.52 0.85

0.92 0.95 1.0 1.0 0.93 1.0 0.90 0.87 0.80 0.88 0.83 0.90 0.90 0.86 0.75 0.90 0.87 0.82 0.95 0.86

Ankylosing spondylitis Ankylosing spondylitis Ankylosing spondylitis Ankylosing spondylitis Ankylosing spondylitis Ankylosing Ankylosing spondylitis spondylitis

Ankylosing spondylitis Ankylosing spondylitis Ankylosing Psoriatic Psoriatic spondylitis arthritis arthritis Ankylosing spondylitis

Psoriatic arthritis Psoriatic arthritis Psoriatic arthritis Reiters syndrome Reiters syndrome

indicates that right sacroiliac

ioint was not included in the study because oi normal findings on CT.

678

AJR:i73,

September

1999

Sonography Fig. 2.-li-year-old boy with sacroiliitis. A, CT scan of sacroiliac joints shows irregular borders with erosions (thin arrows)

of Active

Sacroiliitis 0.91 0.07 afterward (Figs. 2 and 3). The mean was significantly (p (p
< <

RI value for this group ent from the patients ment

differ.001) and

and subchondral sclerosis (thick arrows). B, Color Doppler sonogram reveals vascularization (arrows) within posterior portion

that of the volunteers with osteoarthritis different The findings

.001). Morebefore treatthat after of all patients

of both sacroiliac joints. S = sacrum. C. Spectral Doppler analysis showed lowresistance arterial blood flow. Resistive index value = 0.31.

over, the mean RI value in patients was significantly (p

<

from

treatment

.001).

with sacroiliitis are shown in Table I, and the mean RI value of all study groups are summarized in Table 2. the clinical and laboratory whereas improvements in patients (patients treatment. were partial. In I I , I 3, and I 9 in was simiIn I 8 patients, findings improved, A the three these Table three remaining patients

1), the RI value

after treatment

lar to that before

Discussion Diagnosis of sacroiliitis was based on clinical findings and radiologic evaluation. Conventional radiography is the first step in the
radiographic

evaluation

of the sacroiliac

joints.

However, there is significant inter- and intraobserver variation in the interpretation of conventional the
protein decreased during this time. The measure-

radiographs conventional

[2, 3]. In one series, 20% of radiographic when results compared were with

Vasculanzation that was being [8] was

healthy

around

the sacroiliac of sacral

joint arteries

found
CT

to be misleading

ments were repeated after approximately 3 weeks to determine changes in vascularization and RI value. Results We gray-scale pier fore positive
examined the sacroiliac joints

fed by branches

seen
volunteers

in 13 sacroiliac joints of eight with a mean RI value of 0.97

results [4]. This finding has led clinicians to rely on other radiographic imaging techniques, such as conventional
imaging, in patients

tomography,
with suspected

CT,

and MR

with Dophad a data besub-

0.03 (Fig. 2). There was not any vasculanzation in the other seven healthy volunteers. None of the volunteers sacroiliac
tis,

sacroiliitis

[2]. Although conventional ability, radiation able ease server variation

CF is considered tomography of examination, in interpretation, [9], Cf of active

to be better than of its availinteroband decreased sacroiliitis. Howlesser

sonography, clinical

color

and duplex patients On CT,

had vasculanzation In the patients

around the

inside

the
joint

because

sonography, undergoing

and CT. All the treatment. (a

(n
= =

joint.

with osteoarthrisacroiliac

sign and laboratory

vascularization

was seen mean

RI

in nine joints value was 0.91 However,

of five patients

and the

exposure

alone was not relithat MR sacroiliitis by

chondral sclerosis (n = 10), erosions osseous patients

19), loss ofjoint space 17), and intraarticular

0.09. We could not the 41 affected with sacroiliitis, only inside only around

as a predictor

see any vascularization

in the other five patients among

ankylosis (n = 6) were observed in the with sacroiliitis. On gray-scale sonogwere seen in the mid-

of this group. sacroiliac joints

ever, Battafarano et al. imaging can determine

151 reported
active

in the patients

raphy, spinous processes line as hyperechogenic

areas

with

acoustic

three patients had vascularization the joints, 31 had vascularization

showing subcortical bone marrow edema. We could not find any information in the literature about studies of sacroiliitis using duplex and color Doppler sonography. In our study, the number of those in the healthy in whom sacroiliac vessels volunteer group were visualized

shadow. Sacroiliac joints were found as a hypoechogenic cleft 2-3 cm from the spinous process in both sides (Fig. 1A).

the joints, and seven patients had vascularization both inside and around thejoints. The mean RI value was 0.62

0. 13 before

therapy

and

:;.:-

Fig. 3.-29-year-old woman with sacroiliitis. A, Spectral Doppler analysis obtained before treatment shows artery within
posterior portion ofnght sacroiliac joint with low-resistance blood flow. Resis-

:
. .-

...
.

tive index value = 0.56. B, Spectral analysis obtained on day 20 of treatment shows high-resistance blood flow. Resistive index value = 1.0.

.4i:

s___

AJR:173, September

1999

679

Arslan we found contrary, possible Treatment 0.91 0.07

P#{149}

et al. of these techniques On the using because duthe References I. Resnick

joint
2.

ye Index Groups i.MenRIy&u

.

Values

that an advantage
data

phase.

In addition,

RI

values

may

be a quan-

is that quantitative

can be obtained. of sacroiliitis sonography improve

titative

indicator

of clinical

symptoms

in ac-

the diagnosis once symptoms

tive sacroiliitis.

plex and color Doppler

RI

may not be For this

.SGroup
=

fe Treatment 062 0.13

value is found

to be almost

normal.

Patients with activer sacro,liitis - Healthy volunteers

duplex and color Doppler sonography can be used only for the diagnosis of sacroiliitis
reason,

D, Niwayama disorders, 2nd ed.

G. Diagnosis Philadelphia:

ofbone

and

Saunders,

Patients with osteoarthritis

:,

0.91

0.09

during
increase

the active

phase. On the other hand, the

:-

0.97 t[0.03

Note-Mean RI values of patients with active sacroiliitis: were significantly different from those of healthy volunteers l < .0011. In patients with active sacroililtis, mean RI values before treatment were significantly different from those after treatment lp< .0011. RI = resistive index.

of the RI value and the decrease of symptoms as a response to medical treatment suggested raphy that duplex and color Doppler therapeutic sonogeffican be used to evaluate

1988:932-953 Murphey MD, Wetzel

E, Simpson

LH,

Bramble
HB.

JM, Levine
MR RL.

KM.

Lindsley

Sacroiliitis: PN, Dawkins

imaging 3. Forrester

findings. Radiology DM, Hollingsworth

1991:180:239-244

cacy (Fig.3). In our study, the arteries ten around the sacroiliac

were seen more ofjoint than inside the

4.

Difficulties in the radiographic diagnosis of sacroiliitis. Clin Rheum Dis 1983:9:323-332 Ryan L, Carrera GF, Lightfoot RW, Hoffman RG, Kozin F. The radiographic diagnosis of sacroiliitis: a comparison of different views with computed tomograms of the sacroiliac Rheu,n 1983:26:760-763 joint. Arthritis

with

color

Doppler
RI value

sonography

was low and the numsacroiliitis visualized and

the mean in whom with color

was high, whereas vessels sonography were

sacroiliac joint on color Doppler sonography. This finding may be associated with the structure of the sacroiliac obliquely, and with joint, which is positioned that could not Perthan Dopand the arteries

ber of those in the group with active sacroiliac Doppler

was high

the mean RI value was low. The findings for the patients with osteoarthritis were similar to those
cantly

be visualized in deeper part of the joint. haps more arteries were inside the joints were determined
in this study by

color

for the healthy different findings

volunteers

and signifi-

pier sonography. Limitations of this study are that duplex color Doppler sonographic findings are dependent on the experience of the radiologist. Other limitations
are that the study consisted

5. Bauafarano DF, West SG, Rak KM. Fortenbery El, Chantelois AE. Comparison of bone, computed tomography, and magnetic resonance imaging in the diagnosis of active sacroiliitis. Semin Arthritis Rheu,n 1993:23:161-176 6. Kozin F, Carrera GF, Ryan LM, Foley D, Lawson
1. Computed

tomography

in the diagnosis

of sacPhilaBannister

These

from those of the study group. indicate that duplex and color

roiliitis. Arthritis Rheum 7. Sladge CB, ed. Textbook delphia: Saunders,

1981:24:1479-1485
ofrheumatology.

Doppler sonography may be the preferred techniques in the diagnosis of active sacroiliitis. RI values with
patients

1997:364

ofa small

8. Williams
Grays Livingstone,
LH.

PL, Warwick

R, Dyson

M,

are expected inflammation,

active

to be low in patients as has been seen in

at other ana-

group and the sonologist

knew the diagnosis of or to of in the a

active
with

inflammation

sacroiliitis based on clinical and CT findings. In conclusion, vascularization inside around values decrease active sonography the sacroiliac change with sacroiliitis. of active with the joints symptoms severity Duplex increases and seems Doppler

anatomy, 37th ed. London: Churchill 1989:764-780 9. Vogler JB, Brown WH, Helms CA, Genant HK. The normal tomatic sacroiliac joint: a CT study
1984:151:433-437

of asymp-

tomic

locations

(e.g., the pelvis). inflammation, phase to our data.

In two studies was RI values were [10, 1 1]. These and

and RI

patients.

Radiology

that showed that increased caused by pelvic low during findings color In addition Doppler diagnosis the active

vascularization

of symptoms and color techniques

10. Tinkanen H, Kujansuu ings in tuba-ovarian Ultrasound

E. Doppler ultrasound findinfectious complex. J Clin

1993:21:175-178

were similar

are convenient

1 1. Tepper R, Aviram R, Cohen N, Cohen I, Holtzinger M, Beyth Y. Doppler flow characteristics in

patients spenders Ultrasound with pelvic inflammatory disease: reversus nonresponders to therapy. J Clin
1998:26:247-249

to our findings sonography

that duplex

diagnosis potential monitoring

sacroiliitis.

Moreover,

may be used in the

of sacroiliitis

during the active phase,

advantage of these techniques is therapeutic response of the active

680

AJR:173, September

1999