SI JOINT PATHOLOGIES

ANAT

T1 T2
1 = Gluteus maximus C = Coccyx
2 = Gluteus medius I = Ilium
3 = Gluteus minimus L = L5 vertebral body
4 = Iliacus M = Sacral lateral mass
5 = Psoas S = Sacrum with four sacral elements
6 = Piriformis and four neural foramina with
7 = Common iliac artery visualization of the nerve roots S1–S4
8 = Common iliac vein
9 = Inferior gluteal artery and vein
 Diseases classified as
spondyloarthropathies
• 1.Ankylosing spondylitis
• 2.Arthritis associated with inflammatory
bowel diseases (ulcerative colitis – UC,
Crohn’s disease – CD)
• 3.Reactive arthritis
• 4.Undifferentiated spondyloarthropathies
• 5.Psoriatic arthritis
• 6.Juvenile spondyloarthropathies
 Radiological classification of sacroilitis according to New York
criteria

• Grade 0:- No changes/sacroiliac joint normal

• Grade 1:-Suspected changes (blurry margins of
sacroiliac joint gap)
• Grade 2:-Minimal changes (single erosions and
periarticular sclerosis involving small area of iliac or
sacral bone)
• Grade 3:-Advanced changes (distinct periarticular
sclerosis, numerous erosions with widening of articular
gap, possible partial ankylosis)
• Grade 4:-Total ankylosis
Grade 1,2,3,4
 Two types of inflammatory changes of sacroiliac
joint in MR examination according to ASAS

• Active inflammatory Chronic

inflammatory lesions
lesions1. Bone
1. Subchondral
marrow edema
sclerosis
• 2. Capsulitis 2. Erosions
• 3. Synovitis 3. Fatty bone marrow
• 4. Inflammation of transformation
tendon, ligament and Bony bridges,
capsule attachments. ankylosis
MR examination of sacroiliac joints, images: T1- (A), T2 TIRM ;Turbo inversion recovery
magnitude (TIRM) (B), T1FSCE-weighted (C): bone marrow edema, more pronounced in
right sacroiliac joint, particularly in the iliac bone as well as erosions undergoing strong
enhancement following administration of contrast medium, contrast enhancement and
thickening of synovial membrane in the sacroiliac joint (synovitis), inflammation of right
sacroiliac joint capsule (capsulitis), subchondral sclerosis
Chronic inflammation in sacroiliac joints
in T1- (A) and T1FS-weighted (B) images:
fatty transformation of the sacral bone
and iliac bones, partial sacroiliac joint
ankylosis on right side.
Active inflammatory lesions in MR examination
Bone marrow edema (osteomyelitis, osteitis, BME) 
It is visible as an area of increased signal intensity in T2-weighted images and STIR/TIRM
sequences and as an area of decreased signal intensity in T1-weighted images that become
enhanced on administration of contrast medium. Bone marrow edema is not specific
for sacroilitis, as it also occurs in other inflammatory, traumatic or neoplastic pathologies.
Subchondral, periarticular BME specific for sacroilitis is located in iliac or sacral bones. It may
surround erosions . It is thought that symmetric lesions are characteristic for ankylosing
spondylitis, while unilateral, asymmetric location of bone marrow edema point to other forms of
SpA – most commonly psoriatic arthritis . literature data indicate that at early stage of ankylosing
spondylitis bone marrow edema is asymmetrical and unilateral.
Synovitis and capsulitis 
Synovitis and capsulitis are diagnosed based on the presence of increased synovial signal intensity
in T2-weighted and STIR/TIRM sequences. They are characteristic for inflammation of sacroiliac
joints provided that there is an adjacent area of bone edema . Presence of articular exudate is
often observed in the course of synovitis and capsulitis, which may be differentiated from
synovitis in T1FS-weighted images following intravenous administration of contrast .
Inflammation of tendon, ligament and capsule insertions (enthesitis) 
Enthesitis is visible in the form of increased signal intensity of bony or tendinous (either
ligamentous or fibrous layer of the capsule) part of enthesis on STIR;short inversion time
inversion recovery/TIRM or T1FSCE images .
• CHRONIC INFLAMMATORY CHANGES IN MR EXAMINATION

Subchondral sclerosis of bones that constitute the sacroiliac joint characterized

by low signal in T1-weighted and STIR sequences as well as lack of contrast
enhancement. Area of sclerosis specific for SpA has blurry margins and, as
disease progresses, becomes broader as opposed to osteoarthritis, in which it is
clearly demarcated and narrower .

Erosions in the subchondral layer of sacral or iliac bones, which may be active, i.e.
filled with inflamed tissue (areas of low signal in T1-weighted sequences and
hyperintense in STIR and T1CE sequences), or inactive (hypointense in all
sequences).

Subchondral fatty bone marrow transformation with high signal in T1-weighted

images, which becomes completely suppressed in fat-saturation sequences and
does not become enhanced following administration of contrast medium.

Ankylosis, characterized by low signal in all sequences, is sometimes surrounded

by high signal in T1-weighted images corresponding to fatty bone marrow
transformation.
„Shiny corners” of anterior vertebral bodies in the lumbar region; inflammation of
intervertebral joints L1–L5 with signs of bone marrow edema in T2 TIRM image (A)
enhanced after administration of contrast medium in T2FSCE-weighted image (B).

Visualizing >3 shiny corners indicates SpA with 81% specificity, while in young patients
<40 years old, specificity of this symptom raises to 97% 
Sacroiliitis on MRI. (A) Bone marrow oedema (arrows) on T2W FS oblique coronal
images and (B) corresponding enhancement (arrowheads) on T1W FS post-contrast
axial images. This degree of bone marrow oedema is sufficient to diagnose sacroiliitis.
Capsulitis can be visible (A) anteriorly (arrow) or (B) posteriorly (arrowhead)
and may extend to involve the adjacent bone. The presence of capsulitis
alone is not diagnostic of spondyloarthropathy.
Enthesitis is a common finding in active sacroiliitis on (A) T2W STIR and (B) post-
contrast T1W FS. Enthesitis is seen as ligamentous oedema, bony irregularity and
bone marrow oedema (arrow) deep to areas of ligamentous insertion. Both the sacral
and iliac sides can be involved. In this case, it occurs at the attachment of the
interosseous ligament. Enthesitis can also be seen at muscular attachments and at
the attachments of the extra-articular sacrospinous and sacrotuberous ligaments. The
presence of enthesitis alone is not diagnostic of spondyloarthropathy.
Synovitis (arrow) is best demonstrated on post-contrast images and should be
differentiated from peri-articular vasculature by ensuring that the enhancement
is seen on consecutive images
Peri-articular fatty deposition (arrows) can only be appreciated on MRI.
This finding is suggestive of chronic sacroiliitis, but is non-specific, being
also often seen in osteoarthritis and, less so, in osteitis condensans ilii.
Subchondral sclerosis (arrows) is a non-specific sign of
sacroiliitis. Sclerosis can be physiological, related to
osteitis condensans ilii, physical stress or
osteoarthritis.
Ankylosis or bony bridging (arrows) can be
readily appreciated on MRI. One ideally wants to
make the diagnosis of sacroiliitis well before
ankylosis becomes apparent.
INFECTIVE SACROILIITIS
Three features of infective sacroiliitis are particularly
helpful in differentiating infective from inflammatory
sacroiliitis.
First, bone marrow oedema in infective sacroiliitis tends
to be more intense and there is more intra-articular
fluid (Figure 17A).
Second, inflammation in infective sacroiliitis spreads to
involve the peri-articular soft tissues, particularly the
iliacus and gluteal muscles (Figure 17B).
Third, peri-articular fluid collection or abscess is
practically pathognomonic of an infective sacroiliitis 
infective sacroiliitis. (A) Excessive sacroiliac joint fluid
(red arrow); (B) inflammation of iliacus muscles (white
arrow); and (C) abscess formation (arrowhead)
supports the diagnosis of infective sacroiliitis.
Osteoarthritis. (A) Inferior osteophytosis (arrow) on radiograph and (B)
anterior marginal osteophytosis (arrowhead) seen on MRI as features of
osteoarthritis or instability. (C) Joint irregularity with subchondral
sclerosis is due to osteoarthritis rather than sacroiliitis on radiograph
 Reactive stress-related soft tissue changes
around the sacroiliac joint. Twenty-seven-
Stress reaction. Focal patchy
year-old professional football player.
oedema (arrow) at the mid-sacral
Radiograph was unremarkable. (A) On MRI,
area close to the left sacroiliac
there is severe thickening of the anterior
joint in a 28-year-old male
capsule (arrow) on the right side; (B) more
athlete. No fracture line is
proximally, similar though less severe
evident. The patient recovered
capsular thickening (arrowhead) with
with rest.
osteoarthritis is present on the left side.
insufficiency fracture. MRI has a very high positive and negative
predictive value for insufficiency fracture. It will demonstrate either (A)
bone oedema (arrow) ± or (B) a discrete fracture line (arrowhead).
OSTEITIS CONDENSANS ILII is caused by bone deposition at
stress areas alongside the sacroiliac joint. It is usually seen in
childbearing women and is most likely related to the abnormal
high stresses incurred during pregnancy. Radiography and MRI
typically reveal bilateral, symmetrical, sharply circumscribed,
triangular-shaped areas of subchondral sclerosis, without
erosions or joint space widening, at the anteroinferior aspect of
the iliac bone alongside the sacroiliac joint.

Bone marrow oedema and fatty infiltration are recognized

additional MR features of osteitis condensans ilii .

Bone marrow oedema in osteitis condensans ilii tends to appear

in a continuous pattern as an arcuate line beneath the anterior
subchondral bone sclerosis in contrast to inflammatory
sacroiliitis
Osteitis condensans ilii (arrows). Well-defined
triangular-shaped symmetrical subchondral sclerosis,
without erosions or joint space widening at the
anterior aspect of the iliac bone on (A) radiograph and
(B) MR