Classifications and imaging of juvenile spondyloarthritis

Juvenile spondyloarthritis may be present in at least 3 subtypes of juvenile idiopathic arthritis according to the classification of the International League of Associations for Rheumatology. By contrast with spondyloarthritis in adults, juvenile spondyloarthritis starts with inflammation of peripheral joints and entheses in the majority of children, whereas sacroiliitis and spondylitis may develop many years after the disease onset. Peripheral joint involvement makes it difficult to differentiate juvenile spondyloarthritis from other juvenile idiopathic arthritis subtypes. Sacroiliitis, and especially spondylitis, although infrequent in childhood, may manifest as low back pain. In clinical practice, radiographs of the sacroiliac joints or pelvis are performed in most of the cases even though magnetic resonance imaging offers more accurate diagnosis of sacroiliitis. Neither disease classification criteria nor imaging recommendations have taken this advantage into account in patients with juvenile spondyloarthritis. The use of magnetic resonance imaging in evaluation of children and adolescents with a clinical suspicion of sacroiliitis would improve early diagnosis, identification of inflammatory changes and treatment. In this paper, we present the imaging features of juvenile spondyloarthritis in juvenile ankylosing spondylitis, juvenile psoriatic arthritis, reactive arthritis with spondyloarthritis, and juvenile arthropathies associated with inflammatory bowel disease

Degeneration of the symphysis pubis presenting as a submucosal urinary bladder tumour

Urinary bladder sonography is a sensitive diagnostic technique used for visualizing urinary bladder tumours. The aim of our communication is to present a case of a pseudotumour of the urinary bladder originating from the symphysis pubis syndesmosis. A 58-year-old woman was seen by a urologist with symptoms of lower urinary tract infection. Urinary bladder sonography was performed, followed by magnetic resonance imaging. Sonographic images of the bladder showed an exophytic mass on the urinary bladder's anterior wall. A transurethral resection of the tumour was performed. A histopathological examination revealed a necrotic extramural mass, without traits of malignancy. The mass reappeared in the follow-up vesical sonography. Subsequently, its transurethral resection was repeated with the same histopathological findings. The next urinary bladder sonography revealed the presence of the mass again. Pelvic magnetic resonance imaging was performed, which showed advanced degenerative changes in the pubic symphysis syndesmosis that protruded into the bladder, imitating a urinary bladder tumour. To avoid unnecessary surgery, both radiologists and urologists should be made aware that there is a possibility of similar cases in patients. Magnetic resonance imaging enabled correct determination of the primary site of the growth, which, together with the histopathological examination results, influenced the choice of the implemented therapeutic procedures

Imaging of juvenile spondyloarthritis. Part I: Classifications and radiographs

Juvenile spondyloarthropathies are manifested mainly by symptoms of peripheral arthritis and enthesitis. By contrast with adults, children rarely present with sacroiliitis and spon­dylitis. Imaging and laboratory tests allow early diagnosis and treatment. Conventional radiographs visualize late inflammatory lesions and post-inflammatory complications. Early diagnosis is possible with the use of ultrasonography and magnetic resonance imag­ing. The first part of the article presents classifications of juvenile spondyloarthropathies and discusses their radiographic presentation. Typical radiographic features of individual types of juvenile spondyloarthritis are listed (including ankylosing spondylitis, juvenile psoriatic arthritis, reactive arthritis and arthritis in the course of inflammatory bowel diseases). The second part will describe changes visible on ultrasonography and magnetic resonance imaging. In patients with juvenile spondyloarthropathies, these examinations are conducted to diagnose inflammatory lesions in peripheral joints, tendon sheaths, ten­dons and bursae. Moreover, magnetic resonance imaging also visualizes early inflamma­tory changes in the axial skeleton and subchondral bone marrow edema, which is consid­ered an early sign of inflammation

Ultrasound assessment on selected peripheral nerve pathologies. Part I: Entrapment neuropathies of the upper limb – excluding carpal tunnel syndrome

Ultrasound (US) is one of the methods for imaging entrapment neuropathies, post-trau‑ matic changes to nerves, nerve tumors and postoperative complications to nerves. This type of examination is becoming more and more popular, not only for economic reasons, but also due to its value in making accurate diagnosis. It provides a very precise assess‑ ment of peripheral nerve trunk pathology – both in terms of morphology and localization. During examination there are several options available to the specialist: the making of a dynamic assessment, observation of pain radiation through the application of precise palpation and the comparison of resultant images with the contra lateral limb. Entrap‑ ment neuropathies of the upper limb are discussed in this study, with the omission of median nerve neuropathy at the level of the carpal canal, as extensive literature on this subject exists. The following pathologies are presented: pronator teres muscle syndrome, anterior interosseus nerve neuropathy, ulnar nerve groove syndrome and cubital tun‑ nel syndrome, Guyon’s canal syndrome, radial nerve neuropathy, posterior interosseous nerve neuropathy, Wartenberg’s disease, suprascapular nerve neuropathy and thoracic outlet syndrome. Peripheral nerve examination technique has been presented in previous articles presenting information about peripheral nerve anatomy [Journal of Ultrasonog‑ raphy 2012; 12 (49): 120–163 – Normal and sonographic anatomy of selected peripheral nerves. Part I: Sonohistology and general principles of examination, following the exam‑ ple of the median nerve; Part II: Peripheral nerves of the upper limb; Part III: Peripheral nerves of the lower limb]. In this article potential compression sites of particular nerves are discussed, taking into account pathomechanisms of damage, including predisposing anatomical variants (accessory muscles). The parameters of ultrasound assessment have been established – echogenicity and echostructure, thickness (edema and related increase in the cross sectional area of the nerve trunk), vascularization and the reciprocal relation‑ ship with adjacent tissue

Normal and sonographic anatomy of selected peripheral nerves. Part II: Peripheral nerves of the upper limb

The ultrasonographic examination is frequently used for imaging peripheral nerves. It serves to supplement the physical examination, electromyography, and magnetic resonance imaging. As in the case of other USG imaging studies, the examination of peripheral nerves is non-invasive, well-tolerated by patients, and relatively inexpensive. Part I of this article series described in detail the characteristic USG picture of peripheral nerves and the proper examination technique, following the example of the median nerve. This nerve is among the most often examined peripheral nerves of the upper limb. This part presents describes the normal anatomy and ultrasound picture of the remaining large nerve branches in the upper extremity and neck – the spinal accessory nerve, the brachial plexus, the suprascapular, axillary, musculocutaneous, radial and ulnar nerves. Their normal anatomy and ultrasonographic appearance have been described, including the division into individual branches. For each of them, specific reference points have been presented, to facilitate the location of the set trunk and its further monitoring. Sites for the application of the ultrasonographic probe at each reference point have been indicated. In the case of the ulnar nerve, the dynamic component of the examination was emphasized. The text is illustrated with images of probe positioning, diagrams of the normal course of the nerves as well as a series of ultrasonographic pictures of normal nerves of the upper limb. This article aims to serve as a guide in the ultrasound examination of the peripheral nerves of the upper extremity. It should be remembered that a thorough knowledge of the area’s topographic anatomy is required for this type of examination

Ultrasound assessment of selected peripheral nerve pathologies. Part III: Injuries and postoperative evaluation

The previous articles of the series devoted to ultrasound diagnostics of peripheral nerves concerned the most common nerve pathologies, i.e. entrapment neuropathies. The aim of the last part of the series is to present ultrasound possibilities in the postoperative control of the peripheral nerves as well as in the diagnostics of the second most common neuropathies of peripheral nerves, i.e. posttraumatic lesions. Early diagnostics of posttraumatic changes is of fundamental importance for the course of treatment and its long-term effects. It aids surgeons in making treatment decisions (whether surgical or conservative). When surgical treatment is necessary, the surgeon, based on US findings, is able to plan a given type of operative method. In certain cases, may even abandon the corrective or reconstructive surgery of the nerve trunk (when there are extensive defects of the nerve trunks) and instead, proceed with muscle transfers. Medical literature proposes a range of divisions of the kinds of peripheral nerve injuries depending on, among others, the mechanism or degree of damage. However, the most important issue in the surgeon-diagnostician communication is a detailed description of stumps of the nerve trunks, their distance and location. In the postoperative period, ultrasound is used for monitoring the operative or conservative treatment effects including the determination of the causes of a persistent or recurrent neuropathy. It facilitates decision-making concerning a repeated surgical procedure or assuming a wait-and-see attitude. It is a difficult task for a diagnostician and it requires experience, close cooperation with a clinician and knowledge concerning surgical techniques. Apart from a static assessment, a dynamic assessment of possible adhesions constitutes a crucial element of postoperative examination. This feature distinguishes ultrasound scanning from other methods used in the diagnostics of peripheral neuropathies.W poprzednich dwóch artykułach z serii poświęconej diagnostyce ultrasonograficznej nerwów obwodowych zostały przedstawione najczęstsze patologie, jakimi są neuropatie uciskowe. Celem kończącej cykl III części jest przedstawienie możliwości ultrasonografii w ocenie drugich co do częstości neuropatii obwodowych, tj. zmian pourazowych, oraz w kontroli pooperacyjnej nerwów obwodowych. Wczesna diagnostyka zmian pourazowych ma fundamentalne znaczenie dla przebiegu leczenia oraz jego odległych wyników. Ułatwia chirurgowi podjęcie decyzji o rodzaju postępowania (operacyjnym bądź zachowawczym). W przypadku konieczności leczenia operacyjnego chirurg w oparciu o wynik badania ultrasonograficznego może zaplanować rodzaj metody operacyjnej. W niektórych sytuacjach może nawet odstąpić od zabiegu naprawczego czy rekonstrukcyjnego (przy rozległych ubytkach pni nerwowych) na rzecz transferów mięśniowych. Literatura medyczna proponuje szereg podziałów uszkodzeń nerwów obwodowych, między innymi w zależności od mechanizmu czy stopnia uszkodzenia. Najważniejszy w komunikacji pomiędzy chirurgiem a diagnostą jest jednak szczegółowy opis obrazu kikutów pni nerwowych, ich odległości oraz miejsca położenia. W okresie pooperacyjnym diagnostyka ultrasonograficzna jest wykorzystywana w celu monitorowania efektów leczenia operacyjnego bądź zachowawczego, w tym do określenia przyczyn utrzymującej się bądź nawrotowej neuropatii. Pozwala na podjęcie decyzji o ponownym zabiegu operacyjnym lub przyjęciu postawy wyczekującej. Jest to dla diagnosty trudne zadanie, wymagające doświadczenia, ścisłej współpracy z klinicystą oraz znajomości technik operacyjnych. W ocenie pooperacyjnej bardzo ważny element badania, poza oceną statyczną, stanowi ocena dynamiczna pod kątem ewentualnych zrostów; jest to cecha wyróżniająca badanie ultrasonograficzne spośród innych metod diagnostyki neuropatii obwodowych

Normal and sonographic anatomy of selected peripheral nerves. Part III: Peripheral nerves of the lower limb

The ultrasonographic examination is currently increasingly used in imaging peripheral nerves, serving to supplement the physical examination, electromyography and magnetic resonance imaging. As in the case of other USG imaging studies, the examination of peripheral nerves is non-invasive and well-tolerated by patients. The typical ultrasonographic picture of peripheral nerves as well as the examination technique have been discussed in part I of this article series, following the example of the median nerve. Part II of the series presented the normal anatomy and the technique for examining the peripheral nerves of the upper limb. This part of the article series focuses on the anatomy and technique for examining twelve normal peripheral nerves of the lower extremity: the iliohypogastric and ilioinguinal nerves, the lateral cutaneous nerve of the thigh, the pudendal, sciatic, tibial, sural, medial plantar, lateral plantar, common peroneal, deep peroneal and superficial peroneal nerves. It includes diagrams showing the proper positioning of the sonographic probe, plus USG images of the successively discussed nerves and their surrounding structures. The ultrasonographic appearance of the peripheral nerves in the lower limb is identical to the nerves in the upper limb. However, when imaging the lower extremity, convex probes are more often utilized, to capture deeply-seated nerves. The examination technique, similarly to that used in visualizing the nerves of upper extremity, consists of locating the nerve at a characteristic anatomic reference point and tracking it using the “elevator technique”. All 3 parts of the article series should serve as an introduction to a discussion of peripheral nerve pathologies, which will be presented in subsequent issues of the “Journal of Ultrasonography”

Diagnostyka obrazowa łuszczycowego zapalenia stawów. Część II: rezonans magnetyczny i ultrasonografia

Plain radiography reveals specific, yet late changes of advanced psoriatic arthritis. Early inflammatory changes are seen both on magnetic resonance imaging and ultrasound within peripheral joints (arthritis, synovitis), tendons sheaths (tenosynovitis, tendovaginitis) and entheses (enthesitis, enthesopathy). In addition, magnetic resonance imaging enables the assessment of inflammatory features in the sacroiliac joints (sacroiliitis), and the spine (spondylitis). In this article, we review current opinions on the diagnostics of some selective, and distinctive features of psoriatic arthritis concerning magnetic resonance imaging and ultrasound and present some hypotheses on psoriatic arthritis etiopathogenesis, which have been studied with the use of magnetic resonance imaging. The following elements of the psoriatic arthritis are discussed: enthesitis, extracapsular inflammation, dactylitis, distal interphalangeal joint and nail disease, and the ability of magnetic resonance imaging to differentiate undifferentiated arthritis, the value of whole-body magnetic resonance imaging and dynamic contrast-enhanced magnetic resonance imaging.Radiografia klasyczna pozwala na uwidocznienie szeregu charakterystycznych zmian w przebiegu łuszczycowego zapalenia stawów. Ujawniają się one jednak na radiogramach dopiero w zaawansowanym etapie choroby. Wczesne zmiany zapalne w obrębie stawów obwodowych, pochewek ścięgien i entez widoczne są w badaniu metodą rezonansu magnetycznego oraz w ultrasonografii. Ponadto rezonans magnetyczny umożliwia ocenę zmian zapalnych stawów krzyżowo-biodrowych oraz kręgosłupa. W tej części artykułu przedstawiono aktualne doniesienia dotyczące diagnostyki łuszczycowego zapalenia stawów w badaniu metodą rezonansu magnetycznego i ultrasonografii, charakterystyczne obrazy tej choroby oraz hipotezy związane z jej etiopatogenezą. Omówiono następujące elementy łuszczycowego zapalenia stawów: patologie entez, zapalenie tkanek miękkich przystawowych, zapalenie palca, spektrum zmian na poziomie stawu międzypaliczkowego dalszego i paznokcia. Ponadto przedstawiono przydatność badania metodą rezonansu magnetycznego w diagnostyce różnicowej niezróżnicowanych zapaleń stawów, w tym badania całego ciała oraz badania dynamicznego metodą rezonansu magnetycznego

Normal and sonographic anatomy of selected peripheral nerves. Part I: Sonohistology and general principles of examination, following the example of the median nerve

Ultrasonography is an established method for imaging peripheral nerves. It serves to supplement the physical examination, electromyography, and magnetic resonance imaging. It enables the identification of post-traumatic changes of nerves, neuropathies secondary to compression syndromes, inflammatory or neoplastic nerve lesions as well as the evaluation of postoperative complications. In certain situations, this technique is the imaging method of choice. It is increasingly used in anesthesiology for regional anesthesia. As in the case of other ultrasound imaging studies, the examination of peripheral nerves is non-invasive, well-tolerated by patients, and relatively inexpensive. This article presents the histological structure of peripheral nerves and their appearance in ultrasonography. It also presents the examination technique, following the example of the median nerve, and includes a series of diagrams and ultrasound images. The interpretation of the shape, echogenicity, thickness and vascularity of nerves is described, as well as their relation to the surrounding tissues. The “elevator technique”, which consists of locating a set nerve at a characteristic anatomic point, and following it proximally or distally, has been explained. The undisputed benefits of the ultrasound examination have been presented, including its advantages over other diagnostic methods. These advantages include the dynamic component of the ultrasound examination and the possibility of correlating the patient’s symptoms with the ultrasound images. As an example, the proper anatomy and the ultrasonographic appearance of the median nerve were described. This nerve’s course is presented, its divisions, and characteristic reference points, so as to facilitate its location and identification, and enable subsequent use of the aforementioned “elevator technique”. This article opens a series of publications concerning anatomy, technique of examination and pathologies of peripheral nerves.Ultrasonografia jest uznaną metodą obrazowania nerwów obwodowych, stanowiącą uzupełnienie badania klinicznego, elektromiografii oraz badania metodą rezonansu magnetycznego. Pozwala na rozpoznanie neuropatii na tle zespołów uciskowych, zmian pourazowych nerwów, zmian nowotworowych i zapalnych nerwów oraz na ocenę powikłań pooperacyjnych. W niektórych sytuacjach staje się metodą z wyboru. Coraz częściej jest wykorzystywana w anestezjologii celem prowadzenia znieczuleń regionalnych. Podobnie jak w przypadku innych rodzajów badań ultrasonograficznych, diagnostyka nerwów obwodowych ma nieinwazyjny charakter, jest dobrze tolerowana przez pacjentów i względnie tania. W artykule przedstawiono budowę histologiczną nerwów obwodowych w korelacji z obrazem ultrasonograficznym oraz technikę badania na przykładzie nerwu pośrodkowego, załączając szereg schematów i zdjęć ultrasonograficznych. Opisano sposób interpretacji kształtu, echogeniczności, grubości, unaczynienia nerwu, a także jego stosunku do otaczających tkanek. Wyjaśniono „technikę windy”, polegającą na odnalezieniu nerwu w charakterystycznym punkcie anatomicznym i śledzeniu go w kierunku obwodowym bądź dogłowowym. Zwrócono uwagę na niekwestionowane zalety badania ultrasonograficznego i tym samym jego przewagę nad innymi metodami diagnostycznymi, jakimi są badanie dynamiczne i możliwość jednoczasowej konfrontacji dolegliwości pacjenta z obrazem ultrasonograficznym. Przedstawiono szczegółową anatomię prawidłową i ultrasonograficzną nerwu pośrodkowego. Opisano przebieg nerwu, jego podziały i charakterystyczne punkty referencyjne, ułatwiające jego odnalezienie i identyfikację, a następnie śledzenie wspomnianą „techniką windy”. Artykuł otwiera cykl prac dotyczących anatomii, techniki badania oraz patologii nerwów obwodowych