The Role of Imaging Studies in Today’s Rheumatology









Stephen A. Paget, MD, FACP, FACR, MACR, Editor
The rheumatologist is the ultimate medical detective, using carefully collected pieces of clinical information to fill in a tapestry that defines, with clarity, the diagnosis and leads finally to a well-honed therapeutic approach to an oftentimes complex presentation. It is said that 80% of the diagnosis is based on the “clinical equation” that derives mostly from the history and an illuminating bit from the physical examination. The history and physical examination are the most powerful “biomarkers,” especially in the hands of a master clinician. Although a smaller percentage of the final diagnosis is based on and guided by laboratory tests and imaging studies, these play a critically important role in further refining and clarifying the diagnosis, the extent of disease (EOD, borrowed from our oncology brethren), type, character and amount of visceral damage, and importantly, the response to treatment. The latter is key because our clinical microscope can only “see” just so far and thus we need other more sensitive tools to define with greater precision what is going on in the tissues that we are trying to protect. The perfect example of this is the fact that while we feel comfortable in defining remission and therapeutic victory in the treatment of rheumatoid arthritis with the use of validated scores such as the DAS28, a significant proportion of patients so classified have active inflammation on ultrasound and power Doppler. Stopping the development of erosions is the holy grail of the treatment of rheumatoid arthritis, one of the rheumatologist’s most common foes, but while we employ all kinds of clinical proxies to augur their presence, we are in the dark without the use of imaging.


The number, sensitivity, specificity, accuracy, and diagnostic power of imaging modalities have grown exponentially over the past 30 years and with them have grown our use of and reliance on them. This has occurred because of the excellent clinical-radiologic correlations that have been made by the many rheumatologists who now have cerebral “hard drives” that contain expertise in both areas.


The following clinical vignettes nicely highlight the role of imaging studies in the modern practice of rheumatology will also compare and contrast how decisions would have been made in the time before and after the imaging study was available.


Case 1: rheumatoid arthritis


A 45-year-old woman is being treated by her rheumatologist for seropositive rheumatoid arthritis of 5 years’ duration. She is at a critical point in her care because her rheumatologist believes her current regimen of low-dose prednisone, full-dose subcutaneous methotrexate, and meloxicam has not halted the inflammation or disease progression. Her rheumatologist feels that, on the basis of her clinical assessment, the persistently elevated erythrocyte sedimentation rate, C-reactive protein (CRP), and the presence of anemia and thrombocytosis, high CDAI score, and low MDHAQ, her disease is active and uncontrolled and an anti-tumor necrosis factor (TNF) should be added to her current regimen. However, she is afraid to move on to even more powerful drugs because of their potential side effects, and the devil she is comfortable with and has already learned to live with is better than the devil she doesn’t know. Recent plain radiographs of the hands show no erosions or joint space narrowing, a fact that gives her comfort and supports remaining on her current regimen.


Old paradigm: The rheumatologist would base his/her recommendation on clinical grounds and plain radiographs, and the likelihood that, without a change in treatment, damage will likely ensue.


New paradigm: Given the fact that ultrasound and magnetic resonance imaging (MRI) can detect erosions 2 years before a plain radiograph shows them, an ultrasound of the dominant right hand was performed and the patient was able to actually see the presence of erosions, the power Doppler demonstration of active inflammation on power Doppler (“imaging sedimentation rate”), and synovial hypertrophy and tenosynovial thickening. Based on this, she agrees to starting an anti-TNF and obtaining follow-up ultrasounds at least every year to be sure that her inflammation remains tightly controlled and can be correlated with clinical parameters.

Only gold members can continue reading. Log In or Register to continue

Stay updated, free articles. Join our Telegram channel

Oct 1, 2017 | Posted by in RHEUMATOLOGY | Comments Off on The Role of Imaging Studies in Today’s Rheumatology

Full access? Get Clinical Tree

Get Clinical Tree app for offline access