How to Use Imaging in Juvenile Idiopathic Arthritis

A task force of rheumatologists, radiologists and patients has developed nine points to consider in the clinical management of juvenile idiopathic arthritis (JIA). After conducting a systematic review of 204 studies, the expert group from nine countries discusses the role of imaging in making a diagnosis of JIA, detecting and monitoring inflammation and damage, predicting outcome and response to treatment, use of guided therapies, progression and remission.

The task force felt that the supporting data was not sufficient to produce recommendations and instead categorized nine points to consider: 

Making a diagnosis of juvenile idiopathic arthritis

 1. Ultrasound and magnetic resonance imaging are superior to clinical examination in the evaluation of joint inflammation. These techniques should be considered for more accurate detection of inflammation, in diagnosis and assessing extent of joint involvement.  2. When there is clinical diagnostic doubt, conventional radiography, ultrasound or magnetic resonance imaging can be used to improve the certainty of a diagnosis of juvenile idiopathic arthritis above clinical features alone. 

Detecting damage 

3. If detection of structural abnormalities or damage is required, conventional radiography can be used. However magnetic resonance imaging or ultrasound may be used to detect damage at an earlier time point than conventional radiography. 

Imaging specific joints 

4. In juvenile idiopathic arthritis imaging may be of particular benefit over routine clinical evaluation when assessing certain joints, particularly the use of magnetic resonance imaging in detecting inflammation of the temporomandibular joint (TMJ) and axial involvement. 

Prognosis 

5. Imaging in juvenile idiopathic arthritis may be considered for use as a prognostic indicator. Damage on conventional radiography can be used for the prediction of further joint damage. Persistent inflammation on ultrasound and magnetic resonance imaging may be predictive of subsequent joint damage. 

Monitoring inflammation 

6. In juvenile idiopathic arthritis, ultrasound and magnetic resonance imaging can be useful in monitoring disease activity given their sensitivity over clinical examination and good responsiveness. Magnetic resonance imaging should be considered for monitoring axial disease and temporomandibular joints.

Monitoring damage

 7. The periodic evaluation of joint damage should be considered. The imaging modality used may be joint dependent. 

Guided treatment 

8. Ultrasound can be used for accurate placement of intra-articular injections.

 Remission 

9. Ultrasound and magnetic resonance imaging can detect inflammation when clinically inactive disease is present; this may have implications for monitoring. The task force concluded: “There is still significant research needed in this field, in particular consensus on understanding normative data to allow the interpretation of imaging abnormalities, agreement on appropriate MRI protocols and definitions of bone marrow edema, synovitis and erosions, and suitability of the imaging modalities for detecting changes at specific joints.” It also noted there are differences between imaging children and adults with arthritis, with consideration given to repeated unnecessary exposure to imaging. 

References:

Colebatch-Bourn AN, Edwards CJ, et al. "EULAR-PReS points to consider for the use of imaging in the diagnosis and management of juvenile idiopathic arthritis in clinical practice,"Ann Rheum Dis. Published Online First 5 August 2015 (http://dx.doi.org/10.1136/annrheumdis-2015-207892).