Plain radiographs are still the most common imaging studies done for evaluation and management of rheumatic diseases. Techniques such as magnetic resonance imaging (MRI) and radionuclide scintigraphy (bone scan) are being used more often, although costly and often unnecessary. Many arthritides have characteristic radiographic findings, but these techniques are not indicated for most patients with acute and new symptoms of SLE, gout, mechanical lower back pain, or RA, because radiographs are usually normal early in the course of the disease. Normal radiographs also do not rule out OA. In established RA, the physician might see periarticular osteoporosis, soft tissue swelling, and marginal erosions. Gouty erosions cause characteristic overhanging edges because of reparative changes. (See also Chapter 31.)
The severity of radiographic changes in association with severe symptoms can help guide the aggressiveness of treatment. Overreliance on radiographs, however, can lead to undertreatment or overtreatment of disease. Treatment of RA with a DMARD should usually be initiated long before severe radiographic abnormalities are present. The near-ubiquitous presence of osteophytes on the lumbar vertebrae should not be used to justify aggressive surgical treatment for low back pain; on the other hand, many patients with chronic lower back pain have normal lumbar radiographs. Radiographs for acute joint symptoms might be helpful to rule out fractures, metastases, or infection, especially in older patients. If symptoms persist for more than 10 days, the physician should consider repeat radiography, looking for callus formation.
Besides rotator cuff injuries, MRI studies are particularly useful for possible cruciate ligament, complete lateral collateral ligament (LCL), and meniscal tears in the knee for potential surgical candidates. Although expensive, MRI shows soft tissue destruction long before plain radiographs. Bone scans also are costly and are nonspecific but demonstrate RA changes before radiographs.
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