Where is imaging going in rheumatology?

Four new approaches to imaging are now becoming available. First is filmles s radiology, with flat detectors that 'permit access' to PACS, the picture archiving communication system, and teleteaching. Second is ultrasonography (US), involving three-dimensional volume, harmonic Doppler energy and digi tal technology techniques, with contrast agents and biopsy needles. Next is computer tomography (CT), using volume acquisition multislices, spiral rec onstruction and solid detectors, as well as multidetectors. Finally comes m agnetic resonance imaging (MRI). A low magnetic field with an open MRI scan permits interventional radiology in musculoskeletal disease. High magnetic fields are mainly used for clinical research and permit rapid examination, in approximately 10 minutes. In interventional radiology, many procedures can be performed with the guidance of digital radiography, US or MRI. Two a reas of localization have to be considered: the spine and the peripheral jo ints, particularly the shoulder, wrist and foot. Guidelines contribute to g ood medical practice, but there are other considerations, such as machine a ccessibility, the nature of the treatment, the personality of the patient a nd the role of the hospital. Overinvestigation has to be avoided for four r easons: an increase in patient anxiety, the cost of health-care management, the risk of irradiation and sometimes the lack of diagnostic value of thes e procedures. In rheumatoid arthritis, MRI can detect lesions at an earlier stage of their development and identify subtle lesions and synovitis. Imag ing (using x-rays, MRI and US) is important in the assessment of the effect iveness of slow-acting drugs in rheumatoid arthritis, especially since join t damage can progress in spite of a clinical improvement in joint inflammat ion. In the future, teletransmission, by the Internet or intranet and using PACS, will change our approach to the diagnosis of musculoskeletal disease . Future developments therefore include PACS, filmless radiology, the Inter net and intranet, harmonic US, multidetector CT scanning and open MRI on th e technical side, as well as the study of cartilage and international radio logy on the clinical side.