The role of imaging methods in the diagnosis and management of axial spondyloarthritis

Authors

  • I.Yu. Golovach Clinical Hospital “Feofaniya” of the Agency of State Affairs, Kyiv, Ukraine,
  • Ye.D. Yehudina Modern Rheumatology Clinic, Kyiv, Ukraine,
  • S.Kh. Ter-Vartanіan Modern Rheumatology Clinic, Kyiv, Ukraine,

DOI:

https://doi.org/10.22141/1608-1706.1.21.2020.197805

Keywords:

axial spondyloarthritis, diagnosis, magnetic resonance imaging, computed tomography, radiography

Abstract

Difficulties in the diagnosis of spondyloarthritis are mainly due to the slow, usually for several years, development of characteristic radiological changes (sacroiliitis, syndesmophytes, etc.). Magnetic resonance imaging (MRI) of the sacroiliac joints is considered the leading imaging method in the early diagnosis of axial spondyloarthritis and plays an important role in predicting the disease course. MRI helps detect inflammatory changes in various tissues, primarily bone edema, which precedes the development of structural changes. However, the limited access to MRI, the high cost of this study, and the lack of expertise in interpretation have revived interest in computed tomography (CT), especially the development of low-intensity radiation protocols for assessing the sacroiliac joints. Trials evaluating the efficacy of tumor necrosis factor inhibitors in patients with non-radiographic axial spondyloarthritis have led to a better understanding of MRI and CT role in selecting patients, which might respond well to this therapy. The diagnostic value of active and structural damage in assessing prognostic risk and selecting the appropriate treatment is also an area of modern researches. The purpose of this literature review is to characterize the diagnostic assessment of axial spondyloarthritis using conventional radiography, CT and MRI and the possibility of applying various methods in practice. New promising data are discussed explaining the evolution of recently described MRI lesions and how these data can improve understanding of MRI role as a diagnostic and prognostic tool according to new recommendations of the Assessment of SpondyloArthritis international Society for MRI diagnosis of axial spondyloarthritis.

References

Maksymowyc W.P. The role of imaging in the diagnosis and management of axial spondyloarthritis. Nature Reviews. Rheumatology. 2019. 15(11). 657-672. https://doi.org/10.1038/s41584-019-0309-4.

van Mens L.J., van de Sande M.G., Baeten D.L. New treatment paradigms in spondyloarthritis. Curr. Opin. Rheumatol. 2018. 30. 79-86. doi: 10.1097/BOR.0000000000000457.

Dougados M., D'Agostino M.A., Benessiano J. et al. The DESIR cohort: a 10-year follow-up of early inflammatory back pain in France: study design and baseline characteristics of the 708 recruited patients. Joint Bone Spine. 2011. 78(6). 598-603. doi: 10.1016/j.jbspin.2011.01.013.

Dougados M., Sepriano A., Molto A. et al. Sacroiliac radiographic progression in recent onset axial spondyloarthritis: the 5-year data of the DESIR cohort. Ann. Rheum. Dis. 2017. 76(11). 1823-1828. doi: 10.1136/annrheumdis-2017-211596.

van den Berg R., de Hooge M., van Gaalen F., Reijnierse M., Huizinga T., van der Heijde D. Percentage of patients with spondyloarthritis in patients referred because of chronic back pain and performance of classification criteria: experience from the Spondyloarthritis Caught Early (SPACE) cohort. Rheumatology. 2013. 52(8). 1492-1499. doi: 10.1093/rheumatology/ket164.

Ez-Zaitouni Z., Bakker P.A.C., van Lunteren M. et al. Presence of multiple spondyloarthritis (SpA) features is important but not sufficient for a diagnosis of axial spondyloarthritis: data from the SPondyloArthritis Caught Early (SPACE) cohort. Ann. Rheum. Dis. 2017. 76(6). 1086-1092. doi: 10.1136/annrheumdis-2016- 210119.

Diekhoff T., Hermann K.G., Greese J. et al. Comparison of MRI with radiography for detecting structural lesions of the sacroiliac joint using CT as standard of reference: results from the SIMACT study. Ann. Rheum. Dis. 2017. 76(9). 1502-1508. doi: 10.1136/annrheumdis-2016-210640.

Mandl P., Navarro-Compán V., Terslev L. et al.

EULAR recommendations for the use of imaging in the diagnosis and management of spondyloarthritis in clinical practice. Ann. Rheum. Dis. 2015. 74(7). 1327-1339. doi: 10.1136/annrheumdis-2014-206971.

Sudoł-Szopińska I., Jurik A.G., Eshed I. et al. Recommendations of the ESSR Arthritis Subcommittee for the use of magnetic resonance imaging in musculoskeletal rheumatic diseases. Semin. Musculoskelet. Radiol. 2015. 19(4). 396-411. doi: 10.1055/s-0035-1564696.

Park J.W., Kim M.J., Lee J.S. et al. Impact of tumor necrosis factor inhibitor versus nonsteroidal antiinflammatory drug treatment on radiographic progression in early ankylosing spondylitis: its relationship to inflammation control during treatment. Arthritis Rheumatol. 2019. 71(1). 82-90. doi: 10.1002/art.40661.

Devauchelle-Pensec V., D'Agostino M.A., Marion J., Lapierre M. Computed tomography scanning facilitates the diagnosis of sacroiliitis in patients with suspected spondylarthritis. Arthritis Rheum. 2012. 64(5). 1412-1419. doi: 10.1002/art.33466.

Chahal B.S., Kwan A.L.C., Dhillon S.S. et al. Radiation exposure to the sacroiliac joint from low-dose CT compared with radiography. Am. J. Radiol. 2018. 211(5). 1058-1062. doi: 10.2214/AJR.18.19678.

Li S.G., Liu X., Zhou H., Zhang Q. Interrater reliability and radiation dosage of oblique coronal computed tomography. Br. J. Radiol. 2018. 91(1081). 20150700. doi: 10.1259/bjr.20150700.

de Koning A., de Bruin F., van den Berg R. et al. Low-dose CT detects more progression of bone formation in comparison to conventional radiography in patients with ankylosing spondylitis: results from the SIAS cohort. Ann. Rheum. Dis. 2018. 77(2). 293-299. doi: 10.1136/annrheumdis-2017-211989.

Ez-Zaitouni Z., Robert L., van Lunteren M. et al. Ima-ging of the sacroiliac joints is important for diagnosing early axial spondyloarthritis but not all-decisive. Rheumatology. 2018. 57(7). 1173-1179. https://doi.org/10.1093/rheumatology/key035

Greese J., Diekhoff T., Sieper J. et al. Detection of sacroiliitis by short-tau inversion recovery and T2-weighted turbo spin echo sequences: results from the SIMACT Study. J. Rheumatol. 2019. 46(4). 376-383. doi: 10.3899/jrheum.171425.

Weber U., Lambert R.G., Østergaard M., Hodler J., Pedersen S.J., Maksymowych W.P. The diagnostic utility of magnetic resonance imaging in spondylarthritis: an international multicenter evaluation of one hundred eightyseven subjects. Arthritis Rheum. 2010. 62(10). 3048-3058. doi: 10.1002/art.27571.

Rudwaleit M., van der Heijde D., Khan M., Braun J., Sieper J. How to diagnose axial spondyloarthritis early. Ann. Rheum. Dis. 2004. 63(5). 535-543. doi: 10.1136/ard.2003.011247.

de Hooge M., van den Berg R., Navarro-Compán V. et al. Magnetic resonance imaging of the sacroiliac joints in the early detection of spondyloarthritis: no added value of gadolinium compared with short tau inversion recovery sequence. Rheumatology. 2013. 52(7). 1220-1224. doi: 10.1093/rheumatology/ket012.

Maksymowych W.P., Wichuk S., Chiowchanwisawakit P., Lambert R.G., Pedersen S.J. Development and preliminary validation of the Spondyloarthritis Research Consortium of Canada magnetic resonance imaging sacroiliac joint structural score. J. Rheumatol. 2015. 42(1). 79-86. doi: 10.3899/jrheum.140519.

Maksymowych W.P., Lambert R.G., Østergaard M. et al.

MRI lesions in the sacroiliac joints of patients with spondyloarthritis: update of definitions and validation by the ASAS MRI working group. Ann. Rheum. Dis. 2019. 78(11). 1550-1558. doi: 10.1136/annrheumdis-2019-215589.

Rudwaleit M., Jurik A.G., Hermann K.G. et al. Defi­ning active sacroiliitis on magnetic resonance imaging (MRI) for classification of axial spondyloarthritis: a consensual approach by the ASAS/OMERACT MRI group. Ann. Rheum. Dis. 2009. 68(10). 1520-1527. doi: 10.1136/ard.2009.110767.

van den Berg R., Lenczner G., Thévenin F. et al. Classification of axial SpA based on positive imaging (radiographs and/or MRI of the sacroiliac joints) by local rheumatologists or radiologists versus central trained readers in the DESIR cohort. Ann. Rheum. Dis. 2015. 74(11). 2016-2021. doi: 10.1136/annrheumdis-2014-205432.

Bakker P.A.C., Ramiro S., Ez-Zaitouni Z. et al. Is it useful to repeat magnetic resonance imaging of the sacroiliac joints after three months or one year in the diagnosis of patients with chronic back pain and suspected axial spondyloarthritis? Arthritis Rheumatol. 2019. 71(3). 382-391. doi: 10.1002/art.40718.

Weber U., Jurik A.G., Zejden A. et al. Frequency and anatomic distribution of magnetic resonance imaging features in the sacroiliac joints of young athletes: exploring “background noise” toward a data-driven definition of sacroiliitis in early spondyloarthritis. Arthritis Rheumatol. 2018. 70. 736-745. https://doi.org/10.1002/art.40429.

Weber U., Østergaard M., Lambert R.G. et al. Candidate lesion-based criteria for defining a positive sacroiliac joint MRI in two cohorts of patients with axial spondyloarthritis. Ann. Rheum. Dis. 2015. 74(11). 1976-1982. doi: 10.1136/annrheumdis-2014-205408.

Gong Y., Zheng N., Chen S.B. et al. Ten years’ experience with needle biopsy in the early diagnosis of sacroiliitis. Arthritis Rheum. 2012. 64. 1399-1406. https://doi.org/10.1002/art.33453.

de Winter J., de Hooge M., van de Sande M. et al. Magnetic resonance imaging of the sacroiliac joints indicating sacroiliitis according to the Assessment of SpondyloArthritis international Society definition in healthy individuals, runners, and women with postpartum back pain. Arthritis Rheumatol. 2018. 707. 1042-1048. doi: 10.1002/art.40475.

Varkas G., de Hooge M., Renson T. et al. Effect of mechanical stress on magnetic resonance imaging of the sacroiliac joints: assessment of military recruits by magnetic resonance imaging study. Rheumatology. 2018. 57(3). 508-513. doi: 10.1093/rheumatology/kex491.

Arnbak B., Grethe Jurik A., Hørslev-Petersen K. et al. Associations between spondyloarthritis features and magnetic resonance imaging findings: a cross-sectional analysis of 1,020 patients with persistent low back pain. Arthritis Rheumatol. 2016. 68(4). 892-900. doi: 10.1002/art.39551.

Eshed I., Miloh-Raz H., Dulitzki M. et al. Peripartum changes of the sacroiliac joints on MRI: increasing mechanical load correlating with signs of edema and inflammation kindling spondyloarthropathy in the genetically prone. Clin. Rheumatol. 2015. 34(8). 1419-1426. doi: 10.1007/s10067-015-2976-0.

Ling M.A., Gao Z., Zhong Y., Meng Q. Osteitis condensans ilii may demonstrate bone marrow edema on sacroiliac joint magnetic resonance imaging. Int. J. Rheum. Dis. 2018. 21(1). 299-307. doi: 10.1111/1756-185X.13125.

Weber U., Pedersen S.J., Zubler V. et al. Fat infiltration on magnetic resonance imaging of the sacroiliac joints has limited diagnostic utility in nonradiographic axial spondyloarthritis. J. Rheumatol. 2014. 41(1). 75-83. doi: 10.3899/jrheum.130568.

de Hooge M., van den Berg R., Navarro-Compán V. et al. Patients with chronic back pain of short duration from the SPACE cohort: which MRI structural lesions in the sacroiliac joints and inflammatory and structural lesions in the spine are most specific for axial spondyloarthritis? Ann. Rheum. Dis. 2016. 75(7). 1308-1314. doi: 10.1136/annrheumdis-2015-207823.

Maksymowych W.P., Wichuk S., Dougados M. et al. MRI evidence of structural changes in the sacroiliac joints of patients with nonradiographic axial spondyloarthritis even in the absence of MRI inflammation. Arthritis Res. Ther. 2017. 19(1). 126. doi: 10.1186/s13075-017-1342-9.

Maksymowych W.P., Wichuk S., Chiowchanwi­sawakit P., Lambert R.G., Pedersen S.J. Fat metaplasia and backfill are key intermediaries in the development of sacroiliac joint ankylosis in patients with ankylosing spondylitis. Arthritis Rheumatol. 2014. 66(11). 2958-2967. doi: 10.1002/art.38792.

Maksymowych W.P., Wichuk S., Dougados M. et al. Modification of structural lesions on magnetic resonance imaging of the sacroiliac joints by etanercept in the EMBARK trial: a 12-week randomised placebo-controlled trial in patients with non-radiographic axial spondyloarthritis. Ann. Rheum. Dis. 2018. 77. 78-84. http://dx.doi.org/10.1136/annrheumdis-2017-211605.

Laloo F., Herregods N., Varkas G. et al. MR signal in the sacroiliac joint space in spondyloarthritis: a new sign. Eur. Radiol. 2017. 27(5). 2024-2030. doi: 10.1007/s00330-016-4587-9.

Azmat O., Lambert R.G., Jibri Z., Maksymowych W.P. Subchondral bone sclerosis on computed tomography — does it have any value in the diagnosis of inflammatory sacroiliitis or is it a nonspecific finding? [abstract 684]. Arthritis Rheumatol. 2016. 68(10). 899-901.

Hermann K.G., Baraliakos X., van der Heijde D.M. et al. Descriptions of spinal MRI lesions and definition of a positive MRI of the spine in axial spondyloarthritis: a consensual approach by the ASAS/OMERACT MRI study group. Ann. Rheum. Dis. 2012. 71(8). 1278-1288. doi: 10.1136/ard.2011.150680.

Weber U., Zubler V., Zhao Z. et al. Does spinal MRI add incremental diagnostic value to MRI of the sacroiliac joints alone in patients with non-radiographic axial spondyloarthritis? Ann. Rheum. Dis. 2015. 74(6). 985-992. doi: 10.1136/annrheumdis-2013-203887.

Weber U., Zhao Z., Rufibach K. et al. Diagnostic uti­lity of candidate definitions for a positive MRI of the spine in patients with axial spondyloarthritis. Arthritis Rheumatol. 2015. 67(4). 924-933. doi: 10.1002/art.39001.

Ez-Zaitouni Z., Bakker P.A., van Lunteren M. et al. The yield of a positive MRI of the spine as imaging criterion in the ASAS classification criteria for axial spondyloarthritis: results from the SPACE and DESIR cohorts. Ann. Rheum. Dis. 2017. 76(10). 1731-1736. doi: 10.1136/annrheumdis-2017-211486.

de Bruin F., Treyvaud M.O., Feydy A. et al. Prevalence of degenerative changes and overlap with spondyloarthritis-associated lesions in the spine of patients from the DESIR cohort. RMD Open. 2018. 4(1). e000657. doi: 10.1136/rmdopen-2018-000657.

Rennie W.J., Dhillon S.S., Conner-Spady B., Maksymowych W.P., Lambert R.G. Magnetic resonance imaging assessment of spinal inflammation in ankylosing spondylitis: standard clinical protocols may omit inflammatory lesions in thoracic vertebrae. Arthritis Rheum. 2009. 61(9). 1187-1193. doi: 10.1002/art.24561.

Blachier M., Coutanceau B., Dougados M. et al. Does the site of magnetic resonance imaging abnormalities match the site of recent-onset inflammatory backpain? The DESIR cohort. Ann. Rheum. Dis. 2013. 72(6). 979-985. doi: 10.1136/annrheumdis-2012-201427.

de Hooge M., de Bruin F., de Beer L. et al. Is the site of back pain related to the location of magnetic resonance ima-ging lesions in patients with chronic back pain? Results from the Spondyloarthritis Caught Early Cohort. Arthritis Care Res. 2017. 69(5). 717-723. doi: 10.1002/acr.22999.

Sepriano A., Rubio R., Ramiro S. et al. Performance of the ASAS classification criteria for axial and peripheral spondyloarthritis: a systematic literature review and meta-analysis. Ann. Rheum. Dis. 2017. 76(5). 886-890. doi: 10.1136/annrheumdis-2016-210747.

Sepriano A., Rubio R., Ramiro S., Landewé R., van der Heijde D. Predictive validity of the ASAS classification criteria for axial and peripheral spondyloarthritis after follow-up in the ASAS cohort: a final analysis. Ann. Rheum. Dis. 2016. 75. 1034-1042.

Ez-Zaitouni Z., van Lunteren M., Bakker P.A.C. et al. The influence of discrepant imaging judgements on the classification of axial spondyloarthritis is limited: a replication in the SpondyloArthritis Caught Early (SPACE) cohort. Ann. Rheum. Dis. 2018. 77(1). e1. doi: 10.1136/annrheumdis-2017-211553.

Bakker P.A., van den Berg R., Lenczner G. et al. Can we use structural lesions seen on MRI of the sacroiliac joints reliably for the classification of patients according to the ASAS axial spondyloarthritis criteria? Data from the DESIR cohort. Ann. Rheum. Dis. 2017. 76. 392-398. doi: 10.1136/annrheumdis-2016-209405.

Bakker P.A., van den Berg R., de Hooge M. et al. Impact of replacing radiographic sacroiliitis by magnetic resonance ima-

ging structural lesions on the classification of patients with axial spondyloarthritis. Rheumatology. 2018. 57(7). 1186-1193. https://doi.org/10.1093/rheumatology/kex532.

Molnar C., Scherer A., Baraliakos X. et al. TNF blockers inhibit spinal radiographic progression in ankylosing spondylitis by reducing disease activity: results from the Swiss Clinical Quality Management cohort. Ann. Rheum. Dis. 2018. 77(1). 63-69. doi: 10.1136/annrheumdis-2017-211544.

Ramiro S., Stolwijk C., van Tubergen A. et al. Evolution of radiographic damage in ankylosing spondylitis: a 12-year prospective follow-up of the OASIS study. Ann. Rheum. Dis. 2015. 74. 52-59. doi.org/10.1136/ annrheumdis-2013-204055.

Ramiro S., van der Heijde D., Sepriano A. et al. Spinal radiographic progression in early axial spondyloarthritis: five-year results from the DESIR cohort. Arthritis Care Res. 2019. 71(12). 1678-1684. doi: 10.1002/acr.23796.

Sieper J., van der Heijde D., Dougados M. et al. Efficacy and safety of adalimumab in patients with non-radiographic axi-

al spondyloarthritis: results of a randomised placebo-controlled trial (ABILITY-1). Ann. Rheum. Dis. 2013. 72(6). 815-822. doi: 10.1136/annrheumdis-2012-201766.

Sieper J., van der Heijde D., Dougados M. et al. A randomized, double-blind, placebo-controlled, sixteen-week study of subcutaneous golimumab in patients with active nonradiographic axial spondyloarthritis. Arthritis Rheumatol. 2015. 67(10). 2702-2712. doi: 10.1002/art.39257.

Molto A., Paternotte S., Claudepierre P., Breban M., Dougados M. Effectiveness of tumor necrosis factor α blockers in early axial spondyloarthritis: data from the DESIR cohort. Arthritis Rheumatol. 2014. 66(7). 1734-1744. doi: 10.1002/art.38613.

Baraliakos X., Sieper J., Chen S. et al. Non-radiogra-phic axial spondyloarthritis patients without initial evidence of inflammation may develop objective inflammation over time. Rheumatology. 2017. 56(7). 1162-1166. doi: 10.1093/rheumatology/kex081.

Sengupta R., Marzo-Ortega H., McGonagle D. et al. Short-term repeat magnetic resonance imaging scans in suspected early axial spondyloarthritis are clinically relevant only in HLA-B27-positive male subjects. J. Rheumatol. 2018. 45(2). 202-205. doi: 10.3899/jrheum.170171.

Poddubnyy D., Rudwaleit M., Haibel H. et al. Rates and predictors of radiographic sacroiliitis progression over 2 years in patients with axial spondyloarthritis. Ann. Rheum. Dis. 2011. 70(8). 1369-1374. doi: 10.1136/ard.2010.145995.

Sepriano A., Ramiro S., Landewé R., Dougados M., van der Heijde D., Rudwaleit M. Is active sacroiliitis on MRI associated with radiographic damage in axial spondyloarthritis? Real-life data from the ASAS and DESIR cohorts. Rheumatology. 2019. 58(5). 798-802. doi: 10.1093/rheumatology/key387.

Machado P.M., Baraliakos X., van der Heijde D., Braun J., Landewé R. MRI vertebral corner inflammation followed by fat deposition is the strongest contributor to the development of new bone at the same vertebral corner: a multilevel longitudinal analysis in patients with ankylosing spondylitis. Ann. Rheum. Dis. 2016. 75(8). 1486-1493. doi: 10.1136/annrheumdis-2015-208011.

Baraliakos X., Heldmann F., Callhoff J. et al. Which spinal lesions are associated with new bone formation in patients with ankylosing spondylitis treated with anti-TNF agents? A long-term observational study using MRI and conventional radiography. Ann. Rheum. Dis. 2014. 73(10). 1819-1825. doi: 10.1136/annrheumdis-2013-203425.

Maksymowych W.P., Wichuk S., Chiowchanwisawakit P., Lambert R.G., Pedersen S.J. Fat metaplasia on MRI of the sacroiliac joints increases the propensity for disease progression in the spine of patients with spondyloarthritis. RMD Open. 2017. 3(1). e000399. doi: 10.1136/rmdopen-2016-000399.

Published

2020-02-01

Issue

Section

To Practitioner