Choose wisely: imaging for diagnosis of axial spondyloarthritis

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Abstract

Objective

To assess the diagnostic accuracy of radiography (X-ray, XR), CT and MRI of the sacroiliac joints for diagnosis of axial spondyloarthritis (axSpA).

Methods

163 patients (89 with axSpA; 74 with degenerative conditions) underwent XR, CT and MR. Three blinded experts categorised the imaging findings into axSpA, other diseases or normal in five separate reading rounds (XR, CT, MR, XR +MR, CT +MR). The clinical diagnosis served as reference standard. Sensitivity and specificity for axSpA and inter-rater reliability were compared.

Results

XR showed lower sensitivity (66.3%) than MR (82.0%) and CT (76.4%) and also an inferior specificity of 67.6% vs 86.5% (MR) and 97.3% (CT). XR +MR was similar to MR alone (sensitivity 77.5 %/specificity 87.8%) while CT+MR was superior (75.3 %/97.3%). CT had the best inter-rater reliability (kappa=0.875), followed by MR (0.665) and XR (0.517). XR +MR was similar (0.662) and CT+MR (0.732) superior to MR alone.

Conclusions

XR had inferior diagnostic accuracy and inter-rater reliability compared with cross-sectional imaging. MR alone was similar in diagnostic performance to XR+MR. CT had the best accuracy, strengthening the importance of structural lesions for the differential diagnosis in axSpA.

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Most cited references 18

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The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part II): validation and final selection.

M Rudwaleit, D van der Heijde, R Landewé … (2009)

To validate and refine two sets of candidate criteria for the classification/diagnosis of axial spondyloarthritis (SpA). All Assessment of SpondyloArthritis international Society (ASAS) members were invited to include consecutively new patients with chronic (> or =3 months) back pain of unknown origin that began before 45 years of age. The candidate criteria were first tested in the entire cohort of 649 patients from 25 centres, and then refined in a random selection of 40% of cases and thereafter validated in the remaining 60%. Upon diagnostic work-up, axial SpA was diagnosed in 60.2% of the cohort. Of these, 70% did not fulfil modified New York criteria and, therefore, were classified as having "non-radiographic" axial SpA. Refinement of the candidate criteria resulted in new ASAS classification criteria that are defined as: the presence of sacroiliitis by radiography or by magnetic resonance imaging (MRI) plus at least one SpA feature ("imaging arm") or the presence of HLA-B27 plus at least two SpA features ("clinical arm"). The sensitivity and specificity of the entire set of the new criteria were 82.9% and 84.4%, and for the imaging arm alone 66.2% and 97.3%, respectively. The specificity of the new criteria was much better than that of the European Spondylarthropathy Study Group criteria modified for MRI (sensitivity 85.1%, specificity 65.1%) and slightly better than that of the modified Amor criteria (sensitivity 82.9, specificity 77.5%). The new ASAS classification criteria for axial SpA can reliably classify patients for clinical studies and may help rheumatologists in clinical practice in diagnosing axial SpA in those with chronic back pain. NCT00328068.

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The Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to assess spondyloarthritis.

J Sieper, M Rudwaleit, X Baraliakos … (2009)

The field of spondyloarthritis (SpA) has experienced major progress in the last decade, especially with regard to new treatments, earlier diagnosis, imaging technology and a better definition of outcome parameters for clinical trials. In the present work, the Assessment in SpondyloArthritis international Society (ASAS) provides a comprehensive handbook on the most relevant aspects for the assessments of spondyloarthritis, covering classification criteria, MRI and x rays for sacroiliac joints and the spine, a complete set of all measurements relevant for clinical trials and international recommendations for the management of SpA. The handbook focuses at this time on axial SpA, with ankylosing spondylitis (AS) being the prototype disease, for which recent progress has been faster than in peripheral SpA. The target audience includes rheumatologists, trial methodologists and any doctor and/or medical student interested in SpA. The focus of this handbook is on practicality, with many examples of MRI and x ray images, which will help to standardise not only patient care but also the design of clinical studies.

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MRI lesions in the sacroiliac joints of patients with spondyloarthritis: an update of definitions and validation by the ASAS MRI working group

Walter Maksymowych, Robert Lambert, Mikkel Østergaard … (2019)

The Assessment of SpondyloArthritis international Society (ASAS) MRI working group (WG) was convened to generate a consensus update on standardised definitions for MRI lesions in the sacroiliac joint (SIJ) of patients with spondyloarthritis (SpA), and to conduct preliminary validation. The literature pertaining to these MRI lesion definitions was discussed at three meetings of the group. 25 investigators (20 rheumatologists, 5 radiologists) determined which definitions should be retained or required revision, and which required a new definition. Lesion definitions were assessed in a multi-reader validation exercise using 278 MRI scans from the ASAS classification cohort by global assessment (lesion present/absent) and detailed scoring (inflammation and structural). Reliability of detection of lesions was analysed using kappa statistics and the intraclass correlation coefficient (ICC). No revisions were made to the current ASAS definition of a positive SIJ MRI or definitions for subchondral inflammation and sclerosis. The following definitions were revised: capsulitis, enthesitis, fat lesion and erosion. New definitions were developed for joint space enhancement, joint space fluid, fat metaplasia in an erosion cavity, ankylosis and bone bud. The most frequently detected structural lesion, erosion, was detected almost as reliably as subchondral inflammation (κappa/ICC:0.61/0.54 and 0.60/0.83) . Fat metaplasia in an erosion cavity and ankylosis were also reliably detected despite their low frequency (κappa/ICC:0.50/0.37 and 0.58/0.97). The ASAS-MRI WG concluded that several definitions required revision and some new definitions were necessary. Multi-reader validation demonstrated substantial reliability for the most frequently detected lesions and comparable reliability between active and structural lesions.

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Author and article information

Journal

Journal ID (nlm-ta): Ann Rheum Dis

Journal ID (iso-abbrev): Ann Rheum Dis

Journal ID (hwp): annrheumdis

Journal ID (publisher-id): ard

Title: Annals of the Rheumatic Diseases

Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )

ISSN (Print): 0003-4967

ISSN (Electronic): 1468-2060

Publication date (Print): February 2022

Publication date (Electronic): 28 May 2021

Volume: 81

Issue: 2

Pages: 237-242

Affiliations

[1 ] departmentDepartment of Radiology , Charité Universitätsmedizin Berlin , Berlin, Germany

[2 ] departmentRadiology , Sheba Medical Center , Tel Hashomer, Israel

[3 ] departmentDepartment of Gastroenterology, Infectiology and Rheumatology , Charite Universitatsmedizin Berlin Campus Benjamin Franklin , Berlin, Germany

[4 ] departmentDepartment of Rheumatology and Clinical Immunology , Charité Universitätsmedizin Berlin , Berlin, Germany

[5 ] departmentDivision of Gastroenterology, Infectious Diseases and Rheumatology , Charité Universitätsmedizin Berlin , Berlin, Germany

Author notes

[Correspondence to ] Torsten Diekhoff, Department of Radiology, Charité Universitätsmedizin Berlin, Berlin, Berlin, Germany; torsten.diekhoff@ 123456charite.de

Author information

Torsten Diekhoff http://orcid.org/0000-0003-3593-1449

Iris Eshed http://orcid.org/0000-0002-4655-9606

Katharina Ziegeler http://orcid.org/0000-0002-9763-2420

Fabian Proft http://orcid.org/0000-0003-4306-033X

Robert Biesen http://orcid.org/0000-0002-0434-7832

Denis Poddubnyy http://orcid.org/0000-0002-4537-6015

Article

Publisher ID: annrheumdis-2021-220136

DOI: 10.1136/annrheumdis-2021-220136

PMC ID: 8762031

PubMed ID: 34049855

SO-VID: a86ef9ec-7285-4d63-aa64-572a6ac6c83f

License:

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

History

Date received : 09 February 2021

Date accepted : 24 May 2021

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ScienceOpen disciplines: Immunology

Keywords: spondylitis,ankylosing,magnetic resonance imaging,low back pain

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ScienceOpen disciplines: Immunology

Keywords: spondylitis, ankylosing, magnetic resonance imaging, low back pain

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Choose wisely: imaging for diagnosis of axial spondyloarthritis

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Most cited references 18

The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part II): validation and final selection.

The Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to assess spondyloarthritis.

MRI lesions in the sacroiliac joints of patients with spondyloarthritis: an update of definitions and validation by the ASAS MRI working group

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