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Ziade N, Udod M, Kougkas N, Tsiami S, Baraliakos X. Significant overlap of inflammatory and degenerative features on imaging among patients with degenerative disc disease, diffuse idiopathic skeletal hyperostosis and axial spondyloarthritis: a real-life cohort study. Arthritis Res Ther 2024; 26:147. [PMID: 39097721 PMCID: PMC11297750 DOI: 10.1186/s13075-024-03359-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Accepted: 06/30/2024] [Indexed: 08/05/2024] Open
Abstract
BACKGROUND Differentiating between degenerative disc disease (DDD), diffuse idiopathic skeletal hyperostosis (DISH), and axial spondyloarthritis (axSpA) represents a diagnostic challenge in patients with low back pain (LBP). We aimed to evaluate the distribution of inflammatory and degenerative imaging features in a real-life cohort of LBP patients referred to a tertiary university rheumatology center. METHODS In a retrospective cross-sectional analysis of patients referred for LBP, demographics, symptom information, and available imaging were collected. SpA-like changes were considered in the spine in the presence of one of the following lesions typically related to SpA: erosions, sclerosis, squaring, and syndesmophytes on conventional radiographs (CR) and bone marrow oedema (BMO), erosions, sclerosis, and fat lesions (FL) on MRI. SIJ CR were graded per New York criteria; on MRIs, SIJs were evaluated by quadrant for BMO, erosions, FL, sclerosis and ankylosis, similar to the approach used by the Berlin SIJ MRI scoring system. The final diagnosis made by the rheumatologist was the gold standard. Data were presented descriptively, by patient and by quadrant, and compared among the three diagnosis groups. RESULTS Among 136 referred patients, 71 had DDD, 38 DISH, and 27 axSpA; median age 62 years [IQR55-73], 63% males. On CR, SpA-like changes were significantly higher in axSpA in the lumbar (50%, vs. DDD 23%, DISH 22%), in DISH in the thoracic (28%, vs. DDD 8%, axSpA 12%), and in DDD in the cervical spine (67% vs. DISH 0%, axSpA 33%). On MRI, BMO was significantly higher in DISH in the thoracic (37%, vs. DDD 22%, axSpA 5%) and equally distributed in the lumbar spine (35-42%). FL were significantly more frequently identified in DISH and axSpA in the thoracic (56% and 52%) and DDD and axSpA in the lumbar spine (65% and 74%, respectively). Degenerative changes were frequent in the three groups. Sacroiliitis (NY criteria) was identified in 49% (axSpA 76%, DDD 48%, DISH 29%). CONCLUSION A significant overlap was found among DDD, DISH, and axSpA for inflammatory and degenerative imaging features. Particularly, SpA-like spine CR features were found in one-fourth of patients with DISH, and MRI BMO was found in one-third of those patients.
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Affiliation(s)
- Nelly Ziade
- Hotel-Dieu De France, Saint Joseph University, Beirut, Lebanon
| | - Melanie Udod
- Rheumazentrum Ruhrgebiet Herne, Ruhr-University Bochum, Claudiusstr. 45, 44649, Herne, Germany
| | - Nikolaos Kougkas
- Fourth Department of Internal Medicine, Hippokration University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Styliani Tsiami
- Rheumazentrum Ruhrgebiet Herne, Ruhr-University Bochum, Claudiusstr. 45, 44649, Herne, Germany
| | - Xenofon Baraliakos
- Rheumazentrum Ruhrgebiet Herne, Ruhr-University Bochum, Claudiusstr. 45, 44649, Herne, Germany.
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Cheung STY, Tsang HHL, Cheung PWH, Cheung JPY. Male spondyloarthritis patients and those with longer disease duration have less severe disc degeneration: propensity score-matched comparison. Rheumatol Adv Pract 2024; 8:rkae015. [PMID: 38405075 PMCID: PMC10884529 DOI: 10.1093/rap/rkae015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/14/2024] [Indexed: 02/27/2024] Open
Abstract
Objective Using whole spine sagittal T2 MRI, we aimed to compare the severity and prevalence of disc degeneration (DD) in axial SpA patients vs the general population and to determine any association between spinal inflammation, structural changes, mobility and DD among SpA patients. Methods Two prospectively collected cohorts of SpA patients (n = 411) and the general population (n = 2007) were recruited. Eventually, 967 participants from the populational cohort and 304 participants from the SpA cohort were analysed. Two hundred and nineteen matched pairs were generated by propensity score matching. Imaging parameters, including Pfirrmann grading, disc herniation, high-intensity zone, Schmorl's node, Modic change and anterior marrow change were studied and compared from C2/3 to L5/S1. DD was defined as Pfirrmann grade 4 or 5. Demographic factors, including age, sex and BMI, were collected. Multivariable linear regression was used to determine the association between spinal inflammation [Spondyloarthritis Research Consortium of Canada (SPARCC) spine MRI index], structural changes [modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS)] and mobility (BASMI) with lumbar Pfirrmann score. Results SpA patients had lower prevalence of DD (P < 0.001). The disease stage-stratified regression model showed that SPARCC spinal MRI index was associated with higher lumbar Pfirrmann scores in early disease (β = 0.196, P = 0.044), whereas mSASSS was associated with lower lumbar Pfirrmann scores in later disease (β = -0.138, P = 0.038). Males had higher mSASSS (P < 0.001) and lower odds of whole spine DD (odds ratio = 0.622, P = 0.028). Conclusion SpA patients had lower DD severity than the general population. Males had higher mSASSSs, and increased mSASSS at later disease was associated with less severe DD.
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Affiliation(s)
- Samuel Tin Yan Cheung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China
| | - Helen Hoi Lun Tsang
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China
| | | | - Jason Pui Yin Cheung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China
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Baraliakos X, Pournara E, Coates LC, Navarro-Compán V, Blanco R, O’Brien E, Schulz B, Landewe R. Magnetic resonance imaging characteristics in patients with psoriatic arthritis and axial manifestations from the MAXIMISE cohort. Rheumatology (Oxford) 2024; 63:85-92. [PMID: 37094184 PMCID: PMC10765145 DOI: 10.1093/rheumatology/kead162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 02/23/2023] [Accepted: 03/30/2023] [Indexed: 04/26/2023] Open
Abstract
OBJECTIVE The current analysis of the MAXIMISE trial was conducted to investigate the presence of post-inflammatory and degenerative spinal changes and inflammatory changes in spinal processes identified in baseline MRIs and their potential for predicting differential treatment effects in a cohort of PsA patients with axial manifestations. METHODS Baseline spinal MRIs from the MAXIMISE trial were re-read to identify additional inflammatory (spinal process), post-inflammatory, and degenerative changes, and investigate the differential treatment effect of these imaging features using logistic regression modelling. RESULTS In addition to bone marrow oedema assessed at primary analysis, spinal process inflammation and post-inflammatory changes evaluated by FAt Spondyloarthritis Spine Score were documented in 11.1% and 20.2% patients, respectively. At least one type of degenerative change was noted in 64% patients, with Pfirrmann grade ≥3 (51.1%) being the most common. Combining primary and re-read MRI findings, 67.1% of patients presented with inflammatory or post-inflammatory changes while 21.2% had degenerative changes alone. Although not statistically significant, post-inflammatory changes were associated with a trend for better efficacy outcomes in terms of ASAS20, ASAS40 and BASDAI50 responses; a trend for worse outcomes was observed in the presence of degenerative changes. CONCLUSION The current analysis revealed the occurrence of additional inflammatory and post-inflammatory changes suggestive of axial PsA (axPsA) and a trend for better clinical outcomes for patients treated with secukinumab. These results elucidate the imaging characteristics and improve our current understanding of axPsA thereby supporting the interpretation of future trials. TRIAL REGISTRATION ClinicalTrials.gov, NCT02721966.
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Affiliation(s)
| | - Effie Pournara
- Novartis Pharma AG, Immunology, Hepatology and Dermatology, Basel, Switzerland
| | - Laura C Coates
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Ricardo Blanco
- Divisions of Immunology, Endocrinology, and Rheumatology, Hospital University Marqués de Valdecilla, Santander, Spain
| | | | - Barbara Schulz
- Novartis Pharma AG, Immunology, Hepatology and Dermatology, Basel, Switzerland
| | - Robert Landewe
- Department of Rheumatology, Academic Medical Center/University of Amsterdam, Amsterdam, The Netherlands
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Kiwalkar S, Howard R, Choi D, Deodhar A. A mixed methods study to uncover impediments to accurate diagnosis of nonradiographic axial spondyloarthritis in the USA. Clin Rheumatol 2023; 42:2811-2822. [PMID: 37347434 DOI: 10.1007/s10067-023-06671-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 06/23/2023]
Abstract
INTRODUCTION/OBJECTIVES Delayed diagnosis of axial spondyloarthritis (axSpA) is well documented; little is known about the diagnostic journey and impediments for US patients with nonradiographic axSpA (nr-axSpA). It is hypothesized that impediments are varied and exist at both the healthcare provider (HCP) and patient levels. This study aims to understand patient experiences and contributors to delayed nr-axSpA diagnosis in the USA. METHOD Interviews of adults with rheumatologist-diagnosed nr-axSpA, recruited through Spondylitis Association of America outreach and patient panels, and of rheumatologists, explored the diagnostic journey and diagnostic barriers. Emerging themes were further explored in an online patient survey. A multiple logistic regression analysis evaluated the main outcome variable, factors affecting time to nr-axSpA diagnosis. RESULTS Interviews were conducted with 25 patients and 16 rheumatologists. Survey responses from 186 eligible patients revealed median time from symptom onset to diagnosis of nr-axSpA was 3.25 years. Delayed diagnosis was significantly more likely for women and people in rural areas. Most patients consulted ≥4 different types of HCPs before a rheumatologist and ≥2 rheumatologists before diagnosis. Impediments to timely diagnosis included insidious chronic pain; episodic symptom patterns attributed to activity; symptoms other than chronic lumbosacral back pain requiring medical consultation; and unfamiliarity with and misperceptions about nr-axSpA among HCPs, radiologists, and rheumatologists. CONCLUSIONS Delayed nr-axSpA diagnosis is common and reflects HCP knowledge gaps and frequent patient presentation with dominant nonaxial symptoms. Targeted HCP education, research into early disease patterns, and interventions sensitive to the broader spectrum of nr-axSpA manifestations are needed to improve timely diagnosis. Key Points • Patients with nr-axSpA often see multiple types of HCPs, and multiple rheumatologists, before receiving a diagnosis. • Both patients and HCPs are unfamiliar with nr-axSpA and its symptoms, lacking understanding that nr-axSpA can occur in young people, females, and those presenting with normal x-rays. • Disease recognition by nonrheumatology HCPs is key for early referral. • Education on cardinal features, epidemiology, burden, and benefits of timely nr-axSpA diagnosis is warranted for HCPs who commonly manage back pain.
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Affiliation(s)
- Sonam Kiwalkar
- The Vancouver Clinic, Washington State University, 700 NE 87th Avenue, Suite 330, Vancouver, WA, 98664, USA.
| | - Richard Howard
- Spondylitis Association of America, 16430 Ventura Blvd, Suite 300, Encino, CA, 91436, USA
| | - Dongseok Choi
- Oregon Health & Science University-Portland State University School of Public Health, Oregon Health & Science University, 1810 SW 5th Ave. Suite 510, Portland, OR, 97201, USA
| | - Atul Deodhar
- Division of Arthritis and Rheumatic Diseases, Oregon Health & Science University, 3270 SW Pavilion Loop, Portland, OR, 97239, USA
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Ensslin C, Micheroli R, Kissling S, Götschi A, Bürki K, Bräm R, de Hooge M, Baraliakos X, Nissen MJ, Möller B, Exer P, Andor M, Distler O, Scherer A, Ciurea A. Impact of sex on spinal radiographic progression in axial spondyloarthritis: a longitudinal Swiss cohort analysis over a period of 10 years. RMD Open 2023; 9:e003340. [PMID: 37507208 PMCID: PMC10387740 DOI: 10.1136/rmdopen-2023-003340] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023] Open
Abstract
OBJECTIVE To investigate sex differences in spinal radiographic progression in axial spondyloarthritis (axSpA). METHODS AxSpA patients in the Swiss Clinical Quality Management cohort with available spinal radiographs every 2 years were included. Paired radiographs were scored by two readers according to the modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS). Progression was defined as an increase of ≥2 mSASSS units in 2 years. The relationship between sex and progression was investigated with binomial generalised estimating equation models, considering baseline spinal damage as an intermediate covariate. Additional analyses included adjustments for explanatory variables and multiple imputations for missingness. RESULTS In a total of 505 axSpA patients (317 men and 188 women), mean±SD radiographic progression over 2 years was 1.0±2.8 years in men and 0.3±1.1 years in women (p<0.001). Male sex was associated with enhanced progression in a small model not including baseline damage (OR 3.41, 95% CI 1.87 to 6.21). Both a direct effect of male sex on spinal progression, and an indirect effect, via enhancement of baseline spinal damage were significant (OR 2.06, 95% CI 1.15 to 3.67 and OR 1.04, 95% CI 1.01 to 1.07, respectively). A significant impact of male sex on spinal radiographic progression was still demonstrated after multiple adjustments for covariates known to potentially affect spinal radiographic progression (OR 1.97, 95% CI 1.04 to 3.71). CONCLUSIONS Spinal radiographic progression in axSpA is more severe in men than in women, with three times higher odds of progression in male patients and an effect that is mediated in part through an increase in baseline radiographic damage.
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Affiliation(s)
- Caroline Ensslin
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Raphael Micheroli
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Seraphina Kissling
- Statistics Group, Swiss Clinical Quality Management in Rheumatic Diseases, Zurich, Switzerland
| | - Andrea Götschi
- Statistics Group, Swiss Clinical Quality Management in Rheumatic Diseases, Zurich, Switzerland
| | - Kristina Bürki
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - René Bräm
- Swiss Ankylosing Spondylitis Association, Zurich, Switzerland
| | - Manouk de Hooge
- Department of Rheumatology, University Hospital Gent, Gent, Belgium
| | | | - Michael J Nissen
- Department of Rheumatology, Geneva University Hospitals, Geneve, Switzerland
| | - Burkhard Möller
- Department of Rheumatology and Immunology, Inselspital Universitatsspital Bern, Bern, Switzerland
| | | | | | - Oliver Distler
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Almut Scherer
- Statistics Group, Swiss Clinical Quality Management in Rheumatic Diseases, Zurich, Switzerland
| | - Adrian Ciurea
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Popova V, Kissling S, Micheroli R, Bräm R, de Hooge M, Baraliakos X, Nissen MJ, Möller B, Exer P, Andor M, Distler O, Scherer A, Ospelt C, Ciurea A. Site-specific assessment of spinal radiographic progression improves detection of TNF blocker-associated disease modification in axial spondyloarthritis: longitudinal observational data from the Swiss Clinical Quality Management Registry. Arthritis Res Ther 2023; 25:40. [PMID: 36915202 PMCID: PMC10009926 DOI: 10.1186/s13075-023-03026-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/06/2023] [Indexed: 03/14/2023] Open
Abstract
OBJECTIVES To analyse whether time-varying treatment with tumour necrosis factor inhibitors (TNFi) in radiographic axial spondyloarthritis (r-axSpA) has a differential impact on structural damage progression on different spinal segments (cervical versus lumbar spine). METHODS Patients with r-axSpA in the Swiss Clinical Quality Management cohort were included if cervical and lumbar radiographs were available at intervals of 2 years for a maximum of 10 years. Paired radiographs were scored by two calibrated readers according to the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS). The relationship between TNFi use and progression in the cervical and the lumbar spine was analysed using generalised estimating equation models and adjustment for potential confounding. Radiographic progression per spinal segment was defined as an increase of ≥ 1 mSASSS unit or by the formation of ≥ 1 new syndesmophyte over 2 years. RESULTS Mean ± SD symptom duration was 13.8 ± 9.8 years. Mean ± SD mSASSS progression per radiographic interval was 0.41 ± 1.69 units in the cervical spine and 0.45 ± 1.45 units in the lumbar spine (p = 0.66). Prior use of TNFi significantly reduced the odds of progression in the cervical spine by 68% (OR 0.32, 95% CI 0.14-0.72), but not in the lumbar spine (OR 0.99, 95% CI 0.52-1.88). A more restricted inhibition of progression in the lumbar spine was confirmed after multiple imputation of missing covariate data (OR 0.43, 95% CI 0.24-0.77 and 0.85, 95% CI 0.51-1.41, for the cervical and lumbar spine, respectively). It was also confirmed with progression defined as formation of ≥ 1 syndesmophyte (OR 0.31, 95% CI 0.12-0.80 versus OR 0.56, 95% CI 0.26-1.24 for the cervical and lumbar spine, respectively). CONCLUSION Disease modification by treatment with TNFi seems to more profoundly affect the cervical spine in this r-axSpA population with longstanding disease. Site-specific analysis of spinal progression might, therefore, improve detection of disease modification in clinical trials in axSpA.
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Affiliation(s)
- Vjara Popova
- Department of Rheumatology, Zurich University Hospital, University of Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland
| | - Seraphina Kissling
- Swiss Clinical Quality Management Foundation, Statistics Group, Zurich, Switzerland
| | - Raphael Micheroli
- Department of Rheumatology, Zurich University Hospital, University of Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland
| | - René Bräm
- Swiss Ankylosing Spondylitis Association, Zurich, Switzerland
| | - Manouk de Hooge
- VIB Inflammation Research Center, Ghent University, Ghent, Belgium
- Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
| | | | - Michael J Nissen
- Department of Rheumatology, University Hospital Geneva, Geneva, Switzerland
| | - Burkhard Möller
- Deparment of Rheumatology and Immunology, University Hospital Bern, Bern, Switzerland
| | | | | | - Oliver Distler
- Department of Rheumatology, Zurich University Hospital, University of Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland
| | - Almut Scherer
- Swiss Clinical Quality Management Foundation, Statistics Group, Zurich, Switzerland
| | - Caroline Ospelt
- Department of Rheumatology, Zurich University Hospital, University of Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland
| | - Adrian Ciurea
- Department of Rheumatology, Zurich University Hospital, University of Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland.
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Reijnierse M. Axial Skeleton Bone Marrow Changes in Inflammatory Rheumatologic Disorders. Semin Musculoskelet Radiol 2023; 27:91-102. [PMID: 36868247 PMCID: PMC9984269 DOI: 10.1055/s-0043-1761496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
Magnetic resonance imaging (MRI) of the axial skeleton, spine, and sacroiliac (SI) joints is critical for the early detection and follow-up of inflammatory rheumatologic disorders such as axial spondyloarthritis, rheumatoid arthritis, and SAPHO/CRMO (synovitis, acne, pustulosis, hyperostosis, and osteitis/chronic recurrent multifocal osteomyelitis). To offer a valuable report to the referring physician, disease-specific knowledge is essential. Certain MRI parameters can help the radiologist provide an early diagnosis and lead to effective treatment. Awareness of these hallmarks may help avoid misdiagnosis and unnecessary biopsies. A bone marrow edema-like signal plays an important role in reports but is not disease specific. Age, sex, and history should be considered in interpreting MRI to prevent overdiagnosis of rheumatologic disease. Differential diagnoses-degenerative disk disease, infection, and crystal arthropathy-are addressed here. Whole-body MRI may be helpful in diagnosing SAPHO/CRMO.
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Affiliation(s)
- Monique Reijnierse
- Musculoskeletal Radiology, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
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Kilic G, Senol S, Baspinar S, Kilic E, Ozgocmen S. Degenerative changes of lumbar spine and their clinical implications in patients with axial spondyloarthritis. Clin Rheumatol 2023; 42:111-116. [PMID: 35922576 DOI: 10.1007/s10067-022-06321-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/16/2022] [Accepted: 07/27/2022] [Indexed: 01/11/2023]
Abstract
The objective of this study was to assess degenerative changes (DCs) on magnetic resonance imaging (MRI) of lumbar spine in axial spondyloarthritis (axSpA) and non-specific mechanical low back pain (mLBP). Patients were consecutively recruited and all underwent MRI of the lumbar spine in this cross-sectional study. Disk degeneration (DD, Pfirrmann classification), endplate changes (Modic, types 1, 2, and 3), annular fissure, disk bulging, and protrusion or extrusion at each lumbar spinal level were assessed using anonymized images. Patients with axSpA were assessed for disease activity, functioning, and quality of life. Univariate and subsequent multivariate logistic regression analyses with adjustments of various covariates were used to assess association between MRI findings and clinical variables. One hundred twenty-three patients had non-radiographic (nr-axSpA) and 144 had radiographic axSpA/ankylosing spondylitis (AS). Degenerative changes were more prevalent in patients with mLBP (n = 105) than axSpA. Disk degeneration was the most prevalent MRI finding, followed by annular fissure, disk herniation (protrusion or extrusion), and Modic changes (MCs) in axSpA. Disk herniation was more prevalent in patients with nr-axSpA compared to AS. Modic changes (OR = 6.455), lumbar disk herniation (OR = 2.278), annular fissure (OR = 2.842), conventional synthetic or biologic disease-modifying antirheumatic drugs (csDMARDs) non-users (OR = 2.225), and advanced age (OR = 31.556) were factors associated with an increased risk of DD in axSpA. Coexisting DD increased the burden of disease in axSpA. A considerable proportion of patients with axSpA had DD at the lumbar spine. These degenerative changes might explain some of the complaints and should not been overlooked in patients with axSpA. Key Points • Lumbar herniated nucleus pulposus (LHNP) is more frequent in nr-axSpA while MC is more frequent in AS. • DD may cause an increase in BASFI and BASMI scores in axSpA. • Spinal DCs might be an alternative explanation for low back complaints and should not been overlooked in patients with axSpA.
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Affiliation(s)
- Gamze Kilic
- Division of Rheumatology, Department of Physical Medicine and Rehabilitation, Karadeniz Technical University, Trabzon, Turkey.
| | - Serkan Senol
- Department of Radiology, Sevgi Hospital, Kayseri, Turkey
| | - Sevgi Baspinar
- Department of Physical Medicine and Rehabilitation, Ministry of Health Kayseri City Hospital, Kayseri, Turkey
| | - Erkan Kilic
- Department of Rheumatology, Trabzon Kanuni Training and Research Hospital, Trabzon, Turkey
| | - Salih Ozgocmen
- Department of Rheumatology, Gaziosmanpasa Hospital, Istinye University, Istanbul, Turkey.,Division of Rheumatology, Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Trakya University, Edirne, Turkey
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9
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Mease P, Deodhar A. Differentiating nonradiographic axial spondyloarthritis from its mimics: a narrative review. BMC Musculoskelet Disord 2022; 23:240. [PMID: 35279103 PMCID: PMC8917757 DOI: 10.1186/s12891-022-05073-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 01/29/2022] [Indexed: 11/18/2022] Open
Abstract
Background Optimal treatment of nonradiographic axial spondyloarthritis depends on accurate and timely diagnosis of the underlying disease; however, patients present with common symptoms that, in the absence of radiographic changes, may confound diagnosis. Methods and findings In this narrative review, a PubMed literature search was conducted through January 2021, with no date limits, to identify English-language publications discussing classification of nonradiographic axial spondyloarthritis, with an emphasis on clinical features and presentation, differential diagnoses, and mimics of disease. This review describes the epidemiology, clinical features, and burden of disease of nonradiographic axial spondyloarthritis as it relates to the overall axial spondyloarthritis spectrum and discusses mimics and differential diagnoses of nonradiographic axial spondyloarthritis that should be considered when evaluating patients with suspected nonradiographic axial spondyloarthritis in clinical practice. Conclusions Recognition of clinical features of nonradiographic axial spondyloarthritis, along with an understanding of comorbid conditions such as fibromyalgia, allows for differentiation from its mimics. Appropriate diagnosis of nonradiographic axial spondyloarthritis is important for aggressive management of disease to reduce pain, avoid loss of function, and improve quality of life.
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Zhdan VM, Volchenko HV, Babanina M. MY, Tkachenko MV, Kyrian OA. AXIAL SPONDYLOARTHRITIS. CLINICAL DEFINITION AND DIAGNOSTIC APPROACHES. BULLETIN OF PROBLEMS BIOLOGY AND MEDICINE 2022. [DOI: 10.29254/2077-4214-2022-4-167-49-58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Abstract
BACKGROUND Axial spondyloarthritis (axSpA) is a chronic, rheumatic disease characterized by inflammation of the sacroiliac joint, spine, and entheses. Axial spondyloarthritis affects up to 1.4% of adults in the United States and is associated with decreased quality of life, increased mortality, and substantial health care-related costs, imposing a high burden on patients, their caregivers, and society. SUMMARY OF WORK Diagnosing axSpA can be difficult. In this review, we seek to help rheumatologists in recognizing and diagnosing axSpA. MAJOR CONCLUSIONS A discussion of challenges associated with diagnosis is presented, including use and interpretation of imaging, reasons for diagnostic delays, differences in disease presentation by sex, and differential diagnoses of axSpA. FUTURE RESEARCH DIRECTIONS The early diagnosis of axSpA and advances in available therapeutic options have improved patient care and disease management, but delays in diagnosis and treatment remain common. Additional research and education are critical for recognizing diverse axSpA presentations and optimizing management early in the course of disease.
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Affiliation(s)
- Jessica A. Walsh
- From the University of Utah School of Medicine and Salt Lake City Veterans Affairs Medical Center, Salt Lake City, UT
| | - Marina Magrey
- The MetroHealth System and School of Medicine, Case Western Reserve University, Cleveland, OH
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12
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Braun J, Landewé RB. Response to: Correspondence on 'No efficacy of anti-IL-23 therapy for axial spondyloarthritis in randomised controlled trials but in post-hoc analyses of psoriatic arthritis-related 'physicianreported spondylitis'?' by Braun and Landewe. Ann Rheum Dis 2021:annrheumdis-2021-221816. [PMID: 34844931 DOI: 10.1136/annrheumdis-2021-221816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 11/16/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Juergen Braun
- Rheumazentrum Ruhrgebiet, Ruhr Universität Bochum, Herne, NRW, Germany
| | - Robert Bm Landewé
- Amsterdam Rheumatology Center, AMC, Amsterdam, The Netherlands.,Rheumatology, Zuyderland MC, Heerlen, The Netherlands
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Reveille JD. Biomarkers in axial spondyloarthritis and low back pain: a comprehensive review. Clin Rheumatol 2021; 41:617-634. [PMID: 34674081 DOI: 10.1007/s10067-021-05968-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 09/20/2021] [Accepted: 10/13/2021] [Indexed: 02/07/2023]
Abstract
The spectrum of axial spondyloarthritis (AxSpA) (including both non-radiographic and radiographic AxSpA), also known as ankylosing spondylitis AS, has achieved growing recognition. With the development of treatments not only effective in controlling disease activity but also in slowing radiographic progression, and given the cost and risk profiles of these novel treatments and the limitations of current clinical criteria, imaging and peripheral blood biomarkers (C-reactive protein, HLA-B27 testing), the need for better biomarkers has never been greater. The purpose of this review is to present up-to-date information on the biomarkers for the diagnosis for assessing disease diagnosis, activity, treatment response, and radiographic progression of AxSpA, and entails multiple search strings used to identify articles of interest published in PubMed and the Cochrane database up to May 1, 2021. We present the current status of research in serologic biomarkers such as cytokines, adipokines, matrix metalloproteinases, calprotectin, CD74, antibodies, bone turnover markers, and circulating protein fragments of cartilage and connective tissue degradation and other biomarkers. Despite a great deal of work, most serologic results have been disappointing and to date none perform better than CRP. Recent promising preliminary data for some has been published, but require further confirmation. Transcriptomic biomarkers such as micro-RNAs and genetic biomarkers also show promise to assist in diagnosis and possibly for radiographic severity, including a recently developed panel of genetic risk markers used in a polygenic risk score instrument in AS diagnosis. These need further confirmation and application in AS as well as in nr-AxSpA.
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Affiliation(s)
- John D Reveille
- Department of Internal Medicine, Division of Rheumatology, McGovern Medical School at The University of Texas Health Science Center, 6431 Fannin, MSB 5.270, Houston, TX, 77030, USA.
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Coath FL, Gaffney K. Inflammatory back pain: a concept, not a diagnosis. Curr Opin Rheumatol 2021; 33:319-325. [PMID: 33973548 DOI: 10.1097/bor.0000000000000807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW The concept of inflammatory back pain (IBP) describes a cohort of patients with chronic back pain (CBP) who have distinct clinical characteristics, rather than being a diagnosis in and of itself. IBP is a common and important feature of axial spondyloarthritis (axSpA) but this is not the only differential. This review examines the utility of IBP in both primary and secondary care settings. RECENT FINDINGS There are a number of suggested referral strategies for patients with suspected axSpA that include IBP. These strategies attempt to strike a balance between ensuring potential axSpA patients are not overlooked, whilst simultaneously not overwhelming secondary care services. Their success relies on the clinicians who first encounter these patients being familiar with IBP as a concept; however, it is still poorly recognized by many healthcare professionals. IBP may be helpful as part of a referral strategy; however, other clinical features, laboratory investigations and radiology must be incorporated for the final diagnostic outcome in axSpA. SUMMARY Delayed diagnosis is a major clinical problem in axSpA and is associated with worse clinical outcomes. When recognized and utilized correctly, IBP can be a useful tool to promote prompt referral to rheumatology services.
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Affiliation(s)
- Fiona Louise Coath
- Rheumatology Department, Norfolk and Norwich Hospital, Colney Lane, Norwich, UK
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López-Medina C, Moltó A. Comorbid pain in axial spondyloarthritis, including fibromyalgia. Ther Adv Musculoskelet Dis 2020; 12:1759720X20966123. [PMID: 33133247 PMCID: PMC7576902 DOI: 10.1177/1759720x20966123] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 09/07/2020] [Indexed: 12/16/2022] Open
Abstract
The main symptom in patients with axial spondyloarthritis (axSpA) is inflammatory back pain, caused principally by inflammation of the sacroiliac joints and the spine. However, not all back pain in patients with axSpA is related to active inflammation: other types of pain can occur in these patients, and may be related to structural damage (e.g. ankylosis), degenerative changes, vertebral fractures or comorbid fibromyalgia, which are not uncommon in these patients. Structural damage and ankylosis may lead to a biomechanical stress, which can lead to chronic mechanical pain; and degenerative changes of the spine may also exist in patients with axSpA also leading to mechanical pain. Osteoporosis is more prevalent in axSpA patients than in the general population, and vertebral fractures may result in acute bone pain, which can persist for several months. Fibromyalgia, which is also more prevalent in patients with chronic inflammatory diseases (including axSpA), presents with widespread pain which can mimic entheseal pain. A correct diagnosis of the origin of the pain is crucial, since treatments and management may differ considerably. Recognizing these causes of pain may be a challenge in clinical practice, especially for fibromyalgia, which can coexist with axSpA and may have a significant impact on biologic drug response. In this review, we provide an update of the most common causes of pain other than inflammatory back pain in axSpA patients, and we discuss the latest management options for such causes.
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Affiliation(s)
- Clementina López-Medina
- Rheumatology Department, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Anna Moltó
- Rheumatology Department, Hôpital Cochin, Rue Fbg. Saint Jacques, Paris, 75014, France
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Abstract
PURPOSE OF REVIEW Axial spondyloarthritis (AxSpA) is a distinct clinical entity with characteristic clinical and radiographic features; however, a multitude of other metabolic, infectious and inflammatory disorders mimic it both clinically and radiographically. RECENT FINDINGS We present in this review article recent updates about the various disease entities and conditions that may mimic AxSpA and how to differentiate among them. The sensitivity and specificity of MRI in diagnosing AxSpA has limitations and needs to be interpreted in the context of the clinical picture. Interestingly, some recent studies have highlighted that a relatively high prevalence of bone marrow edema on pelvic MRIs in healthy volunteers which could even be categorized as having a 'positive MRI' as defined by Assessment of Spondyloarthritis International Society. Another study revealed that a substantial proportion of patients with suspected sacroiliitis were more commonly diagnosed with diseases other than inflammatory sacroiliitis. On the basis of these reports, it is prudent to request MRIs in the appropriate clinical context and interpreted with caution taking into considerations the wide differential diagnosis of such MRI changes. SUMMARY Highlighting the clinical pearls that differentiate disorders suspected of having sacroiliitis will lead to earlier and correct diagnosis and management; however, one must always take into considerations the radiographic and MRI findings in addition to the clinical presentations in order to make the appropriate diagnosis.
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Reijnierse M. Radiographic/MR Imaging Correlation of Paravertebral Ossifications in Ligaments and Bony Vertebral Outgrowths: Anatomy, Early Detection, and Clinical Impact. Magn Reson Imaging Clin N Am 2020; 27:641-659. [PMID: 31575398 DOI: 10.1016/j.mric.2019.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This article focuses on the variety of imaging features of paravertebral ossifications that are of practical interest in the diagnosis of diseases. The spinal anatomy is reviewed and correlated to paravertebral ligamentous ossifications and their potential clinical impact. A vertebral bony outgrowth is secondary to inflammation or degeneration and can be characterized based on its origin and growth direction, in addition to appreciation of intervertebral disc space preservation or loss. Imaging in rheumatology patients is highlighted because early detection of disease is of increasing importance. A correlation between radiographs and MR imaging is made.
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Affiliation(s)
- Monique Reijnierse
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, PO Box 9600, 2300RC Leiden, The Netherlands.
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Jensen RK, Jensen TS, Koes B, Hartvigsen J. Prevalence of lumbar spinal stenosis in general and clinical populations: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:2143-2163. [PMID: 32095908 DOI: 10.1007/s00586-020-06339-1] [Citation(s) in RCA: 101] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 01/27/2020] [Accepted: 02/09/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE To estimate the prevalence of degenerative lumbar spinal stenosis (LSS) in adults, identified by clinical symptoms and/or radiological criteria. METHODS Systematic review of the literature. Pooled prevalence estimates by care setting and clinical or radiological diagnostic criteria were calculated and plotted [PROSPERO ID: CRD42018109640]. RESULTS In total, 41 papers reporting on 55 study samples were included. The overall risk of bias was considered high in two-thirds of the papers. The mean prevalence, based on a clinical diagnosis of LSS in the general population, was 11% (95% CI 4-18%), 25% (95% CI 19-32%) in patients from primary care, 29% (95% CI 22-36%) in patients from secondary care and 39% (95% CI 39-39%) in patients from mixed primary and secondary care. Evaluating the presence of LSS based on radiological diagnosis, the pooled prevalence was 11% (95% CI 5-18%) in the asymptomatic population, 38% (95% CI - 10 to 85%) in the general population, 15% (95% CI 13-18%) in patients from primary care, 32% (95% CI 22-41%) in patients from secondary care and 21% (95% CI 16-26%) in a mixed population from primary and secondary care. CONCLUSIONS The mean prevalence estimates based on clinical diagnoses vary between 11 and 39%, and the estimates based on radiological diagnoses similarly vary between 11 and 38%. The results are based on studies with high risk of bias, and the pooled prevalence estimates should therefore be interpreted with caution. With an growing elderly population, there is a need for future low risk-of-bias research clarifying clinical and radiological diagnostic criteria of lumbar spinal stenosis. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Rikke Krüger Jensen
- Department of Sports Science and Clinical Biomechanics, Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark. .,Nordic Institute of Chiropractic and Clinical Biomechanics, Odense, Denmark.
| | - Tue Secher Jensen
- Nordic Institute of Chiropractic and Clinical Biomechanics, Odense, Denmark.,Department of Diagnostic Imaging, Silkeborg Regional Hospital, Silkeborg, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Bart Koes
- Department of Sports Science and Clinical Biomechanics, Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark.,Department of General Practice, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Jan Hartvigsen
- Department of Sports Science and Clinical Biomechanics, Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark.,Nordic Institute of Chiropractic and Clinical Biomechanics, Odense, Denmark
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Tendon and ligament mechanical loading in the pathogenesis of inflammatory arthritis. Nat Rev Rheumatol 2020; 16:193-207. [PMID: 32080619 DOI: 10.1038/s41584-019-0364-x] [Citation(s) in RCA: 117] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2019] [Indexed: 12/18/2022]
Abstract
Mechanical loading is an important factor in musculoskeletal health and disease. Tendons and ligaments require physiological levels of mechanical loading to develop and maintain their tissue architecture, a process that is achieved at the cellular level through mechanotransduction-mediated fine tuning of the extracellular matrix by tendon and ligament stromal cells. Pathological levels of force represent a biological (mechanical) stress that elicits an immune system-mediated tissue repair pathway in tendons and ligaments. The biomechanics and mechanobiology of tendons and ligaments form the basis for understanding how such tissues sense and respond to mechanical force, and the anatomical extent of several mechanical stress-related disorders in tendons and ligaments overlaps with that of chronic inflammatory arthritis in joints. The role of mechanical stress in 'overuse' injuries, such as tendinopathy, has long been known, but mechanical stress is now also emerging as a possible trigger for some forms of chronic inflammatory arthritis, including spondyloarthritis and rheumatoid arthritis. Thus, seemingly diverse diseases of the musculoskeletal system might have similar mechanisms of immunopathogenesis owing to conserved responses to mechanical stress.
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Baraliakos X, Richter A, Feldmann D, Ott A, Buelow R, Schmidt CO, Braun J. Frequency of MRI changes suggestive of axial spondyloarthritis in the axial skeleton in a large population-based cohort of individuals aged <45 years. Ann Rheum Dis 2019; 79:186-192. [DOI: 10.1136/annrheumdis-2019-215553] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 10/12/2019] [Accepted: 11/04/2019] [Indexed: 01/20/2023]
Abstract
ObjectiveTo investigate the frequency of bone marrow oedema (BME) and fatty lesions (FL) suggestive of axial spondyloarthritis (axSpA) on MRI of the spine and sacroiliac joints (SIJ) in a general population sample.MethodsAs part of a community-based cohort project (Study of Health in Pomerania), volunteers underwent spinal (sagittal T1/T2) and SIJ (semicoronal short tau inversion recovery) MRI examinations. Two calibrated readers evaluated the images to detect BME in SIJ and vertebral corners (VC) and FL in VC suggestive of axSpA using Assessment of SpondyloArthritis international Society definitions.ResultsMRIs of 793 volunteers (49.4% males, mean age 37.3±6.3 years, 8.4% human leucocyte antigen-B27+) aged <45 years were evaluated. SIJ BME was seen in 136 (17.2%), VC BME in 218 (27.5%) and FL in 645 (81.4%) volunteers. SIJ BME in ≥1, ≥3 and ≥5 SIJ quadrants was seen in 136 (17.2%), 7 (0.9%) and 1 (0.1%) volunteers, respectively. In VC, BME≥1, ≥3 and ≥5 lesions were seen in 218 (27.5%), 38 (4.8%) and 6 (0.8%) volunteers, respectively, while FL≥1, ≥3 and ≥5 were seen in 645 (81.3%), 351 (44.3%) and 185 (23.3%) volunteers, respectively. Logistic regression analysis showed that BME and FL in VC were related to increasing age: OR 1.33, 95% CI 1.02 to 1.72, and OR 1.73, 95% CI 1.32 to 2.27, per decade increase, respectively.ConclusionsIn this large population-based study, a high frequency of inflammatory and fatty MRI lesions suggestive of axSpA was found, especially in the spine. This indicates a limited value of such MRI findings for diagnosis and classification of axSpA. The increasing frequency with age suggests that mechanical factors could play a role.
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The role of imaging in the diagnosis and management of axial spondyloarthritis. Nat Rev Rheumatol 2019; 15:657-672. [DOI: 10.1038/s41584-019-0309-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2019] [Indexed: 12/15/2022]
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Abstract
The classification of axial spondyloarthritis (axSpA) comprises the classical ankylosing spondylitis (AS), which is characterized by already existing structural changes in the sacroiliac joints, and the so-called non-radiographic axSpA (nr-axSpA), in which by definition such changes are not present. This distinction is based on the ASAS classification criteria for axSpA, which are however not suitable for a diagnosis. According to the current classification, spondyloarthritis (SpA) includes axSpA, which can be associated with psoriasis and/or chronic inflammatory bowel diseases (CED), such as Crohn's disease and ulcerative colitis, and peripheral SpA, which is further divided into SpA associated with psoriasis, partially synonymous with psoriatic arthritis (PsA), reactive SpA, partially synonymous with reactive arthritis (ReA) and SpA associated with CED, partially synonymous with arthritis associated with CED (e.g. Crohn's disease, ulcerative colitis) and peripheral undifferentiated SpA, which by definition is not associated with any of the above. In this article only the most important differential diagnoses are discussed, i. e. diffuse idiopathic skeletal hyperostosis (DISH), fractures and infections in the axial skeleton. In addition, the frequency of certain musculoskeletal findings in the normal population examined by magnetic resonance imaging (MRI) are also discussed.
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