1
|
Roels J, De Craemer AS, Renson T, de Hooge M, Gevaert A, Van Den Berghe T, Jans L, Herregods N, Carron P, Van den Bosch F, Saeys Y, Elewaut D. Machine Learning Pipeline for Predicting Bone Marrow Edema Along the Sacroiliac Joints on Magnetic Resonance Imaging. Arthritis Rheumatol 2023; 75:2169-2177. [PMID: 37410803 DOI: 10.1002/art.42650] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 06/22/2023] [Accepted: 06/26/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE We aimed to develop and validate a fully automated machine learning (ML) algorithm that predicts bone marrow edema (BME) on a quadrant level in sacroiliac (SI) joint magnetic resonance imaging (MRI). METHODS A computer vision workflow automatically locates the SI joints, segments regions of interest (ilium and sacrum), performs objective quadrant extraction, and predicts presence of BME, suggestive of inflammatory lesions, on a quadrant level in semicoronal slices of T1/T2-weighted MRI scans. Ground truth was determined by consensus among human readers. The inflammation classifier was trained using a ResNet18 backbone and five-fold cross-validated on scans of patients with spondyloarthritis (SpA) (n = 279), postpartum individuals (n = 71), and healthy subjects (n = 114). Independent SpA patient MRI scans (n = 243) served as test data set. Patient-level predictions were derived from aggregating quadrant-level predictions, ie, at least one positive quadrant. RESULTS The algorithm automatically detects the SI joints with a precision of 98.4% and segments ilium/sacrum with an intersection over union of 85.6% and 67.9%, respectively. The inflammation classifier performed well in cross-validation: area under the curve (AUC) 94.5%, balanced accuracy (B-ACC) 80.5%, and F1 score 64.1%. In the test data set, AUC was 88.2%, B-ACC 72.1%, and F1 score 50.8%. On a patient level, the model achieved a B-ACC of 81.6% and 81.4% in the cross-validation and test data set, respectively. CONCLUSION We propose a fully automated ML pipeline that enables objective and standardized evaluation of BME along the SI joints on MRI. This method has the potential to screen large numbers of patients with (suspected) SpA and is a step closer towards artificial intelligence-assisted diagnosis and follow-up.
Collapse
Affiliation(s)
- Joris Roels
- Vlaams Instituut voor Biotechnologie - Universiteit Gent (VIB-UGent), Ghent-Zwijnaarde, and Ghent University, Ghent, Belgium
| | - Ann-Sophie De Craemer
- Vlaams Instituut voor Biotechnologie - Universiteit Gent (VIB-UGent), Ghent-Zwijnaarde, and Ghent University Hospital, Ghent, Belgium
| | - Thomas Renson
- Vlaams Instituut voor Biotechnologie - Universiteit Gent (VIB-UGent), Ghent-Zwijnaarde, and Ghent University Hospital, Ghent, Belgium
| | - Manouk de Hooge
- Vlaams Instituut voor Biotechnologie - Universiteit Gent (VIB-UGent), Ghent-Zwijnaarde, and Ghent University Hospital, Ghent, Belgium
| | - Arne Gevaert
- Vlaams Instituut voor Biotechnologie - Universiteit Gent (VIB-UGent), Ghent-Zwijnaarde, and Ghent University, Ghent, Belgium
| | | | | | | | - Philippe Carron
- Vlaams Instituut voor Biotechnologie - Universiteit Gent (VIB-UGent), Ghent-Zwijnaarde, and Ghent University Hospital, Ghent, Belgium
| | - Filip Van den Bosch
- Vlaams Instituut voor Biotechnologie - Universiteit Gent (VIB-UGent), Ghent-Zwijnaarde, and Ghent University Hospital, Ghent, Belgium
| | - Yvan Saeys
- Vlaams Instituut voor Biotechnologie - Universiteit Gent (VIB-UGent), Ghent-Zwijnaarde, and Ghent University, Ghent, Belgium
| | - Dirk Elewaut
- Vlaams Instituut voor Biotechnologie - Universiteit Gent (VIB-UGent), Ghent-Zwijnaarde, and Ghent University Hospital, Ghent, Belgium
| |
Collapse
|
2
|
Østergaard M, Maksymowych WP. Advances in the Evaluation of Peripheral Enthesitis by Magnetic Resonance Imaging in Patients With Psoriatic Arthritis. J Rheumatol 2023; 50:18-22. [PMID: 37419626 DOI: 10.3899/jrheum.2023-0518] [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] [Accepted: 05/30/2023] [Indexed: 07/09/2023]
Abstract
Enthesitis is a key disease manifestation in patients with psoriatic arthritis (PsA) that considerably contributes to pain, lower physical function, and reduced quality of life. Clinical assessment of enthesitis lacks sensitivity and specificity, and therefore better methods are urgently needed. Magnetic resonance imaging (MRI) allows detailed assessment of the components of enthesitis, and consensus-based validated MRI scoring systems exist. These include the Outcome Measures in Rheumatology (OMERACT) Heel Enthesitis MRI Scoring System (HEMRIS) method, which assesses the entheses of the heel region in a detailed manner, and the OMERACT MRI Whole-Body Score for Inflammation in Peripheral Joints and Entheses (MRI-WIPE) method, which provides an overall assessment of the inflammatory burden in the peripheral entheses and joints in the entire body using whole-body MRI. At an MRI workshop at the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) 2022 meeting in Brooklyn, the MRI appearances of peripheral enthesitis were described, as were the scoring methods. The utility of MRI for improved assessment of enthesitis was demonstrated with examples of patient cases. Clinical trials in PsA that evaluate enthesitis by MRI as a key endpoint should include the presence of MRI enthesitis as an inclusion criterion, and apply validated MRI outcomes to assess the effect of therapeutics on enthesitis are recommended.
Collapse
Affiliation(s)
- Mikkel Østergaard
- M. Østergaard, MD, PhD, DMSc, Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Glostrup, and Department of Clinical Medicine, Faculty for Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark;
| | - Walter P Maksymowych
- W.P. Maksymowych, MD, MB ChB, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
3
|
Mauro D, Gandolfo S, Tirri E, Schett G, Maksymowych WP, Ciccia F. The bone marrow side of axial spondyloarthritis. Nat Rev Rheumatol 2023:10.1038/s41584-023-00986-6. [PMID: 37407716 DOI: 10.1038/s41584-023-00986-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2023] [Indexed: 07/07/2023]
Abstract
Spondyloarthritis (SpA) is characterized by the infiltration of innate and adaptive immune cells into entheses and bone marrow. Molecular, cellular and imaging evidence demonstrates the presence of bone marrow inflammation, a hallmark of SpA. In the spine and the peripheral joints, bone marrow is critically involved in the pathogenesis of SpA. Evidence suggests that bone marrow inflammation is associated with enthesitis and that there are roles for mechano-inflammation and intestinal inflammation in bone marrow involvement in SpA. Specific cell types (including mesenchymal stem cells, innate lymphoid cells and γδ T cells) and mediators (Toll-like receptors and cytokines such as TNF, IL-17A, IL-22, IL-23, GM-CSF and TGFβ) are involved in these processes. Using this evidence to demonstrate a bone marrow rather than an entheseal origin for SpA could change our understanding of the disease pathogenesis and the relevant therapeutic approach.
Collapse
Affiliation(s)
- Daniele Mauro
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Saviana Gandolfo
- Unit of Rheumatology, San Giovanni Bosco Hospital, Naples, Italy
| | - Enrico Tirri
- Unit of Rheumatology, San Giovanni Bosco Hospital, Naples, Italy
| | - Georg Schett
- Department of Internal Medicine 3, Friedrich-Alexander University (FAU) Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany
- Deutsches Zentrum Immuntherapie (DZI), FAU Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | | | - Francesco Ciccia
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy.
| |
Collapse
|
4
|
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.
Collapse
Affiliation(s)
- Monique Reijnierse
- Musculoskeletal Radiology, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| |
Collapse
|
5
|
Kiil RM, Mistegaard CE, Loft AG, Zejden A, Hendricks O, Jurik AG. Differences in topographical location of sacroiliac joint MRI lesions in patients with early axial spondyloarthritis and mechanical back pain. Arthritis Res Ther 2022; 24:75. [PMID: 35331320 PMCID: PMC8944150 DOI: 10.1186/s13075-022-02760-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 03/07/2022] [Indexed: 12/24/2022] Open
Abstract
Background Early diagnostics of axial spondyloarthritis (axSpA) remains a challenge. Traditional imaging one-plane sacroiliac joint (SIJ) MRI assessment is used. By introducing a two-plane assessment system, the objective was to analyse the differences in SIJ MRI changes in early axSpA compared with changes in patients with mechanical back pain (MBP) by exploring the differences in volume and location. Methods MRIs in the early diagnostic state of 25 axSpA patients (mean age 31.3 years) and 59 MBP patients (mean age 32.3 years) were included. The MRIs were assessed by two readers regarding the distribution of bone marrow edema (BME) in 14 joint portions and structural changes in six joint portions in addition to SIJ anatomical variations and lumbar spine disc degeneration. Results AxSpA patients had a significantly higher overall BME sumscore (volume) of 25.1 compared to MBP patients 6.8, p < 0.005. The MBP group had the highest prevalence (66%) and sumscore (5.7) in the middle anterior sacrum. The axSpA group had significantly higher prevalence and sumscores in all joint portions except the three cartilaginous anterior sacral joint portions, including the ligamentous compartments (prevalence 40–60% compared to 8–15%, p both < 0.005). The axSpA group had also a significantly higher prevalence of erosions and fatty marrow disposition, but there were no differences in the prevalence of anatomical variations except the bipartite iliac bony plate. Conclusions AxSpA patients demonstrated a widespread distribution of both inflammatory and structural changes, including high BME occurrence in the ligamentous joint portions whereas patients with MBP had the highest occurrence of BME in the middle anterior sacrum. These findings may help differentiate axSpA patients from other back pain conditions in the early diagnostic phase.
Collapse
Affiliation(s)
- Rosa Marie Kiil
- Department of Radiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 35, C105, 8200, Aarhus N, Denmark. .,Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 103, 8200, Aarhus N, Denmark. .,Institute of Regional Health Research, University of Southern Denmark, Winsloewparken 19, 5000, Odense C, Denmark.
| | - Clara E Mistegaard
- Institute of Regional Health Research, University of Southern Denmark, Winsloewparken 19, 5000, Odense C, Denmark.,Department of Rheumatology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 59, 8200, Aarhus N, Denmark
| | - Anne Gitte Loft
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 103, 8200, Aarhus N, Denmark.,Department of Rheumatology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 59, 8200, Aarhus N, Denmark
| | - Anna Zejden
- Department of Radiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 35, C105, 8200, Aarhus N, Denmark
| | - Oliver Hendricks
- Institute of Regional Health Research, University of Southern Denmark, Winsloewparken 19, 5000, Odense C, Denmark.,Danish Hospital for Rheumatic Diseases, Engelshøjgade 9A, 6400, Sønderborg, Denmark
| | - Anne Grethe Jurik
- Department of Radiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 35, C105, 8200, Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 103, 8200, Aarhus N, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Winsloewparken 19, 5000, Odense C, Denmark
| |
Collapse
|
6
|
Truong SL, McEwan T, Bird P, Lim I, Saad NF, Schachna L, Taylor AL, Robinson PC. Australian Consensus Statements for the Assessment and Management of Non-radiographic Axial Spondyloarthritis. Rheumatol Ther 2021; 9:1-24. [PMID: 34962620 PMCID: PMC8814294 DOI: 10.1007/s40744-021-00416-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 12/09/2021] [Indexed: 12/02/2022] Open
Abstract
Background The understanding of non-radiographic axial spondyloarthritis (nr-axSpA) has accelerated over the last decade, producing a number of practice-changing developments. Diagnosis is challenging. No diagnostic criteria exist, no single finding is diagnostic, and other causes of back pain may act as confounders. Aim To update and expand the 2014 consensus statement on the investigation and management of non‐radiographic axial spondyloarthritis (nr-axSpA). Methods We created search questions based on our previous statements and four new topics then searched the MEDLINE and Cochrane databases. We assessed relevant publications by full-text review and rated their level of evidence using the GRADE system. We compiled a GRADE evidence summary then produced and voted on consensus statements. Results We identified 5145 relevant publications, full-text reviewed 504, and included 176 in the evidence summary. We developed and voted on 22 consensus statements. All had high agreement. Diagnosis of nr-axSpA should be made by experienced clinicians, considering clinical features of spondyloarthritis, blood tests, and imaging. History and examination should also assess alternative causes of back pain and related conditions including non-specific back pain and fibromyalgia. Initial investigations should include CRP, HLA-B27, and AP pelvic radiography. Further imaging by T1 and STIR MRI of the sacroiliac joints is useful if radiography does not show definite changes. MRI provides moderate-to-high sensitivity and high specificity for nr-axSpA. Acute signs of sacroiliitis on MRI are not specific and have been observed in the absence of spondyloarthritis. Initial management should involve NSAIDs and a regular exercise program, while TNF and IL-17 inhibitors can be used for high disease activity unresponsive to these interventions. Goals of treatment include improving the frequent impairment of social and occupational function that occurs in nr-axSpA. Conclusions We provide 22 evidence-based consensus statements to provide practical guidance in the assessment and management of nr-axSpA. Supplementary Information The online version contains supplementary material available at 10.1007/s40744-021-00416-7.
Collapse
Affiliation(s)
- Steven L Truong
- School of Medicine and Dentistry, Griffith University, Brisbane, QLD, Australia.
- Coast Joint Care, Maroochydore, QLD, Australia.
| | - Tim McEwan
- School of Clinical Medicine, University of Queensland, Herston Rd, Herston, QLD, 4006, Australia
| | - Paul Bird
- St George Hospital Clinical School, University of New South Wales, Sydney, Australia
| | | | - Nivene F Saad
- Metro South Hospital and Health Service, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
- School of Medicine, University of Queensland, Brisbane, Australia
| | - Lionel Schachna
- Department of Rheumatology, Austin Health, Heidelberg, VIC, Australia
- Department of Medicine, University of Melbourne, Parkville, VIC, Australia
| | - Andrew L Taylor
- Department of Rheumatology, Medical School, Fiona Stanley Hospital, University of Western Australia, Perth, Australia
| | - Philip C Robinson
- Metro North, Hospital and Health Service, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
- School of Clinical Medicine, University of Queensland, Royal Brisbane and Women's Hospital, Bowen Bridge Road, Herston, QLD, 4006, Australia
| |
Collapse
|
7
|
Imaging in Axial Spondyloarthritis: What is Relevant for Diagnosis in Daily Practice? Curr Rheumatol Rep 2021; 23:66. [PMID: 34218356 DOI: 10.1007/s11926-021-01030-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] [Accepted: 05/22/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE OF REVIEW To explore how imaging may assist diagnosing axial spondyloarthritis in rheumatology practice. RECENT FINDINGS A diagnosis of axial spondyloarthritis is based on pattern recognition by synthesizing clinical, laboratory, and imaging findings. In health care settings providing low threshold access to advanced imaging, sacroiliac joint MRI is the preferred imaging modality in clinically suspected axial spondyloarthritis. In daily routine, the optimum protocol to assess suspected inflammatory back pain combines sacroiliac joint and spine MRI fitting a 30-min slot. Contextual assessment of concomitant structural and active MRI lesions is key to enhance diagnostic utility. In women with postpartum back pain suggestive of axial spondyloarthritis, recent reports advocate waiting 6-12 months after delivery before acquiring sacroiliac joint MRI. Major unmet needs are consistent MRI protocols, standardized training modules on how to evaluate axial MRI, and timely dissemination of imaging advances into mainstream practice both in rheumatology and in radiology. In rheumatology practice, MRI has become indispensable to help diagnose early axial spondyloarthritis. However, major gaps in training and knowledge transfer to daily care need to be closed.
Collapse
|
8
|
Seven S, Østergaard M, Morsel-Carlsen L, Sørensen IJ, Bonde B, Thamsborg G, Lykkegaard JJ, Pedersen SJ. Morphological characteristics of sacroiliac joint MRI lesions in axial spondyloarthritis and control subjects. Rheumatology (Oxford) 2021; 61:1005-1017. [PMID: 34097000 DOI: 10.1093/rheumatology/keab468] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 05/17/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To investigate sacroiliac joint(SIJ) MRI inflammation, structural and degenerative lesion characteristics in patients with axial spondyloarthritis(axSpA) and various control groups. METHODS Patients with axSpA(n = 41) and lumbar disc herniation(n = 25), women with(n = 46) and without(n = 14) post-partum(childbirth within 4-16 months) buttock/pelvic pain, cleaning assistants(n = 26), long-distance runners(n = 23) and healthy men(n = 29) had MRI of the SIJs prospectively performed. MRI lesions were assessed on 9 slices covering the cartilaginous compartment by two experienced readers according to the definitions of the Spondyloarthritis Research Consortium of Canada(SPARCC) SIJ inflammation and structural scores, and were evaluated according to depth and extent. Other morphological characteristics were also analysed. RESULTS Total depth scores for bone marrow oedema(BME) and fat lesion(FAT) and total extent score for erosion were statistically significantly highest in axSpA, while scores for sclerosis were numerically highest in women with post-partum pain. Maximum BME depth > 10mm was frequently and exclusively found in axSpA and post-partum women(39% vs 14-17%) while FAT depth > 5mm was predominantly found in axSpA(76% vs 0-10%). Erosions were primarily seen in axSpA, especially when extensive(≥4 or confluent; 17% vs 0%). Capsulitis was absent in non-axSpA groups. BME and FAT in the ligamentous compartment were primarily found in axSpA(17/22% vs 0/2% in non-axSpA groups). In non-axSpA, osteophytes(axSpA vs non-axSpA: 0% vs 3-17%) and vacuum phenomenon(7% vs 30-66%) were more frequent, and the joint space was wider(mean(SD) 1.5(0.9)mm vs 2.2(0.5)mm). CONCLUSIONS FAT depth > 5mm, but not BME depth > 10mm, could almost differentiate axSpA patients from all other groups. When excluding post-partum women, BME >5mm and erosion were highly specific for axSpA.
Collapse
Affiliation(s)
- Sengül Seven
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Rigshospitalet, Glostrup, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Mikkel Østergaard
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Rigshospitalet, Glostrup, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Inge Juul Sørensen
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Rigshospitalet, Glostrup, Denmark
| | - Birthe Bonde
- The Birthe Bonde Clinic of Physiotherapy, Copenhagen, Denmark
| | - Gorm Thamsborg
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Rigshospitalet, Glostrup, Denmark
| | - Jens Jørgen Lykkegaard
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Rigshospitalet, Glostrup, Denmark
| | - Susanne Juhl Pedersen
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Center of Head and Orthopedics, Rigshospitalet, Glostrup, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
9
|
Jones A, Bray TJP, Mandl P, Hall-Craggs MA, Marzo-Ortega H, Machado PM. Performance of magnetic resonance imaging in the diagnosis of axial spondyloarthritis: a systematic literature review. Rheumatology (Oxford) 2020; 58:1955-1965. [PMID: 31046102 DOI: 10.1093/rheumatology/kez172] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 04/04/2019] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES To summarize the evidence on the performance of MRI for the diagnosis of axial SpA. METHODS This was a systematic literature review of all studies from January 2013 to March 2017 including adult patients with clinically suspected axial SpA undergoing MRI. Studies from a previously published systematic literature review up to January 2013 were also included. RESULTS Thirty-one studies were included. Six studies demonstrated good sensitivity and specificity for SI joint (SIJ) bone marrow oedema (BMO). Specificity was increased by the presence of other structural lesions alongside BMO, particularly erosions or fat infiltration. Four studies addressed the utility of SIJ fat infiltration, finding good sensitivity but poor specificity. SIJ erosions showed good specificity in five studies. Studies addressing high T1 signal in the SIJ, fluid signal in the SIJ, ankylosis, sclerosis, capsulitis, backfill and vacuum phenomenon reported limited diagnostic value. In the spine, four studies reported moderate sensitivity and specificity for corner inflammatory lesions, and four reported poor sensitivity and specificity for spinal fat infiltration. Five studies evaluated the added value of spinal MRI over SIJ MRI alone, with variable results depending on the cohort. Six studies addressed the effect of acquisition parameters on diagnostic accuracy: fat-saturated T2-weighted imaging and short tau inversion recovery (STIR) imaging showed comparable utility in identifying BMO. Three studies showed that gadolinium was of minimal added value in the detection of BMO. CONCLUSIONS These results confirmed the diagnostic utility of MRI in axial SpA. Performance varied according to the characteristics of the cohort and the number and combination of MRI lesions considered.
Collapse
Affiliation(s)
- Alexis Jones
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Timothy J P Bray
- Centre for Medical Imaging, University College London, London, UK
| | - Peter Mandl
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | | | - Helena Marzo-Ortega
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, London.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, London
| | - Pedro M Machado
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK.,Department of Rheumatology, Northwick Park Hospital, London North West University Healthcare NHS Trust, London.,Centre for Rheumatology and MRC Centre for Neuromuscular Diseases, University College London, London, UK
| |
Collapse
|
10
|
Tsoi C, Griffith JF, Lee RKL, Wong PCH, Tam LS. Imaging of sacroiliitis: Current status, limitations and pitfalls. Quant Imaging Med Surg 2019; 9:318-335. [PMID: 30976556 DOI: 10.21037/qims.2018.11.10] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The clinical need to diagnose sacroiliitis at an earlier stage has led to the sacroiliac joints being more frequently imaged, particularly with magnetic resonance imaging (MRI). This review outlines the imaging approach to sacroiliitis, emphasizing the imaging protocols, diagnostic criteria, limitations and potential mimics of MRI examination. The value of imaging-guided intervention in sacroiliac joint disease is also briefly outlined.
Collapse
Affiliation(s)
- Carita Tsoi
- Department of Imaging & Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - James Francis Griffith
- Department of Imaging & Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Ryan Ka Lok Lee
- Department of Imaging & Interventional Radiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Priscilla Ching Han Wong
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Lai Shan Tam
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| |
Collapse
|
11
|
Chan CWS, Tsang HHL, Li PH, Lee KH, Lau CS, Wong PYS, Chung HY. Diffusion-weighted imaging versus short tau inversion recovery sequence: Usefulness in detection of active sacroiliitis and early diagnosis of axial spondyloarthritis. PLoS One 2018; 13:e0201040. [PMID: 30086145 PMCID: PMC6080754 DOI: 10.1371/journal.pone.0201040] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 07/06/2018] [Indexed: 11/25/2022] Open
Abstract
Objective To compare the utility of Diffusion weighted imaging (DWI) with short tau inversion recovery (STIR) sequence in the diagnosis of early axial spondyloarthritis (SpA). Methods Three hundred and five patients with chronic back pain were recruited consecutively from 3 rheumatology centers. Clinical, radiological and blood parameters were recorded. Patients with back pain duration no more than 3 years were classified as having early disease. STIR sequence and DWI of the sacroiliac joints were obtained and assessed using the Spondyloarthritis Research Consortium of Canada (SPARCC) method. The Assessment in Spondyloarthritis international Society definition was used to define positive STIR and DWI. Results were compared to expert diagnosed axial SpA. Results When compared to STIR sequence, DWI had similar sensitivity (STIR 0.29, DWI 0.30) and specificity (STIR 0.97, DWI 0.92) in diagnosing sacroiliitis. However, STIR sequence had better reliability (STIR 0.78, DWI 0.61). In early disease group, DWI was not better than STIR sequence in detecting active sacroiliitis (sensitivity DWI vs STIR: 0.34 vs 0.36; specificity DWI vs STIR: 0.93 vs 0.93; positive predictive value DWI vs STIR: 0.92 vs 0.92; negative predictive value DWI vs STIR: 0.36 vs 0.37). Using the Assessment in SpondyloArthritis international Society (ASAS) classification criteria, 67/98 patients with early disease (sensitivity 0.91 specificity 0.90) and 221/305 overall (sensitivity 0.90; specificity 0.92) were classified as axial SpA. Among the expert diagnosed axial SpA patients who did not meet the ASAS criteria, only 2 had positive DWI. Conclusion DWI and STIR have similar sensitivity in diagnosing axSpA in early disease. However, the use of DWI is limited by poorer reliability when compared with STIR.
Collapse
Affiliation(s)
- Chiu Wai Shirley Chan
- Division of Rheumatology and Clinical Immunology, The University of Hong Kong, Hong Kong, China
| | - Helen Hoi Lun Tsang
- Division of Rheumatology and Clinical Immunology, The University of Hong Kong, Hong Kong, China
| | - Philip Hei Li
- Division of Rheumatology and Clinical Immunology, The University of Hong Kong, Hong Kong, China
| | - Kam Ho Lee
- Department of Radiology, Queen Mary Hospital, Hong Kong, China
| | - Chak Sing Lau
- Division of Rheumatology and Clinical Immunology, The University of Hong Kong, Hong Kong, China
| | | | - Ho Yin Chung
- Division of Rheumatology and Clinical Immunology, The University of Hong Kong, Hong Kong, China
- * E-mail:
| |
Collapse
|
12
|
Khmelinskii N, Regel A, Baraliakos X. The Role of Imaging in Diagnosing Axial Spondyloarthritis. Front Med (Lausanne) 2018; 5:106. [PMID: 29719835 PMCID: PMC5913283 DOI: 10.3389/fmed.2018.00106] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 03/29/2018] [Indexed: 01/12/2023] Open
Abstract
Imaging has a central role in the diagnosis, management, and follow-up of patients with axial spondyloarthritis (axSpA). For the early diagnosis of axSpA, magnetic resonance imaging is of utmost relevance. While no novel imaging techniques were developed during the past decade, improvements to the existing modalities have been introduced. This report provides an overview of the applications and limitations of the existing imaging modalities.
Collapse
Affiliation(s)
- Nikita Khmelinskii
- Rheumathology Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon Academic Medical Centre, Lisbon, Portugal
| | - Andrea Regel
- Rheumazentrum Ruhrgebiet Herne, Ruhr-University Bochum, Herne, Germany
| | | |
Collapse
|
13
|
Weber U, Jurik AG, Lambert RGW, Maksymowych WP. Imaging in Spondyloarthritis: Controversies in Recognition of Early Disease. Curr Rheumatol Rep 2016; 18:58. [DOI: 10.1007/s11926-016-0607-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
|
14
|
Maksymowych WP. The role of MRI in the evaluation of spondyloarthritis: a clinician's guide. Clin Rheumatol 2016; 35:1447-55. [PMID: 27094946 DOI: 10.1007/s10067-016-3265-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Revised: 03/28/2016] [Accepted: 03/29/2016] [Indexed: 01/17/2023]
Abstract
Plain radiography remains the benchmark for diagnostic evaluation of spondyloarthritis although MRI has much great sensitivity because it can detect a variety of inflammatory lesions as well as fat metaplasia. So, it is the imaging modality of choice when pelvic radiographs are equivocal and especially when important treatment decisions have to be made. Appropriate imaging includes the use of T1-weighted and short tau inversion recovery sequences of the sacroiliac joint in the tilted coronal plane. If there is localized spinal symptomatology, sagittal scans of the spine may also be helpful. However, routine spinal imaging is not recommended. Current consensus designates a positive MRI for classification purposes as requiring the presence of two definite subchondral inflammatory lesions on a single coronal slice or the presence of one such lesion on two consecutive coronal slices. However, such inflammatory lesions can occur in healthy individuals and in those with nonspecific back pain. Erosions are more specific, and their presence can enhance confidence in the diagnosis. MRI, together with CRP, can be helpful in selecting which patients without radiographic sacroiliitis are most likely to respond to tumor necrosis factor inhibitor therapy. The role of MRI in monitoring of patients with SpA remains unclear although it may be helpful in excluding other sources of back pain. A major unanswered question is whether MRI may be useful in predicting relapse following withdrawal of TNFi in patients who have achieved sustained remission.
Collapse
Affiliation(s)
- Walter P Maksymowych
- Division of Rheumatology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.
| |
Collapse
|