Axial Spondyloarthritis: Updates in Concepts and Reporting in Radiology

Abstract

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease primarily affecting the axial skeleton, historically termed “human leukocyte antigen B27 positive spondyloarthropathy” or ankylosing spondylitis. Improved understanding of the underlying pathologic mechanisms has led to an ongoing redefinition of this disease state, a recognition of the substantial phenotypic and biological variation, and an emphasis on earlier detection. Magnetic resonance imaging has become central to identifying and confirming early axSpA, critical to fulfilling the promise of slowing disease progression and preventing irreversible structural abnormalities. We review the clinical background and current role of medical imaging in axSpA, with a focus on Assessment of SpondyloArthritis International Society consensus definitions, to improve radiology reporting and facilitate discussion between radiologists and other clinical experts in spondyloarthritis.

Keywords

axial spondyloarthritis - Assessment of SpondyloArthritis International Society - ankylosing spondylitis - spondyloarthropathy

Publication History

Article published online:
31 March 2025

• References

• 1 Taurog JD, Chhabra A, Colbert RA. Ankylosing spondylitis and axial spondyloarthritis. N Engl J Med 2016; 374 (26) 2563-2574
• 2 Rudwaleit M, van der Heijde D, Landewé R. et al. The Assessment of SpondyloArthritis International Society classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general. Ann Rheum Dis 2011; 70 (01) 25-31
• 3 Dagfinrud H, Kjeken I, Mowinckel P, Hagen KB, Kvien TK. Impact of functional impairment in ankylosing spondylitis: impairment, activity limitation, and participation restrictions. J Rheumatol 2005; 32 (03) 516-523
• 4 Reveille JD, Witter JP, Weisman MH. Prevalence of axial spondylarthritis in the United States: estimates from a cross-sectional survey. Arthritis Care Res (Hoboken) 2012; 64 (06) 905-910
• 5 Costantino F, Talpin A, Said-Nahal R. et al. Prevalence of spondyloarthritis in reference to HLA-B27 in the French population: results of the GAZEL cohort. Ann Rheum Dis 2015; 74 (04) 689-693
• 6 Boel A, López-Medina C, van der Heijde DMFM, van Gaalen FA. Age at onset in axial spondyloarthritis around the world: data from the Assessment in SpondyloArthritis international Society Peripheral Involvement in Spondyloarthritis study. Rheumatology (Oxford) 2022; 61 (04) 1468-1475
• 7 Haroon N, Inman RD, Learch TJ. et al. The impact of tumor necrosis factor α inhibitors on radiographic progression in ankylosing spondylitis. Arthritis Rheum 2013; 65 (10) 2645-2654
• 8 Ritchlin C, Adamopoulos IE. Axial spondyloarthritis: new advances in diagnosis and management. BMJ 2021; 372: m4447
• 9 van der Linden S, Valkenburg HA, Cats A. Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria. Arthritis Rheum 1984; 27 (04) 361-368
• 10 Boel A, Molto A, van der Heijde D. et al. Do patients with axial spondyloarthritis with radiographic sacroiliitis fulfil both the modified New York criteria and the ASAS axial spondyloarthritis criteria? Results from eight cohorts. Ann Rheum Dis 2019; 78 (11) 1545-1549
• 11 Sieper J, Rudwaleit M, Baraliakos X. et al. The Assessment of SpondyloArthritis International Society (ASAS) handbook: a guide to assess spondyloarthritis. Ann Rheum Dis 2009; 68 (Suppl. 02) ii1-ii44
• 12 Poddubnyy D, Diekhoff T, Baraliakos X, Hermann KGA, Sieper J. Diagnostic evaluation of the sacroiliac joints for axial spondyloarthritis: should MRI replace radiography?. Ann Rheum Dis 2022; 81 (11) 1486-1490
• 13 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) 2019; 58 (11) 1955-1965
• 14 Baraliakos X, Østergaard M, Lambert RG. et al. MRI lesions of the spine in patients with axial spondyloarthritis: an update of lesion definitions and validation by the ASAS MRI working group. Ann Rheum Dis 2022; 81 (09) 1243-1251
• 15 Diekhoff T, Eshed I, Radny F. et al. Choose wisely: imaging for diagnosis of axial spondyloarthritis. Ann Rheum Dis 2022; 81 (02) 237-242
• 16 Aggarwal R, Ringold S, Khanna D. et al. Distinctions between diagnostic and classification criteria?. Arthritis Care Res (Hoboken) 2015; 67 (07) 891-897
• 17 Rudwaleit M, van der Heijde D, Khan MA, Braun J, Sieper J. How to diagnose axial spondyloarthritis early. Ann Rheum Dis 2004; 63 (05) 535-543
• 18 Rudwaleit M, Feldtkeller E, Sieper J. Easy assessment of axial spondyloarthritis (early ankylosing spondylitis) at the bedside. Ann Rheum Dis 2006; 65 (09) 1251-1252
• 19 van den Berg R, de Hooge M, Rudwaleit M. et al. ASAS modification of the Berlin algorithm for diagnosing axial spondyloarthritis: results from the SPondyloArthritis Caught Early (SPACE)-cohort and from the Assessment of SpondyloArthritis international Society (ASAS)-cohort. Ann Rheum Dis 2013; 72 (10) 1646-1653
• 20 Mandl P, Navarro-Compán V, Terslev L. et al; European League Against Rheumatism (EULAR). EULAR recommendations for the use of imaging in the diagnosis and management of spondyloarthritis in clinical practice. Ann Rheum Dis 2015; 74 (07) 1327-1339
• 21 Czuczman GJ, Mandell JC, Wessell DE. et al; Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria® inflammatory back pain: known or suspected axial spondyloarthritis: 2021 update. J Am Coll Radiol 2021; 18 (11S): S340-S360
• 22 Poddubnyy D, Sieper J, Akar S. et al. Radiographic progression in sacroiliac joints in patients with axial spondyloarthritis: results from a five-year international observational study. ACR Open Rheumatol 2024; 6 (02) 103-110
• 23 Sieper J, Poddubnyy D. Axial spondyloarthritis. Lancet 2017; 390 (10089): 73-84
• 24 Weber U, Pfirrmann CWA, Kissling RO, Mackenzie CR, Khan MA. Early spondyloarthritis in an HLA-B27-positive monozygotic twin pair: a highly concordant onset, sites of involvement, and disease course. J Rheumatol 2008; 35 (07) 1464-1466
• 25 Carmona R, Harish S, Linda DD, Ioannidis G, Matsos M, Khalidi NA. MR imaging of the spine and sacroiliac joints for spondyloarthritis: influence on clinical diagnostic confidence and patient management. Radiology 2013; 269 (01) 208-215
• 26 Diekhoff T, Hermann KGA, Greese J. et al. Comparison of MRI with radiography for detecting structural lesions of the sacroiliac joint using CT as standard of reference: results from the SIMACT study. Ann Rheum Dis 2017; 76 (09) 1502-1508
• 27 Ward MM, Deodhar A, Gensler LS. et al. 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network recommendations for the treatment of ankylosing spondylitis and nonradiographic axial spondyloarthritis. Arthritis Rheumatol 2019; 71 (10) 1599-1613
• 28 Maksymowych WP, Lambert RG, Østergaard M. et al. MRI lesions in the sacroiliac joints of patients with spondyloarthritis: an update of definitions and validation by the ASAS MRI working group. Ann Rheum Dis 2019; 78 (11) 1550-1558
• 29 Lambert RGW, Maksymowych WP. The SpondyloArthritis Research Consortium of Canada (SPARCC) Magnetic Resonance Imaging of the Sacroiliac Joints Acquisition Protocol. Available at: https://www.carearthritis.com/wp-content/uploads/2020/05/MRI-SI-Joint-acquisition-protocol-Version-7.0.1-2020.04.23.pdf . Accessed January 17, 2025
• 30 Althoff CE, Feist E, Burova E. et al. Magnetic resonance imaging of active sacroiliitis: do we really need gadolinium?. Eur J Radiol 2009; 71 (02) 232-236
• 31 de Hooge M, van den Berg R, Navarro-Compán V. et al. Magnetic resonance imaging of the sacroiliac joints in the early detection of spondyloarthritis: no added value of gadolinium compared with short tau inversion recovery sequence. Rheumatology (Oxford) 2013; 52 (07) 1220-1224
• 32 Samet JD, Alizai H, Chalian M. et al. Society of Skeletal Radiology position paper - recommendations for contrast use in musculoskeletal MRI: when is non-contrast imaging enough?. Skeletal Radiol 2024; 53 (01) 99-115
• 33 Starekova J, Pirasteh A, Reeder SB. Update on gadolinium-based contrast agent safety, from the AJR Special Series on Contrast Media. AJR Am J Roentgenol 2024; 223 (03) e2330036
• 34 Wolharn L, Guggenberger R, Higashigaito K. et al. Detailed bone assessment of the sacroiliac joint in a prospective imaging study: comparison between computed tomography, zero echo time, and black bone magnetic resonance imaging. Skeletal Radiol 2022; 51 (12) 2307-2315
• 35 Martín-Noguerol T, Casado-Verdugo OL, Beltrán LS, Aguilar G, Luna A. Role of advanced MRI techniques for sacroiliitis assessment and quantification. Eur J Radiol 2023; 163: 110793
• 36 Lambert RGW, Bakker PAC, van der Heijde D. et al. Defining active sacroiliitis on MRI for classification of axial spondyloarthritis: update by the ASAS MRI working group. Ann Rheum Dis 2016; 75 (11) 1958-1963
• 37 Puhakka KB, Melsen F, Jurik AG, Boel LW, Vesterby A, Egund N. MR imaging of the normal sacroiliac joint with correlation to histology. Skeletal Radiol 2004; 33 (01) 15-28
• 38 Almodovar R, Bueno A, Garcia Monco C. et al. Quantification of bone marrow edema by MRI of the sacroiliac joints in patients diagnosed with axial spondyloarthritis: results from the ESPeranza cohort. Scand J Rheumatol 2022; 51 (05) 374-381
• 39 Wang DM, Lin L, Peng JH. et al. Pannus inflammation in sacroiliitis following immune pathological injury and radiological structural damage: a study of 193 patients with spondyloarthritis. Arthritis Res Ther 2018; 20 (01) 120
• 40 Maksymowych WP, Lambert RG, Baraliakos X. et al. Data-driven definitions for active and structural MRI lesions in the sacroiliac joint in spondyloarthritis and their predictive utility. Rheumatology (Oxford) 2021; 60 (10) 4778-4789
• 41 Diekhoff T, Eshed I, Giraudo C. et al. Reporting sacroiliac joint imaging performed for known or suspected axial spondyloarthritis: assessment of SpondyloArthritis International Society Recommendations. Radiology 2024; 311 (03) e231786
• 42 Gorelik N, Tamizuddin F, Rodrigues TC. et al. Comparison between radiography and magnetic resonance imaging for the detection of sacroiliitis in the initial diagnosis of axial spondyloarthritis: a cost-effectiveness study. Skeletal Radiol 2020; 49 (10) 1581-1588
• 43 Schueller-Weidekamm C, Mascarenhas VV, Sudol-Szopinska I. et al. Imaging and interpretation of axial spondylarthritis: the radiologist's perspective–consensus of the Arthritis Subcommittee of the ESSR. Semin Musculoskelet Radiol 2014; 18 (03) 265-279
• 44 van Tubergen A, Heuft-Dorenbosch L, Schulpen G. et al. Radiographic assessment of sacroiliitis by radiologists and rheumatologists: does training improve quality?. Ann Rheum Dis 2003; 62 (06) 519-525
• 45 Battistone MJ, Manaster BJ, Reda DJ, Clegg DO. Radiographic diagnosis of sacroiliitis—are sacroiliac views really better?. J Rheumatol 1998; 25 (12) 2395-2401
• 46 Rodriguez VR, Llop M, Protopopov M. et al. Assessment of radiographic sacroiliitis in anteroposterior lumbar vs conventional pelvic radiographs in axial spondyloarthritis. Rheumatology (Oxford) 2021; 60 (01) 269-276
• 47 Klauser A, Bollow M, Calin A. et al. Workshop report: clinical diagnosis and imaging of sacroiliitis, Innsbruck, Austria, October 9, 2003. J Rheumatol 2004; 31 (10) 2041-2047
• 48 Han Q, Zheng Z, Zhang K, Ding J, Baraliakos X, Zhu P. A comprehensive assessment of hip damage in ankylosing spondylitis, especially early features. Front Immunol 2021; 12: 668969
• 49 MRI compared with low-dose CT scanning in the diagnosis of axial spondyloarthritis. Clin Rheumatol 2020; 39 (04) 1295-1303
• 50 Tan S, Ward MM. Computed tomography in axial spondyloarthritis. Curr Opin Rheumatol 2018; 30 (04) 334-339
• 51 Vereecke E, Diekhoff T, Eshed I. et al. ESR essentials: Imaging of sacroiliitis-practice recommendations by ESSR. Eur Radiol 2024; 34 (09) 5773-5782
• 52 Suh CH, Yun SJ, Jin W, Lee SH, Park SY, Ryu CW. Diagnostic performance of dual-energy CT for the detection of bone marrow oedema: a systematic review and meta-analysis. Eur Radiol 2018; 28 (10) 4182-4194
• 53 Pache G, Krauss B, Strohm P. et al. Dual-energy CT virtual noncalcium technique: detecting posttraumatic bone marrow lesions—feasibility study. Radiology 2010; 256 (02) 617-624
• 54 Wu H, Zhang G, Shi L. et al. Axial spondyloarthritis: dual-energy virtual noncalcium CT in the detection of bone marrow edema in the sacroiliac joints. Radiology 2019; 290 (01) 157-164
• 55 Deppe D, Ziegeler K, Hermann KGA. et al. Dual-energy-CT for osteitis and fat lesions in axial spondyloarthritis: how feasible is low-dose scanning?. Diagnostics (Basel) 2023; 13 (04) 776
• 56 Ramiro S, Nikiphorou E, Sepriano A. et al. ASAS-EULAR recommendations for the management of axial spondyloarthritis: 2022 update. Ann Rheum Dis 2023; 82 (01) 19-34
• 57 Lambert RGW, Salonen D, Rahman P. et al. Adalimumab significantly reduces both spinal and sacroiliac joint inflammation in patients with ankylosing spondylitis: a multicenter, randomized, double-blind, placebo-controlled study. Arthritis Rheum 2007; 56 (12) 4005-4014
• 58 Agrawal P, Machado PM. Recent advances in managing axial spondyloarthritis. Available at: f1000research.com/articles/9-697 . Accessed January 17, 2025
• 59 Rudwaleit M, Claudepierre P, Wordsworth P. et al. Effectiveness, safety, and predictors of good clinical response in 1250 patients treated with adalimumab for active ankylosing spondylitis. J Rheumatol 2009; 36 (04) 801-808
• 60 Milota T, Hurnakova J, Pavelka K, Kristkova Z, Nekvindova L, Horvath R. Delayed treatment with a tumor necrosis factor alpha blocker associated with worse outcomes in patients with spondyloarthritis: data from the Czech National Registry ATTRA. Ther Adv Musculoskelet Dis 2022; 14: 1-13 . 1759720–X221081649
• 61 Maksymowych WP, Claudepierre P, de Hooge M. et al. Structural changes in the sacroiliac joint on MRI and relationship to ASDAS inactive disease in axial spondyloarthritis: a 2-year study comparing treatment with etanercept in EMBARK to a contemporary control cohort in DESIR. Arthritis Res Ther 2021; 23 (01) 43
• 62 Magrey MN, Danve AS, Ermann J, Walsh JA. Recognizing Axial Spondyloarthritis: a guide for primary care. Mayo Clin Proc 2020; 95 (11) 2499-2508
• 63 van den Berg R, van der Heijde DMFM. How should we diagnose spondyloarthritis according to the ASAS classification criteria: a guide for practicing physicians. Pol Arch Intern Med 2010; 120 (11) 452-457
• 64 Navarro-Compán V, Benavent D, Capelusnik D. et al. ASAS consensus definition of early axial spondyloarthritis. Ann Rheum Dis 2024; 83 (09) 1093-1099
• 65 Ciurea A, Götschi A, Bräm R. et al. Early axial spondyloarthritis according to the ASAS consensus definition: characterisation of patients and effectiveness of a first TNF inhibitor in a large observational registry. RMD Open 2023; 9 (04) e003455
• 66 Khan MA. HLA-B27 and its subtypes in world populations. Curr Opin Rheumatol 1995; 7 (04) 263-269
• 67 Ruof J, Stucki G. Validity aspects of erythrocyte sedimentation rate and C-reactive protein in ankylosing spondylitis: a literature review. J Rheumatol 1999; 26 (04) 966-970
• 68 Lorenzin M, Ometto F, Ortolan A. et al. An update on serum biomarkers to assess axial spondyloarthritis and to guide treatment decision. Ther Adv Musculoskelet Dis 2020; 12: 1-19 . 1759720–X20934277