Introduction
In recent years, the latest advances in the diagnosis and treatment of spondyloarthritis (SpA) have been using MRI as the major diagnostic tool and administering anti- tumor necrosis factor (TNF) therapy as the major treatment strategy. Recent prospective data suggest that the spinal inflammatory damage in patients with ankylosing spondylitis (AS) will be eventually converted into fat. In these complex inflammatory lesions, bone formation and inflammation are not synchronized. Researchers have also found fat infiltration to be a repair process and accelerated by some treatments; potentially causing no harm to patients. AS is a disease characterized by new bone formation, and Wnt/β-catenin signaling has been commonly considered the major pathway regulating new bone formation. Thus, the serum level of Dkk-1, the natural inhibitor of Wnt protein, may be a main factor in blocking new bone formation. Therefore, we prospectively analyzed the correlation between MRI findings and Dkk-1 levels of 30 patients with SpA. Current research suggests that spinal inflammation repair, such as fat infiltration, may further stimulate syndesmophyte formation or calcification [
1,
2]. To further determine the therapeutic effects of TNF inhibitors on each vertebra, a total of 690 vertebrae of the 30 patients were also individually evaluated. This study was designed to investigate the molecular mechanism underlying the TNF inhibitors’ blockade on new bone formation, and to provide information for evaluating prognosis and choosing appropriate therapy for patients with SpA.
Materials and methods
Collection of cases
This study enrolled 30 patients with axial spondyloarthritis (axSpA) who fulfilled the Assessment of Spondyloarthritis International Society (ASAS) axSpA criteria. All patients received an injection of recombinant human tumor necrosis factor receptor-antibody fusion protein (YiSaiPu) at a dose of 50 mg/week for 6 months. Physical examination, blood tests, and a spinal and sacroiliac MRI were performed on all patients.
Exclusion criteria were the following: a history of infectious disease 2 weeks before admission, a history of other rheumatic diseases, and spinal surgery or spinal tumor.
Our study was approved by the ethics committee of PLA General Hospital. The reference number was C2014–004-01. Consent for publication was obtained from all patients.
Instruments, software, and imaging assessment protocol
Sagittal spine MRI images were obtained using a 1.5 T MRI scanner (GE, USA), and a ClearCanvas Workstation 2.0 was used for image reading. The sacroiliac joints and spinal MRI imaging of the patients before and after the treatment were blindly reviewed and scored using the Spondyloarthritis Research Consortium of Canada (SPARCC), Canada-Denmark (CANDEN) MRI definitions, and Fat Spondyloarthritis Spine Score (FASSS) scoring system by two individuals who were familiar with the system. We also calculated the difference between before and after treatment scores (the scores at baseline—the scores at 24 weeks).
Scoring of sacroiliac joint inflammatory lesions [3]
The SPARCC scoring method for active inflammatory lesions in the sacroiliac joint relies on the use of a T2-weighted sequence that incorporates the suppression of normal marrow fat signals. Each sacroiliac joint is divided into four quadrants: upper iliac, lower iliac, upper sacral, and lower sacral. The presence of an increased signal on short-time inversion recovery (STIR) sequence in each of these four quadrants was scored on a dichotomous basis, where 1 represents an increased signal and 0 represents a normal signal. The maximal score for an abnormal signal in the two sacroiliac joints of one coronal slice was, therefore, 8. Joints that included a lesion exhibiting an intense signal were each given an additional score of 1 per slice to demonstrate this feature. Similarly, each joint that included a lesion demonstrating a continuous increased signal of a depth of 1 cm from the articular surface was also given an additional score of 1. These additional measures bring the maximal score for a single coronal slice to 12. The scoring was repeated in each of the six consecutive coronal slices leading to a maximal score of 72.
Scoring of sacroiliac joints structural lesions [4]
In this analysis, the SPARCC sacroiliac joint structural score was used to assess the structural lesions of erosion, backfill, fat metaplasia, and ankylosis on T1W MRI. Paired baseline and 24-week T1W MRI scans were scored independently by two different readers blinded to patients.
The presence or absence of lesions in sacroiliac joint quadrants (erosion, fat metaplasia) or sacroiliac joint halves (backfill, ankylosis) was recorded with a yes or no using direct online data entry based on a schematic of the sacroiliac joint. Erosion and fat metaplasia were each scored from 0 to 8 per slice on a total of five slices (total score 0–40). Backfill and ankylosis were each scored from 0 to 4 per slice on a total of five slices (total score 0–20).
Scoring of spine inflammatory lesions [5, 6]
Inflammation scores were developed from the CANDEN definitions of lesions and scoring [
5,
6] in a way similar to FASSS. The development and validation of FASSS based on the CANDEN MRI definitions has previously been reported [
7,
8].
Fat metaplasia (FASSS) was assessed at each DVU, which constitutes the region between two horizontal lines drawn across the midpoint of adjacent vertebrae in the sagittal orientation. Vertebral corner fat metaplasia in either central or lateral slices was scored dichotomously (lesion present or absent = 1 or 0). In DVUs in the thoracic and lumbar (but not cervical) spine, a score of 1 was added if corner fat metaplasia could be classified as large (see above) in central slices. Corner and non-corner lesions in the cervical spine were not assessed for size, because the vertebral bodies here are much smaller when compared with the vertebral bodies of the thoracic and lumbar segments. By definition, there are no lateral slices in the cervical spine, because the pedicles here are located lateral to the vertebral body and, therefore, both structures cannot be seen on the same sagittal slices. Corner fat metaplasia in lateral slices was not assigned a weighting for size, because it was difficult to assess size in relation to anterior–posterior diameter on this curved part of the vertebral body.
Non-corner fat metaplasia was scored only in central slices and assessed dichotomously (lesion present or absent = 2 or 0). In DVUs in the thoracic and lumbar (but not cervical) spine, a score of 2 was added if the non-corner lesion could be classified as large (see above). If corner fat metaplasia in any central slice involved more than 50% of the anterior–posterior diameter of the vertebra, it was considered a combined corner and non-corner fat lesion. DVUs where the height of the disc was reduced unequivocally by ≥ 50% were not assessed since the fat metaplasia here may be caused by coincidental or secondary degenerative disc disease.
Each DVU from C2/C3 to L5/S1 was assessed systematically for the different categories of fat metaplasia. The scoring range for each thoracic and lumbar DVU was 0 to 24, where the central slices provided a maximum score of 16 (four large corner lesions each scoring 2 = 8, and two large non-corner lesions each scoring 4 = 8). The lateral slices provided a maximum score of 8 (four right + four left corner lesions each scoring 1). The maximum score for each cervical DVU was 8 (four corner lesions each scoring 1 = 4, and two non-corner lesions each scoring 2 = 4). The scoring range for all 23 DVUs that comprised the total FASSS spine score was 0 to 456.
Measurement of clinical factors
All patients’ erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Metrology Index (BASMI), and Ankylosing Spondylitis Disease Activity Score (ASDAS-CRP) were tested before and after treatment.
Measurement of the serum Dkk-1
A Dkk-1 ELISA kit (R&D) was used to detect the serum Dkk-1 levels in the 30 patients before and after treatment. All samples were processed in accordance with the manufacturer’s instructions. Changes in serum Dkk-1 levels before and after treatment were calculated (the serum Dkk-1 levels at baseline—the serum Dkk-1 levels at 24 weeks).
Statistical analysis
SPSS 19.0 software was used for statistical analysis. Qualitative data are described as number (%) and quantitative data are described as mean (±SD) and median (IQR). A t test or rank sum test was used for statistical analysis. The correlation between serum levels and radiographic score variables was evaluated by Spearman’s correlation coefficient.
Discussion
Data have shown that TNF-α inhibitors are effective for patients with Ankylosing Spondylitis (AS) [
9]. Besides improving patient symptoms, they may also improve quality of life and slow the radiographic progression of the condition [
10]. In our study, all patients received a TNF-α inhibitor developed by Sunshine Guojian Pharmaceutical (Shanghai) Co., Ltd. The generic name of this inhibitor is Recombinant Human Tumor Necrosis Factor α Receptor: IgG Fc Fusion Protein for Injection (brand name: YiSaiPu). After TNF inhibitor treatment, improvements were demonstrated by significant decreases in BASDAI, BASFI, BASMI, EST, CRP, and ASDAS-CRP, which were observed in all patients.
Various classification methods have been used by scholars to describe the sacroiliac joints and spinal MRI findings of patients with SpA. A commonly accepted method of scoring is the SPARCC method, which divides the SpA-associated lesions into acute inflammation and chronic structural lesions. The acute inflammatory lesions mainly refer to bone marrow edema, while the chronic structural lesions include bone erosion, fat infiltration, backfilling, bone spurs, and bone bridge formation [
11,
12]. To better assess the lesions shown on MRIs of SpA patients, the SPARCC and CANDEN methods were used to score the acute and chronic inflammations of the sacroiliac joints and spinal MRIs in our patients. The results show that TNF inhibitors can significantly improve BME in both the sacroiliac joints and spine, and increase sacroiliac joints backfilling scores; but have no effect on fat infiltration and bone erosion in either the sacroiliac joints or the spine. A total of 690 vertebrae of the 30 patients were then evaluated individually. The results show that a total of 158 vertebrae had BME before treatment, which either decreased or resolved in 137 (86.7%) of those vertebrae after treatment. Among the vertebrae which showed improvement in BME, fat infiltration was not observed in 110 (69.6%). In addition, a total of 38 vertebrae from 18 patients having no BME before treatment developed fat infiltration after treatment. This result indicates that TNF inhibitors are not able to completely prevent chronic lesions like fat infiltration in some vertebrae. In a 5-year study following AS patients who received TNF inhibitor treatment [
13], it has been found that, though the incidences of fat infiltration in the second year was high in vertebrae that showed inflammations at baseline, no new bone formation was noted until the fifth year. In addition, research has also found that the occurrence rates of fat infiltration slowed from the second year to the fifth year during the process of TNF inhibitor treatment, which may indicate that it does no harm to the patient by potentially accelerating the repair process of fat infiltration through some treatments.
To further understand the relationship between the MRI changes and new bone formation in SpA patients, we analyzed their serum Dkk-1 levels and found that those levels in active SpA patients before treatment were significantly higher than those in remission after the treatment. Korkosz’s study also found that serum Dkk-1 decreased significantly after TNF inhibitor treatment in AS patients with high disease activity [
14]. Dkk-1 is an antagonist of the classical Wnt signaling pathway by binding to the LRP5/6 receptor of osteoblasts and inhibiting bone formation by acting at several of differentiation stages of the osteoblasts [
15,
16]. Papapoulos and his team from Leiden University Medical Center of Netherlands [
17] found that the increase of Dkk-1 level was a compensatory response to the lack of sclerostin and the increase in bone formation. Their research indicated that the Dkk-1 levels in sclerosteosis patients were significantly increased when compared to healthy controls. Further, serum Dkk-1 level and (CTX) levels are positively correlated in sclerosteosis patients. This finding also explains why Dkk-1 levels were increased in our active SpA patients.
Biological agents are some of the most effective treatments for SpA; however, the key factor affecting the prognosis of patients with SpA is new bone formation. It has been proved that TNF antagonists do not inhibit bone formation directly. In a mice arthritis model, TNF antagonists promoted new bone formation by inhibiting the effect of TNF-α on osteoblasts. In the same study, even though etanercept inhibited inflammation effectively, it failed to prevent new bone formation [
18]. The ultimate goal of SpA treatment is to improve the prognosis of the patients, and this result complicates the choice of SpA treatment strategies. Two years ago, the German researcher Baraliakos [
19] investigated two cohorts, which were DIKAS that continuously used full doses of infliximab, and Herne that did not use TNF inhibitors. The differences of their modified stroke AS spine scores (mSASSS) were compared in the 8th year of the study. The result revealed that the differences of mSASSS between the two cohorts were not significantly increased during the first 4 years, but gradually increased from the fourth year to the eighth year, and became statistically significant at the eighth year. This study indicates that a prolonged observation period may prove that TNF inhibitors can inhibit new bone formation. However, long-term usage of biological reagents will undoubtedly bring a huge economic burden to society and individuals. For this reason, it is of particular importance for rheumatologists to decide the proper timing to start and stop the application of biological agents. Our research found that, after TNF antagonist treatment, the patients’ clinical symptoms were relieved, and the serum Dkk-1 levels were significantly reduced, which may be the molecular mechanism of TNF antagonists’ inhibitory effects on new bone formation. Nocturne [
20] and his team found that Dkk-1 serum level was correlated with CRP level and the presence of sacroiliitis on radiography, but none of the other studied variables (age, gender, weight, and BASDAI) were significantly correlated with Dkk-1 serum level. However, our research found that Dkk-1 serum level was not correlated with systemic inflammation or disease activity assessed by ESR, CRP level, ASDAS-CRP, BASDAI, BASFI, or BASMI, but positively correlated with the spinal MRI acute inflammation. The change levels of serum Dkk-1 were also positively correlated with the change levels of the spinal MRI acute inflammation, but not with the fat infiltration scores. These same correlations were not found in MRI images of the sacroiliac joints, which indicates that spinal bone marrow edema may predicate new bone formation and can be used as better evidence for prognostic evaluation. Thus, for patients with spinal bone marrow edema, a more progressive treatment may be administered for better prognosis. However, further research is needed on patients who have received long-term TNF antagonist treatment to find the time points when serum Dkk-1 level could reach a stabilized plateau. Increased knowledge in this area will be helpful when assessing a predictive marker for the timing of treatment withdrawal.
In conclusion, this is the first work to find a significant correlation between the spinal bone marrow edema shown on MRI and the serum Dkk-1 levels. Although patient sample size is relatively small, our result still reveal the molecular basis responsible for new bone formation in SpA patients, and provides a theoretical basis for determining the timing of biological agents treatment as well as evaluating patient prognosis.
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.