Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Perspectives
  • Published:

Opinion: Perspectives on imaging in axial spondyloarthritis

Nature Reviews Rheumatology volume 9, pages 498–502 (2013)Cite this article

Subjects

Abstract

The diagnosis of axial spondyloarthritis (axSpA) is based on detection of characteristic inflammatory or structural changes (or a combination of both) in the spine and sacroiliac joints. Imaging of the axial skeleton is, therefore, useful for the identification of these pathological changes. Both inflammation (best detected by MRI) and bone formation (best visualized by conventional radiography) can predict the development of future structural changes. In addition, a high degree of spinal inflammation on MRI is predictive of a successful response to anti-TNF therapy. Emerging data indicate that the combination of acute and chronic changes on MRI has an important influence on progression of nonradiographic axSpA to ankylosing spondylitis. This Perspectives article provides an overview of the role of imaging in the diagnosis and management of axSpA, and also discusses open questions and future perspectives in this field.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1: Imaging scans obtained from a patient with nonradiographic axial spondyloarthritis.

Similar content being viewed by others

References

  1. Rudwaleit, M. et al. The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part II): validation and final selection. Ann. Rheum. Dis. 68, 777–783 (2009).

    Article  CAS  Google Scholar 

  2. Baraliakos, X. et al. Progression of radiographic damage in patients with ankylosing spondylitis: defining the central role of syndesmophytes. Ann. Rheum. Dis. 66, 910–915 (2007).

    Article  CAS  Google Scholar 

  3. Vander Cruyssen, B. et al. The epidemiology of ankylosing spondylitis and the commencement of anti-TNF therapy in daily rheumatology practice. Ann. Rheum. Dis. 66, 1072–1077 (2007)

    Article  Google Scholar 

  4. Bollow, M. et al. Quantitative analyses of sacroiliac biopsies in spondyloarthropathies: T cells and macrophages predominate in early and active sacroiliitis- cellularity correlates with the degree of enhancement detected by magnetic resonance imaging. Ann. Rheum. Dis. 59, 135–140 (2000).

    Article  CAS  Google Scholar 

  5. Francois, R. J., Neure, L., Sieper, J. & Braun, J. Immunohistological examination of open sacroiliac biopsies of patients with ankylosing spondylitis: detection of tumour necrosis factor {alpha} in two patients with early disease and transforming growth factor {beta} in three more advanced cases. Ann. Rheum. Dis. 65, 713–720 (2006).

    Article  CAS  Google Scholar 

  6. Baraliakos, X., Listing, J., Rudwaleit, M., Sieper, J. & Braun, J. The relationship between inflammation and new bone formation in patients with ankylosing spondylitis. Arthritis Res. Ther. 10, R104 (2008).

    Article  Google Scholar 

  7. Rudwaleit, M., Listing, J., Brandt, J., Braun, J. & Sieper, J. Prediction of a major clinical response (BASDAI 50) to tumour necrosis factor alpha blockers in ankylosing spondylitis. Ann. Rheum. Dis. 63, 665–670 (2004).

    Article  CAS  Google Scholar 

  8. van der Linden, S., Valkenburg, H. A. & Cats, A. Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria. Arthritis Rheum. 27, 361–368 (1984).

    Article  CAS  Google Scholar 

  9. van Tubergen, A. et al. Radiographic assessment of sacroiliitis by radiologists and rheumatologists: does training improve quality? Ann. Rheum. Dis. 62, 519–525 (2003).

    Article  CAS  Google Scholar 

  10. Kiltz, U. et al. Do patients with non-radiographic axial spondylarthritis differ from patients with ankylosing spondylitis? Arthritis Care Res. (Hoboken) 64, 1415–1422 (2012).

    Article  Google Scholar 

  11. Rudwaleit, M. et al. Defining active sacroiliitis on magnetic resonance imaging (MRI) for classification of axial spondyloarthritis: a consensual approach by the ASAS/OMERACT MRI group. Ann. Rheum. Dis. 68, 1520–1527 (2009).

    Article  CAS  Google Scholar 

  12. Weber, U. et al. Assessment of structural lesions in sacroiliac joints enhances diagnostic utility of MRI in early spondyloarthritis. Arthritis Care Res. (Hoboken) 62, 1763–1771 (2010).

    Article  Google Scholar 

  13. Hermann, K. G. et al. Descriptions of spinal MRI lesions and definition of a positive MRI of the spine in axial spondyloarthritis: a consensual approach by the ASAS/OMERACT MRI study group. Ann. Rheum. Dis. 71, 1278–1288 (2012).

    Article  Google Scholar 

  14. Maksymowych, W. P. et al. Inflammatory lesions of the spine on magnetic resonance imaging predict the development of new syndesmophytes in ankylosing spondylitis: evidence of a relationship between inflammation and new bone formation. Arthritis Rheum. 60, 93–102 (2009).

    Article  Google Scholar 

  15. van der Heijde, D. et al. MRI inflammation at the vertebral unit only marginally predicts new syndesmophyte formation: a multilevel analysis in patients with ankylosing spondylitis. Ann. Rheum. Dis. 71, 369–373 (2012).

    Article  Google Scholar 

  16. Bennett, A. N. et al. Severity of baseline magnetic resonance imaging-evident sacroiliitis and HLA-B27 status in early inflammatory back pain predict radiographically evident ankylosing spondylitis at eight years. Arthritis Rheum. 58, 3413–3418 (2008).

    Article  CAS  Google Scholar 

  17. Maksymowych, W. P., Morency, N., Conner-Spady, B. & Lambert, R. G. Suppression of inflammation and effects on new bone formation in ankylosing spondylitis: evidence for a window of opportunity in disease modification. Ann. Rheum. Dis. 72, 23–28 (2012).

    Article  Google Scholar 

  18. Baraliakos, X. et al. The relationship of inflammation, fatty degeneration and the effect of long-term TNF-blocker treatment on the development of new bone formation in patients with ankylosing spondylitis. Arthritis Rheum. 64, S338 (2012).

    Article  Google Scholar 

  19. Baraliakos, X., Listing, J., von der Recke, A. & Braun, J. The natural course of radiographic progression in ankylosing spondylitis—evidence for major individual variations in a large proportion of patients. J. Rheumatol. 36, 997–1002 (2009).

    Article  Google Scholar 

  20. Poddubnyy, D. et al. Rates and predictors of radiographic sacroiliitis progression over 2 years in patients with axial spondyloarthritis. Ann. Rheum. Dis. 70, 1369–1374 (2011).

    Article  Google Scholar 

  21. Baraliakos, X., Listing, J., von der Recke, A. & Braun, J. The natural course of radiographic progression in ankylosing spondylitis: differences between genders and appearance of characteristic radiographic features. Curr. Rheumatol. Rep. 13, 383–387 (2011).

    Article  Google Scholar 

  22. Reveille, J. D. et al. for the Australo-Anglo-American Spondyloarthritis Consortium. Genome-wide association study of ankylosing spondylitis identifies non-MHC susceptibility loci. Nat. Genet. 42, 123–127 (2010).

    Article  CAS  Google Scholar 

  23. Pedersen, S. J. et al. ASDAS, BASDAI and different treatment responses and their relation to biomarkers of inflammation, cartilage and bone turnover in patients with axial spondyloarthritis treated with TNFα inhibitors. Ann. Rheum. Dis. 70, 1375–1381 (2011).

    Article  CAS  Google Scholar 

  24. Braun, J. et al. 2010 update of the ASAS/EULAR recommendations for the management of ankylosing spondylitis. Ann. Rheum. Dis. 70, 896–904 (2011).

    Article  CAS  Google Scholar 

  25. Sieper, J. et al. Double-blind, placebo-controlled, 28-week trial of efficacy and safety of infliximab plus naproxen vs. naproxen alone in patients with early, active axial spondyloarthritis treated with a submaximal dose of NSAIDs: preliminary results of INFAST, Part 1. Ann. Rheum. Dis. 71 (Suppl. 3), 247 (2012).

    Google Scholar 

  26. Jarrett, S. J. et al. MRI and clinical findings in patients with ankylosing spondylitis eligible for anti-tumour necrosis factor therapy after a short course of etoricoxib. Ann. Rheum. Dis. 68, 1466–1469 (2009).

    Article  CAS  Google Scholar 

  27. Poddubnyy, D. et al. Effect of non-steroidal anti-inflammatory drugs on radiographic spinal progression in patients with axial spondyloarthritis: results from the German Spondyloarthritis Inception Cohort. Ann. Rheum. Dis. 71, 1616–1622 (2012).

    Article  CAS  Google Scholar 

  28. Kroon, F., Landewe, R., Dougados, M. & van der Heijde, D. Continuous NSAID use reverts the effects of inflammation on radiographic progression in patients with ankylosing spondylitis. Ann. Rheum. Dis. 71, 1623–1629 (2012).

    Article  CAS  Google Scholar 

  29. van der Heijde, D. et al. 2010 Update of the international ASAS recommendations for the use of anti-TNF agents in patients with axial spondyloarthritis. Ann. Rheum. Dis. 70, 905–908 (2011).

    Article  Google Scholar 

  30. Braun, J. et al. Magnetic resonance imaging examinations of the spine in patients with ankylosing spondylitis, before and after successful therapy with infliximab: evaluation of a new scoring system. Arthritis Rheum. 48, 1126–1136 (2003).

    Article  CAS  Google Scholar 

  31. Baraliakos, X., Davis, J., Tsuji, W. & Braun, J. Magnetic resonance imaging examinations of the spine in patients with ankylosing spondylitis before and after therapy with the tumor necrosis factor α receptor fusion protein etanercept. Arthritis Rheum. 52, 1216–1223 (2005).

    Article  CAS  Google Scholar 

  32. Rudwaleit, M. et al. Magnetic resonance imaging of the spine and the sacroiliac joints in ankylosing spondylitis before and during therapy with etanercept. Ann. Rheum. Dis. 64, 1305–1310 (2005).

    Article  CAS  Google Scholar 

  33. Baraliakos, X. et al. Radiographic progression in patients with ankylosing spondylitis after 2 years of treatment with the tumour necrosis factor α antibody infliximab. Ann. Rheum. Dis. 64, 1462–1466 (2005).

    Article  CAS  Google Scholar 

  34. van der Heijde, D. et al. Radiographic findings following two years of infliximab therapy in patients with ankylosing spondylitis. Arthritis Rheum. 58, 3063–3070 (2008).

    Article  Google Scholar 

  35. van der Heijde, D. et al. Radiographic progression of ankylosing spondylitis after up to two years of treatment with etanercept. Arthritis Rheum. 58, 1324–1331 (2008).

    Article  CAS  Google Scholar 

  36. van der Heijde, D. et al. Assessment of radiographic progression in the spines of patients with ankylosing spondylitis treated with adalimumab for up to 2 years. Arthritis Res. Ther. 11, R127 (2009).

    Article  Google Scholar 

  37. Haibel, H. et al. Efficacy of adalimumab in the treatment of axial spondylarthritis without radiographically defined sacroiliitis: results of a twelve-week randomized, double-blind, placebo-controlled trial followed by an open-label extension up to week fifty-two. Arthritis Rheum. 58, 1981–1991 (2008).

    Article  CAS  Google Scholar 

  38. Barkham, N. et al. Clinical and imaging efficacy of infliximab in HLA-B27-Positive patients with magnetic resonance imaging-determined early sacroiliitis. Arthritis Rheum. 60, 946–954 (2009).

    Article  CAS  Google Scholar 

  39. Vastesaeger, N. et al. Predicting the outcome of ankylosing spondylitis therapy. Ann. Rheum. Dis. 70, 973–981 (2011).

    Article  Google Scholar 

  40. Rudwaleit, M. et al. MRI in predicting a major clinical response to anti-tumour necrosis factor treatment in ankylosing spondylitis. Ann. Rheum. Dis. 67, 1276–1281 (2008).

    Article  CAS  Google Scholar 

  41. Braun, J. et al. Magnetic resonance imaging examinations of the spine in patients with ankylosing spondylitis, before and after successful therapy with infliximab: evaluation of a new scoring system. Arthritis Rheum. 48, 1126–1136 (2003).

    Article  CAS  Google Scholar 

  42. Machado, P. et al. MRI inflammation and its relation with measures of clinical disease activity and different treatment responses in patients with ankylosing spondylitis treated with a tumour necrosis factor inhibitor. Ann. Rheum. Dis. 71, 2002–2005 (2012).

    Article  Google Scholar 

  43. Machado, P. et al. Both structural damage and inflammation of the spine contribute to impairment of spinal mobility in patients with ankylosing spondylitis. Ann. Rheum. Dis. 69, 1465–1470 (2010).

    Article  Google Scholar 

  44. Sieper, J. et al. Efficacy and safety of adalimumab in patients with non-radiographic axial spondyloarthritis: results of a randomised placebo-controlled trial (ABILITY-1). Ann. Rheum. Dis. 72, 815–822 (2012).

    Article  Google Scholar 

  45. Lubrano, E., D'Angelo, S., Spadaro, A., Palazzi, C. & Olivieri, I. Rehabilitation for ankylosing spondylitis in the era of biologics: any room left for this treatment? J. Rheumatol. 38, 1228–1230 (2011).

    Article  Google Scholar 

  46. Braun, J., Bollow, M. & Sieper, J. Radiologic diagnosis and pathology of the spondyloarthropathies. Rheum. Dis. Clin. North Am. 24, 697–735 (1998).

    Article  CAS  Google Scholar 

  47. Gong, Y. et al. Ten years' experience with needle biopsy in the early diagnosis of sacroiliitis. Arthritis Rheum. 64, 1399–1406 (2012).

    Article  Google Scholar 

  48. Heldmann, F. et al. The European ankylosing spondylitis infliximab cohort (EASIC): a European multicentre study of long term outcomes in patients with ankylosing spondylitis treated with infliximab. Clin. Exp. Rheumatol. 29, 672–680 (2011).

    CAS  PubMed  Google Scholar 

  49. Bruijnen, S. T. et al. Bone formation rather than inflammation reflects Ankylosing Spondylitis activity on PET-CT: a pilot study. Arthritis Res. Ther. 14, R71 (2012).

    Article  CAS  Google Scholar 

  50. Appel, H. et al. Immunohistologic analysis of zygapophyseal joints in patients with ankylosing spondylitis. Arthritis Rheum. 54, 2845–2851 (2006).

    Article  Google Scholar 

Download references

Acknowledgements

The authors thank Christian Buchbender, MD, Prof. Benedict Ostendorf, MD, and Thorsten Poeppel, MD, for their cooperation in producing the PET-MRI images shown in this Perspectives.

Author information

Authors and Affiliations

  1. Rheumazentrum Ruhrgebiet Herne, Ruhr-University Bochum, Landgrafenstrasse 15, Herne, 44652, Germany

    Xenofon Baraliakos & Jürgen Braun

Authors
  1. Xenofon Baraliakos
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jürgen Braun
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

X. Baraliakos and J. Braun both contributed equally to researching data, discussion of article content, writing and editing of the manuscript before submission.

Corresponding author

Correspondence to Xenofon Baraliakos.

Ethics declarations

Competing interests

The authors declare no competing financial interests.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Baraliakos, X., Braun, J. Opinion: Perspectives on imaging in axial spondyloarthritis. Nat Rev Rheumatol 9, 498–502 (2013). https://doi.org/10.1038/nrrheum.2013.83

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrrheum.2013.83

This article is cited by

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing