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  • Review Article
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The role of imaging in the diagnosis and management of axial spondyloarthritis

Nature Reviews Rheumatology volume 15, pages 657–672 (2019)Cite this article

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Abstract

MRI of the sacroiliac joints is increasingly acknowledged as being indispensable in the early diagnosis of axial spondyloarthritis (axSpA) and as having a prominent role in the prognosis and classification of axSpA. Technological advances include improvements in the resolution of structural lesions and in methodologies for the quantification of lesions. Limited access and expertise in interpretation of MRI have led to a resurgence of interest in CT, especially the development of low radiation protocols for assessing the sacroiliac joints. Trials of TNF inhibitors in patients with non-radiographic axSpA have led to greater understanding of the role of MRI in selecting which patients might respond well to this therapy. The role of MRI features as target end points in treat-to-target strategies remains unclear because the effect of such targeting on structural damage parameters has only recently been explored. The relative importance of active and structural lesions for prognostic risk assessment and selection of appropriate treatment is also an area of current research. Given the increased capacity to visualize a broad array of lesions in both the sacroiliac joints and the spine using MRI and CT, these modalities will probably be increasingly employed for assessment of the disease-modifying activity of new therapies.

Key points

  • Low-dose CT of the sacroiliac joints has superior diagnostic accuracy to plain radiography for axial spondyloarthritis (axSpA) and can be widely implemented.

  • MRI scans of the sacroiliac joint should be interpreted contextually using complementary diagnostic information provided by T1-weighted and fat-suppressed sequences.

  • Routine MRI evaluation of patients presenting with back pain and suspected axSpA should be confined to the pelvis because imaging of the spine is of little additional benefit.

  • The utility of the assessment of sacroiliac joint structural lesions or spinal lesions by MRI for improving current classification for axSpA is still uncertain.

  • Lesions in the sacroiliac joints and spine on MRI have potential prognostic value for structural progression, especially the presence of fat metaplasia.

  • MRI inflammatory scores can discriminate between active therapy and placebo and have been a consistent predictor of the efficacy of novel treatments in clinical trials over the past two decades.

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Fig. 1: T1W and STIR sequences of a healthy sacroiliac joint.
Fig. 2: Bone marrow oedema in the sacroiliac joints on MRI and false positivity for axSpA.
Fig. 3: Structural lesions in the sacroiliac joints on MRI.
Fig. 4: Development of backfill after anti-TNF therapy.

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  1. Department of Medicine, University of Alberta, Edmonton, Alberta, Canada

    Walter P. Maksymowych

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W.P.M. is Chief Medical Officer of CaRE Arthritis and has received research and/or educational grants from Abbvie, Janssen, Novartis, Pfizer and UCB, and consulting fees and/or honoraria from Abbvie, Boehringer, Celgene, Galapagos, Janssen, Lilly, Novartis, Pfizer and UCB.

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Maksymowych, W.P. The role of imaging in the diagnosis and management of axial spondyloarthritis. Nat Rev Rheumatol 15, 657–672 (2019). https://doi.org/10.1038/s41584-019-0309-4

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