Imaging study scores for ankylosing spondylitis

doi:10.1016/j.jbspin.2006.03.007

Joint Bone Spine

Volume 73, Issue 6, December 2006, Pages 655-660

https://doi.org/10.1016/j.jbspin.2006.03.007 Get rights and content

Abstract

Scoring systems have been developed for radiographs and magnetic resonance imaging (MRI) in patients with ankylosing spondylitis (AS). Radiographic scores focus on chronic structural alterations, which occur slowly and show little sensitivity to change in the short-term. Recent clinical studies used the modified Stoke ankylosing spondylitis spine score (mSASSS), which evaluates the cervical and lumbar spine. TNF antagonists were found to modify the mSASSS, indirectly supporting a structural effect of these agents. MRI using specific sequences is a potent tool for evaluating inflammation, most notably at the spine. MRI has proved sensitive to change in patients taking TNF antagonists. An outcome measures in rheumatology clinical trials (OMERACT) task force is working on standardizing MRI scores for the spine and sacroiliac joints.

Introduction

The management of ankylosing spondylitis (AS) and other spondyloarthropathies is undergoing radical changes that are chiefly related to the introduction of TNFα antagonists. These agents have proved capable of improving the signs and symptoms of the disease, as well as overall short- and mid-term outcomes [1]. Studies of the potential structural effects of TNFα antagonists are ongoing in patients with rheumatoid arthritis. A prerequisite to the conduct of similar studies in AS is the availability of validated scoring systems for imaging studies that take into account the specific features of the disease, most notably at the sacroiliac joints and spine. Although work in this field is less advanced for AS than for rheumatoid arthritis, scores for AS are in the final phases of development and have a number of practical applications. Therefore, an overview of these scoring systems is timely.

The many available techniques for imaging the skeleton supply different levels of information. In practice, plain radiography and computed tomography (CT) provide structural information that represents the cumulative effect of the disease over time, indicating either stabilization or progression. These imaging methods are widely used for the diagnosis of AS, and the slow pace of radiological changes may explain the often unacceptably long diagnostic delays. In addition, plain radiography and CT show little sensitivity to short-term changes and are therefore of limited usefulness for evaluating treatment responses. In contrast, magnetic resonance imaging (MRI) with appropriate sequences [2] and power Doppler ultrasonography of the entheses provide an accurate assessment of inflammation at target sites and can show not only progression, but also reversal of abnormalities in the short-term.

A number of studies have led to the development of scoring systems for imaging studies in AS. These scoring systems are used in clinical research and therapeutic trials. Their contribution to everyday clinical practice and to the diagnosis of AS will need to be clarified.

Section snippets

Radiograph scores for AS

The sacroiliac joints and hips are the sites of interest on radiographs of the pelvis. In classification criteria for AS, a five-grade system (0–4) is used to describe sacroiliac joint involvement. Various patterns of inflammatory hip disease may be seen [3]. Hip involvement is associated with worse functional outcomes. Abnormalities of the sacroiliac joints and hips exhibit little sensitivity to change.

Plain radiographs of the spine may show the shiny corner sign (Romanus lesion), squaring of

MRI

Fewer data are available for MRI in AS. An OMERACT task force [17] has found that MRI is useful chiefly for assessing inflammatory changes, as opposed to structural changes. Published and unpublished scores for the sacroiliac joints and spine were compared using various MRI sequences and sections. Intra- and interobserver agreement and sensitivity to change were compared between the global and the analytical method. A validated standardized score suitable for use in everyday practice is being

Ultrasonography

B-mode ultrasonography coupled with power Doppler imaging (which visualizes vascular supply) shows entheseal lesions and detects evidence of inflammation. D'Agostino et al. [30] developed a five-grade ultrasound score for enthesitis, as follows: 1, vascularization at the cortical junction without abnormalities in B mode; 2a: vascularization associated with swelling and/or decreased echogenicity at the cortical junction in B mode; 3a: same as 2a plus erosions of cortical bone and/or

Conclusion

Imaging scores for AS will be used increasingly to meet the growing need for objective data on treatment effects. Although MRI scores hold promise for evaluating spinal inflammation and detecting changes over time, further validation and standardization are needed. With this respect, the conclusions of the OMERACT task force are impatiently awaited. For evaluating structural alterations, the mSASSS seems to be the best tool for clinical studies. However, the slow pace of lesion progression and,

References (30)

X. Baraliakos et al.
Magnetic resonance imaging in spondyloarthritis
Joint Bone Spine
(2006)
D. Wendling et al.
Anti-TNF-alpha therapy in ankylosing spondylitis
Expert Opin. Pharmacother.
(2004)
S. Van Der Linden et al.
Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria
Arthritis Rheum.
(1984)
K. Mac Kay et al.
The Bath ankylosing spondylitis radiology index (BASRI): a new, validated approach to disease assessment
Arthritis Rheum.
(1998)
H.L. Averns et al.
Radiological outcome in ankylosing spondylitis: use of the Stoke ankylosing spondylitis spine score (SASSS)
Br. J. Rheumatol.
(1996)
M.C.W. Creemers et al.
Assessment of outcome in ankylosing spondylitis: an extended radiographic scoring system
Ann. Rheum. Dis.
(2005)
A.J.B. Wanders et al.
What is the most appropriate radiologic scoring method for ankylosing spondylitis? A comparison of the available methods based on the outcome measures in rheumatology clinical trials filter
Arthritis Rheum.
(2004)
D. Van der Heijde et al.
Selection of a method for scoring radiographs for ankylosing spondylitis clinical trials, by the assessment in ankylosing spondylitis working group and OMERACT
J. Rheumatol.
(2005)
S. Brophy et al.
The natural history of ankylosing spondylitis as defined by radiological progression
J. Rheumatol.
(2002)
D. Van der Heijde et al.
How should treatment effect on spinal radiographic progression in patients with ankylosing spondylitis be measured?
Arthritis Rheum.
(2005)

X. Baraliakos et al.

Progression of radiographic damage in patients with AS. Assessment of definite change and definition of predictive factors

Arthritis Rheum.

(2005)

A. Wanders et al.

Non-steroidal anti-inflammatory drugs reduce radiographic progression in patients with ankylosing spondylitis. A randomized clinical trial

Arthritis Rheum.

(2005)

X. Baraliakos 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.

(2005)

X. Baraliakos et al.

Influence of infliximab therapy on radiographic progression in patients with ankylosing spondylitis. Results after 4 years of treatment

Arthritis Rheum.

(2005)

X. Baraliakos et al.

Less radiographic progression in patients with active ankylosing spondylitis after 2 years of anti-TNF therapy

Arthritis Rheum.

(2005)

Cited by (22)

Cervical spine involvement in axial spondyloarthritis
2024, Revue du Rhumatisme (Edition Francaise)
La spondyloarthrite axiale est un rhumatisme inflammatoire chronique débutant habituellement chez l’adulte jeune, ayant comme principale atteinte, des manifestations inflammatoires pelvirachidiennes pouvant être le lit d’une dégradation structurale responsable de conséquences fonctionnelles majeures. Des manifestations périphériques, et extra-articulaires peuvent compléter le tableau phénotypique. L’atteinte structurale rachidienne étant habituellement ascendante, les atteintes cervicales sont rarement le mode d’entrée dans la maladie. Cependant, le rhumatologue doit être averti des présentations cliniques radiologiques. En effet l’ankylose cervicale qui s’intègre habituellement dans une rigidité rachidienne totale est associée à une impotence fonctionnelle majeure et peut être le siège de complications sévères mettant en jeu le pronostic vital des patients, notamment par le biais d’atteinte médullaire secondaire à des fractures vertébrales.
Axial spondyloarthritis is a chronic inflammatory rheumatic disease that usually begins in young adults. Its main symptoms are pelvic and spinal inflammation, which can lead to structural degradation with major functional consequences. Peripheral and extra-articular manifestations may complete the phenotypic picture. As structural damage to the spine is usually ascending, cervical involvement is rarely the mode of entry into the disease. However, rheumatologists need to be aware of radiological clinical presentations. Cervical ankylosis, which usually forms part of total spinal rigidity, is associated with major functional impotence, and can be the site of severe, life-threatening complications, notably spinal cord damage secondary to vertebral fractures.
New bone formation in axial spondyloarthritis
2013, Joint Bone Spine
Citation Excerpt :
These changes selectively affect the vertebral corners, which correspond to entheses. These changes can be quantified by MRI and radiography at both the sacroiliac joints and the spine [3,4]. Inflammation is best assessed by MRI and new bone formation by radiography.
New bone formation of the entheses with possible progression to ankylosis is among the hallmarks of axial spondyloarthritis. Radiographic scores are available for evaluating axial new bone formation. The complex systems that underlie new bone formation involve Wnt bone-formation signaling and the natural Wnt inhibitors DKK-1 and sclerostin, as well as growth factors such as the bone morphogenetic proteins (BMPs); these systems are modulated by proinflammatory cytokines, most notably TNF. Factors that predict progressive new bone formation include the presence of syndesmophytes, various biological markers (CRP, MMP-3, sclerostin, DKK-1, and BMP), smoking, and prior vertebral corner abnormalities (inflammation and, above all, resolved inflammation). Nonsteroidal antiinflammatory agents seem able to slow the pace of radiographic progression, an effect not documented to date with TNF antagonists in patients with axial spondyloarthritis.
The ossification in axial spondyloarthritis
2013, Revue du Rhumatisme (Edition Francaise)
L’ossification des enthèses pouvant aboutir à l’ankylose est une caractéristique des spondyloarthrites axiales. Elle peut être évaluée et quantifiée par les scores radiographiques. Les systèmes impliqués dans cette ossification sont complexes et font intervenir les voies de signalisation d’ostéoformation Wnt et ses inhibiteurs (DKK-1, sclérostine) et également des facteurs de croissance tels que les bone morphogenetic proteins (BMP) ; ces systèmes sont modulés par les cytokines pro-inflammatoires, en particulier le TNF. Les facteurs prédictifs de progression de l’ossification sont la présence de syndesmophytes, certains marqueurs biologiques (CRP, MMP-3, sclérostine, DKK-1, BMP), le tabagisme et les lésions préalables de l’angle vertébral (inflammation et surtout résolution de l’inflammation). Les AINS semblent capables de freiner la progression radiographique, ce qui n’a pas été observé à ce jour avec les agents anti TNF dans les spondyloarthrites axiales.
Non-radiographic spondyloarthritis: A theoretical concept or a real entity?
2012, Joint Bone Spine
Non-radiographic spondylarthritis: Theoretical concept or concrete entity?
2012, Revue du Rhumatisme (Edition Francaise)
Role for imaging studies in ankylosing spondylitis
2011, Joint Bone Spine
Although the diagnosis and structural monitoring of ankylosing spondylitis relies classically on standard radiography, recent classification criteria and recommendations issued by the ASAS-OMERACT working group give considerable weight to modern imaging methods, most notably magnetic resonance imaging (MRI). MRI and, more recently, ultrasonography, yield three major benefits: they ensure the early diagnosis of ankylosing spondylitis in the absence of radiographic sacroiliitis, they provide therapeutic guidance at any time during the course of the disease, and they supply objective information on the degree of inflammation and response to treatment. Prospective longitudinal studies are under way to determine the respective roles for MRI and ultrasonography in the diagnosis and monitoring of axial and peripheral forms of ankylosing spondylitis. The introduction of whole-body MRI, new MRI sequences and positron emission tomography can be expected to further benefit the diagnosis of ankylosing spondylitis.

View all citing articles on Scopus

View full text

ReviewImaging study scores for ankylosing spondylitis

Abstract

Introduction

Section snippets

Radiograph scores for AS

MRI

Ultrasonography

Conclusion

Joint Bone Spine

Anti-TNF-alpha therapy in ankylosing spondylitis

Expert Opin. Pharmacother.

Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria

Arthritis Rheum.

The Bath ankylosing spondylitis radiology index (BASRI): a new, validated approach to disease assessment

Arthritis Rheum.

Radiological outcome in ankylosing spondylitis: use of the Stoke ankylosing spondylitis spine score (SASSS)

Br. J. Rheumatol.

Assessment of outcome in ankylosing spondylitis: an extended radiographic scoring system

Ann. Rheum. Dis.

What is the most appropriate radiologic scoring method for ankylosing spondylitis? A comparison of the available methods based on the outcome measures in rheumatology clinical trials filter

Arthritis Rheum.

Selection of a method for scoring radiographs for ankylosing spondylitis clinical trials, by the assessment in ankylosing spondylitis working group and OMERACT

J. Rheumatol.

The natural history of ankylosing spondylitis as defined by radiological progression

J. Rheumatol.

How should treatment effect on spinal radiographic progression in patients with ankylosing spondylitis be measured?

Arthritis Rheum.

Progression of radiographic damage in patients with AS. Assessment of definite change and definition of predictive factors

Arthritis Rheum.

Non-steroidal anti-inflammatory drugs reduce radiographic progression in patients with ankylosing spondylitis. A randomized clinical trial

Arthritis Rheum.

Radiographic progression in patients with ankylosing spondylitis after 2 years of treatment with the tumour necrosis factor α antibody infliximab

Ann. Rheum. Dis.

Influence of infliximab therapy on radiographic progression in patients with ankylosing spondylitis. Results after 4 years of treatment

Arthritis Rheum.

Less radiographic progression in patients with active ankylosing spondylitis after 2 years of anti-TNF therapy

Arthritis Rheum.

Review
Imaging study scores for ankylosing spondylitis