Role of MRI in Assessment and Diagnosis of Axial Spondyloarthritis

Lebanese Society of Rheumatology 2009 Nov 07

Ulrich Weber MD, Rheumatology

Balgrist University Hospital, Zurich, Switzerland

Disclosure

Nothing to disclose

No advisory board memberships

Funding of the project Whole Body MRI in SpA

• Walter L. and Johanna Wolf Foundation, Zurich, Switzerland

• Foundation for Scientific Research at the University of Zurich, Switzerland

Ankylosing SpondylitisAxial Disease

Ankylosing SpondylitisNonaxial Disease

Uveitis Dactylitis

Anterior chest wall inflammationCoxitis

Objectives

• Role of MRI in early diagnosis of axial SpA

• Whole body MRI – a promising MRI variant

• Emerging roles of MRI in axial SpA

Early diagnosis28y f, fall from horse 15 mo ago, persist. LBP

Early diagnosis28y f, fall from horse 15 mo ago, persist. LBP

22y f with left groin painFemoroacetabular impingement?

Ankylosing SpondylitisDelayed diagnosis

Germany 1999 8.8 years

Switzerland 2005-2008 5.7 years

Feldtkeller E et al. Rheumatol Int 2003;23:61

SCQM AS; Zollikofer A. Medical thesis (unpublished data)

SpA - The challenge of early diagnosis

Early SpA

• No validated diagnostic criteria

Plain radiography

• Equivocal findings in early SpA

• Definite lesions are seen after ~10 years

Rudwaleit M et al. Arthritis Rheum 2005;52:1000

Mau W et al. J Rheumatol 1988;15:1109

Radiographic SIJ classification

grade 1/2 grade 2 grade 3 grade 4

Van der Linden S et al. Arthritis Rheum 1984;27:361

Radiographic SIJ classification Moderate sensitivity and specificity

Scoring of SIJ by23 radiologists and 100 rheumatologists

• Sensitivity 84 % / 80 % Specificity 71 % / 75 %

After training unchanged

• Sensitivity 83 % / 79 % Specificity 80 % / 76 %

Van Tubergen A et al. Ann Rheum Dis 2003;62:519

Modified New York classification criteria

• low back pain >3 months‘ duration improved by exercise and not relieved by rest

• limited lumbar spinal motion in both the sagittal and frontal planes

• decreased chest expansion (rel. to normal values for sex and age)

• bilateral radiographic sacroiliitis grade 2–4

• unilateral radiographic sacroiliitis grade 3–4

Positive: 1 of 2 radiographic AND ≥1 of 3 clinical criteria

Van der Linden S et al. Arthritis Rheum 1984;27:361

ASAS classification criteria for axial SpA

Sacroiliitis on imagingX-ray or MRI

plus

≥1/11 clinical featuresIBP; Arthritis; Enthesitis (heel); Uveitis; Dactylitis; Ps/CD/UC; HLAB27; Response to NSAIDs; FH SpA; CRP

Sensitivity 66%

Specificity 97%

„Imaging arm“

HLA B27

plus

≥2/10 clinical featuresIBP; Arthritis; Enthesitis (heel); Uveitis; Dactylitis; Ps/CD/UC; Response to NSAIDs; FH SpA; CRP

Sensitivity 83%

Specificity 84%

„Clinical arm“

n = 649 pat; LBP >3 mon; symptom onset <45 J; rheumatology practices

Rudwaleit M et al. Ann Rheum Dis 2009;68:777

ASAS classification criteria for axial SpA

MRI equivalent to plain X-ray

however:

What is a positive MRI?

in the spine?

in the SIJ?

Diagnostic utility of spinal MRI lesions

Romanus Lesion (RL)= Spondylitis angularis

≥3 RL: positive LR 12 1

≥2 RL: positive LR 12 2

1Bennett AN et al. Arthritis Rheum 2009;60:1331

2Weber U et al. Arthritis Rheum 2009;61:900

3Jaeschke R et al. JAMA 1994;271:703

Clinical relevance LR+: 3

5-10 moderate

>10 high

SpA ?

„Romanus-Lesion“ in 26% of healthy volunteers

Weber U et al. Arthritis Rheum 2009;61:900

Diagnostic utility of chronicspinal MRI lesions

Fatty Romanus Lesion

>0 FRL: positive LR 5

>5 FRL: positive LR 13

Bennett AN et al. Ann Rheum Dis 2009;published online 9 Aug

T1 STIR

Diagnostic utility of SIJ MRI lesionsASAS/OMERACT consensual approach

• Active inflammatory SIJ lesions required

• Subchondral or periarticular bone marrow edema (BME) highly suggestive of sacroiliitis

• BME score ≥2 on a single SIJ slice and/or ≥1 lesion on 2 consecutive slices

1 slice sufficient

require 2 slices

Rudwaleit M et al. Ann Rheum Dis 2009;68:1520

What about structural lesions?

Symptom duration 24 months; normal pelvic X-ray

T1

STIR

Erosions

Diagnostic utility of SIJ MRI lesions

MORPHO Study

4 abstracts EULAR 2009 Copenhagen

5 abstracts ACR 2009 Philadelphia

Objectives of MORPHO program

• To assess the diagnostic utility of SIJ MRI by - MRI sequences used in routine practice - comparison with appropriate controls

• To assess the relative contribution of T1 (structural lesions) versus STIR (acute lesions) to assess diagnostic utility

• To define a „positive“ MRI for SpA using a data driven approach

MORPHO Methodology

187 subjects / patients

All ≤45 years old

All patients with inflammatory back pain≤10 years duration

Subjects– 59 asymptomatic healthy volunteers (HV)– 26 patients with non-specific back pain (NSBP)– 77 patients with SpA (met modified NY criteria)– 25 patients with inflammatory back pain

(did not meet modified NY criteria)

MORPHO Methodology

STIR

Bone Marrow Oedema Erosion

T1

Ankylosis

T1

Fatty Infiltration

T1

MORPHO resultsMean Sens, Spec and LR+/- for 5 readers

Comparison groups

Sensitivity Specificity Pos. Likeli-hood ratio

Neg. Likeli-hood ratio

AS vs NSBP+HC

0.89 (0.82-0.97) 0.97 (0.94-0.99) 44 (16-73) 0.11 (0.03-0.18)

IBP vs NSBP+HC

0.50 (0.48-0.52) 0.97 (0.94-0.99) 26 (9-43) 0.51 (0.49-0.54)

AS: Ankylosing spondylitis

IBP: Inflammatory back pain = Preradiographic SpA

NSPB: Non-specific back pain

HC: Healthy controls

Diagnostic utility of SIJ MRI lesionsMORPHO proposal

BME score ≥2 on a single SIJ slice and/or≥1 on 2 consecutive slices (ASAS proposal)

OR

Erosion score ≥2 on a single SIJ slice or ≥2 on 2 consecutive slices

OR

BME score ≥1 AND Erosion score ≥1 on any slice

IBP patients: Comparison of diagnostic utilityASAS versus MORPHO proposal

Reader Sensitivity Specificity Pos. Likelihood ratio Neg. Likelihood ratio

Any 2 0.64 0.88 5.4 0.4

Reader Sensitivity Specificity Pos. Likelihood ratio Neg. Likelihood ratio

Any 2 0.84 0.88 7.1 0.2

ASAS proposal

MORPHO proposal

NB: 13/25 (52%) IBP patients diagnosed as SpA by ≥2 readers according to overall assessment of MRI

SpA ?Bone marrow edema-like lesion

STIR T135y old healthy volunteer

SpA ?Fat deposition

STIR T1Healthy volunteer

SpA ?Erosion- and BME-like lesion

STIR T1Healthy volunteer

Inflammatory back pain and SpAMRI – the key for early diagnosis

Suspicion based on clinical grounds(IBP / additional clinical SpA features)

Plain X-ray of the pelvis

Radiographic („late stage“) SpA

MRI (conventional or whole body)

Preradiographic („early“) SpA

Heuft-Dorenbosch L et al. Ann Rheum Dis 2006;65:804

Objectives

• Role of MRI in early diagnosis of axial SpA

• Whole body MRI – a promising MRI variant

• Emerging roles of MRI in axial SpA

WB MRI – a recently introduced imaging modality

Multichannel technology Parallel imaging

Whole body multicoil systemSpatial resolution WB = CON MRI

Moving table platformNo patient or coil repositioning

Fusion of the imagesby a dedicated software

WB MRI in ASPractical issues

Examination time30 minutes including patient positioning

Reporting time15 minutes for a trained reader

Costsabout 1.5 times the expense for CON MRI(in billing systems based on the amount of time needed for

a particular exam)

Additional imaging of lower extremitiespotential objective measure for enthesitisadditional examination time of 20 minutes

WB MRI – introduced for systemic screening in oncology and angiology

Systemic arterial occlusive disease

Nael K et al. AJR 2007;188:529-39

Oncological screening and staging

Schaefer JF et al. Eur Radiol 2006;16:2000-15

Validation Whole body MRI versus Conventional MRI in SpA: SIJ and spine

Weber U et al. Ann Rheum Dis 2009;published online 7 MayWeber U et al. Arthritis Rheum 2009;61:893

MRI lesions in early SpA21y m, HLA B27+, IBP 14 months, ESR 55

Early diagnosis in monozygotic twin23y m, dactylitis, right buttock pain for 4 mo

August 2007 September 2008

Diagnosis 4 months after symptom onset

Weber U et al. J Rheumatol 2008;35:1464

Spinal MRI lesions

Anterior chest wall inflammation

WB MRI in clinical practiceCoxitis

30 yrs old male, disease duration 7 yrs; no hip pain

WB MRI in clinical practice Inflammatory versus mechanical back pain

57 yrs old male, HLA B27+, disease duration 32 yrs, fusion th/l spine

Increasing th/l back pain for 3 yrs, intense night pain

no response to conventional and alternative therapy

Pseudarthrosis T10/11 after transspinal fracture

Weber U, Maksymowych WP. Skelet Radiol 2008;37:487-90

Objectives

• Role of MRI in early diagnosis of axial SpA

• Whole body MRI – a promising MRI variant

• Emerging roles of MRI in axial SpA

Inflammatory MRI spinal lesions Predictive for new syndesmophytes

Prospective observational cohort, follow-up after 24 months by plain X-ray and MRI

New syndesmophytes developed significantly more frequently in vertebral corners with inflammation (14.3%) than in those without inflammation (2.9%) seen on baseline MRI (p<0.003)

Maksymowych WP et al. Arthritis Rheum 2009;60:93

Baraliakos X et al. Arthritis Res Ther 2008;10:R104

Guiding TNFa-inhibitor treatment in early SpA (symptom duration 3mo-3y)

Percentage of ASAS partial remission

Early SpA (MRI) 55.6% 1

Established SpA (Xray) 22.4% 2

1Barkham N et al. Arthritis Rheum 2009;60:946

2Van der Heijde D et al. Arthritis Rheum 2005;52:582

Monitoring response to TNFa-inhibitors

2006 2009

Disease activityMRI versus clinical/laboratory parameters

• No correlation of MRI activity parameters with clinical and laboratory activity in various study designs (cross-sectional, cohort and interventional studies)

• MRI may reflect other aspects of disease activity than the ones expressed by clinical and laboratory parameters

Puhakka KB et al. Rheumatology 2004;43:234Maksymowych WP et al. Arthritis Rheum 2007;57:501Lambert RG et al. Arthritis Rheum 2007;56:4005Weber U et al. Arthritis Rheum 2009;61:893

Roles of MRI in axial SpASummary

• Confirmation of SpA diagnosis suspected on clinical grounds (preradiographic stage)

• Diagnostic MRI thresholds both for SIJ and spine needed

• Emerging role for guiding treatment and predicting disease course

Acknowledgement

• Radiology Balgrist Juerg Hodler Marco Zanetti Christian Pfirrmann

• Rheumatology Balgrist Rudolf Kissling

• Walter Maksymowych, Edmonton Robert Lambert, Edmonton

• Anne Grethe Jurik, Aarhus Anna Zejden, Aarhus

• Mikkel Ostergaard, Copenhagen Susanne Pedersen, Copenhagen

• Asim Khan, Cleveland

• Kaspar Rufibach, Zurich

• Rahel Kubik, Baden

• Stefan Duewell, Frauenfeld

Discussion

White-browed Robin (pair)

% vertebral corners developing syndesmophytes after 2 years

Inflammatory MRI spinal lesions Predictive for new syndesmophytes

Courtesy: Dr Walter Maksymowych, Edmonton