GRAPPA 2023 Debate: Is Psoriatic Disease Really a Primary Enthesitis That Drives Joint Synovitis? The Enthesitis Hypothesis 25 Years On.

The enthesitis hypothesis posits that enthesitis is a primary lesion and that inflammation at the enthesis initiates the musculoskeletal symptoms of psoriatic arthritis (PsA) and spondyloarthropathies (SpA). The hypothesis suggested that inflamed entheseal tissue near the synovium could trigger cytokine-mediated synovitis, that enthesis bone anchorage could explain osteitis, and that the location of entheses at the soft tissue interface could explain dactylitis. Advances in imaging techniques that allow better visualization of enthesitis lesions and the development of animal models have allowed evolution of the concept of enthesitis as a central mechanistic driver of musculoskeletal symptoms in PsA and SpA. A debate between Drs. Dennis McGonagle and Bruce Kirkham at the Group for Research on Psoriasis and Psoriatic Arthritis (GRAPPA) 2023 annual meeting discussed the data supporting and refuting this hypothesis in PsA and SpA, respectively. The major points of this debate are summarized in this article.

The effect of subchondral oedema in T2-weighted Dixon MRI sequence evaluation of sacroiliac joint erosion in axial spondyloarthropathy.

AIM: To evaluate the effect of subchondral oedema in T2-weighted Dixon magnetic resonance imaging (MRI) sequence evaluation of sacroiliac joint erosion in patients with axial spondyloarthropathy. MATERIALS AND METHODS: Twenty patients diagnosed with axial spondyloarthritis underwent MRI at a tertiary referral centre from December 2019 to March 2021 were included. In-phase, opposed-phase and fat-only images were scored by two musculoskeletal radiologists independently for the presence of erosions in eight sacroiliac joint quadrants. Sensitivity, specificity and areas under the curve (AUC) of the receiver operating characteristic curve were determined using T1W sequence as reference standard. Intra-observer and interobserver reliability were calculated using Cohen's kappa coefficient. RESULTS: The diagnostic performance of fat-only and in-phase images were similar (AUC 0.857-0.902 and 0.828-0.868) and better than opposed-phase images (AUC 0.613-0.658). The interobserver reliability of fat-only and in-phase images were substantial (k = 0.747 and 0.712), and moderate for opposed-phase images (k = 0.417). Intra-observer reliability was almost perfect for all the images. In the subgroup analysis, the specificity and AUC for oedema-positive group were lower than oedema-negative group in all image sets. Interobserver reliability was substantial for fat-only and in-phase images in both groups, but slight and moderate for the opposed-phase oedema-positive and negative groups, respectively. CONCLUSION: The presence of subchondral oedema in active sacroiliitis decreased the diagnostic accuracy of sacroiliac joint erosion detection on T2W Dixon MRI images.

A Novel Grading System of Destructive Lumbar Spondyloarthropathy Based on Evaluation of the Facet Joints.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To develop and evaluate a new grading system for destructive lumbar spondyloarthropathy (DLSA) by assessing bony destruction of the facet joints; to evaluate interrater reliability; and to determine the association between anteroposterior (AP) dural sac diameter at the lumbar level and the new grading. SUMMARY OF BACKGROUND DATA: The characteristics of DLSA are unknown, hindering clinical care and research. Imaging to determine the cause of DLSA may positively contribute to patient outcome or well-being by providing prognostic information. PATIENTS AND METHODS: In the magnetic resonance images (MRIs), we measured an axial midline AP dural sac diameter and evaluated bone destruction caused by amyloidosis at the level of the center of each lumbar disk of the lumbar spine. Two orthopedic surgeons independently evaluated each case at two-month intervals and assigned the grade by rating bone destruction at each lumbar level. Weighted κ and intraclass correlation coefficients for interrater reliability were calculated. In addition, the correlation between the AP diameter of the spinal dural sac at the lumbar level and the new MRI-based DLSA grade was examined. RESULTS: The sample size of 82 patients was reached by examining records of 118 consecutive patients. The mean (SD) age of the included patients was 65 (7.2) years, and 36 (43.9%) were women. The grading of DLSA showed moderate to good interrater reliability at both assessments (κ, 0.59-0.78). Intraclass correlation coefficient showed substantial to excellent agreement (intraclass correlation coefficient, 0.63-0.86). The AP diameter of the spinal dural sac at the lumbar level showed a significant correlation with the new grading ( P <0.001). CONCLUSIONS: The new MRI-based grading system for DLSA has good interrater reliability, although the strength of agreement varies somewhat. The new grading system correlates with AP dural sac diameter. Thus, this classification focused on facet erosion, which leads to functional incompetence may be helpful in surgical decision-making.

Multiparametric Large Field of View Rheumatology Imaging for Axial Spondyloarthropathy Detects Enthesitis in Setting of Inactive Sacroiliac Joint Disease and Impacts Clinical Diagnosis.

AIM: To test the diagnostic efficacy of a multiparametric rheumatology lumbosacral magnetic resonance (MR) imaging protocol in detection and characterization of axial spondylarthritis (SpA) and compare it with serology and clinical findings. METHODS: A consecutive series of multiparametric rheumatology lumbosacral MR imaging examinations performed on 3T MR scanner. Three-dimensional inversion recovery turbo spin echo, precontrast and postcontrast fat-suppressed T1-weighted images, as well as diffusion-weighted images were used to detect active erosions and enthesitis using established criteria. Pearson χ2 was used for categorical variables. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were measured for magnetic resonance imaging (MRI) and serology, based on the final diagnosis from rheumatologists. An alpha error below 0.05 was considered statistically significant. RESULTS: The final study sample included 130 consecutive patients (80 women and 50 men; mean ± SD 44 ± 13 and 45 ± 14 years, respectively). Seventy-eight subjects were diagnosed with axial SpA and 52 with non-SpA arthropathy. In the non-SpA group, 27 patients were diagnosed with osteoarthritis, 6 had unremarkable imaging, whereas 19 were considered as clinically undetermined. There was positive correlation between positive MRI results and SpA diagnosis (P < 0.00001). No correlation existed between positive serology alone and SpA diagnosis (P = 0.0634). Although MRI and serology proved equally sensitive in detecting SpA, the specificity and overall accuracy of MRI were significantly higher. Inflammatory activity was detected in 45 (57.7%) cases, in the pelvic enthesis in 29 (37.2%) cases, in the lumbosacral spine in 16 (20.5%) cases, in the hip joints in 15 (19.2%) cases, and in the pubic symphysis in 5 (6.4%). Inactive sacral disease was seen in 7 of 35 enthesitis patients (20.0%), and in 2 SpA cases, there were no sacral lesions. CONCLUSIONS: The results suggest that in patients with suspected SpA, MRI should not be limited to the sacroiliac joints, but also include enthesitis sites and other joints of the axial skeleton. The multiparametric rheumatology protocol increases the efficacy of MRI in detecting enthesitis and joint inflammatory disease, thereby offering additional information to the clinician and assisting in the early diagnosis/detecting disease activity.

Can Bone Erosion in Axial Spondyloarthropathy be Detected by Ultrashort Echo Time Imaging? A Comparison With Computed Tomography in the Sacroiliac Joint.

BACKGROUND: Structural lesion evaluation in axial spondyloarthropathy (SpA) can improve accuracy of diagnosis. However, structural lesions (bone erosions) are difficult to be assessed using conventional MRI compared to computed tomography (CT). PURPOSE: To evaluate the diagnostic performance of ultrashort echo time (UTE) for detecting bone erosion in axial SpA compared to T1WI and three-dimensional double-echo steady-state (3D DESS) imaging using CT as the reference standard. STUDY TYPE: Retrospective. POPULATION: Fourteen patients (eight females, 57.1%) and 14 healthy controls (seven females, 50.0%) who underwent sacroiliac (SI) joint MRI and CT. FIELD STRENGTH/SEQUENCE: 3 T; TSE T1WI, 3D DESS, 2D UTE. ASSESSMENT: The bilateral SI joints were assessed for bone erosion. Three observers scored bone erosion for all three sequences of MRI. CT was used as the gold standard. Diagnostic confidence in axial SpA was measured based on a four-point confidence score. STATISTICAL TESTS: Correlation of erosion scores between CT and MRI were evaluated using Spearman's correlation test. Sensitivity, specificity, and positive-negative predictive values were calculated. Confidence scores were compared using the Wilcoxon sum rank test. Statistical significance was set at P < 0.05. RESULTS: Compared with erosion scores of CT, the correlation coefficients for each MRI sequence showed significant low-to-high positive correlations (0.39-0.72). UTE imaging showed the highest correlation coefficients for all observers (0.70, 0.72, and 0.67, respectively). The specificity of UTE imaging was equal or higher than those of T1WI and 3D DESS for all observers (0.86 vs. 0.71 vs. 0.57; 0.93 vs. 0.71 vs. 0.57; 0.79 vs. 0.79 vs. 0.43). All observers had the highest confidence in interpreting UTE imaging for detecting bone erosion among the three sequences (3.5, 3.4, and 3.3 for UTE; 3.1, 3.0, and 2.6 for T1WI; and 3.2, 2.7, and 2.4 for DESS). DATA CONCLUSION: UTE imaging can detect bone erosions in patients with axial SpA and show higher specificity than conventional T1WI and 3D DESS. EVIDENCE LEVEL: 4 TECHNICAL EFFICACY: Stage 2.

MRI and spondyloarthropathy: diagnostic performance compared to long-term clinical follow-up with evaluation of gadolinium chelates injection.

OBJECTIVES: To evaluate MRI performance on both initial and long-term rheumatologic diagnosis of spondyloarthritis (SpA), taking into account clinical evolution and treatment response, and the impact of gadolinium injection. METHODS: In this single-center study, patients who underwent both spinal and sacroiliac (SI) joint MRI were prospectively recruited between May 2013 and January 2014 and followed for 7 years until 2020. Clinical, biological, and radiologic parameters were collected. At 7-year follow-up (2020), two independent readers reevaluated the initial MRI datasets for specific radiological features of SpA with a 5-point Likert scale to record the estimation of confidence. The centralized MRI interpretations were compared to the established rheumatologic diagnoses in 2013 and 2020. RESULTS: In total, 145 patients (52 men and 93 women) were included. During the 7-year follow-up, the number of patients with positive SpA diagnosis decreased from 93 to 58. Mean sensitivity, specificity, and accuracy of non-contrast MRI were 18, 97, and 49% and 27, 97, and 69% considering 2013 and 2020 rheumatologic diagnoses, respectively. Mean sensitivity, specificity, and accuracy values of gadolinium-enhanced MRI were 26, 97, and 54% and 38, 97, and 73% considering 2013 and 2020 diagnoses, respectively. Post-contrast MRI enabled identification of a subgroup of enthesis-only lesions, without any bone lesions, corresponding to 14% of the pathological cohort. It confirmed uncertain diagnoses in an additional 8.5% of pathological cases. CONCLUSIONS: MRI performance for SpA diagnosis is higher when long-term clinical follow-up is considered than when compared to initial diagnosis. Gadolinium injection increases MRI diagnostic performance and may demonstrate a pure enthesic form of the disease, without bone abnormality. KEY POINTS: • Compared to the rheumatologist's diagnosis over long-term clinical follow-up, MRI performance for SpA is higher than usually estimated. • Gadolinium injection increases diagnostic performance of MRI as it may identify a purely enthesis form of the disease. • Gadolinium injection should be discussed in patients for whom the diagnostic suspicion is strong and whose initial non-injected examination is normal or doubtful.

Quantitative T2 mapping of the sacroiliac joint cartilage at 3T in patients with axial spondyloarthropathies.

OBJECTIVE: To evaluate the diagnostic value of T2 mapping of sacroiliac joint cartilage in patients with axial spondyloarthropathies (SpA). METHODS: Thirty-seven SpA patients and 43 controls (mean age: 36.5 ± 8.2; 20 men) prospectively underwent conventional MRI and T2 mapping of the sacroiliac joints at 3 T. SpA patients and their sacroiliac joints were categorized into active and inactive based on the presence of bone marrow edema on the conventional MRI. T2-relaxation times were measured by drawing six manual ROIs on the cartilaginous part of the joints. T2 values of the bilateral iliac and sacral joint cartilages for each patient (T2subject), iliac and sacral cartilages for each sacroiliac joint (T2joint), iliac cartilage (T2iliac), and sacral cartilage (T2sacral) were calculated and compared between SpA patients and controls, and active and inactive joints. RESULTS: The T2subject of SpA patients (50.48 ± 5.32 ms) was significantly higher than the T2subject of the controls (46.33 ± 3.30 ms, p < 0.001). Selecting an optimal T2subject cut-off value of 48.77 to differentiate SpA patients from controls revealed a sensitivity and a specificity of 62.2% and 81.4% respectively (AUC = 0.739). In SpA patients, T2joint, T2iliac, and T2sacral values of the inactive joints were not significantly different from those of the active joints (p = 0.088, p = 0.179, and p = 0.069). T2joint, T2iliac, and T2sacral values of the inactive joints of SpA patients were significantly higher than those of the controls (p = 0.012, p = 0.029, and p = 0.016). CONCLUSIONS: T2 values of both active and inactive sacroiliac joint cartilages of SpA patients were increased. Thus, T2 mapping may be used in the diagnosis of SpA. KEY POINTS: • Sacroiliac cartilage T2 values of SpA patients increase compared to those of the non-SpA controls. • Sacroiliac cartilage T2 values of active and inactive joints of SpA patients increase compared to those of the non-SpA controls. • Sacroiliac cartilage T2 values of active and inactive joints of SpA patients do not show statistically significant difference.

Effects of ankylosing spondylitis and non-radiographic axial spondyloarthropathy on female sexual functions.

OBJECTIVES: Rheumatologic diseases may impair the quality of life (QoL) by affecting sexual functions in different ways. We aimed to evaluate sexual functions and the disease-related variables, physical and psychogenic states in female patients with ankylosing spondylitis and non-radiographic axial spondyloarthropathy. METHODS: A total of 98 women with axial spondyloarthropathy (axSpA) and 99 healthy females were included in the study. The axSpA group was divided into two subgroups as ankylosing spondylitis (AS) and non-radiographic axial spondyloarthropathy (nr-axSpA) (62 AS and 36 nr-axSpA). The patients' disease-related variables recorded. All the women in the axSpA and control groups were evaluated gynaecologically. The female sexual function index (FSFI), Health Status Questionnaire [Short Form (SF)-36], and Hospital Depression and Anxiety Scale (HADS) were applied to all participants. RESULTS: Clitoral and labial atrophy and speculum pain score were significantly higher in the axSpA group (p<0.05). The FSFI and QoL-SF-36 scores were significantly lower and the HAD-D and HAD-A scores were significantly higher of in the axSpA group than in the control group (p<0.05 for all). There was no significant between the axSpA subgroups in terms of the FSFI, QoL-SF-36 and HAD scores. CONCLUSIONS: In elderly women with axSpA, disease duration and limitation of movement are more effective in genital atrophy and sexual functions, but there is no difference between those with AS and nr-axSpA in relation to sexual functions and psychological burden.

Interobserver reliability of Masei index validation by a multicenter collaborative group of rheumatologists.

MASEI is the main validated ultrasound score for the evaluation of enthesis. The lack of studies facing the agreement to achieve for the interpretation of the MAdrid Sonographic Enthesis Index (MASEI) among researchers from different centers in multicenter studies is of concern. The aim of this multicenter was to evaluate the interobserver reliability of MASEI. An experienced ultrasonographer-rheumatologist performed ultrasound scans of the areas included in MASEI index in three patients with Ankylosing Spondylitis and Psoriatic Arthritis. Videos were captured. The videos were then evaluated by 24 rheumatologists of the ultrasound working group of the Catalan Society of Rheumatology (EcoCAT). A face-to-face training meeting was held. Ten days after the workshop, the study participants evaluated the videos. A reliability assessment was performed. The ICC for the MASEI scores after the workshop was of 0.97 (95% CI 89-99). Reliability did not vary statistically with examiner experience. Globally, no problems of reliability by structures were seen, and all the ICCs were above 0.90 and improved slightly after the educational program. However, the correlation observed between examiners at plantar aponeursis and triceps tendon was weak. The small variability observed in the results of the index validation in our study, suggests that the MASEI index is reproducible by different observers when those are well trained and show awesome results of the enthesis when examined by ultrasound.

Ultrasound definition of enthesitis in spondyloarthritis and psoriatic arthritis: arrival or starting point?

Enthesitis has a key role in the diagnosis, classification and management of patients with spondyloarthritis and psoriatic arthritis. Clinical assessment of enthesitis is known to be inaccurate mainly due to its poor specificity. In this context, ultrasound has the potential to improve the evaluation of enthesitis and, therefore, the management of patients with spondyloarthritis and psoriatic arthritis. In this viewpoint, we review the Outcome Measures in Rheumatology (OMERACT) definitions for ultrasound enthesitis, highlighting their current limits and potential implications on rheumatology research and clinical practice.

[A case of destructive cervical spondylarthropathy related to chronic dialysis]. / Krónikus dialízis kapcsán kialakult destruktív cervicalis spondylarthropathia esete.

A case of a 61-year-old male patient suffered chronic renal failure and dialysed for 23 years with destructive cervical spondylarthropathy is presented. The patient presented with sudden onset of cervical pain radiating into his shoulders without neurological deficits. CT and MRI of the cervical and thoracic spine revealed severe destructive changes and compressive fractures of C6 and C7 vertebrae which caused the narrowing of the nerve root canals at these levels. A 360-degree fixation was performed to treat the unstable fracture and the patient's pain (C6 and C7 corpectomy, autolog bone graft replacement of the two vertebral bodies, anterior plate fixation and posterior instrumentation with screws and rods). Postoperatively the patient had no significant pain, no neurological deficit and he was able to manage independent life himself. During the immediate follow-up CT of the neck showed the satisfactory position of the bone graft and the metal implantations. The 6 months follow-up CT revealed the anterior migration of the two screws from the Th1 vertebral body and 2 mm ventral elevation of the caudal end of the plate from the anterior surface of the Th1 vertebral body. The 1-year follow-up could not be performed because the patient died due to cardio-pulmonary insufficiency. This is the second Hungarian report of a chronic dialysis related severe spondylarthropathy which may cause pathologic fractures of the vertebral bodies. The typical radiological and histological findings are discussed. This disease affect patients' quality of life and the conservative treatment alone seems to be ineffective in most cases. Based on the literature and personal experiences, the authors suggest 360-degree fixation of the spine to provide sufficient stability for the vertebrae of "bad bone quality", and early mobilisation of the patient can be achieved.

Disease progression associated with low bone mass in axial spondyloarthropathy patients.

Through statistical analysis, we have found that inflammation and low femoral and lumbar spine BMD were strongly correlated with a high SIJ CT grade, and inflammation, low vitamin D levels, and a longer disease course within a certain time range influenced bone loss in axSpA. PURPOSE: We investigated the relationship between bone mineral density (BMD), vitamin D, and computed tomography (CT)-based progression of disease grades of the sacroiliac joint (SIJ), and sought to identify parameters predicting low BMD in patients with axial spondyloarthropathy (axSpA). METHODS: We collected the ankylosis spondylitis disease activity score (ASDAS), the course of the disease, HLA-B27 status, and vitamin D and C-reactive protein (CRP) levels of 98 axSpA patients. Lumbar spine and femoral BMD were assessed by dual-energy X-ray (DXA), and SIJ grade was determined by CT. RESULTS: The axSpA patients (71 men, 27 women) with a mean age of 31.9 years (range 18-57 years) and body mass index 21.8 kg/m2 (range 15.6-30.6 kg/m2), with disease duration 4.5 years (range 0.3-30 years) were included. A longer disease course, higher CRP level, and lower femoral and lumbar spine BMD were independently related to a higher CT grade. Older age, longer disease course, elevated CRP, and high SIJ CT grade were independently related to lower BMD (femur and/or lumbar spine L1-L4 T scores ≤ -1). Older age, elevated CRP, low vitamin D levels, and high CT grade were independently associated with low femur and lumbar spine BMD. However, a longer disease course was independently related to low femur BMD, but not low lumbar spine BMD. CONCLUSIONS: Thus, inflammation and low femoral and lumbar spine BMD were strongly correlated with a high SIJ CT grade, and inflammation, low vitamin D levels, and a longer disease course within a certain time range influenced bone loss in axSpA.

Extended-Hours Hemodialysis without Dietary Restrictions Is Associated with Lower Risk for Developing of Dialysis-Related Amyloidosis.

Dialysis-related amyloidosis (DRA) is characterized by the deposition of amyloid consisting of beta2-microglobulin in the musculoskeletal system, causing carpal tunnel syndrome, destructive spondyloarthropathy, and/or bone cysts. Increased cystic radiolucency of the bones and tendon thickening due to inflammation are common findings in DRA. We have developed a new dialysis method, extended-hours hemodialysis without dietary restrictions for the aim of improving both hypertension and malnutrition. We retrospectively evaluated the clinical effects of dialysis time on the risk for developing of DRA. The study subjects were all of the 30 patients who had received this treatment for more than 11 years. They were divided into two groups according to the weekly dialysis hours: 15 patients ≥ 16.5 hours/week (L-group) and 15 patients ≤ 15.5 hours/week (S-group). Plain x-ray imaging and ultrasonography were used to assess cystic radiolucency of the bones and thickness/diameter of the soft tissues. The proportion of the carpal bone cystic radiolucency was lower in the L-group. The severity of median nerve compression at the wrist was significantly less in the L-group (right hand: p = 0.0082, left hand: p = 0.0137). Multivariate regression analysis showed that dialysis time was a predictor of median nerve compression (ß = -0.559, p = 0.005). In conclusion, extended-hours hemodialysis without dietary restrictions contributes to lower the risk for developing of DRA at the wrist. We therefore propose that extended-hours hemodialysis without dietary restrictions is a preferred method which maintains the patients' quality of life compared with the conventional hemodialysis method.

Frequency of pertinent MRI abnormalities of the sacroiliac joints of patients without spondyloarthropathies: a systematic review of the literature.

INTRODUCTION: MRI criteria are central to the diagnosis of non-radiographic axial spondyloarthropathy (nr-axSpA). The cardinal feature of nr-axSpa is inflammatory low back pain, which may be difficult to distinguish from highly prevalent non-specific low back pain. This study aims to determine the frequency of relevant MRI findings in the sacroiliac joints (SIJ) of patients without Spondyloarthropathy (SpA), and therefore estimate the specificity of MRI scans for SpA. METHODS: EMBASE and Medline were searched and limited to English. Titles were screened for relevance, with studies that included primary MRI findings in patients without SpA triggering retrieval. Retrieved papers were reviewed, data extracted by two authors and quality criteria (QUADAS 2) were applied. Findings were considered for asymptomatic and symptomatic individuals. RESULTS: The search recovered 2172 articles. Abstracts of 117 were reviewed for full text retrieval, 11 papers met eligibility criteria. These papers described MRI findings of 1180 asymptomatic patients and 1318 with low back symptoms but without SpA. In relevant populations, bone marrow oedema was found in 22% (95% CI 19-25) of asymptomatic and 20% (95% CI 18-22) of asymptomatic individuals. In all non-Spa patients, sclerosis was found in 13.4% and erosions in 6.5%. CONCLUSIONS: There is a significant frequency of diagnostically pertinent MRI abnormalities in the SIJ of patients without SpA. These are present in both asymptomatic and symptomatic individuals. Findings, such as oedema and sclerosis, lack specificity and should be interpreted with caution. Erosions are less frequent and are likely more specific for SpA.

Tumor Necrosis Factor Inhibitors Reduce Spinal Radiographic Progression in Patients With Radiographic Axial Spondyloarthritis: A Longitudinal Analysis From the Alberta Prospective Cohort.

OBJECTIVE: To investigate whether tumor necrosis factor inhibitors (TNFi) impact spinal radiographic progression in patients with axial spondyloarthritis (SpA) and whether this is coupled to their effect on inflammation. METHODS: Patients with axial SpA fulfilling the modified New York criteria were included in a prospective cohort (the ALBERTA Follow Up Research Cohort in Ankylosing Spondylitis Treatment). Spine radiographs, performed every 2 years for up to 10 years, were scored by 2 central readers, using the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS). The indirect effect of TNFi on mSASSS was evaluated with generalized estimating equations by testing the interaction between TNFi and Ankylosing Spondylitis Disease Activity Score (ASDAS) at the start of each 2-year interval (t). If significant, the association between ASDAS at t and mSASSS at the end of the interval (t+1) was assessed in 1) patients treated with TNFi at all visits, 2) patients treated with TNFi at some visits, and 3) patients who were never treated with TNFi. In addition, the association between TNFi at t and mSASSS at t+1 (adjusting for ASDAS at t) was also tested (direct effect). RESULTS: In total, 314 patients were included. A gradient was seen for the effect of ASDAS at t on mSASSS at t+1 (interaction P = 0.10), with a higher progression in patients never treated with TNFi (ß = 0.41 [95% confidence interval (95% CI) 0.13, 0.68]) compared to those continuously treated (ß = 0.16 [95% CI 0.00, 0.31]) (indirect effect). However, TNFi also directly slowed progression, as treated patients had on average an mSASSS 0.85 units lower at t+1 compared to untreated patients (ß = -0.85 [95% CI -1.35, -0.35]). CONCLUSION: Our findings indicate that TNFi reduce spinal radiographic progression in patients with radiographic axial SpA, which might be partially uncoupled from their effects on inflammation as measured by the ASDAS.

Comparative analysis and differentiation between SAPHO syndrome and spondyloarthropathies using whole-spine MRI.

AIM: To determine the imaging characteristics of SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteitis) syndrome and seronegative spondyloarthropathies (SpAs) on whole-spine magnetic resonance imaging (WS-MRI) and evaluate the role of WS-MRI in the diagnosis and differentiation of the two diseases. MATERIALS AND METHODS: Twenty-eight patients with SAPHO and 44 with SpAs were included. All patients were symptomatic and clinically diagnosed with SAPHO or SpAs, and all underwent WS-MRI for comparison of imaging characteristics. RESULTS: The mean age of the SAPHO patients was 48.7 ± 12.7 years, while that of the SpA patients was 34.7 ± 12.3 years (p<0.001). WS-MRI showed that the frequency of cervical, thoracic, and lumbar spine involvement was 53.6% versus 52.3%, 75% versus 88.6%, and 60.7% versus 63.6%, respectively (p=0.70, 0.13, and 0.80). The frequency of sacroiliac joint involvement was 7.1% and 100% (p<0.001). Continuous spinal involvement accounted for 50% versus 43.2%, 60.7% versus 84.1%, and 39.3% versus 40.9% in the cervical, thoracic, and lumbar vertebrae, respectively (p=0.03). WS-MRI showed that bone marrow oedema of spinal anterior corner was observed in 50% versus 75% (p=0.03). Vertebral body and posterior attachment involvement accounted for 85.7% versus 93.2% and 14.3% versus 34.1% (p=0.3, 0.06). The frequency of bone erosion in mobile spine was 75% and 36.4%, respectively (p=0.02). The frequency of intervertebral disc, endplate, anterior thoracic wall, and paraspinal soft-tissue swelling was 42.9% versus 18.2%, 53.6% versus 22.7%, 85.7% versus 42.2%, and 50% versus 11.4% (p=0.02, 0.00). CONCLUSIONS: Factors differentiating the two groups at WS-MRI were bone marrow oedema of the spinal anterior corner, bone erosion, and swelling of the intervertebral disc, endplate, anterior thoracic wall, and paraspinal soft-tissue.

Does diffusion-weighted magnetic resonance imaging have a place in the differential diagnosis of brucella sacroiliitis and seronegative spondyloarthropathy?

BACKGROUND: The aim of this study is to investigate the role of diffusion-weighted imaging (DWI) in the differential diagnosis of sacroiliitis. PURPOSE: To compare the sacroiliac magnetic resonance imaging (MRI) examinations of patients with suspected active sacroiliitis with patients with acute SpA MR findings and the DWI examinations of patients with acute brucella sacroiliitis, and thereby determine whether DWI can contribute to the differential diagnosis. MATERIAL AND METHODS: A total of 84 patients were included in the study and were separated into three groups: group 1 (13 women, 6 men) comprised cases with brucella positive for sacroiliitis; group 2 (17 women, 19 men) comprised cases negative for brucella but with sacroiliitis; and group 3 (16 women, 13 men) comprised cases negative for brucella and sacroiliitis. RESULTS: The mean bone marrow apparent diffusion coefficient (ADC) values independently of edema were determined as 0.71 × 10-3 in sacroiliitis and brucella-positive patients, as 0.53 × 10-3 in brucella-negative and sacroiliitis-positive patients, and as 0.43 × 10-3 in the control group of brucella-negative sacroiliitis-negative patients. In the ADC measurements taken from areas of evident edema in patients with sacroiliitis, the mean values were 0.13 × 10-3 in the brucella-positive group and 0.12 × 10-3 in the brucella-negative group. CONCLUSION: By adding DWI, which is a rapid MR sequence, to sacroiliac joint MR examination, normal bone marrow and bone marrow with sacroiliitis can be objectively differentiated with ADC measurements in addition to visual evaluation.

Is Treatment in Patients With Suspected Nonradiographic Axial Spondyloarthritis Effective? Six-Month Results of a Placebo-Controlled Trial.

OBJECTIVE: To investigate the efficacy of 16-week treatment with etanercept (ETN) in patients with suspected nonradiographic axial spondyloarthritis (SpA). METHODS: Tumor necrosis factor inhibitor-naive patients with inflammatory back pain with at least 2 SpA features and high disease activity (Bath Ankylosing Spondylitis Disease Activity Index score ≥4), without the requirement of a positive finding on magnetic resonance imaging (MRI) of the sacroiliac (SI) joint and/or elevated C-reactive protein (CRP) level, were randomized (1:1) to receive ETN (n = 40) or placebo (n = 40) for 16 weeks and subsequently were followed up for a further 8 weeks (to 24 weeks from baseline) without study medication. The primary end point was the Assessment of SpondyloArthritis international Society 20 (ASAS20) response at 16 weeks. Secondary end points included the Ankylosing Spondylitis Disease Activity Score (ASDAS) and changes in disease parameters, including the Bath Ankylosing Spondylitis Metrology Index (BASMI), CRP level, erythrocyte sedimentation rate (ESR), and Spondyloarthritis Research Consortium of Canada index scores (MRI of the SI joint), after 16 and 24 weeks. RESULTS: Patient characteristics at baseline were comparable between the ETN and placebo groups. At 16 weeks, there was no significant difference in the percentage of patients exhibiting ASAS20 response between the ETN group (6 patients [16.7%]) and the placebo group (4 patients [11.1%]) (relative risk 0.7 [95% confidence interval 0.2-2.2], P = 0.5). Only the ESR showed more improvement in the ETN group compared to the placebo group at 16 weeks (decreases of 2.2 mm/hour and 1.4 mm/hour, respectively), but the difference did not reach statistical significance. Between 16 and 24 weeks, without study medication, the BASMI, CRP level, and ESR had worsened to a greater extent in the ETN group compared to the placebo group, with the difference being significant for the CRP level. CONCLUSION: This study shows that in patients with suspected nonradiographic axial SpA with high disease activity but without the requirement of a positive finding on SI joint MRI and/or elevated CRP level, treatment with ETN is not effective.