Reliability assessment of the OMERACT whole-body magnetic resonance imaging scoring system for juvenile idiopathic arthritis.

Inter-reader reliability of a new scoring system for evaluating joint inflammation and enthesitis in whole body MRI (WBMRI) in juvenile idiopathic arthritis was tested. The scoring system grades 732 item-region combinations of bone marrow and soft tissue changes for commonly involved joints and entheseal sites. Five radiologists rated 17 WBMRI scans through an online rating platform. Item-wise reliability was calculated for 117 items with non-zero scores in >10 % of readings. Interquartile ranges of the five-reader Kappa reliability coefficients were 0.58-0.73 (range: 0.36-0.88) for the joints, 0.65-0.81 (range: 0.39-0.95) for the entheses, and 0.62-0.75 (range: 0.60-0.76) for chronic nonbacterial osteomyelitis-like lesions.

ESR Essentials: Imaging of sacroiliitis-practice recommendations by ESSR.

Sacroiliitis is commonly seen in patients with axial spondyloarthritis, in whom timely diagnosis and treatment are crucial to prevent irreversible structural damage. Imaging has a prominent place in the diagnostic process and several new imaging techniques have been examined for this purpose. We present a summary of updated evidence-based practice recommendations for imaging of sacroiliitis. MRI remains the imaging modality of choice for patients with suspected sacroiliitis, using at least four sequences: coronal oblique T1-weighted and fluid-sensitive sequences, a perpendicular axial oblique sequence, and a sequence for optimal evaluation of the bone-cartilage interface. Both active inflammatory and structural lesions should be described in the report, indicating location and extent. Radiography and CT, especially low-dose CT, are reasonable alternatives when MRI is unavailable, as patients are often young. This is particularly true to evaluate structural lesions, at which CT excels. Dual-energy CT with virtual non-calcium images can be used to depict bone marrow edema. Knowledge of normal imaging features in children (e.g., flaring, blurring, or irregular appearance of the articular surface) is essential for interpreting sacroiliac joint MRI in children because these normal processes can simulate disease. CLINICAL RELEVANCE STATEMENT: Sacroiliitis is a potentially debilitating disease if not diagnosed and treated promptly, before structural damage to the sacroiliac joints occurs. Imaging has a prominent place in the diagnostic process. We present a summary of practice recommendations for imaging of sacroiliitis, including several new imaging techniques. KEY POINTS: • MRI is the modality of choice for suspected inflammatory sacroiliitis, including a joint-line-specific sequence for optimal evaluation of the bone-cartilage interface to improve detection of erosions. • Radiography and CT (especially low-dose CT) are reasonable alternatives when MRI is unavailable. • Knowledge of normal imaging features in children is mandatory for interpretation of MRI of pediatric sacroiliac joints.

The OMERACT whole-body MRI scoring system for inflammation in peripheral joints and entheses (WIPE) in spondyloarthritis - reference image atlas for the knee region.

OBJECTIVE: To develop a reference image atlas for the Outcome Measures in Rheumatology whole-body MRI scoring system for inflammation in peripheral joints and entheses (OMERACT MRI-WIPE) of the knee region. METHODS: Image examples of each pathology, location and grade, were collected and discussed at web-based, interactive meetings within the OMERACT MRI in Arthritis Working Group. Subsequently, reference images were selected by consensus. RESULTS: Reference images for each grade, pathology and location are depicted, along with definitions, reader rules and recommended MRI-sequences. CONCLUSION: The atlas guides scoring whole-body MRIs for inflammation in joints and entheses of the knee region according to MRI-WIPE methodology in clinical trials and cohorts.

Hip and pelvis region MRI reference image atlas for scoring inflammation in peripheral joints and entheses according to the OMERACT-MRI WIPE scoring system in patients with spondyloarthritis.

OBJECTIVE: To develop a reference image atlas for scoring the hip/pelvis region according to the OMERACT whole-body MRI scoring system for inflammation in peripheral joints and entheses (MRI-WIPE). METHODS: We collected image examples of each pathology, location and grade, discussed them at web-based, interactive meetings and, finally, selected reference images by consensus. RESULTS: Reference images for each grade and location of osteitis, synovitis and soft tissue inflammation are provided, as are definitions, reader rules and recommended MRI-sequences. CONCLUSION: A reference image atlas was created to guide scoring whole-body MRIs for arthritis and enthesitis in the hip/pelvis region in spondyloarthritis/psoriatic arthritis clinical trials and cohorts.

MRI-based synthetic CT for assessment of the bony elements of the sacroiliac joints in children.

OBJECTIVES: The purpose of this study is to assess the equivalency of MRI-based synthetic CT (sCT) to conventional CT for sacroiliac joint bony morphology assessment in children. METHODS: A prospective study was performed. Children who had (PET-)CT-scan underwent additional MRI. sCT-CT image quality was analyzed by two readers subjectively overall, semi-quantitatively in terms of cortical delineation, joint facet defects, growth plate fusion, ossified nuclei, lumbosacral transitional anomaly, and bony bridges, and quantitatively for disc space height, spinal canal width, and sacral vertebrae width and height. Cohen's kappa and equivalence analyses with Bland-Altman plots were calculated for categorical and continuous measures respectively. RESULTS: Ten patients were included (6 boys; aged 9-16 years; mean age 14 years). Overall sCT image quality was rated good. Semi-quantitative assessment of cortical delineation of sacroiliac joints, bony bridges, and joint facet defects on the right iliac and sacral sides showed perfect agreement. Correlation was good to excellent (kappa 0.615-1) for the presence of lumbosacral transitional anomaly, fusion of sacral growth plates, joint facet defect, and presence of ossified nuclei. sCT-CT measurements were statistically equivalent and within the equivalence margins (-1-1 mm) for intervertebral disc space height and spinal canal width. Intra- and inter-reader reliability was excellent for quantitative assessment (0.806 < ICC < 0.998). For categorical scoring, kappa ranged from substantial to excellent (0.615-1). CONCLUSION: sCT appears to be visually equivalent to CT for the assessment of pediatric sacroiliac joints. sCT may aid in visualizing sacroiliac joints compared to conventional MRI, with the benefit that no ionizing radiation is used, especially important in children. CRITICAL RELEVANCE STATEMENT: MRI-based synthetic CT, a new technique that generates CT-like images without ionizing radiation, appears to be visually equivalent to CT for assessment of normal pediatric sacroiliac joints and can potentially assess structural damage as it clearly depicts bony cortex. KEY POINTS: • MRI-based sCT is a new image technique that can generate CT-like images. • We found that sCT performs similarly to CT in displaying bony structures of pediatric sacroiliac joints. • sCT has already been clinically validated in the sacroiliac joints in adults. • sCT can potentially assess structural damage from erosions or ankylosis as it clearly depicts bony cortex.

Association of anatomical variants of the sacroiliac joint with bone marrow edema in patients with axial spondyloarthritis.

OBJECTIVE: To determine the prevalence of sacroiliac joint variants in patients with axial spondyloarthritis (axSpA) using MRI-based synthetic CT images and to evaluate their relationships with the presence of bone marrow edema, as this may potentially complicate diagnosing active sacroiliitis on MRI in patients with suspected axSpA. METHODS: 172 patients were retrospectively included. All patients underwent MRI because of clinical suspicion of sacroiliitis. The diagnosis of axSpA was made by a tertiary hospital rheumatologist. Two readers independently determined the presence of bone marrow edema and the presence of one or more of the nine known sacroiliac joint (SIJ) variants. RESULTS: SIJ variants were common in axSpA patients (82.9%) and the non-SpA group (85.4%); there were no significant differences in prevalence. Bone marrow edema was frequently found in axSpA (86.8%) and non-SpA patients (34%). AxSpA patients with SIJ variants (except for accessory joint) demonstrated 4 to 10 times higher odds for bone marrow edema, however not statistically significant. The more variants were present in this group, the higher the chance of bone marrow edema. However, some multicollinearity cannot be excluded, since bone marrow edema is very frequent in the axSpA group by definition. CONCLUSION: SIJ variants are common in axSpA and non-SpA patients. SIJ variants were associated with higher prevalence of bone marrow edema in axSpA patients, potentially due to altered biomechanics, except for accessory joint which may act as a stabilizer.

Clash of the titans: Current CT and CT-like imaging modalities in sacroiliitis in spondyloarthritis.

Sacroiliitis is characterised by active and structural changes of the joint. While the Assessment of Spondyloarthritis international Society (ASAS) classification criteria stress the importance of bone marrow inflammation, recent reports suggest that osteitis can occur in various diseases, mechanical conditions and healthy individuals. Thus, structural lesions such as joint surface erosion and ankylosis are important factors for differential diagnosis. Various imaging modalities are available to examine these changes. However, computed tomography (CT) is generally considered the reference standard. Nonetheless, recent advances in magnetic resonance imaging (MRI) allow for direct bone imaging and the reconstruction of CT-like images that can provide similar information. This way, the ability of MRI to detect and measure structural lesions is strengthened. The aim of this review is to provide an overview of the pros and cons of CT and CT-like imaging modalities in sacroiliitis.

Update on Pediatric Spine Imaging.

The spine is often difficult to evaluate clinically in children, increasing the importance of diagnostic imaging to detect a wide variety of spinal disorders ranging from congenital abnormalities to severe infections. Clinical history and physical examination can help determine whether imaging is needed and which imaging technique would be best. The most common cause for back pain, even in children, is muscular strain/spasm that does not require any imaging. However, red flags such as pain at age < 5 years, constant pain, night pain, radicular pain, pain lasting > 4 weeks, or an abnormal neurologic examination may require further investigation. Imaging can be of great value for diagnosis but must be interpreted along with the clinical history, physical examination, and laboratory findings to achieve an accurate diagnosis. We discuss imaging for the most common and/or important spine pathologies in children: congenital and developmental pathologies, trauma, infectious processes, inflammatory causes, and tumors.

Current Role of Conventional Radiography of Sacroiliac Joints in Adults and Juveniles with Suspected Axial Spondyloarthritis: Opinion from the ESSR Arthritis and Pediatric Subcommittees.

This opinion article by the European Society of Musculoskeletal Radiology Arthritis and Pediatric Subcommittees discusses the current use of conventional radiography (CR) of the sacroiliac joints in adults and juveniles with suspected axial spondyloarthritis (axSpA). The strengths and limitations of CR compared with magnetic resonance imaging (MRI) and computed tomography (CT) are presented.Based on the current literature and expert opinions, the subcommittees recognize the superior sensitivity of MRI to detect early sacroiliitis. In adults, supplementary pelvic radiography, low-dose CT, or synthetic CT may be needed to evaluate differential diagnoses. CR remains the method of choice to detect structural changes in patients with suspected late-stage axSpA or established disease and in patients with suspected concomitant hip or pubic symphysis involvement. In children, MRI is the imaging modality of choice because it can detect active as well as structural changes and is radiation free.

Machine Learning Pipeline for Predicting Bone Marrow Edema Along the Sacroiliac Joints on Magnetic Resonance Imaging.

OBJECTIVE: We aimed to develop and validate a fully automated machine learning (ML) algorithm that predicts bone marrow edema (BME) on a quadrant level in sacroiliac (SI) joint magnetic resonance imaging (MRI). METHODS: A computer vision workflow automatically locates the SI joints, segments regions of interest (ilium and sacrum), performs objective quadrant extraction, and predicts presence of BME, suggestive of inflammatory lesions, on a quadrant level in semicoronal slices of T1/T2-weighted MRI scans. Ground truth was determined by consensus among human readers. The inflammation classifier was trained using a ResNet18 backbone and five-fold cross-validated on scans of patients with spondyloarthritis (SpA) (n = 279), postpartum individuals (n = 71), and healthy subjects (n = 114). Independent SpA patient MRI scans (n = 243) served as test data set. Patient-level predictions were derived from aggregating quadrant-level predictions, ie, at least one positive quadrant. RESULTS: The algorithm automatically detects the SI joints with a precision of 98.4% and segments ilium/sacrum with an intersection over union of 85.6% and 67.9%, respectively. The inflammation classifier performed well in cross-validation: area under the curve (AUC) 94.5%, balanced accuracy (B-ACC) 80.5%, and F1 score 64.1%. In the test data set, AUC was 88.2%, B-ACC 72.1%, and F1 score 50.8%. On a patient level, the model achieved a B-ACC of 81.6% and 81.4% in the cross-validation and test data set, respectively. CONCLUSION: We propose a fully automated ML pipeline that enables objective and standardized evaluation of BME along the SI joints on MRI. This method has the potential to screen large numbers of patients with (suspected) SpA and is a step closer towards artificial intelligence-assisted diagnosis and follow-up.

Neural network algorithm for detection of erosions and ankylosis on CT of the sacroiliac joints: multicentre development and validation of diagnostic accuracy.

OBJECTIVES: To evaluate the feasibility and diagnostic accuracy of a deep learning network for detection of structural lesions of sacroiliitis on multicentre pelvic CT scans. METHODS: Pelvic CT scans of 145 patients (81 female, 121 Ghent University/24 Alberta University, 18-87 years old, mean 40 ± 13 years, 2005-2021) with a clinical suspicion of sacroiliitis were retrospectively included. After manual sacroiliac joint (SIJ) segmentation and structural lesion annotation, a U-Net for SIJ segmentation and two separate convolutional neural networks (CNN) for erosion and ankylosis detection were trained. In-training validation and tenfold validation testing (U-Net-n = 10 × 58; CNN-n = 10 × 29) on a test dataset were performed to assess performance on a slice-by-slice and patient level (dice coefficient/accuracy/sensitivity/specificity/positive and negative predictive value/ROC AUC). Patient-level optimisation was applied to increase the performance regarding predefined statistical metrics. Gradient-weighted class activation mapping (Grad-CAM++) heatmap explainability analysis highlighted image parts with statistically important regions for algorithmic decisions. RESULTS: Regarding SIJ segmentation, a dice coefficient of 0.75 was obtained in the test dataset. For slice-by-slice structural lesion detection, a sensitivity/specificity/ROC AUC of 95%/89%/0.92 and 93%/91%/0.91 were obtained in the test dataset for erosion and ankylosis detection, respectively. For patient-level lesion detection after pipeline optimisation for predefined statistical metrics, a sensitivity/specificity of 95%/85% and 82%/97% were obtained for erosion and ankylosis detection, respectively. Grad-CAM++ explainability analysis highlighted cortical edges as focus for pipeline decisions. CONCLUSIONS: An optimised deep learning pipeline, including an explainability analysis, detects structural lesions of sacroiliitis on pelvic CT scans with excellent statistical performance on a slice-by-slice and patient level. CLINICAL RELEVANCE STATEMENT: An optimised deep learning pipeline, including a robust explainability analysis, detects structural lesions of sacroiliitis on pelvic CT scans with excellent statistical metrics on a slice-by-slice and patient level. KEY POINTS: • Structural lesions of sacroiliitis can be detected automatically in pelvic CT scans. • Both automatic segmentation and disease detection yield excellent statistical outcome metrics. • The algorithm takes decisions based on cortical edges, rendering an explainable solution.

Determination of Relative Weightings for Sacroiliac Joint Pathologies in the OMERACT Juvenile Arthritis Magnetic Resonance Imaging Sacroiliac Joint Score.

This study aims to determine the relative weights (point value) of items of the juvenile idiopathic arthritis magnetic resonance imaging-sacroiliac joint scoring system (JAMRIS-SIJ). An adaptive multicriteria decision analysis was performed using the 1000Minds web application to determine the relative weights of the items in the JAMRIS-SIJ inflammation and damage domains. Experts in imaging and rheumatology independently completed a conjoint analysis survey (CAS) to determine the point value of the measurement items of the JAMRIS-SIJ. Each CAS survey question asked the expert to compare two hypothetical patient profiles, which were otherwise similar but different at two items at a time, and to select which item showed a more severe stage of inflammation or osteochondral damage. In addition, experts ranked 14 JAMRIS-SIJ grade only or image + grade patient vignettes while blinded to the CAS-derived weights. The validity of the weighted JAMRIS-SIJ was tested by comparing the expert CAS-weighted score and the image + grade ranking method. Seventeen experts completed the CAS (11 radiologists and 6 rheumatologists). Considering the point value for inflammation domain items, osteitis (24.7%) and bone marrow edema (24.3%) had higher group-averaged percentage weights compared to inflammation in erosion cavity (16.9%), joint space enhancement (13.1%), joint space fluid (9.1%), capsulitis (7.3%), and enthesitis (4.6%). Similarly, concerning the damage domain, ankylosis (41.3%) and erosion (25.1%) showed higher group-averaged weights compared to backfill (13.9%), sclerosis (10.7%), and fat metaplasia lesion (9.1%). The Spearman correlation coefficients of the CAS-weighted vignette order and unweighted JAMRIS-SIJ grade only order vignettes for all experts were 0.79 for inflammation and 0.80 for damage. The correlations of image vignettes among imaging experts to CAS were 0.75 for inflammation and 0.90 for damage. The multicriteria decision analysis identified differences in relative weights among the JAMRIS-SIJ measurement items. The determination of the relative weights provided expert-driven score scaling and face validity for the JAMRIS-SIJ, enabling the future evaluation of its longitudinal construct validity.

MRI in pediatric sacroiliitis, what radiologists should know.

MRI is used for early detection of inflammation of sacroiliac joints as it shows active lesions of sacroiliitis long before radiographs show damage to the sacroiliac joints. Early diagnosis of arthritis allows early treatment of inflammation and can help delay disease progression and prevent irreversible damage. Also, early identification of axial involvement in juvenile spondyloarthropathy is crucial, as treatment options are different than for peripheral juvenile spondyloarthropathy. In general, standard sequences used in adults are also applied to children. However, interpreting MR images of pediatric sacroiliac joints is more challenging than in adults, because of normal physiological changes during skeletal maturation, which can simulate disease on MR images. Furthermore, classical definitions of sacroiliitis used in adults, for both active inflammatory and structural lesions, can be difficult to extrapolate to children. The development of reliable pediatric-specific definitions for sacroiliitis is still in active study. Understanding both normal and pathological signal changes in children is important to distinguish physiologic findings from disease and to make a correct diagnosis. In this review, the main imaging characteristics of sacroiliitis on MRI in children and its frequent pitfalls will be illustrated, while also citing some discussion points regarding the scan protocol.

Intermediate-weighted MRI with fat suppression (IW-FS): diagnostic performance for bone marrow edema and erosion detection in axial spondyloarthritis.

BACKGROUND: Bone marrow edema (BME) and erosion of the sacroiliac joint are both key lesions for diagnosing axial spondyloarthritis (axSpA) on magnetic resonance imaging (MRI). PURPOSE: To qualitatively and quantitatively compare intermediate-weighted MRI with fat suppression (IW-FS) with T2-weighted short tau inversion recovery (T2-STIR) in assessment of sacroiliac BME and erosion in axSpA. MATERIAL AND METHODS: Patients aged 18-60 years with axSpA were prospectively enrolled. All patients underwent a 3.0-T MRI examination of the sacroiliac joints. Para-coronal IW-FS, T2-STIR, and T1-weighted (T1W) images were acquired. BME and erosion were scored by two readers in consensus on IW-FS and STIR using a modified Spondyloarthritis Research Consortium of Canada (SPARCC) scoring system. Consensus scores on T1WI were used as the reference for erosion. Signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were measured for BME. RESULTS: In total, 49 patients (mean age=33.4 ± 7.6 years) were included. More patients were scored as having BME on T2-STIR (36 vs. 29, P = 0.016). SPARCC-BME score on IW-FS was lower than that acquired on T2-STIR (mean, 11.5 vs. 14.7, P = 0.002). SNR and CNR of BME were both lower on IW-FS than on T2-STIR (mean SNR, 118 vs. 218, P < 0.001; mean CNR, 44 vs. 137, P < 0.001). The sensitivity of erosion detection was higher on IW-FS (83%) than on T2-STIR (54%, P = 0.006). CONCLUSION: IW-FS is not sufficient for BME detection using T2-STIR as the reference standard in patients with axSpA. IW-FS has a much higher sensitivity than T2-STIR for erosion detection in the sacroiliac joint.

Anatomical variation of the sacroiliac joints: an MRI study with synthetic CT images.

BACKGROUND: Synthetic computed tomography (sCT) images are magnetic resonance imaging (MRI)-based images, generated using artificial intelligence. This study aimed to determine the prevalence of anatomical variants of sacroiliac joints (SIJ) on sCT images and the correlation with age, sex and body weight. METHODS: MRI of the SIJ including sCT images of 215 patients clinically suspected for sacroiliitis were retrospectively analyzed. The presence of anatomical variants of the SIJ was assessed. Age, sex and body mass index at the time of the MRI were recorded. RESULTS: SIJ variants were found in 82.8% (356/430) of the evaluated joints. The most frequent variants were iliosacral complex (27.7%), bipartite iliac bony plate (27.2%) and crescent iliac bony plate (27%). One new variant was identified, consisting of an accessory facet of the SIJ on the superior side. Overall, SIJ variants were slightly more frequent in women (85.8% vs. 77.8%), but iliosacral complex was significantly more frequent in men. Isolated synostosis was more prevalent with advancing age, in contrast to semicircular defect and unfused ossification center. The occurrence of iliosacral complex was associated with higher BMI, while crescent iliac bony plate occurred more in patients with lower BMI. CONCLUSION: Over 80% of patients in this study, who were all suspected of sacroiliitis, had at least one SIJ variant. These variants may actually represent subtypes of the normal SIJ. sCT enables detection of very small or subtle findings including SIJ variants.

Common incidental findings on sacroiliac joint MRI: Added value of MRI-based synthetic CT.

PURPOSE: To determine the prevalence of incidental findings on sacroiliac joint MRI and to determine the added value of MRI-based synthetic CT in the detection and evaluation of these incidental findings. METHOD: In this retrospective study 210 patients clinically suspected of spondyloarthritis who underwent MRI of the sacroiliac joint with synthetic CT sequence were included. The images were reviewed by two radiologists in consensus for the prevalence of sacroiliitis, incidental findings, and the ability of synthetic CT and the conventional MRI to detect and diagnose these findings. RESULTS: In 44.7% of patients sacroiliitis was present. In 89.0% of patients MRI showed at least one incidental finding other than sacroiliitis. Degeneration of the sacroiliac joint was the most prevalent finding (140 patients, 66.6%). The most frequent incidental findings outside the sacroiliac joint were facet joint degeneration (29.0%), disc degeneration (25.2%), enostosis (19.5%) and lumbosacral transitional vertebrae (14.3%). A total of 788 lesions was recorded and synthetic CT was found to be problem solving or necessary for diagnosis in 543 (68.9%) of these lesions. 42.1% of lesions were not visible on conventional MRI (T1 TSE and STIR), most often degenerative osteophytes in the sacroiliac joint or lower lumbar spine. CONCLUSION: Incidental findings are seen more frequently on sacroiliac joint MRI than sacroiliitis, which is relevant as some will have clinical significance or require treatment. Nearly half of these incidental lesions were only visible on synthetic CT, which additionally has been shown to be problem solving for diagnosis in many other cases.

Blurring and Irregularity of the Subchondral Cortex in Pediatric Sacroiliac Joints on T1 Images: Incidence of Normal Findings That Can Mimic Erosions.

OBJECTIVE: To determine prevalence of variations of subchondral bone appearance that may mimic erosions on T1-weighted magnetic resonance imaging (MRI) of pediatric sacroiliac (SI) joints according to age and sex. METHODS: With ethics committee approval and informed consent, SI joint MRIs of 251 children (132 girls), mean age 12.4 years (range 6.1-18.0 years), were obtained in 2 cohorts: 127 children imaged for nonrheumatic reasons, and 124 children with low back pain but no features of sacroiliitis at initial clinical MRI review. MRIs were reviewed by 3 experienced radiologists, blinded from each other, for 3 features of the cortical black line representing the subchondral bone plate on T1-weighted MRI: visibility, blurring, and irregularity. RESULTS: Based on agreement from 2 or more readers, the cortical black line was partially absent in 88.4% of the children, blurred in 34.7%, and irregular in 41.4%. All these features were most common on the iliac side of SI joints and at the first sacral vertebra level. Clearly visualized, sharply delineated SI joints with none of these features were seen in only 8.0% of children, or in 35.1% if we conservatively required agreement of all 3 readers to consider a feature present. There was no significant difference between sexes or cohorts; findings were similar across pediatric age groups. CONCLUSION: Understanding the normal MRI appearance of the developing SI joint is necessary to distinguish physiologic findings from disease. At least two-thirds (65%) of normal pediatric SI joints showed at least 1 feature that is a component of the adult definition of SI joint erosions, risking overdiagnosis of sacroiliitis.

Performance of an MRI scoring system for inflammation of joints and entheses in peripheral SpA: post-hoc analysis of the CRESPA trial.

OBJECTIVES: The aim of this study was to investigate the reliability, validity, and sensitivity to change of a novel MRI scoring system in early peripheral SpA (pSpA). METHODS: MRI of the pelvis and lower extremities was performed before initiation of the TNF inhibitor golimumab in 56 patients and repeated in 46 patients who achieved sustained clinical remission after 24, 36 or 48 weeks. Three readers applied a semi-quantitative MRI scoring system for lower-extremity joint and entheseal inflammation. Four lesion types were assessed: entheseal osteitis, entheseal soft-tissue inflammation, joint osteitis, and joint synovitis/effusion. MRI response was defined as a decrease in MRI lower-extremity inflammation index (sum of scores from 75 sites, each scored 0-3) above the smallest detectable change (SDC). RESULTS: At follow-up, the MRI index decreased in 34 of 46 patients (74%), and 15 (33%) patients achieved MRI response, i.e. a decrease above SDC of 2.8. When restricting the analysis to patients with clinical involvement of lower-extremity sites that were assessed by MRI, 13 of 28 (46%) achieved MRI response. Interreader reliability was very good, with an average-measure intraclass correlation coefficient of 0.92 (95% CI: 0.85-0.95) for status scores and 0.89 (0.80-0.94) for change in scores. The MRI index correlated with other measures of disease activity, including CRP [Spearman's rho 0.41 (0.23-0.56)], swollen joint count of 6 joints [0.47 (0.27-0.63)], tender enthesis count of 14 entheses [0.32 (0.12-0.50)] and pain score [0.28 (0.08-0.46)], all P < 0.05. CONCLUSION: The proposed MRI lower-extremity inflammation index demonstrated reliability, validity, and sensitivity to change in patients with early pSpA. TRIAL REGISTRATION: Clinicaltrials.gov, http://clinicaltrials.gov, NCT01426815.

Post-mortem feasibility of dual-energy computed tomography in the detection of bone edema-like lesions in the equine foot: a proof of concept.

Introduction: In this proof-of-concept study, the post-mortem feasibility of dual-energy computed tomography (DECT) in the detection of bone edema-like lesions in the equine foot is described in agreement with the gold standard imaging technique, which is magnetic resonance imaging (MRI). Methods: A total of five equine cadaver feet were studied, of which two were pathological and three were within normal limits and served as references. A low-field MRI of each foot was performed, followed by a DECT acquisition. Multiplanar reformations of DECT virtual non-calcium images were compared with MRI for the detection of bone edema-like lesions. A gross post-mortem was performed, and histopathologic samples were obtained of the navicular and/or distal phalanx of the two feet selected based on pathology and one reference foot. Results: On DECT virtual non-calcium imaging, the two pathological feet showed diffuse increased attenuation corresponding with bone edema-like lesions, whereas the three reference feet were considered normal. These findings were in agreement with the findings on the MRI. Histopathology of the two pathologic feet showed abnormalities in line with bone edema-like lesions. Histopathology of the reference foot was normal. Conclusion: DECT virtual non-calcium imaging can be a valuable diagnostic tool in the diagnosis of bone edema-like lesions in the equine foot. Further examination of DECT in equine diagnostic imaging is warranted in a larger cohort, different locations, and alive animals.