Spine MRI in SpA What is the rheumatologist interested in? Personal use only

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Joel McBride
6 years ago
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Lugano May 6th 2017 Ulrich Weber MD Consultant, King Christian 10th

1 Spine MRI in SpA What is the rheumatologist interested in? 4th Musculoskeletal MRI Meeting 2017: Spine MRI Ospedale Regionale di Lugano May 6th 2017 Ulrich Weber MD Consultant, King Christian 10th Hospital, Gråsten Associate Professor in Rheumatology, University of Southern Denmark

2 Spine MRI in SpA Key issues in rheumatology How to diagnose axial SpA early? How to predict new bone formation in the spine? How to communicate with a radiologist?

3 Spine MRI in SpA Agenda Diagnostic utility Prognostication Dialogue rad - rheum Weber U, Jurik AG, Lambert RGW, Maksymowych WP. Curr Rheumatol Rep 2016;18:58 [review]

4 Central spinal lesions High sensitivity CIL Corner inflammatory lesions CFL Corner fat lesions Lambert RGW et al. J Rheumatol 2009;84:3. Pedersen SJ et al. Best Pract Res Clin Rheum 2012;26:751

5 Lateral spinal lesions High specificity Left (central slice): No inflammation Centre (lateral slice): Costovertebral arthritis Right (far lateral slice): Costotransverse arthritis Van Tubergen A, Weber U. Nat Rev Rheumatol 2012;8:253

Diagnostic utility of spinal lesions Corner Inflammatory Lesion CIL 3 CIL: positive LR 12 1 Mean age of controls 52.5 y 2 CIL: positive LR 12 2 Median age of controls 30.

6 Diagnostic utility of spinal lesions Corner Inflammatory Lesion CIL 3 CIL: positive LR 12 1 Mean age of controls 52.5 y 2 CIL: positive LR 12 2 Median age of controls 30.8 y Clinical relevance LR+: moderate >10 high 1 Bennett AN et al. Arthritis Rheum 2009;60: Weber U et al. Arthritis Rheum 2009;61:900 3 Jaeschke R et al. JAMA 1994;271:703

7 Positive spinal MRI ASAS consensus definition 3 CIL or «Several» ( 6) CFL Systematic literature review based on spinal MRI alone without taking into account concomitant findings on SIJ MRI Hermann K et al. Ann Rheum Dis 2012;71:1278

8 Poor diagnostic utility of candidate definitions of a positive spinal MRI Nr-axSpA vs NSBP Sensitivity Specificity LR+ LR- 3 CIL 0.43/ / / / CIL 0.24/ / / / CFL 0.26/ / / / CFL 0.12/ / / /0.88 Is the concept of a «positive MRI of the spine alone» valid without taking into consideration concomitant findings on SIJ MRI? Weber U et al. Arthritis Rheum 2015;67:924

9 Daily routine Occasionally good utility of spine MRI 4 CIL 27 CFL STIR T1SE

10 Clinically suspected SpA Negative SIJ MRI but positive spine MRI Pe rso na lu T1SE STIR se on ly STIR T1SE

11 34-year-old female healthy control Negative SIJ MRI but positive spine MRI Pe rso na lu T1SE STIR se on ly STIR T1SE

12 Re-classification of SIJ MRI by Combined SIJ plus Spine MRI SIJ MRI alone negative Combined MRI positive Cohort A (n=62) B (n=88) Group nr-axspa AS NSBP HC nr-axspa AS NSBP Re-Classification (%) % true positive re-classifications in nr-axspa versus 20% false positive re-classifications in controls An additional spine MRI just added to confusion Weber U et al. Ann Rheum Dis 2015;74:985

13 MRI in recognition of early axial SpA What constitutes a positive spine MRI? Corner spine lesions have poor diagnostic utility What about postero-lateral spine lesions? How to integrate concomitant SIJ lesions? No diagnosis of axial SpA based on spinal MRI alone 1 The role of spine MRI in early recognition of axial SpA is not defined 1 Mandl P et al. Ann Rheum Dis 2015;74:1327 [EULAR recommendations]

14 Brush up your Danish Far, får får får? Nej, får får ikke får, får får lam

15 Brush up your Danish Far, får får får? Nej, får får ikke får, får får lam Daddy, do sheep get sheep? No, sheep don t get sheep, sheep get lambs

16 Spine MRI in SpA Agenda Diagnostic utility Prognostication Dialogue rad - rheum

17 Spinal new bone formation (SNBF) Background SIJ diagnostic, spine prognostic compartment in SpA 3 interventional studies with TNF inhibitors in AS showed no impact on SNBF over 2 years 1 2 recent TNF treatment studies showed 50% risk reduction of SNBF after 4 years 2 Do we need to treat for 4 years to prevent SNBF? How to predict spinal progression in individual patients? Type B-CIL? Sequence CIL CFL SNBF? Distribution of lesions? 1 Van der Heijde D et al. Arthritis Rheum 2008;58:1324 and 3063; Arthritis Res Ther 2009;11:R127 2 Haroon N et al. Arthritis Rheum 2013;65:2645. Maas F et al. Arthritis Care Res epub 2016;doi: /acr.23097

18 Spinal MRI predicting new bone formation? STIR T1SE STIR T1SE CIL type B with apical erosion Sequence CIL CFL Maksymowych WP et al. Ann Rheum Dis 2013;72:23 Machado PM et al. Ann Rheum Dis 2016;75:1486

19 Preferentially posterolateral distribution of syndesmophytes along vertebral rim by CT Pe rso na lu se Tan S et al. Ann Rheum Dis 2016;75:1951 on ly

20 Radiographs miss new syndesmophyte formation detected by low dose CT 1 Radiograph 2 Low dose CT BL 3 Low dose CT 2y FU De Bruin F et al. Oral presentation 3160 ACR 2016

21 The Future: «SpA Spine Risk Score» Lesion-based radiology report on spine MRI Type A- and B-CIL and -CFL Sequential CIL and CFL Focus on thoracolumbar junction Focus on posterolateral vertebral area

22 Spine MRI in SpA Agenda Diagnostic utility Prognostication Dialogue rad - rheum

23 Terminology of degenerative spinal lesions Inconsistent language blossoms Example from daily practice Rheum resident: Spinal involvement in clinical SpA? Rad consultant: Modic I TH6/7 in a 30y old man Rheum resident: No TNF despite spinal pain Rheum consultant: Classical inflammation of lateral elements TH6/7 How to validate the plethora of degenerative spinal MRI lesions?

24 Spine MRI in SpA Rheum s summary Don t make a diagnosis of SpA by spine MRI alone Addition of spine MRI to SIJ MRI adds to confusion Spine MRI is emerging for prognostication New taxonomy for degenerative spine lesions needed

25 Barnacle Geese, Rømø, Denmark

Imaging of axial spondyloarthritis including ankylosing spondylitis

Imaging of axial spondyloarthritis including ankylosing spondylitis ACR 2012 Prof. Dr. med. J. Braun Rheumazentrum Ruhrgebiet, Herne Ruhr-Universität Bochum Germany Modified New York Criteria 1984 for