Download PDF
Semin Musculoskelet Radiol 2025; 29(02): 196-209
DOI: 10.1055/s-0045-1802651
Review Article

Axial Spondyloarthritis: Updates in Concepts and Reporting in Radiology

Rolando G. Gerena
1   Department of Radiology, Division of Musculoskeletal Imaging and Intervention, University of Colorado Anschutz Medical Campus, Aurora, Colorado
,
Philip Asamoah
2   Department of Radiology, Division of Musculoskeletal Imaging and Intervention, Massachusetts General Hospital, Boston, Massachusetts
,
Christine E. Loftis
3   Department of Internal Medicine, Division of Rheumatology, University of Colorado, Aurora, Colorado
,
Liron Caplan
3   Department of Internal Medicine, Division of Rheumatology, University of Colorado, Aurora, Colorado
,
Alexander N. Merkle 
1   Department of Radiology, Division of Musculoskeletal Imaging and Intervention, University of Colorado Anschutz Medical Campus, Aurora, Colorado
› Author Affiliations
› Further Information
Also available at
    Permissions and Reprints

Abstract

Axial spondyloarthritis (axSpA) is a chronic inflammatory disease primarily affecting the axial skeleton, historically termed “human leukocyte antigen B27 positive spondyloarthropathy” or ankylosing spondylitis. Improved understanding of the underlying pathologic mechanisms has led to an ongoing redefinition of this disease state, a recognition of the substantial phenotypic and biological variation, and an emphasis on earlier detection. Magnetic resonance imaging has become central to identifying and confirming early axSpA, critical to fulfilling the promise of slowing disease progression and preventing irreversible structural abnormalities. We review the clinical background and current role of medical imaging in axSpA, with a focus on Assessment of SpondyloArthritis International Society consensus definitions, to improve radiology reporting and facilitate discussion between radiologists and other clinical experts in spondyloarthritis.

Keywords

axial spondyloarthritis - Assessment of SpondyloArthritis International Society - ankylosing spondylitis - spondyloarthropathy


Publication History

Article published online:
31 March 2025

© 2025. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Taurog JD, Chhabra A, Colbert RA. Ankylosing spondylitis and axial spondyloarthritis. N Engl J Med 2016; 374 (26) 2563-2574
    CrossrefPubMedSearch in Google Scholar
  • 2 Rudwaleit M, van der Heijde D, Landewé R. et al. The Assessment of SpondyloArthritis International Society classification criteria for peripheral spondyloarthritis and for spondyloarthritis in general. Ann Rheum Dis 2011; 70 (01) 25-31
    CrossrefPubMedSearch in Google Scholar
  • 3 Dagfinrud H, Kjeken I, Mowinckel P, Hagen KB, Kvien TK. Impact of functional impairment in ankylosing spondylitis: impairment, activity limitation, and participation restrictions. J Rheumatol 2005; 32 (03) 516-523
    PubMedSearch in Google Scholar
  • 4 Reveille JD, Witter JP, Weisman MH. Prevalence of axial spondylarthritis in the United States: estimates from a cross-sectional survey. Arthritis Care Res (Hoboken) 2012; 64 (06) 905-910
    CrossrefPubMedSearch in Google Scholar
  • 5 Costantino F, Talpin A, Said-Nahal R. et al. Prevalence of spondyloarthritis in reference to HLA-B27 in the French population: results of the GAZEL cohort. Ann Rheum Dis 2015; 74 (04) 689-693
    CrossrefPubMedSearch in Google Scholar
  • 6 Boel A, López-Medina C, van der Heijde DMFM, van Gaalen FA. Age at onset in axial spondyloarthritis around the world: data from the Assessment in SpondyloArthritis international Society Peripheral Involvement in Spondyloarthritis study. Rheumatology (Oxford) 2022; 61 (04) 1468-1475
    CrossrefPubMedSearch in Google Scholar
  • 7 Haroon N, Inman RD, Learch TJ. et al. The impact of tumor necrosis factor α inhibitors on radiographic progression in ankylosing spondylitis. Arthritis Rheum 2013; 65 (10) 2645-2654
    CrossrefPubMedSearch in Google Scholar
  • 8 Ritchlin C, Adamopoulos IE. Axial spondyloarthritis: new advances in diagnosis and management. BMJ 2021; 372: m4447
    CrossrefPubMedSearch in Google Scholar
  • 9 van der Linden S, Valkenburg HA, Cats A. Evaluation of diagnostic criteria for ankylosing spondylitis. A proposal for modification of the New York criteria. Arthritis Rheum 1984; 27 (04) 361-368
    CrossrefPubMedSearch in Google Scholar
  • 10 Boel A, Molto A, van der Heijde D. et al. Do patients with axial spondyloarthritis with radiographic sacroiliitis fulfil both the modified New York criteria and the ASAS axial spondyloarthritis criteria? Results from eight cohorts. Ann Rheum Dis 2019; 78 (11) 1545-1549
    CrossrefPubMedSearch in Google Scholar
  • 11 Sieper J, Rudwaleit M, Baraliakos X. et al. The Assessment of SpondyloArthritis International Society (ASAS) handbook: a guide to assess spondyloarthritis. Ann Rheum Dis 2009; 68 (Suppl. 02) ii1-ii44
    CrossrefPubMedSearch in Google Scholar
  • 12 Poddubnyy D, Diekhoff T, Baraliakos X, Hermann KGA, Sieper J. Diagnostic evaluation of the sacroiliac joints for axial spondyloarthritis: should MRI replace radiography?. Ann Rheum Dis 2022; 81 (11) 1486-1490
    CrossrefPubMedSearch in Google Scholar
  • 13 Jones A, Bray TJP, Mandl P, Hall-Craggs MA, Marzo-Ortega H, Machado PM. Performance of magnetic resonance imaging in the diagnosis of axial spondyloarthritis: a systematic literature review. Rheumatology (Oxford) 2019; 58 (11) 1955-1965
    CrossrefPubMedSearch in Google Scholar
  • 14 Baraliakos X, Østergaard M, Lambert RG. et al. MRI lesions of the spine in patients with axial spondyloarthritis: an update of lesion definitions and validation by the ASAS MRI working group. Ann Rheum Dis 2022; 81 (09) 1243-1251
    CrossrefPubMedSearch in Google Scholar
  • 15 Diekhoff T, Eshed I, Radny F. et al. Choose wisely: imaging for diagnosis of axial spondyloarthritis. Ann Rheum Dis 2022; 81 (02) 237-242
    CrossrefPubMedSearch in Google Scholar
  • 16 Aggarwal R, Ringold S, Khanna D. et al. Distinctions between diagnostic and classification criteria?. Arthritis Care Res (Hoboken) 2015; 67 (07) 891-897
    CrossrefPubMedSearch in Google Scholar
  • 17 Rudwaleit M, van der Heijde D, Khan MA, Braun J, Sieper J. How to diagnose axial spondyloarthritis early. Ann Rheum Dis 2004; 63 (05) 535-543
    CrossrefPubMedSearch in Google Scholar
  • 18 Rudwaleit M, Feldtkeller E, Sieper J. Easy assessment of axial spondyloarthritis (early ankylosing spondylitis) at the bedside. Ann Rheum Dis 2006; 65 (09) 1251-1252
    CrossrefPubMedSearch in Google Scholar
  • 19 van den Berg R, de Hooge M, Rudwaleit M. et al. ASAS modification of the Berlin algorithm for diagnosing axial spondyloarthritis: results from the SPondyloArthritis Caught Early (SPACE)-cohort and from the Assessment of SpondyloArthritis international Society (ASAS)-cohort. Ann Rheum Dis 2013; 72 (10) 1646-1653
    CrossrefPubMedSearch in Google Scholar
  • 20 Mandl P, Navarro-Compán V, Terslev L. et al; European League Against Rheumatism (EULAR). EULAR recommendations for the use of imaging in the diagnosis and management of spondyloarthritis in clinical practice. Ann Rheum Dis 2015; 74 (07) 1327-1339
    CrossrefPubMedSearch in Google Scholar
  • 21 Czuczman GJ, Mandell JC, Wessell DE. et al; Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria® inflammatory back pain: known or suspected axial spondyloarthritis: 2021 update. J Am Coll Radiol 2021; 18 (11S): S340-S360
    CrossrefPubMedSearch in Google Scholar
  • 22 Poddubnyy D, Sieper J, Akar S. et al. Radiographic progression in sacroiliac joints in patients with axial spondyloarthritis: results from a five-year international observational study. ACR Open Rheumatol 2024; 6 (02) 103-110
    CrossrefPubMedSearch in Google Scholar
  • 23 Sieper J, Poddubnyy D. Axial spondyloarthritis. Lancet 2017; 390 (10089): 73-84
    CrossrefPubMedSearch in Google Scholar
  • 24 Weber U, Pfirrmann CWA, Kissling RO, Mackenzie CR, Khan MA. Early spondyloarthritis in an HLA-B27-positive monozygotic twin pair: a highly concordant onset, sites of involvement, and disease course. J Rheumatol 2008; 35 (07) 1464-1466
    PubMedSearch in Google Scholar
  • 25 Carmona R, Harish S, Linda DD, Ioannidis G, Matsos M, Khalidi NA. MR imaging of the spine and sacroiliac joints for spondyloarthritis: influence on clinical diagnostic confidence and patient management. Radiology 2013; 269 (01) 208-215
    CrossrefPubMedSearch in Google Scholar
  • 26 Diekhoff T, Hermann KGA, Greese J. et al. Comparison of MRI with radiography for detecting structural lesions of the sacroiliac joint using CT as standard of reference: results from the SIMACT study. Ann Rheum Dis 2017; 76 (09) 1502-1508
    CrossrefPubMedSearch in Google Scholar
  • 27 Ward MM, Deodhar A, Gensler LS. et al. 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network recommendations for the treatment of ankylosing spondylitis and nonradiographic axial spondyloarthritis. Arthritis Rheumatol 2019; 71 (10) 1599-1613
    CrossrefPubMedSearch in Google Scholar
  • 28 Maksymowych WP, Lambert RG, Østergaard M. et al. MRI lesions in the sacroiliac joints of patients with spondyloarthritis: an update of definitions and validation by the ASAS MRI working group. Ann Rheum Dis 2019; 78 (11) 1550-1558
    CrossrefPubMedSearch in Google Scholar
  • 29 Lambert RGW, Maksymowych WP. The SpondyloArthritis Research Consortium of Canada (SPARCC) Magnetic Resonance Imaging of the Sacroiliac Joints Acquisition Protocol. Available at: https://www.carearthritis.com/wp-content/uploads/2020/05/MRI-SI-Joint-acquisition-protocol-Version-7.0.1-2020.04.23.pdf . Accessed January 17, 2025
    PubMed
  • 30 Althoff CE, Feist E, Burova E. et al. Magnetic resonance imaging of active sacroiliitis: do we really need gadolinium?. Eur J Radiol 2009; 71 (02) 232-236
    CrossrefPubMedSearch in Google Scholar
  • 31 de Hooge M, van den Berg R, Navarro-Compán V. et al. Magnetic resonance imaging of the sacroiliac joints in the early detection of spondyloarthritis: no added value of gadolinium compared with short tau inversion recovery sequence. Rheumatology (Oxford) 2013; 52 (07) 1220-1224
    CrossrefPubMedSearch in Google Scholar
  • 32 Samet JD, Alizai H, Chalian M. et al. Society of Skeletal Radiology position paper - recommendations for contrast use in musculoskeletal MRI: when is non-contrast imaging enough?. Skeletal Radiol 2024; 53 (01) 99-115
    CrossrefPubMedSearch in Google Scholar
  • 33 Starekova J, Pirasteh A, Reeder SB. Update on gadolinium-based contrast agent safety, from the AJR Special Series on Contrast Media. AJR Am J Roentgenol 2024; 223 (03) e2330036
    CrossrefPubMedSearch in Google Scholar
  • 34 Wolharn L, Guggenberger R, Higashigaito K. et al. Detailed bone assessment of the sacroiliac joint in a prospective imaging study: comparison between computed tomography, zero echo time, and black bone magnetic resonance imaging. Skeletal Radiol 2022; 51 (12) 2307-2315
    CrossrefPubMedSearch in Google Scholar
  • 35 Martín-Noguerol T, Casado-Verdugo OL, Beltrán LS, Aguilar G, Luna A. Role of advanced MRI techniques for sacroiliitis assessment and quantification. Eur J Radiol 2023; 163: 110793
    CrossrefPubMedSearch in Google Scholar
  • 36 Lambert RGW, Bakker PAC, van der Heijde D. et al. Defining active sacroiliitis on MRI for classification of axial spondyloarthritis: update by the ASAS MRI working group. Ann Rheum Dis 2016; 75 (11) 1958-1963
    CrossrefPubMedSearch in Google Scholar
  • 37 Puhakka KB, Melsen F, Jurik AG, Boel LW, Vesterby A, Egund N. MR imaging of the normal sacroiliac joint with correlation to histology. Skeletal Radiol 2004; 33 (01) 15-28
    CrossrefPubMedSearch in Google Scholar
  • 38 Almodovar R, Bueno A, Garcia Monco C. et al. Quantification of bone marrow edema by MRI of the sacroiliac joints in patients diagnosed with axial spondyloarthritis: results from the ESPeranza cohort. Scand J Rheumatol 2022; 51 (05) 374-381
    CrossrefPubMedSearch in Google Scholar
  • 39 Wang DM, Lin L, Peng JH. et al. Pannus inflammation in sacroiliitis following immune pathological injury and radiological structural damage: a study of 193 patients with spondyloarthritis. Arthritis Res Ther 2018; 20 (01) 120
    CrossrefPubMedSearch in Google Scholar
  • 40 Maksymowych WP, Lambert RG, Baraliakos X. et al. Data-driven definitions for active and structural MRI lesions in the sacroiliac joint in spondyloarthritis and their predictive utility. Rheumatology (Oxford) 2021; 60 (10) 4778-4789
    CrossrefPubMedSearch in Google Scholar
  • 41 Diekhoff T, Eshed I, Giraudo C. et al. Reporting sacroiliac joint imaging performed for known or suspected axial spondyloarthritis: assessment of SpondyloArthritis International Society Recommendations. Radiology 2024; 311 (03) e231786
    CrossrefPubMedSearch in Google Scholar
  • 42 Gorelik N, Tamizuddin F, Rodrigues TC. et al. Comparison between radiography and magnetic resonance imaging for the detection of sacroiliitis in the initial diagnosis of axial spondyloarthritis: a cost-effectiveness study. Skeletal Radiol 2020; 49 (10) 1581-1588
    CrossrefPubMedSearch in Google Scholar
  • 43 Schueller-Weidekamm C, Mascarenhas VV, Sudol-Szopinska I. et al. Imaging and interpretation of axial spondylarthritis: the radiologist's perspective–consensus of the Arthritis Subcommittee of the ESSR. Semin Musculoskelet Radiol 2014; 18 (03) 265-279
    Thieme ConnectPubMedSearch in Google Scholar
  • 44 van Tubergen A, Heuft-Dorenbosch L, Schulpen G. et al. Radiographic assessment of sacroiliitis by radiologists and rheumatologists: does training improve quality?. Ann Rheum Dis 2003; 62 (06) 519-525
    CrossrefPubMedSearch in Google Scholar
  • 45 Battistone MJ, Manaster BJ, Reda DJ, Clegg DO. Radiographic diagnosis of sacroiliitis—are sacroiliac views really better?. J Rheumatol 1998; 25 (12) 2395-2401
    PubMedSearch in Google Scholar
  • 46 Rodriguez VR, Llop M, Protopopov M. et al. Assessment of radiographic sacroiliitis in anteroposterior lumbar vs conventional pelvic radiographs in axial spondyloarthritis. Rheumatology (Oxford) 2021; 60 (01) 269-276
    CrossrefPubMedSearch in Google Scholar
  • 47 Klauser A, Bollow M, Calin A. et al. Workshop report: clinical diagnosis and imaging of sacroiliitis, Innsbruck, Austria, October 9, 2003. J Rheumatol 2004; 31 (10) 2041-2047
    PubMedSearch in Google Scholar
  • 48 Han Q, Zheng Z, Zhang K, Ding J, Baraliakos X, Zhu P. A comprehensive assessment of hip damage in ankylosing spondylitis, especially early features. Front Immunol 2021; 12: 668969
    CrossrefPubMedSearch in Google Scholar
  • 49 MRI compared with low-dose CT scanning in the diagnosis of axial spondyloarthritis. Clin Rheumatol 2020; 39 (04) 1295-1303
    CrossrefPubMedSearch in Google Scholar
  • 50 Tan S, Ward MM. Computed tomography in axial spondyloarthritis. Curr Opin Rheumatol 2018; 30 (04) 334-339
    CrossrefPubMedSearch in Google Scholar
  • 51 Vereecke E, Diekhoff T, Eshed I. et al. ESR essentials: Imaging of sacroiliitis-practice recommendations by ESSR. Eur Radiol 2024; 34 (09) 5773-5782
    CrossrefPubMedSearch in Google Scholar
  • 52 Suh CH, Yun SJ, Jin W, Lee SH, Park SY, Ryu CW. Diagnostic performance of dual-energy CT for the detection of bone marrow oedema: a systematic review and meta-analysis. Eur Radiol 2018; 28 (10) 4182-4194
    CrossrefPubMedSearch in Google Scholar
  • 53 Pache G, Krauss B, Strohm P. et al. Dual-energy CT virtual noncalcium technique: detecting posttraumatic bone marrow lesions—feasibility study. Radiology 2010; 256 (02) 617-624
    CrossrefPubMedSearch in Google Scholar
  • 54 Wu H, Zhang G, Shi L. et al. Axial spondyloarthritis: dual-energy virtual noncalcium CT in the detection of bone marrow edema in the sacroiliac joints. Radiology 2019; 290 (01) 157-164
    CrossrefPubMedSearch in Google Scholar
  • 55 Deppe D, Ziegeler K, Hermann KGA. et al. Dual-energy-CT for osteitis and fat lesions in axial spondyloarthritis: how feasible is low-dose scanning?. Diagnostics (Basel) 2023; 13 (04) 776
    CrossrefPubMedSearch in Google Scholar
  • 56 Ramiro S, Nikiphorou E, Sepriano A. et al. ASAS-EULAR recommendations for the management of axial spondyloarthritis: 2022 update. Ann Rheum Dis 2023; 82 (01) 19-34
    CrossrefPubMedSearch in Google Scholar
  • 57 Lambert RGW, Salonen D, Rahman P. et al. Adalimumab significantly reduces both spinal and sacroiliac joint inflammation in patients with ankylosing spondylitis: a multicenter, randomized, double-blind, placebo-controlled study. Arthritis Rheum 2007; 56 (12) 4005-4014
    CrossrefPubMedSearch in Google Scholar
  • 58 Agrawal P, Machado PM. Recent advances in managing axial spondyloarthritis. Available at: f1000research.com/articles/9-697 . Accessed January 17, 2025
    PubMed
  • 59 Rudwaleit M, Claudepierre P, Wordsworth P. et al. Effectiveness, safety, and predictors of good clinical response in 1250 patients treated with adalimumab for active ankylosing spondylitis. J Rheumatol 2009; 36 (04) 801-808
    CrossrefPubMedSearch in Google Scholar
  • 60 Milota T, Hurnakova J, Pavelka K, Kristkova Z, Nekvindova L, Horvath R. Delayed treatment with a tumor necrosis factor alpha blocker associated with worse outcomes in patients with spondyloarthritis: data from the Czech National Registry ATTRA. Ther Adv Musculoskelet Dis 2022; 14: 1-13 . 1759720–X221081649
    CrossrefPubMedSearch in Google Scholar
  • 61 Maksymowych WP, Claudepierre P, de Hooge M. et al. Structural changes in the sacroiliac joint on MRI and relationship to ASDAS inactive disease in axial spondyloarthritis: a 2-year study comparing treatment with etanercept in EMBARK to a contemporary control cohort in DESIR. Arthritis Res Ther 2021; 23 (01) 43
    CrossrefPubMedSearch in Google Scholar
  • 62 Magrey MN, Danve AS, Ermann J, Walsh JA. Recognizing Axial Spondyloarthritis: a guide for primary care. Mayo Clin Proc 2020; 95 (11) 2499-2508
    CrossrefPubMedSearch in Google Scholar
  • 63 van den Berg R, van der Heijde DMFM. How should we diagnose spondyloarthritis according to the ASAS classification criteria: a guide for practicing physicians. Pol Arch Intern Med 2010; 120 (11) 452-457
    CrossrefPubMedSearch in Google Scholar
  • 64 Navarro-Compán V, Benavent D, Capelusnik D. et al. ASAS consensus definition of early axial spondyloarthritis. Ann Rheum Dis 2024; 83 (09) 1093-1099
    CrossrefPubMedSearch in Google Scholar
  • 65 Ciurea A, Götschi A, Bräm R. et al. Early axial spondyloarthritis according to the ASAS consensus definition: characterisation of patients and effectiveness of a first TNF inhibitor in a large observational registry. RMD Open 2023; 9 (04) e003455
    CrossrefPubMedSearch in Google Scholar
  • 66 Khan MA. HLA-B27 and its subtypes in world populations. Curr Opin Rheumatol 1995; 7 (04) 263-269
    CrossrefPubMedSearch in Google Scholar
  • 67 Ruof J, Stucki G. Validity aspects of erythrocyte sedimentation rate and C-reactive protein in ankylosing spondylitis: a literature review. J Rheumatol 1999; 26 (04) 966-970
    PubMedSearch in Google Scholar
  • 68 Lorenzin M, Ometto F, Ortolan A. et al. An update on serum biomarkers to assess axial spondyloarthritis and to guide treatment decision. Ther Adv Musculoskelet Dis 2020; 12: 1-19 . 1759720–X20934277
    CrossrefPubMedSearch in Google Scholar