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Spine MRI in SpAWhat is the rheumatologist interested in?
Ulrich Weber MD
Consultant, King Christian 10th Hospital, Gråsten
Associate Professor in Rheumatology, University of Southern Denmark
4th Musculoskeletal MRI Meeting 2017: Spine MRI
Ospedale Regionale di Lugano May 6th 2017
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Spine MRI in SpAKey issues in rheumatology
• How to diagnose axial SpA early?• How to predict new bone formation in the spine?• How to communicate with a radiologist?
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Spine MRI in SpAAgenda
• Diagnostic utility• Prognostication• Dialogue rad - rheum
Weber U, Jurik AG, Lambert RGW, Maksymowych WP. Curr Rheumatol Rep 2016;18:58 [review]
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Central spinal lesions High sensitivity
CILCorner inflammatory lesions
CFLCorner fat lesions
Lambert RGW et al. J Rheumatol 2009;84:3. Pedersen SJ et al. Best Pract Res Clin Rheum 2012;26:751
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Lateral spinal lesionsHigh 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
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Diagnostic utility of spinal lesions
Corner Inflammatory Lesion CIL
≥3 CIL: positive LR 121
Mean age of controls 52.5 y≥2 CIL: positive LR 122
Median age of controls 30.8 y
1Bennett AN et al. Arthritis Rheum 2009;60:13312Weber U et al. Arthritis Rheum 2009;61:9003Jaeschke R et al. JAMA 1994;271:703
Clinical relevance LR+:3
5-10 moderate
>10 high
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Positive spinal MRIASAS 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
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Poor diagnostic utility of candidate definitions of a positive spinal MRI
Nr-axSpA vs NSBP Sensitivity Specificity LR+ LR-
≥3 CIL 0.43/0.25 0.75/0.89 1.74/2.36 0.75/0.84
≥6 CIL 0.24/0.15 0.98/0.98 13.26/6.74 0.78/0.87
≥6 CFL 0.26/0.40 0.82/0.81 1.47/2.09 0.90/0.75
≥10 CFL 0.12/0.21 0.89/0.90 1.11/2.13 0.99/0.88
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
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Daily routineOccasionally good utility of spine MRI
4 CIL
STIR T1SE
27 CFL
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Clinically suspected SpANegative SIJ MRI but positive spine MRI
T1SE
STIR T1SESTIR
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34-year-old female healthy controlNegative SIJ MRI but positive spine MRI
STIR T1SESTIR
T1SE
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Re-classification of SIJ MRI by Combined SIJ plus Spine MRI
Cohort A (n=62) B (n=88)
Group nr-axSpA AS NSBP HC nr-axSpA AS NSBP
Re-Classification (%) 15.8 0 26.8 17.5 24.2 0 11.4
SIJ MRI alone negative → Combined MRI positive
20% true positive re-classifications in nr-axSpA versus20% false positive re-classifications in controls
Weber U et al. Ann Rheum Dis 2015;74:985
An additional spine MRI just added to confusion
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MRI in recognition of early axial SpAWhat 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 alone1
The role of spine MRI in early recognitionof axial SpA is not defined
1Mandl P et al. Ann Rheum Dis 2015;74:1327 [EULAR recommendations]
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Brush up your Danish
Far, får får får?
Nej, får får ikke får, får får lam
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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
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Spine MRI in SpAAgenda
• Diagnostic utility• Prognostication• Dialogue rad - rheum
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Spinal new bone formation (SNBF)Background
1Van der Heijde D et al. Arthritis Rheum 2008;58:1324 and 3063; Arthritis Res Ther 2009;11:R1272Haroon N et al. Arthritis Rheum 2013;65:2645. Maas F et al. Arthritis Care Res epub 2016;doi:10.1002/acr.23097
• SIJ diagnostic, spine prognostic compartment in SpA
• 3 interventional studies with TNF inhibitors in AS showed no impact on SNBF over 2 years1
• 2 recent TNF treatment studies showed 50% risk reduction of SNBF after ≥4 years2
• 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?
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Spinal MRI predicting new bone formation?
Maksymowych WP et al. Ann Rheum Dis 2013;72:23Machado PM et al. Ann Rheum Dis 2016;75:1486
CIL type B with apical erosion Sequence CIL → CFL
T1SE T1SESTIR STIRPersonal use only
Preferentially posterolateral distribution of syndesmophytes along vertebral rim by CT
Tan S et al. Ann Rheum Dis 2016;75:1951
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Radiographs miss new syndesmophyte formation detected by low dose CT
De Bruin F et al. Oral presentation 3160 ACR 2016
1 Radiograph2 Low dose CT BL3 Low dose CT 2y FU
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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
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Spine MRI in SpAAgenda
• Diagnostic utility• Prognostication• Dialogue rad - rheum
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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 manRheum resident: No TNF despite spinal painRheum consultant: Classical inflammation of lateral elements TH6/7
• How to validate the plethora of degenerative spinal MRI lesions?
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Spine MRI in SpARheum’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
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Barnacle Geese, Rømø, Denmark
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