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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