Bone Marrow Edema Location Helps Distinguish Axial Spondyloarthritis From Similar Conditions

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BONE MARROW EDEMA LOCATION HELPS DISTINGUISH AXIAL SPONDYLOARTHRITIS FROM SIMILAR CONDITIONS

CHICAGO – Detailed analysis of bone marrow edema and their anatomical location can help rheumatologists differentiate patients with axial spondyloarthritis from those with similar, more common conditions according to new research findings presented this week at the 2018 ACR/ARHP Annual Meeting (Abstract #864).

Axial spondyloarthritis (axSpA) is a group of inflammatory rheumatic diseases where inflammation usually affects sacroiliac joints and the entheses of the spine where ligaments and tendons attach to bones. Symptoms may include pain and stiffness in the spine, which with time will lead to destruction of bone, causing spine deformity and reduced function.

The Assessment of Spondyloarthritis International Society’s classification criteria for axSpA considers bone marrow edema (BME), as detected by magnetic resonance imaging (MRI), centrally important. However, bone marrow edema in sacroiliac joints is found in other common conditions, as well as healthy individuals. Researchers in Denmark conducted a study to evaluate the diagnostic utility of the relationship between MRI-detected BME and other MRI sacroiliac lesions when differentiating axSpA patients from patients with other painful conditions.

“We have very effective medical treatments for axSpA that reduce disease activity, and improve the signs and symptoms of the disease. However, it’s clinically difficult to differentiate patients with axSpA from patients with buttock pain for other reasons,” said Sengül Heidi Seven, MD, a PhD student at Copenhagen Center for Arthritis Research and the study’s presenting author. “MRI is frequently used for axSpA diagnosis because it can visualize BME, but these may also occur in other diseases, as well as in very active athletes, such as long-distance runners. There is a need for a better way to establish diagnosis early in the disease course, through more detailed assessment of MRIs of sacroiliac joints.”

The prospective, cross-sectional study focused on 204 patients 45 years of age or older. Patients included 41 patients with axSpA; 46 women with prenatal or postpartum pain within 12 months of delivery and 14 without; 25 patients with lumbar disc herniation, 26 people who worked in jobs involving hard physical labor; 23 long-distance runners who ran 30 or more kilometers a week; and 29 healthy men. Participants with pain all had a score of two or higher on the Visual Analogue Scale for two months or longer. All participants underwent clinical, laboratory and MRI examination, including semi-coronal short tau internal recovery sequence (STIR) and T1-weighted sequences of their sacroiliac joints. MRI scans were evaluated for BME, erosion, fat, ankylosis and sclerosis. In nine different images of each patient’s cartilaginous compartment, they separately assessed the left and right sacroiliac joints for BME in relation to the other structural lesions.

The study’s findings showed that BME adjacent to the joint space, erosions and fat were more frequently seen in patients with axSpA, but these lesions were also seen in patients in the other groups, mainly women with postpartum pain. When the researchers required increasing amounts of lesions, or higher cut-offs, in their analysis, mostly axSpA patients met the requirements. BME adjacent to sclerosis was most frequently seen in women with postpartum pain, and BME adjacent to ankylosis was only seen in patients with axSpA.

Detailed MRI analysis of lesions and their anatomical location may help differentiate axSpA from other conditions when evaluating suspected patients, the study found.

“Improved diagnosis of these patients will result in more patients getting the most appropriate diagnosis and treatment, potentially leading to optimized outcomes for both people with and without axSpA,” said Dr. Seven. “Data from this study will potentially help rheumatologists diagnose axSpA patients more accurately in clinical practice, and this may also potentially improve selection of patients for clinical trials.” 

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The Diagnostic Utility of the Relation between MRI Bone Marrow Edema and Other Types of MRI Lesions in the Sacroiliac Joints in Axial Spondyloarthritis

Sengül Seven¹, Pernille Hededal², Mikkel Østergaard², Lone Morsel-Carlsen³, Inge Juul Sørensen⁴, Birthe Bonde⁵, Gorm Thamborg⁶, Oliver Hendricks⁷, Niklas Rye Jørgensen⁴ and Susanne J Pedersen⁴, ¹Rigshospitalet, University of Copenhagen, Glostrup., 2600 Glostrup, Denmark, ²Rigshospitalet, University of Copenhagen, Glostrup., Glostrup, Denmark, ³Department of Radiology, Bispebjerg-Frederiksberg Hospital, Copenhagen, Copenhagen, Denmark, ⁴Rigshospitalet, University of Copenhagen, Glostrup, Glostrup, Denmark, ⁵Birthe Bonde Clinic of Physiotherapy, Copenhagen, Denmark, ⁶Rigshospitalet, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark, ⁷King Christian 10th Hospital for Rheumatic Diseases, University of Southern Denmark, Institute of Regional Health Research, Graasten, Denmark

Background/Purpose:

MRI detected bone marrow edema (BME) plays a central role in the ASAS (Assessment of Spondyloarthritis International Society) classification criteria for axial spondyloarthritis (axSpA). However, several studies have shown that BME in the sacroiliac joints (SIJs) is also present in other conditions^{1, 2.}. The aim of the study was to investigate the utility of the relation between MRI BME and different types of MRI lesions in the sacroiliac joint to separate patients with axSpA from persons with other conditions.

Methods:

The MASH study is a prospective cross-sectional study of 204 participants, aged ≤45 yrs. The study included 41 patients with axSpA, 46 women with and 14 without pain related to pregnancy or postpartum within 12 months after delivery, 25 patients with lumbar disc herniation, 26 persons with hard physical labor (cleaning assistants), 23 long-distance runners (≥30 km/week) and 29 healthy men. Participants with pain should all have VAS pain >2 (on a scale 0-10) for ≥2 months. Participants in the non-axSpA groups were not allowed to have any clinical SpA features or rheumatological conditions. All participants underwent clinical, laboratory and MRI examination including semi-coronal STIR and T1-weighted sequences of the SIJs. MRIs were evaluated for BME, erosion, fat, ankylosis, and sclerosis according to the SPARCC MRI definitions of lesions^3,4 by two independent readers. In each of the nine slices of the cartilaginous compartment, the left and right SIJs were separately assessed for presence of BME in relation to each of the above mentioned structural lesions (range of total score per patient: 0-18).

Results:

The table shows the clinical characteristics within each participant group, and MRI results based on the mean scores of the two readers. BME located adjacent to joint space, adjacent to erosions and adjacent to fat were more frequent in patients with axSpA, but these lesions were also seen in the other study groups, mainly women with postpartum pain. When increasing amounts of lesions were required (higher cut-offs), almost only AxSpA patients fulfilled the requirements (table). BME adjacent to sclerosis was most frequent in women with postpartum pain, whereas BME adjacent to ankylosis was only seen in patients with axSpA.

Conclusion:

BME located adjacent to joint space, adjacent to erosion and adjacent to fat was most frequent, but did not exclusively occur in patients with axSpA, whilst BME adjacent to sclerosis was most frequent in women with postpartum pain. Detailed analysis of lesions and their anatomical location may help differentiate axSpA from other conditions.

References:

1. Weber et al. AR 2010;62(10):3048-3058
2. Seven et al. Annrheumdis-2018-eular.2586 
3. Maksymowych et al. AR 2005;53:703-9.
4. Maksymowich et al. J Rheumatol. 2015;42:79-86.