The use of MRI in the early diagnosis of spondyloarthritis: A cross-sectional cohort study of secondary care patients with persistent low back pain

Bodil Arnbak

The use of MRI in the early diagnosis of spondyloarthritis: A cross-sectional cohort study of secondary care patients with persistent low back pain

Bidragets oversatte titel: Brugen af MR-scanninger i den tidlige diagnostik af spondylartrit: Et tværsnits kohortestudie af patienter fra sekundær sektoren med vedvarende lændesmerter

Bodil Arnbak

IRS - Sygehus Lillebælt

Publikation: Afhandling › Ph.d.-afhandling

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Abstract

Spondylartritis (SpA) er en gruppe reumatologiske sygdomme, der kan være alvorlige og invaliderende og ofte debuterer i ung alder. Da der ikke findes specifikke tests til at foretage en præcis diagnose af SpA, er diagnosen i stedet baseret på den kliniske præsentation, blodprøver og billeddiagnostiske fund. I 2009 blev et nyt sæt klassifikations-kriterier for SpA udarbejdet af ’Assessment in SpondyloArthritis international Society’ (ASAS). Kriterierne kombinerer kliniske tegn, såkaldte SpA karakteristika, blodprøver og billeddiagnostik af bækkenleddene i form af røntgen fund og som noget nyt også fund på magnetisk resonans (MR) scanning. Selvom MR scanninger i stigende grad anvendes til at diagnosticere SpA er der flere usikkerheder relateret til den diagnostiske anvendelighed. I en systematisk litteratur gennemgang, der indgår i denne afhandling, blev der kun fundet to undersøgelser af høj kvalitet og den forskningsmæssige baggrund for brugen af MR til diagnosticering af SpA vurderedes begrænset. Dette understreger et behov for undersøgelse af en større kohorte af patienter med vedvarende lændesmerter. De to overordnede formål for ph.d.-studiet var i en kohorte af unge patienter med vedvarende lændesmerter 1) at vurdere forekomsten af MR fund og kliniske karakteristika for SpA og 2) at undersøge sammenhængen mellem MR fund og SpA karakteristika.

Fra marts 2011 til oktober 2013 blev 1037 patienter inkluderet i Region Syddanmarks Rygsmerte Kohorte. Kohorten omfattede patienter i alderen 18-40 år, henvist til Rygcenter Syddanmark med vedvarende lændesmerter uden forudgående mistanke om SpA. Dataindsamlingen omfattede MR scanning af hele rygsøjlen og bækkenleddene, blodprøver og spørgeskemaer. Tre erfarne radiologer deltog i vurdereingen af MR scanningerne med anvendelse af et standardiseret evalueringsskema, testet for reproducerbarhed.

Studiet frembragte flere interessante resultater. Af de undersøgte patienter opfyldte 10% ASAS kriterier for SpA. Fund og symptomer, der er blevet betragtet som specifikke for SpA, viste sig at være relativt almindeligt forekomne i denne kohorte f.eks. inflammatorisk rygsmerte, bestemte SpA karakteristika og knoglemarvsødem ved bækkenleddene. Af de tre mest almindelige SpA karakteristika, var kun én svagt forbundet med erosioner i bækkenleddene, mens ingen andre sammenhænge blev fundet mellem MR fund relateret til SpA og disse tre SpA karakteristika. Desuden var let knoglemarvsødem i bækkenleddene relativt hyppig, men uden sammenhæng med SpA karakteristika. Udtalt knoglemarvsødem og strukturelle forandringer i bækkenleddene havde imidlertid sammenhæng med et eller flere SpA karakteristika. Resultaterne fra denne afhandling understreger et behov for en datagenreret revurdering af ASAS kriterierne for SpA, både i forhold til den diagnostiske værdi af SpA karakteristika og minimumskravene til MR fund til diagnosticering af SpA.

Bidragets oversatte titel	Brugen af MR-scanninger i den tidlige diagnostik af spondylartrit: Et tværsnits kohortestudie af patienter fra sekundær sektoren med vedvarende lændesmerter
Originalsprog	Engelsk
Vejledere/rådgivere	Manniche, Claus, Hovedvejleder Jensen, Tue Secher, Bivejleder Hørslev-Petersen, Kim, Bivejleder Jurik, Anne Grethe, Bivejleder, Ekstern person
Udgiver	Syddansk Universitet. Det Sundhedsvidenskabelige Fakultet
Status	Udgivet - 19. jun. 2014

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title = "The use of MRI in the early diagnosis of spondyloarthritis: A cross-sectional cohort study of secondary care patients with persistent low back pain",

abstract = "Spondyloarthritis (SpA) can be a serious and disabling disease often first appearing at a young age. Since there are no specific symptoms or tests available to make a precise diagnosis of SpA, the diagnosis is instead based on a composite of clinical presentation and serological and imaging findings. In 2009, Assessment of SpondyloArthritis International Society (ASAS) proposed a new set of classification criteria for axial SpA. The criteria combine clinical features, so called SpA features, blood samples and imaging in the form of radiographic findings of the sacroiliac joints and as new addition also MRI findings of the sacroiliac joints. Although, MRI is used increasingly in the diagnosis of SpA, several uncertainties remain about the diagnostic utility of this imaging modality. In a systematic review, included in this thesis, only two high quality studies were identified and the evidence for the utility of MRI in the diagnosis of SpA was considered limited. The results from the review underline a requirement for larger cohort studies investigating patients with persistent low back pain. The two main objectives of the PhD study were, in a cohort of secondary care patients aged 18-40 years with persistent low back pain to 1) estimate the prevalence of MRI findings and clinical characteristics previously associated with SpA and 2) investigate the associations between MRI findings and clinical characteristics suggesting SpA. From March 2011 to October 2013, a total of 1037 patients were included in The Back Pain Cohort of Southern Denmark. The cohort included patients aged 18-40 years referred to the Spine Centre of Southern Denmark, with persistent low back pain and without previous suspicion of SpA. The data collection included MRI of the whole spine and the sacroiliac joints, blood samples and questionnaires. Three experienced radiologists participated in the reading of the MRI, using a standardised evaluation form, which was tested for inter- and intra-observer agreement. Several interesting results were found. The ASAS criteria for axial SpA were met by 10\% of the investigated patients. Furthermore, signs and symptoms, which have been regarded as relatively specific for SpA, such as inflammatory back pain characteristics, certain other SpA features and bone marrow oedema at the sacroiliac joints, were found to be relatively common in this cohort. In relation to the association between MRI findings and clinical characteristics, the three most common SpA features were generally not associated with MRI findings related to SpA. Moreover, slight bone marrow oedema by MRI was also common but not associated with any of the SpA features. These results imply a need for a datadriven re-evaluation of the ASAS criteria for axial SpA regarding the diagnostic utility of SpA features and the minimum requirements of MRI findings for the diagnosis of sacroiliitis. ",

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N2 - Spondyloarthritis (SpA) can be a serious and disabling disease often first appearing at a young age. Since there are no specific symptoms or tests available to make a precise diagnosis of SpA, the diagnosis is instead based on a composite of clinical presentation and serological and imaging findings. In 2009, Assessment of SpondyloArthritis International Society (ASAS) proposed a new set of classification criteria for axial SpA. The criteria combine clinical features, so called SpA features, blood samples and imaging in the form of radiographic findings of the sacroiliac joints and as new addition also MRI findings of the sacroiliac joints. Although, MRI is used increasingly in the diagnosis of SpA, several uncertainties remain about the diagnostic utility of this imaging modality. In a systematic review, included in this thesis, only two high quality studies were identified and the evidence for the utility of MRI in the diagnosis of SpA was considered limited. The results from the review underline a requirement for larger cohort studies investigating patients with persistent low back pain. The two main objectives of the PhD study were, in a cohort of secondary care patients aged 18-40 years with persistent low back pain to 1) estimate the prevalence of MRI findings and clinical characteristics previously associated with SpA and 2) investigate the associations between MRI findings and clinical characteristics suggesting SpA. From March 2011 to October 2013, a total of 1037 patients were included in The Back Pain Cohort of Southern Denmark. The cohort included patients aged 18-40 years referred to the Spine Centre of Southern Denmark, with persistent low back pain and without previous suspicion of SpA. The data collection included MRI of the whole spine and the sacroiliac joints, blood samples and questionnaires. Three experienced radiologists participated in the reading of the MRI, using a standardised evaluation form, which was tested for inter- and intra-observer agreement. Several interesting results were found. The ASAS criteria for axial SpA were met by 10% of the investigated patients. Furthermore, signs and symptoms, which have been regarded as relatively specific for SpA, such as inflammatory back pain characteristics, certain other SpA features and bone marrow oedema at the sacroiliac joints, were found to be relatively common in this cohort. In relation to the association between MRI findings and clinical characteristics, the three most common SpA features were generally not associated with MRI findings related to SpA. Moreover, slight bone marrow oedema by MRI was also common but not associated with any of the SpA features. These results imply a need for a datadriven re-evaluation of the ASAS criteria for axial SpA regarding the diagnostic utility of SpA features and the minimum requirements of MRI findings for the diagnosis of sacroiliitis.

AB - Spondyloarthritis (SpA) can be a serious and disabling disease often first appearing at a young age. Since there are no specific symptoms or tests available to make a precise diagnosis of SpA, the diagnosis is instead based on a composite of clinical presentation and serological and imaging findings. In 2009, Assessment of SpondyloArthritis International Society (ASAS) proposed a new set of classification criteria for axial SpA. The criteria combine clinical features, so called SpA features, blood samples and imaging in the form of radiographic findings of the sacroiliac joints and as new addition also MRI findings of the sacroiliac joints. Although, MRI is used increasingly in the diagnosis of SpA, several uncertainties remain about the diagnostic utility of this imaging modality. In a systematic review, included in this thesis, only two high quality studies were identified and the evidence for the utility of MRI in the diagnosis of SpA was considered limited. The results from the review underline a requirement for larger cohort studies investigating patients with persistent low back pain. The two main objectives of the PhD study were, in a cohort of secondary care patients aged 18-40 years with persistent low back pain to 1) estimate the prevalence of MRI findings and clinical characteristics previously associated with SpA and 2) investigate the associations between MRI findings and clinical characteristics suggesting SpA. From March 2011 to October 2013, a total of 1037 patients were included in The Back Pain Cohort of Southern Denmark. The cohort included patients aged 18-40 years referred to the Spine Centre of Southern Denmark, with persistent low back pain and without previous suspicion of SpA. The data collection included MRI of the whole spine and the sacroiliac joints, blood samples and questionnaires. Three experienced radiologists participated in the reading of the MRI, using a standardised evaluation form, which was tested for inter- and intra-observer agreement. Several interesting results were found. The ASAS criteria for axial SpA were met by 10% of the investigated patients. Furthermore, signs and symptoms, which have been regarded as relatively specific for SpA, such as inflammatory back pain characteristics, certain other SpA features and bone marrow oedema at the sacroiliac joints, were found to be relatively common in this cohort. In relation to the association between MRI findings and clinical characteristics, the three most common SpA features were generally not associated with MRI findings related to SpA. Moreover, slight bone marrow oedema by MRI was also common but not associated with any of the SpA features. These results imply a need for a datadriven re-evaluation of the ASAS criteria for axial SpA regarding the diagnostic utility of SpA features and the minimum requirements of MRI findings for the diagnosis of sacroiliitis.

M3 - Ph.D. thesis

PB - Syddansk Universitet. Det Sundhedsvidenskabelige Fakultet

ER -

The use of MRI in the early diagnosis of spondyloarthritis: A cross-sectional cohort study of secondary care patients with persistent low back pain

Abstract

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