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EDUCATION EXHIBIT |
1 Department of Radiology, University of Colorado Health Sciences Center Denver, Colorado
I congratulate Dr Hermann and colleagues on the preceding excellent article (1). Their work should contribute to an improved interpretation of MR imaging studies of the spine by the general radiologist, as well as provide a valuable tool to the subspecialist radiologist embarking on large studies of patients with spondyloarthritis.
Those of us who have participated in the imaging portion of longitudinal rheumatologic studies find it exciting that we will now be able to demonstrate findings of spondyloarthritis early in the disease process, well before the formation of osteitis, shiny corners, syndesmophytes, and ankylosis, which are truly late manifestations of the disease. It is even more exciting that we are likely to be able to demonstrate some reversal in the disease process. Although such reversal was actively sought in early longitudinal studies that used conventional radiography, it could not be demonstrated with that modality, even in the presence of significant clinical improvement (2). This current work by Dr Hermann and colleagues will help legitimize the role of MR imaging in rheumatologic studies, including those conducted to evaluate drug therapies. Subsequent work promised by the authors, further development of their scoring system, and confirmation of its accuracy based on large clinical trials should prove even more valuable. It has long been hoped that imaging could reliably demonstrate acuity versus chronicity or even reversal of rheumatologic diseases over a relatively short interval of time.
I would also like to stress the value of this article to the general radiologist who interprets MR imaging examinations of the spine on a daily basis. We often interpret these cross-sectional images without access to any associated conventional radiographs, and it can be easy to miss seeing syndesmophytes or early erosive lesions, findings that might direct us toward a diagnosis of spondyloarthritis. It is easy to concentrate on disk disease and stenosis when interpreting an MR imaging study of the lumbar spine. However, we also know that many patients have disk disease and stenosis that do not correspond exactly to their symptoms. In fact, it can be notoriously difficult to ascribe symptoms to imaging findings, especially if symptoms do not correspond to the location of the vertebral lesion. A good orthopedic or neurosurgeon knows better than to operate based on "non-matching" imaging findings, since patients do not tolerate failed (or unfruitful) surgery well (one of my colleagues describes undertaking back surgery as "marrying the patient"). It is in everyone’s best interest to identify the source of the patient’s pain as accurately as possible, especially when there can be confounding findings such as disk protrusion or moderate stenosis. Therefore, general radiologists will do well to pay close attention to the descriptions in the preceding article that could lead them to a diagnosis of spondyloarthritis. They should also look at the sacroiliac joints carefully on every MR image of the lumbar spine, especially when seeking an explanation for low back pain in a young adult patient. Making the observations that lead to a previously unsuspected diagnosis of spondyloarthritis could make the radiologist a hero, possibly prevent an unsuccessful surgical procedure, and certainly allow early pharmaceutical intervention.
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2 Department of Radiology, Charité Medical School, Campus Mitte Berlin, Germany
I thank Dr Manaster for her valuable comments on our review article. She raised a number of concerns that are of special interest to radiologists and rheumatologists who perform clinical research and analyze clinical studies.
Although the focus of our article is on MR imaging, there is no doubt that conventional radiography will continue to have a role in the diagnostic evaluation of patients with ankylosing spondylitis. Use of conventional radiography, since it is a highly standardized, well-evaluated, and—not the least of all—inexpensive diagnostic tool, enables adequate diagnostic evaluation of a large proportion of patients with this disease. Moreover, a conventional pelvic survey is necessary to make the definitive diagnosis of ankylosing spondylitis according to the modified New York criteria (1). In contrast, conventional radiography appears to be of limited value in the follow-up of patients treated with the highly effective TNF-
inhibitors in the framework of scientific investigations. In such cases, conventional radiography would not show the acute inflammatory changes because it is a modality that depicts structural changes only (and such changes are irreversible in most cases, as also mentioned by Dr Manaster). However, it has been shown that the sensitivity of radiography in the depiction of subtle structural change can be improved if the interpreting radiologist uses an adequate scoring system. There is general agreement that the modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS) is the most suitable tool for documenting structural changes in clinical studies (2,3).
Scoring methods also have a crucial role in the analysis of longitudinal clinical studies in which MR imaging is used to evaluate outcomes. The classification system presented in our article is not primarily intended for scoring acute changes during therapy but instead aims at promoting a general understanding of the changes in the signal-intensity patterns of the lesions seen at MR imaging and thus standardizing and improving image interpretation and reporting of findings to rheumatologists. Otherwise, there are at least four scoring systems for the spine and at least six scoring systems for the sacroiliac joints that can be used to document the course of acute inflammatory changes in a standardized manner (4). A study group, Outcome Measures in Rheumatology (OMERACT), aims at identifying the optimal scoring system for either of the two parts of the axial skeleton.
I would like to take this opportunity to encourage musculoskeletal radiologists to join one of the study groups of the OMERACT initiative (5). OMERACT is an international and multidisciplinary network of rheumatologists, epidemiologists, pharmacologists, radiologists, and representatives from industry aimed at establishing and improving outcome parameters in rheumatology in a data-driven, interactive consensus process. In this multidisciplinary effort, it would certainly be advantageous to have a team of expert radiologists representing the different areas of our discipline and to improve and highlight the benefits of imaging in rheumatology.
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