How to apply imaging technology in spondyloarthritis?

*Only for medical professionals to read for reference.
Master the imaging technology of rheumatism, early diagnosis and treatment is no longer a slogan! Rheumatology imaging plays an important role in the management of the whole course of rheumatic immune diseases.

Although imaging technology has continued to develop in recent years, and its status in rheumatic immune diseases has become more and more important, the understanding and application of imaging technology by domestic rheumatology immunologists are uneven, and standardized clinical application guidance of rheumatology imaging has been absence.

The "2021 Chinese Expert Consensus on the Application of Imaging Techniques in Spondyloarthritis" (hereinafter referred to as the Consensus), led by the Imaging Group of the Rheumatology and Immunology Branch of the Chinese Medical Doctor Association and domestic experts in this field, will soon be available this year.
Meet with you during the branch (CRA).

This consensus is the first Chinese expert consensus on the application of imaging technology in spondyloarthritis (SpA).

In order to further understand the specific application of imaging technology in the clinical management of SpA, we are honored to invite Professor Li Guangtao and Professor Deng Xuerong from the Department of Rheumatology and Immunology of Peking University First Hospital to express their views and opinions on this.

Professor Li Guangtao Interview Video Professor Deng Xuerong Interview Video 1 The application of imaging technology is an indispensable and important link in the diagnosis and treatment of SpA diseases.
The previous clinically used SpA diagnostic criteria was the New York diagnostic criteria in 1984, which highlighted the X-ray sacroiliitis The status in the diagnosis ensures specificity.

However, during the development of the disease, it takes at least several years from the onset of low back pain to the occurrence of radiological sacroiliac joint destruction that meets the classification and diagnostic criteria, which is not conducive to the early diagnosis and treatment of the disease.

Based on this, in 2009/2010, the International Society for the Assessment of Spondyloarthritis (ASAS) incorporated a new imaging technology-Magnetic Resonance Imaging (MRI) into the diagnostic criteria, enabling SpA diagnosis to reach a new level [1].

Figure: The classification standard of axial and peripheral SpA proposed by ASAS in 2009/2010[2-3] The new standard and the change in diagnosis basis reflect the important significance of imaging technology in the early diagnosis of SpA disease.

But at the same time, clinicians are also required to keep pace with the times, learn SpA's MRI diagnostic standards, and further improve their own and overall diagnosis and treatment levels.

Today, more and more new technologies are used in medical imaging diagnosis, from X-ray to MRI to ultrasound.
The development of imaging technology makes early diagnosis and treatment of SpA no longer just a hope.

Professor Li Guangtao discussed the specific application of imaging technology in the actual clinical process at this stage.

In the field of SpA diseases, different imaging techniques have different scopes of adaptation: MRI is the imaging technique with the most comprehensive detection range.
From inflammatory bone marrow edema to chronic structural changes, almost all SpA images can be observed by this technique.
Learn the types of lesions, but its shortcomings are that it is expensive and takes a long time to operate.

Ultrasound is highly convenient and is one of the most effective imaging methods for diagnosing peripheral joint diseases.

However, its limitation lies in the inability to monitor deep-seated lesions, such as the evaluation and observation of knee joints, hip joints, and sacroiliac joints; ultrasound cannot penetrate the cortex, and it cannot clearly show the inflammatory changes in the bone marrow cavity.

CT and X-rays are mainly used to monitor structural changes during disease progression.

Among them, the structural changes reflected by CT are more comprehensive than X-ray, but X-ray operation is relatively simple, and it is still the most commonly used and most widely used imaging technique.

2 From the perspective of mechanism development, to understand the significance of advanced imaging technology in the diagnosis of SpA enthesitis.
In addition to the clinic, Professor Li Guangtao also introduced the significance of the development of rheumatism imaging technology for the diagnosis of SpA enthesitis from the pathophysiological aspect.

Enthesitis is a characteristic manifestation of SpA disease, and it is also its basic pathological change.

Enthesitis can cause pain and swelling in the corresponding parts.
As the disease progresses, it may also cause structural damage, which is closely related to the patient's overall disease burden and functional prognosis [4-6]. The early diagnosis and treatment of enthesitis has an important impact on the early diagnosis and treatment of SpA.

Figure: The structural progression mechanism of ankylosing spondylitis (AS) [7] Professor Deng Xuerong pointed out that in the past, we did not pay enough attention to enthesitis and did not have appropriate imaging techniques to diagnose and monitor it.

Now, more and more rheumatologists have realized that high-sensitivity imaging techniques can easily detect SpA enclosing inflammation, which can greatly improve the current clinical delayed diagnosis of SpA.

Professor Li Guangtao also believes that in the past when there was only X-ray, we could only diagnose the disease by observing structural damage, but at this time the patient has missed the best time for treatment.

Now, with the development of imaging technology, we can use more advanced imaging technology to detect enthesitis and diagnose SpA with no clinical manifestations or subclinical phenotypes, so as to diagnose more diseases earlier and help patients Achieve early treatment.

In addition, Professor Li Guangtao also introduced that the innovation of clinical treatment programs has also brought more value to the application of imaging technology in SpA.

In the development of SpA structure, fat deposition is relatively difficult to control and reverse imaging lesions, and is closely related to subsequent structural damage.

At present, among many clinical treatment drugs, only IL-17A inhibitors have been found to inhibit fat deposition, thereby delaying the progress of imaging and improving the long-term prognosis of patients.

The significance of this targeted therapy is unique.

Using imaging technology, we can not only realize the early recognition of SpA.

During the treatment process, we can also evaluate and monitor the patient's imaging progress in time to guide disease treatment and achieve better overall disease management.

Finally, Professor Li Guangtao and Professor Deng Xuerong both emphasized that the release of the consensus on imaging in the future will promote the standardized diagnosis and treatment of SpA in the clinic and help the entire management of the disease.

In the current era of increasingly widespread application of imaging technology, the consensus will combine clinical practical issues to further improve Chinese rheumatologists’ understanding of imaging technology, improve the level of SpA diagnosis and treatment, and benefit patients more.

References: [1] Braun J, et al.
Ann Rheum Dis.
2011, 70(6):896-904.
[2] Rudwaleit M, et al.
Ann Rheum Dis.
2009, 68(6):777-83 .
[3] Rudwaleit M, et al.
Ann Rheum Dis.
2011, 70(1)25-31[4] Turan Y, et al.
Joint Bone Spine.
2009 Dec;76(6):642-7.
[5 ] Abdulla Watad, et al.
Curr Rheumatol Rep.
2018; 20(7): 41.
[6] Vibeke S, et al.
ACR/ARP Annual Meeting, November 8-13, 2019, Atlanta, USA, #630.
[ 7] Praveena Chiowchanwisawakit, et al.
arthritis rheum.
2011, 63:2215-2225.
Expert profile Professor Li Guangtao Doctor of Medicine, Department of Rheumatology and Immunology, Peking University First Hospital, and associate chief physician, graduated from Peking University School of Medicine, Beijing Association of Integrative Medicine, Rheumatology Branch Profile of the Young Committee Member of the Standing Committee of the Rheumatology Branch of the Beijing Medical Association Professor Deng Xuerong graduated from the Peking University School of Medicine with a doctor of medicine. He is currently the chief physician of the Department of Rheumatology and Immunology of Peking University First Hospital, deputy leader of the imaging group of the Chinese Medical Doctor Association Rheumatology and Immunology Physician Branch, member and secretary of the imaging group of the Rheumatology Expert Committee of the Cross-Strait Medical and Health Exchange Association.
The main research direction is various types of arthritis In sexual diseases and musculoskeletal ultrasound, EULAR-certified musculoskeletal ultrasound training teachers successively served as visiting scholars at the University of Hong Kong Queen Mary Hospital and the University of Leeds Center for Rheumatology and Musculoskeletal Medicine.
He was awarded the Travel Scholar Award of the Japanese Society of Rheumatology.
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