Rethinking imaging in axial spondyloarthritis: toward diagnostic maturity

Area of Science:

• Rheumatology
• Radiology
• Clinical Medicine

Background:

• Magnetic resonance imaging (MRI) of sacroiliac joints is central to axial spondyloarthritis (axSpA) evaluation due to lack of biomarkers and variable HLA-B27 prevalence.
• The increasing reliance on imaging as a standalone diagnostic tool for axSpA risks undermining essential clinical reasoning.

Purpose of the Study:

• To critically examine the specificity and limitations of imaging findings in axSpA diagnosis.
• To advocate for imaging's role as a supportive tool integrated within a comprehensive clinical framework.

Main Methods:

• Viewpoint analysis of current diagnostic practices in axSpA.
• Review of imaging findings' specificity and limitations in various populations.

Main Results:

• Imaging lesions like bone marrow edema and structural changes can occur in non-axSpA populations, including healthy individuals and those with mechanical back pain.
• Misinterpretation of imaging findings, not inherent limitations, is a primary driver of diagnostic error in axSpA.
• Overreliance on imaging contributes to diagnostic inflation, especially in non-radiographic and atypical axSpA cases.

Conclusions:

• Imaging should be a supportive and prognostic tool, integrated with patient history, clinical features, and laboratory data for axSpA diagnosis.
• Prioritizing clinical reasoning, multidisciplinary collaboration, and appropriate clinical context for imaging interpretation is essential.
• Artificial intelligence tools in imaging require careful validation to avoid amplifying diagnostic challenges in axSpA.