OP0251 DATA-DRIVEN DEFINITIONS BASED ON INFLAMMATORY LESIONS FOR A POSITIVE MRI OF THE SPINE CONSISTENT WITH AXIAL SPONDYLOARTHRITIS
Authors: W. P. Maksymowych, R. G. Lambert, X. Baraliakos, S. Juhl Pedersen, U. Weber, I. Eshed, P. Machado, M. De Hooge, J. Sieper, S. Wichuk, D. Poddubnyy, M. Rudwaleit, D. Van der Heijde, R. B. M. Landewé, M. Østergaard
Journal: Annals of the Rheumatic Diseases (2021)

Background: The ASAS definition of a positive MRI for inflammation in the spine (ASAS-MRIspine+) is intended for classification of patients as having axSpA but is often misused for diagnostic purposes. This is problematic because bone marrow edema (BME) in the spine may occur in 20-40% of those with mechanical back disorders. The ASAS MRI group has generated updated consensus lesion definitions which have been validated on MRI spine images from the ASAS Classification Cohort. Objectives: We aimed to identify quantitative cut-offs based on numbers of vertebral corners that define ASAS-MRIspine+, there being two gold standards: A. majority central reader decision as to the presence of spine MRI findings consistent with axSpA B. rheumatologist expert opinion diagnosis of axSpA. Methods: Eight ASAS-MRI readers recorded MRI lesions in the spine according to recently updated ASAS definitions from 62 cases in an eCRF that comprises global assessment (MRI consistent with axSpA? (yes/no)), and detailed scoring of lesions for all sites in the spine. We calculated sensitivity and specificity for numbers of vertebral corners with BME where a majority of readers (≥5/8) agreed as to the presence of MRI findings consistent with axSpA. We selected cut-offs with ≥95% specificity. These cut-offs were analyzed for their predictive utility for rheumatologist diagnosis of axSpA by calculating positive and negative predictive values (PPV, NPV) and selecting cut-offs with PPV ≥95%. Both criteria were considered requirements for designation of MRI cut-offs defining ASAS-MRIspine+. Results: MRI findings consistent with axSpA were observed by majority read in 8 (20%) of 40 cases diagnosed with axSpA, and 0 (0%) of 19 cases without axSpA. Cut-offs achieving specificity of ≥95% for MRI findings consistent with axSpA were 4 vertebral corners (sensitivity 75%) for all cases, 3 vertebral corners (sensitivity 37.5%) for cases with ≥1 additional location with inflammation, 1 vertebral corner (sensitivity 62.5%) in cases with ≥2 vertebral corner fat lesions (Table 1). All of the above cut-offs also had very high PPV (≥95%) for diagnosis of axSpA in cases diagnosed by the rheumatologist (Table 2). Table 1. Majority readers agree MRI findings consistent with axSpA are present is the gold-standard external reference MRI cut-offs Sensitivity (95%CI ) Specificity (95%CI ) BME in ≥2 vertebral corners 87.5 (47.3 - 99.7) 87.0 (75.1 - 94.6) BME in ≥ 3 vertebral corners 87.5 (47.3 - 99.7) 94.4 (84.6 - 98.8) BME in ≥4 vertebral corners 75.0 (34.9 - 96.8 ) 98.2 (90.1 - 100.0 ) Cases with ≥1 additional non-corner site inflammatory lesion BME in ≥2 vertebral corners 37.5 (8.5 - 75.5) 94.4 (84.6 - 98.8) BME in ≥3 vertebral corners 37.5 (8.5 - 75.5 ) 98.2 (90.1-100.0 ) Cases with ≥2 vertebral corner fat lesions BME in ≥1 vertebral corner 62.5 (24.5 - 91.5 ) 100.0 (93.4-100.0 ) BME in ≥2 vertebral corners 62.5 (24.5 - 91.5) 100.0 (93.4-100.0) Table 2. Predictive values of cut-offs for number of vertebral corners with BME according to the diagnostic ascertainment of the rheumatologist MRI cut-offs Sensitivity (95%CI ) Specificity (95%CI ) PPV NPV MRI findings consistent with axSpA ≥any 2 readers 52.5 (36.1 - 68.5) 94.7 (74.0 - 99.9) 95.5 (75.3 - 99.3) 48.6 (40.2 - 57.2) MRI findings consistent with axSpA ≥majority read 20.0 (9.1 - 35.6) 100.0 (82.4 - 100.0) 100.0 37.3 (33.7 - 40.9) BME in ≥ 4 vertebral corners 17.5 (7.3 - 32.8 100.0 (82.4 - 100.0 ) 100.0 36.5 (33.3 - 39.9 ) Cases with ≥1 additional inflammatory lesion BME in ≥ 3 vertebral corners 10.00 (2.8 - 23.7 ) 100.00 (82.4 - 100.0 ) 100.0 34.5 (32.2 - 36.9 ) Cases with ≥2 vertebral corner fat lesions BME in ≥1 vertebral corner 12.50 (4.2 - 26.8 ) 100.00 (82.4 - 100.0 ) 100.0 35.2 (32.6 - 37.9 ) Conclusion: A cut-off of BME in ≥4 vertebral corners, or ≥3 corners in the setting of additional inflammatory lesions at other locations or corner fat, are primary candidates for defining ASAS-MRIspine+. These cut-offs apply to typical patients referred to a rheumatologist with a high index of suspicion of axSpA and may not be appropriate in other populations. Disclosure of Interests: None declared