Degenerative changes in the lumbar spine on MR and

conventional images in the SPondyloArthritis Caught Early

(SPACE) cohort

Poster No.: C-1851

Congress: ECR 2014
Type: Scientific Exhibit
Authors: 1 1 1 2
F. de Bruin , S. ter Horst , J. Bloem , K. Fagerli , R. Landewé , M.
3

4 1 1 1
van Oosterhout , D. van der Heijde , M. Reijnierse ; Leiden/NL,
2 3 4
Oslo/NO, Amsterdam/NL, Gouda/NL
Keywords: Inflammation, Normal variants, Education, Diagnostic procedure,
MR, Conventional radiography, Musculoskeletal spine,
Musculoskeletal bone, Bones
DOI: 10.1594/ecr2014/C-1851

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Aims and objectives

The early diagnosis of axial spondyloarthritis (axSpA) is difficult, however new

classification criteria are available. The ASAS axSpA criteria. The SPondyloArthritis
Caught Early (SPACE) cohort1, back pain # 3 months, # 2 years, onset < 45 years, was
set up to diagnose SpA early.
In addition to SpA associated features on MR and conventional radiographs,
degenerative changes of the spine might be clinically important. In the literature, some
lesions are reported as a possible cause for back pain, e.g. reactive endplate changes
(Modic changes), a high intensity zone in the disc (Hiz) or lumbosacral congenital
variants.
The purpose of this study is to describe the prevalence of degenerative changes in the
SPACE cohort with chronic back pain and to evaluate whether there is a difference
between ASAS+ and ASAS- patients

Methods and materials

Sagittal T1-TSE and STIR (Short Tau Inversion Recovery) 1.5T MR images of the lumbar
spine were available in 274 patients and in 257 patients lateral radiographs of the lumbar
spine and antero-posterior radiographs of the pelvis were available.

Two trained readers scored for disc degeneration (5 point scale of Pfirrmann) (fig.1,2),
High intensity zone (Hiz) (fig. 3), bulging (extrusion and protrusion) (fig. 3), herniation
(central and lateral), Modic changes
(3 point scale of reactive endplate changes of the vertebral body) (fig. 1) and Schmorl's
nodes on MRI (fig. 2).

On radiographs presence or absence of loss of disc height, facet joint osteoarthritis,

osteophytes, sclerosis, Schmorl's nodes and lumbosacral transitional vertebrae (LSTV)
were scored (fig. 4). The LSTV was scored using the Castellvi classification. A third reader
acted as adjudicator. Chi-square test was used to test for differences between patient
groups.

Images for this section:

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Fig. 1: T1 and STIR sagittal image of the lumbar spine. Modic change type I (b, arrow) at
L5-S1 with bone marrow edema at both sides of the disc, together with a Pfirrmann class
4 (signal loss in (b) and loss of height) and extrusion (circle) in both (a) and (b). Discs at
L2-L3, L3-L4 and L4-L5 show Pfirrmann class 3.

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Fig. 2: T1 and STIR sagittal image of the lumbar spine. Pfirrmann class 3 (signal loss
with normal disc height) at L4-L5 and Pfirrmann class 4 (with loss of disc height) at L5-
S1 (b). Schmorls node (arrow) clearly visible at L2-L3 in (a). Normal discs are seen in
the upper lumbar levels.

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Fig. 3: T1 and STIR sagittal image of the lumbar spine. In (b) a high intensity zone in the
posterior part of the disc at level L5-S1 (circle) together with protrusion and Pfirrmann
class 3 (signal loss without loss of disc height). Other lumbar discs have normal signal
intensity.

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Fig. 4: AP plain radiograph of the pelvis. Complete sacralization on the left (arrow) with an
articulation on the right (dotted arrow) consistent with lumbosacral transitional vertebrae
grade 4.

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Results

Prevalence of degenerative changes is shown in table 1 and fig. 5. On MRI, 48% of

patients had at least one degenerated disc (signal loss with or without loss of height,
Pfirrmann class 3 or higher). No difference between ASAS+ (42%) and ASAS- (53%)
patients was found (P=.078). In addition, loss of height (Pfirrmann 4) was seen in 12%
and collapsed disc space (Pfirrmann 5) in 2%. Modic changes (both type I and II) were
seen in 14% of patients and was significant less present in ASAS+ patients than in ASAS-
patients (10 vs. 29, P=.038).
On radiographs, loss of disc height was found in 23% of patients, in 17% of ASAS+
patients and in 24% of ASAS- patients (P=.047).
Osteophytes were present in 19% of patients (12% of ASAS+ and 21% of ASAS- patients)
and statistically significant more in ASAS- patients (P=.028). No statistically significant
difference between ASAS+ and ASAS- patients was found for the other parameters (table
2).

Images for this section:

Fig. 5: Heatmap of degenerative changes The prevalence of each parameter is shown on

this heatmap, the darker the colour the higher its prevalence. On the horizontal axis the
separate parameters for MR and radiographs are given, on the vertical axis the lumbar
vertebral level is shown.

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Table 1: Percentage of patients with 0, 1 or 2 lesions

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Table 2: Percentage of patients with at least one lesion

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Conclusion

A high prevalence of degenerative changes was found in this young population with
chronic back pain. However, frequencies found are in accordance with the literature2,3.
Reactive endplate changes defined as Modic changes on MRI , loss of disc height,
primary signs of degeneration of the intervertebral discs on radiographs, and osteofytes,
secondary signs of degeneration on radiographs, are statistically significant more
frequently found in ASAS- compared to ASAS+ patients. This might be clinically important
and an explanation for back pain in this group of
ASAS- patients in the SPACE cohort.

Personal information

References

1. van den Berg R, de Hooge M, van Gaalen F, Reijnierse M, Huizinga T, van der
Heijde D. Percentage of patients with spondyloarthritis in patients referred because
of chronic back pain and performance of classification criteria: experience from the
Spondyloarthritis Caught Early (SPACE) cohort. Rheumatology (Oxford, England). 2013
Aug;52(8):1492-9. PubMed PMID: 23650623.
2. Takatalo J, Karppinen J, Niinimäki J, Taimela S, Mutanen P, Sequeiros RB, et al.
Association of Modic Changes, Schmorl's Nodes, Spondylolytic Defects, High-Intensity
Zone Lesions, Disc Herniations, and Radial Tears With Low Back Symptom Severity
Among Young Finnish Adults. Spine. 2012 2012/06//;37(14):1231-9.
3. Niinimäki J, Leboeuf-Yde C. Vertebral endplate signal changes (Modic change): a
systematic literature review of prevalence and association with non-specific low back
pain. European spine journal : official publication of the European Spine Society, the
European Spinal Deformity Society, and the European Section of the Cervical Spine
Research Society. 2008 2008/11//;17(11):1407-22.

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