German researchers have developed a new scoring system using magnetic resonance imaging (MRI) to evaluate inflammatory and structural spinal changes in people with ankylosing spondylitis (AS). MRI is increasingly being used to detect spinal lesions in AS in both the early and active phases of the disease, although the researchers explain that MRI scoring of the lesions has not yet been performed. Dr. Jurgen Braun and colleagues from Berlin, Germany published their findings in the April 2003 issue of Arthritis & Rheumatism.

Traditionally, physicians have used radiography (x-ray) of the spine and pelvis, along with different scoring systems (the Stoke ankylosing spondylitis score and Bath ankylosing spondylitis radiology index) to help determine the localization of spinal inflammation and fusion (a process in which the bones grow together) in AS. Braun and colleagues say that there are major problems with these traditional scoring methods, so they sought to describe inflammatory and structural changes as measured by MRI in AS patients who underwent TNF-a therapy.

TNF-a medications have shown great promise in some people with AS, yet it is not currently FDA-approved for use in AS in the United States. One of the TNF-a medications, infliximab (Remicade), has just been approved for use in AS in Europe. See the SAA news article titled "European Union Approves Remicade (Infliximab) for Treatment of AS" for more details. According to Braun, better methods of detecting spinal inflammation and lesions in AS are needed with the advent of these newer drugs.

70 people with AS in Germany took part in a study involving infiximab. Of the 70 patients, 20 were included in this current study to evaluate a scoring system for changes in AS. Each person had an MRI taken at the start of the study and three months later, and received either infliximab or a placebo medication at weeks 0, 2, and 6. Twice both a rheumatologist and a radiologist evaluated the MRI images to help determine the effectiveness of the new scoring system.

Braun and colleagues say that MRI technology "is superior for imaging of the thoracic spine compared with conventional x-ray." According to people in this study, the thoracic spine was the most frequently and intensively affected area of the spine, yet radiographs are not able to adequately access the important lesions. The researchers suggest that this finding may lead to future use of MRI rather than x-ray for assessment of chronic lesions. Currently, two large studies involving AS patients and either the TNF-a medications or etanercept (Enbrel) are using both MRI and radiographs to access spinal inflammation.

In conclusion, the doctors believe that because MRI is the only technique able to detect active inflamed lesions of the spine in patients with AS, "it may in the future become the gold standard for assessing and documenting the efficacy of anti-inflammatory drugs for spinal inflammation on a short-term basis." However, the long-term performance of MRI is unknown. X-rays will still have a place in assessing changes in the spine and documenting the development of more lesions.

These researchers say that all of the issues brought up by this research will need to be discussed by members of the Assessments in Ankylosing Spondylitis (ASAS) Working Group, "with the possibility of revising the recommendations for the core set of assessments in AS." The ASAS working group is comprised of clinicians, researchers, and members of the Spondylitis Association of America's leadership, and has tackled key issues in AS over the past ten years.