We know about the therapies that we have that they usually work better when the diagnosis is made early on. If the patients have been ill for a long time, then it is difficult to interrupt the inflammatory process, or they can then have additional pain due to muscle tension due to unequal load bearing when walking — and this is not that easy to distinguish.
So the early diagnosis is a very important step in order to see even higher and lasting therapeutic success. And for early diagnosis, imaging is simply essential. Right now, the MRI scan is recommended here. Imaging will certainly continue to develop. We still have patients who we think are sick, yet the MRI does not show any clear findings, because the sensitivity of the MRI scan is probably not 100 % either.
We’re still “missing” patients. The keyword “deep learning” comes to mind here, which is about developing programs which can automatically diagnose imaging. That would also help the rheumatologist enormously if it had a relatively good informative value. I think there are important research questions still to be found.
We briefly mentioned last time that it is a disease of young people. It usually starts in the third decade of life between 20 and 30. So if one is in the middle of life — hence the importance of early diagnosis. And we generally say that if patients have symptoms when they’re older than 45, it’s unlikely that axial spondyloarthritis is the cause. In a nutshell, one can say: the younger, the more likely.
In terms of age, it is not known exactly why … and the same applies to the phenomenon of bone destruction or x-ray changes, which for some reason tend to occur earlier in men than in women — and also a little more often. That’s why people used to think it was a male disease because they developed the ossifications. But if we use the MRI scan, we see that about the same number of women are affected in the inflammatory phase. But for reasons unknown, women develop these ossifications later or perhaps not at all.
ER: This means that the symptoms differ between the sexes.
JS: No, the symptoms are the same. That is, they have similar levels of pain, general unwellness or fatigue, stiffness, but the bone destruction, which sometimes doesn’t play that big of a role in symptoms, seems to be different.
ER: I see. We’ve always talked about the MRI now, but what about computed tomography (CT)? Is it a question of cost that people tend to opt for MRI, or is it really about seeing things better on MRI?
JS: We have more or less 3 imaging methods. X-ray is still inexpensive and still important in the official standards. That’s just how it evolved historically. An X-ray image is not easy to interpret, as it doesn’t show slices, but is rather a “summation image” of all the bones of the pelvis making it difficult for the untrained eye. Therefore, if you ask experts, there is a high discrepancy in interpretation. Yes, the X-ray is used because it is cheap and part of many guidelines, but for the future it should disappear.