The Assessment of Spondyloarthritis international Society (ASAS) and the SpA Research and Treatment Network (SPARTAN) have updated their key classification criteria for axial spondyloarthritis (axSpA).
EULAR – The European Alliance of Associations for Rheumatology – has also recently revised their recommendations on the role of imaging in the diagnosis and clinical management of spondyloarthritis (SpA).
Both were presented at the EULAR 2026 Congress in London, UK.
The currently used ASAS classification criteria for axSpA were developed in 2009. Despite their worldwide acceptance, they lack specificity, and since back pain is common greater specificity would be helpful. In this context, ASAS and SPARTAN decided to update the 2009 criteria, based on a data-driven approach through the large international CLASSIC study.
Overall, 1,015 patients referred to a rheumatologist with undiagnosed back pain indicative of axSpA were assessed and clinical, biological, and imaging criteria and their combinations were compared to the gold standard: The rheumatologist’s diagnosis for axSpA. MRI of the sacroiliac joint (SIJ) indicative of axSpA by assessment of both inflammatory and structural lesions had the highest association with the diagnosis of axSpA. HLA-B27, elevated CRP, and several clinical criteria including inflammatory back pain, inflammatory bowel disease, acute anterior uveitis, heel enthesitis, and psoriasis were also included in the revised criteria. The final proposal achieved sensitivity of 79.5 per cent and specificity of 90.4 per cent in the validation dataset.
Presenting the work, Prof Walter Maksymowych said: “The ASAS–SPARTAN revised classification criteria for axSpA emphasise the central role of imaging and incorporate a more focused set of clinical variables compared to the 2009 ASAS criteria.”
Another timely update was shared in a poster from Peter Mandl and colleagues, updating the original evidence-based EULAR recommendations on the use of imaging in the diagnosis and clinical management of both axial and peripheral SpA. Twelve key research questions on the role of imaging – formulated in the 2015 recommendations using the PICO method – were adopted for the update.
Imaging modalities included radiography, ultrasound, MRI, CT, PET and single photon emission computed tomography (SPECT), DXA, and scintigraphy. The taskforce formulated three new overarching principles. There was also one new recommendation and updates for nine of the originals.
The main changes include replacing radiography with MRI of the SIJ – and spine in case of symptoms in that region – as the first imaging modality for diagnosing axSpA. Radiography or preferably low-dose CT were not mentioned in the previous recommendations for diagnostic purposes, but are now suggested as alternative modalities for the SIJ if MRI is not available or contraindicated.
For monitoring axSpA, MRI can be used to track sacroiliac and spinal inflammation and structural damage, while radiography is suitable for long-term monitoring of structural damage in the spine.
For diagnosis of peripheral SpA, ultrasound or MRI remain the methods of choice, and in addition to inflammatory lesions, structural changes should now also be considered.
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