Imaging in SpA: are we seeing a clearer picture? Save

Attending high-volume, high-impact Rheumatology meetings enables one to expand their clinical knowledge and strengthen research opportunities and collaborations. As EULAR2026 comes to a close, practical learnings take precedence as clinicians head back to their clinics. Among them, the 2026 EULAR Update on Imaging Recommendations in SpA stands out. The diagnosis of SpA is highly dependent on imaging particularly in a young patient with chronic, inflammatory back pain. It is timely enough since there have been rapid developments in imaging techniques like MRI, Ultrasound and CT scan. 

Dr. Peter Mandl gave a concise yet comprehensive presentation of the guideline updates. The new overarching principles are (as taken from the presentation): “A. Imaging modalities should be selected taking into consideration the clinical indication, contraindications, radiation exposure, availability, patient concerns and cost [LOA 9.9 (0.3), 100%]; B. Imaging should be performed in accordance with international and national guidelines concerning equipment, image acquisition, analysis and interpretation [LOA 9.7 (0.8), 96%] and C.  Imaging findings should not be interpreted in isolation, but in the context of demographic, clinical and laboratory information [LOA 9.9 (0.3), 100%].”

For the rheumatologist, perhaps the single most important and relevant update to the recommendation is that of SIJ MRI replacing conventional radiography as the initial imaging modality of choice when suspecting axSpA, with consideration of both inflammatory and structural lesions. 

Other revised recommendations include MRI replacing conventional radiography in monitoring structural damage in axSpA although radiography can still be used in long-term monitoring of structural damage in the spine. Low dose CT was also recommended to provide additional information on structural damage in the spine and SIJs. 

For monitoring structural damage in peripheral SpA, radiography, MRI and ultrasound are on the same level. 

In terms of predicting severity, MRI once again has replaced radiography as the imaging of choice in predicting structural progression and syndesmophyte formation in the spine and SIJs. 

In predicting treatment effect in axSpA, apart from the spine, extensive lesions on MRI now include the SIJs to predict good clinical response not only to TNFis but to the broader effect of b/tsDMARDs as well. 

The updated recommendations regarding spinal fracture states that CT, MRI and/or radiography can be performed when spinal fracture is suspected. Additionally, CR and/or MRI are the recommended imaging modalities in the presence of ankylosis.  

The only new recommendation is the use of radiography in predicting structural progression in peripheral SpA. 

From a broader perspective, the updates and new recommendations may help in the early diagnosis of axSpA particularly in areas where MRIs are available and accessible.  This may not be the case in resource-limited settings, however, I believe the task force did a great job in crafting the overarching principles making them intentional and inclusive .