In this episode of RheumaCast, we dive into the ongoing debate around imaging in axial spondyloarthritis (axSpA). While MRI has revolutionized early detection of sacroiliitis, it has also created new diagnostic challenges. We discuss why bone marrow edema alone is not enough for a confident diagnosis, how mechanical stress and anatomical variations complicate interpretation, and why we might be facing an "imaging crisis" in axSpA.

We explore current workarounds—pattern recognition, quantification of lesions, contextual interpretation—and their limitations. The conversation also highlights emerging solutions, from advanced imaging techniques and AI-based analysis to the critical role of expert radiology assessment.

Tune in to understand why balancing early diagnosis with diagnostic accuracy is essential to avoid misclassification, overtreatment, and ultimately to improve patient outcomes.

This episode is based on the publication: Diekhoff T, Poddubnyy D, et al. Lancet Rheumatol 2025; Published online May 16, 2025. doi:10.1016/S2665-9913(25)00108-0 and developed with NotebookLM.

In this episode of RheumaCast, we discuss one of the most frustrating aspects of axial spondyloarthritis (axSpA): treatment failure. Despite the availability of multiple biologic and targeted therapies, over half of patients do not achieve remission.

What causes this non-response? We explore two major culprits—misdiagnosis and the presence of nociplastic pain—and examine how imaging pitfalls, overlapping mechanical conditions like osteitis condensans ilii, and inadequate communication between clinicians and radiologists can lead to suboptimal management. Learn how standardized MRI protocols, expert interpretation, and emerging tools like AI and molecular imaging can improve diagnostic precision and patient outcomes.

This episode is based on the publication: Poddubnyy D and Baraliakos X. Nat Rev Rheumatol 2025; doi:10.1038/s41584-025-01254-5 and developed with NotebookLM.

In this episode of RheumaCast, we explore how anatomical variations of the sacroiliac joints (SIJ) can complicate the diagnosis and management of axial spondyloarthritis (axSpA). We walk you through common SIJ variants—such as crescent-shaped ilium, accessory joints, and transitional vertebrae—and explain how these can mimic sacroiliitis on MRI.

We discuss how to differentiate true inflammation from mechanical stress reactions, when to use CT for clarification, and the implications of these findings for diagnosis, treatment, and research. If you’ve ever wondered how much “background noise” anatomy adds to SIJ imaging, this episode is for you.

This episode is based on the publication: Diekhoff T and Ziegeler K. Curr Opin Rheumatol 2025 and developed with NotebookLM.