Sacroiliac joint involvement in psoriatic arthritis - MRI, radiographic and clinical findings in 581 European routine care patients

Axial involvement in psoriatic arthritis (axPsA) is associated with more severe disease and increased pain, yet no consensus definition of axPsA exists. This study aims to describe the occurrence and characteristics of MRI and radiographic sacroiliac joint (SIJ) involvement in a European PsA cohort. Patients with a clinical diagnosis of PsA or of axial spondyloarthritis with psoriasis and available routine care SIJ MRIs were included from five European registries in the EuroSpA collaboration. SIJ MRIs and radiographs were centrally assessed for inflammatory and structural lesions, differential diagnoses, and globally evaluated for SpA-indicative findings. Among 581 PsA patients (mean age 45 years, 47% male), 31% exhibited SpA-indicative SIJ-MRI findings (MRI-axPsA). In MRI-axPsA patients, the most common lesions were bone marrow edema (BME) (69%), erosions (68%), and fat lesions (58%), generally present bilaterally. BME ≥ 1 cm, inflammation in an erosion cavity, capsulitis, fat lesions ≥ 1 cm, backfill, and ankylosis were observed almost exclusively in MRI-AxPsA patients. Differential diagnoses included osteitis condensans ilii (8%), probable strain-related BME (11%) and degenerative disease (16%). Among 259 patients with radiographs, 29% met the radiographic mNY criteria for ankylosing spondylitis and 38% had SpA-indicative MRI findings. Male sex, HLA-B27 positivity, elevated CRP and history of inflammatory back pain (but not current back pain) were independently associated with MRI-detected axial involvement. In this large European cohort, one-third of routine care PsA patients had axial involvement, based on global SIJ MRI assessment. The study supports incorporating MRI into the future definition of axPsA to enable early identification.