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Getting axial spondyloarthritis right requires more than ordering a basic MRI — it demands knowing exactly which sequences to request. Experts at PRD 2026 warned that outdated or incomplete imaging can lead to misdiagnosis and years of unnecessary biologic therapy. The newly revised 2025 ASAS-SPARTAN classification criteria, which lean heavily on advanced MRI, now push diagnostic specificity above 90%.
Diagnosing axial spondyloarthritis (axSpA) correctly has never been more dependent on MRI — and experts are urging rheumatologists to stop treating it as a black box. At PRD 2026, Dr. Walter Maksymowych of the University of Alberta made the case that clinicians who don't understand MRI principles are "working with both hands tied behind their back." The core problem: a standard lumbar-spine MRI simply won't cut it. Specific sequences — like short tau inversion recovery for fluid-rich tissues — and imaging in both semicoronal and semiaxial planes are needed to avoid costly false positives and negatives.
The stakes are real. Bone marrow edema confined to the load zone, common in postpartum women and athletes, can mimic axSpA on basic scans but doesn't respond to biologics. Maksymowych noted he has seen patients cycle through five biologics based on a wrong axSpA diagnosis. The 2025 revised ASAS-SPARTAN classification criteria — informed by the SASPIC and CLASSIC studies — now use a weighted point system where MRI evidence carries the most weight (8 points), pushing specificity from ~80% to over 90%.
Key Takeaways:
Why it matters: Misdiagnosing axSpA doesn't just waste resources — it exposes patients to potentially decades of biologic therapy they don't need. Better MRI literacy among rheumatologists could prevent overdiagnosis and ensure the right patients get the right treatment.
