Axial spondyloarthritis: concept, construct, classification and implications for therapy

The axial spondyloarthritis (axSpA) disease concept has undergone substantial change from when the entity ankylosing spondylitis was defined by the modified New York criteria in 1984. Developments in imaging, therapy and genetics have all contributed to changing the concept of axSpA from one of erosions in the sacroiliac joints to a spectrum of disease with and without changes evident on plain radiographs. Changes to the previously held concept and construct of the disease have also necessitated new classification criteria. The use of MRI, primarily of the sacroiliac joints, has substantially altered the diagnosis and differential diagnosis of axSpA. Many in the axSpA community believe that the current classification criteria lack specificity, and the CLASSIC study is underway to examine this area. Although much about the evolving axSpA disease concept is universally agreed, there remains disagreement about operationalizing aspects of it, such as the requirement for the objective demonstration of axial inflammation for the classification of axSpA. New imaging technologies, biomarkers and genetics data will probably necessitate ongoing revision of axSpA classification criteria. Advances in our knowledge of the biology of axSpA will settle some differences in opinion as to how the disease concept is applied to the classification and diagnosis of patients. In this Review, the authors examine how the definition and description of axial spondyloarthritis (axSpA) has evolved, most notably with the introduction of the concept of non-radiographic axSpA, and discuss the implications of these changes for diagnosis, classification and therapy.

Automated summary

The concept of axial spondyloarthritis (axSpA) has evolved significantly since the definition of ankylosing spondylitis in 1984, from solely erosions in the sacroiliac joints to a spectrum of disease with or without visible changes on plain radiographs. The use of MRI has greatly impacted the diagnosis and classification of axSpA, yet there is still controversy surrounding the specificity of current classification criteria.