AJR:202, January 2014 199

subtle joint abnormalities in JIA. Converse-ly, MRI is the diagnostic imaging modality of choice for analysis of joints in patients with JIA [12], allowing assessment of the morpho-logic status of the joints at a given time point for assessment of early changes in soft tissues and articular cartilage and for evaluation of disease progression [13]. The overall high di-agnostic accuracy of MRI for the assessment of JIA in the peripheral joints [14] makes it an appealing resource for early diagnosis, charac-terization, and follow-up assessment of TMJ. Nevertheless, to our knowledge, no previous systematic review has graded the level of evi-dence of studies to assess the ability of MRI for determining the diagnosis and prognosis of JIA in axial joints.

Summarizing the information in the litera-ture in light of evidence-based imaging tools and identifying gaps in the literature are par-amount to determine the status of knowledge and guide future research directions in the field. We applied the Standards for Report-ing of Diagnostic Accuracy (STARD) [15] to determine the quality of reporting of selected studies and the level of evidence of MRI ex-aminations of JIA in the axial skeletal joints according to the Canadian Task Force on Pre-ventive Health Care guidelines [16]. Last, we identified gaps in the literature based on a prio-ri–designed overarching questions that require further research to improve the effectiveness of clinical applications of MRI and to improve medical management of JIA in the future.

Juvenile Idiopathic Arthritis of the Axial Joints: A Systematic Review of the Diagnostic Accuracy and Predictive Value of Conventional MRI

Sohaib Munir1

Kedar Patil2Elka Miller3

Elizabeth Uleryk3

Marinka Twilt3

Lynn Spiegel3

Andrea S. Doria3

Munir S, Patil K, Miller E, et al.

1Faculty of Health Sciences, Queen’s University, Kingston, ON, Canada.

2Department of Diagnostic Radiology, McGill University, Montreal, QC, Canada.

3Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, 555 University Ave, Toronto, ON M5G 1X8, Canada. Address correspondence to A. S. Doria (andrea.doria@sickkids.ca).

Pediatr ic Imaging • Review

AJR 2014; 202:199–210

0361–803X/14/2021–199

© American Roentgen Ray Society

J uvenile idiopathic arthritis (JIA) is the most common chronic muscu-loskeletal disease of childhood; the prevalence of JIA ranges be-

tween 0.07 and 4.01 per 1000 children and var-ies on the basis of ethnicity and geography [1]. The precise pathogenic mechanism of JIA is currently unknown; however, it is believed to involve an autoimmune process, beginning with synovial hypertrophy and subsequently affecting the articular cartilage and subchon-dral bone [1]. Although JIA may be transient and self-limiting, approximately 10% of affect-ed children remain severely disabled in adult-hood [2–4]. The ultimate outcome of progres-sion of disease is changes in joint function [5].

The rate of temporomandibular joint (TMJ) involvement in patients with JIA varies from 17% to 87% [6–8] depending on the method of examination applied and the population inves-tigated. Involvement of the TMJ in JIA often occurs without clinically detectable signs and symptoms, therefore delaying the diagnosis [2]. By the time lower jaw asymmetry or retrogna-thism can be detected clinically, irreversible condylar damage is already established [9, 10]. To prevent irreversible structural JIA complica-tions, early diagnosis and effective treatment of TMJ arthritis [11] are needed. Thus, for the pur-pose of early diagnosis, an accurate diagnostic test besides physical examination is imperative.

Radiography, because of its limitations, is nonspecific for the diagnosis of early JIA changes and cannot always detect early and

Keywords: axial skeleton, children, evidence-based imaging, juvenile idiopathic arthritis, sacroiliac joint, spine, temporomandibular joint

DOI:10.2214/AJR.12.10475

Received December 10, 2012; accepted after revision April 29, 2013.

OBJECTIVE. Our objective was to evaluate the diagnostic accuracy and reliability of MRI and its ability to depict responsiveness to treatment for the evaluation of the axial joints (temporomandibular joint [TMJ], spinal joints, and sacroiliac joints) in juvenile idiopathic arthritis (JIA).

CONCLUSION. There is fair (grade B) evidence that MRI is an accurate diagnostic method for evaluating early and intermediate changes in the TMJ in JIA and insufficient evi-dence to indicate MRI is an accurate diagnostic method for detecting JIA in the spinal (grade I) and sacroiliac (grade I) joints.

Munir et al.MRI for Diagnosis of JIA in the Axial Joints

Pediatric ImagingReview

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Materials and MethodsOverarching Questions

This study assessed whether there is evidence that the currently available MRI techniques are ac-curate for early diagnosis and whether they improve the assessment of the functional status of joints at a single time point and over time in axial skeleton joints of children with JIA. An analytic framework (Fig. 1) was developed before the commencement of this study to facilitate our understanding of the in-terrelationship of overarching questions in the con-text of the proposed systematic review and the per-ception of gaps in the literature in various diagnostic accuracy methodologic aspects. We investigated different bodies of evidence related to the follow-ing five overarching questions: question 1, Can MRI be used to detect early axial joint changes?; ques-tion 2, Can MRI be used to detect intermediate and late axial joint changes with regard to the progres-sion of arthropathy?; question 3, Is MRI useful to monitor the effect of treatment on improving joint

pathology and preventing further damage?; question 4, If early changes can be evaluated using MRI, can this information be used to predict future cartilage degeneration or the functional status of the joint?; and question 5, Can an association be made between intermediate and late findings on MRI and the func-tional status of the joint?

Data Sources and SearchAn electronic literature search was independently

conducted by four reviewers who identified stud-ies pertaining to the diagnostic accuracy of MRI in the assessment of the axial skeleton (i.e., TMJ, sacroiliac joints, and spinal joints) of children with JIA. The MEDLINE database (January 1946–June 2012), EMBASE database (January 1980–June 2012), Database of Abstracts of Reviews of Effects (DARE) of the National Health Service Centre for Reviews and Dissemination, and Cochrane Library database were searched through OvidSP (Wolt-ers Kluwer) using an optimal search strategy. The

search combined medical subject headings and EM-BASE terms with free text words. The search terms included “juvenile idiopathic arthritis,” “juvenile rheumatoid arthritis,” “arthritis,” “cartilage degen-eration,” “magnetic resonance imaging,” “activities of daily living,” “temporomandibular,” “diagnostic sensitivity,” “treatment,” and “outcome.” Manual identification of relevant articles by referring to ref-erence lists of selected articles was also conducted.

Study IdentificationThree reviewers independently assessed the titles

and keywords of all included citations to determine which were ineligible based on the inclusion criteria. When the content was not clear from the title or key-words, the abstracts were retrieved and assessed. All included abstracts were further evaluated using the inclusion criteria. All original articles of the selected studies were assessed in entirety and ineligible studies were eliminated. Finally, all remaining studies writ-ten in English were reviewed independently. At any

Fig. 1—Analytic framework for use of MRI as diagnostic tool for detection of axial skeleton abnormalities in juvenile idiopathic arthritis (JIA). Dashed lines indicate gaps in literature. Items 1–5 represent overarching questions of review. With regard to clinimetric properties of MRI assessed in primary studies, items 1, 2, 4, and 5 related to construct or criterion validity of MRI in relation to clinical or laboratory constructs or to reference standard, respectively; items 1 and 2, to reliability of MRI interpretation by readers; and item 3, to ability of MRI to detect joint changes over specific intervals of time. JIA = juvenile idiopathic arthritis, TMJ = temporomandibular joint, CHAQ = Childhood Health Assessment Questionnaire.

3

Diagnostic accuracy:validity (items 1, 2, 4, and 5),

reliability (items 1 and 2),responsiveness (item 3)

MRI assessment oftreatment effect

Detection of early jointchanges using MRI

Screeningnot

applicable

Reduced morbidity,mortality, or both

Better functionalstatus of joints(CHAQ scores)

Association

Personsat risk

JIA patients0–18 years old

Detection of intermediate and late joint changes using MRI

1 2

In TMJ:• Synovial hypertrophy (pannus)• Synovial enhancement (synovitis)• Joint effusion

4

5

In spinal joints:• Synovial hypertrophy (pannus)• Synovial enhancement (synovitis)• Inflammation around ligaments• Mild disk space narrowing

In sacroiliac joints:• Bone marrow edema• Joint enhancement• Mild joint space widening

Predictive ability

4 Predictive ability

In TMJ:• Abnormalities in mandibular condyle and disk morphology• Erosions• Subchondral cyst abnormalities

In spinal joints:• Decreased joint space• Erosions• Atlantoaxial subluxation (in cervical spine)

In sacroiliac joints:• Widened joint space• Erosions

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MRI for Diagnosis of JIA in the Axial JointsT

AB

LE 1

: D

emog

raph

ic a

nd C

linim

etri

c P

rope

rtie

s, S

emiq

uant

itat

ive

and

Qua

litat

ive

Ass

essm

ents

of Q

ualit

y U

sing

Sta

ndar

ds fo

r R

epor

ting

of

Dia

gnos

tic

Acc

urac

y (S

TA

RD

) Sc

ores

, and

Lev

el o

f Evi

denc

e of

Sel

ecte

d St

udie

s

Refe

renc

e N

o. (Y

ear)

No.

of

Patie

nts

With

JIA

No.

and

Typ

es o

f Joi

nts

Exam

ined

Age

(y)

Sex

Ratio

(M

:F)

STA

RD S

core

Leve

l of

Evid

ence

Rese

arch

De

sign

Cons

truc

t Val

idity

aCr

iterio

n Va

lidity

e of

Oth

er C

onst

ruct

s Ag

ains

t MRI

Relia

bilit

yfRe

spg

Qua

lSe

mi

PIb

EIc

DId

[35]

(199

3)15

30 T

MJ

10.4

(mea

n)4:

110.

43Po

orII-

3Un

clea

rY

[36]

(199

6)20

CS jo

ints

of 2

0 pa

tient

s10

(mea

n)13

:70.

40Po

orII-

3Un

clea

rY

[20]

(199

8)87

SI, n

umbe

rs u

ncle

ar13

.1 (m

ean)

52:3

50.

69Fa

irII-

2P

Y

[21]

(199

8)60

SI, n

umbe

rs u

ncle

ar13

.4 (m

ean)

37:2

30.

69Fa

irII-

2P

Y

[7] (

1998

)15

30 T

MJ

12 (m

ean)

NR

0.67

Fair

II-2

PY

[22]

(200

5)23

TMJ,

num

bers

unc

lear

9 (m

edia

n)3:

200.

56Fa

irII-

2R

YY

Y

[23]

(200

5)15

118

TMJh

12 (m

ean)

NR

0.73

Fair

II-2

PY

[24]

(200

7)15

27 T

MJ

8.3

(mea

n)1:

140.

56Fa

irII-

2R

YY

[25]

(200

8)15

TMJ,

num

bers

unc

lear

Uncl

ear

NR

0.60

Fair

II-2

PY

Y

[31]

(200

8)32

TMJ,

num

bers

unc

lear

≈ 8–

9 (m

edia

n)7:

250.

80Go

odII-

2P

YY

YY

Y

[26]

(201

0)20

40 T

MJ

9.27

(mea

n)8:

120.

61Fa

irII-

2P

Y

[32]

(200

9)30

60 T

MJ

9.8

(mea

n)14

:16

0.86

Good

II-2

PY

YY

Y

[33]

(201

1)48

96 T

MJ

11.2

(mea

n)11

:37

0.81

Good

II-3

RY

Y

[34]

(201

0)59

SI o

f 21

patie

nts

9.33

(mea

n)40

:19

0.85

Good

II-3

RY

YY

[27]

(200

9)46

88 T

MJ

12.7

(mea

n)19

:27

0.54

Fair

II-2

PY

Y

[18]

(201

0)34

68 T

MJ

13.5

(med

ian)

5:29

0.61

Fair

II-3

RY

Y

[19]

(200

3)89

83 j

oint

s (p

unct

ured

)12

.9 (m

ean)

62:2

70.

48Po

orII-

2P

YY

YY

[37]

(201

1)39

63 T

MJ

12.2

5 (m

ean)

4:35

0.29

Poor

II-3

RY

[30]

(201

2)50

Thor

acic

and

lum

bar s

pine

14.8

(med

ian)

9:41

0.69

Fair

II-2

RY

[28]

(201

2)63

137

TMJ

9.5

(mea

n)20

:43

0.64

Fair

II-3

RY

Y

[29]

(201

2)18

737

0 TM

J6.

7 (m

ean)

71:11

60.

78Fa

irII-

2R

Y

Not

e—JI

A =

juve

nile

idio

path

ic a

rthrit

is, Q

ual =

qua

litat

ive,

Sem

i = s

emiq

uant

itativ

e, P

I = p

redi

ctiv

e in

dex,

EI =

eva

luat

ive

inde

x, D

I = d

iscr

imin

ativ

e in

dex,

Res

p =

resp

onsi

vene

ss, T

MJ 

= te

mpo

rom

andi

bula

r joi

nt,

Y =

yes,

CS 

= ce

rvic

al s

pine

, SI =

sac

roili

ac jo

int,

P =

pros

pect

ive,

R =

retro

spec

tive,

NR 

= no

t rep

orte

d.a Co

nstru

ct v

alid

ity: T

his

clin

imet

ric p

rope

rty is

defi

ned

as th

e ex

tent

to w

hich

a p

artic

ular

mea

sure

rela

tes

to o

ther

mea

sure

s in

a m

anne

r tha

t is

cons

iste

nt w

ith th

eore

tical

ly d

eriv

ed h

ypot

hese

s co

ncer

ning

the

conc

epts

(or c

onst

ruct

s) th

at a

re b

eing

mea

sure

d [4

3].

b Pred

ictiv

e in

dex:

An

inde

x th

at is

use

d to

cla

ssify

indi

vidu

als

into

a s

et o

f pre

defin

ed m

easu

rem

ent c

ateg

orie

s w

hen

a re

fere

nce

stan

dard

is a

vaila

ble,

eith

er c

oncu

rren

tly o

r pro

spec

tivel

y, to

det

erm

ine

whe

ther

in

divi

dual

s ha

ve b

een

clas

sifie

d co

rrec

tly [4

3].

c Eval

uativ

e in

dex:

An

inde

x th

at is

use

d to

mea

sure

the

mag

nitu

de o

f lon

gitu

dina

l cha

nge

in a

n in

divi

dual

or g

roup

on

the

dim

ensi

on o

f int

eres

t [43

].d Di

scrim

inat

ive

inde

x: A

n in

dex

that

is u

sed

to d

istin

guis

h be

twee

n in

divi

dual

s or

gro

ups

on a

n un

derly

ing

dim

ensi

on w

hen

no e

xter

nal c

riter

ion

or re

fere

nce

stan

dard

is a

vaila

ble

for v

alid

atin

g th

ese

mea

sure

s [4

3].

e Crite

rion

valid

ity: T

his

clin

imet

ric p

rope

rty is

defi

ned

as th

e ex

tent

to w

hich

a m

easu

re p

rodu

ces

the

sam

e re

sults

as

a re

fere

nce

stan

dard

or c

riter

ion

mea

sure

[43]

.f Re

liabi

lity:

Thi

s cl

inim

etric

pro

perty

is d

efine

d as

the

exte

nt to

whi

ch re

peat

ed m

easu

rem

ents

of a

sta

ble

phen

omen

on g

et s

imila

r res

ults

by

diffe

rent

peo

ple

and

inst

rum

ents

and

at d

iffer

ent t

imes

and

pla

ces

[44]

.g Re

spon

sive

ness

: Thi

s cl

inim

etric

pro

perty

is d

efine

d as

the

abili

ty o

f a m

easu

re to

det

ect c

hang

e in

out

com

es w

hen

one

is p

rese

nt (p

ower

of t

he m

easu

re to

det

ect a

diff

eren

ce) [

45].

h Due

to s

ubse

quen

t exa

min

atio

ns o

f the

sam

e 15

pat

ient

s.

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stage, disagreements were discussed and resolved in a consensus meeting. In contrast, because of logistical reasons, two selected articles written in German were reviewed by one individual and were subsequently discussed and evaluated with two other reviewers.

Inclusion CriteriaIncluded in the systematic review were studies

that tested clinimetric elements, such as inter- or intrareader reliability (or both) of interpretation of MRI findings; construct validity based on a priori–designed hypotheses of correlations between MRI findings or scores and clinical or laboratory find-ings or scores; criterion validity based on compari-son of MRI findings or scores with a reference stan-dard; and the ability of MRI findings or scores to show changes in the joints in response to treatment. We also recorded the role of MRI in the selected studies concerning evaluative, discriminative, and predictive elements regardless of whether this in-formation was explicitly stated in the primary stud-ies. Selected studies included topics on diagnosis, analysis, and interpretation of MRI and the ability of MRI to detect the responsiveness of joints to lo-cal or systemic treatment. This systematic review included randomized or quasirandomized cohorts

(prospective or longitudinal, retrospective) and case-control clinical trials in any phase and meta-analyses. Studies had to pertain specifically to MRI of JIA in the axial joints (TMJ, sacroiliac joints, and spine) and, in case of follow-up studies, an MRI ex-amination had to have been conducted at baseline as well. Studies were included if the mean or me-dian age of participants was 18 years or younger at baseline. Case reports, case reviews, case series, pictorial essays, economic evaluations, decision-analysis models, descriptive studies, review ar-ticles, opinion letters, expert narratives, and com-ments were excluded. Studies that focused on the peripheral joints (i.e., knees, hips, elbows, ankles) and studies that consisted of fewer than 10 children with JIA were excluded. Also excluded were stud-ies written in languages other than English, French, German, Italian, Spanish, or Portuguese.

Data ExtractionThe following data were extracted from all in-

cluded studies: characteristics of the study, num-ber of participants, demographic information about participants, and clinimetric properties of the se-lected studies (Table 1). Data were extracted in-dependently by the reviewers, and the results were

compared. Disagreements were resolved by con-sensus by referring to the original article.

Assessment Tool for Quality of ReportingThe quality of reporting of the included stud-

ies was assessed using the Standards for Reporting of Diagnostic Accuracy (STARD) statement [15]. These standards were developed to improve the re-porting of studies on diagnostic accuracy; hence, STARD is a valuable tool to critically appraise the selected studies in a semiquantitative fashion [15]. The reviewers independently analyzed the studies to locate and assess the quality of the description of each STARD item (25 items), providing a rating for each item as adequately described (yes = 1), not described (no = 0), partially described (unclear = 0.5), or not applicable. Disagreements in the scor-ing of items were discussed and resolved by con-sensus. The scores for the 25 items (or for those applicable) were added together where the maxi-mum total numerical score (25 or total for appli-cable items) for a given article represented 1.00 (100%) and the minimum total score (0) repre-sented 0.00 (0%), with the remainder total scores’ proportions of individual articles ranging between 0.00 (0%) and 1.00 (100%). Each article was grad-ed as poor (0.00–0.49), fair (0.50–0.79), or good (0.80–1.00) based on the overall numeric score.

Assessment Tool for Methodologic QualityFor assessment of methodologic quality, stud-

ies were evaluated by two readers conjointly who reached a consensus for grading of the level of evi-dence according to the guidelines of the Canadian Task Force on Preventive Health Care [17] (Table 2).

ResultsSelection of Studies

The electronic literature search retrieved 1789 unique citations. After selection based on the title and keywords and subsequent as-sessment of the abstracts of these studies, 38 citations were selected. On the basis of the in-clusion criteria, 21 studies were selected for further evaluation and retrieval and were cho-sen for the review (Fig. 2). Included were stud-

TABLE 2: Grading of Levels of Evidence According to the Guidelines of the U.S. Preventive Services Task Force [46]

Grade Definition

I Evidence obtained from at least one properly randomized controlled trial

II-1 Evidence obtained from well-designed controlled trials without randomization

II-2 Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group

II-3 Evidence obtained from multiple time series with or without intervention; dramatic results in uncontrolled experiments could be regarded as this type of evidence

III Opinions of respected authorities based on clinical experience, descriptive studies and case reports, or reports of expert committees

1789 Search results identified inMEDLINE, EMBASE, DARE, and

Cochrane Library databases

17 Articles excluded for thefollowing reasons:• Duplicate articles (n = 9)• Age of patients (n = 5)• Too few patients (n = 1)• Not focused on JIA (n = 2)

38 Articles retrieved forfull-text article review

0 Articles included from bibliographic references

21 Articles consideredfor inclusion

21 Full-text articles included

Fig. 2—Flow diagram shows search and selection process used for identification and quality assessment of articles. JIA = juvenile idiopathic arthritis.

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MRI for Diagnosis of JIA in the Axial Joints

ies in which validity (18/21 [86%] articles), re-sponsiveness (6/21 [29%]), and reliability (4/21 [19%]) were assessed; some of the included ar-ticles measured more than one clinical prop-erty. Fifteen of the 21 (71%) studies evaluated the TMJs, four (19%) evaluated the sacroili-ac joints, and two (10%) evaluated the spinal joints. Nineteen of the 21 (90%) articles were written in English, whereas the remaining two articles were written in German [18, 19].

Overall Quality of ReportingUsing the STARD statement, reviewers

graded 13 of the 21 (62%) articles as fair [7, 18, 20–30], four of 21 (19%) as good [31–34], and four of 21 (19%) as poor [19, 35–37] in terms of the quality of reporting. None of the studies had a reference standard used against MRI as a construct, and therefore several of the STARD items did not apply; the scoring and grading of these articles were determined with this characteristic in consideration. Fig-ure 3 illustrates the distribution of ratings ac-cording to the various STARD items.

Nine of 21 (43%) studies [7, 19, 21, 22, 24, 25, 29, 32, 34] identified a reference standard, although no study used MRI as a construct to evaluate criterion validity against another ref-

erence standard. Therefore, STARD items 7 and 9, which required a reference standard, were not applicable for most studies. Only five of 21 studies (24%) [18, 21, 31, 33, 34] report-ed the reliability of tests (STARD item 24). Other STARD items that had less than 50% adequate reporting included the following: study population description (item 3); reader description (item 10); blinding (item 11); re-porting failure to test (item 16); reporting ad-verse events (item 20); reporting result uncer-tainty (item 21); and reporting indeterminate, missing, and outlying results (item 22).

Summary of EvidenceReliability of MRI for Depicting Findings Suggestive of Juvenile Idiopathic Arthritis: Items 1 and 2 in Figure 1

Temporomandibular joint—Two (10%) stud-ies (level of evidence: II-2 [n = 1] and II-3 [n = 1]) [31, 33] examined the reliability of MRI findings in TMJs. Weiss et al. [31] (level of evidence, II-2 [n = 1]) found perfect interob-server (two radiologists) overall agreement for any acute or chronic disease findings. However, there was lower agreement for individual signs: Agreement for the detection of effusion and synovial thickening on unenhanced MRI was

75% and 62.5%, respectively. Abramowicz et al. [33] (level of evidence, II-3 [n = 1]) reported almost perfect agreement between two radiolo-gists (κ = 0.948). Mussler et al. [18] (level of evidence, II-3 [n = 1]) found an overall good agreement (κ = 0.9) between two radiologists (both blinded for clinical information) who re-viewed MRI examinations of 34 JIA patients with TMJ involvement.

Sacroiliac joints—One study (5%), Pagni-ni et al. [34] (level of evidence, II-3), found moderate to substantial agreement (κ = 0.56–0.82) between two radiologists for sacroiliac joint findings.

Spinal joints—No study examined the reli-ability of MRI findings in the spine.

Accuracy of MRI for the Diagnosis of Early Joint Changes: Item 1 in Figure 1

Question 1: Can MRI be used to detect early axial joint changes?

Of the 21 articles, 18 (86%) investigated the validity of MRI for the evaluation of early joint changes in children with JIA, including 14 (67%) articles on TMJs (level of evidence, II-2 [n = 10] and II-3 [n = 4]) [7, 18, 22–29, 31–33, 35], three (14%) articles on sacroili-ac joints (level of evidence, II-2 [n = 2] and

Fig. 3—Graphic display of Standards for Reporting of Diagnostic Accuracy (STARD) assessment of quality of reporting. Asterisk = item not applicable when no reference standard is identified.

Item 1: Study of diagnostic accuracy

0 10 20 30 40 50 60 70 80 90 100

Item 2: States research questions or aims

Proportion of Studies in Which Item Was Reported,Partially Reported, Not Reported, or Not Applicable (%)

ST

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D It

em

Item 3: Describes study population, inclusion criteria, and settingItem 4: Describes patient recruitment

Item 5: Describes participant samplingItem 6: Describes data collection

Item 7*: Describes a reference standard with rationaleItem 8: Provides technical specifications of tests

Item 9*: Describes cutoffs and units for testsItem 10: Describes the readers

Item 11: Describes blindingItem 12: Describes statistical methods

Item 13: Describes methods used to calculate reliabilityItem 14: Provides time frame of the study

Item 15: Provides the clinical and demographic characteristics of the patientsItem 16: Reports failures to test

Item 17: Reports time interval between testsItem 18: Reports distribution of disease severity

Item 19: Cross-tabulates the results from all testsItem 20: Reports adverse events

Item 21: Reports result uncertaintyItem 22: Reports indeterminate results, missing responses, and outliers

Item 23: Reports variability between subgroups, readers, or centersItem 24: Reports reliability results

Item 25: Discusses clinical applicability of findings

Reported Partially reported Not reported Not applicable

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II-3 [n = 1]) [20, 21, 34], and one (5%) article (level of evidence, II-3 [n = 1]) [36] on spinal joints. Eleven (52%) articles used contrast ma-terial to evaluate synovial characteristics and soft-tissue inflammation (level of evidence, II-2 [n = 9] and II-3 [n = 2]) [20–24, 26, 27, 29, 32–34]. Contrast-enhanced MRI was su-perior in the detection of synovial hypertrophy or early joint inflammation compared with ra-diography in eight (38%) articles (level of evi-dence, II-2 [n = 5] and II-3 [n = 3]) [7, 20, 21, 23, 25, 34–36] and compared with ultrasound in two (10%) articles (level of evidence, II-2 [n = 2]) [31, 32].

Temporomandibular joint—Several studies concluded that MRI was able to detect early JIA outcomes in TMJs, such as pannus (level of evidence, II-2 [n = 4] and II-3 [n = 1]) [7, 23, 25, 31, 35], joint effusions (level of evidence, II-2 [n = 6] and II-3 [n = 3]) [22, 23, 25, 26, 28, 29, 32, 33, 35], and synovial enhancement (level of evidence, II-2 [n = 6] and II-3 [n = 2]) [7, 23, 25, 26, 28, 29, 32, 33]. In one study (5%; level of evidence, II-2) [29], nearly 66% of TMJs with acute findings would have been interpreted as “normal” without IV contrast material. One study (5%; level of evidence, II-2) [23] did not consider bone marrow en-hancement to be an effective indicator of early changes. This issue is a controversial one be-cause other studies in adults, such as that by Kothari et al. [38] (which is out of the scope of this article), have shown that bone marrow le-sions detected on MRI tend to increase the risk of knee osteoarthritis progression and be pre-dictive of subregional cartilage loss.

MRI was deemed to be superior to radi-ography (level of evidence, II-2 [n = 3] and II-3 [n = 1]) [7, 23, 25, 35], ultrasound (lev-el of evidence, II-2 [n = 2]) [31, 32], rheuma-tologic examinations (level of evidence, II-2 [n = 1]) [32], orthodontic examinations (lev-el of evidence, II-2 [n = 1]) [32], and gener-al and musculoskeletal clinical examinations (level of evidence, II-2 [n = 1]) [26] in de-tecting early changes, all of which had poor agreement with MRI. One study (level of evi-dence, II-2 [n = 1]) [25]found radiographs ob-tained by orthopantomogram imaging to have a lower frequency of detection of changes (p < 0.003) compared with MRI. Similarly, anoth-er study (level of evidence, II-2 [n = 1]) [7] found synovial enhancement on MRI in 87% of patients as opposed to radiography, which detected TMJ involvement in 40% of patients. Taylor et al. [35] (level of evidence, II-3 [n = 1]) qualitatively reported a comparable but higher rate of detection for MRI compared with radiography. Ultrasound had 23–81%

sensitivity and 89–100% specificity compared with MRI (level of evidence, II-2 [n = 2]) [31, 32]. Müller et al. [32] (level of evidence, II-2 [n = 1]) found a sensitivity and specificity of 47% and 75%, respectively, for rheumatologic examinations and 66% and 46% for orthodon-tic examinations. Abdul-Aziez et al. [26] (level of evidence, II-2 [n = 1]) found a significant in-crease in the mean Childhood Health Assess-ment Questionnaire (CHAQ) score (t value = 4.0, p < 0.05), erythrocyte sedimentation rate (ESR) (t value = 6.0, p < 0.001), C-reactive pro-tein level (t value = 7.9, p < 0.001), synovial en-hancement (t value = 5.8, p < 0.001), and effu-sion scores (t value = 3.5, p < 0.05) in patients with active disease compared with those who were in remission. Two studies concluded that contrast material was essential to discriminate between synovium hypertrophy and joint effu-sion (level of evidence, II-2 [n = 1] and II-3 [n = 1]) [7, 35]. One study (5%) suggested that TMJ involvement in JIA is underdiagnosed without imaging (level of evidence, II-2 [n = 1]) [27], and two other studies (10%) suggested that JIA patients without clinical signs should be eligi-ble for MRI examination because of the lack of correlation found between MRI and clini-cal examination (level of evidence, II-2 [n = 2]) [23, 29]. Mussler et al. [18] (level of evidence, II-3 [n = 1]) reported the ability of MRI to de-tect contrast enhancement (in 65–76% of cases) based on the interpretation of two radiologists who considered synovial contrast enhancement as a sign of active inflammation in the TMJ.

Sacroiliac joints—Depending on the type of patient group, two studies (10%; level of evidence, II-2 [n = 1] and II-3 [n = 1]) [21, 34] detected higher proportions of early sacroiliac joint outcomes—such as bone marrow edema, joint enhancement, and mild subchondral scle-rosis—with both unenhanced and contrast-en-hanced MRI compared with conventional ra-diography, which failed to detect any early sacroiliac joint outcome. Another study (level of evidence, II-2 [n = 1]) [20] that investigated only contrast-enhanced MRI against radiogra-phy found similar results.

Spinal joints—Only one study (5%; level of evidence, II-3 [n = 1]) [36] investigated the role of MRI in detecting early changes. This study on the cervical spine concluded that MRI is superior to radiography in visu-alizing soft-tissue changes, particularly with regard to pannus. In 13 of 20 (65%) asymp-tomatic patients, pannus proliferation was identified on MRI. This study also suggested that contrast material was not required be-cause of MRI’s satisfactory ability to reveal soft-tissue changes and anatomic structures.

Accuracy of MRI for the Diagnosis of Intermediate and Late Joint Changes: Item 2 in Figure 1

Question 2: Can MRI be used to detect in-termediate and late axial joint changes with re-gard to the progression of arthropathy?

Nineteen (90%) articles investigated the va-lidity of MRI for the evaluation of intermedi-ate joint changes in the axial joints in JIA pa-tients, including 14 articles on TMJs (67%; level of evidence, II-2 [n = 11] and II-3 [n = 3]) [7, 18, 22–29, 31–33, 35], three articles on sacroiliac joints (14%; level of evidence, II-2 [n = 2] and II-3 [n = 1]) [20, 21, 34], and two articles on spinal joints (10%; level of evi-dence, II-3 [n = 2]) [30, 36]. These studies ex-amined articular cartilage degeneration (level of evidence, II-2 [n = 1] and II-3 [n = 3]) [18, 22, 33, 36], subchondral bone degeneration (level of evidence, II-2 [n = 10] and II-3 [n = 3]) [7, 18, 20, 21, 23–27, 31, 32, 34, 35], and disk degeneration (level of evidence, II-2 [n = 3] and II-3 [n = 3]) [7, 18, 25, 27, 33, 35].

Temporomandibular joint—Several stud-ies found that MRI was able to detect articu-lar disk changes in TMJs (level of evidence, II-2 [n = 1] and II-3 [n = 3]) [7, 18, 28, 35], changes in condylar morphology (level of evidence, II-2 [n = 4] and II-3 [n = 3]) [18, 23, 27–29, 32, 35], loss of articular carti-lage (level of evidence, II-2 [n = 1]) [22], and erosions (level of evidence, II-2 [n = 5] and II-3 [n = 3]) [7, 18, 23, 25, 26, 28, 29, 35] but noted that contrast material is ineffective at enhancing cartilage (level of evidence, II-2 [n = 1]) [23]. However, these findings were not confirmed by a reference standard. One study (5%; level of evidence, II-3 [n = 1]) [35] qualitatively reported a similarity be-tween the frequency of MRI findings and radiographic findings pertaining to condyle size and shape and the fossa, but the authors noted that MRI had higher rates of detec-tion. Another study (5%; level of evidence, II-2 [n = 1]) [31] comparing ultrasound with MRI found only 50% agreement (κ = 0.12) between the two imaging techniques for the assessment of chronic TMJ changes, and the authors concluded that MRI is superior at detection. Another study (level of evidence, II-3 [n = 1]) [18] reported that MRI is able to detect alterations in the mandibular con-dyles (88–91% of cases), showing significant correlations between these alterations and TMJ pain (p = 0.03) and decreased mouth opening capacity (p = 0.02), but not between these alterations and disk pathology.

Sacroiliac joints—Three studies (14%) investigated intermediate outcomes in sac-

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MRI for Diagnosis of JIA in the Axial Joints

roiliac joints (level of evidence, II-2 [n = 2] and II-3 [n = 1]) [20, 21, 34], all of which compared the results against radiography. One study (level of evidence, II-3 [n = 1]) [34] concluded that contrast-enhanced MRI is more sensitive than conventional radi-ography because all the radiographs ob-tained were negative. In contrast, MRI de-tected changes in joint space width in eight of 17 patients (47%) and erosions in two of 17 patients (12%). Another study (level of evidence, II-2 [n = 1]) [20] reported a sig-nificantly higher sensitivity (p < 0.001) for MRI compared with radiography for the de-tection of both early and intermediate sacro-iliac joint changes. Another study (level of evidence, II-2 [n = 1]) [21] also found a high-er sensitivity for MRI (p < 0.05) compared with radiography by detecting disease in 29 of 208 joints (14%) by MRI as opposed to 23 of 208 joints (11%) by radiography.

Spinal joints—One study (5%; level of ev-idence, II-3 [n = 1]) on cervical spine joints [36] reported poor sensitivity (57%) for radi-ography compared with MRI: Detection of erosions by MRI was possible in seven pa-tients as opposed to four patients by radiog-raphy. Another study (level of evidence, II-2 [n = 1]) [30] examining the thoracic and lum-bar spine found that MRI was able to detect vertebral fractures, intervertebral disk de-generation, endplate irregularities, and ante-rior corner defects, for a total of abnormal findings in 31 (62%) of 50 patients, but these findings did not significantly correlate with bone densitometry measures in the lumbar spine (p > 0.05).

Ability of MRI to Detect Responsiveness of Joints to Treatment: Item 3 in Figure 1

Question 3: Is MRI useful to monitor the effect of treatment on improving joint pa-thology and preventing further damage?

Temporomandibular joint—Five TMJ arti-cles (24%) reported responsiveness measure-ments (level of evidence, II-2 [n = 3] and II-3 [n = 2]) [22, 24, 28, 31, 37]. These studies inves-tigated the use of MRI in the detection of chang-es in synovial hypertrophy as well as changes in articular cartilage, subchondral bone, and artic-ular disk after corticosteroid injections. In the first study (level of evidence, II-2 [n = 1]) [31], six of 24 (25%) patients received corticosteroid injections and were also evaluated for follow-up changes by MRI. Decreased joint effusions, synovial thickening, or both were found in five of the six (83%) patients, but no improvements were noted in condylar morphology or ero-sions. In the second study (level of evidence,

II-2 [n = 1]) [24], the authors reported a reduc-tion in TMJ effusion in eight of 10 (80%) pa-tients after an average of 9 months of continued treatment. However, in one patient both joints were found to present with worsened effusions, erosions, and bilateral condylar flattening on follow-up MRI. The authors hypothesized that chronic structural changes might not be treated by corticosteroid therapy. Arabshahi et al. [22] (level of evidence, II-2 [n = 1]) found that MRI detected interval resolution of joint effusions in eight of 10 (80%) patients after injection but this finding was not observed for condylar sclerosis. The remaining two (20%) patients presented with persistent joint effusions. In addition, three of 19 (16%) TMJs in 14 pa-tients presented with worsening bony resorp-tion on the follow-up MRI. However, the fourth study (level of evidence, II-3 [n = 1]) [37] re-ported substantial improvement in most treated joints in terms of pain, tenderness, and stiffness (100%); jaw deviation (92.8%); and chewing dysfunction (71.4%) but failed to report MRI results after treatment. The fifth study (level of evidence, II-3 [n = 1]) [28] found evidence of improvement in 51% (24/47) of joints and com-plete resolution of TMJ arthritis in 19% (9/47) of joints. Hence, these five studies indicated that resolution of early inflammatory chang-es was detectable on contrast-enhanced MRI. One study (5%; level of evidence, II-2 [n = 1]) [29] found a low incidence of chronic chang-es in TMJs (5.4%), and the authors postulated that this finding might be a result of aggressive therapy with biologic drugs and corticosteroids.

Although one study (5%; level of evi-dence, II-3 [n = 1]) [18] did not assess the effect of specific treatments on clinical and MRI outcomes in the TMJ, the authors found discrepancies between the progression of pathologic findings on MRI and decrease in clinical symptoms over time, showing the importance of MRI for follow-up of patients under treatment. Similarly, another study (p < 0.003; level of evidence, II-2 [n = 1]) [25] found that MRI was superior to ortho-pantomograms in following condylar chang-es over time.

Sacroiliac joints—Fischer et al. [19] (lev-el of evidence, II-2 [n = 1]) reported that in a group of nonresponders to nonsteroidal anti inflammatory drugs (NSAIDs) (56/89), 87.5% (49/56) of the patients had a signifi-cant decrease in complaints (p < 0.05) af-ter corticosteroid injection into the sacro-iliac joints and that this effect lasted for 12 ± 6 months (mean ± SD). Follow-up MRI showed a significant reduction in con-trast enhancement of the sacroiliac joints in

both groups (NSAID responders and nonre-sponders). One third of the patients in the group of nonresponders had progression of joint destruction on MRI despite the absence of clinical symptoms; this finding suggests the absence of an association between MRI findings and a clinical response to treatment.

Spinal joints—No article studied the abili-ty of MRI to detect treatment responsiveness in the spine.

Predictive Value of MRI for Functional Status of the Joints: Item 4 in Figure 1

Question 4: If early changes can be eval-uated using MRI, can this information be used to predict future cartilage degeneration or the functional status of the joint?

None of the selected articles investigated the predictive value of MRI findings, given that the associations between early and inter-mediate changes and joint function were not measured over time.

One study (5%; level of evidence, II-2 [n = 1]) [26] found significant associations be-tween CHAQ scores and synovial enhance-ment and effusion for TMJs (t value = 3.1, p < 0.05). Several articles evaluated both early joint changes and intermediate changes, such as atlantoaxial subluxation (level of evidence, II-3 [n = 1]) [36], subchondral bone changes (level of evidence, II-2 [n = 3] and II-3 [n = 1]) [7, 21, 23, 35], or disk changes (level of evidence, II-3 [n = 1]) [35] but failed to evalu-ate associations between them. Only one study (5%; level of evidence, II-2 [n = 1]) [32] found a significant association between early and in-termediate changes—namely, synovial en-hancement and condylar deformities in TMJs (chi-square test, p < 0.0001).

Associations Between Intermediate and Late MRI Outcomes and Joint Function: Item 5 in Figure 1

Question 5: Can an association be made between intermediate and late findings on MRI and the functional status of the joint?

Four articles (level of evidence, II-2 [n = 3] and II-3 [n = 1]) [26, 30, 32, 34] used the CHAQ tool to evaluate joint function at the time of examination. One study (level of evi-dence, II-2 [n = 1]) [26] found a significant association between CHAQ scores and con-dylar morphology in TMJs (t value = 3.1, p < 0.05). However, another study [32] did not find a significant association between CHAQ scores and MRI findings in TMJs. The last two studies (level of evidence, II-2 [n = 1] and II-3 [n = 1]) [30, 34] measured both in-termediate MRI findings in sacroiliac joints and thoracic and lumbar spines and CHAQ

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scores but did not report the association be-tween them.

Six other studies (29%; level of evidence, II-2 [n = 5] and II-3 [n = 1]) [7, 22, 25, 27, 29, 36], without using the CHAQ, correlated in-termediate changes in the TMJ—specifically, disk and bony condylar head morphology—with joint function. One study [25] suggested that a loss of function (as measured by clini-cal examination and orthopantomograms) oc-curs during the later stages of JIA as opposed to earlier stages, whereas another study [27] concluded that intermediate outcomes are an independent predictor of abnormal condylar motion. One study (5%; level of evidence, II-2 [n = 1]) [29] found that both mouth-opening deviation findings (odds ratio [OR] = 6.21; 95% CI, 2.87–13.4) and maximal incisal open-ing (r = 0.94; 95% CI, 0.90–0.99) had asso-ciations with intermediate findings. No other study found significant associations between intermediate TMJ findings and measures of loss of function, including clinical examina-tion and orthopantomograms [7], and history and maximal incisal opening [22]. Similarly, no significant association was found between intermediate findings in cervical spine joints and loss of function by one study (5%; level of evidence, II-3 [n = 1]) [36].

Summary of Recommendations According to the Canadian Task Force on Preventive Health Care Guidelines

Table 3 defines the grades used by the Ca-nadian Task Force on Preventive Health Care [17] to characterize the strength of their rec-ommendations, and Tables 4–6 summarize the levels of evidence and recommendation guidelines by joint.

Question 1: Can MRI be used to detect early axial joint changes? There is fair evi-dence in the literature (in quality and quan-tity) to recommend the use of MRI to detect early JIA changes in TMJs (grade B). How-ever, there is insufficient evidence in the lit-

erature (in quantity) to indicate MRI for de-tecting JIA in spinal (grade I) and sacroiliac (grade I) joints.

Question 2: Can MRI be used to detect in-termediate and late axial joint changes with regard to the progression of arthropathy? Fair evidence exists in the literature (in qual-ity and quantity) to allow a recommendation for the use of MRI for detecting intermedi-ate JIA changes in TMJs (grade B). However, there is insufficient evidence in the literature (in quantity) to indicate the use of MRI for spinal (grade I) and sacroiliac (grade I) joints.

Question 3: Is MRI useful to monitor the effect of treatment on improving joint pathol-ogy and preventing further damage? There is insufficient evidence to indicate that MRI is effective at detecting treatment effects in TMJs (grade I). There is no existing litera-ture for sacroiliac (grade I) and spinal (grade I) joints addressing this research question, and hence no recommendation can be made.

Question 4: If early changes can be eval-uated using MRI, can this information be used to predict future cartilage degeneration or the functional status of the joint? Insuffi-cient evidence is present in the literature to address this research question with regard to TMJ (grade I), sacroiliac joints (grade I), or spinal joints (grade I); therefore, no recom-mendation can be made.

Question 5: Can an association be made between intermediate and late findings on MRI and the functional status of the joint? No studies were found pertaining to this re-search question for TMJs (grade I), sacroili-ac joints (grade I), or spinal joints (grade I).

DiscussionThis systematic review of the literature

points toward varying levels of evidence of the diagnostic accuracy of MRI for evaluat-ing early and intermediate joint changes and for assessing clinical responsiveness to treat-ment in axial JIA joints. Current gaps in the

literature of the diagnostic accuracy of MRI for the assessment of JIA axial skeletal joints include a lack of evidence on the following: early joint damage in the spinal and sacroil-iac joints; intermediate changes in the spinal and sacroiliac joints; the long-term effect of therapy on all types of axial joints in cases of JIA diagnosed early in the disease course; and the predictive value of MRI in all types of axial joints in early and intermediate stage JIA using specific treatment methods. Although no studies are currently available in the literature to show the long-term ef-fect of therapy on TMJs, short-term (0.5–23 months) follow-up studies have shown that the majority of children with symptomatic TMJ arthritis improved after intraarticular corticosteroid injection as assessed by MRI [22, 24, 28, 31, 37]. Therefore, this imaging modality holds potential for being a useful tool for long-term follow-up of TMJs accord-ing to different therapeutic approaches once the diagnosis of TMJ involvement is made early during the disease course.

The limitations of the currently available primary studies in the literature with regard to the benefit of MRI for the treatment of JIA patients and prognosis of TMJ arthritis in-clude a small sample size, the lack of an ap-propriate control group, incomplete prepro-cedure and postprocedure imaging, the use of a head coil rather than a surface coil during MR image acquisition, inconsistent measure-ment and recording of related clinical param-eters, and a relatively short follow-up period. These methodologic and technical shortcom-ings of the currently available studies should be addressed in future studies. Furthermore, there is an overall limitation in terms of the quantity and quality of the studies on the spi-nal and sacroiliac joints in the current litera-ture, which opens avenues for active investi-gation on the clinical applications of MRI for the early diagnosis, prognosis, and follow-up of treatment of JIA affecting these joints.

TABLE 3: Grading of Strength of Recommendations According to Guidelines of the Canadian Task Force on Preventive Health Care [17]

Grade Definition

A There is good evidence to recommend the clinical preventive action

B There is fair evidence to recommend the clinical preventive action

C The existing evidence is conflicting and does not allow a recommendation for or against use of the clinical preventive action; however, other factors may influence decision making

D There is fair evidence to recommend against the clinical preventive action

E There is good evidence to recommend against the clinical preventive action

I There is insufficient evidence (in quality or quantity) to make a recommendation; however, other factors may influence decision making

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MRI for Diagnosis of JIA in the Axial JointsT

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ance

men

t (sy

novi

tis),

and

join

t effu

sion

. How

ever

, no

II-1

qual

ity

artic

les

wer

e pr

esen

t

Que

stio

n 2:

Can

MRI

acc

urat

ely

dete

ct in

term

edia

te a

nd la

te

chan

ges?

14 [7

, 18,

22–

29,

31–3

3, 3

5]II-

2 (1

0), I

I-3

(4)

Uncl

ear c

ross

-sec

tiona

l (1)

, pro

spec

tive

cros

s-se

ctio

nal w

ith c

ontr

ol s

ubje

cts

(2),

pros

pect

ive

cros

s-se

ctio

nal w

ithou

t co

ntro

l sub

ject

s (2

), re

tros

pect

ive

cros

s-se

ctio

nal (

3), r

etro

spec

tive

coho

rt

(2),

pros

pect

ive

coho

rt w

ith c

ontr

ol

subj

ects

(2),

pros

pect

ive

coho

rt w

ithou

t co

ntro

l sub

ject

s (2

)

Poor

(1),

fair(

10),

good

(3)

B14

stu

dies

of d

iffer

ent t

ypes

and

qua

litie

s su

gges

ted

that

MRI

, with

and

with

out c

ontr

ast

mat

eria

l, ca

n ef

fect

ivel

y de

tect

inte

rmed

iate

ch

ange

s in

the

TMJ,

incl

udin

g ca

rtila

ge lo

ss,

eros

ions

, and

sub

chon

dral

abn

orm

aliti

es a

nd

cyst

s. H

owev

er, n

o II-

1 qu

ality

art

icle

s w

ere

pres

ent

Que

stio

n 3:

Is th

ere

an

asso

ciat

ion

betw

een

MRI

ev

iden

ce o

f cha

nges

and

cl

inic

al re

spon

se to

trea

tmen

t?

5 [1

8, 2

2, 2

4, 3

1, 3

7]II-

2 (3

), II-

3 (2

)Re

tros

pect

ive

coho

rt (3

), pr

ospe

ctiv

e co

hort

(2)

Poor

(1),

fair

(3),

good

(1)

IFi

ve s

tudi

es in

dica

ted

that

a re

lativ

ely

larg

e pr

opor

tion

of p

atie

nts

seem

to re

spon

d to

co

rtic

oste

roid

inje

ctio

ns in

term

s of

acu

te

sign

s. H

owev

er, i

nter

med

iate

cha

nges

are

less

lik

ely

to s

how

impr

ovem

ent o

n M

RI w

ith

cort

icos

tero

id th

erap

y, w

hich

was

att

ribut

ed to

lim

itatio

ns o

f the

trea

tmen

t. Tw

o ot

her s

tudi

es,

alth

ough

did

not

mea

sure

resp

onsi

vene

ss,

foun

d di

scre

panc

ies

betw

een

prog

ress

ion

of

path

olog

ic fi

ndin

gs o

n M

RI a

nd c

linic

al

sym

ptom

s an

d or

thop

anto

mog

ram

s ov

er ti

me,

sh

owin

g th

e im

port

ance

of M

RI fo

r fol

low

-up

of p

atie

nts

unde

r tre

atm

ent.

How

ever

, in

suffi

cien

t evi

denc

e ex

ists

to m

ake

a re

com

men

datio

n

Que

stio

n 4:

Can

MRI

acc

urat

ely

pred

ict i

nter

med

iate

and

late

ch

ange

s or

join

t fun

ctio

n ba

sed

on e

arly

cha

nges

?

0—

——

IN

o st

udy

trul

y m

easu

red

the

asso

ciat

ion

betw

een

early

cha

nges

and

inte

rmed

iate

ch

ange

s, a

nd e

arly

cha

nges

and

join

t fun

ctio

n as

mea

sure

d by

CH

AQ

scor

es b

y m

easu

ring

thes

e ov

er ti

me

Que

stio

n 5:

Can

MRI

acc

urat

ely

pred

ict j

oint

func

tion

base

d on

in

term

edia

te a

nd la

te

chan

ges?

1 [2

6]II-

2 (1

)Pr

ospe

ctiv

e cr

oss-

sect

iona

l (1)

Fair

(1)

IOn

ly o

ne s

tudy

foun

d a

sign

ifica

nt a

ssoc

iatio

n be

twee

n CH

AQ

scor

es a

nd in

term

edia

te

findi

ngs

Not

e—Da

sh (—

) ind

icat

es n

ot a

pplic

able

. STA

RD =

Sta

ndar

ds fo

r Rep

ortin

g of

Dia

gnos

tic A

ccur

acy,

GR 

= gr

ade

reco

mm

enda

tion,

CH

AQ 

= Ch

ildho

od H

ealth

Ass

essm

ent Q

uest

ionn

aire

.

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208 AJR:202, January 2014

Munir et al.

Concerning the limitations of the methods of this systematic review, one was the fact that we have not used a specific tool for the assess-ment of the quality of the studies but rather graded levels of evidence according to the Ca-nadian Task Force on Preventive Health Care [17]. In contrast, we used the Quality Assess-ment of Diagnostic Accuracy Studies (QUA-DAS) [39] tool for a previous study we con-ducted pertaining to the peripheral joints of patients with JIA [12]. We did not use the QUADAS tool for this review because six of 14 (43%) items in the QUADAS tool and six of the 13 (46%) items of the QUADAS-2 [40] tool require a reference standard, where-as the selected studies for this systematic re-view failed to provide a reference standard against which MRI was compared as a con-struct. Hence, the STARD, of which only two of 25 (8%) items require a reference stan-dard for item assessment, was deemed to be

a more appropriate tool to measure the qual-ity of reporting of the selected studies, which may have an effect on the overall quality of the study and level of evidence of the study results. In this study, the STARD scores were low overall: Few primary studies adequate-ly reported reliability of MRI interpretation (19%) and other items (< 50%) such as study population and reader description; blinding; failure to test; adverse events; and uncertain, indeterminate, missing, and outlying results. Nevertheless, in other systematic reviews that used the STARD statement for the as-sessment of the quality of reporting of diag-nostic accuracy of ultrasound imaging over-all, all items were also poorly reported; for example, in the study by Roposch et al. [41], fewer than 36% of primary studies adequate-ly reported reliability, study population, and other items on process criteria, statistics, and indeterminate results. Of note is the fact that

neither in our study nor in the Roposch et al. study were indeterminate results reported or sources of heterogeneity in reviewers’ read-ings discussed. In systematic reviews that evaluated the quality of reporting of diagnos-tic accuracy of MRI in peripheral JIA joints [42], the overall STARD scores were also low, with only 22% of studies having ade-quately reported exclusion criteria, motion artifacts, and the need for patient sedation for imaging. In the latter systematic review [42], none of the primary studies on the ability of MRI to detect changes over time in joints on treatment used sound statistical methods for the proposed purpose. Like our systematic review, the Miller et al. review [42] found that indeterminate results were not reported in any validity study. Nevertheless, in both our review and that by Miller et al. [42], es-timates of interreader agreement for inter-pretation of MRI findings reported as kappa

TABLE 5: Levels of Evidence and Recommendation Guidelines for Sacroiliac Joints According to the Guidelines of the Canadian Task Force on Preventive Health Care [17]

ManeuverNo. of Articles

[Reference No.]

Level of Evidence

(No. of Studies)Research Design (No. of Studies)

Quality of Reporting Per STARD (No. of

Studies) GR Diagnostic Accuracy

Question 1: Can MRI accurately detect early changes?

3 [20, 21, 34] II-2 (3) Unclear cross-sectional (1), prospective cross-sectional (1), retrospective cross-sectional (1)

Fair (2), good (1) I Three studies suggested that MRI is effective at detecting changes in the sacroiliac joint. However, insufficient evidence exists because only three studies pertained to this research question, two of which were published in 1998

Question 2: Can MRI accurately detect intermediate changes?

3 [20, 21, 34] II-2 (3) Unclear cross-sectional (1), prospective cross-sectional (1), retrospective cross-sectional (1)

Fair (2), good (1) I Three studies concluded that changes in the sacroiliac joint are detectable by MRI. However, insufficient evidence exists because only three studies pertained to this research question, two of which were published in 1998

Question 3: Is there an association between MRI evidence of changes and clinical response to treatment?

1 [19] II-2 (1) Retrospective cross-sectional (1)

Poor (1) I One study found that MRI showed a significant reduction in contrast enhancement of sacroiliac joints in both NSAID responders and nonresponders after corticosteroid injection. However insufficient evidence exists to make a recommendation

Question 4: Can MRI accurately predict intermediate changes or joint function based on early changes?

0 — — — I —

Question 5: Can MRI accurately predict joint function based on intermediate changes?

0 — — — I —

Note—Dash (—) indicates not applicable. STARD = Standards for Reporting of Diagnostic Accuracy, GR = grade recommendation, NSAID = nonsteroidal antiinflamma-tory drug.

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AJR:202, January 2014 209

MRI for Diagnosis of JIA in the Axial Joints

coefficients denoted good (0.40–0.75) or ex-cellent (> 0.75) overall reliability. Based on the overall results of our systematic review, which are in accordance with the results of other recent systematic reviews, there is an urgent need for investigators to improve the quality of reporting of data in imaging studies.

Another limitation present in our sys-tematic review is the fact that a significant amount of heterogeneity existed within the scope of the articles found, especially with regard to the methods of different stud-ies. This heterogeneity includes, for exam-ple, the varying methods with regard to ra-diologic evaluation of the sacroiliac joints or the different corticosteroid treatment schemes used in TMJs. This heterogeneity posed unique challenges with regard to anal-ysis and precluded the possibility of a meta-analysis of results.

Last, whereas two reviewers critically ap-praised all articles published in English using the STARD criteria, the articles published in German were reviewed by only one person. This discrepancy in methodology was because of the limited availability of staff fluent in Ger-man and could have introduced bias due to the subjective nature of some of the STARD items.

ConclusionIn addition to the gaps in the literature that

relate to the overarching questions of this systematic review and require further inves-tigation in the future, the results of this sys-tematic review indicate an urgent need for validation of protocols and single MRI scor-ing systems for the interpretation of findings in specific axial joints with JIA. The results of this review may direct future research in this field to assist in the development of

guidelines for MRI of the axial skeleton in JIA. Evidence-based guidelines can improve the evaluation of these joints, thus ultimately optimizing individualized therapy with the aim of reducing long-term joint morbidity.

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