Significant overlap of inflammatory and degenerative features on imaging among patients with degenerative disc disease, diffuse idiopathic skeletal hyperostosis and axial spondyloarthritis: a real-life cohort study

Abstract Background Differentiating between degenerative disc disease (DDD), diffuse idiopathic skeletal hyperostosis (DISH), and axial spondyloarthritis (axSpA) represents a diagnostic challenge in patients with low back pain (LBP). We aimed to evaluate the distribution of inflammatory and degenerative imaging features in a real-life cohort of LBP patients referred to a tertiary university rheumatology center. Methods In a retrospective cross-sectional analysis of patients referred for LBP, demographics and symptom information were collected. Conventional radiographs (CR) and MRIs of spine and sacroiliac joints (SIJ), ax. SpA-like changes were considered in the spine in the presence of erosions, sclerosis, squaring, and syndesmophytes on CR and bone marrow oedema (BMO), erosions, sclerosis, and fat lesions (FL) on MRI. SIJ CR were graded per New York criteria; BMO, erosions, FL, sclerosis and ankylosis were identified on MRIs. The final diagnosis made by the rheumatologist was the gold standard. Data were presented descriptively, by patient and by quadrant, and compared among the three diagnosis groups. Results Among 136 referred patients, 71 had DDD, 38 DISH, and 27 axSpA; median age 62 years [IQR55-73], 63% males. On CR, SpA-like changes were higher in axSpA in the lumbar (50%, vs DDD 23%, DISH 22%), in DISH in the thoracic (28%, vs DDD 8%, axSpA 12%), and in DDD in the cervical spine (67% vs. DISH 0%, axSpA 33%). On MRI, BMO was higher in DISH in the thoracic (37%, vs DDD 22%, axSpA 5%) and equally distributed in the lumbar spine (35%-42%). FL were more frequently identified in DISH and axSpA in the thoracic (56% and 52%) and in DDD and axSpA in the lumbar spine (65% and 74%, respectively). Degenerative changes were frequent in the three groups. Sacroiliitis (NY criteria) was identified in 49% (axSpA 76%, DDD 48%, DISH 29%). Conclusion A significant overlap was found among DDD, DISH, and axSpA for inflammatory and degenerative imaging features. Particularly, SpA-like spine CR features were found in one-fourth of patients with DISH, and MRI BMO was found in one-third of those patients.