Arthritis Care & Research

Vol. 66, No. 9, September 2014, pp 14171422

DOI 10.1002/acr.22308
2014, American College of Rheumatology

ORIGINAL ARTICLE

Reliability of Radiographic Scoring Methods in

Axial Psoriatic Arthritis
BRADLY J. BIAGIONI,1 DAFNA D. GLADMAN,2 RICHARD J. COOK,3 LIHI EDER,2 ANUPAM WAKHLU,4
HUA SHEN,3 and VINOD CHANDRAN2

Objective. Important differences exist between axial psoriatic arthritis (AxPsA) and ankylosing spondylitis (AS). The
Bath Ankylosing Spondylitis Radiology Index (BASRI), the modied Stoke Ankylosing Spondylitis Spinal Score
(mSASSS), and the Radiographic Ankylosing Spondylitis Spinal Score (RASSS) were developed to score AS, and the
Psoriatic Arthritis Spondylitis Radiology Index (PASRI) to score AxPsA. We aimed to develop a computerized scoring
application and compare the intra- and interrater reliability of these scoring systems in AS and AxPsA.
Methods. A computerized scoring application was developed to facilitate the scoring of radiographic features and
calculate total scores for established scoring methods for AS and AxPsA. Digital spinal radiographs of 18 patients with
AS and 40 patients with AxPsA were read in random order individually by 4 rheumatologists, data were entered into the
application, and scores were obtained. The intraclass correlation coefcients (ICC) of the intra- and interrater reliability
of scores for each method were then computed.
Results. In AS, the intra- and interrater ICC was 0.91 and 0.80 for sacroiliitis grade, 0.96 and 0.86 for BASRI-spine, 0.98
and 0.86 for mSASSS, 0.96 and 0.75 for RASSS, and 0.99 and 0.93 for PASRI, respectively. In AxPsA, the intra- and
interrater ICC was 0.81 and 0.67 for sacroiliitis grade, 0.77 and 0.52 for BASRI-spine, 0.91 and 0.65 for mSASSS, 0.90 and
0.68 for RASSS, and 0.92 and 0.88 for PASRI, respectively.
Conclusion. Available radiographic scoring systems perform well in AS and have moderate intra- and interrater
reliability when applied to AxPsA. However, PASRI may be superior for assessing structural damage in AxPsA.

INTRODUCTION
Psoriatic arthritis (PsA) is a distinct inammatory musculoskeletal disease associated with psoriasis and is classiThe Psoriatic Arthritis Program is funded in part by The
Arthritis Society, Canadian Institutes of Health Research,
and the Krembil Foundation. Dr. Biagionis work was supported by a Canadian Rheumatology Association Roche Research Studentship.
1
Bradly J. Biagioni, MSc, MD: Toronto Western Hospital,
Toronto, Ontario, Canada, and University of British Columbia, Vancouver, British Columbia, Canada; 2Dafna D.
Gladman, MD, FRCPC, Lihi Eder, MD, PhD, Vinod
Chandran, MBBS, MD, DM, PhD: Toronto Western Hospital
and University of Toronto, Toronto, Ontario, Canada;
3
Richard J. Cook, PhD, Hua Shen, MMath: University of
Waterloo, Waterloo, Ontario, Canada; 4Anupam Wakhlu,
MD, DM: Toronto Western Hospital, Toronto, Ontario, Canada, and King George Medical College, Chowk, Lucknow,
Uttar Pradesh, India.
Address correspondence to Vinod Chandran, MBBS, MD,
DM, PhD, University of Toronto Psoriatic Arthritis Clinic,
Centre for Prognosis Studies in the Rheumatic Diseases,
Toronto Western Hospital, Room 1E416, 399 Bathurst
Street, Toronto, Ontario, Canada M5T 2S8. E-mail:
vchandra@uhnresearch.ca.
Submitted for publication June 11, 2013; accepted in revised form February 4, 2014.

ed according to the Classication of Psoriatic Arthritis

[CASPAR] Study Group criteria (1). Involvement of the
axial joints, termed axial PsA (AxPsA), is relatively common and ties PsA to the concept of spondyloarthritis
(SpA). Due to differences in the criteria used for dening
AxPsA, there is wide variability (2570%) in the reported
prevalence of axial involvement in PsA (2). AxPsA can
affect the sacroiliac (SI) joints, as well as the lumbar,
thoracic, and cervical spine (3,4). A number of the radiographic features of AxPsA are similar to those found in
ankylosing spondylitis (AS), although patients with AS
generally have more severe radiographic damage compared to AxPsA (5). For example, the sacroiliitis seen in
AxPsA may be difcult to distinguish radiographically
from that found in AS, and may be milder clinically (2,5).
PsA patients also have new bone formation that resembles
the syndesmophytes seen in AS patients. However, the
syndesmophytes seen in AxPsA tend to be larger, curved
rather than straight, and found paramarginally on the vertebral body, and at times it is difcult to distinguish these
from osteophytes (6). Erosive and sclerotic lesions can also
be found throughout the spine and the disease commonly
manifests in the cervical spine, where facet joint fusion is
the most common lesion found (3,6). AxPsA may be distinguished from AS by the presence of asymmetric sacro1417

1418

Biagioni et al

Signicance & Innovations

Reliability of scoring axial arthritis in psoriatic

arthritis is lower than in ankylosing spondylitis.

Available scoring systems have at least moderate

intra- and interrater reliability when applied to
axial psoriatic arthritis.

The novel computerized scoring application facilitated instant calculation of all axial radiographic
scores after input of individual radiographic features.

iliitis, nonmarginal syndesmophytes, asymmetric syndesmophytes, paravertebral ossication, and frequent involvement of the cervical spine (5).
Assessment of radiographic damage in AxPsA is important for dening and measuring disease outcomes in observational studies, clinical trials, and clinical practice. A
number of scoring systems have been developed to quantify radiographic damage to the spine of AS patients, including the Bath Ankylosing Spondylitis Radiology Index
(BASRI), the modied Stoke Ankylosing Spondylitis Spinal Score (mSASSS), and the Radiographic Ankylosing
Spondylitis Spinal Score (RASSS) (79). These systems,
along with a scoring system developed specically for PsA
called the Psoriatic Arthritis Spondylitis Radiology Index
(PASRI), may be used to evaluate axial radiographic damage in patients with AxPsA, but they have not yet been
validated in AxPsA (10).
In order to validate a measurement tool, the tool should
pass the Outcome Measures in Rheumatology (OMERACT)
lter (11). Radiographic damage to the spine in SpA, including AxPsA, manifests chiey as new bone formation
and corner vertebral erosions. These features are captured
by the radiographic assessment methods mentioned above,
and therefore these tools have face validity. However, the
discriminative ability (reliability and sensitivity to
change) has not been assessed in AxPsA.
Hypothesizing that the reliability of the PASRI instrument, which was developed specically to assess extent of
radiographic damage in axial PsA, is better than mSASSS,
RASSS, and BASRI-spine, we aimed to 1) develop a novel
computerized scoring application to facilitate instant calculation of all axial radiographic scores after input of
individual radiographic features, and 2) compare the intraand interrater reliability of these scoring systems for assessing radiographic spinal damage in AxPsA.

PATIENTS AND METHODS

An application we called a Scoring Module for Axial Radiographs Toronto (SMART) was developed in Microsoft
Access that facilitated the assessment of radiographs and
generated the individual radiographic damage scores (sacroiliitis grade by the New York scoring method, BASRIspine, mSASSS, RASSS, and PASRI) (12). The assessor
had to only input the score for each SI joint, vertebral

corner throughout the spine, or cervical facet joint site.

The program calculated the nal score based on the scores
for the individual sites and the algorithm unique to each
scoring system. The BASRI-spine assesses 3 regions: the
cervical spine on lateral radiographs, the lumbar spine on
lateral and anteroposterior (AP) radiographs, and the SI
joints on the AP pelvis radiograph. Each area is graded
from 0 to 4 (normal, suspicious, mild, moderate, severe) to
provide a total score range from 0 to 12 (7). The mSASSS
assesses the cervical and lumbar spine on lateral radiographs. Each anterior vertebral corner from lower T12 to
upper S1 and lower C2 to upper T1 is given a score from 0
to 3 (0 normal; 1 erosion, sclerosis, or squaring; 2
non-bridging syndesmophytes; and 3 bridging syndesmophytes) to give total scores ranging from 0 to 72 (8). The
mSASSS species rules to handle missing or nonvisualized vertebral corners. The RASSS assesses the cervical,
lumbar, and lower thoracic spines on lateral radiographs.
The anterior corners from lower T10 to upper S1 and lower
C2 to upper T1 are scored using a system similar to the
mSASSS scoring system (from 0 to 3); although no erosions are scored, squaring is evaluated only for the thoracic and lumbar spines and sclerosis is scored for all
available sites (9). The total score ranges from 0 to 84. The
PASRI, developed specically for AxPsA, scores the SI
joints individually from 0 to 4 using the New York scoring
method, vertebral corners of the lumbar spine on both AP
and lateral views from the lower T12 to upper S1, and the
anterior vertebral corners of the cervical spine on lateral
view from the lower C2 to the upper C6 (each corner
scored from 0 to 3) and 1 point is added for every level of
the facet joints (C2/C3, C3/C4, C4/C5, C5/C6) fused posteriorly (10,13). The total score ranges from 0 to 72. These
rules were incorporated in the application so that once the
relevant individual items (vertebral scores, for example)
were entered, clicking on the calculate all icon would
cause the application to automatically provide the observer with the total scores for all the instruments (Figure
1). The accuracy of the calculations was conrmed by
comparing the scores generated by SMART and scores
obtained by manual calculation prior to using SMART for
this study. The application also allowed capture of information on the presence of diffuse idiopathic skeletal hyperostosis (DISH), osteoporosis, vertebral collapse or fracture, and paravertebral ossication.
Initially, in order to evaluate our scoring application,
digital spinal radiographs (Digital Imaging and Communications in Medicine [DICOM]) of 18 patients with primary
AS who satised the modied New York criteria were
obtained and scored by the assessors (13). These patients
had established AS and were being managed as outpatients by one of the assessors (DDG) at the Toronto Western
Hospital. Subsequently, digital spinal radiographs of 40
patients with PsA satisfying CASPAR criteria that had
AxPsA dened as grade 2 or greater, sacroiliitis, and inammatory back pain or restricted spinal mobility were
selected from the University of Toronto Psoriatic Arthritis
Clinic database by an assessor (BJB) independent of the 4
raters (DDG, LE, AW, and VC) who scored the radiographs
for the reliability exercise. This clinic was established in
1978 and follows patients with PsA from the province of

Assessing Scoring Systems for Spinal Damage in Axial PsA

1419

Figure 1. Screenshot of the Scoring Module for Axial Radiograph Toronto (SMART) application developed for scoring of spinal
radiographs. After the individual items are entered, the total score is generated by clicking the icon calculate ALL at the bottom right
corner. AP anteroposterior; SI sacroiliac; NY New York; BASRI Bath Ankylosing Spondylitis Radiology Index; C cervical; L
lumbar; DISH diffuse idiopathic skeletal hyperostosis; PASRI Psoriatic Arthritis Spondylitis Radiology Index; mSASSS modied
Stoke Ankylosing Spondylitis Spinal Score; RASSS Radiographic Ankylosing Spondylitis Spinal Score.

Ontario, Canada regularly using a standard protocol. Clinical assessments are done every 6 12 months and radiographic assessments are done once every 2 years (14). A
convenience sample of patients with longstanding wellestablished disease with a range of abnormalities represented on the radiographs was selected by the independent assessor.
For both AS and AxPsA patients, identiers were digitally removed from the DICOM images, images were duplicated, and the order randomized. Four raters with rheumatology training (1 senior, 2 early-career, and 1 trainee)
and blinded to patient information scored radiographs in
random order. The senior rater has more than 30 years of
experience in reading spine radiographs, whereas the early-career investigators had experience of more than 7
years. Plain radiographs of patients in the Psoriatic Arthritis Program at the University of Toronto are scored once a
week in order to provide trainees an opportunity to become procient in scoring radiographs of both peripheral
and axial joints. For the purpose of this study the raters
were provided in advance with an e-handbook and a
1-hour training session on scoring the radiographs. Radiographic damage scores were generated according to the
various scales.
All the PsA patients participating in the University of

Toronto PsA database have signed consent to have their

data collected and used in studies. Likewise, patients with
AS participate in an AS database and signed similar consents when rst seen in the clinic.
For each score, mixed-effects models were used, including patient-specic random effects, assessor-specic random effects, and a random error term. Measures of reliability were calculated based on the variance components;
specically, the intraclass correlation coefcient (ICC) for
the interrater reliability was dened as the ratio of the
between-patient variance to the total variance, and the ICC
for the intrarater reliability was the sum of the betweenpatient and between-rater variance components divided
by the total variance. Point estimates and 95% condence
intervals were computed for each intraclass correlation
coefcient for each score (15). A consensus score by the 4
raters was also obtained if there was disagreement.

RESULTS
The demographic and disease characteristics of the study
subjects are provided in Table 1, including spinal mobility
measures at the time of radiographic assessment. It can be
seen that this sample is comprised of patients with long-

1420

Biagioni et al

Table 1. Demographic and disease characteristics of study subjects*

Characteristic
Males, no. (%)
Age at time of radiograph, years
Disease duration, years
Number of tender or swollen joints
Number of clinically damaged joints
Psoriasis Area and Severity Index score
Presence of OA of the spine, no. (%)
Presence of DISH, no. (%)
Spinal mobility measures
Occiput-to-wall distance, cm
Cervical rotation, degrees
Chest expansion, cm
Lumbar lateral exion (Domjan method), cm
Schobers test, cm
Intermalleolar distance, cm
Consensus scores
BASRI-spine
mSASSS
RASSS
PASRI

AxPsA
(n 40)

AS
(n 18)

24 (60)
53 14
18 9.7
5 9.3
16 17.8
5.7 7.5
35 (87.5)
2 (5)

12 (75)
45 12
12 12.1
NA
NA
NA
9 (50)
0 (0)

0.37
0.05
0.07

0.01
1.00

2.3 4.3
61 21
5.6 1.9
16 5.2
4.7 2.7
104 20.5

7.4 7.4
37 21
4.3 2.3
10.5 5.9
4.9 5.3
100 16.4

0.03
0.02
0.09
0.02
0.91
0.51

3.98 2.38
8 13.4
6.54 14.1
12 12.3

4.83 3.13
11 18.5
8.26 16.32
18.3 17.7

0.26
0.49
0.70
0.12

* Values are the mean SD unless indicated otherwise. AxPsA axial psoriatic arthritis; AS
ankylosing spondylitis; NA not assessed; OA osteoarthritis; DISH diffuse idiopathic skeletal
hyperostosis; BASRI Bath Ankylosing Spondylitis Radiology Index; mSASSS modied Stoke Ankylosing Spondylitis Spinal Score; RASSS Radiographic Ankylosing Spondylitis Spinal Score;
PASRI Psoriatic Arthritis Spondylitis Radiology Index.

standing disease. The nal column contains P values of

tests of differences between the 2 samples of patients.
Compared to patients with AS, those with AxPsA were
older and had more osteoarthritis of the spine, but had less
restriction of spinal mobility. Also provided are the scores
obtained based on the consensus of the 4 raters determined
after completion of the reliability study. The scores show
that the severity of axial radiographic change in this convenience sample was numerically higher in AS compared
to AxPsA, although the differences are not statistically
signicant. We attribute this to relatively small sample
size, especially in the AS group.
Table 2 shows the results of the exercise to assess the
reliability of scoring of sacroiliitis, BASRI-spine, mSASSS,

RASSS, and PASRI in AS. All methods demonstrated excellent intra- and interrater reliability. Since intrarater ICC
accounts for more variation than interrater ICC, the estimates of the intrarater reliability was higher than that for
the interrater reliability. The PASRI showed the highest
numerical value for inter- and intrarater reliability.
Table 3 shows the results of the exercise to assess the
reliability of scoring of sacroiliitis, BASRI-spine, mSASSS,
RASSS, and PASRI in AxPsA. The ICCs were lower than
those observed for AS. Once again, the intrarater reliability
was higher than interrater reliability. The PASRI showed
the highest numerical value for intra- and interrater reliability. The intrarater reliability of the PASRI was signicantly better than that of the BASRI-spine, but similar to

Table 2. Intra- and interrater reliability of radiographic

scores in ankylosing spondylitis (N 18)*

Table 3. Intra- and interrater reliability of radiographic

scores in axial psoriatic arthritis (N 40)*

Intrarater
reliability

Intrarater
reliability

Interrater
reliability

Interrater
reliability

Scoring system

ICC

95% CI

ICC

95% CI

Scoring system

ICC

95% CI

ICC

95% CI

Sacroiliitis grade
BASRI-spine
mSASSS
RASSS
PASRI

0.91
0.96
0.98
0.96
0.99

0.840.96
0.920.98
0.970.99
0.930.98
0.970.99

0.80
0.86
0.86
0.75
0.93

0.650.91
0.750.94
0.740.94
0.560.89
0.860.97

Sacroiliitis grade
BASRI-spine
mSASSS
RASSS
PASRI

0.81
0.77
0.91
0.90
0.92

0.730.88
0.690.85
0.860.95
0.850.95
0.870.95

0.67
0.52
0.65
0.68
0.88

0.540.79
0.380.67
0.490.80
0.510.82
0.820.93

* ICC intraclass correlation coefcient; 95% CI 95% condence

interval; BASRI Bath Ankylosing Spondylitis Radiology Index;
mSASSS modied Stoke Ankylosing Spondylitis Spinal Score;
RASSS Radiographic Ankylosing Spondylitis Spinal Score;
PASRI Psoriatic Arthritis Spondylitis Radiology Index.
New York scoring method.

* ICC intraclass correlation coefcient; 95% CI 95% condence

interval; BASRI Bath Ankylosing Spondylitis Radiology Index;
mSASSS modied Stoke Ankylosing Spondylitis Spinal Score;
RASSS Radiographic Ankylosing Spondylitis Spinal Score;
PASRI Psoriatic Arthritis Spondylitis Radiology Index.
New York scoring method.

Assessing Scoring Systems for Spinal Damage in Axial PsA

mSASSS and RASSS. The interrater reliability of the
PASRI was signicantly better than the other 3 measures.
Therefore, in AxPsA in contrast to AS, PASRI (a measure
developed specically for AxPsA) performed better than
the 3 other measures that were developed for assessment
of AS. Of note, the intra- and interrater reliability of assessment of sacroiliitis according to the New York scoring
method was lower in AxPsA.
Overall, radiographic scoring using the electronic application was completed by the raters within a mean duration
of 7 minutes.

DISCUSSION
Assessment of structural changes to the axial skeleton
remains the gold standard in the assessment of radiographic severity in axial SpA, both AS and AxPsA. The
BASRI-spine, mSASSS, and RASSS are tools developed
for assessment of AS, whereas the PASRI was developed to
assess AxPsA. These tools, especially the mSASSS, have
not been fully validated in AxPsA, but are commonly used
in observational studies. After conrming the reliability of
these tools and the New York method for assessing sacroiliitis in a group of patients with AS, we evaluated the
intra- and interrater reliability of the mSASSS, RASSS,
PASRI, and the New York scoring method for sacroiliitis in
a group of patients with AxPsA. We show that PASRI, the
scoring method developed specically for AxPsA, has excellent intrarater and interrater reliability in both AS and
AxPsA. mSASSS and RASSS also have very good reliability when used to assess structural damage in AS. However,
in AxPsA, the intrarater reliability of the PASRI was signicantly better than that of the BASRI-spine, but similar
to the mSASSS and RASSS. The interrater reliability of the
PASRI was signicantly better than the other 3 measures
investigated. The reliability of the assessment of sacroiliitis was lower in AxPsA compared to AS. Using an application developed to simultaneously score all methods, the
assessors were able to complete the assessment of spinal
radiographs in an average time of 7 minutes. However, a
further study geared toward replication of these ndings
would be of interest with larger and comparable sample
sizes between disease groups.
The reliability of the BASRI, mSASSS, and RASSS in
patients with AS has been previously demonstrated
(8,9,16 18). The radiographic features of AxPsA are sometimes different from those observed in AS. Asymmetric
sacroiliitis, nonmarginal asymmetric syndesmophytes,
paravertebral ossication, and more frequent involvement
of cervical spine are features more often seen in AxPsA
(5,19,20). Moreover, patients with AxPsA tend to be older
than those with primary AS. Therefore, features such as
degenerative arthritis and DISH are more likely to be present in patients with AxPsA (21). Therefore, it is important
that scoring methods developed for AS be formally validated in patients with AxPsA before being used in the
assessment of AxPsA. It was also of interest to determine
the reliability of PASRI in AS.
The 4 methods showed excellent reliability and performed equally well in AS. However, in AxPsA the results

1421
were less spectacular, with lower ICCs for both inter- and
intrarater reliability. This probably reects the difculty in
reading plain radiographs in the older PsA population
with a higher prevalence of degenerative arthritis and
DISH. As shown in Table 1, AxPsA patients selected for
this study were older and had a higher prevalence of
osteoarthritis of the spine compared to those with AS.
While the BASRI-spine, mSASSS, and RASSS performed
similarly in AxPsA, PASRI had the best intra- and interrater reliability. PASRI performed the best. This may be
expected since this method was developed specically for
AxPsA. The most important distinguishing feature of this
method is that it also scores the posterior elements of the
cervical spine as well as the SI joints. This allows this
scoring method to account for a wider variability of patient-derived data leading to a better ICC score compared
to the other methods.
With respect to the OMERACT lter, all measures have
face validity (11). PASRI may have better face validity in
AxPsA since it scores the posterior elements as well as the SI
joints. All scoring methods are feasible, although BASRI and
PASRI require scoring the SI joints and also require AP views
of the lumbar spine, whereas only lateral views of the lumbar
spine are required for scoring the mSASSS and RASSS. In
AxPsA, the reliability of PASRI seems to be superior. Therefore, once sensitivity to change is demonstrated, this tool
may be used for longitudinal studies in AxPsA.
It is also interesting to note that the reliability of scoring
the sacroiliitis according to the NY method was better for
AS than for AxPsA. This once again reects the difculty
in scoring SI joint on plain radiographs in patients with
PsA who are older and have a higher prevalence of osteoarthritic changes. Therefore, dening AxPsA solely on the
presence of radiographic sacroiliitis may be unreliable.
There have been few studies on the progression of
AxPsA. There have also been no clinical trials in AxPsA.
The impact of therapy with tumor necrosis factor (TNF)
inhibitors and nonsteroidal antiinammatory drugs
(NSAIDs) on structural progression in AS is a subject of
great debate (2224). Previous studies have not shown that
therapy with TNF inhibitors reduces progression of axial
damage in AS (2527). However, a recent study by Haroon
et al has demonstrated that radiographic damage is indeed
reduced, especially with early initiation of therapy with
TNF inhibitors and with longer duration of followup (28).
The current study will help examine the same issues in
patients with PsA by facilitating reliable evaluation of
axial damage. It would be interesting to evaluate whether
new bone formation in peripheral joints parallels that in
the axial joints in patients with PsA. The impact of TNF
inhibitors and NSAIDs on axial and peripheral joints in
PsA will also be of interest.
In conclusion, this study shows that tools currently
available to score axial SpA, with exception of BASRIspine, are reliable for AxPsA. However, the PASRI, the
tool developed specically for AxPsA, may be superior
for assessing structural damage in AxPsA. The sensitivity to change of these tools needs to be evaluated before
being used routinely for assessing structural damage in
AxPsA.

1422

Biagioni et al
AUTHOR CONTRIBUTIONS

All authors were involved in drafting the article or revising it

critically for important intellectual content, and all authors approved the nal version to be submitted for publication. Dr.
Biagioni had full access to all of the data in the study and takes
responsibility for the integrity of the data and the accuracy of the
data analysis.
Study conception and design. Biagioni, Gladman, Cook, Eder,
Wakhlu, Chandran.
Acquisition of data. Biagioni, Gladman, Eder, Wakhlu, Chandran.
Analysis and interpretation of data. Biagioni, Gladman, Cook,
Shen, Chandran.

14.
15.
16.

17.

REFERENCES
1. Taylor W, Gladman D, Helliwell P, Marchesoni A, Mease P,
Mielants H, and the CASPAR Study Group. Classication
criteria for psoriatic arthritis: development of new criteria
from a large international study. Arthritis Rheum 2006;54:
266573.
2. Gladman DD. Axial disease in psoriatic arthritis. Curr Rheumatol Rep 2007;9:455 60.
3. Laiho K, Kauppi M. The cervical spine in patients with psoriatic arthritis. Ann Rheum Dis 2002;61:650 2.
4. Hanly JG, Russell ML, Gladman DD. Psoriatic spondyloarthropathy: a long term prospective study. Ann Rheum Dis
1988;47:386 93.
5. Helliwell PS, Hickling P, Wright V. Do the radiological
changes of classic ankylosing spondylitis differ from the
changes found in the spondylitis associated with inammatory bowel disease, psoriasis, and reactive arthritis? Ann
Rheum Dis 1998;57:135 40.
6. Jacobson JA, Girish G, Jiang Y, Resnick D. Radiographic evaluation of arthritis: inammatory conditions. Radiology 2008;
248:378 89.
7. MacKay K, Mack C, Brophy S, Calin A. The Bath Ankylosing
Spondylitis Radiology Index (BASRI): a new, validated approach to disease assessment. Arthritis Rheum 1998;41:2263
70.
8. Creemers MC, Franssen MJ, van t Hof MA, Gribnau FW, van
de Putte LB, van Riel PL. Assessment of outcome in ankylosing spondylitis: an extended radiographic scoring system.
Ann Rheum Dis 2005;64:1279.
9. Baraliakos X, Listing J, Rudwaleit M, Sieper J, Braun J. Development of a radiographic scoring tool for ankylosing spondylitis only based on bone formation: addition of the thoracic
spine improves sensitivity to change. Arthritis Rheum 2009;
61:764 71.
10. Lubrano E, Marchesoni A, Olivieri I, DAngelo S, Spadaro A,
Parsons WJ, et al. Psoriatic arthritis spondylitis radiology
index: a modied index for radiologic assessment of axial
involvement in psoriatic arthritis. J Rheumatol 2009;36:1006
11.
11. Boers M, Brooks P, Strand CV, Tugwell P. The OMERACT
lter for Outcome Measures in Rheumatology. J Rheumatol
1998;25:198 9.
12. Dale K. Radiographic gradings of sacroiliitis in Bechterews
syndrome and allied disorders. Scand J Rheumatol Suppl
1979;32:927.
13. Van der Linden S, Valkenburg HA, Cats A. Evaluation of
diagnostic criteria for ankylosing spondylitis: a proposal for

18.

19.

20.

21.
22.
23.
24.
25.

26.

27.

28.

modication of the New York criteria. Arthritis Rheum 1984;

27:361 8.
Gladman DD, Chandran V. Observational cohort studies: lessons learnt from the University of Toronto Psoriatic Arthritis
Program. Rheumatology (Oxford) 2011;50:2531.
Burdick RK, Graybill FA. Condence intervals on variance
components. In: Statistics: a series of textbooks and monographs. New York: Marcel Dekker; 1992. p. 127.
Salaf F, Carotti M, Garofalo G, Giuseppetti GM, Grassi W.
Radiological scoring methods for ankylosing spondylitis: a
comparison between the Bath Ankylosing Spondylitis Radiology Index and the modied Stoke Ankylosing Spondylitis
Spine Score. Clin Exp Rheumatol 2007;25:6774.
Baskan BM, Sivas F, Inal EE, Duran S, Elverici E, Ozoran K, et
al. Comparison of the Bath Ankylosing Spondylitis Radiology
Index and the modied Stoke Ankylosing Spondylitis Spine
score in Turkish patients with ankylosing spondylitis. Clin
Rheumatol 2010;29:6570.
Ulusoy H, Kaya A, Kamanli A, Akgol G, Ozgocmen S. Radiological scoring methods in ankylosing spondylitis: a comparison of the reliability of available methods. Acta Reumatol
Port 2010;35:170 5.
Gladman DD, Brubacher B, Buskila D, Langevitz P, Farewell
VT. Differences in the expression of spondyloarthropathy: a
comparison between ankylosing spondylitis and psoriatic arthritis. Clin Invest Med 1993;16:17.
McEwen C, DiTata D, Lingg C, Porini A, Good A, Rankin T.
Ankylosing spondylitis and spondylitis accompanying ulcerative colitis, regional enteritis, psoriasis and Reiters disease:
a comparative study. Arthritis Rheum 1971;14:291318.
Haddad A, Thavaneswaran A, Toloza S, Chandran V, Gladman DD. Diffuse idiopathic skeletal hyperostosis in psoriatic
arthritis. J Rheumatol 2013;40:136773.
Song IH, Maksymowych WP. Therapeutic controversies: tumor necrosis factor inhibitors in ankylosing spondylitis.
Rheum Dis Clin North Am 2012;38:61333.
Haroon N, Kim TH, Inman RD. NSAIDs and radiographic
progression in ankylosing spondylitis: bagging big game with
small arms? Ann Rheum Dis 2012;71:15935.
Machado P. Antitumor necrosis factor and new bone formation in ankylosing spondylitis: the controversy continues [editorial]. Arthritis Rheum 2013;65:2537 40.
Van der Heijde D, Salonen D, Weissman BN, Landewe R,
Maksymowych WP, Kupper H, et al, the Canadian (M03 606)
Study Group, and the ATLAS study group. Assessment of
radiographic progression in the spines of patients with ankylosing spondylitis treated with adalimumab for up to 2 years.
Arthritis Res Ther 2009;11:R127.
Van der Heijde D, Landewe R, Baraliakos X, Houben H, van
Tubergen A, Williamson P, et al, and the Ankylosing Spondylitis Study for the Evaluation of Recombinant Iniximab
Therapy Study Group. Radiographic ndings following two
years of iniximab therapy in patients with ankylosing spondylitis. Arthritis Rheum 2008;58:306370.
Van der Heijde D, Landewe R, Einstein S, Ory P, Vosse D, Ni
L, et al. Radiographic progression of ankylosing spondylitis
after up to two years of treatment with etanercept. Arthritis
Rheum 2008;58:1324 31.
Haroon N, Inman RD, Learch TJ, Weisman MH, Lee M, Rahbar
MH, et al. The impact of tumor necrosis factor inhibitors on
radiographic progression in ankylosing spondylitis. Arthritis
Rheum 2013;65:264554.