OBJECTIVE: Radiography is still used worldwide for detection of sacroiliitis in juvenile spondyloarthritis (SpA), despite low sensitivity and reliability. We aimed to define unequivocal evidence of sacroiliitis on pelvic radiography in skeletally immature youth for use in classification criteria when MRI is unavailable.

METHODS: Subjects were a retrospective cohort of juvenile spondyloarthritis (SpA) patients with a radiograph and MRI as part of a diagnostic evaluation for axial disease. Six musculoskeletal imaging experts underwent an iterative consensus process to define "unequivocal sacroiliitis" on radiography in skeletally immature youth. Radiographs were graded using the modified New York (mNY) criteria and the unequivocal sacroiliitis criteria. Interrater agreement was assessed with Fleiss' kappa statistic. Specificity, area under receiver operator characteristic (AUROC), and sensitivity of the two measures were tested using 2 MRI reference standards.

RESULTS: 112 subjects, median age 14.9 years were included. Fleiss' kappa was fair for the mNY [0.51 (95% CI: 0.39-0.64)] and unequivocal sacroiliitis criteria [0.55 (95% CI: 0.43-0.66)]. The unequivocal sacroiliitis criteria achieved >90% specificity using both MRI reference standards. Sensitivity (59.26/57.14 vs 44.83/43.33) and AUROC (0.76/0.76 versus 0.71/0.71) were higher, for both reference standards, for the unequivocal sacroiliitis in youth definition than the mNY criteria, respectively.

CONCLUSION: We propose the first consensus-derived definition of unequivocal sacroiliitis by radiography in skeletally immature youth. This definition achieved excellent specificity and had higher AUROC and sensitivity than the mNY criteria using both MRI reference standards. This definition has applicability to juvenile SpA axial disease classification imaging criterion when MRI is unavailable.

<p><strong>BACKGROUND: </strong>The SPARCC sacroiliac joint inflammation (SIS) and structural (SSS) scores are reliable measures to quantify abnormalities in the pediatric sacroiliac joint. We aimed to evaluate the utility of online calibration modules for the SIS and SSS and the reliability of their component change scores.</p>

<p><strong>METHODS: </strong>Change score reliability of 6 raters was assessed by overall and pairwise intraclass correlation coefficients (ICCs) before and after the use of real-time iterative calibration (RETIC) modules for both the SIS and SSS comprised of 20 adult cases. Acceptable ICC for change scores was &gt; 0.7 for SIS and &gt; 0.5 for all SSS components. Sensitivity to change was assessed by the standardized response mean (SRM).</p>

<p><strong>RESULTS: </strong>In scoring exercise 1, the SIS had acceptable reliability with a change score ICC of 0.80 and sclerosis was the only SSS lesion that met the acceptability threshold with a change score ICC of 0.52. After RETIC calibration, the SIS overall (ICC = 0.83) and mean pairwise (ICC = 0.83) change scores remained reliable with a large SRM (0.90). All SSS components except sclerosis met the overall and mean pairwise change score ICC acceptability thresholds-backfill: overall = 0.54, mean pairwise = 0.50; fat metaplasia: overall = 0.65, mean pairwise = 0.57; erosion: overall = 0.60, mean pairwise = 0.58; and ankylosis: overall = 0.96, mean pairwise = 0.96. The SSS RETIC module augmented the number of SSS components surpassing the acceptability threshold from 1 to 4. Sensitivity to change, as measured by the SRM, was large for erosion (0.96), moderate for backfill (0.55) and sclerosis (0.70), and small for fat metaplasia (0.36) and ankylosis (0.28).</p>

<p><strong>CONCLUSION: </strong>RETIC modules improved the overall reliability of SPARCC SIS and SSS change scores for previously calibrated raters. SIS recalibration was not as helpful to the most experienced raters who achieved high levels of agreement before recalibration. The SPARCC SIS and all SSS components except sclerosis are reliable measures to quantify change over time in children. A pediatric-specific RETIC tool should be developed to enhance the calibration of readers.</p>

<p><strong>BACKGROUND: </strong>We aimed to evaluate the diagnostic utility of pelvic radiographs versus magnetic resonance imaging (MRI) of the sacroiliac joints in children with suspected sacroiliitis.</p>

<p><strong>METHODS: </strong>This was a retrospective cross-sectional study of children with suspected or confirmed spondyloarthritis who underwent pelvic radiograph and MRI within 6 months of one another. Images were scored independently by five raters. Interrater reliability was calculated using Fleiss's kappa coefficient (κ). Test properties of radiographs for depiction of sacroiliitis were calculated using MRI global sacroiliitis impression as the reference standard.</p>

<p><strong>RESULTS: </strong>The interrater agreement for global impression was κ = 0.34 (95% CI 0.19-0.52) for radiographs and κ = 0.72 (95% CI 0.52-0.86) for MRI. Across raters, the sensitivity of radiographs ranged from 25 to 77.8% and specificity ranged from 60.8 to 92.2%. Positive and negative predictive values ranged from 25.9 to 52% and from 82.7 to 93.9%, respectively. The misclassification rate ranged from 6 to 17% for negative radiographs/positive MRI scans and from 48 to 74% for positive radiographs/negative MRI scans. When the reference standard was changed to structural lesions consistent with sacroiliitis on MRI, the misclassification rate was higher for negative radiographs/positive MRI scans (9-23%) and marginally improved for positive radiographs/negative MRI scans (33-52%).</p>

<p><strong>CONCLUSION: </strong>Interrater reliability of MRI was superior to radiographs for global sacroiliitis impression. Misclassification for both negative and positive radiographs was high across raters. Radiographs have limited utility in screening for sacroiliitis in children and result in a significant proportion of both false negative and positive findings versus MRI findings.</p>

<p><strong>OBJECTIVE: </strong>There is a critical need for measures to evaluate structural progression in the pediatric sacroiliac joint (SIJ). We aimed to evaluate the construct validity and reliability of the Spondyloarthritis Research Consortium of Canada SIJ Structural Score (SSS) in children with suspected or confirmed juvenile spondyloarthritis.</p>

<p><strong>METHODS: </strong>The SSS assesses structural lesions of the SIJ on magnetic resonance imaging (MRI) through the cartilaginous part of the joint. We conducted 3 sequential reading exercises with 6 readers (1 adult and 3 pediatric radiologists, 1 adult and 1 pediatric rheumatologist). Each exercise was preceded by a calibration module. Interobserver reliability was assessed using intraclass correlation coefficients (ICC). Prespecified acceptable reliability thresholds were ICC &gt; 0.5 for erosion, backfill, and sclerosis, and ICC &gt; 0.7 for ankylosis and fat metaplasia.</p>

<p><strong>RESULTS: </strong>The SSS had face validity and was feasible to score in pediatric cases for all 3 reading exercises. Of the cases used in the 3 exercises, 58% were male and the median age was 14 years (range 6.8-18.7 yrs). After calibration, median ICC across all readers for each SSS component were the following: erosion 0.67 (interquartile range 0.54-0.80), backfill 0.33 (0.19-0.52), fat metaplasia 0.74 (0.62-0.85), sclerosis 0.63 (0.48-0.77), and ankylosis 0.44 (0.28-0.62). Prespecified reliability thresholds were achieved in the third exercise for erosion, sclerosis, and fat metaplasia but not for backfill or ankylosis.</p>

<p><strong>CONCLUSION: </strong>The SSS was feasible to score and had acceptable reliability for pediatric SIJ MRI evaluation. The ICC improved with additional calibration and reading exercises, even for readers with limited experience.</p>

<p><strong>BACKGROUND: </strong>Published methods for quantification of magnetic resonance imaging (MRI) evidence of inflammation in the sacroiliac joint lack validation in pediatric populations. We evaluated the reliability and construct validity of the Spondyloarthritis Research Consortium of Canada (SPARCC) sacroiliac joint inflammation score (SIS) in children with suspected or confirmed juvenile spondyloarthritis (JSpA).</p>

<p><strong>METHODS: </strong>The SPARCC SIS measures the presence, depth, and intensity of bone marrow inflammation on MRI through the cartilaginous part of the joint. Six readers blinded to clinical details except age, participated in two reading exercises, each preceded by a calibration exercise. Inter-observer reliability was assessed using intraclass correlation coefficients (ICCs) and for pre-specified acceptable reliability the inraclass correlation coefficient (ICC) was &gt; 0.8.</p>

<p><strong>RESULTS: </strong>The SPARCC SIS had face validity and was feasible to score in pediatric cases in both reading exercises. Cases were mostly male (64%) and the median age at the time of imaging was 14.9 years. After calibration, the median ICC across all readers for the SIS total score was 0.81 (IQR 0.71-0.89). SPARCC SIS had weak correlation with disease activity (DA) as measured by the JSpADA (r = - 0.12) but discriminated significantly between those with and without elevated C-reactive protein (p = 0.03).</p>

<p><strong>CONCLUSION: </strong>The SPARCC SIS was feasible to score and had acceptable reliability in children. The ICC improved with additional calibration and reading exercises, for both experienced and inexperienced readers.</p>