Article Text

Download PDFPDF

Original article
Canada-Denmark MRI scoring system of the spine in patients with axial spondyloarthritis: updated definitions, scoring rules and inter-reader reliability in a multiple reader setting
  1. Simon Krabbe1,2,
  2. Mikkel Østergaard1,2,
  3. Susanne J Pedersen1,2,
  4. Ulrich Weber3,4,
  5. Georg Kröber3,
  6. Walter Makysmowych5,6 and
  7. Robert G W Lambert7,8
  1. 1Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Denmark
  2. 2Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
  3. 3Danish Hospital for Rheumatic Diseases, University Hospital of Southern Denmark, Sønderborg, Denmark
  4. 4Department of Regional Health Research, University Hospital of Southern Denmark, Odense, Denmark
  5. 5CaRE Arthritis, Edmonton, Alberta, Canada
  6. 6Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
  7. 7Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Alberta, Canada
  8. 8Medical Imaging Consultants, Edmonton, Alberta, Canada
  1. Correspondence to Dr Simon Krabbe; simonkrabbe{at}


Objective To validate the Canada-Denmark (CANDEN) MRI scoring system for the spine in axial spondyloarthritis with updated lesion definitions.

Methods Lesion definitions in the CANDEN system were updated and illustrated by a consensus set of reference images. Sagittal spine MRIs of 40 patients with axial spondyloarthritis obtained at baseline and at week 52 after initiation of treatment with the tumour necrosis factor inhibitor golimumab were evaluated in unknown chronology by seven readers blinded to all other data.

Results CANDEN MRI spine inflammation score had very good reliability for status scores (single-measure intraclass correlation coefficient (ICC) of 21 reader pairs median of 0.91 (IQR 0.88–0.92)) and change scores (ICC 0.88 (0.86–0.92)). CANDEN MRI spine fat score had good to very good reliability for status scores (ICC 0.79 (0.75–0.86)) and moderate to good reliability for detecting change (ICC 0.59 (0.46–0.73)). CANDEN MRI spine bone erosion score and CANDEN MRI spine new bone formation score had slight to moderate reliability for status scores (ICC 0.38 (0.32–0.52) and 0.39 (0.27–0.49), respectively).

Conclusion The CANDEN MRI spine scoring system allows a comprehensive evaluation of inflammation, fat, bone erosion and new bone formation of the spine in patients with axial spondyloarthritis. It demonstrated very good reliability for detecting change in inflammation, moderate to good reliability for detecting change in fat, and slight to moderate reliability for detecting bone erosions and new bone formation. Studies with longer follow-up or patients with more advanced spinal involvement may be needed to reliably detect change in bone erosion and new bone formation scores.

Trial registration number NCT02011386.

  • magnetic resonance imaging
  • spondyloarthritis
  • outcomes research

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

View Full Text

Statistics from


  • Contributors The decision to revise the Canada-Denmark MRI spine scoring system and to perform a multireader reliability scoring exercise was made by all authors. SJP and MØ acquired the images. All authors revised the slideshow files that contain definitions and reference images during the six online meetings. All authors read the MRI scans. SK performed the statistical analyses and drafted the manuscript. All authors approved the final version of the reference image set and the manuscript.

  • Funding Images for this analysis were provided from an investigator-initiated trial (MANGO) sponsored by MSD. MSD had no role in the study design or in the collection, analysis or interpretation of the data, the writing of the manuscript, or the decision to submit the manuscript for publication, and publication of this article was not contingent upon approval by MSD. SK received grants from The Danish Rheumatism Association and Rigshospitalet.

  • Competing interests MØ has received research support and/or consultancy/speaker fees from AbbVie, BMS, Boehringer Ingelheim, Celgene, Eli Lilly, Centocor, GSK, Hospira, Janssen, Merck, Mundipharma, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Schering-Plough, Takeda, UCB and Wyeth. SJP has received speaker fees from MSD, Pfizer, AbbVie, Novartis and UCB, has been an advisory board member for AbbVie and Novartis, and has received research support from AbbVie, MSD and Novartis. UW received speaking fees from AbbVie for serving as convenor for workshops on imaging in SpA. WM has received research support and/or consultancy/speaker fees from AbbVie, Boehringer, Celgene, Eli Lilly, Janssen, Novartis, Pfizer and UCB. RGWL has received consultancy fees from Parexel. The remaining authors declare that they have no competing interests.

  • Patient consent for publication Not required.

  • Ethics approval The study was approved by the Regional Committee on Health Research Ethics, Capital Region of Denmark, approval number: H1-2013-118. All patients provided written consent.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.