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Extended report
Development of the CT Syndesmophyte Score (CTSS) in patients with ankylosing spondylitis: data from the SIAS cohort
  1. Freek de Bruin1,
  2. Anoek de Koning2,
  3. Rosaline van den Berg2,
  4. Xenofon Baraliakos3,
  5. Juergen Braun3,
  6. Sofia Ramiro2,
  7. Floris A van Gaalen2,
  8. Monique Reijnierse1,
  9. Désirée van der Heijde2
  1. 1 Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
  2. 2 Department of Rheumatology, Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands
  3. 3 Department of Rheumatology, Rheumazentrum Ruhrgebiet Herne, Herne, Germany
  1. Correspondence to Professor Désirée van der Heijde, Department of Rheumatology, Leiden University Medical Center, Leiden, 2300 RC, The Netherlands; mail{at}


Objectives To develop the CT Syndesmophyte Score (CTSS) for low-dose CT (ldCT) to assess structural damage in the spine of patients with ankylosing spondylitis (AS) and test its reliability.

Methods Patientswith AS in the SIAS cohort had whole spine ldCT at baseline and 2 years. Syndesmophytes were scored in coronal and sagittal planes in eight quadrants per vertebral unit (VU) as absent=0, <50% of the intervertebral disc space (IDS)=1, ≥50%=2 or bridging the IDS=3 (range 0–552). Images were scored by two readers, paired by patient, blinded to time order. Whole spine and spinal segment status and change scores were calculated. Inter-reader reliability was assessed by intraclass correlation coefficient (ICC), smallest detectable change (SDC) and frequency of scores per VU.

Results 49 patients (mean age 50 years (SD 9.8), 84% men, 88% human leucocyte antigen B27 positive) were included. Mean (SD) scores of reader 1 were: whole spine baseline status score 163 (126) and change score 16 (21), spinal segment baseline status scores 30 (41), 97 (77) and 36 (36) and change scores 2 (7), 12 (18) and 3 (4) for the cervical, thoracic and lumbar spine, respectively. Scores of reader 2 were similar. Whole spine status score ICC was 0.99 and 0.97–0.98 for spinal segments. Whole spine change score ICC was 0.77 and 0.32–0.75 for spinal segments. Whole-spine SDC was 14.4. Score distribution pattern per VU was similar between readers.

Conclusions Using the CTSS, new bone formation in the spine of patients with AS can be assessed reliably. Most progression was seen in the thoracic spine.

  • ankylosing spondylitis
  • outcomes research
  • spondyloarthritis

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  • FB and AK contributed equally.

  • Handling editor Tore K Kvien

  • Contributors DvdH: designed the study. AdK, FdB, RvdB and SR: performed the data analyses. XB, JB, FAvG, MR and RvdB: performed the data collection. AdK and FdB: prepared the first draft of the manuscript. All authors: interpreted the results, commented on the draft manuscript and approved the final submission.

  • Funding Dutch Rheumatism Association.

  • Competing interests None declared.

  • Ethics approval Medical Ethics Committee in Leiden and in Herne.

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

  • Data sharing statement There are no additional data from the study available for sharing.