The ‘Tree trunk and root’ model: key imaging findings may anatomically differentiate axial psoriatic arthritis and DISH from axial spondyloarthropathy

Variable axial skeleton inflammation and axial skeleton tissue remodelling with aberrant ligamentous soft-tissue ossification occurs across the axial spondyloarthritis (ax-SpA) axial psoriatic arthritis (ax-PsA) and the diffuse idiopathic skeletal hyperostosis (DISH) spectrum. In this article, we show how imaging has resulted in an enthesis-centric model for different disease pathology compartmentalisation or a ‘root and trunk’ model for pathological process development. Whilst ankylosing spondylitis is predominantly characterised by early entheseal bony anchorage-related osteitis (root inflammation) and DISH is characterised by ligamentous soft-tissue ossification, ax-PsA is more heterogenous. Whilst ax-PsA may share an identical osteitis pattern to ax-SpA, a substantial proportion of ax-PsA cases have a soft tissue or tree trunk pathology that manifests as back pain with lack of osteitis but prominent ligamentous trunk ossification at later stages. We illustrate this using different imaging modalities to create a base for imaging research to elucidate this pattern of pathology.