REVIEWIs it time to move on from pelvic radiography as the first-line imaging modality for suspected sacroiliitis?Eshed, Irisa,∗; Diekhoff, Torstenb,∗; Hermann, Kay Geert A.b Author Information aDepartment of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer, Israel, affiliated with the Sackler School of Medicine, Tel Aviv University, Tel-Aviv, Israel bDepartment of Radiology (CCM), Charité - Universitätsmedizin Berlin, Campus Mitte, Humboldt-Universität Zu Berlin, Freie Universität Berlin, Charitéplatz 1, Berlin, Germany Correspondence to Iris Eshed, MD, Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer 52621, Israel. Tel: +972 3 5302498; fax: +972 3 5302220; e-mail: [email protected] Current Opinion in Rheumatology ():10.1097/BOR.0000000000000925, December 28, 2022. | DOI: 10.1097/BOR.0000000000000925 Buy PAP Metrics Abstract Purpose of review Pelvic radiography in which structural lesions characteristic of sacroiliitis can be detected, is recommended as the first imaging modality when axial spondyloarthritis (axSpA) is suspected clinically. However, cross-sectional modalities like computed tomography (CT) and magnetic resonance imaging (MRI) are superior to radiographs for diagnosing sacroiliitis. Thus, we currently debate the role of radiography as first imaging modality in the diagnostic workup of axSpA. Recent findings Diagnosing sacroiliitis on pelvic radiographs is challenging with large interobserver and intraobserver variation. Low-dose CT (ldCT) of the sacroiliac joints (SIJs) was proved to be more sensitive and reliable than radiographs with comparable ionizing radiation exposure. MRI is the preferred modality for detecting early SIJ inflammation, well before structural lesions evolve. New, promising MRI sequences sensitive to cortical bone improve erosion detection, making MRI a one-stop shop for the diagnosis of sacroiliitis. Summary Given the debatable additive value of pelvic radiographs for the detection of sacroiliitis, and the presence of excellent alternatives for imaging the bony cortex of the SIJs such as ldCT and MRI with state-of-the-art sequences sensitive to cortical bone, it is high time to discuss the use of these more accurate modalities instead of radiographs. Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.