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Pubmed, MEDLINE, EMBASE, and the Cochrane Library databases were searched from inception to August 2019. All comparative and non\u2010comparative studies that evaluated the clinical effectiveness of TNFi on radiographic progression as assessed by mSASSS change at a minimum follow\u2010up of 1\u00a0year were included. The Newcastle\u2013Ottawa Scale and Cochrane Collaboration Risk of Bias Tool were utilized to assess the methodological quality. Pooled analysis was performed for continuous and binomial variables where appropriate. Inter\u2010rater reliability of mSASSS status and change scores were assessed with intra\u2010class coefficients (ICC). Twenty\u2010one studies were identified with a total of 4460 patients (mean age: 40.4\u00a0years [range 25.3\u201050\u00a0years]; 76% male; mean baseline mSASSS: 12.7 units [range 5.5\u201019.8 units]). All studies (3 randomized and 18 observational studies) were considered to have moderate\u2010to\u2010high methodological quality. The inter\u2010rater reliability of mSASSS status and change scores from 14 of the 21 studies were excellent (ICC ranges, 0.91\u20100.99) and moderate\u2010to\u2010excellent (ICC ranges, 0.58\u20100.90), respectively. From the 21 studies, 11\/21 (50%) demonstrated a delayed effect in mSASSS in AS patient administered TNFi. When stratifying these studies into those with \u22644\u00a0years of follow\u2010up and &gt;4\u00a0years follow\u2010up, 3\/11 (27%) and 8\/10 (80%) studies respectively indicated a delayed effect of mSASSS with TNFi in AS patients. Pooling for meta\u2010analysis from 3 studies (1159 patients) with study durations ranging 4\u20108\u00a0years, indicated that TNFi\u2010treated patients had reduced odds of structural progression (odds ratio 0.81; 95% CI 0.68\u20100.96; <jats:italic>P<\/jats:italic>\u00a0=\u00a0.01; <jats:italic>I<\/jats:italic><jats:sup>2<\/jats:sup>\u00a0=\u00a00%). Mean rate of mSASSS change from 16 studies ranged from \u22120.15 to 7.3 mSASSS units for all AS patients. Meta\u2010analysis indicated a numerical, but statistically non\u2010significant, reduction in the rate of mSASSS change with TNFi treatment (7 studies [1438 patients]; mean difference, \u22120.24; 95% CI, \u22120.49\u20100.01; <jats:italic>P<\/jats:italic>\u00a0=\u00a0.06; <jats:italic>I<\/jats:italic><jats:sup>2<\/jats:sup>\u00a0=\u00a00%). This systematic review and meta\u2010analysis indicated that &gt;4\u00a0years of TNFi usage was associated with delayed structural progression by mSASSS. The narrative analysis of the data from 21 studies further confirmed that studies with &gt;4\u00a0years of follow\u2010up had delayed structural progression with TNFi use in AS patients. The systematic review also confirmed that mSASSS has good\u2010to\u2010excellent inter\u2010rater reliability in AS.<\/jats:p>","DOI":"10.1111\/1756-185x.13829","type":"journal-article","created":{"date-parts":[[2020,5,18]],"date-time":"2020-05-18T04:09:30Z","timestamp":1589774970000},"page":"728-743","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":15,"title":["Effect of TNF\u2010inhibitor therapy on spinal structural progression in ankylosing spondylitis patients: A systematic review and meta\u2010analysis"],"prefix":"10.1111","volume":"23","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8819-1347","authenticated-orcid":false,"given":"Prabjit","family":"Ajrawat","sequence":"first","affiliation":[{"name":"Division of Rheumatology Department of Medicine Faculty of Medicine University of Toronto Toronto ON Canada"},{"name":"University Health Network Toronto ON Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zahi","family":"Touma","sequence":"additional","affiliation":[{"name":"Division of Rheumatology Department of Medicine Faculty of Medicine University of Toronto Toronto ON Canada"},{"name":"University Health Network Toronto ON Canada"},{"name":"Institute of Health Policy, Management and Evaluation University of Toronto Toronto ON Canada"},{"name":"Krembil Research Institute Toronto ON Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ismail","family":"Sari","sequence":"additional","affiliation":[{"name":"Division of Rheumatology Department of Medicine Faculty of Medicine University of Toronto Toronto ON Canada"},{"name":"Department of Rheumatology Dokuz Eylul University School of Medicine Izmir Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cameron","family":"Taheri","sequence":"additional","affiliation":[{"name":"Division of Rheumatology Department of Medicine Faculty of Medicine University of Toronto Toronto ON Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Juan Pablo","family":"Diaz Martinez","sequence":"additional","affiliation":[{"name":"Division of Rheumatology Department of Medicine Faculty of Medicine University of Toronto Toronto ON Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nigil","family":"Haroon","sequence":"additional","affiliation":[{"name":"Division of Rheumatology Department of Medicine Faculty of Medicine University of Toronto Toronto ON Canada"},{"name":"University Health Network Toronto ON Canada"},{"name":"Krembil Research Institute Toronto ON Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2020,5,17]]},"reference":[{"key":"e_1_2_7_2_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen-2014-006634"},{"key":"e_1_2_7_3_1","doi-asserted-by":"publisher","DOI":"10.1038\/s41584-018-0006-8"},{"key":"e_1_2_7_4_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.berh.2014.10.008"},{"key":"e_1_2_7_5_1","doi-asserted-by":"publisher","DOI":"10.1136\/ard.2004.020503"},{"key":"e_1_2_7_6_1","doi-asserted-by":"publisher","DOI":"10.1002\/art.20446"},{"key":"e_1_2_7_7_1","first-page":"125","article-title":"Radiological scoring methods in ankylosing spondylitis. 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