{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,7]],"date-time":"2026-05-07T05:10:47Z","timestamp":1778130647980,"version":"3.51.4"},"reference-count":39,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2026,4,27]],"date-time":"2026-04-27T00:00:00Z","timestamp":1777248000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: Dual-energy computed tomography (DECT) with virtual non-calcium (VNCa) reconstruction is emerging as an alternative method for identifying bone marrow edema (BME) in cases of inflammatory sacroiliitis, especially when magnetic resonance imaging (MRI) is contraindicated or unavailable. Objectives: The aim of this systematic review and meta-analysis is to evaluate the diagnostic performance of DECT with VNCa reconstruction for detecting BME in inflammatory sacroiliitis, using MRI as the reference standard. Methods: Following PRISMA-DTA guidelines and a pre-registered PROSPERO protocol (CRD420251103652), we searched PubMed, Web of Science, and the Cochrane Library up to June 2025. Seven studies comprising 358 patients and 591 sacroiliac joints were included. Quality assessment was performed using QUADAS-2. Pooled sensitivity and specificity were calculated using a bivariate random-effects regression model. Heterogeneity was evaluated using the I2 statistic. Subgroup analyses were performed for anatomical site and slice thickness, along with a meta-regression according to anatomical site. Publication bias was assessed using Deeks\u2019 test. Results: Quality assessment revealed a moderate risk of bias, primarily related to patient selection. The pooled sensitivity and specificity of DECT VNCa were 78% (95% CI: 65\u201388%) and 83% (95% CI: 71\u201391%), respectively. The area under the SROC curve was 0.91 (95% CI: 0.88\u20130.93), indicating good diagnostic accuracy. Heterogeneity was moderate for sensitivity (I2 \u2248 68%) and high for specificity (I2 \u2248 88%), largely driven by one outlier study. Sensitivity was lower for sacral BME than for iliac BME (69% vs 79%), although this difference did not reach statistical significance (p \u2248 0.07). Specificity tended to be higher with slice thickness \u22651 mm than with &lt;1 mm (90% vs 84%), although the difference was not statistically significant (p \u2248 0.06). Exclusion of one outlier study (Deppe et al.) increased pooled specificity to 92% and reduced heterogeneity. Deeks\u2019 test did not reveal significant publication bias. Conclusions: DECT VNCa has been shown to be highly accurate in the diagnosis of inflammatory sacroiliac BME. Its high specificity makes it suitable for confirming inflammatory activity when an MRI scan is not feasible. However, its sensitivity is moderate and variable, with a trend towards lower values for sacral lesions. This precludes its use as a standalone test to rule out active inflammatory sacroiliitis, especially in young patients. Standardization of acquisition protocols and site-specific diagnostic thresholds is recommended for optimal clinical implementation. Clinical Impact: Clarifying the diagnostic performance of VNCa of DECT to define its role as a complementary tool to MRI for assessing BME in inflammatory sacroiliitis. These results could guide appropriate patient selection and highlight the need for standardized protocols.<\/jats:p>","DOI":"10.3390\/jcm15093337","type":"journal-article","created":{"date-parts":[[2026,4,28]],"date-time":"2026-04-28T09:55:39Z","timestamp":1777370139000},"page":"3337","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Diagnostic Accuracy of Dual Energy CT for Bone Marrow Edema of the Sacroiliac Joints Compared with MRI: A Systematic Review"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0888-5187","authenticated-orcid":false,"given":"Armando","family":"Perrella","sequence":"first","affiliation":[{"name":"Department of Medical, Surgical and Neuro Sciences, University of Siena, 53100 Siena, Italy"},{"name":"Unit of Diagnostic Imaging, Department of Medical Sciences, Azienda Ospedaliero-Universitaria Senese, 53100 Siena, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-6019-8541","authenticated-orcid":false,"given":"Nunzia","family":"Di Meglio","sequence":"additional","affiliation":[{"name":"Unit of Diagnostic Imaging, Department of Medical Sciences, Azienda Ospedaliero-Universitaria Senese, 53100 Siena, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Giulio","family":"Bagnacci","sequence":"additional","affiliation":[{"name":"Department of Medical, Surgical and Neuro Sciences, University of Siena, 53100 Siena, Italy"},{"name":"Unit of Diagnostic Imaging, Department of Medical Sciences, Azienda Ospedaliero-Universitaria Senese, 53100 Siena, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4826-4809","authenticated-orcid":false,"given":"Paolo","family":"Tini","sequence":"additional","affiliation":[{"name":"Department of Medical, Surgical and Neuro Sciences, University of Siena, 53100 Siena, Italy"},{"name":"Unit of Radiation Oncology, Oncological Department, Azienda Ospedaliero-Universitaria Senese, 53100 Siena, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5504-8237","authenticated-orcid":false,"given":"Giandomenico","family":"Roviello","sequence":"additional","affiliation":[{"name":"Department of Health Sciences, University of Florence, 50134 Florence, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nicole","family":"Martini","sequence":"additional","affiliation":[{"name":"Department of Medical, Surgical and Neuro Sciences, University of Siena, 53100 Siena, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-9638-2318","authenticated-orcid":false,"given":"Chiara","family":"Piscitello","sequence":"additional","affiliation":[{"name":"Department of Medical, Surgical and Neuro Sciences, University of Siena, 53100 Siena, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0924-5883","authenticated-orcid":false,"given":"Chiara","family":"Giraudo","sequence":"additional","affiliation":[{"name":"Department of Cardiac, Thoracic, Vascular Sciences and Public Health\u2014DCTV, University of Padova, 35122 Padova, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7352-1275","authenticated-orcid":false,"given":"Luca","family":"Cantarini","sequence":"additional","affiliation":[{"name":"Department of Medical, Surgical and Neuro Sciences, University of Siena, 53100 Siena, Italy"},{"name":"Rheumatology Unit, Department of Medical Sciences, Azienda Ospedaliero-Universitaria Senese, 53100 Siena, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Bruno","family":"Frediani","sequence":"additional","affiliation":[{"name":"Department of Medical, Surgical and Neuro Sciences, University of Siena, 53100 Siena, Italy"},{"name":"Rheumatology Unit, Department of Medical Sciences, Azienda Ospedaliero-Universitaria Senese, 53100 Siena, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6778-6894","authenticated-orcid":false,"given":"Maria Antonietta","family":"Mazzei","sequence":"additional","affiliation":[{"name":"Department of Medical, Surgical and Neuro Sciences, University of Siena, 53100 Siena, Italy"},{"name":"Unit of Diagnostic Imaging, Department of Medical Sciences, Azienda Ospedaliero-Universitaria Senese, 53100 Siena, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2026,4,27]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"777","DOI":"10.1136\/ard.2009.108233","article-title":"The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part II): Validation and final selection","volume":"68","author":"Rudwaleit","year":"2009","journal-title":"Ann. Rheum. Dis."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"205","DOI":"10.1053\/j.sult.2023.03.006","article-title":"Dual Energy CT in Oncology: Benefits for Both Patients and Radiologists From an Emerging Quantitative and Functional Diagnostic Technique","volume":"44","author":"Guerrini","year":"2023","journal-title":"Semin. Ultrasound CT MRI"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"2269","DOI":"10.21037\/gs-20-543","article-title":"Dual energy CT in gland tumors: A comprehensive narrative review and differential diagnosis","volume":"9","author":"Gentili","year":"2020","journal-title":"Gland Surg."},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Perrella, A., Bagnacci, G., Di Meglio, N., Di Martino, V., and Mazzei, M.A. (2023). Thoracic Diseases: Technique and Applications of Dual-Energy CT. Diagnostics, 13.","DOI":"10.3390\/diagnostics13142440"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"e881","DOI":"10.1002\/mp.14157","article-title":"Principles and applications of multienergy CT: Report of AAPM Task Group 291","volume":"47","author":"McCollough","year":"2020","journal-title":"Med. Phys."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1087","DOI":"10.1148\/rg.2016150220","article-title":"Material Separation Using Dual-Energy CT: Current and Emerging Applications","volume":"36","author":"Patino","year":"2016","journal-title":"Radiographics"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"859","DOI":"10.1148\/rg.2020190173","article-title":"Bone Marrow Edema at Dual-Energy CT: A Game Changer in the Emergency Department","volume":"40","author":"Gosangi","year":"2020","journal-title":"Radiographics"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"111916","DOI":"10.1118\/1.4820478","article-title":"A full-spectral Bayesian reconstruction approach based on the material decomposition model applied in dual-energy computed tomography","volume":"40","author":"Cai","year":"2013","journal-title":"Med. Phys."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"112293","DOI":"10.1016\/j.ejrad.2025.112293","article-title":"Improved accuracy of bone marrow edema detection in patients with hip pain using dual-energy computed tomography: Optimization of blended material density images combining water-calcium and water-hydroxyapatite","volume":"191","author":"Yoshii","year":"2025","journal-title":"Eur. J. Radiol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"110","DOI":"10.1148\/radiol.2021203624","article-title":"DECT in Detection of Vertebral Fracture-associated Bone Marrow Edema: A Systematic Review and Meta-Analysis with Emphasis on Technical and Imaging Interpretation Parameters","volume":"300","author":"Sair","year":"2021","journal-title":"Radiology"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1958","DOI":"10.1136\/annrheumdis-2015-208642","article-title":"Defining active sacroiliitis on MRI for classification of axial spondyloarthritis: Update by the ASAS MRI working group","volume":"75","author":"Lambert","year":"2016","journal-title":"Ann. Rheum. Dis."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1550","DOI":"10.1136\/annrheumdis-2019-215589","article-title":"MRI lesions in the sacroiliac joints of patients with spondyloarthritis: An update of definitions and validation by the ASAS MRI working group","volume":"78","author":"Maksymowych","year":"2019","journal-title":"Ann. Rheum. Dis."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"658","DOI":"10.1016\/j.jfma.2015.07.003","article-title":"A novel diagnostic method (spectral computed tomography of sacroiliac joints) for axial spondyloarthritis","volume":"115","author":"Zhang","year":"2016","journal-title":"J. Formos. Med. Assoc."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"157","DOI":"10.1148\/radiol.2018181168","article-title":"Axial Spondyloarthritis: Dual-Energy Virtual Noncalcium CT in the Detection of Bone Marrow Edema in the Sacroiliac Joints","volume":"290","author":"Wu","year":"2019","journal-title":"Radiology"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"3393","DOI":"10.1007\/s00330-020-06670-7","article-title":"Bone marrow edema in sacroiliitis: Detection with dual-energy CT","volume":"30","author":"Chen","year":"2020","journal-title":"Eur Radiol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1316","DOI":"10.55563\/clinexprheumatol\/xdlfzb","article-title":"Dual-energy computed tomography for the detection of sacroiliac joints bone marrow oedema in patients with axial spondyloarthritis","volume":"39","author":"Carotti","year":"2021","journal-title":"Clin. Exp. Rheumatol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"28","DOI":"10.1186\/s13018-024-05341-3","article-title":"Diagnostic efficacy of dual-energy CT virtual non-calcium technique in the diagnosis of bone marrow edema of sacroiliac joints in ankylosing spondylitis","volume":"20","author":"Lu","year":"2025","journal-title":"J. Orthop. Surg. Res."},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Deppe, D., Ziegeler, K., Hermann, K.G.A., Proft, F., Poddubnyy, D., Radny, F., Makowski, M.R., Muhle, M., and Diekhoff, T. (2023). Dual-Energy-CT for Osteitis and Fat Lesions in Axial Spondyloarthritis: How Feasible Is Low-Dose Scanning?. Diagnostics, 13.","DOI":"10.3390\/diagnostics13040776"},{"key":"ref_19","first-page":"35","article-title":"Value of dual-energy CT virtual noncalcium in the diagnosis of sacroiliac joint bone marrow edema","volume":"27","author":"Chen","year":"2021","journal-title":"J. Hainan Med. Univ."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"110359","DOI":"10.1016\/j.ejrad.2022.110359","article-title":"Diagnostic accuracy of dual-energy computed tomography (DECT) to detect non-traumatic bone marrow edema: A systematic review and meta-analysis","volume":"153","author":"Chen","year":"2022","journal-title":"Eur. J. Radiol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"4182","DOI":"10.1007\/s00330-018-5411-5","article-title":"Diagnostic performance of dual-energy CT for the detection of bone marrow oedema: A systematic review and meta-analysis","volume":"28","author":"Suh","year":"2018","journal-title":"Eur. Radiol."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1558","DOI":"10.1007\/s00330-020-07236-3","article-title":"Diagnostic accuracy of dual-energy CT for the detection of bone marrow edema in the appendicular skeleton: A systematic review and meta-analysis","volume":"31","author":"Wilson","year":"2021","journal-title":"Eur. Radiol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"561","DOI":"10.1007\/s00330-021-08081-8","article-title":"Comprehensive comparison of dual-energy computed tomography and magnetic resonance imaging for the assessment of bone marrow edema and fracture lines in acute vertebral fractures","volume":"32","author":"Cavallaro","year":"2022","journal-title":"Eur. Radiol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"871","DOI":"10.1007\/s00256-020-03646-y","article-title":"Diagnostic accuracy of dual-energy CT for detecting bone marrow edema in patients with acute knee injuries: A systematic review and meta-analysis","volume":"50","author":"Wilson","year":"2021","journal-title":"Skelet. Radiol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"4098","DOI":"10.1007\/s00330-020-06775-z","article-title":"Bone marrow edema around the hip in non-traumatic pain: Dual-energy CT vs MRI","volume":"30","author":"Foti","year":"2020","journal-title":"Eur. Radiol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1712","DOI":"10.1016\/j.ejmp.2016.08.004","article-title":"Water\/cortical bone decomposition: A new approach in dual energy CT imaging for bone marrow oedema detection. A feasibility study","volume":"32","author":"Biondi","year":"2016","journal-title":"Phys. Med."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1374","DOI":"10.1002\/art.10934","article-title":"Anatomic structures involved in early- and late-stage sacroiliitis in spondylarthritis: A detailed analysis by contrast-enhanced magnetic resonance imaging","volume":"48","author":"Muche","year":"2003","journal-title":"Arthritis Rheum."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"375","DOI":"10.1093\/rheumatology\/41.4.375","article-title":"Sacral and iliac articular cartilage thickness and cellularity: Relationship to subchondral bone end-plate thickness and cancellous bone density","volume":"41","author":"McLauchlan","year":"2002","journal-title":"Rheumatology"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"503","DOI":"10.1046\/j.1469-7580.2001.19950503.x","article-title":"The anatomical basis for disease localisation in seronegative spondyloarthropathy at entheses and related sites","volume":"199","author":"Benjamin","year":"2001","journal-title":"J. Anat."},{"key":"ref_30","first-page":"2295","article-title":"Ankylosing spondylitis\u2013at the interface of bone and cartilage","volume":"27","author":"Maksymowych","year":"2000","journal-title":"J. Rheumatol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"171","DOI":"10.1016\/0021-9681(78)90032-2","article-title":"Comparison of osteitis condensans ilii and ankylosing spondylitis in female patients: Clinical, radiological and HLA typing characteristics","volume":"31","author":"Gordon","year":"1978","journal-title":"J. Chronic Dis."},{"key":"ref_32","doi-asserted-by":"crossref","unstructured":"Francavilla, M.L., Brandon, T.G., Khrichenko, D., Xiao, R., Chauvin, N.A., Khwaja, A., and Weiss, P.F. (Arthritis Care Res., 2025). Diffusion-Weighted Imaging for the Evaluation of the Sacroiliac Joint in Pediatric Patients, Arthritis Care Res., ahead of print.","DOI":"10.1002\/acr.25661"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"62","DOI":"10.1016\/j.ejrad.2008.01.056","article-title":"Histopathological perspective on bone marrow oedema, reactive bone change and haemorrhage","volume":"67","author":"Thiryayi","year":"2008","journal-title":"Eur. J. Radiol."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"551","DOI":"10.2214\/AJR.22.28418","article-title":"Photon-Counting Detector CT for Musculoskeletal Imaging: A Clinical Perspective","volume":"220","author":"Baffour","year":"2023","journal-title":"AJR Am. J. Roentgenol."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"e222432","DOI":"10.1148\/radiol.222432","article-title":"Clinical Applications of Photon-counting CT: A Review of Pioneer Studies and a Glimpse into the Future","volume":"309","author":"Douek","year":"2023","journal-title":"Radiology"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"293","DOI":"10.1148\/radiol.2018172656","article-title":"Photon-counting CT: Technical Principles and Clinical Prospects","volume":"289","author":"Willemink","year":"2018","journal-title":"Radiology"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"387","DOI":"10.1007\/s11914-024-00876-0","article-title":"Photon-Counting Computed Tomography for Microstructural Imaging of Bone and Joints","volume":"22","author":"Quintiens","year":"2024","journal-title":"Curr. Osteoporos. Rep."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"68","DOI":"10.1097\/RLI.0000000000001201","article-title":"Dual-Source Dual-Energy Imaging Using Photon-Counting Detector CT for Bone Edema Detection: Leveraging Tin Prefiltration for Improved Spectral Performance","volume":"61","author":"Rajendran","year":"2026","journal-title":"Investig. Radiol."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"n71","DOI":"10.1136\/bmj.n71","article-title":"The PRISMA 2020 statement: An updated guideline for reporting systematic reviews","volume":"372","author":"Page","year":"2021","journal-title":"BMJ"}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/9\/3337\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,7]],"date-time":"2026-05-07T04:15:42Z","timestamp":1778127342000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/9\/3337"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,27]]},"references-count":39,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2026,5]]}},"alternative-id":["jcm15093337"],"URL":"https:\/\/doi.org\/10.3390\/jcm15093337","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,27]]}}}