Ultrasound imaging in spondyloarthropathies

doi:10.1016/j.berh.2010.05.003

Best Practice & Research Clinical Rheumatology

Volume 24, Issue 5, October 2010, Pages 693-700

https://doi.org/10.1016/j.berh.2010.05.003 Get rights and content

Through recent technological advances, ultrasound allows high-resolution visualisation of inflammatory and destructive changes in tendon and joint structures. Over the last few years, the added value of the use of ultrasound for evaluating entheseal involvement in spondyloarthritis (SpA) patients has been demonstrated. Several studies have described the ultrasound features of enthesitis in SpA, revealing the high frequency of clinically asymptomatic abnormal findings. It is, therefore, highly relevant to consider the validity of ultrasonographic measures of entheseal inflammation and damage. This article focusses on ultrasound appearance of peripheral enthesitis, and underlines the advantages and current limitations of the technique for the management of SpA.

Section snippets

Ultrasound appearance of musculoskelal lesions of SpA

Ultrasound manifestations of synovitis, erosions and tenosynovitis in SpA patients are not different from those observed in other inflammatory arthritis including RA. The main difference seems to relate to the ultrasound appearance of enthesitis, that is, inflammation at the insertion of tendons, ligaments and capsules into the bone, which is seen as a primary lesion that may underlie all SpA skeletal manifestations [3], *[4], [5].

The extensive description of entheseal involvement by ultrasound

Can ultrasound be helpful for assessing SpA?

The use of ultrasound in the management of SpA has remained less often evaluated than in RA. This discrepancy is probably due to the greater difficulty of assessing vascular blood flow with Doppler at the entheses compared to other tissues such as the synovium [12], [13], *[14], [15], [16], [17]. This difference can be explained not only by a greater abundance of vessels in the inflamed synovium compared to the enthesis [12], [13], *[14], but also by the possible presence of Doppler artefacts

Early or suspected disease

Although manuscript titles may occasionally suggest so, no studies have truly investigated the diagnostic value of ultrasound in SpA. It would be expected that the ability of ultrasound to visualise intra- as well as extra-articular changes would translate into ultrasound’s ability to assist in the clinical process of diagnosing a specific rheumatologic condition, but this is not scientifically verified. The lack of information may partially be due to the relatively new use of ultrasound in SpA

Follow-up of the disease course

Until recently, the treatment options for SpA were limited. Thus, in the past, no attempts were made to search for an objective tool which might correlate with treatment response. Only two previous studies have investigated the value of ultrasound in following up SpA patients [26], [36]. In those studies, ultrasound was used as a method of detecting improvement both at the entheses and also at the joint. The effect of sulphasalazine therapy on enthesitis was investigated in both studies, and

How to quantify enthesitis involvement by ultrasound?

Quantification of disease still remains an important aspect in the management of SpA, both for activity and structural damage. For this purpose, scoring systems are relevant for monitoring changes. Scoring systems can be qualitative, semi-quantitative or quantitative. Semi-quantitative scoring systems are usually used for quantifying ultrasound lesions.

The first and still most commonly accepted ultrasound scoring system on enthesitis, the Glasgow enthesitis scoring system (GUESS), was developed

Prognosis

No ultrasound data are as yet available about the potential prognostic value of ultrasound in SpA.

Standardisation and reliability

Despite promising results, the use of power Doppler ultrasound in the management of SpA has remained less often evaluated than MRI, which has been widely promoted for the detection of axial inflammation. This discrepancy is probably due to the perception that ultrasound remains an unreliable imaging technique. Few studies have previously evaluated the overall reliability of power Doppler in rheumatology [44], [45], [46]. They all concerned the reliability of joint pathologies in general (i.e.,

Conclusions and future perspectives

Grey-scale ultrasound, coupled with power Doppler, seems to be a reliable imaging method to assess enthesitis in SpA patients. However, further validation is still needed as ultrasound is an evolving technique. Histological studies of enthesis combined with ultrasound imaging may clarify the importance of this technique for this particular use. Despite the concerns about being an operator-dependent imaging modality, all studies have supported the good reproducibility of ultrasound. It should be

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Cited by (45)

Musculoskeletal ultrasonography of the Achilles tendon and plantar fascia in spondyloarthritis patients
2018, Egyptian Rheumatologist
Citation Excerpt :
However, there are no definite clinical criteria to diagnose these manifestations, which may even be asymptomatic and detected only by imaging, such as conventional radiography, bone scintigraphy, magnetic resonance imaging (MRI), or ultrasonography (US) [2–4]. Musculoskeletal ultrasonography (MSKUS) has proved to be a sensitive and non-invasive tool to assess the presence of enthesitis [4–14] which is characterised by tendon thickening, loss of tendon fibrillar pattern with hypoechogenicity, local calcifications, bony erosions and enthesophytes detected using B mode [11,12,14,15]. For more than a decade, several studies have shown the interest of ultrasound to detect enthesopathies, but considering that enthesitis of SpA is often underestimated or attributed by mistake to another cause, power Doppler US (PDUS) technology has allowed recently, the visualization of abnormal vascularisation at the insertion of the entheses into the cortical bone, which it is described as the typical sign of US enthesitis in SpA [13,14,16–18].
To assess the frequency and severity of peripheral enthesitis in spondyloarthritis (SpA) patients using musculoskeletal ultrasound (MSKUS) in B mode associated with power Doppler (PD) compared to a group of patients with mechanical low back pain (M-LBP).
The study included 40 SpA patients and 20 M-LBP patients as a control group. Ultrasound (US) in B mode and PD was performed at Achilles tendon (AT) and plantar fascia (PF).
The mean age of SpA patients was 41.9 ± 14.3 years and disease duration 8.4 ± 5.8 years. Axial form was found in 36 cases (90%) and peripheral form in 4 (10%). The mean ESR was 28.3 ± 23.2 mm/1sth and the CRP was 22.9 ± 31.2 mg/l. In SpA patients 109/160 (68.1%) of the assessed entheseal sites were significantly abnormal compared to 27/80 (33.8%) in M-LBP patients (AT p < .0001 and PF p = .02). Compared to the M-LBP patients, a significant difference was found in AT for hypoechogenicity (p = .006) and bone erosion (p = .005) and at both entheses for cortical hypervascularisation (AT: p < .0001 and PF: p = .03). Otherwise, in SpA patients, 60.2% (53/88) of non tender entheses showed at least one ultrasound abnormality compared to 77.8% (56/72) of tender entheses. A significant correlation was identified between clinical and ultrasound assessment (r = 0.4, p = .01).
The frequency of enthesitis was high among SpA compared with M-LBP patients and AT was the most affected enthesis. Abnormal vascularization in the cortical bone insertion of entheses was detected especially in SpA patients, and there was great evidence of subclinical enthesitis.
Detection of subclinical ultrasound enthesopathy and nail disease in patients at risk of psoriatic arthritis
2018, Revue du Rhumatisme (Edition Francaise)
Détecter des anomalies infracliniques des enthèses et des ongles par échographie en échelle de gris ( mode B) et en mode Doppler puissance (DP) en comparant des patients présentant soit un psoriasis unguéal, soit un psoriasis inversé et du cuir chevelu.
Cette étude prospective monocentrique a inclus des patients atteints de psoriasis unguéal, inversé ou du cuir chevelu ne présentant pas de rhumatisme psoriasique ou ne recevant pas de traitement systémique. Une évaluation clinique et échographique de 14 enthèses et de 12 ongles a été réalisée par un dermatologue (évaluation clinique) et un rhumatologue (échographie).
Cinq cent dix-huit enthèses ont été analysées sans qu’aucune différence statistique ne soit observée entre les deux groupes pour l’enthésopathie en échelle de gris (p = 0,66). Le signal DP des enthèses était faible (< 1 %) dans les deux groupes. La matrice était significativement plus épaisse en cas d’atteinte unguéale (1,94 mm vs 1,77 mm ; p = 0,007). Le signal DP mesuré dans l’épaisseur de la peau au niveau de l’articulation distale et la perte de la structure trilaminaire ont également été associés de manière significative au psoriasis unguéal (p = 0,037 et p < 0,0001 respectivement).
La détection d’enthésopathie infraclinique par échographie est relativement courante dans les deux groupes, contrairement à la détection d’enthésites en mode DP, mais sans que la différence soit statistiquement significative. L’échographie est un outil efficace pour évaluer les composantes de l’ongle psoriasique (perte de la structure trilaminaire, épaississement de l’ongle et inflammation) significativement associées au psoriasis unguéal.
Detection of subclinical ultrasound enthesopathy and nail disease in patients at risk of psoriatic arthritis
2017, Joint Bone Spine
Citation Excerpt :
It is important to keep in mind that enthesitis is different from enthesopathy [30]. Enthesitis was defined as the presence of inflammation in tendons, ligaments and capsules insertions into the bone, which can be detected by PDUS [25]. Abnormal vascularization at these sites is considered to be seen exclusively in SpA patients.
To detect subclinical entheses and nail abnormalities using gray-scale (GS) and power Doppler ultrasonography (PDUS) between patients with nail psoriasis and those with inverse and scalp psoriasis.
In this prospective monocentric study, patients with nail, inverse and scalp psoriasis, without psoriatic arthritis or systemic treatment, were included. Clinical evaluation and ultrasonographic assessment of 14 entheses and 12 nails were done by a dermatologist (clinical assessment) and a rheumatologist (ultrasonographic assessment).
518 entheses were analyzed, with no statistical difference between the two groups when considering GS enthesopathy (P = 0.66). PDUS signal of the entheses were low (< 1%) in both groups. Matrix thickness was significantly higher in patients with nail disease (1.94 mm vs. 1.77 mm; P = 0.007). PDUS of the skin thickness at the level of distal joint and the loss of the trilaminar appearance were also significantly associated with nail psoriasis (P = 0.037 and P < 0.0001 respectively).
Detection of subclinical US enthesopathy is not so rare in both groups, unlike PD signal, but with no statistical difference. US are a good tool to evaluate the different components of psoriatic nails (loss of trilaminar appearance, nail thickening and inflammation of the skin thickness) which are significantly associated with nail psoriasis.
Imaging Evaluation of the Entheses: Ultrasonography, MRI, and Scoring of Evaluation
2016, Rheumatic Disease Clinics of North America
Citation Excerpt :
Moreover, there are not available scoring systems at the moment. Therefore, US should be considered the method of choice both in clinical practice and in the research setting.40,41 The extensive description of US involvement of entheses in SpA patients was made for the first time by Lehtinen and colleagues42 in 1994 and then by Balint and colleagues43 in 2002.
Ultrasound scores: Interest in rheumatology practice (example of rheumatoid arthritis and spondyloarthritis)
2015, Revue du Rhumatisme Monographies
L’échographie a pris une place considérable dans la prise en charge de certains rhumatismes inflammatoires depuis dix ans, comme dans la polyarthrite rhumatoïde, et commence ainsi à apparaître dans certaines recommandations de sociétés savantes internationales pour le suivi de ces rhumatismes. Dans le domaine de la recherche clinique, de nombreux scores ont été développés pour le suivi échographique, essentiellement pour juger l’efficacité des traitements, mais peu ont pu être transposés à la pratique clinique en raison d’une faisabilité médiocre. La plupart des scores ont concerné l’évaluation des synovites et parfois aussi celui des ténosynovites, voire des érosions dans la polyarthrite rhumatoïde, ainsi que l’évaluation de l’atteinte enthésitique de la spondyloarthrite. Peu de ces scores ont été bien validés en termes métrologiques jusqu’à présent, ce qui est pourtant un pré-requis indispensable avant de les incorporer à un suivi en pratique quotidienne. Le DAS28 échographique, la Naredo 12 articulations et le score de Backhaus 7 articulations apparaissent comme les scores les plus intéressants pour la pratique clinique dans le domaine du suivi de la polyarthrite rhumatoïde. Concernant la spondyloarthrite, il reste difficile de recommander un score particulier pour les enthésites pour la pratique quotidienne compte tenu des incertitudes qui persistent sur la définition de l’enthésite échographique et sur la qualité de la validation pour la plupart de ces scores.
The role of ultrasonography in the management of certain inflammatory rheumatisms such as rheumatoid arthritis has grown over the last ten years. Ultrasonography is now beginning to appear in certain recommendations of international learned societies for the follow-up of these rheumatisms. In the field of clinical research, many scores have been developed for ultrasound follow-up, essentially to evaluate treatment efficacy, but few have been transposed to clinical practice because of their mediocre feasibility. Most of these scores concerned the evaluation of synovitis and sometimes tenosynovitis, or even erosions in rheumatoid arthritis, or the evaluation of enthesitis in spondyloarthritis. To date, few of these scores have been satisfactorily validated in terms of their metrological properties, which is nonetheless, a prerequisite before their use in everyday clinical practice for follow-up purposes. The ultrasound DAS28, the 12-joint Naredo and the 7-joint Backhaus score appear to be the most useful scores for the follow-up of rheumatoid arthritis in clinical practice. Concerning spondyloarthritis, it is still difficult to recommend a particular score for enthesitis for use in everyday practice given the persisting uncertainties about the ultrasound definition of enthesitis and on the quality of validation for most of these scores.
The assessment of lesions of the Achilles tendon by ultrasound imaging in inflammatory arthritis: A systematic review and meta-analysis
2015, Seminars in Arthritis and Rheumatism
Ultrasound (US) is a highly sensitive, reliable and non-invasive tool, which allows for the assessment of lesions of tendons and entheseal sites. The aim of this systematic review and meta-analysis is to identify differences in US lesions of the Achilles tendon (AT) between people with inflammatory arthritis (IA) and healthy controls.
An electronic literature search was performed on Medline, CINAHL, SportDiscus and The Cochrane Library. Methodological quality was assessed using a modified Quality Index. Odds ratios with 95% confidence intervals (CI) were determined. Meta-analysis was conducted on those studies that were considered to be homogenous.
A total of 13 high-to-medium quality studies met the inclusion criteria. The majority of studies reported US lesions in spondyloarthropathy (SpA), with limited evidence for other forms of IA. US lesions were not consistently defined with regard to Outcome Measures in Rheumatology Clinical Trials (OMERACT) definitions, and numerous scoring systems were used across the majority of studies. The mean AT thickness at the enthesis in people with SpA was 0.54 mm thicker (95% CI: 0.10–0.97 mm) with more frequent erosions in people with SpA (odds ratio = 7.43, 95% CI: 1.99–27.77, P = 0.003) and rheumatoid arthritis (RA) (odds ratio = 9.60, 95% CI: 1.23–74.94, P = 0.03), compared to controls. There was no significant difference in the frequency of enthesophyte formation in people with SpA compared to the controls (odds ratio = 2.48, 95% CI: 0.64–9.70, P = 0.19).
The systematic review identified that a majority of studies reporting US lesions were in SpA, but limited evidence relating to other forms of IA. Consistent application of the OMERACT US definitions and scoring of US lesions is required in future studies of AT disease in IA. Further work is also required to distinguish between US lesions reflective of inflammation and structural damage.

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9Ultrasound imaging in spondyloarthropathies

Section snippets

Ultrasound appearance of musculoskelal lesions of SpA

Can ultrasound be helpful for assessing SpA?

Early or suspected disease

Follow-up of the disease course

How to quantify enthesitis involvement by ultrasound?

Prognosis

Standardisation and reliability

Conclusions and future perspectives

Joint, Bone, Spine

Best Practice & Research. Clinical Rheumatology

Lancet

Best Practice & Research. Clinical Rheumatology

Clinics in Rheumatic Diseases

Joint, Bone, Spine

Best Practice & Research. Clinical Rheumatology

The enthesopathy of ankylosing spondylitis

British Journal of Rheumatology

Sonographic analysis of enthesopathy in the lower extremities of patients with spondylarthropathy

Clinical and Experimental Rheumatology

Ultrasonography of entheseal insertions in the lower limb in spondyloarthropathy

Annals of the Rheumatic Diseases

Assessment of peripheral enthesitis in the spondylarthropathies by ultrasonography combined with power Doppler: a cross-sectional study

Arthritis and Rheumatism

Power Doppler sonography: applications in musculoskeletal imaging

Seminars in Musculoskeletal Radiology

Detection of soft-tissue hyperemia: value of power Doppler sonography

AJR. American Journal of Roentgenology

Power Doppler ultrasonography and synovitis: correlating ultrasound imaging with histopathological findings and evaluating the performance of ultrasound equipments

Annals of the Rheumatic Diseases

The premiere enthesis

The Journal of Rheumatology

Advances in the understanding of entheseal inflammation

Current Rheumatology Reports

Enthesitis in spondyloarthropathy

Current Opinion in Rheumatology

Histological assessment of the early enthesitis lesion in spondyloarthropathy

Annals of the Rheumatic Diseases

The concept of a “synovio-entheseal complex” and its implications for understanding joint inflammation and damage in psoriatic arthritis and beyond

Arthritis and Rheumatism

‘All that glistens is not gold’–separating artefacts from true Doppler signals in rheumatological ultrasound

Annals of the Rheumatic Diseases

Arthritis of the finger joints: a comprehensive approach comparing conventional radiography, scintigraphy, ultrasound, and contrast-enhanced magnetic resonance imaging

Arthritis and Rheumatism

Doppler ultrasound findings in healthy wrists and finger joints before and after use of two different contrast agents

Annals of the Rheumatic Diseases

Prospective two year follow up study comparing novel and conventional imaging procedures in patients with arthritic finger joints

Annals of the Rheumatic Diseases

Power Doppler ultrasonography for assessment of synovitis in the metacarpophalangeal joints of patients with rheumatoid arthritis: a comparison with dynamic magnetic resonance imaging

Arthritis and Rheumatism

The role of biomechanical factors and HLA-B27 in magnetic resonance imaging-determined bone changes in plantar fascia enthesopathy

Arthritis and Rheumatism

9
Ultrasound imaging in spondyloarthropathies