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Enthesitis, which is inflammation of tendons, ligaments, joint capsules, fascia and bone, is a hallmark and characteristic manifestation of
).
Persistent enthesitis can lead to local structural damage, such as tendon injury and bone erosion, and subsequent body repair can lead to attachment site formation and ultimately functional impairment
of associated anatomical structures.
Professor Gu Jieruo, Department of Rheumatology and Immunology of the Third Affiliated Hospital of Sun Yat-sen University, and his collaborators issued guidelines aimed at providing practical guidance for the screening and evaluation of enthesitis in patients with SpA, so as to improve the understanding and awareness
of rheumatologists on enthesitis detection.
The guide, which contains a total of 17 recommendations, was published on September 12, 2022 in the journal Front.
Immunol.
(impact factor 8.
786).
17 guideline recommendations
1.
Screening for enthesitis in patients with SpA with/without enthesitis symptoms is strongly recommended (level of evidence: high)
2.
It is strongly recommended to ask about the attachment point of pain at the time of history taking of patients with SpA (level of evidence: low)
3.
Physical examination is strongly recommended when assessing enthesitis in patients with SpA (level of evidence: moderate)
Physical examination is the most commonly used method for the evaluation of enthesitis in patients with SpA, and has the advantage of being simple and convenient, requiring no testing equipment, but its sensitivity is lower
than that of imaging.
Therefore, it is recommended that a follow-up examination
using ultrasound or MRI be performed after the physical examination is completed.
4.
The use of the Maastricht
At present, commonly used clinical enthesitis scoring methods include the Ander Enthesitis Index (MEI), Maastricht Ankylosing Spondylitis Enthesitis Score (MASES), Leeds Enthesitis Index (LEI), Canadian Spondyloarthritis Research Alliance (SPARCC) Enthesitis Index, etc
.
Among them, MASES is the simplest and most widely
used.
MASES evaluates the following 13 attachment sites: first costochondral joint, seventh costochondral joint, anterior superior iliac spine, posterior superior iliac spine, iliac crest, fifth lumbar spinous process, and proximal Achilles tendon attachment points, each rated as 0 (nontender) or 1 (tender).
5.
It is conditionally recommended to use the Maastricht Ankylosing Spondylitis Enthesitis Score (level of evidence: moderate) when assessing treatment response to enthesitis in patients with SpA
6.
Ultrasonography is strongly recommended when assessing enthesitis in patients with SpA (level of evidence: high)
Compared with physical examination and x-ray, ultrasound detection of enthesitis has higher sensitivity and can detect both inflammatory and structural lesions
.
The basic lesions defining enthesitis on ultrasonography are still based on the expert consensus of the 2014 Rheumatology Prognostic Assessment (OMERACT) organization, which includes enthesis thickening, echo loss, and the presence of energy Doppler signals, and structural lesions include enthesis osteophytes, calcifications, and erosions2
.
7.
The use of grayscale ultrasound and energy Doppler ultrasound in ultrasound for enthesitis in patients with SpA is strongly recommended (level of evidence: high)
Compared to color Doppler ultrasound, energy Doppler ultrasound can detect small blood vessels or blood vessels with very slow blood flow, with higher sensitivity
.
Energy Doppler ultrasound is preferred for ultrasound
detection of enthesitis.
8.
It is conditionally recommended to include the following attachment sites in ultrasound examination of enthesitis in patients with SpA: proximal plantar fascia, distal Achilles tendon, distal and proximal patellar ligament, distal quadriceps, triceps tendon, total extensor tendon, and trochanter greater (level of evidence: moderate)
9.
Conditional recommendation for the use of Madrid ultrasound enthesitis index in ultrasound of enthesitis in patients with SpA (level of evidence: moderate)
Common scoring systems for enthesitis in ultrasound include the Glasgow Enthesitis Scoring System (GUESS), Ultrasound Enthesitis Index (SEI), Madrid Ultrasound Enthesitis Index (MASEI), etc
.
Given the advantages of MASEI in energy Doppler ultrasound evaluation and combined with upper extremity attachment point indicators, MASEI may be superior, and other scoring systems are also viable options
.
10.
It is conditionally recommended to use ultrasonography when monitoring treatment response to enthesitis in patients with SpA (level of evidence: moderate)
11.
MRI is conditionally recommended in the evaluation of enthesitis in patients with SpA (level of evidence: low)
MRI is a reliable tool for the evaluation of enthesitis, provides high-resolution evidence, and helps distinguish enthesitis from other conditions causing local pain, and is currently the only test
that can show enthesis
This guideline conditionally recommends MRI in patients with SpA with inconclusive ultrasound findings
.
12.
Conditionally recommended not to use whole-body MRI in screening for enthesitis in patients with SpA (level of evidence: low)
Whereas conventional MRI sequences can only image specific sites, whole-body MRI can show inflammation of axial bone and peripheral attachments, but whole-body MRI has lower spatial resolution and longer scanning and evaluation time than conventional
sequences.
Therefore, this guideline recommends the use of whole-body MRI
only in clinical trials.
13.
The use of ultrashort echo time series in MRI of enthesitis in patients with SpA is conditionally recommended (level of evidence: very low)
Ultrashort echo time (UTE) sequences have shorter echo times than conventional sequences, detect short T2 signals at attachment points, and clearly visualize attachment point structures
.
14.
It is strongly recommended not to use contrast-enhanced MRI in MRI of enthesitis in patients with SpA (level of evidence: very low)
Research on the diagnostic accuracy of contrast-enhanced MRI in enthesitis imaging has been limited
.
The use of contrast at peripheral enthesis can only identify a small number of extra-enthesis lesions, and the potential risks associated with contrast injection may outweigh the benefits
of testing.
15.
Conditionally recommend the use of the OMERACT heel enthesitis MRI scoring system when assessing heel enthesitis in patients with SpA (level of evidence: very low)
16.
It is conditionally recommended not to use x-rays during the evaluation of enthesitis in patients with SpA (level of evidence: moderate)
X-rays can only show chronic structural changes, do not provide information about acute inflammatory lesions such as
.
17.
It is strongly recommended not to use PET/CT in the evaluation of enthesitis in patients with SpA (level of evidence: very low)
Only structural damage to the Achilles tendon is weakly associated
with metabolic activity on PET/CT.
Based on current evidence, scholars believe that PET/CT is not a reliable tool
for detecting enthesitis in patients with SpA.
References:
1.
Wu X, Liu D, Li Y, et al.
A clinical practice guideline for the screening and assessment of enthesitis in patients with
Front.
Immunol.
13:978504.
doi: 10.
3389/fimmu.
2022.
978504
2.
Imaging Group, Rheumatology and Immunologist Branch of Chinese Medical Doctor Association.
Chinese expert consensus on the application of imaging technology in spondyloarthritis (2021 edition)[J].
Chinese Journal of Rheumatology, 2021, 25(09):577-583.
