Jump to comment:

• MRI and Ultrasound of the Entheses: Perspective on Juvenile Idiopathic Arthritis
  Kay-Geert A. Hermann
  Published on: 14 May 2008
• The diagnostic role of ultrasonography versus magnetic resonance imaging in early diagnosis of enthe
  Lidia Rutkowska-Sak
  Published on: 31 March 2008

• Published on: 14 May 2008

  MRI and Ultrasound of the Entheses: Perspective on Juvenile Idiopathic Arthritis

  • Kay-Geert A. Hermann, Radiologist
  • Other Contributors:
    • Iris Eshed, Dennis McGonagle

  Dear Editor,

  We thank Dr. Rutkowska-Sak and colleagues for their comments on the use of ultrasound (US) for the diagnosis of enthesitis in juvenile idiopathic arthritis (JIA). The purpose of our article [1] was to bring together a global perspective on magnetic resonance imaging (MRI) for enthesitis at different sites using different methods.

  Firstly, we are interested in their comments that enthesitis...

  Show More

  Dear Editor,

  We thank Dr. Rutkowska-Sak and colleagues for their comments on the use of ultrasound (US) for the diagnosis of enthesitis in juvenile idiopathic arthritis (JIA). The purpose of our article [1] was to bring together a global perspective on magnetic resonance imaging (MRI) for enthesitis at different sites using different methods.

  Firstly, we are interested in their comments that enthesitis is especially common in JIA on US. This fits with the suggestion that JIA should be split into two major categories of joint involvement - synovial and entheseal, rather than the current scheme which includes 7 subgroups based on clinical rather than pathological features [2]. However, this raises the issue of validation of US for the diagnosis of enthesitis [3]. Further work is needed in different patient groups where observers are blinded to the pattern of disease and where intra- and inter -observer reproducibility studies are performed.

  Secondly, we fully agree that US may be the method of choice for the diagnosis of enthesitis in the lower limbs and at some other sites also, especially in JIA. However, for small joint disease the diffuse ostetiis pathology that accompanies enthesitis will not be appreciated on US, especially in early disease. Also, many insertions in the lower limb including many of those in the knee are inaccessible to the ultrasound probe. Furthermore, apart from the spinous processes, virtually all of the spine is otherwise inaccessible to the probe. This limits the utility of US in these settings. However, we entirely agree with Dr. Rutkowska-Sak et al. about the advantages of US and its use in certain circumstances as a first-line imaging test.

  References

  [1] Eshed I, Bollow M, McGonagle DG, Tan AL, Althoff CE, Asbach P, et al. MRI of enthesitis of the appendicular skeleton in spondyloarthritis. Ann Rheum Dis 2007;66:1553-9.

  [2] McGonagle D, Gibbon W, Emery P. Classification of inflammatory arthritis by enthesitis. Lancet 1998;352(9134):1137-40.

  [3] Scheel AK, Schmidt WA, Hermann KG, Bruyn GA, D'Agostino MA, Grassi W, et al. Interobserver reliability of rheumatologists performing musculoskeletal ultrasonography: results from a EULAR "Train the trainers" course. Ann Rheum Dis 2005;64(7):1043-9.

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top
• Published on: 31 March 2008

  The diagnostic role of ultrasonography versus magnetic resonance imaging in early diagnosis of enthe

  • Lidia Rutkowska-Sak, doctor
  • Other Contributors:
    • Barbara Lisowska, Iwona S³owiñska

  Dear Editor,

  This review focuses on the diagnostic role of magnetic resonance imaging (MRI) in early diagnosis of enthesitis [1]. The authors make interesting observations about the role of MRI of enthesitis –related spondyloarthritis. Enthesitis is a distinctive pathological feature of spondyloarthritis (SpA) and may involve synovial joints, cartilaginous joints, syndesmoses and extra-articular entheses. Spondyloarth...

  Show More

  Dear Editor,

  This review focuses on the diagnostic role of magnetic resonance imaging (MRI) in early diagnosis of enthesitis [1]. The authors make interesting observations about the role of MRI of enthesitis –related spondyloarthritis. Enthesitis is a distinctive pathological feature of spondyloarthritis (SpA) and may involve synovial joints, cartilaginous joints, syndesmoses and extra-articular entheses. Spondyloarthritis affects interspinal and supraspinal ligaments of the vertebral spine and interosseous ligaments in the retroarticular space of the sacroiliac joints.

  According to our experience, in children peripheral enthesitis may be observed in all forms of spondyloarthritis, including undifferentiated forms, and may be the only longstanding clinical manifestation of spondyloarthritis. Enthesitis may occur in degenerative and inflammatory conditions and is a major symptom in patients with juvenile idiopathic arthritis (JIA). Juvenile spondyloarthritis is observed in 20% patients with JIA [2, 3]. Peripheral extra-articular enthesitis which is a clinical hallmark of spondyloarthropathy, could be found in 70% children with early spondyloarthritis [4]. Therefore, the ability to image the sites of peripheral enthesitis accurately, i.e. ultrasound and magnetic resonance imaging could be useful in early diagnosis of spondyloarthritis. This is important in interpreting imaging findings in early inflammatory lesions.

  We agree with the authors that magnetic resonance imaging (MRI) is the first choice method to evaluate acute enthesitis, which describes both soft-tissue changes and intraosseous abnormalities. MRI is sensitive enough to depict early inflammatory condition but this method is expensiveand not available in many hospitals. Magnetic resonance imaging can also frighten many children and special planning is necessary for sedation and anaesthesia. Therefore, we may suggest that ultrasonography (US) is a reliable and useful diagnostic tool for the assessment of early inflammatory lesions. It is commonly used both in children and in adults. US is particularly useful as a first hand tool for the evaluation of peripheral enthesitis. However, US assessment is limited to the entheses of the knee and heel using a standard midline. We can agree with Balint et al. that 19–22 US examination has been more sensitive in the detection of enthesitis of the lower limbs in SpA and may provide a more objective and reliable index of enthesitis [5]. US may also show the swelling of the enthesitis, alternations of the echo texture consisting of decreased echogenicity owing to inflammation, the distension of the adjacent burse by fluid collections and peritendinous soft tissue swelling. Our preliminary observations have shown that the MRI which was performed within two – three weeks after US could confirm enteritis diagnosed by US in 70% children. We have observed about 100 children with clinical symptoms of enthesitis which has confirmed using US in 75%. We can conclude based on our observations of the children that US is widely available, inexpensive, readily demonstrates soft tissue inflammation such as enthesitis with sensitivity comparable to MRI.

  References

  1. Eshed I, Bollow M, McGonagle DG, Tan AL, Althoff CE, Asbach P, Hermann KG.MRI of enthesitis of the appendicular skeleton in spondyloarthritis. Ann Rheum Dis 2007;66:1553-9.

  2. Petty RE, Southwood TR, Baum J, Bhettay E, Glass DN, Manners P, Maldonado-Cocco J, Suarez-Almazor M, Orozco-Alcala J, Prieur AM. Revision of the proposed classification criteria for juvenile idiopathic arthritis: Durban, 1997. J Rheumatol 1998;25(10):1991-4.

  3. Rosenberg AM. Juvenile onset spondyloarthropathies. Curr Opin Rheumatol 2000;12(5):425-9.

  4. Cabral DA, Oen KG, Petty RE. SEA syndrome revisited: a longterm followup of children with a syndrome of seronegative enthesopathy and arthropathy. J Rheumatol 1992;19(8):1282-5.

  5. Balint PV, Kane D, Wilson H, McInnes IB, Sturrock RD. Ultrasonography of entheseal insertions in the lower limb in spondyloarthropathy. Ann Rheum Dis 2002;61:905-10.

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top