Elsevier

Joint Bone Spine

Volume 78, Issue 3, May 2011, Pages 270-274
Joint Bone Spine

Original article
Correlations among clinical, radiographic, and sonographic scores for enthesitis in ankylosing spondylitis

https://doi.org/10.1016/j.jbspin.2010.09.010Get rights and content

Abstract

Objectives

To look for correlations among clinical, radiographic, and sonographic scores for enthesitis in patients with ankylosing spondylitis (AS).

Methods

Prospective study of 60 patients meeting modified New York criteria for AS. The clinical evaluation relied on the BASDAI, BASFI, and ASQoL and on a visual analog scale (VAS) for entheseal pain, as well as on two specific enthesitis indices, the Maastricht Ankylosing Spondylitis Enthesitis Score (MASES) and the Spondyloarthritis Research Consortium of Canada Enthesitis Index (SPARCC). Radiographs and ultrasound scans were taken of five entheses on both sides (patellar insertion of the quadriceps tendon, proximal and distal insertions of the patellar tendon, and calcaneal insertions of the Achilles tendon and superficial plantar fascia). Ultrasound scans were obtained using a Philips HD 11™ machine with a high-frequency linear probe.

Results

We studied 48 men and 12 women with a mean age of 36 ± 11 years. The radiographic score correlated with the VAS pain score, BASDAI, and BASFI. The sonographic score for acute enthesitis correlated only with the MASES, and the sonographic score for chronic enthesitis correlated with none of the clinical scores. The Doppler score correlated with the VAS pain score, BASDAI, BASFI, and ASQoL. The overall sonographic score correlated with the MASES and SPARCC.

Conclusion

Good correlations were found between the clinical and sonographic scores for enthesitis. The radiographic score seemed correlated with the general AS parameters rather than with the clinical scores. Larger studies are needed to better define the role for radiographs and sonography of the entheses in the diagnosis of AS and follow-up of treated AS patients.

Introduction

Inflammation of the entheses (enthesitis) is the main anatomic lesion in ankylosing spondylitis (AS) [1], [2]. The demonstration of enthesitis is crucial both to the diagnosis of AS and to the evaluation of disease activity [3]. Enthesitis cannot be convincingly demonstrated based on the clinical examination alone, as evidence of inflammation (swelling, redness, and warmth) is usually lacking and enthesitis may be difficult to distinguish from arthritis in a neighboring joint [1], [4], [5]. Inflammatory enthesitis is clinically detectable in only 10% of patients with early-stage AS and 50% of those with established AS [6]. Several indices have been developed for the clinical evaluation of enthesitis in AS. The earliest is the Mander Enthesitis Index (MEI), which evaluates 66 entheseal sites [7]. However, determining the MEI is often an exacting task. Consequently, several other indices were developed [8], [9], [10], including the Modified Mander Enthesitis Index [8], the Major Enthesitis Index in 2002 [9], the Maastricht Ankylosing Spondylitis Enthesitis Score (MASES) in 2003 [11], and the Spondyloarthritis Research Consortium of Canada (SPARCC) [12] in 2008. None of them has achieved universal recognition [13], as each has advantages and limitations according to OMERACT Filter criteria [14]. The MASES remains the most widely used index, as it has good metrological properties and includes the main peripheral and axial entheseal sites involved in AS. The SPARCC is a new tool that evaluates only the peripheral entheses, which are easier to access for radiographic and sonographic imaging. Thus, the SPARCC may be well suited to comparisons of clinical and imaging data. Radiography remains the first-line investigation for enthesopathies, although the radiographic changes take time to develop after the onset of the inflammatory process [11]. Very few studies have focused on the radiographic evaluation of enthesitis and, to our knowledge, no radiographic enthesitis scores have been developed. Many recent studies have established that ultrasonography coupled with power Doppler imaging is useful for the early diagnosis of enthesitis [15], [16], [17]. This method provides an evaluation of disease activity at target sites and shows changes in either direction (improvement or exacerbation) in the short term. Among sonographic indices, the most widely used seem to be the Glasgow Ultrasound Enthesitis Scoring System (GUESS) [18], Sonographic Entheseal Index (SEI) [19], and Ultrasound Enthesis Score [15]. However, these indices have a few limitations. The GUESS fails to take into account some of the signs of acute enthesitis such as peritendinous edema, hypoechogenicity, and hypervascularization; whereas the SEI fails to include the Doppler imaging results [18], [19].

The objectives of our study in patients with AS were:

  • to perform a clinical evaluation of enthesitis;

  • to describe the distinctive radiographic and sonographic features of enthesitis;

  • to look for correlations among the clinical, radiographic, and sonographic scores.

Section snippets

Methods

We prospectively studied 60 consecutive patients meeting modified New York criteria for AS [20] and seen at the rheumatology department of the M. Kassab Institute in Manouba, Tunisia. We excluded patients having a history of knee or ankle surgery, local corticosteroid injection at the study sites within the six weeks before the clinical and sonographic evaluation, or lower limb neuropathy.

Patient characteristics

We studied 60 patients, 48 (80%) men and 12 women with a mean age of 36 ± 11 years (range, 20–74 years) and a mean disease duration of 8.8 years (range, 0.5–25 years). Laboratory tests indicated systemic inflammation in 51 patients; mean ESR was 33 ± 22 (range, 2–98) and mean serum CRP was 16.9 ± 38 mg/L (range, 0–240 mg/L). Table 1 reports the AS-specific scores and the clinical, radiographic, and sonographic enthesitis scores. Table 2 shows the distribution across entheseal sites of the clinical,

Discussion

Enthesitis is now viewed as the most typical histopathological abnormality in AS [1], [4], [6], [24]. The importance of enthesitis in AS was long underestimated, because no objective assessment tools were available. Since 1987, several clinical indices have been developed for the assessment of enthesitis. At present, preference is given to concise indices, as they offer better feasibility with similar sensitivity compared to the more time-consuming indices [11], [25]. Thus, the MASES is a good

Conflict of interest statement

The authors declare no conflicts of interest.

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