The Role of Ultrasonography in the Assessment of Rheumatic Diseases Karina D. Torralba, MD, MACM, CCD, Assistant Professor of Medicine, Keck School of Medicine, University of Southern California Objective: At the end of this session, the participant is expected to understand current and potential applications of ultrasonography in the diagnosis and management of rheumatic diseases Ultrasonography is a relatively new modality in the evaluation and management of patients with rheumatologic disorders. There has been an increasing interest amongst rheumatologist in the use of this imaging modality over the past two decades. Current and Potential Role of Ultrasonography in Rheumatology Ultrasonography has played a role in the following general areas: Complements physical examination Evaluates for subclinical synovitis in a patient with seemingly normal joint exam In joints that are swollen, US can Distinguish between synovial hypertrophy vs effusion, evaluate for active synovitis (doppler), can distinguish tenosynovitis vs arthritis Increases accuracy of office- procedures Disease activity assessment Treatment response monitoring Management Early Rheumatoid Arthritis: Use of Ultrasound Current studies have established the value of ultrasonography in the diagnosis and management of specific rheumatic diseases (Table 1). Studies are ongoing to further confirm these studies, and to clarify the role of US as part of classification criteria for these conditions. Much of the interest lies in establishing the diagnosis of rheumatoid arthritis early on as conventional radiographs are relatively insensitive in detecting erosions. Updated 2010 classification criteria for rheumatoid arthritis by the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) currently do not include radiologic imaging as part of the criteria. Studies are ongoing to standardize the use of ultrasonography in the assessment of RA.
Table 1. Distinguishing ultrasonographic features noted in certain rheumatologic conditions. Condition Rheumatoid arthritis Spondyloarthropathies Ankylosing spondylitis Psoriatic Arthritis Crohn s Disease Ulcerative Colitis Reactive arthritis (formerly Reiter s) Gout Pseudogout/Calcium pyrophosphate Deposition Disease US: Utility/Findings (joint and tendon findings unless otherwise specified) Evaluation of Early RA* Synovitis or synovial proliferation: echogenic tissue proliferating within the joint cavity which can show PDS signal; Effusion: anechoic or hypoechoic intra- capsular collection which bows the capsule Erosions: an interruption of the bone surface visible in two planes. Tenosynovitis: anechoic or hypoechoic halo around the tendon; in chronic tenosynovitis non- homogeneous or even hyperechoic material (synovial tissue hyperplasia) may be observed within the distended sheath. Increased vascularity may be visualized with power Doppler signal Doppler signals Joint Effusion, Synovitis, Bone erosions Tenosynovitis: anechoic or hypoechoic halo around the tendon; in chronic tenosynovitis non- homogeneous or even hyperechoic material (synovial tissue hyperplasia) may be observed within the distended sheath. Increased vascularity may be visualized with PDS Tendinitis/tendinosis: swelling of the tendon with loss of the normal fibrillar pattern and areas of decreased echogenicity; Tendon rupture: hypoechoic gap in the body of the tendon in partial tear, full- thickness discontinuity in complete tear. Enthesitis: loss of normal fibrillar echogenicity, increasing thickness or intralesional focal changes of tendon insertion, calcific deposits at insertion of the tendon, periosteal changes (erosions or new bone formation). soft tophus- like lesion: homogenously echoic echotexture hard tophus- like lesion: hyperechoic band generating a posterior acoustic shadow mixed tophi: features of both soft and hard tophus double contour: focal or diffuse enhancement of the superficial articular cartilage layer (independent from the deposition of MSU crystals), whose reflectivity is independent of the angle of insonation hyperechoic spots: spots less than 1 mm in size with the same echogenicity of the bony cortex snowstorm appearance: hyperechoic spots floating in synovial fluid within the joint cavity in acute inflammation double contour: thin hyperechoic band (either focal or diffuse) within the cartilage layer punctate pattern: hyperechoic rounded or amorphous- shaped
Hydroxyapatite crystal deposition disease Osteoarthritis Systemic Lupus Erythematosus Sjogren s Syndrome (parotid gland, joints) Scleroderma (skin) Polymyositis/ Dermatomyositis (skin, muscle) Polymyalgia Rheumatica Giant Cell Arteritis/Temporal Arteritis/Cranial Arteritis (involved artery) areas in fibro- cartilage or tendons homogeneous hyperechoic nodular or oval deposits in bursae or articular recesses hypoechoic pattern with associated posterior shadowing, even for calcification less than 2-3 mm Joint Effusion Synovitis Popliteal Cyst in Knee OA Mucous cyst in patients with Heberden s nodes Osteophyte (Irregularity of bone contour) Cartilage damage (loss of cartilage margin sharpness, homogenenicity of cartilage layer, cartilage thinning Synovitis, synovial proliferation, effusion, Femoral head perfusion (CD/PD) Parenchymal echogenicity Homogeneity Presence of hypoechogenic areas Hyperechogenic lines and/or dots Clarity of glandular boundaries Defect in blood flow response pre and post secretory simulation Joints: Effusion, synovitis soft tissue calcifications narrowing of the distance between phalangeal apex and skin surface Soft tissue calcifications Chronic Myositis: Higher muscle echogenicity and more pronounced atrophy was usually present Acute Myositis: Lower echogenicity, muscle edema, +PD Effusions: Tendon sheath (LHBT), joint (GH, hip), bursae (SA/SD) Tenosynovitis (Wrist extensors/flexors; peroneals, ankle flexors, posterior tibial) Entesopathy Intimal edema ( Halo sign ) Stenosis (mix of colors on CD) Occlusion (lack of Doppler) Inflamed vessel: smooth, homogeneous, hypoechoic, concentric wall thickening Takayasu s Arteritis Small, homogeneous, hypoechoic, concentric wall thickening brighter than TA/GCA Macaroni sign Behcet s Disease Enthesopathy Synovial proliferation, effusion, synovitis, erosions; Baker s cyst CD: Color Doppler; PD: Power Doppler; TA/GCA: Temporal Arteritis/Giant Cell arteritis; LHBT: long head of biceps tendon, GH: Glenohumeral: SA/SD: Subacromial/Subdeltoid
Office- based procedures under US guidance Goals of US- guided procedures - increasing accuracy - improving efficacy - decreasing morbidity (i.e. pain, tendon rupture) Accuracy US- guided procedures in general allow increased accuracy of arthrocentesis, including seemingly simple procedures such as knee aspirations. Multiple studies have been done comparing the accuracy and outcomes of palpation- guided (blind) procedures vs ultrasound- guided procedures. In general US- guided procedures for needle placement increases accuracy by at least 90%. Palpation guided procedures have success rates of 30-50%. Ultrasonography increases accuracy of knee arthrocentesis by 96-99%, vs 30% by palpation; increases accuracy of injection/arthrocentesis of PIP and MCP joints up to 96%, vs 59% by palpation. US increases accuracy of hip injections by 97-100%. Efficacy Knowing the general pathology of a joint by ultrasonography also affects decision making on need for injection. For example, ultrasound allows distinction of an effusion vs synovial proliferation/hypertrophy - effusions are suspected by clinical exam, and arthrocentesis may be considered; but when ultrasonography is done, confirms the presence of no effusion and only synovial hypertrophy, then arthrocentesis may then be deferred. Morbidity Arthrocentesis/Joint and tendon injections are associated with risks of pain, bleeding, tendon rupture, skin atrophy. It has been noted that up to 25% of palpation- guided tendon injections are intratendinous. US- guided tendon sheath injections affords better accuracy and potentially less risk of tendon rupture. Studies by WL Sibbitt et al, have shown that pain scores, and outcome measures are improved by doing ultrasonography as opposed to doing them blind/palpation- guided.
Table 2. Studies looking at effectiveness of US- guided joint procedures (sampling) Joints, +/- steroid, +/- control vs comparison Inflamed joints (shoulder, elbow, wrist, knee, ankle), Corticosteroid injection Palpation guided vs US guided Small, interm, large joints Corticosteroid injection Palpation guided vs US guided Hip- native adult hip Corticosteroid injection Hip, OA, Viscosupplementation Knee Arthrocentesis corticosteroid injection Palpation guided vs US guided Ankle, Hind+Mid foot Chronic inflammatory diseases, Peroneal tendon sheath Palpation guided vs US guided Variable, Results Improved joint function (VAS) Accuracy Reference Cunnington J, et al. 2010 Improvements: 43% in Sibbitt WL, et al 2009 procedural pain, 58% in absolute pain at 2 weeks, 75% reduction in significant pain, 25% increase in responder rate, 62% decrease in nonresponder rate; effusion detection 200%, volume of aspirated fluid 337% 97% Accuracy Smith J, et al 2009 80% less pain at 6 months Pourbagher MA, et al. 2005 48% less procedural pain 183% increased aspirated synovial fluid volumes Improved outcomes at 2 weeks Led to change in diagnosis in 56(82%) of 86 patients - cancelled in 15% of 242 proposed sites - done in 74 (8%) of additional sites Efficacy of steroid injections in patients aware of US results (3 months) US guided: 100% accurate Palpation- guided: 60% accurate 2/6 partially accurate, and 2/2 inaccurate injections were intratendinous Sibbitt WL, et al 2012 D Agostino MA, et al 2005 Muir J, et al. 2011
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