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Spondyloarthritis is a group of interrelated disorders which can also be split into patients with predominantly axial and predominantly peripheral SpA with an overlap between the 2subgroups . It is featured with inflammatory enthesitis which is considered the primary lesion in all SpA disorders. Enthesitis is included in Assessment of Spondylo Arthritis International Society (ASAS) classification criteria for axial and peripheral SpA. Peripheral enthesitis is usually detected by clinical findings as pain, tenderness and swelling. Clinical examination of enthesitis is considered a problem, as it lacks sensitivity and reliability and not always detected by clinical examination.
Nowadays, MSUS is sensitive and noninvasive tool which can be used to identify the features of enthesitis in patients with SpA. Combined gray scale and power Doppler technology improves the assessment of US to enthesitis as power Doppler can visualize abnormal vascularization and hyperemia in inflamed enthesitis and so that increase specificity and sensitivity of US for determination of SpA.
The aim of our work is to to assess the value of using high resolution Ultrasonography for diagnosis of enthesopathy in SpA patients and finding the relation to clinical assessment of enthesopathy.
Our study was carried on 20 patients aged between 28 and 68 years and fulfill ASAS classification criteria for axial or peripheral SpA, in 2009 & 2011 respectively. The controls were 10 healthy volunteers free from disease matched in age and sex with the cases. All patients and controls were subjected to history taking, general clinical examination, laboratory investigation, clinical examination of enthesitis according to SPARCC score, and ultrasonography assessment of the 16 enthesial points that were clinically examined.
The present study revealed that, there was a significant increase in detection of enthesitis upon comparing SpA patients with controls (p< 0.021) in most of enthesial sites and also highly significant increase in detection of enthesitis by gray scale U/S examination between SpA patients and controls (p< 0.042) in 11 enthesial sites as 95% of patients had at least one enthesis by clinical examination and 100% of patients had at least 2 enthesitis by US while 0% of controls had enthesitis either by clinical examination or US.
In comparison between clinical examination of enthesitis and gray scale US, we found that 19% of examined entheses were considered abnormal clinically, while 31% of same entheses were considered abnormal according to US examination, with statistical significance (<0.05) between clinical examination and gray scale US.
Abnormal entheses showed calcifications (47%), erosions (38%), decreasing echogenicity (8.7%), swelling (3.9%), bursitis (1.6%), and power Doppler signals (12.6%) with maximum odd ratios of calcification and erosion were at right supraspinatus (72.000&16.000 respectively). Also 45% of patients had power Doppler activity at least at 1 enthesis while no one of controls had enthesis that exhpit power Doppler activity. A comparison between clinical examination of entheses and power Doppler activity, 19% of entheses appeared clinically positive in comparison with only 5% of entheses showed positive power Doppler activity
On 5 stages classification system, 71.2% at stage 3b, 16.8% at stage 3a, 10.8% at stage 2b, and 0.9% at stage 1. This Classification of combined gray scale and power Doppler US has an important value for follow up of enthesitis during efficacious treatment of SpA with anti-TNF by observation of progression of its stages.
Sensitivity of US was 91.94%, while specificity was 83.72% with maximum sensitivity of US to calcification was 85.7%, for erosion was 60%, for decreasing echogenicity was 33.3 %, for swelling was 100.0%, and for bursitis was 25.0 %, while maximum specificity for calcification, erosion, decreasing echogenicity, swelling and bursitis was 100.0%. On other hand sensitivity of power Doppler US was 47.4 and its specificity was 100.0%.
Our study revealed a positive correlation between SPARCC score and gray scale US, power Doppler US and combined US scores. Also, there was a significant positive correlation between power Doppler US score and CRP test.