New EULAR Guidance for Ultrasonography in Rheumatology

Janis C. Kelly

September 05, 2017

A European League Against Rheumatism (EULAR) working group has updated  the 2001 guidelines on use of musculoskeletal (MS) ultrasonography (US) in rheumatology and produced an illustrated electronic manual of these procedures with downloadable images and videos. However, the guidelines do not address key questions raised by North American rheumatologists or focus on when US is likely to improve clinical outcomes enough to be worth the time and expense.

The updated guidelines were published online in the Annals of the Rheumatic Diseases.

"The impetus for these new guidelines was the result of various advances in the practice of musculoskeletal US on multiple levels over these 16 years. There has been dramatic growth in terms of the number of rheumatologists worldwide that utilize US not only in daily practice but in clinical trials and other forms of clinical research and education," coauthor David A. Bong, MD, rheumatologist at Instituto Poal de Reumatologia, Barcelona, Spain, told Medscape Medical News.

"This has been accompanied by a growing level of sophistication in terms of knowledge and technical expertise through research by many institutions and organizations such as OMERACT [Outcome Measures in Rheumatology], along with educational offerings through not only international organizations, such as EULAR and the ACR [American College of Radiology], but also on a national and region level. The technology continues to improve in terms of resolution, portability, accessibility and decrease in price. Finally, there has been a realization that US has value in evaluating the non-articular aspects of systemic rheumatic disorder including nerve, vessels and glandular structures. For these reasons and more, Drs Ingrid Möller, Marina Backhaus, Esperanza Naredo, and colleagues proposed this dramatic expansion in the guidelines," Dr Bong explained.

The EULAR process included a systematic literature review of musculoskeletal US–evaluable structures; a Delphi survey among 227 rheumatologist and radiologist experts in musculoskeletal US to select musculoskeletal and nonmusculoskeletal relevant anatomic structures evaluable by US, abnormalities evaluable by US, and group consensus on the US scanning procedures.

The selected structures included shoulder, elbow, wrist and hand, hip, knee, ankle and foot, peripheral nerves, salivary glands, and large vessels. Scanning procedures included patient position, probe placement, scanning method, and bony/other landmarks. The new guideline includes 10 specific technical recommendations for use of musculoskeletal US in rheumatology.

"The key changes are an expansion of the guidelines of US evaluation of the articular regions as in the 2001 guidelines but also in the periarticular regions and nonarticular regions that affect our patients with systemic inflammatory and non-inflammatory disorders. Examples in the first category include more detailed evaluation of all the articular structures such as the anterior recess of the shoulder," Dr Bong said.

"The greatest area of expansion has been in the periarticular structures (tendons, ligaments and retinacular structures) that support the joints, including their entheses, which play an important, if not the prominent, role in many rheumatic and non-rheumatic disorders seen by the rheumatologist and sonologist. These are also areas of frequent nonrheumatic pathologies that our patients are very susceptible to, such as the hamstring insertion in the posterior hip, the greater trochanter and its gluteal musculotendinous insertions, and the important periarticular structures of the fingers, such as the pulleys and the palmar plate," Dr Bong explained.

"Finally, US is an important imaging technique to evaluate nonarticular structures involved in rheumatic disorders, such as the peripheral nerves, the temporal and axillary arteries in vasculitis, and the salivary glands in Sjögren's syndrome," he added

"The EULAR group has produced a wonderful resource for musculoskeletal scanning with their scanning app, whether the practitioner is in Europe, USA, or elsewhere. This is a great advance over what was available in the 2001 guidelines," Eugene Y. Kissin, MD, associate professor of medicine, Boston University School of Medicine, Massachusetts, and cofounder of the training program for Ultrasound School of North American Rheumatologists, told Medscape Medical News. The Ultrasound School of North American Rheumatologists is the preeminent group for musculoskeletal US education in North America.

Dr Bong explained, "These guidelines ‘raise the bar’ for all of us and provide an updated, comprehensive and readily-accessible resource for the new and the experienced rheumatologist sonologist to expand and improve his/her diagnostic and therapeutic abilities in this fast-paced imaging field."

Dr Bong said that he has been surprised by the enthusiasm with which this project was greeted and that, although it is not a downloadable app, it is available to anyone with an internet connection with images and videos [that] can be downloaded and used.

However, the applicability of the European guidelines to North American clinical practice is not entirely clear. Dr Kissin, who was not involved in the study, noted that the EULAR group asked, in their Delphi survey process, "whether the respondent actually assessed the structure...in my practice" and whether each view "enabled them to detect pathology," but the results of those questions are not reported in the paper. “Since the survey was sent to radiologists as well as rheumatologists, some of the results may not apply to most rheumatology practice in the USA, such as scanning of most ligaments in the ankle," Dr Kissin said.

Dr Kissin added, "The key unanswered questions regarding ultrasound in rheumatology clinical practice in the USA center around when ultrasound should be used.  When does it improve clinical outcomes sufficiently to offset the cost and time expenditure required? For instance, ultrasound is much less expensive than MRI for assessment for rotator cuff disease, but when does rotator cuff disease benefit from any imaging at all? Or even more pointedly, ultrasound is clearly more sensitive for hand and wrist joint inflammation in comparison to clinical exam, but when is this extra sensitivity truly beneficial for the evaluation and treatment of patients being evaluated or treated for inflammatory arthritis?" 

The study was funded by EULAR. Dr Bong and Dr Kissin have disclosed no relevant financial relationships.

Ann Rheum Dis. Published online August 16, 2017. Full text

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