Ultrasound scoring systems for evaluation of synovitis and tenosynovitis in patients with rheumatoid arthritis

Ching-Tsai Lin; Kuo-Lung Lai

doi:10.4103/jmu.jmu_146_21

EDUCATION FORUM

Year : 2022 | Volume : 30 | Issue : 1 | Page : 3-5

Ultrasound scoring systems for evaluation of synovitis and tenosynovitis in patients with rheumatoid arthritis

Ching-Tsai Lin, Kuo-Lung Lai
Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung, Taiwan

Date of Submission	02-Jul-2021
Date of Acceptance	29-Jul-2021
Date of Web Publication	06-Jan-2022

Correspondence Address:
Dr. Kuo-Lung Lai
Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, No. 1650 Taiwan Boulevard Sect. 4, Taichung
Taiwan

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmu.jmu_146_21

How to cite this article:
Lin CT, Lai KL. Ultrasound scoring systems for evaluation of synovitis and tenosynovitis in patients with rheumatoid arthritis. J Med Ultrasound 2022;30:3-5

How to cite this URL:
Lin CT, Lai KL. Ultrasound scoring systems for evaluation of synovitis and tenosynovitis in patients with rheumatoid arthritis. J Med Ultrasound [serial online] 2022 [cited 2022 May 20];30:3-5. Available from: http://www.jmuonline.org/text.asp?2022/30/1/3/335107

Introduction

From the Taiwan National Health Insurance database, rheumatoid arthritis (RA) is one of the most prevalent autoimmune inflammatory diseases which results in chronic synovitis and joint deformities.^[1] For preventing bone erosion and joint deformities, targeted treatment is recommended to reach sustained remission or low disease activity by the American College of Rheumatology/European League Against Rheumatism (EULAR).^[2],[3],[4] However, the response rates for achieving low disease activity and remission were shown optimally no more than 50% and 20%.^[4],[5] Through the remarkable advancement of ultrasound (US) in the clinical practice of inflammatory arthritis, RA probably has the most advantages from true remission which defined as the absence of active disease and progression of anatomical destruction.^[6] With more evidence, EULAR recommended that US is superior to clinical examination in the detection of joint inflammation and a standard care for RA.^[7],[8],[9] This brief review provides the main US scoring systems with semiquantitative measurements on the detection of synovitis and tenosynovitis in patient with RA.^{[10],[11],[12],[13],[14]}

Sonographic findings of Synovitis and Tenosynovitis

In 2017, the EULAR-Outcome Measures in Rheumatology Clinical Trials (OMERACT) US task force published consensus-based definitions for synovitis in RA. The consensus stated that synovial hypertrophy is necessary for synovitis even in the absence of Doppler signal, but the existence of synovial effusion alone is not sufficient to define synovitis.^[10] In 2005, the OMERACT task force reached a wide agreement for tenosynovitis defined as hypoechoic or anechoic thickened tissue with or without fluid within the tendon sheath, which is seen in two perpendicular planes and which may exhibit Doppler signal.^[11] Accordingly, sonographic findings demonstrated that the flexor tendons of the II, III, and IV fingers and the extensor carpi ulnaris tendon involved in RA have the most common hand tenosynovitis [Table 1].^[15]

Table 1: Definitions of the sonographic anomalies in rheumatoid synovitis and tenosynovitis

Click here to view

Semiquantitative Scoring System of synovitis and Tenosynovitis

The values of US scoring systems to evaluate disease activity, and joint and tendon destruction provide evidence for rheumatologists to follow tight control in order to reach targeted therapy for RA. For semiquantitative measurements of synovitis in RA, grayscale, and Doppler findings have been graded independently, and each elementary component devoted to its special scoring system^{[12],[13],[16],[17]} [Figure 1]. However, here, we only introduced two scoring systems in [Table 2]: Leeds score together with EULAR-OMERACT score which were most frequently used recently.^[12],[13] Although RA involved tenosynovitis is very common, the heterogenicity of tenosynovitis morphology makes it difficulty in standardization of scoring system.^[15] In 2012, the OMERACT US task force agreed a four-graded semiquantitative measurement from 0 to 3 for B-mode tenosynovitis, but the interobserver reliability is moderate. They only reached a wide-agreement in semiquantitative scoring system for tenosynovitis on Doppler mode^[14] [Figure 2].

Table 2: Main semiquantitative scoring systems to evaluate the sonographic anomalies in rheumatoid arthritis

Click here to view

Figure 1: (a) (Grayscale) and (b) (Doppler signal) were right PIP2 rheumatoid synovitis, as Grade 2 by EULAR-OMERACT score; (c) (Gray scale) and (d) (Doppler signal) were right radio-scaphoid rheumatoid synovitis, as Grade 3 by EULAR-OMERACT score. EULAR: European League against Rheumatism

Click here to view

Figure 2: (a) (Gray scale) and (b) (Doppler signal) were right 2^nd flexor rheumatoid tenosynovitis, as Grade 1 by EULAR-OMERACT Doppler score; (c) (Gray scale) and (d) (Doppler signal) were rheumatoid tenosynovitis of left ECR tendon as Grade 3 by EULAR-OMERACT Doppler score. EULAR: European League against Rheumatism and ECR: Extensor carpi radialis

Click here to view

Conclusions

In our narrative review, we described the fundamental sonographic abnormalities and highlighted the most frequently useful scoring system in considering synovitis and tenosynovitis of RA. With visualization of the pathologic changes (i.e., proliferative synovitis, tenosynovitis, and bone erosions) by RA, we believed that the real-time US has additionally convincing value over the clinical examination and laboratory inflammatory biomarkers.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	See LC, Kuo CF, Chou IJ, Chiou MJ, Yu KH. Sex and age-specific incidence of autoimmune rheumatic diseases in the Chinese population: A Taiwan population-based study. Semin Arthritis Rheum 2013;43:381-6.
2.	Singh JA, Saag KG, Bridges SL Jr., Akl EA, Bannuru RR, Sullivan MC, et al. 2015 American College of rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis and rheumatology (Hoboken, NJ) 2016;68:1-26.
3.	Smolen JS, Landewé RB, Bijlsma JW, Burmester GR, Dougados M, Kerschbaumer A, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. Ann Rheum Dis 2020;79:685-99.
4.	Aletaha D, Smolen JS. Diagnosis and management of rheumatoid arthritis: A review. JAMA 2018;320:1360-72.
5.	Smolen JS, Aletaha D. Rheumatoid arthritis therapy reappraisal: Strategies, opportunities and challenges. Nat Rev Rheumatol 2015;11:276-89.
6.	Filippucci E, Di Geso L, Grassi W. Progress in imaging in rheumatology. Nat Rev Rheumatol 2014;10:628-34.
7.	Colebatch AN, Edwards CJ, Østergaard M, van der Heijde D, Balint PV, D'Agostino MA, et al. EULAR recommendations for the use of imaging of the joints in the clinical management of rheumatoid arthritis. Ann Rheum Dis 2013;72:804-14.
8.	D'Agostino MA, Terslev L, Wakefield R, Østergaard M, Balint P, Naredo E, et al. Novel algorithms for the pragmatic use of ultrasound in the management of patients with rheumatoid arthritis: From diagnosis to remission. Ann Rheum Dis 2016;75:1902-8.
9.	Combe B, Landewe R, Daien CI, Hua C, Aletaha D, Álvaro-Gracia JM, et al. 2016 update of the EULAR recommendations for the management of early arthritis. Ann Rheum Dis 2017;76:948-59.
10.	D'Agostino MA, Terslev L, Aegerter P, Backhaus M, Balint P, Bruyn GA, et al. Scoring ultrasound synovitis in rheumatoid arthritis: A EULAR-OMERACT ultrasound taskforce-Part 1: Definition and development of a standardised, consensus-based scoring system. RMD Open 2017;3:e000428.
11.	Wakefield RJ, Balint PV, Szkudlarek M, Filippucci E, Backhaus M, D'Agostino MA, et al. Musculoskeletal ultrasound including definitions for ultrasonographic pathology. J Rheumatol 2005;32:2485-7.
12.	Brown AK, Quinn MA, Karim Z, Conaghan PG, Peterfy CG, Hensor E, et al. Presence of significant synovitis in rheumatoid arthritis patients with disease-modifying antirheumatic drug-induced clinical remission: Evidence from an imaging study may explain structural progression. Arthritis Rheum 2006;54:3761-73.
13.	Terslev L, Naredo E, Aegerter P, Wakefield RJ, Backhaus M, Balint P, et al. Scoring ultrasound synovitis in rheumatoid arthritis: A EULAR-OMERACT ultrasound taskforce-Part 2: Reliability and application to multiple joints of a standardised consensus-based scoring system. RMD Open 2017;3:e000427.
14.	Naredo E, D'Agostino MA, Wakefield RJ, Möller I, Balint PV, Filippucci E, et al. Reliability of a consensus-based ultrasound score for tenosynovitis in rheumatoid arthritis. Ann Rheum Dis 2013;72:1328-34.
15.	Filippucci E, Gabba A, Di Geso L, Girolimetti R, Salaffi F, Grassi W. Hand tendon involvement in rheumatoid arthritis: An ultrasound study. Semin Arthritis Rheum 2012;41:752-60.
16.	Scheel AK, Hermann KG, Kahler E, Pasewaldt D, Fritz J, Hamm B, et al. A novel ultrasonographic synovitis scoring system suitable for analyzing finger joint inflammation in rheumatoid arthritis. Arthritis Rheum 2005;52:733-43.
17.	Szkudlarek M, Court-Payen M, Jacobsen S, Klarlund M, Thomsen HS, Østergaard M. Interobserver agreement in ultrasonography of the finger and toe joints in rheumatoid arthritis. Arthritis Rheum 2003;48:955-62.