How do you diagnose enthesopathy (inflammation of the entheses, the sites where tendons or ligaments insert into the bone) of the cervical spine?

From the Guidelines

To diagnose enthesopathy of the cervical spine, a combination of clinical examination and imaging studies, particularly MRI, is crucial, as it can show inflammation, bone marrow edema, and soft tissue changes at enthesis sites, providing the strongest evidence for diagnosis. Start with a thorough physical examination, including palpation of the cervical spine and assessment of range of motion, looking for tenderness at the sites of tendon or ligament attachments to bone, which is characteristic of enthesopathy 1. Imaging is essential for definitive diagnosis, with MRI of the cervical spine being the most sensitive modality to detect inflammatory changes, bone marrow edema, and soft tissue alterations at enthesis sites 1. While X-rays may reveal bony changes or calcifications at attachment points, they are less sensitive than MRI 1. In some cases, CT scans can be useful to evaluate the structural changes of enthesopathy, especially in the costovertebral joints, costotransverse joints, and facet joints, and areas of enthesitis along other vertebral ligamentous attachments 1. Blood tests for inflammatory markers (ESR, CRP) and HLA-B27 may support the diagnosis, especially if an underlying rheumatologic condition is suspected, but are not definitive for enthesopathy diagnosis 1. Key points to consider in the diagnosis of cervical spine enthesopathy include:

• Clinical examination to identify tenderness and limited range of motion
• MRI as the primary imaging modality for detecting inflammatory changes and bone marrow edema
• Consideration of CT scans for evaluating structural changes and chronic enthesopathy
• Potential use of blood tests to support diagnosis in the context of suspected rheumatologic conditions
• Recognition that enthesopathy can be part of various conditions, including spondyloarthropathies, necessitating a broader rheumatologic workup if clinically indicated 1.

From the Research

Diagnosis of Enthesopathy of the Cervical Spine

To diagnose enthesopathy of the cervical spine, which refers to inflammation of the entheses (the sites where tendons or ligaments insert into the bone), several clinical tests and diagnostic approaches can be considered. However, the provided studies do not directly address the diagnosis of enthesopathy but rather focus on the evaluation and diagnosis of cervical spine myelopathy and degenerative diseases of the cervical spine.

Clinical Tests and Diagnostic Approaches

• The study by 2 discusses the interexaminer reliability in physical examination of the neck, highlighting the importance of using clinical tests with high validity and reliability. It suggests that comparing left and right sides can improve the reliability of some clinical tests.
• The study by 3 mentions the use of electrodiagnostic studies, such as nerve conduction studies and electromyography, as an adjunct in diagnosing degenerative cervical myelopathy, especially when the clinical picture is inconsistent or there's a suspicion of overlapping pathology.
• The research by 4 identifies a cluster of clinical findings that can be used to diagnose cervical spine myelopathy, including gait deviation, Hoffmann's test, inverted supinator sign, Babinski test, and age >45 years. These findings, when clustered, can help rule in or rule out cervical spine myelopathy.
• The study by 5 emphasizes the importance of neurophysiological evaluation, including somatosensory and motor evoked potentials and electromyoneurography, in assessing patients with degenerative diseases of the cervical spine. It highlights the value of dynamic tests in detecting subclinical forms of cervical spondylotic myelopathy.
• The systematic review by 6 evaluates the diagnostic accuracy of clinical tests for cervical spine myelopathy, finding that nearly all tests demonstrate high specificity but low sensitivity, making them poor screening tools. It underscores the need for high-quality studies to improve diagnostic accuracy.

Limitations and Future Directions

Given the indirect relevance of the provided studies to the diagnosis of enthesopathy of the cervical spine, it's clear that more specific research is needed to address this condition directly. The current evidence base is more focused on cervical spine myelopathy and degenerative diseases, highlighting the importance of a comprehensive diagnostic approach that may include clinical tests, imaging, and electrodiagnostic studies.