What are the diagnostic criteria and treatment options for enthesopathy (inflammation of the entheses, the sites where tendons or ligaments insert into the bone) of the cervical spine?

From the Guidelines

The diagnosis of enthesopathy of the cervical spine should be approached with a combination of clinical evaluation and imaging studies, with MRI being the gold standard for visualizing inflammation and changes at the entheses, as recommended by recent guidelines 1. The diagnostic criteria for enthesopathy of the cervical spine include:

• Clinical presentation of neck pain with or without radicular symptoms
• Imaging studies such as MRI or X-rays to confirm inflammation and changes at the entheses
• Absence of red flag symptoms such as trauma, malignancy, or infection The treatment options for enthesopathy of the cervical spine typically involve a combination of approaches, including:

1. Non-steroidal anti-inflammatory drugs (NSAIDs): Start with naproxen 500 mg twice daily or ibuprofen 400-800 mg three times daily for 2-4 weeks to reduce inflammation and pain, as recommended by the ASAS/EULAR guidelines 1.
2. Physical therapy: Recommend 2-3 sessions per week for 6-8 weeks, focusing on gentle stretching, strengthening exercises, and posture correction, as suggested by the ASAS/EULAR guidelines 1.
3. Heat and cold therapy: Apply heat for 15-20 minutes before physical activity and cold packs for 10-15 minutes after activity or when pain flares up.
4. Corticosteroid injections: If symptoms persist, consider a local injection of methylprednisolone 40 mg mixed with lidocaine 1% at the affected enthesis site, administered by a specialist, as recommended by the ASAS/EULAR guidelines 1.
5. Lifestyle modifications: Advise on ergonomic adjustments at work and home, proper sleeping posture, and avoiding activities that exacerbate symptoms.
6. In severe cases or if conservative treatments fail, consult with a rheumatologist or orthopedic specialist for advanced therapies such as biologics or surgical intervention, as recommended by the ASAS/EULAR guidelines 1 and recent reviews 1. This multi-faceted approach targets inflammation, promotes healing, and improves function, and is supported by recent guidelines and reviews 1.

From the Research

Diagnostic Criteria for Enthesopathy of the Cervical Spine

• Enthesopathy is a common clinical finding denoting pathology at the 'entheses', i.e. attachment sites of muscles, tendons, joint capsules, ligaments and fascia to the bone 2
• Inflammatory enthesopathy or enthesitis is a key feature of seronegative spondyloarthropathies (SSA) 2
• The diagnosis of enthesopathy can be made using ultrasound with high frequency transducers, which is a simple, cost-effective and feasible test 2

Treatment Options for Enthesopathy of the Cervical Spine

• Treatment of enthesopathy may include local steroid injections, physiotherapy and non-steroidal anti-inflammatory drugs, in addition to treatment of the primary disease 2
• A nonoperative treatment plan using a logical step-wise approach can be successful in the vast majority of patients with cervical radiculopathy, which may be related to enthesopathy 3
• Orthopedic manual therapy focused on correction of body posture, proper alignment of cervical vertebra and restoration of normal function of temporomandibular joint and occlusion may be a crucial non-surgical therapeutic approach for cervicogenic orofacial pain, which may be related to enthesopathy 4

Related Conditions and Treatment Approaches

• Cervical spondylotic myelopathy (CSM) is a major cause of disability, and awareness and understanding of CSM is imperative to facilitate early diagnosis and management 5
• Surgical intervention has shown to be superior for moderate to severe CSM, while conservative options may be employed for mild CSM 5
• The goal of surgery for CSM is to decompress the cord with expansion of the spinal canal, while restoring cervical lordosis, and stabilizing when the risk of cervical kyphosis is high 5