Ultrasound's convenience makes it an attractive imaging modality. “The beauty of ultrasound is that you can pull out the ultrasound machine while the patient is in the office. You can look at a few joints in the hand or the wrist or the elbow. You don't have to go through the process of MRI,” said Dr. Gaylis.
Ultrasound also can be used to visualize erosions, though this is very dependent on the experience of the technician and viewer. “Having experience in ultrasound is something that is critical for the management of these patients.”
Dr. Gaylis has an ultrasound technician in his office. He finds that it is easier to read the image if someone else is handling the technical component. He and the technologist will discuss the reading while it's being done. However, many rheumatologists perform their own ultrasound imaging.
It's almost mandatory to go to ultrasound courses to learn how to perform and read. He recommends 6 months of ultrasound practice without billing, just to become comfortable with the technique.
X-Ray
“X-rays don't help me much if at all in the diagnosis and management of rheumatoid arthritis, especially in the peripheral joints,” said Dr. Gaylis. X-ray doesn't help rheumatologists make biologic treatment choices for their patients with RA. “Changes occur so slowly on x-ray that it really just doesn't fit the rhythm of biologic therapy,” he said.
X-rays allow visualization of erosions and joint space narrowing. “I think if you were doing a SHARP score on every patient, then x-rays would have more validity because then you would be looking at joint-space narrowing and erosions in many joints. But that's a measurement used primarily in research alone and is totally impractical in clinical practice,” he said.
To view a video interview of Dr. Gaylis, go to
http://www.youtube.com/watch?v=8Q6iRPzJ3a8
Ultrasound is a good option when you're not sure what is going on with your patient and you need to know right away. DR. GAYLIS
T1 (left) and STIR imaging (right) reveal a profound, diffusely abnormal signal consistent with osteitis (arrows).
Near complete resolution of osteitis throughout the carpal bones and metacarpal bases (arrows) can be seen. Images courtesy Dr. Steven D. Needell
Resources
▸ ACR letter addressed to insurance companies clarifying the college's position on extremity MRI for rheumatologic conditions:
http://rheumatology.org/practice/advocacy/asc/letters/index.asp
▸ International Society of Extremity MRI in Rheumatology:
▸ American College of Radiology meetings:
www.acr.org/SecondaryMainMenuCategories/
Meetings andEvents.aspx
▸ American College of Radiology accreditation:
www.acr.org/accreditation/mri/mri_reqs.aspx
▸ Intersocietal Commission for the Accreditation of Magnetic Resonance Laboratories: