课件：强直性脊柱炎傅志均.ppt

2011-01-06,顺德和平创伤外科医院,1,骨二区 傅志均,强直性脊柱炎 Ankylosing Spondylitis，AS,2011-01-06,顺德和平创伤外科医院,2,Ankylosing Spondylitis，AS,Ankylosing spondylitis (AS), is a form of arthritis (关节炎）that primarily affects the spine, although other joints can become involved. It causes inflammation (炎症) of the spinal joints that can lead to severe, chronic pain and discomfort. In the most advanced cases (but not in all cases), this inflammation can lead to new bone formation on the spine, causing the spine to fuse in a fixed, immobile position, sometimes creating a forward-stooped posture. This forward curvature of the spine is called kyphosis（驼背）.,2011-01-06,顺德和平创伤外科医院,3,Description（概况）,Low back pain, with prominent morning stiffness; improves with use and warmth; sometimes nocturnal (夜间发生的) Often insidious (潜伏) in onset in young adults Loss of chest expansion (胸廓扩张度) as disease progresses Associated with peripheral arthritis, enthesitis （起止点炎）, and extra-articular manifestations, such as iritis (虹膜炎) Most frequently found in young men under 40,2011-01-06,顺德和平创伤外科医院,4,Clinical findingSymptom：,Non-traumatic back pain and stiffness (僵硬), which improves with activity Decreased range of motion in lumbar spine Thoraco-cervical kyphosis (late) One-third of patients will have acute, unilateral uveitis.（葡萄膜炎）,2011-01-06,顺德和平创伤外科医院,5,Other Complications,Pseudoarthrosis (假关节), cervical spine fracture, C1-C2 subluxation, cauda equina syndrome Peripheral joint ankylosis Restrictive lung disease, upper lobe fibrosis Aortic root dilation (20%) & murmur (2%),2011-01-06,顺德和平创伤外科医院,6,Clinical findingsings：,Bilateral(双侧) sacroiliac(骶髂部) tenderness A dramatic loss of flexibility（柔韧性、灵活性） in the lumbar spine is an early sign (Schober test) Loss of chest expansion, 5cm), from diffuse costovertebral involvement Weight loss (also a symptom),2011-01-06,顺德和平创伤外科医院,7,Clinical findingsings cont：,Recurrent, acute iritis (虹膜炎) presents as a painful red eye Neurologic signs:resulting from compression radiculitis (脊神经根炎) or sciatica（坐骨神经痛） Anemia Aortic insufficiency, angina(咽峡炎), pericarditis （心包炎）,2011-01-06,顺德和平创伤外科医院,8,Radiographic Findings,Ankylosis(强直) of sacroiliac joints(骶髂关节) Syndesmophyte(韧带骨赘) in the lumbar spine Fusion of the interspinous ligament (棘间韧带) Arthropathy(关节病) of both hips Enthesopathy(起止点炎) of ischial tuberosity (坐骨结节),2011-01-06,顺德和平创伤外科医院,9,Diagnosis,Family history: often one parent has AS. Clinical feature: back pain, immobile of joints, correlative sings X-ray: Ankylosis Syndesmophyte Arthropathy Enthesopathy Laboratory tests: erythrocyte sedimentation rate and C-reactive protein elevated,2011-01-06,顺德和平创伤外科医院,10,Medical Treatment,Non-steroidal anti-inflammatory drugs （NSADs） can rapidly reduce the signs and symptoms Sulfasalazine (柳氮磺胺吡啶) has no clinically effective for AS; however, several studies suggest that it may be effective for peripheral arthritis associated with AS Methotrexate (甲氨蝶呤) has not been shown to be effective in clinical trials for either the axial or appendicular manifestations of AS,2011-01-06,顺德和平创伤外科医院,11,Surgical Treatment,Joint replacement surgery and spine surgery should be considered in patients with refractory pain or disability and radiographic evidence of structural damage, independent of age.,2011-01-06,顺德和平创伤外科医院,12,什么是强直性脊柱炎Ankylosing Spondylitis，AS,强直性脊柱炎是主要累及中轴关节的慢性炎症性疾病，主要引起脊柱的强直，主要病理基础是各个椎间关节出现滑膜炎性改变、滑膜增生，血管翳形成致软骨破坏和骨的侵蚀，进而引起机体的修复反应，导致关节的纤维性或者骨性强直和全身骨骼骨质疏松、韧性减弱，因此，在遭受外力作用时容易引起脊柱三柱损伤，并且多伴随脊髓损伤,2011-01-06,顺德和平创伤外科医院,13,1895年-类风湿关节炎 1958类风湿性脊柱炎.“中枢性类风湿”、“中心型类风湿”、“变型性脊柱炎”、“骨化性骨盆部脊柱炎”、“青春期脊柱炎”等。 发现类风湿因子后，“血清阴性关节炎” 1963年美国风湿病学会废弃了“类风湿脊柱炎”病名而选用了“强直性脊柱炎”这一名称。 1982年希氏内科学正式提出强直性脊柱炎不同 于类风湿性关节炎，是独立性的疾病。,为什么要从类风湿关节炎中分出来,2011-01-06,顺德和平创伤外科医院,14,强直性脊柱炎与类风湿关节炎的区别,2011-01-06,顺德和平创伤外科医院,15,骨赘代替椎体间的韧带,2011-01-06,顺德和平创伤外科医院,16,椎体角的骨炎 反应性的硬化 (shiny corners) 进一步侵蚀 椎体方形变 骨桥形成,韧带骨赘的进展,2011-01-06,顺德和平创伤外科医院,17,骨桥形成,2011-01-06,顺德和平创伤外科医院,18,保留间隙边沿和中间的骨化,2011-01-06,顺德和平创伤外科医院,19,炎症修复造成棘上韧带的骨化,2011-01-06,顺德和平创伤外科医院,20,钙化的棘上韧带,2011-01-06,顺德和平创伤外科医院,21,竹节样改变 的腰椎,2011-01-06,顺德和平创伤外科医院,22,2011-01-06,顺德和平创伤外科医院,23,临床表现,临床表现,2011-01-06,顺德和平创伤外科医院,24,概况,以肌腱端炎、指/趾炎或少关节炎起病 伴有或不伴有急性前葡萄膜炎或皮肤粘膜损害等关节外表现 不同程度的骶髂关节受累 炎性腰痛呈隐匿性、很难定位 晨僵,2011-01-06,顺德和平创伤外科医院,25,关节表现,怠或低热 全身症状如厌食、倦 枕墙距、扩胸度 也常见 居多，膝踝关节受累 外周关节炎：以肩髋 压痛 关节外或关节附近骨 著 背部发僵，以晨起为 慢性下腰痛,2011-01-06,顺德和平创伤外科医院,26,关节外表现,急性前色素膜炎(急性虹膜炎)，25%30%的患者可在病程中出现 肺实质病变：少见的晚期表现，表现为缓慢进展的肺上段纤维化 心血管系统较少累及，可出现升主动脉炎、主动脉瓣关闭不全、传导阻滞 神经系统病变：常与脊柱骨折、脱位与马尾综合症相关,2011-01-06,顺德和平创伤外科医院,27,相关体格检查,相关体格检查,2011-01-06,顺德和平创伤外科医院,28,骶髂关节按压试验,2011-01-06,顺德和平创伤外科医院,29,指地试验正常,各方向运动均受限,2011-01-06,顺德和平创伤外科医院,30,Schobers test 肖伯实验,2011-01-06,顺德和平创伤外科医院,31,骶髂关节炎的检查 挤压及牵伸试验,2011-01-06,顺德和平创伤外科医院,32,髋关节病变的代偿,2011-01-06,顺德和平创伤外科医院,33,4字试验与 侧向挤压试验,2019/8/27,34,可编辑,2011-01-06,顺德和平创伤外科医院,35,枕墙距,2011-01-06,顺德和平创伤外科医院,36,强直性脊柱炎的诊断,没有误诊的类风湿,没有不误诊的强柱,2011-01-06,顺德和平创伤外科医院,37,诊断强直性脊柱炎的纽约标准 （1984年修订）,临床标准： 1. 下腰部疼痛至少持续3个月，活动后减轻， 休息后不消失 2. 腰椎活动受限（矢状面与额状面） 3. 扩胸度较同年龄与性别的正常人减小 肯定AS： 至少1条临床标准 + 3级以上单侧骶髂关节炎或双侧 2级骶髂关节炎,2011-01-06,顺德和平创伤外科医院,38,影响学检查常常会误导诊断,60岁以上 椎间盘轻度膨出见于 80% 的正常人 椎间盘轻度脱出可见于 1/ 3的正常人 均具有年龄相关的退行性变 椎管狭窄见于1 / 5的正常人 60岁以下 1 /2,500 能得到有意义的发现 椎间盘轻度膨出可见于 1/ 3的正常人 椎间盘轻度脱出见于 1/ 5的正常人,2011-01-06,顺德和平创伤外科医院,39,骶髂关节炎的X线分级,0级，正常 1级，可疑骶髂关节炎 2级，局限侵蚀、硬化 3级，侵蚀硬化狭窄局限强直 4级，骶髂关节完全强直,2011-01-06,顺德和平创伤外科医院,40,早期硬化与侵蚀,2011-01-06,顺德和平创伤外科医院,41,纤维连接关节和滑膜关节均出现侵蚀病变,2011-01-06,顺德和平创伤外科医院,42,2011-01-06,顺德和平创伤外科医院,43,骶髂关节强直性脊柱炎 骶髂关节面均模糊，边缘呈小囊状骨破坏连成锯齿状，以髂骨面为重，周围骨质硬化增白。,2011-01-06,顺德和平创伤外科医院,44,椎体呈方形 小关节间隙狭窄或消失 关节面模糊不清 椎旁韧带骨化连成竹节样脊柱,腰段强直性脊柱炎,2011-01-06,顺德和平创伤外科医院,45,脊柱X线改变,2011-01-06,顺德和平创伤外科医院,46,2011-01-06,顺德和平创伤外科医院,47,早期的病情评价是治疗的关键,What is the headache 高度的异质性，预后各有不同 前脊柱炎期往往有5-10年 平均诊断延误时间为8.9年 没有公认的病情评价标准,2011-01-06,顺德和平创伤外科医院,48,预后指标,髋关节受累 (OR 23) 腊肠趾/指 (OR 8) 对 NSAID反应不佳 (OR 8) WESR 30 (OR 7) 腰椎活动受限 (OR 7) 单关节炎 (OR 4) 16岁以下发病 (OR 3),Amor et al, J Rheum 1994,2011-01-06,顺德和平创伤外科医院,49,2011-01-06,顺德和平创伤外科医院,50,药物治疗,NSAIDs：迅速控制症状 肾上腺皮质激素：合理使用 NSAIDs无效者；症状严重者； 外周关节受累者；有关节外表现者。,2011-01-06,顺德和平创伤外科医院,51,改善症状药真的只改善症状吗 Symptom Modifying Anti-Rheumatic Drugs (SMARD),对多数NSAID治疗反应良好 消炎痛、莫比克双氯灭痛等疗效好，阿司匹林效差。 改善症状和功能（ASAS 20 ： NSAIDs 49% 对照 24%） 足量NSAID一至二周无效才换另一种 至少应用两种NSAID无效，不到10%,2011-01-06,顺德和平创伤外科医院,52,RCT比较连续和间断应用非甾体药治疗AS 二年，认为连续应用能减缓AS放射学改变。 有待今后进一步证实。,2011-01-06,顺德和平创伤外科医院,53,糖皮质激素,小剂量控制症状有效 全身症状明显 外周关节肿突出 反应性关节炎 不主张长期用于强直性脊柱炎腰痛的治疗 注意副作用的防治 骨质疏松 高血脂症 感染,2011-01-06,顺德和平创伤外科医院,54,柳氮磺砒啶 Salfasalazine,早期（5-10年內）特别是发病六个月内应用 16岁前发病者 疾病活动性较高 外周关节炎症状明显,2011-01-06,顺德和平创伤外科医院,55,改善病情药（ DMARDs ）,目前