脊柱关节病骶髂关节的病理表现

目的 了解不同阶段骶髂关节（SIJ）炎的病理变化,提高脊柱关节病（SpA)的早期诊断水平。方法 8例强直性脊柱炎（AS）及5例未分化脊柱关节病（uSpA)患者行CT导引下SIJ关节内激素治疗前,先取SIJ组织。所得标本行HE染色,普通光学显微镜观察。结果 CT0－I级SIJ炎的uSpA病人,SIJ可见滑膜炎症（包括衬里层细胞肥大增生、疏松结缔组织炎症细胞浸润）,局灶性软骨基质减少、变性、纤维化,软骨下骨板炎症细胞浸润。CTⅡ-Ⅲ级SIJ炎病理变化主要为软骨严重变性、破坏,血管翳形成,大量炎症细胞浸润,软骨下骨板破坏;CTⅣ级SIJ炎的病理改变则以软骨下骨板破坏,大量死骨形成,钙盐沉着为主要特点。3份标本的滑膜和软骨下骨板可见嗜酸性粒细胞（EO）比例增高。结论 滑膜衬里细胞肥大增生、疏松结缔组织炎症细胞浸润等滑膜炎表现,局灶性软骨基质减少、变性、纤维化和软骨下骨板炎症细胞浸润、破坏,是早期SIJ炎的病理特点;在CT未出现改变以前,病理学检查有助于早期诊断。     

骶髂关节病变病理学与影像学诊断的相关性

目的通过了解骶髂关节炎病理特点,并以病理结果为标准,探讨病理表现与放射性核素单光子发射计算机断层成像术(single-photon emission computed tomography,SPECT)、磁共振显像(magnetic resonance imaging,MRI)、计算机断层扫描(computed tomography,CT)、X线等影像学检查的关系。方法对中轴型脊柱关节炎患者进行CT引导下骶髂关节(sacroiliac joint,SIJ)穿刺,所得组织进行病理检查,并同时行SIJ的SPECT、MRI、CT和X线检查,按组织病理结果分为SIJ炎组和无炎性反应组。结果 36例患者获得组织有软骨、软骨下骨板、关节滑膜、骨髓、肌腱或韧带附着点等。获得率以软骨为最高,继以软骨下骨板、关节滑膜、骨髓和韧带附着点,各占92%、83%、75%、72%、22%;其中28例(2836,78%)患者SIJ炎病理变化包括软骨(93%)和软骨下骨板改变(75%)、滑膜炎(64%)、骨髓炎(46%)、附着点炎(32%),8例(22%)未发现有SIJ炎改变。MRI示29例(81%)患者共56个SIJ可见不同程度的异常信号改变,软骨线改变、软骨下骨板改变、骨髓水肿、脂肪沉积、骨质硬化分别为82%、71%、65%、59%、76%;SPECT示29例(81%)共52个SIJ可见骶髂关节感兴趣区的放射性比值有不同程度的升高,23例(64%)CT阳性,19例(53%)X线阳性。以病理结果为标准,SPECT、MRI、CT、X线的阳性预测值分别为89.6%、93.1%、95.6%、94.7%,敏感性分别为92.8%、96.4%、73.3%、64.2%,特异性分别62.5%、75.0%、87.5%、87.5%。4种诊断方法的受试者工作特征曲线下面积分别为0.79、0.84、0.83、0.76。结论病理检查是诊断Sl J炎和活动性炎性反应的主要方法。MRI和SPECT的相互补充,能提高骶髂关节活动性炎症的敏感性和特异性。MRI和SPECT的诊断价值与CT和X线相当,并可通过对炎症的活动度进行量化,有利于随访和疗效的评价,是诊断SIJ炎重要的辅助手段。     

骶髂关节炎磁共振检查意义初探

目的：探讨骶髂关节（SIJ）炎磁共振（MRI）检查的意义。方法：强直性脊柱炎（AS）12例，未分化脊柱关节病（uSpA)7例，作X线平片、CT和MRI检查。其中14例作动态MRI增强，11例作CT导引经皮穿刺活检。8例正常志愿者作MRI平扫和动态MRI增强。结果：CT和MRI对Ⅲ、Ⅳ级SIJ炎的判断基本一致，对0－Ⅱ级的判断二者相差较大。SIJ关节区的强化与组织炎症细胞的检出相关。关节旁骨髓水肿仅见于SIJ炎，也与SIJ的强化及组织炎症相关。结论：MRI通过增强（动态）、关节旁水肿等表现，推断Ⅱ、Ⅲ级SIJ的炎性活动程度，明确0级、I级SIJ炎的诊断，了解IV级SIJ是否存在炎症活动，对SIJ炎的早期诊断和病情活动性判定有重要意义。     

结缔组织生长因子及I型和Ⅲ型胶原在脊柱关节病骶髂关节组织中的表达

目的 了解脊柱关节病(SpA)患者骶髂关节中结缔组织生长因子(CTGF)、I型胶原、Ⅲ型胶原的表达情况,探讨CTGF在spA关节软骨纤维化、骨化、关节强直中的作用.方法 30例spA患者(17例双侧影像学骶髂关节炎≥Ⅱ级,13例影像学骶髂关节炎Ⅰ级)均接受CT引导下骶髂关节穿刺活检术,取得骶髂关节组织.组织标本均行苏木素一伊红(HE)染色确认存在骶髂关节炎后,通过免疫组织化学染色方法,标记CTGF、Ⅰ型胶原及Ⅲ型胶原的表达情况.统计学方法采用单因素方差分析和t检验.结果 30例SpA患者骶髂关节组织中CTGF主要在血管翳炎症细胞及骨髓细胞的胞质中高度表达,阳性细胞数明显多于正常组织对照组[(57.9±42.4)腐倍视野和(2.7±2.5),高倍视野);Ⅰ型胶原及Ⅲ型胶原明显沉积于骨、部分软骨及韧带,平均吸光度均明显高于对照组(分别为0.298±0.080和0.044±0.024;28.254±41.165和0.105±0.054).结论 SpA骶髂关节中存在CTGF的高表达,Ⅰ型胶原及Ⅲ型胶原的沉积增多,提示CTGF参与了SpA骶髂关节局部胶原沉积、软骨纤维化变性过程,可能在SpA关节软骨纤维化、关节强直中起重要的作用.

Abstract：

Objective To investigate the expression of connective tissue growth factor(CTGF),coll agen I and collagen Ⅲ in sacroiliac joint(SIJ)of patients with spondyloarthropathy(SpA).Methods Thirty patients with SpA,including 17 patients with grade Ⅱ saeroiliitis and 13 patients with grade Ⅰ sacroiliitis,were performed on CT guided needie biopsy of SIJ.After sacroiliitis were confirmed by staining with hematoxylin and eosin in sacroiliac joint tissue sample,immunohistochemical assay was performed to determine the expression of CTGF,collagen Ⅰ and collagen Ⅲ in sacroiliac ioint tissue.Univariate Chi-square test was used for data comparison between multiple groups and t-test was used for two group data comparison.Results Contrast to healthy controls,CTGF were found upexpressed on the cytoplasm of inflammatory cells in pannus and bone marrow of sacroiliac tissue samples of patients with SpA,while collagen I and collagen Ⅲ were found up-expressed in bone,cartilage and ligament tissue[(57.9±42.4)/HP vs(2.7±2.5)/HP P<0.05,0.298±0.080 vs 0.044±0.024 and 28.254±41.165 vs 0.105±0.054.P<0.05 respectively].Conclusion CTGF,collagen Ⅰ and collagen Ⅲ are up-expressed in SIJ of SpA patients.CTGF may play an important role in articular cartilage fibrosis and ossification of SpA.     

骨桥蛋白在类风湿关节炎发病机制中的研究进展

类风湿关节炎(rheumatoid arthritis,RA)为慢性炎症性自身免疫病,主要病理特点为滑膜炎、血管翳的形成,以及软骨和骨的破坏.RA病变核心部位在关节滑膜,滑膜主要的组织细胞学改变有:滑膜内膜层细胞[成纤维样滑膜细胞(FLS)和巨噬样细胞]的增生、滑膜内膜下层炎性细胞(巨噬细胞、淋巴细胞等)的浸润,侵蚀关节面的血管翳形成,破骨细胞活化并介导矿化软骨和软骨下骨的侵蚀.病变中涉及到的分子有细胞因子、黏附分子、趋化因子、蛋白酶等.     

强直性脊柱炎骶髂关节内皮质激素注射疗效观察

目的了解强直性脊柱炎(AS)骶髂关节(SIJ)内皮质激素注射的疗效.方法患者取俯卧位,在CT导引下穿刺SIJ滑膜部,取组织标本后,在CT导引下原路进入SIJ,每侧注入丙酮缩去炎舒松15mg.记录分析病人术前、术后临床资料.结果28例中22例(78.6%)疼痛明显减轻,晨僵、夜间痛、SIJ压痛、"4”征、ESR升高及需使用NSAIDs的例数均较术前明显减少.所有SIJ标本均有炎症表现.结论SIJ关节内注射长效激素,可作为对NSAIDs不耐受或无效的AS和uSpA病人的一种有效的缓解腰背痛手段,同时uSpA病人SIJ病理标本的获得,有助于早期诊断.     

超声评估附着点病变的研究现状及进展

脊柱关节炎(SPA)是以中轴、外周关节以及关节周围组织慢性进展性炎症为主要表现的一组疾病,该组疾病以强直性脊柱炎(ankylosing spondylitis,AS)为原型,还包括反应性关节炎、银屑病关节炎(PsA)、炎性肠病相关性关节炎等.附着点炎是指肌腱、韧带、关节囊插入骨部位的炎症,是SpA的特征性改变.SpA患者附着点部位的炎症渐发展为骨破坏及新骨形成,后者导致韧带及关节强直.研究附着点病变的发展规律,对于了解SpA的发病及转归有重要意义.     

趋化因子CXCL16/CXCR6及其在类风湿关节炎发病中的作用及意义

类风湿关节炎(rheumatoid arthritis,RA)是一种主要累及滑膜关节的自身免疫性疾病,其病理改变包括慢性滑膜炎、血管翳形成及大量炎细胞浸润等.滑膜中大量聚集的炎细胞可产生和释放大量炎性介质,破坏关节软骨和骨,最终导致关节破坏和畸形.趋化因子在炎细胞向滑膜组织迁移及活化过程中发挥了关键作用,尤其是白发现CXCL16在RA滑膜中高表达以来,其在RA发病机制中的作用越来越受到重视,且可能成为RA治疗的新靶点.以下就CXCL16/CXCR6及其在RA发病中的作用和意义进行综述.     

老年起病类风湿关节炎研究进展

<正>类风湿关节炎(rheumatoid arthritis,RA)是一种常见的慢性炎症性自身免疫性疾病,可累及全身多系统,以滑膜炎和血管翳为病理特征,增殖的滑膜血管翳可侵蚀关节软骨及软骨下骨,导致关节破坏及功能受损,出现关节畸形,降低患者生活质量。RA全世界发病率为0.3%～1.2%,好发年龄为30～50岁,     

放射性滑膜切除术在关节炎治疗中的应用

放射性滑膜切除术 (ｒａｄｉａｔｉｏｎｓｙｎｏｖｅｃｔｏｍｙ)是将放射性核素注射入关节腔内 ,使之均匀地分布在滑膜表面 ,利用核素发射出 β射线 ,抑制滑膜中的炎性细胞增生 ,使病变的滑膜变性、纤维化直至坏死 ,达到滑膜切除的目的 ,同时减少软骨及骨质破坏。目前已有多种核素用于滑膜切除术 ,国内外先后选用的有198Ａｕ(金 )、90 Ｙ(钇 )、186Ｒｅ(铼 )、169Ｅｒ(铒 )、165Ｄｙ(镝 )、3 2 Ｐ(磷 )、166Ｈｏ(钬 )和153 Ｓｍ(钐 )等[1 8] 。以滑膜增厚、肿胀为主要表现的慢性滑膜炎是风湿病常见的临床表现 ,炎性滑膜及增生的血管翳分泌炎…     

Evaluation of acute and chronic MRI features of sacroiliitis in asymptomatic primary hyperparathyroid patients

Asymptomatic primary hyperparathyroidism (PHPT) is characterized with autonomous overproduction of parathyroid hormone without signs or symptoms associated with hyperparathyroidism. Before symptoms become obvious, PHPT may affect structures like sacroiliac joints, which consist of bone. So, in the asymptomatic PHPT patients, structural and inflammatory changes in sacroiliac joints may lead to confusion during diagnosis workup of axial spondyloarthropathy. In this study, we evaluated active and chronic sacroiliac magnetic resonance imaging (MRI) changes relevant to sacroiliitis in the patients with asymptomatic PHPT and interpreted bone marrow edema within the scope of Assessment of SpondyloArthritis International Society–Outcome Measures in Rheumatology Clinical Trials (ASAS-OMERACT) criteria. Forty-nine patients with asymptomatic PHPT, 26 patients with newly diagnosed axial spondyloarthropathy (SpA), and 37 healthy controls were enrolled. All subjects were evaluated by sacroiliac MRI for four active (bone marrow edema, enthesitis, capsulitis, and synovitis) and four chronic (subchondral sclerosis, subchondral/periarticular erosions, periarticular fat deposition, and bony bridges/ankylosis) lesions relevant to sacroiliitis. Bone marrow edema compatible with ASAS-OMERACT active sacroiliitis criteria in sacroiliac MRI was fulfilled by 16.3 % (8/49) of the asymptomatic PHPT patients which was similar with controls but statistically lower than axial SpA. Moreover, asymptomatic PHPT patients and controls were similar for other chronic or active MRI findings. Also, we detected lower frequency of all other MRI findings, except enthesis, in asymptomatic PHPT patients according to axial SpA. Acute inflammatory including bone marrow edema fulfilling ASAS-OMERACT active sacroiliitis criteria and chronic structural sacroiliac lesions relevant to sacroiliitis in MRI were detected in asymptomatic PHPT similar frequency with controls but as expected, lower than axial SpA. But, these findings could not be attributed to excessive secretion of parathyroid hormone.     

Histopathologic evidence that sacroiliitis in ankylosing spondylitis is not merely enthesitis

OBJECTIVE: To systematically study the histopathology of sacroiliitis in ankylosing spondylitis (AS) at 5 different stages of the disease. METHODS: Two independent observers assessed 75 microscopic features in the sacroiliac (SI) joints in 12 cases of AS (5 biopsies, 7 autopsies) and in 22 control cases (all autopsies). RESULTS: In AS, synovitis, pannus formation, myxoid marrow, superficial cartilage destruction, enthesitis, intraarticular fibrous strands, new bone formation, and bony ankylosis were significantly more frequent than in control cases, in which there was more endochondral bone within deep-zone articular cartilage. Cartilaginous fusion occurred in both groups, but much earlier in AS. There was no residual synovium when the joint lumen was totally occluded. Mild but destructive synovitis and myxoid subchondral bone marrow were the earliest changes identified in AS. These lesions destroyed the adjacent articular tissues, a loss that was followed to varying degrees by fibrous scarring, woven bone, and new cartilage. The original cartilages also fused, and chondral fusion was the predominant mode of ankylosis. Both the original and the reparative cartilaginous tissues were replaced by bone. Active enthesitis occurred in 2 advanced and 3 late cases; fibrous scar tissue, presumed to represent previous enthesitis, was observed in all stages except the earliest. Paraarticular bone was at first dense, and later porotic. CONCLUSION: In the sacroiliitis of AS, two findings predominate: 1) synovitis and subchondral bone marrow changes offer a more rational explanation for widespread joint destruction than does enthesitis; and 2) an unusual form of chondroid metaplasia contributes to ankylosis.     

Imaging of the sacroiliac joint involvement in seronegative spondylarthropathies

Involvement of the sacroiliac joints is the first predominant finding of all seronegative spondylarthropathies (SpA) subsets, such as ankylosing spondylitis, psoriatic arthritis, and undifferentiated SpA. Although conventional radiography is indicated in the initial evaluation of sacroiliac joints diseases, it is often insensitive for demonstrating the early changes of sacroiliitis, so other imaging techniques typically are often necessary to clarify the pathology and for establishing the early diagnosis of seronegative SpA. Other imaging modalities, including computed tomography (CT), magnetic resonance imaging (MRI), ultrasonography (US), and bone scintigraphy have improved visualization of inflammatory changes at the sacroiliac joints (SIJ). CT scans are indicated for disease processes in which bony destruction or ossification may occur. MRI has been proposed as an imaging method to detect sacroiliitis earlier. MRI can identify both inflammation and structural changes caused by inflammation, while radiographs show only structural changes. MRI may be particularly useful in making a diagnosis of SpA. Musculoskeletal US has an increasing and relevant role in the evaluation of SpA mainly for its ability to assess joint and periarticular soft tissue involvement and in particular for its capacity to detect enthesitis. US assessment in general is safe, noninvasive, and comparably cheap, showing itself as a complimentary tool to clinical evaluation in SpA; nevertheless, it is very user dependent. Bone scintigraphy is at most of limited diagnostic value for the diagnosis of established AS, including the early diagnosis of probable/suspected sacroiliitis. The main aim of this study is to introduce the clinical and radiological aspects of the SIJ involvement in SpA, particularly the contribution of the different imaging techniques.     

Incidental computed tomography sacroiliitis: clinical significance and inappropriateness of the New York radiological grading criteria for the diagnosis

The clinical implications of computed tomography (CT) detected sacroiliac joint (SIJ) changes compatible with sacroiliitis has been rarely discussed in the literature. The aim of the present study was to describe prevalence and clinical correlations of sacroiliitis, noted incidentally by abdominal CT in patients referred for non-musculoskeletal complaints, utilizing the New York radiological grading criteria for reference. Five hundred ninety-eight CT scans of the abdomen of patients 18–55 years old, performed at a community medical center, were prospectively examined for the presence of imaging changes consistent with sacroiliitis. Patients with the evidence of bilateral sacroiliitis of grade ≥2 were interviewed and underwent a rheumatologic examination. Twenty-two patients (13 females) were enrolled. Only eight patients (six males) had a history and clinical picture compatible with previously undiagnosed axial spondyloarthritis (SpA). Only the presence of erosions/joint space irregularity and/or inhomogeneous osseous sclerosis around SIJs on CT correlated with the clinical diagnosis of axial SpA. Dense homogenous osseous sclerosis was unrelated to axial SpA and was seen almost exclusively in females. The prevalence of incidental CT sacroiliitis is low, while the New York radiological grading criteria for diagnosing sacroiliitis may be inappropriate for CT imaging. CT noted erosions of the SIJ appear to be a reliable diagnostic sign of sacroiliitis, while the significance of the osseous sclerosis, seen on CT adjacent to SIJs requires better understanding.     

Spondyloarthropathy is underestimated in inflammatory bowel disease: prevalence and HLA association

OBJECTIVE: To determine the overall prevalence of spondyloarthropathy (SpA) among patients with inflammatory bowel disease (IBD) [Crohn's disease (CD) and ulcerative colitis (UC)]. METHODS: One hundred three consecutive patients with IBD from a gastroenterology unit were questioned and examined for SpA symptoms. Patients previously diagnosed with SpA were excluded. All patients were questioned and examined for SpA symptoms such as inflammatory back pain, joint swelling, enthesitis, and psoriasis or a specific family history. Radiographs were taken of all sacroiliac joints. HLA loci A, B, C, and DR were determined in all patients. RESULTS: Thirty-nine percent of the patients with IBD had clinical articular manifestations: 30% had inflammatory back pain, 10% had synovitis, and 7% had a peripheral enthesopathy. The majority (90%) of patients with rheumatic complaints fulfilled the classification criteria for SpA and 10% fulfilled the criteria for ankylosing spondylitis. Asymptomatic sacroiliitis was found in an additional 18% of the patients. Moreover, sacroiliitis, symptomatic or asymptomatic, was related to the disease duration. HLA-B27 conferred an additional risk for inflammatory low back pain in patients with IBD. CONCLUSION: Articular involvement in IBD can be classified as SpA. The appearance of SpA occurs irrespective of the extent of the bowel disease. Moreover, asymptomatic sacroiliac involvement is a common manifestation in IBD and it is related to disease duration, suggesting evidence for a related pathogenic mechanism.     

High frequency of inflammatory back pain and other features of spondyloarthritis in patients with rheumatoid arthritis

The aim of this study was to investigate the frequency of patients with rheumatoid arthritis (RA) who have inflammatory back pain (IBP) and meet the existing classification criteria for ankylosing spondylitis (AS) and spondyloarthritis (SpA). We included 167 patients fulfilling the ACR 1987 revised criteria for RA. After obtaining a medical history and performing a physical examination, standard pelvic X-rays for examination of the sacroiliac joints (SIJ) were ordered in all patients. A computed tomography (CT) or magnetic resonance imaging (MRI) of SIJ was performed in patients with suspected radiographic sacroiliitis and MRI of SIJ in those who have IBP but no radiographic sacroiliitis. IBP was defined according to both Calin and experts’ criteria. The modified New York (mNY) criteria were used to classify AS, both ESSG and Amor criteria for SpA and ASAS classification criteria for axial SpA. There were 135 female and 32 male patients with a mean age of 54.8 years. The mean disease duration was 9.8 years. RF was positive in 128 patients (79.2 %) and anti-CCP in 120 patients (81.1 %). Twenty-eight patients with RA (16.8 %) had IBP (Calin criteria), and four (2.4 %) had radiographic sacroiliitis of bilateral grade 3. Three patients (1.8 %) fulfilled the mNY criteria for AS, 31 (18.6 %) ESSG and 26 (15.6 %) Amor criteria for SpA. Nine patients (five with MRI sacroiliitis) (5.3 %) were classified as having axial SpA according to new ASAS classification criteria. This study suggests that the prevalence of SpA features in patients with RA may be much higher than expected.     

Animal models of ankylosing spondylitis

The pathology of ankylosing spondylitis (AS) and related spondyloarthropathies (SpA) characteristically involve a sacroiliitis and inflammation of the intervertebral discs (IVD) in the lumbar spine, and an enthesitis at sites of ligamentous insertions into bone. The proteoglycans aggrecan and versican are large molecules that aggregate with hyaluronic via a globular 1 domain. These domains share significant homology at the level of B and T cell epitope recognition. Both proteoglycans are present in the intervertebral disc and hyaline cartilages of the sacroiliac joint, as well as in entheses. Whereas aggrecan is most concentrated in the nucleus of the IVD and in articular cartilages and endplates, versican is generally absent from these tissues except in the sacroiliac joint, but is concentrated in ligaments and the annulus. Immunity to these molecules in BALB/c mice results in an AS-like pathology, including sacroiliitis, enthesitis, and discitis. The pathology of AS is closely associated with the expression of the class I molecule human leukocyte antigen-B27. Rats bearing this transgene develop an AS-like pathology, as well as other various signs of autoimmunity. Ankylosing spondylitis is characterized by an ankylosing pathology whereby bone formation in the annulus leads to intervertebral fusion. Mice bearing the ank/ank defect gene develop a bony ankylosis of the spine like that seen in advanced AS and related SpA. These three animal models provide insight into the pathogenesis of SpA, and opportunities to investigate their pathology in relationship to human disease where investigation of the pathobiology is very difficult, because of restricted access to involved tissues.