脊柱夏科氏关节病的诊断与治疗

脊柱夏科氏关节病是一种罕见的具有进展性的严重的退行性脊柱疾病。其临床表现隐匿且不典型,容易导致漏诊、误诊,延误病情,影响预后。目前国内尚无系统性分析脊柱夏科氏关节病的文献。脊柱夏科氏关节病的病因主要分为脊髓损伤及非损伤性神经病变两类,其中脊髓损伤引发脊柱夏科氏关节病的危险因素包括长节段固定、脊柱侧凸、椎板切除、脊柱负荷过大的运动和肥胖。脊柱夏科氏关节病好发于下胸椎或腰椎,常见症状是脊柱畸形、坐姿不平衡和局部疼痛。根据潜在疾病引起本体感觉及痛温觉损害,影像学上大量的骨破坏和吸收以及大量新骨形成,组织学提示非特异性慢性炎症,并排除其他炎性和肿瘤性疾病,可以作出诊断。对稳定性好、未合并感染、神经功能平稳、未出现皮肤瘘口、坐姿不平衡或自主神经功能紊乱的脊柱夏科氏关节病患者,可以考虑保守治疗。对症状持续大于6个月、脊柱不稳定、皮肤出现瘘口或并发感染的患者建议优先选择手术。术前应评估髋关节的异位骨化或强直,术中重视病灶内坏死组织、炎症组织的充分清除以及足量的植骨,建议融合至骶骨或骨盆。术后并发症包括内固定失败、新的夏科氏关节形成、伤口愈合困难、感染等。对脊髓损伤合并截瘫的术后患者,建议定期、系统、长期随访,观察整体胸腰椎而非仅仅手术部位的影像。熟知脊柱夏科氏关节病的危险因素及典型症状,有助于早期发现和诊断,并选择适当的治疗方案。

Diagnosis and treatment of Charcot spinal arthropathy

Charcot Spinal Arthropathy(CSA)is a rare and progressive serious degenerative spinal disease.The clinical manifestations of CSA are concealed and atypical,which could lead to missed misdiagnosis,disease prognosis,and a huge burden on patients.However,there is no systematic review of CSA in China.The causes of CSA are mainly divided into spinal cord injury and non-injury neuropathy.The risk factors for CSA caused by spinal cord injury include long-segment fixation,scoliosis,laminectomy,overload spinal exercise and obesity.CSA usually occurs in the lower thoracic or lumbar spine.The symptoms of CSA include spinal deformity,unbalanced sitting posture and local pain.The CSA can be diagnosed after excluding non-specific chronic inflammation in histology and other inflammatory diseases or tumor based on the following items,damage to proprioception,pain and temperature perception,bone destruction,absorption and new bone formation on imaging.Conservative treatment can be considered for patients with CSA who have good stability without infections,stable nerve function,skin fistulas,balanced sitting posture,and autonomic dysfunction.Surgery is recommended for patients with symptoms lasting for more than 6 months with spinal instability,skin fistulas or complicated infections.Before surgery,it is recommended to evaluate the heterotopic ossification or rigidity of both hip joints.During operation,more attention should be paid to the adequate removal of necrotic tissue and inflammatory tissue in the lesion and sufficient bone grafting.Spinal fusion is recommended at the sacrum or pelvis.Postoperative complications include failure of internal fixation,new Charcot joint formation,difficulty in wound healing and infection.The authors emphasize that the overall thoracolumbar spine should be followed up for patients with spinal cord injury and paraplegia for the long-term.The typical symptoms of CSA are helpful for early diagnosis and selection of appropriate interventions.