强直性脊柱炎的诊疗进展

强直性脊柱炎（ankylosing spondylitis，AS）是一种影响中轴骨骼，引起疼痛和进行性僵硬的慢性炎症性疾病。有学者称为血清阴性的脊柱关节病、关节粘连性脊柱炎、类风湿性脊柱炎、骨化性骨盆脊柱炎和关节僵硬性脊柱炎等。因为本症的临床表现形式和程度有很大的差异，极易漏诊。临床诊治难度较大。现将近几年的诊疗进展综述如下。     

甲氨蝶呤在强直性脊柱炎中的应用

甲氨蝶呤(methotrexate,MTX)又名氨甲蝶呤,是风湿科应用最广的一种细胞毒免疫抑制药.甲氨蝶呤问世早期用于治疗多种肿瘤,1951年开始有学者报道应用MTX治疗银屑病、银屑病关节炎和类风湿关节炎,1988年美国食品与药品管理局批准甲氨蝶呤用于治疗活动性类风湿关节炎.从此,甲氨蝶呤迅速被全球风湿科医生所接受,并已证明它是一种疗效高、起效快、耐受性好,以及效益/毒性比令人满意的二线抗风湿药[1].在这里我们主要讨论甲氨蝶呤在强直性脊柱炎中的应用.     

定量MRI用于强直性脊柱炎研究进展

强直性脊柱炎(AS)是免疫介导的慢性炎性关节炎,早期诊断及治疗可控制病情进展和改善预后。根据定量MRI技术各参数值可定量观察AS患者骶髂关节(SIJ)特定物质含量及结构变化,为早期诊断AS及评价治疗效果提供更准确的信息。本文对定量MRI用于AS的研究进展进行综述。     

强直性脊柱炎的临床研究进展

本文综述了近几十年来国内外医学界对强直性脊柱炎（ankylosing spondylitis，AS）的临床研究进展，普遍认为AS是一种血清学阴性，以中轴骨骼为主，病因不明的慢性全身性疾病。临床发病率较高，青壮年男性最常见，且病因尚未明确，成为脊柱外科界的研究热点。目前认为其发病与多种因素有关，且有高家族性。本文就多年来国内外医学界对该病的大量临床、影像和实验研究进展作一综述，希望籍此对今后的临床诊断和治疗有所参考和启示。     

强直性脊柱炎骨化临床研究进展

强直性脊柱炎（ankylosing spondylitis, AS)是脊柱关节病中最常见的疾病,早期以炎症为主,晚期可出现骨质疏松和骨化两种看似矛盾的表现,骨化的研究有助于AS的治疗。骨化是导致患者出现相关症状、功能障碍、甚至残疾的主要原因。骨化主要发生于脊柱,因为病变组织不易获取,且病程漫长,个体间差异大,目前研究进展缓慢。AS患者骨化平均每年改良的 Stoke强直性脊柱炎脊柱评分（modified Stoke’s AS spine score,mSASSS)进展1分,仅不到30%的患者出现较快进展。基线时炎症与骨化进展有关,主要是红细胞沉降率（erythrocyte sedimentation rate,ESR)、C-反应蛋白（C-reactive protein,CRP)、强直性脊柱炎疾病活动指数（ankylosing spondylitis disease activity score, ASDAS)等客观炎症指标,而与基于患者自我报告结果 (patient-reported outcome,PRO)的 Bath 强直性脊柱炎疾病活动指数（bath ankylosing spondylitis disease activity index, BASDAI) 关系不明确。此外,基线时已存在的骨化程度、磁共振成像（magnetic resonance imaging,MRI)骨髓脂肪沉积、吸烟等也是骨化预测因素。非甾体抗炎药和肿瘤坏死因子拮抗剂对延缓AS病理性成骨的作用尚不明确。     

苏晓教授对强直性脊柱炎的诊疗经验

苏晓教授认为,强直性脊柱炎属于本虚标实,以肝肾亏虚为本,风、寒、湿、热、痰、瘀为标,治疗上总结多年临床经验,结合本病发病特点及中药现代药理学研究成果,采用补肾强督、活血通络之法,注重顾护脾胃.     

强直性脊柱炎下颈椎骨折治疗进展

强直性脊柱炎下颈椎骨折致脊髓损伤的风险很高,治疗存在很大挑战。传统的保守治疗如颈围制动、颈椎牵引、头颈胸石膏背心、Halo-Vest架固定等因并发症发生率高,近年已较少应用。近年推出的胸骨-枕骨-下颌固定支具(SOMI)保守治疗效果良好,但仍需积累病例,以进一步证实。手术治疗是目前治疗的主要手段,近年在术前治疗、手术时机、麻醉、手术方式及术后并发症防治等方面取得了一些进展。该文就此作一综述。     

强直性脊柱炎的诊断与治疗进展

强直性脊柱炎(ankylosing spondylitis,AS)是一种慢性进行性疾病,炎症性腰背痛和腰背部僵硬在疾病早期常见。随着疾病的进展,晚期可造成腰、背、颈、臀、髋部疼痛以及关节肿痛,严重者甚至发生脊柱畸形和关节强直。AS在我国患病率初步调查为0.3%左右。发病年龄通常在13~31岁,高峰为20~30岁。现代医学对其治疗没有切实有效的治愈方案,早诊断、早治疗可控制疾病恶化进展及防止畸形的产生。本文从AS的发病原因、国际上对AS诊断标准的演变、影像学诊断以及治疗等方面的进展情况进行综述。     

Orthopaedic management of ankylosing spondylitis

Ankylosing spondylitis is an inflammatory disease of unknown etiology that affects an estimated 350,000 persons in the United States and 600,000 in Europe, primarily Caucasian males in the second through fourth decades of life. Worldwide, the prevalence is 0.9%. Genetic linkage to HLA-B27 has been established. Ankylosing spondylitis primarily affects the axial skeleton and is characterized by inflammation and fusion of the sacroiliac joints, spine, and hips. The resultant deformity leads to severe functional impairment in approximately 30% of patients. Orthopaedic management primarily involves correction of hip deformity through total hip arthroplasty and, less frequently, correction of spinal deformity with spine osteotomy. Closing wedge osteotomies have the lowest incidence of complications. Whether patients with ankylosing spondylitis are at increased risk for heterotopic ossification remains controversial, but comparison with age- and sex-matched counterparts suggests no dramatically higher risk. Because of the high rate of missed fractures and complications after minor trauma in patients with ankylosing spondylitis, plain radiographs are usually not sufficient for evaluation. Thorough patient assessment should include a comprehensive history, physical examination, and laboratory studies.     

MRI及核素骨显像对强直性脊柱炎的诊断价值

目的探讨动态增强磁共振成像(DMRI)及核素骨显像骶髂关节与骶骨的核素比值测定对强直性脊柱炎(AS)的诊断价值。方法将15例临床诊断为AS的患者共30个骶髂关节(CT诊断为0、Ⅰ、Ⅱ、Ⅲ、Ⅳ期骶髂关节炎)作为实验组。同时将8例志愿者的16个骶髂关节作为对照组。对以上46个骶髂关节分别先行DMRI、核素骨显像骶髂关节与骶骨核素比值测定,1~3d后均在CT引导下行骶髂关节穿刺,取组织行病理组织学检查。结果核素骨显像骶髂关节与骶骨核素比值测定及DMRI检查阳性率两组间比较无显著性差异(P>0.05);诊断阳性患者的病理活检主要表现为骶髂关节均有不同程度的炎症浸润,尤其是滑膜及软骨下骨板。结论核素骨显像骶髂关节与骶骨核素比值测定及DMRI增强检查都有利于AS的骶髂关节炎的早期诊断,且对骶髂关节炎的活动性监测具有重要的应用价值,但前者操作方便、费用较低,可作为临床筛选检查手段。     

Rehabilitation and surgical management of ankylosing spondylitis

Ankylosing spondylitis (AS) is a chronic inflammatory disease which, if untreated, may progress to severe damage of the spine with functional impairment, disability and poor quality of life. An increased mortality has been reported in AS patients compared to the general population. AS requires combined management (pharmacological and non-pharmacological) and advice by different health professionals. Even the pharmacological treatment in the last decade has dramatically changed the outcome, the severity of the disease might require a surgical approach for the hip involvement with total hip replacement, or the corrective spinal surgery. However, this surgery deserves some careful approaches since the complexity of the disease. Rehabilitation still represents a cornerstone of the global management of AS patients. The present review summarizes the state of art of surgical management of these two diseases.     

强直性脊柱炎早期诊断和系统治疗

目的：探讨强直性脊柱炎（AS）早期诊断的可能性和系统治疗的有效性。方法：将32例强直性脊柱炎患者随机分为2组，一组单独应用NSAIDs药物，另一组除应用NSAIDs外，加用柳氮磺胺吡啶和甲氨喋呤，进行疗效观察。结果：两组患者用药后自觉症状均有缓解，前屈，旋转和骶髂关节Gaenslen征与治疗前差异无显著性，而且组间差异也无显著性。结论：原有的AS诊断标准不利早期确诊，应作适当修改，骶髂关节炎是诊断AS的基础上，HLA－B27与AS呈强相关性，但非特异性；慎用慢作用或细胞毒药物治疗AS。     

Airway management in a man with ankylosing spondylitis

We report a case of difficult airway management in a 41-year-old man with ankylosing spondylitis who was scheduled for total left hip replacement surgery. After several failed attempts to achieve regional anesthesia, we converted to general anesthesia with orotracheal intubation using a fiberoptic bronchoscope. Ankylosing spondylitis leads to fibrosis, ossification, and ankylosis along the spinal column and sacroiliac articulations. Cervical column and atlantooccipital articulation mobility are reduced and in severe cases the cervical vertebrae become fixed in a flexed position. This portion of the spine is also the most susceptible to fracture, particularly in hyperextension, an event that could lead to damage to the cervical spinal cord during maneuvers to manage the airway. Patients with this condition may also have temporomandibular joint involvement, further complicating airway management. We report the case of a patient with ankylosing spondylitis with fixation along the entire spine. The airway was managed by intubation with a fiberoptic bronchoscope. Spontaneous ventilation was maintained during the maneuver, and sedation was achieved with perfusion of remifentanil as the only anesthetic agent following failure of intradural anesthesia.     

Anesthetic management of the parturient with ankylosing spondylitis

Pregnancy may occur in patients with ankylosing spondylitis, a chronic inflammatory joint disease. This disease, which is included in the group of seronegative spondylarthropathies, may be characterized by both intra- and extra-articular manifestations. Although most pregnant patients with ankylosing spondylitis experience normal spontaneous vaginal deliveries, manifestations of the disease may interfere with labor and delivery as well as the administration of general and regional anesthesia. Therefore, physicians caring for a pregnant patient with ankylosing spondylitis should be aware of the obstetric and anesthetic implications and the ramifications of active disease. These patients should be referred to an anesthesiologist early in pregnancy so that the obstetrician and anesthesiologist can together formulate a plan.