强直性脊柱炎误诊为股骨头坏死一例报告

强直性脊柱炎(ankylosing spondylitis,AS)是一种主要累计中轴骨骼的血清阴性脊柱关节病,好发于16～25岁青年人,主要累计脊柱,其标记性特点是骶髂关节炎,从骶髂关节发病,沿脊柱向上,严重者可累计下颌关节[1].     

强直性脊柱炎的治疗指南介绍

强直性脊柱炎（ ankylosing spondylitis，AS ）是一种累及中轴及外周关节的慢性炎性进展性风湿病，AS 是脊柱关节炎（ spondyloarthritis，SPA ）的原型。2010年欧洲抗风湿病联盟（ EULAR ）及国际脊柱关节炎协会（ assessments in ankylosing spondylitis international society，ASAS ）共同更新了AS的治疗指南，该指南同样适用于SPA的治疗[1]。同年中华医学会风湿病分会也更新了我国 AS 诊断及治疗指南，两个指南的更新对于AS及SPA的治疗具有指导意义。近年来，随着传统药物及生物制剂治疗 AS 研究的深入，国内外又发表了许多关于 AS 治疗的研究。现综合介绍如下。     

TGF-β、IL-17与骨性关节炎研究新进展

骨性关节炎(osteoarthritis,OA),又称骨关节病、退行性关节病、增生性关节炎、肥大性关节炎、老年性关节炎,是最常见的一种慢性、进展性关节疾病。其病理特点为关节软骨变性、破坏、软骨下骨硬化、关节边缘和软骨下骨反应性     

第二届中国脊柱内镜学术会议通知

中国医疗保健国际交流促进会骨科疾病防治专业委员会脊柱内镜学组与《中国骨与关节杂志》主办，上海市第十人民医院（同济大学附属第十人民医院）承办的第二届中国脊柱内镜学术会议，将于2015年7月31日至8月2日在上海召开。     

血友病性膝关节病误诊一例报告

目的报告1例血友病性关节病误诊35年的病例,为临床医师提供借鉴的经验与教训。方法患者,男,42岁;7岁起发病,35年,多家医院均未能确诊,术后方明确血友病性关节病的诊断。结果患者7岁时出现“双髋、双膝酸困不适及疼痛,渐进性加重,伴关节活动幅度逐渐减小”等症状被当地医院误诊为“类风湿性关节炎”对症治疗,因效果不佳,于1个月后在当地人民医院误诊为“双膝骨结核”,给予口服抗结核药物治疗,症状无缓解,之后双髋、双膝关节反复出现疼痛、肿胀、活动受限达35年。于近期加重,我院以“双膝关节类风湿性关节炎”收住院。行膝关节表面置换术,尽管术后给予伤口处加压包扎、冰敷、常压引流等处理,术后第1天引流量高达2400ml,且伤口敷料持续出现大量渗血。始考虑是否有血液系统疾病漏诊即请血液科会诊。查：特异性凝血因子Ⅷ为13．70（正常值：O．60～1．60）、Ⅸ103．30（正常值：0．80-1．20）方确诊为甲型血友病性关节病。结论本例甲型血友病性关节病长期误诊,教训深刻。提示临床医师须强化病史问诊的能力,重视相关疾病的体征以提高对不同关节炎疾病的鉴别诊断能力,必要时,应及时请相关专科医师会诊。     

成人特发性脊柱侧凸的后路截骨术

目的评价后路脊柱截骨术在治疗成人特发性脊柱侧凸的有效性和安全性。方法回顾性随访2000年1月至2004年12月间接受后路截骨矫形固定融合术并随访2年以上的53例成人特发性脊柱侧凸，男13例，女40例，平均年龄31．2岁（20～48岁）。按照弯曲部位分别为单胸弯23例，胸腰弯15例，双胸弯7例，胸腰双弯8例。术前平均胸椎Cobb角58．8°（44～93），腰椎49．5°（35°～79°），平均柔韧度胸椎28．2％，腰椎37．1％。躯干偏移平均38mm（3～79mm）。本组中37例术前合并腰背痛，5例合并椎管或神经根管狭窄所致的下肢症状。所有患者接受一期后路选择性经关节突椎板截骨矫正、经椎弓根固定融合术。通过病例查阅、X线片测量以及问卷随访，评价矫正情况和功能情况。结果所有患者均安全完成手术，无神经损伤等严重并发症发生。平均截骨节段3．1个（2～5个），平均手术时间3．5h（2．8～5．2h），平均出血量892ml（750～l520m1）。所有患者均获得2年以上随访（2～5年）。术后胸椎侧凸平均17．2°（19°～47°），最终随访时平均19．8°（11°～49°）。术后腰椎侧凸平均16．7°（7°～23°），最终随访时平均l8．9°（8°～26°）。术后躯干偏移平均为l1mm（0～2lmm），平均矫正71％。37例术前存在腰背痛者35例最终随访时腰背痛消失，5例术前存在下肢症状者术后完全消失。结论成人特发性脊柱侧凸行后路经关节突和椎板截骨可以获得满意矫正，疼痛症状缓解，是治疗成人特发性脊柱侧凸的安全有效的手术方法。     

晚发型脊柱骨骺发育不良伴进行性骨关节病

晚发型脊柱骨骺发育不良伴进行性骨关节病（spondylocpiphyscal dysplasia tardy with progressive arthopathy,SEDT—PA）X称儿童进行性假类风湿性关节病,或称进行性假类风湿性骨发育不良,是一种罕见的软骨发育不良为主的常染色体隐性遗传病,发病率约为百万分之一,男女相仿。     

脊柱恶性肿瘤误诊分析

脊柱恶性肿瘤误诊分析福建医学院附属二院骨科（３６２０００）陈献南，李树梁由于脊柱解剖结构和疾病自身的特异性，脊柱恶性肿瘤的临床诊治有不少困难。本文通过对我科１９９０年１月～１９９３年１２月收治脊柱恶性肿瘤误诊１４例原因分析，探讨减少临床误诊方法，提高...     

《骨科手术学》(第3版)简介

由名骨科专家邱贵兴教授和戴克戎院士担任主编的《骨科手术学》（第3版）一书已由人民卫生出版社出版发行，全书分为九篇，共42章，内容包括总论、手术途径、创伤骨科、关节外科、手外科、脊柱外科、关节镜外科、骨肿瘤外科及一些难以分类的疾病等，重点介绍骨科基本手术的手术方法与术式，节别是增加了90年代以来在创伤、关节、脊柱及微创手术方面的新理论、新技术。     

炎症细胞因子在骨性关节炎疼痛中的作用机制

骨性关节炎 （ osteoarthritis,OA ） 是一种常见的退行性关节病,涉及到整个滑膜关节,包括软骨、滑膜和软骨下骨。OA主要的临床表现是关节的疼痛,这不仅会导致功能受限和生活质量的降低,而且是老年人行动不利的主要原因[1]。有报道,60岁以上的人群中,50%在X线片上有骨性关节炎表现,80%有骨性关节炎症状,并且是致残的主要原因之一[2]。尽管目前对于OA疼痛的确切机制尚不明确,但普遍认为其与膝关节局部炎症相关,炎症细胞因子通过直接或间接的途径诱导痛觉过敏是OA疼痛的原因之一。     

Autoimmune disease and subsequent digestive tract cancer by histology

BackgroundDysregulation of the immune function in autoimmune diseases could potentially lead to cancer development and there is definite evidence linking some autoimmune mechanisms with cancer. We analyzed systematically the occurrence of histology-specific digestive tract cancers in patients diagnosed with 33 different autoimmune diseases in order to address the question of shared susceptibility.Patients and methodsStandardized incidence ratios (SIRs) were calculated for subsequent digestive tract cancers up to the year 2008 and in patients hospitalized for autoimmune disease after the year 1964.ResultsMyasthenia gravis associated with five different cancers with SIRs ranging from 1.35 to 2.78. Pernicious anemia, Crohn disease, ulcerative colitis, systemic lupus erythematosis and psoriasis were also associated with cancers at multiple sites. Rheumatoid arthritis associated with no cancer and the standardized incidence ratio was decreased for colon adenocarcinoma, also in ankylosing spondylitis patients.ConclusionsIncreased risks of cancer were observed in patients with several autoimmune diseases. Myasthenia gravis and pernicious anemia were associated with many cancers; this is possibly related to immunosuppressant medication in myasthenia gravis. The decreased risks in colon and rectal adenocarcinomas in rheumatoid arthritis and ankylosing spondylitis suggest underlying inflammatory mechanisms as the risks may have been suppressed by the use of anti-inflammatory medication.     

合并膝关节急性疼痛的强直性脊柱炎早期临床特点分析

【摘要】目的了解以膝关节急性肿痛为首发症状的强直性脊柱炎（ankylosingspondylitis,AS）早期病情特征,以提高诊治水平。方法对2009年12月至2012年12月,我院经治的21例合并膝关节急性肿痛强直性脊柱炎患者的早期临床特点、影像学及实验室检查结果进行回顾性分析。结果年龄17—45岁。21例首发症状以患侧膝关节肿痛为主。膝关节腔积液黄白色、浑浊,涂片镜检白细胞4＋,膝关节滑膜组织为炎性肉芽组织。血沉、C反应蛋白、纤维蛋白原均高于正常,18例HLA—B27阳性。磁共振提示膝关节滑膜增生、关节腔内大量积液。16例骶髂关节及脊柱x线片显示,均无明显异常改变。结论强直性脊柱炎发病隐匿,往往以膝关节急性肿痛为首发症状,误诊率及漏诊率高。加强年轻患者早期筛查、需仔细询问病史、详细查体、密切观察病情变化,对强直性脊柱炎早期诊治有价值。     

The lumbar spine: imaging in rheumatic disease

Seronegative inflammatory spondyloarthropathies include ankylosing spondylitis, psoriatic arthritis, Reiter syndrome, juvenile chronic arthritis and colitic arthritis. These diseases share some characteristics among which the most important is the presence of the histocompatibility antigen HLA B27; moreover the frequent overlapping of the various inflammation patterns have accounted for their classification in a single group. Diagnostic imaging can differentiate among the different forms only if the diagnostic algorithm, based on clinical history and laboratory findings is followed, considering the advantages and limitations of each method. In this respect, it should be kept in mind that the findings relative to the spine and sacroiliac joints allow to establish a definitive diagnosis.     

Magnetic resonance imaging of cauda equina syndrome in long‐standing ankylosing spondylitis

The cauda equina syndrome is an uncommon complication of long‐standing ankylosing spondylitis and its aetiology is controversial. We report a case of the cauda equina syndrome, erosion of the posterior elements of the lumbar spine and traction of the lumbar nerve roots because of multiple dural diverticula in a patient with long‐standing ankylosing spondylitis. Magnetic resonance imaging is valuable in excluding other spinal lesions. Extensive dural diverticula formation is characteristic of ankylosing spondylitis and has the potential to provide an early diagnosis.     

以外周关节炎为首发的青少年强直陛脊柱炎的诊断特点

目的探讨以外周关节炎为首发的青少年强直性脊柱炎（AS）的诊断特点,避免误诊误治。方法回顾性分析我院2003年1月～2008年1月诊治的38例以外周大关节为首发症状的青少年强直性脊柱炎的临床特点。结果38例9～18岁的以外周关节炎为首发的青少年AS男性患者,外周关节炎首发部位分别为膝关节18例,踝关节8例,髋关节7例,肘关节3例,足跟末端跟腱2例。骶髂关节X线拍片或CT检查,单侧Ⅰ级者18例,双侧Ⅰ级者9例,单侧Ⅱ级者6例,双侧Ⅱ级者4例,Ⅲ级者1例,其中Ⅰ级和Ⅱ级单侧者共33例（86．8％）,双侧Ⅱ级以上者共5例（13．2％）。所有患者HLA—B27阳性。结论青少年AS的临床特点是以外周关节炎／滑膜炎为首发主要症状,缺乏典型的影像学表现,早期诊断主要根据病史、体征和实验室检查,X线检查一般不作为主要依据。     

Long term mortality after a single treatment course with X-rays in patients treated for ankylosing spondylitis

Mortality up to 1 January 1983 has been studied in 14,106 patients with ankylosing spondylitis given a single course of X-ray treatment during 1935-54. For neoplasms other than leukaemia or colon cancer, mortality was 28% greater than that of members of the general population of England and Wales, and this increase is likely to have been a direct consequence of the treatment. The proportional increase reached a maximum of 71% between 10.0 and 12.4 years after irradiation and then declined. There was only a 7% increase in mortality from these tumours more than 25.0 years after irradiation and only for cancer of the oesophagus was the relative risk significantly raised in this period. Neither the magnitude of the relative risk, nor its temporal pattern following treatment, were greatly influenced by the age of the patient at first treatment. For leukaemia there was a threefold increase in mortality that is also likely to have been due to the radiotherapy. The relative risk was at its highest between 2.5 and 4.9 years after the treatment and then declined, but the increase did not disappear completely, and the risk was still nearly twice that of the general population more than 25.0 years after treatment. There was some evidence that the risks of acute myeloid, acute lymphatic, and chronic myeloid leukaemia were all increased, but no evidence of any increase in chronic lymphatic leukaemia. The relative risk appeared to be greatest for acute myeloid leukaemia. For colon cancer, which is associated with spondylitis through a common association with ulcerative colitis, mortality was increased by 30%. For non-neoplastic conditions there was a 51% increase in mortality that was likely to be associated with the disease itself rather than its treatment. The increase was apparent for a wide range of diseases and was not confined to diseases that have been associated clinically with ankylosing spondylitis.     

Cancer cachexia

In recent years many efforts of researchers and clinicians were made to improve our knowledge of cachexia syndrome. Not only cancer, but also many chronic or end-stage diseases such as AIDS, chronic obstructive pulmonary disease (COPD), rheumatoid arthritis, tuberculosis and Crohn's disease are associated with cachexia, a condition of abnormally low weight, weakness, and general bodily decline which deteriorates quality of life and reduces the prognosis of the patients who suffer from it. In the present editorial we will focus cachexia related on cancer and provide some insight into this prognosis-limiting syndrome.     

Risk of cancer of unknown primary after hospitalization for autoimmune diseases

Cancer of unknown primary (CUP) is a heterogeneous syndrome diagnosed at metastatic sites. The etiology is unknown but immune dysfunction may be a contributing factor. Patients with autoimmune diseases were identified from the Swedish Hospital Discharge Register and linked to the Swedish Cancer Registry. Standardized incidence ratios (SIRs) were calculated for subsequent CUP and compared with subjects without autoimmune diseases. A total of 789,681 patients were hospitalized for any of 32 autoimmune diseases during years 1964–2012; 2,658 developed subsequent CUP, giving an overall SIR of 1.27. A total of 16 autoimmune diseases were associated with an increased risk for CUP; polymyositis/dermatomyositis showed the highest SIR of 3.51, followed by primary biliary cirrhosis (1.81) and Addison's disease (1.77). CUP risk is known to be reduced in long‐time users of pain‐relieving nonsteroidal anti‐inflammatory drugs (NSAIDs), such as aspirin. For patients with ankylosing spondylitis and with some other autoimmune diseases, with assumed chronic medication by NSAIDSs, CUP risks decreased in long‐term follow‐up. The overall risk of CUP was increased among patients diagnosed with autoimmune diseases, which call for clinical attention and suggest a possible role of immune dysfunction in CUP. The associations with many autoimmune diseases were weak which may imply that autoimmunity may not synergize with CUP‐related immune dysfunction. However, long‐term NSAID medication probably helped to curtail risks in some autoimmune diseases and CUP risks were generally higher in autoimmune diseases for which NSAIDs are not used and for these CUP appears to be a serious side effect.     

Prognosis in node negative breast cancer patients: the importance of tumour diameter and mean nuclear area

In node negative breast cancer patients, tumour size and mean nuclear area (MNA) as single variables have significant impact on prognosis. Combination of the two variables gives additional information on survival, and makes it possible to predict the outcome of the disease correctly in 70% of the patients both early (82 months) and late (154 months). MNA contributes relatively more to prediction of late prognosis than tumour diameter and vice versa for early prognosis. Thus a long follow-up is needed for node negative patients, and more so for patients with favourable prognostic criteria.     

全脊椎截骨联合椎板 V 形截骨在治疗强直性脊柱炎后凸畸形中的应用

目的总结全脊椎截骨联合椎板V形截骨治疗重度强直性脊柱炎后凸畸形的疗效,并对矫形效果和手术适应证进行分析。方法手术治疗重度强直性脊柱炎后凸畸形患者22例,全部为男性,平均手术年龄29.3岁。2例患者术前出现神经损伤症状。全部患者行后路弧顶全脊椎楔形截骨、联合多节段椎板关节突V形截骨、节段椎弓根螺钉固定,术中应用SEP和唤醒试验双向监测。影像学测量脊柱后凸角（CA）、骶骨倾斜角（SEA）、大体像测量颏眉角（CBVA）评价矫形效果。结果术后平均后凸角由术前的76.6°（66°～105°）矫正至29.6°,平均矫正率66.2%,骶骨倾斜角由术前平均17.5°（-5.9°～23.1°）矫正至33.4°,颏眉角由术前平均35.6°（28°～47.1°）矫正至7.4°。19例患者术后平均随访29个月（4～54个月）,植骨融合良好,矫正丢失率平均2.3%。术后2例患者出现暂时神经功能障碍,1个月后完全恢复。术前有神经功能障碍的患者术后完全恢复。结论全脊椎截骨联合椎板V形截骨能够有效恢复躯干矢状面平衡,是治疗重度强直性脊柱炎后凸畸形的有效方法。尤其适用于后凸角度大于70°,特别是弧顶合并楔形变或压缩骨折的重度后凸畸形。