Treatment of ankylosing spondylitis and undifferentiated spondyloarthritis with TNF alpha-antagonists

The spondyloarthritides (SpA) are common inflammatory rheumatic diseases with an overall prevalence of 0.6-1.9%. Ankylosing spondylitis (AS) and undifferentiated spondyloarthritis (uSpA) are the most common subsets of SpA. Women are almost as frequently affected as men, but the total burden of disease may be similar. At least one third of AS patients are severely affected with impaired function and a poor quality of life similar to patients with rheumatoid arthritis. However, AS starts 20-30 years earlier in life. Thus, AS has a relevant socioeconomic impact on society. After decades of no progress concerning treatment options in SpA, there is now accumulating evidence that the new anti-TNF alpha agents do not only reduce signs and symptoms of AS caused by inflammation but they may also diminish structural damage. Very recent magnetic resonance imaging (MRI) data of a follow-up study support this assumption. The following paper reviews the currently available literature on anti-TNF alpha therapy in AS and uSpA. Efficacy, side effects and experiences with different doses are discussed. In expectation of the approval of infliximab and etanercept for the treatment of active AS international guidelines for initiation, monitoring and discontinuation of these agents have been recently proposed.     

强直性脊柱炎影像学分析

目的探讨X线、CT、MRI对强直性脊柱炎的影像特点。方法对本科确诊的68例强直性脊柱炎的影像资料进行分析,所有研究对象都全部做X线、CT、MRI影像学检查。本文通过X线、CT、MRI检测骶髂关节病变程度(诊断AS的主要依据)来诊断分析早、中、晚强直性脊柱炎。结果 X线显示1例(5.0%)正常,表明X线存在早期AS漏诊的可能,X线结果显示Ⅰ级为15例(75.0%)、4例(20.0%)Ⅱ级与CT,MR比较得出,其在诊断早期AS上存在难度,X线24例(50.0%)Ⅲ级,24例(50.0%)Ⅳ级与CT的23例(47.9%)Ⅲ级,25例(52.1%)Ⅳ级比较,两者相差不大;CT8例(40.0%)Ⅰ级,12例(60.0%)Ⅱ级,与MRI 1例(5.0%)Ⅰ级,19例(95.0%)Ⅱ级比较,得出MRI能更好更准确的检测早期AS,CT与X线、CT与MRI、X线与MRI比较,分别计算得P值0.05,故3个因素两两间差异存在统计学意义。结论强直性脊柱炎影像学检查可先用X线平片做基本诊断,若正常可基本排除AS(不排除漏诊的可能);若不正常,疑似或早期可用CT和MRI明确诊断,中晚期X线可基本明确诊断,医生应根据具体情况考虑是否还需要CT和MRI检查。     

光棒与纤维支气管镜用于强直性脊柱炎困难气道气管插管的比较

目的 比较光棒（light wand,LW）与纤维支气管镜（fiberoptic bronchoscope,FOB）用于强直性脊柱炎患者的困难气道行气管插管的应用效果.方法 选择62例行择期手术的强直性脊柱炎患者,随机分为LW引导气管插管组（LW组,n=32）和FOB引导气管插管组（FOB组,n=30）,经口行气管插管,记录插管时间、成功率,评估血流动力学及插管相关并发症.结果 LW组患者气管插管时间明显短于FOB组（P＜0.01）,在插管成功率、气管插管相关并发症及血流动力学变化等方面,两组之间差异无统计学意义（P＞0.05）.结论 LW和FOB均可用于强直性脊柱炎患者困难气道的气管插管,成功率高,并发症少,对血流动力学影响轻微,而LW操作更为简单,并能缩短气管插管时间.     

强直性脊柱炎髋关节改变的X线、CT和MRI对比研究

目的 探讨强直性脊柱炎(AS)髋关节受累的影像表现,比较X线平片、CT和MRI显示AS髋关节受累的敏感度.方法 对55例AS患者行骨盆X线平片和MR检查,其中29例行髋关节CT检查.MR平扫均包括冠状面T1WI、T2WI、STIR、附加水激励的三维稳态快速梯度回波序列(3D-BTFE-WATS),其中24例同时行脂肪抑制T1WI增强检查.分析患者的影像资料,应用x2检验对X线平片、CT和MRI显示AS髋关节受累改变的敏感度进行分析.结果 55例AS患者110侧髋关节中,X线平片和MRI显示异常分别为13侧和85侧;X线平片改变包括关节面下骨侵蚀破坏13侧、关节间隙变窄4侧、韧带骨赘5侧;MRI显示关节面下骨侵蚀破坏31侧、关节间隙变窄4侧、关节少量积液80侧、骨髓水肿32侧、脂肪沉积28侧、韧带附着点炎21侧,24例行MR增强检查患者中19例见双侧滑膜异常强化.CT检查29例共58侧髋关节,CT在显示X线平片和MRI所显示的骨破坏同时,发现X线平片未能显示的10侧骨破坏和MRI未显示的1侧骨破坏.X线平片、CT、MRI显示异常分别为10.3％ (6/58)、27.6％ (16/58)和77.6％ (45/58),MRI显示髋关节受累的敏感度优于X线平片和CT(x2值分别为53.22和29.08,P值均＜0.05).MRI除显示X线平片和CT所能显示的慢性骨结构改变外,还发现X线平片和CT未能显示的急性炎症改变.结论 MRI能显示X线平片和CT不能显示的AS髋关节受累的急性炎症改变,滑膜炎所致的少量积液和滑膜异常强化是髋关节受累最常见的MRI表现.     

伸直位骨性强直膝的全膝关节置换术

 目的 探讨伸直位骨性强直膝全膝关节置换术的手术方法与临床疗效。方法 2000 年6月至2007 年6 月, 对10 例伸直位骨性强直膝患者施行全膝关节置换术。男4 例, 女6 例;年龄29~63岁, 平均49 岁。双膝关节置换2 例, 单膝关节置换8 例。强直性脊柱炎3 例, 类风湿关节炎2 例, 血友病性关节炎1 例, 创伤性关节炎3 例, 化脓性关节炎1 例。膝关节均处于伸直位骨性强直畸形, 活动度0°, 美国特种外科医院(the Hospital for Special Surgery, HSS)膝关节评分(32.5±10.26)分。结果 全部病例随访3~10 年, 平均5.3 年。末次随访时HSS 膝关节评分提高至(87.75±6.45)分, 与术前比较差异有统计学意义(t=18.668, P=0.000)。关节活动度提高至97.08°±11.57°, 与术前比较差异有统计学意义(t=29.063, P=0.000)。术后发生皮肤坏死2 例、下肢深静脉栓塞1 例、假体周围骨折1 例、假体深部感染翻修1 例。术后X线复查未见假体松动。结论 采用髌旁内侧入路、股四头肌切开、二次截骨加软组织松解的全膝关节置换术可矫正伸直位骨性强直膝关节畸形, 配合正确的康复锻炼, 患者的膝关节功能和生活质量能得到明显提高。     

强直性脊柱炎后凸截骨矫形致神经损伤并发症分析

 目的 探讨截骨矫形治疗强直性脊柱炎后凸畸形神经系统并发症的原因及预防措施。方法 回顾性分析2006年1月至2012年1月行截骨矫形术治疗126例强直性脊柱炎后凸畸形患者资料,其中18例术后发生神经系统并发症,男15例,女3例;手术时年龄25～56岁,平均36.8岁;术前后凸Cobb角57°～96°,平均76.3°;患者术前ASIA分级均为E级。回顾术中操作情况,分析术后发生神经并发症的原因。结果 18例患者均获得随访,随访时间6～49个月,平均35个月;术后后凸Cobb角为19°～38°,平均27°;获得截骨角度31°～76°,平均49.3°,外观得到明显改善。3例(2.4%,3/126)发生脊髓损伤,其中1例在T12截骨处产生矢状面移位,术中经调整上下螺钉高度和预弯棒角度,重新恢复截骨处的矢状面排列后患者无异常;1例截骨闭合后椎管狭窄导致脊髓受压,重新减压后患者随访无异常;1例术中发生医原性颈椎骨折脱位造成脊髓损伤,复位固定后6个月随访时ASIA分级为B级。15例(11.9%,15/126)发生神经根损伤,其中2例为截骨闭合时L3神经根受到挤压,1例为L3椎弓根置钉失误所致,以上3例患者表现为股四头肌乏力;其余12例表现为相应神经根区域皮肤麻木,主要原因是截骨时神经根受到过度牵拉,截除椎弓根下壁时过度激惹神经根;经脱水、神经营养治疗后恢复正常。结论 神经损伤是截骨矫形术中灾难性并发症。认识强直性脊柱炎的病理特点,避免截骨端发生位移,截骨处充分减压,正确摆放患者手术体位,能够有效降低神经损伤的发生。     

强直性脊柱炎早期CT表现——白边征

目的 探讨强直性脊柱炎患者中骶髂关节白边征的形态学表现及临床意义。 方法 收集92例强直性脊柱炎患者,均接受骶髂关节CT检查,分析其影像学表现,并进行统计学分析。 结果 白边征表现为CT图像上骶髂关节髂骨关节面骨皮质带状、不均匀骨质致密区,骨缘不光滑。92例中,双侧骶髂关节受累84例(84/92,91.30%),单侧骶髂关节受累8例(8/92,8.70%);单纯髂骨面受累73例(73/92,79.35%)。骶髂关节炎Ⅰ级19例(19/92,20.65%),其中白边征9例(9/19,47.37%);Ⅱ级24例(24/92,26.09%),其中白边征13例(13/24,54.17%);Ⅲ级35例(35/92,38.04%),Ⅳ级14例(14/92,15.22%),均未见白边征。Ⅰ级、Ⅱ级及Ⅲ级以上骶髂关节炎中白边征出现率的差异有统计学意义(χ²=33.218,P<0.001)。 结论 骶髂关节白边征是AS的早期CT征象,可以考虑将其作为骶髂关节炎分级的参考指标。     

Nuclear and cytoplasmic antigens and antibodies—antibody profiles

Summary In a retrospective study of 148 patients with well-defined ankylosing spondylitis (AS), psoriatic arthritis (PSA) or reactive arthritis (ReA) an 11% prevalence of idiopathic hematuria, proteinuria, or cylinduria was found in the former two groups. None of the patients with ReA had unexplained pathological urinary findings. Such findings were associated with raised ESR and presence of peripheral arthritis in AS and with the duration of disease in PSA. No patient lacking sacroiliitis showed pathological urinary findings. We believe that such findings may reflect nephropathy associated with AS and PSA.     

Combined anterior and posterior surgery for treatment of cervical fracture-dislocation in patients with ankylosing spondylitis

To discuss the pathological characteristics of cervical spinal fracture complicating ankylosing spondyli-tis-(AS) and the effect of combined anterior and posterior operation. Methods: Eighteen AS patients with traumatic cervical fracture-dislocation were treated operatively from January 2000 to January 2006. The symptom duration of AS was 14.5 years on average. Three cases had undergone osteotomy in lumbar spine. There were 4 cases of Grade A, 3 cases of Grade B, 9 cases of Grade C and 2 cases of Grade D accord-ing to Frankel's score. There were 15 cases of Grade Ⅲ dislocation and 3 cases of Grade Ⅱ. All patients underwent surgical procedures by combined anterior and posterior approach.Results: There were 4 anterior-posterior procedures, 8 anterior-posterior-anterior procedures and 6 posterior-an-terior procedures. Seven patients had one stage operation and 11 cases underwent two stage surgeries. There was certain extent of neorological improvement in 14 incomplete paraplegic patients, but no improvement in 4 complete paraplegic patients. The follow-up period was 21.2 months on average and the time for bone fusion was 3.6 months. There were 4 complications during operation and a long-term complication in follow-up. Conclusions: The study suggests that anterior com-bined with posterior approach makes the spine stable and relieves the pressure immediately. It is a reasonable surgical strategy for treatment of cervical spinal fracture-dislocation with AS.     

儿童强直性脊柱炎HLA-B27抗原表达与骨损害关系的临床研究

目的探讨HLA—B27表达与儿童强直性脊柱炎骨代谢功能损伤的关系。方法检测HIA—B27不同型别的儿童强直性脊柱炎患者和对照群体骨代谢功能指标。结果分析显示各实验组间各项指标存在有不同程度的差异（FCT=87．3，P〈0．01；FBGP=197．1，P〈0．01），具体表现为：（可检测水平B27＋AS〉B27-AS〉B27＋对照和B27-对照（q12=7．48，q13=16．33，q14=20．87，q23=9．01，q24=12．47，P均〈0．01），而B27＋和B27-对照之间差异无显著意义（q34=2．33，P〉0．05）；BGP检测水平B27＋AS〉B27-AS〉B27＋对照和B27-对照（q12=11．6，q13=25．8，q14=30．7，q23=14．3，q24=17．7，P均〈0．01），而B27＋和B27-对照之间差异亦无显著意义（q34=1．69，P〉0．05）。结论儿童强直性脊柱炎HLA—B27的表达与骨质损害具有一定的关联性，为临床深入研究提供了有益的线索。