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1、2011-01-06,1,骨二区 傅志均,强直性脊柱炎 Ankylosing Spondylitis，AS,2011-01-06,2,Ankylosing Spondylitis，AS,Ankylosing spondylitis(AS),is a form of arthritis(关节炎）that primarily affects the spine,although other joints can become involved.It causes inflammation(炎症)of the spinal joints that can lead to severe,chronic
2、 pain and discomfort.In the most advanced cases(but not in all cases),this inflammation can lead to new bone formation on the spine,causing the spine to fuse in a fixed,immobile position,sometimes creating a forward-stooped posture.This forward curvature of the spine is called kyphosis（驼背）.,2011-01-
3、06,3,Description（概况）,Low back pain,with prominent morning stiffness;improves with use and warmth;sometimes nocturnal(夜间发生的)Often insidious(潜伏)in onset in young adults Loss of chest expansion(胸廓扩张度)as disease progresses Associated with peripheral arthritis,enthesitis（起止点炎）,and extra-articular manifes
4、tations,such as iritis(虹膜炎)Most frequently found in young men under 40,2011-01-06,4,Clinical findingSymptom：,Non-traumatic back pain and stiffness(僵硬),which improves with activity Decreased range of motion in lumbar spineThoraco-cervical kyphosis(late)One-third of patients will have acute,unilateral
5、 uveitis.（葡萄膜炎）,2011-01-06,5,Other Complications,Pseudoarthrosis(假关节),cervical spine fracture,C1-C2 subluxation,cauda equina syndromePeripheral joint ankylosisRestrictive lung disease,upper lobe fibrosisAortic root dilation(20%)&murmur(2%),2011-01-06,6,Clinical findingsings：,Bilateral(双侧)sacroiliac(
6、骶髂部)tenderness A dramatic loss of flexibility（柔韧性、灵活性）in the lumbar spine is an early sign(Schober test)Loss of chest expansion,5cm),from diffuse costovertebral involvement Weight loss(also a symptom),2011-01-06,7,Clinical findingsings cont：,Recurrent,acute iritis(虹膜炎)presents as a painful red eye N
7、eurologic signs:resulting from compression radiculitis(脊神经根炎)or sciatica（坐骨神经痛）Anemia Aortic insufficiency,angina(咽峡炎),pericarditis（心包炎）,2011-01-06,8,Radiographic Findings,Ankylosis(强直)of sacroiliac joints(骶髂关节)Syndesmophyte(韧带骨赘)in the lumbar spineFusion of the interspinous ligament(棘间韧带)Arthropath
8、y(关节病)of both hipsEnthesopathy(起止点炎)of ischial tuberosity(坐骨结节),2011-01-06,9,Diagnosis,Family history:often one parent has AS.Clinical feature:back pain,immobile of joints,correlative singsX-ray:Ankylosis Syndesmophyte Arthropathy EnthesopathyLaboratory tests:erythrocyte sedimentation rate and C-rea
9、ctive protein elevated,2011-01-06,10,Medical Treatment,Non-steroidal anti-inflammatory drugs（NSADs）can rapidly reduce the signs and symptoms Sulfasalazine(柳氮磺胺吡啶)has no clinically effective for AS;however,several studies suggest that it may be effective for peripheral arthritis associated with AS Me
10、thotrexate(甲氨蝶呤)has not been shown to be effective in clinical trials for either the axial or appendicular manifestations of AS,2011-01-06,11,Surgical Treatment,Joint replacement surgery and spine surgery should be considered in patients with refractory pain or disability and radiographic evidence o
11、f structural damage,independent of age.,2011-01-06,12,什么是强直性脊柱炎Ankylosing Spondylitis，AS,强直性脊柱炎是主要累及中轴关节的慢性炎症性疾病，主要引起脊柱的强直，主要病理基础是各个椎间关节出现滑膜炎性改变、滑膜增生，血管翳形成致软骨破坏和骨的侵蚀，进而引起机体的修复反应，导致关节的纤维性或者骨性强直和全身骨骼骨质疏松、韧性减弱，因此，在遭受外力作用时容易引起脊柱三柱损伤，并且多伴随脊髓损伤,2011-01-06,13,1895年-类风湿关节炎 1958类风湿性脊柱炎.“中枢性类风湿”、“中心型类风湿”、“变型性
12、脊柱炎”、“骨化性骨盆部脊柱炎”、“青春期脊柱炎”等。发现类风湿因子后，“血清阴性关节炎”1963年美国风湿病学会废弃了“类风湿脊柱炎”病名而选用了“强直性脊柱炎”这一名称。1982年希氏内科学正式提出强直性脊柱炎不同 于类风湿性关节炎，是独立性的疾病。,为什么要从类风湿关节炎中分出来,2011-01-06,14,强直性脊柱炎与类风湿关节炎的区别,2011-01-06,15,骨赘代替椎体间的韧带,2011-01-06,16,椎体角的骨炎 反应性的硬化(shiny corners)进一步侵蚀 椎体方形变 骨桥形成,韧带骨赘的进展,2011-01-06,17,骨桥形成,2011-01-06,18,
13、保留间隙边沿和中间的骨化,2011-01-06,19,炎症修复造成棘上韧带的骨化,2011-01-06,20,钙化的棘上韧带,2011-01-06,21,竹节样改变的腰椎,2011-01-06,22,2011-01-06,23,临床表现,临床表现,2011-01-06,24,概况,以肌腱端炎、指/趾炎或少关节炎起病 伴有或不伴有急性前葡萄膜炎或皮肤粘膜损害等关节外表现 不同程度的骶髂关节受累 炎性腰痛呈隐匿性、很难定位 晨僵,2011-01-06,25,关节表现,怠或低热全身症状如厌食、倦枕墙距、扩胸度 也常见 居多，膝踝关节受累外周关节炎：以肩髋 压痛关节外或关节附近骨 著背部发僵，以晨起为
14、慢性下腰痛,2011-01-06,26,关节外表现,急性前色素膜炎(急性虹膜炎)，25%30%的患者可在病程中出现 肺实质病变：少见的晚期表现，表现为缓慢进展的肺上段纤维化 心血管系统较少累及，可出现升主动脉炎、主动脉瓣关闭不全、传导阻滞 神经系统病变：常与脊柱骨折、脱位与马尾综合症相关,2011-01-06,27,相关体格检查,相关体格检查,2011-01-06,28,骶髂关节按压试验,2011-01-06,29,指地试验正常,各方向运动均受限,2011-01-06,30,Schobers test肖伯实验,2011-01-06,31,骶髂关节炎的检查挤压及牵伸试验,2011-01-06,3
15、2,髋关节病变的代偿,2011-01-06,33,4字试验与 侧向挤压试验,2011-01-06,34,枕墙距,2011-01-06,35,强直性脊柱炎的诊断,没有误诊的类风湿,没有不误诊的强柱,2011-01-06,36,诊断强直性脊柱炎的纽约标准（1984年修订）,临床标准：1.下腰部疼痛至少持续3个月，活动后减轻，休息后不消失 2.腰椎活动受限（矢状面与额状面）3.扩胸度较同年龄与性别的正常人减小肯定AS：至少1条临床标准+3级以上单侧骶髂关节炎或双侧 2级骶髂关节炎,2011-01-06,37,影响学检查常常会误导诊断,60岁以上椎间盘轻度膨出见于 80%的正常人椎间盘轻度脱出可见于
16、1/3的正常人均具有年龄相关的退行性变椎管狭窄见于1/5的正常人60岁以下1/2,500 能得到有意义的发现椎间盘轻度膨出可见于 1/3的正常人 椎间盘轻度脱出见于 1/5的正常人,2011-01-06,38,骶髂关节炎的X线分级,0级，正常1级，可疑骶髂关节炎2级，局限侵蚀、硬化3级，侵蚀硬化狭窄局限强直4级，骶髂关节完全强直,2011-01-06,39,早期硬化与侵蚀,2011-01-06,40,纤维连接关节和滑膜关节均出现侵蚀病变,2011-01-06,41,2011-01-06,42,骶髂关节强直性脊柱炎骶髂关节面均模糊，边缘呈小囊状骨破坏连成锯齿状，以髂骨面为重，周围骨质硬化增白。,
17、2011-01-06,43,椎体呈方形小关节间隙狭窄或消失关节面模糊不清椎旁韧带骨化连成竹节样脊柱,腰段强直性脊柱炎,2011-01-06,44,脊柱X线改变,2011-01-06,45,2011-01-06,46,早期的病情评价是治疗的关键,What is the headache高度的异质性，预后各有不同前脊柱炎期往往有5-10年平均诊断延误时间为8.9年没有公认的病情评价标准,2011-01-06,47,预后指标,髋关节受累(OR 23)腊肠趾/指(OR 8)对 NSAID反应不佳(OR 8)WESR 30(OR 7)腰椎活动受限(OR 7)单关节炎(OR 4)16岁以下发病(OR 3)
18、,Amor et al,J Rheum 1994,2011-01-06,48,2011-01-06,49,药物治疗,NSAIDs：迅速控制症状肾上腺皮质激素：合理使用 NSAIDs无效者；症状严重者；外周关节受累者；有关节外表现者。,2011-01-06,50,改善症状药真的只改善症状吗 Symptom Modifying Anti-Rheumatic Drugs(SMARD),对多数NSAID治疗反应良好消炎痛、莫比克双氯灭痛等疗效好，阿司匹林效差。改善症状和功能（ASAS 20：NSAIDs49%对照 24%）足量NSAID一至二周无效才换另一种至少应用两种NSAID无效，不到10%,20
19、11-01-06,51,RCT比较连续和间断应用非甾体药治疗AS 二年，认为连续应用能减缓AS放射学改变。有待今后进一步证实。,2011-01-06,52,糖皮质激素,小剂量控制症状有效全身症状明显外周关节肿突出反应性关节炎不主张长期用于强直性脊柱炎腰痛的治疗注意副作用的防治骨质疏松高血脂症感染,2011-01-06,53,柳氮磺砒啶 Salfasalazine,早期（5-10年內）特别是发病六个月内应用16岁前发病者疾病活动性较高外周关节炎症状明显,2011-01-06,54,改善病情药（DMARDs）,目前还缺乏证据支持将MTX用于AS治疗,甲氨蝶呤（MTX）,2011-01-06,55,
20、帕米膦酸盐,阻断TNF and IL-6途径只有开放研究报道，结果不一致。最好的证据是III级重症活动性对AS中轴关节疼痛和功能有明显改善，尚未见对外周关节有效的报告不良反应常见，包括有困倦，眩晕，头痛，便秘，恶心（15%），且有因不良反应停药的报道,2011-01-06,56,其他治疗方法,阿米替林（Amitriptyline）放射治疗白细胞清除术干细胞移植,2011-01-06,57,外科治疗,全髋关节置换(THR)脊柱矫正手术,2011-01-06,58,全髋关节置换(THR),2011-01-06,59,2011-01-06,60,2011-01-06,61,脊柱矫正手术,2011-01-06,62,2011-01-06,63,2011-01-06,64,总 结,强直性脊柱炎是以附 着点炎和滑膜炎为特点 的全身性疾病治疗AS首先要评估病情理想的治疗需非药物和 药物治疗的结合NSAIDs是治疗AS疼痛和 僵硬的一线用药,无证据DMARDs（改 善病情抗风湿药物）对AS的中轴关节有效对于持续高活动性 AS，应考虑肿瘤坏死 因子抑制剂保守治疗无效或病情 较重，可考虑手术治 疗,2011-01-06,65,谢谢大家,山高人为峰,
