强直性脊柱炎傅志均.ppt

2011-01-06 顺德和平创伤外科医院顺德和平创伤外科医院 1 骨二区骨二区 傅志均傅志均 强直性脊柱炎强直性脊柱炎 Ankylosing Spondylitis，AS 2011-01-06 顺德和平创伤外科医院顺德和平创伤外科医院 2 Ankylosing SpondylitisAnkylosing Spondylitis，ASAS Ankylosing spondylitis(AS),is a form of arthritis(关节炎关节炎）that primarily affects the spine,although other joints can become involved.It causes inflammation(炎症炎症)of the spinal joints that can lead to severe,chronic 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（驼背驼背）.2011-01-06 顺德和平创伤外科医院顺德和平创伤外科医院 3 Description（概况）Low back pain,with prominent morning stiffness;improves with use and warmth;sometimes nocturnal(夜间发生的夜间发生的)Often insidious(潜伏潜伏)in onset in young adults Loss of chest expansion(胸廓扩张度胸廓扩张度)as disease progresses Associated with peripheral arthritis,enthesitis（起止点炎起止点炎）,and extra-articular manifestations,such as iritis(虹膜炎虹膜炎)Most frequently found in young men under 40 2011-01-06 顺德和平创伤外科医院顺德和平创伤外科医院 4 Clinical findingClinical findingSymptomSymptom：Non-traumatic back pain and stiffness(僵硬僵硬),which improves with activity Decreased range of motion in lumbar spine Thoraco-cervical kyphosis(late)One-third of patients will have acute,unilateral uveitis.（葡萄膜炎葡萄膜炎）2011-01-06 顺德和平创伤外科医院顺德和平创伤外科医院 5 Other ComplicationsOther Complications Pseudoarthrosis(假关节假关节),cervical spine fracture,C1-C2 subluxation,cauda equina syndrome Peripheral joint ankylosis Restrictive lung disease,upper lobe fibrosis Aortic root dilation(20%)&murmur(2%)2011-01-06 顺德和平创伤外科医院顺德和平创伤外科医院 6 Clinical findingClinical findingsingssings：Bilateral(双侧双侧)sacroiliac(骶髂部骶髂部)tenderness A dramatic loss of flexibility（柔韧性、灵活性柔韧性、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 顺德和平创伤外科医院顺德和平创伤外科医院 7 Clinical findingClinical findingsings contsings cont：Recurrent,acute iritis(虹膜炎虹膜炎)presents as a painful red eye Neurologic signs:resulting from compression radiculitis(脊神经根炎脊神经根炎)or sciatica（坐骨神经痛坐骨神经痛）Anemia Aortic insufficiency,angina(咽峡炎咽峡炎),pericarditis （心包炎心包炎）2011-01-06 顺德和平创伤外科医院顺德和平创伤外科医院 8 Radiographic FindingsRadiographic Findings Ankylosis(强直强直)of sacroiliac joints(骶髂关节骶髂关节)Syndesmophyte(韧带骨赘韧带骨赘)in the lumbar spine Fusion of the interspinous ligament(棘间韧带棘间韧带)Arthropathy(关节病关节病)of both hips Enthesopathy(起止点炎起止点炎)of ischial tuberosity (坐骨结节坐骨结节)2011-01-06 顺德和平创伤外科医院顺德和平创伤外科医院 9 DiagnosisDiagnosis Family history:often one parent has AS.Clinical feature:back pain,immobile of joints,correlative sings X-ray:Ankylosis Syndesmophyte Arthropathy Enthesopathy Laboratory tests:erythrocyte sedimentation rate and C-reactive protein elevated 2011-01-06 顺德和平创伤外科医院顺德和平创伤外科医院 10 Medical Treatment Non-steroidal anti-inflammatory drugs（NSADs）can rapidly reduce the signs and symptoms Sulfasalazine(柳氮磺胺吡啶柳氮磺胺吡啶)has no clinically effective for AS;however,several studies suggest that it may be effective for peripheral arthritis associated with AS Methotrexate(甲氨蝶呤甲氨蝶呤)has not been shown to be effective in clinical trials for either the axial or appendicular manifestations of AS 2011-01-06 顺德和平创伤外科医院顺德和平创伤外科医院 11 Surgical Treatment Joint replacement surgery and spine surgery should be considered in patients with refractory pain or disability and radiographic evidence of structural damage,independent of age.2011-01-06 顺德和平创伤外科医院顺德和平创伤外科医院 12 什么是强直性脊柱炎什么是强直性脊柱炎Ankylosing SpondylitisAnkylosing Spondylitis，ASAS 强直性脊柱炎是主要累及中轴关节的慢性炎症性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引起脊柱三柱损伤，并且多伴随脊髓损伤 2011-01-06 顺德和平创伤外科医院顺德和平创伤外科医院 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 顺德和平创伤外科医院顺德和平创伤外科医院 14 ASAS RARA 男女比例男女比例 3 3-5 5：1 1 1 1：4 4 家族史家族史 明显明显 不明显不明显 发病年龄发病年龄 1010-3030岁岁 3030-5050岁岁 HLAHLA-B27B27 (+)(+)(-)RFRF (-)(+)(+)病理病理 附着点炎附着点炎 滑膜炎滑膜炎 骶髂关节炎骶髂关节炎 (+)(+)(-)关节受累关节受累 大关节、少关节不对称大关节、少关节不对称 小关节、多关节对称小关节、多关节对称 脊柱脊柱 全部，上升性全部，上升性 颈椎颈椎 关节外表现关节外表现 较少较少 较多较多 X X线线 骨强直，骶髂关节炎骨强直，骶髂关节炎 侵蚀性关节炎侵蚀性关节炎 病情进展病情进展 慢，慢，总致残率:15205%严重致残 快，快，总致残率 强直性脊柱炎与类风湿关节炎的区别强直性脊柱炎与类风湿关节炎的区别 2011-01-06 顺德和平创伤外科医院顺德和平创伤外科医院 15 骨赘骨赘代替代替椎体椎体间的间的韧带韧带 2011-01-06 顺德和平创伤外科医院顺德和平创伤外科医院 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 顺德和平创伤外科医院顺德和平创伤外科医院 17 骨桥形成 2011-01-06 顺德和平创伤外科医院顺德和平创伤外科医院 18 保留间隙边沿和中间的骨化 2011-01-06 顺德和平创伤外科医院顺德和平创伤外科医院 19 炎症修复造成棘上韧带的骨化 2011-01-06 顺德和平创伤外科医院顺德和平创伤外科医院 20 钙化的棘上韧带 2011-01-06 顺德和平创伤外科医院顺德和平创伤外科医院 21 竹节样改变 的腰椎 2011-01-06 顺德和平创伤外科医院顺德和平创伤外科医院 22 2011-01-06 顺德和平创伤外科医院顺德和平创伤外科医院 23 临