强直性脊柱炎的诊断与治疗相关研究

发布时间：2018-04-27 07:05

本文选题：强直性脊柱炎 + 骶髂关节　；参考：《中国人民解放军医学院》2015年硕士论文

【摘要】：研究背景：强直性脊柱炎(Ankylosing Spondylitis, AS)是一种慢性、多系统、自身炎性疾病,其主要累及骶髂关节、中轴骨,也可累及外周关节及关节外器官,如皮肤、眼及心血管系统。近期,国内对依那西普已上市粉针剂型的基础上研发了水针剂型,外包装采用一次性预充式注射器,其规格、临床适应症、用法用量、给药途径,均与依那西普已上市粉针剂型相同。而目前国内对于依那西普治疗强直性脊柱炎的疗效评价观察周期较短。而在·]盏床实践及科研中,核磁共振(magnetic resonance imaging, MRI)已经成为评价风湿性疾病的重要工具,目前对于强直性脊柱炎的骶髂关节及脊柱MRI评价主要应用加拿大脊柱关节炎国际研究组(Spondyloarthritis Research Consortium of Canada, SPARCC)评分方法及脊柱关节炎脊柱脂肪浸润评分(The FAt Spondyloarthritis Spine Score, FASSS),对于应用以上评价方法评价依那西普治疗活动期强直性脊柱炎前后的MRI变化,国内尚无相关报道。另外感染性骶髂关节炎是一种少见疾病,常出现臀区或腰骶部疼痛,影像学病变与脊柱关节炎非常相似,临床上容易误诊。本研究旨在初步评估依那西普水针剂型对于活动期强直性脊柱炎的疗效、探究规律应用依那西普治疗强直性脊柱炎前后骶髂及全脊柱MRI变化、并回顾性分析今年来我院收治的感染性骶髂关节炎临床及影像学特点,为临床医生避免误诊误治提供依据。方法：研究一,以依那西普为试验药物,按不同给药方式设计的随机、双盲、平行组临床试验。纳入符合入组标准、不符合排除标准的活动期强直性脊柱炎患者70例,按给药方式不同随机分配至试验A组及试验B组。在给药第0、2、4、8、12、16、20、24周进行疗效观察并在整个试验周期前后对受试者进行骶髂关节及全脊柱MRI扫描,(1)疗效指标主要包括Bath强直性脊柱炎病情活动指数(Bath Ankylosing Spondylitis Disease Activity Index, BASDAI); Bath强直性脊柱炎功能指数调查表(Bath Ankylosing Spondylitis Functional Index, BASFI)评分：Bath强直性脊柱炎计量指数(Bath Ankylosing Spondylitis Metrology Index, BASMI)评定；强直性脊柱炎疾病活动评分(Ankylosing Spondylitis Disease Activity Score, ASDAS);(2)血清学指标主要包括血浆沉降率(erythrocyte sedimentation rate, ESR)、C反应蛋白(C-reactive protein, CRP);(3)采用盲法对患者脊柱MRI进行阅片,并采用SPARCC及FASSS评分方法进行评价。对依那西普水针剂型不同给药方式治疗活动期强直性脊柱炎的疗效进行评价,并对治疗前后MRI病变程度及转归做出总结。研究二,回顾性分析2005年6月-2014年9月主诉为臀区或腰骶部疼痛入住解放军总医院的1241例患者中经实验室检查、血培养、影像学检查及治疗确诊为感染性骶髂关节炎的21例临床资料,总结感染性骶髂关节炎的临床及影像学特点,为避免临床实践中与脊柱关节炎相混淆而造成误诊误治提供依据。结果：在研究一中,在30例患者接受试验药物治疗后,治疗24周后所有患者均达到ASAS 20,达到ASAS 40为20例(66.7%)：治疗2周开始,除BASMI外,PLT、ESR、CRP、BASDAI、BASFI、ASDAS等观察指标较0周均出现明显下降(P值0.05)：治疗8周时,BASFI较0周是出现明显统计学差异(P值0.05)：治疗前30例受试者中共24例(80%)出现骨髓水肿,其中治疗后22例骨髓水肿出现不同程度减轻或消失,2例骨髓水程度加重：另外有1例受试者在治疗前未出现骨髓水肿,治疗后出现骨髓水肿；治疗后整体脊柱骨髓水肿评分较治疗前明显下降,并呈现统计学意义：共统计690个椎体,治疗前共158个椎体出现骨髓水肿,占椎体总数的22.9%,其中治疗后137个椎体的骨髓水肿减轻或消失,而骨髓水肿好转的椎体中仅28个椎体出现脂肪侵蚀增加,治疗前后脂肪侵蚀程度不呈现统计学意义。在研究二中,21例患者均以明显的臀区或腰骶部疼痛为主要,临床表现,其中男性9例,女性12例,平均年龄28.2岁,平均病程261天。其中ISI 10例,BSI 3例,TSI 8例。大部分患者ESR及CRP明显升高,仅1例IS1患者HLA-B27为阳性。病理检查中ISI病理结果以急性或慢性炎性细胞及粒细胞浸润为主,BSI以淋巴细胞及浆细胞浸润为主,TSI以肉茅肿形成伴坏死为主。21例患者中影像学检查显示单侧受累18例,双侧受累3例。12例行骶髂关节CT检查,关节面模糊1例,骨侵蚀5例,软骨硬化3例,骨赘形成1例,关节融合1例。1 7例行骶髂关节MRI,其中轻度异常6例,明显异常11例。2例行PET-CT检查,均提示病变部位骶骨及髂骨放射性浓聚、代谢活跃。通过合理应用抗生素治疗,21例患者均明显好转。结论：1.依那西普水针剂型可迅速改善活动期强直性脊柱炎PLT、ESR、CRP、 BASDAI、BASFI、ASDAS等指标,降低疾病活动度,提高患者运动功能指数：在本研究组中,一周一次50mg给药与一周两次、每次50mg给药方式在疗效方面无统计学差异；依那西普可显著改善骶髂及脊柱椎体骨髓水肿程度,降低急性期炎症水平。该研究提示在临床中,活动期强直性脊柱炎骶髂及脊柱椎体出现骨髓水肿时,应用依那西普治疗会得到较好的预后：2.感染性骶髂关节炎常出现臀区或腰骶部疼痛,极易与脊柱关节炎混淆,需综合分析患者临床、影像学检查及实验室指标才能做出正确判断,避免误诊误治。
[Abstract]:Background: Ankylosing Spondylitis (AS) is a chronic, multi system, and self inflammatory disease. It mainly involves the sacroiliac joint, the middle axis bone, and the peripheral and articular organs, such as skin, eye and cardiovascular system. In the near future, a water needle is developed on the basis of the listed powder injection of etancept. The specifications, clinical indications, usage and dosage, and the way of administration are the same as that of etancept, and the therapeutic evaluation period of etancept on the treatment of ankylosing spondylitis is short. In the practice and research of calyx (magnetic resonan) CE imaging, MRI) has become an important tool for the evaluation of rheumatic diseases. Currently, the evaluation of the sacroiliac joint and spinal MRI for ankylosing spondylitis is mainly used by the Canadian International Research Group on spinal arthritis (Spondyloarthritis Research Consortium of Canada, SPARCC) and the spine fat infiltration score (The FAt). Spondyloarthritis Spine Score, FASSS), there are no relevant reports on the evaluation of MRI changes before and after the treatment of etancept at the active stage of ankylosing spondylitis. In addition, infectious sacroilitis is a rare disease, often occurring in the hip or lumbosacral pain, and the imaging pathological changes are very similar to the spinal arthritis. The purpose of this study is to evaluate the effect of etancept on active ankylosing spondylitis, and to explore the changes of MRI in the sacroiliac and total spinal column before and after etancept treatment of ankylosing spondylitis, and to review the clinical and imaging features of infectious sacroilitis in our hospital this year, and to review the clinical and imaging features of the infectious sacroilitis in our hospital. Method: a randomized, double blind, parallel group clinical trial, designed with etancept as an experimental drug, was designed with etancept as a test drug and included 70 patients with active ankylosing spondylitis that were in accordance with the standard of entry and were not in accordance with the exclusion criteria, and were randomly assigned to group A and test according to the different ways of administration. B group. Observe the efficacy of the drug at week 0,2,4,8,12,16,20,24 and carry out the sacroiliac joint and the whole spinal MRI scan before and after the whole test period. (1) the curative effect index mainly includes the Bath ankylosing spondylitis disease activity index (Bath Ankylosing Spondylitis Disease Activity Index, BASDAI); the Bath ankylosing spondylitis function finger The Bath Ankylosing Spondylitis Functional Index (BASFI) score: the Bath ankylosing spondylitis measurement index (Bath Ankylosing Spondylitis Metrology Index) evaluation, the ankylosing spondylitis disease activity score, and (2) the serological index mainly includes plasma sinks. The reduction rate (erythrocyte sedimentation rate, ESR), C reactive protein (C-reactive protein, CRP); (3) a blind method was used to read the patients' spinal MRI, and the SPARCC and FASSS scoring methods were used to evaluate the efficacy of the treatment of ankylosing spondylitis in the active phase of the ankylosing spondylitis with different administration methods of etancept. Study two. Retrospective analysis of 21 cases of infectious sacroiliac arthritis diagnosed as infectious sacroilitis by laboratory examination, blood culture, imaging examination and treatment in 1241 patients who complained of hip or lumbosacral pain in general hospital of PLA General Hospital in September -2014 June 2005, and summarized infectious sacroilitis. Clinical and imaging features provide a basis for misdiagnosis and misdiagnosis in clinical practice. Results: in study one, after 24 weeks of treatment in 30 patients, all patients reached ASAS 20 and ASAS 40 were 20 (66.7%): 2 weeks, except BASMI, PLT, ESR, CRP, BASDAI, BASFI, ASDAS and other observation indexes were significantly lower than 0 weeks (P 0.05): at 8 weeks of treatment, BASFI was significantly different from 0 weeks (P value 0.05): 24 cases (80%) of 30 patients before treatment had bone marrow edema, of which 22 cases of bone marrow edema appeared in 22 cases, and 2 cases of bone marrow water increased: another 1. There was no bone marrow edema before treatment and bone marrow edema after treatment. The total spinal marrow edema score after treatment was significantly lower than before treatment, and the statistics were statistically significant: a total of 690 vertebral bodies were counted, and 158 vertebral bodies appeared bone marrow edema before treatment, accounting for 22.9% of the total number of vertebral bodies, and the bone marrow edema in the 137 vertebral bodies after treatment. Only 28 vertebrae in the vertebral body with improved bone marrow edema increased fat erosion, and the degree of fat erosion was not statistically significant before and after treatment. In the second study, 21 patients were all with obvious hip or lumbosacral pain, including 9 men and 12 women, with an average age of 28.2 years and an average course of 261 days. Among them, there were 10 cases of ISI, 3 cases of BSI and 8 cases of TSI. Most of the patients were significantly elevated in ESR and CRP, and only 1 cases of IS1 patients were positive. The pathological findings of ISI were mainly with acute or chronic inflammatory cells and granulocyte infiltration, BSI with lymphocyte and plasma cell infiltration, TSI with meongrass formation with necrosis and.21 cases of middle shadow examination. 18 cases of unilateral involvement, bilateral involvement in 3 cases of.12 routine sacroiliac joint CT examination, articular surface blurred 1 cases, bone erosion 5 cases, cartilaginous sclerosis 3 cases, osteophyte formation 1 cases, joint fusion 1 cases of.1 7 routine sacroiliac joint MRI, mild abnormal 6 cases, obviously abnormal 11 cases of.2 routine PET-CT examination, all suggest the radioactive concentration of sacral and iliac bone in the lesion site, metabolism 21 patients were obviously improved through rational use of antibiotics. Conclusion: 1. etancept water needle type can rapidly improve the active period ankylosing spondylitis PLT, ESR, CRP, BASDAI, BASFI, ASDAS and other indicators to reduce the degree of disease activity and improve the patient's motor function index: in this study group, once a week and two times a week and two times a week, There is no statistically significant difference in the efficacy of 50mg medication each time. Etancept can significantly improve the degree of bone marrow edema in the sacroiliac and spinal vertebrae and reduce the acute stage of inflammation. This study suggests that the treatment of the sacroiliac and spinal vertebrae in active ankylosing spondylitis will have a better prognosis with etancept. 2. infectious sacroilitis often appears hip or lumbosacral pain. It is very easy to be confused with arthritis of the spine. It is necessary to make a comprehensive analysis of the patient's clinical, imaging examination and laboratory indicators to make a correct judgment and avoid misdiagnosis and mistreatment.

【学位授予单位】：中国人民解放军医学院
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R593.23

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