本文選題：強直性脊柱炎 + 骶髂關(guān)節(jié)�。� 參考：《中國人民解放軍醫(yī)學(xué)院》2015年碩士論文

【摘要】：研究背景：強直性脊柱炎(Ankylosing Spondylitis, AS)是一種慢性、多系統(tǒng)、自身炎性疾病,其主要累及骶髂關(guān)節(jié)、中軸骨,也可累及外周關(guān)節(jié)及關(guān)節(jié)外器官,如皮膚、眼及心血管系統(tǒng)。近期,國內(nèi)對依那西普已上市粉針劑型的基礎(chǔ)上研發(fā)了水針劑型,外包裝采用一次性預(yù)充式注射器,其規(guī)格、臨床適應(yīng)癥、用法用量、給藥途徑,均與依那西普已上市粉針劑型相同。而目前國內(nèi)對于依那西普治療強直性脊柱炎的療效評價觀察周期較短。而在·]盞床實踐及科研中,核磁共振(magnetic resonance imaging, MRI)已經(jīng)成為評價風(fēng)濕性疾病的重要工具,目前對于強直性脊柱炎的骶髂關(guān)節(jié)及脊柱MRI評價主要應(yīng)用加拿大脊柱關(guān)節(jié)炎國際研究組(Spondyloarthritis Research Consortium of Canada, SPARCC)評分方法及脊柱關(guān)節(jié)炎脊柱脂肪浸潤評分(The FAt Spondyloarthritis Spine Score, FASSS),對于應(yīng)用以上評價方法評價依那西普治療活動期強直性脊柱炎前后的MRI變化,國內(nèi)尚無相關(guān)報道。另外感染性骶髂關(guān)節(jié)炎是一種少見疾病,常出現(xiàn)臀區(qū)或腰骶部疼痛,影像學(xué)病變與脊柱關(guān)節(jié)炎非常相似,臨床上容易誤診。本研究旨在初步評估依那西普水針劑型對于活動期強直性脊柱炎的療效、探究規(guī)律應(yīng)用依那西普治療強直性脊柱炎前后骶髂及全脊柱MRI變化、并回顧性分析今年來我院收治的感染性骶髂關(guān)節(jié)炎臨床及影像學(xué)特點,為臨床醫(yī)生避免誤診誤治提供依據(jù)。方法：研究一,以依那西普為試驗藥物,按不同給藥方式設(shè)計的隨機、雙盲、平行組臨床試驗。納入符合入組標(biāo)準(zhǔn)、不符合排除標(biāo)準(zhǔn)的活動期強直性脊柱炎患者70例,按給藥方式不同隨機分配至試驗A組及試驗B組。在給藥第0、2、4、8、12、16、20、24周進(jìn)行療效觀察并在整個試驗周期前后對受試者進(jìn)行骶髂關(guān)節(jié)及全脊柱MRI掃描,(1)療效指標(biāo)主要包括Bath強直性脊柱炎病情活動指數(shù)(Bath Ankylosing Spondylitis Disease Activity Index, BASDAI); Bath強直性脊柱炎功能指數(shù)調(diào)查表(Bath Ankylosing Spondylitis Functional Index, BASFI)評分：Bath強直性脊柱炎計量指數(shù)(Bath Ankylosing Spondylitis Metrology Index, BASMI)評定；強直性脊柱炎疾病活動評分(Ankylosing Spondylitis Disease Activity Score, ASDAS);(2)血清學(xué)指標(biāo)主要包括血漿沉降率(erythrocyte sedimentation rate, ESR)、C反應(yīng)蛋白(C-reactive protein, CRP);(3)采用盲法對患者脊柱MRI進(jìn)行閱片,并采用SPARCC及FASSS評分方法進(jìn)行評價。對依那西普水針劑型不同給藥方式治療活動期強直性脊柱炎的療效進(jìn)行評價,并對治療前后MRI病變程度及轉(zhuǎn)歸做出總結(jié)。研究二,回顧性分析2005年6月-2014年9月主訴為臀區(qū)或腰骶部疼痛入住解放軍總醫(yī)院的1241例患者中經(jīng)實驗室檢查、血培養(yǎng)、影像學(xué)檢查及治療確診為感染性骶髂關(guān)節(jié)炎的21例臨床資料,總結(jié)感染性骶髂關(guān)節(jié)炎的臨床及影像學(xué)特點,為避免臨床實踐中與脊柱關(guān)節(jié)炎相混淆而造成誤診誤治提供依據(jù)。結(jié)果：在研究一中,在30例患者接受試驗藥物治療后,治療24周后所有患者均達(dá)到ASAS 20,達(dá)到ASAS 40為20例(66.7%)：治療2周開始,除BASMI外,PLT、ESR、CRP、BASDAI、BASFI、ASDAS等觀察指標(biāo)較0周均出現(xiàn)明顯下降(P值0.05)：治療8周時,BASFI較0周是出現(xiàn)明顯統(tǒng)計學(xué)差異(P值0.05)：治療前30例受試者中共24例(80%)出現(xiàn)骨髓水腫,其中治療后22例骨髓水腫出現(xiàn)不同程度減輕或消失,2例骨髓水程度加重：另外有1例受試者在治療前未出現(xiàn)骨髓水腫,治療后出現(xiàn)骨髓水腫；治療后整體脊柱骨髓水腫評分較治療前明顯下降,并呈現(xiàn)統(tǒng)計學(xué)意義：共統(tǒng)計690個椎體,治療前共158個椎體出現(xiàn)骨髓水腫,占椎體總數(shù)的22.9%,其中治療后137個椎體的骨髓水腫減輕或消失,而骨髓水腫好轉(zhuǎn)的椎體中僅28個椎體出現(xiàn)脂肪侵蝕增加,治療前后脂肪侵蝕程度不呈現(xiàn)統(tǒng)計學(xué)意義。在研究二中,21例患者均以明顯的臀區(qū)或腰骶部疼痛為主要,臨床表現(xiàn),其中男性9例,女性12例,平均年齡28.2歲,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明顯升高,僅1例IS1患者HLA-B27為陽性。病理檢查中ISI病理結(jié)果以急性或慢性炎性細(xì)胞及粒細(xì)胞浸潤為主,BSI以淋巴細(xì)胞及漿細(xì)胞浸潤為主,TSI以肉茅腫形成伴壞死為主。21例患者中影像學(xué)檢查顯示單側(cè)受累18例,雙側(cè)受累3例。12例行骶髂關(guān)節(jié)CT檢查,關(guān)節(jié)面模糊1例,骨侵蝕5例,軟骨硬化3例,骨贅形成1例,關(guān)節(jié)融合1例。1 7例行骶髂關(guān)節(jié)MRI,其中輕度異常6例,明顯異常11例。2例行PET-CT檢查,均提示病變部位骶骨及髂骨放射性濃聚、代謝活躍。通過合理應(yīng)用抗生素治療,21例患者均明顯好轉(zhuǎn)。結(jié)論：1.依那西普水針劑型可迅速改善活動期強直性脊柱炎PLT、ESR、CRP、 BASDAI、BASFI、ASDAS等指標(biāo),降低疾病活動度,提高患者運動功能指數(shù)：在本研究組中,一周一次50mg給藥與一周兩次、每次50mg給藥方式在療效方面無統(tǒng)計學(xué)差異；依那西普可顯著改善骶髂及脊柱椎體骨髓水腫程度,降低急性期炎癥水平。該研究提示在臨床中,活動期強直性脊柱炎骶髂及脊柱椎體出現(xiàn)骨髓水腫時,應(yīng)用依那西普治療會得到較好的預(yù)后：2.感染性骶髂關(guān)節(jié)炎常出現(xiàn)臀區(qū)或腰骶部疼痛,極易與脊柱關(guān)節(jié)炎混淆,需綜合分析患者臨床、影像學(xué)檢查及實驗室指標(biāo)才能做出正確判斷,避免誤診誤治。
[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.

【學(xué)位授予單位】：中國人民解放軍醫(yī)學(xué)院
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2015
【分類號】：R593.23

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相關(guān)碩士學(xué)位論文 前10條

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