【作者】 王庆文；

【导师】 曾庆馀；

【作者基本信息】 汕头大学 ， 内科学， 2002， 硕士

【摘要】 目的 评价CT导引下骶髂关节(Sacroiliac Joint 简称SIJ)穿刺术的临床应用价值，了解SIJ炎病理表现。方法 3具尸体标本、40例脊柱关节病(Spondyloarthropathy SPA)和3例致密性髂骨炎(Osteitis Condensana Ilii OCI)患者，在CT导引下行骶髂关节穿刺，取组织标本后，在CT导引下原路进入骶髂关节，注入丙酮缩去炎舒松15mg／侧，术后定期随访。骶髂关节标本行HE染色，普通光学显微镜观察。 结果 穿刺注射成功率100％；尸体标本穿刺注射(染料)后解剖证实，注射液进入关节内并向关节旁渗透。100％(21例，21／21)强直性脊柱炎(Ankylosing Spondylitis AS)患者SIJ存在炎症表现，包括SIJ滑膜炎症(衬里细胞增生、疏松结缔组织增厚及炎症细胞浸润)，软骨变性、破坏或骨化，软骨下骨板破坏、死骨形成、钙盐沉着增多或黏液样变性，血管翳形成、炎症细胞浸润，骨髓中成熟淋巴细胞、浆细胞、巨噬细胞等增多，附着点炎症等表现。80％(12例，12／15)未分化脊柱关节病(undifferentiated spondyloarthropathy 简称uSpA)患者SIJ存在病理变化：所见表现与上述相同，但韧带或关节囊附着点未见炎症。3例OCI患者中，2例SIJ可见血管翳形成、炎症细胞浸润，软骨变性、破坏及软骨下骨板破坏等炎症性表现，1例无炎症表现。接受骶髂关节内皮质激素注射的40例SPA患者中，35例(88％)疼痛明显减轻，晨僵、夜间痛、SIJ压痛、“4”字试验、血沉升高及需使用非甾体抗炎药(NSAIDs)的例数均较术前明显减少，夜间痛 汕头大学医学院风湿病研究室硕士主论文 及血沉升高的程度也较术前明显减轻。16例仍需使用 NSAIDS的病 例中除 2例用量同术前外，余 14例均减量使用。芳移 1．应用 CT 导引下SIJ穿刺术，既能取得关节活体组织标本进行病理检查，早期 发现SIJ炎，有助于AS的早期诊断和鉴别诊断，又能进行关节内局’部给药，解决对NSAIDS或小剂量皮质激素疗效不满意或不耐受病 例的用药问题。值得临床应用。2 AS SIJ炎病理表现主要为衬里细 胞肥大增生、疏松结缔组织增厚及炎症细胞浸润等滑膜炎，软骨变 性、破坏、骨化，软骨下骨板破坏、死骨形成、钙盐沉着增多或郭 液样变性，血管需形成、炎症细胞浸润，骨髓中成熟淋巴细胞、浆 细胞、巨噬细胞等增多及附着点炎等表现。早期SIJ炎病变可能始自 软骨下骨板炎症，而非滑膜炎和附着点炎。更多还原

【Abstract】 Objective To evaluate the clinical value of CT guided sacroiliac joint biopsy and intraarticular corticosteroid injection for sacroiliitis in patients with spondyloarthropathy (SPA). To Study the pathological feature of sacroiliitis to improve the threshold of early diagnosis of ankylosing spondylitis (AS). Methods 3 adult specimens and 43 patients suffering from refractory back pain, including 23 cases with AS, 17 cases with undifferentiated spondyloarthropathy (uSpA) and 3 cases with osteitis condensana ilii (OCI) were studied. The patient/specimen was placed in a prone position. Guided by CT, the biopsy needle tip was posited in the synovium compartment of sacroiliac join (SIJ). After the tissue sample was taken out, 15mg triamcinolone acetonide was injected into each joint (the specimen was injected in blue ink). All patients underwent continuous clinical follow-up at 4 to 12 week intervals after the intervention, while specimens were performed section anatomy. The pathological feature and the clinical data were recorded and analyzed. Result 1. The section anatomy of specimens revealing the blue ink was inside the sacroiliac joint and diffused to paraarticular. 2. After intervention, 35 of the 40 cases (88%) showed a statistically significant abatement of subjective complaints. The case number of night pain, morning stiff, pain in SIJ, "4" sign and the dose of the nonsteroidal anti-inflammation drugs were demonstrated a statistically significant reduce. 3. Synovitis, including lining cell hyperplasiaand inflammatory cell infiltration in loose connective tissue, local cartilage degeneration and destruction, pannus formation, inflammatory cells infiltration and destruction subchondral bony plate, enthesitis, as well as hematopoietic cells within the subchondral bone marrow were largely replaced by inflammation cells, were found in all SIJ samples of patients with AS (21/21,100%). The same pathological manifestations except enthesitis were discovered in 12 (12/15,80%) cases with uSpA. Of 3 cases with OCI, 2 cases were found the inflammation evidences in their SIJ samples, whereas the remainder was showed no inflammatory manifestation. Conclusion 1. CT guided SIJ biopsy could detect sacroiliitis in early stage, improve the threshold of early diagnosis and differentiated diagnosis in AS. Meanwhile, intraarticular corticosteroid injection was an effective and safe local treatment for sacroiliitis. 2. Synovitis, including lining cell hyperplasia and inflammatory cell infiltration in loose connective tissue, local cartilage degeneration and destruction, pannus formation, inflammatory cells infiltration and destruction subchondral bony plate, enthesitis, as well as hematopoietic cells within the subchondral bone marrow were largely replaced by inflammation cells, were the pathological manifestation of sacroiliitis in patients with SPA. The pathological change of sacroiliitis might initiate in the subchondral bony plate, rather than synovium or enthesis.更多还原