【作者】 王庆文；

【导师】 曾庆馀；

【作者基本信息】 汕头大学 ， 病理学与病理生理学， 2005， 博士

【摘要】 目的 了解骶髂关节(SIJ)炎的病理表现,提高强直性脊柱炎(AS)的早期诊断水平。方法　对118例炎症性腰痛或不对称性下肢滑膜炎患者进行CT导引下SIJ细针活检,3例非脊柱关节病(SpA)死亡病例SIJ开放性取材所得组织为对照组。记录病理、临床资料进行分析。结果 118例患者中,37例CT SIJ炎≥Ⅱ级,81例CT SIJ炎0-Ⅰ级;其中95例的SIJ存在炎症表现,包括骨髓炎、血管翳形成和炎症细胞浸润,软骨下骨板破坏,软骨变性、破坏,滑膜炎,附着点炎等。58例0-Ⅰ级CT SIJ炎存在骨髓炎、血管翳形成和炎症细胞浸润、软骨下骨板炎、软骨变性等改变。除IV级外,各级均有病例取到骨髓,且均见骨髓炎。所有取到软骨下骨板的病例(97%,92/95)均见血管翳形成、炎症细胞浸润、骨板破坏等。0-Ⅰ级CT SIJ炎软骨破坏较Ⅱ、Ⅲ、Ⅳ级少见(分别为80%、91%、93%、100%),且破坏主要见于软骨下骨板侧,关节面侧未见明显破坏,双侧均明显破坏者见于≥Ⅲ级病例。0-Ⅰ级CT SIJ炎4例取到滑膜,其中3例(0级2例、Ⅰ级1例),虽然软骨下骨板和软骨均有炎症,滑膜却未见异常,另1例(Ⅰ级)可见滑膜炎。Ⅱ级和Ⅲ级各1例取到滑膜,均见炎症。5例0-Ⅰ级SIJ炎取到附着点,均未见炎症;3例Ⅱ级、2例Ⅲ级取到附着点,其中分别各有1例见附着点炎。炎症细胞浸润程度Ⅲ级最高(3.1±1.3),Ⅱ级和0-Ⅰ级稍低之(2.9±0.9和2.8±1.4),Ⅳ级(1.3±0.5)则显著低于其他各级(p<0.05)。58例0-Ⅰ级CT SIJ炎的uSpA经病理检查诊断为AS;其平均病程(3.9±3.6)显著低于Ⅱ级-Ⅵ者(分别为5.8±3.2,6.4±6.1,12.3±5.2)(p<0.05)。结论 SIJ炎在出现CT异常前就可存在。SIJ炎可能自骨髓开始,继而血管翳形成,软骨下骨板破坏,软骨变性、破坏,最后纤维化、骨化而导致关节融合。滑膜炎和附着点炎不是SIJ炎的最早改变。病理检查有利于AS的早期诊断和鉴别诊断。更多还原

【Abstract】 Objective To study the pathological features of sacroiliitis, aiming at improving the early diagnosis of ankylosing spondylitis (AS).Methods CT guided needle biopsy of sacroiliac joint (SIJ) was performed in 118 cases with inflammatory low back pain / asymmetric synovitis on low limb, with 3 autopsy materials of non-spondyloarthropathy (SpA) sacroiliac joints serving as control. Pathological and clinical data were collected and analyzed.Results Among 118 cases, 37 cases were of ≥ grade Ⅱ and 81 cases were of grade 0/I CT sacroiliitis. No pathological change was noticed in the control group. Among them, pathological changes were found in 95 cases, including bone marrow inflammation, pannus formation, subchondral bony plate destruction, cartilage degeneration/erosion, synovitis, and enthesitis. The aforementioned first 4 findings were presented in 58 cases of grade 0/I CT sacroiliitis. Bone marrow was obtained in some cases of every grade of CT sacroiliitis except grade Ⅳ, and was all showed inflammation. Inflammatory cells infiltration, pannus formation and bony destruction could be seen in all specimens which subchondral bony were obtained. Frequency rate of cartilage erosion and ossification in grade 0/I CT sacroiliitis was the lowest in comparison with the other groups, being 80%, 91%, 93% and 100% respectively. Moreover, in cases of grade 0/I CT sacroiliitis, cartilage erosion only present at the bony plate side, while the joint cavity side was not affected. Synovial specimens were obtained in 2 cases of grade 0, 2 cases of grade Ⅰ, 1 case of grade Ⅱ and 1 case of grade Ⅲ CT sacroiliitis, but synovitis was only found in 1 case of grade Ⅰ, 1 case of grade Ⅱ, and 1 case of grade Ⅲ CT sacroiliitis. Enthesis were obtained in 5cases of grade 0/1, 3 cases of grade II and 2 cases of grade III CT sacroiliitis. However enthesitis was only presented in 1 cases of grade II and 1 case of grade III CT sacroiliitis. The inflammatory index of grade III CT sacroiliitis was the highest (3.1±1.3), followed by that of grade II and grade 0/1 CT sacroiliitis (2.9±0.9 and 2.8±1.4). The inflammatory index was significantly lower in cases of grade IV CT sacroiliitis (1.3±0.5) than that in the other groups(p<0.05). Among the 81 patients with uSpA, 58 patients were diagnosed as AS after SIJ pathological examination. The mean disease duration of these 58 cases (3.9±3.6 years) was significantly shorter than that in cases of grade II, grade III and grade IV CT sacroiliitis (5.8±3.2 years, 6.4±6.1 years and 12.3±5.2 years)(p<0.05).Conclusion Inflammatory changes of SIJ did exist before SIJ abnormality was detected by CT scan. Sacroiliitis probably initiated with bone marrow inflammation, followed by pannus formation, subchondral bony plate destruction, and cartilage degeneration/erosion, eventually leading to fibrosis, ossification and joint fusion. Synovitis and enthesitis were not the very early changes of sacroiliitis. Pathological examination was beneficial to the early diagnosis and differential diagnosis of ankylosing spondylitis.更多还原