Symptoms:
Slow onset, mild systemic symptoms, early fatigue, reduced signs, or nausea and fever. Low back pain, muscle spasm and stiffness gradually appear, and the symptoms are often aggravated after rest and relieved after exercise. Later, typical sacroiliac joint pain gradually appeared, and the spine was involved in an ascending way. Pain, tenderness, stiffness, limited activity and flexion deformity gradually appear in the affected part. Symptoms worsen after cloudy days or fatigue, and relieve after warmth or rest. Recurrent iriditis often coexists, and some patients may have sciatica. If the lesion spreads to intercostal joints, chest expansion may be limited or lost during breathing, and intercostal neuralgia may occur.
In the late stage, the spine is stiff and in a deformed position, and the neck and waist cannot rotate. When looking sideways, he must turn his whole body, which may lead to severe hunchback deformity and inability to look forward. The lesion can sometimes spread to the hip joint and knee joint, and when the hip joint is involved, it shows a swinging gait. With the gradual disappearance of bone stiffness and pain in the affected area, it left a lifelong disability.
What is ankylosing spondylitis?
Ankylosing spondylitis is a very old disease. As early as thousands of years ago, evidence of ankylosing spondylitis was found in the bones of ancient Egyptians. Ankylosing spondylitis was once considered as the central type of rheumatoid arthritis, but with the development of medicine and the improvement of detection methods, it was found that the disease was very different from rheumatoid arthritis, so it was defined as an independent disease.
Modern medicine recognizes that ankylosing spondylitis is a chronic, progressive and inflammatory disease, and the lesion sites are mainly in sacroiliac joint, spine, soft tissue adjacent to spine and joints of limbs. This disease often starts from sacroiliac joint, gradually spreads to spine and paravertebral tissues, and finally causes ankylosis. At present, it is considered that the disease is seronegative arthropathy of connective tissue and one of the more common low back pain diseases.
What is the cause of ankylosing spondylitis?
The etiology of ankylosing spondylitis is not completely clear, and it is believed to be related to the following factors:
(1) genetic factors: the incidence of this disease is closely related to genetic factors. HLA of ankylosing spondylitis? The positive rate of B27 was as high as 90% ~ 96%, and the positive rate of family inheritance was 23.7%. The family incidence of rheumatoid patients is 2 ~ 10 times that of normal people, while the family incidence of ankylosing spondylitis is 30 times that of normal people.
(2) Infection factors: Genitourinary tract infection is one of the important factors causing this disease. Pelvic infection spreads to sacroiliac joint and then to spine through lymphatic route, and can also spread to the great circulation, resulting in systemic symptoms and pathological changes of surrounding joints, tendons and ocular pigment membranes.
(3) Endocrine disorder or metabolic disorder: Because rheumatoid disease is more common in women and ankylosing spondylitis is more common in men, it is considered that endocrine disorder is related to this disease. However, the use of hormones in the treatment of rheumatoid arthritis has not achieved obvious results, and the relationship between hormone imbalance and this disease is uncertain. The incidence of rheumatoid or ankylosing spondylitis in patients with hyperthyroidism has not increased or decreased significantly.
(4) Other factors: age, physique, malnutrition, climate, soil and water, humidity and cold. Others, including trauma, parathyroid disease, upper respiratory tract infection, local purulent infection, etc. It may have something to do with this disease, but the evidence is insufficient.
What is HLA-B27?
HLA is the big letter of three English words, H stands for human, L stands for Leuc ocyte, and A stands for antigen, namely human leukocyte antigen (hereinafter referred to as HLA). HLA is an individual-specific antigen controlled by tissue and cell genetics. It was first found in white blood cells and platelets. Now it is found that HLA is widely distributed on the cell membrane of nucleated cells in skin, kidney, spleen, lung, intestine, heart and other tissues and organs. The eighth international conference on histocompatibility confirmed that there are 92 HLA loci, which belong to five sites, namely, A, B, C, D and DR. They are called HLA-A, HLA-B, HLA-C, HLA-D and HLA-DR respectively. There are 42 HLA-B loci, and B27 is one of them. It has been proved that the probability of ankylosing spondylitis in HLA-B27 positive people is much higher than that in HLA-B27 negative people.
Is HLA-B27 positive ankylosing spondylitis?
HLA-B27 refers to human leukocyte antigen B27, also known as W-27. The positive rate of HLA-B27 in patients with ankylosing spondylitis can be as high as over 90%. About 50% of the first-degree relatives of patients with ankylosing spondylitis are positive for HLA-B27 antigen, while only 3% of ordinary people are positive. At the same time, there are other diseases such as psoriasis, ulcerative colitis, Crohn's disease and Whipple's disease, and HLA-B27 antigen is also positive. Therefore, HLA-B27 positive is not necessarily ankylosing spondylitis, but it is more likely. At present, HLA-B27 is still one of the methods to detect early ankylosing spondylitis.
Can people with negative HLA-B27 also get ankylosing spondylitis?
The positive rate of HLA-B27 in patients with ankylosing spondylitis varies greatly from country to country, ranging from 22% in some cases to 90% in most cases, with a maximum of 100%. On the other hand, these data show that 10% ~ 78% of patients with ankylosing spondylitis are negative for HLA-B27, and there are also ankylosing spondylitis, indicating that there is no absolute correlation between HLA-B27 and ankylosing spondylitis.
What is the diagnostic standard of ankylosing spondylitis?
The diagnosis of ankylosing spondylitis mainly has the following six indicators:
(1) sacroiliitis is one of the main diagnostic criteria of this disease, and normal sacroiliac joints can almost be ruled out. X-ray changes of sacroiliac joint are earlier than those of spine, which is beneficial to early diagnosis. X-ray manifestations of sacroiliitis can be divided into three stages. At the early stage, the joint margin is slightly blurred and the joint space is widened. In the middle stage, it can be seen that the joint space is narrow, the proliferation and corrosion of the joint edge alternate, and the dense zone of iliac bone is widened, and the maximum width can reach 3cm. In the late stage, it can be seen that the joint space disappears, the dense zone of bone disappears, and the trabecular bone passes through, which has become bony rigidity.
(2) Chest pain and rigidity.
(3) Low back pain and rigidity have been more than 3 months, but rest can't relieve them.
(4) Restrict waist movement.
(5) Limited chest expansion.
(6) Iritis or other secondary diseases.
The diagnosis can be made by adding one item to 1 of the above six indicators. Four of the last five items can also be diagnosed.
Where is the best position for patients with ankylosing spondylitis to take X-rays of sacroiliac joints?
X-ray film confirms that sacroiliitis is a necessary condition for the diagnosis of ankylosing spondylitis. Therefore, it is of great significance to choose a suitable location to shoot sacroiliac joint films to best display the location and degree of the lesions. Foreign experience shows that the positive radiograph of sacroiliac joint is enough to clearly show the bilateral sacroiliac joint lesions, and the oblique radiograph or other radiographs are not helpful to improve the positive rate, so it is not necessary to use it. In the Affiliated Hospital of Shantou Medical College, Guangdong Province, through the comparative study of the positive film and oblique film of sacroiliac joint in patients with ankylosing spondylitis, it is found that the result of the positive film is better than that of the oblique film, which is consistent with the observation conclusion abroad.
What are the main symptoms of ankylosing spondylitis?
This disease mostly occurs in young and middle-aged men, with slow onset and alternating onset and remission. At first, the symptoms are mild and easy to be ignored. The main part of the disease is the spine, that is, the symptoms of lumbar vertebrae, thoracic vertebrae and cervical vertebrae appear from the bottom to the top of sacroiliac joints. At the initial stage of the disease, patients occasionally experience pain and stiffness in the back, sacrum and buttocks. About 65,438+00% patients' pain can radiate down the hip to the flexion side of thigh and calf (along the distribution range of sciatic nerve), but there is generally no positive finding in nervous system examination. After several months or years, the patient's symptoms gradually worsen, and there is persistent pain in the waist, chest or neck. He often wakes up in the middle of the night and has difficulty turning over. He needs to get up and exercise to relieve it. With the development of the disease, dyspnea or banded chest pain may occur after the thoracic and costal joints are involved, and the neck movement is limited when the lesions spread to the cervical spine. Finally, the whole spine may be stiff, and some of them are complicated with severe hunchback deformity, so that when the patient stands or walks, his eyes can't look straight, and he can only see a small piece of ground in front of his feet. The volume of chest and abdomen decreased, and the cardiopulmonary function and digestive function were obviously damaged.
Can patients with ankylosing spondylitis have ophthalmia?
Irisocyclitis is an inflammatory disease of the eye, which usually manifests as eyeball pain, congestion and photophobia. About 25% patients with ankylosing spondylitis can develop iridocyclitis during the course of the disease. Most patients' iridocyclitis occurs a few days or years before the symptoms of ankylosing spondylitis appear, so it is difficult to conclude that iridocyclitis is related to ankylosing spondylitis. There are also patients who develop iridocyclitis several days to 20 years after the symptoms of ankylosing spondylitis appear. Irisocyclitis can appear on one side or both sides, or alternately on both sides. The duration of inflammation is generally about half a month, which may be very stubborn, persistent or recurrent, but rarely leads to blindness. The occurrence of iridocyclitis has no obvious correlation with the severity of peripheral arthritis or spondylitis symptoms of ankylosing spondylitis.
How do patients with ankylosing spondylitis choose drugs for treatment?
At present, there is no special treatment for ankylosing spondylitis to prevent the development of the disease. The main purpose of treatment is to relieve pain, reduce inflammation, strengthen exercise and maintain good posture and function. Indomethacin (also known as indomethacin) has strong anti-inflammatory, analgesic and antipyretic effects, 25mg, three times a day, taken immediately after meals. Futalin has stronger anti-inflammatory and analgesic effects than indomethacin, and has fewer side effects. It has a sustained-release dosage form, and the frequency of taking medicine can be reduced to twice a day. The dosage of Voltalin enteric-coated tablets is 25 ~ 50 mg, three times a day, which is worthy of clinical application. Other good anti-inflammatory drugs for ankylosing spondylitis are naproxen and ibuprofen. The above drugs should be treated continuously for several months, and then gradually reduced after the symptoms are completely controlled or disappeared. It is best to maintain an asymptomatic period with the minimum amount that can control symptoms, such as about half a year. Attention should be paid to the adverse reactions of the above drugs, such as gastrointestinal discomfort, liver and kidney damage, headache, edema and so on. Blood, urine routine and liver and kidney function should be checked regularly before and after treatment.
Can patients with ankylosing spondylitis be treated with corticosteroids?
Peripheral arthritis, sacroiliitis or spondylitis in patients with ankylosing spondylitis are not indications for corticosteroids. Because of the above performance, non-hormonal anti-inflammatory drugs and sulfasalazine can get obvious results. Therefore, considering joint diseases, hormone therapy is not suitable, but about 25% patients with ankylosing spondylitis can develop iridocyclitis during the course of the disease. Once diagnosed as iridocyclitis by an ophthalmologist, hormone therapy should be started. For patients with mild illness, 0.5% cortisone eye drops can be used four times a day. Some cases need to take prednisone for systemic treatment. These treatments should be carried out under the guidance of a doctor.
How does TCM treat ankylosing spondylitis?
The TCM treatment of ankylosing spondylitis takes tonifying kidney and strengthening waist as the main treatment principle, and at the same time, it is necessary to clean up phlegm fire. Gui You Pill and Erchen Decoction are used for patients with kidney-yang deficiency, while Baizhi Dihuang Pill and Erchen Decoction are used for patients with kidney-yin deficiency. In extreme heat, Cortex Phellodendri, Rhizoma Anemarrhenae, Radix Rehmanniae, Radix Scrophulariae and Gypsum Fibrosum can be added to clear away heat and nourish yin; For patients with severe pain, Asari, Ramulus Cinnamomi and Rhizoma Corydalis are added to dredge collaterals and relieve pain. Tripterygium wilfordii decoction alone has certain curative effect. External application of Jin Shu Huoluo ointment, such as Baozhen ointment and Ding Tong ointment, or rubbing with musk rheumatism oil can have certain analgesic effect.
What non-drug treatment can ankylosing spondylitis carry out?
Physical therapy and massage have auxiliary effects on the treatment of this disease. Commonly used are infrared radiation, ultrasound, microwave, wax therapy, hot water bath, iontophoresis and so on. Patients can also massage themselves, massage the joint skin with their palms and press the muscles. Physical therapy massage can promote blood circulation and remove blood stasis, relax muscles, dilate blood vessels, improve blood supply and promote the absorption of inflammatory products. When the deformity continues to develop, it can be corrected with stents or instruments. Skin traction or bone traction is suitable for the elderly with minor deformity and short existence time, with 4 ~ 6 kg of hip joint and 2 ~ 4~6kg of knee joint. If conservative treatment fails, synovectomy, joint cleaning, release, fusion, plasty and joint replacement are feasible.
Should patients with ankylosing spondylitis adhere to exercise therapy?
Ankylosing spondylitis patients and their families often make the affected joints completely or basically inactive for a long time in order to avoid or alleviate the joint pain of patients, leading to muscle atrophy and joint contracture, so that the joints and limbs that are not serious and may fully recover are actually in a disabled state or lose their mobility. The correct way is to actively accept anti-inflammatory drugs to control joint pain and conduct joint activities in a timely and cautious manner. In the acute stage of the disease, 1 ~ 2 times a day to gently help joint activity, so that it just reaches the degree of pain, which is helpful to relieve joint contracture. When not exercising, the acute inflamed joints should be placed in proper positions and/or braked with splints, so as to retain some functions when inevitable contractures and deformities cannot be corrected in the future. In the subacute and chronic stages of the disease, we should adhere to the stretching exercise of limbs and spine, and gradually increase the number, time and frequency of activities according to the degree of pain tolerance. Patients should know that it is very important to keep exercising in all parts. The pain symptoms disappear completely. After stopping drug treatment, you should keep exercising for a long time and keep the function of each joint as normal as possible.
How is ankylosing spondylitis treated by manipulation?
Manipulation therapy is effective for early ankylosing spondylitis, which can relieve pain, help the spine and double hip joints recover motor function, reduce stiffness, prevent hunchback deformity or slow down the development of deformity. The specific treatment method is as follows:
(1) prone position: place 2 ~ 3 pillows in front of the upper chest and thighs, so that the chest and abdomen are suspended and the arms are bent in front of the head. The doctor stood by and treated the patient's back and back by pulling up and down along the spine and both sides. At the same time, the other palm pressed the back along the spine, which should match the patient's breathing, press down when exhaling, and relax when inhaling.
(2) Connecting the potential: press the bladder meridian and hip rank on both sides of the spine to jump around and live? FDDD？ Equal scores.
(3) supine position of the patient: the front of the hip joint is pulled with abduction and external rotation of the hip joint. Then take the inner thigh muscle and rub the thigh.
(4) Sitting posture of the patient: The doctor stands at the back, applies massage to both sides of the neck and scapula, and at the same time, cooperates with the left-right rotation and pitching of the neck, and then pushes both sides of the cervical vertebra up and down several times by massage or one-finger meditation, and then takes the wind pool and both sides of the cervical vertebra to the shoulder well.
(5) Attachment: The patient is required to bend his elbow, hold it on the occipital part of the back of the head, and make a fist with his hands folded. The doctor stands behind his back, puts his knees against the patient's back, and then holds the patient's elbow with his hands to expand his chest and pitch. In this passive activity, the patient should cooperate with breathing movement (exhale when leaning forward and inhale when leaning back). Pitch 5 ~ 8 times.
(6) Sitting position of the patient: expose the back, lean forward with the doctor standing by and apply elbow pressure on both sides of the spine. Then directly rub the back du meridian and bladder meridian on both sides, and horizontally rub the sacrum, all of which are mainly hot compress, and hot compress can be added.
How does TCM recognize ankylosing spondylitis?
Traditional Chinese medicine believes that this disease is mostly caused by cold-dampness invasion, wet-heat immersion, traumatic injury, blood stasis blocking collaterals, poor circulation of qi and blood, or congenital deficiency, kidney essence deficiency and bone pulse dystrophy.
(1) Wind-cold invasion: The disease is caused by staying in a wet and cold place for a long time, or wading in the rain, sweating when the wind blows, wearing wet and cold clothes, or the sudden change of climate, alternating cold and heat, which makes wind-cold invade the human body, inject into meridians, detain joints and block qi and blood.
(2) Damp-heat immersion: When the qi is damp-heat, or the summer is long, the damp-heat vapor or cold-dampness accumulates over time, which turns into heat. The evil of damp-heat invades the meridians, blocks the qi and blood, and cannot nourish the bones and muscles, so this disease is acquired.
(3) Obstruction of collaterals by blood stasis: bruises from falls, back injuries, blood stasis, obstruction of meridians, poor circulation of qi and blood, and dystrophy of bones and muscles.
(4) Deficiency of kidney essence: Congenital deficiency, plus overwork, or chronic illness, or old age, or atrioventricular node deficiency, bone and muscle dystrophy, and kidney essence deficiency.
To sum up, deficiency of congenital endowment, deficiency of kidney essence and dystrophy of bones and muscles are the main pathological basis of this disease, while stagnation of cold and dampness, immersion of damp and heat, obstruction of collaterals by blood stasis and poor circulation of qi and blood are the basic pathological factors that cause this disease.
How does western medicine understand ankylosing spondylitis?
(1) etiology
The etiology of this disease is not clear at present, but summarizing the research reports at home and abroad is probably related to the following factors.
① Genetic factors: Ankylosing spondylitis has a stronger family genetic tendency than rheumatoid arthritis. Its family aggregation degree is about 40. About 5 1% HLA-B27 antigen was positive in the first-degree relatives of as patients.
② Infection factors: Some people think that urogenital infection is an important factor causing this disease. Male patients are mostly caused by prostatic seminal vesiculitis, and its infection can reach sacroiliac joint first, then lymph or vein to spine, and also spread to the great circulation, resulting in systemic symptoms and diseases such as peripheral joints and tendons.
③ Other factors: including trauma, parathyroid diseases, tuberculosis, lead poisoning, upper respiratory tract infection, gonorrhea, local purulent infection, endocrine and metabolic defects, allergies, etc. , can be the cause of this disease, but the evidence is not sufficient, and further research is needed to confirm.
(2) Pathology
Although AS is a disease different from rheumatoid arthritis, in the early stage, their pathology is very similar. Both begin with synovitis characterized by hyperplastic granulation tissue. Microscopically, synovial thickening, villus formation and infiltration of plasma cells and lymphocytes can be seen. Most of these inflammatory cells gather around small blood vessels and are nested. Unlike rheumatoid arthritis, chronic inflammatory lesions unrelated to synovial lesions can also occur in nearby bones.
The lesions mostly started from the sacroiliac joint, gradually invaded the lumbar vertebrae, thoracic vertebrae and finally invaded the cervical vertebrae. Shoulder, hip, ribs, sternal stalk and pubic symphysis are often involved. About 25% patients suffer from knee, ankle and other peripheral joint diseases at the same time.
The late disease of ankylosing spondylitis is completely different from rheumatoid arthritis. Ankylosing spondylitis, with slight joint damage, rarely occurs bone resorption or dislocation, but the ossification of joint capsule and ligament is very prominent. Therefore, it is easy to cause bone stiffness in the end.
Ankylosing spondylitis, the lesions at the junction of ligament, tendon, joint capsule and cancellous bone are very characteristic. The granulation tissue here not only destroys cancellous bone, but also spreads to ligaments, tendons or joint capsules. In the process of tissue repair, too much bone is formed, and the new bone tissue not only fills the cancellous bone defect, but also extends into the nearby ligament, tendon or joint capsule, forming ligament osteophyte.
The proliferation and development of ligament osteophyte (including tendon and joint capsule osteophyte) can eventually lead to joint ankylosis, especially in hip joint.
The cardiac lesions of ankylosing spondylitis are quite characteristic: aortic valve hypertrophy and fibrosis are the most prominent, aortic ring enlargement is accompanied by Va lsalva sinus bulging, and elastic fibers in the middle aorta are replaced by fibrous tissue after being destroyed.
What is the incidence of ankylosing spondylitis?
Myelitis is a common disease with unknown etiology. The prevalence of this disease varies with the sex and age of the population, but it is more common in men, ranging from 1959 to 1982. According to the statistics of five authors, the ratio of male to female is 9: 1 ~ 14: 1. According to Kellgren's reports from different authors, the average prevalence rate of this disease is about 0. 1% of the population, so it is estimated that there will be as many polio patients as 1 10,000 people in China.
Professor Zhang Naizheng, chairman of the National Rheumatology Society and Peking Union Medical College, investigated that the incidence rate of normal people in Beijing suburbs was 3 ~ 5 ‰; Zeng Duyu reported that the incidence rate of normal population was 1.97, that of Sun Guitian was 0.6, and that of Zhang Fengshan was 0.9 in the northern alpine region. Laiwang Guo in Jiaocheng, Shanxi reported 0.2‰. The above report is far lower than the prevalence rate of Caucasians in Europe, America and Canada 1%. The sex ratio is 8.7 ∶1~19 ∶1.
Primary AS usually occurs at 10 and 20 years old, but juvenile AS (a subclass of juvenile chronic polyarthritis) can occur at a younger age, and secondary types can occur at any age.
What tests do you need to do to diagnose ankylosing spondylitis?
(1) ESR test: In the early and active stage, the ESR of 80% patients increased rapidly; In the resting period and late stage, ESR mostly decreased to normal.
(2) Cerebrospinal fluid examination: Cerebrospinal fluid protein increased slightly (45 mg% ~ 60 mg%), especially in patients with sciatica.
(3) Examination of histocompatibility antigen: Recently, it was found that more than 90% of patients were positive for the histocompatibility antigen HLA-B27, while only 5% ~ 6% of normal Caucasians were positive.
(4)X-ray examination
① sacroiliac joint changes: sacroiliitis is one of the main basis for diagnosis of this disease. At the early stage, the margin of sacroiliac joint was slightly blurred and the joint space was widened. The middle joint space is narrow, and the proliferation and corrosion of the joint edge are staggered, which is serrated. The iliac compact zone is widened, and the maximum width can reach 3cm. In the late stage, the joint space disappeared, the dense zone of bone disappeared, and the trabecular bone passed through, which became bony rigidity.
② Changes of spine: A. Changes of fibrous ring: Fibrous ring ossification is one of the characteristics of this disease, with the most common cases in the late stage. When the fibrous ring of the whole spine ossifies, the spine looks like bamboo, so it is called bamboo-like spine. B. Anterior Vertebrae Inflammation and Square Vertebrae: The bone corrosion at the upper and lower edges of the vertebral body disappears, and the bone regeneration behind the anterior longitudinal ligament makes the normal depression at the anterior edge of the vertebral body disappear and straighten, so the vertebral body is square on the lateral X-ray film, and some even protrude forward, so it is called Square Vertebrae. C. Changes of the joint between the articular processes: joint corrosion occurs first, then the joint space narrows, and finally the ankylosis is formed. D ossification of paravertebral ligament: with the ossification of fibrous ring, supraspinous ligament, interspinous ligament, ligamentum flavum and anterior longitudinal ligament are ossified one after another. E. Destruction and dislocation of vertebral body: Fatigue fracture of thoracic vertebra may occur after ossification of the whole spine. X-ray films at the early stage of fracture can be seen similar to the destruction of spinal tuberculosis, and irregular callus will appear in the future, but the shadow of cold abscess will never appear. For example, taking photos of flexion and extension, we can see that the ossified vertebral arch also has irregular fracture lines passing through it. Individual patients with advanced stage may have atlantoaxial subluxation similar to rheumatoid arthritis.
③ Changes of hip and knee joint: Osteoporosis, swelling of joint capsule and reduction of obturator foramen can be seen in the early stage of hip joint. In the middle stage, joint space stenosis, cystic degeneration of joint edge or hyperosteogeny (ligament osteophyte) of acetabulum and femoral head edge can be seen. Late acetabular invagination or ankylosis can be seen. Soft tissue swelling and osteoporosis can be seen in the early stage of knee joint, joint space stenosis can be seen in the middle stage, and bone rigidity can appear in the late stage, and rigidity is mostly in flexion position.
④ Changes of tendon attachment point: The bone at the tendon attachment point of ischial tubercle is not smooth, with irregular corrosion and new bone, and the bone shape is fluffy. Huge ligament osteophyte, dense bone and irregular corrosion can be seen at the plantar aponeurosis attachment of calcaneal tubercle.
What is the significance of special X-ray examination in the diagnosis of ankylosing spondylitis?
Computed tomography (CT): CT can be performed for those who are clinically suspected but cannot be diagnosed by X-ray. It can clearly display the sacroiliac joint space, which is unique in judging whether the joint space is widened, narrowed, stiff or partially stiff.
Magnetic resonance imaging (MRI) and single photon emission computed tomography (SPECT): American scientists studied 36 patients, including 24 patients with inflammatory low back pain and 12 patients with low back pain caused by mechanical compression. The standard X-ray showed that the sacroiliac joint was normal. However, MRI showed that 54% patients with inflammatory low back pain and 17% patients with mechanical low back pain had sacroiliitis. SPECT showed that 38% patients with inflammatory low back pain had sacroiliitis, but no sacroiliitis was found in mechanical group. The positive detection rate of MRI and SPECT increased significantly at the same time. 58% patients with inflammatory low back pain and 17% patients with mechanical low back pain have sacroiliitis. Therefore, the researchers believe that MRI and SPECT scintigraphy of sacroiliac joints are very helpful for very early diagnosis and treatment, which are obviously superior to ordinary X-rays, but they are expensive and are not recommended as routine examinations.
What is the diagnostic standard of ankylosing spondylitis?
(1) Diagnostic criteria formulated by the symposium on rheumatism of integrated traditional Chinese and western medicine in some provinces and cities (1985) (1adopted by Kunming National Symposium on Rheumatology of Integrated Traditional Chinese and Western Medicine in April, 1988)
① Symptoms: Recurrent pain in sacroiliac joint and back.
② Signs: In the early and middle stage, the spinal motion is limited to varying degrees; in the late stage, the spinal rigidity and hunchback fixation appear, and the thoracic spine motion decreases or disappears.
③ Laboratory examination: ESR increased rapidly and RF was negative. How positive is HLA-B27?
④X-ray examination: typical changes of ankylosing spondylitis and sacroiliac joint.
A. Early stage: the spinal motor function is limited, the X-ray shows that the sacroiliac joint space is blurred, the spinal facet joints are normal or the joint space changes.
B. Mid-term: limited spinal activity or even partial rigidity; X-ray showed jagged changes in sacroiliac joints, calcification of some ligaments, bone destruction of square vertebrae and small joints, and blurred gaps.
C. Late stage: spinal rigidity or kyphosis deformity fixation; X-ray film shows sacroiliac joint fusion, and the spine is bamboo-like.
(2) International diagnostic standards
① Diagnostic criteria formulated by Rome Conference (1963)
A. Low back pain and low back stiffness lasted for more than 3 months, and the rest did not relieve.
B. chest pain and stiffness.
C. limited waist movement.
D. the activity of chest expansion is limited.
E. history, phenomenon or sequelae of iritis.
Bilateral sacroiliac arthritis combined with one of the clinical criteria can be considered as myositis.
② Clinical diagnostic criteria revised by new york Conference (1973).
A. The mobility of lumbar spine in all three aspects (flexion, lateral curvature and kyphosis) is limited, and Sauber test is positive.
B chest, waist or waist pain or pain history.
C. thoracic dilatation is limited.
Positive ankylosing spondylitis
(1) Ⅲ Ⅳ Bilateral sacroiliitis with at least one clinical manifestation.
(2) Grade Ⅲ ~ Ⅳ unilateral sacroiliitis or Grade Ⅱ bilateral sacroiliitis, clinical standard ① (Sauber test positive) or clinical standard ② and ③.
Suspected ankylosing spondylitis
There is no clinical standard for grade ⅲ and ⅳ bilateral sacroiliitis.
The above criteria are helpful for diagnosis, but they cannot be applied mechanically, and should still be decided after comprehensive consideration. For example, symptoms appear for the first time after the age of 45, and it is rarely possible that it is ankylosing spondylitis. Patients with iriditis, uveitis, achilles tendinitis and family history all support the diagnosis of AS, which is more important for early diagnosis.
Which diseases should be differentiated from the diagnosis of ankylosing spondylitis?
The diseases that need to be identified are:
(1) Tuberculosis of sacroiliac joint: Patients often have a history of tuberculosis contact or illness, or have tuberculosis of lung or other parts at the same time. The vast majority (98%) were unilateral, with more female patients. X-ray film shows that there is more bone destruction on one side of the joint, and dead bones are often seen. Severe joint injuries can lead to subluxation. If there is an abscess or sinus, it is easier to identify.
(2) Suppurative arthritis of sacroiliac joint: It is also common in female patients, because there are more opportunities for female pelvic infection. At first, the local pain is severe, with fever and leukocytosis, and then the inflammation can turn chronic. On the X-ray film, the joint space is widened in the early stage, and the joint edge is corroded, dense, hardened or ossified in the late stage. Lesions are often unilateral, and the lumbar and thoracic vertebrae are normal.
(3) Dense iliitis: It is more common in young and middle-aged women, and there are more postpartum patients, often bilateral. Symptoms are mostly mild, and ESR is generally unpleasant. On the X-ray film, the ilium is obviously dense, narrow in dense bandwidth, slightly kidney-shaped, and its concave surface faces the joint. The joint space is good and the lumbar motion is normal.
(4) Spinal tuberculosis: Patients often have a history of tuberculosis contact or disease, or have tuberculosis in the lungs or other parts at the same time. The limitation of spinal movement is only found in the affected area, and the humpback is mostly angular. On the X-ray film, the vertebral body and intervertebral disc are obviously damaged, and the shadow of dead bone and abscess is common.
(5) Suppurative osteomyelitis of the spine: the onset is sudden, the body temperature rises rapidly, the white blood cells increase, the local pain is obvious, the paraspinal muscles spasm, and the spinal movement is obviously limited. Other parts of the body also often have purulent infections. X-ray film shows the destruction of vertebral body or intervertebral disc, common dead bone and abscess shadow. Bone mineral density was obvious in the later stage.
(6) Proliferative arthritis of the spine: This disease mostly occurs after the age of 40, and the spinal movement is slightly limited, and the hunchback deformity is not obvious. Common in cervical and lumbar vertebrae. X-ray shows that the sacroiliac joint is normal, or only the lower edge has osteophyte hyperplasia. Most of the space stenosis and osteophyte hyperplasia can be seen in the spine, and the osteophyte develops along the transverse direction, which is different from the osteophyte of the annulus fibrosus ligament. The patient's erythrocyte sedimentation rate is not fast.
What is the treatment principle of ankylosing spondylitis?
(1) Although there is no cure at this stage, most patients can live well.
(2) Popular science education for patients is beneficial to control the disease.
(3) Early diagnosis is very important, especially early identification and treatment of extraarticular manifestations.
(4) Non-steroidal anti-inflammatory drugs can control pain and inflammatory reaction.
(5) Daily physical therapy is conducive to maintaining good physiological curvature, reducing deformity and maintaining good thoracic dilatation; Swimming is a good whole-body exercise.
(6) Hip replacement and spinal joint orthopedic surgery have certain benefits.
(7) Psychological, social and family support of patients is beneficial to treatment.
(8) Knowing the family history of AS and the physical examination of relatives of AS patients can find out the family aggregation and the misdiagnosed or undiagnosed patients among relatives of AS patients.
How to treat ankylosing spondylitis based on syndrome differentiation in TCM.
(1) exogenous pathogenic wind and cold
Main symptoms: acute pain in waist and back, or hip and thigh joints, or traction of knee and tibia, or cold and heat, cold pain in waist and back, severe cold pain, decreased warm pain, tight pulse and white greasy fur.
Analysis of the main syndrome: the evil of cold and dampness invades the back, blocking the meridians, and the cold nature leads to dampness stagnation, so the back feels acute pain and cold; Warming qi and blood is smoother, so its pain is relieved; When it is cold, the blood will stagnate, so the pain will increase; Rheumatic cold pathogen either stays in hip and thigh or bets on knee and tibia, so it causes pain in hip, thigh or knee and tibia; The wind and cold bind the exterior, and the camp and the guard are not in harmony, so they see cold and heat. Tight pulse and white greasy fur are the symptoms of rheumatism and cold evil.
Treatment principle: expelling wind and cold, eliminating dampness and relieving pain.
Prescription: Sanbi Decoction.
Radix Angelicae Pubescentis 10g, Radix Gentianae Macrophyllae 12g, Asari 6g, Rhizoma Chuanxiong 10g, Radix Angelicae Sinensis 12g, Radix Rehmanniae Preparata 15g, Radix Paeoniae Alba 10g, and Poria/kloc-0.
Prescription: Radix Angelicae Pubescentis, Asari, Radix Aconiti and Radix Aconiti Kusnezoffii are the main drugs for expelling wind, removing dampness, dispelling cold and relieving pain, and Guizhi warms meridians and unblocks collaterals. Radix Rehmanniae Preparata, Radix Dipsaci, Eucommiae Cortex and Achyranthis Radix can supplement liver and kidney and strengthen bones and muscles as auxiliary drugs; Ligusticum chuanxiong, Radix Paeoniae Alba and Radix Angelicae Sinensis enrich blood and promote blood circulation; Astragalus membranaceus, Codonopsis pilosula, Poria cocos and Glycyrrhiza uralensis Fisch are all adjuvant drugs, which make qi and blood exuberant and help the main drug to drive away evil spirits. Therefore, Gentiana macrophylla and Saposhnikovia divaricata can dispel rheumatism and cold evil from the outside. All the medicines are combined to strengthen the body resistance and eliminate pathogens, and * * * plays the role of dispelling wind, dispelling cold and eliminating dampness? /ca & gt；