強(qiáng)直性脊柱炎合并脊髓栓系綜合征1例

唐 輝,徐永清,湯 遜,梅良斌,馬 濤,范新宇,李 川,秦培韜

·個(gè)案·

強(qiáng)直性脊柱炎合并脊髓栓系綜合征1例

唐 輝,徐永清,湯 遜,梅良斌,馬 濤,范新宇,李 川,秦培韜

強(qiáng)直性脊柱炎；脊髓栓系綜合征

[1] Diaz-Pena R,Lopez-Vazquez A,Lopez-Larrea C.Old and new HLA associations with ankylosing spondylitis[J].Tissue Antigens,2012,80(3):205-213.

[2] Chen J,Liu C.Is sulfasalazine effective in ankylosing spondylitis? A systematic review of randomized controlled trials[J].J Rheumatol,2006,33(4):722-731.

[3] Haibel H,Rudwaleit M,Braun J,et al.Six months open label trial of leflunomide in active ankylosing spondylitis[J].Ann Rheum Dis,2005,64(1):124-126.

[4] Goh L,Samanta A.Update on biologic therapies in ankylosing spon-dylitis:a literature review[J].Int J Rheum Dis,2012,15(5):445-454.

[5] Kirchhoff TD,Mittendorf T,Schmidt RE,et al.Cost-effectiveness of TNF-alpha inhibition in active ankylosing spondylitis:a systematic appraisal of the literature[J].Expert Rev Pharmacoecon Outcomes Res,2012,12(3):307-317.

[6] Ozgocmen S,Akgul O,Altay Z,et al.Expert opinion and key recommendations for the physical therapy and rehabilitation of patients with ankylosing spondylitis[J].Int J Rheum Dis,2012,15(3):229-238.

[7] Filippidis AS,Kalani MY,Theodore N,et al.Spinal cord traction,vascular compromise,hypoxia,and metabolic derangements in the pathophysiology of tethered cord syndrome[J].Neurosurg Focus,2010,29(1):E9.

[8] Selcuki M,Umur AS,Duransoy YK,et al.Inappropriate surgical interventions for midline fusion defects cause secondary tethered cord symptoms:implications for natural history report of four cases[J].Childs Nerv Syst,2012,28(10):1755-1760.

[9] Hsieh PC,Stapleton CJ,Moldavskiy P,et al.Posterior vertebral column subtraction osteotomy for the treatment of tethered cord syndrome:review of the literature and clinical outcomes of all cases reported to date[J].Neurosurg Focus,2010,29(1):E6.

650032 昆明,成都軍區(qū)昆明總醫(yī)院全軍骨科研究所(唐 輝,徐永清,湯 遜,梅良斌,馬 濤,范新宇,李 川),神經(jīng)外科(秦培韜)

徐永清,電話：0871-64774655；E-mail：xuyongqingkm@163.com

R 681.51

B

1004-0188(2014)09-1005-01

10.3969/j.issn.1004-0188.2014.09.055

2014-01-15)

病例 女,23歲,因“反復(fù)腰痛并彎腰障礙1個(gè)月”來(lái)院?；颊?個(gè)月來(lái)反復(fù)下腰痛,伴晨僵、彎腰困難,深呼吸時(shí)感胸廓僵硬,休息后不緩解,活動(dòng)后改善,夜間疼痛影響睡眠,翻身及改變體位困難,左側(cè)髖關(guān)節(jié)陣發(fā)疼痛。無(wú)強(qiáng)直性脊柱炎(AS)家族史,無(wú)心、肺、肝、腎等器質(zhì)性疾病史。查體：腰部僵直,豎棘肌痙攣,腰部前屈、左右側(cè)屈活動(dòng)差,指地距37 cm,擴(kuò)胸度2.8 cm,Schober試驗(yàn)2.9 cm,骶髂關(guān)節(jié)壓痛、叩痛明顯,雙下肢“4”字試驗(yàn)陽(yáng)性,雙下肢深淺感覺(jué)未見(jiàn)異常,各肌肌力可,會(huì)陰部感覺(jué)可,生理反射可,病理反射未引出?；颊連oth AS活動(dòng)指數(shù)7.9,Bath AS功能指數(shù)7.4。實(shí)驗(yàn)室檢查：血沉64 mm/h,C反應(yīng)蛋白47 mm/L,人類白細(xì)胞抗原B27(HLA-B27)陽(yáng)性。骨盆平片、骶髂關(guān)節(jié)CT提示骶髂關(guān)節(jié)間隙模糊變窄,邊緣硬化呈輕度鋸齒樣改變；腰椎MRI提示脊髓圓錐下降至腰4椎體水平,腰骶椎椎管明顯擴(kuò)大,終絲明顯增粗,終絲固定,骶椎椎管內(nèi)脂肪瘤。診斷：強(qiáng)直性脊柱炎合并脊髓栓系綜合征；骶椎椎管內(nèi)脂肪瘤。目前予以柳氮磺胺吡啶+來(lái)氟米特藥物治療,并指導(dǎo)患者功能鍛煉。下一步待強(qiáng)直性脊柱炎穩(wěn)定后,擬針對(duì)脊髓栓系綜合征進(jìn)行手術(shù)治療。

討論 AS患者早期累及中軸骨骼以及骶髂關(guān)節(jié),以腰骶部疼痛為主要癥狀[1],目前多數(shù)臨床研究證明,柳氮磺胺吡啶對(duì)早期血沉增快并伴有外周關(guān)節(jié)炎的AS治療有效[2]。而來(lái)氟米特對(duì)合并外周關(guān)節(jié)炎的AS治療效果較好,可維護(hù)脊柱功能[3]。在口服藥物治療效果較差或者無(wú)效時(shí),可應(yīng)用生物療法,如抗腫瘤壞死因子抗體治療[4],但這些治療都非常昂貴[5]。此外,功能鍛煉對(duì)于AS的治療也起著至關(guān)重要的作用[6]。盡管本例患者左側(cè)髖部疼痛,但髖臼、股骨頭骨質(zhì)尚未見(jiàn)異常,因此尚屬于AS病變?cè)缙?行藥物治療以及功能鍛煉有效。

脊髓栓系綜合征(tethered cord syndrome,TCS)系脊髓圓錐下終絲或馬尾固定于椎管,于脊柱生長(zhǎng)期中,牽拉脊髓圓錐,使之不能向頭側(cè)移動(dòng)而產(chǎn)生脊髓或圓錐牽拉損害癥狀之綜合征。目前認(rèn)為其病理生理學(xué)基礎(chǔ)為終絲牽拉造成脊髓血供減少,代謝紊亂,進(jìn)而造成感覺(jué)、運(yùn)動(dòng)神經(jīng)損傷[7]。對(duì)脊髓栓系綜合征建議盡早手術(shù),如等待神經(jīng)癥狀的出現(xiàn)再行手術(shù),則可能出現(xiàn)神經(jīng)不可逆損傷[8]。脊柱后路截骨治療栓系綜合征有效[9]。本例患有強(qiáng)直性脊柱炎,且屬于活動(dòng)期,無(wú)明顯栓系綜合征癥狀,因此,暫時(shí)予以控制強(qiáng)直性脊柱炎,待控制后再盡早行栓系綜合征手術(shù)治療。