强直性脊柱炎合并脊髓栓系综合征1例

唐 辉,徐永清,汤 逊,梅良斌,马 涛,范新宇,李 川,秦培韬

·个案·

强直性脊柱炎合并脊髓栓系综合征1例

唐 辉,徐永清,汤 逊,梅良斌,马 涛,范新宇,李 川,秦培韬

强直性脊柱炎；脊髓栓系综合征

[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,成都军区昆明总医院全军骨科研究所(唐 辉,徐永清,汤 逊,梅良斌,马 涛,范新宇,李 川),神经外科(秦培韬)

徐永清,电话：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岁,因“反复腰痛并弯腰障碍1个月”来院。患者1个月来反复下腰痛,伴晨僵、弯腰困难,深呼吸时感胸廓僵硬,休息后不缓解,活动后改善,夜间疼痛影响睡眠,翻身及改变体位困难,左侧髋关节阵发疼痛。无强直性脊柱炎(AS)家族史,无心、肺、肝、肾等器质性疾病史。查体：腰部僵直,竖棘肌痉挛,腰部前屈、左右侧屈活动差,指地距37 cm,扩胸度2.8 cm,Schober试验2.9 cm,骶髂关节压痛、叩痛明显,双下肢“4”字试验阳性,双下肢深浅感觉未见异常,各肌肌力可,会阴部感觉可,生理反射可,病理反射未引出。患者Both AS活动指数7.9,Bath AS功能指数7.4。实验室检查：血沉64 mm/h,C反应蛋白47 mm/L,人类白细胞抗原B27(HLA-B27)阳性。骨盆平片、骶髂关节CT提示骶髂关节间隙模糊变窄,边缘硬化呈轻度锯齿样改变；腰椎MRI提示脊髓圆锥下降至腰4椎体水平,腰骶椎椎管明显扩大,终丝明显增粗,终丝固定,骶椎椎管内脂肪瘤。诊断：强直性脊柱炎合并脊髓栓系综合征；骶椎椎管内脂肪瘤。目前予以柳氮磺胺吡啶+来氟米特药物治疗,并指导患者功能锻炼。下一步待强直性脊柱炎稳定后,拟针对脊髓栓系综合征进行手术治疗。

讨论 AS患者早期累及中轴骨骼以及骶髂关节,以腰骶部疼痛为主要症状[1],目前多数临床研究证明,柳氮磺胺吡啶对早期血沉增快并伴有外周关节炎的AS治疗有效[2]。而来氟米特对合并外周关节炎的AS治疗效果较好,可维护脊柱功能[3]。在口服药物治疗效果较差或者无效时,可应用生物疗法,如抗肿瘤坏死因子抗体治疗[4],但这些治疗都非常昂贵[5]。此外,功能锻炼对于AS的治疗也起着至关重要的作用[6]。尽管本例患者左侧髋部疼痛,但髋臼、股骨头骨质尚未见异常,因此尚属于AS病变早期,行药物治疗以及功能锻炼有效。

脊髓栓系综合征(tethered cord syndrome,TCS)系脊髓圆锥下终丝或马尾固定于椎管,于脊柱生长期中,牵拉脊髓圆锥,使之不能向头侧移动而产生脊髓或圆锥牵拉损害症状之综合征。目前认为其病理生理学基础为终丝牵拉造成脊髓血供减少,代谢紊乱,进而造成感觉、运动神经损伤[7]。对脊髓栓系综合征建议尽早手术,如等待神经症状的出现再行手术,则可能出现神经不可逆损伤[8]。脊柱后路截骨治疗栓系综合征有效[9]。本例患有强直性脊柱炎,且属于活动期,无明显栓系综合征症状,因此,暂时予以控制强直性脊柱炎,待控制后再尽早行栓系综合征手术治疗。