11.發炎性背痛之診斷新進展

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11.發炎性背痛之診斷新進展

  1. 1. 發炎性背痛之診斷新進展 魏 正 宗 MD., PhD. 中山醫學大學附設醫院過敏免疫風濕科主任 中藥臨床試驗中心主任 醫學研究所副教授
  2. 2. Outlines <ul><li>發炎性背痛 (inflammatory back pain, IBP) </li></ul><ul><li>脊椎關節炎 (spondyloarthritis, SpA) </li></ul><ul><li>Diagnostic clues </li></ul><ul><li>Classification criteria for AS and SpA </li></ul>
  3. 3. Diagnosis of AS / SpA <ul><li>1960: seronegative arthritis </li></ul><ul><li>1970: Seronegative spondyloarthropathy </li></ul><ul><li>1984: Modified New York Criteria for AS </li></ul><ul><li>1991: ESSG criteria for Spondyloarthritis </li></ul><ul><li>2009: ASAS criteria for axial SpA </li></ul>
  4. 4. 下背痛 <ul><li>80% 一生至少痛一次 </li></ul><ul><li>50% 在一週內痊癒 </li></ul><ul><li>90% 在二個月內痊癒 </li></ul>
  5. 5. 下背痛的臨床診斷 <ul><li>Mechanical disorders </li></ul><ul><ul><li>Strain </li></ul></ul><ul><ul><li>Disk herniation </li></ul></ul><ul><ul><li>Spinal stenosis/ Osteoarthritis </li></ul></ul><ul><ul><li>Spondylolithesis </li></ul></ul><ul><ul><li>Fracture </li></ul></ul><ul><ul><li>Transitional segment </li></ul></ul><ul><ul><li>Scoliosis </li></ul></ul><ul><li>Inflammatory disorders </li></ul><ul><ul><li>Spondyloarthropathy </li></ul></ul><ul><ul><li>Myofascial pain/ Fibromyalgia </li></ul></ul><ul><ul><li>Diffuse idiopathic skeletal hyperostosis </li></ul></ul><ul><ul><li>Osteitis condensans ilii </li></ul></ul><ul><ul><li>Polymyalgia rheumatica </li></ul></ul><ul><li>Metabolic disorders </li></ul><ul><ul><li>Osteoporosis </li></ul></ul><ul><ul><li>Osteomalacia </li></ul></ul><ul><ul><li>PTH, GH </li></ul></ul><ul><li>Infection </li></ul><ul><ul><li>Vertebral osteomyelitis </li></ul></ul><ul><ul><li>Disc infection </li></ul></ul><ul><ul><li>Pyogenic sacroiliitis </li></ul></ul><ul><ul><li>Herpes zoster </li></ul></ul><ul><li>Visceral referred pain </li></ul><ul><ul><li>Aneurysm </li></ul></ul><ul><ul><li>GI/ GU/ Gyn conditions </li></ul></ul><ul><li>Neoplasm </li></ul><ul><ul><li>Primary or metastatic </li></ul></ul><ul><li>Psychogenic </li></ul>
  6. 7. Royal National Hospital for Rheumatic Diseases, Bath, UK.
  7. 8. 指導教授 Andrei Calin 是僵直性脊椎炎臨床研究的權威, 已出版兩百多篇論文及數本教科書。
  8. 12. Inflammatory back pain is key feature of axial SpA Back pain IBP SpA AS
  9. 13. 脊椎關節炎 Spondyloarthritis <ul><li>僵直性脊椎炎 (Ankylosing Spondylitis) </li></ul><ul><li>反應性關節炎 (Reactive arthritis, 過去稱為萊特氏症候群 Reiter syndrome) </li></ul><ul><li>乾癬性關節炎( Psoriatic arthritis ) </li></ul><ul><li>發炎性大腸疾病( Enteropathic arthropathy ) </li></ul><ul><li>未分化型脊椎關節炎( Undifferentiated spondyloarthritis ) </li></ul>
  10. 14. Diagnostic clues for SpA <ul><li>發炎性下背痛 : 薦腸關節炎 (sacroiliitis) 及脊椎炎 (spondylitis) 。 </li></ul><ul><li>接骨點炎 (enthesitis) 。 </li></ul><ul><li>不對稱性的下肢關節炎。 </li></ul><ul><li>與 HLA-B27 基因有關聯。 </li></ul><ul><li>有關節外的表徵:如乾癬 、 腸炎 、 尿道炎 、 葡萄膜炎。 </li></ul>
  11. 15. Finger to floor test
  12. 17. Posterior SI compression test Patrick test
  13. 18. Enthesopathy, dactylitis
  14. 19. Uveitis Psoriasis Extra-articular manifestations of SpA
  15. 20. <ul><li>European Spondyloarthropathy Study Group Classification Criteria for Spondyloarthropathy (ESSG, 1991) </li></ul><ul><li>Inflammatory spinal pain OR Peripheral synovitis (asymmetrical or lower limb) </li></ul><ul><li>PLUS any one of the following: </li></ul><ul><ul><ul><li>alternate buttock pain </li></ul></ul></ul><ul><ul><ul><li>psoriasis </li></ul></ul></ul><ul><ul><ul><li>sacroiliitis </li></ul></ul></ul><ul><ul><ul><li>inflammatory bowel disease </li></ul></ul></ul><ul><ul><ul><li>enthesopathy </li></ul></ul></ul><ul><ul><ul><li>urethritis or cervicitis or acute diarrhea </li></ul></ul></ul><ul><ul><ul><li>positive family history </li></ul></ul></ul>Dougadous, 1991
  16. 21. International Congress on Spondyloarthropathy Gent, Belgium
  17. 23. Anterior Squaring of vetebral bodies Syndesmophyte Corner enthesitis X ray finding of spondylitis
  18. 24. Lt: AS with bamboo spine Rt: Diffuse idiopathic skeletal Hyperostosis(DISH)
  19. 25. Three Problems of the MNY criteria <ul><li>Ignore the other features associated with SpA, e.g. enthesitis, psoriasis and uveitis </li></ul><ul><li>Ignore the role of HLA-B27 in diagnosis </li></ul><ul><li>Too much reliance on plain X-ray changes of sacroiliiac joints </li></ul>
  20. 28. HLA-B27, when to test? <ul><li>When you are not so sure about the diagnosis of SpA. </li></ul><ul><li>Genetic counseling </li></ul>
  21. 29. 薦腸關節炎 sacroiliitis
  22. 30. Rt side grade 3 sacroiliitis Lt side grade 2 sacroiliitis
  23. 31. Sacroiliitis Osteiitis condensans ilii
  24. 36. A breakthrough in diagnosis
  25. 38. Chronic low back pain (5% probability of axial SpA) Inflammatory back pain yes (14% probability) no (<2% probability) HLA-27 No further testing unless SpA is strongly suspected because of the presence of other features. Presence of other SpA-features: heel pain (enthesitis), dactylitis, uveitis, positive family history, Crohn‘s disease, alternating buttock pain, psoriasis, asymmetrical arthritis, positive response to NSAIDs, acute phase reactants (elevated ESR/CRP) MRI Axial SpA** pos (80-90%) neg (<10%) Consider other diagnosis X-rays pos neg AS HLA-27 <ul><li>3 SpA features </li></ul><ul><li>(80-95%) </li></ul>1-2 SpA feature(s) (35-70%)* no SpA feature (14%) pos (59%) neg (<2%) pos (80-95%) neg (<15%) Consider other diagnosis Axial SpA**
  26. 39. Take home message Diagnosis of SpA <ul><li>Clinical manifestations </li></ul><ul><ul><li>Articular: axial, peripheral </li></ul></ul><ul><ul><li>Extra-articular </li></ul></ul><ul><li>Family history and/or HLA-B27 </li></ul><ul><li>Image studies </li></ul><ul><ul><li>X-ray </li></ul></ul><ul><ul><li>CT </li></ul></ul><ul><ul><li>MRI </li></ul></ul>
  27. 40. Thank you 魏正宗 MD,PhD.      中山醫學大學附設醫院過敏免疫風濕科 Tel: 0975128095 Email: wei3228@gmail.com

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