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modified by Medscape Rheumatology education, Expanding
the spectrum for TNF antagonist: Safty & Efficacy in the
Spondyloarthropathies: Ankylosing Spondylitis
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20140802 crc trainging image for ra & as 講義版
文档探讨类风湿性关节炎和僵直性脊椎炎的影像诊断与生物制剂的应用。强调超声和核磁共振在早期诊断、治疗效果评估及疾病监测中的重要性，并提出了能量多普勒信号在评估炎症和预测结构损伤方面的应用。整体来看，影像学技术在改善类风湿性关节炎患者的护理中具有潜力。
20140802 crc trainging image for ra & as 講義版
- 1. Rheumatoid arthritis 類風溼性關節炎 Ankylosing spondylitis 僵直性脊椎炎 台北醫學大學附設醫院風濕免疫科 主治醫師 蔡凱倫 影像判讀 與 生物製劑健保申請之應 用
- 2. The rapid expansionof the therapeutic bioagents has the potential to dramatically improve RA patient care. NEJM 2001 NEJM, 2006. NEJM 2012 Others: 小分子標靶藥物 Tofacitinib(Xeljanz Or Anti-IL17…..
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- 11. RA clinical coarse Therole of image? Radiography, Ultrasound, CT MRI
- 12. 類風溼性關節炎 臨床進程 時間 健康 滑膜發炎臨床症狀， 關節痛，腫 無症狀期 早期類風濕性 關節炎 晚期類風濕性 關節炎 基因與環境因素 自體抗體產生 RF, anti-CCP 關節破壞 關節變形 X 光片 超音波 核磁共振
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- 14. MRI and Miniarthroscopyof MCP Joints in RA . Arthritis Rheum 2001; 44:2492–2502. TI + contrast
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- 16. 類風溼性關節炎在核磁共振下可觀 察到的病理變化 Synovitis 滑膜炎 Tenosynovitis 肌腱滑膜炎 Bone Erosions 骨侵蝕 Bone Marrow Edema 骨質發炎水腫 Bursitis 滑囊炎
- 17. contrast-enhanced MRIdepicted more abnormalities within the osseous structures of the rheumatoid wrist than corresponding fat-suppressed T2-weighted fast spin-echo imaging. Contrast-enhanced T1-weighted images are considered more sensitive and specific in the assessment of acute synovitis AJR:187, August 2006
- 18. Tenosynovitis AJR:189, December 2007 T1FS+ C Effusion: dark(T1) ; bone: dark(T1 white -> T1FS :no fat signals, dark) Synovitis, contrast median: water
- 19. Contrast-enhanced axial T1- weightedfat-saturated MR image
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- 23. 價格 敏感度 安排所 需等待 時間 是否有助急性發 炎診斷 骨折診斷放射性 傳統X光片 便宜 差 快 否 是 是 核磁共振 昂貴 高 須排程 是，但視情況需 顯影劑 是 是 骨骼肌肉超 音波 便宜 高 快 是 否 無 類風濕性關節炎的影像診斷工具
- 24. Clinical applications inRA 髖關節 膝關節 腳踝 趾關節 肩關節 手肘 手腕 手指關節
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- 26. 類風溼性關節炎 三大臨床特色 Synovitis Jointeffusion(GS) Synovial hypertrophy(GS) Synovial vascularization(CD/PD) Bone erosion Tendon pathology A B C DE F
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- 29. 0: no erosions 1:very small ( <1 mm) 2: small (1 - 2 mm) 3: moderate ( 2 - 4 mm) 4: large ( > 4 mm) 骨骼侵蝕 第二指關節 longitudinal Lateral views transverse
- 30. Power Doppler signals 能量都普勒代表 發炎訊號
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- 32. Power Dopplersignals代表active inflammation，訊號越強，代表發炎 越厲害。 有證據顯示之前Power Doppler signals 發現發炎越厲害，之後骨面磨損侵蝕 越嚴重，關節破壞越嚴重。 消滅 Power Doppler signals為什麼那 麼重要?
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- 39. 達標治療 Treat totarget 除了傳統的我們知道的 DAS28 超音波也可以當作一個治 療追蹤指標 MSU treat to target 發炎訊號的消失 關節積水變少 滑膜增生變薄
- 40. Objective. Toinvestigate the construct validity and reliability of US DAS compared with 28-joint DAS(DAS-28) in assessing joint inflammation and in prediction of structural damage in patients with RA. Rheumatology (Oxford). 2012 Jan;51(1):120-8. 超音波比DAS28在評估關節發炎程度和預測 結構破壞上更準確性和可靠性
- 41. 是否可以當作退場機制申覆上的輔助工具? ARTHRITIS & RHEUMATISM Vol.64, No. 1, January 2012, pp 67– 76 Conclusion. For RA patients whose disease is in remission or who have low levels of disease activity, PD signals on ultrasonography could predict relapse or radiographic progression and identify those whose disease is adequately controlled, which is especially helpful when considering treatment tapering or interruption.. 能量嘟普勒訊號可以預測傳統X光上結構破 壞，和正確評估病患是否有適當的疾病控制
- 44. 正常脊椎 早期僵直性脊椎炎 晚期僵直性脊椎炎 發炎沾黏融合 病情嚴重及控制不良者: 脊椎沾黏: 竹子狀，變形，駝背 脊椎沾黏嚴重: 喪失柔軟度，提高骨折風險，甚至有壓迫 神經導致下肢麻木問題。
- 45. [image tool: MRI] modifiedby Medscape Rheumatology education, Expanding the spectrum for TNF antagonist: Safty & Efficacy in the Spondyloarthropathies: Ankylosing Spondylitis Image tool: MRI, Ultrasound
- 46. Sacroiliitis 0 Normal 1 Someblurring of the joint margins - suspicious 2 Minimal sclerosis with some erosions 3 Severe erosions with widening of joint space +/- some ankylosis (Pseudo-widening of the joint space: Subchondral bone resorption— blurring ; Erosion sclerosis ;Calcification leading to ankylosis) 4 complete ankylosis Grade 0 Grade 1 Grade 3 Grade 4
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- 54. anterior corner erosionsat vertebral bodies (vertebral enthesitis) shiny corner sign (Romanus lesion) Vertebral body squaring Vertebral fusion
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- 56. AS, Andersson lesion,discovertebral destruction, spine (severe back pain!)
- 57. 2～5年 Modified NewYork criteria 1984 1. 下背痛僵硬 休息無法減輕 三個月以上 2. 腰椎活動範圍受限 3. 擴胸範圍受限 4. X光有薦腸關節炎雙側2級或單側3級以上 4+ 1 or 2 or3
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- 59. T1 white, STIRdark Bone marrow edema, STIR white, T1 dark Romanus lesion Active lesion Chronic lesion
- 60. SPARCC MRI spinalscore (0–108) Arthritis Rheum. 2005 Aug 15;53(4):502-9. T2 SPARCC 2 SPARCC 13 Spondyloarthritis Research Consortium of Canada magnetic resonance imaging index
- 61. Arthritis Rheum. 2003Apr;48(4):1126-36
- 62. STIR Frequency of active inflammationin the spine (vertebral units) Ann Rheum Dis 2013;72:967–973
- 63. Ann Rheum Dis2013;0:1–7.
- 64. Enthesitis T1 T1FS +C C7~ T3 supraspinal ligament RadioGraphics 2005; 25:559 –570
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- 67. Synovitis, SpA Synovitis, Tendonitis/tenosynovitis Enthesopathy Dactylitis
- 68. Elemental lesions Ossification/cortical bone changes Achilles Tendon
- 69. Achilles Tendon Cortical boneirregularities: erosion, doppler
- 71. Taipei Medical UniversityHospital HIP joint
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- 73. 傳統X光片仍是評估關節炎很重要的工具 核磁共振與骨骼肌肉超音波對於關節炎軟組織部份 的評估較傳統X光片敏感許多。 類風濕性關節的重要病理病變為滑膜發炎，僵直性 脊椎炎的重要病理變化為著骨點發炎。 類風溼性關節炎的發炎評估以手腕關節與2nd MCP掌 指關節最為重要。 能量督普勒代表的是發炎訊號，超音波的達標治療 目標以消滅能量嘟普勒訊號為最重要。 Take home massage