强直性脊柱炎寒热证型超声下外周附着点炎表现的差异研究

Study on the difference of ultrasonic manifestations of peripheral enthesitis between cold and heat syndrome in ankylosing spondylitis

目的研究强直性脊柱炎患者寒热证型超声下外周附着点炎表现的差异及其与临床指标的相关性。方法选择2018年12月—2019年12月上海中医药大学附属光华医院关节内科门诊和病房收治的强直性脊柱炎患者58例,收集患者临床信息,检测C反应蛋白(CRP)、血沉(ESR)水平,记录强直性脊柱炎疾病活动评分(ASDAS-CRP、ASDAS-ESR)、Bath AS疾病活动指数(BASDAI)、Bath AS功能指数(BASFI)、Bath AS测量指数(BASMI)及寒热证型中医证候评分;采用肌肉骨骼超声对患者进行外周肌腱附着点扫查,根据MASEI评分系统进行超声下附着点炎病变评分。根据Maastrict强直性脊柱炎附着点炎评分将外周附着点炎患者分为临床附着点炎组和亚临床附着点炎组,比较2组超声下6项病变评分及附着点炎总评分;按照中医辨证将患者分为寒证组与热证组,比较2组超声下6项病变评分及附着点炎总评分;分析58例患者超声下附着点炎总评分与临床指标的相关性、寒热证型患者超声下附着点炎总评分及超声下6项病变评分与临床指标的相关性、寒热证型患者超声下附着点炎总评分与中医证候评分的相关性。结果58例患者中有55例存在超声下附着点炎,其中亚临床附着点炎43例,临床附着点炎12例;中医辨证属于寒证30例,热证28例。临床附着点炎组患者超声下附着点炎总评分及能量多普勒血流评分均明显高于亚临床附着点炎组(P均<0.05);热证组患者超声下附着点炎总评分、肌腱厚度评分、滑囊炎评分均明显高于寒证组患者(P均<0.05)。58例患者超声下附着点炎总评分与CRP、ESR、ASDAS-CRP、ASDAS-ESR、BASDAI、BASFI、BASMI、MASES、病程均呈正相关(P均<0.05)。热证组患者超声下附着点炎总评分与CRP、ASDAS-CRP、BASDAI均呈正相关(P均<0.05),肌腱结构评分与ESR、ASDAS-ESR均呈正相关(P均<0.05),能量多普勒血流评分与CRP、ESR、ASDAS-CRP、ASDAS-ESR、BASDAI均呈正相关(P均<0.05),滑囊炎评分与CRP、ESR、ASDAS-CRP、BASDAI均呈正相关(P均<0.05);寒证组患者超声下附着点炎总评分与病程、BASFI、BASMI均呈正相关(P均<0.05),肌腱结构评分与BASFI呈正相关(P<0.05),骨侵蚀评分与ASDAS-CRP、BASDAI、BASFI、BASMI均呈正相关(P均<0.05),能量多普勒血流评分、钙化评分与BASMI均呈正相关(P均<0.05)。热证组和寒证组患者超声下附着点炎总评分与中医证候评分均呈正相关(P均<0.05)。结论强直性脊柱炎患者超声下亚临床附着点炎发生率高,超声下附着点炎评分能反映疾病活动度。热证患者较寒证患者外周附着点炎表现更严重;热证患者附着点炎症性病变与疾病活动密切相关,寒证患者附着点结构性病变与病程及功能密切相关。

Objective It is to explore the difference of ultrasonic manifestations of peripheral enthesitis between cold and heat syndrome and its correlation with clinical indicators in patients with ankylosing spondylitis(AS).Methods A total of 58 patients with AS who were admitted to the outpatient and ward of joint medicine department of Guanghua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine from December 2018 to December 2019 were selected,the clinical information of the patients was collected,and the levels of C-reactive protein(CRP)and erythrocyte sedimentation rate(ESR)were detected,the scores of AS disease activity(ASDAS-CRP,ASDAS-ESR),Bath AS Disease Activity Index(BASDAI),Bath AS Functional Index(BASFI),Bath AS Measurement Index(BASMI)and scores of TCM syndrome of cold and heat syndrome were recorded.The peripheral tendon attachment points of the patients were scaned by musculoskeletal ultrasound,and the enthesitis lesions under ultrasound were scored according to the MASEI scoring system.According to the Maastrict AS enthesitis scores,the patients with peripheral enthesitis were divided into a clinical enthesitis group and a subclinical enthesitis group,and the scores of 6 lesions and the total enthesitis score under ultrasound were compared between the two groups.According to TCM syndrome differentiation,the patients were divided into a cold syndrome group and a heat syndrome group,and the scores of 6 lesions and the total score of enthesitis under ultrasound were compared between the two groups.The correlation between the total score of enthesitis under ultrasound and clinical indicators,the correlation between the total score of enthesitis under ultrasound and the six lesion scores under ultrasound and clinical indicators in patients with cold syndrome and heat syndrome,and the correlation between the total score of enthesitis under ultrasound and the score of TCM syndromes in patients with cold syndrome and heat syndrome were analyzed.Results Among the 58 patients,55 had enthesitis under ultrasound,including 43 cases of subclinical enthesitis and 12 cases of clinical enthesitis;30 cases with cold syndrome and 28 cases with heat syndrome.The total enthesitis score and power Doppler blood flow score under ultrasound in the clinical enthesitis group were significantly higher than those in the subclinical enthesitis group(P<0.05).The total score of enthesitis,tendon thickness score and bursitis score under ultrasound in the heat syndrome group were significantly higher than those in the cold syndrome group(all P<0.05).The total score of enthesitis under ultrasound in 58 patients was positively correlated with CRP,ESR,ASDAS-CRP,ASDAS-ESR,BASDAI,BASFI,BASMI,MASES,and disease course(all P<0.05).In the heat syndrome group,the total score of enthesitis under ultrasound was positively correlated with CRP,ASDAS-CRP,and BASDAI(all P<0.05),tendon structure score was positively correlated with ESR,ASDAS-ESR(all P<0.05),power Doppler flow score was positively correlated with CRP,ESR,ASDAS-CRP,ASDAS-ESR,and BASDAI(all P<0.05),bursitis score was significantly correlated with CRP,ESR,ASDAS-CRP,and BASDAI(all P<0.05).In the cold syndrome group,the total score of enthesitis under ultrasound was positively correlated with the disease course,BASFI and BASMI(all P<0.05),the tendon structure score was positively correlated with BASFI(P<0.05),and the bone erosion score was positively correlated with ASDAS-CRP,BASDAI,BASFI and BASMI(all P<0.05),and the power Doppler blood flow score and calcification score were positively correlated with BASMI(all P<0.05).The total score of enthesitis under ultrasound in the heat syndrome group and the cold syndrome group was positively correlated with the TCM syndrome score(all P<0.05).Conclusion The incidence of subclinical enthesitis was high in patients with AS,and the ultrasonic score of enthesitis could reflect the disease activity of AS.The manifestations of peripheral enthesitis were more serious in patients with heat syndrome.Inflammatory lesions of enthesitis in patients with heat syndrome were closely related to disease activity,while structural lesions of enthesitis in cold syndrome were closely related to disease course and function.