脊柱关节病
许多不同类型的风湿性疾病影响着脊柱。风湿性疾病是一个影响全身的疾病，例如众所周知的类风湿性关节炎。当风湿性疾病影响到脊柱时，称为脊柱关节病。这个术语由希腊语组成：“Spondylo”是指“脊椎”，“arthro”是指“关节”，“pathos”是指“疾病”。
The most common diseases in the spondyloarthropathies include:
· Ankylosing Spondylitis (AS)
· Psoriatic Arthritis (PsA)
· Reactive Arthritis (ReA)
· Enteropathic Arthritis (EA)
· Rheumatoid Arthritis (RA)
最常见的脊柱关节病包括：
· 强直性脊柱炎
· 银屑病关节炎
· 反应性关节炎
· 肠病性关节炎
· 类风湿性关节炎
This guide will help you understand
· which parts of the spine are affected
· what causes these diseases
· what the most common symptoms are
· what tests your doctor may recommend
· what treatment options are available
本指南将帮助您了解
· 脊柱的哪个部分受到了影响
· 这些疾病由什么引起
· 最常见的症状是什么
· 你的医生可能会推荐的检查
· 有什么治疗方法可以选择
What parts of the spine are involved?
涉及脊柱哪些部分？
This group of diseases cause damage by creating inflammation that attacks the connective tissues of the body. In most cases, the cause of these diseases is unknown. There is increasing evidence that the underlying cause may be a combination of genetics and infection. A person born with certain genes may react differently to certain types of infections. Once that person is exposed to certain infections, the body responds by defending itself. The way the body defends itself against infection is through an inflammatory response. This is normal. What is not normal is that long after the infection is gone, the inflammation continues. This chronic inflammation causes damage to many of the connective tissue structures in the body and leads to the symptoms.
这类疾病是由炎症攻击身体的结缔组织造成的损伤。在大多数情况，这些疾病的病因尚不明确。有越来越多的证据表明：潜在的因素可能是基因和感染的结合。与生俱来的某些基因可能对某些不同类型感染产生反应。人一旦暴露于某些感染，身体会做出自我保护的反应。通过炎症反应保卫自己是正常的。感染消除很长时间后炎症仍然持续就不正常了。这种慢性炎症造成身体内很多结缔组织结构损害，导致出现一些症状。
There are several rheumatological diseases that can affect the spine. The rheumatological diseases that affect the spine primarily affect the connective tissues. One of the most common rheumatological diseases is rheumatoid arthritis (RA). RA primarily attacks the synovial joints.
有一些风湿性疾病可以影响到脊柱。影响脊柱的风湿性疾病主要影响的是结缔组织。类风湿性关节炎是其中最常见的一种风湿性疾病。类风湿性关节炎中滑膜关节最先受损。
Most of the joints in the body are synovial joints – such as theknee, hip and shoulder. A synovial joint is where two bones come together to form a connection that needs to be flexible – the two bones need to move against one another. The ends of the bones are covered with articular cartilage. Articular cartilage is a white, shiny material that is very slippery. It provides shock absorption and allows the bones to glide against one another easily. The synovial joint is completely enclosed by a joint capsule made up of tough connective tissue on the outside and a thin layer of tissue on the inside called the synovial lining. The joint is water tight. Inside the joint there is a small amount of fluid called synovial fluid. Articular cartilage does not have any blood vessels. The synovial fluid brings nutrients to the articular cartilage as it lubricates the joint.
体内的多数关节如髋关节、膝关节、肩关节都是滑膜关节。滑膜关节是由两个骨头形成的一个灵活的链接，两块骨头相互间可以活动。骨头的两端覆盖着关节软骨。关节软骨是白色、发亮的，很光滑的材料。它提供减震、让骨之间的滑动更加容易。滑膜关节是由外面坚韧的结缔组织和里面被称为滑膜的薄膜层组织形成的完全封闭的关节囊。关节是密不透水的。在关节内的少量液体称为滑液。关节软骨不含任何血管。滑液提供的营养物质能够润滑关节软骨。
In RA, the synovial lining of the joint is affected. The normally thin tissue of the synovial lining becomes inflamed and thickened. This material begins to produce inflammatory chemicals that damage the articular cartilage and bone underneath. The joint is slowly destroyed until bone rubs against bone. There are synovial joints between each vertebra in the spine and between the skull and the first cervical vertebra. It is easy to see why RA affects the spine.
在类风湿性关节炎中，关节的滑膜受到了影响。滑膜的正常薄膜组织发炎、增厚。这种材质开始产生损害关节软骨和软骨下面的炎性化学物质。关节被慢慢的破坏直到骨与骨之间相互磨损。滑膜关节出现在每个脊柱的椎体、头颅、第一颈椎之间。这就很容易理解为什么类风湿性关节炎容易影响到脊柱。
In some rheumatological diseases, the inflammatory process affects other connective tissue structures. One structure that is commonly affected is where ligaments and tendons attach to the bone. This area is called an enthesis. There are entheses located all over the body – wherever tendons and ligaments need to attach to bone. There are also many entheses in the spine itself, such as where the intervertebral disc attaches to the vertebra. Many of the rheumatological diseases that affect the spine seem to attack these areas of the spine. It is unclear why this occurs.
Related Document: A Patient’s Guide to Lumbar Spine Anatomy
Related Document: A Patient’s Guide to Lumbar Spine Anatomy
相关阅读：腰椎解剖患者指南（翻译招募中，有意者留言）
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What causes this problem?
本病的病因是什么？
The cause, or causes, of all of these rheumatological diseases is still unknown. There is increasing evidence that the underlying cause in many of these conditions is a combination of a person’s genetic makeup and how that person responds to certain types of infections.
这些风湿性疾病的原因或病因仍然是未知的。有越来越多的证据表明：多数情况的潜在因素是人类基因构造和人们对某一类型感染的反应方式的结合。
For many years, doctors have been aware that people with these diseases have a higher percentage of a gene called HLA-B27. The HLA-B27 gene plays a role in determining how the cells of the body react against infection. Not everyone with this gene will develop a rheumatological disease, but the vast majority of people with any of the diseases have the gene. Recently, more research has shown that there are a number of variations of the HLA-B27 gene. This further complicates a very complex situation in trying to understand what role genetics plays in the cause of these diseases.
多年来，医生已经意识到，患有此类疾病的患者有较高比率的HLA-B27基因。HLA-B27基因的作用是人体细胞如何反抗感染的角色，并不是每个有这种基因的人都会发展为风湿性疾病，但绝大多数有此类疾病的人都有这种基因。现在，很多研究表明有一些HLA-B27基因发生变异。这将进一步使遗传学在了解基因在这些疾病中的作用变得更加复杂化。
There are also a number of different infections that have been found to be related to the development of the rheumatological diseases. When patients with these diseases are studied, there seems to be certain bacterial infections that are more likely to precede the development of the rheumatological disease. The infection may be over, but the body continues to mount an inflammatory response that instead attacks the connective tissue
structures of the body itself.
有许多不同的感染也发现与风湿性疾病的病情进展有关联。当对此类疾病患者研究时，似乎某些细菌感染更先于风湿性疾病的进展。感染可能被消除了，但是身体继续增加炎症应答反而破坏自身的结缔组织结构。
The current evidence suggests that people with certain genes are more likely to react to certain types of infections by developing a rheumatological disease.
Related Document: A Patient’s Guide to Rheumatoid Arthritis
目前有证据表明：人类的某些基因似乎对通过风湿性疾病的进展产生对某些类型的感染反应。
Related Document: A Patient’s Guide to Rheumatoid Arthritis
相关阅读：类风湿性关节炎患者指南（翻译招募中，有意者留言）
What does the condition feel like?
患本病时会有什么感觉？
Most of these diseases cause pain and stiffness as the primary symptoms affecting the spine. The pain and stiffness is worse in the morning and improves with activity. The flexibility of the spine decreases as time passes and the disease progresses.
多数此类疾病影响脊柱的早期症状是疼痛和僵硬。早上疼痛、僵硬加重，活动后减轻。随着时间的推移和疾病的进展，脊柱的活动范围会减小。
In diseases that affect the synovial joints, destruction of the joints can result in instability of the spine and may cause pressure on the spinal nerves or spinal cord. In the diseases that affect the entheses, the spine more commonly develops large bone spurs and may fuse together and become stiff. Instability occurs if the stiff spine is fractured.
当疾病影响滑膜关节时，关节的破坏会导致脊柱的不稳定或压迫脊髓或神经根。当疾病影响到附着点时，脊柱通常会出现大的骨刺、可能会发生融合使脊柱变得僵硬。如果僵硬的脊柱不稳定，就会发生骨折。
Because these diseases are systemic, meaning that they affect the entire body, the symptoms also affect the entire body. The symptoms include pain in areas that are affected, such as the other synovial joints, and the other entheses of the body.
因为此类疾病属于全身性疾病，意味着它将影响人的整个身体，症状也会影响人的整个身体。症状包括受影响区域的疼痛，如其他的滑膜关节和身体上的附着点。
Besides back pain, sacroiliac, hip, and shoulder pain are also common. The exact location of symptoms depends on the type of spondyloarthropathy (SpA) present. Some of the diseases may include a skin rash, such as psoriasis. Several of the spondyloarthropathies affect the eyes, causing uveitis (inflammation of the iris). Inflammation of the urethra (the tube from the bladder to the outside) can cause pain when urinating, called urethritis. Ankylosing Spondylitis (AS) can also affect the gut, aorta, or heart. All of the symptoms mentioned here are called extraskeletal manifestations. This means the symptoms affect some part of the body other than the tendons and bones.
除了后背痛，骶髂关节、髋关节、肩关节疼痛也很常见。症状出现的具体位置取决于脊柱关节炎的类型。一些症状可能包括皮疹，如牛皮癣。一些脊柱关节病影响到眼睛，造成葡萄膜炎（巩膜炎）。尿道炎（从膀胱到尿道）排尿时可引起疼痛。强直性脊柱炎也能够影响内脏、心脏、主动脉。所有这里提到的症状都是骨骼以外表现，意思是症状也影响着除了骨骼和肌腱以外的身体的一些其他部位。
How do doctors diagnose the problem?
医生如何诊断本病？
The diagnosis requires a careful history followed by a thorough physical examination. Many patients have someone directly related to them that suffers from the same disease. Your doctor may ask questions about symptoms of recent infections such as diarrhea, burning with urination, difficulty with vision and eye pain.
诊断需要详细的询问病史后进行全面的身体检查。很多患者的直系亲属也患有同样的毛病。你的医生可能会问你一些近期感染的症状，如腹泻、排尿时烧灼感、眼痛和视觉障碍。
The laboratory evaluation is very useful in the diagnosis. Tests such as C-reactive protein (CRP) level and erythrocyte sedimentation rate (ESR) may be ordered to look for signs of infection and chronic inflammation. Other tests can be done for rheumatoid arthritis and the presence of the HLA-B27 gene. The HLA-B27 gene is not always present in patients with spondyloarthropathy. And it may be present in normal, healthy individuals without spondyloarthropathies.
实验室诊断在临床诊断中很有帮助。医生会申请C反应蛋白（CRP）和血沉（ESR）等检查来寻找感染或慢性炎症的迹象。其他测试用于发现类风湿性关节炎、HLA-B27基因的存在。HLA-B27基因不总是出现在于脊柱关节病，也有可能出现在正常健康的没有脊柱关节病的人。
Analysis of synovial fluid may be needed to rule out (infectious) arthritis. Additional tests may be ordered for patients with inflammatory bowel disease(IBD) or when reactive arthritis is suspected.
滑液分析可能需要排除脓毒性关节炎（感染）。临床怀疑有炎症性肠病、反应性关节炎的患者需要额外的检验试。
X-rays can be very useful to show the changes in the spine, joints and pelvis that are common with many of these diseases. X-rays are usually the first test ordered before any of the more specialized tests. In the early stages the x-rays may be negative, but as time passes, the changes may appear and confirm the diagnosis.
X光片能够显示在脊柱、关节、骨盆上许多这些疾病的变化。X光片常作为先于许多更专业检查之前的检查。在初期，X线检查可能是阴性结果，但是随着时间的推移，能够诊断此病的改变可能会出现。
Other radiological imaging tests may be useful. A bone scan can show the sites of inflammation before the changes appear on x-rays. A bone scan is a special test where radioactive tracers are injected into your blood stream. The tracers then show up on special x-rays of your back. The tracers build up in areas where bone is undergoing a rapid repair process, such as a healing fracture or the area surrounding an infection or tumor. Usually the bone scan is used to locate the problem. Other tests such as the computed tomography (CT) scan ormagnetic resonance imaging (MRI) scan are then used to look at the area in detail.
其他影像学检查可能也是有用的。骨扫描能够在X光检查出变化之前显示炎症的位置。骨扫描是一个将放射性指示剂注入您的血流中的特别检查。然后指示剂以特殊X光在您的后背显影。指示剂在正在进行快速修复过程的骨组织中积聚，例如骨折愈合、周围感染或肿瘤的区域。通常骨扫描用于定位，而其他的检查如CT、MRI用于观察病变区域的细节。
If there are symptoms suggesting the spinal nerves or spinal cord are in danger, an MRI scan may be recommended to look at the spine more closely. The MRI scan uses magnetic waves to create pictures of the lumbar spine in slices. The MRI scan shows the lumbar spine bones as well as the soft tissue structures such as the discs, joints and nerves. MRI scans are painless and don’t require needles or dye. Specialized MRI techniques are now available that can detect inflammatory changes in the sacroiliac and vertebral joints long before they appear on rays.
如果有症状表明脊髓神经或脊髓处于危险中，可以进行一次核磁共振检查，能更清楚地观察脊柱。MRI利用电磁波建立腰椎断层成像。MRI能够显示腰椎椎体、软组织、椎间盘、关节以及神经。MRI是无痛的检查，不需要打针和造影剂。特殊MRI技术能够在X光发现改变很早以前检测到骶髂关节和椎间关节的炎症变化。
Treatment
治疗
What treatment options are available?
有哪些治疗方法？
There is no cure for any of these diseases. The goal of treatment is to manage the pain and, when possible, to slow the progression of the damage to the underlying structures.
目前这些疾病无法治愈。治疗的目的是减轻疼痛、尽可能减缓病情进展带来的损伤。
Remaining as active as possible is critical to maintaining your function. A physical therapy program can teach you how to maximize your function and retain as much flexibility as possible. Learn all you can about what you can do to control your symptoms and remain as healthy as possible.
尽可能多活动来保持关节功能是很重要的。一个物理治疗方案能够教您如何最大限度的使用关节功能和保持关节的灵活度。了解一切您可以做到的有关如何控制您的症状和保持健康治疗。
If you smoke or use tobacco products, long-term outcomes are worse. You should quit as soon as possible. Your doctor can help you with this important step.
如果您长期抽烟或使用一些烟草产品会有一些不好的结果，您需要尽 快远离这些烟草类产品。您的医生能够给您提供帮助。
Medications are the primary tools available for treatment.Non-steroidal anti-inflammatory drugs (NSAIDs) are the main drugs used for treatment of the pain associated with these diseases. These drugs include aspirin, ibuprofen, indomethacin and naprosyn. There are others in the group as well. These drugs reduce the inflammation and control pain. There is no evidence that they stop or slow the progression of the disease.
药物治疗是首选，非甾体抗炎药是治疗这类疾病引起相关疼痛的主要药物。包括阿司匹林、布洛芬、消炎痛、甲氧基甲基萘乙酸等。可以减轻炎症和疼痛。但是目前没有证据表明这些药物可以阻止或延缓病情的发展。
Cortisone can be used to control flare-ups of pain. Cortisone is a powerful anti-inflammatory medication. When used for short periods of time, the medication is safe and well tolerated. When used continuously over a period of months, the side effects can be significant. Your doctor will probably not want to use cortisone if possible. In some cases, such as with advanced rheumatoid arthritis it may become necessary to use cortisone indefinitely to control the disease.
可的松是一种有效的抗炎药物，可以用来控制疼痛的发作。短期应用这种药物是安全、耐受性良好的。当在数月内连续使用，药物副作用就有可能出现。你的医生可能会尽量避免让您使用可的松。但有些病例，例如晚期风湿关节炎可能需要长期使用可的松控制病情。
There are newer medications that have been developed to control rheumatoid arthritis that are sometimes beneficial in the spondyloarthropathies. Some of these medications actually slow the progression of the damage from the disease. These medications are known as disease modifying anti-rheumatic drugs(DMARDs). DMARDs include gold injections, methotrexate, sulfasalazine and azothioprine. These medications may be used primarily to control the symptoms in other parts of the body, but may also improve the spinal disease as well.
一些新开发的药物已经用于控制类风湿性关节炎，可能对脊柱关节病的治疗有作用。其中一些药物能够延缓病情进展带来的损伤，这些药物称为抗风湿药(DMARDs)，包括金制剂、甲氨蝶呤，柳氮磺胺吡啶和硫唑嘌呤。这些药物可用于改善脊柱疾病，也可以控制其他部位的症状。
Recently, new medications have been available that may prove to be very beneficial for these diseases. One of the chemicals that seems to make the inflammation worse in these diseases is tumor necrosis factor (TNF). Drugs that block the effect of this chemical are called tumor necrosis factor-a inhibitors. TNF-a inhibitors are used to treat a variety of inflammatory diseases. These have recently begun to be used to treat a variety of inflammatory diseases. These drugs have shown promise in helping control the inflammation and symptoms of the spondyloarthropathies as well. TNF-a inhibitors result in dramatic decreases in CRP levels and ESR improvements are also seen on MRIs.
近年来，新的药物证明对这些疾病有效。其中肿瘤坏死因子药物能够减轻炎症反应。阻断这种效果的药物称为肿瘤坏死因子a-抑制剂。TNF-a抑制剂用于治疗可用于治疗各种炎症性疾病。这些药物也能够帮助脊柱关节病控制炎症和症状。TNF-a抑制剂能够使C反应蛋白和血沉水平大幅度下降。MRI上也有所改善。
Treatment with TNF-a inhibitors must be kept up over the long-term to stay in control of the disease. If one agent doesn’t work, your doctor may switch you to another. There are some serious side effects with these agents, so they aren’t used with everyone. We don’t know yet if these agents will prevent the bony changes that lead to spinal fusion. More study is needed to determine this.
TNF-a抑制剂的治疗必须是长期使用才能控制病情，如果药物效果不佳，你的医生会给你换药。这些药物有严重的副作用，并不适合所有人。我们还不知道这些药物是否能够阻止骨质改变的脊柱融合，还需要更多的研究来确定。
Surgery is rarely indicated in the treatment of these diseases, except where the damage caused by the disease has caused pressure on the spinal nerves or spinal cord. Total joint replacement may be needed for patients with severe damage to the hip or knee. Some patients elect to have surgery to correct kyphosis (forward curve or humpback of the upper spine) or to correct spine instability from fracture.
这类疾病很少手术。除非这些疾病造成的损伤压迫脊髓或神经，病人有严重的髋、膝关节损伤时需要全关节置换，一些患者选择手术纠正驼背或脊柱骨折不稳定。
Finally, learning as much as you can about how you can take care of yourself is an important part of managing these chronic diseases. Support groups are available online and in many cities where people can come together and help with information and support. There is nothing as valuable as getting advice and guidance from someone who has experience with the disease and can provide tips and pointers for living with the disease on a daily basis. It is always nice to know that you are not alone.
最后，尽量多学习一些关爱自我的方法是这类慢性病的很重要的部分。患者们通过网络和各个城市聚在一起、提供有用的信息，没有什么能够比患者之间的建议和指导经验更有价值，提供在这些疾病的基础上生活中的小技巧、小诀窍。这让您很好的知道在对抗疾病的路上您并不孤独。
(李程 译）
李程，男，德国柏林自由大学Charite医学院在读博士。德国华人医学创新协会骨科学组组长、《现代医药卫生杂志》专职审稿人、《中国医学影像学杂志》编辑、Annals of Joint杂志section editor、中华医学会骨科通讯员。
主要研究方向：假体关节感染、脊柱外科手术机器人。
联系方式：cheng.li@charite.de
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