肌骨超声在血清学阴性类风湿关节炎早期诊断中的作用

doi:10.3969/j.issn.1004-583X.2025.08.006

摘要/Abstract

摘要：

目的探讨肌骨超声在早期鉴别诊断血清学阴性类风湿性关节炎(seronegative rheumatoid arthritis,SNRA)中的价值。方法纳入2018年1月-2022年12月于兰州大学第二医院风湿科首次就诊,腕或手指掌指关节、近端指间关节肿胀、压痛阳性的患者112例,随访6个月确诊后,分为SNRA组(n=45)和非类风湿关节炎(rheumatoid arthritis,RA)组(n=67)。肌骨超声观察两组双腕、双手指关节及肌腱滑膜增生二维灰度(grayscale,GS)、能量多普勒(power doppler,PD)及骨侵蚀(bone erosion, BE),并进行半定量评分。记录患者年龄、性别、病程、C反应蛋白(C-reactive protein,CRP)、红细胞沉降率(erythrocyte sedimentation rate,ESR)等临床资料。分析两组超声评分的差异,并分析SNRA组超声评分与病程、ESR、CPR等的相关性。通过绘制受试者工作特征曲线,评价超声指标对SNRA的诊断效能。结果 ①两组年龄、性别、病程差异均无统计学意义(P>0.05), SNRA组CRP和ESR均高于非RA组,差异有统计学意义(P<0.01)。②两组关节GS、PD和BE评分差异均有统计学意义(P<0.05),而肌腱GS差异无统计学意义(P>0.05),SNRA组肌腱PD评分高于非RA组,差异有统计学意义(P<0.05);两组发病部位差异无统计学意义(P>0.05),SNRA组关节病变、BE占比均大于非RA组,差异有统计学意义(P<0.05);两组关节GS、PD、BE分级差异均有统计学意义(P<0.01);③SNRA组关节GS、PD与CPR、ESR呈低度正相关(r值分别为0.366、0.306、0.444和0.384,P均<0.05),肌腱GS、PD与CPR、ESR呈中度正相关(r值分别为0.732、0.532、0.772、0.538,P均<0.05);关节BE与CRP呈中度正相关(r=0.539,P<0.05);④SNRA组关节与肌腱PD评分总和对其诊断效能最大,以10分为预测界值,SNRA诊断的敏感度为82.2%,特异度为90.0%。结论肌骨超声可作为早期鉴别诊断SNRA的无创影像学方法之一。

关键词: 血清阴性类风湿关节炎, 骨性关节炎, 肌骨超声

Abstract:

Objective To explore the value of musculoskeletal ultrasound in the early differential diagnosis of seronegative rheumatoid arthritis (SNRA). Methods A total of 112 patients with swelling and positive tenderness of wrist or finger metacarpophalangeal joint, and proximal interphalangeal joint who for the first time visited the Department of the Rheumatology, the Second Hospital, Lanzhou University from January 2018 to December 2022 were selected. After 6 months of follow-up, patients were divided into the SNRA group(n=45) and the non-RA group(n=67). Musculoskeletal ultrasound was used to observe the two-dimensional gray scale (GS), power Doppler (PD) and bone erosion (BE) of synovial hyperplasia in the bilateral wrists, bilateral finger joints and tendons of the two groups, and semi-quantitative scoring was performed. Clinical data, such as age, gender, course of disease, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) were recorded. The differences in ultrasound scores between the two groups were analyzed, and the correlations of ultrasound scores with course of disease, ESR, CPR in the SNRA group were also analyzed. The receiver operating characteristic (ROC) curve was used to evaluate the diagnostic efficacy of ultrasound indicators for SNRA. Results There were no significant differences in age, gender, and course of disease between the two groups (P>0.05). However, CRP and ESR levels were significantly higher in the SNRA group compared to the non-RA group (P<0.01). Joint GS, PD, and BE scores showed significant differences between the two groups (P<0.05), whereas tendon GS scores did not (P>0.05). Patients in the SNRA group had significantly higher tendon PD scores than the non-RA group (P<0.05). No significant differences were observed in lesion locations between groups (P>0.05), but patients in the SNRA group exhibited a significantly higher proportion of joint lesions and BE involvement compared to the non-RA group (P<0.05). Joint GS, PD, and BE grades also demonstrated significant differences between groups (P<0.01). Joint GS and PD scores in the SNRA group showed low positive correlations with CRP and ESR (r=0.366, 0.306, 0.444, and 0.384, respectively; all P<0.05). Tendon GS and PD scores exhibited moderate positive correlations with CRP and ESR (r=0.732, 0.532, 0.772, and 0.538, respectively; all P<0.05). Joint BE scores showed a moderate positive correlation with CRP (r=0.539; P<0.05). The sum of joint and tendon PD scores in the SNRA group demonstrated the highest diagnostic efficacy. Using a cutoff value of 10, the sensitivity and specificity for diagnosing SNRA were 82.2% and 90.0%, respectively. Conclusion Musculoskeletal ultrasound can be used as a non-invasive imaging method for the early differential diagnosis of SNRA.

Key words: seronegative rheumatoid arthritis, osteoarthritis, musculoskeletal ultrasound

中图分类号:

R593.22

沈雪娇, 王挺, 王媛, 李燕, 魏佳琪. 肌骨超声在血清学阴性类风湿关节炎早期诊断中的作用[J]. 临床荟萃, 2025, 40(8): 705-710.

Shen Xuejiao, Wang Ting, Wang Yuan, Li Yan, Wei Jiaqi. Role of musculoskeletal ultrasound in the early diagnosis of seronegative rheumatoid arthritis[J]. Clinical Focus, 2025, 40(8): 705-710.

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https://www.lchc.cn/CN/Y2025/V40/I8/705

图/表 7

图1 手指关节滑膜炎 a.GS示指关节滑膜增生2级; b. PD示增生滑膜血流2级

Fig.1 Synovitis of the finger joints a. GS shows grade 2 synovial hyperplasia of the finger joint;b.PD shows blood flow in the grade 2 hyperplastic synovium

图2 手指屈肌腱腱鞘炎 a.GS示屈肌腱腱鞘广泛扩张,分级3级; b. PD示腱鞘炎血流分级2级

Fig.2 Tenosynovitis of the finger flexor tendons a.GS shows extensive dilation of the flexor tendon sheath (grade 3);b. PD shows blood flow in grade 2 tenosynovitis

表1 两组临床资料和发病部位比较

Tab.1 Comparison of clinical data and site of onset between the two groups

项目	SNRA组(n=45)	非RA组(n=67)	统计值	P值
年龄(岁)	53.17±13.21	49.88±11.34	t=-1.740	0.120
男性[例(%)]	8(17.8)	24(35.8)	χ²=-2.02	0.090
病程(月)	12.11±16.12	10.92±7.67	t=-2.410	0.070
CRP(μg/L)	51.04±45.35	17.33±21.30	t=-5.480	<0.01
ESR(mm/h)	46.38±34.30	15.03±15.47	t=-5.560	<0.01
发病部位[例(%)]
腕关节	65(72.2)	82(61.2)	χ²=1.090	0.300
MCP1-5	143(31.8)	164(24.5)	χ²=3.260	0.160
PIP1-5	80(17.8)	142(21.2)	χ²=0.280	0.540

表2 两组超声评分指标比较

Tab.2 Comparison of ultrasound scoring indicators between the two groups

组别	例数	关节			肌腱		关节病变	肌腱病变	BE
组别	例数	GS1	PD1	BE评分	GS2	PD2	关节病变	肌腱病变	BE
SNRA组	45	16.20±12.23	12.82±9.24	1.60±1.60	8.82±6.55	10.13±8.01	356(36.0)	252(23.3)	48(4.8)
非RA组	67	7.40±5.68	5.49±5.04	1.18±1.95	6.92±5.94	6.97±6.09	297(20.1)	459(28.5)	56(3.8)
统计值		t=-4.790	t=-5.237	t=-2.083	t=-1.616	t=-2.082	χ²=-3.914	χ²=-1.283	χ²=-2.217
P值		<0.001	<0.001	0.037	0.106	0.037	<0.001	0.200	0.027

表3 SNRA组超声指标与临床资料相关性分析

Tab.3 Correlation analysis of ultrasound indicators and clinical data in the SNRA group

	GS1		PD1		BE分级		GS2		PD2
	r值	P值	r值	P值	r值	P值	r值	P值	r值	P值
CRP	0.366	0.013	0.444	0.002	0.539	0.003	0.732	<0.01	0.772	<0.01
ESR	0.306	0.041	0.384	0.009	0.290	0.127	0.532	<0.01	0.538	<0.01
病程	-0.104	0.497	-0.103	0.502	-0.063	0.745	-0.161	0.290	-0.055	0.721

图3 两组关节GS、PD、BE分级比较注:***为P<0.01

Fig.3 Comparison of GS, PD, and BE grading in joints between the two groups

图4 关节滑膜、肌腱GS、PD评分对SNRA的诊断效能的ROC曲线

Fig.4 ROC curve analysis of the diagnostic efficacy of GS and PD scores for synovium and tendon in SNRA

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