手部骨關節炎:可用MRI預測病程進展


  【24drs.com】根據線上發表於9月9日風濕病學報的一篇研究,可以使用核磁共振(MRI)預測手部骨關節炎的影像檢查進展。
  
  「The Oslo Hand Osteoarthritis」是首篇運用MRI資料探討手部骨關節炎的縱向研究。
  
  第一作者、挪威奧斯陸Diakonhjemmet醫院風濕科Ida K. Haugen博士表示,藉由影像檢查,我們可以辨別病患的進展。在這篇研究中,可以從發炎、骨髓病灶、關節間隙明顯預測約5年的影像檢查進展。
  
  根據Haugen博士表示,骨關節炎不只影響軟骨,整個關節都受影響。目前在例行臨床實務上,MRI被建議用於評估手部骨關節炎,在於它可以看到整個關節,這優於其他影像檢查方式。與發炎有關的滑膜炎和軟組織腫脹,可以用臨床檢查和超音波評估,傳統的X光可以用來評估關節間隙狹窄,但是,只有MRI可以看見骨髓病灶。
  
  迄今的多數研究都是在探討膝蓋骨關節炎,科學家們對手部骨關節炎所知有限。Haugen博士指出,「The Oslo Hand Osteoarthritis」是重要的研究,因為增加了我們對於手部骨關節炎的病程風險因素與自然史的瞭解。
  
  Haugen博士強調,不幸的是,目前沒有疾病修飾療法,因此是用症狀修飾療法治療患者,效果相當有限,所以必須進行後續研究探討是否使用非炎性藥物治療滑膜炎會導致比較少的影像檢查進展。
  
  Haugen博士等人追蹤74名研究對象5年,他們的平均年齡為67.9歲,且研究開始時(2008-2009年間)和追蹤時(2013年)都有慣用手的MRI資料與雙手的X光資料,研究者探討三方面的影像檢查進展:以關節間隙狹窄測量軟骨流失,以Kellgren-Lawrence分數代表整體骨關節炎嚴重度之增加情況,發生新的關節侵蝕。
  
  作者們指出,只有一位判讀員評估這些MRI資料,這可能使研究受限,不過,這位判讀員對於臨床與其他影像資訊皆不知情,此外,研究者使用前手X光資料,可能會低估了骨關節炎進展的量。
  
  超過50%的研究對象有嚴重的手部骨關節炎,56.8%有侵蝕性病灶。開始時無侵蝕性病灶者,後來有9.1%發生侵蝕性病灶。開始時關節間隙狹窄者中,17.0%在追蹤時顯示有影像檢查進展;開始時有骨髓病灶者中,24.1% 顯示有影像檢查進展。
  
  研究結果認為,關節處的發炎和機械壓力都對手部骨關節炎的進展有影響,在開始時以MRI發現滑膜炎(勝算比[OR],3.52;95%信心區間[CI],1.29 - 9.59)、骨髓病灶(OR,2.73;95% CI,1.29 - 5.78)和關節間隙狹窄(OR,11.05;95% CI,3.22 - 37.90)可預測關節間隙狹窄之進展。Kellgren-Lawrence分數增加和發生新的關節侵蝕依循類似的模式,關節失準和發生新的關節侵蝕之關聯性最強(OR,10.18;95% CI,2.01 - 51.64)。
  
  Gregory Middleton醫師表示,雖然這篇研究支持使用MRI作為研究工具,但研究結果對於臨床實務可能沒有影響。Middleton醫師是加州大學聖地牙哥分校骨外科臨床醫學副教授,他未參與此次研究。
  
  Middleton醫師評論指出,這篇研究基本上確認了我們臨床已知的事項,原本病況較差的病患,後來的病況也會比較差。
  
  Middleton醫師結論表示,不幸的是,迄今的研究並未顯示治療手部骨關節炎之任何效益,Middleton醫師不會建議將手部MRI作為臨床實務工具,因為目前還無法改變那些有風險者的疾病病程。
  
  資料來源:http://www.24drs.com/professional/list/content.asp?x_idno=7116&x_classno=0&x_chkdelpoint=Y
  

Hand Osteoarthritis: MRI Predicts Progression

By Veronica Hackethal, MD
Medscape Medical News

Magnetic resonance imaging (MRI) findings can be used to predict radiographic progression of hand osteoarthritis, according to a study published online September 9 in the Annals of Rheumatic Diseases.

The Oslo Hand Osteoarthritis cohort is the first longitudinal study that has used MRI data to study hand osteoarthritis.

"With imaging modalities, we were able to identify patients who are most likely to progress. In our study, inflammation, bone marrow lesions, and joint space narrowing could significantly predict radiographic progression over 5 years," first author Ida K. Haugen, MD, PhD, from the Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway, told Medscape Medical News.

Osteoarthritis is thought to affect the whole joint, not just the cartilage, according to Dr. Haugen. MRI, which is not currently recommended for evaluating hand osteoarthritis in routine clinical practice, has the advantage over other imaging modalities of visualizing the whole joint, she added. Synovitis and soft tissue swelling associated with inflammation can be assessed on clinical exam and with ultrasound. Conventional X-rays can be used to evaluate joint space narrowing. But only MRI can visualize bone marrow lesions, according to Dr. Haugen.

Most research to date has looked at osteoarthritis of the knees, and scientists have limited knowledge about osteoarthritis of the hands. The Oslo Hand Osteoarthritis Cohort study is "important," Dr. Haugen pointed out, because it will add to our knowledge about the natural history and risk factors for disease progression in hand osteoarthritis.

"Unfortunately, no disease-modifying treatment is available, and patients are therefore treated with symptom-modifying treatment with little to moderate effect, if any," Dr. Haugen emphasized. "Future studies are needed in order to explore whether treating synovitis with noninflammatory drugs, for example, leads to less radiographic progression."

Dr. Haugen and colleagues followed 74 participants for 5 years. Included participants had a mean age of 67.9 years and had data available for MRI of the dominant hand and bilateral hand X-rays at baseline (between 2008 and 2009) and at follow-up (2013). The researchers looked at 3 aspects of radiographic progression: joint space narrowing as a measure of cartilage loss, Kellgren-Lawrence scores as an indication of increasing overall osteoarthritis severity, and development of new joint erosions.

Only a single reader evaluated the MRI data, which could have limited the study. The reader, however, was blinded to clinical and other imaging information, the authors note. In addition, researchers used frontal hand X-rays, which could underestimate the amount of osteoarthritis progression.

More than 50% of participants had severe hand osteoarthritis, and 56.8% had erosive disease. Erosions developed in 9.1% of those without erosions at baseline. Of participants with joint space narrowing at baseline, 17.0% showed radiographic progression on follow-up. Among those with bone marrow lesions at baseline, 24.1% showed radiographic progression.

The results suggest that both inflammation and mechanical stresses on the joint play a role in the progression of hand osteoarthritis. MRI visualization at baseline of synovitis (odds ratio [OR], 3.52; 95% confidence interval [CI], 1.29 - 9.59), bone marrow lesions (OR, 2.73; 95% CI, 1.29 - 5.78), and joint space narrowing (OR, 11.05; 95% CI, 3.22 - 37.90) predicted progression of joint space narrowing. Increasing Kellgren scores and development of new joint erosions followed a similar pattern. Malalignment had the "strongest" association in the case of new joint erosions (OR, 10.18; 95% CI, 2.01 - 51.64).

Although the study provides support for using MRI as a research tool, its results will likely have "zero effect on clinical practice," Gregory Middleton, MD, told Medscape Medical News. Dr. Middleton is a rheumatologist and associate clinical professor of medicine in the Department of Orthopaedic Surgery at the University of California, San Diego. He was not involved with the study.

"This study basically confirms what we know clinically," Dr. Middleton commented. "Patients with worse disease at baseline have worse disease in the future."

"Unfortunately, studies to date have not shown any benefit of treating the inflammation in hand osteoarthritis," Dr. Middleton concluded. "I would not recommend hand MRI as a clinical practice tool, since we cannot yet alter the course of the disease of those most at risk."

The authors and Dr. Middleton have disclosed no relevant financial relationships.

Ann Rheum Dis. Published online September 9, 2014.

    
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