A case of rheumatoid arthritis with cervical vertebral disease as its first diagnosis

Rheumatoid arthritis (rheumatoid arthritis, RA) is a chronic, systemic inflammatory disease characterized by polyarthritis in the surrounding joints, the most common effect of which is the joints of the hand and footIn addition, the cervical vertebrae are also often affected by RA, its incidence rate of about 80%, second only to the hands and feetNevertheless, the atypical RA concurrent cervical vertebral disease, and the symptoms of typical cervical vertebral disease are rare in clinical lysis, so they are often neglected, and therefore prone to misdiagnosis or missed diagnosisThe first case of rheumatoid arthritis, which will be treated in our hospital, is reported below, with a view to raising awareness and vigilance of the disease1Medical history, female, 56 years old, with "repeated neck and shoulder and upper limb pain for 3 years, then 2 months, aggravated by 2 weeks" on December 10, 2018 admitted to the hospitalPatients 3 years ago no obvious cause of neck and shoulder and double upper limb pain, in the local hospital intermittent oral analgesic sashimi drug "depain tablets, etc" treatment, pain relief slightlyPatients in 2 months ago due to fatigue after the neck and shoulderback and double upper limb pain, sore, occasionally dizzy and foot on cotton, no nausea, vomiting, rest after a little reliefHe was hospitalized in a hospital, diagnosed as "cervical vertebral disease", to acupuncture, small needle knife, scraping and other treatment, after treatment pain no reliefthe symptoms worsened further 2 weeks ago and she went to my hospitalOutpatient snorta is admitted to the hospital with "cervical vertebral disease"Since the patient's illness, the spirit, diet and sleep is ok, no nausea, vomiting, no tinnitus, weight does not increase or decrease, size is normalPast history: six months ago due to anemia in our hospital hospital treatment, diagnosed with iron deficiency anemia, after drug treatment slightly improved2CheckT 37.00C, P 76times/min, R 20 times/min, BP119/78 mm Hg (1 mm Hg-0.133 kPa)The mind is clear, the development is normal, the nutrition is moderate, the heart and lungs are not abnormalSpecialist body check: The nRS rating of the digital evaluation scale is 8Spinal no malformation, cervical vertebral activity is limited, neck 3-7 ratchet side tender, double-sided cervical intervertebral hole extrusion test positive, double-sided arm plexus nerve pull test positive, top test positive, neck test positive, left upper limb extmort, upper lift limited, cornea Reflections, abdominal wall reflections, and reflections, biceps, triceps, tibia, knee, ankle, Babinski negative, Oppenheim negative, Chaddock negative, Gordon negative, Hoffmann negativePreliminary diagnosis: (1) cervical vertebral disease (mixed) ;( 2) cervical shoulder fascia pain syndrome;3The diagnosis and treatment processadmission to a walk biochemical examination, the total number of red blood cells 3.34x1012/L, hemoglobin 84.0 g/L, erythropoietin product 0.27, the average hemoglobin concentration of 309 g/L, the total number of platelets 374 x 1012/LAnemia three tests show: vitamin B1 500.00 pg/ml, ferritin 15.3 ug/Limaging examination:(1) chest flat: right lung calcification stove, upper chest scoliosis(2) cervical vertebrae flat: osteoporosis, cervical vertebrae 3-7 joints before the back edge see lip-like, bird's beak-like bone, cervical 3 vertebrae like small flakes low density shadow, the right side of the 3-4, 4-5 intervertebral hole stenosis, aoser calcificationDiagnosis: Cervical degenerative variable, right side 3-4, 4-5 intervertebral pore stenosis (see Figure 1)(3) cervical vertebral MRI shows: cervical spinal physiological bending exists, intervertebral joint alignment is normal, tooth burst position shift, higher than Qian's line 3 mm, mild pressure, mild cranial depression, neck 6-7 vertebral disc slightly puffed outDiagnosis: Mild cranial depression, neck 6-7 intervertebral disc expansion (see Figure 2) (4) MRI thoracic lumbar vertebrae flat sweep show: lumbar vertebral lipid composure, vertebral tube did not see stenosis (5) double-energy x-ray body bone density detection: T-2.0, bone mass reduction after admission to the hospital for the patient's neck and shoulder back pain to rely on the testxtablet tablets (etoricoxib) oral, 120 mg / time, 1 time / d; ozone self-blood transfusion, the specific operation is as follows: extract the patient's forearm elbow vein blood 250 ml, with ozone (concentration 30 ug/ml) according to a ratio of 1:1 Elbow veins re-entered in the patient, 1 time/d; nutritional nerves are taken orally with mecobalamine tablets (mecobalamine), 0.5 mg/time, 3 times/d, 3D gluvitamin and calcium calcium chewing tablets (trivitamin and calcium, calcium phosphate chewable tablet), 2 tablets/twice, 1 time/d At the same time row neck 4-6 vertebrae nerve block 3 times, the next day 1 time, the specific operation is as follows: the patient takes the seat, after measuring vital signs to the mastoid table to locate bone signs The front or rear nodules of a vertebrae are marked from the mastoid vertical downwards every 1.5 cm for the front or rear nodules of the vertebrae The skin is routinely disinfected with a 0.5% lidocaine local anaesthetic, and then a pin is used to pierce the needle in the bureau's hemp puncture pinhole When the needle touches the vertebral nodule bone reflux airless, bloodless, no fluid, and the patient has no special discomfort, the pain point injection of analgesic compound The compound liquid is 0.33% lidocain 5 ml with injection with betamethasone sodium phosphate (betamethasone sodium for phosphate) 5.26 mg/ml, diluted to 15 ml with 0.9% sodium chloride injection simultaneous shock wave treatment, 1 time per week, the specific operation is as follows: the patient takes the seat, fully exposed neck and shoulder and marks the pain area, give shock wave treatment, the number of shock s3,000 times, frequency 8 Hz, pressure 200 kPa Small needle knife treatment, the specific operation is as follows: the patient takes the seat, disinfection towel, takes the left neck shoulder pain point 6 points, the local anesthesia vertical needle touch bone, vertical vertical cross peeling each 3 knife, the operation of the knife, the operation smoothly Deep neck heat therapy, the specific operation is as follows: the patient takes the head sitting position, exposed the neck, will be infrared light on the neck area, lasting 20 min Various operations are carried out at different times, its treatment procedure is, neck deep heat therapy 1 time / d neck 4-6 vertebrae nerve block 1 time / 2d a shock wave 1 time, week, ozone self-blood transfusion 1 / d, shock wave 1 time / Monday small needle knife basically alleviated back pain in the neck and shoulder after the above treatment After 1 week of hospitalization, the patient complained of limited mobility in part of his limbs, and asked for medical history to complain of morning stiffness and weakness of his or her limbs four years ago Further examination found that the small joints of his limbs were slightly deformed, and the ankle back movement was obviously limited Further examination, biochemical examination found: red blood cell deposition rate (blood sinking) 58 mm/h, C one-reactive protein (CRP) 17.00 mg/L, anti-cyclanine peptide antibody (Anti-CCP) 500.00 U/ml, rheumatoid factor (-), anti-nuclear antibody spectrum (-) imaging examination: (1) double ankle MRI: bipedal bone hyperplial hardening of the bone edge, joint surface multiple patch slightly longer T1, T2 signal, part of the joint surface blurry, double-sided ankle gap multiple long T1, long T 2 signal; double foot, ankle slide film thickening; intraankle tricial, aphrite, adhexatox, a small amount of water-like signal around the pre-femur, later ligament and fibula tendon; the soft tissue around the bilateral foot and ankle joint sees the flaky long T2 signal Diagnosis: Bipedal small joint degenerative change with bone marrow edema; double foot, ankle slide membrane thickening; multiple joint sacs and tendon fluid; soft tissue edema around the foot and ankle (see Figure 3) (2) hands flat: the two hands composed of bone density reduction, right wrist moon bone see round low density shadow, the joint bone hyperplasia of the hands, hardening, no abnormality, joint gap did not see narrow, surrounding tissue did not see significant swelling Diagnosis: The degenerative change son of the hands (see Figure 4) (3) electromyography: No obvious abnormality was observed in the induced potential of the double lower limb diagnosed with rheumatoid arthritis based on symptoms, signs and imaging Has invited the hospital hematology, renal rheumatology department consultation to the right-hand caricature iron dispersal tablet (iron dextran tablet) 50 mg oral, 3 times / d; (methotrexate tablet) 5 mg oral, 1 time/week; folic acid tablet sic 5 mg oral, 1 time/week; hydroxychloroquine 200 mg oral, 2 times/d After the above-mentioned anti-inflammatory, pain relief treatment 15 d, anti-rheumatism treatment 6 d after the back of the neck shoulder back pain symptoms significantly alleviated, ankle pain, swelling reduction, NRS score of 3 , the infrared thermal imaging evaluation report showed that after treatment, the right ankle saw a point of mass metabolic temperature increase, cervical vertebrae see the metabolic temperature increase, radiation to the left shoulder; Thermal imaging assessment suggests: cervical vertebral disease, cervical disc protrusion, double ankle arthritis, see Figure 5 Among them, figure (1) and figure (2) show that the metabolic skin temperature of the patient's neck and shoulder increased, the figure (3) shows that the metabolic skin temperature of the back of the patient's back increased significantly, the right side is higher than the left, and the figure (5) shows that the metabolic skin temperature of the two-sided ankle is increased, and the right side is significantly higher than the left Although the infrared imaging report suggested that the metabolic skin temperature in the back of the neck and shoulders and ankles increased after treatment, after anti-RA treatment, the pain in the neck and shoulders and ankles was more pronounced before anti-RA treatment