3讨论
MS是一种青壮年时期的中枢神经系统脱髓鞘疾病,多发病灶,病程中常有缓解与复发,起病急、病程短、青壮年女性多见。相当一部分视神经炎最后发展为MS。我们持续3a的研究中有12%的视神经炎患者最终被诊断为MS(其中大部分脊髓型),这一结果与蓝育青等[3]的研究结果相似。在西方Beck等[4]研究发现在视神经炎发病10a内约有38%发展为MS。Rizzo等[5]研究发现在视神经炎发病15a内,约有58%发展为MS。Nilsson等[6]在追踪研究86例视神经炎31a后发现其中有34例最终确诊为MS。我们的研究的病例从视神经炎的发生到确诊为MS时间最长为3.5a。Nilsson等[6]研究的34例中有20例是在视神经炎发病3a内发生的,有33例是18a内发生的。我们的研究在视神经炎和MS中都未发现性别差异,这与Rodriguez[7]和Ghezzi[8]的研究结果一致,但Beck[4]得出的结论却是男性患者的危险性低。年龄方面多数认为本病为青壮年多见[9],但老年人发病也常有报道[1012]。本研究中就有一位高达62岁,其先为单眼视力障碍就诊,42mo后,即66岁时出现右侧肢体无力,检查脊髓MR发现脊髓中央管扩张而确诊。在本研究中单眼或双眼发病似乎与MS的发生并无关联,相关研究在这方面是有争议的。Hutchinson等[13]发现双侧同时发病或在2wk内先后累及两眼的患者发生多发性硬化的可能性增加了,但Redriguez[14]未观察到同样结果。本研究发现眼球周围疼痛更多发生在发展为MS的视神经炎中,但无统计学差异。西方的一些研究[4,15]则表明眼球周围疼痛是视神经炎发展为MS的一个危险因素。文献报道出现严重视盘水肿和视力降至无光感的视神经炎不易发展为MS[4],我们未能得出相同结论。我们的研究中MS患者视神经炎的复发率较高,6例中有3例复发,另一组45例中有2例复发。这与Redriguez等[14]的研究结果一致。血沉的改变是很少文献提到的指标,我们发现行血沉检查的3例MS患者均在正常范围,而另一组却有高于正常26%,且这部分患者均没有复发。这可能意味着他们的视神经炎由感染等其他因素引起的可能性更大。文献报道MRI对判断本病的意义较大[1619],但由于经济等原因,我们的患者多数只检查了头颅CT,发现筛窦炎性囊肿1例,其余结果全部都正常。MS的患者中头颅MRI发现问题只1例,却有4例脊髓MRI发现病灶,另有1例出现双下肢功能障碍,行头颅MRI检查未见异常,但未行脊髓MRI检查。这说明我们的MS患者多为脊髓型(也有人诊断为视神经脊髓炎)[20]。鉴于以上情况,我们建议对我国的视神经炎患者尽量行头颅MRI而非CT检查,条件允许时行脊髓MRI检查[21]。
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