齿状突加冠综合征（crowned dens syndrome, CDS）由于发病率较低，通常容易被临床低估。CDS以急性颈项部疼痛、颈椎僵硬不适、发热等为主要症状，实验室检查显示C反应蛋白（C-reactive protein, CRP）与血沉（erythrocyte sedimentation rate, ESR）明显升高。CT是诊断CDS的金标准，但其临床文献报道较少，CDS的诊断尚无统一的循证医学证据，容易误诊。本文报道了中西医结合治疗CDS患者1例，治疗效果显著，可为临床提供新的诊疗思路。

齿状突加冠综合征（crowned dens syndrome, CDS）是由于颈椎齿状突周围韧带及软组织的异常钙盐沉积导致，CT表现为齿状突高密度影，后侧多发，形似“皇冠”[1]。流行病学调查显示，通常老年女性多发CDS。目前对于CDS的诊断尚无统一的循证医学证据，且由于临床发病率较低，报道较少，主要临床表现为急性头颈部疼痛伴活动受限，同时伴有不明原因的发热等症状，这与许多疾病症状相似，容易误诊[2]。既往研究显示，CDS通常预后良好[3-5]。2023年5月，甘肃省中医院脊柱骨一科收治一名CDS患者，现报道如下。

1 临床资料

患者，女，61岁，因颈部疼痛不适伴活动受限1月余，加重1周，自行口服甲钴胺胶囊后未见明显好转，来我科门诊就诊。自发病以来，患者自感颈部针刺样疼痛，颈部活动时上述症状加重，无头晕、视物昏花、双上肢皮肤感觉异常等不适症状，遂以“颈椎病待查”收治入院。患者既往有高血压病史15年，口服硝苯地平缓释片，每日1次，一次1片，血压控制良好，无冠心病、肺气肿、胃溃疡病史，无手术外伤史。入院后体格检查：体温36.8℃，血压138/75 mmHg，呼吸20次/分，脉搏75次/分。专科检查：颈椎（C2-C7）棘突、椎旁压痛（+），双侧臂丛神经牵拉实验（-），四肢肌张力正常，四肢肌力V级，四肢皮肤感觉未见异常，肱二头肌反射、桡骨膜反射双侧对称引出，病理反射未引出，颈椎疼痛视觉模拟评分（visual analogue scale, VAS）7分。实验室检查：白细胞（white blood cell, WBC）11.08×10⁹ L^-1，中性粒细胞8.64×10⁹ L^-1，血沉（erythrocyte sedimentation rate, ESR）30 mm/h，凝血酶原时间测定（TT）22.70 sec，C反应蛋白（C-reactive protein, CRP）12.8 mg/L，其余指标均在正常范围。影像学检查：颈椎张口正侧位DR显示，颈椎椎体序列如常，生理曲度变直，C3-C6椎体缘骨质增生，椎间隙适度，寰齿寰枢间隙基本对称，见图1；颈椎CT平扫显示，颈椎序列如常，曲度直，寰齿间隙左右基本对称，C3-C6颈椎间盘突出，脊椎受压，椎管大小形态正常，齿状突上缘可见弧形高密度影，见图2；颈椎MRI显示，C3-C6颈椎间盘变形性，后突出，颈椎退行性改变。综合上述检查，患者被诊断为CDS。

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  图1 颈椎DR（正侧位）

  Figure 1.Cervical spine DR (anterolateral view)

  注：a. 寰齿间隙基本对称；b. 生理曲度变直。

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  图2 颈椎CT平扫

  Figure 2.Noncontrast CT scan of the cervical spine

  注：c. 矢状位弧形高密度影；d、e. 冠状位齿状突高密度影。

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患者采用中西医结合保守治疗，颈椎颈托制动，口服COX-2抑制剂塞来昔布胶囊200 mg/d，地塞米松5 mg，静脉滴注，每日1次，共用5天。患者入院中医四诊合参，观患者面色苍白、食欲不振、体倦乏力、少气懒言、疼痛不移状如针刺、舌淡有点状瘀斑、脉涩缓，证属气虚血瘀证，治当补气活血、通络止痛，给予自拟方：当归20 g、川芎15 g、羌活15 g、黄芪40 g、麸炒苍术15 g、赤芍20 g、秦艽15 g、葛根20 g、姜黄15 g、细辛5 g、苏木20 g、桂枝6 g、红花5 g、丹参10 g、茯苓20 g、生姜8 g、大枣5 g，共7剂，每日2服，饭后服用，同时配合甘肃省中医院院内制剂舒筋活络洗剂（桑枝、伸筋草、苍术、当归、红花等）颈部热敷，用法：取上述洗剂药包于锅中，清水覆盖，煮沸，取黄酒150 mL，加锅盖焖煮5 min，取药包毛巾覆盖6层，热敷于颈下，治疗30 min，每日2次。治疗7天后，患者自感颈部疼痛等不适症状明显缓解，颈部活动度趋于正常，再次行实验室检查：WBC 8.65×10⁹ L^-1，中性粒细胞4.33×10⁹ L^-1，ESR 20.1 mm/h，CRP 11.4 mg/L。患者治疗有效，遂出院继续按照此治疗方案治疗7天后停药，1个月后门诊随访时，患者自诉颈肩部不适症状消失，生活质量有所提高，患者治疗过程中相关指标见表1。

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  表格1 患者治疗相关指标

  Table 1.Relevant indicators of treatment of the patient

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2 讨论

CDS的发病机制目前尚不明确，国际上学者们一致认为CDS是由于焦磷酸钙的异常沉积造成[6-9]。CDS临床报道相对较少，由于临床诊断依据的缺乏，CT检查成为诊断CDS的金标准[10-24]。CDS的主要临床表现为急性颈部疼痛伴活动受限、不明原因发热，严重者可出现偏瘫或感觉异常[25]。颈椎病、脑膜炎、颈椎脱位、脊髓血管及炎性病变、痛风、风湿病等多种疾病均可导致上述症状，若不加以鉴别容易误诊，对此计算机断层扫描可发挥重要作用，针对CDS临床上要综合考虑，避免有创性诊断[26-29]。

目前CDS的常用治疗药物包括非甾体类抗炎药、皮质类固醇、秋水仙碱等，其中非甾体类抗炎药是CDS的首选治疗药物，研究表明非甾体类抗炎药对CDS有较好的治疗效果[24, 30-31]。皮质类固醇药物常与非甾体类抗炎药联合使用，用于治疗因CDS引起的急性疼痛，但此类药物不可长期使用，以免引起严重并发症，如激素性股骨头坏死、免疫抑制等。对于单用非甾体类抗炎药、非甾体类抗炎药与皮质类固醇药物联合使用效果不明显及顽固性疼痛的CDS患者，可使用秋水仙碱治疗[32-34]。

CDS的临床表现主要为颈肩部疼痛、僵硬不适、发热等，与中医学中的“项痹”一致，其基本病机为外邪、劳损、体虚[35]。《内经》曰：“所谓痹者，各以其时，重感于风寒湿之气也”，指出项痹的主要致病因素为风邪、寒邪、湿邪，治法应为祛风散寒除湿[36]。张仲景在《伤寒论》和《金匮要略》中对太阳风湿、湿痹、历节风进行了辨证论治，桂枝附子汤、桂枝芍药知母汤、乌头汤等至今仍为治痹的常用效方[37]。《伤寒论》中记载：“太阳病，项背强几几，无汗恶风，葛根汤主之。”“太阳病，项背强几几，反汗出恶风者，桂枝加葛根汤主之。”[38]。葛根增液舒筋、祛风通络，桂枝散寒止痛、助阳化气，羌活散寒通络止痛，三药同入膀胱经。且根据经络学说，颈部为足太阳膀胱经与督脉所过，体现了中药归经理论。长期低头伏案工作，易导致颈部筋骨劳损，局部经脉气血运行不畅，气滞血瘀，不通则痛，法当行气通络止痛。在该病例自拟方中，川芎行气活血，秦艽活血舒经，姜黄行气破淤，苏木、丹参、红花活血化瘀。本例中患者为老年女性，因脏腑功能减退，气血生化无力，水谷精微无法濡养筋骨肌肉，不荣则痛，法当益气养血，和营止痛，黄芪健脾益气，当归补血活血，苍术、茯苓燥湿健脾，生姜、大枣补益心脾。

综上，目前CDS临床报道较少，容易被误诊或漏诊，对于急性颈部疼痛不适伴活动受限、发热的患者需注意鉴别诊断，颈椎CT是诊断CDS的金标准，应尽早诊断和治疗，避免不必要的有创性诊疗。本例中西医结合治疗CDS效果显著，且预后良好，可为临床提供新的诊疗思路。

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