腰椎滑脱合并单侧关节突关节痛风石沉积1例

2020-07-30 任之强 何升华 张秀芳 脊柱外科杂志

痛风是嘌呤代谢障碍引起的代谢性疾病,尿酸盐结晶沉积于软组织形成痛风石,多数累及全身肢体末端关节,也可侵犯脊柱。脊柱痛风可发于椎间隙、椎管、关节突等组织,颈椎、胸椎、腰椎均可受累,其中发于腰椎者最为常见

痛风是嘌呤代谢障碍引起的代谢性疾病,尿酸盐结晶沉积于软组织形成痛风石,多数累及全身肢体末端关节,也可侵犯脊柱。脊柱痛风可发于椎间隙、椎管、关节突等组织,颈椎、胸椎、腰椎均可受累,其中发于腰椎者最为常见(56%),胸椎次之,颈椎少见。2019年2月,本院收治1例因腰痛、左下肢疼痛入院患者,确诊为L4椎体Ⅰ度前滑脱并左侧关节突关节痛风石沉积,经手术治疗后症状明显缓解,现将诊疗过程报告如下。

病例资料

患者,男,49岁,因腰痛10年、左下肢疼痛3个月入院。既往有痛风病史10余年,间断口服苯溴马隆及非甾体抗炎药物,尿酸控制不佳,痛风先后侵犯第1跖趾关节、双膝关节、左腕关节。入院时患者右手中指可见痛风石沉积(图1a),主诉腰痛,右侧为甚,屈伸活动困难;左下肢放射痛,右膝关节疼痛,活动受限。查体:下腰椎压痛、叩击痛阳性,右侧重于左侧,腰椎前凸增加,臀部后凸;右膝红肿,局部皮温升高;左下肢胫前肌及第一足趾背伸肌肌力减弱(4级),左下肢直腿抬高试验阳性(40°),左侧膝跳反射减弱,双下肢肌力、感觉、腱反射检查未见异常。实验室检查:C反应蛋白(CRP)0.7mg/L、红血胞沉降率(ESR)4mm/h、尿酸605μmol/L;白细胞计数9.47×109/L、中性粒细胞计数5.84×109/L。影像学检查:CT示L4椎体双侧椎弓峡部裂(图1b、c);动力位X线片示L4/L5椎间不稳,L4椎体向前滑脱(图1d、e);MRI示L4/L5椎间盘向后突出,相应水平硬膜囊受压(图1f~g),L4/L5右侧关节突关节T2WI信号增高(图1h);右膝关节双能双源CT示关节腔内大量痛风石沉积(图1i)。肌电图示左下肢神经源性损伤电生理改变,累及L4,5神经根为主。疼痛视觉模拟量表(VAS)评分右侧腰痛6分,左下肢疼痛3分。入院前在当地社区康复医院行口服止痛药、针灸、理疗等非手术治疗3周,效果不佳。患者入院后继续非手术治疗,疼痛仍无明显缓解,故要求手术治疗。术前完善相关检查,在全身麻醉下行L4/L5椎间盘切除减压、椎体滑脱复位、椎间植骨融合、椎弓根螺钉内固定术。术中去除L4右侧下关节突时发现关节突关节面广泛白色沙砾状异物沉积(图1j),左侧未发现异物沉积(图1k)。白色沙砾状异物送病理检查,结果示局部炎性细胞浸润、软组织周围有点状钙化灶,符合痛风改变(图1l)。术后患者低嘌呤饮食,给予抗炎、促进尿酸排泄等治疗;第2天佩戴腰部支具下床活动;术后3dX线片示滑脱复位满意(图1m、n),腰痛及左下肢疼痛明显缓解。术后8个月电话随访,患者腰痛及左下肢疼痛消失,VAS评分右侧腰痛2分,左下肢疼痛0分,恢复正常工作生活,继续口服苯溴马隆治疗痛风,尿酸控制良好。





讨论

脊柱痛风主要是由于长期高尿酸血症未得到有效控制引起。据统计,35%的脊柱痛风患者痛风病史超过3年。Jegapragasan等认为,对于久治不愈的腰背痛患者,有痛风病史,特别是体格检查时发现皮肤或关节有痛风结节时,应考虑痛风性脊柱炎可能;本例患者入院时主诉腰痛及左下肢放射痛,临床表现缺乏典型性,这与文献报道脊柱痛风患者临床表现缺乏特异性相一致。患者入院时右侧腰痛为甚,术中发现痛风石沉积于右侧关节突关节,左侧未发现痛风石组织,可部分解释右侧腰痛症状重于左侧的临床表现。本例患者有痛风病史10余年,入院见中指痛风石沉积,术中见关节突关节痛风石沉积,病理证实为痛风结晶。因此,当慢性腰背痛患者既往有较长的痛风病史,又有相应痛风体征时,应考虑脊柱痛风的可能。

有文献报道,当尿酸盐侵袭脊柱关节时,脊柱各个部位均可受到侵犯,包括椎体、椎间盘、关节突、韧带及硬膜外组织等,其中关节突关节率先受到侵蚀。尿酸盐首先沉积于滑囊,造成滑囊炎,引起腰背痛,随后逐渐侵蚀关节面及椎体其他部分进而导致脊柱失稳,甚至造成退行性滑脱。有研究显示,当痛风累及关节突关节时,可造成关节囊炎性反应,并对韧带、关节及骨质造成破坏,导致节段不稳。此外,根据生物力学分析,下腰椎是人体承重的重要部位,当关节突关节因痛风石沉积破坏时,容易导致脊柱的稳定性破坏。腰椎滑脱合并关节突关节痛风石沉积的机制目前尚不明确。Bonaldi等的研究指出,脊柱痛风的发生与脊柱的退行性变密切相关,由于在脊柱各部位当中,腰椎负重最大,最先发生退行性变,因而腰椎发生痛风的概率远高于颈椎和胸椎。谭小云等的研究发现,腰椎关节突关节相比其他部位血液供应较差,关节突关节局部血供障碍可能是导致脊柱痛风好发于关节突关节的潜在原因。此外,俞娟等的研究进一步发现,关节突关节局部pH值偏低,表明该处内环境偏酸性,酸性环境有利于尿酸盐溶解沉积,部分解释了为何尿酸盐首先沉积于关节突关节。Chang的研究也同样发现关节液的pH值较低,因而导致血液中的尿酸盐容易最先沉积于关节突关节。

目前,脊柱痛风的诊断离不开临床症状、体征、实验室及影像学检查的支持,但诊断的金标准仍然有赖于组织病理学检查。实验室检查方面,绝大部分患者均伴有血尿酸异常升高。影像学检查(X线、CT及MRI)对脊柱痛风的诊断均缺乏特异性。病变早期X线检查表现多为阴性,中晚期时X线及CT检查可显示受累椎体及小关节穿凿或不规则状骨质破坏。MRI在诊断脊柱痛风上具有较高的灵敏性,但特异性不强,有文献报道,沉积于脊柱的尿酸盐结晶组织在T1WI上表现为中等或低信号,在T2WI上往往表现为高信号,增强MRI为不均匀的增强信号。本例患者MRI示右侧关节突关节T2WI信号增高,左侧关节突关节信号正常,术中去除双侧关节突关节时发现右侧关节突关节面痛风石沉积,左侧未见痛风石,术前MRI表现与术中探查结果一致。本例患者椎体及关节突未见骨质破坏,可能与痛风石沉积时间不长、尚未对骨质造成破坏有关。

综上,脊柱痛风的影像学表现复杂,缺乏特异性,难以确诊脊柱痛风。双能双源CT确诊痛风的灵敏度可达91.9%、特异度为85.4%,其工作原理主要以原子数衰减为基础,由于钙的原子数比尿酸盐高,在衰减时有更大的能量变化,该能量衰减上的差异通过计算机直接转化为不同的CT值,最终输出显示为尿酸盐(绿光)和钙盐(紫光),从而准确区分定性尿酸盐结晶。由于其不但能清晰显示痛风结晶,还能确定尿酸盐沉积部位,被认为是最具潜力的痛风筛查工具。本例患者由于入院主诉腰痛及左下肢放射痛,结合术前影像学检查,考虑L4/L5椎间盘突出及滑脱是腰腿痛主要原因,故未对患者痛风性脊柱炎诊断引起足够重视,忽略了术前腰椎双能双源CT检查。本例患者术前行膝关节双能双源CT检查,明确关节腔大量痛风石沉积,或对痛风性脊柱炎的诊断具有一定的提示价值。在接诊脊柱疾病患者时,对于既往有痛风病史或存在外观可见的痛风石沉积或四肢关节双能双源CT明确有痛风石沉积者,应引起临床医师对痛风性脊柱炎诊断的高度重视。

目前对于无神经损伤症状的痛风性脊柱炎患者一般采用非手术治疗,包括低嘌呤饮食和药物治疗(秋水仙碱、非甾体抗炎药和糖皮质激素),并注意避免诱发因素等。当患者出现明显的脊髓和神经根受压并引起相应临床症状时,应首选手术治疗,通过手术减压、清除痛风石、融合内固定重建脊柱的稳定性。焦根龙等认为,对于确诊为痛风性脊柱炎且影像学显示骨质明显破坏伴随神经压迫症状者,应尽快手术治疗,保护神经功能。由于痛风性脊柱炎病例临床少见,目前文献仅见于散在的个案报道当中,且单纯通过临床症状、体征、影像学表现及实验室检查难以确诊,临床确诊通常依赖术中探查发现痛风石,且术后病理切片提示符合痛风样改变。Draganescu等认为,痛风性脊柱炎治疗的关键在于降低体内尿酸浓度,由于长时间高尿酸水平会加剧尿酸盐的沉积,因而无论是否手术,都需要系统制订降尿酸方案。邹云龙等报道1例L4椎体向后滑脱并神经压迫患者,通过手术治疗最终确诊为L4/L5痛风性椎间盘炎,由于治疗及时加之术后规范的抗尿酸治疗,术后神经功能明显改善。

King等认为,腰椎痛风急性发作患者,多伴有剧烈腰痛症状,此时如果忽视降尿酸治疗而单纯止痛往往治疗效果不理想,且延误治疗有导致截瘫的风险,故应该尽早确诊和治疗。Dh?te等也强调早期药物治疗对于痛风性脊柱炎的重要性,通过长期规范的降尿酸治疗有望使沉积于脊柱各部位的尿酸盐结晶逐渐消失,从而避免手术治疗。笔者前期报道1例颈椎痛风性脊柱炎病例,予以手术治疗,术后予低嘌呤饮食、抗炎、促尿酸排泄等治疗,患者颈痛及右上肢疼痛明显缓解,效果良好。腰椎痛风性脊柱炎临床表现不典型、实验室及影像学检查缺乏特异性,临床不易确诊。长期的尿酸盐侵蚀将导致椎体关节骨质破坏,引发椎体不稳,甚至出现痛风石压迫脊髓神经根,有导致患者截瘫的风险。故临床医师应对痛风性脊柱炎的诊断引起足够重视,术前行脊柱双能双源CT检查有利于早期诊断,术中探查发现白色沙砾样物质时应高度怀疑尿酸盐结晶并尽快送病理检查,有助于确诊。回顾以往个案报道,大部分痛风性脊柱炎均采取手术治疗,手术能够充分减压并重建脊柱稳定性,效果理想。术后结合饮食、药物等规范抗痛风治疗多可获得满意的疗效。

原始出处:

任之强,何升华,张秀芳.腰椎滑脱合并单侧关节突关节痛风石沉积_1例报告并文献复习[J].脊柱外科杂志,2020,18(03):213-216.

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#插入话题
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  2. [GetPortalCommentsPageByObjectIdResponse(id=2018338, encodeId=1794201833856, content=<a href='/topic/show?id=698b301313d' target=_blank style='color:#2F92EE;'>#关节突#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=30131, encryptionId=698b301313d, topicName=关节突)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d784426, createdName=isabellayj, createdTime=Mon Nov 30 03:46:05 CST 2020, time=2020-11-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=892759, encodeId=3c70892e598e, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=90, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=db295214726, createdName=14769249m80暂无昵称, createdTime=Sun Oct 18 08:13:53 CST 2020, time=2020-10-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=805876, encodeId=77408058e696, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=107, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200730/0796f7e875f34e9fa3ee1d7b9da19c2b/711d476a19144354a05a422d24d495ec.jpg, createdBy=2d425268433, createdName=新斯的明, createdTime=Mon Aug 03 09:23:38 CST 2020, time=2020-08-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1272145, encodeId=da8012e214544, content=<a href='/topic/show?id=cd1a854340b' target=_blank style='color:#2F92EE;'>#腰椎#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=85434, encryptionId=cd1a854340b, topicName=腰椎)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e93e105, createdName=anminleiryan, createdTime=Sat Aug 01 01:46:05 CST 2020, time=2020-08-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1316101, encodeId=ae2c1316101b0, content=<a href='/topic/show?id=c573e1174d0' target=_blank style='color:#2F92EE;'>#痛风石#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=71174, encryptionId=c573e1174d0, topicName=痛风石)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=cfab443, createdName=saikp, createdTime=Sat Aug 01 01:46:05 CST 2020, time=2020-08-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1560107, encodeId=3786156010ed6, content=<a href='/topic/show?id=41d9301263d' target=_blank style='color:#2F92EE;'>#关节痛#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=30126, encryptionId=41d9301263d, topicName=关节痛)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=c04e15069172, createdName=zhao4621, createdTime=Sat Aug 01 01:46:05 CST 2020, time=2020-08-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1566116, encodeId=5bc5156611663, content=<a href='/topic/show?id=41d9301263d' target=_blank style='color:#2F92EE;'>#关节痛#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=30126, encryptionId=41d9301263d, topicName=关节痛)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=c04e15069172, createdName=zhao4621, createdTime=Sat Aug 01 01:46:05 CST 2020, time=2020-08-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=805173, encodeId=b8f68051e33b, content=<a href='/topic/show?id=23e3454e353' target=_blank style='color:#2F92EE;'>#学习#</a>学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=422, replyNumber=1, topicName=null, topicId=null, topicList=[TopicDto(id=45473, encryptionId=23e3454e353, topicName=学习)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a3ed5316682, createdName=1489c3c7m62暂无昵称, createdTime=Thu Jul 30 11:17:40 CST 2020, time=2020-07-30, status=1, ipAttribution=)]
    2020-10-18 14769249m80暂无昵称

    学习了

    0

  3. [GetPortalCommentsPageByObjectIdResponse(id=2018338, encodeId=1794201833856, content=<a href='/topic/show?id=698b301313d' target=_blank style='color:#2F92EE;'>#关节突#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=30131, encryptionId=698b301313d, topicName=关节突)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d784426, createdName=isabellayj, createdTime=Mon Nov 30 03:46:05 CST 2020, time=2020-11-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=892759, encodeId=3c70892e598e, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=90, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=db295214726, createdName=14769249m80暂无昵称, createdTime=Sun Oct 18 08:13:53 CST 2020, time=2020-10-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=805876, encodeId=77408058e696, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=107, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200730/0796f7e875f34e9fa3ee1d7b9da19c2b/711d476a19144354a05a422d24d495ec.jpg, createdBy=2d425268433, createdName=新斯的明, createdTime=Mon Aug 03 09:23:38 CST 2020, time=2020-08-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1272145, encodeId=da8012e214544, content=<a href='/topic/show?id=cd1a854340b' target=_blank style='color:#2F92EE;'>#腰椎#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=85434, encryptionId=cd1a854340b, topicName=腰椎)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e93e105, createdName=anminleiryan, createdTime=Sat Aug 01 01:46:05 CST 2020, time=2020-08-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1316101, encodeId=ae2c1316101b0, content=<a href='/topic/show?id=c573e1174d0' target=_blank style='color:#2F92EE;'>#痛风石#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=71174, encryptionId=c573e1174d0, topicName=痛风石)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=cfab443, createdName=saikp, createdTime=Sat Aug 01 01:46:05 CST 2020, time=2020-08-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1560107, encodeId=3786156010ed6, content=<a href='/topic/show?id=41d9301263d' target=_blank style='color:#2F92EE;'>#关节痛#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=30126, encryptionId=41d9301263d, topicName=关节痛)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=c04e15069172, createdName=zhao4621, createdTime=Sat Aug 01 01:46:05 CST 2020, time=2020-08-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1566116, encodeId=5bc5156611663, content=<a href='/topic/show?id=41d9301263d' target=_blank style='color:#2F92EE;'>#关节痛#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=30126, encryptionId=41d9301263d, topicName=关节痛)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=c04e15069172, createdName=zhao4621, createdTime=Sat Aug 01 01:46:05 CST 2020, time=2020-08-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=805173, encodeId=b8f68051e33b, content=<a href='/topic/show?id=23e3454e353' target=_blank style='color:#2F92EE;'>#学习#</a>学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=422, replyNumber=1, topicName=null, topicId=null, topicList=[TopicDto(id=45473, encryptionId=23e3454e353, topicName=学习)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a3ed5316682, createdName=1489c3c7m62暂无昵称, createdTime=Thu Jul 30 11:17:40 CST 2020, time=2020-07-30, status=1, ipAttribution=)]
    2020-08-03 新斯的明

    学习了

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=2018338, encodeId=1794201833856, content=<a href='/topic/show?id=698b301313d' target=_blank style='color:#2F92EE;'>#关节突#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=30131, encryptionId=698b301313d, topicName=关节突)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d784426, createdName=isabellayj, createdTime=Mon Nov 30 03:46:05 CST 2020, time=2020-11-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=892759, encodeId=3c70892e598e, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=90, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=db295214726, createdName=14769249m80暂无昵称, createdTime=Sun Oct 18 08:13:53 CST 2020, time=2020-10-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=805876, encodeId=77408058e696, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=107, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200730/0796f7e875f34e9fa3ee1d7b9da19c2b/711d476a19144354a05a422d24d495ec.jpg, createdBy=2d425268433, createdName=新斯的明, createdTime=Mon Aug 03 09:23:38 CST 2020, time=2020-08-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1272145, encodeId=da8012e214544, content=<a href='/topic/show?id=cd1a854340b' target=_blank style='color:#2F92EE;'>#腰椎#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=85434, encryptionId=cd1a854340b, topicName=腰椎)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e93e105, createdName=anminleiryan, createdTime=Sat Aug 01 01:46:05 CST 2020, time=2020-08-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1316101, encodeId=ae2c1316101b0, content=<a href='/topic/show?id=c573e1174d0' target=_blank style='color:#2F92EE;'>#痛风石#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=71174, encryptionId=c573e1174d0, topicName=痛风石)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=cfab443, createdName=saikp, createdTime=Sat Aug 01 01:46:05 CST 2020, time=2020-08-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1560107, encodeId=3786156010ed6, content=<a href='/topic/show?id=41d9301263d' target=_blank style='color:#2F92EE;'>#关节痛#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=30126, encryptionId=41d9301263d, topicName=关节痛)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=c04e15069172, createdName=zhao4621, createdTime=Sat Aug 01 01:46:05 CST 2020, time=2020-08-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1566116, encodeId=5bc5156611663, content=<a href='/topic/show?id=41d9301263d' target=_blank style='color:#2F92EE;'>#关节痛#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=30126, encryptionId=41d9301263d, topicName=关节痛)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=c04e15069172, createdName=zhao4621, createdTime=Sat Aug 01 01:46:05 CST 2020, time=2020-08-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=805173, encodeId=b8f68051e33b, content=<a href='/topic/show?id=23e3454e353' target=_blank style='color:#2F92EE;'>#学习#</a>学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=422, replyNumber=1, topicName=null, topicId=null, topicList=[TopicDto(id=45473, encryptionId=23e3454e353, topicName=学习)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a3ed5316682, createdName=1489c3c7m62暂无昵称, createdTime=Thu Jul 30 11:17:40 CST 2020, time=2020-07-30, status=1, ipAttribution=)]
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    2020-08-01 saikp
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    2020-07-30 1489c3c7m62暂无昵称

    #学习#学习了

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