从骨髓水肿探讨股骨头坏死从瘀论治的辨证基础
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摘要
目的:关节置换术治疗股骨头坏死成功率的提高使得保留患者股骨头(下称保髋)的治疗受到一定挑战,故而在临床中必须把握好适应症,需要进一步加深对疾病的认识。核磁共振(MRI)技术自上世纪80年代用于骨科临床后发展迅速,目前在骨坏死方面主要用于早期诊断和判断坏死的范围、位置。除手术治疗外中医药是治疗股骨头坏死的重要方法。而从瘀论治在中医药治疗中得到普遍应用,往往在各种辩证分型基础上加上活血化瘀中药。基于MRI对组织特性的良好识别性,本研究观察其对于股骨头坏死的骨髓水肿程度的表现,以期发现更多信息,为临床辨证论治提供更多参考依据。
方法:随机选取18例患者因股骨头坏死行全髋置换切除后的股骨头标本共20个,进行切片HE染色。观察MRI片骨髓水肿表现,并在组织病理切片上观察以下结构:坏死的骨组织、脂肪组织、造血组织、肉芽组织、纤维组织。每张切片取5个视野,上述结构在视野中见到即记为一次。比较病理切片脂抑像非水肿组和水肿组在显微镜下观察到的上述结构频次差异是否有统计学意义。临床研究共纳入30例54髋激素性股骨头坏死病例。观察项目包括:人口学(年龄、性别)、基础病、ARCO分期、X片上硬化带表现、骨代谢标志物水平(TRACP 5b、骨钙素)、VAS疼痛评分、髋关节活动范围。分析上述因素和骨髓水肿程度的关系。疼痛和活动范围作为痹症的主症进行研究。结果采用SPSS13.0软件包进行统计学分析,P＜0.05视为差异有统计学意义。
结果:组织病理学研究显示,股骨头坏死的镜下表现包括:坏死的骨组织(坏死骨小梁、崩解骨组织)、脂肪组织、造血组织、肉芽组织、纤维组织。比较骨髓水肿组和非水肿以上结构显示,水肿组和非水肿组观察到的坏死骨小梁频次、崩解组织频次、纤维组织频次的差异无统计学意义(p＞0.05);非水肿组观察到脂肪组织频次较水肿组多,差异有统计学意义(P＜0.05);水肿组观察到肉芽组织频次较非水肿组多,差异有统计学意义(P＞0.05),显示水肿组含有较多肉芽组织。临床研究显示,Ⅲ期和Ⅳ期股骨头坏死骨髓水肿评分均值高于Ⅰ期和Ⅱ期,差异有统计学意义(P＜0.05),说明塌陷后股骨头骨髓水肿程度明显,按基础病比较肾脏病组骨髓水肿评分较其他组低、差异有统计学意义(P＜0.05)。按骨代谢标志物水平比较,骨髓水肿和TRACP 5b值成正相关,差异有统计学意义(P＜0.05):骨髓水肿和OC值成负相关,但无统计学意义(P＞0.05)。Ⅲ期和Ⅳ期股骨头坏死疼痛评分均值高于Ⅰ期和Ⅱ期,且活动范围均值小于Ⅰ期和Ⅱ期,差别有统计学意义(P＜0.05);骨髓水肿程度和疼痛成正相关,差异有统计学意义(p＜0.05);和活动范围成负相关,但没有统计学意义(P＞0.05)。按年龄比较30岁以上组患者骨髓水肿评分高于30岁以下患者组,差异为统计学意义临界值(P=0.049)。按性别比较男性组骨髓水肿评分高于女性组、停用激素组骨髓水肿评分高于继续使用组、有硬化带组骨髓水肿评分高于无硬化带组,但差异均没有统计学意义(P＞0.05)。
结论:本研究发现,常规的MRI检查可以发现坏死股骨头内的一些不同信号特点,以反映股骨头的修复过程,病理组织学上股骨头坏死骨髓水肿组的表现多见肉芽组织和修复过程相关;从临床研究方面,骨髓水肿多见于塌陷后病例,并且和骨代谢标志物中骨吸收指标TRACP 5b相关,可能提示股骨头内不稳定的情况。并且骨髓水肿程度还和痹症的主症之一疼痛程度相关。进一步理论探讨发现骨髓水肿以上的一些特点和“瘀”证的表现有相似之处。故而MRI检查所显示的骨髓水肿也许可以作为中医从瘀论治股骨头坏死的客观指征之一,并且可以丰富对股骨头坏死中瘀邪含义的认识。本研究结果显示用MRI信号表现的骨髓水肿可能是股骨头坏死病理因素瘀的表现,将骨髓水肿和中医骨伤科学的瘀证概念相联系,对于进一步中医从瘀论治提供了一定客观化指标,为临床用药提供证据。并且本研究将骨髓水肿和股骨头内骨折相联系,为治疗选择和预后判断提供参考。此外,综合组织病理学、骨代谢指标、临床表现研究,扩展骨坏死研究思路。
Objects:It is critical to choose suitable cases with intensive knowledge if preserving treatment is considered.Beyond surgery,traditional Chinese medicine(TCM) is a kind of important treatment on osteonecrosis of the femoral head.The stasis is an outstanding factor in TCM theory about osteonecrosis, while sometimes there is few clinical symptoms.On osteonecrosis of femoral head,MRI is used for diagnosing early,judging site and extent of lesion. Now that MRI represents the character of tissue well,this study is to find more information by MRI for clinical decision. Methods:20 femoral heads of osteonecrosis were chosen randomly after total hip arthroplasty.The pathological sections were made and the reacting regions were divided into two groups according to the BME on STIR image.Every section was observed 5 times randomly and the pathologic changes were recorded such as necrotic bone,disintegrated bone,fat tissue,hemopoietic tissue, granulation tissue and fibrous tissue.There were 30 cases(54 hips) included in the clinical study.Such factors were observed as demographic character(age, gender),baseline diseases,ARCO classification,sclerotic band in X-ray, level of bone markers(TRACP 5b,osteocalcin),VAS scores,range of motion. The pain scores and range of motion were regarded as the main symptoms of bi syndrome.The influence of the clinical factors on BME was analyzed.SPSS13.0 software was used for statistics and p＜0.05 was considered as significant difference.
Results:The histopathology study showed the granulation tissue in BME group was more common than non-BME group(p＜0.05).The fat tissue in non-BME group were more common than BME group(p＜0.05).The necrotic and disintegrated bone and fibrous tissue were similar in both group(p＞0.05).Cases in collapsed stage had more edema,the more serious edema was,the higher level the TRACP 5b was,with significant difference(p＜0.05).Although osteocalcin level decreased with edema,the result had no significant difference(p＞0.05).While age more than 30 years group showed more serious edema than younger group, but there was no significant difference(p＞0.05).Furthermore,there was no significant difference between the groups with sclerosis band;the groups with gender and the groups with steroid use.Pain was more serious and range of motion was more poor in collapsed stage(P＜0.05).Although pain was positively related to the BME(p＜0.05),there was no significant difference in negative correlation between range of motion and BME(P＞0.05). Conclusions:This study suggests that common MRI can show the progress of repair and unstable condition,which is connected with the histopathology, bone marker(TRACP 5b),radiology classification and clinical information (pain is a main symptom of bi syndrome).BME in MRI is some kind of reference for Traditional Chinese Medicine treatment based on stasis theory.It is practical to prognosis and treat ONFH based on syndrome differentiation referring to MRI signal character.The presentation of BME
方法:随机选取18例患者因股骨头坏死行全髋置换切除后的股骨头标本共20个,进行切片HE染色。观察MRI片骨髓水肿表现,并在组织病理切片上观察以下结构:坏死的骨组织、脂肪组织、造血组织、肉芽组织、纤维组织。每张切片取5个视野,上述结构在视野中见到即记为一次。比较病理切片脂抑像非水肿组和水肿组在显微镜下观察到的上述结构频次差异是否有统计学意义。临床研究共纳入30例54髋激素性股骨头坏死病例。观察项目包括:人口学(年龄、性别)、基础病、ARCO分期、X片上硬化带表现、骨代谢标志物水平(TRACP 5b、骨钙素)、VAS疼痛评分、髋关节活动范围。分析上述因素和骨髓水肿程度的关系。疼痛和活动范围作为痹症的主症进行研究。结果采用SPSS13.0软件包进行统计学分析,P＜0.05视为差异有统计学意义。
结果:组织病理学研究显示,股骨头坏死的镜下表现包括:坏死的骨组织(坏死骨小梁、崩解骨组织)、脂肪组织、造血组织、肉芽组织、纤维组织。比较骨髓水肿组和非水肿以上结构显示,水肿组和非水肿组观察到的坏死骨小梁频次、崩解组织频次、纤维组织频次的差异无统计学意义(p＞0.05);非水肿组观察到脂肪组织频次较水肿组多,差异有统计学意义(P＜0.05);水肿组观察到肉芽组织频次较非水肿组多,差异有统计学意义(P＞0.05),显示水肿组含有较多肉芽组织。临床研究显示,Ⅲ期和Ⅳ期股骨头坏死骨髓水肿评分均值高于Ⅰ期和Ⅱ期,差异有统计学意义(P＜0.05),说明塌陷后股骨头骨髓水肿程度明显,按基础病比较肾脏病组骨髓水肿评分较其他组低、差异有统计学意义(P＜0.05)。按骨代谢标志物水平比较,骨髓水肿和TRACP 5b值成正相关,差异有统计学意义(P＜0.05):骨髓水肿和OC值成负相关,但无统计学意义(P＞0.05)。Ⅲ期和Ⅳ期股骨头坏死疼痛评分均值高于Ⅰ期和Ⅱ期,且活动范围均值小于Ⅰ期和Ⅱ期,差别有统计学意义(P＜0.05);骨髓水肿程度和疼痛成正相关,差异有统计学意义(p＜0.05);和活动范围成负相关,但没有统计学意义(P＞0.05)。按年龄比较30岁以上组患者骨髓水肿评分高于30岁以下患者组,差异为统计学意义临界值(P=0.049)。按性别比较男性组骨髓水肿评分高于女性组、停用激素组骨髓水肿评分高于继续使用组、有硬化带组骨髓水肿评分高于无硬化带组,但差异均没有统计学意义(P＞0.05)。
结论:本研究发现,常规的MRI检查可以发现坏死股骨头内的一些不同信号特点,以反映股骨头的修复过程,病理组织学上股骨头坏死骨髓水肿组的表现多见肉芽组织和修复过程相关;从临床研究方面,骨髓水肿多见于塌陷后病例,并且和骨代谢标志物中骨吸收指标TRACP 5b相关,可能提示股骨头内不稳定的情况。并且骨髓水肿程度还和痹症的主症之一疼痛程度相关。进一步理论探讨发现骨髓水肿以上的一些特点和“瘀”证的表现有相似之处。故而MRI检查所显示的骨髓水肿也许可以作为中医从瘀论治股骨头坏死的客观指征之一,并且可以丰富对股骨头坏死中瘀邪含义的认识。本研究结果显示用MRI信号表现的骨髓水肿可能是股骨头坏死病理因素瘀的表现,将骨髓水肿和中医骨伤科学的瘀证概念相联系,对于进一步中医从瘀论治提供了一定客观化指标,为临床用药提供证据。并且本研究将骨髓水肿和股骨头内骨折相联系,为治疗选择和预后判断提供参考。此外,综合组织病理学、骨代谢指标、临床表现研究,扩展骨坏死研究思路。
Objects:It is critical to choose suitable cases with intensive knowledge if preserving treatment is considered.Beyond surgery,traditional Chinese medicine(TCM) is a kind of important treatment on osteonecrosis of the femoral head.The stasis is an outstanding factor in TCM theory about osteonecrosis, while sometimes there is few clinical symptoms.On osteonecrosis of femoral head,MRI is used for diagnosing early,judging site and extent of lesion. Now that MRI represents the character of tissue well,this study is to find more information by MRI for clinical decision. Methods:20 femoral heads of osteonecrosis were chosen randomly after total hip arthroplasty.The pathological sections were made and the reacting regions were divided into two groups according to the BME on STIR image.Every section was observed 5 times randomly and the pathologic changes were recorded such as necrotic bone,disintegrated bone,fat tissue,hemopoietic tissue, granulation tissue and fibrous tissue.There were 30 cases(54 hips) included in the clinical study.Such factors were observed as demographic character(age, gender),baseline diseases,ARCO classification,sclerotic band in X-ray, level of bone markers(TRACP 5b,osteocalcin),VAS scores,range of motion. The pain scores and range of motion were regarded as the main symptoms of bi syndrome.The influence of the clinical factors on BME was analyzed.SPSS13.0 software was used for statistics and p＜0.05 was considered as significant difference.
Results:The histopathology study showed the granulation tissue in BME group was more common than non-BME group(p＜0.05).The fat tissue in non-BME group were more common than BME group(p＜0.05).The necrotic and disintegrated bone and fibrous tissue were similar in both group(p＞0.05).Cases in collapsed stage had more edema,the more serious edema was,the higher level the TRACP 5b was,with significant difference(p＜0.05).Although osteocalcin level decreased with edema,the result had no significant difference(p＞0.05).While age more than 30 years group showed more serious edema than younger group, but there was no significant difference(p＞0.05).Furthermore,there was no significant difference between the groups with sclerosis band;the groups with gender and the groups with steroid use.Pain was more serious and range of motion was more poor in collapsed stage(P＜0.05).Although pain was positively related to the BME(p＜0.05),there was no significant difference in negative correlation between range of motion and BME(P＞0.05). Conclusions:This study suggests that common MRI can show the progress of repair and unstable condition,which is connected with the histopathology, bone marker(TRACP 5b),radiology classification and clinical information (pain is a main symptom of bi syndrome).BME in MRI is some kind of reference for Traditional Chinese Medicine treatment based on stasis theory.It is practical to prognosis and treat ONFH based on syndrome differentiation referring to MRI signal character.The presentation of BME
引文
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