腰椎间盘终板变化与慢性下腰痛相关性的临床研究
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摘要
目的：探讨腰椎间盘终板Modic改变与慢性下腰痛的相关性,研究肿瘤坏死因子(TNF-α)、降钙素基因相关肽(CGRP)、P物质(substance P)和蛋白基因产物9.5(PGP9.5)标记的内生性神经末梢在人腰椎髓核髓核和终板组织中的表达,及其在Modic各型中的分布差异。分别检测椎间盘中髓核和终板组织中IL-8、IL-6、前列腺素E2(PGE-2)的基因含量。揭示终板变化与慢性下腰痛的相关性,终板中的炎症介质和神经末梢分布在Modic各型中的差异表达。观察自拟腰痛方对下腰痛患者的治疗效果。
方法：对2010.6—2011.10因下腰痛手术的70例患者进行疼痛评分和MRI检查,观察腰椎终板Modic改变的分型、测量各组终板Modic变化面积,测量有终板Modic变化腰椎的曲度。统计学分析腰椎终板MRI上Modic改变的发生率及其与下腰痛的相关性,分析终板面积与曲度的相关性。收集病变椎间盘的髓核和终板组织,作HE染色,观察病理变化；免疫组化观察Modic各组中的髓核和终板组织中TNF-α、CGRP、P物质和PGP9.5的含量。采用Real-time PCR法检测髓核和终板组织中1L-8、IL-6、PGE-2的基因含量。
结果：1.70例患者中男性39例,女31例,年龄29-80岁,中位年龄50.0岁,平均年龄51.0±11.89岁。病程6月至54月,平均26±4.3月。Modic改变分型,其中无Modic变化型16例,ModicI型15例,Modic Ⅱ型21例,Modic Ⅲ型11例、混和型7例。疼痛评分JOA和VAS评分如下：无Modic变化型(15.0±2.7,3.8±0.5)；ModicⅠ型(13.2±4.5,4.2±0.2); Modic Ⅱ型(18.4±3.1,3.9±0.1);ModicⅢ型(20.0±2.4,3.2±0.2)；Modic混合型(19.7±3.9,3.4±0.3)。面积改变率和曲度如下：ModicⅠ型(21.36±13.86%,0.96±0.43cm), ModicⅡ型(15.14±12.07%,0.87±0.25cm), ModicⅢ型(16.28±8.68%,0.92±0.36cm)、 Modic昆合型(11.14±7.66%,0.95±0.28cm)。 Pearson相关性分析ModicⅠ型、ModicⅡ型面积改变率分别与下腰痛的疼痛评分呈正相关。2.椎间盘髓核和终板组织HE染色,ModicⅠ型：终板及终板下区域有丰富的肉芽组织,纤维血管组织替代了增厚的骨小粱间的正常骨髓。ModicⅡ型：在慢性受损的终板及终板下区域大量脂肪细胞沉积。ModicⅢ型：终板及终板下骨质硬化。Modic混合型：同一终板可见黄骨髓和血管化。无Modic改变型：则无上述变化。3.免疫组化染色结果显示各型髓核和终板中软骨细胞内均见棕黄颗粒,呈灶状或弥漫状分布。TNF-α免疫组化染色积分：ModicⅠ型终板和髓核组织中的TNF-α免疫组化染色积分比较,终板高于髓核,有统计学差异(P<0.05)。ModicⅡ型和IModicⅢ型TNF-α免疫组化染色积分比较相近,无统计学差异,但与无Modic改变型比较,差异明显(P<0.05).CGRP.P物质和PGP9.5的含量在髓核组织中含量较低,在终板组织中基本没有。4.无Modic改变型髓核和终板组织中的IL-8、IL-6、PGE-2的基因含量△Ct值分别为(14.41±1.98,13.99±2.35).(11.48±3.04,11.75±3.83).(11.61±2.38,10.75±3.29);ModicⅠ型△Ct值分别为(6.34±1.82,4.07±1.86).(10.62±1.88,5.92±1.31).(9.97±2.21,5.94±1.78);ModicⅡ型△Ct值分别为(13.15±3.67,14.52±0.91)、(12.44±4.10,10.37±3.21)、(12.26±3.10,10.37±3.21);ModicⅢ型△Ct值分别为(8.16±3.71,13.48±2.01)、(6.72±0.38,10.06±0.15)、(7.88±2.58,10.41±2.06)；Modic混合型△Ct值分别为(9.21±2.00,10.38±1.50)、(7.38±0.65,8.15±0.67)、(6.54±1.45,6.44±0.23)。5.Modic改变率与终板中TNF-α炎性因子浓度在ModicⅠ、Ⅱ型中呈正相关性,在ModicⅢ型和Modic混合型中则没有相关性。6.ModicⅠ型常规组治疗前后JOA评分t=6.4,P<0.01,Modic Ⅰ型中药组治疗前后JOA评分t=8.84,P<0.01;MocdicⅡ型常规组治疗前后JOA评分t=9.74,P<0.01, ModicⅡ型中药组t=10.87, P<0.01。
结论：
1.下腰痛患者中ModicⅠ、Ⅱ型面积改变率分别与下腰痛的疼痛程度有密切关系。
2.下腰痛患者中疼痛与腰椎曲度改变没有关系。
3.ModicⅠ型终板和髓核组织中的TNF-α、IL-8、IL-6、PGE-2含量,终板高于髓核。ModicⅡ型髓核和终板浓度无明显差异,ModicⅢ型炎症因子在髓核的浓度大于终板浓度,Modic混合型炎症因子在髓核和终板中的浓度无差异。
4. CGRP.P物质和PGP9.5的含量在髓核组织中含量低,在终板组织中基本没有。
5. Modic改变率与终板炎性因子TNF-α浓度在ModicⅠ、Ⅱ型,呈正相关性,在ModicⅢ型(?)(?)Modic混合型中则没有相关性。
6.中药对伴有ModicⅠ、Ⅱ型的下腰痛具有症状缓解作用。
Objective:Chronic low back pain is a common orthopedic diseases. This study explored the relationship between Modic endplate change and lumbar MRI imaging of the patients with low back, the inflammatory factor tumor necrosis factor (TNF alpha) and somatostat (CGRP), substance P (substance P) and protein gene product9.5(PGP9.5) marked expression of endogenous nerve endings in lumbar nucleus and end plate tissue, different expression in various modic type of the inflammation media and nerve endings of the endplate. Observe the treatment effect by Chinese prescription for patients with low back pain.
Methods:During June of2010to October2011, we recorded the pain score of70low back pain in-patients, MRI, lumbar endplate Modic change type, the area of modic endplate changes in MRI, lumbar curvature of the patients whose endplate have Modic changes. We analyzed the incidence of Modic MRI changes, the correlation with low back pain, and the correlation of endplate area and the curvature. Nucleus pulposus and endplate organization were dyed with HE collected Intra-operatively. Pathological changes were observed. The content of TNF alpha, CGRP, substance P and PGP9.5in nucleus pulposus and endplate tissue were measured through immuno-histochemical method. The Real-time PCR method was adopted to detect the gene content of IL-8, IL-6, PGE-2in pulp nuclear and end plate.
Results:
1.70patients (male39cases, female31cases, aged29-80years old, the median age is50.0years, mean age is51.0±11.89years old. The Course of disease last6to54months, average time is26±4.3months). Modic changes classification were observed in70patients, of which16cases (22.8%) has no Modic change,15cases (21.4%) is Modic type I,21cases (30.0%) is Modic Ⅱ type,11patients (15.7%)is Modic type Ⅲ,7patients (10.0%) is Modic mixed type. JOA and VAS score were as follows:no Modic change type (15.0±2.7,3.8±0.5);Modic type Ⅰ (13.2±4.5,4.2±0.2), Modic Ⅱ type (18.4±3.1,3.9±0.1), Modic III type (20.0±2.4,3.2±0.2Modic mixed type (19.7±3.9,3.4±0.3). Except no Modic change type, the area change rate of the MRI image and the curvature of other Modic type is as follows:Modic type Ⅰ (area change rate21.36±13.86%, curvature0.96±0.43cm), Modic Ⅱ type (area change rate15.14±12.07%, curvature0.87±0.25cm), Modic Ⅲ type (area change rate16.28±8.68%, curvature0.92±0.36cm), Modic mixed type (area change rate11.14±7.66%, curvature0.95±0.28cm). Modic type Ⅰ, Modic Ⅱ type area change rate positively associated with the pain score and has significant difference statistically in multiple regression analysis.
2. Nucleus pulposus and endplate organization were taken from Modic change patient, dyed with HE and gone pathology observing. Modic Ⅰ type (inflammation period or edema period):osseous endplate was torn, end plate and subendplate area is rich in the compact granulation tissue, fiber blood essels replaced thickening of bone between small beams of normal bone marrow. Modic Ⅱ type (fat period or yellow bone marrow period):yellow bone marrow substituted, a lot of fat cells deposition was fund in chronic damaged endplate and subendplate area. Modic Ⅲ type (bone sclerosis period):end plate and subendplate bone hardened. Modic mixed type: yellow bone marrow and vascularization could be seen in the same end plate. No modic change type:no pathological changes were observed.
3. Immuno-histochemical stains results show that brownish yellow particles were seen in each nucleus pulposus and end plate cartilage cells, spoted or spreading. The results of TNF alpha immuno-histochemical stains:The score of TNF alpha immuno-histochemical stains of endplate is statistically higher (P<0.05) than that of nucleus pulposus in Modic Ⅰ type. Modic Ⅱ type and Modic Ⅲ type are similar, no statistic difference were observed. Obvious differences (P<0.05) were foud compare Modic Ⅱ type and Modic Ⅲ type to no Modic change type. CGRP, substance P and PGP9.5content in the nucleus pulposus are low,and could not found in endplate organization.
4. Gene content of IL-8, IL-6and PGE-2in nucleus pulposus and end plate are different.The values of ΔCT in no Modic type separately are (14.41±1.98,13.99±2.35),(11.48±3.04,11.75±3.83),(11.61±2.38,10.75±3.29). The values of△Ct in Modic Ⅰ type separately are(6.34±1.82,4.07±1.86).(10.62±1.88,5.92±1.31).(9.97±2.21,5.94±1.78)；The values of△Ct in Modic Ⅱ type separately are(13.15±3.67,14.52±0.91).(12.44±4.10,10.37±3.21).(12.26±3.10,10.37±3.21)；The values of△Ct in Modic Ⅲ type separately are(8.16±3.71,13.48±2.01).(6.72±0.38,10.06±O.15).(7.88±2.58,10.41±2.06); The values of△Ct in Modic mixed type separately are(9.21±2.00,10.38±1.50).(7.38±0.65,8.15±0.67).(6.54±1.45,6.44±0.23)
5.Modic change rates and end-plate TNF--α concentration of inflammatory cytokines has a positive correlation between Modic Ⅰ and Ⅱ type.But there is no correlation between Modic Ⅲ-and Modic mixed type.
6.Before and after Chinese prescription treatment,the JOA scores of Modic Ⅰ type have a significant difference,t=6.4,P<0.01.And the JOA scores of Modic Ⅱ type also have a significant difference,t=8.84,P<0.01
Conclusions:
1.Modic type Ⅰ,Modic Ⅱ type area change rate positively associated with the pain score and has significant difference statistically in patients with low back pain.
2.Modic area change rate of patients with low back pain has no correlation with lumbar curvature change.
3.TNF alpha,IL-8,IL-6,PGE-2content of elldplate is statistically higher(P<0.05) than that of nucleus pulposus in Modic Ⅰ type.Type Ⅰ is inflammatory edema period, inflammatory factor levels in the endplate is higher than in the nucleus pulposus presents low back pain and endplate changes were positively correlated.The concentration of nucleus pulposus and endplate in Modic Ⅱ type has no obvious difierence.Because Modic Ⅱ type endplate is stable,low back pain of patients is the results of degeneration of endplate and nucleus pulposus.The concentration of inflammation factors in nucleus pulposus is higher than that in endplate of Modic Ⅲ type.The reason is endplate of this type is in a stable phase.The pathologic change is bone sclerosis.Low back pain symptoms usually caused by the degeneration of nucleus pulposus.The inflmmation factors concentration is no difierence in Modic mixed type because it's the transition phrase.
4. CGRP, substance P and PGP9.5content in the nucleus pulposus is low, and could not fond in endplate organization.
5. Modic changes rates and end-plate TNF--α concentration of inflammatory cytokines has a positive correlation between Modic Ⅰ and Ⅱ type. But there is no correlation between Modic Ⅲ-and Modic mixed type.
6. Chinese medicine have an effect of relief symptom on Modic Ⅰ and Ⅱ types.
方法：对2010.6—2011.10因下腰痛手术的70例患者进行疼痛评分和MRI检查,观察腰椎终板Modic改变的分型、测量各组终板Modic变化面积,测量有终板Modic变化腰椎的曲度。统计学分析腰椎终板MRI上Modic改变的发生率及其与下腰痛的相关性,分析终板面积与曲度的相关性。收集病变椎间盘的髓核和终板组织,作HE染色,观察病理变化；免疫组化观察Modic各组中的髓核和终板组织中TNF-α、CGRP、P物质和PGP9.5的含量。采用Real-time PCR法检测髓核和终板组织中1L-8、IL-6、PGE-2的基因含量。
结果：1.70例患者中男性39例,女31例,年龄29-80岁,中位年龄50.0岁,平均年龄51.0±11.89岁。病程6月至54月,平均26±4.3月。Modic改变分型,其中无Modic变化型16例,ModicI型15例,Modic Ⅱ型21例,Modic Ⅲ型11例、混和型7例。疼痛评分JOA和VAS评分如下：无Modic变化型(15.0±2.7,3.8±0.5)；ModicⅠ型(13.2±4.5,4.2±0.2); Modic Ⅱ型(18.4±3.1,3.9±0.1);ModicⅢ型(20.0±2.4,3.2±0.2)；Modic混合型(19.7±3.9,3.4±0.3)。面积改变率和曲度如下：ModicⅠ型(21.36±13.86%,0.96±0.43cm), ModicⅡ型(15.14±12.07%,0.87±0.25cm), ModicⅢ型(16.28±8.68%,0.92±0.36cm)、 Modic昆合型(11.14±7.66%,0.95±0.28cm)。 Pearson相关性分析ModicⅠ型、ModicⅡ型面积改变率分别与下腰痛的疼痛评分呈正相关。2.椎间盘髓核和终板组织HE染色,ModicⅠ型：终板及终板下区域有丰富的肉芽组织,纤维血管组织替代了增厚的骨小粱间的正常骨髓。ModicⅡ型：在慢性受损的终板及终板下区域大量脂肪细胞沉积。ModicⅢ型：终板及终板下骨质硬化。Modic混合型：同一终板可见黄骨髓和血管化。无Modic改变型：则无上述变化。3.免疫组化染色结果显示各型髓核和终板中软骨细胞内均见棕黄颗粒,呈灶状或弥漫状分布。TNF-α免疫组化染色积分：ModicⅠ型终板和髓核组织中的TNF-α免疫组化染色积分比较,终板高于髓核,有统计学差异(P<0.05)。ModicⅡ型和IModicⅢ型TNF-α免疫组化染色积分比较相近,无统计学差异,但与无Modic改变型比较,差异明显(P<0.05).CGRP.P物质和PGP9.5的含量在髓核组织中含量较低,在终板组织中基本没有。4.无Modic改变型髓核和终板组织中的IL-8、IL-6、PGE-2的基因含量△Ct值分别为(14.41±1.98,13.99±2.35).(11.48±3.04,11.75±3.83).(11.61±2.38,10.75±3.29);ModicⅠ型△Ct值分别为(6.34±1.82,4.07±1.86).(10.62±1.88,5.92±1.31).(9.97±2.21,5.94±1.78);ModicⅡ型△Ct值分别为(13.15±3.67,14.52±0.91)、(12.44±4.10,10.37±3.21)、(12.26±3.10,10.37±3.21);ModicⅢ型△Ct值分别为(8.16±3.71,13.48±2.01)、(6.72±0.38,10.06±0.15)、(7.88±2.58,10.41±2.06)；Modic混合型△Ct值分别为(9.21±2.00,10.38±1.50)、(7.38±0.65,8.15±0.67)、(6.54±1.45,6.44±0.23)。5.Modic改变率与终板中TNF-α炎性因子浓度在ModicⅠ、Ⅱ型中呈正相关性,在ModicⅢ型和Modic混合型中则没有相关性。6.ModicⅠ型常规组治疗前后JOA评分t=6.4,P<0.01,Modic Ⅰ型中药组治疗前后JOA评分t=8.84,P<0.01;MocdicⅡ型常规组治疗前后JOA评分t=9.74,P<0.01, ModicⅡ型中药组t=10.87, P<0.01。
结论：
1.下腰痛患者中ModicⅠ、Ⅱ型面积改变率分别与下腰痛的疼痛程度有密切关系。
2.下腰痛患者中疼痛与腰椎曲度改变没有关系。
3.ModicⅠ型终板和髓核组织中的TNF-α、IL-8、IL-6、PGE-2含量,终板高于髓核。ModicⅡ型髓核和终板浓度无明显差异,ModicⅢ型炎症因子在髓核的浓度大于终板浓度,Modic混合型炎症因子在髓核和终板中的浓度无差异。
4. CGRP.P物质和PGP9.5的含量在髓核组织中含量低,在终板组织中基本没有。
5. Modic改变率与终板炎性因子TNF-α浓度在ModicⅠ、Ⅱ型,呈正相关性,在ModicⅢ型(?)(?)Modic混合型中则没有相关性。
6.中药对伴有ModicⅠ、Ⅱ型的下腰痛具有症状缓解作用。
Objective:Chronic low back pain is a common orthopedic diseases. This study explored the relationship between Modic endplate change and lumbar MRI imaging of the patients with low back, the inflammatory factor tumor necrosis factor (TNF alpha) and somatostat (CGRP), substance P (substance P) and protein gene product9.5(PGP9.5) marked expression of endogenous nerve endings in lumbar nucleus and end plate tissue, different expression in various modic type of the inflammation media and nerve endings of the endplate. Observe the treatment effect by Chinese prescription for patients with low back pain.
Methods:During June of2010to October2011, we recorded the pain score of70low back pain in-patients, MRI, lumbar endplate Modic change type, the area of modic endplate changes in MRI, lumbar curvature of the patients whose endplate have Modic changes. We analyzed the incidence of Modic MRI changes, the correlation with low back pain, and the correlation of endplate area and the curvature. Nucleus pulposus and endplate organization were dyed with HE collected Intra-operatively. Pathological changes were observed. The content of TNF alpha, CGRP, substance P and PGP9.5in nucleus pulposus and endplate tissue were measured through immuno-histochemical method. The Real-time PCR method was adopted to detect the gene content of IL-8, IL-6, PGE-2in pulp nuclear and end plate.
Results:
1.70patients (male39cases, female31cases, aged29-80years old, the median age is50.0years, mean age is51.0±11.89years old. The Course of disease last6to54months, average time is26±4.3months). Modic changes classification were observed in70patients, of which16cases (22.8%) has no Modic change,15cases (21.4%) is Modic type I,21cases (30.0%) is Modic Ⅱ type,11patients (15.7%)is Modic type Ⅲ,7patients (10.0%) is Modic mixed type. JOA and VAS score were as follows:no Modic change type (15.0±2.7,3.8±0.5);Modic type Ⅰ (13.2±4.5,4.2±0.2), Modic Ⅱ type (18.4±3.1,3.9±0.1), Modic III type (20.0±2.4,3.2±0.2Modic mixed type (19.7±3.9,3.4±0.3). Except no Modic change type, the area change rate of the MRI image and the curvature of other Modic type is as follows:Modic type Ⅰ (area change rate21.36±13.86%, curvature0.96±0.43cm), Modic Ⅱ type (area change rate15.14±12.07%, curvature0.87±0.25cm), Modic Ⅲ type (area change rate16.28±8.68%, curvature0.92±0.36cm), Modic mixed type (area change rate11.14±7.66%, curvature0.95±0.28cm). Modic type Ⅰ, Modic Ⅱ type area change rate positively associated with the pain score and has significant difference statistically in multiple regression analysis.
2. Nucleus pulposus and endplate organization were taken from Modic change patient, dyed with HE and gone pathology observing. Modic Ⅰ type (inflammation period or edema period):osseous endplate was torn, end plate and subendplate area is rich in the compact granulation tissue, fiber blood essels replaced thickening of bone between small beams of normal bone marrow. Modic Ⅱ type (fat period or yellow bone marrow period):yellow bone marrow substituted, a lot of fat cells deposition was fund in chronic damaged endplate and subendplate area. Modic Ⅲ type (bone sclerosis period):end plate and subendplate bone hardened. Modic mixed type: yellow bone marrow and vascularization could be seen in the same end plate. No modic change type:no pathological changes were observed.
3. Immuno-histochemical stains results show that brownish yellow particles were seen in each nucleus pulposus and end plate cartilage cells, spoted or spreading. The results of TNF alpha immuno-histochemical stains:The score of TNF alpha immuno-histochemical stains of endplate is statistically higher (P<0.05) than that of nucleus pulposus in Modic Ⅰ type. Modic Ⅱ type and Modic Ⅲ type are similar, no statistic difference were observed. Obvious differences (P<0.05) were foud compare Modic Ⅱ type and Modic Ⅲ type to no Modic change type. CGRP, substance P and PGP9.5content in the nucleus pulposus are low,and could not found in endplate organization.
4. Gene content of IL-8, IL-6and PGE-2in nucleus pulposus and end plate are different.The values of ΔCT in no Modic type separately are (14.41±1.98,13.99±2.35),(11.48±3.04,11.75±3.83),(11.61±2.38,10.75±3.29). The values of△Ct in Modic Ⅰ type separately are(6.34±1.82,4.07±1.86).(10.62±1.88,5.92±1.31).(9.97±2.21,5.94±1.78)；The values of△Ct in Modic Ⅱ type separately are(13.15±3.67,14.52±0.91).(12.44±4.10,10.37±3.21).(12.26±3.10,10.37±3.21)；The values of△Ct in Modic Ⅲ type separately are(8.16±3.71,13.48±2.01).(6.72±0.38,10.06±O.15).(7.88±2.58,10.41±2.06); The values of△Ct in Modic mixed type separately are(9.21±2.00,10.38±1.50).(7.38±0.65,8.15±0.67).(6.54±1.45,6.44±0.23)
5.Modic change rates and end-plate TNF--α concentration of inflammatory cytokines has a positive correlation between Modic Ⅰ and Ⅱ type.But there is no correlation between Modic Ⅲ-and Modic mixed type.
6.Before and after Chinese prescription treatment,the JOA scores of Modic Ⅰ type have a significant difference,t=6.4,P<0.01.And the JOA scores of Modic Ⅱ type also have a significant difference,t=8.84,P<0.01
Conclusions:
1.Modic type Ⅰ,Modic Ⅱ type area change rate positively associated with the pain score and has significant difference statistically in patients with low back pain.
2.Modic area change rate of patients with low back pain has no correlation with lumbar curvature change.
3.TNF alpha,IL-8,IL-6,PGE-2content of elldplate is statistically higher(P<0.05) than that of nucleus pulposus in Modic Ⅰ type.Type Ⅰ is inflammatory edema period, inflammatory factor levels in the endplate is higher than in the nucleus pulposus presents low back pain and endplate changes were positively correlated.The concentration of nucleus pulposus and endplate in Modic Ⅱ type has no obvious difierence.Because Modic Ⅱ type endplate is stable,low back pain of patients is the results of degeneration of endplate and nucleus pulposus.The concentration of inflammation factors in nucleus pulposus is higher than that in endplate of Modic Ⅲ type.The reason is endplate of this type is in a stable phase.The pathologic change is bone sclerosis.Low back pain symptoms usually caused by the degeneration of nucleus pulposus.The inflmmation factors concentration is no difierence in Modic mixed type because it's the transition phrase.
4. CGRP, substance P and PGP9.5content in the nucleus pulposus is low, and could not fond in endplate organization.
5. Modic changes rates and end-plate TNF--α concentration of inflammatory cytokines has a positive correlation between Modic Ⅰ and Ⅱ type. But there is no correlation between Modic Ⅲ-and Modic mixed type.
6. Chinese medicine have an effect of relief symptom on Modic Ⅰ and Ⅱ types.
引文
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