补肾强督方治疗强直性脊柱炎合并骨质疏松症的骨密度及骨代谢指标的研究

【作者】 路平；

【导师】 阎小萍；

【作者基本信息】 北京中医药大学 ， 中医内科， 2005， 硕士

【摘要】 强直性脊柱炎(Ankylosing Spondylitis,AS)是一种以中轴关节和肌腱、韧带、骨附着点的慢性炎症为主的全身性疾病。骨质疏松症(Osteoporosis,OP)是强直性脊柱炎的一个常见并发症,在疾病早期即可出现,常可引起脊柱畸形、骨折,严重影响本病的预后。强直性脊柱炎引起骨质疏松的发病机制不明,考虑与激素失衡、免疫炎症等方面的作用有关,但诸学者尚存较大争议。对强直性脊柱炎合并骨质疏松症的治疗尚没有得到足够的重视,所以探索强直性脊柱炎患者合并骨质疏松症的发病机制,研究强直性脊柱炎患者骨量和骨代谢的变化,及早治疗强直性脊柱炎合并骨质疏松症,从而减少并发症的危害,改善强直性脊柱炎的预后,是一个非常有意义的课题。中医学中并没有强直性脊柱炎的病名,但诸医家据其发病特点及临床表现将其名之为“骨痹”、“肾痹”、“顽痹”、 “尪痹”等,现代医家多认为肾虚督空,肝肾不足,加之感受外邪,内外合邪是形成本病的病机。导师阎小萍教授在学习、深研前贤理论继承其恩师焦树德教授学术思想,主张强直性脊柱炎相关的中医病名为大(?)较为恰当,并认为大(?)的发病虽然病因众多,病机复杂,但究其主要病因病机不外乎在肾督亏虚、阳气不足的情况下,或因风寒湿邪(尤其是寒湿偏重者)或因湿热之邪深侵肾督,督脉行于脊背通于肾,总督人身诸阳,督脉受邪则阳气开阖不得,布化失司而致。并将本病扩展为以下六种常见证型:肾虚督寒证、邪郁化热证、湿热伤肾证、邪痹肢节证、邪及肝肺证及缓解稳定证,以补肾壮督方为主进行治疗。本课题研究强直性脊柱炎合并骨质疏松症的发生情况,以补肾壮督法为主治疗强直性脊柱炎合并骨质疏松症,检测、评估患者服药前后的BMD、骨代谢生化指标及临床症状、脊柱功能状态等,验证治疗效果,初步揭示了AS患者发生骨质疏松症的相关因素,验证了补肾强督方对AS合并骨质疏松症具有良好的治疗效果,为AS合并骨质疏松症的病因、发病机制及中医药治疗提供了新的思路。结果显示:189例强直性脊柱炎患者符合骨质疏松诊断标准者30例(15. 87%),符合骨量减少诊断标准者84例(45. 50%);腰椎骨量减少者24例(28. 57%),骨质疏松者10例(33. 33%);股骨骨量减少者26例(30. 95%),骨质疏松者1例(3. 33%),腰椎与股骨均骨量减少者34例(40. 48%),均骨质疏松者19例(63. 33%)。骨量减少的平均年龄26. 80±4. 47。本组AS患者BGP、PTH、BALP、CICP较对照组显著降低(P<0. 05) ,BGP与股骨颈、三角区BMD呈正相关;CTX、尿DPD较对照组显著升高,并CTX与腰椎BMD呈负相关,BALP、CICP、PTH、尿DPD与各处骨密度无显著相关性。说明AS合并骨质疏松症与骨形成的减少(成骨细胞活性降低)和骨吸收的增强(破骨细胞活性增强)有关。在本组AS患者中ESR、CRP与腰椎、股骨近端、三角、粗隆BMD呈显著负相关,同时,我们观察到ESR与骨形成指标BGP显著的负相关,说明免疫炎症反应可能抑制了AS患者的更多还原

【Abstract】 Ankylosing Spondylitis(AS) is a chronic inflammatory rheumatic disease which mainly impinge on sacroiliac joint and vertebral column, the peripheral arthritis is also be involved. Osteoporosis (OP) is a common complication in AS,even in the early stages.OP can lean to spine’ s deformities, osteoporotic fractures, and affects prognosis of disease. The pathogenesis of OP in AS remains unclear. It might be due to imbalancing of hormones restricted movement,and so on. However ,the etiology of that still remains controversial,and the treatment of OP in AS has not received much attention .Therefore, it is a significative task that determine the pathogenes of OP in AS, investigate the bone mass and bone metabolism, treating AS OP so that decrease the harm of complication and improve prognosis of disease.In Tradtional Chinese Medicine (TCM), basing on the pathogeny and manifestation of AS,a lot of physicians think that AS is belonged to "Gubi’ "Wangbi’ "Wanbi"ect, and most of them think that the pathogenesis of AS is related to asthenis of kidney and Du meridian, evils intrusion infirmity of inside and evils of outside’s combination. According to Professor Jiao shude and basing earlier worthies my teather Professor Yan xiaoping named AS the "DALU", and binding decades of clinical experiece,teather think that the pathogenesis of AS (DALU) is mainly related to the asthenia of kidney and Du meridian ,wind cold wet and heat evils (especially cold and wet evils) deeply intrude kidney and Du meridian , and divide AS (DALU) into six symptoms: kidney-asthenia and Du-cold, evils intrude extrarthron,evils intrude liver and lung, evils luxuriate and turn into heat, kidney injuried by wet and haet evils, remissive and stable. My treater treating AS (DALU) mainly with strong kindey - Du Fa.This paper has a report for treatment of OP in AS with strong kidney -Du Fa , basing AS flaring up due to asthenia of kidney and Du meridian ,determined the bone mineral density (BMD), biochemical markers of bone metabolism, and spinal movement of AS patients, in order to test curative effect, explore pathogenesis of OP in AS , definite the treatment of strong kindey -Du Fa . Our study show : the total frequency of osteooporosis and osteoporosis and osreopenia in AS patient was 15.87% and 45.50%. We found 33.33% and 3.33% osteoporosis in the total proximal,23.71% and 29.90% osteopnia in the lumbar and in the total proximal femur. OP in AS is related with released bone formation and increased bone resorption . Increased levels of PTH and immune inflammatory take a role in increasing bone resorption . Moreover , immobilization caused by joit pain, stiffnesscan not be neglected in the pathogenese of AS OP. For this reason ,OP could result from AS by multifactor include imbalances of hormones ,immune inflammation , restricted movement and so on . Total proximal femur is the better ulace than lumbar to evaluate the OP in AS,especially in advanced AS . Bone mineral densities of the five symptoms in TCM were all reduced at different levels. Among them kidney-asthenia and Du-cold’ s BMD reduced most strikingly. The reduced BMD maybe represent "the asthebia of kindey and Du meridian". Treament based on strong kidney-Du Fa could regulated the balance between bone formation and bone resporption, increased bone formation, could also decreased immune inflammation and PTH level consequently reduced the influence to bone resporption, and the treatment was also beneficial for bone formation through reducing joit pain and increasing spine mobility. Our data shows that treatment with strong kidney-Du Fa could significantly increasing both lumbar and total proximal BMD particularly in the total proximal. We assume that Strong kidney-Du Fa treatment is effective to OP in AS .The increasing of BMDin AS patient reflect the decreasing of asthenia of kidney and Du meridian.更多还原