Wen | Dr. Wang
Editor|small soup
The causes of osteoporosis are diverse, such as decreased bone density and bone strength due to decreased bone mass and destruction of bone fine structures, which in turn are prone to bone pain, fractures, and even multiple fractures. Osteoporotic compression fractures can occur when the vertebral body of the spine is subjected to slight external forces or even daily activities such as bending over and sneezing, and is one of the serious consequences of osteoporosis.
Osteoporotic compression fractures often occur in the vertebral body, hip joint, distal radius, proximal humerus, and pelvis, with the thoracolumbar junction being the most common.
The reduction in muscle mass is sarcopenia, or sarcopenia, first named by Rosenberg in 1989. Sarcopenia refers to an age-related, progressive condition that manifests as a decrease in muscle mass and/or decreased muscle strength or function throughout the body.
The occurrence of osteoporosis and sarcopenia is related to age, and the two influence and promote each other. Bones and muscles are anatomically close to each other, functionally complementary to each other, and are also regulated by immune, nutritional, endocrine, neurological and mechanical stimuli, and the two are also regulated by endocrine and mechanical mechanics.
Studies have shown that many similar molecular signaling pathways exist in bones and muscles, and these pathways are promising to be common targets for intervention. Therefore, the relationship between osteoporotic compression fractures and the reduction of muscle mass is inseparable and affects each other.
The musculoskeletal system plays a vital role in maintaining position, coordinating movement, protecting internal organs and maintaining the stability of the human internal environment, so the occurrence of fractures in elderly patients is closely related to the musculoskeletal system. In daily life and medical practice, while preventing and treating osteoporosis, the prevention and treatment of sarcopenia should be strengthened.
Methods of checking bone density
At present, the methods for measuring bone density include dual-energy X-ray bone densitometry, calcaneal quantitative ultrasonic bone densitometry and quantitative CT detection.
Dual-energy X-ray bone density testing is currently the most commonly used method for detecting bone density in clinical practice. Clinically, the diagnosis is based on the different T values measured by DXA, which is the comparison of the bone density value of the measured person with the peak bone density and standard deviation of a normal reference population.
The World Health Organization describes the diagnosis of osteoporosis as follows: for postmenopausal women and men over 50 years old, the bone density T value measured by DXA is reduced by 2.5 or more standard deviations with the peak bone mass of young women in Caucasia, that is, the T value of the subject W-2.5SD, as the diagnostic criteria for osteoporosis.
But DXA also has its limitations, because the peak bone density of the reference population set by different manufacturers will be different, so for the same person, the T value measured on different machines will be different.
Secondly, DXA is a planar projection technology, measuring the area of bone density, and the measured bone density value will be affected by bone hyperplasia, soft tissue calcification, fracture deformation or rotational deformity at the measured site, especially in the elderly population.
The calcaneal quantitative ultrasonic bone densitometry method uses a proprietary ultrasonic transducer to emit ultrasonic waves from one end of the bone to be measured, and the other end receives ultrasound that is attenuated by the amplitude of bone and soft tissue, and by calculating the sound velocity and sound attenuation slope, the two are combined to obtain bone parameters through non-acoustic conversion, and the standard values are compared to obtain diagnostic conclusions.
QUS test results are positively correlated with bone mineral density. The cancellous bone in the calcaneus is rich in content and sensitive to changes in bone mass, and is the most commonly used detection site for QUS, followed by radius, tibia, etc.
Compared with DXA measurement, the advantages of QUS detection method are that the instrument has no radiation, low patient cost, and easier popularization; However, QUS also has shortcomings, with few clinical practices, low accuracy of measured values, and inability to measure bone density of large joints such as lumbar spine and hip. The clinical application of QUS remains to be observed.
Quantitative CT is based on clinical CT scan images, combined with QCT professional body model and analysis software to measure bone density. Unlike DXA, which measures area bone density, QCT measures bone density as true volumetric bone density, which can selectively measure vertebral cancellous bone density.
This volumetric bone density is not affected by the patient's height and weight, vertebral body size, bone hyperplasia and soft tissue calcification, which reduces the false negative of osteoporosis and is currently the most accurate measurement method.
The International Society for Clinical Bone Density (ISCD) and the American Society of Radiology (ACR) both recommend that the standard for the diagnosis of osteoporosis by QCT is that the bone density of the lumbar spine is less than 80mg/cm3oQCT, and the disadvantage is that the radiation dose is greater than DXA, but as far as QCT itself is concerned, patients undergo routine physical examination, lung CT non-contrast scan, or spine CT scan at the same time.
Physicians can obtain bone density results through professional software measurement, QCT itself does not increase the scanning time, does not increase the amount of radiation, with the advancement of CT scanning technology, the amount of radiation is gradually reduced, the application of QCT is also developing.
In this study, the most advanced and accurate QCT was used to measure bone density to maximize the true reflection of the patient's bone density and reduce the error.
Characteristics and functions of psoas major, multifissured muscle and erector spinal muscle
The psoas major muscle, multifissure muscle and erector spinal muscle are the active systems of spinal movement and are the main muscles that maintain the movement and stability of the lumbar spine. The psoas major muscle is shaped like a long fusiform, most of which is located in the groove between the T12-L4 vertebral body and the transverse process, starting from both sides of the lumbar vertebral body, and ending at the small trochanter of the femur together with the iliac muscle, which stabilizes the spine, flexes the hip joint, and provides power for walking.
Many studies have confirmed that patients with lumbar disc herniation, lumbar spinal stenosis and other lumbar degenerative diseases, their psoas muscles have obvious atrophy and degeneration, the strength of the psoas muscles is significantly weakened, the degree of psoas muscle atrophy is positively correlated with the degree of disc herniation or spinal stenosis, and the atrophy of the side of the intervertebral disc herniation or spinal stenosis is more serious than the normal side.
Yang Pei et al. analyzed the relationship between age, area of paravertebral muscles and bone density of 204 patients, and concluded that:
The content of the left psoas muscle in men aged 40-60 years and women under 40 years old increased rapidly, while the content of the right psoas muscle in men and women was negatively correlated with age, the content of paravertebral muscle in men was higher than that in women, and the content of paravertebral muscles including psoas muscle was positively correlated with bone density, and the correlation in men was higher than that in women.
Multifidus muscle is located in the innermost part of the lumbar muscle group, is the thickest lumbar muscle, starting from the muscle fibers of the lamina and ending at the transverse process of the next vertebral body, the lumbar articular process except for the ventral side connected to the ligament flavum, the rest are all covered by the multifissure muscle, this structure allows the joint capsule to maintain tension, thereby avoiding friction and collision between joint cartilage.
It plays an important role in trunk rotation, maintaining the stability and physiological curvature of the spine, and preventing spinal fractures, and Wilke et al. found that the multifidus muscle is the muscle that affects the most range of motion of the lumbar spine, and the multifidus muscle can increase the overall stability of the lumbar spine by increasing the stability of the motor phase.
LIU ET AL., WANG ET AL. HAVE EXPERIMENTALLY PROVED THAT LOW BACK PAIN IS RELATED TO THE DEGENERATION OF MULTIFISSURE MUSCLE, AND THE SPECIFIC MECHANISM OF MUSCLE DEGENERATION IS STILL UNCLEAR, AND WASTE AND DENERVATION ARE THE TWO MOST ACCEPTED MECHANISMS AT PRESENT.
Waste refers to the patient's passive restriction of lumbar activities or fixation of a compensatory posture due to low back pain, so that the muscles are in a static state for a long time, and over time, the capillary reactivity around the muscles is reduced, the blood supply to the muscles is insufficient, the long-term hypoxia and the glycogen utilization is poor, resulting in further aggravation of the degeneration of polyfissure muscle;
Dedenervation refers to lumbar intervertebral disc herniation compressing nerves, so that the polyfissure muscle loses the innervation of the nerve, eventually leading to degeneration, multifidus degeneration will lead to lumbar spine instability, aggravate the degeneration of the intervertebral disc, intervertebral disc herniation will compress the nerve and lead to accelerated degeneration of the multifissure muscle, the two promote each other, mutual causation, after nerve root injury, multifidus muscle degeneration is also accompanied by fat infiltration.
In addition, lumbosacral radiculopathy, reflex suppression of disc-induced low back pain, dorsal branch syndrome, and various genetic, environmental, and iatrogenic factors may contribute to paravertebral muscle degeneration and fat infiltration.
The erector spine muscle is located posterior to the spine, lateral to the multifidus muscle, from the bottom up from the dorsal surface of the sacrum to the posterior occipital bone, filling in the groove between the costal angle and the spinous process, covering almost the entire spine, and is the longest muscle in the back. The common erector tendon originates on the back of the sacrum, the posterior iliac crest, the spinous process of the lumbar vertebra, and the thoracolumbar fascia and is divided upwards into three parts:
The medial side is the spinous muscle terminating at the spinous process, the middle is the longest muscle terminating at the transverse process and its nearby costal angle, and the lateral is the iliac costal muscle terminating at the costal angle. The erector spinal muscles are the key structures for maintaining upright posture in the human body, contracting both sides simultaneously to extend the spine backward, one side to contract the trunk lateral flexion to the ipsilater, and the erector spinal muscles also play an important role in maintaining spinal stability, retrospinal extension and lateral flexion.
Analysis of the results of the study
1. Analysis of bone density
The primary fracture group and the multiple fracture group all belonged to the category of osteoporosis, with average values of 76.31mg/cm3 and 60.98mg/cm3, respectively, and the bone density values of patients in the multiple fracture group were lower, which indicated that bone density was one of the influencing factors for the occurrence of osteoporotic compression fractures of the lumbar spine.
Many experiments and studies have confirmed that in patients with osteoporosis, the bone density of patients with compression fractures is much lower than that of patients without fractures, and the reduction of bone density is one of the important risk factors for compression fractures.
The bone density value reflects the amount of bone cancelling content on the lumbar vertebral body, so the decrease in bone density value means that the bone cancellous content is reduced, bone fragility increases, the risk of fracture increases, the possibility of multiple fractures is also greater, and it will also affect the healing of fractures, resulting in slow or even non-union of fractures.
2. Analysis of bilateral paravertebral muscle cross-sectional area
In this study, the cross-sectional area of bilateral paravertebral muscles from large to small was normal group, primary fracture group, and multiple fracture group, with average values of 3716.73mm2, 3366.81mm2^3080.09mm2, respectively, which showed obvious differences, which indicated that the decrease in the number of paravertebral muscles of the lumbar spine would also promote the occurrence of osteoporotic compression fractures and increase the possibility of refracture.
The paravertebral muscles play a vital role in maintaining the motor process and stability of the spine. The survey showed that the average paravertebral muscle area of patients in the chronic low back pain group was reduced by about 10% compared with the asymptomatic group, and the difference was obvious. It shows that the degeneration of paravertebral muscles is closely related to chronic low back pain.
The influence of muscle on the pathogenesis of osteoporotic compression fracture has also attracted more and more attention from scholars at home and abroad. Anderson et al. found that the weakening of trunk muscle strength is closely related to vertebral fractures in old age.
According to the biomechanical model of the lower back, the moment arm length of the paravertebral muscle and the strength of the muscle itself determine the spinal segment load The spine is prone to deformation in the elderly, and kyphosis can increase the torque arm length of the paravertebral muscle.
And the muscle strength of the elderly will decrease, and the superposition of the two factors will lead to a great increase in the gravity load of the spine; At the same time, kyphosis will change the center of gravity of the human body, and the instability of the center of gravity will further increase the probability of fractures in falls.
Mokhtarzadeh et al. pointed out that compared with people without vertebral fractures, patients with vertebral fractures have more fat infiltrates in their trunk muscles, lower trunk stretch strength, and muscle activation patterns are also altered.
Trunk muscles can also increase the load on the vertebral body and reduce the strength of the vertebral body, leading to an increased risk of vertebral fracture, while muscle exercise can increase muscle strength, improve bone density, reduce the load of vertebral bodies at high risk of fracture, and improve body balance to avoid fractures due to falls.
At Sinakietal et al. at up to 10 years of follow-up, 27 women who received muscle-strengthening exercises had a lower incidence of vertebral fractures than 23 women who did not receive exercise interventions.
3. Analysis of the proportion of steatosis
In this study, the proportion of steatosis in the normal group, the first fracture group and the multiple fracture group increased sequentially, and the proportion of steatosis in both fracture groups was significantly higher than that in the normal group, which indicated that the high proportion of steatosis was also one of the important influencing factors leading to fracture and refracture after fracture.
GrecoEA et al. have shown that the amount of bone formation in the bone marrow is inversely correlated with the number of adipocytes. Excess fat cells inhibit osteoblast activity, followed by obstruction of bone perfusion, abnormally active osteoclasts, and the release of inflammatory cytokines TNF-a and IL-6 in fat can lead to lipotoxicity, osteopenia, and loss of skeletal muscle mass.
The relationship between sarcopenia and osteoporotic compression fractures was elaborated from "musculoskeletal blind date"
Traditional Chinese medicine believes that the relationship between the kidney and the spleen is very close, the main bone of the kidney, the main muscle of the spleen, the kidney is the innate foundation, the innate essence is hidden, the spleen is the acquired essence, the acquired essence, the innate essence is mutually reinforcing, the relationship is close, known as "spleen and kidney homology", the relationship between the kidney and the spleen is actually the relationship between bone and muscle.
If the spleen and kidney are insufficient, the pulp is reduced and the bone is withered, and the weakness is weak, that is, "muscles and bones are not related" and "flesh and bone are not related". "Difficult Scripture • Twenty-Four Difficulties" cloud: "If you have less yin qi, your bones will wither." Those who have less yin, winter veins also, and those who are lying down and wet in the bone marrow. Therefore, if the bones are not wet, the flesh is not wet; If the flesh and bone are not related, the flesh is soft; The flesh is soft, so the teeth are long and dirty, and the hair is matte; Those who have no color, the bones die first."
The kinship of muscles and bones is actually the rise and fall of the spleen and kidney. From the perspective of the Five Elements Theory, the spleen belongs to the soil, the water valley is subtle, the water valley is subtle, the qi and blood are biochemically active, and the flesh is nourished and the body is robust;
The kidney is water, the main bone is pulp, the bone marrow is biochemically active, and the medullary filling is strong. The five elements are born together, native gold, gold and water, and the spleen and soil are healthy and lucky, and the kidney water is active, and then the muscles and bones are strong; In patients with osteoporosis, the spleen is not strong, the kidney water is against the spleen soil, the muscles are weak, the bone withers with the flesh, and the flesh does not catch the flesh.
If the congenital kidney water is exhausted, the acquired spleen and soil are corrupted, that is, the spleen and kidney essence are both exhausted, the flesh will be deboned and the flesh will die. The kidney is originally a sealed place, if the fire is too strong, the heat is stagnant in the kidney, and the water is not victorious over the fire, the bone is empty, and the bone will eventually occur; The spleen likes to be dry and damp, and the wet and sleepy spleen is prone to flesh hemorrhage.
The pathogenesis and manifestation of scutomatosis and osteoporotic hemorrhoids are similar to those of sarcopenia and osteoporotic compression fractures, both of which are spleen and kidney deficiency or external evil internal invasion, spleen and kidney loss, and the latter appearance is in various diseases. There is also the "Yellow Emperor's Internal Canon" as evidence, which says: "If the essence is born from itself, and the flesh is from Shengzangfu, it is more compatible with the flesh and bones, and holding the great meridian qi is calming Fuer." ”
Therefore, for sarcopenia and osteoporotic compression fractures, from the prevention, diagnosis, differentiation to treatment of the disease, the theory of musculoskeletal affinity and spleen and kidney complementary thinking should run throughout.
The use of Sijunzi soup and solitary parasitic soup at the same time added and subtracted the use of Liuwei Dihuang Pill, kidney tonic and spleen formula and other traditional Chinese medicine formulas, poria, barley, yam and other drugs that nourish the spleen and qi and dispel dampness and take them together with psoralen, dodder seed, cistanche and other kidney and bone strengthening drugs. When selecting acupuncture points, in addition to the Yangming meridian, you can also choose acupuncture points on the kidney meridian, including kidney Yu, Meimen, waist Yangguan and so on.
In daily life, pay attention to a balanced diet and adequate nutrition combined with good living habits such as strengthening physical exercise and more sun exposure. These are beneficial for the prevention and treatment of sarcopenia and osteoporotic compression fractures.