脊柱退行性疾病需手术治疗患者骨代谢指标与骨密度关系的研究

摘要

Objective The aims of this study were to evaluate the morbidity of osteoporosis and the relationship between bone mineral density ( BMD ) and bone metabolic markers in the patients with spine degeneration disease needing surgery, at the same time to observe the influence of type 2 diabetes mellitus on bone metabolism and BMD.Methods This retrospective analysis included 139 patients suffered by spine degeneration disease needing surgery from the October 2013 to October 2014 in Beijing Jishuitan Hospital. Lumbar BMD was measured by quantitative computed tomography ( QCT) before surgery.Serum N-terminal propeptide of type I procollagen ( PINP) , βC-terminal cross-linked telopeptide of type I collagen (β-CTX), osteocalcin (OC) , 25-hydroxyvitamin D[25(OH)D], parathyroid hormone (PTH), calcium and phosphorus were quantified simultaneously.The relationship between the results of lumbar BMD measured by QCT and bone metabolic markers was analyzed by partial correlation.The differences of bone metabolic markers among three groups classified according to BMD were performed by one-way ANOVA and analysis of covariance.The influence factors of lumbar BMD measured by QCT were analyzed by multifactor linear regression.T-test was used to analyze the differences of BMD and bone metabolic markers between two groups with and without type 2 diabetes mellitus.Results The average age of 139 patients was(62.74 ± 6.83) years old.Lumbar BMD revealed that the percentage of osteoporosis, osteopenia and normal BMD were 40.2%(56/139) , 43.8% (61/139) and 16% (22/139) separately.The percentage was 47%(66/139) in subjects with 25(OH)D below 30 nmol/L.The percentage of subjects with the concentrations of 25 ( OH ) D between 30-50 nmol/L was 40% ( 55/139 ) , while the percentage of subjects with the concentrations of 25(OH)D between 50-125 nmol/L was only 13% (18/139).Partial correlation analysis revealed that lumbar BMD measured by QCT was negatively correlated with PINP ( r=-0.352, P<0.01) ,β-CTX ( r=-0.356, P<0.01 ) and OC ( r=-0.276, P=0.001 ) with gender and type 2 diabetes mellitus as covariates.Along with the age of patients increasing and BMD reducing, the levels of PINP,β-CTX and OC increased gradually and the differences were statistically significant ( F=11.575, P<0.01;F=11.550, P<0.01; F=9.738, P<0.01).Multiple linear regression analysis revealed that age and PINP were the main factors that influenced the change of BMD in the patients with spine degeneration disease needing surgery (β=-1.863, t=-5.425, P<0.01;β=-0.393, t=-2.061, P=0.041) .Subjects were divided into diabetes group and non-diabetes group according to the clinical diagnosis and whether having abnormal serum glucose.The levels of PINP (36.56 ±14.56 versus 49.51 ±16.68μg/L) ,β-CTX (0.39 ±0.20 versus 0.52 ±0.21 μg/L) and OC (14.21 ±5.13 versus 20.74 ±6.84 μg/L) in serum between two groups had significant differences (t=3.648, P<0.01;t=2.754, P<0.01;t=4.573, P<0.01) .Conclusions There was prevalence of osteoporosis, osteopenia and vitamin D deficiency in the patients with spine degeneration disease needing surgery.The patients with high level of PINP and age were more prone to appear lower BMD which increasing the risk of osteoporosis.The patients combined with type 2 diabetes mellitus had suppressed bone markers which maybe the risk factor, independent of BMD, increasing fracture risk.%目的：探讨脊柱退行性疾病需手术治疗患者骨质疏松的发生情况，并分析其骨代谢指标与骨密度（ BMD）之间的关系以及合并2型糖尿病对骨代谢和BMD的影响。方法回顾性研究。选取2013年10月至2014年10月期间北京积水潭医院脊柱外科收治的脊柱退行性疾病需手术治疗患者139例。患者术前进行腰椎定量CT（ QCT）骨密度测量，同时测定其血清中Ⅰ型前胶原氨基端延长肽（PINP）、Ⅰ型胶原羧基端肽β特殊序列（β－CTX）、N－端骨钙素（OC）、25－羟基维生素D[25（OH） D]、甲状旁腺激素（ PTH）和血清钙、磷的水平。采用偏相关分析腰椎QCT骨密度与骨代谢指标的关系，方差、协方差分析BMD水平不同的3组间骨代谢指标的差异，多因素线性回归分析腰椎QCT骨密度的影响因素。 t检验比较BMD与骨代谢指标在2型糖尿病有无的两组间的差异。结果研究对象平均年龄（62．74±6．83）岁，腰椎BMD结果显示骨质疏松的发生率为40．2％（56／139），骨量减少的发生率为43．8％（61／139），骨量正常的比例仅有16．0％（22／139）。25（OH）D ＜30 nmol／L的比例为47％（66／139），30～50 nmol／L的比例为40％（55／139），50～125 nmol／L的比例仅为13％（18／139）。偏相关分析提示在控制性别、糖尿病的作用后，腰椎QCT骨密度与PINP、β－CTX、OC呈负相关（r＝－0．352，P＜0．01；r＝－0．356， P＜0．01；r＝－0．276， P＝0．001）。并且随着患者年龄的增大、BMD的下降，PINP、β－CTX、OC水平逐渐升高，差异有统计学意义（ F＝11．575，P＜0．01；F＝11．550， P＜0．01；F＝9．738，P＜0．01）。多因素线性回归分析结果提示年龄、PINP是决定脊柱退行性疾病需手术患者BMD变化的主要影响因素（β＝－1．863，t＝－5．425，P＜0．01；β＝－0．393，t＝－2．061， P＝0．041）。根据有无血糖异常及2型糖尿病的诊断，将研究对象分为糖尿病组和无糖尿病组，两组间的PINP（36．56±14．56和49．51±16．68μg／L）、β－CTX（0．39±0．20和0．52±0．21μg／L）、OC （14．21±5．13和20．74±6．84μg／L）水平差异均有统计学意义（ t＝3．648， P＜0．01； t＝2．754， P＜0．01；t＝4．573， P＜0．01）。结论脊柱退行性疾病需手术治疗患者普遍存在骨质疏松、骨量减少和维生素D缺乏的状况。伴有PINP水平升高的老龄患者，更容易发生BMD的降低，增加骨质疏松症的发病风险。合并2型糖尿病的患者处于一种低骨转换状态，这可能是不依赖于BMD、增加骨折风险的独立危险因素。（中华检验医学杂志，2016，39：267－271）