Definition of osteoporosis: a systemic bone loss disease with chronic low back pain and even deformity and fracture as the main manifestation. It is a systemic bone disease that predisposes middle-aged and elderly people to suffer from.
Osteoporosis (osteoporosis) is a systemic bone disease characterized by decreased bone mass and destruction of the microstructure of bone, Zhang Ge, Department of Acupuncture and Moxibustion, Chen Yong Studio, Department of Orthopedic Surgery, Chengfei Hospital
It manifests as increased brittleness of bone and thus a much increased risk of fracture, which can easily occur even with minor trauma or without trauma. Osteoporosis is a chronic disease caused by multiple factors. There are usually no specific clinical manifestations until a fracture occurs. The disease is more common in women than men, and is commonly seen in postmenopausal women and the elderly. With the increase of the elderly population in China, the incidence of osteoporosis is on the rise and is a health concern in China and worldwide.
Osteoporosis was introduced by Pornmer in 1885, but people’s understanding of osteoporosis has gradually deepened with the development of history and technological advances. In the early years, it was generally considered that a decrease in bone mass throughout the body was osteoporosis, while in the United States, fractures in the elderly were considered osteoporosis. It was not until the 3rd International Symposium on Osteoporosis held in Denmark in 1990 and the 4th International Symposium on Osteoporosis held in Hong Kong in 1993 that osteoporosis was given a clear definition and recognized worldwide: primary osteoporosis is a systemic bone disease characterized by a decrease in bone mass and degeneration of bone microstructure, resulting in an increase in bone fragility and susceptibility to fracture. International Osteoporosis Day is celebrated on October 20 every year.
Understanding of the definition of the concept and understanding
①Decrease in bone mass: It should include the decrease of bone mineral and its matrix in equal proportion.
②Bone microstructure degeneration: due to imbalance of bone tissue resorption and formation, which is manifested by destruction, thinning and fracture of bone trabecular structure.
③Bone brittleness increases, bone mechanical strength decreases, fracture risk increases, and microfracture or complete fracture easily occurs due to reduced load bearing capacity. Compression fractures of the lumbar spine may occur silently, or fractures of the distal end of the flexor, proximal femur, and upper end of the limb bone may occur with little external force.
Causes of morbidity
The specific causes of osteoporosis are not fully understood and are generally considered to be related to the following factors.
Endocrine factors
In female patients, osteoporosis is caused by estrogen deficiency, while in men, it is caused by a decrease in testosterone levels due to hypogonadism. Osteoporosis is particularly common in postmenopausal women, and premature ovarian failure causes osteoporosis to appear earlier, suggesting that a decrease in estrogen is an important factor in the development of osteoporosis.
Osteoporosis
The osteoporosis is a major factor in the development of osteoporosis. About 20%-30% of early menopausal women have bone loss >3%/year, which is called rapid bone loss, while 70%-80% of women have bone loss <3%/year, which is called normal bone loss. Lean women are more prone to osteoporosis and fractures than fat women, as a result of the conversion of androgens to estrogens in the latter's adipose tissue. Compared to normal women of similar age, no significant differences in blood estrogen levels were seen in patients with osteoporosis, suggesting that decreased estrogen is not the only factor causing osteoporosis.
In general, the presence of physiological decompensation of renal function in the elderly is manifested by reduced production of 1,25-(OH2)D3 and lower blood calcium, which in turn stimulates the secretion of parathyroid hormone, so most scholars report that blood parathyroid hormone concentrations often increase with age, with increases of up to 30% or more. Studies of parathyroid function in postmenopausal women with osteoporosis have shown hypo-, normal-, and hyper-function. It is generally believed that osteoporosis in the elderly is associated with hyperparathyroidism.
Some studies have shown lower calcitonin levels in women than in men in all age groups, and lower calcitonin levels in women in the menopausal group than in menopausal women, so it is thought that lower calcitonin levels may be one of the reasons for women’s susceptibility to osteoporosis. The increased value of blood calcitonin in women after intravenous calcium drip was significantly lower than that in men, and both the basal and increased values of blood calcitonin were negatively correlated with age. The Department of Endocrinology at Peking Union Medical College Hospital reported that no significant difference in calcitonin reserve function was seen in premenopausal and postmenopausal healthy volunteers who underwent intravenous calcitonin excitation tests. In contrast, calcitonin reserve function was reduced in both patients with reduced bone mass and osteoporosis, with the latter being more pronounced, suggesting that reduced calcitonin reserve function may be involved in the development of osteoporosis. Blood calcitonin levels in postmenopausal women with osteoporosis have mostly been reported to be reduced, but normal and mildly elevated levels have also been reported.
Osteoblast function, 1-alpha-hydroxylase activity of the kidney, which is impaired with aging, and the associated decrease in 1,25-(OH2)D3 concentration, are also involved in the formation of osteoporosis. Other endocrine disorders, such as Cushing’s syndrome, which produces excessive endogenous corticosteroids or chronic thyrotoxicosis, lead to increased bone resorption or excretion, which are associated with osteoporosis formation.
Osteoporosis
Genetic factors
Osteoporosis is more common in whites, especially in northern European races, followed by Asians, and less common in blacks. BMD is an important indicator for the diagnosis of osteoporosis, and the value of BMD is mainly determined by genetic factors, followed by environmental factors. The difference in BMD between young twins has been reported to be four times greater than the difference between monozygotic twins; while in adults the difference in BMD between twins is 19 times greater than that between monozygotic twins. In 1994, Morrison et al. reported that the vitamin D receptor genotype predicted differences in BMD, accounting for 75% of the overall genetic effect, and that BMD was about 15% higher in bb genotypes than in BB genotypes after adjustment for various environmental factors; in terms of vertebral fracture incidence, bb Preliminary results of this study show that there are significant differences among races and countries, and the final results need to be further investigated. Other studies on the relationship between collagen and estrogen receptor genes and osteoporosis have also been reported, but no definite conclusions have been drawn yet.
Nutritional factors
Calcium intake in adolescence has been found to be directly related to peak bone mass in adulthood. Calcium deficiency leads to increased PTH secretion and bone resorption, and people on low-calcium diets are prone to osteoporosis. Vitamin D deficiency leads to impaired mineralization of the bone matrix and can lead to osteochondrosis. Long-term protein deficiency causes insufficient synthesis of bone mechanism protein, resulting in backward new bone production, and if there is also calcium deficiency, osteoporosis will appear faster. Vitamin C is indispensable for the synthesis of hydroxyproline in bone matrix, which can maintain the normal growth of bone matrix and maintain bone cells to produce sufficient amount of alkaline phosphatase, and the lack of vitamin C can reduce the synthesis of bone matrix.
Abuse factors
Muscle produces mechanical force on bone tissue, and strong bones with developed muscles have high bone density values. Due to the reduced activity of the elderly, muscle strength is weakened, mechanical stimulation is less, and bone mass is reduced. At the same time, the weakened muscle strength and coordination disorders make the elderly more prone to falls and fractures when accompanied by reduced bone mass. In addition, the elderly are prone to osteoporosis because of the loss of bone mass due to disuse factors after prolonged bed rest and inactivity after stroke and other diseases.
Drugs and diseases
Anticonvulsants, such as sodium phenytoin, phenobarbital, and carbamazepine, cause treatment-related vitamin D deficiency, as well as impaired intestinal calcium absorption, and secondary hyperparathyroidism. Excessive use of acid preparations, including aluminum preparations, can inhibit phosphate absorption and lead to the breakdown of bone minerals. Glucocorticoids directly inhibit bone formation, decrease intestinal absorption of calcium, increase renal excretion of calcium, secondary parathyroid dysfunction, and production of sex hormones. Long-term use of heparin is associated with osteoporosis, and the exact mechanism is not known. Chemotherapeutic agents, such as cyclosporine A, have been shown to increase bone renewal in rodents.
Cytokines produced by tumor cells in tumors, especially multiple myeloma, activate osteoclasts, as well as leukemia and lymphoma in children or adolescents, in which osteoporosis is often limited. Gastrointestinal disorders, such as inflammatory bowel disease leading to malabsorption and eating disorders; anorexia nervosa leading to rapid weight loss as well as malnutrition, and associated with absence of menstruation. Dysgerminogenic anemia, resulting from excessive bone marrow hyperplasia and thinning of the trabecular junction, and secondary hypogonadism are also seen in this group of patients.
Other factors
Alcohol abuse has a direct toxic effect on bone. Smoking increases the metabolism of estrogen by the liver and has a direct effect on bone, as well as causing weight loss and early menopause. Prolonged heavy exercise can lead to idiopathic osteoporosis.
Pathogenesis
Osteoporosis is the result of a combination of genetic and environmental factors that affect peak bone mass and the loss of bone mass and eventual progression to osteoporosis. These factors include medications, diet, race, gender, and lifestyle. Osteoporosis can be primary or secondary. Primary osteoporosis can be classified as type I and type II, and secondary osteoporosis is also known as type III osteoporosis. In this article, we focus on primary osteoporosis.
Type I or known as postmenopausal osteoporosis
It is believed that its primary cause is a defect in gonadal (estrogen and testosterone) function, and that estrogen and testosterone deficiency, which occurs at any age, accelerates bone loss. The exact mechanism of bone loss is not fully understood and the causes are multifaceted, the most important of which are the increased recruitment and sensitivity of preosteoclastic cells and the rate of bone resorption that exceeds bone formation. In postmenopausal women, bone loss increases at a rate of 1% to 5% per year during the first 5-7 years, resulting in a reduction in bone trabeculae and a predisposition to Colles’ fracture and vertebral fractures.
Estrogen deficiency increases the sensitivity of bone to the action of parathyroid hormone (PTH), resulting in increased calcium loss from bone, decreased renal excretion of calcium, and increased production of 1,25-(OH)2D3. increased 1,25-(OH)2D3 promotes calcium absorption in the intestine and kidneys and promotes bone resorption by increasing the activity and number of osteoclasts. secretion of PTH decreases through a negative feedback mechanism, causing the opposite effect as described above. PTH secretion decreases through a negative feedback mechanism, causing the opposite effect as described above. Osteoclasts are also affected by cytokines such as TNF-α, IL-1 and IL-6, which are produced by monocytes and are increased in the absence of sex hormones.
Type II, or senile osteoporosis
is seen in both men and women and stems from decreased bone formation and decreased renal formation of 1,25-(OH)2D3 in the elderly. The result of these physiological changes is a loss of bone cortex as well as bone trabeculae, increasing the risk of fracture of the hip, long bones, and vertebrae.
Type III osteoporosis secondary to medications
especially glucocorticoids, or various other pathologies that increase bone loss.
In type I and type II osteoporosis, women are more common, with a male to female ratio of 6:2 (type I) and 2:1 (type II), respectively, while in type III osteoporosis, there is no difference in the incidence ratio between men and women. The peak age of onset of type I osteoporosis is 50 to 70 years old, the high incidence of type II osteoporosis is over 70 years old, and the onset of type III osteoporosis has little relationship with age and can be seen at any age.
Examination
Blood calcium, phosphorus and alkaline phosphatase
In primary osteoporosis, serum calcium, phosphorus and alkaline phosphatase levels are usually normal, and alkaline phosphatase levels may increase several months after fracture.
Blood parathyroid hormone
Parathyroid function should be checked to exclude secondary osteoporosis. Blood parathyroid hormone levels may be normal or elevated in primary osteoporosis.
Markers of bone renewal
Some serologic biochemical markers in patients with osteoporosis can respond to the state of bone turnover (including bone formation and bone resorption). These markers can be elevated in a state of high bone turnover (e.g., type I osteoporosis) and can also be used to monitor the early response to treatment. However, their clinical significance in osteoporosis remains to be further investigated. These biochemical measures include bone-specific alkaline phosphatase (BSP), tartrated resistant acid phosphatse (TSP), osteocalcin (Osteocalcin), type I procollagenpeptidase (Type I procollagenpeptidase), and osteoporosis. I procollagenpeptidase, in response to bone formation), Urinary pyridinoline and Urinary deoxypyridinoline, in response to bone resorption, and N-C-terminal cross-linked peptide of type I collagen (cross-linked N- and C-telopeptide of type I collagen, in response to bone resorption).
Morning urine calcium/creatinine ratio
The normal ratio is 0.13±0.01. Excessive urinary calcium excretion increases the ratio, suggesting a possible increase in bone resorption.
Bone imaging and bone density
X-rays should be taken for patients with localized symptoms Lateral films of the area should be taken even for patients without spinal symptoms to avoid missing vertebral fractures X-rays can detect fractures and other lesions such as osteoarthritis, disc disease, and anterior spinal displacement Bone loss (low bone density) is seen on radiographs with increased bone translucency, decreased bone trabeculae and widened gaps, loss of transverse trabeculae, and blurred bone structure, but usually requires a 30% or greater decrease in bone volume to be observed. Biconcave deformation of the vertebral body due to disc bulge and collapse of the anterior edge of the vertebral body in a wedge shape, also known as compression fracture, are commonly seen in the 11th and 12th thoracic vertebrae and the 1st and 2nd lumbar vertebrae.
Bone mineral density (BMD) is the best predictor of fracture. Measuring BMD at any site can be used to assess the overall risk of fracture; measuring BMD at a specific site can predict the risk of localized fracture.
According to the latest treatment guidelines of the National Osteoporosis Foundation, BMD testing is required for the following groups: postmenopausal women over 65 years of age who are at risk for osteoporosis despite preventive measures and should be treated accordingly if osteoporosis is present; postmenopausal women younger than 65 years of age who have one or more risk Postmenopausal women younger than 65 years of age with one or more risk factors; postmenopausal women with fragility fractures; women who need treatment based on BMD measurements; women on long-term hormone replacement therapy; men with fractures following minor trauma; and people with X-rays showing bone loss and other conditions that can lead to osteoporosis.
By comparing BMD with that of healthy adults, WHO recommends grading osteoporosis based on BMD values, specifying that BMD values plus or minus 1 standard deviation (SD) in normal healthy adults are normal, and that a decrease (1 to 2.5) SD from normal is considered bone loss; a decrease of 2.5 SD or more is considered osteoporosis; and a decrease of 2.5 SD or more with a fragility fracture is considered severe osteoporosis.
There are various methods to determine BMD, among which quantitative computerized tomography (QCT) is the most accurate method to measure BMD in g/cm3, which is not affected by bone size and can be used in adults and children. However, QCT can only measure the BMD of the spine, and bone redundancy can interfere with the measured value, and the cost is high, and the radiation exposure should not be underestimated.
Dual energy x-ray absorptiometry (DXA) is a less expensive and more reproducible method than QCT and can be used in both adults and children. DXA can measure BMD of the spine as well as the hip and is considered the standard method for measuring BMD, although there are differences in DXA correction values. It is recommended that patients be followed up on the same machine for continuous BMD measurements. factors affecting DXA measurements include spinal fractures, bone fragments, and extra-spinal calcifications such as aorta. Peripheral DXA can determine BMD of the wrist.
Quantitative ultrasound (US) of the heel can be used for general screening, which is inexpensive, portable, and free of ionizing radiation, but the method is not as accurate as QCT and DXA and therefore is not used to monitor treatment outcomes.
Radiography (radiogrametry), usually used to determine the bone cortex of the hand, especially the second metacarpal. This method can be used to determine BMD in children and is the most inexpensive. However, it is not as accurate as DXA and is not as sensitive to changes in BMD.
Clinical manifestations
(1) Pain. The most common symptom of primary osteoporosis is low back pain, which accounts for 70%-80% of patients with pain. The pain spreads along the spine to both sides, decreases when lying on the back or sitting, increases when posterior extension or prolonged standing or sitting, is light during the day, increases at night and when waking up in the morning, and increases when bending, muscle movement, coughing and stooling. Bone pain generally occurs when 12% or more of bone mass is lost. In old age osteoporosis, the vertebral trabeculae atrophy and decrease in number, the vertebral body compresses and deforms, the spine flexes forward, the lumbar rash muscle doubles its contraction in order to correct the forward flexion of the spine, the muscle fatigue or even spasm, producing pain. A recent compression fracture of the thoracolumbar spine can also produce acute pain, with strong pressure pain and percussion pain in the spinal spinous process at the corresponding site, which can generally be gradually reduced after 2-3 weeks, and some patients can present with chronic low back pain. If the corresponding spinal nerve is compressed, radiating pain in the extremities, sensory-motor disorders in both lower extremities, intercostal neuralgia, retrosternal pain similar to angina pectoris, or epigastric pain similar to acute abdomen may occur. If compression of the spinal cord and cauda equina also affects bladder and rectal function.
(2) Shortening of body length and hunchback. Most of them appear after the pain. The front part of the vertebrae of the spine is composed of almost all cancellous bones, and this part is the pillar of the body with a large weight, especially the 11th and 12th thoracic vertebrae and the 3rd lumbar vertebrae, which have a greater load and are easily compressed and deformed, causing the spine to tilt forward and the dorsal curvature to increase, resulting in a hunchback. Each person has 24 vertebrae, the height of each vertebra is about 2cm in normal people, the vertebrae compress when the elderly osteoporosis, each vertebrae shorten about 2mm, the average length of the body shortened 3-6cm.
(3) Fracture. This is the most common and serious complication of degenerative osteoporosis, which not only increases the patient’s pain, aggravates the economic responsibility, and seriously limits the patient’s activities, and even shortens life expectancy. According to our statistics, the incidence of fractures in the elderly is 6.3%-24.4, especially in elderly women (over 80 years old). Fractures caused by osteoporosis are more common in the early stages of old age with distal radius fractures (Colles fractures), and later in old age with fractures of the lumbar spine and upper femur. Fractures generally occur when 20% or more of bone mass is lost, and for every 1.0 DS decrease in BMD, the incidence of vertebral fractures increases 1.5-2 times. About 20%-50% of patients with vertebral compression fractures have no obvious symptoms.
(4) Decreased respiratory function. Compression fractures of the thoracic and lumbar spine, backward curvature of the spine, and thoracic deformity can significantly reduce lung capacity and maximum ventilation, and the incidence of lobar emphysema in the anterior region of the upper lobe of the lung can be as high as 40%. Most elderly people have no degree of emphysema, lung function decreases with age, and if combined with thoracic deformity due to osteoporosis, patients often have symptoms such as chest tightness, shortness of breath, and difficulty breathing.
Once the symptoms arise, the body shape changes, which is a blow to people who love beauty, plus pain, mobility problems, medical payment for fracture surgery, etc., which is a great burden to individuals, families and society. At present, there is no safe and effective method in the medical field to help restore the original shape of the loosened bones, therefore, preventive health care is very important, do not neglect the “bone care” work is not yet your turn, and do not think that you are too old to do so, it is never too late to preserve the bones.
Classification
Osteoporosis can be divided into three main categories.
The first category is primary osteoporosis, which is a physiological degenerative lesion that inevitably occurs with age. This type is divided into 2 types, type Ι for postmenopausal osteoporosis, which is seen in women shortly after menopause. type Π for senile osteoporosis, which occurs mostly after the age of 65.
The second type is secondary osteoporosis, which is triggered by some factors such as other diseases (e.g. kidney failure, excess thyroid hormones or leukemia), or drugs (e.g. steroids).
The third category is idiopathic osteoporosis, which is mostly seen in adolescents or adults between the ages of 8 and 14 years old, most of whom have a genetic family history and more women than men. Osteoporosis that occurs during pregnancy and lactation in women can also be included in idiopathic osteoporosis.
Treatment
Western medical treatment
There are five types of medications used to treat osteoporosis as follows.
1. Hormonal supplementation therapy: estrogen plus luteinizing hormone can prevent and treat osteoporosis. If there is no uterus, progesterone is not needed.
2. Alendronate (alendronate): the trade name Fosamax inhibits the action of osteoclasts and has the effect of preventing and treating osteoporosis.
Calcitonin: absorbed by subcutaneous, intramuscular or nasal injection, effective for women with osteoporosis who have stopped menstruating for more than five years. Side effects include loss of appetite, flushing, rash, nausea and dizziness.
However, as soon as the medication is stopped, the rate of bone loss will begin to accelerate, so long-term treatment is necessary.
4. calcium and vitamin D: the combination is more effective.
5. Bone peptide preparation, a new clinical drug used to treat rheumatoid rheumatism, is effective for osteoporosis.
Postmenopausal osteoporosis is a high prevalence of postmenopausal women, foreign statistics show that the risk rate of occurrence in women over 60 years old is 58%. It is associated with reduced levels of hormones synthesized by the ovaries, resulting in bone pain and fractures, which seriously affects the quality of life of women and increases their disability and mortality rates. Since its pathogenesis has not been completely elucidated, the treatment of drugs has certain limitations, and the long-term use of Western medicine is likely to bring many side effects to patients.
A scientific study on health care acupuncture for the middle-aged and elderly found that moxibustion can increase serum estrogen levels in healthy elderly people. Inspired by this, the researchers, based on traditional Chinese medical theory and modern medical research on postmenopausal osteoporosis, concluded that the root cause of postmenopausal osteoporosis is “kidney deficiency”, combined with acquired disorders and other causes of osteoporosis, and that treatment is based on kidney tonification, combined with the method of strengthening the spleen. The clinical effect was observed by using dual-energy X-ray bone densitometry (DEXA) and related biochemical test indexes, and a drug control group was set up to compare the efficacy. After treatment, the patient’s bone pain and other symptoms were first relieved or disappeared, and the biochemical indexes improved significantly. After 6 months, the bone density test had improved to different degrees, and the bone density of the 2nd to 4th lumbar vertebra and the upper end of the femur increased significantly.
Traditional Chinese medicine treatment: Patients may use it at their discretion.
Prevention of osteoporosis in addition to drug treatment, at the same time to apply nutrition, diet, exercise and other methods at the same time, often can achieve satisfactory results.
Prevention
Osteoporosis brings great inconvenience and pain to patients’ lives, and the treatment is slow and life-threatening in case of fracture, therefore, special emphasis should be placed on the implementation of the three levels of prevention.
(1) Primary prevention: We should start with children and adolescents, such as paying attention to proper diet and nutrition, and consuming more foods with high Ca and P content, such as fish, shrimp, shrimp skin, kelp, milk (250ml contains Ca300mg), dairy products, bone broth, eggs, beans, refined grains, sesame seeds, melon seeds, green leafy vegetables, etc. Try to get rid of “risk factors”, adhere to a scientific lifestyle, such as adhere to physical exercise, more sunbathing, do not smoke, do not drink alcohol, less coffee, strong tea and carbonated beverages, less sugar and salt, animal protein should not be too much, late marriage, less childbearing, breastfeeding period should not be too long, as far as possible to preserve the calcium in the body, enrich the calcium pool, the bone The best measure to prevent osteoporosis in the later stages of life is to increase the peak value of calcium to the maximum. Strengthen the basic research of osteoporosis, and focus on the follow-up and early prevention for the high-risk groups with genetic predisposition.
(2) Secondary prevention: bone loss accelerates in middle age, especially after menopause in women. Bone density examination should be conducted annually during this period, and prevention and control measures should be taken early for people with rapid bone loss. In recent years, most scholars in Europe and the United States advocate starting long-term estrogen replacement therapy within 3 years after menopause, and at the same time insisting on long-term preventive calcium supplementation or using bone peptide oral preparation bone peptide tablets for preventive treatment, in order to safely and effectively prevent osteoporosis. In Japan, it is mostly advocated to prevent osteoporosis with active Vit D (rocalciferol) and calcium, and to pay attention to the active treatment of diseases related to osteoporosis, such as diabetes, rheumatoid arthritis, steatorrhea, chronic nephritis, hyperparathyroidism/hyperthyroidism, bone metastatic cancer, chronic hepatitis, liver cirrhosis, etc.
(3) Tertiary prevention: Patients with degenerative osteoporosis should be actively treated with medication to inhibit bone resorption (estrogen, CT, Ca), promote bone formation (active Vit D), oral preparations of bone peptide (bone peptide tablets), and should also strengthen measures to prevent falls, bumps, trips and upsets. For middle-aged and elderly fracture patients, they should be actively operated, implement strong internal fixation, early activity, physical therapy, physiotherapy psychological, nutrition, calcium supplementation, pain relief, promote bone growth, curb bone loss, improve immune function and overall quality and other comprehensive treatment.
Degenerative osteoporosis is the basic law of bone development, growth and aging, but is subject to hormonal regulation (mainly PTH bone breaking: estrogen, CT osteogenesis; Vit D3 two-way regulation), nutritional status, physical factors (sunlight, weight), immune status (systemic physique, disease), genetics, lifestyle (smoking, alcohol, coffee, diet, exercise, mental and emotional), economic and cultural If we can strengthen the awareness of self-care, improve the level of self-care and actively intervene scientifically at an early stage, degenerative osteoporosis can be delayed and prevented, which will have important and realistic social and economic benefits to improve the physical and mental health and quality of life of hundreds of millions of middle-aged and elderly people in China.