I. Concept of osteoporosis
Primary osteoporosis is a systemic skeletal disease with reduced bone mass, degradation of bone microstructure, increased bone fragility and easy fracture, and is an age-related degenerative disease. Secondary osteoporosis is osteoporosis induced by other diseases or drugs. The pathological anatomy shows thin bone cortex and sparse atrophy of bone trabeculae.
Epidemiological profile
Osteoporosis is mostly seen in the elderly. The prevalence of osteoporosis in people over 40 years old is 12.4% in the five major regions of northeast, north, east, south and southwest China, and is higher in women than in men. Women lose an average of 10% of their bone mass every 10 years. 1/3 of women aged 60-70 years suffer from osteoporosis, and 2/3 of women aged 80 years or older. Although the prevalence of osteoporosis in older men is lower than that of women in the same age group, they are also at risk of serious fractures.
Third, the harm
Long-term pain affects the quality of life. Fractures can occur if you are not careful, and they are difficult to heal.
Bone structure
Bone is composed of four types of cells: osteoblasts, osteoclasts, osteoblasts and osteoprogenitor cells. Osteoblasts are located in the inner layer of the periosteum and are the stem cells of bone tissue, which can continuously proliferate and differentiate into osteoblasts. Osteoblasts can synthesize and secrete bone-like material and embed themselves in it, then become osteocytes. Osteoblast cells are larger in size and their main function is to absorb bone, one osteoblast can absorb the bone formed by 100 osteoblasts.
The bone matrix consists of organic matrix (including type I collagen and mucopolysaccharide) and bone mineral salts (calcium phosphate and calcium carbonate). Calcium salts are deposited into the bone-like matrix to harden the bone tissue.
V. Bone reconstruction
Osteoclasts resorb the old bone locally and then form new bone by osteoblasts to fill the gap, this dynamic equilibrium state of “how much is broken and how much is built” is called “reconstruction coupling”. This dynamic balance of “how much is broken and how much is built” is called “reconstruction coupling”. 9% of the body’s annual bone volume undergoes bone reconstruction. This means that every 11 years, the entire body is renewed. Bone reconstruction allows for the repair of microscopic damage within the bone, maintains bone biomechanical function and contributes to mineral stability.
The process of bone reconstruction is also called “bone turnover”, which requires five stages: initiation, activation, resorption, formation and mineralization, and its active degree is called bone turnover rate.
Sixth, the factors that induce osteoporosis
Calcium deficiency is a recognized factor. Calcitonin and vitamin D deficiency is also important sex hormone secretion is reduced.
With age, the secretion of calcium-regulating hormones becomes dysregulated. Tooth loss and reduced digestive function, nutritional deficiencies. Decreased mechanical stimulation of bones due to reduced outdoor exercise and non-weight bearing. Vitamin D receptor gene variants are closely related. Bone loss is more likely to occur in acidic body types. The cause of idiopathic osteoporosis is unknown.
VII. Endocrine diseases causing osteoporosis.
1, cortisolism.
2, hyperthyroidism.
3, diabetes mellitus.
4, acromegaly.
5.Primary hyperparathyroidism.
6, Osteogenesis imperfecta.
7, Cystinuria.
8, rheumatoid arthritis.
Eight, osteoporosis pain mechanism
Increased bone resorption during bone transformation, destruction of bone trabeculae, destruction of subperiosteal cortical bone, and osteolysis by osteoclasts itself can cause pain, mainly nocturnal pain. Microfractures caused by mechanical stress, usually appear after minor trauma, with pain mainly after exertion vertebral compression deformation, spinal forward flexion, lumbar major muscle in order to correct spinal forward flexion, doubling contraction muscle fatigue or even spasm, resulting in pain. Recent compression fractures of the thoracolumbar spine can also produce acute pain, and the corresponding part of the spinal spinous process can be strongly compressed and percussion pain and chronic low back pain. The corresponding spinal nerve compression produces radiating pain in the extremities, sensory-motor disorders in both lower extremities, intercostal neuralgia, retrosternal pain similar to angina pectoris, and also epigastric pain similar to acute abdomen.
Clinical characteristics of osteoporosis pain There are no obvious symptoms in the early stage, and pain mostly appears in the middle and late stages of the disease. In general, bone pain can appear when 12% or more of bone mass is lost. 67-80% of patients show bone pain and muscle pain in the lower back, both hips, lower limbs and even the whole body. 10% of patients have numbness in the limbs and 9% have radiating pain in the limbs. The pain is relieved when lying down or sitting, and increased when posterior extension or prolonged standing or sitting;
The pain is light during the day and worsens at night and when waking up in the early morning; it is aggravated when bending, muscle movement and exertion. Once a fracture occurs, including microfractures that are difficult to detect clinically, severe acute pain can erupt, and the slightest activity can cause “excruciating” pain.
Men have lower bone pain than women, probably due to their higher pain threshold, their education and character development, their reluctance to express pain, and their lower level of concern for themselves than women, resulting in a lower rate of visits to the doctor for pain. The proportion of men who originally suffered from osteoporosis was lower than that of women.
IX. Differential diagnosis of osteoporosis pain
(1) Lumbar sprain and lumbar strain.
Patients with osteoporosis not only have muscle pain, but also pain caused by fractures of the thoracic and lumbar vertebrae. This pain is usually confined to the spinous process, and there is localized pressure and percussion pain of the spinous process.
(2) Pain caused by local bone destruction due to spinal metastases from malignant tumors or spinal tuberculosis.
Pain caused by fractures in patients with osteoporosis may gradually decrease after mandatory fixation of the spine or continuous fixation for 2-3 weeks, while the latter does not.
(3) Differential diagnosis of other common diseases.
Osteoarthritis
osteochondrosis
primary hyperparathyroidism
Multiple myeloma
X. Anti-osteoporosis treatment
1.Anti-bone resorption drugs.
1.Hormone replacement therapy (ERT).
Estrogen is the drug of choice to prevent and treat postmenopausal osteoporosis. Estradiol 1~2mg/day, ethylene estradiol 0.25mg/night, compound estrogen 0.625mg/d, nil estrol 2mg/half month. The commonly used representative drug is Liviai (Livia). This drug contains the activity of three steroid hormones: estrogen, progesterone and androgen. 1/4 of the normal dose (1.25~2.5mg/day) can significantly increase bone mass with few side effects. The use of ERT can reduce 33% of vertebral fractures and 27% of non-vertebral fractures.
The therapeutic effect of ERT diminishes with age. Long-term estrogen use is associated with breast pain, vaginal bleeding, procoagulant tendencies and increased incidence of breast cancer, so clinical promotion is compromised. Experts believe that if hormone replacement therapy is used properly, the benefits still outweigh the disadvantages.
2. Calcitonin.
Calcitonin secreted by thyroid C cells can inhibit osteoclast activity and bone ablation; it can also prevent multifunctional hematopoietic stem cells from transforming into osteoclasts, reduce the number of osteoclasts and resist bone resorption. Calcitonin can increase urinary calcium excretion to lower blood calcium, but its calcium-lowering effect is mainly through the inhibition of osteolysis and bone resorption.
Calcitonin has a significant effect on osteoporosis, acute and chronic pain caused by fractures, and bone pain caused by bone tumors, with a total efficiency of 95% in improving bone pain. Mechanism: Induces an increase in plasma β-endorphin levels; inhibits the synthesis of inflammatory mediators prostaglandins; strong anti-osteolytic effect
Commonly used drugs.
Calcineurin (calcitonin, eel calcitonin) 20U intramuscular injection, once a week for 10 times;
Calcitonin (salmon calcitonin) 50~100U intramuscular injection, starting from once a day or every other day, and then changed to twice a week after a week, with 1500U continuous injection.
Calcitonin is also available as a subcutaneous injection, absorbed by nasal spray and other delivery preparations and methods.
Side effects.
Include loss of appetite, flushing of the face, rash, nausea and dizziness. Occasionally, allergies may occur. Some calcitonin preparations are clinically required to be skin tested prior to use to increase the safety of this class of drugs.
Salmon calcitonin
A 32 amino acid peptide, salmon calcitonin has the highest biological activity of all calcitonins, 40-50 times that of human calcitonin, with better clinical efficacy and faster onset of action. Salmon calcitonin treats acute pain of osteoporosis, and also treats bone pain caused by other diseases.
3.Diphosphonate
Diphosphonates can selectively inhibit the maturation of osteoclast precursor transformation, inhibit the activity of osteoclasts, bind tightly with bone minerals, and directly block the resorption of bone by osteoclasts.
The representative drug of the third generation is alun phosphate sodium, which is the most adequate bisphosphonate in terms of evidence-based medicine. Compared to the placebo group, alendronate significantly reduced the cumulative incidence of hip fractures by 63% at 18 months of treatment. Alendronate improves BMD for at least 6 to 12 months of treatment and prevents fracture for at least 12 months of treatment.
2.Mineralizing effect drugs
1. Calcium agents.
Calcium is the basic therapeutic drug for osteoporosis, which increases bone mineral content by reducing bone conversion rate.
Since the absorption of calcium requires the participation of vitamin D, the clinical practice prefers calcium complexes containing vitamin D, such as calcium carbonate preparation Calcium-D, each capsule contains 600mg of calcium and 125U of vitamin D.
2, vitamin D.
Vitamin D active metabolite (1,25 a dihydroxyvitamin D) helps the absorption of calcium in the intestine.
Commonly used drugs are rocalciferol and alfacalcidol.
Medication is a long-term uninterrupted process, and bone loss will begin to accelerate as soon as medication is stopped, so lifelong treatment must be adhered to.
Other treatment measures
1.Analgesic drugs: Non-steroidal anti-inflammatory analgesics often cannot satisfactorily relieve pain in severe pain, and weak opioids are needed.
2.Nerve block and pain point injection.
3.Electromagnetic field, heat therapy, low-frequency pulse, transcutaneous electrical nerve stimulation: the pole plate is placed at the painful site and stimulated with high frequency and low voltage. L～2 times a day, 20-30min each time, 10 times a course of treatment.
4, percutaneous vertebroplasty: for patients with painful vertebral compression fractures. The direct fixation of vertebral microfractures by bone cement may be the main analgesic treatment mechanism, and also the temporary high temperature (local temperature can temporarily reach 70℃) caused by the heat released during the polymerization reaction of bone cement, which can cause the destruction of peripheral nerve endings and is also beneficial to pain relief.
XI. Special emphasis on the implementation of tertiary prevention
Primary prevention: universal health education stage.
Starting from children and adolescents, pay attention to diet to prevent osteoporosis.
Try to get rid of “risk factors”. Smoking, excessive alcohol consumption, strong coffee, excessive salt intake, excessive protein, etc.
Adhere to a scientific lifestyle, such as physical exercise, sunbathing.
Marry late, have fewer children, and do not breastfeed for too long, so as to preserve calcium in the body as much as possible and increase the peak bone mass to the maximum.
Secondary prevention.
Focus on follow-up and early prevention for high-risk groups with genetic predisposition. People with a family history of skeletal disease, Caucasians, fair complexion, smaller skeleton, less body fat, removed ovaries, never had children, early menopause, and allergic to dairy products are more likely to develop osteoporosis.
European and American scholars advocate starting long-term estrogen replacement therapy within 3 years after menopause, while insisting on long-term preventive calcium supplementation or using solid bone peptide preparation bone peptide tablets for prevention, in order to safely and effectively prevent osteoporosis. In Japan, active Vit D (rocalciferol) and calcium are mostly advocated for the prevention of osteoporosis.
Actively treat diseases related to osteoporosis, such as diabetes, rheumatoid arthritis, steatorrhea, chronic nephritis, hyperparathyroidism/hyperthyroidism, bone metastatic cancer, chronic hepatitis, liver cirrhosis, etc.
Tertiary prevention.
Patients with degenerative osteoporosis should be actively treated with drugs to inhibit bone resorption and promote bone formation to improve symptoms, prevent fractures and reduce the incidence of fractures.
Strengthen measures to prevent falls, bumps, trips and upsets.
Patients with middle-aged and elderly fractures should be actively operated, practiced internal fixation, early activity, physical therapy, physiotherapy, psychology, nutrition, calcium supplementation, pain relief, promotion of bone growth, curbing bone loss, improving immune function and overall quality, and other comprehensive treatment.