B GIO DC V O TO B Y T TRNG I HC Y H NI MC THY CHI NGHIÊN CứU ĐặC ĐIểM GãY XƯƠNG ĐốT SốNG NGựC Và THắT LƯNG TRÊN X QUANG BệNH NHÂN Nữ LOãNG XƯƠNG NGUYÊN PHáT LUN VN THC S Y HC H NI 2016 B GIO DC V O TO B Y T TRNG I HC Y H NI MC THY CHI NGHIÊN CứU ĐặC ĐIểM GãY XƯƠNG ĐốT SốNG NGựC Và THắT LƯNG TRÊN X QUANG BệNH NHÂN Nữ LOãNG XƯƠNG NGUYÊN PHáT Chuyờn ngnh: Ni khoa Mó s: 60720140 LUN VN THC S Y HC Ngi hng dn khoa hc: PGS.TS NGUYN MAI HNG H NI 2016 LI CM N Tụi xin c gi li cỏm n chõn thnh n ng y- Ban giỏm hiu, Phũng o to Sau i hc, b mụn Ni tng hp trng i hc Y H Ni ng y - Ban giỏm c, Phũng k hoch tng hp, Khoa C Xng - Khp, khoa Chn oỏn hỡnh nh - bnh vin Bch Mai ó to iu kin cho tụi thi gian hc v hon thnh lun Vi tt c lũng kớnh trng v bit n sõu sc tụi xin trõn trng cỏm n PGS.TS Nguyn Mai Hng, ngi thy luụn ng viờn dỡu dt, ginh nhiu thi gian quý bỏu, trc tip dy bo tụi v kin thc chuyờn mụn cng nh hng dn, giỳp tụi tng bc trng thnh trờn ng nghiờn cu khoa hc v hot ng chuyờn mụn Tụi xin trõn trng cm n cỏc thy cụ hi ng thụng qua cng v hi ng chm lun tt nghip, cỏc thy cụ ó úng gúp cho tụi nhiu ý kin quý bỏu giỳp tụi hon thin lun ny Tụi xin chõn thnh cm n Ban giỏm c, lónh o cỏc khoa phũng Bnh vin Chõm cu Trung ng, cựng cỏc ng nghip ó ht lũng ng h giỳp ng viờn tụi sut quỏ trỡnh hc v nghiờn cu Cui cựng cho tụi gi li cỏm n gia ỡnh, ngi thõn v bn bố Nhng ngi ó luụn bờn tụi, ng vin chia s, ginh cho tụi nhng iu kin tt nht giỳp tụi yờn tõm hc v nghiờn cu H Ni, ngy 15 thỏng 12 nm 2016 Hc viờn Mc Thựy Chi LI CAM OAN Tụi l Mc Thựy Chi, hc viờn cao hc khúa 23 - Trng i hc Y H Ni, chuyờn ngnh Ni khoa, xin cam oan: õy l lun bn thõn tụi trc tip thc hin di s hng dn ca PGS TS Nguyn Mai Hng Cụng trỡnh ny khụng trựng lp vi bt k nghiờn cu no khỏc ó c cụng b ti Vit Nam Cỏc s liu v thụng tin nghiờn cu l hon ton chớnh xỏc, trung thc v khỏch quan, ó c xỏc nhn v chp thun ca c s ni nghiờn cu Tụi xin hon ton chu trỏch nhim trc phỏp lut v nhng cam kt ny H Ni, ngy 15 thỏng 12 nm 2016 Mc Thựy Chi DANH MC CC CH VIT TT BMD Bone mineral Density ( mt xng) BMI Body Mas Index (Ch s c th) CSTL Ct sng tht lng CX C xng ựi DEXA Dual Energy Xray Absortiometry (phng phỏp o hp th tia X nng lng kộp) GXS Góy xng t sng IOF International Osteoporosis Foundation (Hip hi loóng xng Quc t) MX Mt xng OB Osteoblast (t bo to xng) OC Osteoclast (t bo hy xng) PTH Parathyroid Hormone (hormone cn giỏp) T-score lch so vi MX trung bỡnh ca ngi tr, trng thnh, cựng gii WHO World Health Organization (T chc y t th gii) MC LC T VN CHNG .3 TNG QUAN TI LIU 1.1 Gii phu ct sng 1.1.1 Gii phu v ct sng .3 1.2 i cng v cu trỳc, chc nng, chuyn húa ca xng 1.2.1 Cu trỳc xng 1.2.2 Chc nng ca xng .5 1.2.3 Cỏc yu t nh hng n chuyn húa xng 1.3 Tng quan v bnh loóng xng .7 1.3.1 nh ngha 1.3.2 C ch bnh sinh ca loóng xng 1.3.3 Phõn loi loóng xng 11 1.3.4 Cỏc yu t nguy c gõy loóng xng 12 1.4 Chn oỏn loóng xng 13 1.4.1 Triu chng lõm sng .13 1.4.2 Triu chng cn lõm sng .14 1.4.3 Tiờu chun chn oỏn loóng xng 16 1.4.4 Chn oỏn góy xng t sng loóng xng .16 1.5 Tỡnh hỡnh nghiờn cu loóng xng v góy xng ụt sng loóng xng hin 20 CHNG 22 I TNG V PHNG PHP NGHIấN CU 22 2.1 Thi gian v a im nghiờn cu 23 2.2 i tng nghiờn cu 23 2.2.1 Tiờu chun la chn 23 2.2.2 Tiờu chun loi tr 23 Bnh nhõn cú ớt nht mt cỏc tiờu chun sau: 23 2.3 Phng phỏp nghiờn cu 23 2.3.1 Thit k nghiờn cu 23 2.3.2 Chn mu nghiờn cu .23 2.3.3 Cụng c nghiờn cu 23 2.3.4 Cỏc bc tin hnh nghiờn cu .24 2.3.5 Ch s v bin s nghiờn cu 24 2.4 X lý s liu 30 2.5 o c nghiờn cu 30 2.6 S nghiờn cu 31 CHNG 32 KT QU NGHIấN CU 32 3.1 c im chung .32 3.1.1 Tui 32 3.1.2 c im ngh nghip 33 3.1.3 c im ch s nhõn trc, t s T-score, tui kinh, s nhúm nghiờn cu 33 3.1.4 Hon cnh xut hin bnh .34 3.1.5 c im triu chng lõm sng .35 3.1.6 c im cỏc yu t v tin s 36 3.2 c im góy xng t sng 36 3.2.1 T l góy xng t sng .36 3.2.2 V trớ góy xng t sng .37 3.2.3 S t sng b góy 37 3.2.4 Phõn b t sng góy 38 3.2.5 Mc góy xng ct sng ngc 38 3.2.6 Mc góy xng ct sng tht lng .39 3.2.7 Hỡnh dng t sng góy 40 3.2.8 Mc góy xng t sng 40 Xột tng s 98 t sng góy, mc góy ca cỏc t sng c th l:.40 3.3 ỏnh giỏ mt s yu t liờn quan n góy xng loóng xng nguyờn phỏt 41 3.3.1 Tui 41 3.3.2 Mi liờn quan gia c thự ngh nghip vi góy xng t sng 42 3.3.3 Mi liờn quan gia tin s góy xng vi góy xng t sng .43 3.3.4 Mi liờn quan gia s nm kinh vi góy xng t sng 43 3.3.5 Mi liờn quan gia s ngi sinh trờn vi góy xng t sng44 3.3.6 Mi liờn quan gia BMI vi góy xng t sng 44 3.3.7 Mi liờn quan gia T score v cú góy xng t sng 45 3.4 Phõn tớch hi qui logistic mt s c im lõm sng, cn lõm sng liờn quan n tỡnh trng góy xng S 46 3.5 Phõn tớch hi quy linear mt s c im lõm sng, cn lõm sng liờn quan n s t góy .47 3.6 Phõn tớch hi quy linear mt s c im lõm sng, cn lõm sng liờn quan n mc góy xng t sng .48 CHNG 50 BN LUN 50 4.1 c im chung ca bnh nhõn 50 4.1.1 Tui 50 4.1.2 Ch s ca c th .51 4.1.3 Tui kinh 52 4.1.4 T l gim mt xng ti cỏc v trớ o 52 4.1.5 c im, triu chng lõm sng 54 4.2 Nhng c im v góy xng t sng 54 4.2.1 T l góy xng t sng .54 4.2.2 Mt s c im v tn sut góy, hỡnh dng v v trớ góy xng t sng .57 4.3 Nhng nh hng ca cỏc YTNC n gim mt xng v bin dng t sng 60 4.3.1 Mi liờn quan gia tui, c thự ngh nghip vi góy xng t sng .61 4.3.2 Mi liờn quan gia tin s góy xng vi góy xng t sng .62 4.4 Ch s BMI 62 4.5 Ch s T- score .64 4.6 Mi liờn quan gia thi gian kinh vi nguy c góy xng t sng 65 4.7 S 66 KT LUN 68 KIN NGH 69 TI LIU THAM KHO .1 DANH MC CC BNG Bng 1.1 Tiờu chun chn oỏn loóng xng ca WHO da vo mt xng tớnh theo T-score .16 Bng 1.2 Tiờu chun chn oỏn góy t sng theo phng phỏp bỏn nh lng 18 Bng 3.1 c im ngh nghip 33 Bng 3.2 c im ch s nhõn trc, t s T-score, tui kinh, s nhúm nghiờn cu .33 Hon cnh xut hin bnh xột trờn 38 trng hp cú góy xng t sng 34 Bng 3.3 c im v hon cnh xut hin bnh 34 Bng 3.4 c im v triu chng lõm sng 35 Bng 3.5: Mc góy xng ct sng ngc 38 Bng 3.6 Mc góy xng ct sng tht lng 39 Bng 3.7 Hỡnh dng t sng góy 40 Bng 3.8 Mc góy xng t sng 40 Bng 3.9 So sỏnh tui trung bỡnh nhúm cú góy xng v khụng góy xng t sng 41 Bng 3.10: T l GXS nhúm < 60 tui v 60 tui .42 Bng 3.11: T l GXS nhúm lao ng nng v lao ng nh 42 Bng 3.12: T l GXS nhúm cú v khụng cú tin s góy xng 43 Bng 3.13: So sỏnh tui kinh trung bỡnh gia nhúm cú v khụng GXS .43 Bng 3.14: T l GXS nhúm cú s nm kinh < 15 nm v 15 nm .43 Bng 3.15 T l GXS nhúm cú s v >4con 44 Bng 3.16 T l GXS nhúm cú BMI < 18,5 v 18,5 44 63 qu nghiờn cu ca tỏc gi Trn Th Uyờn Linh v Trn Hong Minh Chõu thỡ u tỡm thy s khỏc bit cú ý ngha thng kờ v s tng quan gia yu t nh cõn vi nguy c góy xng Tm vúc ca c th l mt nhng yu t xỏc nh lng xng ti a Ngi cú vúc dỏng nh l yu t nguy c ca góy xng t sng Tỏc gi Kung W.C.A , kho sỏt cỏc yu t nguy c ca tt c cỏc loi góy xng ph n kinh cng cho thy BMI < 19kg/(m) cú nguy c góy xng nhiu hn (RR=1,8 KTC 95% 1.0-3.2) Trong mt nghiờn cu bnh chng vin dinh dng Quc Gia, Trung Tõm Dinh Dng tr em, Trung tõm Chn thng chnh hỡnh phi hp vi i hc Monash tin hnh 1996 ti thnh ph H Chớ Minh cng cho kt qu l BMI thp tng nguy c góy xng 4,8 ln ngi gi Li ớch ca mụ gy v mụ m i vi xng ó c ghi nhn Mụ m chuyn húa to Estradiol kớch thớch quỏ trỡnh to xng v c ch quỏ trỡnh hy xng, m ph n loóng xng v ngi cao tui thỡ ớt mụ m nờn tng nguy c góy xng Ngi cú lng m nhiu v BMI cao, cú mt phõn b m cỏc vựng c th nhiu nht l vựng hụng, chỳng cú vai trũ nh chic gi m bo v xng c bit l u trờn xng ựi lm gim hoc trit tiờu lc va chm nờn gim nguy c góy xng tộ ngó, v ngc li ngi cú BMI thp tng nguy c góy xng Kt qu ca chỳng tụi cha tỡm thy c s khỏc bit v BMI gia nhúm góy xng v khụng góy xng t sng cú th i tng nghiờn cu ca chỳng tụi l ph n, cao tui cú loóng xng Cú th õy l nhúm i tng cú tỡnh trng dinh dng kộm 64 4.5 Ch s T- score Mc dự cho n ỏnh giỏ tỡnh trng xng cú nhiu phng phỏp, nhng tiờu chun vng chn oỏn loóng xng l o mt xng bng phng phỏp DXA, t ú da vo ch s T- score chn oỏn phõn loi theo WHO 1994 Cỏc nghiờn cu u cho thy mt khoỏng xng thp u liờn quan n nguy c góy xng , Nhng ph n cú mt xng thp bt k v trớ o no l yu t nguy c c lp vi góy xng t sng mi , Tuy nhiờn mi liờn h gia mt xng xng rừ rt nht l o mt xng ct sng tht lng C thp hn mt lch chun (SD) thỡ nguy c góy xng t sng tng gp ln Kt qu ca chỳng tụi cho thy cú mi liờn quan ý ngha gia ch s Tscore vi tỡnh trng góy xng t sng C th l nhng bnh nhõn cú GXS cú ch s T- score trung bỡnh c v trớ o l c xng ựi v ct sng tht lng thp hn cú ý ngha thng kờ so vi nhúm khụng GXS (p< 0,001) (bng 3.17) Trong nghiờn cu ca chỳng tụi tt c cỏc bnh nhõn u cho kt qu o T- score trung bỡnh ti ct sng tht lng -2,5, kt qu o MX ti v trớ CX a s bnh nhõn cho kt qu T- score > -2,5 (chim 68,5%) Do ú chỳng tụi xột mi liờn quan ca T- score ct sng tht lng vi t l góy xng t sng thu c kt qu t l góy xng S nhng bnh nhõn cú ch s T-score ct sng tht lng -3,5 cao hn cú ý ngha thng kờ so vi nhúm cú T- score > -3,5(p< 0,001) (bng 3.18) Kt qu ny tng t vi tỏc gi Trn Hong Minh Chõu cng cho kt lun tng t, c gim mi lch chun ca giỏ tr T-score lm tng góy xng lờn ln i vi n Ch s T-score di hoc bng -1,5 lch chun nu khụng cú yu t nguy c no thỡ kh nng tiờn oỏn góy xng vũng nm l 8,3%, nu cú cng nhiu yu t nguy c thỡ tng kh nng góy xng 65 4.6 Mi liờn quan gia thi gian kinh vi nguy c góy xng t sng Nm 1940 Albright l ngi u tiờn ó tỡm thy c mi liờn h gia loóng xng v gim chc nng ca bung trng ph n Sau ú nhiu kt qu nghiờn cu ó khng nh kt lun ca Albright Mc dự mt xng l hin tng sinh lý xut hin sau tui 40 c hai gii, song rừ rng tc mt xng c nam v n l hon ton khỏc tui 70 cú ti 50% ph n sau kinh cú biu hin mt xng nam gii ch cú 25% cú biu hin mt xng tui 80 S mt xng n xut hin sm hn t 15-20 nm so vi nam gii l hu qu ca s suy gim chc nng bung trng mt cỏch nhanh chúng Trong vũng 05 nm ti 10 nm u tiờn sau kinh, ph n cú th b mt 2% - 4% MX mi nm tng ng vi mt 25% - 30% MX khong thi gian ny Tng tc mt xng sau kinh l nguyờn nhõn chớnh gõy loóng xng ph n (loóng xng sau kinh) To ct bo v hy ct bo cú cha th th ca estrogen Sau kinh nng Estrogen gim, kớch thớch hot ng hy ct bo, tng quỏ trỡnh hy xng gõy mt xng khong 20% - 30% xng xp, v 5% - 10% xng c giai on u ca thi k sau kinh, ngoi hy xng nờn nng canxi mỏu tng, gim tit PTH v gim calcitriol lm gim hp thu canxi ti rut nờn xng thiu nguyờn liu, d góy xng hn , Trong nghiờn cu ca chỳng tụi khụng cú trng hp no kinh trc 40 tui Tui kinh sm nht l 40 tui v mun nht l 54 tui Tui kinh trung bỡnh gia nhúm cú v khụng góy xng t sng l khỏc cú ý ngha thng kờ (p= 0,026 < 0,05) (bng 3.13) V so sỏnh t l góy xng gia cỏc nhúm i tng vi cỏc mc thi gian khỏc chỳng tụi thy t l góy xng t sng nhúm bnh nhõn kinh t 15 66 nm cú cao hn cú ý ngha thng kờ so vi nhúm kinh < 15 nm (p = 0,002< 0,05, OR = 1,59 1,29- 3,82) T l ny cng cú ý ngha vi nhng i tng cú thi gian kinh t 20 nm tr lờn (p = 0,002, OR = 2,07; 1,31 3,26) (bng 3.14) Vy nhng i tng n kinh t 15 nm tr lờn cú nguy c góy xng t sng cao hn Kt qu ca tỏc gi V Th Thanh Thy ỏnh giỏ cỏc yu t liờn quan n góy lỳn t sng loóng xng ph n sau kinh nm 1996 Kt qu thu c l ph n sau kinh t 20 nm tr lờn l ngng cú nh hng n lỳn t sng loóng xng sau kinh Khỏc bit ny l khỏc v i tng nghiờn cu, nhúm i tng nghiờn nghiờn cu ca tỏc gi l 270 ph n kinh v 32 ph n tr Chỳng tụi nghiờn cu trờn 89 bnh nhõn kinh v loóng xng nguyờn phỏt 4.7 S S phn ỏnh s ln mang thai v cho bỳ mt cỏch tng i Phn ln ph n Vit Nam sinh tui 20 30, l tui t c lng xng nh, ú khu phn n ca ngi Vit Nam thiu canxi Kốm theo ch n ung cũn cha khoa hc, kiờng khem nhiu quỏ trỡnh mang thai v thi gian c (ớt ng, trỏnh ỏnh nng ) l mt yu t nguy c loóng xng v góy xng Trong nghiờn cu ca chỳng tụi kt qu cho thy t l góy xng t sng nhúm bnh nhõncú s > cao hn cú ý ngha thng kờ so vi nhúm cú ( p= 0,04< 0,05, OR = 1,7; 1,07- 2,69%) (bng 3.15) Kt qu ny hon ton tng ng vi kt qu ca tỏc gi V Th Thanh Thy ( 1996) , xỏc nh vic sinh trờn ln l yu t nguy c nh hng n lỳn xp t sng loóng xng ph n sau kinh 67 Tuy nhiờn nghiờn cu ca tỏc gi Thỏi Hũa mi ch cho thy s trung bỡnh ca nhúm cú góy xng t sng (6,7 3,4) cao hn nhúm khụng góy xng (5,3 2,7), v s khỏc bit cú ý ngha (p = 0,021) Tuy nhiờn so sỏnh gia nhúm sinh t tr lờn v nhúm sinh di thi cha thy s khỏc bit iu ny cú th i tng nghiờn cu bao gm c nam v n, t l sinh ụng, ngi sinh nhiu nht 14 ngi Qua phõn tớch n bin chỳng tụi nhn thy cỏc bin s: s con, T-score CSTL, tui, s nm kinh, TSGX u cú s liờn quan cú ý ngha thng kờ n t l bnh nhõn GXS Sau phõn tớch hi qui logistic, ch cú bin s liờn quan n t l GXS cú s khỏc bit v tỏc ng c lp n tỡnh trng GXS l ch s Tscore v s cú mt ng thi cỏc yu t khỏc C th s cng nhiu v ch s Tscore gim lm tng t l GXS (vi p = 0,02 OR = 1,75, 1,08 2,82 v p = 0,004 OR = 0,27 0,11 0,65) Cú mi tng quan nghch bin cht ch gia ch s T-score v s t góy vi r= 0,56; p < 0,001 Tc l nu ch s T-score gim i n v thỡ s t góy s tng 0,56 t (biu 3.10) Cú mi tng quan thun cht ch gia s nm MK v mc góy xng S vi r= 0,53; p < 0,001 Tc l nu s nm kinh nhiu thờm nm thỡ mc góy xng nng s tng lờn 0,53 ln (biu 3.12) Cú mi tng quan nghch bin cht ch gia ch s Tscore v mc góy vi r= 0,54; p < 0,001 Nu ch s T score CSTL gim i thỡ mc góy s nng thờm 0,54 ln (biu 3.11) 68 KT LUN Qua nghiờn cu 89 bnh nhõn n loóng xng nguyờn phỏt chỳng tụi thu c mt s kt qu sau c im góy xng ct sng ngc v tht lng bnh nhõn n loóng xng nguyờn phỏt T l GXS: 38/89 (42,9%) V trớ góy: S ngc : 21,1%; CSTL : 26,3% c v trớ : 52,6% T l GXS L1: 22,5%; D12: 21,3%; L2: 19,1% S lng góy: < t : 57,9% t l 42,1% Hỡnh dng góy: góy b: 31,6%; góy b v a: 25,5% Cỏc yu t liờn quan n góy xng t sng bnh nhõn n loóng xng Cỏc yu t lm tng nguy c GXS bnh nhõn n LX Tui 60 Con > T- score CSTL - 3,5 Thi gian kinh 15 nm Trong ú Ch s T score cú mi tng quan nghch bin cht ch vi s t góy (= 0,56; p < 0,001) 69 Cú mi tng quan nghch bin cht ch gia ch s T-score vi mc góy (r= 0,54; p < 0,001) Cú mi tng quan thun cht ch gia TGMK v mc GXS (r= 0,53; p < 0,001) KIN NGH Tm soỏt GXS trờn BN cao tui cú gim mt xng nhm hn ch bin chng góy xng t sng gõy Vic cụng nhn v iu tr thớch hp góy xng t sng giai on u cú th lm gim nguy c góy xng tng lai cng nh gim mc tn ph v gỏnh nng kinh t iu tr Tng cng giỏo dc sc khe v loóng xng cng nh góy xng cng ng, c bit cỏc i tng tui cao, T-score thp, bnh nhõn cú tin s sinh nhiu 70 TI LIU THAM KHO Nguyen ND, Nguyen TV (2006), 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DC V O TO B Y T TRNG I HC Y H NI MC THY CHI NGHIÊN CứU ĐặC ĐIểM GãY X ƠNG ĐốT SốNG NGựC Và THắT LƯNG TRÊN X QUANG BệNH NHÂN Nữ LOãNG X ƠNG NGUYÊN PHáT Chuyờn ngnh: Ni khoa Mó s: 60720140 LUN... mineral Density ( mt xng) BMI Body Mas Index (Ch s c th) CSTL Ct sng tht lng CX C xng ựi DEXA Dual Energy Xray Absortiometry (phng phỏp o hp th tia X nng lng kộp) GXS Góy xng t sng IOF International... hy xng tng hn mc to xng S mt cõn i dn n vic c th mt xng tng dn, khin lc ca xng suy gim v lm tng nguy c góy xng * C ch mt xng n gii sau kinh Trung bỡnh ph n mt khong 50% xng xp v 35% xng c