Osteoporosis A racionális és irracionális diagnosztika- diagnosztikai hibák

OsteoporosisA racionlis s irracionlis diagnosztika- diagnosztikai hibkSzekeres Lszl dr.Szent Andrs Krhz, Hvz

Az ember idnknt belebotlik az igazsgba

Murphy...de legtbbszr feltpszkodik s tovbbmegy.

A tmkOsteoporosis j defincii, de rgi felosztsa s az ebbl add hiba- lehetsgekA klinikai diagnzis alapja a trs s/vagy a fjdalom? A klinikus hibiGold-standard az ODM (?)Mgis mi a helyes diagnosztikus protokoll?

Mi is az osteoporosis?A csontvz-rendszer-betegsge, a csont svnyi anyag tartalmnak progresszv megfogyatkozsa, majd ennek kvetkeztben a mikroarchitektra krosodsnak okaknt a csontok fokozott trkenysgevs. loklis osteoporosisvs. stagnl osteoporosisvs. ms eredet patholgis trs

Mi is az osteoporosis?WHO (1994) ajnlsa szerint T-scoreNormal 0- -1 SDOsteopenia 1-2.5 SDOsteoporosis > -2.5 SDSlyos osteoporosis osteoporosis+fractura

Klinikai dg.?csak mennyisgikrds?

Metaanalzisekbl ismert, hogy a lumbalis gerinc BMD T-score 1 SD cskkense a kvetkezmnyes trsek RR-t 2.6 - 2.4 emeli

A cskkent BMD jl korrell a trsi rizik fokozdsval

Tscore

Watts, ASBMR 2001

You can see that fracture risk goes up, when BMD goes down. With the risk of fractures roughly doubling with each SD decrease in BMD.

Mi is az osteoporosis?A csont mennyisge megfogyatkozik, anlkl, hogy a szerves s szervetlen sszetevinek arnya megvltozna

csak mennyisgi vltozs?

osteomalciaosteogenesis imperfecta

Mi is az osteoporosis?Jellemzje:

Az alacsony csont mennyisg, normlis mineralizci mellettMicroarchitectura krosodsa A fokozd csont fragilits mellett a trsi rizik emelkedik.

*Consensus Development Conference Statement 1993

Bone Mineral Density (BMD)+ csont turnover + microarchitectura Bone Strength (szilrdsg)

Norml vs. osteoporosisos remodellingresorptio s formation egyenslyaresorptio tlyslya

A csont formci biokmiai markerei

serum alkalikus phosphataseserum ostocalcinserum C- and N-propeptides of type I collagenN Engl J Med 1998;338:736-746

A csont resorptio biokmiai markereiVizeletben rtett kollagn kereszt-ktsek (cross-links) (pyridinoline, deoxypyridinoline)kollagn C- and N-telopeptides(galactosyl hydroxylysine)hydroxyprolineserum tartrate-resistant acid phosphataseN Engl J Med 1998;338:736-746

Bone Mineral Density (BMD)+ csont turnover + microarchitectura Bone Strength (szilrdsg)

16x1xA kompresszis szilrdsg cskkense a trabekulris rendszer vltozsa esetn

A csigolya trabecularis architekturjnak vltozsa (egszsges vs osteoporosis)Egszsges 54 ves nCsigolya kompresszival ksrt osteoporosis 84 ves nA csonttmeg s a horizontlis trabecula folyamatossgnak cskkenseBorah, et al. Anat. Rec. 20013-D computer tomography, human cadaver vertebral bone

Microarchitektura mrhet paramtereiCsont mennyisg Bone volume/bone tissue (BV/TV) a minta relatv csont mennyisgnek indiktoraSzerkezeti tulajdonsgTrabecular number (mm-1) trabecularis gerendk szma / mmTrabecular thickness (mm) trabecularis gerendk vastagsgaStrukturra jellemz paramter(ek) Marrow star volume (mm3) a porozits mrtke. Trabecular spacing three-dimensional (mm) a trabeculk kztti tvolsg.Connectivity Density (mm3)- z p (folyamatos) trabeculk szma / mm3

Borah, 2001 A struktra megfogyatkozsa esetn az Ma.St.Vol. n

A tmkOsteoporosis j defincii, de rgi felosztsa s az ebbl add hiba lehetsgekA klinikai diagnzis alapja a trs s/vagy a fjdalom? A klinikus hibiGold-standard az ODM (?)Mgis mi a helyes diagnosztikus protokoll?

Az els kvetkezmny: mikro-fractura

Az igazi kvetkezmny: fracturacsigolyatestradiuscsptji - femur distalis

Cooper et al: Trends Endocrinol Metab 3:224-9, 1992

A csptji trsek rizik-faktoraianticonvulsiv th.2.8alsvgtagot rint krkpek2.1pozitv (anyai) anamnesis2.0hyperthyreosis (elzm.)1.8tachycardia (pulse > 80)1.8 rossz ltalnos llapot1.74 rnl tbb talpon lls1.7nyugtatk-altatk1.6letkor1.5percepcis zavarok1.5

faktorRelative RiskCummings et al. N Engl J Med 1995;332:767

Enyhe1714380.0% 20.0%Kzpslyos/242178 slyos57.6%42.4%Fraktra slyossg (Rtg)Klinikai csigolyatrsNemIgenSiris E et al. Osteoporos Int 2002; 13: 903-913.A radiolgiai slyossg s a panaszokat okoz (klinikai) csigolyatrsek sszefggse A kzpslyos/slyos radiolgiai csigolyatrsek nagyobb valsznsggel okoznak panaszokat.

Nem171242 41.4% 58.6% Igen4317819.5% 80.5%Morfolgiai slyossgKlinikai csigolya-trsekEnyheKzepes/SlyosSiris E et al. Osteoporos Int 2002; 13: 903-913.Panaszokat okoz (klinikai) csigolyatrsek s a radiolgiai slyossg sszefggseA klinikai tneteket okoz csigolyatrsek nagyobb valsznsggel radiolgiailag is slyosabbak.

BMD s a diagnzis (?)

Cscs-csonttmeg elgtelensge vs. fokozott csontbontsMenopausaPostmenopausacsont mennyisgcsont mennyisgCscs-csonttmeg hatsaCsontveszts hatsaMenopausaPostmenopausa

A DEXA vizsglat ltal adott BMD rtk nem ad informcit a trabekulris hlzat folyamatossgrl

Diagnzis: krtrtnetrizik-tnyezk felismersejelek s tnetek (szimptmk)fiziklis vizsglat Bone Mineral Density (BMD) mrs (ODM)(testmagassg-mrs)rutin s csak indokolt esetekben (diff.dg.) specifikus laboratriumi vizsglat(ok)rntgenolgiai vizsglat (szvdmnyek s diff. dg. clzattal)

Laboratriumi vizsglatok: a secunder osteoporosisok tisztzsra is...Els szint (rutin)teljes vrkpkalciumfoszforkreatininealkalikus phosphatase albuminmj-enzimekthyroid-stimulating hormone (TSH)

Anyagcsere csontbetegsgek - rutin labor. Alk PhosCaPPTHHyperPTH

Osteomalacia( )( )

OsteoporosisNNNN

PagetsNNN

Metast( )N( )

Msodik szint (specilis tesztek)vizelet kalcium rtsevizelet szabad cortisolvrsvrtest-sllyeds (We)parathyhormon (PTH)25-hydroxy D vitamin fehrje electrophoresisLaboratriumi vizsglatok: a secunder osteoporosisok tisztzsra is...

In adults, skeletal size is neither increased nor decreased but is continuously turned over in a balance of bone resorption and bone formation. When osteoporosis occurs as a result of menopause, the activation of resorption sites is increased as is the depth of resorption pits, and osteoblastic formation, though also increased, is unable to refill the eroded pit entirely. The net effect is less bone.This slide is a 3-D rendering of the trabecular architecture of vertebral bone from human cadavers. It was created using 3-D micro computed tomography by P&GP scientists.On the left is the trabecular architecture from a young (52 yr) women without osteoporosis. You can see the dense matrix of vertical and horozontal trabeculae. It is easy to imagine the strength provided by this highly interconnected matrix.On the right is the trabecular architecture from an older (84 yr) women with osteoporosis. This woman has sustained a vertebral fracture, which is further evidence of the relative severity of her osteoporosis.Note, in the older osteoporotic woman there is preservation of trabeculae in the vertical (load-bearing) plane. However, there is substantial loss of trabeculae in the horizontal plane. This women has not only lost significant bone mass, but she has also lost a large amount of the connectivity between horizontal trabeculae.While it is intuitive that the trabecular architecture on the right would be weaker in response to the loading forces from gravity or physical activity, it is important to understand the role that perforation of horizontal trabeculae play in the decreased trabecular strength. A study by Cummings et al published in the New England Journal of Medicine in 1995 provided relative risks for a number of factors associated with hip fracture. All of these have a relative risk of 1.5 or greater, indicating that risk is increased by at least 50 percent in the presence of these factors.This study also showed a protective effect from walking for exercise and an increase in weight since age 25. Walking was associated with a 30 percent decreased risk and weight increase since age 25 was associated with a 40 percent decreased risk.

(Cummings SR, Nevitt MC, Browner WS et al. Risk factors for hip fracture in white women. N Engl J Med 1995;332:767-73.)While adequate peak bone mass at the onset of menopause is advantageous, it is no guarantee that bone mass will be protected in menopause. This slide shows that a woman with medium peak bone mass who experiences rapid bone loss in menopause may be just as susceptible to fracture as a woman with low peak bone mass and normal bone loss..

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Osteoporosis A racionális és irracionális diagnosztika- diagnosztikai hibák