帕金森病伴骨骼肌疼痛患者中脑经颅超声回声改变研究

Tranraniai sonographic features of Parkinson＇s disease patients with musculoskeletal pain

目的探索中脑黑质、中脑中线经颅超声回声变化与帕金森病伴骨骼肌疼痛的关系。方法将2014年10月至2016年5月在苏州大学附属第二医院就诊的115例帕金森病患者分为伴骨骼肌疼痛组（54例）与不伴疼痛组（61例）或伴抑郁组（74例）与不伴抑郁组（41例），使用统一帕金森病评定量表（UPDRS）、Hoehn-Yahr分期、非运动症状问卷（NMSQ）、汉密尔顿抑郁量表（HRSD，24项）、贝克抑郁量表第二版（BDI-Ⅱ）、视觉模拟评分法（VAS）等进行评估，并行经颅超声检查。结果帕金森病伴骨骼肌疼痛组UPDRS-Ⅱ、-Ⅲ评分，Hoehn-Yahr分期，NMSQ、HRSD、BDI评分均明显高于不伴疼痛组[UPDRS-Ⅱ评分分别为（12.56±6.01）、（8.79±4.38）分，t=-3.801，P〈0.01；UPDRS-Ⅲ评分分别为（24.43±12.43）、（20.07±11.12）分，t=-1.986，P=0.049；Hoehn-Yahr分期分别为2.0（1.5，2.6）、1.5（1.0，2.0），Z=-3.011，P=0.003；NMSQ评分分别为（8.57±4.06）、（5.60±3.38）分，t=-4.193，P〈0.01；HRSD评分分别为（11.65±6.94）、（8.38±5.36）分，t=-2.844，P=0.005；BDI评分分别为（14.09±6.20）、（9.74±6.00）分，t=-3.826，P〈0.01]；帕金森病伴抑郁组病程更长，UPDRS-Ⅱ和-Ⅲ评分、NMSQ评分以及Hoehn-Yahr分期明显高于不伴抑郁组[病程分别为（54.15±38.79）、（38.56±38.79）个月，t=-2.064，P=0.041；UPDRS-Ⅱ评分分别为（12.03±5.77）、（7.90±3.85）分，t=-4.579，P〈0.01；UPDRS -Ⅲ评分分别为（25.45±12.44）、（16.10±7.96）分，t=-4.902，P〈0.01；NMSQ评分分别为（8.61±3.90）、（4.20±2.21）分，t=-7.601，P〈0.01；Hoehn-Yahr分期分别为2.0（1.5，2.6）、1.5（1.0，2.0），Z=-3.702，P〈0.01]。根据患者是否存在骨骼肌疼痛、抑郁症状，将其细分为4个亚组，比较经颅超声参数中脑中线阳性率在4组间的分布差异有统计学意义（χ2=19.097，P〈0.01）；两两比较提示帕金森病不伴疼痛伴抑郁组中脑中线阳性率明显高于帕金森病不伴疼痛不伴抑郁组（分别为63.6%、14.3%），差异有统计学意义（χ^2=15.25，P〈0.01）。中脑中线阳性与性别（r=0.228，P=0.014）、年龄（r=0.184，P=0.049）、病程（r=0.196，P=0.035）、抑郁症状（r=0.396，P〈0.01）呈正相关，中脑中线阳性与UPDRS-Ⅱ、-Ⅲ评分及骨骼肌疼痛无显著相关性，中脑黑质阳性与各项临床特征均无显著相关性。结论虽然伴有骨骼肌疼痛的帕金森病患者运动症状和非运动症状更严重，中脑黑质、中脑中线回声强度与是否伴有骨骼肌疼痛无关，但中脑中线回声减低或中断与帕金森病伴抑郁相关。

Objective To investigate the substantia nigra（SN） and brainstem raphe（BR） echogenic features of Parkinson′s disease （PD） patients with musculoskeletal pain. Methods A total of 115 PD patients recruited in the Second Affiliated Hospital of Soochow University from October 2014 to May 2016 were assessed with the following rating scales： Unified Parkinson′s Disease Rating Scale（UPDRS）, Hoehn and Yahr Staging Scale （H/Y）, Hamilton Rating Scale for Depression （HRSD）, Beck Depression Inventory Ⅱ（BDI-Ⅱ） and Visual Analogue Scale （VAS）. All the subjects underwent transcranial sonography during the clinical evaluation. And the patients were divided into PD with musculoskeletal pain（n=54） and PD without musculoskeletal pain（n=61） groups, or PD with depression（n=74） and PD without depression（n=41） groups.Results Compared with PD patients without pain, PD patients with musculoskeletal pain had higher scores of UPDRS-Ⅱ, -Ⅲ, HRSD, BDI, NMSQ and H/Y （UPDRS-Ⅱ score： 12.56±6.01 vs 8.79±4.38, t=-3.801, P〈0.01; UPDRS-Ⅲ score： 24.43±12.43 vs 20.07±11.12, t=-1.986, P=0.049; HRSD score： 11.65±6.94 vs 8.38±5.36, t=-2.844, P=0.005; BDI score： 14.09±6.20 vs 9.74±6.00, t=-3.826, P〈0.01; NMSQ score： 8.57±4.06 vs 5.60±3.38, t=-4.193, P〈0.01; H/Y： 2.0（1.5, 2.6） vs 1.5（1.0, 2.0）, Z=-3.011, P=0.003）. Positive BR was more frequent in depressed than in non-depressed PD patients without pain（63.6% vs 14.3%; χ^2=15.25, P〈0.01）. Positive BR was positively associated with sex（r=0.228, P=0.014）, age（r=0.184, P=0.049）, disease duration（r=0.196, P=0.035）, and depression（r=0.396, P〈0.01）. However, positive BR did not correlate with musculoskeletal pain. No correlation was found between positive SN and clinical characteristics of PD patients.Conclusions PD patients with musculoskeletal pain have worse activity of daily living, more severe motor symptoms, more non-motor symptoms, and are more depressed. SN and BR echogenecity do not correlate with musculoskeletal pain, however, hypoechogenic or interrupted BR is associated with depression in PD patients.