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UDC 616.833.24-002-074:612.017.1
CYTOKINES PERIPHERAL BLOOD AS A MARKER OF TREATMENT EFFECTIVENESS LUMBOSACRAL RADICULOPATHY IN THE ACUTE STAGE
Altai State medical University, Barnaul
Multiprofile hospital of JSC Russian Railways at the Barnaul station
M.V. Goryacheva, G.I. Shumakher, M.P. Kuznetsova, N.A. Cencheva, A.A. Belousov, K.V. Gorycheva, O.O. Mikheyeva
The content of interleukin-1 (IL-1), endothelin -1 (E-1), soluble adhesion molecules of vascular endothelium-1 (sVCAM-1) and soluble molecules of intercellular adhesion -1 (sICAM-1) in peripheral blood of patients suffering from neurologic syndromes of lumbosacral radiculupathy (LSR) in recrudescence phase on the background of treatment was investigated. The content of these cytokines in blood serum was determined by means of immunoenzymometric analysis. Increase of concentration of IL-1, E-1, sVCAM-1 and sICAM-1 in peripheral blood serum in patients having lumbosacral radiculopathy was detected; the fact is statistically significant. With diosmin included in standard complex therapy of lumbosacral radiculopathy, which is considered to be a vasoprotectivе-veintonic drag, we observed normalization of concentration of the investigated cytokines, except sICAM-1, in peripheral blood serum in patients having lumbosacral radiculopathy.
Key words: lumbosacral radiculopathies (LSR), interleukin-1 (IL-1), endothelin - 1 (E-1), soluble adhesion molecules of vascular endothelium - 1 (sVCAM-1), soluble molecules of intercellular adhesion - 1 (sICAM-1), diosmin.
Introduction
According to WHO, up to 70% of the working population of planet suffer from chronic or acute pain syndromes in dorsal area [1,2]. They are chiefly developed on the background of the most common degenerative-dystrophic diseases of the spine (DDDS) - lumbar spine osteochondrosis (LSO) [3, 4, 5, 6, 7, 8, 10, 11, 12]. According to modern concepts, LSO is the multi-factor disease with genetic predisposition, characterized by degenerative-dystrophic changes in the intervertebral disks and surrounding tissues, with further involvement of peripheral and central nervous system into the process [3, 4, 5, 6, 7, 8, 10, 11, 12].
Due to the specifics of structure and functional loads of human spine, 85-90% of clinically significant radiculopathies are accounted for the pathology of the roots of lumbosacral spine [10, 11, 12]. Lumbosacral radiculopathies (LSR) are usually the result of the compression of the spinal nerve by the substance of the intervertebral disk hernia, osteophytes, hypertrophic yellow ligament, distorted facet joints. Besides the elements of spinal motion segment (SMS), in the area of location of spinal nerve roots one of the pathogenic factors, leading to LSR, can be the spondylogenic compression of epidural venous plexuses with the development of venous stasis.
These phenomena are most expressed in the area of dural veins and in the point of passage of the spinal nerve root through dura mater, which leads to the nerve ischemia due to the spasm of feed vessels [13,14,15]. Discirculatory phenomena appear in the zone of injured spinal motion segments (SMS) and interconnected vessels and
are expressed in the form of reduction of local blood circulation in the system of epidural venous plexuses [14], which contributes to the formation of venous stasis, and, consequently, the development of local epiduritis of the injured SMS [14, 15].
These disorders are developed on thebackground of reactive inflammatory processes, reaction of cell and humoral immunity appearing in the zone of burned-out intravertebral disk [14, 15, 16, 17, 18]. At the same time, in the periods of LSR acute conditions, the neurological symptom complex in patients is accompanied by the manifestations of systemic inflammatory process in the peripheral blood stream and endothelial dysfunction, which is expressed by the increase of concentration in peripheral blood of such inflammatory markers, as C-reactive protein (determined by qualitative highly specific method), i n t e r l e u k i n e -
1p, endothelin-1, soluble adhesion molecules (sVCAM-1 and sICAM-1) [20, 21, 22, 23, 24, 25, 26, 27].
The objective of the current research: to study the possibility of correction of pro-inflammatory processes and endothelial dysfunction, manifested in the growth of concentration of interleukine-1p, endothelin-1, adhesion molecules of vascular endothelium 1 (sVCAM-1) and molecules of cell-cell adhesion-1 (sICAM-1) in patients with lumbosacral radiculopathies (LSR) in the acute form on the background of inclusion of vein tonic of diosmin y-benzopyrone group into the complex therapy.
Materials and methods
The research was conducted on the basis of the neurology department of Bultiprofile hospital of JSC Russian Railways at the Barnaul station (Barnaul). The conditions of prospective randomized placebo-non-controlled study of the effectiveness of the vein tonic drug diosmin administration in complex therapy of lumbosacral radiculopathies at the level of vascular therapy corresponded to the provisions of World Medical Association Declaration of Helsinki "Ethical Principles for Medical Research Involving Human Subjects" with amendments of 2000.
For the achievement of stated objectives the study included 202 people, who constituted three main groups of the research. Out of the examined people 150 patients had acute forms of LSR. Among the compression of L4 root was registered in 6 patients (4 %), L5 - in 26 patients (17 %), S1 - in 52 patients (35%), biradicular syndrome (L5, S1) was registered in 66 patients (44%). Among the examined patients men constituted 65% (98 people), women - 35% (52 people). The age of patients ranged from 20 to 55 years. The average age constituted 41,1 + 9,7 years.
Patients with radiculopathies were divided into two groups: the first group consisted of 76 people with LSR syndrome, receiving standard complex medicinal treatment including nonsteroidal anti-inflammatory drugs, vasoprotectives unrelated to the group of vein tonics, cartilage protectors; the second group consisted of 74 people with LSR syndrome, received the vein tonic of diosmin y-benzopyrone group (Flebodia 600®, Innotex, France, in the dose of 600 mg 2 times a day during 7 days, then 1 pill 2 times a day in the morning during 7 days more) besides the analogous unified treatment.
All patients were exposed to standard neurological and vertebral- neurological examination according to the methods of Ya.Yu. Popelyansky and F.A. Khabirov [7,8,9]. Out of the additional methods of examination there were used: classical X-ray radiography of the lumbosacral spine, CT/MRT of lumbar spine. The peripheral blood for the serum obtaining was taken in fasting state before and after the treatment in patients of both groups out of the cubital vein under regional anesthesia. The serum obtained before the treatment was preserved frozen at -52°C. The parameters of 52 people without neurological manifestations of LSO served as control parameters, comparable to the groups of patients with LSR according to the age and gender.
The exclusion criteria for the control and experimental groups were the following diseases: IHD, hypertensive disease, hyperlipidemia of various genesis, accelerated ESR syndrome, diseases of lower limb vessels, chronic infectious
viral and autoimmune diseases, inflammatory joint diseases of different etiology, diseases of gastrointestinal tract and ENT-organs in acute form. For this purpose all patients were exposed to clinic-biochemical examination: general blood and urine analysis, biochemical analysis of blood with the determination of fibrinogen and prothrombin index, blood lipids, ECG, duplex scanning of lower limb vessels, the examined people were consulted by therapist. The concentration of IL-1 ( was measured by solid-phase enzyme immunoassay (EIA) using standard sets of reagents («BenderMedSystem 224/2» firm, Austria) according to the manual. The calibration curve built according to the standards of IL-1( had linear character in the whole range of examined values.
The concentration of endothelin-1 in the blood serum was measured by means of solidphase enzyme immunoassay. The study was performed using the standard diagnostic set of reagents of "BioMedica" firm, (Austria). The concentration sICAM-1 and sVCAM-1 in the blood serum was determined by the solid-phase enzyme immunoassay by means of commercial sets («Bender MedSystem», Austria (BMS201, BMS 232)), intended for research use only.
For all examined biomarkers the concentration of the determined specimen ranged within the sensibility limit, recommended for the determination in standard sets.
The statistical processing of the obtained data was performed by non-parametric methods for analysis (after the test of distribution of the stated values for normality). The differences of average values of quantitative parameters between the groups of ill and healthy persons was determined according to Mann-Whitney U test for pairwise non-connected values. The differences of average values of qualitative parameters between the groups of patients before and after treatment were determined by Wilcoxon test. The results are presented in the table in the form of corresponding value of median (M) for every group of examined persons with the stated standard deviation (SD) for each case. The criteria for statistical significance of the obtained result was the generally accepted value: p<0,05. The statistical analysis was carried by means of software pack SPSS.
Results and discussion
In the early research it had been stated, that LSR are accompanied by the changes of a number of immune-biochemical parameters of the peripheral serum [19]. Statistically significant changes were spread on both biochemical markers of inflammatory processes (C-reative protein) and a wide spectrum of cytokines - either of anti-inflammatory character - IL-1(, and the markers of endothelium dysfunction - endothelin-1, sVCAM-1
and sICAM-1. The results of the study of cytokines - markers of inflammation and endothelium dysfunction in the period of complex treatment of acute LSR are presented in Table 1.
The level of IL-1p in patients of this group normalized to the values comparable to the IL-1p concentration in the control group, where it constituted 0,58 ± 0,07 pkg/ml (p > 0,05). In the group of patients with LSR, who did not receive diosmin in terms of complex treatment, the IL-1p concentration decreased significantly after the treatment from 5,45 ± 0,39 pkg/ml to 3,87 ± 0,30 pkg/ml (p < 0,05), but the differences with the control group preserved and were statistically significant (p < 0,01). The IL-1p concentration in the blood serum after the treatment in the group with inclusion of diosmin drug was 5,7 times lower, that in the compared group (p < 0,001). This fact, as well as the more significant reduction of IL-1p concentration, could be the evidence of a quicker dynamics of reduction of inflammatory processes of systemic character in the second group of patients.
The state of endothelium of peripheral blood stream was evaluated according to the change of concentration of the markers of endothelium dysfunction E-1, b soluble molecules of adhesion sVCAM-1 and sICAM-1.
In patients of the first group the concentration of E-1 in peripheral blood after the course of treatment had a tendency to reduction (20,3%), but the differences were not significant within the terms of observation, (p>0,05). The significant differences of E-1 concentration between this group of patients and the control group of healthy persons retained after the treatment (p<0,01).
In patients of the second group the concentration of E-1 decreased after the course of treatment by 2,3 times and constituted 0,400 + 0,120 fmol/ml. It was significantly lower, than before the treatment (0,925 + 0,161 fmol/ml, p < 0,01). By the comparison with the control group the differences in the current parameter in patients of the second group were statistically insignificant (p>0,05).
The EN-1 concentration in the peripheral blood serum after the course of treatment of patients of the second group was 1,95 times lower than in the comparison group (p<0,01), which indicates the quick restoration of concentration of one of the main markers of endothelial dysfunction in this group of patients.
The analysis of concentration of the soluble molecules of adhesion in the second and first groups before and after the treatment (Table 1) shows, that in patients of the second group the concentration of sVCAM-1 after the treatment reduced by 2,1 times and constituted 897,10 ± 93,81 ng/ml against 1874,82 ± 128,31 ng/ml before the treatment, (p<0,01). The concentration of sVCAM-1
in patients of the second group after the treatment did not differ significantly from the values of the control group of healthy persons (911,60 ± 77,93 ng/ ml; p > 0,05).
In patients of the first group the decrease of cVCAM-1 after the treatment was insignificant and constituted 1648,60 ± 124,65 ng/ml against 1896,94 ± 138,11ng/ml. The differences were not statistically significant (p>0,05). The concentration of sVCAM-1 in patients of this group exceeded the control values (911,60 ± 77,93 ng/ml) by 1,8 times (p<0,01).
The comparison of sVCAM-1 concentration in the peripheral blood of both groups revealed the accelerated normalization of sVCAM-1 concentration in patients of the second group as a result of treatment. Its value (897,10 ± 93,81 ng/ml) nearly corresponded to the sVCAM-1 concentration in healthy persons (911,60 ± 77,93 ng/ml), (p > 0,05).
The sVCAM-1 concentration after the treatment in the second group (897,10 ± 93,81 ng/ml) was 1,8 times lower than in the first group (1648,60 ± 124,65 ng/ml). The differences between the sVCAM-1 concentrations in these groups were statistically significant (p < 0,01).
The sICAM-1 concentration in the serum of peripheral blood, in contradiction to sVCAM-1, did not have positive dynamics during the period of treatment. In both groups by the treatment with the compared methods there was revealed a slight tendency of the reduction of sICAM-1 concentration in the serum of peripheral blood for the period of course treatment (14016 days). Thus, in the first group the sICAM-1 concentration before the treatment was 998,59 ± 127,35ng/ml, after the treatment - 891,85 ± 110,42 ng/ml, (p > 0,05). In patients o the second group the sICAM-1 concentration constituted 990,91 ± 121,62 ng/ml u 871,65 ± 102,33 ng/ml, (p > 0,05) respectively. The differences in the sICAM-1 concentration during the studied period between the examined groups are not revealed (p>0,05). The lack of expressed changes of sICAM-1 concentration on the background of treatment in both groups is probably determined by the different physiological role of sVCAM-1 and sICAM-1 in the metabolic processes of endothelial cells.
The obtained results confirm the working hypothesis on the fact, that the restoration of hemodynamics of the venous compartment of blood circulation system is significant for the activation of recovery processes by LSR, as they determine the improvement of trophism of the roots of spine nerves and the nerves in their stretch.
The positive dynamics of the endothelium state of the peripheral blood stream was revealed by the inclusion of vasoprotective-vientonic diosmin into the complex LSR therapy. The profile of cytokine-markers of inflammation and endothelial
dysfunction of peripheral blood can be used as a diagnostic and prognostic criteria of the dynamics of treatment of acute LSR.
Thus, by the inclusion of diosmin into the complex therapy, there is observed quick and expressed normalization of cytokine concentration characterizing the state of endothelium of peripheral vascular stream: non-specific marker of inflammation - IL-1p and markers of endothelial dysfunction of endothelin-1, soluble molecules of adhesion sVCAM-1 and sICAM-1 in comparison with the complex therapy without vein tonics.
Consequently, the inclusion of diosmin into the complex treatment contributes to the quicker and expressed decrease of systemic inflammatory processes in the vessels of peripheral stream and recovery of the physiological state of endothelium of peripheral vascular stream in patients with LSR at the early recovery stage.
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Altai State Medical University.
Tel.: (3852) 566927.
Email: goryachevamarina@mail.ru
