Value of shear wave elastography in the early diagnosis of DPN in patients with type 2 diabetes mellitus
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摘要:
目的 探讨剪切波弹性成像（SWE）对2型糖尿病患者并发糖尿病周围神经病变（DPN）的早期诊断价值。 方法 该研究为诊断性病例对照研究。2021年5月—2022年10月,遵义医科大学附属医院收治68例符合入选标准的2型糖尿病患者,其中男45例、女23例,年龄（57±10）岁,根据是否并发DPN将患者分为DPN组（38例）和非DPN组（30例）；同期招募在该院体检中心体检的30名健康志愿者作为健康对照组,其中男19人、女11人,年龄（56±10）岁。比较健康对照组志愿者和2组患者入院时采用彩色多普勒超声诊断仪在二维超声模式下测量的双侧腓总神经和胫神经横截面积、在SWE模式下测量的双侧腓总神经和胫神经硬度。在3组受试者中,筛选DPN发病的独立危险因素。在2组患者中,采用受试者操作特征曲线评价腓总神经硬度、腓总神经横截面积、胫神经硬度和胫神经横截面积诊断DPN的价值。分析DPN组患者腓总神经硬度、腓总神经横截面积与多伦多临床评分系统（TCSS）评分的相关性。 结果 DPN组患者入院时双侧腓总神经横截面积均显著大于非DPN组患者和健康对照组志愿者（P<0.05）,且DPN组患者入院时右侧胫神经横截面积显著大于非DPN组（P<0.05）。非DPN组与DPN组患者入院时双侧胫神经和腓总神经硬度均显著高于健康对照组志愿者（P<0.05）,DPN组患者入院时左侧胫神经和双侧腓总神经硬度均显著高于非DPN组（P<0.05）。多因素有序logistic回归分析结果显示,在3组受试者中,腓总神经硬度、胫神经硬度、腓总神经横截面积均为DPN发病的独立危险因素（OR分别为0.91、0.93、0.75,95%CI分别为0.89~0.95、0.89~0.97、0.58~0.96,P<0.05）。在2组患者中,腓总神经硬度诊断DPN的曲线下面积最大,为0.85（95%CI为0.74~0.92）,其最佳截断值为75.29 kPa,最佳截断值下的敏感度为76.32%、特异度为90.00%。在DPN组患者中,腓总神经硬度、腓总神经横截面积均与TCSS评分呈显著正相关（rs值分别为0.83、0.89,P<0.05）。 结论 SWE在评估2型糖尿病患者周围神经硬度方面表现优异,其中SWE测量的腓总神经硬度对患者并发DPN具有较高的诊断价值,并与临床严重程度相关,可作为DPN早期筛查和病情评估的辅助影像学指标。 Abstract:Objective To investigate the value of shear wave elastography (SWE) in the early diagnosis of diabetic peripheral neuropathy (DPN) in patients with type 2 diabetes mellitus. Methods This study was a diagnostic case-control study. From May 2021 to October 2022, 68 patients with type 2 diabetes mellitus who met the inclusion criteria were admitted to the Affiliated Hospital of Zunyi Medical University, including 45 males and 23 females, aged (57±10) years. According to the presence or absence of DPN, the patients were divided into DPN group (38 patients) and non-DPN group (30 patients). During the same period, 30 healthy volunteers who underwent physical examinations at the health examination center of the hospital were recruited as healthy control group, including 19 males and 11 females, aged (56±10) years. Cross-sectional areas of the bilateral common peroneal nerves and tibial nerves measured using a color Doppler ultrasonography system in two-dimensional ultrasonography mode, and the stiffness of the bilateral common peroneal nerves and tibial nerves measured in SWE mode were compared among volunteers in healthy control group and two groups of patients at admission. Independent risk factors for the development of DPN were screened among the participants in the three groups. Among the two groups of patients, receiver operating characteristic curves were used to evaluate the diagnostic value of common peroneal nerve stiffness, common peroneal nerve cross-sectional area, tibial nerve stiffness, and tibial nerve cross-sectional area for DPN. The correlations of common peroneal nerve stiffness and common peroneal nerve cross-sectional area with the Toronto clinical scoring system (TCSS) score were analyzed in DPN group of patients. Results At admission, the cross-sectional areas of the bilateral common peroneal nerves of patients in DPN group were significantly larger than those of patients in non-DPN group and volunteers in healthy control group (P<0.05); the cross-sectional area of the right tibial nerve of patients was also significantly greater in DPN group than in non-DPN group (P<0.05). The stiffness of the bilateral tibial nerves and common peroneal nerves of patients in both non-DPN group and DPN group was significantly greater than that of volunteers in healthy control group (P<0.05). The stiffness of the left tibial nerve and the bilateral common peroneal nerves of patients was significantly greater in DPN group than in non-DPN group (P<0.05). The results of multivariable ordinal logistic regression analysis showed that common peroneal nerve stiffness, tibial nerve stiffness, and common peroneal nerve cross-sectional area were independent risk factors for the development of DPN among the participants in the three groups (with OR of 0.91, 0.93, and 0.75, respectively, 95%CI of 0.89 to 0.95, 0.89 to 0.97, and 0.58 to 0.96, respectively, P<0.05). Among the two groups of patients, common peroneal nerve stiffness yielded the largest area under the curve for diagnosing DPN, which was 0.85 (with 95%CI of 0.74 to 0.92). The optimal cutoff value was 75.29 kPa, with a sensitivity of 76.32% and a specificity of 90.00% at the optimal cutoff value. In DPN group, common peroneal nerve stiffness and common peroneal nerve cross-sectional area of patients were significantly positively correlated with the TCSS score (with rs values of 0.83 and 0.89, respectively, P<0.05). Conclusions SWE performs well in assessing peripheral nerve stiffness in patients with type 2 diabetes mellitus. In particular, common peroneal nerve stiffness measured using SWE has relatively high diagnostic value for complication of DPN in patients and is correlated with clinical severity. It may serve as an auxiliary imaging marker for the early screening and severity assessment of DPN. -
参考文献
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图 1 采用二维超声与SWE测量的1例并发糖尿病周围神经病变的2型糖尿病患者右侧腓总神经和胫神经横截面积与硬度。1A.腓骨小头下方2 cm处腓总神经横截面积的二维超声图像；1B.腓骨小头下方2 cm处腓总神经硬度的SWE图像；1C.内踝上3 cm处胫神经横截面积的二维超声图像；1D.内踝上3 cm处胫神经硬度的SWE图像
注：SWE为剪切波弹性成像
图 3 38例并发糖尿病周围神经病变的2型糖尿病患者腓总神经硬度和横截面积与TCSS评分的相关性。3A.腓总神经硬度与TCSS评分呈显著正相关,rs=0.83,P<0.001；3B.腓总神经横截面积与TCSS评分呈显著正相关,rs=0.89,P<0.001
注：TCSS为多伦多临床评分系统
Table 1. 健康对照组志愿者与2组2型糖尿病患者入院时一般资料比较
组别 例数/人数 性别（例/人） 年龄（岁, 体重指数（kg/m2, 糖尿病病程（年, 糖化血红蛋白水平（%, TCSS评分（分, 男 女 DPN组 38 28 10 57±9 22.8±2.9 9.4±4.8 9.3±2.0 9.7±1.7 非DPN组 30 17 13 56±10 24.2±4.6 5.0±2.9 8.0±2.0 4.6±1.7 健康对照组 30 19 11 56±10 22.3±2.2 — — — 统计量值 χ2=2.22 F=0.18 F=2.62 t=4.79 t=2.64 t=13.21 P值 0.330 0.834 0.087 <0.001 0.010 <0.001 注：DPN为糖尿病周围神经病变,TCSS为多伦多临床评分系统；“—”表示未检测或不适用 
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Table 2. 健康对照组志愿者与2组2型糖尿病患者入院时双下肢胫神经和腓总神经横截面积比较（mm2,
组别 例数/人数 胫神经 腓总神经 t1值 P4值 t2值 P5值 左侧 右侧 左侧 右侧 DPN组 38 11.5±2.6 11.6±2.8 15.5±4.8 15.4±4.8 0.38 0.711 0.10 0.918 非DPN组 30 10.6±2.4 10.3±1.9 13.0±2.3 12.6±1.9 1.19 0.245 1.08 0.291 健康对照组 30 11.1±2.4 10.9±2.4 11.9±1.8 11.6±2.8 0.61 0.549 0.79 0.434 F值 0.93 2.31 10.20 11.24 P值 0.399 0.105 <0.001 <0.001 P1值 0.186 0.036 0.007 0.002 P2值 0.580 0.316 <0.001 <0.001 P3值 0.462 0.250 0.063 0.154 注：DPN为糖尿病周围神经病变；P1值、P2值、P3值分别为DPN组与非DPN组、DPN组与健康对照组、非DPN组与健康对照组各指标比较所得,t1值与P4值、t2值与P5值分别为各组左右侧胫神经、腓总神经比较所得
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Table 3. 健康对照组志愿者与2组2型糖尿病患者入院时双下肢胫神经和腓总神经硬度比较（kPa,
组别 例数/人数 胫神经 腓总神经 t1值 P4值 t2值 P5值 左侧 右侧 左侧 右侧 DPN组 38 57±16 53±16 89±33 87±26 0.24 0.814 0.42 0.677 非DPN组 30 46±15 48±13 59±16 60±13 -0.80 0.427 -0.49 0.627 健康对照组 30 34±10 38±13 43±16 45±13 -1.78 0.118 -0.47 0.644 F值 19.74 8.95 32.18 43.14 P值 <0.001 <0.001 <0.001 <0.001 P1值 0.006 0.165 <0.001 <0.001 P2值 <0.001 <0.001 <0.001 <0.001 P3值 0.004 0.004 0.001 <0.001 注：DPN为糖尿病周围神经病变；P1值、P2值、P3值分别为DPN组与非DPN组、DPN组与健康对照组、非DPN组与健康对照组各指标比较所得；t1值与P4值、t2值与P5值分别为各组左右侧胫神经、腓总神经比较所得
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Table 4. 健康对照组志愿者与2组2型糖尿病患者DPN发病相关因素的多因素有序logistic回归分析结果
变量 OR 95%CI P值 年龄（岁） 1.03 0.98~1.10 0.239 体重指数（kg/m2） 0.94 0.80~1.10 0.438 腓总神经硬度（kPa） 0.91 0.89~0.95 <0.001 胫神经硬度（kPa） 0.93 0.89~0.97 0.002 腓总神经横截面积（mm2） 0.75 0.58~0.96 0.022 胫神经横截面积（mm2） 1.24 0.98~1.57 0.073 注：DPN为糖尿病周围神经病变
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Table 5. 腓总神经与胫神经横截面积与硬度对68例2型糖尿病患者并发糖尿病周围神经病变的诊断价值比较
指标 AUC 95%CI 最佳截断值 约登指数 敏感度（%） 特异度（%） 腓总神经硬度 0.85 0.74~0.92 75.29 0.66 76.32 90.00 腓总神经横截面积 0.70 0.58~0.81 15.00 0.41 44.74 96.67 胫神经硬度 0.69 0.57~0.80 51.22 0.36 65.79 70.00 胫神经横截面积 0.63 0.51~0.75 10.50 0.28 68.42 60.00 注：硬度、横截面积的最佳截断值单位分别为kPa、mm2
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