基于“肾–髓–骨–节”轴探析膝骨关节炎合并骨髓水肿的辨治思路

Exploring the Treatment Strategy for Knee Osteoarthritis Complicated by Bone Marrow Edema Based on the “Kidney-Marrow-Bone-Joint” Axis

摘要: 骨髓水肿(Bone Marrow Edema, BME)是一种磁共振成像(Magnetic Resonance Imaging, MRI)中特征性影像学表现，与膝骨关节炎(Knee Osteoarthritis, KOA)患者关节疼痛及病情进展密切相关，是近年骨关节炎研究的热点靶点。现代医学多从软骨下骨重塑、力学负荷异常、局部炎症损伤等角度阐释其发病机制，目前中医对本病的研究多聚焦肾虚、血瘀、水湿等单一病机，缺乏系统性、层级化的病机链条与辨治体系。本文依托《黄帝内经》“肾主骨生髓”“肝主筋”“肝肾同源”等经典理论，构建“肾–髓–骨–节”轴中医病机框架，明确本病肾精亏虚、髓失充养为本，络脉痹阻、气血失和为变，瘀水互结、浊阻髓络为标，筋骨失和、关节痹阻为果的核心病机特点，梳理“髓失充养–骨损失稳–筋骨失和–关节痹阻”的动态演变规律。同时结合本病急性期、虚实夹杂期、慢性迁延期的临床特征，建立分期论治、标本兼顾、内外合治的规范化辨治体系。丰富了KOA合并BME的中医理论内涵，为临床辨证施治、影像辨证结合及后续基础与临床研究提供理论参考。

Abstract: Bone marrow edema (BME) is a characteristic imaging manifestation on magnetic resonance imaging (MRI) and is closely associated with joint pain and disease progression in patients with knee osteoarthritis (KOA). It has become a focal target in osteoarthritis research in recent years. Modern medicine interprets its pathogenesis mainly from the perspectives of subchondral bone remodeling, abnormal mechanical loading, and local inflammatory injury. In traditional Chinese medicine (TCM), current studies on this condition have mostly focused on a single pathogenic mechanism such as kidney deficiency, blood stasis, or dampness accumulation, lacking a systematic and hierarchical pathological chain as well as a corresponding syndrome differentiation and treatment system. Based on the classical theories in Huangdi Neijing that “the Kidney governs the bones and generates marrow,” “the Liver governs the sinews,” and “the Liver and Kidney share the same origin,” this article constructs a TCM pathomechanistic framework of the “Kidney-Marrow-Bone-Joint” axis. It clarifies that the core pathogenesis of this disorder is rooted in deficiency of kidney essence and failure of marrow nourishment; develops into collateral obstruction and disharmony of qi and blood; manifests as mutual binding of stasis and fluid with turbid obstruction of the marrow collaterals; and culminates in disharmony of the sinews and bones as well as obstruction of the joints. The dynamic evolution pattern of “failure of marrow nourishment, bone damage and instability, disharmony of sinews and bones, and joint obstruction” is thereby delineated. Meanwhile, in light of the clinical features during the acute stage, the mixed deficiency-excess stage, and the chronic protracted stage, a standardized syndrome differentiation and treatment system is established, emphasizing staged treatment, simultaneous attention to root and branch, and combined internal-external therapy. This enriches the TCM theoretical connotation of KOA complicated by BME and provides a theoretical reference for clinical syndrome differentiation and treatment, integration of imaging with syndrome differentiation, and future basic and clinical research.