椎间盘炎mri诊断课件

椎间盘炎MRI诊断 青岛大学医学院附属医院放射科 徐文坚 Department of Radiology, Medical School Hospital of Qingdao University 椎间盘炎概念 n概念：椎间盘、终板和邻近椎体感染 n椎间型感染性脊椎炎 n椎间隙感染 n化脓性椎间盘炎 n脊椎-椎间盘炎 n nIM 1989：椎间盘炎（Discitis） Department of Radiology, Medical School Hospital of Qingdao University 椎间盘炎病因与病理 n结构 n纤维环 n髓核 n软骨终板 n营养 n婴幼儿 n血供丰富 n来源：椎体骨化中心， 前、后纵韧带血管 n 13岁 n无血供（纤维环周围结 缔组织血管和淋巴管） n营养来源：软骨终板和 纤维环弥散 Department of Radiology, Medical School Hospital of Qingdao University 椎间盘炎病因与病理 椎间盘解剖 椎间盘炎病因与病理 n发病率：约占骨髓炎2% n易感因素 n机遇性感染 n免疫缺陷 n糖尿病 n全身性感染 n透析 n器官移植 n嗜可卡因 Department of Radiology, Medical School Hospital of Qingdao University 椎间盘炎病因与病理 n致病菌 n革兰氏阳性菌：葡萄球菌（48.4）、链球菌 、淋病双球菌、肠球菌等 n革兰氏阴性菌：假单胞菌、布氏杆菌、沙门氏 菌、艾希氏大肠杆菌、嗜血菌、克雷白杆菌、 肺炎双球菌、霉菌、KKingae菌等 n混合感染 Department of Radiology, Medical School Hospital of Qingdao University 椎间盘炎病因与病理 n感染途径 n血行性 n医源性操作(如手术、介入等) n椎体骨髓炎 n腹腔感染 n泌尿系统感染 n腹膜后感染 Department of Radiology, Medical School Hospital of Qingdao University 椎间盘炎病理 n纤维环、髓核 n早期：水肿、渗出 n进展期：液化坏死、椎间盘脓肿 n后期：椎间盘退变、瘢痕形成、“真空征” n终板 n不规则侵蚀、破坏 Department of Radiology, Medical School Hospital of Qingdao University 椎间盘炎病理 n邻近椎体 n骨髓内充血、渗出：骨质破坏 n骨髓血管血栓形成：梗死 n皮质中断 n上或下1/31/2或全椎体破坏 n椎体塌陷 n椎体积气 n愈合期：骨髓内脂肪沉积及骨硬化（1012周） Department of Radiology, Medical School Hospital of Qingdao University 椎间盘炎病理 n硬脊膜外和/或椎旁软组织 n脓肿 n蜂窝组织炎 n马尾和脊髓 n压迫 n功能损害：炎症介质毒性、血管血栓 n脊髓水肿（组织结构无破坏） Department of Radiology, Medical School Hospital of Qingdao University 椎间盘炎临床 n年龄：7个月-83岁，青壮年多见 n发病率：男：女=1.53:1 n症状：疼痛、运动后加剧，持续性发烧 n实验室 n白细胞、血沉、C反应蛋白（） n部位 n腰椎（52）胸椎（26）颈椎（22） Department of Radiology, Medical School Hospital of Qingdao University 椎间盘炎MRI nMRI检查方法 n方位 n矢状位 n横轴位 n冠状位 n序列 nFat-Sat FSE T2WI, STIR nSE T1WI nFat-Sat PDWI nFat-Sat SE T1WI +C(Gd-DTPA) Department of Radiology, Medical School Hospital of Qingdao University 椎间盘炎MRI n髓核改变 n正常椎间盘 n髓核显示率：94 nT2WI：髓核裂隙征（ intranuclear cleft sign） n椎间盘炎 n髓核裂隙征：阳性 n诊断敏感性：83.3% Department of Radiology, Medical School Hospital of Qingdao University 椎间盘炎MRI n纤维环改变 n信号 n早期：长/等T1信号，长T2高信号，信号均匀 n慢性期：长T1长T2信号，信号不均匀 n脓肿：长T1长T2液性信号 n诊断敏感性 nT1WI低信号：29.5% nT2WI高信号或液性信号：93.2% n形态 n不规则 n突入邻近椎体上、下缘破坏区 n增强扫描 n位置：纤维环中央或上、下缘 n形态：弥漫性或间断性、带状或斑片状强化 n诊断敏感性：95.4% Department of Radiology, Medical School Hospital of Qingdao University 椎间盘炎MRI n终板改变 n形态：不连续破坏 n信号：长T1长T2信号 n增强扫描：破坏区明显强化 n诊断敏感性：84.1% n出现时间：发病14周 n终板假性残留：化学位移伪影 Department of Radiology, Medical School Hospital of Qingdao University Department of Radiology, Medical School Hospital of Qingdao University 椎间盘炎MRI n邻近椎体改变 n部位：邻近两侧椎体，少数单侧 n位置：椎体上或下1/3部，少数全椎体 n表现 n早期：骨髓水肿，长T1长T2信号 n骨质破坏：长T1长T2信号 n压缩骨折 n痊愈期：椎体边缘脂肪沉积或骨硬化 n增强扫描：不均匀性强化，强化时间略迟于椎间盘 n出现时间：终板破坏之后，少数终板完整 n诊断敏感性：96；准确性：94；特异性：92 Department of Radiology, Medical School Hospital of Qingdao University 1M Later Department of Radiology, Medical School Hospital of Qingdao University 椎间盘炎MRI n椎间隙改变 n早期：椎间隙无变窄 n进展期（24周后） n变窄 n1/2椎间隙 n特异性 n诊断敏感性：52.3% n椎间隙增宽：椎间盘脓肿、邻近椎体压缩 Department of Radiology, Medical School Hospital of Qingdao University 椎间盘炎MRI n椎旁软组织改变 n蜂窝组织炎/脓肿：发生率90，特异性 n蜂窝组织炎：长T1长T2信号，均匀或不均匀性 强化 n脓肿 n见于急性期 n长T1长T2信号 n增强扫描：环样不均匀强化 n诊断敏感性：97.7% Department of Radiology, Medical School Hospital of Qingdao University 椎间盘炎MRI n硬脊膜外间隙改变 n部位：硬脊膜前方间隙，少数后方或环绕 n范围：4个椎体，突向椎间孔 n增强扫描：硬脊膜受累呈细线状强化 n硬脊膜及脊髓：受压 n脊髓改变 n受压变形 n水肿：长T1长T2信号 Department of Radiology, Medical School Hospital of Qingdao University 椎间盘炎鉴别诊断 n椎间骨软骨炎 n发病年龄早 n椎间盘高度减低 n邻近终板纤维环条带状强化 n椎间盘“真空征” n椎体骨髓水肿：条带状或半球形，1/2椎体 n对侧终板：无受累 n骨质破坏：无 n椎旁或硬脊膜外间隙软组织肿块：无 Department of Radiology, Medical School Hospital of Qingdao University 椎间骨软骨炎 Department of Radiology, Medical School Hospital of Qingdao University 椎间盘炎鉴别诊断 n脊椎结核 n临床症状和体征：不明显 n病变分布：可呈跳跃性 n椎旁炎性肿块：大 n硬脊膜外/韧带下：侵犯 n信号：不均匀长T1长T2信号 n寒性脓肿：环状强化 Department of Radiology, Medical School Hospital of Qingdao University 椎间盘炎鉴别诊断 Department of Radiology, Medical School Hospital of Qingdao University 椎间盘炎鉴别诊断 n骨髓肿瘤 n椎体骨质破坏区 n信号：软组织信号 n部位：椎体及附件 n增强：均匀或不均匀强化 n压缩性骨折 n椎间盘信号、高度：无异常 Department of Radiology, Medical School Hospital of Qingdao University 多发性骨髓瘤 Department of Radiology, Medical School Hospital of Qingdao University 肺癌骨转移 Department of Radiology, Medical School Hospital of Qingdao University 椎间盘炎鉴别诊断 n椎间盘退行性变 n椎体边缘部及终板骨质增生 n长T1短T2信号 n椎间盘真空征 n椎间隙变窄 n无椎旁及硬膜外炎性肿块 n实验室检查：无异常 Department of Radiology, Medical School Hospital of Qingdao University Department of Radiolo