椎间盘炎MRI诊断-徐文坚教学内容

椎间盘炎MRI诊断(zhěnduàn)青岛大学医学院附属(fùshǔ)医院放射科徐文坚DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity第一页，共39页。椎间盘炎—概念(gàiniàn)概念(gàiniàn)：椎间盘、终板和邻近椎体感染椎间型感染性脊椎炎椎间隙感染化脓性椎间盘炎脊椎-椎间盘炎……IM@1989：椎间盘炎（Discitis）DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity第二页，共39页。椎间盘炎—病因(bìngyīn)与病理结构纤维环髓核软骨终板营养婴幼儿血供丰富(fēngfù)来源：椎体骨化中心，前、后纵韧带血管>13岁无血供（纤维环周围结缔组织血管和淋巴管）营养来源：软骨终板和纤维环弥散DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity第三页，共39页。椎间盘炎—病因(bìngyīn)与病理椎间盘解剖(jiěpōu)第四页，共39页。椎间盘炎—病因(bìngyīn)与病理发病率：约占骨髓炎2%易感因素机遇性感染免疫(miǎnyì)缺陷糖尿病全身性感染透析器官移植嗜可卡因DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity第五页，共39页。椎间盘炎—病因(bìngyīn)与病理致病菌革兰氏阳性菌：葡萄球菌（48.4％）、链球菌、淋病双球菌、肠球菌等革兰氏阴性菌：假单胞菌、布氏杆菌、沙门氏菌、艾希氏大肠杆菌、嗜血(shìxuè)菌、克雷白杆菌、肺炎双球菌、霉菌、K－Kingae菌等混合感染DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity第六页，共39页。椎间盘炎—病因(bìngyīn)与病理感染途径血行性医源性操作(如手术、介入等)椎体骨髓炎腹腔感染泌尿系统(mìniàoxìtǒnɡ)感染腹膜后感染DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity第七页，共39页。椎间盘炎—病理(bìnglǐ)纤维环、髓核早期(zǎoqī)：水肿、渗出进展期：液化坏死、椎间盘脓肿后期：椎间盘退变、瘢痕形成、“真空征”终板不规则侵蚀、破坏DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity第八页，共39页。椎间盘炎—病理(bìnglǐ)邻近椎体骨髓内充血、渗出：骨质破坏骨髓血管血栓(xuèshuān)形成：梗死皮质中断上或下1/3－1/2或全椎体破坏椎体塌陷椎体积气愈合期：骨髓内脂肪沉积及骨硬化（10－12周）DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity第九页，共39页。椎间盘炎—病理(bìnglǐ)硬脊膜外和/或椎旁软组织脓肿蜂窝组织炎马尾和脊髓压迫功能(gōngnéng)损害：炎症介质毒性、血管血栓脊髓水肿（组织结构无破坏）DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity第十页，共39页。椎间盘炎—临床(línchuánɡ)年龄(niánlíng)：7个月-83岁，青壮年多见发病率：男：女=1.5～3:1症状：疼痛、运动后加剧，持续性发烧实验室白细胞↑、血沉↑、C－反应蛋白（＋）部位腰椎（52％）>胸椎（26％）>颈椎（22％）DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity第十一页，共39页。椎间盘炎—MRIMRI检查(jiǎnchá)方法方位矢状位横轴位冠状位序列Fat-SatFSET2WI,STIRSET1WIFat-SatPDWIFat-SatSET1WI+C(Gd-DTPA)DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity第十二页，共39页。椎间盘炎—MRI髓核改变正常椎间盘髓核显示率：94％T2WI：髓核裂隙(lièxì)征（intranuclearcleftsign）椎间盘炎髓核裂隙(lièxì)征：阳性诊断敏感性：83.3%DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity第十三页，共39页。第十四页，共39页。椎间盘炎—MRI纤维环改变信号早期：长/等T1信号，长T2高信号，信号均匀慢性期：长T1长T2信号，信号不均匀脓肿：长T1长T2液性信号诊断敏感性T1WI低信号：29.5%T2WI高信号或液性信号：93.2%形态不规则突入邻近椎体(zhuītǐ)上、下缘破坏区增强扫描位置：纤维环中央或上、下缘形态：弥漫性或间断性、带状或斑片状强化诊断敏感性：95.4%DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity第十五页，共39页。第十六页，共39页。第十七页，共39页。椎间盘炎—MRI终板改变形态：不连续破坏信号：长T1长T2信号增强扫描(sǎomiáo)：破坏区明显强化诊断敏感性：84.1%出现时间：发病1－4周终板假性残留：化学位移伪影DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity第十八页，共39页。第十九页，共39页。DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity第二十页，共39页。椎间盘炎—MRI邻近椎体改变部位：邻近两侧椎体，少数单侧位置：椎体上或下1/3部，少数全椎体表现早期：骨髓水肿，长T1长T2信号骨质破坏：长T1长T2信号压缩骨折(gǔzhé)痊愈期：椎体边缘脂肪沉积或骨硬化增强扫描：不均匀性强化，强化时间略迟于椎间盘出现时间：终板破坏之后，少数终板完整诊断敏感性：96％；准确性：94％；特异性：92％DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity第二十一页，共39页。1MLaterDepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity第二十二页，共39页。椎间盘炎—MRI椎间隙改变早期：椎间隙无变窄进展期（2－4周后）变窄<1/2椎间隙特异性诊断敏感性：52.3%椎间隙增宽：椎间盘脓肿(nóngzhǒng)、邻近椎体压缩DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity第二十三页，共39页。第二十四页，共39页。椎间盘炎—MRI椎旁软组织改变蜂窝组织炎/脓肿：发生率90％，特异性蜂窝组织炎：长T1长T2信号，均匀或不均匀性强化脓肿见于(jiànyú)急性期长T1长T2信号增强扫描：环样不均匀强化诊断敏感性：97.7%DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity第二十五页，共39页。第二十六页，共39页。椎间盘炎—MRI硬脊膜外间隙(jiànxì)改变部位：硬脊膜前方间隙(jiànxì)，少数后方或环绕范围：<4个椎体，突向椎间孔增强扫描：硬脊膜受累呈细线状强化硬脊膜及脊髓：受压脊髓改变受压变形水肿：长T1长T2信号DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity第二十七页，共39页。第二十八页，共39页。椎间盘炎—鉴别(jiànbié)诊断椎间骨软骨炎发病年龄早椎间盘高度减低邻近终板纤维环条带状强化椎间盘“真空征”椎体骨髓水肿：条带状或半球形，<1/2椎体对侧终板：无受累(shòulěi)骨质破坏：无椎旁或硬脊膜外间隙软组织肿块：无DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity第二十九页，共39页。椎间骨软骨(ruǎngǔ)炎DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity第三十页，共39页。椎间盘炎—鉴别(jiànbié)诊断脊椎结核临床症状和体征：不明显(míngxiǎn)病变分布：可呈跳跃性椎旁炎性肿块：大硬脊膜外/韧带下：侵犯信号：不均匀长T1长T2信号寒性脓肿：环状强化DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity第三十一页，共39页。椎间盘炎—鉴别(jiànbié)诊断DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity第三十二页，共39页。椎间盘炎—鉴别(jiànbié)诊断骨髓肿瘤椎体骨质破坏区信号(xìnhào)：软组织信号(xìnhào)部位：椎体及附件增强：均匀或不均匀强化压缩性骨折椎间盘信号(xìnhào)、高度：无异常DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity第三十三页，共39页。多发性骨髓瘤DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity第三十四页，共39页。肺癌(fèiái)骨转移DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity第三十五页，共39页。椎间盘炎—鉴别(jiànbié)诊断椎间盘退行性变椎体边缘部及终板骨质增生长T1短T2信号椎间盘真空(zhēnkōng)征椎间隙变窄无椎旁及硬膜外炎性肿块实验室检查：无异常DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity第三十六页，共39页。DepartmentofRadiology,MedicalSchool