椎间盘炎MRI诊断--徐文坚

椎间盘炎MRI诊断青岛大学医学院附属医院放射科徐文坚DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity椎间盘炎—概念概念：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椎间盘炎—病因与病理结构纤维环髓核软骨终板营养婴幼儿血供丰富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椎间盘炎—病因与病理椎间盘解剖椎间盘炎—病因与病理发病率：约占骨髓炎2%易感因素机遇性感染免疫缺陷糖尿病全身性感染透析器官移植嗜可卡因DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity椎间盘炎—病因与病理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、嗜血菌、克雷白杆菌、肺炎双球菌、霉菌、K－Kingae菌等混合感染DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity椎间盘炎—病因与病理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泌尿系统感染腹膜后感染DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity椎间盘炎—病理纤维环、髓核早期：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椎间盘炎—病理邻近椎体骨髓内充血、渗出：骨质破坏骨髓血管血栓形成：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椎间盘炎—病理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椎间盘炎—临床年龄：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椎间盘炎—MRIMRI检查方法方位矢状位横轴位冠状位序列Fat-SatFSET2WI,STIRSET1WIFat-SatPDWIFat-SatSET1WI+C(Gd-DTPA)DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity椎间盘炎—MRI髓核改变正常椎间盘髓核显示率：94％T2WI：髓核裂隙征（intranuclearcleftsign）椎间盘炎髓核裂隙征：阳性诊断敏感性：83.3%DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity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：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,MedicalSchoolHospitalofQingdaoUniversityDepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity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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,MedicalSchoolHospitalofQingdaoUniversity1MLaterDepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity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、邻近椎体压缩DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity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椎间盘炎—MRI硬脊膜外间隙改变部位：硬脊膜前方间隙，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椎间盘炎—鉴别诊断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骨质破坏：无椎旁或硬脊膜外间隙软组织肿块：无DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity椎间骨软骨炎DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity椎间盘炎—鉴别诊断脊椎结核临床症状和体征：不明显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椎间盘炎—鉴别诊断DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity椎间盘炎—鉴别诊断骨髓肿瘤椎体骨质破坏区信号：软组织信号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、高度：无异常DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity多发性骨髓瘤DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity肺癌骨转移DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity椎间盘炎—鉴别诊断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,MedicalSchoolHospitalofQingdaoUniversityDepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity椎间盘退变椎间盘炎—鉴别诊断DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversity压缩性骨折DepartmentofRadiology,MedicalSchoolHospitalofQingdaoUniversityThankYou!!