【原】脊柱感染性疾病和炎症/退变性疾病的鉴别诊断：磁共振的临床价值（三）

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本次文献选自Salaffi F, Ceccarelli L, Carotti M, Di Carlo M, Polonara G, Facchini G, Golfieri R, Giovagnoni A. Radiol Med. 2021 Jun;126(6):843-859.  本次学习由杨聪娴副主任医师主讲。

Axial inflammatory manifestations can involve multiple sites and combine in different ways. Elementary radiological lesions include angular lesions of the vertebral body, non-specific spondylodiscitis (very similar to infectious forms), osteolytic lesions with varying degrees of collapse of the vertebral body (visible lesions even in childhood), osteosclerosis of one or more vertebral bodies with development of hyperostosis, paravertebral ossification, and sacroiliitis (more common in adulthood). Angular erosions seen on MRI may suggest enthesitis and are somehow the equivalent of Romanus' lesion in axSpA. Similar to axSpA, active MRI lesions appear as BME and soft tissues edema. With the attenuation of the inflammatory process, in MRI in T1-weighted sequences the lesions may become hyperintense rather than hypointense due to post-inflammatory fatty bone marrow degeneration. Non-specific spondylodiscitis lesions of two or more contiguous vertebrae, with cortical erosions and underlying subchondral sclerosis in the endplates, on either side of an intervertebral disc, mimicking infectious spondylodiscitis, are usually located in the central or anterior part of the discovertebral junction. The intervertebral disc space is usually well preserved; the height may be reduced. The low signal intensity of the disc on fluid-sensitive images and the absence of post-contrastographic enhancement of the disc space help to differentiate the SAPHO from infectious forms. However, the presence of both high signal intensity on T2-weighted images and post-contrastographic disc space enhancement is visible in up to 30% of cases. The differential diagnosis of SAPHO syndrome compared to infectious spondylodiscitis may also be made difficult by the possible coexistence of prevertebral soft tissue swelling. SAPHO can be a multifocal disease, and total body MRI, with T1-weighted coronal sequences and STIR, is increasingly used to assess this condition.

中轴炎症可出现多处病灶，并以不同途径结合。基本影像学改变包括椎角病变、非特异性脊柱间盘炎(与感染性病变非常相似)、溶骨性病变伴有不同程度的塌陷椎体(即使在儿童时期也可见病变)、一个或多个椎体的骨硬化伴骨质增生，椎旁骨化和骶髂关节炎(在成年期更常见)。MRI上看到的椎角侵蚀可能提示肌腱炎，在某种程度上相当于脊柱关节炎中的Romanus病变。与脊柱关节炎相似，MRI活动性病变表现为骨髓水肿和软组织水肿。在炎症的衰退过程中，由于炎症后骨髓脂肪变性，病灶T1WI可能变成高信号而不是低信号。两个或多个相邻椎体的非特异性脊柱间盘炎病变，椎间盘两侧有皮质侵蚀和终板软骨下骨硬化，这些表现和感染性脊柱间盘炎相似，通常位于椎体间盘结合部的中央或前部。椎间隙通常变化不明显，椎间隙高度可以降低。T2WI椎间盘的低信号强度和椎间隙没有强化有助于区分SAPHO和感染性疾病。然而，高达30%的病例在T2WI加权图像上同时存在高信号和椎间隙强化。与感染性椎间盘炎相比，SAPHO综合征的鉴别诊断因椎旁软组织肿胀而变得困难。SAPHO是一种多灶性疾病，具有T1WI和压脂像的全身MRI越来越多地被用于评估这种情况。

CRMO consists of an autoinflammatory bone disorder that results in bone lesions, usually seen in children (approximately 7–12 years old, 2:1 female-to-male ratio). Patients usually have non-specific clinical findings and present with localized bone pain in the lower extremities, clavicle, and/or pelvis. One-third of patients has low grade fever. There is an association with other autoimmune disorders like inflammatory bowel diseases, psoriasis, and palmar plantar pustulosis.

CRMO是一种自身免疫性骨骼疾病，通常见于儿童(约7-12岁，男女比例为2:1)。患者通常有非特异性的临床表现，表现为下肢、锁骨和/或骨盆的局限性骨痛。三分之一的患者为低烧。与其他自身免疫性疾病相关，如炎症性肠病、牛皮癣和掌跖脓疱病。

CRMO is characterized by lytic lesion with a well-defined sclerotic hem. Bone lesions can occur anywhere throughout the body. However, they tend to have a predisposition to the metaphyseal region of bones (75%). Spinal involvement is not so rare and often involves different soma with bone edema and vertebral collapse. On MRI, abnormal lesions have increased signal on the STIR sequence and decreased signal on the T1-weighted sequence. Whole body MRI is recommended to determine clinically silent lesions.

CRMO的特点是溶骨性病变，伴明确的硬化边缘。骨质缺损可能发生在全身任何地方。然而，他们倾向于破坏骨干骺端(75%)。脊柱受累并不少见，常累及不同节段，伴有骨水肿和椎体塌陷。MRI上，异常病变在压脂序列上信号增强，在T1WI上信号减弱。建议采用全身MRI来确定临床无症状病灶。

Modic type 1 lesion

Modic 1 lesions are alterations involving the subchondral bone of two adjacent vertebrae associated with degenerative disease of the intervertebral disc. Modic 1 lesions are acute conditions, characterized in MRI by a hyperintensity of signal on T2- or STIR-weighted sequences and by hypointensity in T1-weighted sequences, compared to the bone marrow signal (Fig. 4).

Modic 1型病变

Modic 1型病变是指与椎间盘退变相关的两个相邻椎体的软骨下骨改变。Modic 1型病变为急性病变，与骨髓信号相比，MRI表现为T2WI或压脂像高信号，T1WI低信号（图4）。

Modic 2 lesions represent a chronic phase of the degenerative process, characterized by an isointense signal in T2- or STIR-weighted sequences and a higher signal intensity on T1-weighted sequences, considering the signal intensity always in relation to the bone marrow signal (Fig. 5).

Modic 2型病变是退变的一个慢性阶段，与骨髓信号相比，T2WI或压脂像等信号，T1WI高信号。（图5）

Modic 3 lesions are the final stage of the degenerative process, and the main characteristic is the decrease in signal intensity in both STIR/T2 and T1 sequences.

Modic 3型病变是退变过程的终末阶段，主要特征是压脂像/T2WI和T1WI低信号。

往期回顾：

脊柱感染性疾病和炎症/退变性疾病的鉴别诊断：磁共振的临床价值（二）

脊柱感染性疾病和炎症/退变性疾病的鉴别诊断：磁共振的临床价值（一）

神经病理性疼痛:癌症疼痛患者的临床分类和评估（六）