【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（七）

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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。

MRI is the most sensitive technique in the diagnosis of spondylodiscitis. Although it is the most sensitive tool for early detection of signs of infection, MRI results may lag behind clinical symptoms. If the clinical picture is uncertain, an MRI one week after the previous one may be useful to show an evolution. Sagittal-weighted T1 images typically show hypointense and poorly defined vertebral bone marrow in contiguous vertebral bodies. Intervertebral disc space is involved with loss of end plate definition on both sides of the disc. Weighted spin-echo T2 images detect increased water content expression of inflammatory exudate. Intravenous gadolinium contrast is usually administered in all suspected cases of spondylodiscitis. In patients who cannot receive gadolinium contrast, diffusion-weighted imaging (DWI) can be used.

MRI是诊断脊柱间盘炎的最敏感的技术。虽然它是早期检测感染迹象的最敏感的工具,但MRI结果可能滞后于临床症状。如果临床情况不确定,在最初的一周进行核磁共振成像可能有助于显示进展。矢状位T1WI显示低信号，相邻椎体边界不清。椎间隙上下的椎板界限不清。炎性渗出导致T2WI含水量增加。对疑似脊柱间盘炎的患者静脉注射钆造影检查。在无法注射造影剂的患者,可以使用弥散加权成像(DWI)。

Infectious granulomatous diseases

Some infectious processes within the spinal elements can lead to the formation of granulomas. The organisms causing granulomatous inflammation include various bacteria, fungi or other parasites. Among the bacteria, those most frequently found are Mycobacterium tuberculosis and Brucella. The onset of granulomatous infections is often insidious and often leads to a late diagnosis.

感染性肉芽肿性疾病

脊柱的一些感染性疾病可以导致肉芽肿的形成。导致肉芽肿性炎症的生物包括各种细菌、真菌或寄生虫。在这些细菌中,最常见的是结核分枝杆菌和布鲁氏菌。肉芽肿性感染的发生往往是不明显的,经常导致诊断延迟。

Tubercular spondylodiscitis

Spinal involvement in tuberculosis (Pott's disease) occurs mainly by haematological spread. The clinical presentation of vertebral tuberculosis is insidious, with symptoms that can last up to 3 years before diagnosis. From an epidemiological point of view, tubercular spondylodiscitis is significantly more common in patients under 40 years of age than in patients older.

结核性脊柱间盘炎

脊柱结核(Pott’s病)多由血行传播。脊柱结核的临床表现是不明显的,在确诊前症状可持续3年。从流行病学的角度来看,脊柱结核在40岁以下的患者中发病率高于40岁以上的患者。

Thoracolumbar region is the most commonly affected site, while the cervical and sacrum regions are less commonly involved. Usually more than one vertebra is affected because of its segmental arterial distribution and subligamentous spread of the disease.

胸腰椎区是最常见的受累部位,而颈椎和骶骨则不常见。由于节段动脉的分布和韧带下传播,通常累及一个以上的椎体。

Tubercular spondylodiscitis usually begins in the antero-inferior part of the vertebral body. The spread of infection occurs under the anterior longitudinal ligament, a structure that involves adjacent vertebral bodies. The narrowing of the disc space occurs secondarily and is not as pronounced as in pyogenic infections. The relative saving of the intervertebral disc appears to be due to the lack of proteolytic enzymes in Mycobacterium tuberculosis. MRI is the diagnostic technique of choice, more sensitive than X-ray and more specific than CT in the diagnosis of spinal tuberculosis. MRI demonstrates involvement of vertebral bodies, disc destruction, cold abscess, vertebral collapse and spinal deformities (Fig. 11). Compared to pyogenic infections, the disc may not show a signal increase in T2-weighted images. The involvement of posterior elements is more common in tubercular infections than in pyogenic infections. Posterior lesions enter into differential diagnosis with neoplastic lesions, particularly when there is relative preservation of disc space. Tubercular infections classically spread to adjacent ligaments and soft tissue in an antero-lateral direction (Fig. 12). The paravertebral abscesses are surrounded by a rim characterized by a robust and irregular enhancement, which can be seen in MRI. These abscesses tend to be larger in tubercular infections than in pyogenic infections (Fig. 13).

结核性脊柱间盘炎通常从椎体的前下部开始。感染自前纵韧带下传播。继而发生椎间隙变窄,但不如化脓性感染明显。椎间隙高度相对正常可能是由于结核分枝杆菌缺乏蛋白水解酶。脊柱结核选择MRI来进行诊断,比X线敏感性高,比CT特异性高。MRI显示椎体、椎间盘破坏、冷脓肿、椎体塌陷和脊柱畸形(图11)。与化脓性感染相比,T2WI椎间盘的信号增加不明显。脊柱后部受累在结核性感染中比在化脓性感染中更常见。后部病变需要与肿瘤病变进行鉴别诊断,特别是在椎间隙相对正常的情况下。结核性感染沿向前向外的方向传播到相邻韧带和软组织（图12)。MR上椎旁脓肿边界清晰，不规则强化。这些脓肿倾向于在结核性感染中比在化脓性感染中更大(图13)。