【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（八）

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山东省立医院疼痛科英语晨读已经坚持10余年的时间了，每天交班前15分钟都会精选一篇英文文献进行阅读和翻译。一是可以保持工作后的英语阅读习惯，二是可以学习前沿的疼痛相关知识。我们会将晨读内容与大家分享，助力疼痛学习。

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。

Abscess formation is common and can grow to a very large size. The site of cold abscess depends on the region of the vertebral column affected. In the cervical region, the pus accumulates behind prevertebral fascia to form a retropharyngeal abscess. The abscess may track down to the mediastinum to enter into the trachea, oesophagus, or the pleural cavity. In the thoracic spine, the cold abscess usually presents as a fusiform or bulbous paravertebral swellings. At lumbar vertebrae, cold abscesses most commonly present as a swelling in the groin and thigh and pus collection can spread to the gluteal region.

脓肿的形成很常见，并且可以长到很大。冷脓肿的部位取决于受影响的脊柱区域。在颈椎，脓液积聚在椎前筋膜后形成咽后脓肿。脓肿可延伸至纵隔，进入气管、食道或胸膜腔。在胸椎，冷脓肿通常表现为梭形或球茎状的椎旁肿胀。在腰椎，冷脓肿最常见的表现为腹股沟和大腿肿胀，脓液聚集可扩散到臀部。

Brucellar spondylodiscitis

Brucellosis can account for up to about half of spinal infections in areas where the zoonosis is endemic, being the predominant cause in some case series in the Mediterranean basin and the Middle East. The aetiological agent is Brucella melitensis, an intracellular bacterium. Osteoarticular involvement is a common complication of brucellosis, found in up to 85% of patients. In decreasing order of frequency, spinal involvement concerns the lumbar (60%), sacral (19%) and cervical (12%) vertebrae . Spondylodiscitis during brucellosis can be multifocal. This type of involvement can be observed in 3–14% of patients. Spinal brucellosis usually starts from the upper terminal vertebral end plate, but sometimes the lower terminal end plate may also be involved. In MRI, the lesion is detectable as a destructive aspect at the antero-superior vertebral angle accompanied by prominent osteosclerosis, and it is a pathognomonic sign (Pedro Pons' sign). The intervertebral disc can be infected without spondylitis, being only a discitis. Epidural abscess is a rare complication of spinal brucellosis, but can lead to severe neurological outcomes.

布氏杆菌引起的脊柱间盘炎

在人畜共患病流行的地区，布鲁氏菌病可占脊柱感染的约一半，是地中海盆地和中东某些病例系列的主要原因。病原菌是布鲁氏菌，一种细胞内细菌。骨关节受累是布鲁氏菌病的常见并发症，可在85%的患者中发现。脊柱受累的频率依次为腰椎(60%)、骶椎(19%)和颈椎(12%)。布鲁氏菌病导致的脊柱间盘炎可为多灶性。这种类型的受累可在3-14%的患者中观察到。脊柱布鲁氏菌病通常从椎体上终板开始，但有时也可累及椎体下终板。MRI可见病变在椎体前上角破坏，并伴有明显的骨硬化，是一种病理征象(Pedro Pons’征象)。可以只有椎间盘炎，而没有脊柱炎。硬膜外脓肿是脊柱布鲁氏菌病的一种罕见并发症，但可导致严重的神经系统后果。

Fungal vertebral infections

Fungal spondylodiscitis is rare (up to 1.6%) even in larger case series; however, the incidence of these conditions is increasing as the population of immunocompromised patients increases. Candida spp., Aspergillus spp. and Cryptococcus neoformans are present worldwide, while dimorphic fungi such as Coccidioides immitis and Blastomyces dermatitidis are only endemic in some geographical areas. Spinal fungal infection includes spondylodiscitis, osteomyelitis and meningitis.

真菌性脊柱感染

真菌感染比较少见（发病率1.6%），但是随着免疫抑制剂的使用增加，病例数量在增加。念珠菌属、曲霉菌属和新型隐球菌属在世界范围内均有发现，而双态性真菌如粗球孢子菌属和皮炎芽生菌属仅在某些地理区域存在。真菌性脊柱感染包括脊柱间盘炎、骨髓炎和脊膜炎。

MRI features, such as focal partial soft tissue abnormality and partial involvement of the disc/endplate, in combination with clinical features may help to predict fungal discitis/osteomyelitis.

MR检查可以发现部分软组织形态异常，部分累及间盘/终板，结合临床症状可以预测真菌性间盘炎/骨髓炎。

Candida

Although there are at least 10 species of Candida pathogenic to humans, Candida albicans is responsible for more than half of all cases of spondylodiscitis supported by Candida spp., followed by Candida tropicalis (19%) (Fig. 14), and Candida glabrata (formerly Torulopsis glabrata, 14%). Spondylodiscitis supported by Candida glabrata is becoming increasingly common. Overall, Candida spp. is responsible for 0.7–2.7% of spinal infections. The lower dorsal and lumbar vertebral segments are the most frequently involved sites. The few reported cases occurring at a higher spinal or sacral level are anecdotal. At diagnosis, 83% of patients have been complaining of back pain for at least one month, while only 32% of patients are febrile.

念珠菌

虽然至少有10种念珠菌对人类致病，但白色念珠菌占所有念珠菌支持的椎间盘炎病例的一半以上，其次是热带念珠菌(19%)(图14)，以及光滑念珠菌（14%)。由光滑念珠菌引起的脊柱间盘炎越来越常见。总的来说，脊柱感染中念珠菌占0.7-2.7%。下背侧和腰椎节段是最常见的受累部位。少数报道的病例发生在较高的脊柱或骶骨水平是轶事。在确诊时，83%的患者抱怨背痛至少一个月，而只有32%的患者出现发热。