读片细节-不稳征象

SPINELEE 2024-01-12 发布于上海

展开全文

脊柱不稳定是疼痛和疾病进展的一个重要来源，

脊柱不稳是手术决策是否内固定融合的重要指标，

术前对稳定性评估是关键。

退变导致不稳

退变性滑脱自然进程分为：功能障碍期、不稳定期、自稳定期。

通过评估稳定性可分为：稳定型，可能不稳定和不稳定型。

征象

关节突关节积液；关节突关节囊肿；棘突间积液；关节突关节肥大；空气征。

项韧带骨化提示节段不稳。

牵张型骨赘提示节段不稳。

特别是屈曲位椎间盘角度

前屈后伸位。

疼痛影响前屈后伸位的完成度

疼痛影响前屈后伸位的完成度。

镇痛前：角度变化6度，滑移0.6mm;

镇痛后：角度变化25.4度，滑移4.7mm。

滑移和角度变化

动力位片变化标准：滑移：3.5mm；角度变化11度？

最新文献：3mm，10度

客观评分

综合：腰痛（症状性）；自稳定征象（高度丢失，爪样骨赘形成、终板硬化和韧带骨化）；屈曲位椎间盘角度；屈曲位滑移小于3mm，3-5mm，大于5mm；MRI中关节突关节积液。

主观评分

综合：自稳定（椎间隙高度丢失提示节段不稳趋向稳定，爪样骨赘形成、终板硬化和韧带骨化））；动力片滑移4mm；屈曲位椎间盘角度；腰痛（症状性）；关节突关节积液。

I型稳定的DLS

1例Ⅰ型(稳定型) L4~5 DLS。注意站立位X线片上的再稳定征象、椎间隙高度丢失、稳定的滑脱平移（和躺着做的MRI无差别），以及MRI上小关节没有积液。

II型可能不稳定的DLS

1例Ⅱ型(可能不稳定) L4-5 DLS。注意站立位X线片上滑脱移位增加(相比于躺着做的MRI)，MRI上关节突关节中度积液，站立位高度丢失存在再稳定作用征象。

III型不稳定DLS

1例Ⅲ型(不稳定) L4-5 DLS。注意站立位X线片上滑动平移的增加（相比于躺着的CT），MRI上关节突关节积液。椎间隙高度存在提示自稳定不足。

感染导致不稳

脊柱感染稳定性评分系统-SITE评分。

五个关键变量：1、感染引起的神经功能缺失；2、感染部位；3、CT和MRI的放射学改变；4、疼痛；5、患者合并症

影像学评分

影像学评分：神经压迫和后凸畸形的重要性。

肿瘤导致不稳

脊柱肿瘤研究学组创建了SINS评分系统来评估脊柱的稳定性。包括六个方面：肿瘤病灶的位置、疼痛、骨损伤的类型、有无脱位或畸形、椎体塌陷程度及后外侧结构累及的程度。最低分为0分，最高分为18分，分数越高则其不稳定的程度越大。

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