蒋伟,俞冬叶,黄丙仓*,刘放,张宁
STIR序列在腰骶部浅筋膜炎中的诊断价值
蒋伟1,俞冬叶2*,黄丙仓1*,刘放1,张宁1
[摘要]目的 探讨核磁共振短T1反转回复序列(short T1 inversion-recovey,STIR)在诊断腰骶部浅筋膜炎的诊断价值。材料与方法 回顾分析100例腰腿痛患者腰椎MRI检查图像,其中男43例,女57例,年龄21~87岁,平均年龄56岁。除了进行T1WI、T2WI腰椎常规序列外,均采用STIR序列扫描。结果 100例腰腿痛患者腰椎MRI检查图像中,31例在MRI STIR序列显示腰椎棘突后方浅筋膜深层片状、条带状高信号,并伴异常的长T1、长T2信号,但STIR序列更明显、更直观地显示腰骶部浅筋膜炎,而T1WI、T2WI序列常常被掩盖。结论 腰骶部疼痛患者浅筋膜水肿发生率较高,MRI STIR序列成像对显示浅筋膜炎敏感,根据临床表现、影像学表现、治疗和随访确诊。
[关键词]磁共振成像;STIR序列;腰骶部;筋膜炎
作者单位:1.上海市浦东新区公利医院医学影像科,上海 200135 2.上海交通大学附属第六人民医院南院,上海 201400
接受日期:2016-01-08
蒋伟, 俞冬叶, 黄丙仓, 等. STIR序列在腰骶部浅筋膜炎中的诊断价值. 磁共振成像, 2016, 7(2): 126–130.
*Correspondence to: Yu DY, Email: T-zhen@126.com; Huang BC, E-mail:hbc9209@163.com
Received 5 Dec 2015, Accepted 8 Jan 2016
ACKNOWLEDGMENTS This work was part of project of 2011 Pudong New Area Health Bureau(No. PWRd2011-05).
腰骶部浅筋膜炎是导致腰腿痛的重要原因之一,腰腿痛在临床上比较常见,因对浅筋膜炎认识不足,在影像诊断中常被忽视,导致漏诊。腰骶痛包含软组织与骨性两种病变,有些病例目前不知道病因,无法做出明确诊断。梁杰群[1]、王宏伟[2]报告腰背浅筋膜炎是引起下腰痛的常见病。本文报告了从100例腰腿痛患者中检查出,经MRI诊断并经临床证实的腰背部浅筋膜炎患者31例,目的在于提高临床及影像医生对该病的认识,避免漏诊及误诊。
1.1临床资料
随机收集本院2013年12月至2015年2月间临床诊断为腰椎病变患者100例,且这100例病人无外伤史和腰骶部按摩等局部治疗病史,其中男43例,女57 例,年龄21~87岁,平均年龄56岁。给予初步体格检查和记录,并详细询问患者病史和临床症状,全部患者有腰骶部疼痛,伴或不伴有臀部和下肢放射性痛,病程在3天至6个月,或长期慢性腰痛病史近期急性加重。
1.2MR检查
采用东芝EXCELART VantageAtlas1.5 T磁共振扫描仪,脊柱线圈。定位像扫描后按照常规椎间盘检查方法,MRI平扫包括腰椎矢状位FSE序列T1WI(TR=400 ms,TE=15 ms)及腰椎矢状位FSE序列T2WI(TR=3000 ms,TE=100 ms),层厚4.5 mm,层距0.5 mm,矩阵256×192。腰椎间盘层面横断位FSE 序列T2WI(TR=3000 ms,TE= 90 ms),层厚5 mm,层距1 mm,矩阵224×320。在常规扫描序列的基础上加做横断位、冠状位或矢状位STIR序列。扫描条件分别是:STIR(短T1反转回复)脉冲横断位和冠状位序列扫描,TR=3800 ms,TE=90 ms,FOV 34 mm,层厚4.5 mm,层间0.5 mm,矩阵192×256,NAQ:2。
1.3图像后处理方法
把100例腰腿痛患者腰椎MRI检查图像经过最大密度投影成像(maximum intensity projection,MIP)处理,并与常规图像比较,STIR序列显示浅筋膜深层片状、条带状高信号的图像用标尺测量高信号的长、宽、高,并记录和汇总,根据MR表现分为4型:片状型、条状型、积液型、混合型。
1.4影像分析评价
图像由两位有经验的影像学专家通过双盲法读片,如判断不一致,重新讨论,最后达成一致意见。
1.5统计方法
采用统计软件SPSS 10.0对所得数据进行分析,如P>0.05则无统计学差异,P<0.01则有统计学差异,用配对四格表χ2检验。
表1 31例腰骶部浅筋膜炎常规序列与STIR序列对阳、阴性预测值的关系Tab. 1 The relationship between PPY and NPV of the general sequence and STIR sequence of 31 cases in the superficial fascia
100例腰腿痛患者中经MRI诊断并经临床证实的腰背部浅筋膜炎患者有31例,STIR序列与常规序列对31例腰骶部浅筋膜炎显示见表1。通过统计分析,STIR序列与常规序列磁共振检查对腰骶部浅筋膜的诊断具有统计学差异(P<0.01),STIR序列更能够显示腰骶部皮下水肿,其敏感性为94.4%,特异性为100%。31例在MRI STIR序列显示腰椎棘突后方浅筋膜深层片状、条带状明显高信号水肿带影,腰椎矢状位T1WI序列表现为低信号,腰椎矢状位T2WI序列表现为中高或稍高信号。从浅筋膜炎4型MR图像中,片状型、条状型分别表现为片状和条状异常水肿信号,即T1WI稍低信号,T2WI稍高信号,STIR高信号;积液型表现为腰背部浅筋膜层内出现液性信号,表现为T1WI低信号,T2WI高信号,STIR非常明显高信号,边缘清晰;而混合型表现较为复杂,同时出现片状、条状或积液型的表现。31例患者治疗l个月后,腰骶部浅筋膜炎临床症状基本消失。6个月后随访,在21例中,腰骶部浅筋膜层中有15例异常信号完全消失,范围缩小明显者6例,余下10例变化不大。因此31例患者依据腰痛的临床表现、影像学特征性的表现以及治疗后的随访,MRI诊断结果均符合临床诊断。
31例浅筋膜异常信号中,并有椎间盘和椎体退行性病变者有23例,23例中表现为腰椎间盘脱出与突出的有9例,表现为腰椎间盘变性与椎体骨质增生的有14例。并有椎体血管瘤的有2例;没有腰椎间盘病变与椎体病变的有6例,见表2。
表2 100例腰腿痛患者STIR序列在浅筋膜信号异常中的显示统计(例)Tab. 2 STIR sequence of 100 cases with lumbocrural pain in the superficial fascia abnormal signal shown statistics(n)
图1 男,63岁,腰痛半年。A:矢状位T1WI腰骶部浅筋膜中见条状低信号影,边界尚清楚;B:矢状位T2WI腰骶部浅筋膜中见条状中高或稍高信号影,边界尚清楚;C:矢状位STIR腰骶部浅筋膜中见明显高信号,边界清楚;D:横断位STIR腰骶部浅筋膜中见明显高信号,边界清楚;E:冠状位STIR腰骶部浅筋膜中见明显高信号,边界清楚图2 女,68岁,腰痛3月余。A:矢状位T1WI腰骶部浅筋膜中见条状低信号影,边界尚清楚;B:矢状位T2WI腰骶部浅筋膜中见条状中高或稍高信号影,边界尚清楚;C:矢状位STIR腰骶部浅筋膜中见明显高信号,边界清楚;D:横断位STIR腰骶部浅筋膜中见明显高信号,边界清楚;E:冠状位STIR腰骶部浅筋膜中见明显高信号,边界清楚Fig. 1 Male, sixty-three year old, low back pain for six months. A: Sagittal T1WI demonstrated that strip low signal were seen in the lumbosacral superficial fasciitis, and the boundary was clear; B: Sagittal T2WI demonstrated that strip middle or slightiy high signal were seen in the lumbosacral superficial fasciitis, and the boundary was clear; C: Sagittal STIR demonstrated that obviously high signal were seen in the lumbosacral superficial fasciitis, and the boundary was clear; D: Axial STIR demonstrated that obviously high signal were seen in the lumbosacral superficial fasciitis, and the boundary was clear; E: Coronary STIR demonstrated that obviously high signal were seen in the lumbosacral superficial fasciitis, and the boundary was clear. Fig. 2 Female, sixty-eight year old, low back pain for 3 months. A: Sagittal T1WI demonstrated that strip low signal were seen in the lumbosacral superficial fasciitis, and the boundary was clear; B: Sagittal T2WI demonstrated that strip middle or slightiy high signal were seen in the lumbosacral superficial fasciitis, and the boundary was clear; C: Sagittal STIR demonstrated that obviously high signal were seen in the lumbosacral superficial fasciitis, and the boundary was clear; D: Axial STIR demonstrated that obviously high signal were seen in the lumbosacral superficial fasciitis, and the boundary was clear; E: Coronary STIR demonstrated that obviously high signal were seen in the lumbosacral superficial fasciitis, and the boundary was clear.
3.1浅筋膜炎的概念及主要表现
腰骶部浅筋膜炎是因为劳损、风寒等原因引起腰骶部纤维结缔组织(如筋膜、肌膜、肌腱、韧带)的一种非特异性炎性变化[3],长久不愈和形成粘连及纤维病变,继而形成此病。它的发病原因目前暂无满意的结论,估计与以下因素有关:慢性损伤[4]、感染[5]、寒冷刺激、痛风、风寒症及其他结缔组织病[6-7]。主要表现为腰臀腿部疼痛,通常为自发性局部酸痛、钝痛和难以忍受的剧痛,伴弥漫性下肢放散痛。
3.2浅筋膜炎的 MRI STIR序列特征
腰骶部浅层筋膜炎的典型MRI表现为:腰骶部出现异常信号,表现为T 1 W I稍低信号,T2WI稍高信号,STIR高信号,一般表现为条状或条带状[8-9]。笔者发现,浅筋膜炎MRI表现可以分为片状型、条状型、积液型、混合型4种。T1WI腰骶部浅筋膜(皮下脂肪层)中的条、片状低信号边界较清楚(图1、图2A),T2WI呈条、片状高信号(图1、图2B),STIR呈明显高信号影(图1、图2C~E),边界清楚[10]。这种高信号的表现是腰骶部浅筋膜炎的特征性MR表现。STIR技术是脂肪抑制技术,基于脂肪组织短T1的特性,由于浅筋膜中脂肪含量较多,T1值短,在浅筋膜炎发生时、局部有水肿病理改变时,STIR序列恰恰能够显示出来。因此选择短T1则有效抑制了脂肪组织的信号。从表1看出,STIR序列31例中只有一例未检出,原因在于浅筋膜炎症较轻,而常规序列有13例未检出,原因是由于T1WI/T2WI序列有脂肪成分干扰,从而被掩盖。根据数据测算,STIR序列的敏感性是94.4%,特异性是100%。
STIR序列不仅能够抑制全部脂肪组织信号,而且能够抑制部分水的信号,更可以突出水肿样病变的高信号,特别是对MRI常规序列难以发现的病变,在STIR上可清楚显示[11]。并且核磁共振脂肪抑制技术能在抑制软组织脂肪成分的同时提升结合水的信号[12-13],使软组织炎性病变的高信号得以凸现,它可以通过均匀弥漫的脂肪抑制,将隐藏于脂肪组织内的病变突显出来[14]。因此,STIR序列是目前惟一对磁场非均匀性不敏感的脂肪抑制技术。笔者认为STIR序列成像对显示浅筋膜炎具有特别重要的意义,大大减少了腰骶部浅筋膜炎的误诊率,特别对腰腿痛患者常规T1WI、T2WI序列无明显阳性表现时,应想到腰骶部浅筋膜炎存在的可能性[15],加扫STIR序列,结合T1WI、T2WI表现作出明确诊断。
3.3浅筋膜炎的重要意义
目前腰腿痛病因复杂且常见,其中以盘源性腰痛最为常见,导致椎间盘源性神经根性疼痛的主要原因[16-17]是椎间盘突出对腰神经根的机械性压迫和髓核突出物质的致炎作用所引起。所以凡是患者有腰腿臀痛,尤其是有坐骨神经痛的病人,很多学者都认为只要有腰椎影像学改变,且又对浅筋膜炎认识不足,常依据影像学表现与临床症状错误作出腰椎间盘突出症的诊断结果[18],而忽视了浅筋膜炎的存在可能[19]。本组腰骶部浅筋膜炎患者中有6例有明显腰腿痛症状但无腰椎间盘突出,经对症治疗后症状减轻或消失,而且经过核磁共振STIR序列复查后,其炎症有不同程度好转;12例有腰椎间盘突出、脱出,26例椎间盘变性骨质增生,但没有浅筋膜炎。因此,导致腰腿痛的重要原因之一常常恰是腰骶部浅筋膜炎,它与盘源性腰痛的症状有相似处,如果对该病认识不清容易把两种疾病混淆而误诊。
因此,笔者认为,依据临床表现、影像学表现以及治疗后病人的随访结果可以对腰骶部浅筋膜炎做出明确诊断,而MRI STIR序列是对腰骶部浅筋膜炎具有特征性的影像表现,是目前最敏感、最具说服力的诊断腰骶部浅筋膜炎的影像学检查方法,是对临床治疗方案选择提供可靠的依据。
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Value of STIR sequence in diagnosis of lumbosacral superficial fasciitis
JIANG Wei1, YU Dong-ye2*, HUANG Bing-cang1*, LIU Fang1, ZHANG Ning11Department of Radiology, Shanghai Pudong New Area Gongli hospital, Shanghai 200135, China2The south campus of sixth People's hospital affiliated to Shanghai Jiao Tong University, Shanghai 201400, China
Key wordsMagnetic resonance imaging; STIR sequence; Lumbar and sacral region;Fasciitis
AbstractObjective: To assess the diagnostic value of MRI STIR sequence in lumbosacral superficial fasciitis. Materials and Methods: Analysis of 100 cases of MRI pictures of patients with low back pain or leg pain was taken. Including 43 males and 57 females, with a mean age of 56(21–87 years). The MRI pictures included T1WI, T2WI and STIR sequence scanning. Results: Strip high signals with long T1,long T2 abnormal signal behind lumbar vertebra were showed in 31 cases. The STIR sequence was more obvious, more intuitive to display lumbosacral superficial fasciitis,while the abnormal fascia signals in T1WI and T2WI sequences were often covered. Conclusion: The fascia superficialis edema is at a high rate in the patients with lumbosacral pain. The MRI STIR sequence can display the lumbosacral subcutaneous fibrositis sensitively and clearly, according to clinical manifestations, imaging findings, treatment and follow-up confirmed.
基金项目:2011年度浦东新区卫生局课题项目(编号:PWRd2011-05)
通讯作者:俞冬叶,E-mail:T-zhen@126.com;黄丙仓,E-mail:hbc9209@163.com
收稿日期:2015-12-05
中图分类号:R445.2;R686.3
文献标识码:A
DOI:10.12015/issn.1674-8034.2016.02.008