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功能不全性骨折(insufficiency fracture,IF)是应力性骨折的一种,也称为衰竭性骨折或矿物质缺乏性骨折,是正常或生理性肌肉活动作用于矿物质减少或弹性抵抗力减弱的骨骼而导致的脆性骨折。IF常见于绝经后骨质疏松的女性患者,也见于其他原因骨质疏松的患者,如长期服用激素、糖尿病、骨质软化及恶性肿瘤放疗后患者等[1-2]。IF患者常无临床症状或症状不明显,临床容易漏诊或误诊[3-5]。99Tcm-MDP SPECT全身骨显像对骨病的诊断具有较高的灵敏度,但特异度低,SPECT/CT可提高诊断的特异度,拓展了其临床应用范围。本研究回顾性分析90例骨质疏松患者的99Tcm-MDP SPECT全身骨显像及局部SPECT/CT融合显像的影像学资料,探讨联合显像对IF的诊断价值,以及对新鲜或陈旧性IF的鉴别诊断价值。
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99Tcm-MDP SPECT全身骨显像共检出病灶234个,均表现为不同程度的点状、条形或团状显像剂摄取增高;局部SPECT/CT显像可见骨折线、硬化带/线或椎体高度降低,显像剂沿着骨折线周围摄取增高,提示均为IF且随访证实均为真阳性。99Tcm-MDP SPECT全身骨显像联合SPECT/CT融合显像对骨质疏松患者IF的诊断灵敏度为100%(234/234),准确率为100%。90例患者中,单发IF 21例、多发IF 69例,合计234个IF病灶,具体部位见表1。
IF部位 例数(例) 病灶数(个) 骨盆 22 78 腰椎 36 49 胸椎 24 46 肋骨 11 45 股骨 6 8 胫骨 4 4 跟骨 2 3 胸骨 1 1 合计 234 注:表中,IF:功能不全性骨折 表 1 90例骨质疏松患者IF的分布部位及病灶数
Table 1. Distribution of insufficiency fracture and the number of lesions in 90 cases of osteoporosis
68.89%(62/90)的患者联合显像检出的IF病灶数目多于显像之前已知的病灶数目。22例患者的解剖影像学结果为阴性,而联合显像为阳性;68例患者行联合显像之前,局部解剖影像学检出患者局部骨骼有IF,显像之后,40例患者的IF病灶部位多于显像之前诊断的病灶数目。234个IF病灶,其中86个IF病灶患者的临床症状不明显,由联合显像首先发现(图1、图2)。
图 1 全身多发功能不全性骨折患者(女性,76岁)的99Tcm-MDP SPECT全身骨显像图(A)和骨盆SPECT/CT显像图(B、C) 患者臀部疼痛不适15 d。图中,A:双侧多发肋骨骨折呈“串珠状”改变,骶椎、双侧髂骨及双侧耻骨显像剂局部摄取增高;B:CT图像示骨盆呈骨质疏松改变,骶椎双侧、双侧髂骨翼及双侧耻骨骨折;C:融合图像示显像剂沿着骨折线摄取增高。MDP:亚甲基二膦酸盐;SPECT:单光子发射计算机体层摄影术;CT:计算机体层摄影术
Figure 1. 99Tcm-MDP SPECT whole-body bone scan (A) and local SPECT/CT tomography (B, C) of a 76-year-female patient with multiple insufficiency fracture
图 2 全身多发功能不全性骨折患者(女性,69岁)的99Tcm-MDP SPECT全身骨显像图(A)和腰椎SPECT/CT显像图(B、C) 患者胸背部疼痛不适10余天。图中,A:胸9、胸11椎体显像剂条形摄取增高;B:CT图像示胸8~胸12、腰1、腰3~腰4椎体高度不同程度降低;C:融合图像示胸9、胸11椎体显像剂呈条形摄取增高,提示新鲜骨折,余形态改变的椎体显像剂无明显摄取,提示陈旧性骨折。MDP:亚甲基二膦酸盐;SPECT:单光子发射计算机体层摄影术;CT:计算机体层摄影术
Figure 2. 99Tcm-MDP SPECT whole-body bone scan (A) and local SPECT/CT tomography (B, C) of a 69-year-female patient with multiple insufficiency fracture
在局部SPECT/CT融合显像检查范围内,CT显示骨折病灶293个,其中234个显像剂摄取明显增高,提示为新鲜IF;59处无明显显像剂摄取或略显显像剂摄取,提示为陈旧性IF,随访证实均为陈旧性IF(图2)。SPECT/CT对新鲜IF的诊断灵敏度为100%(234/234)、特异度为100%(59/59)。
99Tcm-MDP SPECT全身骨显像显示11例患者的肋骨IF,其中9例患者的肋骨IF呈点状纵向排列的显像剂摄取增高(图1)。在22例骨盆IF患者中,6例骶椎显像剂摄取增高,呈“H”形改变(图3),占总数的27.28%。
全身骨显像联合局部SPECT/CT对功能不全性骨折的诊断价值
Diagnostic value of whole-body bone scan and local SPECT/CT for insufficiency fracture
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摘要:
目的 探讨99Tcm-MDP SPECT全身骨显像联合局部SPECT/CT融合显像对骨质疏松患者功能不全性骨折(IF)的诊断价值。 方法 回顾性分析2012年12月至2017年6月于河南省骨科医院收治的90例符合骨质疏松症诊断标准的患者的99Tcm-MDP SPECT全身骨显像和阳性部位的局部SPECT/CT融合显像结果,分析联合显像对IF的临床诊断效能。90例患者中,男性32例、女性58例,年龄(67.56±7.68)岁,其中22例可疑IF、68例已确诊局部IF。所有患者的最终诊断结果均经过6个月以上临床及影像学随访证实。 结果 99Tcm-MDP SPECT全身骨显像共检出IF病灶234个,均表现为显像剂摄取增高,病变部位及个数为骨盆78个、腰椎49个、胸椎46个、肋骨45个、股骨8个、胫骨4个、跟骨3个及胸骨1个。全身骨显像联合局部SPECT/CT融合显像对IF的诊断灵敏度为100%(234/234)。68.89%(62/90)的患者联合显像检出的IF数目多于显像之前已知的骨折数目。在局部SPECT/CT融合显像检查范围内,CT显示骨折病灶293个,其中SPECT/CT诊断新鲜IF病灶234个、陈旧性IF病灶59个,SPECT/CT对新鲜IF的诊断灵敏度为100%(234/234)。 结论 99Tcm-MDP SPECT全身骨显像联合局部SPECT/CT融合显像对骨质疏松患者IF病灶数目的全身显示及诊断具有较高的临床应用价值。 -
关键词:
- 骨折,应力性 /
- 体层摄影术,发射型计算机,单光子 /
- 体层摄影术,X线计算机 /
- 99m锝美罗酸盐
Abstract:Objective To investigate the diagnostic value of 99Tcm-MDP SPECT whole-body bone scan and local SPECT/CT tomography fusion imaging for insufficiency fracture (IF). Methods Ninety patients (including 32 males and 58 females, aged 67.56±7.68, 22 cases with suspected IF, 68 cases with confirmed local IF) who were either diagnosed with IF in their partial skeleton or suspected to suffer from IF were enrolled in this study. The diagnostic value of 99Tcm-MDP SPECT whole-body bone scan and local SPECT/CT tomography fusion imaging for IF were retrospectively analyzed. The correct diagnosis were confirmed by clinical assessment and over 6 months of imaging follow-up. Results A total of 234 lesions were detected in 90 patients by 99Tcm-MDP SPECT whole-body bone scan, which showed high radioactivity in all lesions. The common sites of the lesions were the pelvis (78 lesions), lumbar vertebrae (49 lesions), thoracic vertebrae (46 lesions), ribs (45 lesions), femur (8 lesions), tibia (4 lesions), calcaneus (3 lesions), and sternus (1 lesion). The sensitivity of 99Tcm-MDP whole-body bone scan and local SPECT/CT tomography fusion imaging for IF was 100% (234/234). A greater number of lesions were determined in approximately 68.89% (62/90) of the patients by combined imaging than the lesions which were confirmed as IF before combined imaging. A total of 293 fractures were identified in the scope of CT examination; of these, 234 were diagnosed as acute fractures and 59 were diagnosed as chronic fractures by SPECT/CT. The diagnostic sensitivity of SPECT/CT toward acute IF was 100% (234/234). Conclusion 99Tcm-MDP SPECT whole body-bone scan and local SPECT/CT fusion imaging has high clinical value in the systemic display and diagnosis of IF in patients with osteoporosis. -
图 1 全身多发功能不全性骨折患者(女性,76岁)的99Tcm-MDP SPECT全身骨显像图(A)和骨盆SPECT/CT显像图(B、C) 患者臀部疼痛不适15 d。图中,A:双侧多发肋骨骨折呈“串珠状”改变,骶椎、双侧髂骨及双侧耻骨显像剂局部摄取增高;B:CT图像示骨盆呈骨质疏松改变,骶椎双侧、双侧髂骨翼及双侧耻骨骨折;C:融合图像示显像剂沿着骨折线摄取增高。MDP:亚甲基二膦酸盐;SPECT:单光子发射计算机体层摄影术;CT:计算机体层摄影术
Figure 1. 99Tcm-MDP SPECT whole-body bone scan (A) and local SPECT/CT tomography (B, C) of a 76-year-female patient with multiple insufficiency fracture
图 2 全身多发功能不全性骨折患者(女性,69岁)的99Tcm-MDP SPECT全身骨显像图(A)和腰椎SPECT/CT显像图(B、C) 患者胸背部疼痛不适10余天。图中,A:胸9、胸11椎体显像剂条形摄取增高;B:CT图像示胸8~胸12、腰1、腰3~腰4椎体高度不同程度降低;C:融合图像示胸9、胸11椎体显像剂呈条形摄取增高,提示新鲜骨折,余形态改变的椎体显像剂无明显摄取,提示陈旧性骨折。MDP:亚甲基二膦酸盐;SPECT:单光子发射计算机体层摄影术;CT:计算机体层摄影术
Figure 2. 99Tcm-MDP SPECT whole-body bone scan (A) and local SPECT/CT tomography (B, C) of a 69-year-female patient with multiple insufficiency fracture
表 1 90例骨质疏松患者IF的分布部位及病灶数
Table 1. Distribution of insufficiency fracture and the number of lesions in 90 cases of osteoporosis
IF部位 例数(例) 病灶数(个) 骨盆 22 78 腰椎 36 49 胸椎 24 46 肋骨 11 45 股骨 6 8 胫骨 4 4 跟骨 2 3 胸骨 1 1 合计 234 注:表中,IF:功能不全性骨折 -
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