颈4-5椎小关节脓毒性关节炎 (Septic arthritis of the C4-C5 facet joint)MRI病例图片影像诊断分析

脊椎   2011-01-11

 【临床病史】:患者,59岁男性,有良性前列腺增生病史,出现14天的持续性尿路感染,采用了数种抗生素治疗。在第13天病人出现颈痛。A 59-year-old male with a history of BPH presented with a 14-day history of a persistent UTI treated with various antibiotics. On the 13th day the patient developed neck pain.

【影像图片】MRI图像


【影像表现】

Figure 1 and Figure 2: There is increased T2 signal at the right sided soft tissues of C4-C5 centered at the facet articulation (red arrow). In addition there is involvement of the adjacent right paravertebral muscles.

图1-2:以C4-5椎体关节突为中心,周围右侧软组织内可见T2高信号影(红箭),除此之外,右侧的椎旁肌肉亦有受累。

Figure 3 and Figure 4: Post contrast images demonstrate enhancement of the right facet articulation of C4-C5 with enhancement of the paravertebral muscles (red arrow). No focal rim enhancing fluid collection

图3-4:增强后图像显示右侧C4-5关节突及椎旁肌肉强化(红箭)。无明显的局限性环状强化的积液。

【影像诊断】:Septic arthritis of the C4-C5 facet joint 颈4-5椎小关节脓毒性关节炎

【诊断要点】

  • Septic arthritis is a relatively uncommon disorder but must always be suspected in a patient with a new onset spinal symptoms and fever. 脓毒性关节炎是一种相对少见的病变,但是在病人出现新发的颈部症状和发热是需要考虑到其可能性。
  • The source of infection is hematogenous spread from a distant septic focus of which UTIs are the most common source.感染是由远处的脓毒性病灶血性播散而来,而尿路感染是最常见的感染源

【讨论】

Septic arthritis of the facet joints (SAFJ) is uncommon, with only about 40 cases reported to date. Septic arthritis of the facet joint typically presents with fever and localized back pain aggravated by movement. The most common scenario is hematogenous dissemination from a distant focus of infection, which is usually in the urinary tract. Of 54 previously reported cases of SAFJ, 47 were documented by bacteriological studies. The organism was S. aureus in 33 (70%) cases, a streptococcus in 7 (16%) cases, a gram-negative rod in 3 (7%) cases, several organisms were recovered in 2 (4%) cases

椎小关节脓毒性关节炎并不常见,目前大约有40例报道。典型的椎小关节脓毒性关节炎表现为发热和局部背痛。最常见的起病是由于远处的局部感染灶血行播散而来,通常是泌尿道。在之前的54例(奇怪?)报道中,47例行细菌培养,在33例中发现金葡菌,链球菌有7例,3例革兰氏阴性杆菌,2例为其他细菌。

Radiographs may show destructive change around the facet joint but may be normal initially. Standard radiographs may remain normal for up to 1 month after symptom onset. In addition, the changes are not specific: they consist of joint space narrowing or widening, erosions, and/or subchondral geodes. Tc 99m bone scanning is a key investigation that localizes the infection to the facet joint, detects other foci (e.g., discitis), and helps to select further imaging studies (CT or MRI). MRI is the investigation of choice for assessing the extent of the infection. MRI is sensitive and more specific than CT. Soft tissue signal abnormalities may be visible after only 48 h. The capsule and ligaments typically produce a low-intensity signal on T1-weighted images that enhances after gadolinium injection. T2-weighted images show high-intensity signal. MRI can rule out concomitant discitis and, above all, detect local spread. Local spread may manifest as abscesses, pyomyositis of the spinal muscles or ilio-psoas muscle, or posterior epidural abscess potentially responsible for spinal cord or nerve root compression.

放射学改变可以显示为围绕着关节面的骨质破坏,但在最初也可以是正常的。在起病1个月后平片检查可以保持正常,另外,这些改变可以是非特异性:包括关节面的狭窄和增宽、骨质侵蚀、和/或软骨下坏死。Tc99m骨扫描是一种关键性的检查方式,明确感染位于小关节突,发现其他的病灶(如椎间盘炎),并且可以帮助选择更进一步的检查(CT或MR)。对于评估感染的扩展MRI是首选的检查方式。MRI比CT更敏感、更特异。软组织异常在48小时后既可以在MRI上显示出来。病变包膜和韧带通常在T1序列上显示为低信号,增强后有强化,T2序列显示为高信号。MRI可以排除伴发的椎间盘炎,尤其是发现局部的扩散。局部的扩散可以表现为脓肿、棘肌或髂腰肌化脓性肌炎、或者后部的硬膜外脓肿并可能压迫脊髓或神经根。

(参考来源:,医影志ACR,September, 2009,作者:freemanpyw编译)
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