骨质疏松 脊柱转移瘤 多发性骨髓瘤致椎体压缩骨折临床诊断与诊断流程

Clinical diagnosis of vertebral compression fracture caused by osteoporosis, spinal metastases and multiple myeloma

目的探讨三种病因致椎体压缩骨折的临床症状、实验室结果、影像学变化,分析并总结临床诊断流程,从而进一步指导临床,降低误诊率。方法回顾2017年7月至2008年2月济南军区总医院骨病科椎体压缩骨折病例368例,男116例,女262例,按随机数字表,随机分为3组。骨质疏松组215例(A组)、脊柱转移瘤组119例(B组)、多发性骨髓瘤组44例(C组)。临床特点观察指标:性别、年龄、体重指数、下肢神经体征、疼痛视觉模拟评分(visual analogue scale,VAS)。实验室检查观察指标:血红蛋白、血沉、白球比、肿瘤标记谱。影像学观察指标:脊柱椎体形态学特点,MRI中病椎信号,椎弓根及附件,椎体内线性高信号,软组织肿块,椎体后缘表现。组间均值比较采用独立样本t检验或MannWhitney U检验,计数资料采用χ~2进行比较。结果骨质疏松组平均年龄较大(t_(AB)=-3.581,P=0.023;t_(AC)=-3.979,P=0.011)、女性多见(χ_(AB)~2=38.369,P=0.000;χ_(AC^2=69.295,P=0.000)、低体重指数(Z_(AB)=-4.011,P=0.015;Z_(AC)=-7.454,P=0.000)、VAS评分低(Z_(AB)=-2.375,P=0.045;Z_(AC)=-2.463,P=0.047);转移瘤组常伴下肢神经症状(χ_(AB)~2=120.297,P=0.000;χ_(BC)~2=35.108,P=0.000);转移瘤组肿瘤标记谱阳性率较高(χ_(AB)~2=122.738,P=0.000;χ_(BC)~2=30.032,P=0.000);骨髓瘤组血沉、白球比倒置、血色素三项均异常阳性率较高(χ_(AC)~2=124.213,P=0.000;χ_(BC)~2=81.941,P=0.000);椎体楔形改变常见于骨质疏松组(χ_(AB)~2=87.765,P=0.000;χ_(AC)~2=58.607,P=0.000);椎体双凹形改变常见于骨质疏松组及骨髓瘤组(χ_(AB)~2=12.309,P=0.000;χ_(BC)~2=14.677,P=0.000);椎体扁平型改变常见于转移瘤组及骨髓瘤组(χ_(AB)~2=177.179,P=0.000;χ_(AC)~2=80.349,P=0.000);骨质疏松组与骨髓瘤组病椎MRI多表现为T_1低信号、T_2高信号(χ_(AB)~2=62.127,P=0.000;χ_(BC)~2=25.329,P=0.000);椎弓根受累多见于转移瘤组(χ_(AB)~2=173.577,P=0.000;χ_(BC)~2=38.564,P=0.000);病椎周围软组织肿块多见于转移瘤组(χ_(AB)~2=317.126,P=0.000;χ_(AC)~2=233.000,P=0.000);椎体内线性高信号多见于骨质疏松组(χ_(AB)~2=317.126,P=0.000;χ_(AC)~2=233.000,P=0.000);椎体后缘膨隆多见于转移瘤组(χ_(AB)~2=174.031,P=0.000;χ_(BC)~2=58.704,P=0.000)。结论骨质疏松、脊柱转移瘤、多发性骨髓瘤致椎体压缩骨折的诊断需结合临床特点、实验室检查及影像学资料综合分析,对于诊断不明患者应进一步行ECT、PET-CT、骨髓穿刺、椎体病灶穿刺活检明确诊断,减少误诊率。

Objective To observe the clinical symptoms, laboratory results, images of vertebral compression fractures to analyze the diagnosis procedures to reduce the misdiagnosis rate. Methods All 368 cases of vertebral compression fractures were reviewed from 2008.2 to 2017. 7. There were 116 males, 262 females. All patients were divided into 3 groups： Group A (osteoporosis, n = 215); Group B (metastases, n = 119); Group C (multiple myeloma, n = 44). Observation index： sex, age, BMI, nerve signs, VAS. Laboratory examination： Hemoglobin, ESR, A / G, tumor markers. Imaging features： morphological characteristics, vertebral signals, pedicle and appendage, linear high signals in the vertebral body, soft tissue mass, vertebral edge. An independent sample t test or Mann-Whitney U test was used to compare the results among 3 groups. Chi square test was used to compare the counting data. Results Group A： the average age was older (tAB =-3.581, P = 0.023; tAC =-3.979, P = 0.011); more women （x2AB = 38.369, P = 0.000; x2AC = 69.295, P = 0.000); lower BMI (ZAB =-4.011, P = 0.015; ZAC =-7.454, P = 0.000); lower VAS score (ZAB =-2.375, P = 0.045; ZAc =-2.463, P = 0.047). Group B： Neuropathic symptoms often occurred （x2AB = 120.297, P = 0.000; Z2BC = 35.108, P = 0.000); more positive tumor markers （x2AB = 122.738, P = 0.000; x2BC = 30.032, P = 0.000); Group C： more positive ESR A/G and HGB rates （x2AC = 124.213, P = 0.000; x2Bc = 81.941, P = 0.000). Vertebrae wedge often occurred in Group A (x2AB = 87.765, P = 0.000; x2AC = 58.607, P = 0.000). Vertebrae biconcave often occurred in Group A and C (x2AB = 12.309, P = 0.000; x2BC = 14.677, P = 0.000). Vertebrae plana often occurred in Group B and C （x2AB = 177.179, P = 0.000; x2AC = 80.349, P = 0.000). The MRI signal short T1 and long Tz often occurred in Group A and C (x2AB = 62.127, P = 0.000; x2BC = 25.329, P = 0.000). Pedicle involvement often occurred in Group B （x2AB = 173.577, P = 0.000;x2BC = 38.564, P = 0.000). Soft tissue mass often occurred in Group B （x2AB = 317.126, P = 0.000; x2AC = 233.000, P = 0.000). Linear high signal often occurred in Group A （x2AB = 317.126, P = 0.000; x2AC = 233.000, P = 0.000). Bulge of posterior vertebral edge often occurred in Group B (x2AB = 174.031, P = 0.000; x2BC = 58.704, P = 0.000). Conclusions The diagnosis of vertebral compression fractures caused by osteoporosis, spinal metastases and multiple myeloma should be made combining with clinical features, laboratory examination and radiological data. For the patients with unidentified diagnosis, ECT, PET-CT, bone marrow aspiration and lesion biopsy should be further performed to reduce the misdiagnosis rate.