代谢性及内分泌性骨质软化的影像学研究
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摘要
目的
通过对不同代谢性及内分泌性骨病所致骨质软化的影像学表现进行分析，探讨一些骨质软化影像学征象—夹心椎、假骨折线、骨营养孔增大的成因、它们在诊断和鉴别诊断上的意义及其对临床的有用性；探讨夹心椎椎体骨小梁分布特征，选出适于进行定量CT测量的骨量变化敏感的部位；界定影像学对代谢性及内分泌性骨质软化症诊断的能力与限度，设置合理而实用的检查程序。
资料与方法
收集X线片上具有骨质软化表现的病例36例，均进行了骨结构及骨密度的影像学分析。在X线片发现有夹心椎表现的病人中选取无脊柱侧弯者12例行腰椎CT扫描，另选取32例健康者作为对照组亦行腰椎CT扫描，然后选择椎体不同部位测量CT值并进行比较分析。6例X线片发现有假骨折线的病人行局部薄层CT扫描，22例病人行双能X线吸收法(DXA)骨密度测量，1例病人行骨组织形态计量学检查。
天津医科大学硕士研究生学位论文
结果
本研究的病例均有不同程度的骨弯曲变形和骨密度异常。骨密度异常包
括骨密度减低和骨密度增高。骨密度减低见于所有病例的不同部位，分全身
性及部分性。骨密度增高以椎体表现明显，分弥漫性密度增高及夹心椎两种。
13例出现假骨折，3例出现真骨折，2例出现衰竭骨折。6例出现假骨折病人
行局部薄层CT扫描后显示假骨折线较X线片更加清晰。3例病人X线片示
双手指骨营养孔增大。腰椎CT值测量结果:(1)夹心椎组椎体上层和下层CT
值均数均大于对照组，中层CT值均数与对照组差异无统计学意义;(2)夹心
椎组椎体上层和下层CT值均数均大于中层，上层与下层之间CT值均数差异
无统计学意义;(3)夹心椎组椎体上层和下层区组间CT值差异无统计学意义，
中层区组间CT值差异有统计学意义，其结果与对照组所测结果一致。DXA
测量结果:X线片示椎体密度减低病人的骨矿密度(BMD)测值也减低，与
其X线表现一致;2例X线片示椎体弥漫性密度增高的病例BMD测值减低，
与其X线表现不相符;夹心椎病人BMD测值表现多样，骨量增多、正常和
减少均可见到。1例病人行骨组织形态计量学检查证实为骨质软化。
结论
1.夹心椎是代谢性及内分泌性骨病较常见的影像学表现。如进行定量
CT测量，则对夹心椎椎体上层和下层的测量更有意义，而分区测量似无必要。
夹心椎虽无诊断特异性，但可以反映病情的发展情况，它可随病情的好转而
逐渐消退，也可随病情的加重而日益明显，宜视为评估病情变化的影像学指
标之一。
2.在代谢性及内分泌性骨质软化症中出现的骨折线可能是多种原因造
成的，可以是假骨折、真骨折和衰竭骨折。文内归纳并提出了这三种骨折的
诊断标准。薄层CT扫描可以更准确地显示假骨折线的形态、边缘有无硬化、
断端有无骨痴形成等，并可应用三维重建等后处理技术对其进行多角度、多
天津医科大学
硕士研究生学位论文
层次地显示。假骨折线既是骨质软化广义诊断的可信征象，又可作为监测病
情发展情况的一个指标。
3.骨营养孔增大可能是骨质软化的一个重要提示征象。
4.骨质软化X线片表现骨密度减低代表着骨量减少:但X线片表现骨
密度增高并不一定代表骨量增多，其中尚含有正常骨量甚至是骨量减低者，
此时，必须注意到有硬化样骨软化的可能。以DXA测量椎体BMD值来区分
真性骨硬化和硬化样骨软化是可取的。
5.对骨质软化与骨质疏松的骨小梁影像学表现不同的病理基础作了进
一步解释。
6.代谢性及内分泌性骨质软化症的诊断宜采用初选、初诊和确诊的检查
程序，在影像学表现与临床资料相结合的基础上作综合分析，才可得出可信
的结论。
Objective: To probe mechanisms and diagnostic values of some osteomalacic imaging features (rugger-jersey spine, pseudofracture line and enlargement of nutrient foramen), demonstrate the regional distribution of bone trabeculae and find out sensitive loci of bone mass changing for quantitative CT examination in rugger-jersey vertebral body, define the diagnostic ability and limitation of imaging in metabolic and endocrine osteomalacia, set up a suitable examination procedure.
Materials and Methods: Thirty-six patients who had osteomalacic appearance in radiograms were collected in this study. All of them were performed radiologic analysis of bone structure and density. Twelve patients with rugger-jersey spine and without scoliosis were performed lumbar CT scan. Thirty-two healthy volunteers as control group were performed lumbar CT scan too. CT values of two groups were measured from different portions of vertebral body, and then were analysed. Six patients with pseudofracture line were examined by thin slice CT scan, 22 patients were performed dual-energy x-ray absorptiometry (DXA), 1 patient was performed bone histomorphometry.
Results: All patients showed different degree bending deformity and abnormal density of bone. Abnormal density included decreased and increased density. Decreased density was found in different portions of all patients, which divided into general and regional type. Increased density was obviously in vertebrae, including diffusely increased density and rugger-jersey spine. Thirteen patients had pseudofractures, 3 had true fractures, 2 had insufficiency fractures. Six patients who had pseudofractures underwent thin slice CT scan, which displayed pseudofracture line more clearly than plain film. Three patients' nutrient foramina of phalanges showed enlarged in plain film. CT measurement of vertebra showed that the mean CT values of both superior and inferior portions of rugger-jersey vertebral body were higher than control group's. The mean CT value difference of
middle portions between rugger-jersey spine group and control group had no statistical significance. The mean CT values of superior and inferior portions of rugger-jersey spine were higher than middle portion's. The difference of mean CT values between superior and inferior portions had no statistical significance. The difference of CT values among the regions of superior and inferior portions had no statistical significance. The difference of CT values among the regions of middle portion had statistical significance, which accorded with the control group. This investigation showed that low bone mineral density (BMD) of lumbar vertebrae accorded with the radiographic appearance. Two patients showed low BMD in DXA but appeared diffusely increased bone density in plain film. In our study, the DXA measurement of rugger-jersey spine showed high, normal and low BMD. One patient who underwent histomorphometry was confirmed osteomalacia. Conclusion:
1. The rugger-jersey spine as a radiographic feature is more frequently in metabolic and endocrine bone diseases. It is useful to measure superior and inferior portions of rugger-jersey vertebral body if QCT would be performed, while regional measurement seems to be unnecessary. Although rugger-jersey spine is not a specific feature for diagnosis, it may reflect the progress of disease. So it can be used as an imaging index of condition evaluation.
2. The fracture line in metabolic and endocrine osteomalacia may be caused by several reasons. It may be pseudofracture, true fracture or insufficiency fracture. This study inducted diagnostic criteria of these three kinds of fracture. Thin slice CT scan can exactly display the form, marginal sclerosis, callus formation. Furthermore, by three-dimensional reconstruction technique the pseudofracture line will be demonstrated from multiple directions. The pseudofracture line is a confident feature to diagnose osteomalacia, and it can be an index to monitor the progress of the disease.
3. Enlarging nutrient foramen of bone may
通过对不同代谢性及内分泌性骨病所致骨质软化的影像学表现进行分析，探讨一些骨质软化影像学征象—夹心椎、假骨折线、骨营养孔增大的成因、它们在诊断和鉴别诊断上的意义及其对临床的有用性；探讨夹心椎椎体骨小梁分布特征，选出适于进行定量CT测量的骨量变化敏感的部位；界定影像学对代谢性及内分泌性骨质软化症诊断的能力与限度，设置合理而实用的检查程序。
资料与方法
收集X线片上具有骨质软化表现的病例36例，均进行了骨结构及骨密度的影像学分析。在X线片发现有夹心椎表现的病人中选取无脊柱侧弯者12例行腰椎CT扫描，另选取32例健康者作为对照组亦行腰椎CT扫描，然后选择椎体不同部位测量CT值并进行比较分析。6例X线片发现有假骨折线的病人行局部薄层CT扫描，22例病人行双能X线吸收法(DXA)骨密度测量，1例病人行骨组织形态计量学检查。
天津医科大学硕士研究生学位论文
结果
本研究的病例均有不同程度的骨弯曲变形和骨密度异常。骨密度异常包
括骨密度减低和骨密度增高。骨密度减低见于所有病例的不同部位，分全身
性及部分性。骨密度增高以椎体表现明显，分弥漫性密度增高及夹心椎两种。
13例出现假骨折，3例出现真骨折，2例出现衰竭骨折。6例出现假骨折病人
行局部薄层CT扫描后显示假骨折线较X线片更加清晰。3例病人X线片示
双手指骨营养孔增大。腰椎CT值测量结果:(1)夹心椎组椎体上层和下层CT
值均数均大于对照组，中层CT值均数与对照组差异无统计学意义;(2)夹心
椎组椎体上层和下层CT值均数均大于中层，上层与下层之间CT值均数差异
无统计学意义;(3)夹心椎组椎体上层和下层区组间CT值差异无统计学意义，
中层区组间CT值差异有统计学意义，其结果与对照组所测结果一致。DXA
测量结果:X线片示椎体密度减低病人的骨矿密度(BMD)测值也减低，与
其X线表现一致;2例X线片示椎体弥漫性密度增高的病例BMD测值减低，
与其X线表现不相符;夹心椎病人BMD测值表现多样，骨量增多、正常和
减少均可见到。1例病人行骨组织形态计量学检查证实为骨质软化。
结论
1.夹心椎是代谢性及内分泌性骨病较常见的影像学表现。如进行定量
CT测量，则对夹心椎椎体上层和下层的测量更有意义，而分区测量似无必要。
夹心椎虽无诊断特异性，但可以反映病情的发展情况，它可随病情的好转而
逐渐消退，也可随病情的加重而日益明显，宜视为评估病情变化的影像学指
标之一。
2.在代谢性及内分泌性骨质软化症中出现的骨折线可能是多种原因造
成的，可以是假骨折、真骨折和衰竭骨折。文内归纳并提出了这三种骨折的
诊断标准。薄层CT扫描可以更准确地显示假骨折线的形态、边缘有无硬化、
断端有无骨痴形成等，并可应用三维重建等后处理技术对其进行多角度、多
天津医科大学
硕士研究生学位论文
层次地显示。假骨折线既是骨质软化广义诊断的可信征象，又可作为监测病
情发展情况的一个指标。
3.骨营养孔增大可能是骨质软化的一个重要提示征象。
4.骨质软化X线片表现骨密度减低代表着骨量减少:但X线片表现骨
密度增高并不一定代表骨量增多，其中尚含有正常骨量甚至是骨量减低者，
此时，必须注意到有硬化样骨软化的可能。以DXA测量椎体BMD值来区分
真性骨硬化和硬化样骨软化是可取的。
5.对骨质软化与骨质疏松的骨小梁影像学表现不同的病理基础作了进
一步解释。
6.代谢性及内分泌性骨质软化症的诊断宜采用初选、初诊和确诊的检查
程序，在影像学表现与临床资料相结合的基础上作综合分析，才可得出可信
的结论。
Objective: To probe mechanisms and diagnostic values of some osteomalacic imaging features (rugger-jersey spine, pseudofracture line and enlargement of nutrient foramen), demonstrate the regional distribution of bone trabeculae and find out sensitive loci of bone mass changing for quantitative CT examination in rugger-jersey vertebral body, define the diagnostic ability and limitation of imaging in metabolic and endocrine osteomalacia, set up a suitable examination procedure.
Materials and Methods: Thirty-six patients who had osteomalacic appearance in radiograms were collected in this study. All of them were performed radiologic analysis of bone structure and density. Twelve patients with rugger-jersey spine and without scoliosis were performed lumbar CT scan. Thirty-two healthy volunteers as control group were performed lumbar CT scan too. CT values of two groups were measured from different portions of vertebral body, and then were analysed. Six patients with pseudofracture line were examined by thin slice CT scan, 22 patients were performed dual-energy x-ray absorptiometry (DXA), 1 patient was performed bone histomorphometry.
Results: All patients showed different degree bending deformity and abnormal density of bone. Abnormal density included decreased and increased density. Decreased density was found in different portions of all patients, which divided into general and regional type. Increased density was obviously in vertebrae, including diffusely increased density and rugger-jersey spine. Thirteen patients had pseudofractures, 3 had true fractures, 2 had insufficiency fractures. Six patients who had pseudofractures underwent thin slice CT scan, which displayed pseudofracture line more clearly than plain film. Three patients' nutrient foramina of phalanges showed enlarged in plain film. CT measurement of vertebra showed that the mean CT values of both superior and inferior portions of rugger-jersey vertebral body were higher than control group's. The mean CT value difference of
middle portions between rugger-jersey spine group and control group had no statistical significance. The mean CT values of superior and inferior portions of rugger-jersey spine were higher than middle portion's. The difference of mean CT values between superior and inferior portions had no statistical significance. The difference of CT values among the regions of superior and inferior portions had no statistical significance. The difference of CT values among the regions of middle portion had statistical significance, which accorded with the control group. This investigation showed that low bone mineral density (BMD) of lumbar vertebrae accorded with the radiographic appearance. Two patients showed low BMD in DXA but appeared diffusely increased bone density in plain film. In our study, the DXA measurement of rugger-jersey spine showed high, normal and low BMD. One patient who underwent histomorphometry was confirmed osteomalacia. Conclusion:
1. The rugger-jersey spine as a radiographic feature is more frequently in metabolic and endocrine bone diseases. It is useful to measure superior and inferior portions of rugger-jersey vertebral body if QCT would be performed, while regional measurement seems to be unnecessary. Although rugger-jersey spine is not a specific feature for diagnosis, it may reflect the progress of disease. So it can be used as an imaging index of condition evaluation.
2. The fracture line in metabolic and endocrine osteomalacia may be caused by several reasons. It may be pseudofracture, true fracture or insufficiency fracture. This study inducted diagnostic criteria of these three kinds of fracture. Thin slice CT scan can exactly display the form, marginal sclerosis, callus formation. Furthermore, by three-dimensional reconstruction technique the pseudofracture line will be demonstrated from multiple directions. The pseudofracture line is a confident feature to diagnose osteomalacia, and it can be an index to monitor the progress of the disease.
3. Enlarging nutrient foramen of bone may
引文
1．朱宪彝主编．代谢性骨病X线诊断学．天津：天津科学技术出版社，1985：54-55
2．廖二元主编．内分泌学．北京：人民卫生出版社，2001：1824
3．王晨光，肖湘生，陈星荣，等．人腰椎标本的区域骨密度分布特征．中华放射学杂志，1998，32：557-560
4．中国老年学学会骨质疏松委员会骨质疏松诊断标准学科组．中国人骨质疏松症建议诊断标准(第二稿)．中国骨质疏松杂志，2000，6：1-3
5. Resnick D. The sclerotic vertebral body. JAMA, 1983, 249:1761-1763
6．陈凡主编．放射诊断学征象．上海：同济大学出版社，1995：244
7. Shapiro R. Radiologic aspects of renal osteodystrophy. Radiol Clin North Am, 1972, 10:557
8. Grampp S, Jergas M, Lang P, et al. Quantitative CT assessment of the lumbar spine and radius in patients with osteoporosis. AJR, 1996,167:133-140
9．徐均超，梅其在，任忠，等．正常人群的骨密度定量CT测量．中华放射学杂志，1991，25：325-329
10. Cody DD, Flynn MJ, Vickers DS. A technique for measuring regional bone mineral density in human lumbar vertebral bodies. Med Phys, 1989, 16:766-772
11. Nepper-Rasmussen J, Mosekilde L. Local differences in mineral content in vertebral trabecular bone measured by dual-energy computed tomography. Acta Radiol, 1989, 30:369-371
12. Gilsanz V, Boechat MI, Gilsanz R, et al. Gender differences in vertebral sizes in adults: biomechanical implications. Radiology, 1994, 190:678-682
13. Resnick D. Diagnosis of bone and joint disorders. W. B. Saunders Company. 1988:2098
14. Steinbach HL, Kolb FO, Gilfillan R: A mechanism of the production of pseudofractures in osteomalacia (Milkman's syndrome). Radiology, 1954, 62: 388
15. Yamashita H, Kitagawa M. Histomorphometric study of ribs with looser zones in Itai-itai disease. Calcif Tissue Int, 1996, 58:170-176
16. Resnick D. Diagnosis of bone and joint disorders. W. B. Saunders Company. 1988:2773
17. Resnick D. Diagnosis of bone and joint disorders. W. B. Saunders Company. 1988:2148
18. Garner A, Ball J. Quantitative observation on mineralized and unmineralised
bone in chronic renal azotaemia and intestinal malabsorption. J Path Bacteriol, 1966, 91: 545
19. Weinstein RS, Underwood JL, Hutson MS, et al. Bone histomorphometry in vitamin D-deficient rats infused with calcium and phosphorus. Am J Physiol, 1984,246(P): E499-505
20. Noy R, Lipton JF, Vigorita VJ, et al. Osteoclast dysfunction in the osteosclerotic variant of renal osteodystrophy. Orthopedics, 2002, 25:739-743
21. Eugenidis N, et al. Osteosclerosis in hyperparathyroidism. Radiology, 1972,105:265-275
22．李景学，蔡跃增，邱明才，等．骨硬化还是骨软化?中华放射学杂志，1987，21：65-68
23．李景学，孙鼎元．骨关节X线诊断学．北京：人民卫生出版社，1993：245
24. Lenchik L, Sartoris DJ. Current concepts in osteoporosis. AJR, 1997,168:905-911
25. Torres A, Lorenzo V, Gonzalez-Posada JM. Comparison of histomorphometry and computerized tomography of the spine in quantitating trabecular bone in renal osteodystrophy. Nephron, 1986, 44:282-287
26．廖二元主编．内分泌学．北京：人民卫生出版社，2001：313
2．廖二元主编．内分泌学．北京：人民卫生出版社，2001：1824
3．王晨光，肖湘生，陈星荣，等．人腰椎标本的区域骨密度分布特征．中华放射学杂志，1998，32：557-560
4．中国老年学学会骨质疏松委员会骨质疏松诊断标准学科组．中国人骨质疏松症建议诊断标准(第二稿)．中国骨质疏松杂志，2000，6：1-3
5. Resnick D. The sclerotic vertebral body. JAMA, 1983, 249:1761-1763
6．陈凡主编．放射诊断学征象．上海：同济大学出版社，1995：244
7. Shapiro R. Radiologic aspects of renal osteodystrophy. Radiol Clin North Am, 1972, 10:557
8. Grampp S, Jergas M, Lang P, et al. Quantitative CT assessment of the lumbar spine and radius in patients with osteoporosis. AJR, 1996,167:133-140
9．徐均超，梅其在，任忠，等．正常人群的骨密度定量CT测量．中华放射学杂志，1991，25：325-329
10. Cody DD, Flynn MJ, Vickers DS. A technique for measuring regional bone mineral density in human lumbar vertebral bodies. Med Phys, 1989, 16:766-772
11. Nepper-Rasmussen J, Mosekilde L. Local differences in mineral content in vertebral trabecular bone measured by dual-energy computed tomography. Acta Radiol, 1989, 30:369-371
12. Gilsanz V, Boechat MI, Gilsanz R, et al. Gender differences in vertebral sizes in adults: biomechanical implications. Radiology, 1994, 190:678-682
13. Resnick D. Diagnosis of bone and joint disorders. W. B. Saunders Company. 1988:2098
14. Steinbach HL, Kolb FO, Gilfillan R: A mechanism of the production of pseudofractures in osteomalacia (Milkman's syndrome). Radiology, 1954, 62: 388
15. Yamashita H, Kitagawa M. Histomorphometric study of ribs with looser zones in Itai-itai disease. Calcif Tissue Int, 1996, 58:170-176
16. Resnick D. Diagnosis of bone and joint disorders. W. B. Saunders Company. 1988:2773
17. Resnick D. Diagnosis of bone and joint disorders. W. B. Saunders Company. 1988:2148
18. Garner A, Ball J. Quantitative observation on mineralized and unmineralised
bone in chronic renal azotaemia and intestinal malabsorption. J Path Bacteriol, 1966, 91: 545
19. Weinstein RS, Underwood JL, Hutson MS, et al. Bone histomorphometry in vitamin D-deficient rats infused with calcium and phosphorus. Am J Physiol, 1984,246(P): E499-505
20. Noy R, Lipton JF, Vigorita VJ, et al. Osteoclast dysfunction in the osteosclerotic variant of renal osteodystrophy. Orthopedics, 2002, 25:739-743
21. Eugenidis N, et al. Osteosclerosis in hyperparathyroidism. Radiology, 1972,105:265-275
22．李景学，蔡跃增，邱明才，等．骨硬化还是骨软化?中华放射学杂志，1987，21：65-68
23．李景学，孙鼎元．骨关节X线诊断学．北京：人民卫生出版社，1993：245
24. Lenchik L, Sartoris DJ. Current concepts in osteoporosis. AJR, 1997,168:905-911
25. Torres A, Lorenzo V, Gonzalez-Posada JM. Comparison of histomorphometry and computerized tomography of the spine in quantitating trabecular bone in renal osteodystrophy. Nephron, 1986, 44:282-287
26．廖二元主编．内分泌学．北京：人民卫生出版社，2001：313
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