磁共振弥散张量成像对脊髓型颈椎病患者术后神经功能恢复的预测作用【临床论着】
Thepredictive effect of diffusion tensor imaging in the postoperative neurologicalrecovery of cervical spondylotic myelopathy
李 翔1、2，陆瓞骥2，胡 勇1、2
（1 香港大学深圳医院骨科 深圳市创伤骨科新技术重点实验室 518053 广东省深圳市；2 香港大学矫形及创伤外科学系 香港特别行政区）
LIXiang, Keith D.K. Luk, HU Yong
(1Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, TheUniversity of Hong Kong-Shenzhen Hospital, Shenzhen, 518053, China; 2Department of Orthopaedics and Traumatology, The University of Hong Kong, HongKong, China)
基金项目：
深圳市科技研发基金（编号：JCYJ0413162540673）
第一作者简介：
男（1984-），主治医师，医学博士
研究方向：颈椎病
电话：（0755）86913333
E-mail：lix7@hku-
通讯作者：胡勇
E-mail：yhud@hku.hk
【摘 要】
目的：探讨磁共振弥散张量成像（diffusion tensor imaging，DTI）在预测脊髓型颈椎病（cervicalspondylotic myelopathy，CSM）患者术后神经功能恢复中的作用。
方法：前瞻性分析50例行手术治疗的CSM患者的临床资料，患者年龄43~86岁（64.3±11.2岁）。以19例年龄50~62岁（54.6±4.2岁）的健康志愿者作为对照组。应用3.0T磁共振DTI成像序列，观察患者术前各神经纤维束感兴趣区（包括整个颈髓、颈髓前束、侧束及后束）中的各向异性分数（fractional anisotropy，FA）、平均弥散率（mean diffusivity，MD）、轴向弥散系数（axial diffusivity，AD）及径向弥散系数（radial diffusivity，RD），将患者按术后神经功能日本骨科协会（Japanese Orthopedic Association，JOA）评分改善率（recovery rate，RR）分为3组：优良疗效组（RR>0.7）、中等疗效组（RR 0.4~0.7）和一般疗效组（RR<0.4）。比较对照组和3个患者组之间DTI参数值的差异，分析CSM患者脊髓神经束感兴趣区中的FA、MD、AD和RD值与神经功能改善率的相关性，并比较年龄、术前JOA评分、发病时间、MRI T2加权像脊髓高信号及DTI参数在预测CSM患者手术预后中的效果。
结果：3个患者组的年龄、发病时间及术前JOA评分均无显着性差异（P>0.05）。除优良疗效组整个颈髓的FA值外，3个患者组的FA、MD和RD值与对照组比较均存在显着性差异（P<0.01）。3个患者组之间仅优良疗效组的整个颈髓、脊髓侧束和后束的FA值与一般疗效组有显着性差异（P<0.05）。除后束MD值外，CSM患者所有脊髓神经束感兴趣区中的FA、MD和RD值均与神经功能改善率有显着相关性（P<0.05）；FA值在所有脊髓神经束感兴趣区中与神经功能改善率呈正相关，MD和RD值与神经功能改善率呈负相关（P<0.05），后束FA值有最好的相关性（r2=0.253，P<0.001）。ROC分析显示FA值的曲线下面积显着大于年龄、术前JOA评分、发病时间及T2加权像中脊髓高信号（P<0.05）。脊髓侧束的FA值在预测CSM患者优良手术效果中最为准确。
结论：CSM患者术前DTI参数值，尤其是脊髓后束及侧束FA值，在预测患者术后神经功能康复程度中表现出优于临床及传统影像学指标的特性，具有潜在的临床应用前景。
【关键词】 脊髓型颈椎病；弥散张量成像；手术预后
【Abstract】
Objectives: To investigatethe usage of diffusion tensor imaging(DTI) in predicting postoperativeneurologic recovery of cervical spondylotic myelopathy(CSM).
Methods: Theclinical >
Results: None of age, duration ofsymptoms and preoperative JOA scores showed significant difference among thethree patient groups(P>0.05). Except for the FA value in the whole cord ofRR>0.7 group, the FA, MD and RD values in the three patient groups showedsignificant differences from those in the control grouprespectively(P<0.01). In the three patient groups, only the FA values in thewhole cord, lateral column and dorsal column of RR>0.7 group showedsignificant differences from those of RR<0.4 group. The FA, MD and RD valuesin all the investigated ROIs were significantly correlated with neurologicrecovery rate(P<0.05), except for MD value in the dorsal column. A positivecorrelation existed between the FA value and the recovery rate in all theinvestigated ROIs(P<0.05), while MD and RD values showed negativeassociations with the recovery rate(P<0.05), in which FA value in the dorsalcolumn showed the strongest correlation(r2=0.253, P<0.001). In the receiveroperating characteristic curve(ROC) analysis, the areas under the curve(AUC) ofthe FA value in all the ROIs were significantly larger than those of age,preoperative JOA scores, duration of symptoms and increased signal intensitywithin cervical cord on the T2-weighted images. Among them, FA value of lateralcolumn presented the best ability of predicting surgical outcome for CSMpatients.
Conclusions: Preoperative DTI parameters, especially the FA values inthe dorsal and lateral columns, has superior capacity in predicting surgicaloutcome for patients with CSM compared to clinical and traditional MRIfeatures. DTI may be a promising tool in the clinical practice of CSM.
【Keywords】Cervical spondylotic myelopathy; Diffusion tensor imaging; Prognosis
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图1 颈椎MRI T2加权像矢状位像上显示DTI轴向扫描布局
图2 在提取的FA图像中确定各脊髓神经束的感兴趣区，包括全脊髓（whole cord，WC）、脊髓前束（ventralcolumn，VC）、侧束（lateral column，LC）及后束（dorsal column，DC）
图3 MRI T2加权像矢状位像上C5/6脊髓高信号
Figure 1 Sections for the axial diffusion tensorimaging(DTI) scaned on a sagittal T2W image
Figure 2 Regions of interestcovering the whole cord(WC), the ventral columns(VC), the lateral columns(LC)and the dorsal column(DC) were drawn on DTI FA map
Figure 3Increased signal intensity(ISI) was observed on sagittal T2-weighted MRIimages of patients
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图4 脊髓型颈椎病患者在WC、VC、LC和DC中的FA值与神经功能改善率之间的线性回归分析
图5 脊髓型颈椎病患者在WC、VC、LC和DC中的MD值与神经功能改善率之间的线性回归分析
Figure 4 Linear regressions of FA values in WC, VC, LCand DC with neurologic recovery rate in CSM patients
Figure 5 Linear regressions of MD values in WC, VC, LCand DC with neurologic recovery rate in CSM patients
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图6 脊髓型颈椎病患者在WC、VC、LC和DC中的RD值与神经功能改善率之间的线性回归分析
Figure 6 Linear regressions of RD values in WC, VC, LCand DC with neurologic recovery rate in CSM patients
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图7 应用不同临床及DTI参数预测脊髓型颈椎病患者神经功能改善率准确性的ROC曲线
Figure 7 Receiver operating characteristic curves thatusing different clinical and DTI parameters to test the prognostic accuracy ofneurologic recovery rate of CSM patients
本文为删节版，原文请见《中国脊柱脊髓杂志》5月刊
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