应用CT值及形态学变化推断外伤性椎间盘突出时间的研究

发布时间：2018-06-05 23:14

本文选题：法医临床学 + 外伤　；参考：《华中科技大学》2006年硕士论文

【摘要】： 【研究背景】在法医临床学检案实践中,椎间盘突出症的鉴定经常遇到。遇到此类案件时,被鉴定人往往自述因受伤而导致椎间盘突出。有经验的法医师就应该仔细询问被鉴定人的临床症状、受伤经过、受伤方式,既往是否有受伤史、手术史,并仔细地进行体格检查,复阅影像学资料及其他特殊检查资料。但法医鉴定椎间盘突出的原因时在外伤与病理性改变的关系认定上较为复杂。病理性改变所致的椎间盘突出症在脊柱外科学和影像学研究较多,尤其影像学,如CT、MRI对其诊断已经到了成熟、准确的阶段。而外伤性椎间盘突出鉴定为一难点,因既缺乏统一的标准,又没有客观、简单、实用、有效的指标。许多法医鉴定工作者往往通过结合受伤史、临床症状和体征、影像学征象,认定或排除椎间盘突出中的外伤因素。其实只要相对准确地判定椎间盘突出的时间,就可使这一问题迎刃而解。如果椎间盘突出的时间与受伤时间相符,就应该考虑椎间盘突出中的外伤因素,反之,如果椎间盘突出的时间较受伤时间明显短或长,就应该排除此次外伤在椎间盘突出中的因素。而椎间盘突出时间的判定,国内外学者研究甚少。将椎间盘突出后的病理生理的变化和椎间盘突出患者CT检查的普遍性、检查后所得的影像资料的可保存性与客观性结合起来,应用专用的计算机软件进行定量的分析和定性的观察具有可行性。全面了解椎间盘突出后髓核的突出部分的CT值的变化和形态的变化为本研究的重要内容。【目的】以椎间盘为研究对象,根据随时间而变化的外伤性椎间盘突出突出髓核的CT值与未突出髓核中心部CT值的差值和髓核突出部分形态推断椎间盘突出的时间,从而为外伤性椎间盘突出的鉴定提供客观依据。【材料与方法】搜集同济医院用同一螺旋CT机以相同的条件作CT扫描的274个受检者的336个正常椎间盘与139个符合纳入标准的外伤性椎间盘突出者CT扫描后的.DCM文件,在同一台计算机上应用eFilm Workstation 2.0软件,对颈椎和腰椎分别采取不同的窗宽和窗位(同一部位采取相同的窗宽和窗位)进行定量与定性研究。根据文献报导以受伤时间进行分组。测量计算外伤性椎间盘突出不同时间椎间盘突出部髓核与未突出中心部髓核CT值差值,采用统计软件SPSS for Windows对组间的CT值差值进行统计学处理。同时观察不同时间突出的椎间盘髓核的大小、边缘、密度与形态。【结果】正常的颈椎间盘中心部CT值均值之间、边缘部CT值均值之间无明显统计学差异(P 0.05),但边缘部较相应中心部CT值高,平均高18.2Hu(Hounsfield Unit);正常的腰椎间盘中心部之间、边缘部之间CT值均值无明显统计学差异(P 0.05),但边缘部较中心部CT值高,平均高17.3 Hu。外伤后0d～15d内,椎间盘突出部髓核与未突出中心部髓核CT值差值x为负值,差值均值x等于-22.8±5.5 Hu;15d～1m内x为负值,x等于-19.2±5.4 Hu;1m～3m内x为负值,x等于-5.7±1.9 Hu;3m～6m x为正值, x等于4.6±2.6 Hu;6m～9m x为正值, x等于16.0±3.9 Hu;超过9m,x等于27.5±7.0 Hu。CT值差值x与损伤时间t呈曲线相关。外伤后3m内,80.0%的病例突出的髓核呈半圆弧形,近1/2圆面积,密度低而均匀,边缘光滑、饱满;外伤后超过3m,82.6%的病例突出的髓核在1/3圆弧以下面积,形态多不规则,密度较高、不均匀,边缘不光整或模糊。【结论】正常的颈、腰椎间盘的边缘部较中心部的CT值高。突出的椎间盘边缘部与中心部的CT值的差值随突出时间的延长而由负值到正值变化,有增高趋势,在各时间段有统计学差异。CT值差值与损伤时间呈曲线相关。突出的椎间盘的突出髓核的形态随时间而变化。可利用CT值和形态判断外伤性椎间盘突出时间。
[Abstract]:[background] the identification of protrusion of intervertebral disc is often encountered in the practice of forensic clinical trials. When such cases are encountered, the identified person often claims to cause the disc herniation due to injury. An experienced forensic physician should carefully inquire about the clinical symptoms, the way of the injury, the way of the injury, the history of the injury, and the operation. History, and careful examination of physical examination, review of imaging data and other special examination data. However, forensic identification of the causes of intervertebral disc herniation is more complex in the relationship between trauma and pathological changes. Pathological changes of disc herniation are found in spinal surgery and imaging studies, especially in imaging, such as CT, MRI, The diagnosis has reached a mature and accurate stage. The identification of traumatic intervertebral disc herniation is a difficult point because of the lack of unified standards and no objective, simple, practical and effective indicators. Many forensic experts often identify or exclude injuries in the protrusion of intervertebral disc by combining the history of injury, clinical symptoms and signs, imaging signs. If the time of the disc herniation is consistent with the time of the injury, we should consider the trauma factors in the disc herniation. Otherwise, if the time of the disc herniation is shorter or longer than the injury time, the injury should be excluded. The factors in the protrusion of intervertebral disc, and the determination of the time of the intervertebral disc herniation, there are few scholars at home and abroad. The changes of the pathophysiology after the protrusion of the disc and the universality of the CT examination in the patients with intervertebral disc herniation, the preservation of the image data obtained after the examination are combined with the objectivity, and the quantitative classification is carried out by the special computer software. A comprehensive understanding of the changes in the CT value of the protrusion of the nucleus pulposus after the disc herniation is an important part of this study.
[Objective] to provide an objective basis for the identification of traumatic intervertebral disc herniation, the CT value of the nucleus pulposus protruding with time and the difference between the CT value of the central nucleus of the nucleus pulposus and the nucleus pulposus shape of the nucleus pulposus were deduced according to the intervertebral disc.
[materials and methods] the.DCM files of 336 normal intervertebral discs and 139 cases of traumatic intervertebral disc herniation in Tongji Hospital were collected from 336 normal intervertebral discs with the same condition for CT scan with the same spiral CT, and the eFilm Workstation 2 software was used on the same computer to pick up the cervical and lumbar vertebrae respectively. Quantitative and qualitative studies were conducted with different window width and window position (the same window width and window position). According to the literature report, the difference between the nucleus pulposus of the intervertebral disc protrusion and the nucleus pulposus CT of the central part of the intervertebral disc herniated at different time was measured, and the statistical software SPSS for Windows was used to determine the difference between the groups. The difference of CT value was statistically analyzed. At the same time, the size, edge, density and morphology of nucleus pulposus at different time were observed.
[results] there was no significant difference between the mean value of CT value of the center of the cervical intervertebral disc and the mean CT value of the marginal part (P 0.05), but the marginal part was higher than that of the corresponding central part, and the average high 18.2Hu (Hounsfield Unit). There was no significant difference between the mean value of CT value between the normal lumbar intervertebral disc and the margin between the edges (P 0.05), but the margin of the margin was not significant (P 0.05). The CT value of the Department is higher than the central part, and the average height of 17.3 Hu. after trauma is 0d to 15d. The CT value difference between the nucleus pulposus of the disc herniation and the CT value of the nucleus pulposus in the central part is negative, the mean value x is equal to -22.8 + 5.5 Hu, and 15d to 1m internal x is minus 5.4. X is positive, x equals 16 + 3.9 Hu; exceeding 9m, X equal to 27.5 + 7 Hu.CT value difference x is associated with damage time t, and within 3M, 80% of the cases are semicircular arcs, near 1/2 circle area, low density and uniform, smooth and full; after trauma, more than 3m, 82.6% cases prominent nucleus in below 1/3 arc area, morphology Many irregular, high density, uneven, edge is not whole or fuzzy.
[Conclusion] the CT value of the marginal part of the normal neck and the lumbar intervertebral disc is higher than that of the central part. The difference between the CT value of the protruding intervertebral disc and the center is changed from negative to positive with the prolongation of the protruding time, and there is a tendency to increase. There is a statistical difference between the.CT value and the damage time in each time period. The morphology of the nucleus pulposus varies with time. The CT value and morphology can be used to determine the time of traumatic disc herniation.
【学位授予单位】：华中科技大学
【学位级别】：硕士
【学位授予年份】：2006
【分类号】：D919

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